Each Employee will become eligible for coverage under this Plan with respect to himself or herself on the date of hire, provided the Employee has begun work for his or her Participating Employer. If the Employee is unable to begin work as scheduled, then his or her coverage will become effective on such later date when the Employee begins work. Each Employee who was covered under the Prior Plan, if any, will be eligible on the Effective Date of this Plan.
Reinstatement of Coverage
If employment is terminated and the Employee returns to Active Employment within two months from the date of termination, the Service Waiting Period will be waived and coverage will take effect on the first day the Employee returns to Active Employment.
Eligibility for Retiree Coverage
A person is eligible for retiree coverage from the first day that he or she meets one of the following requirements:
- Is a retired Employee of the Employer, prior to June 30, 2001
- Is an Active Employee who retired prior to June 30, 2001. Spouses and Dependents of a retiree are also eligible provided they meet the requirements stated in the provision entitled “Eligibility for Dependent Coverage.”
Retiree coverage will be paid for by the retiree. Rates will be one-half of the prevailing COBRA rates for each class of Employees.
Eligibility Dates for Dependent Coverage
Each Employee will become eligible for coverage under this Plan for his or her Dependents on the latest of the following dates:
- His or her date of eligibility for coverage for himself or herself under the Plan.
- The date coverage for his or her Dependents first becomes available under any amendment to the
Plan, if such coverage was not provided under the Plan on the Effective Date of the Plan.
- The first date upon which he or she acquires a Dependent.
- The date the Dependent Child is eligible due to a qualifying status change event, as outlined in the
Section 125 plan.
In no event will any Dependent Child be covered as a Dependent of more than one Employee who is covered under the Plan.
In order for an Employee’s Dependent to be covered under the Plan the Employee must be enrolled for coverage under the Plan.
“Michelle’s Law” prohibits a group health plan, or a health insurance issuer that provides health insurance coverage in connection with a group health plan, from terminating coverage of a Dependent Child due to a qualifying “Medically Necessary Leave of Absence” from, or other change in enrollment at, a postsecondary educational Institution prior to the earlier of:
- The date that is one year after the first day of the Medically Necessary Leave of Absence.
- The date on which such coverage would otherwise terminate under the terms of the Plan.
In order to be a Medically Necessary Leave of Absence the student’s leave must meet all of the following requirements:
- Commence while the Dependent Child is suffering from a serious Illness or Injury.
- Be Medically Necessary.
- Cause the Dependent Child to lose student status for purposes of coverage under the terms of the
parents’ plan or coverage.
A Child is a “Dependent Child” under the law if he or she meets all of the following requirements:
- Is a Dependent Child of a Participant under the terms of the Plan or coverage.
- Was enrolled in the Plan or coverage, on the basis of being a student at a postsecondary educational Institution, immediately before the first day of the Medically Necessary Leave of
A treating Physician of the Dependent Child must certify that the Dependent Child is suffering from a serious Illness or Injury and that the Leave of Absence (or other change of enrollment) described is Medically Necessary.
Effective Dates of Coverage; Conditions
The coverage for which an individual is eligible under this Plan will become effective on the date specified below, subject to the conditions of this section.
- Enrollment Application (paper or electronic as applicable): Employee(s) may seek to obtain coverage for themselves and/or Dependents via a form (either paper or electronic as applicable) furnished by the Plan Administrator, in a manner that is satisfactory to the Plan Administrator, and within 7 days following the applicable date of eligibility. If coverage is available and appropriate, coverage will become effective after review of the form, and upon the subsequent date such Employee or Dependents are eligible.
- Coverage as Both Employee and Dependent: An eligible Participant may enroll in this Plan either as an Employee or as a Dependent, but not both.
- Birth of Dependent Child: A newborn Child of a covered Employee will be considered eligible and will be covered from the moment of birth for Injury or Illness, including the Medically Necessary care and treatment of medically diagnosed congenital defects, birth abnormalities and prematurity, newborn care and Preventive Care if written notification to add the Child is received by the Plan Administrator within 30 days following the Child’s date of birth. If written notification to add a newborn Child is received by the Plan Administrator AFTER the 30 day period immediately following the Child’s date of birth, the Child is considered a late enrollee and not eligible for the Plan until the next Open Enrollment Period. A newborn Child of a Dependent Child is not eligible for this Plan unless the newborn Child meets the definition of an eligible Dependent.
- Newly Acquired Dependents: If while an Employee is enrolled for coverage, that Employee acquires a Dependent, coverage for the newly acquired Dependent shall be effective on the date the Dependent becomes eligible only if the existing coverage extends to Dependents. If coverage for Dependents has not already been secured by the Employee, a written application must be made to the Plan within 30 days of the date of the newly acquired Dependent’s eligibility, and any required contributions are also to be made if enrollment is otherwise approved by the Plan Administrator.
- Requirement for Employee Coverage: Coverage for Dependents shall only be available to Dependents of Employees eligible for coverage for him or herself.
- Dependents of Multiple Employees: If a Dependent may be deemed to be a Dependent of more than one Covered Employee, such Dependent shall be deemed to be a Dependent of one such Employee only.
- Medicaid Coverage: An individual’s eligibility for any State Medicaid benefits will not be taken into account by the Plan in determining that individual’s eligibility under the Plan.
- FMLA Leave: Regardless of any requirements set forth in the Plan, the Plan shall at all times comply with FMLA.
It is the responsibility of the enrolled Employee to notify his or her Employer of any changes in the Dependent’s status.
Special and Open Enrollment
Federal law requires and the Plan provides so-called “Special Enrollment Periods,” during which Employees may enroll in the Plan, even if they declined to enroll during an initial or subsequent eligibility period. The Special Enrollment rules are described in more detail within the Eligibility for Coverage section.
Loss of Other Coverage
This Plan will permit an eligible Employee or Dependent (including his or her spouse) or civil union partner who is eligible, but not enrolled, to enroll for coverage under the terms of the Plan if each of the following conditions is met:
- The eligible Employee or Dependent was covered under another group health plan or had other health insurance coverage at the time coverage under this Plan was offered.
- The eligible Employee stated in writing at the time this Plan was offered, that the reason for declining enrollment was due to the eligible Employee having coverage under another group health plan or due to the Employee having other health insurance coverage.
- The eligible Employee or Dependent lost other coverage pursuant to one of the following events:
- The eligible Employee or Dependent was under COBRA and the COBRA coverage was exhausted.
- The eligible Employee or Dependent was not under COBRA and the other coverage was terminated as a result of loss of eligibility (including as a result of Legal Separation, divorce, loss of Dependent status, death, termination of employment, or reduction in the number of hours worked).
- The eligible Employee or Dependent moved out of an HMO service area with no other option available.
- The Plan is no longer offering benefits to a class of similarly situated individuals.
- The benefit package option is no longer being offered and no substitute is available.
- The Employer contributions were terminated.
If an Employee is currently enrolled in a benefit package, the Employee may elect to enroll in another benefit package under the Plan if the following requirements are met:
- Multiple benefit packages are available.
- A Dependent of the enrolled Employee has a special enrollment right in the Plan because the Dependent has lost eligibility for other coverage.
Special enrollment rights will not be available to an Employee or Dependent if the following requirements is met:
- The Employee or Dependent lost the other coverage as a result of the individual’s failure to pay premiums or required contributions or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the Other Plan).
For an eligible Employee or Dependent(s) who has met the conditions specified above, this Plan will be effective at 12:01 A.M. on the first day following enrollment and the request is made within 30 days from loss of coverage. For example, if the Employee loses his or her other health coverage on April 22, he or she must notify the Plan Administrator and apply for coverage by close of business on May 22.
An Employee or Dependent who is eligible, but not enrolled in this Plan, may be eligible to enroll during a special enrollment period if an Employee acquires a new Dependent as a result of marriage, civil union partnership, legal guardianship, birth, adoption, or placement for adoption. To be eligible for this special enrollment, the Employee must apply in writing or electronically, as applicable, no later than 30 days after he or she acquires the new Dependent. For example, if the Employee or Employee’s spouse gives birth to a baby on June 22, he or she must notify the Plan Administrator and apply for coverage by close of business on July 22. The following conditions apply to any eligible Employee and Dependents:
An Employee or Dependent who is eligible, but not enrolled in this Plan, may enroll during a special enrollment period if one of the following conditions are met:
- The eligible Employee is a covered Employee under the terms of this Plan but elected not to enroll during a previous enrollment period.
- An individual has become a Dependent of the eligible Employee through marriage, civil union partnership, legal guardianship, birth, adoption, or placement for adoption.
If the conditions for special enrollment are satisfied, the coverage of the Dependent and/or Employee enrolled during the Special Enrollment Period will be effective at 12:01 A.M. for the following events:
- In the case of marriage, on the date of the marriage.
- For a civil union partnership, on the date of the civil union partnership agreement.
- For a legal guardianship, on the date on which such Child is placed in the covered Employee’s home pursuant to a court order appointing the covered Employee as legal guardian for the Child.
- In the case of a Dependent’s birth, as of the date of birth.
- In the case of a Dependent’s adoption or placement for adoption, the date of the adoption or placement for adoption.
Additional Special Enrollment Rights
Employees and Dependents who are eligible but not enrolled are entitled to enroll under one of the following circumstances:
- The Employee’s or Dependent’s Medicaid or State Child Health Insurance Plan (i.e. CHIP) coverage has terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60 days after the termination.
- The Employee or Dependent become eligible for a contribution / premium assistance subsidy under Medicaid or a State Child Health Insurance Plan (i.e. CHIP), and the Employee requests coverage under the Plan within 60 days after eligibility is determined.
If the conditions for special enrollment are satisfied, coverage for the Employee and/or his or her Dependent(s) will be effective at 12:01 A.M. on the first day following the enrollment.
Prior to the start of a Plan Year, this Plan has an Open Enrollment Period. Eligible Participants who are not covered under this Plan may enroll for coverage during Open Enrollment Periods. Employees who are enrolled will be given an opportunity to change their coverage effective the first day of the upcoming Plan Year. A Participant who fails to make an election during the Open Enrollment Period will automatically retain his or her present coverages. Coverage for Participants enrolling during an Open Enrollment Period will become effective on January 1, as long as all other eligibility requirements have been met. If the other eligibility requirements have not been met, coverage for Participants enrolling during an Open Enrollment Period will become effective as stated in the provision, “Eligibility for Individual Coverage”.
The terms of the Open Enrollment Period, including duration of the election period, shall be determined by the Plan Administrator and communicated prior to the start of an Open Enrollment Period.
“Open Enrollment Period” shall mean the time frame specified by the Plan Administrator.
Relation to Section 125 Cafeteria Plan
This Plan may also allow additional changes to enrollment due to change in status events under the employer’s Section 125 Cafeteria Plan. Refer to the employer’s Section 125 Cafeteria Plan for more information.
Qualified Medical Child Support Orders
This Plan will provide for immediate enrollment and benefits to the Child or Children of a Participant who are the subject of a Qualified Medical Child Support Order (QMCSO), regardless of whether the Child or Children reside with the Participant, provided the Child or Children are not already enrolled as an eligible Dependent as described in this Plan. If a QMCSO is issued, then the Child or Children shall become Alternate Recipient(s) of the benefits under this Plan, subject to the same limitations, restrictions, provisions and procedures as any other Participant. The Plan Administrator will determine if the order properly meets the standards described herein. A properly completed National Medical Support Notice (NMSN) will be treated as a QMCSO and will have the same force and effect.
To be considered a Qualified Medical Child Support Order, the Medical Child Support Order must contain the following information:
- The name and last known mailing address (if any) of the Participant and the name and mailing address of each such Alternate Recipient covered by the order.
- A reasonable description of the type of coverage to be provided by this Plan to each Alternate Recipient, or the manner in which such type of coverage is to be determined.
- The period of coverage to which the order applies.
- The name of this Plan.
A National Medical Support Notice shall be deemed a QMCSO if all of the following requirements are met:
- It contains the information set forth in the Definitions section in the definition of “National Medical Support Notice.”
- It identifies either the specific type of coverage or all available group health coverage. If the Employer receives a NMSN that does not designate either specific type(s) of coverage or all available coverage, the Employer and the Plan Administrator will assume that all are designated.
- It informs the Plan Administrator that, if a group health plan has multiple options and the Participant is not enrolled, the issuing agency will make a selection after the NMSN is qualified, and, if the agency does not respond within 20 days, the Child will be enrolled under the Plan’s default option (if any).
- It specifies that the period of coverage may end for the Alternate Recipient(s) only when similarly situated dependents are no longer eligible for coverage under the terms of the Plan, or upon the occurrence of certain specified events.
A NMSN need not be recognized as a QMCSO if it requires the Plan to provide any type or form of benefit, or any option, not otherwise provided to the Participants and eligible Participants without regard to the provisions herein, except to the extent necessary to meet the requirements of a State law relating to Medical Child Support Orders, as described in Social Security Act §1908 (as added by Omnibus Budget Reconciliation Act of 1993 §13822).
In the instance of any Medical Child Support Order received by this Plan, the Plan Administrator shall, as soon as administratively possible, perform the following:
- In writing, notify the Participant and each Alternate Recipient covered by such Order (at the address included in the Order) of the receipt of such Order and the Plan’s procedures for determining whether the Order qualifies as a QMCSO.
- Make an administrative determination if the order is a QMCSO and notify the Participant and each affected Alternate Recipient of such determination.
In the instance of any National Medical Support Notice received by this Plan, the Plan Administrator shall perform the following:
- Notify the State agency issuing the notice with respect to the Child whether coverage of the Child is available under the terms of the Plan and, if so:
- Whether the Child is covered under the Plan.
- Either the effective date of the coverage or, if necessary, any steps to be taken by the custodial parent or by the official of a State or political subdivision to effectuate the coverage.
- Provide to the custodial parent (or any State official serving in a substitute capacity) a description of the coverage available and any forms or documents necessary to effectuate such coverage.
As required by Federal law, the Plan Administrator shall perform the following:
- Establish reasonable procedures to determine whether Medical Child Support Order or National Medical Support Notice are Qualified Medical Child Support Orders.
- Administer the provision of benefits under such qualified orders. Such procedures shall
- Be in writing.
- Provide for the notification of each person specified in a Medical Child Support Order as eligible to receive benefits under the plan (at the address included in the Medical Child Support Order) of such procedures promptly upon receipt by the plan of the Medical Child Support Order.
- Permit an Alternate Recipient to designate a representative for receipt of copies of notices that are sent to the Alternate Recipient with respect to a Medical Child Support Order.
A Participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO determinations from the Plan Administrator.
Eligible Employees of an acquired company who are Actively at Work and were covered under the Prior Plan of the acquired company will be eligible for the benefits under this Plan on the date of acquisition. Any waiting period previously satisfied under the prior health plan will be applied toward satisfaction of the Service Waiting Period of this Plan. In the event that an acquired company did not have a health plan, all eligible Employees will be eligible on the date of the acquisition.
Genetic Information Nondiscrimination Act (“GINA”)
“GINA” prohibits group health plans, issuers of individual health care policies, and employers from discriminating on the basis of genetic information.
The term “genetic information” means, with respect to any individual, information about any of the following:
- Such individual’s genetic tests.
- The genetic tests of family members of such individual.
- The manifestation of a Disease or disorder in family members of such individual.
The term “genetic information” includes participating in clinical research involving genetic services. Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes. Genetic information is a form of Protected Health Information (PHI) as defined by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is subject to applicable Privacy and Security Standards.
Family members as it relates to GINA include dependents, plus all relatives to the fourth degree, without regard to whether they are related by blood, marriage, or adoption. Underwriting as it relates to GINA includes any rules for determining eligibility, computing premiums or contributions, and applying pre- existing condition limitations. Offering reduced premiums or other rewards for providing genetic information would be impermissible underwriting.
GINA will not prohibit a health care Provider who is treating an individual from requesting that the patient undergo genetic testing. The rules permit the Plan to obtain genetic test results and use them to make claims payment determinations when it is necessary to do so to determine whether the treatment provided to the patient was medically advisable and/or necessary.
The Plan may request, but not require, genetic testing in certain very limited circumstances involving research, so long as the results are not used for underwriting, and then only with written notice to the individual that participation is voluntary and will not affect eligibility for benefits, premiums or contributions. In addition, the Plan will notify and describe its activity to the Health and Human Services secretary of its activities falling within this exception.
While the Plan may collect genetic information after initial enrollment, it may not do so in connection with any annual renewal process where the collection of information affects subsequent enrollment. The Plan will not adjust premiums or increase group contributions based upon genetic information, request or require genetic testing or collect genetic information either prior to or in connection with enrollment or for underwriting purposes.