Download Plan 1 Summary Plan Description

UNITED FOOD AND COMMERCIAL WORKERS
LOCAL 400
AND EMPLOYERS
HEALTH AND WELFARE PLAN
SUMMARY PLAN DESCRIPTION
PLAN 1
For eligibility on and after September 1, 2012:

Employees hired on or before October 15, 2005 with five years of seniority
from date of hire and who average a minimum of 18 hours per week

Employees hired after October 15, 2005 and before January 1, 2012 with
five years of seniority from date of hire and who average a minimum of 20
hours per week
And
Plan S and Plan V
For Retired Employees
January 2014 Edition
[INSERT TO FRONT COVER]
HOW TO FILE A MEDICAL CLAIM
All Medical claims, other than Vision and Dental, should be submitted
electronically by your provider to the local Blue Cross Blue Shield. Make sure
you present your current Blue Cross Blue Shield card with Identification and
Group numbers to your provider.
For Dental and Vision claims, follow the procedures listed below:
1. Provider submits paper claim to the Plan Office at:
600 D Street, Suite 250, South Charleston, WV 25303
2. Provider submits any x-rays or doctor notes needed for processing.
3. You may submit all receipts and bills to the Plan Office if the provider
does not bill for services.
All Medical, Dental and Vision claims should be submitted as soon as possible
after the date of service, and no later than the last day of the calendar year after
the year of the date of service.
Remember that your claims cannot be paid until all of the information needed to
process the claim is given to the Plan Office. An annual Enrollment Form must
also be on file.
HOW TO FILE A PRESCRIPTION CLAIM
Please refer to Page 85 of this booklet for information regarding the prescription
drug benefits.
If you are filing a Pharmacy paper claim, it must be submitted to the Plan Office
within three months of the date the prescription is filled at a pharmacy.
Submit the prescription receipt along with cash register receipts, tapes or
computer printout for all drugs purchased.
IMPORTANT: Keep a separate record of all medical expenses incurred for
yourself and each of your dependents, such as bills for doctors, hospital,
laboratory, services, drugs, etc. These must show the date the expense was
incurred and the type of expense. Expenses for prescription drugs must show
the date of purchase and name of the doctor who issued the prescription.
UNITED FOOD AND COMMERCIAL WORKERS
LOCAL 400 AND EMPLOYERS
HEALTH AND WELFARE PLAN
600 D Street
Suite 250
South Charleston, WV 25303
304-343-7682
BOARD OF TRUSTEES
Union Trustees
Mark Federici
James Slivosky
Charles Miller, Alternate
Employer Trustees
Steve Loeffler
Mike Christle
Steven Springer, Alternate
Only the full Board of Trustees is authorized to interpret the Plan of Benefits
described in this booklet. The provisions of this document are subject to amendment and
interpretation by the Board of Trustees and to the rules, regulations or procedures of the
Plan in effect at the time of a claim. The Board of Trustees has the power to interpret,
apply, construe, and amend the provisions of the Plan and this Summary Plan Description
(“SPD”) and make factual determinations regarding its construction, interpretation and
application. The Board’s interpretation will be final and binding on all individuals
dealing with or claiming a benefit from the Plan. No agent, representative, officer or
other individual from a Union or an Employer has authority to speak for the Trustees or
to act contrary to the written terms of the governing Plan documents. If you wish to
receive any information regarding the Plan, such information must be submitted to you in
writing by the Trustees, or if authorized by the Trustees, in writing signed by the Fund
Office.
Most of the benefits described in the Plan’s legal documents and in this booklet
are self-funded. The benefits payable are limited to Plan assets available for such
purposes.
This booklet describes Plan 1 for active employees and Plans S and V for retired
employees. Other booklets describe other plans of benefits. Be sure you have the
booklet that applies to you.
UNITED FOOD AND COMMERCIAL WORKERS
LOCAL 400 AND EMPLOYERS
HEALTH AND WELFARE PLAN
TO ALL PARTICIPANTS:
We are pleased to present you with this booklet to give you an up-to-date
summary description of the benefits provided by the Health and Welfare Plan. This
booklet is called the SPD. This SPD describes the benefits provided by the Plan in
general terms. The Plan’s Rules and Regulations and Trust Agreement, which are
available for your review at the Plan Office or by written request, comprise the legal
documents of the Plan and contain a detailed description of the rules, regulations, benefits
and provisions of the Plan. If there is any inconsistency between the SPD and the Plan
and Trust, the Plan and Trust will control.
The Plan is also required under federal law to provide you with other documents,
including a Summary of Benefits and Coverage (“SBC”). In the event of an inconsistency
between the SBC and the SPD, the SPD will govern. In the event of an inconsistency
between the SBC or the SPD and the Plan document, the Plan document will govern.
You will note that the term “benefits” is used and not “insurance.” The Health
and Welfare Plan is not an insurance company. It is a self-funded health benefit program
operated under federal law and guidelines and is not subject to state insurance regulations
or laws. The Life Insurance and Accidental Death and Dismemberment and Loss of
Sight portion of the Plan is insured under a contract with Hartford Life and Accident
Insurance Company (The Hartford).
Since the last SPD was printed, a number of important changes have been made to
the Plan. The deductibles and copayments have been changed, a utilization and disease
management provider, InforMed, has been added, pre-certification requirements have
been modified, and other changes have been made to benefits as required by changes in
the law.
Please review this SPD carefully and keep it with your other important papers so
that you will be familiar with the benefits available for you and your eligible dependents.
While it is our hope that you and your family will enjoy good health, it is comforting to
know that these benefits are available when needed.
If you have any questions regarding the benefits to which you are entitled, how to
file a claim, or eligibility, please contact the Plan Office.
Sincerely,
THE BOARD OF TRUSTEES
1
TABLE OF CONTENTS
Page
SCHEDULE OF BENEFITS .....................................................................................
Schedule I – Plan 1 (Active Employees) .......................................................
Schedule II – Plan S (Retired Employees Age 65 or Older)..........................
Schedule III – Plan V (Retired Employees Under Age 65) ...........................
4
4
12
16
DEFINITIONS ...........................................................................................................
20
ELIGIBILITY ............................................................................................................
30
Qualified Medical Child Support Orders (“QMCSO”) .................................
Uniformed Services Employment and Reemployment Rights Act
of 1994 (“USERRA”) ....................................................................................
Family and Medical Leave Act (“FMLA”) ...................................................
35
35
36
CONTINUATION OF COVERAGE UNDER THE CONSOLIDATED
OMNIBUS BUDGET RECONCILIATION ACT (“COBRA”) ...............................
37
EXTENSION OF BENEFITS ...................................................................................
43
RETIREE COVERAGE ............................................................................................
44
SURVIVING SPOUSE BENEFIT ............................................................................
46
GENERAL EXCLUSIONS AND LIMITATIONS...................................................
49
LIFE INSURANCE BENEFIT ..................................................................................
55
ACCIDENTAL DEATH, DISMEMBERMENT AND
LOSS OF SIGHT BENEFITS ...................................................................................
58
DISABILITY BENEFIT ............................................................................................
61
RETIREE DEATH BENEFIT ...................................................................................
62
GENERAL RULES ...................................................................................................
64
PPO NETWORK OPTIONS .....................................................................................
66
HOSPITAL AND PHYSICIAN PPO NETWORK ...................................................
66
PHARMACY NETWORK ........................................................................................
67
HOSPITAL PREADMISSION CERTIFICATION REQUIREMENT
(MATERNITY ADMISSIONS SEE PAGE 70) .......................................................
67
PREAUTHORIZATION OF SURGICAL PROCEDURE AND OTHER BENEFITS
68
2
Page
MAJOR MEDICAL EXPENSE BENEFITS.............................................................
Overview ........................................................................................................
Deductible Requirement ................................................................................
Percentage Payable ........................................................................................
Benefits ..........................................................................................................
70
70
70
70
71
BASIC MEDICAL EXPENSE BENEFIT.................................................................
80
DENTAL EXPENSE BENEFIT................................................................................
Benefits ..........................................................................................................
Covered Dental Services ................................................................................
Limitations .....................................................................................................
Exclusions ......................................................................................................
81
81
81
82
83
PRESCRIPTION DRUG EXPENSE BENEFIT .......................................................
Benefits ..........................................................................................................
Self-Injectable Drugs .....................................................................................
Step Therapy ..................................................................................................
Exclusions and Limitations ............................................................................
85
85
86
87
88
HOSPITAL SELF-AUDIT PROGRAM ...................................................................
90
COORDINATION OF BENEFITS ...........................................................................
With Other Plans ............................................................................................
With Medicare ...............................................................................................
91
91
94
SUBROGATION AND REIMBURSEMENT ..........................................................
95
GENERAL PLAN INFORMATION ........................................................................
Plan Administration .......................................................................................
Financial Information.....................................................................................
Plan Information ............................................................................................
HIPAA Certificates of Creditable Coverage from This Plan.........................
Claims Filing and Appeal Procedure .............................................................
Review of Plan Documents ............................................................................
99
99
101
101
103
104
112
NOTICE OF PRIVACY PRACTICES ......................................................................
114
CERTIFICATE OF INSURANCE ............................................................................
124
3
SCHEDULE I
UNITED FOOD AND COMMERCIAL WORKERS
LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN
PLAN 1
Schedule of Benefits for Eligible Full-Time Employees,
Part-Time Employees and Eligible Dependents
Where the Required Self-Contribution is Paid
(Effective as of January 1, 2014)
ELIGIBLE FULL-TIME EMPLOYEES ONLY
Life Insurance Benefit:
Total and Permanent Disability limited to $30,000.00
$50,000
Accidental Death, Dismemberment and Loss of Sight Benefit
Disability Benefit: (Totally Disabled Employees Only)
Maximum payment per month
Maximum period
$50,000
$200
5 months
ELIGIBLE PART-TIME EMPLOYEES ONLY
Life Insurance Benefit:
$10,000
Accidental Death, Dismemberment and Loss of Sight Benefit
$10,000
Disability Benefit: (Totally Disabled Employees Only)
Maximum payment per month
$200
Maximum period
5 months
ELIGIBLE DEPENDENTS OF ELIGIBLE FULL-TIME
EMPLOYEES ONLY
Life Insurance Benefit:
Spouse
Dependent Child:
Over 14 days but less than 6 months of age
6 months but less than 2 years of age
2 years but less than 3 years of age
3 years but less than 19 years of age
Maximum Benefit
$2,000
$ 200
$ 400
$ 800
$1,000
4
ELIGIBLE FULL-TIME EMPLOYEES, PART-TIME EMPLOYEES
AND DEPENDENTS
Benefits are payable only for Covered Charges.
MAJOR MEDICAL EXPENSE BENEFITS
MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per
Covered Family Member
ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED
TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON
NON-ESSENTIAL HEALTH BENEFITS UNDER THE
MAJOR MEDICAL EXPENSE BENEFIT UNLESS
OTHERWISE STATED
There is no annual maximum for essential health benefits (see page
24 for more information).
The annual maximum for non-essential health benefits is:
(-----$400,000-----)
LIFETIME MAXIMUM BENEFIT FOR NON-ESSENTIAL
HEALTH BENEFITS
(-----$400,000-----)
LIFETIME MAXIMUM BENEFIT For eligible Surgeries by
licensed podiatrists (DPM) Per Covered Family Member
(--------$1,000-----)
MAXIMUM IN-NETWORK OUT-OF-POCKET per Covered
Family Member per Calendar Year
(Covered Charges incurred during a calendar year in excess of the
deductible are paid at 100% U&C after Calendar Year
Out-of-Pocket Maximum is reached)
Per Person
Per Family
(-------$3,000---------)
(-------$6,000---------)
MAXIMUM OUT-OF-NETWORK OUT-OF-POCKET per
Covered Family Member per Calendar Year
Per Person
Per Family
CALENDAR YEAR IN-NETWORK DEDUCTIBLE
Single (Employee Only) Coverage
Family (Employee and Dependents) Coverage
5
(----------$6,000------)
(--------$12,000------)
(--------$400-----)
(--------$800-----)
CALENDAR YEAR OUT-OF-NETWORK DEDUCTIBLE
Single (Employee Only) Coverage
Family (Employee and Dependents) Coverage
(--------$800-----)
(------$1,600-----)
CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE
Per Employee and Covered Family Member
Covered Charges With an In PPO Network Provider or where No
80% of U&C before
PPO Network applicable
Calendar Year Outof-Pocket Maximum
is reached
(except if otherwise
shown)
Covered Charges With a Non PPO Network Provider
URGENT CARE OFFICE VISITS
In Network
50% of U&C before
Calendar Year Outof-Pocket Maximum
is reached
(except if otherwise
shown)
100% after $30.00
co-payment. Out-Of
Network, 100% after
$30.00 co-payment
PRIMARY CARE PHYSICIAN OFFICE VISITS*
In Network
SPECIALIST OFFICE VISITS*
In Network
*Services administered the same day as the office visit in the same
office by the same provider and for the same diagnosis would be
covered within the 100% after co-pay in-network coverage. Copayments are not applied to the out-of-pocket maximums.
100% after $25.00
co-payment. Out-Of
Network, 50% after
deductible
100% after $30.00
co-payment. Out-Of
Network, 50% after
deductible
All Hospital Covered Charges
(subject to preadmission certification requirement)
(Includes inpatient, outpatient and preadmission testing)
Daily Room and Board Limit
Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations
6
Physician Covered Charges (subject to review for charges above base service)
Chiropractors or physical therapists employed by or in same office as Chiropractors
(subject to deductible and co-insurance and additional limits below)
MAXIMUM NO. OF VISITS Per calendar year
30 Visits + additional visits subject to pre-certification.
Physical Medicine (therapy) (subject to deductible and co-insurance and additional limits
below)
MAXIMUM NO. OF VISITS Per calendar year
20 Visits + additional visits subject to pre-certification.
Durable Medical Supplies
(any charge above $500 is subject to preauthorization requirement)
U&C
Diagnostic Laboratory & X-ray Expenses
(Non-emergency MRIs, PET and CAT scans
are subject to preauthorization requirement)
U&C
Convalescent Care Accommodations
(subject to preauthorization requirement and following limits)
CALENDAR YEAR MAXIMUM NO. OF DAYS
120 Days
Home Health Care (Subject to preauthorization requirement and
following limits)
MAXIMUM NO. OF VISITS Per 12-Month Period
40 Visits
Hospice Care (Subject to preauthorization requirement and
following limits)
MAXIMUM LIFETIME BENEFIT
6 Months
Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient
Treatment
All mental health and substance abuse benefits are provided according to the Major Medical
Benefit rules under the Plan unless otherwise indicated.
Office Visit
100% after $25 co-payment
7
Emergency Room Services
In-Network Emergency
80%/20%
In-Network Non-Emergency
50%/50%
Out-of-Network Emergency
80%/20%
Out-of-Network Non-Emergency
50%/50%
Allergy Injections
U&C
Diabetes Education (subject to additional limits below)
U&C
CALENDAR YEAR MAXIMUM BENEFIT FOR
REEDUCATION OR REFRESHER EDUCATION
$100
U&C
Ambulance Charges
Hearing Expense Benefit (Must utilize an in-network Provider)
Hearing Screening and Examination by a Licensed Audiologist
Lifetime Maximum per person for Hearing Aid/Device
8
80% of U&C
$1,500
BASIC MEDICAL EXPENSE BENEFIT
PREVENTIVE -- IN-NETWORK without deductible
(Participants, Dependent spouse and children, all subject to age and
100% NO MAXIMUM
frequency limits)
Please see www.healthcare.gov for more information about which
preventive services are covered as required by the health care reform
law.
PREVENTIVE -- OUT-OF-NETWORK (except as provided under
Wellness Benefit)
Not Covered
WELLNESS BENEFITS
The Plan also provides for the following services to the extent not
In-Network 100%
covered by the above preventive services benefit: annual physical,
diagnostic radiology and laboratory services related to routine exam,
Out-Of-Network, 50%
routine colonoscopies (up to age 50), routine mammograms (up to
coverage after deductible
age 40), PSA testing, testicular cancer screening.
One examination per calendar year
HOSPITAL ROOM & BOARD (Non Diagnosis Related Group (“DRG”) charges)
(Effective 1/1/2009) $165.00 per day (70 days);
ICU-$330, first ten days, $165 a day afterwards for 70 days, then coverage provided under
Major Medical
Vision Care Expense Benefit
One examination and/or set of lenses and frames
allowed during any two calendar year period up to
MAXIMUM BENEFIT
*For children up to age 19, only the expenses for lenses and frames
will be counted towards the maximum benefit
$200*
DENTAL EXPENSE BENEFIT
MAXIMUM BENEFIT Per Calendar Year
*The maximum benefit only applies to adult dental benefits, not to
dental benefits for children up to age 19
Maximum Plan
Payment of $750*
Diagnostic, Preventive & Emergency Services
100% of Schedule
Basic (except periodontic), Major & TMJ Services
80% of Schedule
Orthodontic and Periodontal Services
*Lifetime maximum does not apply to periodontal services for
children up to age 19
9
50% up to $1,250 per
person lifetime
maximum*
RETAIL PRESCRIPTION DRUG EXPENSE BENEFIT
Drug Classification
Participant Co-Payment
Amount*
Generic drug
Lesser of $7.50 or 10%*
(See Below)
Formulary Brand Name drug
Lesser of $20 or 20%**
Multi-source Brand Name drug
Paid as Generic***
(See Below)
Co-Payment Amount
depends on Generic,
Multi-Source Brand
Name drug or Formulary
Brand Name drug.
Formulary Co-Payment is
Greater of $15 or 15%
with Max co-pay of
$75.00****(See Below)
Maintenance Medication
Oral Contraceptives for birth control
Generic Covered
Erectile Dysfunction Medication (subject to pre-authorization)
Mental and Nervous Disorders
Paid as Generic
Co-Payment Amount
depends on Generic,
Formulary Brand Name
drug or Multi-source
Brand Name drug
Injectable Prescription Medications (non-self- injectable not
available through a pharmacy)
Medically Necessary Growth hormones
Paid under Major
Medical Benefit
50%
Maximum Supply Per Retail Fill
34 Days
Maximum Participant Co-Payment per fill
$75.00
*The maximum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is $7.50.
**The maximum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is
$20.00.
***When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic
equivalent is available, the Plan/KPP covers the amount it would pay for the Generic drug equivalent, and the
Covered Family Member is responsible for the remainder of the cost.
****A Maintenance Medication is a prescription drug or medicine taken on a continual basis for treatment of a
chronic health condition such as but not limited to, high blood pressure (anti-hypertensive), high cholesterol,
asthma, glaucoma, osteoporosis, diabetes and diabetic related supplies. The minimum Participant Co-payment
Amount (subject to the provisions and limitations of the Plan) is $15.00. If the Participant Co-Payment % for
a prescription produces an amount less than $15.00, then the Participant Co-Payment is $15.00.
10
MAIL ORDER PRESCRIPTION DRUG EXPENSE BENEFIT
FOR KROGER EMPLOYEES
Drug Classification
Participant Co-Payment
Amount
Generic drug
Greater of $15 or 10%*
Formulary Brand Name drug
Greater of $40 or 20%**
Multi-source Brand Name drug
Paid as Generic***
(See Below)
Maintenance Medication
Greater of $30 or
15%****
Maximum Supply Per Fill
102 Days
Maximum Participant co-payment per fill
$150.00
*The minimum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is
$15.00. If the Participant Co-Payment % for a prescription produces an amount less than $15.00, then the
Participant Co-Payment Amount is $15.00.
**The minimum Participant Co-Payment Amount (subject to the provisions and limitations of the Plan) is
$40.00. If the Participant Co-Payment % for a prescription produces an amount less than $40.00, then the
Participant Co-Payment Amount is $40.00.
***When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic
equivalent is available, KPP will pay the amount it would pay for the Generic drug equivalent, and the
Covered Family Member is responsible for the remainder of the cost.
****A Maintenance Medication is a prescription drug or medicine taken on a continual basis for treatment
of a chronic health condition such as but not limited to, high blood pressure (anti-hypertensive), high
cholesterol, asthma, glaucoma, osteoporosis, diabetes and diabetic-related supplies. The minimum Participant
Co-Payment Amount (subject to the provisions and limitations of the Plan) is $30.00. If the Participant
Co-Payment % for a prescription produces an amount less than $30.00, then the Participant Co-Payment is
$30.00.
The Trustees reserve the right to amend, change, eliminate or decrease
benefits from time to time and at any time for all eligible Employees and their
eligible Dependents.
11
SCHEDULE II
Retiree Coverage
(Senior Program – Plan S)
Schedule of Benefits for all Eligible Employees who
Retired before March 1, 1990 and Eligible Dependents
And
Eligible Retired Employees Age 65
and Older and Eligible Dependents
(Effective as of January 1, 2014)
ELIGIBLE RETIRED EMPLOYEES ONLY
Self-funded Death Benefit
(Retirees Receiving Disability Pensions Excluded)
$5,000
ELIGIBLE RETIRED EMPLOYEES AND DEPENDENTS
Benefits are payable only for Covered Charges.
MAJOR MEDICAL EXPENSE BENEFITS
MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per
Covered Family Member
ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED
TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON
NON-ESSENTIAL HEALTH BENEFITS UNDER THE MAJOR
MEDICAL EXPENSE BENEFIT UNLESS OTHERWISE
STATED
There is no annual maximum for essential health benefits (for
more information, see page 24).
The annual maximum for major medical benefits for nonessential health benefits is:
(-----$350,000-----)
LIFETIME MAXIMUM FOR NON-ESSENTIAL HEALTH
BENEFITS
(-----$350,000-----)
LIFETIME MAXIMUM BENEFIT For eligible Surgeries by
licensed podiatrists (DPM) Per Covered Family Member
(-------$1,000------)
12
MAXIMUM OUT-OF-POCKET per Covered Family Member
per Calendar Year
(Covered Charges incurred during a calendar year in excess of the
deductible are paid at 100% U&C after Calendar Year
Out-of-Pocket Maximum is reached)
Per Person
Per Family
CALENDAR YEAR DEDUCTIBLE
(--------$4,000--------)
(--------$8,000--------)
Single (Employee Only) Coverage
Family (Employee and Dependents) Coverage
(--------$350--------)
(--------$700--------)
CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE
Per Covered Family Member
Covered Charges With an In PPO Network Provider or where
80% of U&C before
No PPO Network applicable
Calendar Year Outof-Pocket Maximum
is reached (except if
otherwise shown)
Covered Charges With a Non PPO Network Provider
50% of U&C before
Calendar Year Outof-Pocket Maximum
is reached (except if
otherwise shown)
All Hospital Covered Charges
(subject to preadmission certification requirement)
(Includes inpatient, outpatient and preadmission testing)
Daily Room and Board Limit
Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations
Physician Covered Charges (subject to review for charges above base service)
Chiropractors or physical therapists employed by or in same office as Chiropractors
(subject to additional limits below)
MAXIMUM NO. OF VISITS Per Calendar Year
30 Visits + additional visits subject to pre-certification. Subject to deductibles and coinsurance
Physical Medicine (therapy) (subject to additional limits below))
MAXIMUM NO. OF VISITS Per Calendar Year
20 Visits + additional visits subject to pre-certification
13
Durable Medical Supplies (any charge above $500 subject to preauthorization requirement) U&C
Diagnostic Laboratory & X-ray Expenses
(Non-emergency MRIs, PET and CAT scans are subject to preauthorization requirement) U&C
Convalescent Care Accommodations
(subject to preauthorization requirement and following limits)
CALENDAR YEAR MAXIMUM NO. OF DAYS
120 Days
Home Health Care (Subject to preauthorization requirement and
following limits)
MAXIMUM NO. OF VISITS Per 12-Month Period
40 Visits
Hospice Care (Subject to preauthorization requirement and
following limits)
MAXIMUM LIFETIME BENEFIT
6 months
Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient
Treatment
U&C
All mental health and substance abuse benefits are provided according to the Major Medical
Benefit rules under the Plan unless otherwise indicated.
Allergy Injections
U&C
Diabetes Education (subject to additional limits below)
U&C
CALENDAR YEAR MAXIMUM BENEFIT FOR
REEDUCATION OR REFRESHER EDUCATION
$100
Ambulance Charges
U&C
PREVENTIVE -- IN-NETWORK without deductible
(Participants, Dependent spouse and children subject to age limits)
100% NO
MAXIMUM
PREVENTIVE -- OUT-OF-NETWORK
Not Covered
14
PRESCRIPTION DRUG EXPENSE BENEFIT
Effective January 1, 2006, if you are eligible for Medicare, you are eligible to receive
prescription benefits through the federal government Medicare Part D program and you
will no longer receive prescription benefits from the Plan. However, your non-Medicare
eligible spouse and/or other dependents will continue to receive prescription benefits
from the Plan.
Drug Classification
Participant Co-Payment
Amount*
Generic drug
Greater of $10 or 10%*
Formulary Brand Name drug
Greater of $20 or 20%*
Multi-source Brand Name drug
Paid as Generic
**(See Below)
Medically Necessary Growth hormones
50%
Maximum Supply Per Fill
34 Days
Maximum Participant Co-Payment Per Fill
$75.00
*The minimum Generic drug Participant Co-Payment Amount is $10.00. If the Participant Co-Payment %
for a prescription produces an amount less than $10.00, then the Participant Co-Payment Amount is $10.00.
The Plan will pay the remainder, subject to the provisions and limitations of the Plan. This calculation also
applies to the Formulary drug Co-Payment of $20.00.
**When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug when a Generic
equivalent is available, the Plan will pay the amount it would pay for the Generic drug equivalent, and the
Covered Family Member is responsible for the remainder of the cost.
The Trustees reserve the right to amend, change, eliminate or decrease
benefits from time to time and at any time for all eligible Employees and their
eligible Dependents.
15
SCHEDULE III
Retiree Coverage
(Senior Program – Plan V)
Schedule of Benefits for all Eligible Employees who
Retired after February 28, 1990 and Before Age 65 and
Eligible Dependents
(Effective as of January 1, 2014)
ELIGIBLE RETIRED EMPLOYEES ONLY
Self-funded Death Benefit
(Retirees Receiving Disability Pensions Excluded)
$5,000
ELIGIBLE RETIRED EMPLOYEES AND DEPENDENTS
Benefits are payable only for Covered Charges.
MAJOR MEDICAL EXPENSE BENEFITS
MAXIMUM MAJOR MEDICAL EXPENSE BENEFIT Per Covered
Family Member
ALL ESSENTIAL HEALTH BENEFITS ARE APPLIED
TOWARD THE ANNUAL AND LIFETIME MAXIMUMS ON
NON-ESSENTIAL HEALTH BENEFITS UNDER THE MAJOR
MEDICAL EXPENSE BENEFIT UNLESS OTHERWISE STATED
There is no annual maximum for essential health benefits (for more
information, see page 24).
The annual maximum for non-essential health benefits is:
(-----$100,000-----)
LIFETIME MAXIMUM BENEFIT FOR NON-ESSENTIAL
HEALTH BENEFITS
(-----$100,000-----)
LIFETIME MAXIMUM BENEFIT For eligible Surgeries by
licensed podiatrists (DPM) Per Covered Family Member
(-----$1,000-----)
MAXIMUM OUT-OF-POCKET per Covered Family Member per
Calendar Year
(Covered Charges incurred during a calendar year in excess of the
deductible are paid at 100% U&C after Calendar Year Out-of-Pocket
Maximum is reached)
Per Person
Per Family
(----$4,000----)
(----$8,000----)
16
CALENDAR YEAR DEDUCTIBLE
Single (Employee Only) Coverage
Family (Employee and Dependents) Coverage
(----$350----)
(----$700----)
CO-INSURANCE PERCENTAGE PAYABLE AFTER DEDUCTIBLE
Per Covered Family Member
Covered Charges With an In PPO Network Provider or where No
80% of U&C
PPO Network applicable
before Calendar
Year Out-ofPocket Maximum
is reached (except
if otherwise
shown)
Covered Charges With a Non PPO Network Provider
50% of U&C
before Calendar
Year Out-ofPocket Maximum
is reached
(except if
otherwise shown)
All Hospital Covered Charges
(subject to preadmission certification requirement)
(Includes inpatient, outpatient and preadmission testing)
Daily Room and Board Limit
Average Semi-Private Room Charge or 100% U&C for Intensive Care Accommodations
Physician Covered Charges (subject to review for charges above base service)
Chiropractors or physical therapists employed by or in same office as Chiropractors
(subject to additional limits below)
MAXIMUM NO. OF VISITS Per Calendar Year
30 Visits + additional visits subject to pre-certification
Physical Medicine (therapy) (subject to additional limits below)
MAXIMUM NO. OF VISITS Per Calendar Year
20 Visits + additional visits subject to pre-certification
Durable Medical Supplies (any charge above $500 is subject to preauthorization
requirement)
U&C
Diagnostic Laboratory & X-ray Expenses
(Non-emergency MRIs, PET and CAT scans are subject to preauthorization
requirement)
U&C
17
Convalescent Care Accommodations
(subject to preauthorization requirement and following limits)
CALENDAR YEAR MAXIMUM NO. OF DAYS
120 Days
Home Health Care (Subject to preauthorization requirement and
following limits)
MAXIMUM NO. OF VISITS Per 12-Month Period
40 Visits
Hospice Care (Subject to preauthorization requirement and
following limits)
MAXIMUM LIFETIME BENEFIT
6 months
Mental and Nervous Disorder/Alcohol and Substance Abuse - Inpatient and Outpatient
Treatment
U&C
All mental health and substance abuse benefits are provided according to the Major Medical
Benefit rules under the Plan unless otherwise indicated.
Allergy Injections
U&C
Diabetes Education (subject to additional limits below)
U&C
CALENDAR YEAR MAXIMUM BENEFIT FOR REEDUCATION
OR REFRESHER EDUCATION
$100
Ambulance Charges
U&C
PREVENTIVE -- IN-NETWORK without deductible
(Participants, Dependent spouse and children subject to age limits)
100% NO
MAXIMUM
PREVENTIVE -- OUT-OF-NETWORK
Not Covered
18
PRESCRIPTION DRUG EXPENSE BENEFIT
Effective January 1, 2006, if you are eligible for Medicare, you are eligible to receive
prescription benefits through the federal government Medicare Part D program and you will
no longer receive prescription benefits from the Plan.
Drug Classification
After Satisfaction of
Calendar Year
Deductible, Participant
Co-Payment Amount*
Generic drug
Greater of $10 or
10%*
Formulary Brand Name drug
Greater of $20 or
20%*
Multi-source Brand Name drug
Paid as Generic
**(See Below)
Medically Necessary Growth hormones
50%
Maximum Supply Per Fill
34 Days
Maximum Participant Co-Payment Per Fill
$75.00
*The minimum Generic drug Participant Co-Payment Amount is $10.00. If the Participant
Co-Payment % for a prescription produces an amount less than $10.00, then the Participant
Co-Payment Amount is $10.00. The Plan will pay the remainder, subject to the provisions
and limitations of the Plan. This calculation also applies to the Formulary drug Co-Payment
of $20.00.
**When a Covered Family Member, Physician or pharmacy chooses a Brand Name drug
when a Generic equivalent is available, the Plan will pay the amount it would pay for the
Generic drug equivalent, and the Covered Family Member is responsible for the remainder of
the cost.
The Trustees reserve the right to amend, change, eliminate or decrease
benefits from time to time and at any time for all eligible Employees and their
eligible Dependents.
19
DEFINITIONS
When used in this booklet, the following terms are defined as follows:
Convalescent or Intermediate Care Facility. An institution that is exclusively reserved
for patients following surgery or hospitalization, requiring only limited care as prescribed
by the Physician attending the Participant or Dependent and that meets all of the
following requirements:
1.
is regularly engaged in providing skilled nursing care for ill and injured persons
under 24-hour a day supervision of a Doctor of Medicine or a Registered Nurse
(R.N.);
2.
has available at all times the services of a Doctor of Medicine who is a staff
member of a general hospital;
3.
has on duty 24 hours a day a Registered Nurse (R.N.) and Licensed Practical
Nurse (L.P.N.) on duty at least eight (8) hours per day;
4.
maintains a complete daily medical record for each patient;
5.
complies with all licensing and other legal requirements; and
6.
is not, other than incidentally, a place of rest, a place for the aged or a nursing
home.
Covered Charges. The Usual and Customary (U&C) charges that a Participant or
Dependent incurs while covered under the Plan for medical care, services and supplies
and prescription drugs ordered by a Physician that are Medically Necessary for the
treatment of a Non-occupational Injury or a Non-occupational Sickness. The term does
not mean that all Covered Charges will be paid. Payments will be made only for Covered
Charges up to the maximum benefit amount shown on the Schedules of Benefits and only
according to any other limitations and rules that may apply.
Covered Family Member.
defined by the Plan.
A Participant and the Dependents of that Participant as
Dentist. A licensed D.D.S. or D.M.D. rendering services within the scope of his license.
Dependent. A Participant’s:
1.
Spouse, provided the Participant and the spouse are living together
under the same household and in a common marital relationship.
2.
Until age 26 and regardless of the child’s residency, financial
status, student status or marital status, your
(a)
natural child;
20
(b)
legally adopted child and a child who has been placed with
you for adoption. For purposes of this section a child being
“placed for adoption” means the assumption and retention
by the Participant of a legal obligation for total or partial
support of such child under age 18 in anticipation of
adoption of such child.
Your adult child under age 26 is eligible for this extended
coverage even if he is otherwise eligible for employer-sponsored
coverage (including employer-sponsored coverage offered through
his spouse’s employer) even if he does not enroll in the employersponsored coverage. If your adult child is eligible for coverage
under this Plan both as an Employee and as a Dependent child or
spouse, the adult child can choose between coverage as an
Employee, as a Dependent or as both an Employee and a
Dependent.
3.
4.
Your child who does not meet the rules under number 2 above, but
is unmarried, under 19 years of age and living in a parent-child
relationship with the Participant. The Plan may waive this living
with Participant requirement if the child is under age 18 and the
Participant is required by a “Qualified Medical Child Support
Order (“QMCSO”) (a domestic relations or other court order) to
provide primary health benefits for the child. This waiver will not
be extended until a copy of the court order is received by the Plan
Office. The term “child” includes:
(a)
a natural child;
(b)
a legally adopted child and a child who has been placed for
adoption. For purposes of this section, a child being
“placed for adoption” means the assumption and retention
by the Participant of a legal obligation for total or partial
support of such child under age 18 in anticipation of
adoption of such child;
(c)
any other child, such as a step-child or foster child, if
legitimately named as a dependent on the Participant’s
Federal Income Tax return; and
(d)
a grandchild of a Participant who has been awarded
permanent custody and care of the grandchild as the result
of a court order.
Unmarried child (as described in #3 above) age 19 to 23, if he is
attending an educational institution as a full-time student (for at
least 12 semester credits or full-time according to the school’s
21
standards). The child must continue to be dependent upon the
Participant for support and maintenance and must have been
covered under this Plan immediately prior to his 19th birthday.
If a Dependent child, who is enrolled in Plan coverage under this
paragraph, has full-time student status immediately before a
medically necessary leave of absence from a post-secondary school
and loses full-time student status because of a serious injury or
illness, coverage under this Plan will be extended, during the leave
of absence until the earlier of (i) the one-year anniversary of the
date on which the leave of absence began, or (ii) the date on which
the Dependent child’s coverage under the Plan would otherwise
terminate. To be eligible for this extended coverage, the
Participant must provide the Plan with written certification from
the Dependent child’s treating physician that the leave of absence
from school is medically necessary and is as a result of a serious
illness or injury. The extended coverage commences on the date
such certification is received by the Fund, but will be retroactive to
the date on which the leave of absence began. As permitted by
law, extended coverage under this paragraph will run concurrently
with coverage under COBRA (See Section “Length of SelfContribution Period,” pg. 39. This means that if the Dependent
child receives one year of coverage under this paragraph and, after
the expiration of this one-year period, the Dependent child is not
eligible for Plan coverage (for reasons such as, but not limited to,
failing to return to school, attaining age 23 or getting married), the
child can only elect to continue coverage under COBRA for up to
an additional 24 months (for total of 36 months).
5.
Unmarried child age 19 (in the case of a child described in #3
above) or 26 (in the case of a child described in #2 above) or older
who is mentally or physically handicapped and who meets all of
the following conditions:
(a)
the child must be dependent upon the Participant for
support and maintenance;
(b)
the child must have become mentally or physically
handicapped before he became age 19 (in the case of a
child described in #3 above) or 26 (in the case of a child
described in #2 above);
(c)
the child must remain mentally or physically handicapped;
and
(d)
the child must be incapable of supporting himself.
22
The coverage of the physically or mentally handicapped child will
continue as long as the Employee continues to be a Participant of
the Plan and as long as the child remains incapable of supporting
himself because of his handicap. The Participant must furnish
proof to the Plan Administrator, at his own expense, of the child’s
incapacity within 31 days of the date the child’s coverage under
the Plan would end due to attainment of age 19 (in the case of a
child described in #3 above) or 26 (in the case of a child described
in #2 above). Proof must be furnished on an annual basis. For
information on the procedure to be followed to prove incapacity
and dependency, contact the Plan Administrator.
Except as provided by a QMCSO, the Participant must be legally
responsible to provide support for a “child.” Any child who loses
dependent status will not be allowed to regain dependent status. A
limited exception to this provision is available to a dependent child
age 19 to 23 who meets the qualifications established by the Plan.
For information on this limited exception, contact the Plan Office.
The Plan may require acceptable proof that an individual is a
dependent of the Participant before a claim will be processed.
Durable Medical Supplies. Supplies or equipment which:
1) can withstand use;
2) is primarily and customarily used to serve a medical purpose;
3) generally is not useful to a person in the absence of illness or injury; and
4) is appropriate for use in the home.
Eligible Expenses. Covered Charges incurred during a calendar year in excess of
the deductible, up to the annual maximum.
Employee. Any employee on whose behalf payments are required to be made to the Plan
by an Employer pursuant to a collective bargaining or other written agreement which is
adopted by the Trustees pursuant to the terms of the Trust Agreement. For Kroger
Employees, high school students hired on or after October 13, 2006 will be excluded
from coverage during the time that they are or remain high school students.
Employer. Any employer, who (1) on or after the effective date of the Plan has a
collective bargaining or other written agreement with the Union or the Trustees requiring
periodic contributions to be made to the Plan; (2) otherwise meets the requirements of the
Trust Agreement and (3) is accepted for participation in the Plan. An employer’s status
as an Employer may be suspended or terminated for failure to make timely contributions.
The term “Employer” may also include the Union and the Plan if such organization
becomes obligated pursuant to a Participation Agreement with the Trustees to contribute
to the Plan on behalf of its Employees on substantially the same basis upon which other
participating Employers are contributing to the Plan and meets the requirements of the
Trust Agreement.
23
Essential Health Benefits. Under PPACA, a group health plan is prohibited from
imposing a lifetime dollar limit, effective for the first plan year after September 23, 2010,
or an annual dollar limit, effective January 1, 2014, on certain health care services.
Currently, such benefits shall include at least the following general categories and the
items and services covered within the categories:
1.
2.
3.
4.
5.
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services; including behavioral health
treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
Effective January 1, 2014, any annual limits on benefits that the Plan determines are
Essential Health Benefits no longer apply. Lifetime and annual limits still apply to
benefits that are not considered Essential Health benefits, however.
Experimental. The use of any treatment, procedure, facility, equipment, drugs, devices or
supplies not yet generally recognized as accepted medical practice and/or any items
requiring federal or other governmental agency approval for which such approval had not
been granted at the time services were rendered.
Home Health Care Agency. A public agency or private organization (or a subdivision of
such an agency or organization) that meets all of the following criteria:
1.
it is primarily engaged in providing skilled nursing services and other therapeutic
services in the homes of its patients;
2.
it has established policies governing the services which it provides, such policies
being established by a group of professional personnel associated with the agency
or organization, including one or more doctors and one or more registered
professional nurses;
3.
it provides for the supervision of its services by a doctor or registered professional
nurse;
4.
it maintains clerical records of all patients;
5.
it is licensed according to the applicable laws of the State of West Virginia or the
state in which services are provided and of the locality in which it is located or
provides services; and
6.
it is eligible to participate under Medicare.
24
Home Health Aide. A person who has had specific training to be able to:
1.
monitor and record patient’s vital signs, i.e., pulse and temperature;
2.
plan and prepare nutritious meals with appropriate restrictions according to a
Physician’s orders;
3.
perform simple procedures, i.e., irrigating foley catheters, giving enemas,
changing colostomy bags; and
4.
assist the patient in personal care, i.e., bathing, eating, dressing and grooming.
Hospice Care Agency. A public agency or private organization (or a subdivision of such
an agency or organization) that meets all of the following criteria:
1.
must have a staff which includes at least one doctor and one R.N.;
2.
must maintain central clinical records on all patients; and
3.
must meet the standards of the National Hospice Organization (“NHO”).
Hospital. An institution that meets all of the following requirements:
1.
is engaged primarily in providing medical care and treatment of sick and injured
persons on an inpatient basis at the patient’s expense and maintains diagnostic and
therapeutic facilities for surgical and medical diagnosis and treatment of such
persons by or under the supervision of a staff of duly qualified Physicians;
2.
continuously provides 24-hour a day nursing service by or under the supervision
of registered graduate nurses and is operated continuously with organized
facilities for operative surgery on the premises; and
3.
is not, other than incidentally, a place of rest, a place for the aged or a nursing
home.
Illness (Sickness). The state of being sick or diseased, an ailment, being unwell. Any
disability arising out of and as a result of any type of elective surgery or procedure will
not be considered an “Illness.”
Injury. Traumatic damage to some part of the body.
Intensive Care Accommodation. An accommodation, including a coronary care
accommodation, which (1) is exclusively reserved for critically and seriously ill patients
requiring constant audio-visual observation as prescribed by the Physician attending the
Participant or Dependent, (2) provides Room and Board, specialized registered nursing
care and other nursing care and special equipment or supplies immediately available on a
standby basis and (3) is segregated from the rest of the Hospital facilities.
25
Medical Emergency. A situation which arises suddenly and which poses a serious threat
to life or health. Medical emergencies include heart attack, cardiovascular accidents,
poisonings, loss of consciousness or respiration, convulsions, and other acute conditions.
The diagnosis or the symptoms, and the degree of severity, must be such that immediate
medical care would normally be required.
Medically Necessary. Only those services, treatments or supplies provided by a Hospital
or ordered by a Physician (or other licensed healthcare provider) that are required to
identify or treat a Participant’s or Dependent’s injury or Illness and which are:
1.
consistent with the symptoms or diagnosis and treatment of the Participant’s or
Dependent’s condition, disease, ailment, or injury;
2.
appropriate according to standards of good medical practice;
3.
not solely for the convenience of a Participant, Dependent, Physician or Hospital;
and
4.
the most appropriate which can be safely provided to the Participant or
Dependent.
The fact that a service or supply is prescribed by a physician or another provider does not
alone mean it is medically necessary.
Mental and Nervous Disorder. An emotional disease or mental disorder of any kind
including a neurosis, psychoneurosis, psychopathy, or psychosis. For purposes of the
Plan, Mental and Nervous Disorder includes eating disorders, including, but not limited
to, anorexia nervosa, bulimia and exogenous obesity.
Non-occupational Injury. A bodily injury sustained while not doing any act or thing
pertaining to any occupation or employment for remuneration or profit.
Non-occupational Sickness. A sickness for which no benefits are payable in accordance
with the provisions of any workers’ compensation or similar law.
Other Hospital Services and Supplies. The actual charges made by a Hospital, on its
behalf, for services and supplies rendered to the individual, and required for treatment of
such person, for which the Participant or Dependent incurs a legal obligation to pay.
These charges include charges made by a professional anesthetist and certified registered
nurse anesthetist (CRNA) for the administration of anesthetics. These charges do not
include charges for Room and Board and the professional services of any Physicians,
private duty nurses or any individual or intensive nursing care, regardless of what it is
called and regardless of whether such services are rendered under the direction of the
Hospital or otherwise.
Participant. Any Employee or former Employee who is eligible for benefits provided
under this Plan, as set forth on pages 30-32.
26
Periods of Disability. Successive periods of disability will be considered within the same
period of disability unless there was complete recovery from the cause of the previous
disability or evidence satisfactory to the Trustees is furnished that:
1.
the cause or causes of the latest disability is entirely dissimilar and unrelated to
the cause or causes of any previous disability;
2.
in the case of the Participant only, the latest period of disability commenced after
the Participant had returned to active work for at least two continuous weeks since
the previous period of disability; or
3.
in the case of a Dependent or a retiree, the periods of disability are separated by
three (3) months.
Physician. A licensed doctor of medicine, osteopathy, chiropractor, dentistry, or clinical
psychology who is licensed by the appropriate state agency of the state in which the
services are performed and who is acting within the scope of his license. A doctor of
optometry will not be recognized as a Physician under the Plan. A licensed doctor of
podiatry will be recognized as a Physician under the Plan when the treatment in question
is rendered by the podiatrist pursuant to a referral by a Physician and the treatment in
question is preauthorized by the Plan Office.
Plan. United Food and Commercial Workers Local 400 and Employers Health and
Welfare Plan.
PPACA. The Patient Protection and Affordable Care Act.
Preferred Provider Organization (PPO). The Plan has contracted with a Preferred
Provider Organization which has entered into an agreement with Physicians, Hospitals,
clinics and pharmacies to provide quality medical care and services to Participants and
Dependents in accordance with established and prearranged procedures and fees, a list of
which is available from the Plan Office.
Primary Care Physician (PCP). A Provider who is a practitioner specializing in
Obstetrics, General Practice, Family Practice, Gynecology, Internal Medicine, Pediatrics,
Clinical/Multi-Specialty who supervises, coordinates and provides initial care and basic
medical services to a Member. The PCP is responsible for maintaining continuity of
patient care. In addition to Physicians, a PCP may also include an Advanced Nurse
Practitioner and Physician’s Assistant.
Preventive Care. Those services which are determined to be preventive care that must be
covered without a copayment, coinsurance or requirement to meet a deductible under
PPACA. A complete list of the services can be found at www.healthcare.gov. Plan 1
will also pay for in-network Wellness Benefits as Preventive Care as defined in the
Schedule of Benefits.
Room and Board. All charges made by a Hospital, on its behalf, for room, board, general
duty nursing and any other charges which are made at a daily or weekly rate, or which are
27
regularly made as a condition of occupancy of the class of accommodations occupied, for
which the Participant or Dependent incurs a legal obligation to pay. Room and Board
includes charges for intensive nursing care when combined with a charge for an Intensive
Care Accommodation, but does not include charges for professional services by
Physicians.
Rules and Regulations. The Plan document as adopted by the Trustees and as thereafter
amended from time to time by the Trustees.
Schedule of Benefits. The benefits enumerated on pages 4 through 18.
Self-Contributions. Payments made directly to the Plan by Employees, former
Employees or Dependents for the purpose of continuing eligibility on a temporary basis
or for the purpose of providing Dependent coverage.
Specialist (Specialty Care Physician/SCP). A provider, other than a Primary Care
Physician, who provides services within a designated specialty area of practice.
Surgical Operation or Procedure. Any operation or procedure listed in the Annual
Relative Values for Physicians—Relative Values Based on Physician Survey Data from
Relative Value Studies, Inc. and any other Surgical Operation or Procedure in the
categories listed below:
1.
the incision, excision or electro cauterization of any organ or part of the body;
2.
the manipulation or reduction of a fracture or dislocation;
3.
the suturing of a wound; and
4.
the removal by endoscopic means of a tumor, stone or foreign object from the
larynx, bronchus, trachea, esophagus, stomach, urinary bladder or ureter,
provided, however, that the term Surgical Operation or Procedure will not include any
Experimental medical treatment, whether or not such Experimental medical treatment is
in lieu of or accomplishes the same result as the performance of the corresponding
Surgical Operation or Procedure.
Total Disability. The complete inability of a Participant to perform any and every duty
pertaining to his occupation or employment or the complete inability of a Dependent to
perform the normal activities of a person of like age and sex.
Trust. The assets of the Plan, held in trust by the Trustees.
Trust Agreement. United Food and Commercial Workers Local 400 and Employers
Health and Welfare Fund Trust Agreement as originally effective February 1, 1959, as
amended from time to time.
28
Trustees. Those persons who are named according to the Trust Agreement and who have
authority to control and manage the operation and administration of the Plan and who
also have authority to control and manage the Trust.
Union. United Food and Commercial Workers Local 400 or such other Union which
qualifies as a participating Union under the terms of the Plan’s Trust Agreement.
Urgent Care. An Urgent Care medical problem is an unexpected episode of illness or an
injury requiring treatment, which cannot reasonably be postponed for regularly scheduled
care but which is not considered a Medical Emergency.
Urgent care medical problems include, but are not limited to, earache, sore throat, and
fever (not above 104 degrees). Treatment of an Urgent Care medical problem is not an
Emergency and does not require use of an emergency room at a Hospital.
Usual and Customary (U&C). The usual charge made by the Hospital, facility, person,
group or other entity rendering or furnishing the medical care, service or supply or
prescription drug but in no event will it mean a charge in excess of the lesser of (1) actual
charge or (2) the general level of charges made by others rendering or furnishing similar
medical care, service or supply or prescription drug within the area in which the charge is
incurred, for a Non-occupational Injury or for a Non-occupational Sickness comparable
in severity and nature to the one being treated. The Plan uses AMA/CPT codes listed in
the Annual Relative Value for Physicians—Relative Values Based on Physician Survey
Data from Relative Value Studies, Inc. and Annual Health Care Consultants of America,
Inc. Physician Fee and Coding Guide Comprehensive Fee and Coding Reference
(“HCCA”) to determine payment to Physicians. Presently, the Plan uses the 90th
percentile of the Usual and Customary Index. The Usual and Customary (U&C) charge
for a PPO Hospital, PPO Physician or other PPO provider will not exceed the
prearranged fee established under the PPO arrangement with the Plan.
29
ELIGIBILITY
General Provisions. The Plan will provide the benefits described in this booklet to
eligible Participants and Dependents without physical or medical examination or other
requirement except the recipient’s compliance with the Rules and Regulations of the
Plan.
Employees
Initial Eligibility.
1.
A Full-Time or Part-Time Employee hired on or before October 15, 2005 with
five years of seniority from date of hire who averages 18 or more hours per week
will become a Participant, eligible for Full-Time Employee benefits or Part-Time
Employee benefits, as appropriate, as described in Schedule I of the Schedule of
Benefits, on the first day of the calendar month an Employer is required to make
contributions to the Fund for Plan 1 benefits on his behalf as an Employee under
its collective bargaining agreement and the Employee timely enrolls for such
coverage.
2.
A Full-Time or Part-Time Employee hired after October 15, 2005 and before
January 1, 2012 with five years of seniority from date of hire who averages 20 or
more hours per week (520 hours during a 26-week lookback) will become a
Participant, eligible for Full-Time Employee benefits or Part-Time Employee
benefits, as appropriate, as described in Schedule I of the Schedule of Benefits on
the first day of the calendar month an Employer is required to make contributions
to the Fund for Plan 1 benefits on his behalf as an Employee under its collective
bargaining agreement and the Employee timely enrolls for such coverage.
3.
For Kroger Employees, high school students hired on or after October 13, 2006
will be excluded from coverage during the time that they are or remain high
school students.
Initial Enrollment Requirement. In addition to the requirements described above, you
must submit an enrollment form to the Plan within the time period established by the
Trustees to be entitled to benefits under the Plan. If required by a collective bargaining
agreement, you must also execute all enrollment forms required by the Trustees to
authorize any payroll deduction. If you fail to execute any enrollment form within the
time period established by the Trustees to enroll or to authorize any required payroll
deduction when first eligible, you, the Employee, will not be entitled to enroll for benefits
under the Plan until the earlier of:
1.
The next Annual Open Enrollment as described on page 31; or
2.
The day that you experience a “Life Event” as described on pages 33-34 provided
you submit a written explanation of the event to the Plan and request enrollment
30
within 30 days or 60 days in the case of State premium assistance subsidy
eligibility, or such other time period as established by the Trustees, of such event.
Continuing Eligibility. Once an Employee becomes a Participant, his eligibility for
Employee Benefits as described in Schedule I of the Schedule of Benefits, will continue
for any month so long as the required contributions are made or other required amounts
are remitted on his behalf as an Employee by an Employer and by any required payroll
deduction by an Employee.
In addition, the Plan will continue a Participant’s eligibility for Employee benefits for up
to nine months during periods of personal Illness or Injury. If a Participant timely elected
Dependent coverage and maintained that coverage uninterrupted, the Plan will also
continue the Dependent’s coverage.
Employee Contributions. Employees must make a contribution, via payroll deduction, in
order to enroll in or maintain coverage under the Plan. Only those Employees who
authorize a deduction for the Employee contribution will have coverage under the Plan.
The Employer will collect the Employee contribution via payroll deduction on a pre-tax
basis. The rate of the Employee contribution is determined by your collective bargaining
agreement.
Annual Open Enrollment. Each year, eligible Employees will need to elect their level of
benefit coverage to be provided by the Fund. An Employee who does not complete the
enrollment process when eligible to do so will not be able to enroll until the next open
enrollment period (unless the employee experiences a “Life Event” as described on pages
32-33).
Termination of Eligibility. A Full-Time or Part-Time Employee’s eligibility for FullTime Employee benefits or Part-Time Employee benefits, as appropriate, will terminate
as of the earliest of the following dates:
1.
the last day of the calendar month in which employment terminates;
2.
the date he enters duty with the armed forces of any country (see pages 35-36 for
more details regarding coverage during U.S. military service under the Uniformed
Services Employment and Reemployment Rights Act of 1994 (“USERRA”));
3.
as of any month for which contributions are not paid, as noted above, including
timely Employee or Self-Contributions; or
4.
the last day of the calendar year if you fail to timely enroll for the next year
during annual open enrollment (unless the Employee experiences a “Life Event”
as described on page 33-34).
Reinstatement of Eligibility.
1.
An Employee whose benefits terminate due to termination of employment must
requalify under the Initial Eligibility rules (see page 30).
31
2.
An Employee returning from the armed forces will be reinstated for Full-Time, or
Part-Time as appropriate, Employee benefits on the first day of any calendar
month following return to active employment with an Employer, subject to the
federal rules and regulations applicable to reemployment following military
service (see pages 35-36 for more details regarding coverage during U.S. military
service under USERRA).
3.
An Employee whose benefits terminate in a month due to insufficient hours of
service for a contribution to be required under the collective bargaining or other
agreement and who remains employed will not be required to requalify under the
Initial Eligibility rules. Such Employee will be eligible for benefits in any month
in which a contribution is required to provide coverage for such month.
Dependents
Dependents of an Employee are eligible for benefits if the Employee (1) elects
Dependent coverage and (2) makes payment of any necessary Employee Contribution
within 30 days of the date he is first eligible for Plan 1 coverage, or if later, the date the
Employee first acquires a Dependent. Coverage is effective on the date the Employee is
first eligible and elects coverage for his Dependents or the date the Employee acquires
the Dependent.
If the Dependents are covered under another group health plan at the time the Employee’s
eligibility for Dependent coverage becomes effective, the Participant may preserve the
opportunity to later enroll the Dependents in the Plan by declining coverage for his
Dependents under the Plan in writing, explaining that they are covered under a different
group health plan within the 30-day enrollment period. If the Participant timely declines
coverage in writing, the Dependents may be enrolled if there is a loss of coverage due to
a “Life Event” as described on pages 33-34.
Working Spouse Payment. If an Employee enrolls his or her spouse for primary
coverage under the Plan and the spouse has coverage available through his or her
employment but elects not to enroll in his or her employer-provided plan, a working
spouse payroll deduction is required from the Employee. The amount of this Working
Spouse payroll deduction will be determined by the collective bargaining agreement. To
avoid this deduction, an Employee’s spouse must be enrolled in his or her employer’s
plan. (The Plan pays as secondary if the spouse does not enroll and no working spouse
payment is elected by the Employee.)
In addition, the Plan will also permit a Dependent who does not exhaust COBRA
coverage under another plan to enroll in the Plan within 30 days of the date that coverage
terminates, but the Plan will coordinate benefits and pay only as secondary until the
maximum period of time expires during which the Dependent could have maintained
COBRA coverage.
When a Participant who is eligible to elect Dependent coverage acquires a Dependent
through marriage, birth, adoption or placement for adoption, the Participant must request
enrollment of the Dependent within 30 days of the event along with evidence of acquiring
32
the new Dependent (such as a marriage certificate or birth certificate) and must authorize
any necessary payroll deduction or pay any necessary Self-Contribution to provide
coverage for Dependents at the time enrollment is requested. This is described more
fully under “Life Events” on page 33-34.
When the necessary enrollment form, evidence and Self-Contribution is made, the
effective date of coverage will be:
1. marriage – date of marriage.
2. birth – date of birth;
3. adoption or placement for adoption – date of adoption or placement for adoption.
The failure to make a timely election to enroll Dependents for coverage as described
above prevents a Participant from providing Plan coverage for his Dependents until the
next open enrollment period or the occurrence of a “Life Event” as described below.
Life Event. A Life Event is:
1.
Loss of Other Coverage. If you are an Employee eligible for benefits but did not
enroll yourself or your eligible Dependent(s) for coverage when eligible to do so, you
will be allowed to enroll yourself and/or your eligible Dependent(s) for coverage if all of
the following four conditions are met:
(a)
You and/or the eligible Dependent were covered under a different group
health plan or health insurance coverage at the last time the Employee was able to
enroll for Plan coverage; and
(b)
You and/or the Dependent’s coverage subsequently ends because of any of
the following:
(1)
Loss of eligibility, including legal separation, divorce, death,
termination of employment, reduction in the number of hours of
employment, or change in employment status;
(2)
Termination of an employer’s contribution toward such other
coverage;
(3)
Exhaustion of the maximum period of COBRA continuation
coverage;
(4)
Denial of a claim due to application of a lifetime limit on all
benefits;
(5)
If coverage was provided by an HMO, you or the eligible
Dependent is no longer residing, living, or working in the HMO service
area and the HMO does not provide coverage for that reason; or
(6)
That plan no longer offers any benefits to you.
33
(c)
You request enrollment in this Plan for yourself and/or eligible
Dependent(s) no later than 30 days after the date other coverage was lost for one
of the reasons listed in 1(b) above; and
(d)
You authorize the necessary payroll deduction or pay the SelfContribution for Dependent coverage, if required, to provide coverage for
yourself and/or eligible Dependent(s) at the time enrollment is requested.
2.
Loss of Medicaid or CHIP Coverage. Effective April 1, 2009, you may be able to
enroll yourself and your dependents in this Plan if you or your dependents are eligible for
Plan coverage, and lose eligibility for coverage under Medicaid or the State Children’s
Health Insurance Program (“CHIP”) such as WVCHIP. You must request enrollment
within 60 days of the date that CHIP or Medicaid coverage is terminated for you or your
dependent. Written proof of the last day of coverage will be needed.
Also effective April 1, 2009, you may be able to enroll yourself and your
dependents in this Plan if you or your dependents are eligible for Plan coverage and
become eligible to participate in a health insurance premium assistance program under
Medicaid or CHIP. You must request enrollment within 60 days of the date you or your
dependent is eligible for are determined to be eligible for the premium assistance through
Medicaid or CHIP.
3.
Acquisition of Eligible Dependent. An Employee, Dependent spouse, and
Dependent children may enroll under the Plan following the acquisition of a new
dependent at any time if all of the following four conditions are met:
(a)
You and your Dependents are eligible for coverage;
(b)
You acquire a Dependent through marriage, birth, adoption, or placement
for adoption;
(c)
You request enrollment for yourself, Dependent spouse (whether or not
previously eligible), and/or the child(ren) newly acquired through marriage, birth,
adoption, or placement for adoption within 30 days of the event; and
(d)
You authorize the payroll deduction, if any, or pay the Self-Contribution
for Dependent coverage, if required, to provide coverage for yourself and/or
eligible Dependent(s).
4.
Effective Date of Coverage. If the enrollment is requested and any necessary
payroll deduction is authorized in a timely fashion, the effective date of coverage will be,
as applicable, the date of:
(a)
Marriage;
(b)
Birth;
(c)
Adoption or placement for adoption; or
34
(d)
Loss of other coverage.
Termination of Eligibility. Dependent benefits will terminate on the earliest of the
following dates:
1.
the date the Participant’s coverage under the Plan terminates;
2.
the date the Dependent fails to meet the definition of Dependent;
3.
the date the Dependent enters duty with the armed forces of any country;
4.
the first day of the month in which the Participant fails to make the required SelfContribution for Dependent coverage; or
5.
the last day of the calendar year if the Participant fails to timely enroll the
Dependent for the next calendar year during the Annual Open Enrollment (unless
the Employee experiences a “Life Event” as described on pages 33-34).
Qualified Medical Child Support Order (“QMCSO”). A QMCSO may require that
accidental death and dismemberment benefits payable by the Plan be paid to satisfy child
support obligations with respect to your child. If the Plan receives such an order and
benefits are currently payable, or become payable in the future while the order is in
effect, the Plan will make payments either to the Child Support Agency, or the recipient
listed in the order.
The Plan will provide Dependent coverage to a child if it is required to do so under the
terms of a QMCSO. A QMCSO is a court or state administrative agency order that
complies with the requirements of federal law. The Plan will provide coverage to a child
under a QMCSO even if the Participant does not have legal custody of the child, the child
is not dependent on the Participant for support, or the child does not reside with the
Participant. If the Plan receives a QMCSO and if the Participant does not enroll the
affected child, the Plan will allow the custodial parent or state agency to complete the
necessary enrollment forms on behalf of the child. A copy of the Plan’s procedures for
determining whether an order is a QMCSO may be obtained from the Plan Office at no
charge.
The Uniformed Services Employment and
Reemployment Rights Act of 1994 (“USERRA”)
A Participant who is absent from employment due to military service in the uniformed
services of the United States, including Reserve and National Guard Duty, as described in
the Uniformed Services Employment and Reemployment Rights Act of 1994
(“USERRA”), can elect to continue coverage for himself and his Dependent(s) under the
provisions of USERRA for the period of absence, up to 24 months, beginning on the date
on which the absence begins. If the absence is for less than 31 days, Plan coverage will
be continued and the Participant will be required to pay the same share of the monthly
cost, if any, as if the Participant had not entered the military service.
35
If military service is for 31 days or more, the Participant must pay the full cost of
coverage. This coverage will include the same health benefits offered under COBRA
continuation coverage. The cost paid to continue benefits and the election period will be
determined in the same manner as for coverage under COBRA. The period of coverage
for the Participant and Dependent(s) ends on the earlier of:
1. the end of the 24 month period beginning on the date on which the absence begins; or
2. the day after the date on which the Participant is required to but fails to apply for or
return to a position of Employment. For example, for periods of service over 180
days, generally the Participant must reapply for employment within 90 days of
discharge.
Please note that in order to be eligible for the rights provided by USERRA, the
Participant must notify his Employer and the Plan that the Participant will be absent from
employment due to military service unless the Participant cannot give notice because of
military necessity or unless, under all the relevant circumstances, notice is impossible or
unreasonable. The procedures for electing USERRA coverage and continuing this
coverage generally are the same as the procedures for electing COBRA coverage (pages
37-42), unless the procedures are impossible or unreasonable for the person as a result of
his military service and the Trustees agree to a waiver of the rule. The Participant also
must notify the Plan if he wishes to elect continuation coverage for himself or his eligible
Dependent(s) under the provisions of USERRA within sixty (60) days after the military
absence begins, unless the Trustees agree to waive that requirement under the relevant
circumstances.
Even if the Participant chooses not to elect USERRA continuation coverage for himself
or herself and the eligible Dependents, the Participant and each Dependent covered under
the Plan have the independent right to elect COBRA continuation coverage. The health
coverage under both USERRA and COBRA run concurrently (at the same time).
Payment of the USERRA payment, retroactive to the date on which coverage under the
Plan terminated, must be made within forty-five (45) days after the date of the election of
USERRA coverage. Failure to pay the full payment by each due date (or within the thirty
(30) day grace period thereafter) will result in loss of all USERRA coverage. However,
for periods in which the Participant is entitled to both USERRA and COBRA
continuation coverage, the more favorable coverage will apply to the period of military
service.
If the Participant satisfies the Plan’s eligibility requirements at the time he entered the
uniformed services and he qualifies for coverage under USERRA, the Participant will not
be subject to any additional exclusions or a waiting period for coverage under the Plan
when he returns from uniformed service.
Family and Medical Leave (“FMLA”)
The Family and Medical Leave Act of 1993 (“FMLA”) requires employers with 50 or
more employees to provide eligible employees with up to 12 weeks per year of unpaid
leave:
36
1.
to care for a newly born or adopted child;
2.
to care for a spouse, child or parent who has a serious health problem; or
3.
if a Participant has a serious health problem that prevents him from performing
his job.
An employee may also take a qualified FMLA leave of up to 26 weeks to care for a
service member who is a family member, as further described by law. If a Participant is
absent due to a qualified FMLA leave, the Employer must notify the Plan that the
Participant is on leave, must continue to include the Participant on its monthly remittance
report to the Plan, and must continue to make contributions on the Participant’s behalf.
While the Participant is on FMLA leave, he (and other eligible Dependents, if any) will
continue to participate in the Plan just as if employment has not stopped, unless the
Participant’s Employer fails to make the required contribution for the Participant.
Beginning on or after January 16, 2009, the FMLA requires employers with 50 or more
employees to provide eligible employees with an FMLA leave for a qualifying exigency
that arises in connection with the active military service or an impending call to active
duty of the employee’s child, spouse, or parent. A qualifying exigency includes a variety
of circumstances relating to a service member’s deployment, including: a) attending
military events and related activities; b) childcare and school activities, such as arranging
for or providing childcare; c) making financial and legal arrangements; d) up to 5 days’
leave to spend time with a covered military member during temporary rest and
recuperation leave and; e) additional activities not specifically mentioned above, but
agreed to by the employer and employee.
If the Participant’s Employer ceases to make contributions on his behalf, or when the
Participant exhausts FMLA leave, the Participant will be provided an opportunity to elect
continuation coverage in accordance with COBRA.
CONTINUATION OF COVERAGE UNDER THE CONSOLIDATED OMNIBUS
BUDGET RECONCILIATION ACT (“COBRA”)
The Consolidated Omnibus Budget Reconciliation Act, more commonly known as
COBRA, generally requires that group health plans offer Participants and their
Dependents the opportunity to temporarily continue their health coverage at group rates
when coverage under the Plan would otherwise end. This extended coverage is called
“COBRA coverage.” COBRA coverage will include all benefits that the person was
entitled to before the “Qualifying Event” (defined below) except as provided below. If
the Participant, his spouse and/or Dependent child(ren) are covered under the Plan, the
Participant and/or his spouse or Dependent children can continue coverage for a time if
coverage ends for one of the several reasons even if the Participant or his Dependents are
already covered by another group health plan or Medicare.
Plan 1 Employees and their Eligible Dependents. A Participant who is an Employee in
Plan 1 may make COBRA Self-Contributions to the Plan in order to continue coverage
37
for the Participant and the Participant’s Dependents, if applicable, if the Employee loses
coverage due to one of the following Plan 1 Qualifying Events:
1.
the Participant’s termination of employment (unless due to gross misconduct),
including retirement;
2.
the Participant’s reduction in hours of employment to fewer than the number
required for participation in the Plan;
3.
the Participant becomes entitled to Medicare;
4.
death of the Participant;
5.
divorce or legal separation of the Participant; or
6.
loss of status as a Dependent. (See the definition of Dependent on pages 20-23
for the qualifications for Dependent status.)
Eligible Dependents of Plan S and Plan V Participants. Eligible Dependents of a
Participant in either Plan V or Plan S may make COBRA Self-Contributions to the Plan
in order to continue their coverage if coverage under the applicable Plan ceases due to
one of the following Retiree Plan Qualifying Events:
1.
death of the Participant;
2.
divorce or legal separation of the Participant; or
3.
loss of status as a Dependent. (See the definition of Dependent on pages 20-23
for the qualifications for Dependent status.)
Notice Requirement. The Participant’s Employer must notify the Plan Office in writing
of Plan 1 Qualifying Events (1) through (4) within 30 days of their occurrence.
Information provided by the Employer should be sent to the attention of the COBRA
Department and must include sufficient information for the Plan to be able to verify that
the Plan is the appropriate entity to receive the notice, information sufficient to identify
the Participant, the Qualifying Event and the date of the Qualifying Event. The
Participant or Dependent must notify the Plan Office in writing within 60 days from the
later of the Plan 1 Qualifying Events (5) or (6) or Retiree Plan Qualifying Events (1), (2)
or (3), or the date in which there is a loss of coverage as a result of the Qualifying Event.
Information provided by the Participant or Dependent should be sent to the attention of
the COBRA Department at the Plan Office and must include sufficient information for
the Plan to identify the Participant or Dependent, the Qualifying Event and the date of the
Qualifying Event. The Participant or Dependent must also notify the Plan Office in
writing of a second Qualifying Event or a disability after the Participant or Dependent is
receiving COBRA coverage. This notice should be sent to the attention of the COBRA
Department and must be provided in the same time frame and provide the same
information as explained herein.
38
Financial Responsibility for Failure to Give Notice. If a Participant or Dependent fails to
give written notice within 60 days of the date of the Qualifying Event, or an Employer
within 30 days of the Qualifying Event, and as a result, the Plan pays a claim for a
Participant or Dependent whose coverage terminated due to a Qualifying Event and who
does not elect COBRA coverage under this provision, then the Participant, Dependent or
the Employer, as appropriate, must reimburse the Plan for all claims that should not have
been paid. If the Participant, Dependent or Employer does not reimburse the Plan, then
all amounts due may be deducted from other benefits payable on behalf of that individual
or on behalf of the Participant, if the individual was his Dependent.
Length of Self-Contribution Period.
1.
2.
In the case of the following events, a Participant or a Participant’s Dependent may
continue coverage for a maximum period of 18 consecutive months from the date
of the loss of coverage:
(a)
the Participant’s termination of employment (unless due to gross
misconduct), including retirement; or
(b)
the Participant’s reduction in hours of employment (such as leaving fulltime employment and becoming part-time).
In the case of the following events, a Dependent may continue coverage for a
maximum period of 36 consecutive months from the date of the loss of coverage:
(a)
the death of the Participant;
(b)
the divorce or legal separation of the Participant;
(c)
the loss of status as a Dependent; or
(d)
the Participant becomes entitled to Medicare.
A child born to, adopted by or placed with a Participant who has elected
continuing coverage, may be added as a Dependent in the same manner as other
Dependents.
Extension of Self-Contribution Period. The following situations may extend the
18-month period described in paragraph 1 above:
1.
if the death of the Employee, divorce or legal separation of the Employee, the
Employee’s Medicare entitlement or the loss of status as a Dependent occurs
within the 18-month period, the 18-month period for the Employee’s Dependents
may be extended up to a maximum period of 36 months;
2.
if the Social Security Administration determines that a Participant or Dependent
was disabled at any time during the first 60 days of COBRA coverage, the
18-month period described above can be extended to a maximum of 29 months.
To be eligible for the extra 11 months of coverage, the Participant or Dependent
39
must notify the Plan Office in writing within 60 days after the later of the
following: 1) the date of the Social Security determination; or 2) the date on
which the Participant or Dependent loses or would lose coverage; or 3) the date
on which the Participant or Dependent is informed as to the obligation to provide
notice of disability. Please note that such notification must be made before the
expiration of the 18-month coverage period. If the disability ends during the
29-month period, the Participant or Dependent must notify the Plan Office within
30 days of the termination of the disability.
COBRA Self-Contribution Advice. COBRA coverage requires timely election of the
coverage within 60 days of the date of the COBRA election notice or the date of the
termination of coverage, if later. Upon receiving notice from the Participant’s Employer,
the Participant or the Participant’s Dependents, the Plan Office will send the Participant
and/or Participant’s Dependents a notice informing such individuals of their right to make
COBRA Self-Contributions. The due date for COBRA Self-Contributions is the first day
of the month in which COBRA coverage begins. For example, payments for the month
of November must be paid on or before November 1st. The payment due for the initial
period of COBRA coverage must include payment for the period of time dating back to
the date that coverage terminated. If you fail to pay the full payment by each due date (or
within the thirty day grace period for payments other than your initial payment) you will
lose all COBRA coverage. There is an initial grace period of 45 days to pay the first
amounts due starting with the date COBRA coverage was elected.
In determining whether to elect COBRA coverage, you should consider the following
consequences if you fail to continue your group health coverage through COBRA and do
not obtain other health coverage from another plan:

You may have preexisting condition exclusions applied to you by other group health
plans if you have more than a 63-day gap in health coverage. Election of COBRA
Coverage may help you avoid such a gap.

You may lose the guaranteed right to purchase individual health insurance policies
that do not impose such preexisting condition exclusions if you do not elect COBRA
Coverage for the maximum time available to you.

You should take into account that you have special enrollment rights under federal
law. You have the right to request special enrollment in another group health plan for
which you are otherwise eligible (such as a plan sponsored by your spouse’s
employer) within 30 days after your group health coverage ends because of the
qualifying event. You will also have the same special enrollment rights at the end of
continuation coverage if you elect COBRA Coverage for the maximum time available
to you.
The monthly cost of COBRA coverage is set by the Board of Trustees, based on the
provisions of federal law. The COBRA self-contributions rate may be changed annually.
If any individual or family coverage is extended beyond 18 months because of
entitlement to Social Security disability income benefits, the cost of COBRA coverage
may be increased in accordance with the provisions of federal law. The Plan Office will
40
provide the cost of COBRA coverage at the time notice of entitlement to COBRA
coverage is sent. COBRA Self-Contributions are to be in the form of a check or money
order payable to the Plan.
The Trade Act of 2002 created a tax credit for certain individuals who become eligible
for trade adjustment assistance and for certain retired employees who are receiving
pension payments from the Pension Benefit Guaranty Corporation (“PBGC”) (“eligible
individuals”). Under the tax provisions, eligible individuals can either take a tax credit or
get advance payment of 65% of premiums paid for qualified health insurance, including
continuation coverage. Additionally, the Trade Act generally provides a second 60-day
COBRA election period for eligible individuals, and establishes different election periods
and effective dates for COBRA coverage for such individuals. If you have questions
about these tax provisions, you may call the Health Coverage Tax Credit Customer
Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at
1-866-626-4282.
More information about the Trade Act is also available at
www.doleta.gov/tradeact.
Types of Benefits Provided. An individual eligible to make COBRA Self-Contributions
for the 18 month or 36 month period can continue all benefits for which they were
eligible on the date of the Qualifying Event except Life Insurance, and Accidental Death,
Dismemberment and Loss of Sight and Disability Benefits.
Termination of Eligibility for Self-Contribution. A Participant or Dependent who is
eligible for continued coverage by COBRA Self-Contribution will no longer be entitled
to make COBRA Self-Contributions upon the occurrence of the earliest of the following
events:
1.
the first date after the COBRA election date that the Participant or Dependent is
covered under any group health benefit program, insured or self-funded, such as
coverage maintained by the Participant’s spouse that does not contain an
exclusion or limitation with respect to the Participant’s or Dependent’s
preexisting condition or such exclusion does not apply to the Participant or
Dependent as a result of federal law;
2.
the date after the COBRA election date that the Participant becomes eligible for
Medicare, except that Dependents of the Participant who are continuing Coverage
will be able to continue coverage by COBRA Self-Contribution until the end of
the 18-month period immediately after the first 18 months during which the
Participant could have continued Coverage;
3.
the date after the COBRA election date that the Participant or Dependent becomes
eligible for Medicare;
4.
the first day of any month for which a timely COBRA Self-Contribution is not
made to the Plan;
5.
the Plan is terminated or the Plan no longer provides coverage to similarly
situated Participants or Dependents;
41
6.
the Employer ceases to maintain any group health plan for any employee;
7.
the expiration of the maximum COBRA Self-Contribution period as described
above; or
8.
if the Employer withdraws from the Plan and makes coverage available under any
group health plan to a class of Employees formerly covered under the Plan, then
that other plan (and not this Plan) is obligated from that date forward to make
coverage available to the Employer’s COBRA beneficiaries.
Additional Information. Additional information regarding COBRA coverage may be
obtained by contacting the Plan Office, UFCW Local 400 and Employers Health and
Welfare Fund, 600 D Street, Suite 250, South Charleston, WV 25303, (304) 343-7682.
In order to ensure protection of rights under COBRA coverage, Participants and
Dependents should keep the Plan Office informed of any changes in mailing addresses.
Special Continuation Coverage for
Employer Going Out of Business and
Ceasing to Participate in the Plan
In addition to any rights the Participant may have under COBRA, if an Employer stops
making contributions to the Plan on behalf of a Participant who is an Employee because
of the Employer’s going out of business that results in the Employer ceasing to provide
any group health plan, the Participant may continue the same level of benefit coverage
for six months by making Self-Contributions for a period of six consecutive months from
the date his Employer ceased contributing to the Plan on his behalf.
Amount of Self-Contribution. Each Self-Contribution, unless otherwise specified, will be
in an amount equal to the current Employer contribution rate for such level of benefits.
Time to Begin Self-Contributions. A Participant must begin making Self-Contributions
beginning with the first month following termination of his Employer’s contribution on
his behalf and must continue uninterrupted. A Participant making Self-Contributions
may not resume payments after a payment is missed. Payments must be received at the
Plan Office on or before the 15th day of each consecutive month.
Termination of Eligibility for Self-Contribution. A Participant continuing coverage
under this special provision will no longer be entitled to make Self-Contributions upon
the occurrence of the earliest of the following events:
1.
the Participant’s return to any type of gainful employment that qualifies him for
health benefits coverage with his new employer;
2.
the Participant’s eligibility for coverage under another group health benefit
program, insured or self-funded, such as coverage maintained by the Participant’s
spouse;
42
3.
the first day of any month for which a timely Self-Contribution is not made to the
Plan; or
4.
the last day of the month for which a Self-Contribution is permitted under this
section.
EXTENSION OF BENEFITS
If the coverage of a Participant or Dependent has terminated as a result of a Nonoccupational Injury or Non-occupational Sickness for which benefits are payable under
this Plan and the Participant or Dependent suffers a Total Disability as a result of such
Non-occupational Injury or Sickness, the Participant or Dependent will be entitled to
whatever benefits would have been payable for the Totally Disabling condition had the
coverage remained in effect for a period of 90 days following termination of coverage,
except for the Life, Accidental Death, Dismemberment and Loss of Sight, Dental, and
Major Medical Benefits.
Major Medical Benefits will continue for the Totally Disabling condition for up to 12
months or until the maximum benefit (as shown on the Schedule of Benefits) is paid, if
earlier.
HOWEVER, no benefits will be extended under this Plan beyond the date on which the
Participant or Dependent becomes eligible under another employer-sponsored plan or
union/management negotiated plan, including any plan sponsored by any state, county,
municipality or government agency except as required by law.
43
RETIREE COVERAGE
(Senior Program)
Eligibility. A Participant who is an Employee may be eligible for the benefits described
in one of the Schedules of Benefits for retirees (also known as the Senior Program),
provided the retired Employee makes the required Self-Contributions to the Plan and
satisfied all of the following conditions:
1.
the retired Employee must retire from employment covered by the Plan on or after
attaining age 55 and be eligible to receive benefits from the United Food and
Commercial Workers International Union-Industry Pension Fund or its successor
or a retirement plan sponsored by an Employer;
2.
the retired Employee must have been eligible for coverage under this Plan on the
date of his retirement;
3.
the retired Employee must have been eligible under this Plan as a result of
Employer contributions made on his behalf for the three consecutive years
immediately preceding the date of his retirement;
4.
the retired Employee must make proper application for the Retiree Coverage on
forms available at the Plan Office and agree to make the required SelfContributions;
5.
the retired Employee must apply for continuation of eligibility at the same time
application is made for retirement benefits under the United Food and
Commercial Workers International Union-Industry Pension fund or its successor
or the retirement plan sponsored by the Employer, whichever is the case; and
6.
the retired Employee must reject the right to continue coverage under
Continuation of Coverage on pages 37-42. (COBRA)
A retired Employee may continue Coverage for his or her Dependents who are covered
under the Plan if the required Self-Contributions for that level of Coverage is made by the
retired Employee.
Self-Contributions. The amount of Self-Contribution is determined by the Trustees in
their sole discretion and may be changed by the Trustees from time to time to cover the
increased costs of providing benefits. Advance notice of any change will be given to all
Senior Program participants.
Payments must be in the form of a check or money order made payable to the Plan. After
initial enrollment, Self-Contributions must be received by the Plan Office by the 10th of
the month for which coverage is to be provided. Self-contributions must be made
consecutively.
44
Benefits Provided.
1.
All Employees who retired before March 1, 1990 and their Dependents, and
Employees retiring at age 65 or older and their Dependents will be eligible for the
benefits described in Schedule II, the Plan S Schedule of Benefits.
2.
Beginning March 1, 1990, Employees retiring before age 65 and their Dependents
will be eligible for the benefits described in Schedule III, the Plan V Schedule of
Benefits. Upon attainment of age 65, the retired Employee and his covered Dependents
will become eligible for the benefits described in Schedule II, the Plan S Schedule of
Benefits.
3.
A retired Employee may elect single (Employee only) or family (Employee and
all eligible Dependents) coverage. If a retired Employee has Dependents at the time of
the election and chooses single coverage he or she may not, in the future change to family
coverage.
4.
Beginning February 1, 2001, a retired Employee who elects single coverage under
the Senior Program and who acquired a dependent after this election may enroll the
newly acquired dependent under the Plan’s Senior Program if all four of the following
conditions are met:
■ The Employee is a participant in the Senior Program, and
■ A spouse and/or a child becomes a Dependent of the retired Employee through
marriage, birth, adoption or placement for adoption; and
■ The retired Employee requests enrollment for his new Dependent acquired
through marriage, birth, adoption or placement for adoption within 30 days of the
event and supplies evidence of acquiring the Dependent (such as a marriage
certificate or birth certificate); and
■ The retired Employee makes the necessary Self-Contribution to provide coverage
for Dependents at the time enrollment is requested.
If the necessary enrollment form, evidence and self-contribution is made within the 30
days, the effective date of coverage will be:
1.
marriage – no later than the first day of the first calendar month beginning after
receipt of completed request for enrollment.
2.
birth – date of birth.
3.
adoption or placement for adoption – date of adoption or placement for adoption.
Termination of Coverage. Coverage for a retired Employee and his or her dependents
will terminate upon the occurrence of the first of the following events:
1.
on the date of discontinuance of the Senior Program or the Plan; or
45
2.
on the last day of the calendar month in which the retired Employee ceases to be a
Retiree (except as provided below under “Return to Employment”); or
3.
on the last day of any calendar month for which the retired Employee failed to pay
the required Self-Contribution in a timely manner; or
4.
for a Dependent, on the date of the retired Employee’s death. However, benefits
may continue for a surviving Dependent spouse as provided for under the
Surviving Spouse Benefit as described on page 46 or under COBRA coverage as
described on page 37-42; or
5.
for a Dependent, the date of the divorce or legal separation of the retired
Employee or loss of status as a Dependent (see the definition of Dependent on
pages 20-23 for the qualifications for Dependent status). Benefits may continue
under COBRA coverage as described on pages 37-42.
Return to Employment. A retired Employee who returns to employment covered by the
Plan for which coverage is provided as an active Employee may elect either (1) to
continue coverage as a retired Employee in addition to Plan coverage as a result of the
individual’s reemployment or (2) to suspend retiree coverage for himself and Dependents
so that the individual’s only coverage under the Plan for himself and Dependents is that
coverage available under the Plan as a result of the individual’s reemployment. If the
individual maintains dual coverage as a retired Employee and active Employee, benefits
shall be coordinated as set forth in the Coordination of Benefits section (see pages 9195). Upon subsequent retirement from employment covered by the Plan, a retired
Employee who suspended such coverage under (2) above is allowed a one-time election
to reinstate coverage under the Retiree Coverage for himself and his eligible Dependents.
Such reinstated coverage must be uninterrupted with the individual’s coverage as an
active Employee.
SURVIVING SPOUSE BENEFIT
Eligibility. The surviving spouse of:
1.
an active Participant who was at least age 55 and who had at least ten years of
continuous service under the Plan (an absence due to sick leave or other approved
absences does not interrupt service) at the time of his or her death; or
2.
a retired Participant who was at least age 55 at the time of his or her death and
was eligible for coverage under the Plan’s Retiree Coverage which is also known
as the Senior Program,
may continue Retiree Coverage for himself/herself and any eligible dependents, if
applicable, by making Self-Contributions if the spouse and dependents were covered by
the Plan at the time of the Participant’s death and they reject the right to continue
coverage under COBRA Continuation Coverage on page 37-42. The surviving spouse
must elect to continue coverage and pay the initial Self-Contributions within 60 days of
the date of the Participant’s death.
46
Effective Date. The effective date of coverage will be the first day of the month
immediately following the month in which the eligible Participant died.
Self-Contributions. The amount of Self-Contributions is determined by the Trustees in
their sole discretion and may be changed by the Trustees from time to time to cover the
increased costs of providing benefits. Advance notice of any change will be given to all
surviving spouses.
Payments must be in the form of a check or money order made payable to the Plan. After
initial enrollment, Self-Contributions must be received by the Plan Office by the 10th of
the month for which coverage is to be provided. Self-Contributions must be made
consecutively. If a payment is missed, a surviving spouse cannot resume eligibility by
continuing payments at a future time.
Length of Coverage. A surviving spouse may continue coverage by Self-Contributions
for a maximum period established by the Trustees after the Participant’s death if timely
Self-Contributions are made. The Trustees may lengthen or shorten this maximum
period of coverage at their sole discretion. As of April 1, 2008, the maximum period is
not limited.
If the surviving spouse is eligible for Medicare benefits, then the Plan’s coverage will be
coordinated with Medicare Parts A and B whether or not actually elected. Medicare will
be considered to pay first and the Plan second if the surviving spouse is at least age 65 (or
under age 65 with Medicare disability).
Termination of the Surviving Spouse Benefit. A surviving spouse’s eligibility for
benefits will terminate upon the earliest of the following events:
1.
the last day of the maximum period established by the Trustees following the
Participant’s death;
2.
the first day of any month for which a Self-Contribution is not received by the
Plan Office on a timely basis;
3.
the date the surviving spouse becomes eligible to enroll in a state or federal
program (excluding Medicare) that the Trustees determine to be comparable to
the Plan’s coverage;
4.
the date the surviving spouse is eligible for employer-sponsored group health
benefit coverage that the Trustees determined to be comparable to the Plan’s
coverage;
5.
the date of the surviving spouse’s remarriage; or
6.
the date the Trustees discontinue the Surviving Spouse Benefit.
A Dependent child’s eligibility for benefits will terminate as of the earlier of the
following events:
47
1.
the date the dependent no longer qualifies as a Dependent under the terms of the
Plan; or
2.
the date the surviving spouse’s coverage ceases.
Benefits Provided. The Plan provides Major Medical Expense Benefits as described in
Schedule II or Schedule III of the Schedule of Benefits. The Plan does not provide life
insurance, accidental death, dismemberment and loss of sight, weekly disability income,
dental care, and vision care and physical examination/wellness program expense benefits
that are provided to active Participants except the preventative benefits required by law.
48
GENERAL EXCLUSIONS AND LIMITATIONS
Limitations and Exclusions. Except as otherwise explicitly provided by the Plan or
required by law, in addition to the exclusions and limitations listed in each section, no
benefits will be payable under this Plan for charges:
1.
incurred prior to the effective date of Plan coverage. Expenses are considered for
payment only if the person who incurs them is eligible under the Plan at the time
they are incurred (Participant or Dependent). An expense is incurred at the time
the service or supply is provided to a person. Receipt of this SPD does not
automatically qualify you for coverage under the Plan. See the eligibility rules on
pages 30 to 37;
2.
which are not prescribed and approved by a Physician who is attending the
Participant or Dependent;
3.
in or by a hospital that does not meet the definition of “Hospital” contained
herein;
4.
in or by a Hospital, institution or other facility owned or operated by the United
States, or any agency, or instrumentality (including, without limitation, the
Department of Veterans Affairs (VA)) provided, however, that if such charges are
made by a VA hospital for care of a nonservice-related disability, such charges
will be considered for reimbursement by the Plan to the extent required by law
and to the extent the Plan would have considered such charges as eligible
expenses had the VA not been involved;
5.
which the Participant or Dependent would have no legal obligation to pay without
this or any similar coverage;
6.
for retirees, for or relating to “well baby care” except that if, because of premature
birth, disease, injury, congenital abnormality or hereditary complications, a
newborn Dependent child incurs charges for services over and above the normal
cost of routine nursery charges, benefits will be payable from birth or whatever
date such complications commence, whichever is later;
7.
for blood or blood plasma for which the Hospital or other supplier makes a refund
to or on behalf of the Participant or Dependent either as a result of the operation
of a group blood bank, private donor or otherwise;
8.
for or relating to medical care, services or supplies, received or furnished in
connection with, or as a result of any cosmetic surgery, including, but not limited
to, breast reconstruction, breast reduction or implants and tummy tucks, except
for:
(a)
charges in connection with and as a result of the necessary repair of
disfigurement caused by a Non-occupational Injury sustained in an
49
accident, provided such cosmetic surgery is received promptly after such
accident;
(b)
charges in connection with and as a result of an abnormal congenital
condition in a child;
(c)
charges in connection with breast reconstructive surgery following a
mastectomy and charges on related surgery and reconstruction on the
patient’s other breast to produce a symmetrical appearance and prostheses
and physical complications at all stages of mastectomy, including
lymphedemas;
9.
for or relating to eye refraction, eye glasses (except as specifically provided under
the Vision Care Expense Benefit), after cataract surgery consideration of lens
only under the Major Medical Expense Benefit, hearing aids (except as
specifically provided under the Major Medical Expense Benefit), dental prosthetic
appliances, the fitting of any thereof, except as may be required on account of a
Non-occupational Injury to a physical organ sustained in an accident;
10.
for or relating to medical care, services or supplies received or furnished in
connection with or as a result of any injury or sickness resulting from or caused,
directly or indirectly, wholly or partly, by:
11.
(a)
war or any act of war, whether declared or undeclared;
(b)
service in any military, naval or air force of any country while such
country is engaged in war, whether declared or undeclared unless required
by law;
(c)
police duty as a member of any military, naval or air force organization;
(d)
insurrection;
(e)
any atomic explosion or other release of nuclear energy (except only when
being used solely for medical treatment of a Non-occupational Injury or a
Non-occupational Sickness) whether in peace or in war and whether
intended or accidental;
(f)
participation in a riot;
(g)
participation in the commission of a felony;
for or relating to any medical care, services or supplies received or furnished in
connection with or as a result of:
(a)
any bodily injury that arises out of, or in the course of, any employment or
occupation for compensation or profit, or
50
(b)
any sickness for which benefits are payable under any Workers’
Compensation Law, Occupational Disease Law or any other legislation of
similar purpose;
12.
for or relating to prescription drugs, except as specifically provided under the
Plan;
13.
for a dental service or procedure, dental work or treatment, under the medical
benefits of the Plan, except that:
(a)
charges in connection with the surgical removal of impacted teeth will be
covered up to a maximum Covered Charge of $25.
(b)
charges in connection with and as a result of injuries to natural teeth,
including the initial replacement of such natural teeth sustained in an
accident, to the extent the dental work or treatment is received promptly
after such accident, will be covered as any other medical expense under
the Plan;
14.
for or relating to surgical treatment rendered by a doctor of podiatry, except to the
extent the treatment for which coverage is requested was rendered pursuant to a
referral by a Physician for the specific surgery and the referral is documented to
the satisfaction of the Trustees and such surgical treatment does not exceed a
lifetime maximum of $1,000 per person;
15.
with respect to Major Medical Expense Benefits, nonsurgical treatment of chronic
foot conditions including but not limited to: care of corns, bunions (except
capsular or bone surgery therefore), callouses, nails of the feet, fallen arches,
weak feet, chronic foot strain, routine care for symptomatic complaints of the feet,
except when major surgery is performed or in conjunction with the treatment of
diabetes. Chronic conditions are those that develop over time, and do not end.
Symptoms may be continual or intermittent, but the condition generally exists for
life.
16.
for or relating to routine care and other treatments or procedures which are not
Medically Necessary;
17.
for or relating to services and procedures which are Experimental in nature,
except as required by law;
18.
for or relating to any treatment by any method of jaw joint problems, including
Temporomandibular Joint Syndrome and craniomandibular disorders, or other
conditions of the joint linking the jawbone and skull and the complex of muscles,
nerves or other tissues related to that joint except as stated in the Dental Expense
Benefit;
51
19.
for or relating to confinement, treatment or services related to the restoration of
fertility or the promotion of conception, including any and all artificial
insemination techniques;
20.
for or relating to any service, supply, treatment or procedure which is not
rendered for the treatment or correction of, or in connection with, an Illness or
Injury, unless specifically identified as a Covered Charge in the Rules and
Regulations; or
21.
except in the case of special education regarding diabetes management, for or
relating to any special education rendered to any eligible Participant or Dependent
regardless of the type of education, the purpose of the education, the
recommendation of the attending Physician or the qualifications of the individuals
rendering the special education including, but not limited to, programs for the
monitoring and managing of pain, including biofeedback;
22.
for or relating to any service, supply, treatment or procedure which is rendered
for:
(a)
penile implantation unless the Participant or Dependent establishes that
the implant is Medically Necessary as a result of a demonstrated
disability;
(b)
a sex change, including, but not limited to, sex changes, psychotherapy
and analysis relating to a sex change and hormonal treatments relating to a
sex change;
23.
for or relating to introduction into the body of an organ or portion of any organ
from an animal or from another human body, including but not limited to
confinements, treatments, procedures, services, supplies and medicines provided
in connection with pre-transplant evaluation, organ procurement (including donor
expense), transportation of organ recipient, admission, surgery and post-transplant
care, with the exception that a kidney or cornea transplant will be covered by the
Plan;
24.
for or relating to introduction into or attachment to the body of an artificial organ;
25.
for or relating to removal of an organ or portion thereof for donor purposes;
26.
where benefits or amounts would have been available to the Participant or
Dependent under another group health program or plan if the person had acted to
qualify for benefits—such as going to an HMO or PPO provider, using a
utilization review service or enrolling in an employer’s health plan —and where
the Plan would pay second under its Rules for Order of Benefit Determination
(see pages 92-93). However, where treatment involves a Dependent child, then
the coverage of the parent whose date of birth occurs earlier in the calendar year
shall be primary to the coverage of the parent whose date of birth occurs later in
the calendar year;
52
27.
drugs to induce growth or growth hormones, except as specifically provided under
the Prescription Drug Expense Benefit;
28.
for services rendered or provided to a Participant or a Dependent by the
Participant’s spouse or child, brother, sister or parent of the Participant or of the
Participant’s spouse, or by any person who ordinarily resides in the Participant’s
home;
29.
for any non-emergency MRI, CAT or PET Scan that is not authorized in advance
by the Plan Office;
30.
for charges for care, services or supplies for treatment received by a Participant or
Dependent outside the United States, except that the Plan shall provide benefits
for care, services or supplies of a medical emergency rendered to a Participant or
Dependent, provided that such coverage shall be limited to the extent and at the
currency rate of exchange or appropriate value of services determined by the
Trustees and provided that such care, services or supplies are not covered under
the provisions of the health plan of any government or other national health
coverage. For purposes of this exclusion, care, services or supplies for treatment
of a medical emergency shall mean care or treatment for an injury or the sudden
and unexpected onset of a sickness with symptoms so severe that immediate
medical relief is necessary and for which immediate medical attention is normally
required;
31.
any service or treatment, the cost of which may be recoverable by, or on behalf of,
a Participant or a Dependent in any action at law, any judgment, compromise,
settlement of any claims against any party, or any other payment the Participant or
Dependent or their attorney or legal representative may receive as a result of the
Injury, no matter how these amounts are characterized or who pays these
amounts, as provided beginning on page 95, “Subrogation and Reimbursement”;
32.
any Injury or Sickness arising from an automobile, motorcycle or related accident
if personal injury protection coverage or no-fault benefits are recoverable under
state law, even if coverage is denied by the insurance carrier for any reason such
as, for example, because the Participant or Dependent are injured while
intoxicated, or there is a no-fault insurance deductible;
33.
acupuncture, massage and aquatic therapy;
34.
in excess of the maximum benefits shown on the Schedule of Benefits that applies
to the Participant or Dependent;
35.
not incurred within any applicable time limitations stated on the Schedule of
Benefits, General Exclusions and Limitations Section or that are stated in any
benefit explanation;
53
36.
incurred by dependent children for maternity, pregnancy or pregnancy-related
conditions, except as required by law;
37.
for which the Plan’s preauthorization requirements are not met. Failure to get
preauthorization may result in a denial of payment;
38.
Injuries resulting from an act of domestic violence or from a medical condition,
including mental health medical conditions, are not excluded solely because the
source of the Injury was a medical condition or domestic violence; and
39.
Effective January 1, 2011, if you make fraudulent statements or intentionally
misrepresent material facts in any communications to the Plan Office, including
benefit claims or enrollment forms, the Plan has the right to recover from you, or
any dependents receiving benefits based on their relationship to you, any amounts
that the Plan would not have paid, but for the fraudulent statements or
misrepresentations. You have an obligation to notify the Plan of events that
would give rise to a loss of coverage for you or your Dependents, including any
change in the status of your Dependents. The Plan can also terminate your
coverage retroactively for failure to pay premiums and contributions.
54
LIFE INSURANCE BENEFIT
(Provided by Hartford Life and Accident Insurance Company)
(Retirees Excluded)
Eligible Employees
Death Benefit. In the event of an eligible Employee’s death from any cause, the Amount
of Insurance applicable, as shown in the applicable Schedule of Benefits, will be paid in a
lump sum to the beneficiary last named by the Employee, as recorded.
If an individual has individual life insurance in force on his life which was issued in
accordance with the Conversion Privilege below, the amount of insurance applicable to
such individual will be reduced by the amount of such individual life insurance.
Any change in the amount of insurance due to an increase in the Employee’s age will
become effective on the policy anniversary date coincident with or next following the
date of the increase in such person’s age.
Changes in coverage that are due to a change in employment status (for example, a PartTime Employee becoming a Full-Time Employee), earnings or this insurance will
become effective on the date of such change, except that, with respect to an increase in
coverage, a retroactive change in the rate of earnings will become effective on the date of
determination of the change in the rate of earnings.
Beneficiary. An eligible Employee may designate or change a beneficiary on the
beneficiary card available from the Plan Office or any form satisfactory to Hartford Life
and Accident Insurance Company (The Hartford) by giving written notice of such
designation or change to the Plan Office. Once received, the designation or change will
become effective as of the date the notice was signed. The consent of the beneficiary is
not required for any change of beneficiary. If no beneficiary has been designated or if the
beneficiary is not alive when the Participant dies, then Hartford may pay the death benefit
in accordance with the terms of the Group Life Insurance Policy.
A beneficiary also may be designated in an entered court order, provided that such order
contains a clear designation of rights. The designation will become effective only when
it is entered on the Plan’s records, as long as Hartford has not made payment or taken
other action before the entry on its records was made. A beneficiary designation in a
court order meeting the above requirements will supersede any prior or subsequent
conflicting beneficiary designation that is filed with the Plan Office.
A beneficiary may waive his or her rights as a beneficiary under the Plan in an entered
court order, provided that such order contains a clear waiver of rights. The waiver will
become effective only when it is entered on the Plan’s records, as long as Hartford has
not made payment or taken other action before the entry on its records was made. A
waiver in a court order meeting the above requirements will supersede any prior
conflicting beneficiary designation that has been filed with the Plan Office. If a court
order meeting the above requirements contains a waiver of rights by the beneficiary on
file with the Plan Office, and the Participant subsequently dies without naming a new
55
beneficiary, then Hartford may pay the death benefit in accordance with the rules in this
Section. The Trustees are the sole judges of the effectiveness of the designation, change
or waiver of a beneficiary under this Section.
Installments. For proceeds under $10,000, a lump sum payment will be issued to the
beneficiary. For proceeds of at least $10,000, an interest bearing draftbook/checking
account will be established for the beneficiary while deciding when and how to use the
money. Your beneficiary will be able to write a draft at any time for any amount of $250
or more, up to the total amount in the account. A minimum balance of $1500 must
remain in the account or a check for the balance will be issued to the beneficiaries and the
account will be closed. Important information regarding the account will be provided to
the beneficiary once the account is established.
If interest earned on the account during the year equals $10 or more, The Hartford will
mail a 1099 form to the account holder at the end of the year.
Extension of Insurance if Disabled. If an Employee becomes totally disabled prior to age
60, while insured under the policy, and remains so disabled, his insurance will continue
in force for one year from the date of termination of active employment as a result of the
disability, without payment of further premiums.
If, during the first year of total disability, due proof is furnished that the disability will be
total and permanent until death, the amount of insurance in force at the time of
commencement of the total disability will be paid to the Employee in 120 monthly
installments, the first installment to be payable after receipt of proof, but in no event
before total disability has continued for a period of at least five months.
If the Employee ceases to be totally and permanently disabled and returns to work, the
waiver of premium and monthly installments will automatically terminate on the date the
total and permanent disability ceases, and the Employee’s insurance will be continued in
a reduced amount.
Any installments remaining unpaid at death will be paid to the designated beneficiary in a
lump sum.
Conversion Privilege. If the Employee’s insurance terminates because of termination of
employment, the Employee will be entitled to convert his insurance to an individual
policy on any one of the forms then customarily issued by The Hartford, except term
insurance.
However, if elected such policy may be preceded by single premium term insurance for a
period of one year. Application for conversion and payment of the required premium
must be made within 31 days of such termination.
The premium will be that applicable to the class of risk to which the Employee belongs
and to the form and amount at the then attained age. No evidence of insurability will be
required.
56
If the Group Life Insurance Policy terminates or is amended so as to terminate the
insurance of any eligible class, any Employee who has been insured under it for at least
3 years may convert his insurance under the conditions stated above, but not in excess of
the smaller of (a) $2,000 and (b) the amount of his terminated insurance less any amount
of life insurance for which he may be eligible under any other Group Life Insurance
Policy.
Additional Death Benefit. Should the Employee die during the 31 days allowed for
conversion but before any individual policy has become effective, The Hartford will pay
the Amount of Insurance for which the Employee would have been entitled to make
application.
Claims. Upon the Employee’s or Dependent’s death, the beneficiary will provide their
address, Social Security number and a certified copy (raised seal) of the death certificate
to the Plan Office. The appropriate claim form will be completed by the Plan Office and
sent to The Hartford for processing.
Eligible Dependents of Full-Time Employees
Benefits. If one of the insured Dependents of an eligible Employee dies from any cause,
The Hartford will pay (via a lump-sum check) the Employee the applicable amount of
insurance, as shown in the Schedule of Benefits. The insurance will be paid to the
Employee, if living at the time of payment, otherwise to the executors or administrators
of the Employee’s estate or, at the option of The Hartford, to the Employee’s surviving
spouse.
Conversion Privilege. If an Employee’s Dependent’s insurance terminates because of
termination of the Employee’s employment or because of his death, his dependent will be
entitled to the issuance of an individual policy on any one of the forms then customarily
issued by The Hartford, except term insurance.
Application for the conversion policy and payment of the required premium must be
made within 31 days of such termination.
If Life Insurance for Dependents terminates under the Group Life Insurance Policy or the
Group Life Insurance Policy terminates and if the individual has been insured under the
policy for at least 3 years, a Dependent will be entitled to the issuance of an individual
policy under the conditions stated above, except that the amount of the conversion policy
will not exceed the smaller of (a) $2,000 and (b) the amount of insurance on the
Dependent upon termination of the Life Insurance for Dependents less any amounts of
life insurance for which the individual may be eligible with respect to his Dependent
under any other Group Life Insurance Policy.
Additional Death Benefit. Should the Employee’s Dependent die during the 31 days
allowed for conversion but before any individual policy has become effective, The
Hartford will pay the Amount of Insurance for which his Dependent would have been
entitled to make application.
57
ACCIDENTAL DEATH, DISMEMBERMENT AND
LOSS OF SIGHT BENEFITS
(Provided by Hartford Life and Accident Insurance Company)
(Retirees Excluded)
Eligible Employees
Benefits. The Hartford Life and Accident Insurance Company (The Hartford) agrees,
with respect to accidental bodily injuries which an Employee sustains while covered
under the policy, from which loss results directly and independently of all other causes, to
pay a benefit determined from the Schedule of Losses and Benefits below, provided that
such loss occurs within 90 days after the date of accident causing the loss.
The Maximum Benefit will be the amount stated in the applicable Schedule of Benefits.
This benefit is subject to the following exclusions:
1.
any loss caused by sickness or disease or medical or surgical treatment therefore,
except pyogenic infection that occurs through an accidental cut or wound;
2.
any loss caused by intentionally self-inflicted injuries or suicide;
3.
any loss caused or contributed to by:
(a)
war or act of war, whether war is declared or not; or
(b)
sickness contracted or injuries sustained while in any of the armed forces,
whether land, water or air, of any country or international authority at war,
whether war is declared or not, or engaged in any armed conflict.
Any change in the amount of insurance due to an increase in the Employee’s age will
become effective on the policy anniversary date coincident with or next following the
date of the increase in such person’s age.
Changes in coverage that are due to a change in employment status (for example, a Parttime Employee becoming a Full-Time Employee), earnings or this insurance will become
effective on the date of such change, except that, with respect to an increase in coverage,
a retroactive change in the rate of earnings will become effective on the date of
determination of the change in the rate of earnings.
Schedule of Losses and Benefits
Description of Loss
For loss of:
Benefit
Life ................................................................................... Maximum Benefit
A hand ........................................................ One-Half the Maximum Benefit
58
A foot ......................................................... One-Half the Maximum Benefit
An eye ........................................................ One-Half the Maximum Benefit
More than one of the
above resulting from one accident ................................... Maximum Benefit
Loss of a hand or foot means the dismemberment by severance through or above the
wrist or ankle joint. Loss of an eye means the entire and irrevocable loss of sight of the
eye.
Beneficiary. You may designate a beneficiary, or change your beneficiary, on the
Designation Card available from the Plan Office or any form satisfactory to The Hartford
by giving notice of such designation or change to the Plan Office.
Claims. Written notice of claim must be given to The Hartford within 20 days after the
occurrence or commencement of any loss covered by the policy, or as soon thereafter as
is reasonably possible. Notice given by an Employee or on behalf of an Employee to The
Hartford at its Home Office, or to any authorized agent of The Hartford, with information
sufficient for identification purposes, will be considered notice to The Hartford.
The Hartford, upon receipt of a written notice of claim, will furnish you the forms
necessary for filing proof of loss. If these forms are not furnished within 15 days after
the giving of notice, the Employee will be deemed to have complied with the
requirements of the policy as to proof of loss upon submitting, within the time fixed in
the policy for filing proofs of loss, written proof covering the occurrence, the character
and the extent of the loss for which claim is made.
Written proof of loss must be furnished to The Hartford in case of claim for any loss
within 90 days after the date of such loss. Failure to furnish proof within the time
required will not invalidate or reduce any claim if it was not reasonably possible to give
proof within such time provided the proof is furnished as soon as reasonably possible and
in no event, except in the absence of legal capacity, later than one year from the time
proof is otherwise required.
Indemnities. Indemnities payable under the policy for any loss will be paid as they
accrue immediately upon receipt of due written proof of the loss.
Indemnity for loss of life under any Accidental Death, Dismemberment and Loss of Sight
Benefit included in this Plan will be payable in accordance with the beneficiary
designation and the provisions respecting such payment which are prescribed therein and
effective at the time of payment. If no such designation or provision is then effective,
such indemnity will be payable to the Employee’s estate. Any other accrued indemnities
unpaid at death may, at the option of The Hartford, be paid either to such beneficiary or
to such estate.
All other indemnities will be payable to the Employee.
Right to Examine. The Hartford at its own expense will have the right and opportunity to
examine the person of any individual whose injury or sickness is the basis of a claim
59
when and as often as it may reasonably require during the pendency of a claim under the
policy and to make an autopsy in case of death, where it is not forbidden by law.
Action of Law or In Equity. No action at law or in equity will be brought to recover on
the policy prior to the expiration of 60 days after written proof of loss has been furnished
in accordance with the requirements of the policy. No such action will be brought, after
the expiration of the shortest period of time permitted by the laws of the State* in which
the policy is issued, after the time written proof of loss is required to be furnished.
*Kansas--5 years
*Missouri--10 years
*South Carolina--6 years
*All other states--3 years
60
DISABILITY BENEFIT
(Participants except for Retirees)
If a Participant suffers a Disability (described below) due to a Non-occupational Injury or
Non-occupational Sickness, the Plan will pay to the Participant monthly benefits at the
rate shown in the Schedule of Benefits.
Eligibility. Benefits are payable only to Participants who become entitled to either Social
Security disability benefits or a disability pension under the United Food and Commercial
Workers International Union-Industry Pension Fund or its successor.
Period of Coverage. Benefits are payable for the period beginning with the inception
date of the disability and terminating on the earlier of the maximum period in the
Schedule of Benefits, or the Participant becoming eligible for Social Security disability
benefits or the disability pension benefits provided under the United Food and
Commercial Workers International Union-Industry Pension Fund or its successor.
Under no conditions will payment be made for a period while the Participant is
receiving sick pay benefits or weekly disability benefits from his Employer or any
Employer-sponsored plan or a period of more than five consecutive months.
61
RETIREE DEATH BENEFIT
(Retirees Receiving Disability Pensions Excluded)
If a Participant covered under the Senior Program dies, the Plan will pay a death benefit
in the amount shown on the applicable Schedule of Benefits to the Participant’s
designated beneficiary. As noted above, the death benefit does not apply to persons
covered under the Senior Program who are receiving a Disability Pension or a Vested
Pension benefit due to termination of covered employment before age 55. The Plan will
defer payment until a copy of the retired Employee’s certificate of death is received by
the Plan.
Beneficiary. Any Death Benefits payable to a minor or incompetent may be paid to the
legally appointed guardian of the minor or the incompetent. If no such guardian exists,
benefits may be paid to such adult or adults as have, in the Trustees’ opinion, assumed
the custody and principal support of such minor or incompetent. If two or more
beneficiaries become entitled to Death Benefits under this section, they shall share
equally, unless otherwise designated on the retired Employee’s valid beneficiary
designation form (i.e., duly signed and witnessed designation form).
If there is no valid beneficiary designation form on file with the Plan Office, the Plan,
upon receipt of a claim by the retired Employee’s estate, will pay the death benefit to the
estate of the retired Employee. If at the time of death, there is no designated beneficiary
with respect to all or any part of the benefits or if no designated beneficiary survives the
retired Employee, upon the Plan’s receipt of a claim by the retired Employee’s estate, the
Plan shall pay this death benefit to the retired Employee’s estate.
Payment to one described above will release the Plan from all further liability to the
extent of the payments made.
The retired Employee may designate a beneficiary or may change a previously designated
beneficiary by filing a valid beneficiary designation form. Such designation or change,
when received by the Plan, shall take effect as of the date the written notice is received by
the Plan, whether or not the retired Employee is living at the time of such receipt.
However, any payment made by the Plan prior to such designation or change shall fully
discharge the Plan to the extent of such payment.
The right to change beneficiaries is reserved to the retired Employee and the consent of
the beneficiary or beneficiaries shall not be required to change a beneficiary.
A beneficiary also may be designated in an entered court order, provided that such order
contains a clear designation of rights, as determined by the Trustees in their sole
discretion. The designation will become effective when it is entered in the Plan’s
records, as long as the Plan has not made payment or taken other action before the entry
on its records was made. A beneficiary designation in a court order meeting the above
requirements will supersede any prior conflicting beneficiary designation that is filed
with the Plan Office.
62
A beneficiary may waive his or her rights as a beneficiary under the Plan in an entered
court order, provided that such order contains a clear waiver of rights, as determined by
the Trustees in their sole discretion. The waiver will become effective when it is entered
on the Plan’s records, as long as the Plan has not made payment or taken other action
before the entry on its records was made. A waiver in a court order meeting the above
requirements will supersede any prior conflicting beneficiary designation that has been
filed with the Plan Office. If a court order meeting the above requirements contains a
waiver of rights by the beneficiary on file with the Plan Office, and the retired Participant
subsequently dies without naming a new beneficiary, then the Plan will pay any death
benefits as if there is no valid beneficiary designation form on file with the Plan Office.
63
GENERAL RULES
The benefits provided under this Plan for Participants and Dependents are explained on
the following pages.
Each benefit explanation in the following sections tells you what is covered under that
benefit and lists certain items that are not covered. The General Exclusions and
Limitations section starting on page 49 lists the types of expenses for which benefits are
limited or for which benefits are not payable under any of the Plan benefits. Be sure to
read those limitations.
Keep this list of rules in mind. These rules apply to all of your benefits.
1.
Expenses incurred by female Participants and Dependent spouses of male
Participants for maternity, pregnancy or pregnancy-related conditions are treated
as expenses incurred for an Illness, except as required by law.
2.
A listing of participating PPO Hospitals is available by contacting the Hospital
PPO Network at the telephone number or website on the Inside Back Cover.
3.
Some Hospitals, Physicians and other service providers “unbundle fees.” This
means the provider breaks down one procedure into many small ones and charges
separately for each one. In these cases, the Plan will treat all of the segments as
one procedure and will pay its benefits accordingly.
4.
All claims, enrollment forms and any other information submitted or provided to
the Plan, directly or indirectly, must be accurate and complete. Any claim form
submitted by or on the behalf of a Participant that contains a material alteration or
forged information, including signatures, will be rejected by the Plan Office. If
the Board of Trustees finds, at any time, that false or inaccurate information has
been submitted or provided to the Plan, directly or indirectly, in support of a
claim, such claim will be denied and the Trustees will offset the amount
improperly paid and/or terminate future coverage for the affected individual and
the affected individual’s Covered Family Members. The Board of Trustees
reserves the right to forward the altered or forged document to the local law
enforcement agency for whatever legal action said agency deems to be
appropriate.
5.
The Plan complies with the Women’s Health and Cancer Rights Act of 1998, by
providing benefits for mastectomy-related services including reconstruction and
surgery to achieve symmetry between the breast, prosthetic and complications
resulting from a mastectomy (including lymphedemas). Call the Plan Office for
more information.
6.
The benefits payable under this Plan will not be subject in any manner to
anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge
by any person. However, a Participant may direct that benefits due him be paid
64
directly to any provider of medical services or supplies in consideration for
medical or hospital services rendered or to be rendered, or supplies furnished or to
be furnished, provided the required assignment is received by the Plan Office
prior to the benefit payment.
7.
If any payment is made by the Plan to or on behalf of an individual who is not
entitled to all of or part of this payment, the Plan is entitled to be reimbursed the
amount of this erroneous payment. If necessary, the Plan can recover the
erroneous payment by suspending or withholding payment of claims or reducing
future benefit payments to or on behalf of this individual and/or his or her covered
family members participating in the Plan by the amount of any erroneous payment
and the amount incurred by the Plan in pursuing recovery of the overpayment.
The Plan and Trustees may also take other actions to recover the erroneous
payments and other amounts including, but not limited to, commencing a
restitution action under ERISA.
65
PPO NETWORK OPTIONS
The Plan provides a Preferred Provider Option (PPO) Network option for care rendered
at Hospitals and by Physicians and certain other health care providers. The Plan provides
a separate PPO Pharmacy Network option when prescription drugs must be obtained.
A PPO Network Organization negotiates with physicians, clinics, hospitals, pharmacies,
etc., to provide necessary medical care and services at a lower cost to you and the Plan.
Therefore, by having covered treatment provided through a PPO provider, the cost of
health care for both you and the Plan should be lower.
Neither the Plan, the Trustees, Employers nor Union have conducted a quality review of
the Hospitals, Physicians or other health care providers and facilities associated with the
PPO Networks as part of the agreements with the Plan. In other words, while the
Hospitals and Physicians or other health care provider and facilities associated with the
PPO Networks make a discounted fee available, the Plan in no way guarantees the quality
of care provided by them. Neither the Plan nor the Trustees have a financial interest in or
direct control of any of the health care providers or facilities associated with the PPO
Networks.
HOSPITAL AND PHYSICIAN PPO NETWORK
You can determine whether a hospital, radiology facility, physician or specialist
participates in the PPO Network by calling the PPO Hotline listed on the inside back
cover of this booklet. Because the list of participating hospitals, physicians and other
providers changes from time to time, you should double check whether or not the
hospital, physician or provider is in the PPO at the time of the treatment.
IMPORTANT: Not all Physicians working out of a PPO Hospital are participating
providers in the PPO Network. You should ask each Physician whether they
participate to maximize your benefits under the Plan and reduce your out-of-pocket
expenses.
The PPO Co-Payment Percentage will only apply when care or treatment is provided by a
PPO Provider. However, when treatment is provided for an Illness or Injury at a PPO
Provider Hospital emergency room and the Participant or Dependent is admitted to the
Hospital as a direct result of the visit, those emergency room and emergency room
Physician Covered Charges will be payable at the PPO Co-Payment Percentage.
When you use a PPO Physician, you can use the PPO Hotline listed on your I.D. card to
confirm that the Physician and his office location participate in the PPO. Some of the
Physicians have offices in several locations and not all locations may participate in the
PPO. For example, a Physician who practices at two locations might have office hours at
a participating PPO location on three days of the week but the location where he practices
on the other days of the week does not participate in the PPO. Benefits for the
Physician’s care will be paid under the PPO coverage only if you see the Physician at the
participating location.
66
If a PPO Physician refers you or any of your Dependents for additional services (such as
lab work, x-rays or referral to specialist) and you wish to have the services performed by
a PPO Network provider, you should advise the physician to refer you to a PPO Network
provider.
It is very important that you (and your covered Dependents) show your I.D. card
whenever you receive any type of health care. The I.D. card shows the name and phone
number of both the Plan and the PPO Network and the Plan address. And the I.D. card
identifies to providers that you are a member of the PPO so that they can send their bill to
the PPO Network for initial processing. If you need I.D. cards, contact the Plan Office.
PHARMACY NETWORK
The Plan and KPP have entered into an arrangement with a Pharmacy Network to secure
discounts on prescription drugs when you have a prescription filled at a pharmacy
participating in this Network. Using a Network pharmacy is very important for you to
receive the maximum benefits, or, in some cases, any benefits at all, except in emergency
situations. See the Prescription Drug Expense Benefit, beginning on page 85 for more
details.
HOSPITAL PRE-ADMISSION CERTIFICATION REQUIREMENT
(MATERNITY ADMISSIONS SEE PAGE 71).
1.
Nonemergency Hospital Admissions. A Participant or Dependent who will be
admitted as a Hospital inpatient must have all nonemergency Hospital admissions
authorized in advance by InforMed at 1-877-687-9982 (“Preadmission
Certification Requirement”). The Participant will then be notified of the
authorized length of stay, which will be based on the diagnosis of the patient’s
condition, information from the attending physician and guidelines adopted from
time to time by the Plan for effective and necessary inpatient care. Failure to
have an admission preauthorized will result in a disallowance of expenses
that exceed the amount that would have been preauthorized plus a $250
deductible will be applied against expenses that would have been
preauthorized.
2.
Emergency Hospital Admissions. A Participant or Dependent who undergoes an
emergency Hospital admission must have the admission authorized within
72 hours after admission by InforMed at 1-877-687-9982. The Participant will
then be notified of the authorized length of stay, which will be based on the
diagnosis of the patient’s condition, information from the attending physician and
guidelines adopted from time to time by the Plan for effective and necessary care.
Failure to have an emergency admission authorized within 72 hours after
admission will result in a disallowance of expenses that exceed the amount
that would have been authorized and a $250 deductible will be applied
against expenses that would have been preauthorized.
67
With respect to coverage of emergency room visits, 50% co-insurance will apply
(rather than 80%) if the emergency room visit is not the direct result of a medical
emergency.
3.
Continued Length of Stay. Approval of a length of stay for all Hospital
admissions beyond that originally authorized must be obtained from InforMed at
1-877-687-9982 at least 24 hours in advance of the expiration of the authorized
stay. In the event the authorized stay expires on a weekend or holiday, approval
of a continued length of stay must be obtained by the last working day before the
weekend or holiday. Failure to obtain approval will result in a disallowance of
expenses that exceed the authorized amount.
4.
Limitations and Exclusions. The Plan will not pay benefits for:
(a)
a Hospital inpatient length of stay beyond the approved length of stay as
described above;
(b)
charges for a Hospital confinement for days prior to the date of surgery
unless precertified as Medically Necessary by InforMed.
PREAUTHORIZATION OF SURGICAL
PROCEDURES AND
OTHER BENEFITS
The following Surgical Operations or Procedures must be preauthorized by InforMed at
1-877-687-9982. The preauthorization will also include a length of stay authorization
under the Hospital Preadmission Certification Requirement. Failure to have a
nonemergency Surgical Operation or Procedure preauthorized will result in a $400
deductible being applied against Covered Charges for the surgery.
Adenoidectomy
Hysterectomy
Spinal or Vertebral Surgery
Tonsillectomy
Varicose Vein excision and ligation
Repair of deviated septum
Knee Surgery
Prostatectomy
Gastric bypass or lap band surgery
Surgery of eyelids
Bunionectomy
Joint replacement
Additional requirements apply to gastric bypass and lap band surgery (see page 72).
In addition to the above preauthorization requirements, some Plan benefits require
preauthorization. They are identified on the Schedule of Benefits and include non68
emergency MRIs, PET and CAT scans, convalescent care, home health care, hospice
care, and durable medical equipment above $500.
69
MAJOR MEDICAL EXPENSE BENEFITS
Overview. The Major Medical Expense Benefit provides Participants and Dependents
coverage for Covered Charges incurred which exceed the deductible required under this
section. The Major Medical Expense Benefit is subject to an annual maximum per
person. Certain expenses are subject to separate individual lifetime maximums or limits.
Please refer to the Schedule of Benefits.
The total amount of benefits payable for all Covered Charges with respect to any one
person (whether or not there is any interruption in the coverage with respect to such
person under this Plan and whether or not there is any change in status of such person
from Participant to Dependent or vice versa) will not exceed the maximums shown in the
Schedule of Benefits.
Deductible Requirement.
1.
Calendar Year Deductible.
(a)
Single Coverage Deductible. The Single Coverage deductible requirement
shown in Schedules I (Plan 1), II (Plan S) and III (Plan V) of the Schedule
of Benefits will be applied against Covered Charges incurred in each
calendar year. Unless the Plan’s Rules and Regulations provide otherwise,
the deductible for the Participant shall be considered satisfied for the
remainder of the calendar year after the out-of-pocket Covered Charges
for the Participant total the amount of the Single Coverage deductible per
calendar year shown in Schedules I, II, or III of the Schedule of Benefits
(whichever applies to the Participant).
(b)
Family Coverage Deductible (Participants and Dependents). The Family
Coverage deductible requirement shown in Schedules I, II, and III of the
Schedule of Benefits will be applied against Covered Charges incurred in
each calendar year to Participants covered by Family (Participant and
Dependent) coverage. After the out-of-pocket Covered Charges for all
Covered Family Members of the same family unit total the amount of the
Family Coverage deductible per calendar year shown in Schedules I, II, or
III of the Schedule of Benefits (whichever applies to the Participant and
Dependents), the deductible for all Covered Family Members in the same
family unit will be considered satisfied for the remainder of the calendar
year.
Percentage Payable. Once the deductible requirement as shown in the Schedule of
Benefits is met, the Plan will provide benefits for Covered Charges at the percentage
payable in the Schedule of Benefits not to exceed the maximums shown in the Schedule
of Benefits.
Reinstatement of Benefits. For benefits to which a lifetime limit is applicable, up to
$1,000 annually is automatically restored to the Major Medical Expense Benefit lifetime
70
maximum as shown in the Schedule of Benefits for Participants or Dependents who have
received benefits under Major Medical. The annual restoration is made on January 1 of
each calendar year and will not be applicable to any retired Participant or his or her
Dependent who, as of that time, has reached age 65. Also, a Participant or Dependent
who has received Major Medical Expense Benefits in excess of $1,000 under the Plan
will receive an automatic annual restoration of up to 5% of the lifetime maximum benefit,
but not greater than the lifetime maximum benefit amount.
Benefits. Benefits are payable only for Covered Charges (see page 20) that exceed the
deductible but do not exceed any applicable annual or lifetime maximum shown in the
Schedule of Benefits. Benefits are payable for the following:
1.
Inpatient Expenses. If a Participant or Dependent has been confined as an
inpatient in a Hospital, the Plan will provide benefits for Covered Charges in
connection with any one period of Hospital confinement for:
(a)
Daily Hospital Room and Board;
(b)
Other Hospital Services and Supplies; and
(c)
Physician’s Expenses (excluding services rendered by the surgeon
throughout the patient’s entire hospital stay that are covered under surgical
expenses).
Note about length of maternity hospitalizations– a female Participant or female
Dependent spouse and her newborn infant are entitled to 48 hours of inpatient
hospital care following normal vaginal delivery and 96 hours of inpatient hospital
care following a Cesarean section without obtaining preauthorization. (The
attending provider may, however, after consulting with the mother, discharge the
mother and the newborn earlier than 48 hours following a vaginal delivery or 96
hours following a Cesarean section.) The Plan requires the provider (Hospital
or Physician) to obtain preauthorization for a length of stay in excess of these
periods. The Plan will provide benefits for the Covered Charges incurred during
the prescribed time periods, subject to all applicable Plan benefit provisions,
maximums and limitations.
2.
Outpatient Expense. If a Participant or Dependent received care and treatment in
a Hospital in connection with, and at the time of, a Surgical Operation or
Procedure performed in the Hospital by a Physician and the Participant or
Dependent was not confined as an inpatient in the Hospital, the Plan will provide
benefits for the Covered Charges for Other Hospital Services and Supplies.
3.
Pre-Admission Testing. The Plan will provide benefits for Covered Charges for
diagnostic tests and x-rays performed in the outpatient department of a Hospital
within seven days of an actual admission to the Hospital, provided the tests are
ordered by a Physician, and the Participant or Dependent is scheduled for
admission to the Hospital for treatment of the condition that made the tests
necessary. In the event that the scheduled admission does not take place, the pre71
admission testing Covered Charges will not be covered unless the admission is
postponed or cancelled for one or more of the following reasons:
4.
5.
(a)
the tests indicated that the condition requires medical treatment prior to
admission;
(b)
the tests indicated that a medical condition has developed that delays the
admission;
(c)
a Hospital bed is not available on the scheduled date of admission; or
(d)
the tests indicated that, contrary to the attending Physician’s expectation,
the admission is not necessary.
Gastric Bypass and Lap Band Surgery. Subject to preauthorization requirements,
the Plan covers Gastric Bypass/lap band Surgery, if the Participant or Dependent
meets certain criteria. In addition to meeting the requirements of being
“Medically Necessary,” as discussed on page 26, all of the following must also
be satisfied:
●
the Participant or Dependent must possess a body mass index of at least
50; and
●
the Participant or Dependent must first complete an integrated program
approved by the Plan’s medical consultant on a preauthorization basis
which shows that the candidate is prepared to make the lifestyle changes
necessary for the gastric bypass/lap band surgery to successfully address
morbid obesity; and
●
the Participant or Dependent must be between the ages of 21 and 65; and
●
the Participant or Dependent must exhibit a history of morbid obesity and
confirm that all other lesser weight loss efforts have tried and failed.
Operating Physician. The Plan will provide benefits for Covered Charges by a
Physician as a surgical fee for performing a Surgical Operation or Procedure.
Covered Charges will include all Medically Necessary pre- and post-operative
visits.
Out-of-Network Covered Charges for two or more Surgical Operations or
Procedures due to the same or related cause or causes performed at different times
during one Period of Disability will be paid up to the maximum amount per
disability as shown in the Schedule of Benefits. However, two or more Out-ofNetwork Surgical Operations or Procedures performed through the same
abdominal incision will be considered as one Surgical Operation or Procedure and
the maximum amount payable will be the maximum amount shown in the
Schedule of Benefits for the Surgical Operation or Procedure performed that has
the largest applicable maximum amount.
72
Covered Charges, up to a lifetime maximum per Covered Family Member, will be
payable by the Plan for surgical treatment performed by a doctor of podiatry
provided that treatment is rendered pursuant to a referral by a Physician for the
specific surgery and is so documented to the satisfaction of the Trustees. The
Lifetime Maximum Benefit for this coverage is set forth in the Schedule of
Benefits.
Podiatrist Surgical Expenses are limited as explained on page 5.
The Plan will pay the Covered Charges of a Surgical Assistant based on the U&C
for the Surgical Operation or Procedure CPT Code.
6.
Consulting Physician. The Plan will provide benefits for Covered Charges for
Consulting Physician expenses.
7.
Anesthesiology. The Plan will provide benefits for Covered Charges for the
administration of anesthetics by a professional anesthetist, certified registered
nurse anesthetist (CRNA) and Physician. However, if out-of-network charges
from all providers for the administration of anesthetics exceed the U&C, the
payment will be pro-rated to each provider.
8.
Physician’s Expenses. The Plan will provide benefits for Covered Charges for
Physician’s expenses. However, in situations where a Physician charges for
different levels of office visits with respect to the same or related condition, any
charge above the charge for the base service will only be paid to the extent that
the Plan, based on advice from the Plan’s medical consultant, determines that
such additional services were Medically Necessary.
9.
Maternity Expenses (Female Participants and Dependent Spouses) Benefits.
Covered Charges incurred as the result of pregnancy, childbirth or related medical
conditions will be treated the same as any other medical Illness for a female
Participant or female Dependent spouse of a Participant, except as required by
law. No payment will be made to a female Participant or female Dependent
spouse of a Participant on account of elective abortions, except where the life of
the woman would be endangered if the fetus were carried to term or where
medical complications arise from an abortion.
Extension of Maternity Expense Benefits. Benefits resulting from pregnancy,
childbirth, or related medical conditions will continue to be paid on the same basis
as any other Illness if, on the date of termination of eligibility, the female
Participant or Dependent spouse of a Participant or retiree is Totally Disabled as a
result of pregnancy, childbirth, or related medical conditions.
10.
Voluntary Sterilization (Participants and Dependent Spouses). The Plan will
provide benefits for Covered Charges of Participant or a Dependent spouse who
incurs expenses in connection with a Surgical Operation or Procedure for the
purpose of sterilization of the reproductive system. Benefits will not be payable
for the reversal of any such operation or procedure.
73
11.
Chiropractor Services. The Plan will provide benefits for Covered Charges, not to
exceed the maximum number of visits as shown in the Schedule of Benefits, for
the professional services of a chiropractor (D.C.) or physiotherapist (RPT)
employed by or in the same office as a chiropractor for administering physical
medicine.
12.
Physical Medicine (Therapy) and Speech Therapy Services. The Plan will
provide benefits for Covered Charges for the professional services of a Physician
or physiotherapist (RPT) for the administration of physical medicine (therapy) to
a Covered Family Member, up to the maximum number of visits specified in the
Schedule of Benefits. The Plan will provide benefits for Covered Charges for the
professional services of a licensed speech therapist for loss of speech function as a
result of Illness or Injury. If in the judgment of the Physician attending the
Covered Family Member as further supported by the patient’s medical records
and prognosis, significant improvement can be achieved, the Plan may permit an
additional number of visits on a week-by-week basis, provided such additional
visits are preauthorized by InforMed. The Plan reserves the right to have such
additional visits reviewed by the Plan’s medical consultant before preauthorizing
such visits. Benefits are not payable by the Plan for physical therapy services or
speech therapy services to maintain a Covered Family Member’s function at the
level to which it has been restored or when no further significant practical
improvement can be expected. Physical therapy that is prescribed by a Physician
in place of nonmedical treatment (for example, exercise) is not considered
Medically Necessary treatment and is not payable by the Plan.
13.
Diagnostic X-ray and Laboratory Examination Expenses. The Plan will provide
benefits for Covered Charges for diagnostic x-ray and laboratory examination
expenses. All nonemergency Magnetic Resonance Imaging (MRI), Positron
Emission Tomography (PET Scan) and Computerized Axial Tomography (CAT
Scan) diagnostic tests must be preauthorized by InforMed in order to be covered.
The Plan reserves the right to have a request for a preauthorized test reviewed by
the Plan’s medical consultant before preauthorizing such tests.
14.
Durable Medical Supplies. The Plan will provide benefits for Covered Charges
for medically necessary Durable Medical Supplies, subject to the limitations,
exclusions, and preauthorization requirements below. All expenses for Durable
Medical Supplies exceeding $500 must be preauthorized by InforMed. Where
preauthorization by InforMed for Durable Medical Supplies is required, the Plan’s
benefit is limited to the least costly supply or equipment appropriate for the
Participant’s or Dependent’s condition.
Limitations and Exclusions of Durable Medical Supplies:
(a)
prostheses, such as an artificial eye, limb, or portions of a limb and in the
event of a mastectomy, breast prosthesis, must be preauthorized in
advance by InforMed;
74
(b)
a truss, brace or support must be preauthorized by InforMed;
(c)
rental of a manually operated wheelchair, manually operated Hospital type
bed or other durable medical equipment must be preauthorized by
InforMed;
(d)
rental of mechanical equipment required for the treatment of respiratory
paralysis must be preauthorized by InforMed;
(e)
coverage for compression stockings is limited to two pairs per year;
(f)
the Plan will cover one wig when hair loss is due to chemotherapy, up to a
maximum Covered Charge of $150.
Note: If it is determined in advance by the Plan to be more cost effective to
purchase, rather than rent, Durable Medical Supplies such as a manually operated
wheel chair, Hospital type bed or other mechanical equipment, the Plan reserves
the right to reclaim the equipment when the Participant or Dependent no longer
requires the use of the equipment.
15.
Expenses for the Services of a Registered Graduate Nurse, Licensed Practical
Nurse or a Physiotherapist. Subject to the Plan’s limitations, the Plan will provide
benefits for Covered Charges for services rendered to a Participant or Dependent
by a registered graduate nurse, licensed practical nurse or a physiotherapist.
16.
Convalescent Care Accommodations. The Plan will provide benefits for Covered
Charges not to exceed the maximum as shown in the Schedule of Benefits made
by a Convalescent or Intermediate Care Facility for its Room and Board
accommodations, provided:
17.
(a)
the individual is confined as a registered bed patient on the certification of
his Physician that such Convalescent Facility confinement is necessary;
(b)
Convalescent Facility confinement commences after discharge from a
Hospital confinement of at least three consecutive days of acute care stay;
and
(c)
Convalescent Facility confinement is necessary for the care or treatment of
the Injury or Illness that was the cause of the preceding Hospital
confinement.
Home Health Care Services. The Plan will provide benefits for Covered Charges
not to exceed the maximum as shown in the Schedule of Benefits for home health
care services (as described below) provided the services meet all of the following
requirements:
(a)
they are preauthorized by InforMed;
75
(b)
they are furnished in the patient’s home because Hospital or Convalescent
or Intermediate Care Facility accommodations would have been required
if such services were not furnished at home;
(c)
they are given under a plan of care established, approved in writing and
reviewed at least every two months by the attending Physician, unless
such Physician determines that a longer interval between reviews is
sufficient. If the patient was a Hospital inpatient immediately prior to the
start of home health care, the plan of care must also be initially approved
by the Physician who was the primary provider of services during the
Hospital stay;
(d)
they are provided by a Hospital, a licensed or certified Home Health Care
Agency, or a certified rehabilitation facility;
(e)
necessary care is not available from members of the person’s immediate
family without causing undue hardship. Immediate family means the
spouse, children, parents, grandparents, brothers and sisters of the
Participant and the Participant’s spouse; and
(f)
they would have been covered if provided in a Hospital.
Home health care services include:
(a)
nursing service by a registered nurse (R.N.) or by a licensed practical
nurse;
(b)
Home Health Aide service consisting mainly of care of the patient;
(c)
physical, occupational, respiratory or speech therapy;
(d)
medical supplies, drugs and laboratory work;
(e)
nutritional counseling by or under the supervision of a registered dietician;
and
(f)
evaluation of the need for and development of a plan for home health care
by a registered nurse, physician extender or medical social worker when
approved by or requested by the attending Physician.
A “visit” as used in the Schedule of Benefits is either a visit by members of a
home health care team or four consecutive hours of Home Health Aide services.
For a person eligible for Medicare, the above benefits will be paid only for Home
Health Care visits beyond those provided by Medicare, up to an aggregate total of
365 visits under Medicare and the Home Health Care benefit per 12-month
period.
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18.
Hospice Care. Subject to preauthorization by InforMed, the Plan will provide
benefits for Covered Charges not to exceed the maximum as shown in the
Schedule of Benefits for the following hospice care services provided by a
Hospice Care Agency:
(a)
nursing care;
(b)
medical social services;
(c)
counseling services;
(d)
chaplaincy;
(e)
physical therapy;
(f)
occupational therapy;
(g)
speech language pathology;
(h)
medical supplies and equipment; and
(i)
drugs and biologicals used for pain and symptom control.
The Plan will not pay Covered Charges for the following:
19.
(a)
bereavement counseling;
(b)
inpatient care;
(c)
administrative expenses;
(d)
transportation (except in emergency situations); or
(e)
Surgical Operations or hospitalizations due to medical complications of
the terminal condition.
Mental and Nervous Disorders, Alcoholism and Substance Abuse Expenses.
Subject to the Hospital preadmission requirements on pages 67-68, the Plan will
provide benefits for Covered Charges for a Participant or Dependent who has
incurred Covered Charges as a Hospital inpatient for treatment of psychosis and
associated organic illness or for treatment of alcoholism or substance abuse.
If a Participant or Dependent incurs Covered Charges for outpatient treatment of a
Mental and Nervous Disorder, alcoholism or substance abuse, benefits will be
payable under the Plan for the following:
(a)
Charges for services rendered on an outpatient basis for the treatment of
alcoholism or substance abuse.
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(b)
Charges for services rendered on an outpatient basis by a Physician for
treatment of Mental and Nervous Disorders.
20.
Expenses for Administering Allergy Injections. The Plan will provide benefits for
Covered Charges for the administration of allergy injections by a registered
graduate nurse, licensed practical nurse or a Physician who are not family
members.
21.
Diabetes Self-Management Education. Charges actually made to the Participant
for education for the care and self-management of diabetes, including nutritional
counseling, that are provided to a Participant or Dependent after the initial
diagnosis of the condition, shall be limited to the following:
(a)
visits Medically Necessary upon the diagnosis of diabetes;
(b)
visits under circumstances where a Physician identifies or diagnoses a
significant change in the symptoms or conditions of a Participant or
Dependent that necessitates changes in the person’s self-management; and
(c)
where a new medication or therapeutic process relating to the Participant’s
or Dependent’s treatment and/or management of diabetes has been
identified as Medically Necessary by a licensed Physician.
Coverage for reeducation or refresher education shall be limited to a maximum
Plan payment of $100 per calendar year.
Diabetes education must be provided by the Physician as part of an office visit for
diabetes diagnosis or treatment, by a licensed pharmacist for instructing and
monitoring a Participant or Dependent regarding the properties of covered
equipment, supplies and medications prescribed by a Physician, by a certified
diabetes educator (i.e., certified by a national diabetes educator certification
program), or by a registered dietitian (i.e., registered by a nationally recognized
professional organization of dietitians) upon the referral of a Physician. The
national diabetes education certification program or the nationally recognized
professional association of dieticians must be certified to the commissioner of
insurance by the commissioner of the bureau of public health. The Plan requires
acceptable proof that a diabetes educator or a registered dietitian meets the
appropriate certification or registration before a claim will be processed.
22.
Ambulance Expenses. If the Participant or Dependent has been transported by an
ambulance provided by the Hospital or by an ambulance service that customarily
renders ambulance transportation in the usual course of its business to or from the
Hospital in connection with a Hospital confinement for which Hospital Expense
Benefits are payable, the Plan will provide benefits for Covered Charges. All
nonemergency transportation and any special ambulance service, including
air ambulance, other than to the nearest Hospital in the case of an
emergency, must be preauthorized by InforMed .
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23.
Emergency Accident Expense Benefits. If a covered Participant or Dependent
who sustained a Non-occupational Injury and, as a result of such injury, actually
incurs charges for:
(a)
care and treatment by a Physician, or
(b)
outpatient charges for Other Hospital Services and Supplies
and the Participant or Dependent is not entitled to similar benefits under the Plan,
the Plan will provide benefits for Covered Charges.
24.
Hearing Expenses (Retirees Excluded). The Plan will pay the Covered Charges
not to exceed the maximum as shown in the Schedule of Benefits for hearing
expenses when an in-network Provider is utilized. In addition to those items
shown on the Schedule of Benefits, the Plan will pay Covered Charges for a
Physician’s visit if a hearing problem is determined by the licensed audiologist
and the patient is referred to the Physician by the audiologist.
25.
Genetic Testing. In addition to any genetic counseling and evaluation for BRCA
testing required under PPACA, the Plan will pay covered charges for BRCA
mutation testing for breast and ovarian cancer susceptibility when an individual
has either already been diagnosed with either breast or ovarian cancer or has a
family history on the maternal side of breast or ovarian cancer, upon receipt of
sufficient documentation.
79
BASIC MEDICAL EXPENSE BENEFITS
1.
Preventive Care (In-network) services required by PPACA will be covered at
100%. The Plan will provide coverage for and not impose any cost sharing
requirements for Preventive Care services at an in-network facility. The Plan will
cover those services listed in the definition of Preventive Care on page 27. To the
extent not covered as Preventive Care, the Plan will provide benefits for Covered
Charges incurred by a Participant, eligible Dependent spouse and children subject
to age limits for one examination for routine checkups and related diagnostic
laboratory and radiology services, well baby care, immunizations, flu shots,
colonoscopies, pap smears, mammograms, PSA testing, HPV vaccine, HIV
screening, and testicular cancer screening.
2.
Wellness Care Expense. The Plan will provide benefits for Covered Charges
incurred by a Participant, eligible Dependent spouse and Children subject to age
limits for one examination for routine checkup and related diagnostic laboratory
and radiology services, routine colonoscopies (up to age 50), routine
mammograms (up to age 40), PSA testing and testicular cancer screening not to
exceed the maximum as shown in the Schedule of Benefits.
3.
Vision Care Expenses. The Plan will provide benefits for Covered Charges not to
exceed the maximum as shown in the Schedule of Benefits for a vision
examination performed by a qualified optometrist or ophthalmologist and/or
lenses and frames prescribed or
provided by a qualified optometrist,
ophthalmologist or optician.
Only one examination and/or lenses and frames and/or contacts will be considered
for payment during any two calendar year period. No vision care benefits will be
payable by the Plan for vision training procedures, any lenses that did not require
a prescription, or sunglasses, prescription or non-prescription.
Retirees are excluded from these benefits except for the Preventive Care (Innetwork) services required by PPACA that will be covered at 100%. The Plan will
cover those services referenced in the definition of Preventive Care on page 27.
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DENTAL EXPENSE BENEFIT
(Retirees Excluded)
Benefits. The Plan will provide benefits for Covered Charges not to exceed the
maximum as shown in the Schedule of Benefits for Covered Dental Services (described
below) if performed by a Dentist.
The total amount of benefits payable for all Covered Dental Services with respect to any
one person (whether or not there is any interruption in coverage with respect to such
person under this Plan or any change in status from Participant to Dependent or vice
versa) will not exceed the maximums shown in the Schedule of Benefits.
Covered Dental Services. The following services if performed by a Dentist:
1.
Diagnostic Services. Procedures to assist the Dentist in evaluating the existing
conditions to determine the required dental treatment.
2.
Preventive Services. Prophylaxis twice in each 12 months; topical application of
fluoride solutions for Dependent children less than 19 years of age; and space
maintainers.
3.
Emergency Services. Treatment for relief of pain.
4.
Basic Services.
5.
(a)
Oral Surgery. Procedures for extractions and other oral surgery including
pre- and post-operative care.
(b)
General Anesthesia. Anesthesia administered by a Dentist for a covered
oral surgery procedure.
(c)
Restorative. Amalgam, synthetic porcelain and plastic restorations for
treatment of carious lesions.
(d)
Endodontic. Procedures for pulpal therapy and root canal filings
(treatment of non-vital teeth).
(e)
Periodontic. Procedures for treatment of the tissues supporting the teeth.
Major Services.
(a)
Prosthodontics. Procedures for construction of bridges, partial and
complete dentures.
(b)
Restorative Crowns and Inlays. Gold restorations, crowns and jackets will
be provided when teeth cannot be restored with amalgam, synthetic
porcelain and plastic materials.
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6.
7.
TMJ Services. Intra-oral services provided by a Dentist when necessary and
customary according to the standards of generally accepted dental practice for the
treatment of acute dental symptoms associated with malfunction of
temporomandibular (jaw) joint (TMJ).
(a)
Temporary Repositioning Appliance. A removable appliance to move any
teeth that are obstructing the normal occlusion.
(b)
Occlusal Guard.
grinding.”
(c)
Occlusal Adjustment.
(d)
Orthodontic Appliance. Where it can be established that such appliance
was primarily for treatment of TMJ and was obtained in combination with
other TMJ Services.
(e)
Removable Overlay Stabilizing Appliance.
To relieve injurious effects of bruxism or “night-
Orthodontic Services. Coverage is provided in connection with diagnostic
services, the treatment plan, fitting, making and placing of the active appliance
and related office visits up to the maximum benefit set forth in the Schedule of
Benefits.
Limitations.
1.
X-rays. Complete mouth x-rays are provided only once in a three-year period,
unless the Participant or Dependent demonstrates a special need. Supplementary
bite-wing x-rays are provided upon request, but not more than four bite-wing
x-rays once every six months.
2.
Prosthodontics. Replacement of an existing prosthodontic appliance will be made
only if the Participant or Dependent can demonstrate it is unsatisfactory and
cannot be made satisfactory. Prosthodontic appliances (including partial and
complete dentures, crowns and bridges) will be replaced only after five years have
elapsed following any prior provision of such appliances. This limitation will not
apply if replacement is necessary for reasons of health, i.e., excessive tissue
change, extensive loss of remaining teeth or changes in supporting tissues, which
renders the appliance unusable.
3.
Orthodontic and Periodontic. Combined lifetime benefit as outlined in Schedule
of Benefits.
4.
Optional. In all circumstances in which the patient selects a more expensive
treatment plan than the Plan customarily provides, the Plan will pay the applicable
percentage of the lesser fee for the following treatments:
82
(a)
Partial Dentures. The Plan will provide a standard cast chrome or acrylic
partial denture or will allow the cost of such procedure toward a more
complicated or precision appliance that the patient and Dentist may choose
to use. Any denture for which a charge is made that exceeds the U&C fee
will be considered an optional service.
(b)
Complete Dentures. If in the construction of a denture the Participant or
Dependent and Dentist decide on “personalized” restorations or to imply
“specialized techniques” as opposed to standard procedures, the Plan will
allow the appropriate amount for the standard denture toward such
treatment and the Participant or Dependent must bear the difference in
cost. The term “complete dentures or standard dentures” will mean an
acrylic based denture constructed by methods and with materials approved
by the Council on Dental Materials and Devices of the American Dental
Association, and the term “specialized techniques” as used in this
paragraph, will mean those techniques employing but not limited to
precision attachments, swing-lock attachments and precious metals.
(c)
Occlusion. The Plan will allow the appropriate amount for procedures
necessary to eliminate oral disease and to replace missing teeth.
Procedures or restorations necessary to increase vertical dimension and/or
restore or maintain the occlusion are considered optional and the cost is
the responsibility of the patient. Such procedures include but are not
limited to equilibration, periodontal splinting, restoration of tooth structure
lost from attrition, and restoration for malalignment of the teeth.
(d)
Implants. If implants are utilized, the Plan will allow the cost of a
standard complete or partial denture toward the cost of implants and
appliances constructed in association therewith. The Plan will not provide
surgical removal of implants.
Exclusions. In addition to the General Exclusions and Limitations beginning on page 49,
no Dental Expense Benefits will be payable for a dental operation or procedure or
for charges in connection with:
1.
services with respect to developmental malformations or cosmetic surgery or
dentistry for purely cosmetic reasons, including but not limited to cleft palate,
maxillary and mandibular malformations, enamel hypoplasis, fluorosis and
anodontia;
2.
drugs and appliances other than prosthodontic appliances;
3.
hygiene instruction and dietary instruction;
4.
sealants, except for eligible children up to age 15 on permanent teeth only;
5.
orthodontic treatment in excess of the Plan’s lifetime maximum, other than for
extractions;
83
6.
plaque control programs;
7.
myofunctional therapy;
8.
more than two prophylactic treatments during each 12-month period;
9.
treatment by other than a legally qualified and licensed dentist (D.D.S. or
D.M.D.), except charges for dental prophylaxis performed by a licensed dental
hygienist, under the supervision and direction of a qualified and licensed dentist
(D.D.S. or D.M.D.);
10.
more than one full-mouth x-ray during any three-year period (unless special need
is demonstrated) or for more than four bite-wing x-rays during any six-month
period;
11.
prosthodontic appliances (including partial and complete dentures, crowns and
bridges) and related expenses for replacement made less than five years after the
appliance was originally made or last replaced and cannot be made serviceable;
12.
charges for anesthesia, other than general anesthesia administered by a Dentist in
connection with covered oral surgery services;
13.
charges for the repair or replacement of any appliance in whole or in part which is
provided under TMJ Services; or
14.
charges that may be associated with TMJ but that would normally be provided
under medical care, including but not limited to, psychotherapy, special joint
exams and x-rays, joint surgery and medications.
15.
charges for services that exceed the Usual and Customary fee allowance.
84
PRESCRIPTION DRUG EXPENSE BENEFIT
For Kroger Employees, your prescription drug benefit will be administered by the Kroger
Prescription Plans (KPP) along with mail order prescriptions. You should contact KPP at
the number in the inside back cover with any questions about a prescription drug claim or
if you lose your card. For Employees of other Employers and Plan S and Plan V Retired
Participants, your prescription drug benefits will continue to be administered by the Plan
Office and you should contact the Plan Office at the number on the inside back cover
with any questions about a prescription drug claim or if you lose your card. Refer to the
Schedule of Benefits for appropriate benefits.
The Plan and KPP have entered into an arrangement with a Pharmacy Network to secure
discounts on prescription drugs when you have a prescription filled at a pharmacy
participating in the Network. Present your separate Pharmacy Network identification
card at the pharmacy when you have your prescription filled. To secure the greatest
discount, you should have prescriptions filled at a Kroger pharmacy, which is the
exclusive pharmacy within 5 miles of where you live or work. Using a Network
pharmacy is very important to you to receive the maximum benefits, or, in some cases,
any benefits at all, except in emergency situations.
Benefits. The Plan covers the Covered Charges not to exceed the maximum as shown in
the Schedule of Benefits for FDA approved legend drugs or medications (filled in bottles
or containers which must be marked “Federal law prohibits dispensing without a
prescription”) and injectable insulin requiring a written prescription when prescribed by a
Physician to treat a Non-occupational Injury or Illness and when the Participant or
Dependent also satisfies one of the following three requirements:
1.
Where a Participant or Dependent lives or works within a five-mile radius of a
Priority PPO Pharmacy, then the Participant’s or Dependent’s prescription is only
covered by the Plan if it is filled at a Priority PPO Pharmacy.
2.
Where a Participant or Dependent does not live or work within a five-mile radius
of a Priority PPO Pharmacy but lives or works within a five-mile radius of a PPO
Pharmacy, then the Participant’s or Dependent’s prescription is covered by the
Plan if it is filled at a PPO Pharmacy.
3.
Where a Participant or Dependent does not live or work within a five-mile radius
of a Priority PPO Pharmacy or a PPO Pharmacy, then the prescription will be
covered if it is filled at any licensed pharmacy.
When a prescription is filled at a Priority PPO Pharmacy (#1 above) or a PPO Pharmacy
(#2 above), A Participant or Dependent must pay the Participant Co-Payment Amount set
forth in the applicable Schedule of Benefits when the prescription is filled. When a
prescription is filled under the provisions of #3 above, the Participant or Dependent must
first pay the prescription in full and then submit a claim for reimbursement to the Plan
Office or KPP, depending on whether the Employee is a Kroger Employee or not. You
will only be reimbursed for a covered prescription drug or medication based on the Usual
85
and Customary Charge less the Participant Co-Payment set forth in the applicable
Schedule of Benefits.
A Priority PPO Pharmacy means a Kroger Company pharmacy. A PPO Pharmacy means
any pharmacy participating in the Pharmacy Network. See the inside back cover for the
toll free number to call for information about other PPO participating pharmacies.
A written prescription must be filled by a licensed pharmacist or by a Hospital pharmacy
for take-home use.
Mail Order Program (Plan 1 Kroger Employees Only).
In addition to the Plan 1 benefits listed above, prescriptions may be submitted through
KPP’s Mail Order Prescription Drug Program, in which case both the Participant CoPayment Amount and Maximum Supply Per Fill will be different from prescriptions
filled at a retail pharmacy. Please see the Schedule of Benefits for a full description of
these differences. Contact KPP for more information about the Mail Order Prescription
Drug Program.
Self-Injectable Drugs (All Plans)
The Plan covers self-injectable drugs approved by the FDA for self-injection, in addition
to insulin.
A Covered Family Member can choose to receive self-injectable medications through the
pharmacy benefit rather than administered in their Physician’s office or in the Hospital.
Self-injectable drugs are those that have been approved by the FDA for self-injection or
based on standard medical practice have been deemed appropriate and safe to be injected
by the patient. Covering self-injectables through the pharmacy benefit allows a Covered
Family Member the convenience of picking up most self-injectable medications at your
local retail pharmacy.
The self-administered injectable drug coverage extends to many injectable drugs
approved by the FDA. These drugs must be prescribed by your Physician and dispensed
by a PPO Pharmacy. The prescription benefit co-payment will apply if you receive your
medication from your PPO Pharmacy. Because drugs obtained through the prescription
benefit are subject to discounted pricing and those obtained from your Physician are not,
your co-payment on the self-injectable will generally be lower if you get it through the
pharmacy than from the doctor, even if your co-payment would be 20% for both
prescription and medical benefits. See the applicable Schedule of Benefits for more
information on your prescription drug co-payment amount.
Quantity limits and Pre-Authorization for Medical Necessity apply to some drugs. A
quantity limit means that the Plan will only pay for a set amount of a particular drug per
prescription. Quantity limits are set in accordance with FDA approved prescribing
limitations and standard medical practice. Prior authorization is the process of obtaining
coverage approval for a particular self-injectable medication. The following selfinjectables require a prior authorization to be covered:
Protropin (Somatren),
86
Norditropin, Nutropin, Nutropin AQ,
(Promlintide), and Byetta (Exenatide.)
Nutropin
Depot
(Somatropin),
Symlin
This list will be changed from time-to-time based on new drugs coming to market and
clinical recommendations.
The clinical staff normally issues authorizations after review of the Physician’s orders
and other documentation to ensure that certain drugs are Medically Necessary, such as
erectile dysfunction drugs. A set standard, or protocol, is used to determine if the
medication will be approved or not. You can obtain a medication request form from the
Plan Office. Your Physician will need to complete the form and fax it back to the Plan
Office.
Step Therapy
The Plan uses step therapy on two types of drugs--Cox-2 Inhibitors and Angiotensin
Receptor Blockers (ARBs) for Covered Family Members who have not used one of these
types of drugs before. If a Covered Family Member has had a prescription filled for
an ARB or a Cox-2 Inhibitor (before February 1, 2006), you will be allowed to
continue using that type of drug without going through the Step Therapy process.
The step-by-step procedure for how this process works is described below:
ARBs (Angiotensin Receptor Blockers)
ARBs (including, but not limited to Benicar, Benicar HCT, Avapro, Avalide, Cozaar,
Hyzaar, Diovan, and Diovan HCT) will be covered by the Plan only after you try an ACE
Inhibitor, an appropriate cost-effective alternative medication, first.
Cox-2 Inhibitors
Cox-2 Inhibitor drugs (including, but not limited to Celebrex) will be covered by the Plan
only after you try a Non-Steroidal Anti-Inflammatory Drug (NSAID), an appropriate,
cost-effective alternative medication, first.
The step-by-step process:
1.
Present a prescription for an ARB or a Cox-2 Inhibitor to the PPO pharmacy.
2.
Pharmacy Team fills the prescription and adjudicates the prescription
electronically.
3.
The pharmacy system reviews your history for a:
ARB Prescription
a.
Prior prescription for an ACE Inhibitor filled, or
b.
Prior prescription for an ARB filled.
Cox-2 Inhibitors Prescription
a.
b.
Prior prescription for a NSAID filled, or
Prior prescription for a Cox-2 Inhibitor filled.
87
4.
If either criteria is met, your prescription is approved. (If you have received either
prescription in the past but the pharmacy system does not reflect it, please contact
the Plan Office to help you get the prescription filled.)
5.
If neither criteria is met, your prescription will not be covered by the Plan until
you try an alternative drug for that ARB or the Cox-2 Inhibitor.
For an ARB, the pharmacist should call the Physician and explain that you are
required to try an alternative to the ARB drug, called an ACE Inhibitor, before the Plan
will cover a prescription for an ARB. Most ACE Inhibitors are available generically.
Generic alternatives include Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin
HCT, Monopril, Monopril HCT, Prinivil, Prinzide, Vasotec, Vasoretic, Zestril, and
Zestoretic. Generics can save you money-the use of a brand name drug may result in a
higher co-payment (see pages 10-11).
For a Cox-2 Inhibitor, the pharmacist should call the Physician and explain that
you are required to try an alternative to the Cox-2 Inhibitor drug, called an NSAID,
before the Plan will cover a prescription for the Cox-2 Inhibitor. Most NSAIDs are
available generically. Generic alternatives include: Anaprox, Anaprox DS, Ansaid,
Clinoril, Daypro, Feldene, Indocin, Indocin SR, Lodine, Meclofenamate, Motrin, and
Nalfon. Generics can save you money--the use of a brand name drug may result in a
higher co-payment (see pages 10-11).
If it is Medically Necessary for you to receive an ARB or a Cox-2 Inhibitor drug
without trying an alternative first, contact the Plan Office for the necessary form. After it
is completed, return it to the Plan Office. For questions, call the Pharmacy Network at
the number on the inside back cover.
If you have any questions or need further clarification of these benefits, contact
the Plan Office or the Pharmacy PPO at the number on the back cover.
Proton Pump Inhibitors
The Plan provides a higher level of coverage for omeprazole (know by the trade name
Prilosec). The co-pay for a one month supply is reduced from the normal level. In
addition, a 90-day supply of omeprazole is be available with the payment of two co-pays
rather than three. Other medications classified as proton pump inhibitors include
Nexium, Prevacid, Aciphex, Zegerid, Kapidex, Dexilant, pantoprazole, and lansoprazole.
Exclusions and Limitations. In addition to the General Exclusions and Limitations
beginning on page 49, no prescription drug expense benefits will be paid for:
1.
drugs which are legally obtainable without a prescription, except injectable
insulin (including premeasured syringes) or as required by law;
88
2.
therapeutic devices or appliances (including but not limited to hypodermic
needles, syringes, support garments, over-the-counter patent medicines and other
nonmedical substances) regardless of their intended use;
3.
any charge for the administration of a prescription legend drug or injectable
insulin;
4.
drugs labeled “Caution-limited by Federal law to investigational use,” or
Experimental drugs, even though a charge is made to the Participant or
Dependent, except as required by law;
5.
drugs and injectable insulin dispensed to a Participant or Dependent while
confined in a Hospital or Convalescent Facility;
6.
for Plan 1, contraceptives and contraceptive devices, except as required by law;
7.
health foods, vitamins, dietary supplements, appetite suppressants or smoking
cessation products, except as required by law;
8.
drugs or medicines for which a benefit is payable under any other section of this
Plan, except under the self-injectible benefit described above;
9.
drugs or medicines for or relating to treatment to restore fertility or to promote
conception, including, but not limited to, Pergonal; and
10.
for or relating to drugs to induce growth or growth hormones, except if Medically
Necessary. In such circumstance, the Plan will pay benefits but they will not
exceed 50% of the Usual and Customary Charge.;
11.
Lotronex, regardless of for whom prescribed;
12.
Self-injectable drugs which are not on the list approved by the Plan or when a
Participant or Dependent fails to comply with the guidelines and requirements
adopted by the Plan; and
13.
Cox-2 Inhibitors and ARBs for a Participant or Dependent who does not comply
with the Plan’s step therapy program for these prescription drugs.
14.
If Medicare is primary for a retired Participant or a Dependent of a retiree, no
prescription coverage is available.
89
HOSPITAL SELF-AUDIT PROGRAM
The Plan will pay a cash incentive to a Participant or Dependent for recovering
overcharges made by a Hospital.
Conditions and Limitations.
1.
The Plan will pay to the Participant or Dependent 50% of the actual amount of the
overcharge that the Hospital agrees is valid as a result of direct negotiations
between the Participant or Dependent and the Hospital, up to $500 per calendar
year. Hospital overcharges totaling less than $100 per Hospital confinement are
not eligible for the cash incentive.
2.
Only Hospital expenses that are covered under the Plan, not expenses such as
telephone bills, television rental, newspapers, etc., will be eligible for a cash
incentive.
3.
Proof of eligibility for a cash incentive must be submitted to the Plan Office in the
form of a copy of the initial itemized Hospital bill with the overcharges circled,
and a copy of the adjusted bill showing that the Hospital agreed to reduce its
billing. Such proof must be submitted to the Plan Office within 45 days following
the date of discharge from the Hospital. If the Plan has already paid the
overcharge, then the award is also conditioned on the Plan’s recovery of the
overpaid amount.
4.
Cash incentives will not be awarded if changes in a Hospital bill are initiated by
the Hospital.
5.
The Trustees reserve the right to modify or terminate this program at any time,
including retroactively, if necessary, to comply with applicable law.
90
COORDINATION OF BENEFITS
Coordination of Benefits with Other Plans
Because of the growing number of group health plans and the increasing number of twoincome families, more and more people are becoming covered under two group plans.
Under this coordination of benefits provision, if you or your eligible Dependents are
covered under two or more plans, the total benefits received by any one person from all
plans combined may not amount to more than 100% of the Allowable Expenses. You
must report such duplicate coverage on the claim forms you submit for reimbursement of
Allowable Expenses.
Definitions for this Provision.
1.
Plan. Any plan or program which provides health, prescription, dental, or vision
benefits or services, including:
(a)
group or blanket insurance coverage;
(b)
service benefits, whether through Blue Cross Blue Shield, group practice,
HMO or other prepayment coverage;
(c)
any coverage or program provided through a school or other educational
institution;
(d)
any coverage or governmental programs required or provided by statute
other than Medicare;
(e)
no-fault motor vehicle coverage; or
(f)
any other group coverage or program, whether on an insured or
self-funded basis.
Each policy, contract or other arrangement for benefits or services is considered a
separate Plan, and that portion of any such Plan which reserves the right to
consider other Plan benefits when determining its benefits will be considered as a
separate Plan from that portion which does not.
2.
Allowable Expense. Any necessary, Usual and Customary (U&C) charges which
are covered, wholly or partially, under this Plan.
3.
Benefits Payable. Benefits that would have been payable if a claim for them had
been made under any Plan. Benefits Payable does not include Allowable
Expenses which would have been covered by another Plan but which were not
covered because the covered person failed to take the actions required under the
Plan’s rules to qualify for benefits, unless the Working Spouse Rule applies.
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How it Works. The Benefits Payable under any other Plan will be taken into account in
determining the Benefits Payable for Allowable Expenses under this Plan. This Plan will
pay benefits in accordance with its provisions or will pay a reduced amount which, when
added to benefits provided under any other Plan, will reimburse up to 100% of the
Allowable Expenses.
Rules for Order of Benefit Determination. The following rules will be applied by this
Plan to establish the order of benefit determination for Benefits Payable:
1.
The Plan covering a person as an employee, as a laid-off employee or retired
employee will determine its benefits before a Plan covering that person as a
dependent. If a Dependent under this Plan has health care coverage available
under his Employer’s Plan, this Plan will pay second whether or not the
Dependent had elected coverage under his employer’s Plan, unless the spouse
elects and pays for coverage under the Plan’s Working Spouse benefit.
2.
The Plan covering a person as an active employee will determine its benefits
before a Plan covering that person as a laid-off employee or retired employee.
This rule also applies to the dependents of a person covered as both an active
employee and as a laid-off or retired employee.
3.
The Plan covering a person as an employee, member or subscriber or as the
dependent of such person will determine its benefits before a Plan covering that
person under a COBRA continuation coverage provision. This rule also applies if
the person is offered COBRA coverage but does not elect it.
4.
On claims involving dependent children of parents who are not separated or
divorced and who are both Participants who are Employees eligible for benefits
under this Plan, the Plan will determine its benefits using the “birthday rule.”
Under this rule, benefits will first be determined for the child under the coverage
of the Employee whose date of birth, excluding year of birth, occurs earlier in the
year and then under the coverage of the Employee whose date of birth, excluding
year of birth, occurs later in the calendar year. If the date is the same (excluding
year of birth), the plan that has covered the parent the longer period of time shall
determine its benefits before the plan that has covered the other parent the shorter
period of time.
5.
On claims involving dependent children of parents who are separated or divorced,
the order of benefit determination will be as follows:
(a)
if the parent with custody of the child has not remarried, the Plan covering
the child as a dependent of the parent with custody of the child will
determine its benefits before a Plan covering that child as a dependent of
the parent without custody; and
(b)
if the parent with custody of the child has remarried, the Plan covering the
child as a dependent of the parent with custody will determine its benefits
before a Plan covering the child as the dependent of the stepparent, and the
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Plan covering the child as a dependent of the stepparent will determine its
benefits before a Plan covering that child as a dependent of the parent
without custody.
However, if there is a court decree (such as a QMCSO, described on page 35)
which establishes financial responsibility for the medical, dental or other health
care expenses with respect to a dependent child, the Plan covering the child as a
dependent of the parent with such financial responsibility will pay its benefits
before any other plan which covers the child as a dependent child.
6.
When this Plan covers injuries in a motor vehicle accident and the Participant or
Dependent covered by this Plan is eligible for reimbursement under no-fault
motor vehicle coverage, the no-fault motor vehicle coverage will pay its benefits
before this Plan pays. If a Participant or Dependent is not eligible for
reimbursement as a result of failure to purchase no-fault motor vehicle coverage
when required, this Plan shall pay claims secondary to the extent benefits would
have been paid if the Participant or Dependent had purchased such no-fault motor
vehicle coverage.
7.
Where (1) benefits would have been available to the Participant or the Dependent
under another group health program or plan if the person had acted to qualify for
benefits at the time of the claim --such as going to an HMO or PPO provider,
using a utilization review service or enrolling in the employer’s group health
program or plan; (2) the Participant or the Dependent has not acted to qualify for
such benefits; and (3) where the Plan would pay second for the treatment
involving a Dependent child if such other coverage existed, then the coverage for
the parent whose date of birth, excluding year of birth, occurs earlier in the
calendar year shall be deemed primary to the coverage of the parent whose date of
birth, excluding year of birth, occurs later in the calendar year.
8.
If none of the rules above establish the order of benefit determination, the Plan
that has covered the person for the longer period of time will pay its benefits
before a Plan which has covered the person for the shorter period of time.
Coordination of Benefits with Noncomplying Plans. If it is determined that this Plan
should pay second under the rules for order of benefit determination but this Plan is
coordinating its benefits with a Plan that is unable or unwilling to pay benefits when due,
always pays second or uses different rules for order of benefit determination, this Plan
will pay its benefits first, but the amount of the Benefits Payable will be determined as if
this Plan were the secondary Plan. In such a situation, such payment by this Plan will be
the limit of this Plan’s liability. Additional rules may apply. Contact the Plan Office for
additional information.
Obtaining and Releasing Information. Without the consent of or notice to any person, the
Plan may obtain or release information with respect to any person when it considers it
necessary to do so to apply and implement this coordination of benefits provision (or a
provision of similar purpose under another Plan). Any person claiming benefits under
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this Plan is required to furnish this Plan with any such information which may be needed
for that purpose and is treated as having consented to the release of information.
Facility of Payment. Whenever it is determined that a payment which was made under
another Plan should have been made under this Plan, in accordance with this coordination
of benefits provision, the Plan will have the right (exercisable by it alone and at its sole
discretion) to pay to the organization making that payment any amount this Plan
determines is warranted to satisfy the intent of this provision. Any amount so paid will
be considered a benefit paid under this Plan and this Plan will be released from further
liability for that amount.
Right of Recovery. Whenever the payments made by this Plan for Allowable Expenses
are determined to be greater in total than the maximum amount of payment required to
satisfy the intent of this coordination of benefits provision at that time, this Plan will have
the right to recover the excess paid.
Offset. If payment is made by the Plan to a Participant or Dependent who is not entitled
to payment for whatever reason, the Plan has the right to reduce future payments due the
Participant or Dependent by the amount of the erroneous payment. This right of offset
does not limit the rights of the Plan to recover overpayments in any other manner.
Coordination with Medicare
Medicare (Title XVIII of the Social Security Act of 1965) provides a comprehensive
program of health insurance for persons age 65 or over and disabled persons under age
65.
In order to avoid duplicate payment of benefits, the Benefits Payable under this Plan for
Allowable Expenses will be coordinated with the Benefits Payable under Medicare for
the same expenses. “Allowable Expenses” under this provision will be the necessary,
Usual and Customary (U&C) charges as determined by Medicare which are covered
under both Medicare and this Plan.
Rules for Order of Benefit Determination. The following rules apply to establish the
order of benefit determination:
1.
If a Participant continues to work for a contributing Employer after attaining age
65 and becoming eligible for Medicare, the Participant and his eligible
Dependents are entitled to the same benefits as Employees under age 65 as long
as he meets the regular eligibility rules on pages 30 to 37. This Plan will pay first
and Medicare will pay second for Allowable Expenses.
2.
If a Participant is age 65 or older, is eligible for Medicare and is not actively
employed (retired), Medicare will pay first and this Plan will pay second for
Allowable Expenses.
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3.
If a Participant or eligible Dependent is entitled to Medicare for reasons other
than attaining age 65, federal law may require this Plan to pay first – for example,
for a Totally Disabled person. Contact the Plan Office for more information.
4.
Participants or eligible Dependents who become eligible for Medicare as an End
Stage Renal Disease (ESRD) beneficiary should contact the Plan Office to
determine if this Plan or Medicare will pay its benefits first. Generally this Plan
will be primary for the first 30 months of ESRD treatment. After the 30 month
period, regardless of your age, Medicare becomes primary and the Plan is
secondary. If a Participant is covered by Medicare, except as an ESRD
beneficiary, and by this Plan under the provisions of COBRA continuation
coverage, Medicare will pay first and this Plan will pay second for Allowable
Expense.
Participants and eligible Dependents are responsible for enrolling in Part A and Part B of
Medicare. If a Participant and his eligible Dependents fail to enroll, this Plan will
coordinate with Medicare benefits and if this Plan is determined to pay second, will
reduce its benefits regardless of whether the Participant and/or his eligible Dependents
have enrolled for Medicare benefits. At present, there is no cost for Part A, which
provides hospital benefits. Part B covers such items as doctors’ and nurses’ services.
There is a monthly charge for Part B.
If you or your spouse wants information about Medicare enrollment or about the
voluntary prescription drug program available through Medicare (Medicare Part D),
contact your local Social Security office (at least two months before your 65th birthday, if
possible, or two years after your disability benefits begin).
SUBROGATION AND REIMBURSEMENT
If a Participant or Dependent is injured in an accident or in any other manner where
someone else is liable, such as a car accident, that person (or his/her insurance) is
responsible for paying the Participant’s or Dependent’s medical and disability expenses
and these expenses would not be covered under the Plan. However, waiting for a third
party to pay for these injuries may be difficult. Recovery from a third party may take a
long time (the Participant or Dependent may have to go to court) and creditors may not
wait patiently. Because of this, as a service to Participants and Dependents, the Plan will
advance benefit payments based on the understanding that the Participant or the
Dependent is required to reimburse the Plan in full from any recovery received, no matter
how it is characterized. This process is called “subrogation.” The Plan may step into the
shoes of a Participant or Dependent, or the trustee, guardian or representative of a
Participant or Dependent or a Trust set aside for the benefit of a Participant or Dependent.
The Plan’s subrogation and reimbursement rights apply with regard to all rights of
recovery of a Participant or Dependent, or representatives, guardians, beneficiaries,
fiduciaries, trustees, estate representatives, heirs, executors, administrators of any special
needs trusts, and any other agents, persons or entities that may receive a benefit on behalf
of the Participant or Dependent (collectively, for purposes of this section, “Individual”) to
the extent of any amounts which the Plan has paid or may become obligated to pay on
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account of any claim against any person, organization or other entity in connection with
the Injury, Illness (Sickness), accident or condition, including accidental death or
dismemberment, to which the claim relates. The Plan's subrogation and reimbursement
rights apply on a priority, first-dollar basis to any recovery, whether by suit, settlement or
otherwise, whether a partial or full recovery and regardless whether the claimant is made
whole, from any source liable for making a payment related to the Injury, Illness
(Sickness), accident or condition to which the claim relates ("Source") regardless of
whether liability is admitted to or contested by any Source. A Source includes, but is not
limited to, a responsible party and/or a responsible party's insurer (or self-funded
protection), no fault protection, personal injury protection, medical reimbursement of
coverage, financial responsibility, uninsured motorist coverage, and underinsured
motorist coverage.
Participants or Dependents are required to notify the Plan within ten days of any accident
or Injury for which someone else and/or any Source may be liable or responsible.
Further, the Plan must be notified within ten days of the initiation of any lawsuit arising
out of the accident. The Participant or Dependent must immediately notify the Plan of
any settlement offer, judgment or payment relating to the accident.
If the Individual receives any benefit payments from the Plan for an Injury or Illness and
the Individual recovers any amount from any third party and/or Source in connection
with such Injury or Illness, the Individual must reimburse the Plan from that recovery the
total amount of all benefit payments the Plan made or will make on the Participant’s or
Dependent’s behalf in connection with such Injury or Illness. This is referred to as the
Plan’s right of reimbursement.
In addition, if the Individual receives any benefit payments from the Plan for an Injury or
Illness for which someone else may be liable, the Plan is subrogated to all rights of
recovery available arising out of any claim, demand, cause of action or right of recovery
which has accrued, may accrue or which is asserted in connection with such Injury or
Illness, to the extent of any and all related benefit payments made or to be made by the
Plan on the Participant’s or Dependent’s behalf. This means that the Plan has an
independent right to bring an action in connection with such Injury or Illness in the
Individual’s name and also has a right to intervene in any such action brought by the
Individual, including any action against an insurance carrier under any uninsured or
underinsured motor vehicle policy.
The Plan’s rights of reimbursement and subrogation apply regardless of the terms of the
claim, demand, right of recovery, cause of action, judgment, award, settlement,
compromise, insurance or order, regardless of whether the third party is found
responsible or liable for the Injury or Illness, regardless of whether the injured person has
been made whole, and regardless of whether the Individual actually obtains the full
amount of such judgment, award, settlement, compromise, insurance or order. The
Plan’s rights of reimbursement and subrogation provide the Plan with first priority to any
and all recovery from any Source in connection with the Injury and Illness with first
priority to any and all recovery in connection with the Source, whether such recovery is
full or partial and no matter how such recovery is characterized, why or by whom it is
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paid, or the type of expense for which it is specified. The Plan specifically disavows any
claims that an Individual may make under any federal or state common law defense,
including but not limited to the common fund doctrine, the double-recovery rule, the
make whole doctrine or any similar doctrine or theory, including the contractual defense
of unjust enrichment. Accordingly, the Plan’s subrogation and reimbursement rights
apply on a priority, first-dollar basis to any recovery of the Individual from any Source
without regard to legal fees and expenses of the Individual and the Individual will be
solely responsible for paying all legal fees and expenses. The Plan shall have a priority,
first dollar security interest and a lien on any recovery received from any Source, whether
by suit, settlement or otherwise, whether there is a full or partial recovery and regardless
of whether the amounts are characterized or described as payment for medical expenses
or as amounts other than for medical expenses of such injury, sickness, accident or
condition and regardless of whether liability is admitted to or contested by any Source.
The Plan’s rights of reimbursement and subrogation are for the full amount of all related
benefits payments. This amount is not offset by legal costs, attorneys’ fees or other
expenses incurred by the Individual in obtaining recovery. The Plan has an equitable
interest and lien on any amount received by the Participant or Dependent (or their
representatives) that is due to the Plan under this provision. Any amount received by you
or your representative that is due to the Plan under this provision will be considered to be
held in trust by you or your representative for the benefit of the Plan. The Plan’s
equitable lien by agreement imposes a constructive trust upon the assets received as a
result of a recovery by the Individual, as opposed to the general assets of the Individual,
and enforcement of the equitable lien by agreement does not require that any of these
particular assets received or identifiable amounts be traced to a specific account or other
destination after they are received by the Individual.
If the injured person can no longer care for himself or herself, the Plan’s rights apply to a
special needs trust set up for the benefit of that person, and the appointed representative
of the trust must comply with the Plan’s rules to the same extent as the injured person.
This includes special needs trusts which include funds recovered from another party or
any Source.
Consistent with the Plan’s rights set forth in this section, if the Participant or Dependent
submit claims for or receive any benefit payments from the Plan for an Injury or Illness
that may give rise to any claim against any third party and/or Source, the Participant or
Dependent will be required to execute a Subrogation, Assignment of Rights, and
Reimbursement Agreement (“Subrogation Agreement”) affirming the Plan’s rights of
reimbursement and subrogation with respect to such benefit payments and claims. This
Subrogation Agreement must also be executed by the Participant’s or Dependent’s
attorney, if applicable. If a Participant or Dependent had not retained an attorney at the
time the Subrogation Agreement was signed, the Participant or Dependent must notify
the Plan within 10 days of retaining an attorney.
Because benefit payments are not payable unless the Participant or Dependent signs a
Subrogation Agreement, the Participant’s or Dependent’s claims will not be considered
filed and will not be paid until the fully signed Subrogation Agreement that has not been
modified in any way without consent of the Plan is received by the Plan. This means
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that, if the Participant or Dependent file a claim and the Subrogation Agreement is not
received promptly, the claim will be untimely and will not be paid if the time period for
filing claims passes before the Subrogation Agreement is received. However, in its sole
discretion, if the Plan advances claims in the absence of a Subrogation Agreement, or if
the Plan advances claims in error, said payments will not waive, compromise, diminish,
release, or otherwise prejudice any of the Plan’s rights to reimbursement or subrogation.
If the Individual is a minor or incompetent to execute the Subrogation Agreement, that
person’s parent, the Individual (in the case of a minor dependent child), the Individual’s
spouse, or legal representative (in the case of an incompetent adult) must execute the
Subrogation Agreement upon request of the Plan. An Individual must comply with all
terms of the Subrogation Agreement, including the establishment of a trust for the benefit
of the Plan. In this regard, the Individual agrees that out of any Source, the identified
amount that the Plan has advanced or is obligated to advance in benefits will be
immediately deposited into a trust for the Plan’s benefit and the Plan shall have an
equitable lien by agreement which shall be enforceable under legal, equitable and/or
injunctive action to ensure that these amounts are preserved and not disbursed. The
Plan’s subrogation and reimbursement rights shall apply regardless whether the
Individual executes a Subrogation Agreement.
Under this provision, the Individual is obligated to take all necessary action and
cooperate fully with the Plan in its exercise of its rights of reimbursement and
subrogation, including notifying the Plan of the status of any claim or legal action
asserted against any party or insurance carrier and of the Participant’s or Dependent’s
receipt of any recovery. The Individual also must do nothing to impair or prejudice the
Plan’s rights. For example, if the Individual chooses not to pursue the liability of a third
party, or potential reimbursement from any Source, the Individual may not waive any
rights covering any conditions under which any recovery could be received. If the
Individual is asked to do so, they must contact the Plan Office immediately.
If the Individual refuses to reimburse the Plan from any recovery or refuses to cooperate
with the Plan regarding its subrogation or reimbursement rights, the Plan has the right to
recover the full amount of all benefits paid for that Injury or Illness by methods which
include, but are not necessarily limited to, offsetting the amounts paid against future
benefit payments under the Plan to a Participant or any eligible Dependent as well as
pursuing legal and equitable claims. “Non-cooperation” includes the failure of any party
to execute a Subrogation Agreement and the failure of any party to respond to the Plan’s
inquiries concerning the status of any claim or any other inquiry relating to the Plan’s
rights of reimbursement and subrogation, and the failure or refusal to provide the Plan
with its portion of any recovery.
The Trustees of the Plan may waive the above right to subrogation and reimbursement if
they determine that doing so is in the best interest of the Plan and its participants.
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GENERAL PLAN INFORMATION
Plan Administration
Name of the Plan. United Food and Commercial Workers Local 400 and Employers
Health and Welfare Plan.
Type of Plan. This Plan is a multiemployer health and welfare plan maintained for the
purpose of providing medical, dental, vision care, prescription drug and death benefits.
Board of Trustees.
1.
2.
Members. A Board of Trustees is responsible for the operation of the Plan. The
Board of Trustees consists of an equal number of Employer and employee
representatives, selected by the Employers and the Union(s) which have entered
into collective bargaining agreements that relate to the Plan. The Trustees of the
Plan are:
UNION TRUSTEES
EMPLOYER TRUSTEES
Mark Federici
United Food and Commercial
Workers Local 400
4301 Garden City Drive
Landover, MD 20785
Steve Loeffler
The Kroger Co.
4111 Executive Parkway
Westerville, OH 43081
James Slivosky
United Food and Commercial
Workers Local 400
4301 Garden City Drive
Landover, MD 20785
Michael Christle
The Kroger Co.
P.O. Box 14002
Roanoke, VA 24038
Charles Miller, Alternate
United Food and Commercial
Workers Local 400
4301 Garden City Drive
Landover, MD 20785
Steven Springer, Alternate
The Kroger Co.
P.O. Box 14002
Roanoke, VA 24038
Address and Telephone Number. If you wish to contact the Board of Trustees,
you may use the address and telephone number below:
600 D Street, Suite 250
South Charleston, WV 25303 (304) 343-7682
A complete list of the employers and employee organizations sponsoring the Plan
may be examined at this address. A Plan Participant or beneficiary may obtain a
copy of this list for a reasonable charge by writing to the Trustees at this address.
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In addition, upon written request to the Trustees at this address, a Plan Participant
or beneficiary may obtain information as to whether a particular Employer or
employee organization is a sponsor, and the Trustees will furnish the sponsor’s
address to the Participant or the beneficiary.
Plan Administrator. The name, address and telephone number of the Plan Administrator
is:
Board of Trustees
United Food and Commercial Workers Local 400
and Employers Health and Welfare Plan
600 D Street, Suite 250
South Charleston, WV 25303
(304) 343-7682
Plan Office.
United Food and Commercial Workers Local 400
and Employers Health and Welfare Plan
600 D Street, Suite 250
South Charleston, WV 25303 (304) 343-7682
The Plan Office has been designated as the Plan’s Agent for service of legal process.
Accordingly, if legal disputes involving the Plan arise, any legal document should be
served upon the Plan at the Plan Office.
In addition, service of legal process may be made upon any member of the Board of
Trustees at the address of the Plan Office listed above.
Statute of Limitations and Forum for Disputes. If you wish to file suit for a denial of a
claim of benefits, you must do so within five years of the date the Trustees denied your
appeal. For all other actions, you must file suit within five years of the date on which the
violation of Plan terms is alleged to have occurred. Additionally, if you wish to file suit
against the Plan or the Trustees, you must file suit in a federal district court in the state of
West Virginia. These rules apply to you, your spouse, dependent, or beneficiary, and any
provider who provided services to you or your spouse, dependent or beneficiary. This
Section applies to all litigation against the Plan, including litigation in which the Plan is
named as a third party defendant.
Identification Numbers. The Employer Identification Number assigned by the Internal
Revenue Service to the Board of Trustees is 55-0393244. The Plan number assigned by
the Board of Trustees is 501.
Plan Year. For purposes of maintaining the Plan’s records, the fiscal year of the Plan
begins on February 1st of each year and ends on January 31st of the next year.
Collective Bargaining Agreements. This Plan is maintained pursuant to one or more
collective bargaining agreements. Plan Participants and beneficiaries may examine these
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collective bargaining agreements at the Plan Office address listed above and may obtain a
copy of any such agreement for a reasonable charge by writing to the Board of Trustees
at this address.
Financial Information
Funding Medium. Most of the benefits that are described in this Summary Plan
Description are provided from the Plan’s assets that are accumulated under the provisions
of the collective bargaining agreements and the Trust Agreement and held in a Trust
Fund for the purpose of providing benefits to covered participants and defraying
reasonable administrative expenses.
Major Medical, Basic, Dental, and Vision Benefits are provided directly by the Plan. For
Kroger Employees, the Prescription Drug benefit for Plan 1 is funded directly by the
employer and is administered by KPP. For Plan 1 Employees employed by other
Employers and all Retirees, the Prescription Drug Benefit is funded directly by the Plan
and is administered by the Plan Office. The Plan has entered into an insurance contract
for Life Insurance and Accidental Death and Dismemberment Benefits with Hartford Life
and Accident Insurance Company. The complete terms of the Plan’s Rules and
Regulations (Plan Document) and copies of the Insurance Contracts are available for
review, upon request at the Plan Office.
Type of Administration. The administrative operations of the Plan are handled by the
Plan Office employees. For Kroger Employees, the Prescription Drug Benefit for Plan 1
is administered by KPP. For Plan 1 Employees employed by other Employers and all
Retirees without Medicare, the Prescription Drug Benefit is administered by the Plan
Office.
Contribution Source. Contributions to the Plan are made by Employers in accordance
with collective bargaining agreements between the Union and Employer and, in some
instances, by direct Employee payments. The amount of the Employer contributions is
determined by the provisions of the collective bargaining agreements.
Plan Information
Eligibility. The Plan’s requirements with respect to eligibility as well as circumstances
that may result in disqualification, ineligibility, or denial or loss of any benefits are fully
described on pages 30 through 37 of this booklet.
Rights and Protections Under the Employee Retirement Income Security Act of 1974. As
a participant in the United Food and Commercial Workers Local 400 and Employers
Health and Welfare Plan, you are entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all
Plan Participants shall be entitled to:
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Receive Information about the Plan and Benefits
1.
Examine, without charge, at the Plan administrative office and at other specified
locations, such as worksites and union halls, all documents governing the Plan,
including insurance contracts and collective bargaining agreements, and a copy of
the latest annual report (Form 5500 series) filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the
Employee Benefits Security Administration.
2.
Obtain, upon written request to the Plan Administrator, copies of documents
governing the operation of the Plan, including insurance contracts and collective
bargaining agreements, and copies of the latest annual report (Form 5500 series)
and updated summary plan description. The Plan Administrator may make a
reasonable charge for such copies.
3.
Receive a summary of the Plan’s annual financial report. The Plan Administrator
is required by law to furnish each participant with a copy of the summary annual
report.
4.
Continue Group Health Plan Coverage. You may continue health care coverage
for yourself, spouse or dependents if there is a loss of coverage under the plan as a
result of a qualifying event. You and your dependents may have to pay for such
coverage. Review this summary plan description and the documents governing
the Plan on the rules governing your COBRA continuation coverage rights.
There can be a reduction or elimination of exclusionary periods of coverage for
preexisting conditions under your group health plan, if you have creditable coverage from
another plan. You should be provided a certificate of creditable coverage, free of charge,
from your group health plan or health insurance insurer when you lose coverage under
the Plan, when you become entitled to elect COBRA continuation coverage, when your
COBRA continuation coverage ceases, if you request it before losing coverage, or if you
request it up to 24 months after losing coverage. Without evidence of creditable
coverage, you may be subject to a preexisting condition exclusion for 12 months (18
months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan Participants, ERISA imposes duties upon the people
who are responsible for the operation of the employee benefit plan. The people who
operate the Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in
the interest of you and other Plan Participants and beneficiaries. No one, including your
Employer, your union or any other person, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining welfare benefits under the Plan or
exercising your rights under ERISA.
Enforce Your Rights. If your claim for welfare benefits is denied in whole or in part, you
have a right to know why this was done, to obtain copies of documents relating to the
decision without charge and to appeal any denial, all within certain time schedules.
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Under ERISA, there are steps you can take to enforce the rights listed above. For
instance, if you request a copy of Plan documents or the latest annual report from the
Plan and do not receive them within 30 days, you may file suit in a federal court in
accordance with the Statute of Limitations and Forum Selection provision on page 100.
In such a case, the court may require the Plan Administrator to provide the materials and
pay you up to $110 a day until you receive the materials, unless the materials were not
sent because of reasons beyond the control of the Plan Administrator. If you have a
claim for benefits that is denied or ignored, in whole or in part, you may file suit under
ERISA 502(a), in accordance with the Statute of Limitations and Forum Selection
provision. In addition, if you disagree with the Plan’s decision or lack thereof concerning
the qualified status of a medical child support order, you may file suit in federal court in
accordance with the Statute of Limitations and Forum Selection provision. If it should
happen that the Plan fiduciaries misuse the Plan’s money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a federal court in accordance with the Statute of
Limitations and Forum Selection provision. The court will decide who should pay court
costs and legal fees. If you are successful, the court may order the person you have sued
to pay these costs and fees. If you lose, the court may order you to pay these costs and
fees, for example, if it finds your claim is frivolous.
Assistance with your Questions. If you have any questions about the Plan, you should
contact the Plan Administrator. If you have any questions about this statement or about
your rights under ERISA, or if you need assistance in obtaining documents from the Plan
Administrator, you should contact the nearest office of the Employee Benefits Security
Administration, U.S. Department of Labor, listed in your telephone directory or the
Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue, NW, Washington,
DC 20210. You may also obtain certain publications about your rights and
responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
HIPAA CERTIFICATES OF CREDITABLE COVERAGE FROM THIS PLAN
In certain circumstances, federal law requires that the Plan provide you and your
Dependent(s) with evidence of your coverage under the Plan for use as proof of prior
coverage when beginning coverage under another health plan. Accordingly, the Plan will
provide a Certificate of Creditable Coverage to you and your Dependent(s) within a
reasonable time after the occurrence of any of the following events:
1.
loss of coverage under the Plan in the absence of COBRA Continuation
Coverage;
2.
loss of coverage under the Plan;
3.
loss of COBRA Continuation Coverage;
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4.
upon written request within the first two (2) years of the loss of coverage under
the Plan.
The Certificate of Creditable Coverage may be necessary or reduce any exclusion for preexisting conditions that may apply to you or your Dependents under a new group health
plan or health insurance policy and will indicate the period of coverage under this Plan
and certain additional information that is required by law. The Certificate of Creditable
Coverage will be sent to you or your Dependents by first class mail. To request a
Certificate, write to the Plan Office. If you request a Certificate, the Plan will send it
within a reasonable and prompt period of time. You can request a free copy of the Plan’s
procedure for requesting a HIPAA Certificate of Creditable Coverage from the Plan
Office.
CLAIMS FILING AND APPEAL PROCEDURE
To make a claim for benefits under this Plan, follow these instructions. The Plan Office
must have a recent Enrollment Form on file. Forms are available from the Plan Office.
Medical Benefit Claims
Initial Claim for Medical Benefits. All medical claims, other than Dental and Vision,
should be submitted electronically by your provider to the Local Blue Cross Blue
Shield. Make sure you present your current Blue Cross Blue Shield card with
Identification and Group numbers to your provider. For Dental and Vision
claims, you must follow the following procedure:
(a)
Dental.
A.
B.
C.
(b)
Provider submits paper claim to the Plan Office.
Provider submits any x-rays or doctor notes needed for processing
of claim.
Dental claims must be mailed to the Plan Office at 600 D Street,
Suite 250, South Charleston, WV 25303.
Vision.
A.
B.
C.
Provider submits paper claim to the Plan Office.
Insured must submit all receipts and bills to the Plan Office if the
provider does not bill.
Vision claims must be mailed to the Plan Office at 600 D Street,
Suite 250, South Charleston, WV 25303.
All Medical, Dental and Vision claims should be submitted as soon as possible
after the date of service, and no later than the last day of the calendar year after
the year of the date of service.
Remember that your claim cannot be paid until all of the information needed to
process the claim is given to the Plan Office. This includes the Enrollment Form,
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which you must complete annually, and which must also be on file at the Plan
Office.
Initial Prescription Drug Claims. To receive benefits under the Prescription Drug
Expense Benefit, you must present your prescription ID Card at the time your
prescription is filled.
(a)
Covered Employees and Eligible Dependents Employed by the Kroger
Company: Your prescription drug benefit is administered by the Kroger
Prescription Plans (KPP). You should contact KPP at the number on the
inside back cover with any questions about a prescription drug claim or if
you lose your prescription ID Card.
(b)
Covered Employees and Eligible Dependents Employed By Other
Employers: Contact KPP if you lose your prescription ID Card. If you
are filing a paper claim, it must be submitted to the Plan Office within
three months of the date the prescription is filled at a pharmacy. Submit
prescription receipt along with cash register receipts, tapes or computer
printouts for all drugs purchased and attach them to the claim form.
(c)
Retirees and Eligible Dependents Not Eligible for Medicare: Contact KPP
if you lose your prescription ID Card. If you are filing a paper claim, it
must be submitted to the Plan Office within three months of the date the
prescription is filled at a pharmacy. Complete the Statement of
Prescription Drug Charges Licensed Pharmacist’s Statement (available
from the Plan Office) with cash register receipts, tapes or computer
printouts for all drugs purchased and attach them to the claim form.
Medical Benefit Review and Appeal Procedure
The Plan and Board of Trustees, in making decisions on claims and on appeal,
will apply the terms of the Plan and any applicable guidelines, rules, and
schedules, and will periodically verify that benefit determinations are made in
accordance with such documents, and where appropriate, applied consistently
with respect to similarly situated claimants. Additionally, the Plan and
Trustees will take into account all information you submit in making decisions
on claims and on appeal.
You may name a representative to act on your behalf. To do so, you must
notify the Plan in writing of the representative’s name, address and telephone
number.
(1)
Claim Denial. The length of time required to process the claim
depends upon the type of claim. A claim can fall into one of the
following categories:
1. Pre-service claim – A Pre-service claim is one that requires preapproval before services are performed under the terms of the Plan
105
of benefits. The requirements for preauthorization or preapproval
are described elsewhere in the Summary Plan Description. Your
Pre-service claims will be decided within 15 days of receipt by
InforMed. If InforMed determines that an extension of this time is
necessary, the claim will be decided within 30 days of receipt
(unless the period is tolled while InforMed waits for information it
requested from you). You will be notified of the need for an
extension within 15 days of receipt of the claim and the reasons
why the extension is needed.
If InforMed needs more information from you to process the
claim, you will have 45 days to provide the needed information to
InforMed. If you do not provide the information requested,
InforMed will have to decide the claim on the information it has,
and your claim may be denied. InforMed will issue its decision
within 15 days of the earlier of your submission of the requested
information or the end of the 45-day period.
If your claim is filed improperly, you will be notified within five
days of filing the deficient claim and told how to correct it.
Urgent Care claim – An Urgent Care claim is a
pre-service claim that must be processed quickly to prevent
serious jeopardy to you or your Dependent’s life or health.
Urgent Care claims also include those claims that, in the
opinion of your doctor, would subject you to severe pain
that cannot be managed without the care or treatment
requested under the claim. Your Urgent Care claims will
be processed within 72 hours after receipt by InforMed.
If InforMed needs more information from you to process
the claim, you will have 48 hours to provide the necessary
information. InforMed then has 48 hours to decide the
claim after receiving this information. An Urgent Care
claim to extend Concurrent Care (described below) will be
decided within 24 hours (if you make the claim at least
24 hours before treatment expires).
If your Urgent Care claim is filed improperly, then you will
be notified by telephone, told how to correct it and given a
chance to correct it within 24 hours. If you do not provide
the information requested, or do not properly refile the
claim, InforMed will have to decide the claim on the
information it has, and your claim may be denied. Due to
the nature of an Urgent Care claim, you may be notified of
a decision via telephone. This will be followed by a
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written notice of the same information within three days of
the oral notice.
2. Post-service claim – A Post-service claim is any other type of
claim under the Plan, such as a payment for covered services after
a doctor visit and whenever you have already received the
treatment or supply for which payment is now being requested.
You will be notified if your claim is denied within 30 days after
receipt of the claim by InforMed. If InforMed determines that an
extension of this time is necessary to decide the claim, the claim
will be decided within 45 days of receipt (unless the period is
tolled while InforMed waits for information it requested from you).
You will be notified of the need for an extension within 30 days of
receipt of the claim and the reasons why the extension is needed.
3. Concurrent Care claim – A Concurrent Care claim is one for
which the Plan is requested to approve, or has already approved
and is requested to extend such approval, for coverage of an
ongoing course of treatment to be provided over a period of time or
a certain number of treatments. If the Plan determines that course
of treatment will be stopped or reduced before the previously
approved number of treatments or period of time expires, you will
be notified within a sufficient amount of time to allow an appeal
before the Plan stops or reduces coverage for the ongoing
treatment. If you request that a Concurrent Care treatment be
extended beyond the initially determined time, your claim will be
decided no later than 24 hours after your claim is received by the
Plan (if you make the claim at least 24 hours before the period or
number of treatments expires).
(2)
Notice of Claim Denial. If all or part of your claim is denied, you
will receive a written explanation that describes information sufficient
to identify the claim involved, the specific reason for the denial, the
specific provisions of the Plan document on which the decision was
based, any additional information necessary to reconsider your claim
(and the reasons why that information is necessary), the Plan’s appeal
procedures and the time limits for use of those procedures and
explaining the initial decision is final unless the decision is appealed
according to the appeal procedures. The explanation will also advise
you of your right to bring an action under ERISA if you decide to
appeal and that appeal is denied, or, for certain health claims only, to
request an external review with an independent review organization.
If the Plan relied on an internal rule, guideline or protocol in making
the decision, you will receive either a copy of the rule, etc., or a
107
statement that it was relied upon and is available upon request and free
of charge. Additionally, if the Plan based its decision on medical
necessity, experimental treatment or a similar exclusion or limit, you
will receive either an explanation of the scientific or clinical judgment
related to your condition or a statement that such an explanation is
available upon request and free of charge. If the Plan received the
advice of any medical or vocational expert with respect to your claim,
the Plan will identify the expert upon your request.
(3)
Appeal Procedure. If your claim is not an Urgent Care claim and is
denied, you (or your authorized representative) may, within 180 days
from receipt of the denial, request a review by writing to the Board of
Trustees. If you are appealing an Urgent Care claim denial, you may
do so orally by calling the Plan Office at the number on the Inside
Back Cover or in writing. Your written appeal should state the reason
for your appeal. You (or your authorized representative) may receive,
upon request and free of charge, reasonable access to and copies of
any documents relevant to your claim and may submit issues and
comments in writing. You (or your authorized representative) will
also receive copies of all new or additional information considered,
relied upon or generated during the appeal as well as any new or
additional rationale for the denial, if any.
The Board of Trustees will determine all requests for review for claims
that were denied on the basis of the Plan’s eligibility rules.
If the Trustees review your appeal, the amount of time the Trustees
have to issue a decision after receiving your appeal will depend on the
type of claim.
1. Pre-service claims – Appeals of Pre-service claims will be
decided within 30 days after the Trustees or its authorized
Committee receive the appeal.
Urgent Care claims – Appeals of Urgent Care claims will
be decided within 72 hours after the Trustees or its
authorized Committee receives the appeal. You may
appeal denials of Urgent Care claims either orally by
calling the Plan Office at 1-304-343-7682 or in writing.
All information necessary to decide the appeal may be
transmitted via telephone, facsimile or other available
method.
2. Post-service claims – Appeals of Post-service claims will be
decided at the next quarterly meeting of the Trustees or its
authorized Committee immediately following the receipt of your
appeal unless your appeal was received by the Trustees within
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30 days of the date of the meeting. In this case, your appeal will
be reviewed at the second quarterly meeting following receipt of
the appeal. If special circumstances require an extension of the
time for review by the Trustees, you will receive a decision no
later than the third quarterly meeting, and you will be notified in
writing of the need for the extension, why the extension is needed,
and when a decision is expected. The Trustees will send you a
notice of this decision within 5 days of the decision.
3. Concurrent Care claims – Appeals of Concurrent Care claims are
governed by the provisions above for Urgent Care, Pre-service or
Post-service claims, whichever applies to the particular claim.
(4)
Notice of Appeal Denial. If all or part of your claim is denied on
appeal, you will receive a written explanation that describes
information sufficient to identify the claim involved, the specific
reason for the denial, a discussion of the decision, the specific
provisions of the Plan document on which the decision was based, any
additional information necessary to reconsider your claim (and why
that information is necessary), notice that you may receive on request
access to and free copies of documents and records relevant to your
claim, and a statement of your right to bring a lawsuit under ERISA,
or, for certain health claims, to request an external review from an
independent review organization.
If the Trustees relied on an internal rule, guideline or protocol in
making the decision, you will receive either a copy of the rule,
guideline or protocol, or a statement that it was relied upon and is
available upon request and free of charge. If the Trustees based their
decision on a medical claim on medical necessity, experimental
treatment or a similar exclusion or limit, you will receive either an
explanation of the scientific or clinical judgment related to your
condition or a statement that such an explanation is available upon
request and free of charge. If the initial decision on a medical claim
was based in whole or in part on a medical judgment, the Trustees will
consult with a health care professional in the appropriate field who
was not consulted in the initial determination (but not a subordinate of
such person). In reviewing a denied medical claim, the Trustees will
not automatically presume that the Plan’s initial decision was correct.
Rather, the medical claim will be reviewed independently based on all
information you provided to the Trustees, including any new
information that you provide that was not reviewed during the Plan’s
initial decision.
If your claim is denied, in whole or in part, you are not required to
appeal the decision to the Board of Trustees. However, it is important
to note that you must exhaust your administrative remedies by
109
appealing the denial of your claim for benefits to the Board of Trustees
before you have the right to file suit under Section 502(a) of ERISA in
accordance with the Statute of Limitations and Forum Selection
provision on page 100. Failure to exhaust these administrative
remedies will result in the loss of your right to file suit, as described in
the ERISA Rights statement in the SPD. The Board of Trustees’
decision will be final and binding on all individuals dealing with or
claiming a benefit from the Plan.
(5)
External Review of a Denied Health Claim. The Plan offers
claimants covered by Plan 1 the right to request an external review of
their denied health claim. The Plan will offer this right in accordance
with and to the extent required by federal law. Only health claims that
have been denied for medical judgment or rescission of coverage are
eligible for external review. Disability and all other benefit claims are
not eligible for external review. If a claimant wants to have the denied
health claim reviewed, the claimant must send a written request for an
external review of the claim denial to the Plan no later than four
months after the date the claimant receives the notice of denial. Any
claimant filing a timely request for review may submit additional
materials for consideration on review, including a written explanation
of and comments on the issues. Participants covered by Plans S and V
may not request an external review of a denied health claim.
Life Insurance Benefit Claims and
Accidental Death, Dismemberment and
Loss of Sight Benefit Claims
(1)
Claim Denial. Claims for benefits should first be submitted to The Hartford. For
claims filed on or after January 1, 2002, if a claim for benefits is denied, in whole or in
part (or benefits reduced or terminated), the claimant will receive a written explanation of
the reason(s) it was denied within 90 days after the claim has been received by The
Hartford. If additional time (up to 90 days) is required because of special circumstances,
the claimant will be notified in writing of the reason for the delay, and the date that The
Hartford expects to issue a final decision. A decision will be made with respect to the
claim no more than 180 days from the date the claim is first filed with The Hartford.
If the claim is denied, the claimant will receive a written explanation that describes the
specific reason for the denial, the specific provisions of the plan document on which the
decision was based, any additional information necessary to reconsider the claim, The
Hartford’s appeal procedures, and also the claimant’s right to bring an action under
ERISA if the claimant decides to appeal and that appeal is denied.
(2)
Appeal Procedure. The claimant can appeal the claim denial directly to The
Hartford. If the claimant decides to appeal within 60 days after the claimant receives
written notice that the claim has been denied the claimant must send a request for review
(appeal) to:
110
The Hartford
Employee Benefits Division
The Falls
125 Sanctuary Parkway, Suite 450
Alpharetta, GA 30004
The claimant must include in the written appeal all the facts regarding the claim as well
as the reason(s) the claimant feels the denial was incorrect. The claimant will receive, if
requested, reasonable access to and free copies of documents relevant to the claim. The
claimant may submit issues and comments in writing, and documents, relating to the
claim.
The claimant may name a representative to act on his behalf. To do so, the claimant must
notify The Hartford in writing of the representative’s name, address, and telephone
number. The claimant may, at his own expense, have legal representation at any stage of
these review procedures. Regardless of the outcome of the appeal, neither The Hartford
nor the Plan will be responsible for paying any legal expenses incurred during the course
of the appeal. The Hartford, in making its decisions on claims and on appeal, will apply
the terms of the Plan’s document and any applicable guidelines, rules and schedules, and
will periodically verify that benefit determinations are made in accordance with such
documents, and where appropriate, applied consistently with respect to similarly situated
claimants.
The Hartford will take into account all information the claimant submits in making its
decision. The Hartford will make a decision as to the claim within 60 days after receipt
of the request for review. If there are special circumstances requiring delay, the claimant
will be notified of the final decision no later than 120 days after the request for review is
received. The claimant will receive written notice of the decision explaining the basis for
upholding or for modifying the original disposition of the claim. The decision of The
Hartford is final and binding.
Disability Benefit Claims and
Retiree Death Benefit Claims
All claims by Participants and Beneficiaries for benefits under the Plan shall be filed in
writing on forms provided by the Trustees. If a claim for benefits is denied, in whole or
in part (or benefits are reduced or terminated), the claimant will receive a written
explanation of the reason(s) it was denied, within 90 days after the claim has been
received by the Plan Office. If additional time of up to 90 days is required because of
special circumstances, the claimant will be notified in writing of the reason for the delay,
and the date that the Plan expects to issue a final decision. A decision will be made with
respect to the claim no more than 180 days from the date the claim is first filed with the
Plan Office.
If the claim is denied, the claimant will receive a written explanation that describes the
specific reason for the denial, the specific provisions of the plan document on which the
decision was based, any additional information necessary to reconsider the claim, the
111
Plan’s appeal procedures, and also the right to bring an action under ERISA if the
claimant decides to appeal and that appeal is denied.
The claimant can appeal the claim denial directly to the Board of Trustees. If the
claimant decides to appeal, he must make written request for a review within 60 days
after he received written notice the claim has been denied. The claimant must send his
request for review (appeal) to:
Board of Trustees
United Food and Commercial Workers
Local 400 and Employers Health and Welfare Plan
600 D Street, Suite 250
South Charleston, WV 25303
The claimant must include in his written appeal all the facts regarding the claim as well
as the reason(s) the claimant feels the denial was incorrect. The claimant will receive, if
requested, reasonable access to and copies of documents relevant to the claim at no
charge. The claimant may submit issues and comments in writing, and documents,
relating to the claim.
The claimant may name a representative to act on his behalf. To do so, the claimant must
notify the Plan in writing of the representative’s name, address, and telephone number.
The claimant may, at his own expense, have legal representation at any stage of these
review procedures. Regardless of the outcome of the appeal, neither the Board of
Trustees nor the Plan will be responsible for paying any legal expenses that the claimant
incurs during the course of the appeal.
The Board of Trustees or its authorized Committee will take into account all information
submitted in making its decision. The Board of Trustees or its authorized Committee will
review the appeal at the next regular meeting following receipt of the appeal. However,
if the claimant submits the appeal less than 30 days before the next scheduled meeting, it
will be reviewed at the next following meeting. If special circumstances require a further
extension of time, a determination will be made no later than the third Board of Trustees
meeting following the date the Plan Office receives the appeal. If the Board of Trustees
requires a postponement of the decision to the next meeting, the claimant will be sent a
notice describing the reason for the delay and an expected date of the decision.
The Plan will notify you in writing of the Trustees’ decision within 5 days after a
decision is made. If the appeal is denied, you have the right to bring a civil action under
ERISA section 502(a) in accordance with the Statute of Limitations and Forum Selection
provision on page 100. The decision of the Board of Trustees is final and binding.
Review of Plan Documents
You may examine the following documents at the Plan Office during regular business
hours, Monday through Friday, except holidays:
1.
Trust Agreement and all Amendments,
112
2.
Collective Bargaining Agreements(s),
3.
Plan Document, or Rules and Regulations, and all Amendments,
4.
Current Summary Plan Description and subsequent Summary of Material
Modifications,
5.
The latest Form 5500 or full Annual Report filed with the Internal Revenue
Service and Department of Labor.
You may also obtain copies of the documents by writing for them and paying the
reasonable cost of duplication. You should find out what the charges will be before
requesting copies. If you prefer, you can arrange to examine the documents during
business hours at your union office or at your Employer’s establishment, if at least
50 plan Participants are employed there. To make such arrangements, call or write the
Administrator at the Plan Office. A summary of the annual report which gives details of
the financial information about the Plan’s operations is furnished free of charge to all
participants.
113
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective Date of Notice
September 23, 2013
The United Food and Commercial Workers Local 400 and Employers
Health and Welfare Fund (the “Plan”) is required by law to take reasonable steps
to ensure the privacy of your personally identifiable health information and to
inform you about:
1.
the Plan’s uses and disclosures of Protected Health Information
(PHI);
2.
your privacy rights with respect to your PHI;
3.
the Plan’s duties with respect to your PHI;
4.
your right to file a complaint with the Plan and to the Secretary of
the U.S. Department of Health and Human Services; and
5.
the person or office to contact for further information about the
Plan’s privacy practices.
The term “Protected Health Information” (PHI) includes all individually
identifiable health information transmitted or maintained by the Plan, regardless of
form (oral, written, electronic).
Section 1.
Notice of PHI Uses and Disclosures
Required PHI Uses and Disclosures
Upon your request, the Plan is required to give you access to your PHI in
order to inspect and copy it.
Use and disclosure of your PHI may be required by the Secretary of the
Department of Health and Human Services to investigate or determine the Plan’s
compliance with the privacy regulations.
Uses and disclosures to carry out treatment, payment and health care operations.
114
The Plan and its business associates will use PHI without your
authorization to carry out treatment, payment and health care operations. The Plan
and its business associates (and any health insurers providing benefits to Plan
participants) may also disclose the following to the Plan’s Board of Trustees: (1)
PHI for purposes related to Plan administration (payment and health care
operations); (2) summary health information for purposes of health or stop loss
insurance underwriting or for purposes of modifying the Plan; and (3) enrollment
information (whether an individual is eligible for benefits under the Plan). The
Trustees have amended the Plan to protect your PHI as required by federal law.
Treatment is the provision, coordination or management of health care and
related services. It also includes but is not limited to consultations and referrals
between one or more of your providers.
For example, the Plan may disclose to a treating physician the name of your
treating radiologist so that the physician may ask for your X-rays from the treating
radiologist.
Payment includes but is not limited to actions to make coverage
determinations and payment (including billing, claims processing, subrogation,
reviews for medical necessity and appropriateness of care, utilization review and
preauthorizations).
For example, the Plan may tell a treating doctor whether you are eligible for
coverage or what percentage of the bill will be paid by the Plan.
Health care operations include but are not limited to quality assessment
and improvement, reviewing competence or qualifications of health care
professionals, underwriting, premium rating and other insurance activities relating
to creating or renewing insurance contracts. It also includes case management,
conducting or arranging for medical review, legal services and auditing functions
including fraud and abuse compliance programs, business planning and
development, business management and general administrative activities.
However, no genetic information can be used or disclosed for underwriting
purposes.
For example, the Plan may use information to project future benefit costs or
audit the accuracy of its claims processing functions.
Uses and disclosures that require that you be given an opportunity to agree or
disagree prior to the use or release.
Unless you object, the Plan may provide relevant portions of your protected
health information to a family member, friend or other person you indicate is
115
involved in your health care or in helping you receive payment for your health
care. Also, if you are not capable of agreeing or objecting to these disclosures
because of, for instance, an emergency situation, the Plan will disclose protected
health information (as the Plan determines) in your best interest. After the
emergency, the Plan will give you the opportunity to object to future disclosures to
family and friends.
Uses and disclosures for which your consent, authorization or opportunity to
object is not required.
The Plan is allowed to use and disclose your PHI without your
authorization under the following circumstances:
(1)
For treatment, payment and health care operations.
(2)
Enrollment information can be provided to the Trustees.
(3)
Summary health information can be provided to the Trustees for the
purposes designated above.
(4)
When required by law.
(5)
When permitted for purposes of public health activities, including
when necessary to report product defects and to permit product recalls. PHI may
also be disclosed if you have been exposed to a communicable disease or are at
risk of spreading a disease or condition, if required by law.
(6)
When required by law to report information about abuse, neglect or
domestic violence to public authorities if there exists a reasonable belief that you
may be a victim of abuse, neglect or domestic violence. In such case, the Plan will
promptly inform you that such a disclosure has been or will be made unless that
notice would cause a risk of serious harm. For the purpose of reporting child
abuse or neglect, it is not necessary to inform the minor that such a disclosure has
been or will be made. Disclosure may generally be made to the minor’s parents or
other representatives although there may be circumstances under federal or state
law when the parents or other representatives may not be given access to the
minor’s PHI.
(7)
The Plan may disclose your PHI to a public health oversight agency
for oversight activities required by law. This includes uses or disclosures in civil,
administrative or criminal investigations; inspections; licensure or disciplinary
actions (for example, to investigate complaints against providers); and other
activities necessary for appropriate oversight of government benefit programs (for
example, to investigate Medicare or Medicaid fraud).
116
(8)
The Plan may disclose your PHI when required for judicial or
administrative proceedings. For example, your PHI may be disclosed in response
to a subpoena or discovery request.
(9)
When required for law enforcement purposes, including for the
purpose of identifying or locating a suspect, fugitive, material witness or missing
person. Also, when disclosing information about an individual who is or is
suspected to be a victim of a crime but only if the individual agrees to the
disclosure or the Plan is unable to obtain the individual’s agreement because of
emergency circumstances. Furthermore, the law enforcement official must
represent that the information is not intended to be used against the individual, the
immediate law enforcement activity would be materially and adversely affected by
waiting to obtain the individual’s agreement and disclosure is in the best interest
of the individual as determined by the exercise of the Plan’s best judgement.
(10) When required to be given to a coroner or medical examiner for the
purpose of identifying a deceased person, determining a cause of death or other
duties as authorized by law. Also, disclosure is permitted to funeral directors,
consistent with applicable law, as necessary to carry out their duties with respect
to the decedent.
(11) When consistent with applicable law and standards of ethical
conduct if the Plan, in good faith, believes the use or disclosure is necessary to
prevent or lessen a serious and imminent threat to the health or safety of a person
or the public and the disclosure is to a person reasonably able to prevent or lessen
the threat, including the target of the threat.
(12) When authorized by and to the extent necessary to comply with
workers’ compensation or other similar programs established by law.
Except as otherwise indicated in this notice, uses and disclosures will be
made only with your written authorization subject to your right to revoke such
authorization.
Uses and disclosures that require your written authorization.
Other uses or disclosures of your protected health information not described above
will only be made with your written authorization. For example, in general and
subject to specific conditions, the Plan will not use or disclose your psychiatric
notes; the Plan will not use or disclose your protected health information for
marketing; and the Plan will not sell your protected health information, unless you
provide a written authorization to do so. You may revoke written authorizations at
any time, so long as the revocation is in writing. Once the Plan receives your
written revocation, it will only be effective for future uses and disclosures. It will
117
not be effective for any information that may have been used or disclosed in
reliance upon the written authorization and prior to receiving your written
revocation.
Section 2
Rights of Individuals
Right to Request Restrictions on Uses and Disclosures of PHI
You may request the Plan to restrict the uses and disclosures of your PHI.
However, the Plan is not required to agree to your request (except that the Plan
must comply with your request to restrict a disclosure of your confidential
information for payment or health care operations if you paid for the services to
which the information relates in full, out of pocket).
You or your personal representative will be required to submit a written
request to exercise this right.
Such requests should be made to the Plan’s Privacy Official.
Right to Request Confidential Communications
The Plan will accommodate reasonable requests to receive communications
of PHI by alternative means or at alternative locations if necessary to prevent a
disclosure that could endanger you.
You or your personal representative will be required to submit a written
request to exercise this right.
Such requests should be made to the Plan’s Privacy Official.
Right to Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a
“designated record set,” for as long as the Plan maintains the PHI. If the
information you request is in an electronic designated record set, you may request
that these records be transmitted electronically to yourself or a designated
individual.
“Protected Health Information” (PHI) includes all individually identifiable
health information transmitted or maintained by the Plan, regardless of form.
“Designated Record Set” includes the medical records and billing records
about individuals maintained by or for a covered health care provider; enrollment,
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payment, billing, claims adjudication and case or medical management record
systems maintained by or for the Plan; or other information used in whole or in
part by or for the Plan to make decisions about individuals. Information used for
quality control or peer review analyses and not used to make decisions about
individuals is not in the designated record set.
The requested information will be provided within 30 days if the
information is maintained on site or within 60 days if the information is
maintained off site. A single 30-day extension is allowed if the Plan is unable to
comply with the deadline.
You or your personal representative will be required to submit a written
request to request access to the PHI in your designated record set. Such requests
should be made to the Plan’s Privacy Official.
If access is denied, you or your personal representative will be provided
with a written denial, setting forth the basis for the denial, a description of how
you may appeal the Plan’s decision and a description of how you may complain to
the Secretary of the U.S. Department of Health and Human Services.
The Plan may charge a reasonable, cost-based fee for copying records at
your request.
Right to Amend PHI
You have the right to request the Plan to amend your PHI or a record about
you in your designated record set for as long as the PHI is maintained in the
designated record set.
The Plan has 60 days after the request is made to act on the request. A
single 30-day extension is allowed if the Plan is unable to comply with the
deadline. If the request is denied in whole or part, the Plan must provide you with
a written denial that explains the basis for the denial. You or your personal
representative may then submit a written statement disagreeing with the denial and
have that statement included with any future disclosures of your PHI.
Such requests should be made to the Plan’s Privacy Official.
You or your personal representative will be required to submit a written
request to request amendment of the PHI in your designated record set.
Right to Receive an Accounting of PHI Disclosures
At your request, the Plan will also provide you an accounting of disclosures
by the Plan of your PHI during the six years prior to the date of your request.
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However, such accounting will not include PHI disclosures made: (1) to carry out
treatment, payment or health care operations (except as noted in the following
paragraph); (2) to individuals about their own PHI; (3) pursuant to your
authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible
under the law and the Plan’s privacy practices. In addition, the Plan need not
account for certain incidental disclosures.
If the accounting cannot be provided within 60 days, an additional 30 days
is allowed if the individual is given a written statement of the reasons for the delay
and the date by which the accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan
will charge a reasonable, cost-based fee for each subsequent accounting.
Such requests should be made to the Plan’s Privacy Official.
Right to Receive a Paper Copy of This Notice Upon Request
You have the right to obtain a paper copy of this Notice.
Such requests should be made to the Plan’s Privacy Official.
A Note About Personal Representatives
You may exercise your rights through a personal representative. Your
personal representative will be required to produce evidence of his/her authority to
act on your behalf before that person will be given access to your PHI or allowed
to take any action for you. Proof of such authority may take one of the following
forms:
1.
a power of attorney for health care purposes;
2.
a court order of appointment of the person as the conservator or
guardian of the individual; or
3.
an individual who is the parent of an unemancipated minor child
may generally act as the child’s personal representative (subject to
state law).
The Plan retains discretion to deny access to your PHI by a personal
representative to provide protection to those vulnerable people who depend on
others to exercise their rights under these rules and who may be subject to abuse or
neglect.
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Section 3
The Plan’s Duties
The Plan is required by law to maintain the privacy of PHI and to provide
individuals (participants and beneficiaries) with notice of the Plan’s legal duties
and privacy practices.
This Notice is effective September 23, 2013, and the Plan is required to
comply with the terms of this Notice. However, the Plan reserves the right to
change its privacy practices and to apply the changes to any PHI received or
maintained by the Plan prior to that date. If a privacy practice is changed, a
revised version of this Notice will be provided to all participants for whom the
Plan still maintains PHI. The revised Notice will be distributed in the same
manner as the initial Notice was provided or in any other permissible manner.
If the revised version of this Notice is posted on the Plan’s website,
ufcwl400healthandwelfare.org, you will also receive a copy of the Notice, or
information about any material change and how to receive a copy of the Notice in
the Plan’s next annual mailing. Otherwise, the revised version of this Notice will
be distributed within 60 days of the effective date of any material change to the
Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy
rights, the duties of the Plan or other privacy practices stated in this Notice.
Minimum Necessary Standard
When using or disclosing PHI or when requesting PHI from another
covered entity, the Plan will make reasonable efforts not to use, disclose or request
more than the minimum amount of PHI necessary to accomplish the intended
purpose of the use, disclosure or request, taking into consideration practical and
technological limitations. When required by law, the Plan will restrict disclosures
to the limited data set, or otherwise as necessary, to the minimum necessary
information to accomplish the intended purpose.
However, the minimum necessary standard will not apply in the following
situations:
1.
disclosures to or requests by a health care provider for treatment;
2.
uses or disclosures made to the individual;
3.
disclosures made to the Secretary of the U.S. Department of Health
and Human Services;
4.
uses or disclosures that are required by law; and
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5.
uses or disclosures that are required for the Plan’s compliance with
legal regulations.
De-Identified Information
This notice does not apply to information that has been de-identified.
De-identified information is information that does not identify an individual and
with respect to which there is no reasonable basis to believe that the information
can be used to identify an individual.
Summary Health Information
The Plan may disclose “summary health information” to the Trustees for
obtaining insurance premium bids or modifying, amending or terminating the
Plan. “Summary health information” summarizes the claims history, claims
expenses or type of claims experienced by participants and excludes identifying
information in accordance with HIPAA.
Notification of Breach
The Plan is required by law to maintain the privacy of participants’ PHI and
to provide individuals with notice of its legal duties and privacy practices. In the
event of a breach of unsecured PHI, the Plan will notify affected individuals of the
breach unless the Plan determines that there is a low probability that the unsecured
PHI has been compromised.
Section 4
Your Right to File a Complaint With the Plan or the HHS Secretary
If you believe that your privacy rights have been violated, you may
complain to the Plan. Such complaints should be made to the Plan’s Privacy
Official.
You may file a complaint with the Secretary of the U.S. Department of
Health and Human Services, Hubert H. Humphrey Building, 200 Independence
Avenue SW, Washington, D.C. 20201.
The Plan will not retaliate against you for filing a complaint.
Section 5
Whom to Contact at the Plan for More Information
If you have any questions regarding this notice or the subjects addressed in
it, you may contact the Plan’s Privacy Official. Such questions should be directed
to the Plan’s Privacy Official at:
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United Food and Commercial Workers Local 400
and Employers Health and Welfare Fund
600 D Street, Suite 250
South Charleston, WV 25303
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as
HIPAA (the Health Insurance Portability and Accountability Act). You may find
these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends
to comply with these regulations. This Notice attempts to summarize the
regulations. The regulations will supersede any discrepancy between the
information in this Notice and the regulations.
Nothing in this booklet is meant to interpret or extend or change in any way the
provisions expressed in the Plan documents. The Trustees reserve the right to
amend, modify or discontinue all or part of the Plan whenever, in their judgment,
conditions so warrant.
Unless otherwise indicated, the benefits described in the Plan document and in this
Summary Plan Description are self-funded by the Plan. The benefits payable are
limited to Plan assets available for such purposes.
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HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY
Hartford, Connecticut
(Herein called The Hartford)
_______________________________________________________________
CERTIFICATE OF INSURANCE
Under
Group Insurance Policy
GL-19282 Effective December 1, 1981
Issued by
The Hartford
to
UNITED FOOD AND COMMERCIAL WORKERS
LOCAL 400 AND EMPLOYERS
HEALTH AND WELFARE PLAN
(Herein called the Policyholder)
THIS IS TO CERTIFY that The Hartford has issued and delivered to the Policyholder the
above specified group policy insuring certain employees of the Policyholder. Provisions
of the Policy principally affecting the insurance of the employee are summarized in the
Schedule of Benefits and participants can request a full copy of the Certificate from the
Plan Office.*
Beneficiary: The Beneficiary designated by the employee in writing and filed at the
office where the records of insurance are maintained.
This individual Certificate is furnished in accordance with and subject to the terms of said
group policy and is merely evidence of insurance provided under said group policy which
insurance if effective only if the employee is eligible for insurance and becomes and
continues insured in accordance with the terms, provisions and conditions of said policy.
The coverage with respect to an Insured Person’s dependents will be applicable only if
such person is eligible, has enrolled, and is insured for such coverage.
This Certificate replaces any and all Certificates previously issued for delivery to the
employee by the Policyholder.
Hartford Life and Accident Insurance Company
Christine Hayer Repasy, Secretary
Thomas M. Marra, President
* The Certificate, in full, may be examined at the Plan Office during regular business
hours, Monday through Friday, except holidays.
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[INSIDE BACK COVER]
IMPORTANT ADDRESSES AND TELEPHONE NUMBERS
PLAN OFFICE
United Food and Commercial Workers Local 400
and Employers Health and Welfare Plan
600 D Street, Suite 250
South Charleston, WV 25303
1-304-343-7682 Member Assistance
1-866-343-7682 Member Assistance Outside Charleston Area
INFORMED UTILIZATION AND DISEASE MANAGEMENT
Including Pre-certifications: 1-877-687-9982
HOSPITAL AND PHYSICIAN PPO NETWORK
Anthem Blue Cross and Blue Shield
Provider Assistance: 1-800-518-1638
Provider Access Information: 1-800-810-BLUE or www.anthem.com
PHARMACY NETWORK
Plan 1 Kroger Employees
Kroger Prescription Plans (KPP) and Mail Order Information
1-800-575-7712
Plan 1 Employees of Other Employers and Plan S and Plan V Retirees
Contact Plan Office or
Kroger Prescription Plans (KPP)
1-800-482-1285
20069621v1
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