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Summary Plan Description and Plan Document 2005 Edition
TABLE OF CONTENTS
Section 1: Life Events
At some point in your life, you will experience a life event that impacts health care coverage for you and your Dependents. You may have experienced some of these life events already. Life events such as these can affect your benefit coverage:
· Marriage |
· Birth or adoption of a child |
· Divorce or legal separation |
· Your child reaches the maximum age for coverage |
· Your spouse loses a job or starts a new job |
· Medical leave |
· Military duty |
· You become disabled |
· Your death |
· Retirement |
· You stop working |
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Your benefits are designed to adapt to your needs at different stages of your life. This section describes how your coverage is affected when these different events occur.
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1.02 Getting Married.
When you get married, your spouse is eligible for medical, dental, prescription drug, and vision care benefits. Once you provide the required information about your spouse, coverage for your spouse begins on the date of your marriage, provided you are eligible for benefits. If your spouse is covered under another group medical plan, you must report that other coverage to the Fund Office so that benefits may be coordinated with your spouse’s other coverage. You may want to consider changing your beneficiary designation for your Death Benefit and Accidental Death and Dismemberment Benefit. |
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Your natural born child will be eligible for coverage on the date of birth. If you adopt a child or have a child placed with you for adoption, coverage will become effective on the date of placement as long as you are responsible for health care coverage and your child meets the Plan’s definition of a Dependent child. Stepchildren who live in your home are eligible for coverage on the date of your marriage, provided that you can provide satisfactory proof that: a) they are living in your home and b) they are financially dependent on you for support and c) another party is not responsible for providing health coverage. |
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If you and your spouse obtain a legal separation or divorce, your spouse will no longer be eligible for coverage as a Dependent under the Plan. However, your spouse may elect to continue coverage under COBRA for up to 36 months. See Section 3.03 for additional information and the requirements for electing COBRA Continuation Coverage.
You should contact the Fund Office if a Qualified Medical Child Support Order (QMCSO) has been issued as a result of your divorce or legal separation. A QMCSO may affect benefit coverage for your Dependents. Therefore, it is important to notify the Fund Office immediately to avoid unnecessary delays in claim payments or denial of benefits. |
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1.05 Child Loses Eligibility.
In general, your child is no longer eligible for coverage when your child is no longer dependent on you for support or reaches age 19 (age 23 if a full-time student). However, if your child is mentally or physically disabled before reaching age 19 and continues to be mentally or physically disabled and dependent on you for more than half of their support and maintenance, that child will continue to be covered as your Dependent. You should notify the Fund
Office immediately
when your child is no longer eligible for coverage.
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Your Dependent child
may
consider applying for COBRA coverage as your child nears the age of
19 or
23 (if a full-time student). Your Dependent child may, if eligible, elect to continue coverage under COBRA for up to 36 months. However, if you do not notify the Fund Office that your child is no longer a Dependent within 60 days of the time that your child loses Dependent status, your child will not be eligible to elect COBRA Continuation Coverage. See
Section 19.01 for a definition of Dependent and full-time student and see
Section 3.03 for the rules governing COBRA coverage. |
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When your spouse loses employer-provided insurance due to the loss of employment, you should contact the Fund Office to let them know that this Plan’s coverage will be primary. Please provide a copy of the letter from your spouse’s insurance carrier advising as to the date of termination.
If your spouse takes a new job and enrolls in the coverage offered by your spouse’s employer, then this Plan will cover your spouse’s medical expenses as the secondary plan under the coordination of benefits provisions. |
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If you take maternity or paternity leave, a leave of absence under the Family and Medical Leave Act (FMLA) or if you take military leave under the Uniformed Services Employment and Reemployment Rights Act (USERRA), your eligibility under this Plan may be affected. You should refer to the explanation of these types of leave in
Section 3.01(I) and Section 3.01(J). |
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If you become disabled because of a certified disability, you will be eligible for Weekly Accident and Sickness Disability Benefits for a maximum of 26 weeks. During that time, you will be credited with disability hours to help maintain your eligibility under the Plan. When your coverage ends, you may elect COBRA coverage as explained in
Section 3.03. |
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1.09 Enroll and pay for COBRA to continue Plan coverage,
or In the Event of Your Death.
At the time of your death, your spouse or beneficiary should notify the Fund Office and provide a copy of your death certificate. Your spouse or beneficiary should complete a Death Benefit application from the Plan and/or an application for Accidental Death and Dismemberment Benefits, if applicable. If your spouse and Dependents are covered under the Plan on the date of your death, their eligibility will continue for as the hours in your Accumulation Account allow. Then, they may continue health care coverage for up to 36 months by electing COBRA Continuation Coverage and making the necessary self-payments. There is also Enhanced Continuation Coverage for surviving spouses who are age 60 to 65 at the time of the employee’s death as explained in
Section 3.03(F).
If you are retired at the time of your death, your surviving spouse and Dependents may be eligible for continuation of your Retiree coverage. To determine if your spouse and/or Dependents are eligible to continue coverage under the Retiree health plan, please review the information in
Section 3.02 or contact the Fund Office. |
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If you are eligible for Active Employee Benefits, coverage for you and your Dependents will end on the last day of any benefit quarter for which you do not have the required hours of contributions in your Accumulation Account. You may elect COBRA Continuation Coverage when your coverage ends, as explained beginning in
Section 3.03. |
| When you retire, you may continue coverage if you meet the requirements for Retiree coverage. Retiree coverage converts to Supplemental Medical Benefits when you become eligible for Medicare. |
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When you retire, if you are not yet eligible for Medicare, you may continue coverage if you meet the Plan’s requirements for Retiree coverage. If you retired and are eligible for Medicare, the Plan provides a Supplemental Medical Benefit that supplements the benefits you receive from Medicare. See the Schedule of Benefits in
Section 2 and
Section 3.02 regarding Retired Employee Eligibility.
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Section 2: Schedules of Benefits
A Schedule of Benefits is a list of benefit amounts and exclusions that apply to the plan of benefits. Each specific benefit is described in more detail in the section concerning that particular benefit. When reading the specific benefit section you should reference the applicable Schedule of Benefits and vice versa. If there is a discrepancy between the Schedule and a specific Plan section, the specific Plan section will usually govern. However, the Board has discretionary decision making authority to interpret the terms of the Plan.
This Section provides information for each type of participant under the Plan.
Section 2.01 provides a Schedule for Active Employees.
Section 2.02 provides a Schedule for Retired Employees not yet eligible for Medicare.
Section 2.03 provides a Schedule for Retired Employees who are eligible for Medicare.
Section 2.04 provides Schedules for Prescription and Specialty Drug Benefits for Active and Retired Employees
The following Schedule provides an overview of the benefits that apply to each type of participant.
* When you retire; if you meet the eligibility requirements for retiree medical benefits, those benefits will commence after eligibility for active Employee benefits ceases due to the exhaustion of your Accumulation Account.
Benefit |
Benefit Amount or Limitation |
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Death Benefit for Active Employees Only |
$10,000 |
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Accidental Death and Dismemberment Benefit for Active Employees Only |
For loss of: |
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Life |
$10,000 |
Both hands, both feet, or sight of both eyes |
$10,000 |
One hand and one foot, one hand and sight of
one eye, or one foot and sight of one eye |
$10,000 |
One hand, one foot, or sight of one eye |
$5,000 |
Weekly Accident and Sickness Disability Benefit for Active Employees Only |
Weekly Benefit Amount |
$350 |
Maximum Number of Weeks of Benefit |
26 |
Medical Expense Benefits for Active Employees and Dependents |
Calendar Year Deductible |
$300 per Person
Maximum 3 deductibles per Family |
Maximum Benefit |
Maximum per Disability |
$1,000,000 per Person |
Spinal Manipulation Maximum
(including diagnostic tests) |
$1,000 per Calendar Year (for covered individuals age 16 and older) |
Confinement in a Skilled Nursing Care Facility |
60 Days per Confinement |
Covered Expenses Payable by the Fund
up to the Usual and Customary Fees |
PPO Charges |
Non-PPO Charges |
Physician, Hospital/Facility
(inpatient and outpatient) |
85% |
75% |
Skilled Nursing Care |
60 days per confinement; See Sec. 7.08 (A) (11) |
Out-of-Pocket Maximum per Calendar Year
Out-of-Pocket Maximum Does Not Include:
· Deductible Amount
· Prescription Drug Copayments
· Dental Expense Payments
· Vision Care Expense Payments
· Copayments for Outpatient Treatment of Mental and Nervous Disorders, or Chemical Dependency |
$1,000 per Person for PPO expenses
$2,500 per Person for Non-PPO expenses
Once you reach the Out-of-Pocket Maximum, the Plan pays 100% of allowable expenses for the calendar year up to the Maximum Benefit listed above. Expenses that apply towards the Non-PPO out-of-pocket limits apply towards the PPO out-of-pocket limits and vice versa. |
Note: Durable Medical Equipment and Local Ambulance Service for which PPO services are not available will be covered the same as PPO charges |
Mental and Nervous Disorders |
PPO Charges |
Non-PPO Charges |
Outpatient |
50% |
50% |
Inpatient |
85% |
75% |
Chemical Dependency |
PPO Charges |
Non-PPO Charges |
Outpatient |
50% |
50% |
Inpatient |
85% |
75% |
Inpatient Maximum |
$6,000 per Course of Treatment
Limited to Two Courses of Treatment per Lifetime | |