ibew local no. 461 welfare fund summary plan description
Transcription
ibew local no. 461 welfare fund summary plan description
IBEW LOCAL NO. 461 WELFARE FUND SUMMARY PLAN DESCRIPTION BENEFITS AND ELIGIBILITY RULES AUGUST 2014 IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ PAGE INTRODUCTION SECTION I - SCHEDULE OF BENEFITS CLASS A Active Members & Their Dependents...................................................................... A-E CLASS B Retired Or Disabled Members And Their Eligible Dependents Who are not Eligible For Medicare................................................................................................... F CLASS C Retired Or Disabled Members And Their Eligible Dependents Who are Eligible For Medicare...................................................................................................G SECTION II - ELIGIBILITY RULES Disqualifying Employment .......................................................................................... 1 Initial Eligibility (Bargaining Unit Employees............................................................. 1 Continuation of Eligibility – Employer Contributions ................................................. 2 Reserve Accumulation Account “Hour Bank” ............................................................. 2 Self-Payment of Contributions ................................................................................... 2 Participation Agreements for Non-Bargaining Unit Participants ............................... 3 Self-Pay When Disabled .............................................................................................. 4 Continuation of Eligibility During Disability ............................................................... 4 Total and Permanent Disability .................................................................................. 5 Self-Payment............................................................................................................... 5 Work Outside Trust Fund Jurisdiction - Reciprocity................................................... 5 Termination of Eligibility for Employees and their Dependents When Entering Military Service.......................................................................................................... 6 Reinstatement of Eligibility ........................................................................................ 6 Employees ................................................................................................................... 6 RETIREE PROGRAM Coverage Classifications Defined................................................................................ 7 Class B ......................................................................................................................... 7 Class C ......................................................................................................................... 7 General Eligibility Requirements ................................................................................ 7 Self-Payment of Contributions ................................................................................... 8 Benefit Limitations...................................................................................................... 8 Effective Dates Of Coverage ....................................................................................... 9 Employee..................................................................................................................... 9 Dependents ................................................................................................................. 9 Termination Dates of Coverage .................................................................................. 9 Employee..................................................................................................................... 9 Dependents ................................................................................................................. 9 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ General Provisions .................................................................................................... 10 Change of Eligibility Rules ........................................................................................ 10 A Note of Explanation ............................................................................................... 10 Health Insurance Portability and Accountability...................................................... 11 Family and Medical Leave ......................................................................................... 11 Cobra Continuation Coverage ................................................................................... 12 Employee................................................................................................................... 12 Spouse....................................................................................................................... 13 Dependent Children .................................................................................................. 14 Disabled Eligible Employee ....................................................................................... 14 Employee Obligations to Notify the Fund Office of a Qualifying Event.................... 15 Second Qualifying Event ........................................................................................... 16 Proof of Insurability is not Necessary to Elect Continuation Coverage ................... 17 Procedure for Obtaining Continuation Coverage ..................................................... 17 Termination of Continuation Coverage..................................................................... 17 Qualified Medical Child Support Orders.................................................................... 18 Receipt of Order ........................................................................................................ 18 Determination of Qualification ................................................................................. 18 Effect of National Medical Support Notices .............................................................. 18 Status of Alternate Recipients .................................................................................. 18 Direct Payments........................................................................................................ 18 Notification Issues .................................................................................................... 18 General Definitions ................................................................................................... 20 SECTION III - MAJOR MEDICAL BENEFITS Introduction .............................................................................................................. 33 Preferred Provider Organization (PPO) .................................................................... 33 Non-Preferred Provider Organization (PPO) ............................................................ 33 The Deductible Amount ............................................................................................ 33 Maximum Deductible Amount for Families.............................................................. 33 Co-Payment.............................................................................................................. 34 The Maximum Amount ............................................................................................. 34 Co-Payment Limit for Individuals ............................................................................ 34 Hospital Expense Benefits ....................................................................................... 34 Daily Room Benefit .................................................................................................. 34 Miscellaneous Charges While Confined ................................................................... 35 Out-Patient Hospital Treatment .............................................................................. 35 Charges Related to Hospital Treatment................................................................... 35 Limitations ............................................................................................................... 35 Hospital Pre-Admission Testing ................................................................................ 36 Surgical Expense Benefit .......................................................................................... 37 Limitations................................................................................................................ 37 Second Surgical Opinion Benefits ............................................................................. 38 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ Diagnostic X-Ray and Lab Benefits........................................................................... 38 Limitations ................................................................................................................ 39 In-Hospital Physician Benefits.................................................................................. 39 Covered Expenses ..................................................................................................... 40 Limitations ................................................................................................................ 41 Pregnancy Expense Benefits..................................................................................... 42 Limitations ................................................................................................................ 43 Statement of Rights Under the Mother’s and Newborn’s Health Protection Act ..... 43 Newborn Dependent Child Benefits.......................................................................... 43 Crib Care.................................................................................................................... 44 Newborn Examination .............................................................................................. 44 Newborn Circumcision .............................................................................................. 44 Birth Coverage ............................................................................................................ 44 Limitations ................................................................................................................ 44 SECTION IV – BENEFITS WITH SPECIAL LIMITATIONS Weekly Accident and Sickness Benefits (Loss of Time) ........................................... 47 Active Employees Only.............................................................................................. 47 Application for Loss of Time Benefits ....................................................................... 47 Period of Disability.................................................................................................... 47 Limitations ................................................................................................................ 47 Chiropractic Expense Benefits ...................................................................................... 48 Limitations ................................................................................................................ 48 Physical Therapy Expense Benefits ......................................................................... 49 Home Health Care Benefits....................................................................................... 49 Limitations ................................................................................................................ 49 Elective Sterilization Benefit (Employee or Spouse Only)........................................ 50 Limitations ................................................................................................................ 50 Mental Health and Substance Abuse Benefits .......................................................... 50 In-Patient Treatment ................................................................................................ 50 Out-Patient Treatment.............................................................................................. 51 Limitations ................................................................................................................ 51 Co-Payment............................................................................................................... 51 Maximum amount Payable ....................................................................................... 52 In-Patient Benefits.................................................................................................... 52 Out-Patient Benefits ................................................................................................. 52 Covered Expenses ..................................................................................................... 53 Limitations ................................................................................................................ 53 Well Child Care Benefits and Routine Physical Examination Benefit ....................... 54 Limitations ................................................................................................................ 54 Prescription Drug Benefits........................................................................................ 54 Hearing Care Benefits ............................................................................................... 55 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ Eligibility ................................................................................................................... 55 The Deductible Amount ............................................................................................ 55 Co-Payment............................................................................................................... 55 The Maximum Amount .............................................................................................. 55 Covered Expenses ..................................................................................................... 55 Limitations ................................................................................................................ 56 Organ Transplant Benefit.......................................................................................... 56 Eligibility ................................................................................................................... 56 Co-Payment - PPO..................................................................................................... 56 Co-Payment – Non-PPO ............................................................................................ 57 The Maximum Amount .............................................................................................. 57 Limitations ............................................................................................................... 57 SECTION V – DENTAL CARE BENEFITS Predetermination of Benefits.................................................................................... 59 The Maximum Amount .............................................................................................. 59 Covered Expenses ..................................................................................................... 59 Expense Incurred ...................................................................................................... 61 The Maximum Amount .............................................................................................. 62 Treatment in Progress When Eligibility Terminates ................................................. 62 Limitations ................................................................................................................ 62 SECTION VI – VISION CARE BENEFITS The Maximum Amount .............................................................................................. 65 Covered Expense....................................................................................................... 65 Limitations ................................................................................................................ 66 Surgery to Correct Vision Deficiencies ..................................................................... 66 Vision Therapy........................................................................................................... 67 SECTION VII – DEATH AND DISMEMBERMENT BENEFITS Death Benefits........................................................................................................... 69 Beneficiary Designation ............................................................................................ 69 Notice of Claim .......................................................................................................... 69 SECTION VIII – MEDICAL SAVINGS BENEFIT How the Medical Savings Benefit Works .................................................................. 71 What the Money Can Be Used For............................................................................. 71 How to Use the Medical Savings Plan ....................................................................... 71 Medical Savings Benefit and Supplemental Benefit Account ................................... 72 Eligible Healthcare Expenses .................................................................................... 72 Eligible Medical Expenses ......................................................................................... 72 Eligible OTC Expenses – Without a Prescription....................................................... 73 Eligible OTC Expenses – With a Prescription ............................................................ 73 Ineligible Medical Expenses...................................................................................... 73 SECTION IX – SUPPLEMENTAL BENEFIT ACCOUNT Funding ..................................................................................................................... 75 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ Participation.............................................................................................................. 75 Eligibility ................................................................................................................... 75 Reimbursable Benefits .............................................................................................. 75 Reimbursement......................................................................................................... 75 Accruing Account Balances ....................................................................................... 76 Non Covered Expenses.............................................................................................. 76 Work in an area outside of the jurisdiction of the Fund........................................... 76 SECTION X – GENERAL PLAN EXCLUSIONS AND LIMITATIONS Routine Care and Elective Procedures...................................................................... 77 Medical Necessity...................................................................................................... 77 Work Related Disabilities.......................................................................................... 77 Organ Transplants..................................................................................................... 78 Reasonable and Customary Charges ........................................................................ 78 Treatment Sponsored by Governmental Units ......................................................... 78 Treatment Without Charge ....................................................................................... 79 Illegal Occupation or Commission of Felony ............................................................ 79 Experimental Treatment of Procedures.................................................................... 79 Liability for Accidental Injuries ................................................................................ 79 General Limitations................................................................................................... 80 SECTION XI – OTHER GENERAL PLAN PROVISIONS Physical or Dental Examination and Autopsy ........................................................... 85 Free Choice of Physician ........................................................................................... 85 Workers' Compensation Not Affected....................................................................... 85 Time Limits for Filing Claims..................................................................................... 85 Circumstances That May Result in Loss of Eligibility of Benefits ............................. 86 Claims Review and Appeal Procedures..................................................................... 86 Coordination of Benefits With Other Group Plans.................................................... 90 Benefit Determination .............................................................................................. 91 Claim for a Covered Employee .................................................................................. 91 When Claim is on the Dependent Spouse ................................................................. 92 When Claim is for a Dependent Child ....................................................................... 94 Coordination of Benefits with Medicare ................................................................... 94 Active Employees and/or Their Spouses Who are Eligible for Medicare.................. 95 Active Employees with Dependents Eligible for Medicare........................................ 96 HIPAA- CONFIDENTIAL INFORMATION ............................................................................. 97 SECTION XII - STATEMENT OF PARTICIPANT’S RIGHTS Information Required by the Employee Retirement Income Security Act (ERISA). 99 Introduction .............................................................................................................. 99 Your Rights as a Participant ..................................................................................... 99 SECTION XIII - OTHER IMPORTANT INFORMATION The Trustees Interpret the Plan ............................................................................. 105 The Plan Can be Changed ....................................................................................... 105 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description ________________________________ Your Plan is Tax Exempt ...................................................................................... 106 Right to Receive and Release Necessary Information ........................................ 106 Facility of Payment............................................................................................... 106 Right of Recovery................................................................................................. 107 Payment of Claims ............................................................................................... 107 Name of the Plan.................................................................................................. 107 Type of Plan.......................................................................................................... 108 Type of Plan Administration................................................................................. 108 Name and Address of Administrator .................................................................... 108 Name and Address of the Agent for Service of Legal Process ............................. 108 Name and Address of Claims Agent ..................................................................... 109 Name and Address of Investment Consultant ..................................................... 109 Name and Address of Member Assistance Program (MAP) ................................. 109 Name and Address of Preferred Provider Organization (PPO) ............................ 109 Name and Address of Prescription Drug Vendor ................................................. 109 Name and Title of Each Trustee ........................................................................... 110 Name and Address of Local Union Office ............................................................. 110 Parties to the Collective Bargaining Agreement.................................................. 110 Internal Revenue Service Employer and Plan Identification Numbers............... 110 Eligibility Requirements ....................................................................................... 111 Sources of Trust Fund Income ............................................................................. 111 Method of Funding Benefits ................................................................................. 111 Fiscal Year of the Plan.......................................................................................... 111 The Plan May be Terminated................................................................................ 111 August 2014 Table of Contents IBEW Local No. 461 Welfare Fund Summary Plan Description _____________________________________________ IBEW LOCAL NO. 461 WELFARE FUND TO: ALL PARTICIPANTS We are pleased to distribute this new Summary Plan Description (SPD) which explains the benefits available under your Welfare Plan, summarizes the eligibility rules for participation in the Fund, and presents your rights as a participant. You should take time to read this new SPD so that you are up-to-date on the protection provided. The Trustees have elected to provide many of the plan benefits directly from the assets of the Trust Fund. The Trustees have also elected to use the services of the Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Network, and purchased insurance for catastrophic loss. This arrangement is expected to result in cost savings which will contribute to greater financial security for the Plan, and which may also allow the Trustees to improve benefits more frequently. From time to time, changes and improvements in your Plan will be made. We will keep you fully informed about any changes as they occur. After you read it, keep this SPD in a convenient place. If you have questions about your benefits, please call or write the Fund Office for assistance, and have your SPD available for reference. We encourage each eligible person to use medical care and these benefits wisely and only when genuinely necessary. Sincerely, THE BOARD OF TRUSTEES Management Trustees Bruce Anderson, Chairman Paul Hopkins Craig Martin Adam Mata Union Trustees Joel Pyle, II, Secretary Michael Angelo Steve Musich Mark Seppelfrick The Union Administrative Office is open: Monday, through Friday from 8:00 a.m. to 4:30 p.m. 591 Sullivan Road, Suite 100 Aurora, IL 60506 (630) 897-0461 (630) 897-7605 FAX August 2014 Introduction Letter IBEW Local No. 461 Welfare Fund Summary Plan Description _____________________________________________ THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Introduction Letter IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION I SCHEDULE OF BENEFITS – CLASS A ACTIVE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS Deductible Co-pay Dollar Maximum Lifetime Maximum Preventive Services Health Maintenance Exam – includes chest xray, EKG, annual OBGYN exam, mammogram & select lab procedures Well Child & Infant care – (Birth to age 18) Immunizations Fecal Occult Blood Screening Flexible Sigmoidoscopy Exam Prostate Specific Antigen (PSA) Screening In-Network BCBSIL $100 per person $300 per family (per calendar year, combined with out-of-network deductible) $1,600 per person $3,300 per family (per calendar year) None Out-of-Network $100 per person $300 per family (per calendar year, combined with out-of-network deductible) $3,100 per person $6,300 per family (per calendar year) None Covered at 100% (no deductible, no co-pay; one per person per calendar year) Covered at 80% of R&C (no deductible, no copay; one per person per calendar year) Covered at 100% no deductible, no co-pay Covered at 100% no deductible, no co-pay Covered at 100% no deductible, no co-pay Covered at 100% no deductible, no co-pay Covered at 100% no deductible, no co-pay Covered at 80% of R&C no deductible, no co-pay Covered at 80% of R&C no deductible, no co-pay Covered at 80% of R&C no deductible, no co-pay Covered at 80% of R&C no deductible, no co-pay Covered at 80% of R&C no deductible, no co-pay Patient is Responsible for any Charges over Reasonable & Customary August 2014 Section I - Schedule of Benefits Page A IBEW Local No. 461 Welfare Fund Summary Plan Description SCHEDULE OF BENEFITS – CLASS A ACTIVE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS Major Medical Hospital Confinement, Surgery & Physician Services Physician Office Services Office Visits Outpatient & Home visits Office Consultations Urgent Care visits Emergency Medical Care Hospital Emergency Room – medically necessary Ambulance Services – medically necessary Diagnostic Services Laboratory & Pathology Testing Diagnostic Tests & Xrays Radiation Therapy Maternity Services Pre-natal & Post-natal care (by a physician) Delivery & Nursery care (by a physician) Hospital Care Semi-private room, Inpatient Inpatient Consultations Chemotherapy In-Network BCBSIL Out-of-Network Covered at 80% of the first $15,000 after the deductible then 100% thereafter Covered at 65% of the first $15,000 after the deductible then 100% thereafter Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible August 2014 Section I - Schedule of Benefits Page B IBEW Local No. 461 Welfare Fund Summary Plan Description SCHEDULE OF BENEFITS – CLASS A ACTIVE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS In-Network BCBSIL Out-of-Network Inpatient: 80% after deductible Outpatient: paid as Home Health Care Inpatient: paid as Major Medical 80% after the deductible Outpatient: paid as Home Health Care Benefit Maximum 4 hours/day up to 30 days/calendar year – maximum $100/hour – 80% after the deductible Inpatient: 65% of the R&C after deductible Outpatient: paid as Home Health Care Inpatient: paid as Major Medical 65% of R&C after the deductible Outpatient: paid as Home Health Care Benefit Maximum 4 hours/day up to 30 days/calendar year – maximum $100/hour – 65% of R&C after the deductible Covered at 80% after the deductible Covered at 80% after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Alternatives to hospital care Skilled nursing care Hospice Care Home Health care Surgical Services Surgery – includes related surgical services Voluntary sterilization Human Organ Transplants Specified Organ Covered at 80% after the Transplants deductible Bone marrow Covered at 80% after the deductible Kidney, Cornea & Skin Covered at 80% after the deductible Mental Health & Substance Abuse Treatment In-patient Mental Health Covered at 80% after the Care deductible In-patient Substance Covered at 80% after the Abuse Care deductible Out-patient Mental Covered at 80% after the Health Care deductible Out-patient Substance Covered at 80% after the Abuse Care deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible Covered at 65% of R&C after the deductible August 2014 Section I - Schedule of Benefits Page C IBEW Local No. 461 Welfare Fund Summary Plan Description SCHEDULE OF BENEFITS – CLASS A ACTIVE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS Benefits paid under this section are not eligible for and do not contribute to the Co-Payment Limit which allows for 100% payment under the Major Medical Expenses Other Services Outpatient Diabetes Management Program Chiropractic Spinal Manipulation Chiropractic Diagnostic X-ray & Laboratory Outpatient Physical & Occupational Therapy (Facility, Clinic & Physicians Office) Durable Medical Equipment Prosthetic & Orthotic Appliances Private Duty Nursing Vision (no PPO network) Laser Eye surgery (Lasik) Hearing Aid In-Network BCBSIL Out-of-Network Covered at 80% after the deductible Covered at 65% of R&C after the deductible Not Covered if Out-ofNetwork Covered at 50% after the deductible – Maximum 24 visits per person, per calendar year Covered at 50% after Not Covered if Out-ofthe deductible Network $200 per person, per calendar year maximum Covered at 50% after Not Covered if Out-ofthe deductible Network $1,500 maximum per calendar year Covered at 80% after Covered at 65% of the deductible R&C after the Rental up to purchase deductible price covered under Major Medical Covered at 80% after Covered at 65% of the deductible R&C after the 1 per person, per year, deductible per diagnosis Not covered $600 per person, per benefit period (benefit period is two years) 50% of R&C after the deductible. Lifetime maximum of $2,000 per eye 50% of R&C after the deductible. Maximum payable $2,500 per ear, per person every 5 years August 2014 Section I - Schedule of Benefits Page D IBEW Local No. 461 Welfare Fund Summary Plan Description Other Services Dental (no PPO network) TMJ Prescription Drugs (including contraceptive medications paid by Citizens-Rx) Preventive – No deductible. Covered at 100% (exam, cleaning & x-rays) Restorative & Routine Care – Covered at 80% (Xrays, restorative care, extractions, periodontics & implants) No deductible. Orthodontics – (Dependent children only) Maximum 36 month treatment. Covered at 80%. All Dental (preventive, restorative, routine care & orthodontics) have a combined maximum of $1,500 per person, per calendar year for members 19 & older. Covered at 50% of the R&C up to a lifetime maximum of $3,000 for both In-network & Out-ofnetwork Coverage is through Citizens-Rx: Generic is covered at 80% and Brand Name is covered at 70%. No Prescriptions are covered when filled at a WalMart. Note: If a Brand Name is available as a Generic but elected to be filled as a Brand Name, the Participant will be responsible for all costs above the 80% coverage of the Generic cost. Life Insurance – Death (All causes) Participant only Weekly Loss of Time Benefits $1,000 Non-Occupational Injury or Illness Benefit – Payment Begins – For accident 1st day disabled and For sickness 8th day disabled Weekly Payment Rate - $400 Maximum Payment Period – 18 weeks Occupational Injury or Illness Benefit – Not Covered. August 2014 Section I - Schedule of Benefits Page E IBEW Local No. 461 Welfare Fund Summary Plan Description SCHEDULE OF BENEFITS – CLASS B RETIRED EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS WHO ARE NOT ELIGIBLE FOR MEDICARE Your benefits are the same as those listed for Class A except as noted below: Death Benefit – All causes (Retirees ONLY) Weekly Loss of Time Benefit Comprehensive Major Medical Benefits Dental Care Benefit Vision Care Benefit $500 Non-Occupational or Occupational – Not Covered Generally the same as Class A Benefits except: Excludes Elective Sterilization Excludes Pregnancy Expense Benefits & Newborn Child Benefits Same as Class A Same as Class A Patient Is Responsible For All Charges Over Reasonable and Customary August 2014 Section I - Schedule of Benefits Page F IBEW Local No. 461 Welfare Fund Summary Plan Description SCHEDULE OF BENEFITS – CLASS C RETIRED EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS WHO ARE ELIGIBLE FOR MEDICARE Maximum Benefit (All Plan Benefits, Including Prescription Drugs) Death Benefit – All causes, Retiree only Weekly Loss of Time Benefit Major Medical Benefits Medicare Hospital (Part A) Medicare Professional Services (Part B) Prescription Drug Benefits – Citizens-Rx Dental Care Benefit Vision Care Benefit Maximum per person, per calendar year (includes prescriptions purchased through Citizens-Rx) - $3,000 $500 Non-Occupational or Occupational – Not Covered Generally the same as Class A Benefits except: Excludes Elective Sterilization Excludes Pregnancy Expense Benefits & Newborn Child Benefits Deductible – Not covered Deductible – Not covered Plan Pays 100% of patient’s 20% of Medicare’s Allowable Amounts in Excess of Medicare’s Allowable – Not covered (subject to yearly maximum Coverage is through Citizens-Rx: Generic is covered at 80% and Brand Name is covered at 70%. No Prescriptions are covered when filled at a WalMart. Note: If a Brand Name is available as a Generic but elected to be filled as a Brand Name, the Participant will be responsible for all costs above the 80% coverage of the Generic cost. Not Covered Not Covered August 2014 Section I - Schedule of Benefits Page G IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section I - Schedule of Benefits Page H IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION II ELIGIBILITY RULES – BARGAINING UNIT EMPLOYEES Disqualifying Employment Effective October 21, 2002, the Trustees have amended the Plan to provide that a Participant who works in Disqualifying Employment shall forfeit all of the unused accumulated hours in his/her hour bank. “Disqualifying Employment” has three (3) components: 1. employment for a non-contributing employer, or self-employment as a non-contributing employer, 2. in a position as an electrician or a supervisor in the electrical industry, 3. within the geographical area that includes the State of Illinois plus the remainder of any Standard Metropolitan Statistical Area which falls in part within the State of Illinois. A Participant who engages in any Disqualifying Employment will forfeit the accumulated unused hours in his/her hour bank irrespective of whether the Participant has also performed work for a Contributing Employer during the same time period. All Employees working for a Contributing Employer or Employers within the jurisdiction of the Fund shall be eligible to receive benefits after meeting the following eligibility requirements. Eligibility is based on Work Month and Eligibility Month. Initial Eligibility (Bargaining Unit Employees) You will become initially eligible on the first day of the month following a two-month accounting period if you have been employed by a contributing Employer or Employers and those Employers have made contributions to the Fund on your behalf for at least 300 hours worked within a period of twelve (12) consecutive calendar months or less. Your initial period of eligibility continues for the remainder of that “Eligibility Month”. August 2014 Section II - Eligibility Rules Page 1 IBEW Local No. 461 Welfare Fund Summary Plan Description Continuation of Eligibility – Employer Contributions After your period of initial eligibility, you continue to be eligible so long as you are working for a contributing Employer or Employers and those Employers made contributions on your behalf for at least one hundred fifteen (115) hours in one month. You are then eligible the first day of the month following a twomonth accounting period in which the hours were worked. For example, because the contributions for hours worked in any month are not made to the Plan until the following month, your current work earns future eligibility as follows: Contribution Month Work Performed During….. Eligibility Month Determines Eligibility For….. January February March April May June July August September October November December April May June July August September October November December January February March Reserve Accumulation Account “Hour Bank” After initial eligibility all hours worked in excess of the one hundred fifteen (115) credited hours per month required thereafter for continued monthly eligibility will be credited to your individual Hour Bank. Accumulated hours in your Hour Bank allow you to continue your eligibility during periods of unemployment and underemployment. The Hour Bank maximum can afford you up to six (6) months of eligibility. If you become ineligible for more than thirtysix (36) months any accumulated bank hours will become forfeit. Self-Payment of Contributions After becoming initially eligible, you may be allowed to make selfpayments of contributions if you are in danger of losing eligibility due to a period of unemployment. To be eligible to make self-payments, you must be available August 2014 Section II - Eligibility Rules Page 2 IBEW Local No. 461 Welfare Fund Summary Plan Description for work at covered employment in the Industry with an Employer who participates in this Fund. If your monthly contributions are less than the required one hundred fifteen (115) any available hours in your hour bank are utilized and then you can self-pay the difference based on the number of hours short at the current contribution rate. Self-payments must be received at the Fund Office within ten (10) days of the date the Termination Notice is received by you. All Notices are sent by first class mail to the last known address on file at the Fund Office so it is important that any address changes are reported immediately. Eligibility by means of self-payments can be continued for no more than twelve (12) consecutive Benefit Months, whether or not the self-payment is full or partial. After your right to make self-contributions is exhausted, you may be able to elect COBRA Continuation Coverage at a self-contribution level based on the actual cost of coverage to the Plan. This is allowed for a maximum of twentyfour (24) months. When you are eligible by self-payments, you and your eligible Dependents are covered by the same benefits as all other Employees; all normal Plan provisions apply. Participation Agreements for Non-Bargaining Unit Participants Employers, that have executed a Participation Agreement, must contribute at the prescribed rate as determined by the Board of Trustees for all full time (as defined in their Participation Agreement) Non-Bargaining Unit Employees regardless of the number of actual hours worked by such Employees. Employers are required to remit fringe benefit contributions by the fifteenth (15th) of the month with all regular Monthly Payroll Reports. Eligibility will begin on the first day of the second calendar month after the employer has contributed the required contributions on the Participant’s behalf. The participant will remain eligible so long as the employer continues to remit the required contributions per month for all applicable employees in accordance with payment requirements. August 2014 Section II - Eligibility Rules Page 3 IBEW Local No. 461 Welfare Fund Summary Plan Description Delinquent contributions for all non-bargained employees must be received prior to the first day of the month for which all such coverage is being provided or coverage will cease and will not be reinstated. Eligibility ceases on the first day of the calendar month following the last month for which coverage was provided by the contribution received from the Employer. Non-Bargaining Unit Participants are not eligible for Loss of Time Benefits. Self-Pay When Disabled If a Participant is prevented from engaging in covered employment by total disability, he will be allowed to make self-payment of contributions for up to twelve (12) consecutive Benefit Months. The self-payment amount is determined by the Board of Trustees. Continuation of Eligibility During Disability If you become disabled and are unable to perform covered employment while you are eligible in this Plan, you must either utilize your banked contributions or remit self-payments to maintain eligibility. All disability absences will be considered a single disability unless: 1. You return to active covered employment for at least one day and you submit evidence satisfactory to the Trustees that the cause(s) of the latest disability absence cannot be connected with the cause(s) of any prior disability absences, or 2. You return to active covered employment for at least two weeks even though a connection can be established between the cause(s) of two successive disability absences. The Trustees retain the right to have you medically examined by a physician of their own choice at the Plan’s expense to determine whether a disability qualifies under this Rule. August 2014 Section II - Eligibility Rules Page 4 IBEW Local No. 461 Welfare Fund Summary Plan Description Total and Permanent Disability In order for you to be eligible to make self-payments when totally and permanently disabled, you must: 1. Be totally and permanently disabled on or after January 1, 1992, and so unable to perform any work for remuneration or profit on the date you would otherwise lose eligibility under these Rules, and 2. Be awarded a disability benefit from the Social Security Administration, and 3. Have a minimum of five (5) years of continuous eligibility in this Plan prior to the disability. This self-payment provision applies to the Employee coverage and your Dependents (if any) until the earlier of: 1. The date you are eligible in any other group health care plan; or 2. The date you are no longer totally disabled, or 3. The date you become eligible for Medicare, When you are covered by a total and permanent disability self-payment, you are not covered by Weekly Accident and Sickness (Loss of Time) Benefits. Self-Payment You will be required to make self-payments in the amount equal to the self-payment rate(s) established for active participants. Work Outside Trust Fund Jurisdiction - Reciprocity Once you are eligible in this Fund, the Trustees of this Fund have entered into contracts known as Reciprocity Agreements with the Trustees of similar IBEW Welfare Funds which, once you are eligible in this Fund, may allow contributions you earn for work in IBEW jurisdictions outside the jurisdiction of this Trust Fund to be transferred for eligibility credit in this Fund. If you plan to work at covered employment outside the jurisdiction of this Fund, you should contact the IBEW Local 461 Union Office to ask whether you would be allowed to transfer contributions for that work. All reciprocity transfers are processed through the Electronic Reciprocal Transfer System (ERTS). All participants are required to file a reciprocity form through the Internet via their Local Union. Please contact the Local Union for more information. August 2014 Section II - Eligibility Rules Page 5 IBEW Local No. 461 Welfare Fund Summary Plan Description You are not allowed to transfer contributions to establish initial eligibility under this Plan unless you are a Local 461 member. TERMINATION OF ELIGIBILITY FOR EMPLOYEES DEPENDENTS WHEN ENTERING MILITARY SERVICE AND THEIR An Employee’s or Dependent’s eligibility ceases the date he is inducted into the Armed Forces of the United States. When you are inducted, your Dependents’ eligibility terminates on the last day of the Benefit Month in which the induction occurs. You and your dependents may be eligible to remit up to 18 months of COBRA payments to maintain your coverage under the Fund, (please contact the Fund Office for more information). Your accumulated eligibility, if any, will be kept on the records of the Fund, provided you notify the Fund Office in writing that you are entering the Armed Forces of the United States. Such accumulated eligibility will be made available to you upon discharge and return to work for a contributing Employer. If covered employment is available and you are physically fit, you must return to work for a contributing Employer within ninety (90) days after a discharge to retain your rights to your eligibility; then your eligibility and that of your Dependents, if any, is then reinstated on the day you return to work for a contributing Employer. If you fail to return to work for a contributing Employer within ninety (90) days from the date you are discharged, you must again satisfy the Initial Eligibility requirements of these Rules. Reinstatement of Eligibility Employees If you once establish eligibility under this Plan and lose that eligibility at a later date, you will be reinstated when you meet the requirements under “Continuation of Eligibility” (page 1) in these Rules, provided you remain ineligible for at least one month. If you remain ineligible more than thirty-six (36) months, you must meet the requirements under “Initial Eligibility” in these Rules to become eligible again. August 2014 Section II - Eligibility Rules Page 6 IBEW Local No. 461 Welfare Fund Summary Plan Description RETIREE PROGRAM Coverage Classifications Defined Employees eligible to participate in the Retiree Program and their eligible Dependents, if any, are covered under one of two benefit classes, depending on whether the covered person is also eligible for Medicare. Class B: Coverage for Employees and/or eligible Dependents who are NOT eligible for Medicare Class C: Coverage for Employees and/or eligible Dependents who ARE eligible for Medicare (Medicare coverage includes both Part A & B) For example, you and your spouse would both be covered under Class B if neither of you are eligible for Medicare. If you are eligible for Medicare and your Spouse is not, you would be eligible in Class C and your spouse would be eligible in Class B. General Eligibility Requirements Each normal or early retired Employee may continue coverage for himself and his Dependents through this Plan under the Retiree Program provided he meets all of the following requirements: 1. He is at least fifty-five (55) years old; and 2. He has been eligible in this Plan at least sixty-four (64) of the eighty (80) coverage months immediately prior to his request for coverage under this Retiree Program; and 3. He is eligible in this Plan at the time of his retirement. If you are eligible to participate in the Retiree Program, you must exercise that option when first eligible to do so. If you do not exercise your option to participate in the Retiree Program immediately upon retirement, you will not be allowed to begin participation at a later date. The rate of self-payment for retirees between ages fifty-five (55) and sixty-two (62) will be based upon one hundred fifteen (115) hours per month at the current contribution rate. August 2014 Section II - Eligibility Rules Page 7 IBEW Local No. 461 Welfare Fund Summary Plan Description The rate of self-payments for retirees over age sixty-two (62) will be determined by the Board of Trustees. Please contact the Fund Office for the applicable rate. Self-Payment of Contribution If the participant is age sixty-two (62) to sixty-five (65) in Class B coverage, the rate established by the Board of Trustees will provide coverage for the participant and his dependents. If the participant is eligible for Medicare and his spouse is sixty-two (62) to sixty-five (65), the participant has no self-payment and is in Class C coverage; however, the spouse must pay the rate established by the Board of Trustees to maintain coverage. If the participant is eligible for Medicare but the spouse is not yet sixty-two (62), the participant has no selfpayment for Class C coverage but for coverage for the spouse must pay the full self-payment rate of one hundred (115) hours per month at the current collective bargaining rate to maintain continuous coverage. The self-payment amounts required for eligibility in the Retiree Program are those determined by the Trustees to be necessary to run the Plan. Selfpayments must be received at the Fund Office on or before the first day of the coverage month for which the payment is due. You will receive only one Notice describing the self-payment procedure; you are responsible for making subsequent monthly payments on time and without further Notice. All Notices are sent by mail to the last known address on file at the Fund Office so it is important that any address changes are reported immediately. Self-payments are required on a monthly basis. A change in coverage circumstances (such as eligibility for Medicare) will re-determine the covered person’s Coverage Class effective the first day of the calendar month co-incident with or next following the date the change in circumstance occurs. Benefit Limitations All normal Plan provisions apply to Retiree Program coverages. Employees and their Dependents eligible in Class B are not covered for: 1. Weekly Accident and Sickness Benefits (Loss of Time Benefits) Employees and their Dependents eligible in Class C are not covered for: 1. Weekly Accident and Sickness Benefits (Loss of Time); or 2. Dental Care or Vision Care Benefits August 2014 Section II - Eligibility Rules Page 8 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. Excess Risk Insurance (stop loss). Please see the Schedule of Benefits and the Benefits Section as described for more information. EFFECTIVE DATES OF COVERAGE Employees Your effective date of coverage as an Employee will normally be the date you satisfy the requirements of the Eligibility Rules. Dependents Your effective date of coverage as a Dependent will be the date the Employee who sponsors you becomes eligible or the date you first satisfy the definition of Dependent, whichever is later. TERMINATION DATES OF COVERAGE Employees Your coverage as an Employee under all benefit provisions of the Plan terminates when the earliest of the following events occurs: 1. Failure to meet the requirements for continuing eligibility as shown in the Eligibility Rules, including a failure to make any selfpayments of contributions in a timely manner; 2. Termination of the coverage classification under which you were continuing your eligibility; 3. Induction into the Armed Forces of the United States, except for temporary duty of thirty (30) days or less; 4. Termination of the Plan itself. Dependents Your coverage as a Dependent under all benefit provisions of the Plan terminates when the earliest of the following events occurs: 1. Termination of eligibility for the Employee who sponsors you (for reasons other than the receipt of a Maximum Amount Payable); August 2014 Section II - Eligibility Rules Page 9 IBEW Local No. 461 Welfare Fund Summary Plan Description 2. On the first of the month next following the date you fail to meet the definition of Dependent; 3. Induction into the Armed Forces of the United States, except for temporary duty of thirty (30) days or less; The surviving spouse of an eligible retiree will be eligible under the same provisions as his/her spouse until he/she either remarries, or becomes eligible for Medicare, or is covered under another Plan. General Provisions Change of Eligibility Rules The Trustees, at their discretion, are empowered to change or to amend these Eligibility Rules at any time. A Note of Explanation The Eligibility Rules represent the requirements which must be satisfied for you and your dependents to become and to remain eligible for benefits from this Plan. In the event the requirements are not satisfied, eligibility is lost and benefits are not payable. The Trustees reserve the right to deny benefits to any claimant who is, in their opinion, attempting to subvert the purpose of the Plan or who does not present a bona fide claim. Remember: Changes in employment may have an effect on Employer contributions paid on your behalf. For example, Employer contributions may cease in the event you: 1. Change job classifications from covered to non-covered employment, even if that employment is with the same employer; or 2. Change employment from a participating to a non-participating Employer. You and your dependents may obtain, upon written request to the Union Office, information as to the address of a particular Employer and whether that Employer is required to pay contributions to the Plan. August 2014 Section II - Eligibility Rules Page 10 IBEW Local No. 461 Welfare Fund Summary Plan Description Health Insurance Portability and Accountability The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before you enroll. Under the law, a pre-existing condition exclusion generally may not be imposed for more than twelve (12) months (eighteen [18] months for late enrollees). The twelve (12) month (or eighteen [18] month) exclusion period is reduced by your prior health coverage. You are entitled to a certificate that will show evidence of your prior health coverage. If you buy health insurance other than through an employer group health plan or other source, a certificate of proof of coverage may help you obtain coverage without a pre-existing condition exclusion. If you have questions about your rights under ERISA, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington D.C., 20210. You have a right to receive a certificate of prior health coverage since July 1, 1996. You may need to provide other documentation for earlier periods of health care coverage. Check with your new Plan Administrator to see if your new Plan excludes coverage for pre-existing conditions and if you need to provide a certificate or documentation of your previous coverage. To receive a certificate, please contact the Fund Office. Family and Medical Leave You may be eligible for up to twelve (12) weeks of unpaid, job protected leave for certain family and medical reasons under the Family and Medical Leave Act of 1993. You are eligible under the Act if: 1. You are employed by an employer with at least fifty (50) employees at your work site or with at least fifty (50) employees within a seventyfive (75) mile radius of your work site; and 2. You have been employed by the employer at least twelve (12) months; and 3. You have worked at least one thousand, two hundred fifty (1,250) hours for the employer during the twelve (12) months immediately before the requested leave. Your employer determines whether you are eligible for family or medical leave under the Act, not this Plan or its Trustees. August 2014 Section II - Eligibility Rules Page 11 IBEW Local No. 461 Welfare Fund Summary Plan Description Both you and your employer are required to notify the Fund Office if you take a family or medical leave and to provide certain other information as required by the Trustees. Your coverage in the Plan will continue during the period of your family or medical leave, provided self-payments are made or your employer makes contributions to the Plan at the same rate and in the same amount as if you were continuously employed during the period of your leave and fully complies with all requirements established by the Trustees. Cobra Continuation Coverage This section is intended to explain to you and your eligible dependents, in a summary fashion, about rights and obligations under the Continuation Coverage provisions of the Consolidated Omnibus Budget Reconciliation Act, or “COBRA.” You, your spouse (if any), and your dependents (if any) should take time to read this section carefully. Certain terms are used in this section and are defined as follows: Continuation Coverage – the coverage available to you and your family in the event you lose eligibility due to a Qualifying Event. If you elect Continuation Coverage, the Plan must provide coverage which, as of the time such coverage is provided, is identical to the coverage provided for other similarly situated beneficiaries for basic hospital, medical, and surgical benefits. Burial Benefits and Accidental Death and Dismemberment Benefits are not provided. Qualified Beneficiary – an individual who is covered under the Plan on the day before a Qualifying Event, as well as a newborn child or child placed for adoption with you during the period of Continuation Coverage. Qualified Beneficiaries are you, your spouse or your dependant child(ren). Qualifying Event – an event that causes you and/or your family to lose coverage under the Plan. The specific events which are Qualifying Events for you, your spouse and/or your children are explained in detail in the following sections. Depending on the Qualifying Event, Continuation Coverage is available for eighteen (18), twenty-nine (29) or thirty-six (36) months. Employee Right to Elect Continuation Coverage You, as a Qualified Beneficiary, have the right to choose Continuation Coverage if you lose eligibility for coverage under the Plan due to a reduction in the amount of employer contributions remitted or termination of employment for any reason, unless termination is due to gross misconduct on your part. Either of those circumstances is what is known as a “Qualifying Event” for you, as an employee. These Qualifying Events entitle you and/or your family to elect eighteen (18) months of Continuation Coverage. August 2014 Section II - Eligibility Rules Page 12 IBEW Local No. 461 Welfare Fund Summary Plan Description The Trustees, through the Fund Office, determine when a Qualifying Event occurs as a result of a reduction of employer contributions or a termination of employment based on information contained on submitted employer contribution forms. The Fund Office will determine when the COBRA Qualifying Event has occurred within one hundred twenty (120) days following receipt of the employer contribution form. The Fund Office will mail the COBRA election notice within sixty (60) days after it has determined that you or a qualified beneficiary has lost eligibility for coverage. You have sixty (60) days from the date you receive the election notice to elect to receive Continuation Coverage. If you do not make an election for coverage within sixty (60) days, you no longer have a right to receive Continuation Coverage. If you qualify for Continuation Coverage under COBRA but do not elect such coverage for your entire family, your spouse and/or dependent children are still entitled to elect Continuation Coverage for themselves. Your Spouse’s Right to Elect Continuation Coverage Spouses of employees or Retired Participants covered under the Plan, as Qualified Beneficiaries, have the right to choose Continuation Coverage for themselves if they lose their group health care coverage under the Plan for any of the following reasons: Termination of your employment (for reasons other than gross misconduct), or a reduction in the hours worked by you which results in your losing eligibility under the Fund; Your death if you are a participant in the Plan; Divorce or legal separation from you; or You become entitled to Medicare and are not eligible to continue coverage for your spouse under another portion of the Plan or choose not to continue such coverage. These reasons are known as Qualifying Events for your spouse. The first Qualifying Event entitles your spouse to elect eighteen (18) months of Continuation Coverage. The other Qualifying Events would entitle your spouse to elect thirty-six (36) months of Continuation Coverage. August 2014 Section II - Eligibility Rules Page 13 IBEW Local No. 461 Welfare Fund Summary Plan Description Your Dependent Children’s Right to Elect Continuation Coverage All of your dependent children covered under the Plan, as Qualified Beneficiaries, have the right to Continuation Coverage if they lose their eligibility for coverage under the Plan for any of the following five reasons: Termination of their parent’s employment (for reasons other than gross misconduct) or a reduction in the number of hours worked by their parent, who is the covered Employee under the Plan; Death of the parent, who is the covered employee under the Plan: Divorce or legal separation of their parents; You become entitled to Medicare and either are not eligible to continue coverage for the children or choose not to continue such coverage; or The child or children cease to satisfy the Plan’s definition of a “dependent child.” These reasons are known as Qualifying Events for your dependent children. The first Qualifying Event entitles your dependant child (ren) to elect eighteen (18) months of Continuation Coverage. The other Qualifying Events would entitle your dependant children to elect thirty-six (36) months of Continuation Coverage. A newborn or adopted child will automatically be extended COBRA coverage if the parents already have COBRA coverage. This may involve an increase in the COBRA premium charged. A newborn child or an adopted child (or the child’s custodian or guardian) has a right; separate from his or her parents to elect Continuation Coverage for eighteen (18) or thirty-six (36) months, depending on the Qualifying Event, even if the child’s parent(s) do not elect Continuation Coverage. Continuation Coverage for Disabled Persons If you, as a covered employee, your spouse, or any dependent child, as Qualified Beneficiaries, qualify for Social Security disability benefits at the time of a Qualifying Event that entitles the Qualified Beneficiary to elect eighteen (18) months of Continuation Coverage (or any time during the first sixty (60) days after you lose coverage due to a Qualifying Event), you may purchase up to an additional eleven (11) months of Continuation Coverage (or a total of twentynine [29] months). August 2014 Section II - Eligibility Rules Page 14 IBEW Local No. 461 Welfare Fund Summary Plan Description This additional Continuation Coverage may be purchased not only for the disabled person but also for other eligible family members who are not disabled (subject to the applicable premium). To obtain this additional Continuation Coverage, the Qualified Beneficiary must be determined eligible for Social Security disability benefits before the end of the eighteen (18)-month Continuation Coverage period and must notify the Fund Office during the eighteen (18) month period and within sixty (60) days after the Social Security Administration awards Social Security benefits to the disabled person. The Fund is permitted to charge a higher premium (up to one hundred fifty percent [150%] of the regular COBRA premium) for the additional eleven (11) months of Continuation Coverage available to disabled persons and their families. The higher premium applies to the disabled person and for other family members who opt for additional COBRA coverage. Eligibility for extended Continuation Coverage because of disability ends the first day of the month that is more than thirty (30) days after the date that the person is determined under the Social Security Administration to be no longer disabled. Federal law requires a disabled person to notify the Fund within thirty (30) days of a final Social Security Administration determination that they no longer are disabled. Employee Obligations to Notify the Fund Office of a Qualifying Event Under COBRA, you or a family member must notify the Fund Office immediately about a divorce, legal separation, or a child losing dependent status under the Plan. If such an event is not reported to the Fund Office within sixty (60) days after it occurs, Continuation Coverage will not be permitted. Your surviving spouse (or dependent child) should contact the Fund Office immediately after your death. This assures that Continuation Coverage is offered to your surviving spouse and children at the earliest possible date. The law requires the COBRA election notice to be sent to the last known address on file at the Fund Office. If the election notice is sent to the wrong address due to your failure to notify the Fund Office about a change in address, the sixty (60) day time limit will not be extended and you may lose the opportunity to elect COBRA. August 2014 Section II - Eligibility Rules Page 15 IBEW Local No. 461 Welfare Fund Summary Plan Description You are also required to notify the Fund Office if you or any family members are covered under another group health care plan at the time you received a COBRA election notice (e.g., if you are covered as a dependent under your spouse’s plan) or if you elect Continuation Coverage, at any time you or a family member later becomes covered under another group health care plan, including Medicare. The Fund Office may require you to provide information about your coverage under another group health care plan. The Fund may seek reimbursement directly from you if medical expenses are paid by the IBEW Local 461 Welfare Fund through Blue Cross Blue Shield of Illinois because you or your dependents do not notify the Fund of other health care coverage. Second Qualifying Events The following rules concerning the occurrence of a second Qualifying Event only apply if the original Qualifying Event was termination of the employee's employment (for reasons other than gross misconduct) or reduction in the number of hours worked by the employee. If a second Qualifying Event should occur during the eighteen (18) months of coverage available as a result of the first Qualifying Event [or, twenty-nine [29] months if the eleven (11) month extension due to disability applies], then you may purchase additional Continuation Coverage for up to a total of thirty-six (36) months. An example of a second Qualifying Event would be: Death of the employee, if he or she is a covered employee under the Plan; Divorce or legal separation of the employee and his/her spouse; The employee, if a covered employee under the Plan, becomes enrolled in by Medicare (Part A, Part B, or both); or For dependent children, the dependent child ceases to satisfy the Plan's definition of a "dependent child” (The rules for second qualifying events also apply to newborn or adopted children.) This thirty-six (36) months total of Continuation Coverage available when a second Qualifying Event occurs includes the number of months you have already been covered under Continuation Coverage because the first Qualifying Event. The thirty-six (36) month total is not in addition to any months of Continuation Coverage you have already had because of the first Qualifying Event. The Plan Administrator must be notified within sixty (60) days of the second Qualifying Event or the additional extended coverage will not be allowed. August 2014 Section II - Eligibility Rules Page 16 IBEW Local No. 461 Welfare Fund Summary Plan Description Proof of Insurability is Not Necessary to Elect Continuation Coverage You and your family members do not have to show that you are insurable to purchase Continuation Coverage; however, you must make the required selfpayment(s) for such coverage in accordance with specific due dates. The amount(s) and the due date(s) will be shown on the COBRA election notice. Procedure for Obtaining Continuation Coverage Once the Fund Office knows that an event has occurred which qualifies you or other family members for Continuation Coverage, the Fund Office will attempt to notify you or your family member of their rights to elect Continuation Coverage. Once you receive this election notice, you will have sixty (60) days after the date on the election notice within which to notify the Fund Office whether or not you want the Continuation Coverage. If you do not elect the coverage within the sixty (60) day time period, your right to continue your continuation coverage will end. Termination of Continuation Coverage The law provides that Continuation Coverage may be cancelled by the Fund for any of the following reasons: 1. The Fund no longer provides group health care coverage to any Employees 2. The required self-payment for Continuation Coverage is not paid on time 3. The person remitting Continuation Coverage payments becomes covered under any group health care plan, after the Qualifying Event, that does not include a pre-existing condition exclusion 4. The person remitting Continuation Coverage payments becomes entitled to Medicare. Although your Continuation Coverage may be canceled as soon as you are covered by Medicare, a spouse or dependent child receiving Continuation Coverage at that time may continue purchasing such coverage for up to eighteen (18) or thirty-six (36) months minus any months of Continuation coverage received immediately prior to your coverage under Medicare. This option applies only if a spouse or dependent child is not also covered by Medicare. August 2014 Section II - Eligibility Rules Page 17 IBEW Local No. 461 Welfare Fund Summary Plan Description QUALIFIED MEDICAL CHILD SUPPORT ORDERS The Omnibus Budget Reconciliation Act of 1993 requires that group health plans recognize and comply with “Qualified Medical Child Support Orders.” This document sets forth the Fund’s procedure for processing medical child support orders that are claimed to be Qualified Medical Child Support Orders. Receipt of Order The Fund Office shall promptly notify the participant and each alternate recipient (i.e., a person to receive benefits according to the Order) of the Order’s receipt and the Fund’s procedures for determining whether a medical child support order is a Qualified Medical Child Support Order. The Fund Office shall forward a copy of the order to Fund Counsel. Determination of Qualification Within a reasonable period after receipt of such Order, the Plan Administrator, with the assistance of the Fund Counsel, shall determine whether such order is a qualified medical child support order and notify the participant and each alternate recipient of such determination. The procedures to determine whether medical child support orders are qualified medical child support orders shall follow the criteria established by Section 609 of the Employee Retirement Income Security Act of 1974, as amended and any applicable regulation and administration actions by agencies charged to enforce Section 609. Those criteria include: 1. Inclusion of the order in a judgment order or decree made pursuant to state domestic relations law or is made pursuant to state domestic relations law or made pursuant to a law relating to medical child support described in 42 U.S.C. 1396g issued by a court of competent jurisdiction or administrative process that has the force or effect of law in the state issuing the order. 2. Creation, assignment or recognition of the right of an alternate recipient to receive Fund benefits to which a participant or a beneficiary is entitled. 3. Whether the alternate recipient is a child of the participant or a child adopted by or placed for adoption with a participant. August 2014 Section II - Eligibility Rules Page 18 IBEW Local No. 461 Welfare Fund Summary Plan Description 4. Inclusion of the name and last known mailing address of the affected participant and the name and last known mailing address of the alternate recipient. 5. Inclusion of a description of the type of coverage to be provided by the Fund or the manner in which such coverage is to be determined. 6. Identification of the period for which the order applies. 7. Identification of the Fund as the plan to which the order supplies. 8. Verification that the order does not require the Fund to provide benefits or a form of benefits other than one provided by the Fund, provided that the Fund shall satisfy requirements of applicable laws relating to medical child support described in 42 U.S.C. 1908. Effect of National Medical Support Notices The Fund shall recognize as Qualified Medical Child Support Orders “National Medical Support Notices” that comply with the provisions of applicable final regulations effective March 27, 2001. Status of Alternate Recipients Alternate Recipients shall be deemed Fund participants for purposes of applicable reporting and disclosure requirements and shall be treated as Fund beneficiaries for all other purposes. Direct Payments Payments for benefits or claims for reimbursements made by Alternate Recipients under Qualified Domestic Child Support Orders shall be made to the Alternate Recipients or their legal guardians as applicable. Notification Issues The Fund Office shall notify an Alternate Recipient or the Alternate Recipient’s legal guardian of its determination concerning a medical child support order which is claimed to be a Qualified Medical Child Support Order within a reasonable time after receipt. Alternate Recipients shall be entitled to designate a representative for the receipt of copies of notices that are sent to the Alternate Recipient with respect to a medical child support order. The custodial parents or guardians of minor Alternate Recipients shall be considered their designated representatives absent an express written request of other representatives. August 2014 Section II - Eligibility Rules Page 19 IBEW Local No. 461 Welfare Fund Summary Plan Description GENERAL DEFINITIONS Accident An Accident must contain some degree of unexpected violence, such as a fall, blow, laceration, contusion, or abrasion. Accidental Bodily Injury and Sickness Accidental Bodily Injury and Sickness, with respect to a covered person, does not include accidental bodily injury or sickness which arises out of or in the course of employment, except that this provision shall not apply to the Death Benefit. Ambulatory Surgical Center An Ambulatory Surgical Center is a free standing facility, which is wholly owned and operated by a hospital on the same basis as the outpatient department of its main facility or a legally constituted institution, which meets all of the following requirements: 1. Is established, equipped and operated primarily for the purpose of performing surgical procedures; and 2. Operates under the supervision of one or more physicians as defined by the Plan; and 3. Is equipped with at least two operating rooms, at least one post-anesthesia recovery room, and has the ability to perform diagnostic X-ray and laboratory procedures as required in conjunction with the surgery to be performed; and 4. Continually provides nursing services by registered nurses for patient care in the operating rooms and the postanesthesia recovery room(s); and 5. Is licensed by the appropriate State agency and is recognized by the local medical society. Behavioral Disorders Behavioral Disorders include but are not limited to: Attention Deficit Disorder August 2014 General Definitions Page 20 IBEW Local No. 461 Welfare Fund Summary Plan Description Childhood Disorders-treatment of reading or learning disorders or developmental disability Counseling for adoption, custody, family planning, pregnancy, or catastrophic illness diagnosis in the absence of psychiatric diagnosis generally recognized and accepted by the medical profession such as the American Psychiatric Association’s Diagnostic and Statistical Manual of psychiatric diagnosis. Court-Ordered Confinement – Any confinement of a Covered Person in a public or private institution as the result of a court order. Educational or Vocational Testing or Training – Testing and/or training for educational purposes or to assist an individual in pursuing a trade or occupation. Custodial Care Custodial Care means care, services or supplies, which are furnished mainly to train or to assist in personal hygiene or other activities of daily living, rather than to provide therapeutic treatment. Care, services or supplies will also be considered “custodial” if they can be safely and adequately provided by persons who do not have the technical skills of a covered health care provider. Dental Hygienist Dental Hygienist means a person who is currently licensed (if licensing is required in the State) to practice dental hygiene by the governmental authority having jurisdiction over the licensing and practice of dental hygiene and who works under the supervision of a Dentist. Dentist Dentist means a person who is currently licensed to practice dentistry by the governmental authority having jurisdiction over the licensing and practice of dentistry. Diagnosis Diagnosis refers to the statement of the medical condition requiring the care of a physician. August 2014 General Definitions Page 21 IBEW Local No. 461 Welfare Fund Summary Plan Description Elective or Voluntary Sterilization Elective Sterilization is sterilization not medically required but requested by the patient and will include among others, vasoligation, vasectomy, salpingectomy, and tubal ligation. Eligibility Rules The Eligibility Rules shall apply to Active Employees and their Dependents, Totally and Permanently Disabled Employees and their Dependents, and Self-Pay Employees and their Dependents and Retirees and their Dependents. Eligible Dependents Eligible Dependents are the following: 1. The legal spouse of the eligible Employee provided he/she is not legally separated from the eligible Employee; or 2. Any natural child of the eligible Employee and the legal spouse if: a. the child is less than nineteen (19) years old, excluding a person who would otherwise be entitled to benefits under this Plan as an Employee; or b. the child is less than twenty-six (26) years of age, will be considered an Adult ; or c. the child is over twenty-six (26) years of age and he/she is totally and permanently disabled because of a qualifying physical handicap or mental retardation. To be considered a qualified physical handicap or mental retardation under this definition, it must: 1) occur before the child reaches age twenty-six (26); and 2) be certified by a Physician; and 3) render the child incapable of self-sustaining employment so as to make the child dependent upon the parents for financial support and maintenance. Initial proof of such disability and financial dependency must be furnished to the Trustees August 2014 General Definitions Page 22 IBEW Local No. 461 Welfare Fund Summary Plan Description within sixty (60) days of the child's reaching twenty-six (26) years of age. Subsequent proofs may be required by the Trustees after the child reaches twenty-six (26), but not more frequently than annually. 3. Your natural child, provided the child's surname is the same as the eligible employee; a legally adopted child; including the legally required trial period prior to the approval of the adoption by a court. In order to qualify under the definition of an eligible dependent the following conditions must be met: a. the Employee contributes more than fifty percent (50%) toward the maintenance and support of the child; and b. legal documentation is presented, upon request, supporting the Dependent's status. It is understood that coverage of a dependent child may also be established in those cases where the Welfare Fund has received a "Qualified Medical Child Support Order" (QMCSO) entered by an appropriate court as defined under applicable federal law. Normally, such an order will be issued in a divorce or other family law action, which recognizes the child's right to health benefits under the Plan. The term Eligible Dependent does not include a child delivered by a female other than the eligible employee or the eligible employee’s legal spouse, unless: a. A blood test is performed to prove that the child was actually fathered by the member, and a certified copy of the birth certificate or b. The Fund is provided with a Qualified Medical Child Support Order (QMCSO) which indicates the member is to maintain health coverage for the dependent. Dependent coverage terminates on the date: 1. The qualifying disability ceases; or 2. The QMCSO terminates; or August 2014 General Definitions Page 23 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. The Employee's coverage is terminated; or 4. The first day of the following the month in which the dependent reaches the age twenty-six (26). If one spouse is covered under the Plan pursuant to the terms of a Collective Bargaining Agreement and one spouse is covered under the terms of a Participation Agreement: 1. Their children may be covered as Dependents of the husband or the wife; but not both 2. Neither may be covered as the Dependent of the other at the same time. If both the husband and the wife are covered under the Plan pursuant to the terms of a Collective Bargaining Agreement: 1. Their children may be covered as Dependents of the husband and the wife; 2. One spouse may also be covered as the Dependent of the other spouse. The term Eligible Dependent does not include a child fathered by a Dependent child or delivered by a female other than the eligible Employee or the Employee's legal spouse except as previously indicated. Eligible Member An Eligible Member means any person who: (1) is working within the jurisdiction of and covered under the terms of the Collective Bargaining Agreement or NonBargaining Unit Participation Agreement entered into between the Trustees and the Employer, and (2) is eligible for benefits as set forth in the IBEW Local No. 461 Welfare Eligibility Rules. Eligible Person An Eligible Person means either the eligible Employee or such employee’s eligible Dependents. August 2014 General Definitions Page 24 IBEW Local No. 461 Welfare Fund Summary Plan Description Employee An Employee means a person, actively employed by an Employer, on whose behalf Employer contributions are required to be made. Employer Employer or Contributing Employer means any association or individual employer who has duly executed a collective bargaining agreement with the Union or a Welfare Fund participation agreement, and is required to make contributions to this Fund on behalf of its Employees. Expense Incurred Expense Incurred includes only those charges made for services and supplies, which are reasonably priced and reasonably necessary for treatment of the injury or sickness. Family Medical Leave Unpaid job protected leave of absence. Health Insurance Portability and Accountability Act Law, which limited the circumstances under which coverage may be excluded for medical conditions before your enroll. Hines & Associates Provides Case Management and Utilization Review services related to inpatient hospital admissions. Hospital A Hospital is any legally constituted institution, which meets all the following requirements: 1. Maintains permanent and full time facilities for bed care of five (5) or more resident patients; and 2. Has a doctor in regular attendance; and 3. Continually provides a twenty-four (24) hour-a-day nursing service by registered nurses; and August 2014 General Definitions Page 25 IBEW Local No. 461 Welfare Fund Summary Plan Description 4. Is primarily engaged in providing diagnostic and therapeutic facilities for medical and surgical care of injured and sick persons on a basis other than as a rest home, nursing home, convalescent home, a place for the aged, a place for drug addicts, or a place for alcoholics; and 5. Is operating lawfully in the jurisdiction where it is located. In-patient In-patient means a person who is a resident patient using and being charged for the room and board facilities of the hospital. Intensive Care Unit Intensive Care Unit means a special area of a hospital, exclusively reserved for critically ill patients requiring constant observation, which in its normal course of operation provides: 1. Personal care by specialized registered professional nurses and other nursing care on a twenty-four (24) hour per day basis; 2. Special equipment and supplies which are immediately available on a stand-by basis; and 3. Care required, but not rendered, in the general surgical or medical nursing units of the hospital. The term “Intensive Care Unit” shall also include an area of the hospital designated and operated exclusively as a Coronary Care Unit or as a Cardiac Care Unit. Medicare Government Health Insurance Program for people sixty-five (65) or older, certain disabled people under sixty-five (65), and people who have permanent kidney failure. As referred to in this document, Medicare means both Parts A & B of Medicare. Medical Equipment Medical Equipment means equipment, which meets all of the following requirements: August 2014 General Definitions Page 26 IBEW Local No. 461 Welfare Fund Summary Plan Description 1. Is primarily and customarily used to serve a medical purpose; and 2. Is generally not useful to a person in the absence of illness or injury; and 3. Is necessary and reasonable for the treatment of an illness or injury, which is covered by the terms of this Plan. To be considered “medical equipment,” a device must make a meaningful contribution to the treatment of a patient’s illness or injury or to the improved functioning of a malformed or damaged body member. Equipment, which primarily serves a comfort or convenience function for the patient or the patient’s caretaker (such as a wheelchair ramp or a vehicle lift device), is not considered “medical equipment.” N.E.C.A. National Electrical Contractors Association Optician, Optometrist and Ophthalmologist Optician, Optometrist and Ophthalmologist means any person who is qualified and currently licensed (if licensing is required in the State) to practice each such profession by the appropriate government agency or authority having jurisdiction over the licensing and practice of such a profession, and who is acting within the usual scope of his practice. Out-patient Out-patient means a person who receives hospital services and treatments, but is not an in-patient. Period of Disability Confinement Successive periods of disability or hospital confinement are considered one continuous disability and period of confinement for the purpose of determining maximum benefits payable unless: 1. The later treatment period is due to causes entirely unrelated to the causes of the prior treatment; or 2. The periods of treatment are separated by ninety (90) calendar days; or August 2014 General Definitions Page 27 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. For an Employee, a return to covered employment for at least two (2) weeks. Physician, Doctor, or Surgeon (M.D.) Physician, Doctor, or Surgeon (M.D.) includes Osteopaths, Dentists, and Podiatrists or Chiropodists when practicing within the scope of their respective licenses. A Chiropractor is not considered to be a Physician for most benefits under this Plan. A naprapath is not considered to be a Physician for benefits under this Plan. Pregnancy Pregnancy includes resulting childbirth, miscarriage, and any complications of pregnancy. Protected Health Information Information maintained by a health care provider, health plan, employer, health care clearinghouse which relates to past, present, or future physical mental health or condition of an individual that identifies the individual or which there is a reasonable basis to believe the information can be used identify an individual. or or to to Reasonable and Customary Charge Reasonable and Customary Charge is determined by uniform reference standards as adopted by the Board of Trustees. To be considered reasonable and customary, the charge by any provider for a service must be similar to the charges generally incurred for cases of comparable nature and severity by a physician of similar training and experience in that geographical area. Area means a metropolitan area, county or such greater area as is necessary to obtain a representative cross-section of providers rendering such service or furnishing such supplies. With respect to medical equipment, a charge will be considered "reasonable" only if the following requirements are met: 1. The expense of the equipment must be clearly proportionate to the therapeutic benefits ordinarily derived from its use; and August 2014 General Definitions Page 28 IBEW Local No. 461 Welfare Fund Summary Plan Description 2. The equipment may not be substantially more costly than a medically appropriate and realistically feasible alternative pattern of care; and 3. The equipment may not serve essentially the same purpose as equipment already available to the patient. Routine Physical Examination A Route Physical Examination is an examination done by a physician for screening purposes. If there is no diagnosis or symptoms presented on a claim form or itemized bill by the physician, the care will be considered routine. Sickness Sickness means a deviation from a healthy condition which: 1. Alters the state of the body; and 2. Interrupts or disturbs the performance of vital functions; and 3. Tends to undermine or weaken the constitution. Sickness does not include a limitation on or a loss of body function or a temporary indisposition, which does not progressively undermine or weaken the constitution. Sickness caused or contributed by self-abuse, such as alcoholism or intentional overdose of drugs, are generally subject to special limitations and may be excluded from coverage entirely. Skilled Nursing Care Facility Skilled nursing care facility means an institution or that part of any institution, which operates to provide convalescent or nursing care and: 1. 2. Is primarily engaged in providing to inpatients: a. skilled nursing care and related services for patients who require medical or nursing care; or b. rehabilitation services for the rehabilitation of injured, disabled or sick persons; and Has a requirement that the health care of every patient be under the supervision of a physician; and August 2014 General Definitions Page 29 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. Has a physician available to furnish necessary medical care in case of emergency; and 4. Has policies, which are developed with the advice (and with provision for review of such policies from time to time) by a group of professional personnel, including one (1) or more physicians and one (1) or more registered professional nurses, to govern the skilled nursing care and related medical or other services it provides; and 5. Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies; and 6. Maintains clinical records on all patients; and 7. Provides twenty-four hour nursing services which is sufficient to meet nursing needs in accordance with the policies developed as provided in paragraph two (2), and has at least one (1) registered professional nurse employed full time; and 8. Provides appropriate methods and procedures for the dispensing and administering of drugs and biologicals; and 9. In the case of an institution in any state in which state or applicable local law provides for the licensing of institutions of this nature; and 10. a. is licensed pursuant to such law; or b. is approved by the agency of the state or locality responsible for licensing institutions of this nature as meeting the standards established for such licensing; and Meets any other conditions relating to the health and safety of individuals who are furnished services in such institution or relating to the physical facilities thereof. Surgical Procedure Surgical procedure means certain invasive procedures, including the reduction of fractures or dislocations, in addition to recognized cutting procedures. August 2014 General Definitions Page 30 IBEW Local No. 461 Welfare Fund Summary Plan Description Totally Disabled and Total Disability Totally Disabled and Total Disability, unless otherwise specifically defined, refer to disability resulting solely from a sickness or accidental bodily injury which prevents an Employee from engaging in any occupation or employment for compensation or profit or prevents a Dependent from engaging in substantially all the normal activities of a person of like age and sex in good health and the person is eligible for Social Security Disability Benefits. A copy of the Social Security Administration Award Letter is required for proof of total disability. Trust Agreement Trust Agreement means the Agreement and Declaration of Trust establishing the IBEW Local No. 461 Welfare Fund and that instrument as may be amended from time to time. Trust Fund Trust Fund or Fund means the IBEW Local No. 461 Welfare Fund. Trustees Trustee means the Employer Trustees and the Union Trustees, collectively, as selected under the Trust Agreement, and as constituted from time to time in accordance with the provisions of the Trust Agreement. Union Union means those Unions, which have executed an Agreement of Collective Bargaining with an Employer who, in accordance with such Agreement of Collective Bargaining, participates in and contributes to the IBEW Local No. 461 Welfare Fund. August 2014 General Definitions Page 31 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 General Definitions Page 32 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION III MAJOR MEDICAL BENEFITS Introduction When you or your Dependent require hospital confinement, surgery or other eligible medical treatment, most covered expenses will be paid according to a single benefit formula known as "Major Medical Benefits". There may be some other expenses that have other benefit levels. "Treatment with Special Limitations" is explained in a separate Section of this booklet. You must contact Hines and Associates at (888) 236-2652 to pre-certify all hospital admissions. The telephone number for Hines and Associates is also on the back of your Fund ID Card. Preferred Provider Organization (PPO) This plan uses a “Preferred Provider Organization” or “PPO” known as Blue Cross Blue Shield of Illinois or “BCBSIL” to obtain medical treatment on a discounted basis. Using a PPO hospital or doctor is voluntary, but the Trustees encourage you to do so if possible because it will save money for both you and the Plan. To qualify for the discount, you must identify yourself as a PPO member, so be sure to carry and to present the Identification Card which is issued to you when you become initially eligible. Non-Preferred Provider Organization (PPO) The Plan pays sixty-five percent (65%) of the first fifteen thousand dollars ($15,000) of covered reasonable and customary expenses incurred after the deductible and one hundred percent (100%) thereafter with no overall maximum. The Deductible Amount The deductible amount is the amount that you have to pay from your own pocket before any benefits are payable. That amount, as shown in the Schedule of Benefits, generally applies to each individual person each calendar year. Maximum Deductible Amount for Families When three (3) or more people of the same family satisfy the family deductible in the same calendar year, a deductible is not required for other family members in that year. This is called the “family limit” on the deductible amount. August 2014 Section III - Major Medical Benefits Page 33 IBEW Local No. 461 Welfare Fund Summary Plan Description Co-Payment The Major Medical Benefits do not pay covered expenses in full; the amount you or your Dependent has to pay depends on the type of treatment. The Maximum Amount All payments under Major Medical Benefits are limited to the maximum amount shown in the Schedule of Benefits. The maximum amount applies to you and each of your Dependents separate on a Lifetime basis unless the Trustees grant a reinstatement of the maximum. The maximum amount paid in Major Medical Benefits by the Plan is one hundred fifty thousand dollars ($150,000) per person, per calendar year. After this point, the benefits are paid by an “Excess Risk” insurance carrier. You may be asked to re-submit medical evidence at your own expense which satisfies the Excess Risk Carrier that you or your Dependent’s claim is payable under the Plan. Co-Payment Limit for Individuals The Plan limits the out-of-pocket expense due to the co-payment requirement for most (not all) conditions per person, per calendar year. When an individual reaches the co-payment limit of one thousand, six hundred dollars ($1,600) per person and three thousand, three hundred dollars ($3,300) per family for in-network services and three thousand, one hundred dollars ($3,100) per person and six thousand, three hundred dollars ($6,300) per family for outof-network services in a calendar year, the Plan will pay one hundred percent (100%) of such person's covered expenses incurred in the rest of the year. This amount is based on eligible expenses only; it does not apply to expenses applied toward any deductibles or "Treatment With Special Limitations". THE PLAN WILL NOT CONSIDER ANY AMOUNT OVER WHAT IS CONSIDERED TO BE A REASONABLE OR CUSTOMARY CHARGE FOR ANY SERVICES RENDERED. HOSPITAL EXPENSE BENEFITS Daily Room Benefit When the Eligible Person is hospital confined, the Plan pays for each day's room and board charges up to the semi-private room rate and the reasonable and customary amount charged in the area. August 2014 Section III - Major Medical Benefits Page 34 IBEW Local No. 461 Welfare Fund Summary Plan Description Miscellaneous Charges While Confined The Plan pays for miscellaneous charges made by the hospital during the Eligible Person’s confinement. Examples of eligible miscellaneous items include: the use of an operating room, X-rays, laboratory tests, blood, drugs and medications prescribed by a physician and used while confined. Out-Patient Hospital Treatment The Plan pays for hospital charges due to treatment when the Eligible Person is not charged for a room under certain circumstances: 1. When surgery is performed at the hospital on an out-patient basis; or; 2. For emergency treatment of a non-occupational accidental bodily injury on the day of the accident or the next two following days; or 3. Tests required by the hospital prior to admission. Charges Related to Hospital Treatment The Plan pays for certain charges which are not billed by the hospital but are related to hospital treatment eligible under the Plan. Examples of related charges include: 1. Charges for professional local ambulance services for transportation to or from the hospital; and 2. Charges made by a physician, other than the operating physician or his assistant, for the administration of anesthesia by other than local infiltration; and 3. Charges made by a radiologist or pathologist. Limitations Hospital Expense Benefits are not payable for: 1. Personal conveniences or grooming items such as guest tray meals, television rental, barber or beautician services or admission kits; 2. Confinement, which is not medically necessary, including early admission or late discharge and confinement related to August 2014 Section III - Major Medical Benefits Page 35 IBEW Local No. 461 Welfare Fund Summary Plan Description elective surgical procedures such as sterilization reversal procedures or cosmetic surgery. Hospital Expense Benefits may be subject to additional exclusions and limitations for some conditions; see the Treatment with Special Limitations section. Hospital Expense Benefits are also subject to all General Plan Exclusions and Limitations. HOSPITAL PRE-ADMISSION TESTING Benefits will be payable if you or your eligible Dependent undergoes diagnostic tests and X-rays in a hospital's out-patient department prior to actual admission to the hospital for treatment of the condition which makes the tests necessary provided: 1. The tests or x-rays are otherwise eligible expense under the Hospital Expense Benefit; and 2. The patient is scheduled for subsequent admission to the hospital for treatment of the condition which makes the tests necessary, and 3. The tests are ordered by a physician. Amounts paid for Pre-Admission Testing will be applied to the maximum Hospital Miscellaneous charges for that confinement. However, in the event that the scheduled admission does not take place, the testing may still be covered if the admission is postponed or canceled for one or more of the following reasons: 1. The tests show a condition requiring medical treatment prior to admission; or 2. A medical condition is developed that delays the admission; or 3. A hospital bed is not available on the scheduled date of admission; or 4. The tests indicate that, contrary to the attending physician's expectation, the admission is not necessary. August 2014 Section III - Major Medical Benefits Page 36 IBEW Local No. 461 Welfare Fund Summary Plan Description Pre-Admission Testing Benefits are also subject to all General Plan Exclusions and Limitations. SURGICAL EXPENSE BENEFITS When a surgical procedure is performed on you or your Dependent for treatment of a non-occupational sickness or accidental bodily injury, the Plan will pay the surgical fee charged by a physician up to the reasonable and customary amount charged in the area and as described in this section. "Surgical procedure" means certain invasive procedures, including the reduction of fractures or dislocations, in addition to recognized cutting procedures. Surgical procedures may be performed in a hospital, physician's office or elsewhere. Surgical benefits include charges for necessary and related pre- and post-operative care and any anesthetic customarily administered by the surgeon. When a mastectomy is considered an eligible surgical procedure under the Plan, the Plan will also provide benefits for: 1. reconstruction of the breast on which the mastectomy has been performed; 2. reconstruction of the other breast to produce a symmetrical appearance; and 3. prostheses and treatment of physical complications of mastectomy, including lymphedemas (swelling of the lymph vessels or lymph nodes). Limitations Surgical Expense Benefits are not payable for: 1. Dental work or treatment, except as specifically provided; or 2. Elective cosmetic or plastic surgery procedure such as rhinoplasty or breast augmentation. Breast reduction (reduction mammoplasty) may be considered an eligible expense in certain cases which are determined to be "medically necessary. Examples of medical necessity include: severe skin disorder (such as rash or ulceration under the breast) and/or severe musculoskeletal symptoms (such as back pain or shoulder disfiguration) which generally requires that no less than five hundred fifty (550) grams of tissue be August 2014 Section III - Major Medical Benefits Page 37 IBEW Local No. 461 Welfare Fund Summary Plan Description removed from each breast; breast reconstructive surgery in connection with a mastectomy is covered for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and physical complications for all stages of mastectomy; or 3. Cosmetic or reconstructive surgery which is not necessary for prompt repair of an accidental bodily injury, which occurs while the patient is eligible. Charges by an assistant surgeon will be considered as a covered expense provided his assistance is considered medically necessary. Surgical Expense Benefits are also subject to all General Plan Exclusions and Limitations. SECOND SURGICAL OPINION BENEFITS When you or your Dependent wishes to secure a second opinion regarding the medical necessity or an in-patient surgical procedure of a non-emergency nature, the Plan will pay the physician's fee and related expenses provided: 1. You or your Dependent is examined in person by a board certified specialist; and 2. The specialist submits a written report of his findings and recommendation; and 3. The specialist physician who renders the second surgical opinion does not also perform the recommended surgical procedure. Second Surgical Opinion Benefits are also subject to all General Plan Exclusions and Limitations. DIAGNOSTIC X-RAY AND LAB BENEFITS When you or your Dependent incurs out-patient expense for examination by X-ray or laboratory testing to aid in diagnosis of non-occupational sickness or accidental bodily injury, the Plan will pay those expenses up to the reasonable and customary amount charged in the area and as described in this section. August 2014 Section III - Major Medical Benefits Page 38 IBEW Local No. 461 Welfare Fund Summary Plan Description Diagnostic Benefits are payable for examination and testing in a physician's office, clinic or hospital out-patient department. Limitations Diagnostic X-Ray and Lab Benefits are not payable for: 1. Testing or examination not recommended as medically necessary to diagnose sickness or injury (e.g., marital or employment examinations, research studies, camp or school admission); 2. X-ray or testing related to dental care or treatment; 3. Eye examination for prescribing corrective lenses, including contact lenses; or 4. Testing or examination performed while the Eligible Person is hospital confined. Diagnostic X-ray and Lab Benefits are also subject to all General Plan Exclusions and Limitations. IN-HOSPITAL PHYSICIAN BENEFITS When you or your Dependent requires non-surgical treatment by a physician for non-occupational sickness or accidental bodily injury while confined in a hospital, the Plan will pay the reasonable and customary medical fee charged by the physician. Benefits may be paid for medical treatment rendered during a period of confinement when a surgical procedure is also performed. In-Hospital Physician Benefits pay for one physician’s visit per day when you are confined in a hospital for reasons other than surgery. If surgery is recommended and performed, these benefits are not paid on or after the day of surgery unless you are seen by a physician, other than the one who performed the surgery, for a co-existent medical condition. August 2014 Section III - Major Medical Benefits Page 39 IBEW Local No. 461 Welfare Fund Summary Plan Description COVERED EXPENSES The following hospital, medical and other expenses are covered by the Comprehensive Major Medical Benefits: 1. Daily hospital charges for ward or semi-private room and general nursing services; 2. Daily hospital charges for treatment at an intensive or coronary care unit; 3. Other medically necessary services and supplies furnished by the hospital; 4. The services of a legally qualified physician; 5. The services of a graduate registered nurse (R.N.) or legally licensed physiotherapist, provided those services are not rendered by someone who ordinarily resides in your home or by a member of your or your spouse's family; 6. Diagnostic laboratory and x-ray examinations, x-ray or radium therapy treatment; 7. Casts, splints, trusses, braces and crutches and artificial limbs and eyes replacing limbs or eyes which are lost while a person is eligible for these benefits; 8. Whole blood or blood plasma, including the cost of their administration, other than those charges for "elective” testing and donation. Autologous transfusion procedures will be considered if medically necessary due to surgery and only those pints used as a result of the surgery will be considered an eligible expense; 9. Anesthetics and oxygen, including their administration, or rental of equipment; 10. Rental, up to the purchase price, of durable medical equipment (such as wheel chair, hospital bed, or braces) based on at least one (1) purchase estimate for such equipment; 11. Medically necessary professional local ambulance service to and from a hospital or between hospitals if necessary for more highly specialized care; August 2014 Section III - Major Medical Benefits Page 40 IBEW Local No. 461 Welfare Fund Summary Plan Description 12. Drugs and medicines which require a physician's prescription and are legally obtained from a licensed pharmacist that are not vitamins, minerals, food supplements or substitutes; 13. Cardiac rehabilitation (not to exceed six [6] weeks unless medically necessary) following a heart attack or surgery; 14. Physical therapy, only when prescribed by a medical doctor and performed by a licensed physical therapist. Physical therapy charges for conditions or diagnosis generally covered under the Chiropractic Benefit are not eligible under the Major Medical Benefit if the Trustees determine such treatment is of the type customarily rendered by a Chiropractor (refer to Section II, Benefits with Special Limitations “Physical Therapy Expense Benefit” for a more detailed description of coverage). 15. Treatment for allergies such as allergy therapy and/or allergy extract. Limitations Major Medical Benefits are not payable for: 1. Eye refraction (for fitting glasses only), eyeglasses, lasik surgery, hearing aids or dental prosthetic appliances or charges for the fitting of any of these applications, unless such appliances are required due to accidental injury: 2. Cosmetic or reconstructive surgery which is not necessary for the prompt repair of an accidental bodily injury, which occurs while the patient is eligible; 3. Dental care or treatment except as specifically provided; 4. Rest cures or custodial care; 5. Ambulance service or transportation between cities, such as by air ambulance, railroad or bus; 6. Maintenance or repairs of durable medical equipment; 7. Shoes or shoe inserts for treatment of the feet, unless prescribed by a physician and custom-fitted for the patient; 8. Orthoptics or aniseikonia; August 2014 Section III - Major Medical Benefits Page 41 IBEW Local No. 461 Welfare Fund Summary Plan Description 9. Testing or examination not recommended as medically necessary to diagnose sickness or injury (e.g., pre-marital or employment examination or research studies); or 10. Experimental or investigational procedures. 11. Vitamins, supplements, including pre-natal vitamins. 12. Lifestyle drugs, for example: Viagra, diet drugs, or drugs for smoking cessation. 13. Acupuncture 14. Massage 15. Naprapath In-Hospital Medical Expense Benefits are subject to additional exclusion and limitations for some conditions; see Treatment with Special Limitations Section for additional information when treatment is related to drug abuse or overdose or alcoholism or alcohol abuse and treatment or evaluation of nervous or mental disorders. The Major Medical Benefits are also subject to all General Plan Exclusions and Limitations. All benefits are subject to additional exclusions and limitations for some conditions. Refer to the Treatment with Special Limitations Section for additional information. In-Hospital Medical Expense Benefits are also subject to all General Plan Exclusions and Limitations. PREGNANCY EXPENSE BENEFITS When you or your Dependent Spouse incurs expense for hospital confinement or treatment by a physician due to pregnancy, including normal childbirth, Caesarean section or miscarriage, the plan will pay those expenses on the same basis as any sickness or injury, up to the reasonable and customary amount charged in the area and as described in this section. Obstetrical procedures are eligible under the Surgical Expense Benefits of the Plan. Benefits for pregnancy are effective immediately for expenses incurred on or after the Eligible person's individual effective date of coverage. Pregnancy is not considered a pre-existing condition. August 2014 Section III - Major Medical Benefits Page 42 IBEW Local No. 461 Welfare Fund Summary Plan Description The Fund also covers maternity care benefits when provided by a certified nurse midwife. Delivery must be in an approved hospital or birthing center. Limitations Pregnancy Expense Benefits are not payable for pregnancy expenses incurred by a Dependent child. The newborn of a dependent child is not considered eligible for any benefit under the Plan. Pregnancy Expense Benefits are subject to all the limitations which apply to individual benefits payable for any sickness or injury, including the General Plan Exclusions and Limitations. Statement of Rights Under the Newborn’s and Mother’s Health Protection Act Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than forty-eight (48) hours following a vaginal delivery, or less than ninety-six (96) hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket cost so that any later portion of the forty-eight (48) hour (or ninety-six [96] hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization of prescribing a length of stay of up to forty-eight (48) hours (or ninety-six [96] hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact the Fund Office. NEWBORN DEPENDENT CHILD BENEFITS When a female Employee or the Dependent wife of a male Employee delivers a child or children while eligible under the Plan, benefits are payable for the newborn, up to the reasonable and customary amount charged in the area and as described in this section. August 2014 Section III - Major Medical Benefits Page 43 IBEW Local No. 461 Welfare Fund Summary Plan Description Crib Care Benefits for the care of each newborn Dependent child are payable in the same manner as hospital room and board and miscellaneous charges are paid under Hospital Expense Benefits. Crib care is payable during the period the mother of the child is hospital confined as a result of giving birth to the child. Newborn Examination Benefits for medical examination and care of a newborn Dependent, while hospital confined, by a physician specializing in pediatrics are payable for the day of birth or the next following day. Newborn Circumcision Benefits for circumcision of a newborn Dependent male child by a physician are payable in the same manner as Surgical Expense Benefits. Birth Coverage Benefits for special care and treatment medically required by a newborn Dependent child as a result of: 1. Sickness contracted or injury suffered; or 2. Congenital defect; or 3. Premature birth. Benefits are payable in the same manner as any other disability, up to the reasonable and customary amount charged in the area. Limitations Crib care, Newborn Examination and Newborn Circumcision Benefits are not payable for expenses incurred: 1. After the mother of the child is no longer hospital confined as a result of giving birth to such child unless the child requires extended confinement; except however, 2. During a period of confinement for the mother which is longer than that for a normal delivery. August 2014 Section III - Major Medical Benefits Page 44 IBEW Local No. 461 Welfare Fund Summary Plan Description Newborn Dependent Child Benefits are not payable for expense incurred by the newborn child or children of an Eligible Person's Dependent child. Newborn Dependent Child Benefits are also subject to all General Plan Exclusions and Limitations. August 2014 Section III - Major Medical Benefits Page 45 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section III - Major Medical Benefits Page 46 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION IV BENEFITS WITH SPECIAL LIMITATIONS WEEKLY ACCIDENT AND SICKNESS BENEFITS (LOSS OF TIME) If you become totally disabled from non-occupational accidental bodily injury or sickness, the Plan will pay the Weekly Benefit shown in the schedule of Benefits. Active Employees Only Application for Loss of Time Benefits For the Fund to consider Loss of Time, you must submit a fully completed claim form. 1. Both you and the physician must complete the form. 2. The Fund must receive a "Return to Work Notice" completed by your physician. Period of Disability All disability absences will be considered as having occurred during a single period of disability unless evidence acceptable to the Trustees is furnished that: 1. The cause of the latest disability absence cannot be connected with the causes of any prior disability absences, and the latest disability absence occurs after return to active work for at least one day; or 2. The causes of the latest disability absence can be connected with the causes of a prior disability, but the two were separated by a return to active work for at least two weeks. Limitations No benefits are payable under this benefit provision for any period or day of disability for which the Employee is not under the regular care and attendance of a physician. A Chiropractor is not considered a physician for the purposes of disability benefits. August 2014 Section IV - Benefits With Special Limitations Page 47 IBEW Local No. 461 Welfare Fund Summary Plan Description No benefits are payable under this benefit provision for any period on or after the date an Employee retires, even if such Employee would normally be considered eligible based on Employer contributions for hours worked before retirement. The benefits provided under this provision are not assignable. Weekly Accident and Sickness Benefits are also subject to all General Plan Exclusions and Limitations Benefits paid under this Section are not eligible for and do not contribute to the Co-payment Limit which allows for one hundred percent (100%) payment under the Major Medical Expense Benefits. CHIROPRACTIC EXPENSE BENEFITS When you or your Dependent is treated by a Chiropractor in connection with the detection, treatment and correction of structural imbalance, subluxation or misalignment of the vertebral column for the purposes of alleviating pressure or spinal nerves, benefits for all related services, supplies and procedures will be paid as described in this section. After satisfying the calendar year deductible, chiropractic treatment charges are payable at fifty percent (50%) of the BCBSIL approved amount after the deductible for In-Network providers and not covered for Out-of-Network providers. Covered services include office visits, manipulations, adjustments and diagnostic x-ray or laboratory services. The benefit maximum is twenty-four (24) visits per person per calendar year. Chiropractic x-rays are paid at fifty percent (50%) of the approved for in-network services and not covered for out of network services after the applicable deductible. The maximum benefit payable per person, per calendar year for chiropractic x-rays is two hundred dollars ($200). Limitations This Plan does not provide benefits for: 1. More than one treatment per day; 2. Services or conditions other than those indicated above. August 2014 Section IV - Benefits With Special Limitations Page 48 IBEW Local No. 461 Welfare Fund Summary Plan Description Expenses related to chiropractic treatment, other than the Chiropractic Services specified above are not eligible under the Major Medical Expense Benefits. Benefits for or related to treatment by a Chiropractor are subject to all General Plan Exclusions and Limitations. Benefits paid under this Section are not eligible for and do not contribute to the Co-Payment Limit which allows for one hundred (100%) percent payment under the Major Medical Expense Benefit. PHYSICAL THERAPY EXPENSE BENEFIT When you or your dependents undergo physical therapy that is prescribed by a medical doctor and performed by a licensed physical therapist, reasonable and customary charges will be considered as described in the schedule of benefits. Charges for treatment by a medical doctor or licensed physical therapist that is normally performed by a chiropractor will be considered under the chiropractic benefit. Benefits for or related to Physical Therapy are subject to all general plan exclusions and limitations allowing for fifty percent (50%) payment after the deductible and subject to a maximum payable of one thousand, five hundred dollars ($1,500) per person, per calendar year. *Physical Therapy Benefits prescribed for surgical procedures and commencing within six (6) weeks of a covered surgery are considered under the Major Medical Benefit. HOME HEALTH CARE BENEFITS When you or your dependents incur expenses for Home Health Care, and when such expenses are deemed medically necessary, the Fund will reimburse those expenses as follows: 1. Part-time intermediate skilled nursing care up to a maximum of four (4) hours of reasonable and necessary care per day. 2. A maximum of thirty (30) days per calendar year. 3. A maximum of one hundred dollars ($100) per hour. August 2014 Section IV - Benefits With Special Limitations Page 49 IBEW Local No. 461 Welfare Fund Summary Plan Description Limitations Services must be rendered by a registered nurse. Benefits are subject to the Plan co-payment inclusive of the calendar year deductible. Home Health Care Benefits are also subject to all General Plan Exclusions and Limitations. ELECTIVE STERILIZATION BENEFIT (EMPLOYEE OR SPOUSE ONLY) Charges in connection with an elective sterilization are paid under the Plan’s Major Medical Benefit. Limitations Elective Sterilization Benefits are not payable for: 1. Expense incurred by a Dependent other than an eligible dependent spouse; 2. More than one sterilization procedure per Eligible Family; and 3. Expense incurred for the purpose of reversing a sterilization procedure. Elective Sterilization Benefits are also subject to all General Plan Exclusions and Limitations. MENTAL HEALTH & SUBSTANCE ABUSE BENEFITS All treatment in-patient or out-patient should be pre-certified by the Member Assistance Program (MAP). In-Patient Treatment Treatment rendered by a certified, registered psychologist (PhD) on the referral of a physician (MD) will be considered an eligible expense on the same basis as a physician only if such treatment was recommended by that MD. No benefits are payable for any portion of a course of inpatient treatment that is terminated against the medical advice of the MD of record. August 2014 Section IV - Benefits With Special Limitations Page 50 IBEW Local No. 461 Welfare Fund Summary Plan Description Treatment must be provided by a state licensed facility or provider. Benefits are paid under the Plan’s Major Medical Provisions: eighty percent (80%) of the charges for in-network treatment and 65% of reasonable and customary charges for out-of-network treatment. Yearly major medical deductibles apply to this benefit. Out-Patient Treatment Treatment rendered by a certified, registered psychologist (PhD) on the referral of a physician (MD) will be considered an eligible expense on the same basis as a physician only if such treatment was recommended by that MD. No benefits are payable for any portion of an intensive outpatient treatment that is terminated against the advice of the MD of record. Benefits are paid under the Plan’s Major Medical Provisions: eighty percent (80%) of the charges for in-network treatment and sixty-five percent (65%) of reasonable and customary charges for out-of-network treatment. Yearly major medical deductibles apply to this benefit. Attention Deficit Disorder (ADD) is considered an eligible diagnosis under this Benefit. Prescriptions for ADD will be eligible for payment under the Comprehensive Major Medical Expense Benefit provision of the Plan. Limitations Benefits for treatment of mental and nervous disorders are not payable for: 1. Behavioral disorders (see definition); 2. Charges related to primal therapy, rolfing, psychodrama, megavitamin therapy, vision perception training, or carbon dioxide training. 3. Charges related to marriage, family, parental, child career, social adjustment, pastoral or financial counseling services. 4. Counseling for adoption, custody, family planning, pregnancy, or catastrophic illness diagnosis in the absence of psychiatric diagnosis generally recognized and accepted by the medical profession such as the American Psychiatric Association’s Diagnostic and Statistical Manual of psychiatric diagnosis. August 2014 Section IV - Benefits With Special Limitations Page 51 IBEW Local No. 461 Welfare Fund Summary Plan Description 5. Court-Ordered Confinement – Any confinement of a Covered Person in a public or private institution as the result of a court order. 6. Educational or Vocational Testing or Training – Testing and/or training for educational purposes or to assist an individual in pursuing a trade or occupation. 7. Biofeedback, Recreational or Educational Therapy, or other forms of self-care or self-help training or any related diagnostic testing. Treatment of Mental and Nervous Disorders are also subject to General Plan Exclusions and Limitations. Co-Payment Mental Health and Substance Abuse Benefits do not pay covered expenses in full, so you will share in the cost of your treatment. The Plan pays covered expenses for in-patient or out-patient rehabilitation programs up to a maximum lifetime benefit as outlined in the Schedule of Benefits. Maximum Amount Payable Aggregate benefits for treatment of alcoholism and substance abuse will not exceed the maximum amount payable as stated in the Schedule of Benefits. In-Patient Benefits 1. one hundred dollars ($100) deductible per person, three hundred dollars ($300) per family annual deductible applies; and 2. Payment at eighty percent (80%) for In-Network Services; and 3. Payment at sixty-five percent (65%) for Out-of-Network Services. Out-Patient Benefits 1. one hundred dollars ($100) per person, three hundred dollars ($300) per family annual deductible applies; and August 2014 Section IV - Benefits With Special Limitations Page 52 IBEW Local No. 461 Welfare Fund Summary Plan Description 2. No more than fifty dollars ($50) paid by the Plan per day for out of network services; and 3. Payment at eighty percent (80%) for In-Network Services; and 4. Payment at sixty-five percent (65%) for Out-of-Network Services. Covered Expenses Only expenses considered eligible under the Major Medical Expense Benefits are covered under this Section. Recognized facilities may include nonhospital facilities specializing in substance abuse treatment as well as normal hospital in-patient facilities. Limitations Benefits for treatment of alcoholism and substance abuse will not be paid if the patient does not complete the full course of treatment prescribed by the approved program, including initial confinement and/or all group or individual counseling sessions during the customary treatment program. Benefits for treatment of alcoholism and substance abuse are not payable for: 1. Treatment programs for which the patient does not complete the full course of treatment prescribed by the approved program, including initial confinement and/or all group or individual counseling sessions during or after confinement. 2. Treatment programs, which are not conducted by a state licensed facility. Benefits for treatment of alcoholism and substance abuse are subject to the same terms, conditions and limitations governing individual benefits for any other illness or injury under this Plan. Benefits paid under this Section are eligible for and do contribute to the Co-Payment Limit which allows for one hundred (100%) payment under the Major Medical Expense Benefit. August 2014 Section IV - Benefits With Special Limitations Page 53 IBEW Local No. 461 Welfare Fund Summary Plan Description WELL CHILD CARE BENEFITS AND ROUTINE PHYSICAL EXAMINATION BENEFIT (WELLNESS BENEFITS) When you, your Dependent spouse, or your Dependent child (up to the age of nineteen [19]) incurs eligible expenses for a routine physical examination performed by a physician, the Plan will pay those reasonable expenses up to the amounts shown in the Schedule of Benefits Section and as described in this Section. Eligible expenses include the physician's professional fees, immunizations and diagnostic x-ray or laboratory charges. The examination may be performed in a physician's office, clinic or hospital out-patient department. Limitations Routine Physical Examination Benefits are not payable for: 1. Testing or examination related to accidental bodily injury, sickness or pregnancy (including resulting child birth or complications); 2. Testing or examination related to or as a condition of employment or to the issuance of any insurance policy; 3. Expense incurred by a Dependent other than the Employee's spouse (except for children up to the age of nineteen [19]). Routine Physical Examination Benefits are also subject to all General Plan Exclusions and Limitations. Benefits paid under this Section are eligible for and do contribute to the Co-Payment Limit which allows for one hundred percent (100%) payment under the Comprehensive Major Medical Expense Benefit. Benefits are also not payable under any other benefit. PRESCRIPTION DRUG BENEFITS The Plan will pay for Prescription Drugs, in generic or brand form, when prescribed by a physician, and after applicable co-payments have been satisfied. Benefits for Active Participants are provided through the Citizens-Rx Prescription Drug Program. You should automatically receive a prescription drug card when you become eligible under the Plan. Benefits are paid based upon the Schedule of Benefits on Pages A-G. August 2014 Section IV - Benefits With Special Limitations Page 54 IBEW Local No. 461 Welfare Fund Summary Plan Description HEARING CARE BENEFITS When you or your Dependent incurs expenses for hearing care, the Plan will pay those expenses up to the amount shown in the Schedule of Benefits and as described in this Section. Eligibility The benefit is available to all eligible members and their Dependents on a recurring basis each five years. The Deductible Amount There is no deductible. Co-Payment Hearing Care Benefits are paid at fifty percent (50%) of the usual, reasonable, and customary covered expenses for eligible hearing care treatment expenses. The Maximum Amount All payments under Hearing Care Benefits are limited to the maximum amount shown in the Schedule of Benefits. The maximum amount applies to you and each of your Dependents separately. The maximum amount cannot be reinstated and is not renewed if eligibility is lost and then regained at a later date. Covered Expenses Hearing Care Benefits are divided into three main parts: a physical examination by a specialist physician (otologist or otorhinolaryngolist); a test of hearing ability and condition by a specialist physician or a licensed audiologist; and the purchase of a hearing aid, if required. Fitting and purchase of a hearing aid includes the reasonable charges for the manufacture of ear molds by a specialist physician or licensed audiologist; and the purchase of a hearing aid, including hearing aid rental and audiologist consultation fees during an evaluation period (whether or not a hearing aid is found to be satisfactory and is purchased). August 2014 Section IV - Benefits With Special Limitations Page 55 IBEW Local No. 461 Welfare Fund Summary Plan Description Limitations Hearing Care Benefits are not payable for: 1. Examination or testing by other than an otologist, otorilinolaryngolist or licensed audiologist; 2. Services or supplies provided by an audiologist, which are not prescribed by a specialist physician; 3. Charges for hygienic cleaning of the hearing aid; 4. Batteries and their installation; 5. Charges for repair due to accidental damage or for replacement of a lost hearing aid. Hearing Care Benefits are also subject to all General Plan Exclusions and Limitations. Benefits paid under this Section are not eligible for and do not contribute to the Co-Payment Limit, which allows for one hundred (100%) percent payment under the Major Medical Expense Benefit. Organ Transplant Benefit When you or your Dependent require organ transplant procedures (as approved by Medicare), benefit payments by the Plan are subject to the rules described in this section in addition to those governing individual benefits. Eligibility To be considered eligible for benefits under this section, the patient must have been continuously eligible in the Plan for at least twelve (12) calendar months immediately before covered expense is incurred. Co-Payment - PPO The Plan pays eighty percent (80%) of covered expenses based upon the BCBSIL approved amounts in lieu of benefit amounts or payment formulas applicable to any other sickness or accidental bodily injury. August 2014 Section IV - Benefits With Special Limitations Page 56 IBEW Local No. 461 Welfare Fund Summary Plan Description Co-Payment – Non-PPO The Plan pays sixty-five percent (65%) of covered expenses in lieu of benefit amounts or payment formulas applicable to any other sickness or accidental bodily injury. The Maximum Amount The maximum amount is the same as any other illness or injury as described in the Schedule of Benefits. Payments made by the Plan shall be applied to the Transplant Benefit as the expense is incurred on and after the date a transplant is determined to be medically necessary. Limitations Transplant Benefits are not payable for: 1. Expense incurred by any person other than an Eligible Person as determined by the Eligibility Rules, including but not limited to a living tissue or organ donor, and 2. Transplants other than those approved by Medicare, and 3. Treatment employing experimental or investigational medical or surgical procedures, and 4. Participation in study Programs. “Experimental” or “Investigative” means the use of any treatment, procedure, facility, equipment, drugs, devices or supplies not yet recognized as acceptable general medical practice and any such items requiring federal or governmental agency approval for which such approval has not been granted at the time the service was provided. The Trustees have the sole authority to determine whether the treatment shall be considered “experimental or investigational” for the purposes of this Plan. Transplant Benefits are also subject to all General Plan Exclusions and Limitations. August 2014 Section IV - Benefits With Special Limitations Page 57 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section IV - Benefits With Special Limitations Page 58 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION V Dental Care Benefits When you or your Dependent incurs expenses for dental care, the Plan will pay those expenses to a maximum amount as shown in the Schedule of Benefits and as described in this Section. The Plan also requires co-payments for eligible types of care so you will share the cost of your treatment. Co-payment levels are specified for each group of eligible expenses. The annual deductible does not apply to dental benefits. Predetermination of Benefits You are not required to have the dentist submit an estimate of charges before work begins. However, the Trustees recommend that the dentist give the Claims Office a description of the procedures to be performed and the estimated fees before treatment starts if the total charges will be over two hundred dollars ($200). This will let you and your dentist know if the treatment plan is considered reasonable and what benefits will be paid. The Maximum Amount All payments under Dental Care Benefits are limited to the maximum amount shown in the Schedule of Benefits for the type of care involved. The maximum amount applies to you and each of your eligible Dependents separately for all covered expenses. Covered Expenses Dental Care Benefits are divided into four main parts: preventive; diagnostic expenses; restorative expenses (such as most fillings and extractions); prosthodontics expenses (such as gold work and dentures or orthodontics). The percentage payable by the Plan is determined separately for each type of treatment group. 1. Preventive Expense. The Plan pays one-hundred percent (100%) of the reasonable expense for the following dental care: Oral Examinations, twice (2) per calendar year; Preventive treatment consisting of: (1) Oral prophylaxis (cleaning and scaling of teeth) but not more than twice (2) in a calendar year; August 2014 Section V -Dental Care Benefits Page 59 IBEW Local No. 461 Welfare Fund Summary Plan Description (2) Topical sodium and stannous fluoride treatment or sealants are available only to eligible persons under age nineteen (19), but not more than one treatment per tooth in a calendar year; and Space Maintainers for replacement of deciduous prematurely lost teeth for an eligible person under age nineteen (19). Diagnostic Expense. The Plan pays one hundred percent (100%) of the reasonable and customary expenses for x-rays, consisting of: 2. Bitewing x-rays, not more than twice in a calendar year; and Full mouth x-rays, once in a thirty-six (36) consecutive month period. All Other Dental Expenses Restorative Expenses. The Plan pays eighty percent (80%) of the reasonable and customary expenses for the following dental care: Extractions not related to orthodontics; Oral surgery, including medically necessary administration of local or general anesthetics; Fillings, other than gold; Periodontal treatment (diseases of gums); Endodontic therapy); Injections of antibiotic drugs; treatment (pulp infection and root canal Prosthodontics Expenses. The Plan pays eighty percent (80%) of the reasonable expense for the following dental care: Initial installation of complete or partial bridgework fixed or removable; Initial installation of gold fillings or crowns as abutments, provided that amalgam, silicate, plastic or other materials will not adequately restore the teeth; August 2014 Section V -Dental Care Benefits Page 60 IBEW Local No. 461 Welfare Fund Summary Plan Description Replacement of provided that: previously existing gold restorations (1) Amalgam, silicate, plastic or other materials will not adequately restore the tooth, and (2) The previous restoration was installed five (5) or more years prior to this replacement. Replacement of previously existing complete or partial removable dentures or fixed bridgework provided that: (1) the previous denture or bridgework was installed three or more years prior to its replacement. Dental implants. Orthodontic Expense. When a dependent child through the age of eighteen (18) (through the age of twenty-two [22] if dependent is a full-time student) undergoes Orthodontic Treatment, the Plan pays eighty percent (80%) of the reasonable and customary expense for the following services and supplies during the first thirty-six (36) months of treatment: diagnostic procedures, including cephalometric xrays; surgical therapy, including repositioning of the jaw or facial bones or teeth to correct malocclusion; appliance therapy (braces), including related periodic oral exams, surgery and extractions. Expense Incurred Expense Incurred means the date a dental service or treatment is performed, except for the following services or treatments: 1. Dentures or bridgework – the date the impressions are taken. 2. Crowns, in-lays, on-lays – the date the teeth are first prepared. 3. Root canal therapy – the date the pulp chamber is opened. August 2014 Section V -Dental Care Benefits Page 61 IBEW Local No. 461 Welfare Fund Summary Plan Description The Maximum Amount The maximum amount for all other Covered Expenses applies to payments for treatment each calendar year and so is renewed each January 1st. Benefits not used in a prior year cannot be carried forward to increase the maximum amount for the next calendar year. Treatment in Progress When Eligibility Terminates The Plan will generally not pay for services or supplies furnished after the date you or your Dependent’s eligibility terminates, even if the Claims Office has predetermined the payments for a treatment plan submitted before the termination date. The Plan will pay for services or supplies related to the following covered expenses if the treatment is rendered and delivered to the patient within ninety (90) days after the termination date and the following conditions are met: 1. A prosthetic device (such as full or partial dentures) if the dentist took the impressions and prepared the abutment teeth while the patient was covered under the Plan; 2. A crown if the dentist prepared the tooth for the crown while the patient was covered under the Plan; and 3. Root canal therapy if the dentist opened the tooth while the patient was covered under the Plan. LIMITATIONS Dental Care Benefits are not payable for: 1. Any service rendered, supply ordered or treatment plan begun before coverage became effective; 2. Treatment other than by a licensed dentist or licensed physician, except that scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of and billed for by the dentist; 3. Services or supplies that are primarily cosmetic in nature, including charges for personalization or characterization of dentures; August 2014 Section V -Dental Care Benefits Page 62 IBEW Local No. 461 Welfare Fund Summary Plan Description 4. Replacement of a lost, missing or stolen prosthetic device; 5. Services rendered through a medical department, clinic or similar facility provided or maintained by the patient’s employer or governmental agency; 6. Services or supplies which do not meet accepted standards of dental practice, including charges for services or supplies which are experimental in nature; 7. Any duplicate appliance or prosthetic device; 8. Athletic mouth guards; 9. A plaque control program (a series of instructions on the care of the teeth); 10. Periodontal splinting; 11. Services which are provided under other sections of this Plan; 12. Myofunctional therapy (correction of harmful habits); 13. Sealants and fluorides painted on the teeth in an attempt to prevent further decay (more than once a year); 14. Services or supplies which are not necessary according to accepted standards of dental practice; 15. Oral hygiene or dietary instructions. 16. Occusual guards or bite splints. Limitations for: Dental Care Benefits for Orthodontic Treatment are not payable 1. a Dependent other than a Dependent child; 2. any orthodontic treatment program begun on or after the Dependent child’s nineteenth (19th) birthday, (or twentythird [23rd] birthday if a full-time student); 3. any orthodontic treatment procedures performed after the first thirty-six (36) months of treatment. Dental Care Benefits are also subject to all General Plan Exclusions and Limitations. August 2014 Section V -Dental Care Benefits Page 63 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section V -Dental Care Benefits Page 64 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION VI VISION CARE BENEFITS When you or your Dependent incurs expense for vision care, the Plan will pay those expenses up to the maximum amount shown in the Schedule of Benefits and as described in this Section. There is no deductible required by the Plan before Vision Care Benefits become payable. Vision Benefits renew every even calendar year. The Maximum Amount Payments under the Vision Care Benefits are limited to the individual maximum as shown in the Schedule of Benefits and renew every other calendar year. For example, the benefit periods January 1, 2012 through December 31, 2013 and January 1, 2014 through December 31, 2015. Covered Expense Services or supplies must be provided by an Optician, Optometrist, or Ophthalmologist to be considered Covered Expenses. Typical services are shown below. 1. 2. Vision Examination - A vision screening includes: a. a check of principle vision functions, and; b. determination of vision ability and condition. Vision analysis may be done. Vision analysis includes: a. complete case history; b. measuring and recording of visual acuity, corrected and uncorrected; c. examination of fundus, media, crystalline lens, optic disc and pupil reflex for pathology, anomalies or injury, corneal curvature measurements, retinoscopy; d. fusion determination, distance and near, subjective determination, distance and near, and stereopsis determination, distance and near; e. color discrimination and amplitude or accommodation; August 2014 Section VI –Vision Care Benefits Page 65 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. f. analysis of findings, lens prescription (if needed); and g. measuring and recording of visual acuity, distance and near, with new prescription if required. Contact Lenses or Lenses and Frames. Related services and supplies include: a. professional advice on frame selection; b. facial measurement, and preparation of specifications for optical laboratory and verifying and fitting of prescription glasses or contact lenses; c. re-evaluation and progress report after fitting new prescription and subsequent servicing. Limitations Vision Care Benefits are not payable for: 1. Examinations or materials more frequently than specifically provided; 2. Lenses, frames or contact lenses which are lost or broken except at the normal intervals when benefits are available; 3. Special procedures such as orthoptics, vision training or aniseikonia; 4. Non-Prescription sun glasses or tinted glasses; 5. Services or supplies not listed as covered vision expenses; 6. Services, treatment or supplies, related to medical or surgical treatment of the eyes; 7. Services, treatment or supplies which are rendered or finished before the date a person becomes initially eligible or after the date a person's eligibility terminates; Surgery to correct vision deficiencies a. Radial Keratotomy’s Surgery (RK); b. Lasik Surgery; August 2014 Section VI –Vision Care Benefits Page 66 IBEW Local No. 461 Welfare Fund Summary Plan Description The Plan will pay the covered amount at 50% after the applicable deductible up to a maximum of two thousand dollars ($2,000) per eye per lifetime. Vision Care Benefits are also subject to all General Plan Exclusions and Limitations. Vision Therapy Vision Training/Therapy is a separate benefit and must be performed by an optometrist, an opthamologist, or an MD trained in vision therapy. The benefit is paid at 100% and has a maximum allowable expense of $400 per person per year. Coverage is for Class A and Class B participants and their eligible dependents. August 2014 Section VI –Vision Care Benefits Page 67 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section VI –Vision Care Benefits Page 68 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION VII EMPLOYEES ONLY DEATH AND DISMEMBERMENT BENEFITS Death Benefits If you die from any cause, a Death Benefit is payable in the amount specified in the Schedule of Benefits. The Fund Office must be provided with acceptable proof of death on forms provided by the Trustees. Beneficiary Designation You must file a written designation of Beneficiary with the Fund Office on a properly completed form. If you have not made an irrevocable designation of Beneficiary, you may name a new Beneficiary without your prior Beneficiary's consent, by filing a new form with the Fund Office. The change of Beneficiary will be effective retroactively to the date you sign the form, whether or not you are living when the Fund Office receives it. The Plan is not responsible for any payments made before the change of Beneficiary form is received. If you do not designate a Beneficiary or if your Beneficiary does not outlive you, the Death Benefit will be paid to the living in the following order: 1. Spouse; 2. Children, including legally adopted children; 3. Parents; 4. Brothers and sisters; or 5. Executor or administrator of the Employee's estate. If two (2) or more persons are entitled to the Death Benefit, they will share equally. Notice of Claim Written notice of the death of an Employee whose coverage has been continued under this provision must be given to the Fund Office within twelve (12) months of the date of death. If written notice is not given within such twelve (12) month period, the Plan will not be liable for any person on account of that death. August 2014 Section VII - Death and Dismemberment Benefits Page 69 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section VII - Death and Dismemberment Benefits Page 70 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION VIII MEDICAL SAVINGS BENEFIT The Medical Savings Benefit is currently five hundred dollars ($500) per participant. Each year the Trustees will determine whether an allocation to the Medical Savings Benefit will be made and if so, the amount of the allocation. How the Medical Savings Benefit Works As of January 1, each year, the Trustees will determine the amount that will be allocated to the Medical Savings Benefit. This is the total amount payable per calendar year for the participant and their eligible dependents. In order to qualify for the Medical Savings Benefits, you must be eligible on the date services were incurred. What the Money Can Be Used For The Medical Savings Plan can be used to pay for certain eligible health care expenses NOT reimbursed by the IBEW Local 461 Welfare Fund or any other benefit or insurance plan under which you or your dependents are eligible. Among the eligible items are: a. Your medical deductibles; b. The medical, dental or vision care co-payments; c. Federally recognized covered Medical, dental or vision care expenses not eligible for payment under this or any other Plan; How to Use the Medical Savings Plan To receive payment from your Medical Savings Plan: a. You should accumulate at least twenty-five dollars ($25) in reimbursable expenses before you file a claim for payment from your Medical Savings Plan. b. Fill out a request form, provided by the Administration Office, indicating which expenses you want reimbursed from your Medical Savings Plan. c. Submit, along with the form, itemized bills or Explanation of Benefits forms. August 2014 Section VIII – Medical Savings Benefit Page 71 IBEW Local No. 461 Welfare Fund Summary Plan Description d. Send the above items to IBEW Local 461 Welfare Fund Medical Savings Plan, 6525 Centurion Drive, Lansing, MI 48917. e. You must apply for Medical Savings Benefits within 90 days of the end of the calendar year for which your medical savings apply. For example, claims for calendar year 2014 should be submitted by March 31, 2015. MEDICAL SAVINGS BENEFIT AND SUPPLEMENTAL BENEFIT ACCOUNT Eligible Healthcare Expenses There are a wide range of eligible healthcare expenses for your Medical Savings Benefit and Supplemental Benefit Account, including prescriptions, over-thecounter medications, medical co-payments, and health insurance deductibles, for you, your spouse, and your eligible children. The tables below provide examples of eligible medical expenses, eligible overthe-counter (OTC) expenses, OTC expenses that are eligible only with a prescription, and ineligible expenses. You must be eligible in the Welfare Plan on the date of purchase. ELIGIBLE MEDICAL EXPENSES Acupuncture Alcoholism treatment Ambulance services Artificial limbs & teeth Automobile modified for physically handicapped Birth control pills Blood pressure monitoring Braille publications (above regular printed cost) Breast pumps and lactation devices Chiropractic care Christian Science practitioners COBRA premiums Contact lenses Crutches Dental treatment Dentures Diagnostic services Disability care expenses Drug addiction treatment Eye examination & glasses Fertility treatments or abortions Flu shot Guide dog or animal aides Hearing aids & batteries Hospital services Immunization Insulin Insurance premiums Laboratory fees Laser eye surgery Lodging & meals for medical care Long-term care premiums or expenses Medical & testing devices Medicare premiums Nursing services Obstetrical expenses Organ transplant Orthodontia (not for cosmetic reasons) Oxygen Physical exam Physical therapy Prescription drugs Psychiatric care Retiree medical insurance premiums Special schooling for disabilities Speech therapy, lip reading Smoking cessation programs Sunscreen (SPF 15+ broad spectrum) Surgery Telephone & TV for deaf Transportation & travel exp for medical care Weight loss program to treat obesity Wheelchairs X-rays and body scans August 2014 Section VIII – Medical Savings Benefit Page 72 IBEW Local No. 461 Welfare Fund Summary Plan Description ELIGIBLE OTC EXPENSES - WITHOUT A PRESCRIPTION Bandages Braces & supports Catheters Contact lens supplies & solutions Denture adhesives Diagnostic tests & monitors Family planning items First aid supplies Insulin & diabetic supplies Ostomy products Reading glasses Wheelchairs, walkers, canes ELIGIBLE OTC EXPENSES - WITH A PRESCRIPTION Acid controllers Allergy & sinus medicine Antibiotics Anti-diarrheals Anti-gas products Anti-itch & anti-fungal Anti-parasitic treatments Arthritis creams Baby rash ointments Cold sore remedies Cough, cold & flu treatments Digestive aids Dietary and weight loss supplements* Electrolysis, hair removal* Feminine creams Fiber supplements* Hemorrhoidal preps Incontinence pads, diapers Laxatives Lead paint removal* Legal healthcare orders* Motion sickness Nutritional supplements Orthopedic shoes and inserts* Pain relievers Respiratory treatments Shampoo psoriasis or lice Sleep aids & sedatives Snoring cessation aids* Stomach remedies Vaporizers & humidifiers Veterinary fees Vitamins and herbal supplements* Wigs & hair transplant* Prescription means a written or electronic order for a medicine or drug that meets the legal requirements of a prescription in the state in which the medical expense is incurred and that is issued by an individual who is legally authorized to issue a prescription in that state. The items marked with an * are eligible with a prescription, a doctor’s directive, or letter of medical necessity. INELIGIBLE MEDICAL EXPENSES (The expenses below are never eligible for reimbursement) Childcare regular services Cosmetics Cosmetic surgery Dance or swim lessons Deodorant Diaper services Exercise equipment Fitness programs, dues Funeral expenses Hair transplants Healthcare tax exp Household help Illegal substances, treatments, or operations Moisturizers and wrinkle creams Maternity clothes Teeth whitening services & products Toothpaste & mouth wash August 2014 Section VIII – Medical Savings Benefit Page 73 IBEW Local No. 461 Welfare Fund Summary Plan Description DRAFT COPY - July 9, 2014 THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section VIII – Medical Savings Benefit Page 74 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION IX SUPPLEMENTAL BENEFIT ACCOUNT The Supplemental Benefit Account (SBA) provides for coverage of deductibles, co-payments and other benefits under the plan (please refer to the “Covered Benefits” in this section for a detailed listing of the covered benefits. Funding For every hour worked, employer contributions are placed into the individuals Supplemental Benefit Account (SBA). These are not vested benefits; the Trustees have the legal right to use any or all of your SBA balance for any Plan purposes or obligations. Participation Contributions are required from the employers for Active participants working within the jurisdiction of and covered under the terms of the Collective Bargaining Agreement and Non-Bargaining Unit (NBU) participants employed by Local Union 461 or the Joint Apprenticeship and Training Fund. Eligibility The participant must be eligible based upon the Plans regular active participant eligibility provisions or self-payments on the date services are rendered. The participant may continue to utilize the SBA provided he/she is eligible by way of employer contributions, the hour bank or retiree self-payments. Reimbursable Benefits Eligible expenses include reimbursement of self-payments and those defined by the Internal Revenue Service (IRS) which are listed under Covered Benefits in this section. Reimbursement Participants must submit an itemized bill, for dental and vision services. For all other services the participant must submit the appropriate payment voucher or rejection from Blue Cross Blue Shield of Illinois to the Fund Office. August 2014 Section IX – Supplemental Benefit Account Page 75 IBEW Local No. 461 Welfare Fund Summary Plan Description Claims will be reimbursed on a weekly basis however; participants can submit claims as frequently as they want. The Fund Office will hold the claims until the next reimbursement period. Please refer to Section VIII under the Medical Savings Benefit for a complete list of Eligible Health Care Expenses Accruing Account Balances The account balance will continue to grow each year if the participant does not use it. If however the participant has an account balance which is less than one hundred dollars ($100) and he/she has had no contributions to the account for more than twenty-four (24) months, the account will be closed and the monies will be utilized by the Fund. Non Covered Expenses ● Expenses incurred prior to May 1, 2014 ● Expenses for which you are eligible to receive reimbursement from another source ● Occupational Injuries ● Non-eligible expenses For a more complete listing of expenses not covered, please refer to section for “Examples of Non-Eligible Health Care Expenses”. Work in an area outside of the jurisdiction of the Fund Contributions be remitted at the current contribution rate which includes the SB allocation at the IBEW Local 461 Collective Bargaining Agreement (CBA) rate. If contributions are reciprocated that are less than the current contribution rate but in excess of the amount determined by the Board of Trustees (currently ten dollars and eleven cents [$10.11]) then that excess amount will be credited. August 2014 Section IX – Supplemental Benefit Account Page 76 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION X GENERAL PLAN EXCLUSIONS AND LIMITATIONS The following exclusions and general limitations apply to all benefits provided by the IBEW Local No. 461 Welfare Fund unless specifically waived by a particular benefit section. Routine Care and Elective Procedures Benefits under this Plan are for the treatment of sickness or accidental bodily injury when rendered by hospitals and physicians. Routine care, cosmetic surgery, diet medication or supplements, which are not medically necessary to correct a condition which threatens the health of an Eligible person are not eligible for Benefits from this Plan unless specifically provided for. The Trustees reserve the right to have an Eligible Person examined by a physician of their own choice and at their own expense to make their determination regarding any benefit payable or eligibility rule of this Plan. Treatment designed to merely improve bodily functions is not considered medically necessary or an eligible expense for benefits. Medical Necessity Benefits under this Plan are payable only for services and supplies which are considered by the Trustees to be medically necessary in view of the patient's condition and diagnosis. For example, non-emergency hospital admission and confinement over a weekend will be presumed not medically necessary and not an eligible expense incurred. Hospital admission for surgery which is generally performed on an out-patient basis will not be considered eligible for benefits unless such admission is medically necessary due, for example, to a co-existent medical condition. Work Related Disabilities Payment will not be made by the Plan for expenses incurred because of disease, defect or accidental injury which occurs during, or arises out of, any occupation for wage or profit. Occupational refers to any activity involving wages or profit, not simply collective bargaining employment. If the Eligible Person’s claim under Workers’ Compensation or any Occupational Disease Law is rejected, the illness or injury will not be considered work-related and payment will be made. August 2014 Section X - General Plan Exclusions and Limitations Page 77 IBEW Local No. 461 Welfare Fund Summary Plan Description 1. A claim under Workers’ Compensation will be considered to have been rejected under the following circumstances: a. when, after a hearing in the Illinois Industrial Commission (or a corresponding agency in another state), there has been a final administrative determination denying the claim and no lawsuit seeking court review of the decision has been filed; or b. when a decision has been rendered by the Illinois Industrial Commission (or corresponding agency in another state), a party has sought court review of the decision and a final court determination has been made rejecting the claim. Occupational injury and illness claims are not subject to subrogation/repayment agreements, and as such no coverage for occupational injuries or illnesses can be accessed through any subrogation or repayment agreement. Organ Transplants Payment will be limited to the usual, customary and reasonable fee schedule incurred as a result of any type of organ transplants, such as, but not limited to the liver, lung, heart, kidney or cornea. Reasonable and Customary Charges Payment will not be made by this Plan for any expense incurred or charge made, which the Trustees determine is not reasonable or customary as defined herein. Treatment Sponsored by Governmental Units Payment will not be made by the Plan for expenses incurred: 1. While confined in a hospital owned or operated by the Federal Government or other government unit; or 2. For treatment by a physician employed by the Federal Government or other governmental unit; or 3. For services or supplies furnished by or at the request or direction of the Federal Government, any of its agencies, or August 2014 Section X - General Plan Exclusions and Limitations Page 78 IBEW Local No. 461 Welfare Fund Summary Plan Description other government unit unless the Eligible person is legally required to pay. This exclusion will not prevent coordination of benefits with a plan specifically established by a governmental unit for its own civilian employees and their dependents. Treatment Without Charge Payment will not be made for confinement in any hospital or treatment by a physician when the hospital or physician makes no charge that the Eligible Person is legally required to pay or would not be charged in the absence of these benefits. Illegal Occupation or Act or Commission of Felony Any condition, disability, or expense resulting from or sustained as a result of being engaged in: 1) an illegal act or occupation which is considered to be a felony in the jurisdiction in which the act occurred, regardless of whether charged or convicted; 2) commission or attempted commission of assault, battery, criminal trespass, criminal damage to property, theft, robbery, burglary, or arson, regardless of whether charged with or convicted of a felony; or 3) participation in civil insurrection or riot; provided, however, that this exclusion shall not apply if the condition, disability or expense resulted from a medical condition. Experimental Treatment of Procedures Benefits under this Plan are for the treatment of accidental bodily injury or sickness by generally recognized medicines, surgery and other techniques or devices. Medicines, treatment techniques and devices which are not generally recognized by professional peer groups (such as the American Medical Association) or by regulatory governmental authorities (such as the Food and Drug Administration) will be considered experimental and will not be considered eligible expenses under this Plan. For the purposes of this provision, recognized treatment or medicines used in a non-routine manner (frequency or dosage) will be considered experimental. Liability for Accidental Injuries Benefits under this Plan are considered secondary and excess coverage, including but not limited to, any automobile insurance or individual common carrier's liability (such as bus or commercial airline). No payment shall be made August 2014 Section X - General Plan Exclusions and Limitations Page 79 IBEW Local No. 461 Welfare Fund Summary Plan Description until proof is submitted to and judged acceptable by the Trustees that a proper claim has been made for other coverage. Normal Plan benefits shall be paid if other coverage has been denied or shall be coordinated with other coverage payments, if any. General Limitations Benefits of this Plan do not cover any loss caused by, incurred for or resulting from: 1. Declared or undeclared war, or any act thereof, or military or naval services of any country; 2. Services, treatment or supplies received from a dental or medical department maintained by a mutual benefit association of this or another employee benefit plan or labor union; 3. Services, treatment or supplies, which are payable or furnished under any policy of insurance or other medical benefit plan or service plan for which the Trustees shall, directly or indirectly, have paid for all or a portion of the cost; 4. Services or treatment rendered or supplies furnished primarily for cosmetic purposes; a) Unless necessary for the prompt repair of an accidental bodily injury or sickness or disease; and b) Performed within two (2) years of a covered event. 5. Expenses incurred for services performed or supplies furnished by other than a physician; 6. Services, treatment or supplies rendered or furnished: 7. a. Before the individual concerned became an Eligible Person; or b. Without the recommendation and approval of a legally qualified physician; Services related to obesity, diet or weight control, including but not limited to: exercise programs, surgery, special diet or diet supplements, smoking cessation programs and drugs, amphetamines, or any form of diet medication whether or not recommended or supervised by a physician, including August 2014 Section X - General Plan Exclusions and Limitations Page 80 IBEW Local No. 461 Welfare Fund Summary Plan Description dietary or nutritional counseling, books, pamphlets or classes; 8. Mental counseling, physical therapy, supplies or prosthesis for sexual dysfunction or inadequacies; 9. Implantation within the human body of artificial mechanical devices designed to replace human organs other than pacemakers or similar such devices which merely assist rather than replace the function of the organ; 10. Ambulance service or transportation between cities or states (such as by ambulance, air ambulance, railroad or bus) unless judged by the Trustees as essential for treatment of a life-threatening illness or injury; 11. Growth hormones;(testing covered if medically necessary) 12. Expenses incurred for the purpose of reversing tubal ligations, vasectomies or other sterilization procedures; 13. Special home construction to accommodate a disabled person; 14. Education, special education, job training or work hardening whether or not given in a facility that also provides medical or psychiatric treatment beyond the first medically necessary visit. Special education or like services, regardless of: the type of education, the purpose of the education, their recommendation of the attending physician or the qualification of the individual rendering the educational services; 15. Rest cures or custodial care; 16. Speech therapy, other than charges for speech therapy that is expected to restore speech to a person who has lost existing speech function (the ability to express thoughts, speak words and form sentences) while eligible in the Plan and as the result of a disease or accidental injury. Speech therapy to improve speech in the absence of disease or accidental injury (such as for a learning disability or speech delay) is considered special education and is not covered; 17. Supplies or equipment for personal hygiene, comfort or convenience; August 2014 Section X - General Plan Exclusions and Limitations Page 81 IBEW Local No. 461 Welfare Fund Summary Plan Description 18. Services, treatment or care rendered by a member of the Eligible Member's family; 19. Treatment or services for or in connection with marriage, family, child, career, social adjustment, pastoral, or financial counseling; 20. Treatment or services for primal therapy, rolfing, psychodrama, megavitamin therapy, bioenergetic therapy, vision perception training, or carbon dioxide therapy except as previously provided for; 21. Dietary or nutritional counseling, books, pamphlets or classes; 22. Charges incurred for travel, whether or not recommended by a physician. 23. Treatment to improve fertility such as artificial insemination, invitro fertilization, or embryo transfer process or infertility. 24 Expenses for services related to sex transformations or sexual dysfunctions or inadequacies (including impotency), other than diagnosis and treatment of organic impotency. 25 Voluntary acceptance of extraordinary risks such as speed contests or fighting. 26. Programs or prescription medications for the purpose of smoking cessation. 27. Pre-natal vitamins. 28. Charges incurred for any abortion procedure except where the pregnancy is the result of rape as evidenced by a Police Report. 29. Accidental Injuries For Which a Third Party May Be Liable No benefits will be paid to you or your eligible dependent for expenses incurred due to an accidental injury for which a third-party may be liable. The Trustees, in their sole discretion, may agree to pay such benefits provided that you and/or your eligible dependent sign a Repayment/Subrogation agreement in a form approved by the Trustees. In this Repayment/Subrogation agreement you and/or your eligible dependent must agree to the following: August 2014 Section X - General Plan Exclusions and Limitations Page 82 IBEW Local No. 461 Welfare Fund Summary Plan Description 1. That if there is any recovery from a third-party relating to the accidental injury you will repay the Fund the benefits which have been paid without deduction for expenses or attorneys fees. 2. That you will only hire an attorney who agrees, in writing, to waive the common fund doctrine and agrees to remit to the Fund from any settlement or judgment the gross amount of benefits paid by the Fund without any claim for legal fees. 3. That, if the Fund receives from any settlement or judgment less than full re-payment of the benefits which it paid, you will be personally liable for all amounts required to make the Fund whole. This provision will not apply if the judgment in the case establishes that the third party was not liable for the accident. 4. That, if you do not prosecute a claim against a third-party to recover for the injuries, then you must agree to authorize the Fund, at its option, to bring a claim in your name against the third-party, including the filing of a lawsuit in court. 5. That, you will cooperate fully with the Fund in any action which the Fund may take. 6. That, you will not take any action, or sign any document which impairs the Fund’s right to recover the benefits paid. If you or an eligible dependent accept a settlement or receive an award or judgment, future medical expense for any injury or illness that has been caused by the third-party will not be considered eligible expenses under this Plan. August 2014 Section X - General Plan Exclusions and Limitations Page 83 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section X - General Plan Exclusions and Limitations Page 84 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION XI OTHER GENERAL PLAN PROVISIONS Physical or Dental Examination and Autopsy The Trustees at their own expense have the right and opportunity to examine the person of any individual whose injury or sickness is the basis of a claim when and as often as it may reasonably require during pendency of claim under the Plan, and to make an autopsy in case of death, where it is not forbidden by law. Free Choice of Physician The covered person has free choice of any physician and the physicianpatient relationship will be maintained. Workers' Compensation Not Affected The Plan is not in lieu of and does not affect any requirement for coverage of Workers' Compensation insurance. Time Limits for Filing Claims The Fund will furnish to the claimant, on request, the forms approved by the Trustees for filing proof of loss covered under this Plan. The Trustees may accept other written forms as proofs of loss, if in their sole judgement; the written proofs contain complete and credible information as to the occurrence, character and extent of the loss for which the claim is made. Written proof of expense incurred due to hospital confinement or due to total disability must be furnished to the Fund within ninety (90) days after the termination of the period for which the claim is made. Written proof of other covered expense incurred must be furnished within ninety (90) days of the date the expense is incurred. Failure to furnish notice or proof of loss within the time period provided in the Plan will not invalidate or reduce any claim: 1. if it was not reasonably possible to give proof within that time; and 2. if proof is furnished as soon as reasonably possible; and August 2014 Section XI - Other General Plan Provisions Page 85 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. no later than one (1) year from the time proof is otherwise required (except this time limit will not apply to a claimant who is legally incapacitated). 4. Medical Savings Benefits must be filed within ninety (90) days of the end of the calendar year. Benefits payable under the Plan for any loss other than Weekly Accident and Sickness Benefits will be paid as they accrue and upon receipt of due written proof of loss. Subject to due written proof of loss, Weekly Accident and Sickness Benefits will be paid at the times set forth in the applicable benefit provision. CIRCUMSTANCES THAT MAY RESULT IN LOSS OF ELIGIBILITY OF BENEFITS Throughout this booklet the Trustees have tried to bring to your attention those circumstances which might lead to a loss of eligibility and to describe any limitations, exclusions, or restrictions applicable to specified benefits. The Trustees urge you to familiarize yourself with this information, especially as it relates to the requirements which must be met in order to maintain your eligibility for benefits. REMEMBER: You must work the required number of hours or make timely self-payments in order to maintain your eligibility. If at any time you are uncertain about how a specific circumstance might affect your eligibility or benefit coverage, please contact the Fund Office and, if possible, try to do so before any circumstance arises. Claims Review & Appeal Procedures Your Right to Receive an Explanation of and to Ask for Review of an Adverse Benefit Determination You or your provider must file claims for Fund Benefits with Blue Cross Blue Shield of Illinois or the Claim processor, TIC International Corporation. If you have questions about decisions made on claims or requests for Medical benefits, you can address them by telephone to the Claims processor. Their telephone number is in the top right hand corner of the first page of the Explanation of Benefits sent to you by the Claims processor and on the denial letter notifying you that your claim for benefits has not been approved. August 2014 Section XI - Other General Plan Provisions Page 86 IBEW Local No. 461 Welfare Fund Summary Plan Description If you are not satisfied that the Claims processor’s denial of your request for benefits was proper, the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) requires that you can ask for review or appeal that “adverse benefit determination.” An adverse benefit determination is a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any denial based on your eligibility to participate in the Plan. You may ask for review of or appeal an adverse benefit determination on a pre-service claim, an urgent care claim, or a post-service claim. A “pre-service claim” is a claim for a benefit conditioned, in whole or in part, on obtaining advance approval of medical care. An “urgent care claim” is a claim for medical care or treatment where applying the normal time periods for claims determination could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of a physician who knows your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that you are seeking. A claim will be found to be an urgent care claim if either (1) a physician with knowledge of your medical condition determines that the claim is an urgent care claim or (2) the Plan using the judgment of a prudent layperson with average knowledge of health and medicine determines that it is an urgent care claim. A “post-service claim” is any claim that is not a pre-service claim or an urgent care claim. You must follow the review procedure set forth below to appeal or obtain review of an adverse benefit determination on pre-service, post-service and urgent care claims. Except for appeals or requests for review of adverse benefit determinations involving urgent care claims, all appeals or requests for review must be in writing. You normally must follow these review procedures before you can file a civil lawsuit under ERISA to get a court to order the Plan to provide you with the benefits that you have requested. Medical Benefit Claim Review Procedure A. Review Procedure – Post-service claims August 2014 Section XI - Other General Plan Provisions Page 87 IBEW Local No. 461 Welfare Fund Summary Plan Description The review procedure is triggered when the Plan provides you with a written adverse benefit determination, which must be done within thirty (30) days of the Plan’s receipt of your claim. To start the review, you, or your authorized representative, must send a written statement to the Fund Office explaining why you disagree with the Plan’s adverse benefit determination to the following address: IBEW Local No. 461 Welfare Fund 6525 Centurion Drive Lansing, MI 48917 The mailing address also is found at the top of the first page of your Explanation of Benefits form and in the letter we send notifying you that the Plan has not approved a benefit or service that you have requested. You must include in your request all documents, records or comments that you believe support your position. You must request review no later than one hundred eighty (180) calendar days after you receive the Plan’s decision on your claim for benefits. You will receive a written determination of your request for review by the later of (a) the Plan’s next regularly scheduled meeting which is at least thirty (30) days after the date of your appeal request for review or (b) thirty (30) days following your request for review unless the Trustees tell you that they need more time. The written determination that you receive as a result of your appeal request for review will be the final determination involving your claim for benefits. If you disagree with the Plan’s determination, or a determination is not issued by the time required, or the procedures for a review are not followed by the Plan, you have the right to bring a civil lawsuit under ERISA Section 502 (a) to try to obtain the benefits that you have requested. B. Review Procedure – Pre-service claims The review procedure for pre-service claims is identical to the review procedure for post-service claims, except that the Claims processor must provide you with written determinations within shorter time frames. A determination of preservice claims will be issued within fifteen (15) calendar days of receipt of your request for a review. If you disagree with the final determination, or if the determination is not issued within the fifteen (15) day time frame or the review procedures are otherwise August 2014 Section XI - Other General Plan Provisions Page 88 IBEW Local No. 461 Welfare Fund Summary Plan Description not complied with, you have the right to bring a civil action under section 502(a) of ERISA to obtain your benefits. C. Review Procedure – Urgent care claims The review procedure for urgent care claims is as follows: 1. You or your physician may submit your request for an internal review orally or in writing. If you choose to submit your request for review orally, please call: (866) 461-4329. 2. The Claims Processor must provide you with their decision as soon as possible, taking into account the medical exigencies, but not later than seventy-two (72) hours after receipt of your request for review. All necessary information, including the Claims processor decision on review, will be transmitted to you or to your authorized representative by telephone, facsimile, or other available similarly expeditious method. If the decision is communicated orally, they must provide you or your authorized representative with written confirmation of their decision within two (2) business days. 3. If you disagree with the final determination or if the Claims processor fails to issue the determination within seventy-two (72) hours, or otherwise fail to comply with the review procedures, you have the option to bring a civil action under section 502(a) of ERISA to obtain your benefits. In addition to the information found above, the following requirements apply to review of pre-service, post-service, and urgent care claims. a. You may authorize in writing another person, including, but not limited to, a physician, to act on your behalf at any stage in the standard internal review procedure.’ b. No fees or costs may be imposed as a condition to requesting review. c. Although there are set timeframes within which you must receive the final determination on all three types of claims, you have the right to allow additional time if you wish. d. You will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claims for benefits. e. You may submit written comments, documents, records, and other information relating to your claim for benefits, and this August 2014 Section XI - Other General Plan Provisions Page 89 IBEW Local No. 461 Welfare Fund Summary Plan Description information will be considered even if it was not submitted or considered in the initial benefit determination. f. The person who reviews your adverse benefit determination will be someone other than the person who issued the initial adverse benefit determination. The determination on review will be a new determination; the initial determination on your claim will not be afforded deference on review. g. If your request for review involves an adverse benefit determination that is based in whole or in part on a medical judgment, including whether a particular treatment, drug or other item is experimental, investigational, or not medically necessary or appropriate, a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment will be consulted. h. Upon request, the medical experts whose advice was obtained in connection with the adverse benefit determination will be identified, even if their advice was not relied upon in making the determination. i. On review, you will be advised of the specific reason for an adverse determination with reference to the specific plan provisions on which the determination is based. j. If an internal rule, guideline, protocol, or other similar criterion is relied upon in making the adverse determination, you will be advised and provided a copy of the rule, guideline, protocol, or other similar criterion free of charge upon request. k. If the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, you will be advised and provided an explanation of the scientific or clinical judgment free of charge upon request. Coordination of Benefits With Other Group Plans - How Benefits Are Reduced To alleviate the problem of excess coverage, which needlessly increases the costs of protection, all the Plan benefits will be coordinated with the following coverage: 1. Individual, group, blanket, franchise, common carrier insurance coverage; or general liability, August 2014 Section XI - Other General Plan Provisions Page 90 IBEW Local No. 461 Welfare Fund Summary Plan Description 2. Hospital or medical service organizations, group practice, and other prepayment coverage; or 3. Any coverage under any labor-management trusted plans, union welfare plans, employer organization plans or Employee benefit organization plans; or 4. Any coverage under governmental programs coverage required or provided by any statute. or any Benefits will be reduced under certain circumstances when an individual is covered under this Plan and under one or more other plans, but it is intended that the individual will be fully reimbursed for allowable expenses under the various plans to the extent combined benefits equal one hundred (100%) percent of the total allowable expenses. Benefit Determination As stated above, the Plan will coordinate benefits with all group programs providing coverage to the Employee or his dependent for all claims. 1. When the other group plan does not have a provision for Coordination of Benefits, they must be considered the primary carrier and must make benefit payment first before this Fund will consider payment. 2. When the other group plan does have a provision for Coordination of Benefits, the order of benefit payments will be determined by the Industry Standard Provision of the birth date rule. 3. If you elect to make COBRA self-payments under this Plan while you are also covered by another Plan, the other Plan will pay first and this Plan’s COBRA coverage will pay second. Claim for a Covered Employee The covered employee must first submit all charges to the group with the earliest effective date. After the charges have been considered, copies of all charges and payment statements should then be submitted to the secondary plan for consideration. The eligible person must claim benefits due from the "primary" plan determined by these rules for its share of eligible expenses, including benefits or August 2014 Section XI - Other General Plan Provisions Page 91 IBEW Local No. 461 Welfare Fund Summary Plan Description services available from prepayment coverage programs such as Health Maintenance Organizations. When this Plan is "secondary" according to the established order of benefit determination, the term "benefits payable under another Plan" will include the benefits that would have been paid if the eligible person made a proper claim on that Plan or used its services. This Plan's liability and its benefit payments will not increase simply because the eligible person elects not to use the "primary" coverage. When Claim is on the Dependent Spouse Effective January 1, 2012 the IBEW Local No. 461 Welfare Fund (“Fund”) implemented a Working Spouse Rule requiring that working spouses of participants enroll in their employers’ health plans. Spouses that do not enroll in their employers’ health plans will have their coverage reduced to twenty percent (20%) of allowable charges rather than eighty percent (80%) of the BCBSIL approved amount for in-network services and sixty-five percent (65%) of the BCBSIL approved amount for out of network services unless they qualify for the HARDSHIP EXEMPTION as explained below. The participant must provide information regarding their marital status and the spouse’s employment status (if they are married) on an annual basis. THE BASIC “WORKING SPOUSE RULE” If the participant’s spouse works and is eligible for coverage through his or her employer (a plan in which the employer contributes some or all of the premiums), then his or her plan is primary and the Fund will be secondary for all the spouse’s medical claims. The Fund will only pay twenty percent (20%) of the allowable charges rather than eighty percent (80%) of the BCBSIL approved. Below is the HARDSHIP EXEMPTION for the Working Spouse Rule: HARDSHIP EXEMPTION – the Working Spouse Rule will not apply if your spouse: 1. Has gross annual wages of less than twenty thousand dollars ($20,000), or 2. Has gross annual wages greater than or equal to twenty thousand dollars ($20,000) but less than thirty thousand dollars ($30,000) and must pay more than one hundred dollars ($100) per month toward the cost of the least expensive health plan offered by his or her employer. August 2014 Section XI - Other General Plan Provisions Page 92 IBEW Local No. 461 Welfare Fund Summary Plan Description You are responsible for demonstrating your spouse’s entitlement to a hardship exemption by submitting a letter to the Fund Office attesting to your spouse’s wages and cost of coverage from your spouse’s employer on company letterhead. The Fund Office will determine whether a spouse with variable wages qualifies for the hardship exemption by looking at the spouse’s average wages over the past twelve (12) months. Dual Coverage Saves you Money – When your spouse is covered by his or her employer’s plan and this Plan at the same time, the two plans together will usually pay one hundred percent (100%) of his or her covered claims under the coordination of benefits rules. If your spouse requires a hospitalization or surgery, you will generally come out ahead financially from the dual coverage, even after your spouse’s premiums are taken into account. Additional provisions and exceptions to the Working Spouse Rule: 1. The Working Spouse Rule only applies to your spouse’s claims, not to claims incurred by your children. 2. It applies to retirees as well as active employees, but only if the retiree’s spouse is till actively employed. 3. It does not apply to COBRA coverage, meaning that if your spouse terminates employment and declines COBRA, this Plan will pay its normal benefits. 4. The Working Spouse Rule only applies to medical and drug expenses. 5. The Rule applies without regard to whether or not your spouse’s employer requires its employees to pay for part of the premium, whether or not the employer offers an incentive to induce employees not to enroll, and whether or not the employer offers a single-only coverage option. It also applies if the employer only offers medical coverage as an option under a cafeteria plan. 6. No reductions will apply to a particular claim if you can demonstrate that your spouse’s claim would have been denied under the employer’s plan (for example, if the claim was for a pre-existing condition incurred during the preexisting waiting period). 7. The provision will also be waived if the only health plan offered by your spouse’s employer is an HMO plan, and your residence is more than twentyfive (25) miles outside the HMO service area. 8. If your spouse is covered under his or her employer’s plan, then your spouse must receive his or her medical care in accordance with that plan’s rules. This Fund will not cover the amount of the other plan’s noncompliance penalties, or any charges incurred because of failure to follow the other plan’s rules, August 2014 Section XI - Other General Plan Provisions Page 93 IBEW Local No. 461 Welfare Fund Summary Plan Description including failure to use HMO providers or follow the HMO’s referral procedures. (This is not a new rule, and it also applies to claims for your children when your spouse’s plan is primary). 9. You are required to provide accurate and timely information to the Fund about your spouse’s employment status and benefit entitlement, and the Fund Office may require verification of this information from your spouse’s employer. When Claim is for a Dependent Child The Trustees have adopted, in principle, the coordination provision known as the "birthday rule" effective July 1, 1985. The "birthday rule" provides that: In claims involving children, the order of benefit payments will be as follows: 1. The plan covering the parent whose birthday occurs earliest in the calendar year will pay first. 2. The plan covering the parent whose birthday occurs later in the calendar year, and having a provision for Coordination of Benefits, will pay second. Special Note: If an Employee covered under this Plan has two types of group coverage, the plan with the earliest effective date must pay first. The Plan covering the Employee for the shortest period of time will consider the balance due upon receipt of: 1. A copy of itemized bills; and 2. A copy of the payment statement. If there is a divorce and/or remarriage, the financial and medical responsibility is generally stipulated by court decree. Members are required to submit legal documents that are requested by the Fund Office so that the order of benefit determination can be established. Contact the Fund Office for further information. Coordination of Benefits with Medicare If you are not active under Class A or Class B eligibility when you or your Dependent becomes eligible for Medicare (officially known as Title XVII of the Social Security Amendments of 1954, amended effective July 1, 1973, and as August 2014 Section XI - Other General Plan Provisions Page 94 IBEW Local No. 461 Welfare Fund Summary Plan Description thereafter may be amended) in addition to this Plan, the Trustees require that you enroll in Medicare Part A & B. This applies when you are retired due to attained age or to a qualifying disability. Effect on Benefits When a person is eligible in this Plan and eligible for Medicare, Medicare generally is required to pay first. Benefits payable by this Plan may be reduced by the amount Medicare pays, but only if the total of this Plan's normal benefits and Medicare's payment will be more than one hundred (100%) percent of eligible expenses. Once retired, you or your Dependent will be considered to be currently eligible and covered by Medicare as soon as you would be eligible to enroll whether or not you actually enroll as you should. The Plan will remain the primary payer of benefits to the end of the quarter of Medicare entitlement. Limitations To comply with Federal regulations, the provision will not apply to an Employee who is still eligible in this Plan due to Employer contributions or to the spouse of such an Employee. Medicare will always be required to pay first when eligible expenses are incurred by: 1. Retired Employees and their Dependents (except for the end of the quarter of entitlement); or 2. Employees eligible for Medicare on the basis of permanent kidney failure, after the first thirty (30) months of treatment. Active Employees and/or Their Spouses Who Are Age 65 or Older If you are an Active Employee and continue to work, or remain eligible via banked contributions or self-contributions, beyond the date you or your spouse become eligible for Medicare at age sixty-five (65), you have the option to have either the Fund or Medicare as your primary payer of benefits. If you elect Medicare as the primary payer of benefits, your out-of-pocket expenses will generally be greater than they would be if the Fund is the primary payer. August 2014 Section XI - Other General Plan Provisions Page 95 IBEW Local No. 461 Welfare Fund Summary Plan Description Because of the additional costs to you if Medicare is the primary payer of benefits, the Trustees have decided that the Fund should be the primary payer of benefits for all Active Employees and Their Spouses who are over age sixtyfive (65) and entitled to Medicare. What this means is that in those cases where Medicare and the Fund cover the same items or services, the Fund will pay first and then Medicare will supplement the Fund’s coverage up to the Medicare limit. In most cases, the Fund’s benefits are more generous than those provided under Medicare. Where they are not, you retain the right to file your claim with Medicare for whatever supplemental coverage is available. Your combined benefits from Medicare and the Fund will remain unchanged. Any time after the age of sixty-five (65) that you cease to meet the definition of an Active Employee, Medicare automatically becomes the primary payer. If for some reason you or your spouse would rather have Medicare as the primary payer, you must state this preference in writing to the Fund Office when you become eligible for Medicare. Regardless of your election, you should not forget to pay the Part B Medicare premium for medical services for your own protection. Failure to pay the Part B premium on time will result in the loss of Medicare protection for medical services. You are considered active until you retire with the Social Security Administration, or cease to apply for active employment. Active Employees with Dependents Eligible for Medicare The Fund must act as the primary payer of benefits for any Active Employee and/or your covered family members who are eligible for Medicare due to a disability. This requirement ends when you cease to meet the definition of an Active Employee. Claims for the Covered Persons affected by this provision are considered primary to the Fund first. Any portions not paid should then be submitted to Medicare for payment. In those cases where Medicare and the Fund cover the same items or services, the Fund will pay first up to its limits and then Medicare will supplement the Fund’s coverage up to the Medicare limits. In some instances, only the Fund will provide coverage for some items. Covered persons affected by this provision are advised to pay the premium for Part B (Medical) coverage through Medicare. This assures the most complete coverage for medical expenses and is required to qualify for participation in certain programs available through the Fund. August 2014 Section XI - Other General Plan Provisions Page 96 IBEW Local No. 461 Welfare Fund Summary Plan Description HIPAA Privacy - Confidential Information The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides stringent requirements for the Fund, its Trustees, and its service vendors concerning the use and disclosure of Participants’ personally identifiable ‘Protected Health Information’ (PHI). Broadly speaking, PHI includes demographic information about you and/or your dependents, such as your name, address, telephone number and Social Security Number, in conjunction with information concerning you and/or your dependents, such as: (1) eligibility for Benefits, (2) medical treatment provided or (3) payment for such medical treatment. Specifically, the Plan will use and disclose PHI only for purposes related to health care treatment, payment for health care and health care operations or otherwise allowed or required by law. The Plan’s use and disclosures of PHI is set out in detail in the Privacy Notice previously mailed to you. If you would like another copy of this notice, please contact the Fund Office. The Plan and the Trustees are committed to observing these privacy rules and in ensuring the confidentiality of your PHI. Your cooperation and understanding in working with the Plan to achieve compliance with these federal requirements is appreciated. August 2014 Section XI - Other General Plan Provisions Page 97 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section XI - Other General Plan Provisions Page 98 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION XII STATEMENT OF PARTICIPANT’S RIGHTS Information Required by the Employee Retirement Income Security Act (ERISA) Introduction You have probably heard about ERISA. ERISA stands for the Employee Retirement Income Security Act, which was signed into law in 1974. This federal law establishes certain minimum standards for the operation of employee benefits plans including the IBEW Local No. 461 Welfare Fund. The Trustees of your Fund, in consultation with their professional advisors, have reviewed these standards carefully and have taken the steps necessary to assure full compliance with ERISA. ERISA requires that Plan participants and beneficiaries be provided with certain information about their benefits, how they may qualify for benefits, and the procedures to follow when filing a claim for benefits. This information has already been presented in the preceding pages of this Summary Plan Description. ERISA also requires that participants and beneficiaries be furnished with certain information about the operation of the Plan and about their rights under the Plan. This information follows: READ THIS SECTION CAREFULLY. Only by doing so can you be sure that you have the information you need to protect your rights and your best interests under this Plan. Your Rights as a Participant As a participant in the IBEW Local No. 461 Welfare Plan: 1. You will automatically receive a Summary Plan Description (this booklet). The purpose of this booklet is to describe all pertinent information about the Plan. 2. If any substantial changes are made in the Plan, you will be notified within the time limits required by ERISA. August 2014 Section XII - Statement of Participants Rights Page 99 IBEW Local No. 461 Welfare Fund Summary Plan Description 3. Each year you will automatically receive a summary of the Plan’s latest annual financial report. A copy of the full report is also available upon written request. You will also receive a copy of the Summary of Benefits and Coverage each year or more frequently if requested. 4. You may examine, without charge, all documents relating to this Plan. These documents include: the legal Plan Document, collective bargaining agreements, and copies of all documents filed by the Plan with the Department of Labor or the Internal Revenue Service, such as annual reports and Plan descriptions. Such documents may be examined at the Fund Office (or at other required locations such as work sites or union halls) during normal business hours. To assure that your request is handled promptly and that you are given the information you want, the Trustees have adopted certain procedures which you should follow: - Your request should be in writing; It should specify what materials you wish to look at; and It should be received at the Fund Office at least three days before you want to review the materials at the Fund Office. Although all pertinent Plan documents are on file at the Fund Office, arrangements can be made upon written request to make the documents you want available at any work site or union location at which fifty (50) or more participants report to work. Allow ten days for delivery. 5. You may obtain copies of any Plan document upon written request to the Trustees, addressed to the Fund Office. ERISA provides that the Trustees may make a reasonable charge for the actual cost of reproducing any documents you request. You are entitled to know, however, what the charge will be in advance. Just ask the Fund Office. 6. No one may take any action which would prevent you from obtaining a benefit to which you may be entitled or from exercising any of your rights under ERISA. 7. In accordance with Section 503 of ERISA and related regulations, the Trustees have adopted certain procedures to August 2014 Section XII - Statement of Participants Rights Page 100 IBEW Local No. 461 Welfare Fund Summary Plan Description protect your rights if you are not satisfied with the action taken on your claim. 8. These procedures appear in the Appeal section of this booklet. Basically they provide that: - If your claim for a welfare benefit is denied in whole or in part, you will receive a written explanation of the reason(s) for the denial. - Then, if you are still not satisfied with the action on your claim, you have the right to have the Plan review and reconsider your claim in accordance with the Plan’s claims review procedures. - These procedures are designed to give you a full and fair review and to provide maximum opportunity for all the pertinent facts to be presented on your behalf. 9. In addition to creating rights for Plan participants, ERISA also defines the obligations of people involved in operating employee benefit plans. These persons are known as “fiduciaries”. They have the duty to operate your Plan with reasonable care and with your best interests in mind as a participant under the Plan. Be assured that the Trustees of this Plan will do their best to know what is required of them as “fiduciaries” and to take whatever actions are necessary to assure full compliance with all state and federal laws applicable to the Plan. 10.Under ERISA, you may make certain actions to enforce the rights listed above. a. For instance, if you request materials from the Plan and do not receive them within thirty (30) days, you may file suit in federal court. Of course, before taking such action, you will no doubt want to check again with the Fund Office to make sure that: (1) the request was actually received, and (2) the material was mailed to the right address, or (3) the failure to send the material was not due to circumstances beyond the Trustees’ control August 2014 Section XII - Statement of Participants Rights Page 101 IBEW Local No. 461 Welfare Fund Summary Plan Description If you are still not able to get the information you want, you may wish to take legal action. The Court may require the Trustees to provide the materials promptly and/or pay you a fine until you actually receive the materials (unless the delay was caused by reasons beyond the Trustees’ control). b. Although the Trustees will make every effort to settle any disputed claims with participants fairly and promptly, in accordance with the Fund’s rules, there is always the possibility that differences can not be resolved to everyone’s satisfaction. For this reason, you may file suit in a state or federal court if you feel that you have been improperly denied a benefit. Before exercising this right, however, you will normally find it advisable to exhaust all the claim review procedures available under your Plan and then proceed only upon the advice of your attorney. c. If it should happen that Plan fiduciaries misuse the Plan’s money or discriminate against you for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. 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 the court finds your claim is frivolous, you may be required to pay court costs and legal fees. We trust this Summary Plan Description has provided you with most important information about your Plan and your rights under ERISA. If you have any questions about your Plan, you should contact the Fund Office by writing to: IBEW Local No. 461, 6525 Centurion Drive, Lansing, Michigan, 48917 or by telephone: (630) 897-0461. If you have any questions about this Statement or about your rights under ERISA which have not been answered in this Summary Plan Description or by the August 2014 Section XII - Statement of Participants Rights Page 102 IBEW Local No. 461 Welfare Fund Summary Plan Description Fund Office, you should contact the nearest Area Office of the U.S. Department of Labor. The Fund Office will be glad to furnish the address. Nothing in this statement is meant to interpret or extend or change in any way the provisions expressed in the Plan. The Trustees reserve the right to amend, modify or discontinue all or part of this Plan whenever, in their judgment, conditions so warrant. Participants will be notified of any plan changes. August 2014 Section XII - Statement of Participants Rights Page 103 IBEW Local No. 461 Welfare Fund Summary Plan Description THIS PAGE LEFT INTENTIONALLY BLANK August 2014 Section XII - Statement of Participants Rights Page 104 IBEW Local No. 461 Welfare Fund Summary Plan Description SECTION XIII OTHER IMPORTANT INFORMATION The Trustees Interpret the Plan Under the Trust Agreement creating the Welfare Fund, and the terms of this Plan, the Board of Trustees have the sole authority to make final determinations regarding any application for benefits and the interpretation of the Plan and any administrative rules adopted by the Trustees. The Trustees have full discretionary authority to interpret and construe the Plan, all Plan Documents, the Trust Agreement, and all Plan rules and procedures. The Trustees interpretation will be given the maximum deference permitted by law for the exercise of such full discretionary authority. The Trustees’ decisions in such matters are final and binding on all persons dealing with the Plan or claiming a benefit from the Plan. If a decision of the Trustees is challenged in court, it is the intention of the parties to the Plan, and the Welfare Plan provides, that such decision is to be upheld unless it is determined to be arbitrary or capricious. Any interpretation of the Plan’s provisions rests with the Board of Trustees. No employer or union, nor any representative of any employer or union, is authorized to interpret this Plan on behalf of the Board nor can an employer or union act as an agent of the Board of Trustees. However, the Board of Trustees has authorized the Administrative Manager and the Fund Office staff to handle routine requests from participants regarding eligibility rules, benefits, and claims procedures. But, if there are any questions involving interpretation of any Plan provisions, the Administrative Manager will ask the Board of Trustees for a final determination. The Plan Can Be Changed The Trustees have the legal right to change the Plan, subject to any collective bargaining agreement that applies to it. Although the Trustees hope to maintain the present level of benefits and to improve upon them if possible, a primary concern of the Trustees is to protect the financial soundness of the Plan at all times. To do so may require Plan changes from time to time. Changes in the Plan may also be required in order to preserve the Fund’s tax exempt status under Internal Revenue Service rules and regulations. These August 2014 Section XIII - Other Important Information Page 105 IBEW Local No. 461 Welfare Fund Summary Plan Description rules and regulations may change and as a result, Trustees may find it necessary to change Plan provisions so that the Trust does not lose its tax exempt status. Your Plan is Tax Exempt Your Welfare Plan is classified by the Internal Revenue Service as a 501(c) (9) Trust. This means that the employers contributions to the Trust are tax deductible and are not included as part of your income. Also, in most cases, the benefits paid on your behalf are not taxable as personal income and investment earnings on Plan assets are excluded as taxable income of the Trust since they are specifically set aside for the purpose of providing benefits to participants. Obviously, such tax exemption works to the benefit of both employer and employee. In effect, it means that money which otherwise might be payable as taxes can be used to purchase benefits and to cover administrative expenses. The Trustees are well aware of these advantages and will take whatever steps are necessary to keep your Plan “Qualified” as a tax exempt Trust under Internal Revenue Service rules. Right to Receive and Release Necessary Information To determine the applicability of and to implement the terms of this Plan or the similar terms of any other plan, the Fund will not, without consent, notice and signed authorization to any covered person, release to or obtain from any insurance company or other organization or individual, any information, with respect to any covered person which is considered individually identifiable protected health information unless such information is deemed necessary for payment of medical claims. Facility of Payment Whenever payments which should have been made under this Plan in accordance with its provision have been made under any other plans, the Fund shall have the right, exercisably alone and at its sole discretion, to pay any organization making such other payments any amounts it shall determine to be warranted. If any Plan benefits become payable to the estate of an eligible person or to an eligible person or Beneficiary who is a minor or otherwise not competent to give a valid release, the Plan may pay up to one thousand dollars ($1,000) in benefits to that person’s relative by blood or connection by marriage who the Trustees find is equally entitled thereto. August 2014 Section XIII - Other Important Information Page 106 IBEW Local No. 461 Welfare Fund Summary Plan Description Any payment made by the plan in good faith under this provision shall fully discharge the Plan to the extent of such payment. Right of Recovery Whenever payments have been made by the Fund with respect to allowable expenses in excess of the maximum amount of payment necessary at the time to satisfy its provisions, the Fund shall have the right to recover such payments, to the extent of such excess, from among one or more of the following as the Fund shall determine: 1. Any individual to whom or from whom such payments were made; or 2. Any insurance organization. company, hospital, physician or any other The Fund may also recover such excess payments by reducing future benefit payments, if any, which become due a Participant, Dependent or Beneficiary. Payment of Claims Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which are prescribed herein effective at the time of payment. If no such designation or provision is then effective, the indemnity will be payable as described on Page sixty-nine (69) “Beneficiary Designation”. Any other accrued indemnities unpaid at the Employee’s death may, at the option of the Trustees, be paid either to the beneficiary or to the estate. Subject to any written direction of the Employee, all or a portion of any indemnities provided by the Fund for services rendered by a hospital, nursing, medical, surgical, dental or vision service may, at the Trustees’ option, and unless the Employee requests otherwise in writing no later than the time for filing proof of loss, be paid directly to the hospital or provider of services. Name of the Plan The Plan is the IBEW Local No. 461 Welfare Fund. August 2014 Section XIII - Other Important Information Page 107 IBEW Local No. 461 Welfare Fund Summary Plan Description Type of Plan This Plan provides Health Care Benefits for expenses due to hospitalization, surgery, medical treatment, vision or dental care. This Plan also provides benefits for Death, and Weekly Accident and Sickness (Loss of Time). Type of Plan Administration The Administrator is responsible for carrying out the Trustees’ policy decisions, record keeping, and accounting. The Trustees have also selected a professional Third Party Administrator, TIC International Corporation to process the payment of medical, dental, vision and disability benefits. TIC International is responsible for the payment of claims, coordination of benefits, maintains participant census information and performs other routine activities under the direction of the Trustees. Name and Address of the Administrative Manager The Administrative Manager selected by the Trustees is: Joel Pyle II, Administrative Manager IBEW Local No. 461 Welfare Fund 591 Sullivan Road, Suite 100 Aurora, IL 60506 Telephone: (630) 897-0461 Facsimile: (630) 897-7605 FAX Agent for Service of Legal Process Roger Gold James Neuman Baum Sigman Auerbach & Neuman, Ltd. 200 West Adams Street, Suite 2200 Chicago, IL 60606 (312) 236-4316 (312) 236-0214 FAX Service of legal process may also be made upon any Plan Trustee. August 2014 Section XIII - Other Important Information Page 108 IBEW Local No. 461 Welfare Fund Summary Plan Description Name and Address of Claims Agent (Claims Inquiries) TIC International Corporation 6525 Centurion Drive Lansing, MI 48917-9275 (517) 321-7502 (866) 461-4329 (IBEW) (517) 321-7508 FAX Name and Address of Investment Consultant Ted Disabato Disabato Advisers 525 West Monroe Street, Suite 560 Chicago, IL 60661 (312) 474-0900 Main (312) 474-0905 Direct Name and Address of Member Assistance Program (MAP) Employee Resource Systems, Inc. 29 East Madison Street, Suite 1600 Chicago, IL 60602 (800) 292-2780 Name and Address of Preferred Provider Organization Blue Cross Blue Shield of Illinois PO Box 1364 Chicago, IL 60601 Claim Inquiry (800) 571-1043 www.bcbsil.com Name and Address of Prescription Drug Vendor Citizens-Rx 103 Vandalia Edwardsville, IL 62025 (888) 545-1120 www.citizensrx.com August 2014 Section XIII - Other Important Information Page 109 IBEW Local No. 461 Welfare Fund Summary Plan Description Name and Title of Each Trustee The Trustees of this Fund are: Union Trustees Management Trustees Joel Pyle, II, Secretary Michael Angelo Steve Musich Mark Seppelfrick Bruce Anderson, Chairman Paul Hopkins Craig Martin Adam Mata Name and Address of Local Union Office IBEW Local No. 461 Welfare Fund 591 Sullivan Road, Suite 100 Aurora, IL 60506 Telephone: (630) 897-0461 Facsimile: (630) 897-7605 FAX Parties to the Collective Bargaining Agreement The Fund is established and maintained under the terms of a collective bargaining agreement. This agreement sets forth the conditions under which participating Employers are required to contribute to your Fund. The parties to the collective bargaining agreement are: Local Union Number 461, International Brotherhood of Electrical Workers And Northeastern Illinois Chapter of the National Electrical Contractors Associations, Inc.; Internal Revenue Service Employer and Plan Identification Numbers The Employer Identification Number (EIN) issued to the Board of Trustees is 362514448 the Plan Number is 501. August 2014 Section XIII - Other Important Information Page 110 IBEW Local No. 461 Welfare Fund Summary Plan Description Eligibility Requirements The Plan’s requirements with respect to eligibility for benefits are shown in the Eligibility Rules in the Eligibility Section of this Document. Circumstances which may cause you to lose eligibility are explained in the Eligibility Rules in the Eligibility Section of this Document. Sources of Trust Fund Income Sources of Trust Fund income include Employer contributions, Employee self-payment of contributions and investment earnings. All Employer contributions paid to the Trust Fund are subject to the provisions in the collective bargaining agreement between the Union and the Employer Association; or are subject to a separate individual collective bargaining agreement with the Union; or are subject to a Fund Participation Agreement for contributions for noncollectively bargained employees. The agreements specify the amount of contribution, due date of Employer contributions, type of work for which contributions are payable and the geographic area covered by the labor contract. Method of Funding Benefits Benefits payable under this Plan are self-funded and paid directly from the accumulated assets of the Trust Fund. A portion of Fund assets are also allocated for reserves to meet future liabilities and to carry out the objectives of the Plan. Fiscal Year of the Plan The financial records of this Plan are based on a fiscal year which begins June 1 and ends May 31. The Plan May be Terminated Although the Trustees do not foresee that the Plan will be terminated, the Trust Agreement provides that termination may occur when: 1. The Trustees determine that the Trust Fund assets are not adequate to carry out the purpose for which the Welfare Fund is intended; or August 2014 Section XIII - Other Important Information Page 111 IBEW Local No. 461 Welfare Fund Summary Plan Description 2. There is no longer a collective bargaining agreement or other written agreement in effect that requires Employer contributions to be made to the Trust Fund and negotiations for extension thereof have ceased. The Trustees are obligated to use the Trust Assets for payment of expenses incurred up to the date of termination and expenses related to the termination as their first priority. Remaining assets, if any, must be used to continue Plan benefits after the Plan termination date for those persons eligible when the Plan was terminated. Upon written request, you may examine the agreement at the Administration Office or other specified locations. Or you may request of a copy of the agreement which will be provided for a reasonable charge. August 2014 Section XIII - Other Important Information Page 112