THE HEALTH INSURANCE PLAN FOR THE EMPLOYEES OF
WESTMINSTER COLLEGE
Amended and Restated Effective July 1, 2011
TABLE OF CONTENTS
Page
ARTICLE I DEFINITIONS ........................................................................................................... 1
ARTICLE II PARTICIPATION AND COVERAGE .................................................................... 3
2.01
Eligibility for Benefits ............................................................................................ 3
2.02
Termination of Coverage ........................................................................................ 3
2.03
Benefits ................................................................................................................... 3
ARTICLE III PLAN FUNDING .................................................................................................... 3
3.01
Employer Contributions .......................................................................................... 3
3.02
Participant Contributions ........................................................................................ 3
3.03
Insurance Contracts ................................................................................................. 3
ARTICLE IV CLAIMS PROCEDURE ......................................................................................... 4
4.01
General .................................................................................................................... 4
4.02
Notice and Proof of Claim ...................................................................................... 4
4.03
Consideration of Claim; Rendering of Decision ..................................................... 4
4.04
Limitation of Action ............................................................................................... 6
4.05
Overpayments ......................................................................................................... 6
4.06
Appellate Review Procedure................................................................................... 7
4.07
External Review ...................................................................................................... 8
ARTICLE V AMENDMENT AND TERMINATION ................................................................ 13
5.01
Right to Amend ..................................................................................................... 13
5.02
Form of Amendment ............................................................................................. 13
5.03
Benefit Reduction and Termination ...................................................................... 13
ARTICLE VI GENERAL PROVISIONS .................................................................................... 13
6.01
Privacy of Protected Health Information .............................................................. 13
6.02
Headings and Gender ............................................................................................ 16
6.03
Right to Employment ............................................................................................ 16
6.04
Powers and Duties of Plan Administrator ............................................................. 16
6.05
Bonding, Expenses and Compensation of Plan Administrator ............................. 16
6.06
Plan Advisors ........................................................................................................ 17
6.07
Assignment of Benefits ......................................................................................... 17
6.08
Applicable Law ..................................................................................................... 17
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6.09
Dispute Over Benefits ........................................................................................... 17
EXHIBIT “A” COMPONENT PROGRAMS ................................................................................1
EXHIBIT “B” GENERAL INFORMATION ABOUT THE PLAN ..............................................1
ii
THE HEALTH INSURANCE PLAN FOR EMPLOYEES OF
WESTMINSTER COLLEGE
Amended and Restated Effective July 1, 2011
Westminster College, a Utah non-profit corporation (the “Company”), previously
adopted The Health Insurance Plan for Employees of Westminster College (the “Plan”) which
consists of various component benefit plans and programs, including insurance contracts, to
provide welfare benefits to eligible Employees, all of which are incorporated herein by reference.
The Company hereby memorializes the Plan, effective as of July 1, 2011.
ARTICLE I
DEFINITIONS
The following words and phrases are used in this Plan and shall have the meaning set
forth in this Article unless a different meaning is clearly required by the context:
“Affiliate” shall mean any member of a group of trades or businesses under common
control (within the meaning of Section 3(40)(B)(i) of ERISA) that includes the Company as a
member of the group.
“Claim” shall mean a request by a Claimant in accordance with Article IV for coverage
under the Plan (including a coverage rescission) or a benefit under the Plan.
“Claim Involving Urgent Care” shall mean any claim for medical care or treatment with
respect to which the application of the time period for making non-urgent care determinations
(a) could seriously jeopardize the life or health of the Claimant or the ability of the Claimant to
regain maximum function; or (b) in the opinion of a physician with knowledge of the Claimant’s
medical condition, would subject the Claimant to severe pain that cannot be adequately managed
without the care or treatment that is the subject of the claim. Whether a claim is a “Claim
Involving Urgent Care” shall be determined by an individual acting on behalf of the Plan,
applying the judgment of a prudent lay person who possesses an average knowledge of health
and medicine, except that any claim that a physician with knowledge of the Claimant’s medical
condition determines that is a “Claim Involving Urgent Care” shall be treated as a Claim
Involving Urgent Care.
“Claimant” shall mean any Participant, enrolled dependent or other person who claims to
be entitled to a benefit under the Plan.
“Code” shall mean the Internal Revenue Code of 1986, as amended.
“Company” shall mean Westminster College, a Utah non-profit corporation, and each
successor in interest to the Company resulting from merger, consolidation or transfer of
substantially all of the assets that elects to continue the Plan.
“Component Program” shall mean the component plan, fund or program identified in
Exhibit “A”, attached hereto and by this reference incorporated herein, which provides the
welfare benefits contemplated by the Plan.
“Concurrent Care Decision” shall mean a decision by the Plan Administrator with respect
to coverage of a previously approved ongoing course of treatment to be provided over a period of
time or number of treatments.
“Contract Administrator” shall mean the persons, firm, or corporation appointed by the
Plan Administrator from time to time to perform certain duties with respect to administration of
the Plan or Program(s).
“Eligible Employee” shall mean each person classified by an Employer as a common-law
employee who is in an eligible class of employees in accordance with the terms of the applicable
Component Program. See Exhibit “B” Eligible Employees. Employees who are not U.S.
residents shall not be considered “Eligible Employees.” The term “Eligible Employee” shall not
include any person characterized by an Employer as an independent contractor. If an Employer
modifies its classification or treatment of an individual, the modification shall be applied
prospectively only, unless the Employer indicates otherwise, in which case the modification will
be effective as of the date specified by the Employer. If an individual is characterized as a
common law employee of an Employer by a governmental agency or court but not by the
Employer, such individual shall be treated as an employee who has not been designated for
participation in the Plan.
“Employer” shall mean the Company and, except as otherwise clearly indicated by the
context, shall include each Affiliate which has elected to adopt this Plan. Employers may adopt
this Plan with the consent of the Company. Each Employer adopting the Plan shall be deemed to
have delegated to the Company all authority to amend or terminate the Plan and to appoint and
remove the Plan Administrator. Each Employer that properly adopts the Plan shall be treated as
the “Employer” of its Employees participating in the Plan.
“ERISA” shall mean the Employee Retirement Income Security Act of 1974, as
amended.
“Participant” shall mean an Eligible Employee who enrolls in a Component Program
pursuant to the terms and procedures of such program.
“Plan” shall mean The Health Insurance Plan for Employees of Westminster College as
set forth herein.
“Plan Administrator” shall mean the Company or such other persons, committee, firm or
corporation appointed by the Company from time to time to perform the duties required herein to
be performed by the Plan Administrator.
“Plan Year” shall mean the 12-month period ending on June 30 of each year.
“Pre-Service Claim” shall mean any claim for a benefit under the Plan with respect to
which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of
the benefit in advance of obtaining medical care.
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ARTICLE II
PARTICIPATION AND COVERAGE
2.01 Eligibility for Benefits. This Plan is maintained for the exclusive benefit of
Participants and their covered dependents. A Participant and his or her covered dependents shall
qualify for and receive Plan benefits pursuant to the terms of the respective Component
Programs with respect to which the Participant and his or her covered dependents are eligible.
Unless the Component Program provides otherwise, benefits for an Eligible Employee begin as
set forth on Exhibit “B” Coverage.
2.02 Termination of Coverage. The coverage of any Participant and his or her covered
dependents under a Component Program will terminate pursuant to the terms of such Component
Program in which the Participant is participating.
2.03 Benefits. The amount and form of benefits paid under this Plan will be as set
forth in the terms of the respective Component Programs. Benefits will be paid to Participants
or, where applicable, their covered dependents or beneficiaries pursuant to the terms of the
respective Component Programs.
ARTICLE III
PLAN FUNDING
3.01 Employer Contributions. Benefits shall be funded, at least in part, by Employer
contributions. The Employer shall pay premiums to insurance companies, or fund benefits from
the Employer’s general assets in the amounts required pursuant to the terms of the respective
Component Programs.
3.02 Participant Contributions. Participants covered by a Component Program shall be
required to contribute to the cost of such Component Program by paying a premium or an
amount determined by the Company or Contract Administrator. Required premiums or
payments from Participants who are Eligible Employees shall be withheld from the Eligible
Employees’ pay by the Employer. Participants who are not currently Eligible Employees shall
pay their required premiums or payments to the Company pursuant to uniform procedures
established by the Plan Administrator. Such premiums or payments shall be used to fund
benefits under the Component Programs or paid by the Employer to insurance companies,
whichever is applicable, as of the earliest date on which such contributions can reasonably be
segregated from the Employer’s general assets, but in any event no later than 90 days from the
date on which such amounts would otherwise have been payable to the Eligible Employees in
cash. Anything else to the contrary notwithstanding, Participant payments toward the cost of
self-funded Component Programs shall be expended prior to expending any Employer funds.
3.03 Insurance Contracts. The Company has entered into various insurance contracts
for the purpose of funding the benefits provided under the Component Programs.
3
ARTICLE IV
CLAIMS PROCEDURE
4.01 General. Any Claimant seeking benefits under a Component Program shall
follow the claims procedure set forth in the respective Component Program. In the event, and
only in the event that a Component Program does not have a claims procedure or the Component
Program’s claims procedure does not address the Claim (e.g., a Claim for eligibility to
participate in the Component Program), the procedure set forth in this Article shall apply.
4.02 Notice and Proof of Claim. Each Claimant shall have the right to submit a Claim
with respect to a benefit sought hereunder. Written notice of any Claim hereunder must be
addressed and delivered to the Plan Administrator either personally or by certified or registered
mail, return receipt requested, at the following address:
Westminster College
1840 South 1300 East
Salt Lake City, Utah 84108
Attn.: Director of Human Resources
Such Claim shall state with particularity:
(a)
The benefit claimed;
(b)
The provisions of the Component Program and the particular provisions
of law, if any, upon which the Claimant relies in support of his Claim; and
(c)
All facts believed to be relevant in connection with such Claim.
Claims submitted more than two (2) years following the date service is rendered or the supply
furnished will not be accepted unless it is shown not to have been reasonably possible to timely
furnish such notice or proof and that such notice or proof was furnished as soon as reasonably
possible. Persons claiming benefits under the Plan are required to cooperate with administrators
and provide information necessary to implement the provisions of the Plan.
4.03 Consideration of Claim; Rendering of Decision. Upon receipt of a Claim
hereunder, the Plan Administrator shall consider the merits of the Claim and shall, within 30
days from the receipt of the Claim, render a decision on the merits and communicate the same to
the Claimant. This 30-day period may be extended one time by the Plan Administrator for up to
15 days, provided that the Plan Administrator determines that such an extension is necessary due
to matters beyond the control of the Plan and notifies the Claimant, prior to the expiration of the
initial 30-day period, of the circumstance requiring the extension of time and the date by which
the Plan Administrator expects to render to a decision. If such an extension is necessary due to a
failure of the Claimant to submit the information necessary to decide the claims, the notice of
extension shall specifically describe the required information and the Claimant shall be afforded
at least 45 days from the receipt of the notice within which to provide the specified information.
4
In the case of a Claim Involving Urgent Care, the Plan Administrator shall notify the
Claimant of its benefit determination (whether adverse or not) as soon as possible, taking into
account the medical exigencies, but not later than 72 hours after receipt of the claim by the Plan,
unless the Claimant fails to provide sufficient information to determine whether, or to what
extent, benefits are covered or payable under the Plan. In the case of such a failure, the Plan
Administrator shall notify the Claimant as soon as possible, but not later than 24 hours after
receipt of the claim by the Plan Administrator, of the specific information necessary to complete
the claim. The Claimant shall be afforded a reasonable amount of time, taking into account the
circumstances, but not less than 48 hours, to provide the specified information. The Plan
Administrator shall notify the Claimant of its benefit determination as soon as possible, but in no
case later than 72 hours after the earlier of: (a) the Plan’s receipt of the specified information, or
(b) the end of the period afforded the Claimant to provide the specified additional information.
In the case of a Concurrent Care Decision, any reduction or termination by the Plan of the
previously approved course of treatment (other than by Plan amendment or termination) before
the end of such period of time or number of treatments shall constitute an adverse benefit
determination. The Plan Administrator shall notify the Claimant, in accordance with this
Section 4.03, of the adverse benefit determination at a time sufficiently in advance of the
reduction or termination to allow the Claimant to appeal and obtain a determination on review of
that adverse benefit determination before the benefit is reduced or terminated. Any request by a
Claimant to extend the course of treatment beyond the period of time or number of treatments
that constitutes a Claim Involving Urgent Care shall be decided as soon as possible, taking into
account the medical exigencies. The Plan Administrator shall notify the Claimant of the benefit
determination, whether adverse or not, within 24 hours after receipt of the claim by the Plan
Administrator, provided that any such claim is made to the Plan Administrator at least 24 hours
prior to the expiration of the prescribed period of time or number of treatments. Notification of
any adverse benefit determination concerning a request to extend the course of treatment,
whether or not a Claim Involving Urgent Care, shall be made in accordance with this
Section 4.03 and any appeal shall be governed by Section 4.06.
In the case of a Pre-Service Claim, the Plan Administrator shall notify the Claimant of its
benefit determination (whether adverse or not) within a reasonable period of time appropriate to
the medical circumstances, but not later than 15 days after receipt of the claim by the Plan. This
period may be extended one time by the Plan Administrator for up to 15 days, provided that the
Plan Administrator both determines that such an extension is necessary due to matters beyond
the control of the Plan and notifies the Claimant, prior to the expiration of the initial 15-day
period, of the circumstances requiring the extension of time and the date by which the Plan
Administrator expects to render a decision. If such an extension is necessary due to a failure of
the Claimant to submit the information necessary to decide the claim, the notice of extension
shall specifically describe the required information, and the Claimant shall be afforded at least 45
days from receipt of the notice within which to provide the specified information.
In the case of a failure by the Claimant to follow the Plan’s procedures for filing a PreService Claim, the Plan Administrator shall notify the Claimant of such failure and provide the
proper procedures to be followed in filing a claim for benefits. The notification shall be
provided, as soon as possible, but not later than five (5) days (24 hours in the case of a failure
with respect to a Claim Involving Urgent Care) following such failure.
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In the event the Plan Administrator denies the Claim in whole or in part, the Claimant
shall be so notified in writing, which notice shall be addressed and delivered to him or her
personally or by mail, and shall set forth the following in a manner reasonably calculated to be
understood by the Claimant:
(a)
The specific reason(s) for rejection of the Claim;
(b)
A reference to the specific provisions of the Plan and the particular
provisions of law, if any, relied upon in reaching such determination;
(c)
A description of any additional material or information needed from the
Claimant in order for him or her to perfect his or her Claim and an explanation of why
such information is necessary;
(d)
A statement describing the Appellate Review Procedure (including time
limits applicable to such procedure) as set forth in Section 4.06 and the Claimant’s
right to bring a civil action under Section 502 of ERISA following a denial on appeal;
(e)
If an internal rule, guideline, protocol or other similar criterion was
relied upon in making the adverse determination, either the specific rule, guideline,
protocol or other similar criterion; or a statement that such a rule, guideline, protocol
or other similar criterion was relied upon in making the adverse determination and that
a copy of such rule, guideline, protocol or other similar criterion will be provided free
of charge to the Claimant upon request;
(f)
If the adverse benefit determination is based on a medical necessity or
experimental treatment or similar exclusion or limit, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to
the Claimant’s medical circumstances, or a statement that such explanation will be
provided free of charge upon request; and
(g)
In the case of a Claim Involving Urgent Care, a description of the
expedited review process applicable to such Claims.
4.04 Limitation of Action. No action shall be commenced under Section 502(a)(1)(B)
of ERISA, or under any other provision of law, to recover under the Plan unless the Eligible
Employee has exhausted the claims and appeals procedures set forth in this Article 4. No such
action shall be brought after the expiration of the later of (a) two (2) years after the time written
proof of loss is required to be submitted to the Plan Administrator, and (b) 90 days following the
final denial or deemed denial of the claim for benefits under the claims and appeals procedure of
the Plan.
4.05 Overpayments. If for any reason the Plan or Plan Administrator directs the
Employer to pay any amounts to or on behalf of an Eligible Employee or enrolled dependent (or
person believed to be an enrolled dependent) of an Eligible Employee (a) for services, supplies
or accommodations not covered under the Plan, or (b) with respect to a enrolled dependent (or
person believed to be a enrolled dependent) not covered under the Plan, or (c) which exceed
amounts eligible to be paid as benefits under the Plan, the Eligible Employee, enrolled dependent
6
or health care service provider receiving the overpayment shall reimburse the Plan upon
discovery or on demand of the Plan Administrator for all and any such amounts.
The Plan Administrator reserves the right to offset the amount of overpayments by the
Plan made to or on behalf of an Eligible Employee or enrolled dependent (or person believed to
be an enrolled dependent) of such Eligible Employee, as well as any other amount an Eligible
Employee or his or her enrolled dependent is obligated to repay the Plan, against future benefits
payable to or on behalf of such eligible Employee and/or enrolled dependent of such Eligible
Employee until any or all overpayments have been recouped by the Plan. The Plan
Administrator shall be entitled to reasonable attorney’s fees and costs incurred to recover
overpayments or repayment amounts under this Section 4.05.
4.06 Appellate Review Procedure. Where a Claim has been or is deemed denied, the
Claimant shall have the right within 180 days after the date he or she receives notice that his or
her Claim has been rejected, in whole or in part, to an Appellate Review Procedure as set forth
herein. Such procedure shall enable the Claimant to appeal from an adverse decision by
delivering a written request for an appeal to the Plan Administrator. Such request shall be in a
written form reasonably acceptable to the Plan Administrator and shall set forth the reasons why
the Claimant believes the decision rejecting his or her Claim is erroneous and shall be signed by
the Claimant. The Claimant shall be provided, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the Claimant’s
Claim for benefits. A document, record or other information shall be considered “relevant” to
the Claim if the document constitutes a statement of policy or guidance with respect to the Plan
concerning the denied benefit without regard to whether such advice or statement was relied
upon in making the benefit determination. A decision with respect to the merits of the Claim
shall be rendered by the Plan Administrator not later than 60 days after the deliver of the written
request for an appeal hereunder.
The Appellate Review shall take into account all comments, documents, records and
other information submitted by the Claimant relating to the Claim, without regard to whether
such information was submitted or considered in the initial benefit determination. The Plan
Administrator, in rendering its decision, shall afford no deference to the initial adverse benefit
determination by the Plan Administrator. If in deciding an appeal of any adverse benefit
determination that is based in whole or part on a medical judgment, including a determination
with regard to whether a particular treatment, drug, or other item is experimental, investigational
or not medically necessary or appropriate, the Plan Administrator shall consult with a healthcare
professional who has appropriate training and experience in the field of medicine involved in the
medical judgment. Such individual shall not be an individual who was consulted in connection
with the initial adverse benefit determination that is the subject of the appeal, nor the subordinate
of any such individual.
The Appellate Review decision shall include specific reasons believed to support such
decision, including specific references to provisions of the Plan and of law, shall be written in a
manner reasonably calculated to be understood by the Claimant, and shall be delivered to the
Claimant personally, by facsimile, or by mail. The Plan Administrator’s determination upon
review shall include:
7
(a)
The specific reason(s) for the adverse determination;
(b)
A reference to the specific Plan provisions on which the benefit
determination is based;
(c)
The statement that the Claimant is entitled to receive, upon request and
free of charge, reasonable access to, and copies of, all documents, records and other
information relevant to the Claimant’s Claim for benefits;
(d)
A statement regarding the Claimant’s right to bring a civil action under
Section 502 of ERISA;
(e)
If an internal rule, guideline, protocol or other similar criterion was
relied upon in making the adverse determination, either the specific rule, guideline,
protocol or other similar criterion, or a statement that such a rule, guideline, protocol
or other similar criterion was relied upon in making the adverse determination and that
a copy of such rule, guideline, protocol or other similar criterion will be provided free
of charge to the Claimant upon request;
(f)
The following statement: “You and your Plan may have other
voluntary alternative dispute resolution options, such as mediation. One way to find
out what may be available is to contact your local United States Department of Labor
office and your state insurance regulatory agency.”
4.07 External Review. This Section 4.07 is effective January 1, 2011 or such later date
as permitted by the U.S. Department of Labor. Unless the Plan Administrator elects to
voluntarily comply with the provisions of an applicable state (e.g., State of Utah) external review
process, the Plan Administrator shall comply with the following external review process
pursuant to U.S. Department of Labor Technical Release 2010-10 or subsequent guidelines or
regulations issued pursuant to the Public Health Service Act as amended by the Patient
Protection and Affordable Care Act.
(a)
Request for External Review. A claimant whose Claim has been or is
deemed denied may file a request for an external review with the Plan Administrator;
provided that the request is filed within four (4) months after the date of receipt of a
notice of an adverse benefit determination or final internal adverse benefit
determination.
(b)
Preliminary Review. Within five (5) business days following the date
of receipt of the external review request, the Plan Administrator must complete a
preliminary review of the request to determine whether:
(i)
The Claimant is or was covered under the Plan at the time the
health care item or service was requested or, in the case of a retrospective review,
was covered under the Plan at the time the health care item or service was
provided;
8
(ii)
The adverse benefit determination or the final adverse benefit
determination does not relate to the Claimant’s failure to meet the requirements
for eligibility under the terms of the Plan (e.g., worker classification or similar
determination);
(iii)
The Claimant has exhausted the Plan’s internal appeal process
unless the claimant is not required to exhaust the internal appeals process under
the interim final regulations; and
(iv)
The Claimant has provided all the information and forms required
to process an external review.
Within one business day after completion of the preliminary review, the Plan
Administrator must issue a notification in writing to the Claimant. If the request is
complete but not eligible for external review, such notification must include the reasons
for its ineligibility and contact information for the Employee Benefits Security
Administration (toll-free number 866-444 EBSA (3272)). If the request is not complete,
such notification must describe the information or materials needed to make the request
complete and the plan must allow a Claimant to perfect the request for external review
within the four-month filing period or within the 48 hour period following the receipt of
the notification, whichever is later.
(c)
Referral to Independent Review Organization. The Plan Administrator
must assign an independent review organization (IRO) that is accredited by URAC or
by a similar nationally-recognized accrediting organization to conduct the external
review. Moreover, the Plan must take action against bias and to ensure independence.
Accordingly, the Plan must contract with at least three (3) IROs for assignments under
the plan and rotate claims assignments among them (or incorporate other independent,
unbiased methods for selection of IROs, such as random selection). In addition, the
IRO may not be eligible for any financial incentives based on the likelihood that the
IRO will support the denial of benefits.
A contact between the Plan and an IRO must provide the following:
(i)
The assigned IRO will utilize legal experts where appropriate to
make coverage determinations under the Plan.
(ii)
The assigned IRO will timely notify the Claimant in writing of the
request’s eligibility and acceptance for external review. This notice will include a
statement that the Claimant may submit in writing to the assigned IRO within ten
business days following the date of receipt of the notice additional information
that the IRO must consider when conducting the external review. The IRO is not
required to, but may, accept and consider additional information submitted after
ten business days.
(iii)
Within five (5) business days after the date of assignment of the
IRO, the Plan Administrator must provide to the assigned IRO the documents and
any information considered in making the adverse benefit determination or final
9
internal adverse benefit determination. Failure by the Plan Administrator to
timely provide the documents and information must not delay the conduct of the
external review. If the Plan fails to timely provide the documents and
information, the assigned IRO may terminate the external review and make a
decision to reverse the adverse benefit determination or final internal adverse
benefit determination. Within one business day after making the decision, the
IRO must notify the Claimant and the Plan Administrator.
(iv)
Upon receipt of any information submitted by the Claimant, the
assigned IRO must within one business day forward the information to the Plan
Administrator. Upon receipt of any such information, the Plan Administrator may
reconsider its adverse benefit determination or final internal adverse benefit
determination that is the subject of the external review. Reconsideration by the
Plan Administrator must not delay the external review. The external review may
be terminated as a result of the reconsideration only if the Plan Administrator
decides, upon completion of its reconsideration, to reverse its adverse benefit
determination or final internal adverse benefit determination and provide
coverage or payment. Within one business day after making such a decision, the
Plan Administrator must provide written notice of its decision to the claimant and
the assigned IRO. The assigned IRO must terminate the external review upon
receipt of the notice from the Plan Administrator.
(v)
The IRO will review all of the information and documents timely
received. In reaching a decision, the assigned IRO will review the claim de novo
and not be bound by any decisions or conclusions reached during the Plan
Administrator’s internal claims and appeals process applicable under paragraph
(b) of the interim final regulations under Section 2719 of the Public Health
Service Act. In addition to the documents and information provided, the assigned
IRO, to the extent the information or documents and information provided, the
assigned IRO, to the extend the information or documents are available and the
IRO considers them appropriate, will consider the following in reaching a
decision:

The Claimant’s medical records;

The attending health care professional’s recommendation;

Reports from appropriate health care professionals and other documents
submitted by the Plan Administrator or issuer, Claimant, or the Claimant’s
treating provider;

The terms of the Claimant’s plan to ensure that the IRO’s decision is not
contrary to the terms of the Plan, unless the terms are inconsistent with
applicable law;

Appropriate practice guidelines, which must include applicable evidencebased standards and may include any other practice guidelines developed
10
by the Federal government, national or professional medical societies,
boards, and associations;

Any applicable clinical review criteria developed and used by the Plan
Administrator, unless the criteria are inconsistent with the terms of the
Plan or with applicable law; and

The opinion of the IRO’s clinical reviewer or reviewers after considering
the information described in this notice to the extent the information or
documents are available and the clinical reviewer or reviewers consider
appropriate.

The assigned IRO must provide written notice of the final external review
decision within 45 days after the IRO receives the request for the external
review. The IRO must deliver the notice of final external review decision
to the Claimant and the Plan Administrator.

The assigned IRO’s decision notice will contain:

A general description for the reason for the request for external review,
including information sufficient to identify the claim (including the date or
dates of service, the health care provider, the claim amount (if applicable),
and the reason for the previous denial);

The date the IRO received the assignment to conduct the external review
and the date of the IRO decision;

References to the evidence or documentation, including the specific
coverage provisions and evidence-based standards, considered in reaching
its decision;

A discussion of the principal reason or reasons for its decision, including
the rationale for its decision and any evidence-based standards that were
relied on in making its decision;

A statement that the determination is binding except to the extent that
other remedies may be available under State or Federal law to either the
Plan or to the Claimant;

With respect to benefit denials, a statement describing the opportunity to
request diagnosis and treatment codes (and their corresponding meanings)
and statement that judicial review may be available to the Claimant; and

Current contact information, including phone number, for any applicable
office of health insurance consumer assistance or ombudsman established
under Section 2793 of the Public Health Service Act.
11
(vi)
After a final external review decision, the IRO must maintain
records of all claims and notices associated with the review process for six years.
An IRO must make such records available for examination by the Claimant, Plan
Administrator, or State or Federal oversight agency upon request, except where
such disclosure would violate State or Federal privacy laws.
(d)
Reversal of Plan Administrator’s Decision. Upon receipt of a notice of
a final external review decision reversing the adverse benefit determination or final
internal adverse benefit determination, the Plan must immediately provide coverage or
payment (including immediately authorizing or immediately paying benefits) for the
claim.
(e)
Request for Expedited External Review. The Plan Administrator must
allow a Claimant to make a request for an expedited external review with the Plan
Administrator at the time the Claimant receives:
(i)
An adverse benefit determination if the adverse benefit
determination involves a medical condition of the Claimant for which the
timeframe for completion of an expedited internal appeal under the interim final
regulations would seriously jeopardize the life or health of the claimant or would
jeopardize the claimant’s ability to regain maximum function and the clamant has
filed a request for an expedited internal appeal; or
(ii)
A final adverse benefit determination, if the claimant has a medical
condition where the timeframe for completion of a standard external review
would seriously jeopardize the life or health of the claimant or would jeopardize
the claimant’s ability to regain maximum function, or if the final internal adverse
benefit determination concerns an admission, availability of care, continued stay,
or health care item or service for which the claimant received emergency services,
but has not been discharged from a facility.
(f)
Preliminary Review. Immediately upon receipt of the request for
expedited external review, the Plan Administrator must determine whether the request
meets the reviewability requirements set forth in Section 4.07(b) above for standard
external review. The Plan Administrator must immediately send a notice that meets the
requirements set forth in Section 4.07(a) above for standard external review to the
Claimant of its eligibility determination.
(g)
Referral to Independent Review Organization. Upon a determination
that a request is eligible for external review following the preliminary review, the Plan
Administrator will assign an IRO pursuant to the requirements set forth in Section
4.07(c) above for standard review. The Plan Administrator must provide or transmit
all necessary documents and information considered in making the adverse benefit
determination or final internal adverse benefit determination to the assigned IRO
electronically or by telephone or facsimile or any other available expeditious method.
12
The assigned IRO, to the extent the information or documents are available and
the IRO considers them appropriate, must consider the information or documents
described above under the procedures for standard review. In reaching a decision, the
assigned IRO must review the claim de novo and is not bound by any decisions or
conclusions reached during the Plan Administrator’s internal claims and appeals process.
(h)
Notice of Final External Review Decision. The Plan’s contract with the
assigned IRO must require the IRO to provide notice of the final external review
decision, in accordance with the requirements set forth in paragraph Section 4.07(c)
above, as expeditiously as the Claimant’s medical condition or circumstances require,
but in no event more than 72 hours after the IRO receives the request for an expedited
external review. If the notice is not in writing, within 48 hours after the date of
providing that notice, the assigned IRO must provide written confirmation of the
decision to the Claimant and the Plan Administrator.
ARTICLE V
AMENDMENT AND TERMINATION
5.01 Right to Amend. The Company reserves the right to amend any provisions under
the Plan or Component Program(s), in whole or in part, at any time and to any extent that it may
deem advisable without the consent of any Employee.
5.02 Form of Amendment. Any amendment to the Plan or Component Program(s)
shall be set forth in an instrument in writing executed on behalf of the Company by a duly
authorized officer.
5.03 Benefit Reduction and Termination. The Company reserves the right at any time
and in its sole and absolute discretion to reduce or alter any benefits provided under the Plan or
Component Program(s), in whole or in part, or to terminate the Plan or any and all Component
Programs.
ARTICLE VI
GENERAL PROVISIONS
6.01 Privacy of Protected Health Information. The provisions of this Section 6.1 are
effective only to the extent that the Plan is a “health plan” and is not otherwise exempt from the
requirements of the Privacy Rules (defined below). To the extent permitted by the Privacy
Rules, the Health Flexible Spending Account (FSA) and the self-funded portions of the Plan that
are considered a health plan under the Privacy Rules (hereinafter referred to as “Covered Plans”)
are part of one “organized health care arrangement.” As such, each of the Covered Plans may
disclose PHI to another Covered Plan maintained by the Company for purposes of facilitating
treatment, payment and health care operations under the Covered Plans. If a Covered Plan
becomes a fully insured health plan (i.e., benefits are paid entirely through a health insurance
policy issued by an insurance carrier) the Covered Plan will no longer be considered part of the
“organized health care arrangement” effective as of the date the Covered Plan becomes fully
insured.
13
(a)
Definitions. For purposes of this Section 6.01, the following words and
phrases shall have the meaning set forth in this subsection:
“Privacy Rules” shall mean the Health Insurance Portability and Accountability
Act of 1996 and regulations promulgated thereunder (45 CFR Parts 160 and 164) and
other applicable federal or state laws relating to privacy of Protected Health Information.
“Protected Health Information (‘PHI’)” shall mean individually identifiable health
information, in whatever medium it is transmitted or maintained (e.g., paper, electronic or
oral), including demographic information, that is created or received by a health care
provider, health plan, employer or health care clearinghouse and that relates to the past,
present or future physical or mental health or condition of an individual; the provision of
health care to an individual; or the past, present or future payment for the provision of
health care to an individual, as more specifically defined in the Privacy Rules.
“Summary Health Information” shall mean information, that may be individually
identifiable health information, and that summarizes the claims history, claims expenses,
or types of claims experienced by individuals for whom the Company or the Employer
has provided health benefits under the Plan and from which identifying information has
been deleted, except that the geographic information need only be aggregated to the level
of a five digit zip code, as more specifically defined in the Privacy Rules.
(b)
Summary Health Information Disclosure. The Plan Administrator may
disclose Summary Health Information to the Company, if the Company requests the
Summary Health Information for the purpose of:
(i)
Obtaining premium bids from health plans for providing health
insurance coverage under the Plan; or
(ii)
Modifying, amending, or terminating the Plan.
(c)
Certification for Disclosure of PHI. The Company shall provide to the
Plan Administrator a certification that the Plan incorporates the following provisions
and that the Company agrees to comply with the following conditions regarding the
use and disclosure of the PHI provided to it by, or at the direction of, the Plan
Administrator:
(i)
required Not use or further disclose the information other than as
permitted or by the Plan or as required by law;
(ii)
Ensure that any agents, including a subcontractor, to whom it
provides the PHI agree to the same restrictions and conditions that apply to the
Company with respect to the PHI;
(iii)
Not use or disclose the PHI for employment-related actions and
decisions or in connection with any other benefit or employee benefit plan of the
Company unless authorized by the individual or the Plan is part of the “organized
health care arrangement”;
14
(iv)
Report to the Plan Administrator any use or disclosure of the PHI
that is inconsistent with the uses or disclosures provided for of which it becomes
aware;
(v)
Make available to individuals their PHI in accordance with the
Privacy Rules (45 CFR § 164.524);
(vi)
Make available PHI for amendment and incorporate any
amendments to PHI in accordance with the Privacy Rules (45 CFR § 164.526);
(vii) Make available the information required to provide an accounting
of disclosures in accordance with the Privacy Rules (45 CFR § 164.528);
(viii) Make its internal practices, books, and records relating to the use
and disclosure of PHI available to the Secretary of Health and Human Services
for purposes of determining compliance by the Plan Administrator with the
Privacy Rules;
(ix)
If feasible, return or destroy all of the PHI that the Company still
maintains in any form and retain no copies of such information when no longer
needed for the purpose for which disclosure was made, except that, if such return
or destruction is not feasible, limit further uses and disclosures to those purposes
that make the return or destruction of the PHI infeasible; and
(x)
Ensure that the adequate separation is established and maintained
between the Company and the Plan Administrator.
(d)
Permitted Use and Disclosure of PHI. The Plan Administrator shall not
disclose any PHI to the Company until the receipt of the certification from the
Company described in paragraph (c) above. Thereafter, to the extent needed to carry
out Plan administrative functions and in a manner consistent with this Section 6.01, the
Plan Administrator may disclose PHI to Employer.
The following employees of the Company will be given access as necessary or
appropriate to the PHI: (1) employees in the Human Resources Department of the Company
assigned to process and adjudicate appeals of denied benefit claims (including benefit
administrators, benefit specialists, administrative assistants, managers and directors) including
executive officers of the Company responsible for the Human Resources Department;
(2) internal auditors responsible for auditing the Plan; (3) computer technology and human
resource accounting personnel responsible for reports and interfacing with Contract
Administrators. Access to and use by such employees will be restricted to the Plan
administration functions that the Company performs for the Plan as Plan Administrator.
(e)
Enforcement. Any complaints or issues of noncompliance by persons
described in paragraph (d) shall be immediately directed to a Human Resource
Director of the Company for resolution. In the event the Privacy Rules are violated by
any employee of the Employer, the Company and /or the Employer will promptly
15
mitigate any deleterious effect of improper use or disclosure of PHI and subject the
person(s) responsible for such noncompliance to corrective action.
(f)
Compliance with the Security Rules. The Company further agrees that
if it creates, receives, maintains, or transmits any electronic PHI (other than
enrollment/disenrollment information and Summary Health Information, which are not
subject to these restrictions) on behalf of the Plan, it will implement administrative,
physical, and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity, and availability of the electronic PHI, and it will ensure that
any agents (including subcontractors) to whom it provides such electronic PHI agrees
to implement reasonable and appropriate security measures to protect the information.
The Company will report to the Plan any security incident of which it becomes aware.
6.02 Headings and Gender. The headings of the Plan have been inserted for
convenience of reference only and are to be ignored in any construction of the provisions hereof.
Whenever a personal pronoun is used in the masculine gender, it shall be deemed to include the
feminine also, unless the context indicates the contrary.
6.03 Right to Employment. Nothing herein contained shall be construed as giving any
Employee the right to be retained in the service of the Employer, nor upon dismissal or upon his
voluntary termination, to have any right or interest in the Plan other than as provided herein or
therein.
6.04 Powers and Duties of Plan Administrator. The Plan Administrator shall enforce
the Plan in accordance with its terms, shall be charged with the general administration of the
Plan, and shall have all powers necessary to accomplish those purposes, including, but not by
way of limitation to, the following:
(a)
To resolve, in its discretion, all questions relating to the eligibility of
Employees for benefits, as well as the amount and payment of benefits;
(b)
To otherwise construe and interpret the Plan in its discretion;
(c)
To authorize all disbursements from the Plan;
(d)
To maintain all the necessary records for the administration of the Plan;
(e)
To make and publish such rules for the regulation of the Plan as are not
inconsistent with the terms hereof; and
(f)
To delegate to a Contract Administrator, the administrator of a
Component Program and Employees of the Employer such powers and duties as the
Plan Administrator shall determine.
6.05 Bonding, Expenses and Compensation of Plan Administrator. The Plan
Administrator and all other Plan fiduciaries shall be bonded to the extent required by Section 412
of ERISA. The Plan Administrator shall serve without compensation for its services hereunder.
All expenses of the Plan Administrator shall be paid by the Company and the Company shall
16
furnish the Plan Administrator with such clerical and other assistance as is necessary in the
performance of its duties. Any accounting or bookkeeping services which may be rendered from
time to time by the Company to the Plan or to the Plan Administrator shall be rendered without
charge.
6.06 Plan Advisors. The Plan Administrator may employ professional advisors and
services as may be necessary or advisable in the administration of the Plan, including but not
limited to legal, accounting, actuarial, administrative, and auditing services.
6.07 Assignment of Benefits. Unless otherwise consented to in writing by the Plan
Administrator, and to the extent permitted by law, no interest in the Plan shall be subject to
assignment, alienation, transfer or anticipation, either by voluntary or involuntary act of any
Employee or by operation of law, nor shall payment or right of interest be subject to the demands
or claims of any creditor of such person, nor be liable in any way for such person’s debts,
obligations or liabilities.
6.08 Applicable Law. The validity of the Plan or any of its provisions shall be
determined under and construed according to the state law of Utah, except to the extent Utah law
is preempted by federal law including, but not limited to, ERISA. The Company intends that the
terms of the Plan, including those relating to coverage and benefits, are legally enforceable under
such law. If any provision of the Plan shall be held illegal or invalid for any reason, such
determination shall not affect the remaining provisions of this Plan and it shall be construed as if
said illegal or invalid provision had never been included.
6.09 Dispute Over Benefits. If a dispute arises as to the proper recipient of any
payment, the Plan Administrator, in its sole discretion, may withhold or cause to be withheld
such payment until the dispute shall have been settled by the parties concerned or shall have been
determined by a court of competent jurisdiction.
IN WITNESS WHEREOF, the Company has caused its officer, duly authorized by its
Board of Directors, to execute the Plan this ____ day of ________________, 2011.
WESTMINSTER COLLEGE,
a Utah corporation
By
Its
17
EXHIBIT “A”
COMPONENT PROGRAMS
(1)
Flexible Spending Accounts (FSA) (Health Care and Dependent Care Reimbursement Accounts)
funded by Participants
(2)
Medical Plan – fully insured plan providing medical benefits through insurance policies issued
by Altius Health Plans with premiums paid by Company and Participants
(3)
Dental Plan – fully insured plan providing dental benefits through a policy issued by MetLife
Dental with premiums paid by Company and Participants
(4)
Vision Plan – fully insured plan providing vision benefits through a policy issued by EyeMed
with premiums paid by Participants
(5)
Basic Life and Accidental Death and Dismemberment Plan – fully insured plan providing basic
life and AD&D benefits through insurance policies issued by The Hartford with premiums paid
by Company
(6)
Long Term Disability Plan – fully insured plan providing long term disability benefits through
insurance policies issued by The Hartford with premiums paid by Participants
(7)
Supplemental Life Plan – fully insured plan providing supplemental life benefits through
insurance policies issued by The Hartford with premiums paid by Participants
(8)
Short Term Disability Plan – self funded plan providing short-term disability coverage paid for
by Company
(9)
Long Term Care Plan – fully insured plan providing long-term care coverage through policies
issued by UNUM with premiums paid by Participants
(10)
Colonial Voluntary Benefits – fully issued programs providing cancer, critical illness and
accident coverage with premiums paid by Participants
EXHIBIT “B”
GENERAL INFORMATION ABOUT THE PLAN
This Exhibit contains certain general information which you may need to know about the Plan.
General Plan Information
Plan Name: The Health Insurance Plan for the Employees of Westminster College
Type of Plan: Group health plan (welfare plan subject to ERISA)
Plan Number: 501
Effective Date of the amended Plan: 7/1/2011
Plan Year: July 1 to June 30
The Plan consists of various Component Programs listed on Exhibit “A”.
Employer Information
Westminster College
1840 South 1300 East
Salt Lake City, Utah 84108
EIN: 87-0212470
(801) 832-2573
Plan Administrator Information
Westminster College
1840 South 1300 East
Salt Lake City, Utah 84108
EIN: 87-0212470
(801) 832-2573
Attention: Director of Human Resources
The Plan Administrator keeps the records for the Plan and is responsible for the administration of
the Plan. The Plan Administrator will also answer any questions you may have about the Plan. You
may contact the Plan Administrator for any further information about the Plan.
Service of Legal Process
The name and address of the Plan’s agent for service of legal process is:
Westminster College
1840 South 1300
Salt Lake City, Utah 84108
EIN: 87-0212470
1
Attention: Vice President of Finance & Administration
Eligible Employees
1.
Medical Plan – General Coverage. The following classes of employees, together with
their eligible dependents, who are eligible for coverage under the Medical Plan:
Full-time Faculty - All faculty granted a regular faculty contract who are scheduled to
teach a minimum of 18 credit hours per year, or the equivalent combination of teaching
and administrative duties and all full-time faculty on any type of professional leave.
Staff - Employees who are not in the Faculty category and who are regularly scheduled to
work 30 or more hours per week. Substitute or temporary employees are ineligible.
President Emeritus - President Emeritus who maintains enrollment in Medicare Part A &
B is eligible for secondary coverage under the Medical Plan and Dental Plan.
2.
Medical Plan – Leave of Absence
a.
Family and Medical Leave Act (FMLA) – Participants (i.e., faculty and staff) on
leave under the FMLA remain eligible for coverage.
b.
Medical Leave of Absence
(1)
Faculty – Participants who become totally disabled remain eligible for
coverage for the duration of the disability or 24 months (including any
periods of FMLA leave), whichever occurs first, if:


The Participant is totally disabled, as defined by the Employer’s
short and/or long-term disability plans or the Social Security
Administration; and
The Participant was employed by the Employer in a benefits
eligible position and was enrolled in the Medical Plan on the day
immediately preceding the date the Participant became totally
disabled.
If the Participant remains totally disabled and is eligible for
and enrolled in the Medical Plan at the end of the 24 month period
(including any periods of FMLA leave), the Participant and the
Participant’s enrolled dependents may be eligible for COBRA
continuation of coverage, as determined by the Employer.
(2)
Staff – Participants who become totally disabled remain eligible for
coverage for the duration of the disability or 6 months (including any
periods of FMLA leave), whichever occurs first, if:
2


The Participant is totally disabled, as defined by the Employer’s
short and/or long-term disability plans or the Social Security
Administration; and
The Participant was employed by the Employer in a benefits
eligible position and was enrolled in the Medical Plan on the day
immediately preceding the date the Participant became totally
disabled.
If the Participant remains totally disabled and is eligible for and enrolled
in the Medical Plan at the end of the 6 month period (including any
periods of FMLA leave), the Participant and the Participant’s enrolled
dependents may be eligible for COBRA continuation of coverage, as
determined by the Employer.
c.
Military Leave of Absence – Participants (i.e., faculty and staff who take a leave
of absence for active military duty remains eligible for the Medical Plan for up to
24 months, in accordance with the Uniformed Services Employment and
Reemployment Rights Act (USERRA). Coverage under this provision runs
concurrently with COBRA continuation coverage.
Participants who do not elect to continue coverage during military leave of
absence are eligible for reenrollment in the Medical Plan upon return to work,
without a pre-existing condition waiting period, pursuant to the provisions of
USERRA.
d.
Parental Leave of Absence – Faculty
When a Participant will be the primary care giver in the year following the birth,
adoption, or fostering a child, the Participant remains eligible for coverage during
a leave of absence or reduced credit course schedule for a maximum of two
semesters. Eligibility for and duration of coverage will be determined by the
Employer.
3.
All Other Component Programs (Vision, Dental, Basic Life, STD and LTD, etc.)
a.
All staff who are scheduled to work 30 hours per week or more.
b.
All faculty granted a minimum of a one-year contract who are regularly scheduled
to teach 18 credit hours/year.
c.
All Faculty on any type of Employer approved professional or personal leave,
paid or unpaid, where the leave does not alter the Employee’s full time status.
d.
All faculty regularly scheduled to teach fewer than 18 credit hours/year, but who
have additional administrative responsibilities to compensate for teaching fewer
than 18 credit hours.
3
Coverage Begins
Plan
Coverage Eligibility Begins
Medical & EAP
Dental & Vision
Basic & Optional Life & Accident Insurance
Long Term Care
Faculty are eligible on their date of hire.
Staff are eligible on the first of the month after 30
days of full-time employment (i.e., 30 or more
hours per week)
After 6 months of full-time employment.
After 1 year of full-time employment.
After new hire waiting period satisfied
Flexible Benefits Plan (FSA)
Short-Term Disability
Long-Term Disability
Colonial Voluntary Benefits Supplemental Life
Plan Funding and Type of Administration
The Plan is fully insured. Benefits are provided under the insurance contracts between the
Company and insurance carriers. Claims for benefits are sent to insurance carriers, which are
responsible for paying claims. Insurance premiums for employees and their eligible dependents are paid
in part by the Company out of it general assets, and in part by employees’ payroll deductions. The Plan
is administered by the Company.
Important Disclaimer
Plan benefits are provided under insurance contracts between the Company and insurance
carriers. If the terms of this document conflict with the terms of the insurance contracts, the terms of the
insurance contracts will control, unless superseded by applicable law.
Claims Process
You should follow the claims process for the applicable Component Program for which you are
seeking benefits. If the benefits of a Component Program are provided or administered by an insurance
company, insurance service, or other similar organization, the claims procedure of that company,
service, or organization will apply and that organization will be the entity to which claims are addressed.
Ask the Plan Administrator if you have questions regarding the proper person or entity to which claims
should be addressed.
Your Rights Under ERISA
As a participant in the Plan you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be
entitled to:
(a)
Examine, without charge, at the Plan Administrator’s office and at other
specified locations, such as worksites and union halls, all documents governing the Plan,
including insurance contracts and collective bargaining agreements, and a copy of the latest
4
annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and
available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
(b)
Obtain, upon written request to the Plan Administrator, copies of all documents
governing the operation of the Plan, including insurance contracts and collective bargaining
agreements, copies of the latest annual report (Form 5500 Series) and updated summary plan
description. The Plan Administrator may charge a reasonable fee for the copies.
(c)
Receive a summary of the Plan’s annual financial report. The Plan
Administrator is required by law to furnish each participant with a copy of this summary
annual report.
(d)
Continue health care coverage for yourself, spouse or Dependents if there is a
loss of coverage under the Plan as a result of a qualifying event. You or your Dependents
may have to for such coverage. Review this summary plan description and the documents
governing the Plan on the rules governing your COBRA continuation coverage rights.
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who
are responsible for the operation of an employee benefit plan. The people who operate your Plan, called
“fiduciaries” of the Plan, have a duty to do so prudently and in the best interest of you and other Plan
participants. No one, including your employer or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights
under ERISA.
If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why
this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules.
Under ERISA there are steps you can take to enforce the above rights. For instance, if you
request materials from the Plan and do not receive them within thirty (30) days, you may file suite in a
Federal court. In such a case, the court may request the Plan Administrator to provide the materials and
pay you up to $110 a day until you receive the materials, unless the materials were not sent because of
reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied
or ignored, in whole or in part, you may file suit in a state of Federal court. If it should happen that the
Plan’s fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights,
you may seek assistance from the U. S. Department of Labor, or you may file suit in a Federal court.
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 if, for example, it finds your claim is frivolous.
If you have any questions about the Plan, you should contact the Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U. S. Department of Labor, listed in the telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U. S. Department of
Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain
5
publications about your rights and responsibilities under ERISA by calling the publications hotline of
the Employee Benefits Security Administration.
Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act
The Medical Benefits Plan generally may not, under federal law, restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law
generally does not prohibit the mother’s or newborn’s attending physician, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).
In any case, the Plan may not, under federal law, require that a provider obtain authorization from the
Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Qualified Medical Child Support Order (QMCSO)
When you or your lawful spouse are required by a court or administrative order to provide health
insurance coverage for a child, the child will be enrolled in your family coverage under the Medical
Benefits Plan or any other Component Program providing health care only to the minimum extent
required by applicable law.
A QMCSO can be issued by a court of law or by a state or local child welfare agency. In order
for the medical child support order to be qualified, the order must specify the following: (1) your name
and last known mailing address (if any) and the name and mailing address of each alternate recipient
covered by the order; (2) a reasonable description of the type of coverage to be provided, or the manner
in which the coverage will be determined; and (3) the period to which the order applies. A National
Medical Support Notice ( NMSN) is a QMCSO issued by a state or local child welfare agency to
withhold from your income any contributions required by the Plan to provide health insurance coverage
for an eligible child.
You and the dependent child must be eligible for coverage, unless specifically required otherwise
by applicable law. You and/or the dependent child will be enrolled without regard to annual open
enrollment restrictions and will be subject to applicable waiting period requirements and pre-existing
conditions provisions. The Plan will not recognize dependent eligibility for a former spouse as the result
of a court order.
The Effective Date of coverage under a QMCSO will be the later of: (a) the start date indicated
in the order; (b) the date any applicable waiting period is satisfied; or (c) the date the Plan receives the
order. Court-ordered coverage for a dependent child will be provided to the age of 18.
Family Medical Leave Act
If you are on a leave required by the Family Medical Leave Act (FMLA), you and your enrolled
dependents may continue your coverage under the Component Programs of the Plan to the minimum
extent required by the FMLA as long as you arrange with your employer to pay the applicable employee
contributions towards the cost of coverage. If your employee contributions are not paid, your coverage
will be terminated. Upon your return to work, you and any previously enrolled dependents who are still
eligible will be prospectively reinstated on the date you return to employment if the applicable
6
contributions are paid to the Plan within 30 days. The Plan will not be responsible for any claims
incurred by you or your dependents during the break in coverage.
Medical Benefits Plan – Continuation Coverage (COBRA)
Qualifying Events. As mandated by federal law, the Medical Benefits Plan and any other
Component Program providing health care coverage offer optional continuation coverage (also referred
to as COBRA coverage) to you and/or your eligible dependents if such coverage would otherwise end
due to one of the following qualifying events:
(a)
Termination of your employment for any reason except gross misconduct.
Coverage may continue for you and/or your eligible dependents;
(b)
A reduction in your hours. Coverage may continue for you and/or your
eligible dependents;
(c)
(d)
dependents;
Your death. Coverage may continue for your eligible dependents;
Your divorce or legal separation. Coverage may continue for your eligible
(e)
Your becoming entitled to Medicare. Coverage may continue for your eligible
dependents; and
(f)
Your covered dependent child’s ceasing to be a dependent child under the Plan.
Coverage may continue for that dependent.
Note: To choose this continuation coverage, an individual must be covered under the Plan on the
day before the qualifying event. In addition, your newborn child or child placed for adoption with you
during a period of continuation coverage will remain eligible for continuation coverage for the
remaining period of coverage even if you and/or your spouse terminate continuation coverage following
the child’s birth or placement for adoption.
Notification Requirements. You or the applicable dependent have the responsibility to inform
the Plan Administrator, in writing, within 60 days of a divorce or legal separation or of a child losing
dependent status under the Plan. Failure to provide this written notification within 60 days will result in
the loss of continuation coverage rights. Your employer has the responsibility to notify the Plan
Administrator of your death, termination of employment, reduction in hours, or entitlement to Medicare
within 30 days of the qualifying event.
Subject to the Plan Administrator being informed in a timely manner of the qualifying events
described above, the Plan will promptly notify you and other qualifying individuals of their continuation
coverage rights. You and any applicable dependents must elect continuation coverage within 60 days
after Plan coverage would otherwise end, or, if later, within 60 days of the notice of continuation
coverage rights. Failure to elect continuation coverage within this 60-day period will result in loss of
continuation coverage rights.
7
If the Plan Administrator receives a notice of a qualifying event from you or your dependent and
determines that the individual (you or your dependent) is not entitled to continuation coverage, the Plan
Administrator will provide to the individual an explanation as to why the individual is not entitled to
continuation coverage. This notice will be provided within the same time frame that the Plan
Administrator would have provided the notice of right to elect continuation coverage.
Maximum Period of Continuation Coverage. The maximum period of COBRA continuation
coverage is 36 months from the date of the qualifying event, unless the qualifying event is your
termination of employment or reduction in hours. In that case, the maximum period of continuation
coverage is generally 18 months from the date of the qualifying event.
However, if a qualifying individual is disabled (as determined under the Social Security Act) at
the time of your termination or reduction in hours or becomes disabled at any time during the first 60
days of continuation coverage, continuation coverage for the qualifying individual and any non-disabled
eligible dependents who are also entitled to continuation coverage may be extended to 29 months
provided the qualifying individual, if applicable, notifies the Plan Administrator in writing within the
18-month continuation coverage period and within 60 days after receiving notification of determination
of disability.
If a second qualifying event occurs (for example, your death or divorce) during the 18- or 29month coverage period resulting from your termination of employment or reduction in hours, the
maximum period of coverage will be computed from the date of the first qualifying event, but will be
extended to the full 36 months if required by the subsequent qualifying event.
A special rule applies if the qualifying individual is your spouse or dependent child whose
qualifying event was the termination or reduction in hours of your employment and you became entitled
to Medicare within 18 months before such qualifying event. In that case, the qualifying individual’s
maximum period of continuation coverage is the longer of 36 months from the date of your Medicare
entitlement or their otherwise applicable maximum period of coverage.
Cost of Continuation Coverage. The cost of COBRA continuation coverage is determined by the
employer and paid by the qualifying individual. If the qualifying individual is not disabled, the
applicable contribution cannot exceed 102 percent of the Plan’s cost of providing coverage. The cost of
coverage during a period of extended continuation coverage due to a disability cannot exceed
150 percent of the Plan’s cost of coverage.
Contribution payments for COBRA continuation coverage for you or your eligible dependents’
initial contribution month(s) are due by the 45th day after electing continuation coverage. The initial
contribution month(s) are any months that end on or before the 45th day after you or the qualifying
individual elects continuation coverage. All other contributions are due on the first of the month for
which coverage is sought, subject to a 30-day grace period. Contribution rates are established by your
employer and may change when necessary due to Plan modifications. The cost of continuation coverage
is computed from the date coverage would normally end due to the qualifying event.
Failure to make the first payment within 45 days or any subsequent payment within 30 days of
the established due date will result in the permanent cancellation of COBRA continuation coverage.
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When COBRA Continuation Coverage Ends. COBRA continuation coverage ends on the
earliest of:
(a)
(b)
employees;
(c)
The date the maximum continuation coverage period expires;
The date your employer no longer offers a group health plan to any of its
The first day for which timely payment is not made to the Plan;
(d)
The date the qualifying individual becomes covered by another group health plan.
However, if the new plan contains an exclusion or limitation for a pre-existing condition of the
qualifying individual, continuation coverage will end as of the date the exclusion or limitation no
longer applies;
(e)
The date the qualifying individual becomes entitled to coverage under Medicare;
and
(f)
The first day of the month that begins more than 30 days after the qualifying
individual who was entitled to a 29-month maximum continuation period is subject to a final
determination under the Social Security Act that he or she is no longer disabled.
Note: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that
all health insurance carriers that offer coverage in the individual market accept any eligible individuals
who apply for coverage without imposing a pre-existing condition exclusion. In order to be eligible to
apply for such coverage from a carrier after ceasing participation in the Plan, you or your eligible
dependents must elect continuation coverage under the Plan, continue through the maximum
continuation coverage period (18, 29, or 36 months, as applicable), and then apply for coverage with the
individual insurance carrier before a 63-day lapse in coverage. For more information about your right to
such individual insurance coverage, contact an independent insurance agent or your state insurance
commissioner.
Notice of Termination Before Maximum Period of COBRA Coverage Expires. If continuation
coverage for a qualifying individual terminates before the expiration of the maximum period of
continuation coverage, the Plan Administrator will provide notice to the individual of the reason that the
continuation coverage terminated, and the date of termination. The notice will be provided as soon as
practicable following the Plan Administrator’s determination regarding termination of the continuation
coverage.
Uniformed Services Employment and Reemployment Rights Act (USERRA)
If you were covered under the Medical Benefits Plan or other Component Program providing
health care coverage immediately prior to taking a leave for service in the uniformed services, you may
elect to continue your health care coverage under USERRA for up to 24 months from the date your
leave for uniformed service began, if you pay any required contributions toward the cost of the coverage
during the leave. This USERRA continuation coverage will end earlier if one of the following events
takes place:
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(a)
You fail to make a premium payment within the required time;
(b)
You fail to report to work or to apply for reemployment within the time period
required by USERRA following the completion of your service; or
(c)
discharge.
You lose your rights under USERRA, for example, as a result of a dishonorable
If the leave is 30 days or less, your contribution amount will be the same as for active employees.
If the leave is longer than 30 days, the required contribution will not exceed 102% of the cost of
coverage. Coverage continued under this provision runs concurrently with any continuation coverage.
If your coverage under the Medical Benefits Plan is terminated because of your service in the
uniformed services, your coverage will be reinstated on the first day you return to employment if you are
released under honorable conditions and you return to employment within the time period(s) required by
USERRA.
When coverage under the health care plan is reinstated, all of the plan’s provisions will apply to
the extent that they would have applied if you had not taken military leave and your coverage had been
continuous. This waiver does not provide coverage for any illness or injury caused or aggravated by
your military service, as determined by the Veterans Administration. (For complete information
regarding your rights under USERRA, contact the Plan Administrator.)
For purposes of continuation coverage under USERRA, members of the uniformed services
include the Armed Forces, the Army National Guard and the Air National Guard when engaged in active
duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the
Public Health Service, and any other category of persons designated by the President in time of war or
national emergency.
In this section, service means the performance of a duty on a voluntary or involuntary basis in a
uniformed service under competent authority and includes:
(a)
Active duty;
(b)
Active duty for training;
(c)
Initial active duty training;
(d)
Inactive duty training;
(e)
Full-time National Guard duty;
(f)
A period for which you are absent from your job for purpose of an examination to
determine your fitness to perform any such duties;
(g)
A period for which you are absent from your job for the purpose of performing
certain funereal honors duty; and
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(h)
Certain service by intermittent disaster response appointees of the National
Disaster Medical System.
Women’s Health and Cancer Rights Act (WHCRA)
In accordance with the Women’s Health and Cancer Rights Act, the Medical Benefits Plan
covers mastectomies and reconstructive surgery after a mastectomy. If you are receiving benefits in
connection with a mastectomy, coverage for reconstructive surgery, including modifications or
revisions, will be provided according to insurance carrier’s health care management criteria and in a
manner determined in consultation with you and the attending physician, for:
(a)
performed;
All stages of reconstruction on the breast on which the mastectomy was
(b)
Surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
(c)
Prostheses and treatment of physical complications of the mastectomy, including
lymphedema.
Benefits are subject to the same deductibles, copays and coinsurance amounts applicable to other
medical and surgical procedures covered by the Plan.
Pre-Existing Condition Waiting Period
Services are not covered by the Medical Benefits Plan if they are provided during the 12-month
period (i.e., waiting period) following enrollment in the Plan with respect to a Participant’s condition
(excluding pregnancy) for which medical advice, diagnosis, care, or treatment (including prescription
and over-the-counter medication recommended by a provider) was either received from or
recommended by a provider during the six-month period prior to enrollment in the Plan. However, any
previous period of creditable healthcare coverage, not separated by a break in coverage of 63 days or
more, is applied toward satisfying all or part of the 12-month waiting period. In addition, no preexisting condition waiting periods are ever imposed on persons under age 19.
Special Enrollment Rights
The Medical Benefits Plan provides special enrollment rights in the following circumstances:
Loss of Other Coverage. If you do not enroll in the Medical Benefits Plan for yourself and/or
your dependents when initially eligible, you may enroll at a time other than annual open enrollment if
each of the following conditions is met:
(a)
You initially declined to enroll in the Medical Benefits Plan due to the existence
of other health plan coverage;
(g)
The loss of the other health plan coverage occurred because of a loss of
eligibility (this special enrollment right will not apply if the other coverage is lost due to
nonpayment of contributions); and
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(h)
You and/or your dependents who lost the other coverage must enroll in the
Plan within 30 days after the date the other coverage is lost.
Proof of loss of the other coverage (for example, a certificate of creditable coverage) must be submitted
to the Plan as soon as reasonably possible. Proof of loss of other coverage must be submitted before any
benefits will be paid.
If you properly enroll under this special enrollment right, coverage will be effective on the date
the other coverage was lost.
New Dependents. If you are enrolled in the Medical Benefits Plan (or are eligible to be covered
but previously declined to enroll), and gain a dependent through marriage, birth, adoption, placement for
adoption with you or your lawful spouse, then you may enroll the dependent (and yourself, if applicable)
in the Plan. In the case of birth, adoption or placement for adoption of a child, you may also enroll your
eligible spouse, even if he or she is not newly eligible as a dependent. However, this special enrollment
right is only available by enrolling within 30 days of the marriage, birth, adoption, or placement for
adoption.
If you properly enroll under this special enrollment right, coverage will be effective as indicated:
(a)
As of the date of marriage;
(b)
As of the date of birth; or
(c)
If the child is less than 30 days old when adopted or placed for adoption, as of the
date of birth; if the child is more than 30 days old when adopted or placed for adoption, as of the
child’s date of placement.
Qualification for a Subsidy Through Utah’s Premium Partnership. You and/or your eligible
dependents who qualify for a subsidy through the state Medicaid program to purchase health insurance
may enroll in the Medical Benefits Plan if application is made within 30 days of receiving written
notification of eligibility for the subsidy. If you timely enroll, the effective date of coverage is the first
of the month following date of enrollment.
Loss of Medicaid or CHIP Coverage. If you and/or your eligible dependents lose coverage under
a Medicaid or CHIP plan due to loss of eligibility, you may enroll in the Medical Benefits Plan if
application is made within 60 days. If you enroll within 60 days, the effective date of coverage is the
first day after your Medicaid or CHIP coverage ended.
Lifetime Limit No Longer Applies
The lifetime limit on the dollar value of benefits under the Medical Benefits Plan no
longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the Plan
are eligible to enroll in the Plan.
Dependent Coverage
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Coverage under the Medical Benefits Plan is extended for adult children until age 26,
regardless of student status, marital status, financial dependence or place or residence.
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