PLAN DOCUMENT SUMMARY PLAN DESCRIPTION C.W.

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PLAN DOCUMENT
SUMMARY PLAN DESCRIPTION
FOR
C.W. MATTHEWS CONTRACTING CO., INC.
CWM EMPLOYEE BENEFIT TRUST
G - 2001
PLAN EFFECTIVE DATE:
May 1, 1984
RESTATEMENT DATE:
June 1, 2014
NOTICE
This Plan Document is issued and effective on the dates shown, and replaces all
booklets bearing an earlier date of issue.
The provisions of this Plan Document do not describe or create any right or
status of employment of any employee of C.W. Matthews Contracting Co. Inc.
TABLE OF CONTENTS
Page No.
Privacy of Medical Information
1
Introduction
7
Medical Benefits
10
Prescription Drug Benefits
15
Routine Preventive Care
16
Definitions
21
When Coverage Begins
39
When Coverage Ends
43
Conversion Privilege
47
Eligible Charges
48
Exclusions and Limitations
52
Outpatient Surgery
59
Mandatory Second Surgical Opinion
61
Managed Care
65
Coordination of Benefits
67
Subrogation and Reimbursement
70
Filing a Claim for Benefits
75
Misc. Plan Provisions
91
ERISA
93
HIPPA Privacy
95
PRIVACY OF MEDICAL INFORMATION
THIS PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION, made by C.W. Matthews
Contracting Co., Inc. (the “Company” or the “Plan Sponsor”) as of June 1, 2014, hereby amends
and restates the C.W. Matthews Contracting Co., Inc. CWM Employee Benefit Trust (the “Plan”),
which was originally adopted by the Company, effective May 1, 1984.
Effective Date
The Plan Document is effective as of the date first set forth above, and each amendment is effective
as of the date set forth therein.
Adoption of the Plan Document
The Plan Sponsor, as the settlor of the Plan, hereby adopts this Plan Document as the written
description of the Plan. This Plan Document represents both the Plan Document and the Summary
Plan Description, which is required by the Employee Retirement Income Security Act of 1974, 29
U.S.C. et seq. (“ERISA”). This Plan Document amends and replaces any prior statement of the
health care coverage contained in the Plan or any predecessor to the Plan.
IN WITNESS WHEREOF, the Plan Sponsor has caused this Plan Document to be executed.
C.W. Matthews Contracting Co., Inc.
By:
Name: Ray A. Rodriguez
Date: June 1, 2014
C.W. Matthews Contracting Co., Inc.
Title: Division Vice President
1
Plan Document
PRIVACY OF MEDICAL INFORMATION
We understand that your medical information is private, and we are committed to maintaining the
privacy of your medical information. Effective on or after April 14, 2004, the Plan will follow the
policies below to help ensure that your medical information remains private.
Each time you submit a claim to the Plan for reimbursement, and each time you see a health care
provider who is paid by the Plan, a record is created. The record may contain your medical
information. In general, the Plan will only use or disclose your medical information without your
authorization for the specific reasons detailed below. Except in limited circumstances, the amount of
information used or disclosed will be limited to the minimum necessary to accomplish the intent of
the use or disclosure.
PERMITTED USES AND DISCLOSURES. The following categories describe different ways
that the Plan may use or disclose your medical information. Not every use or disclosure in a
category will be listed. However, all of the ways the Plan is permitted to use and disclose
information will fall within one of the categories.
Treatment. The Plan may use or disclose your medical information to facilitate medical treatment
or services by providers. The Plan may disclose your medical information to providers, including
doctors, nurses, technicians, pharmacists, medical students, or other hospital personnel who are
involved in your care. For example, the Plan might disclose information about your prior
prescriptions to a pharmacist to determine if a pending prescription is contraindicative with prior
prescriptions.
Payment. The Plan may use and disclose your medical information to determine eligibility for Plan
benefits, to facilitate payment for the treatment and services you receive from health care providers,
to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the
Plan may tell your health care provider about your medical history to determine whether a particular
treatment is Experimental/Investigational, or Medically Necessary or to determine whether the Plan
will cover the treatment. The Plan may also share medical information with a utilization review or
pre-certification service provider. Likewise, the Plan may share medical information with another
entity to assist with the adjudication or subrogation of health claims or to another health plan to
coordinate benefit payments.
Health Care Operations. The Plan may use and disclose your medical information for other Plan
operations. These uses and disclosures are necessary to run the Plan. For example, the Plan may use
medical information in connection with: conducting quality assessment and improvement activities;
underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for
stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit
services, and fraud and abuse detection programs; business planning and development such as cost
management; and business management and general Plan administrative activities.
Requirement by Law. The Plan will disclose your medical information when required to do so by
federal, state, or local law. For example, the Plan may disclose medical information when required
by a court order in a litigation proceeding such as a malpractice action.
C.W. Matthews Contracting Co., Inc.
2
Plan Document
PRIVACY OF MEDICAL INFORMATION
Aversion of a Serious Threat to Health or Safety. The Plan may use or disclose your medical
information when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would only be to someone able to
help prevent the threat. For example, the Plan may disclose your medical information in a
proceeding regarding the licensure of a physician.
Organ and Tissue Donation. If you are an organ donor, the Plan may release your medical
information to organizations that handle organ procurement or organ, eye, or tissue transplantation or
to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, the Plan may release your
medical information as required by military command authorities. The Plan may also release
medical information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. The Plan may release your medical information for workers’
compensation or similar programs. These programs provide benefits for work-related injuries or
illness.
Public Health Risks. The Plan may disclose your medical information for public health activities.
These activities generally include the following:
•
to prevent or control disease, injury, or disability;
•
to report births and deaths;
•
to report child abuse or neglect;
•
to report reactions to medications or problems with products;
•
to notify people of recalls of products they may be using;
•
to notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; or,
•
to notify the appropriate government authority if we believe a patient has been the
victim of abuse, neglect, or domestic violence. We will only make this disclosure if
you agree or when required or authorized by law.
Health Oversight Activities. The Plan may disclose medical information to a health oversight
agency for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, the Plan may disclose your
medical information in response to a court or administrative order.
The Plan may also disclose your medical information in response to a subpoena, discovery request,
or other lawful process by someone else involved in the dispute, but only if efforts have been made
to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. The Plan may release your medical information if asked to do so by a law
C.W. Matthews Contracting Co., Inc.
3
Plan Document
PRIVACY OF MEDICAL INFORMATION
enforcement official:
•
in response to a court order, subpoena, warrant, summons or similar process;
•
to identify or locate a suspect, fugitive, material witness or missing person;
•
if you are, or are suspected to be, the victim of a crime, under certain limited
circumstances, and the Plan Administrator is unable to obtain your agreement;
•
about a death the Plan Administrator believes may be the result of criminal conduct;
•
about criminal conduct on the Company’s premises; or,
•
in emergency circumstances to report a crime, the location of the crime or victims, or
the identity, description, or location of the crime or victims, or the identity,
description, or location of the person who committed the crime.
Department of Health and Human Services. The Plan will disclose your medical information to
the U.S. Department of Health and Human Services when requested for purposes of determining the
Plan’s compliance with applicable regulations.
Coroners, Medical Examiners, and Funeral Directors. The Plan may release medical information
to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person
or determine the cause of death. The Plan may also release medical information about patients of the
hospital to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. The Plan may release your medical information to
authorized federal officials for intelligence, counterintelligence, and other national security activities
authorized by law.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement
official, the Plan may release your medical information to the correctional institution or law
enforcement official. This release would be necessary for the institution to provide you with health
care; to protect your health and safety or the health and safety of others; or, for the safety and
security of the correctional institution.
DISCLOSURES TO THE COMPANY. The Plan will disclose medical information about you to
the Company only upon receipt of a certification from the Company that the Company agrees:
•
not to further use or disclose medical information about you other than as permitted
or required by the Plan documents or as required by law;
•
to ensure that any agents, including a subcontractor, to whom it provides medical
information received from the Plan agree to the same restrictions and conditions that
apply to the Company with respect to such information;
•
not to use or disclose the medical information for employment-related actions and
decisions or in connection with any other benefit or employee benefit plan of the
Company;
•
to report to the Plan any use or disclosure of the medical information that is
inconsistent with the permitted uses and disclosures;
•
to make its internal practices, books, and records relating to the use and disclosure of
medical information received from the Plan available to the Department of Health
and Human Services for purposes of determining whether the Plan is complying with
C.W. Matthews Contracting Co., Inc.
4
Plan Document
PRIVACY OF MEDICAL INFORMATION
•
•
applicable regulations;
if feasible, to return or destroy all medical information received from the Plan about
you and retain no copies of the information when it is no longer needed for the
purpose for which disclosure was made, except that, if such return or destruction is
not feasible, to limit further uses or disclosures to those purposes that make such
return or destruction infeasible; and,
to ensure that there is adequate separation between the Plan and the Company
(described below).
ACCESS TO MEDICAL INFORMATION. The Plan will make your medical information
available to you for inspection and copying upon your written request to the Plan Administrator.
The Plan may charge a fee for the costs of copying, mailing or other supplies associated with your
request. The Plan may deny your request to inspect and copy in certain very limited circumstances.
If you are denied access to medical information, you may request that the denial be reviewed.
AMENDMENT OF MEDICAL INFORMATION. If you feel that medical information the Plan
has about you is incorrect or incomplete, you may ask the Plan to amend the information. You have
the right to request an amendment for as long as the information is kept by or for the Plan. Your
request must be made in writing and submitted to the Plan Administrator. In addition, you must
provide a reason that supports your request.
The Plan Administrator may deny your request for an amendment if it is not in writing or does not
include a reason to support the request. In addition, the Plan Administrator may deny your request if
you ask the Plan Administrator to amend information that:
•
is not part of the medical information kept by or for the Plan;
•
was not created by the Plan, unless the person or entity that created the information is
no longer available to make the amendment;
•
is not part of the information which you would be permitted to inspect and copy; or,
•
is accurate and complete.
ACCOUNTING OF DISCLOSURES. If you wish to know to whom medical information about
you has been disclosed for any purpose other than (1) treatment, payment, or health care operations,
(2) pursuant to your written authorization, and (3) for certain other purposes, you may make a
written request to the Plan Administrator.
Your request must state a time period which may not be longer than six (6) years and may not
include dates before April 14, 2004. Your request should indicate in what form you want the list (for
example, paper or electronic). The first list you request within a twelve (12) month period will be
free. For additional lists, the Plan Administrator may charge you for the costs of providing the list.
The Plan Administrator will notify you of the cost involved and you may choose to withdraw or
modify your request at that time before any costs are incurred. The accounting will not include
disclosure for the purposes of treatment, payment, or health care operations. In addition, the
accounting will not include disclosures which you have authorized in writing.
C.W. Matthews Contracting Co., Inc.
5
Plan Document
PRIVACY OF MEDICAL INFORMATION
SEPARATION BETWEEN THE PLAN AND THE COMPANY. Only employees of the
Company who are involved in the day-to-day operation and administrative functions of the Plan will
have access to your medical information. In general, this will only include individuals who work in
the Company’s Human Resources or Employee Benefits departments. These individuals will receive
appropriate training regarding the Plan’s privacy policies. In the event an individual fails to comply
with the Plan’s provisions regarding the protection of your medical information, the Company will
take appropriate action in accordance with its established policy for failure to comply with the Plan’s
privacy provisions.
OTHER USES OF MEDICAL INFORMATION. Any other uses and disclosures of medical
information will be made only with your written authorization. If you provide the Plan authorization
to use or disclose medical information about you, you may revoke that authorization, in writing, at
any time. If you revoke your authorization, the Plan will no longer use or disclose medical
information about you for the reasons covered by your written authorization. Please note that the
Plan is unable to take back any disclosures it has already made with your authorization, and that the
Plan is required to retain records of the care provided to you.
COMPLAINT RESOLUTION PROCESS. If you are concerned that your privacy rights have
been violated; or, disagree with a decision made regarding access to your health information; or,
in response to a request you made to amend or restrict the use or disclosure of your health
information; you may contact the privacy officer in writing at the address listed below. You may
also submit a written complaint to the U.S. Department of Health and Human Services.
We support your right to the privacy of your health information. We will not retaliate in any
way if you choose to file a complaint with us or with the U.S. Department of Health and Human
Services.
Privacy Officer:
C.W. Matthews Contracting Co., Inc.
Ray A. Rodriguez
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, Georgia 30061
Fax No: 770-423-7529
6
Plan Document
INTRODUCTION
C.W. Matthews Contracting Co., Inc. (“Company”) hereby establishes this welfare plan for the benefit of
eligible employees and their dependents. The Plan provides benefits as described on the following pages
of this Plan Document. Funds for providing plan benefits are administered under a Trust Agreement
established by the Plan Sponsor. Health medical benefits and Short Term Disability Indemnity benefits
are self-funded. Life Insurance and Accidental Death & Dismemberment benefits are underwritten and
provided by insurance carriers as selected by the Company.
The cost of coverage is paid for by employee and employer contributions, as follows:
a.
b.
c.
d.
e.
f.
g.
for medical coverage, the cost is shared by employee and employer contributions;
for Extended Life and Extended AD& D, the cost is paid entirely by employer
contributions;
for Supplemental Life Coverage, the cost is paid entirely by employee contributions;
for Short Term Disability (STD) Coverage, the cost is shared by employee and employer
contributions;
for Basic Life and AD&D, the cost is shared by employee and employer contributions;
employee contributions for medical coverage will be made on a pre-tax basis in
compliance with Section 125 of the Internal Revenue Code as explained under the
Section 125 tab in this book; and
dependent life is provided all participants in the medical plan as part of the employer
contribution, at no cost to the employee.
The Company reserves the right to make adjustments to the levels of employee contributions. Employee
contributions will be set at smoker and non-smoker rates for all coverages.
In order to make contributions at the level of a non-smoker, the employee must attest to the fact that he
and his covered family members DO NOT use tobacco in any form, including but not limited to smoking
(cigarettes, cigars, pipes), chewing or dipping, or that he or such covered family member is actively
involved in a smoking/nicotine cessation program. This is a reward, as a part of an over-all wellness
program.
If it is unreasonably difficult due to a medical condition for the employee to achieve the standards for the
reward under this program, or if it is medically inadvisable for the employee to attempt to achieve the
standards for the reward under this program, contact the Company and they will work with the employee
to develop another way to qualify for the reward.
Amendment or Termination - The continued maintenance of the Plan is completely voluntary on the
part of the Company and neither its existence nor its continuation shall be construed as creating any
contractual right to or obligation for its future continuation. While the Company intends to continue the
Plan indefinitely, it reserves the right at any time and for any reason, in its sole and absolute discretion,
through the procedure of an execution of a document by any officer who is authorized, to curtail benefits
under, or otherwise amend or terminate the Plan or any portion thereof, including, without limitation,
those portions of the Plan outlining the benefits provided or the classes of employees or dependents
eligible for benefits under the Plan.
Summary Plan Description - The Company will issue to each covered employee a Summary Plan
Description (SPD). The SPD will state:
C.W. Matthews Contracting Co., Inc.
7
Plan Document
INTRODUCTION
a.
b.
c.
the benefits provided;
to whom benefits will be paid; and
limitations or requirements of the Plan that may apply to the covered person.
The SPD and the Plan Document are the same.
General Plan Information
Name of Plan:
CWM Employee Benefit Trust
 CWM Preferred Coverage Plan Option
 PPACA Mandated Minimum Coverage Plan
Option
Plan Sponsor:
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, Georgia 30061
Plan Administrator:
(Named Fiduciary)
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, Georgia 30061
Plan Sponsor ID No. (EIN):
58-0652729
Source of Funding:
Self-Funded
Applicable Law:
ERISA
Plan Year:
May 1 through April 30
Plan Number:
2001
Plan Type:
Medical
Prescription Drugs
Short-Term Disability
Third Party Administrator:
Integrity Benefit Network
P.O. Box 4537
Marietta, GA 30061
770-428-1604
Participating Employer(s):
C.W. Matthews Contracting Co., Inc.
Bright Star Energy, Inc.
Agent for Service of Process:
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, GA 30061
C.W. Matthews Contracting Co., Inc.
8
Plan Document
INTRODUCTION
Legal Entity; Service of Process
The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan
Administrator.
Not a Contract
This Plan Document and any amendments constitute the terms and provisions of coverage under
this Plan. The Plan Document shall not be deemed to constitute a contract of any type between
the Company and any Participant or to be consideration for, or an inducement or condition of,
the employment of any Employee. Nothing in this Plan Document shall be deemed to give any
Employee the right to be retained in the service of the Company or to interfere with the right of
the Company to discharge any Employee at any time; provided, however, that the foregoing shall
not be deemed to modify the provisions of any collective bargaining agreements which may be
entered into by the Company with the bargaining representatives of any Employees.
Mental Health Parity
This plan complies with the Mental Health Parity and Addiction Equity Act of 2008, In accordance
with this act, no benefits will be paid for an illness, including, but not limited to, a neurosis,
psychoneurosis, psychopathy, psychosis, personality disorder, or any other illness, the layman’s
understanding of which is a mental or nervous disorder.
Applicable Law
The Plan shall be governed by ERISA and the regulations promulgated there under. Any
assignee of a covered person under this Plan shall be treated as the covered person with respect
to any claim or request for payment of expenses for medical services submitted to the Plan, the
Plan Administrator, the Plan Sponsor, the Third Party Administrator or any agent or employee
thereof. Any claims or causes of action asserted by any covered person or assignee shall be
subject to ERISA, and no state law claims or causes of action shall be applicable with respect to
any expenses related to the provision of health care services.
Discretionary Authority
The Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan
provisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions
in the Plan and related documents; to make determinations in regards to issues relating to
eligibility for benefits; to decide disputes that may arise relative to a Plan Participants’ rights;
and to determine all questions of fact and law arising under the Plan.
C.W. Matthews Contracting Co., Inc.
9
Plan Document
MEDICAL BENEFITS
Maximum Benefits Per Covered Person
Maximum Calendar Year Benefit while under
this plan
CWM Preferred
Coverage Plan
Unlimited-No
Maximum
PPACA Mandated
Minimum Coverage Plan
Unlimited-No Maximum
*Exceptions to the Maximum Calendar Year Benefit are as follows:*
Exceptions to the Maximum Calendar Year
Benefit
Maximum Benefit while covered under this
plan for Hospice Care
Maximum Calendar Year Benefit for
Chiropractic treatments and services
Maximum Per Accident Supplemental
Accident Expense Benefit
Maximum Calendar Year Benefit for Home
Health Care Treatments
Maximum Calendar Year Benefits for Skilled
Nursing Facility Care
CWM Preferred
Coverage Plan
$10,000
PPACA Mandated
Minimum Coverage Plan
$10,000
$1,000
$1,000
$400
$400
120 Visits
120 Visits
60 Days
60 Days
Hospital Room & Board Charges
The maximum eligible daily charge for room and board will be the lesser of:
a.
b.
the total charge made; or
the hospital’s average charge for a semi-private room.
For hospitals equipped with private rooms only, the maximum eligible daily charges will be 90%
of the private room charge.
The maximum eligible daily Intensive Care Unit charge will be the lesser of:
a.
b.
c.
the actual charge made; or
3 times the hospital’s average charge for a semi-private room; or
3 times the maximum eligible daily charge for a private room, when the hospitals
equipped with private rooms only.
Normal/Basic Deductible Amounts Per Calendar Year (See Deductible Provisions)
Per Person Deductible
C.W. Matthews Contracting Co., Inc.
CWM Preferred
Coverage Plan
$750/person;
$1,500/family
10
PPACA Mandated
Minimum Coverage Plan
$1,500/person;
$3,000/family
Plan Document
MEDICAL BENEFITS
The deductible is waived for eligible charges:
a.
b.
c.
d.
e.
for Pre-Admission Testing;
made by physicians for second surgical opinions;
for routine physical exams;
for supplemental accident expense benefits; and
for office visits at Preferred Provider Organizations/Network approved
physicians.
Separate In-Patient Hospital
Expense Deductible
CWM Preferred
Coverage Plan
$750 per
confinement
PPACA Mandated
Minimum Coverage Plan
$1,500 per confinement
This deductible applies to each hospitalization incurred by a covered person, except for:
a.
b.
a mother’s confinement for the birth and delivery of a child; and
a newborn child’s initial confinement for routine newborn care.
Additional Penalty Deductibles
The following penalty deductibles will be assessed the covered person, in addition to any other
deductibles:
Hospitalization incurred without
compliance with pre-certification program
except for emergency services
For surgery performed without a second
opinion, when required by the plan
CWM Preferred
Coverage Plan
$250 per
admission
PPACA Mandated
Minimum Coverage Plan
$500 per admission
$250 per surgery
$500 per surgery
Primary Care Providers
A current list of primary care providers is available at the Preferred Provider Organization’s
website at www.Firsthealth.com.
Each Participant has a free choice of any physician or surgeon, and the physician-patient
relationship shall be maintained. The Participant, together with his or her Physician, is
ultimately responsible for determining the appropriate course of medical treatment, regardless of
whether the Plan will pay for all or a portion of the cost of such care. The PPO providers are
merely independent contractors; neither the Plan nor the Plan Administrator make any warranty
as to the quality of care that may be rendered by any PPO provider.
Out-of-Pocket Maximum
The out-of-pocket maximum is the most you could pay per covered person during a coverage
C.W. Matthews Contracting Co., Inc.
11
Plan Document
MEDICAL BENEFITS
period (usually one year) for your share of the cost of covered services. The out-of-pocket limit
does not include premiums, balance billed charges, cost containment penalties, copayments,
amounts over usual, customary and reasonable, as well as ineligible amounts and health care this
plan doesn’t cover.
In-Network Annual Out-of-Pocket
Maximum(excluding deductibles and copays)
Out-of-network Annual Out-of- Pocket
Maximum(excluding deductibles and copays)
CWM Preferred
Coverage Plan
$4,500 per person
PPACA Mandated
Minimum Coverage Plan
$6,250 per person
$9,000 per person
$12,500 per person
Benefit Percentages
Pre-Admission Testing: (if performed w/in 72
hours of admission)**
Second Surgical Opinion (physician charges)**
Non-PPO
PPO
Supplemental Accident Expense Benefit**
Non-PPO
PPO
Routine Physical Exams**
Non-PPO
PPO
**Deductible Waived for these benefits
Hospital Charges at Facilities
Non-PPO
PPO
Out-Patient Surgery
Surgeon’s Fees:
Non-PPO
PPO
Other Charges:
Non-PPO
PPO
Preventative Wellness
CWM Preferred
Coverage Plan
100%
PPACA Mandated
Minimum Coverage Plan
100%
50%
100%
50%
60%
50%
100%
50%
60%
60%
100%
50%
60%
50%
70%
50%
60%
50%
70%
50%
60%
50%
70%
50%
60%
100%
100%
Preventative services as defined by the U.S. Preventative Services Task Force for in-network services only!
Ambulance Charges
Non-PPO 50%
PPO 70%
C.W. Matthews Contracting Co., Inc.
12
50%
60%
Plan Document
MEDICAL BENEFITS
Anesthesia
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO Not Covered
PPO Not Covered
Not Covered
Not Covered
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO $250 Co-pay then
50% after deductible
PPO $250 Co-pay then
70% after deductible
$250 Co-pay then 50% after
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO 50%
PPO 70%
50%
60%
Assistant Surgeon
Diagnostic X-rays or Lab Tests
Alcohol and/or Substance Abuse
Durable Medical Equipment
Emergency Room Illness
deductible
$250 Co-pay then 60% after
deductible
Emergency room co-pay waived if admitted to the hospital within 24 hours of emergency room visit.
Home Health Care
Hospice
Hospital
Non-PPO 50%
50%
PPO 70%
60%
Hospital charges subject to deductible. Maximum eligible charge is the average semi-private
room rate if the hospital has private rooms only.
Hospital Inpatient and Outpatient/
Outpatient Surgical Centers
Non-PPO
PPO
Mental and Nervous
Non-PPO
PPO
Occupational, Speech & Hearing Therapy
Non-PPO
PPO
Organ Transplant
Non-PPO
PPO
C.W. Matthews Contracting Co., Inc.
50%
70%
50%
60%
Not Covered
Not Covered
Not Covered
Not Covered
50%
70%
50%
60%
50%
70%
50%
60%
13
Plan Document
MEDICAL BENEFITS
Other Eligible Expenses
Non-PPO 50%
PPO 70%
50%
60%
Non-PPO 50%
PPO 70%
50%
60%
Physical Therapy
Surgery-In-patient
Non-PPO 50%
50%
PPO 70%
60%
Subject to deductible, reasonable and customary guidelines, and multiple surgical procedure
reduction.
Surgery-Out-Patient
Non-PPO 50%
50%
PPO 70%
60%
Subject to deductible, reasonable and customary guidelines, and multiple surgical procedure
reduction.
Prosthetics
Non-PPO 50%
50%
PPO 70%
60%
Skilled Nursing Facility
Non-PPO 50%
50%
PPO 70%
60%
Chiropractic Care & Spinal Manipulation
Non-PPO 50%
50%
PPO 50%
50%
Chiropractic subject to deductible and $1,000 annual limit.
Office Visit Co-Payments
Primary Care Physician
CWM Preferred
Coverage Plan
$40.00
PPACA Mandated
Minimum Coverage Plan
$60.00
$75.00
$120.00
Expenses eligible under Co-pay are Professional Fee,
injection fee, lab & x-ray performed at time of visit in
physician office and billed by physician ONLY.
Additional charges apply to deductible and
coinsurance.
Specialist
Expenses eligible under Co-pay are Professional Fee,
injection fee, lab & x-ray performed at time of visit in
physician office and billed by physician ONLY.
Additional charges apply to deductible and
coinsurance.
$250.00
$250.00
Emergency Room Illness*
*Deductibles and normal plan charges still apply. Emergency room illness co-payment is waived
if admitted to hospital within 24 hours of emergency room visit.
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MEDICAL BENEFITS
Prescription Drug Card Benefits
Out-patient prescription drugs are provided through a designated drug plan program as follows:
CWM Preferred
Coverage Plan
Out-Patient Prescription Drugs
Deductibles
PPACA Mandated
Minimum Coverage
Plan
$150.00
$50.00
$20.00 copayment per
prescription
*Deductible waived for Generic Prescriptions
$75.00 copayment per
Tier 2 –Brand Named Drugs
Prescription after
deductible when generic
equivalent is not
available.
Tier 1 -All Generic Drugs*
$30.00 Copayment per
prescription
$100.00 copayment per
Prescription after
deductible when
generic equivalent is
not available.

When generic equivalent is available for a name brand medication the plan will only cover
the generic equivalent cost. The employee will be required to cover the difference.

All prescriptions filled through the mail order prescription program will require three (3) copays for all 90 day supplies of medication.
Prescription Drugs & Medicine Dispensed by Hospital while hospitalized
CWM Preferred
Coverage Plan
Prescription Drugs & Medicine Dispensed
by Hospital while hospitalized
Non-PPO 50%
PPO 70%
PPACA Mandated
Minimum Coverage Plan
40%
60%

Covered Drugs:
Prescription oral contraceptive; non-injectable Federal Legend
Drugs; State Restricted Drugs; insulin (including syringes and test strips). Prilosec OTC
and omeprazole OTC will now be allowed under Tier 1 with a copayment for a 28 day
supply. Chantix will be covered as a Tier 2 prescription. Chantix will be limited to one
(1) course of treatment (90 days) per person.

Excluded Drugs:
Medications prescribed for the treatment of mental and nervous
disorders; Contraceptives (other than oral); injectables (except insulin); vitamins and over
the counter drugs; therapeutic devices or appliances; needles and syringes (other than for
insulin injection); immunization agent, biological sera, blood or blood plasma;
prescriptions refilled after one year from the physician’s original order; fertility drugs;
drugs used primarily to stimulate hair growth; smoking deterrent; retin-A; stadol;
C.W. Matthews Contracting Co., Inc.
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MEDICAL BENEFITS
impotency drugs; growth hormones; all over the counter medications; prescriptions
dispensed to an eligible covered person while confined in a hospital, nursing home or
other institution; and drugs or medicines which are Experimental/ Investigational (see
”EXCLUSIONS AND LIMITATIONS” section of this Plan for further details). This is
not a complete list of drugs that are excluded. Please contact the prescription drug service
provider at the toll-free number on your drug card to determine specific drug coverage.
Routine Preventive Care Benefit
Routine Preventive Care Covered Charges under Medical Benefits are payable for routine
Preventive Care as described herein, and in the Schedule of Benefits. Additional preventive care
shall be provided as required by applicable law if provided by a Panel/Network/Participating
Provider. Below is a listing of the current Preventive Services covered under the Affordable Care
Act as of 2012. A current listing of required preventive care can be accessed at:
www.HealthCare.gov/center/regulations/preventive.html
Charges for Routine Well Adult Care. Routine well adult care is care by a Physician that is not
for an Injury or Sickness.
Charges for Routine Well Child Care. Routine well child care is routine care by a Physician
that is not for an Injury or Sickness.
Covered Preventive Services for Adults
1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have
ever smoked.
2. Alcohol Misuse screening and counseling.
3. Aspirin use for men and women of certain ages (available through the Prescription
Drug Plan).
4. Blood Pressure screening for all adults.
5. Cholesterol screening for adults of certain ages or at higher risk.
6. Colorectal Cancer screening for adults over 50.
7. Depression screening for adults.
8. Type 2 Diabetes screening for adults with high blood pressure.
9. Diet counseling for adults at higher risk for chronic disease.
10. HIV screening for all adults at higher risk.
11. Immunization vaccines for adults--doses, recommended ages, and recommended
populations vary:
o
o
o
o
o
Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Influenza (Flu Shot)
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MEDICAL BENEFITS
o
o
o
o
o
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Tetanus, Diphtheria, Pertussis
Varicella
12. Obesity screening and counseling for all adults.
13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk.
14. Tobacco Use screening for all adults and cessation interventions for tobacco users.
15. Syphilis screening for all adults at higher risk.
Covered Preventive Services for Women, Including Pregnant Women
The eight new prevention-related health services marked with an asterisk ( * ) must be covered
with no cost-sharing in plan years starting on or after August 1, 2012.
1. Anemia screening on a routine basis for pregnant women.
2. Bacteriuria urinary tract or other infection screening for pregnant women.
3. BRCA counseling about genetic testing for women at higher risk.
4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40.
5. Breast Cancer Chemoprevention counseling for women at higher risk.
6. Breastfeeding comprehensive support and counseling from trained providers, as well
as access to breastfeeding supplies, for pregnant and nursing women.*
7. Cervical Cancer screening for sexually active women.
8. Chlamydia Infection screening for younger women and other women at higher risk.
9. Contraception: Food and Drug Administration-approved contraceptive methods,
sterilization procedures, and patient education and counseling, not including
abortifacient drugs.*
10. Domestic and interpersonal violence screening and counseling for all women.*
11. Folic Acid supplements for women who may become pregnant.
12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high
risk of developing gestational diabetes.*
13. Gonorrhea screening for all women at higher risk.
14. Hepatitis B screening for pregnant women at their first prenatal visit.
15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active
women.*
16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three
years for women with normal cytology results who are 30 or older.*
17. Osteoporosis screening for women over age 60 depending on risk factors.
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Plan Document
MEDICAL BENEFITS
18. Rh Incompatibility screening for all pregnant women and follow-up testing for
women at higher risk.
19. Tobacco Use screening and interventions for all women, and expanded counseling for
pregnant tobacco users.
20. Sexually Transmitted Infections (STI) counseling for sexually active women.*
21. Syphilis screening for all pregnant women or other women at increased risk.
22. Well-woman visits to obtain recommended preventive services for women under 65.*
Covered Preventive Services for Children
1. Alcohol and Drug Use assessments for adolescents.
2. Autism screening for children at 18 and 24 months.
3. Behavioral assessments for children of all ages.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
4. Blood Pressure screening for children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
5. Cervical Dysplasia screening for sexually active females.
6. Congenital Hypothyroidism screening for newborns.
7. Depression screening for adolescents.
8. Developmental screening for children under age 3, and surveillance throughout
childhood.
9. Dyslipidemia screening for children at higher risk of lipid disorders.
Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
10. Fluoride Chemoprevention supplements for children without fluoride in their water
source.
11. Gonorrhea preventive medication for the eyes of all newborns.
12. Hearing screening for all newborns.
13. Height, Weight and Body Mass Index measurements for children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
14. Hematocrit or Hemoglobin screening for children.
15. Hemoglobinopathies or sickle cell screening for newborns.
16. HIV screening for adolescents at higher risk.
17. Immunization vaccines for children from birth to age 18 —doses, recommended ages,
and recommended populations vary:
o
o
o
o
o
Diphtheria, Tetanus, Pertussis
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Human Papillomavirus
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Plan Document
MEDICAL BENEFITS
o
o
o
o
o
o
o
Inactivated Poliovirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Rotavirus
Varicella
18. Iron supplements for children ages 6 to 12 months at risk for anemia.
19. Lead screening for children at risk of exposure.
20. Medical History for all children throughout development.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
21. Obesity screening and counseling.
22. Oral Health risk assessment for young children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
23. Phenylketonuria (PKU) screening for this genetic disorder in newborns.
24. Sexually Transmitted Infection (STI) prevention counseling and screening for
adolescents at higher risk.
25. Tuberculin testing for children at higher risk of tuberculosis.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
26. Vision screening for all children.
Women’s Health and Cancer Rights
Pursuant to the Women’s Health and Cancer Rights Act of 1998, this plan provides benefits for
Covered Persons for mastectomy-related services, including reconstructions and surgery to
achieve symmetry between the breasts, prostheses, and complications resulting from mastectomy
(including lymphedema). For further details see subsection “s” of the “ELIGIBLE CHARGES”
section of this Plan.
Claims Audit
In addition to the Plan’s Medical Record Review process, the Plan Administrator may use its
discretionary authority to utilize an independent bill review and/or claim audit program or
service for a complete claim. While every claim may not be subject to a bill review or audit, the
Plan Administrator has the sole discretionary authority for selection of claims subject to review
or audit.
The analysis will be employed to identify charges billed in error and/or charges that are not
Usual and Customary and/or Medically Necessary and Reasonable, if any, and may include a
patient medical billing records review and/or audit of the patient’s medical charts and records.
Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent
to identify the charges deemed in excess of the Usual and Customary and Reasonable amounts or
C.W. Matthews Contracting Co., Inc.
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Plan Document
MEDICAL BENEFITS
other applicable provisions, as outlined in this Plan Document.
Despite the existence any agreement to the converse, the Plan Administrator has the
discretionary authority to reduce any charge to a Usual and Customary and Reasonable charge,
in accord with the terms of this Plan Document.
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
As used in this Plan, the following words and phrases shall have the meanings indicated:
Actively At Work or Active Employment shall mean performance by the Employee of all the
regular duties of his or her occupation at an established business location of the Participating
Employer, or at another location to which he or she may be required to travel to perform the
duties of his or her employment. An Employee shall be deemed Actively at Work if the
Employee is absent from work due to a health factor. In no event will an Employee be
considered Actively at Work if he or she has effectively terminated employment.
ADA shall mean the American Dental Association.
Administrative Service Agent means the firm providing administrative services to the employer
in connection with the operation of the Plan, such as maintaining current eligibility data, billing,
processing and payment of claims and providing the employer with any other information
deemed necessary.
AHA shall mean the American Hospital Association.
Allowable Expenses shall mean the Usual and Customary charge for any Medically Necessary,
Reasonable eligible item of expense, at least a portion of which is covered under this Plan.
When some Other Plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service rendered, in the amount that would be payable in
accordance with the terms of the Plan, shall be deemed to be the benefit. Benefits payable under
any Other Plan include the benefits that would have been payable had claim been duly made
therefore.
AMA shall mean the American Medical Association.
Ambulatory Surgical Center shall mean any public or private State licensed and approved
(whenever required by law) establishment with an organized medical staff of Physicians, with
permanent facilities that are equipped and operated primarily for the purpose of performing
Surgical Procedures, with continuous Physician services and registered professional nursing
service whenever a patient is in the facility, and which does not provide service or other
accommodations for patients to stay overnight.
Assignment of Benefits shall mean an arrangement whereby the Plan Participant assigns their
right to seek and receive payment of eligible Plan benefits, in strict accordance with the terms of
this Plan Document, to a Provider. If a provider accepts said arrangement, Providers’ rights to
receive Plan benefits are equal to those of a Plan Participant, and are limited by the terms of this
Plan Document. A Provider that accepts this arrangement indicates acceptance of an
“Assignment of Benefits” as consideration in full for services, supplies, and/or treatment
rendered
Assistance Eligible Individual shall mean any Qualified Beneficiary who elects COBRA
continuation coverage, and has satisfied all of the following conditions:
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
1. The qualifying event occurred at any time during the period that begins with September 1,
2008, and ends with May 31, 2010, and the Qualified Beneficiary was eligible for COBRA
continuation coverage during this period;
2. The covered Employee or Qualified Beneficiary must elect COBRA or applicable state
continuation coverage;
3. The qualifying event with respect to the COBRA continuation coverage consists of the
involuntary termination of the covered Employee’s employment and occurred during such
period*; and
4. The covered Employee must have had a modified adjusted gross income of less than
$145,000, if single, or $290,000, if married filing jointly, for each tax year in which the
subsidy is received. Note that the available COBRA subsidy will be reduced for years in
which the covered Employee’s gross income exceeds $125,000 (or $250,000 for joint
returns).
*Important Note: If you experienced a reduction of hours during the period that begins with
September 1, 2008 and ends with May 31, 2010, followed by an involuntary termination of
employment on or after March 2, 2010 and by May 31, 2010, then your termination will
constitute a qualifying event and you are entitled to a new election period for COBRA
continuation coverage. Under the new election period, COBRA continuation coverage (but not
the 18-month COBRA period) and the 15 months of subsidy would begin starting with the first
period of coverage after the termination.
Calendar Year means each period of time beginning on January 1 and ending on December 31.
Child shall mean, in addition to the Employee’s own blood descendant of the first degree or
lawfully adopted Child, a Child placed with a covered Employee in anticipation of adoption, a
covered Employee’s Child who is an alternate recipient under a Qualified Medical Child Support
Order as required by the federal Omnibus Budget Reconciliation Act of 1993, any stepchild or
any other Child for whom the Employee has obtained legal guardianship.
CHIP refers to the Children’s Health Insurance Program or any provision or section thereof,
which is herein specifically referred to, as such act, provision or section may be amended from
time to time.
CHIPRA refers to the Children’s Health Insurance Program Reauthorization Act of 2009 or any
provision or section thereof, which is herein specifically referred to, as such act.
A Clean Claim is one that can be processed in accordance with the terms of this document
without obtaining additional information from the service Provider or a third party. It is a claim
which has no defect or impropriety. A defect or impropriety shall include a lack of required
sustaining documentation as set forth and in accordance with this document, or a particular
circumstance requiring special treatment which prevents timely payment as set forth in this
document, and only as permitted by this document, from being made. A Clean Claim does not
C.W. Matthews Contracting Co., Inc.
22
Plan Document
DEFINITIONS
include claims under investigation for fraud and abuse or claims under review for Medical
Necessity and Reasonableness, or fees under review for Usual and Customariness, or any other
matter that may prevent the charge(s) from being covered expenses in accordance with the terms
of this document.
Filing a Clean Claim. A Provider submits a Clean Claim by providing the required data elements
on the standard claims forms, along with any attachments and additional elements or revisions to
data elements, attachments and additional elements, of which the Provider has knowledge. The
Plan Administrator may require attachments or other information in addition to these standard
forms (as noted elsewhere in this document and at other times prior to claim submittal) to ensure
charges constitute covered expenses as defined by and in accordance with the terms of this
document. The paper claim form or electronic file record must include all required data elements
and must be complete, legible, and accurate. A claim will not be considered to be a Clean Claim
if the Plan Participant has failed to submit required forms or additional information to the Plan as
well.
COBRA shall mean the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Co-Insurance - means the percentage of an eligible charge that is paid by the Plan on behalf of
the covered person.
Company means C.W. Matthews Contracting Co., Inc. or any affiliate which is participating in
the Plan with the permission of C.W. Matthews Contracting Co., Inc.
Complications of Pregnancy means conditions requiring hospital confinement (when
pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely
affected by pregnancy or caused by pregnancy.
Co-Pay - means the amount which is required to be paid to a provider by a covered person at the
time of service.
Cosmetic Treatment means treatment performed for the purpose of improving appearance
rather than for restoring bodily function necessary to correct deformities or accidental injury.
Covered Expense means a Usual and Customary fee for a Reasonable, Medically Necessary
service, treatment or supply, meant to improve a condition or participant’s health, which is
eligible for coverage in this Plan. Covered Expenses will be determined based upon all other
Plan provisions. When more than one treatment option is available, and one option is no more
effective than another, the Covered Expense is the least costly option that is no less effective
than any other option.
All treatment is subject to benefit payment maximums shown in the Summary of Benefits and as
determined elsewhere in this document.
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
Covered Person means an employee or a dependent for whom the coverage provided by this
Plan is in effect. A covered person may be covered under this Plan as an employee or as a
dependent, but not both at the same time.
Creditable Coverage shall mean coverage of an individual under any of the following: a group
health plan, health insurance coverage, Medicare, Medicaid (other than coverage consisting
solely of benefits under the program for distribution of pediatric vaccines), medical and dental
care for members and certain former members of the Uniformed Services and their dependents, a
medical care program of the Indian Health Service or a tribal organization, a State health benefits
risk pool, a health plan offered under the Federal Employees Health Benefits Program, a public
health plan, or a health benefit plan under Section 5(e) of the Peace Corps Act, or Title XXI of
the Social Security Act (State Children’s Health Insurance Program). To the extent that further
clarification is needed with respect to the sources of Creditable Coverage listed in the prior
sentence, please see the complete definition of Creditable Coverage that is set forth in 45 C.F.R.
§ 146.113(a).
Deductible means the amount of eligible charges that a covered person must incur before
benefits will be payable, as listed in the Schedule of Medical Benefits.
Dependent shall mean one or more of the following person(s):
An Employee’s lawfully married spouse possessing a marriage license who is not divorced
from the Employee. [For purposes of this section, “marriage or married” means a legal
union between one man and one woman as husband and wife];
2. An Employee’s Child who is less than 26 years of age;
3. An Employee’s Child, regardless of age, who was continuously covered prior to attaining the
limiting age under the bullets above, who is mentally or physically incapable of sustaining
his or her own living. Such Child must have been mentally or physically incapable of
earning his or her own living prior to attaining the limiting age under the bullets above.
Written proof of such incapacity and dependency satisfactory to the Plan must be furnished
and approved by the Plan within 31 days after the date the Child attains the limiting age
under the bullets above. The Plan may require, at reasonable intervals, subsequent proof
satisfactory to the Plan during the next two years after such date. After such two year period,
the Plan may require such proof, but not more often than once each year.
1.
“Dependent” does not include any person who is a member of the armed forces of any Country or
who is a resident of a Country outside the United States.
The Plan reserves the right to require documentation, satisfactory to the Plan Administrator,
which establishes a Dependent relationship.
Durable Medical Equipment means equipment which is:
a.
able to withstand repeated use;
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
b.
c.
primarily and customarily used to serve a medical purpose; and
not generally used by a person in the absence of illness or injury.
Eligible Charges means those charges described under the section entitled “ELIGIBLE
CHARGES” of this Plan.
Emergency shall mean a situation where necessary treatment is required as the result of a sudden
and severe medical event or acute condition. An Emergency includes poisoning, shock, and
hemorrhage. Other Emergencies and acute conditions may be considered on receipt of proof,
satisfactory to the Plan, that an Emergency did exist. The Plan may, at its own discretion, request
satisfactory proof that an Emergency or acute condition did exist.
Emergency Medical Condition shall mean a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act (42 U.S.C. 1395dd(e)(1)(A)). In that provision of the
Social Security Act, clause (i) refers to placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn child) in serious jeopardy; clause (ii)
refers to serious impairment to bodily functions; and clause (iii) refers to serious dysfunction of
any bodily organ or part.
Emergency Services shall mean, with respect to an Emergency Medical Condition:
1. A medical screening examination (as required under section 1867 of the Social Security Act,
42 U.S.C. 1395dd) that is within the capability of the emergency department of a Hospital,
including ancillary services routinely available to the emergency department to evaluate such
Emergency Medical Condition; and
2. Such further medical examination and treatment, to the extent they are within the capabilities
of the staff and facilities available at the Hospital, as are required under section 1867 of the
Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.
Employee means a person:
a.
b.
c.
d.
whose employment with the Company is:
1.
on a permanent full-time basis; and
2.
the person’s principle occupation; and
3.
for regular wage or salary; and
who is regularly scheduled to work at such occupation at least 30 hours each
week; and
who is a member of an employee class which is eligible for coverage under this
Plan; and
who is a permanent resident of the United States or legal alien.
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
Employee does not include a person who:
a.
b.
performs services of a recognized profession, including but not limited to, an
attorney or an accountant; or
is paid on a basis other than regular wage or salary.
Experimental and/or Investigational (“Experimental”) shall mean services or treatments that are
not widely used or accepted by most practitioners or lack credible evidence to support positive short
or long-term outcomes from those services or treatments; these services are not included under or as
Medicare reimbursable procedures, and include services, supplies, care, procedures, treatments or
courses of treatment which:
Do not constitute accepted medical practice under the standards of the case and by the
standards of a reasonable segment of the medical community or government oversight
agencies at the time rendered; or
2. Are rendered on a research basis as determined by the United States Food and Drug
Administration and the AMA’s Council on Medical Specialty Societies.
1.
All phases of clinical trials shall be considered Experimental.
A drug, device, or medical treatment or procedure is Experimental:
1. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and
Drug Administration and approval for marketing has not been given at the time the drug or
device is furnished;
2. If reliable evidence shows that the drug, device or medical treatment or procedure is the
subject of ongoing Phase I, II, or III clinical trials or under study to determine its:
a) maximum tolerated dose;
b) toxicity;
c) safety;
d) efficacy; and
e) efficacy as compared with the standard means of treatment or diagnosis; or
3. if reliable evidence shows that the consensus among experts regarding the drug, device, or
medical treatment or procedure is that further studies or clinical trials are necessary to
determine its:
a) maximum tolerated dose;
b) toxicity;
c) safety;
d) efficacy; and
e) efficacy as compared with the standard means of treatment or diagnosis.
Reliable evidence shall mean:
1. Only published reports and articles in the authoritative medical and scientific literature;
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Plan Document
DEFINITIONS
2. The written protocol or protocols used by the treating facility or the protocol(s) of another
facility studying substantially the same drug, device, or medical treatment or procedure; or
3. The written informed consent used by the treating facility or by another facility studying
substantially the same drug, device, or medical treatment or procedure.
The Plan Administrator retains maximum legal authority and discretion to determine what is
Experimental.
FMLA shall mean the Family and Medical Leave Act of 1993, as amended.
FMLA Leave shall mean a leave of absence, which the Company is required to extend to an
Employee under the provisions of the FMLA.
GINA shall mean the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110233), which prohibits group health plans, issuers of individual health care policies, and
employers from discriminating on the basis of genetic information.
HIPAA shall mean the Health Insurance Portability and Accountability Act of 1996, as
amended.
Home Health Care means the following services and supplies furnished in the home by a Home
Health Care Agency in accordance with a Home Health Care Plan, provided that the physician
certifies that hospital confinement would otherwise be required:
a.
b.
c.
d.
part-time or intermittent nursing care by a Registered Graduate Nurse (R.N.) or
Licensed Practical Nurse (L.P.N.) under the supervision of a Registered Graduate
Nurse (R.N.);
part-time or intermittent home health aide services;
occupational therapy, speech therapy and physical therapy which are provided by
a Home Health Care Agency; and
medical supplies and medications prescribed by a physician and laboratory
services of a hospital if such items would have been covered while confined in a
hospital.
Home Health Care is provided to a covered person in accordance with a Home Health Care Plan
only if:
a.
b.
the covered person was confined in a hospital for at least three consecutive days
and the Home Health Care begins within 14 days following this period of hospital
confinement; and
the Home Health Care is given for the same or related condition for which the
covered person was hospitalized.
The term “Home Health Care” does not include:
C.W. Matthews Contracting Co., Inc.
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Plan Document
DEFINITIONS
a.
b.
c.
d.
e.
services or supplies not included in the Home Health Care Plan;
services of a person who ordinarily resides in a covered person’s home or is a
member of the covered person’s family or the covered person’s spouse’s family;
custodial care consisting of services and supplies which are provided to the
covered person primarily to assist in the activities of daily living;
care received in any period during which the covered person is not under the
continuing care of a physician; or
transportation.
Hospice means a public agency or private organization which meets all of the following
requirements:
a.
b.
is primarily engaged in providing care to terminally ill patients;
provides 24-hour care to control the symptoms associated with terminal illness;
c.
has on its staff an interdisciplinary team which includes at least one physician,
one Registered Graduate Nurse (R.N.), one social worker and one counselor;
is a licensed organization whose standards of care meet those of the National
Hospice Organization;
maintains central clinical records on all patients;
provides appropriate methods of dispensing drugs and medicines; and
offers a coordinated program of home care and inpatient care for the terminally ill
patient and the patient’s family.
d.
e.
f.
g.
The term “Hospice” does not include an organization or part thereof which is primarily engaged
in providing:
a.
b.
c.
custodial care;
care for drug addicts and alcoholics; or
domestic services.
The term “Hospice” does not include an organization or part thereof which is primarily:
a.
b.
c.
a place of rest;
a place for the aged; or
a hotel or similar institution.
Hospital means a place which meets all of the following requirements:
a.
b.
c.
is accredited as a general hospital by the Joint Commission on Accreditation of
hospitals;
is open at all times;
is operated chiefly for the treatment of sick or injured persons as inpatients;
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Plan Document
DEFINITIONS
d.
e.
f.
has a staff of one or more physicians available at all times;
provides 24 hour nursing services by Registered Graduate Nurses (R.N.’s); and
includes areas designed for diagnosis and major surgical procedures, or, if it is
chiefly a place for the treatment of mentally retarded persons, has an agreement
with a hospital to perform surgery which may be required.
The term “Hospital” does not include:
a.
b.
a convalescent facility, nursing home, rest home or skilled nursing facility; or
a facility chiefly operated for treatment of the aged, drug addicts or alcoholics.
Illness means a disorder of the body or mind, a disease or pregnancy. All illnesses which are
due to the same cause or to a related cause or causes will be deemed to be one illness.
Incurred shall mean that a covered expense is Incurred on the date the service is rendered or the
supply is obtained. With respect to a course of treatment or procedure which includes several steps
or phases of treatment, covered expenses are Incurred for the various steps or phases as the services
related to each step are rendered and not when services relating to the initial step or phase are
rendered. More specifically, covered expenses for the entire procedure or course of treatment are not
Incurred upon commencement of the first stage of the procedure or course of treatment.
Injury means bodily injury caused by an accident and which results directly from the accident
and independently of all other causes.
Inpatient means an individual confined as a registered bed patient in a hospital, skilled nursing
facility or hospice.
Leave of Absence shall mean a leave of absence of an Employee that has been approved by his or
her Participating Employer, as provided for in the Participating Employer’s rules, policies,
procedures and practices.
Legal Guardian means a person recognized by a court of law as having the duty of taking care
of the person of and managing the property and rights of a minor child.
Maximum Benefit and/or Maximum Allowable Charge shall mean the benefit payable for a
specific coverage item or benefit under the Plan. Maximum Allowable Charge(s) will be the lesser
of:
 The Usual and Customary amount,
 The allowable charge specified under the terms of the Plan,
 The negotiated rate established in a contractual arrangement with a Provider, or
 The actual billed charges for the covered services
The Plan will reimburse the actual charge billed if it is less than the Usual and Customary
amount. The Plan has the discretionary authority to decide if a charge is Usual and Customary
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DEFINITIONS
and for a Medically Necessary and Reasonable service.
The Maximum Allowable Charge will not include any identifiable billing mistakes including,
but not limited to, up-coding, duplicate charges, and charges for services not performed.
Medical Emergency means a sudden and unexpected onset of a medical condition requiring
medical care which the patient secures immediately after the onset and, as a general rule, is a
condition which would be life threatening or would cause serious impairment if immediate care
were not received.
Medical Care Necessity, Medically Necessary, Medical Necessity and similar language refers
to health care services ordered by a Physician exercising prudent clinical judgment provided to a
Plan Participant for the purposes of evaluation, diagnosis or treatment of that Plan Participant’s
Sickness or Injury. Such services, to be considered Medically Necessary, must be clinically
appropriate in terms of type, frequency, extent, site and duration for the diagnosis or treatment of
the Plan Participant’s Sickness or Injury. The Medically Necessary setting and level of service is
that setting and level of service which, considering the Plan Participant’s medical symptoms and
conditions, cannot be provided in a less intensive medical setting. Such services, to be
considered Medically Necessary must be no more costly than alternative interventions, including
no intervention and are at least as likely to produce equivalent therapeutic or diagnostic results as
to the diagnosis or treatment of the Plan Participant’s Sickness or Injury without adversely
affecting the Plan Participant’s medical condition.
a.
b.
c.
d.
e.
It must not be maintenance therapy or maintenance treatment.
Its purpose must be to restore health.
It must not be primarily custodial in nature.
It must not be a listed item or treatment not allowed for reimbursement by CMS
(Medicare).
The Plan reserves the right to incorporate CMS (Medicare) guidelines in effect on
the date of treatment as additional criteria for determination of Medical Necessity
and/or an Allowable Expense.
For Hospital stays, this means that acute care as an Inpatient is necessary due to the kind of services
the Participant is receiving or the severity of the Participant’s condition and that safe and adequate
care cannot be received as an outpatient or in a less intensified medical setting. The mere fact that
the service is furnished, prescribed or approved by a Physician does not mean that it is “Medically
Necessary.” In addition, the fact that certain services are excluded from coverage under this Plan
because they are not “Medically Necessary” does not mean that any other services are deemed to be
“Medically Necessary.”
To be Medically Necessary, all of these criteria must be met. Merely because a Physician or
Dentist recommends, approves, or orders certain care does not mean that it is Medically
Necessary. The determination of whether a service, supply, or treatment is or is not Medically
Necessary may include findings of the American Medical Association and the Plan
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DEFINITIONS
Administrator’s own medical advisors. The Plan Administrator has the discretionary authority to
decide whether care or treatment is Medically Necessary.
Medically Necessary Leave of Absence shall mean a Leave of Absence by a full-time student
Dependent at a postsecondary educational institution that:
1.
2.
3.
Commences while such Dependent is suffering from a serious Illness or Injury;
Is Medically Necessary; and
Causes such Dependent to lose student status for purposes of coverage under the terms of the
Plan.
Medical Record Review is the process by which the Plan, based upon a medical record review
and audit, determines that a different treatment or different quantity of a drug or supply was
provided which is not supported in the billing, then the Plan Administrator may determine the
Maximum Allowable Charge according to the medical record review and audit results.
Medicare shall mean the program of health care for the aged established by Title XVIII of the Social
Security Act of 1965, as amended.
Mental or Nervous Disorder shall mean any disease or condition, regardless of whether the cause
is organic, that is classified as a Mental or Nervous Disorder in the current edition of International
Classification of Diseases, published by the U.S. Department of Health and Human Services, is
listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by
the American Psychiatric Association or other relevant State guideline or applicable sources.
Open Enrollment Period means the period determined by the Company on an annual basis when
employees are allowed to enroll, drop or change coverage.
Other Plan shall include, but is not limited to:
1.
2.
3.
4.
5.
6.
7.
8.
Any primary payer besides the Plan;
Any other group health plan;
Any other coverage or policy covering the Participant;
Any first party insurance through medical payment coverage, personal injury protection,
no-fault coverage, uninsured or underinsured motorist coverage;
Any policy of insurance from any insurance company or guarantor of a responsible party;
Any policy of insurance from any insurance company or guarantor of a third party;
Worker’s compensation or other liability insurance company; or
Any other source, including but not limited to crime victim restitution funds, any
medical, disability or other benefit payments, and school insurance coverage.
Outpatient means an individual receiving medical services, but not confined as a registered bed
patient in a hospital, skilled nursing facility or hospice.
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DEFINITIONS
Outpatient Surgical Center means any public or private establishment which:
a.
b.
c.
has a staff of physicians;
has permanent facilities that are equipped and operated primarily for the purpose
of performing surgical procedures; and
provides continuous physician and nursing services while patients are in the
facility.
Period of Disability means that time a covered person is disabled due to illness or injury.
Physician means a person who has successfully completed the prescribed course of studies in
medicine in a medical school and who has acquired the requisite qualifications for licensure in
the practice of medicine; and
a.
b.
is a legally qualified physician or surgeon; and
is acting within the lawful scope of his or her license.
The term “physician” does not include a person who:
a.
b.
is the covered person receiving treatment; or
is a relative by blood or marriage of the covered person receiving treatment.
Plan Year is May 1st to April 30th.
Preferred Provider Organization (PPO) means the Plan has retained the services of a
Preferred Provider Organization in order to provide quality medical care to participants who are
within the PPO’s area of operation, at lower costs to both the Plan and participants. The PPO’s
vary among the type of services to be provided. Utilization of PPO network providers will
usually result in an increase in the amount of benefits paid on eligible expenses.
Pre-Admission Testing means x-ray and laboratory examinations which:
a.
b.
c.
are performed on an outpatient basis;
are performed within seven days of a scheduled surgery which is performed
within 48 hours following the covered person’s admission to the hospital; and
are related to the illness or injury that caused hospital confinement or the need for
surgery.
Pre existing Condition is any Sickness, Illness, Disease or Injury (other than Pregnancy), regardless
of cause, for which medical advice, diagnosis, care or treatment was recommended or received, by or
from a Provider or practitioner duly licensed to provide such care under applicable State law and
operating within the scope of practice authorized by such State law, during the six months
immediately prior to the date an Employee’s Service Waiting Period commences (the “Enrollment
Date”).
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DEFINITIONS
Coverage will be available for such condition on the day immediately following the expiration of
12 months or, in the case of a Late Enrollee, 18 months after the Enrollment Date. A Participant
has the right to demonstrate any Creditable Coverage, and the applicable period shall be reduced
by any Creditable Coverage unless that Creditable Coverage occurred before a Significant Break
in Coverage.
“Prior to Effective Date” or “After Termination Date” are dates occurring before a Participant
gains eligibility from the Plan, or dates occurring after a Participant loses eligibility from the
Plan, as well as charges incurred prior to the effective date of coverage under the Plan or after
coverage is terminated, unless Extension of Benefits applies.
Psychiatric Hospital shall mean an Institution constituted, licensed, and operated as set forth in the
laws that apply to Hospitals, which meets all of the following requirements:
1.
2.
3.
4.
5.
It is primarily engaged in providing psychiatric services for the diagnosis and treatment of
mentally ill persons either by, or under the supervision of, a Physician;
It maintains clinical records on all patients and keeps records as needed to determine the
degree and intensity of treatment provided;
It is licensed as a psychiatric hospital;
It requires that every patient be under the care of a Physician; and
It provides 24-hour-a-day nursing service.
The term Psychiatric Hospital does not include an Institution, or that part of an Institution, used
mainly for nursing care, rest care, convalescent care, care of the aged, Custodial Care or
educational care.
Qualified Medical Child Support Order or QMCSO is a Medical Child Support Order that creates
or recognizes the existence of an Alternate Recipient’s right to, or assigns to an Alternate Recipient
the right to, receive benefits for which a Participant or Eligible Dependent is entitled under this Plan.
Reasonable and/or Reasonableness shall mean in the administrator’s discretion, services or
supplies, or fees for services or supplies which are necessary for the care and treatment of illness
or injury not caused by the treating Provider. Determination that fee(s) or services are
reasonable will be made by the Plan Administrator, taking into consideration unusual
circumstances or complications requiring additional time, skill and experience in connection with
a particular service or supply; industry standards and practices as they relate to similar scenarios;
and the cause of injury or illness necessitating the service(s) and/or charge(s).
This determination will consider, but will not be limited to, the findings and assessments of the
following entities: (a) The National Medical Associations, Societies, and organizations; and (b)
The Food and Drug Administration. To be Reasonable, service(s) and/or fee(s) must be in
compliance with generally accepted billing practices for unbundling or multiple procedures.
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DEFINITIONS
Services, supplies, care and/or treatment that results from errors in medical care that are clearly
identifiable, preventable, and serious in their consequence for patients, are not Reasonable. The
Plan Administrator retains discretionary authority to determine whether service(s) and/or fee(s)
are Reasonable based upon information presented to the Plan Administrator. A finding of
Provider negligence and/or malpractice is not required for service(s) and/or fee(s) to be
considered not Reasonable.
Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for
payment (exceed the Maximum Allowable Charge), when they result from Provider error(s)
and/or facility-acquired conditions deemed “reasonably preventable” through the use of
evidence-based guidelines, taking into consideration but not limited to CMS guidelines.
The Plan reserves for itself and parties acting on its behalf the right to review charges processed
and/or paid by the Plan, to identify charge(s) and/or service(s) that are not Reasonable and
therefore not eligible for payment by the Plan.
Rehabilitation Hospital shall mean an Institution which mainly provides therapeutic and restorative
services to Sick or Injured people. It is recognized as such if:
It carries out its stated purpose under all relevant Federal, State and local laws;
It is accredited for its stated purpose by either the Joint Commission on Accreditation of
Hospitals or the Commission on Accreditation for Rehabilitation Facilities; or
3. It is approved for its stated purpose by Medicare.
1.
2.
Reliable Evidence means only published reports and articles in the authoritative medical and
scientific literature; the written protocol or protocols used by the treating facility or the
protocol(s) of another facility studying substantially the same drug, device, medical treatment or
procedure; or the informed consent used by the treating facility or by another facility studying
substantially the same drug, device, medical treatment or procedure.
Scheduled benefit or Scheduled benefit amount means a specified dollar amount that will be
considered for reimbursement under the Plan for a particular type of medical care, service or
supply provided. Scheduled benefits are based upon covered expenses not otherwise limited or
excluded under the terms of the Plan. A partial listing of scheduled benefit amounts may be
found in the section, “Summary of Benefits”. A complete listing of scheduled benefit amounts
may be obtained free of charge on request to:
Marnie King
P.O. Drawer 970
Marietta, GA 30061
770-422-7520
Scheduled benefit amounts are determined taking into consideration (but not restricted to) the
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DEFINITIONS
lesser of the Usual and Customary fee for services and/or supplies, which are deemed to be both
Reasonable and Medically Necessary, and:
•
For inpatient hospital expenses, the Medicare Diagnosis Related Group (“DRG”)
scheduled dollar conversion amounts based upon the CMS weighted values.
•
For outpatient hospital expenses, the CMS Ambulatory Payment Classification
(APC) based upon the CMS weighted values.
•
For physicians and other eligible Providers, scheduled benefit amounts, the lesser
of the scheduled benefit amount or [125%] of the CMS Reimbursement Schedule
for the CMS area.
•
For Ambulatory Surgical Centers (ASC) the lesser of the scheduled benefit
amount or [125%] of the CMS Reimbursement Schedule for the CMS area.
•
At the Plan Administrator’s discretion, Medicare cost to charge ratios, average
wholesale price (AWP) for prescriptions and/or manufacturer’s retail pricing
(MRP) for supplies and devices.
•
If the Plan Administrator is unable to determine scheduled benefit amounts
utilizing the aforementioned process, it shall, at its sole discretion, determine
scheduled benefit amounts considering accepted industry-standard documentation
uniformly applied without discrimination to any Plan Participant.
Significant Break in Coverage shall mean a period of 63 consecutive days during each of which an
individual does not have any Creditable Coverage.
Skilled Nursing Care means those charges incurred for:
a.
b.
visiting nurse care by an R.N. or L.P.N. The term “visiting nursing care” means a
visit of not more than two hours for the purposes of performing specific skilled
nursing tasks; and
private duty nursing by an R.N. or L.P.N. if the patient’s condition requires
skilled nursing services and visiting nurse care is not adequate.
The term “Skilled Nursing Care” does not include:
a.
b.
that part or all of any nursing care that does not require the skills of an R.N.; or
any nursing care given while the person is an inpatient in a health care facility that
could safely and adequately be furnished by the facility’s general nursing staff if
it were fully staffed.
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DEFINITIONS
Skilled Nursing Facility means a place, or a distinct part of a place, which meets all of the
following criteria:
a.
is licensed according to state or local laws;
b.
provides as its chief purpose skilled nursing treatment to patients who are
recovering from an illness or injury;
c.
includes areas for medical treatment;
d.
provides 24-hour-a-day nursing services under the full-time supervision of a
physician or a Registered Graduate Nurse (R.N.);
e.
maintains daily health records for each patient;
f.
has an agreement which provides for the services of a physician;
g.
has a suitable method for providing drugs and medicines to patients;
h.
has an arrangement with one or more hospitals for the transfer of patients;
i.
has an effective utilization review plan;
j.
develops functions with the advice and review of a skilled group which includes
at least one physician; and
k.
is not solely a place for:
1.
rest, rehabilitation or custodial care;
2.
the aged;
3.
drug addicts;
4.
alcoholics; or
5.
those who are mentally retarded or who have mental disorders.
Special Enrollment means enrollment in the Plan pursuant to the provision of the “SPECIAL
ENROLLMENT PERIOD” subsection of the “WHEN COVERAGE BEGINS” section of the
Plan.
Substance Abuse shall mean any use of alcohol, any Drug (whether obtained legally or illegally),
any narcotic, or any hallucinogenic or other illegal substance, which produces a pattern of
pathological use, causing impairment in social or occupational functioning, or which produces
physiological dependency evidenced by physical tolerance or withdrawal. It is the excessive use of a
substance, especially alcohol or a drug. The DSM-IV definition is applied as follows:
A. A maladaptive pattern of substance use leading to clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring within a 12-month
period:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at
work, school or home (e.g., repeated absences or poor work performance related to
substance use; substance-related absences, suspensions or expulsions from school;
neglect of children or household)
2. Recurrent substance use in situations in which it is physically hazardous (e.g.,
driving an automobile or operating a machine when impaired by substance use)
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DEFINITIONS
3. Recurrent substance-related legal problems (e.g., arrests for substance-related
disorderly conduct
4. Continued substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance (e.g.,
arguments with spouse about consequences of intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for this class of
substance.
Substance Abuse Treatment Center shall mean an Institution which provides a program for the
treatment of Substance Abuse by means of a written treatment plan approved and monitored by a
Physician. This Institution must be:
1. Affiliated with a Hospital under a contractual agreement with an established system for
patient referral;
2. Accredited as such a facility by the Joint Commission on Accreditation of Hospitals; or
3. Licensed, certified or approved as an alcohol or Substance Abuse treatment program or
center by a State agency having legal authority to do so.
Substance Dependence: Substance use history which includes the following: (1) substance abuse
(see above); (2) continuation of use despite related problems; (3) development of tolerance (more
of the drug is needed to achieve the same effect); and (4) withdrawal symptoms.
Total Disability or Totally Disabled means an injury or illness which:
a.
b.
with respect to an employee, prevents the employee from performing the main
duties of the employee’s occupation with the Company; and
with respect to a dependent, prevents the dependent from performing the normal
activities of a healthy person of the same age and sex.
Uniformed Services shall mean 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 of the United States in time of war or
Emergency.
USERRA shall mean the Uniformed Services Employment and Reemployment Rights Act of
1994 (“USERRA”).
Usual and Customary (U&C) shall mean covered expenses which are identified by the Plan
Administrator, taking into consideration the fee(s) which the Provider most frequently charges
the majority of patients for the service or supply, the cost to the Provider for providing the
services, the prevailing range of fees charged in the same “area” by Providers of similar training
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DEFINITIONS
and experience for the service or supply, and the Medicare reimbursement rates. The term(s)
“same geographic locale” and/or “area” shall be defined as a metropolitan area, county, or such
greater area as is necessary to obtain a representative cross-section of Providers, persons or
organizations rendering such treatment, services, or supplies for which a specific charge is
made. To be Usual and Customary, fee(s) must be in compliance with generally accepted billing
practices for unbundling or multiple procedures.
The term “Usual” refers to the amount of a charge made for medical services, care, or supplies,
to the extent that the charge does not exceed the common level of charges made by other medical
professionals with similar credentials, or health care facilities, pharmacies, or equipment
suppliers of similar standing, which are located in the same geographic locale in which the
charge is incurred.
The term “Customary” refers to the form and substance of a service, supply, or treatment
provided in accordance with generally accepted standards of medical practice to one individual,
which is appropriate for the care or treatment of the same sex, comparable age and who receive
such services or supplies within the same geographic locale.
The term “Usual and Customary” does not necessarily mean the actual charge made nor the
specific service or supply furnished to a Plan Participant by a Provider of services or supplies,
such as a physician, therapist, nurse, hospital, or pharmacist. The Plan Administrator will
determine what the Usual and Customary charge is, for any procedure, service, or supply, and
whether a specific procedure, service or supply is Usual and Customary.
Usual and Customary charges may, at the Plan Administrator’s discretion, alternatively be
determined and established by the Plan using normative data such as, but not limited to,
Medicare cost to charge ratios, average wholesale price (AWP) for prescriptions and/or
manufacturer’s retail pricing (MRP) for supplies and devices.
Waiting Period means the time period that begins with an employee’s first hour of service
during his most recent employment with the Company. For any late enrollee, as defined in the
“WHEN COVERAGE BEGINS” section of the Plan, any period before the late enrollee’s
enrollment in the Plan is not a waiting period.
Well Baby Care means a covered dependent child receiving preventative medical care, i.e.,
periodic checkups and immunizations as set forth by the AMA Board of Pediatrics.
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Plan Document
WHEN COVERAGE BEGINS
Benefits for a covered person are determined by the covered person’s eligibility classification
and by the terms of this Plan. Any change in benefits as a result of a change in the classification
will be effective on the date the change in class occurs.
A covered person will not receive benefits:
a.
b.
for which such person is not eligible; or
in excess of the maximum amount provided under any benefit for which the
person is covered.
Eligibility Classification - Description of Eligible Classes - All employees in an eligible class.
No benefits are provided for retired employees or their dependents.
Waiting Period for Plan Membership - The period of ninety (90) days that begins with an
employee’s first hour of service during his employment with the Company.
Required Employee Contributions - Employees do contribute towards the cost of employee
coverage. Employees do contribute towards the cost of dependent coverage. The amount that
Employees contribute is calculated by the Plan Administrator and is a portion of the cost of
coverage under the Plan.
Eligibility for Employee Coverage - An employee becomes eligible for coverage provided by
the Plan on the later of:
a.
b.
effective date of Plan; or
completion of three (3) months of continuous active work.
Special Enrollment Rights - If an employee declines enrollment for himself or his dependents
(including spouse) because of other health coverage, the employee may in the future be able to
enroll himself or his dependents in this Plan, provided that the employee requests enrollment
within 30 days after the other coverage ends. In addition, if the employee has a new dependent
as a result of marriage, birth, adoption or placement for adoption, the employee may be able to
enroll himself and his dependents, provided that the employee requests enrollment within 30
days after the marriage, birth, adoption or placement for adoption. The subsection entitled
“SPECIAL ENROLLMENT PERIOD” below describes the procedures for special enrollment.
Special Enrollment for Previously Enrolled Participants - Dependents who had ceased to be
eligible to enroll in the Plan prior to the passage of the Patient Protection and Affordable Care Act
shall be provided with a 30-day Special Enrollment opportunity. This Special Enrollment
opportunity will begin May 1, 2011. All Dependents whose coverage under this Plan had previously
ended, or who were denied coverage (or were not eligible for coverage) because the availability of
Dependent coverage of Children ended before age 26, are eligible to enroll, or re-enroll in the plan or
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Plan Document
WHEN COVERAGE BEGINS
coverage under this Special Enrollment period. Coverage for Dependents who enroll through this
Special Enrollment opportunity must take effect no later than May 1, 2011
Participants who were previously enrolled, but were terminated from Plan participation because
of a prior lifetime limitation provision shall be provided with a 30-day Special Enrollment
opportunity. This Special Enrollment opportunity will begin May 1, 2011. Participants whose
coverage under this Plan had previously ended, or who were denied coverage (or were not
eligible for coverage) because a prior lifetime limitation provision, are eligible to enroll, or reenroll in the plan or coverage under this Special Enrollment period. Coverage for Participants
who enroll through this Special Enrollment opportunity must take effect no later than May 1,
2011
Special Enrollment Period - Notwithstanding any other provisions in the Plan to the contrary,
employees and their dependents shall be eligible to enroll in the Plan within 30 days of the
occurrence of one of the following:
a.
the employee or dependent loses other health coverage and meets the following
conditions:
1.
the individual had other health coverage at the time he became eligible for
the Plan;
2.
the employee stated in writing that he was declining to enroll himself
and/or his dependents in the Plan because of the other coverage.
3.
coverage being lost was (i) COBRA coverage that was exhausted, (ii)
other coverage for which the individual is no longer eligible (for example,
by reason of legal separation, divorce, death, termination of employment
or reduction in the number of hours of employment), or (iii) provided by
another employer which ceased to pay for it. (However, loss of coverage
due to a failure to pay premiums will not trigger a special enrollment
period; nor will loss of coverage for cause [such as making a fraudulent
claim or an intentional misrepresentation] trigger a special enrollment
period); and
4.
the individual makes a request in writing, in the form prescribed by the
Plan Administrator, for enrollment under the Plan within 30 days after
losing the other coverage.
b.
an employee marries, has a child, adopts a child or has a child placed for
adoption, and makes a request, in writing, in the form prescribed by the Plan
Administrator, for enrollment under the Plan within 30 days of such event.
Effective Date for Employee Coverage - Except as stated in “DELAYED EFFECTIVE DATE
OF EMPLOYEE COVERAGE” below, coverage for an employee becomes effective as follows:
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WHEN COVERAGE BEGINS
a.
for a Special Enrollment:
1.
in the case of a loss of coverage or marriage, the date of the loss of
coverage or marriage; and
2.
in the case of a dependent’s birth, adoption or placement for adoption, the
date of the birth, adoption or placement for adoption, respectively; and
b.
for all other enrollments, the date which is the later of:
1.
the date the employee becomes eligible for coverage; or
2.
the date the employee makes written application and written election to
pay for coverage provided said application is made within 30 days of the
eligibility date.
Delayed Effective Date for Employee Coverage - If an employee fails to make written
application for coverage within 30 days of his initial eligibility under the Plan (or during a
special enrollment period, if applicable), he shall be deemed a “late enrollee” and he may not
apply for coverage until the earlier of (1) the next open enrollment period if applicable, or (2) a
special enrollment period. See page 62 for guidelines concerning pre-existing conditions
pertaining to your coverage.
Eligibility for Dependent Coverage - An employee becomes eligible for dependent coverage on
the later of:
a.
b.
the date the employee becomes eligible for coverage; or
the date the employee first acquires a dependent.
Effective Date for Dependent Coverage - Except as stated in “DELAYED EFFECTIVE DATE
FOR DEPENDENT COVERAGE” below, coverage for a dependent becomes effective as
follows:
a.
for a Special Enrollment:
1.
in the case of a loss of coverage; and
2.
in the case of a dependent’s birth, adoption or placement for adoption, the
date of the birth, adoption or placement for adoption, respectively; and
b.
for all other enrollments, the date which is the later of:
1.
the date the employee becomes eligible for dependent coverage; or
2.
the date the employee makes written application and written election to
pay for dependent coverage, provided said application is made within 30
days of the eligibility date.
Delayed Effective Date for Dependent Coverage - If an employee fails to make written
application for coverage of the dependent when the dependent first becomes eligible (or during a
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WHEN COVERAGE BEGINS
Special Enrollment Period, if applicable), the dependent shall be deemed a “late enrollee” and
the employee may not apply for coverage for the dependent until the earlier of (1) the next open
enrollment period, if applicable, or (2) a special enrollment period. See page 62 for guidelines
concerning pre-existing conditions pertaining to your coverage.
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Plan Document
WHEN COVERAGE ENDS
Employee Coverage - An employee’s coverage will terminate on the earliest of:
a.
b.
c.
d.
e.
the date this Plan is terminated;
the end of the period for which the last required employee contribution for the
employee’s coverage has been paid;
the date the covered employee ceases to be in a class eligible for coverage under
the Plan;
the date on which the covered employee’s employment with the Company
terminates; or
the date the covered employee declines further coverage under the Plan in writing
furnished to the Plan Administrator.
Ceasing active work is deemed termination of employment unless:
a.
the covered employee is disabled due to illness or injury. In that event coverage
may be continued up to six (6) months during the disability provided required
employee contributions, if any, are made by such covered employee; or
b.
cessation of work is due to an approved leave of absence. In that event, coverage
may be continued for up to twelve (12) weeks, in compliance with the Family and
Medical leave Act of 1993. Required contributions, if any, must be made by the
covered employee in accordance with the agreement reached between the
employee and employer prior to the leave of absence becoming effective.
A covered employee’s coverage for any specific benefit will terminate on the earlier of:
a.
b.
the date coverage under the Plan for such benefit ends; or
the date the covered employee ceases to be eligible for that benefit.
Dependent Coverage - Dependent coverage will cease for any dependent on the earliest of:
a.
b.
c.
d.
e.
f.
g.
the date the covered employee’s coverage terminates;
the date this Plan is terminated;
the date dependent coverage is discontinued under this Plan;
the date the covered employee ceases to be in a class eligible for dependent
coverage;
the end of the period for which the last required employee contribution for
dependent coverage has been paid;
the date the covered employee no longer has any dependents; or
the date the individual ceases to qualify as a dependent under this Plan.
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Plan Document
WHEN COVERAGE ENDS
Limited Continuation of Coverage - As described below, and in accordance with the
Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), covered
persons may be able to continue their coverage under this Plan in certain limited circumstances.
A covered person may elect to continue coverage under this Plan for up to 18 months if his
coverage terminates because:
a.
b.
the covered employee’s employment is terminated (for reasons other than gross
misconduct); or
the covered employee’s number of hours of employment is reduced such that he is
no longer eligible for coverage under this Plan.
The 18 months of continuation coverage may be extended to 29 months if the Social Security
Administration determines, according to Title II or XVI of the Social Security Act, that a
covered person was disabled during the first 60 days of the continuation coverage, or for a child
born to or placed for adoption with a covered person during the continuation coverage period,
during the first 60 days of birth or adoption. All covered persons with respect to the disabled
individual who would otherwise lose coverage are entitled to the extension. It is the covered
person’s responsibility to obtain this disability determination from the Social Security
Administration and the responsibility of any of the covered persons to provide a copy of the
determination letter to the Plan Administrator within 60 days of the date of determination and
before the original 18 months of continuation coverage ceases. If there is a final determination
that the covered person is no longer disabled, the Plan Administrator must be notified within 30
days of the determination by the covered person, and any coverage extended beyond the
maximum that would otherwise apply will be terminated for all qualified beneficiaries.
A covered dependent may elect to continue coverage under this Plan for up to 36 months, if such
dependent’s coverage terminates because:
a.
b.
c.
d.
the covered employee dies;
the covered employee is divorced or legally separated;
the covered employee becomes entitled to Medicare benefits under Title XVII of
the Social Security Act; or
a child covered under the Plan ceases to be a dependent.
Notice - The covered person must notify the Plan Administrator of a divorce or legal separation
or when a child ceases to be a dependent within 60 days of such event. Failure to do so will
result in the loss of coverage under this Limited Continuation of Coverage provision. Upon
notice that one of these events or another qualifying event has occurred, the Plan Administrator
or its designee will notify the covered person of his Limited Continuation of Coverage rights.
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Plan Document
WHEN COVERAGE ENDS
Election - A covered person is entitled to an election period of 60 days in which to elect to
continue coverage under the Plan. The 60-day election period begins on the date the covered
person would lose Plan coverage because of one of the events described above, and ends on the
later of 60 days following such date or the date the covered person is sent a notice about
eligibility to elect to continue coverage.
If a covered person elects continuation coverage within the 60-day election period, continuation
coverage will generally begin on the date regular Plan coverage ceases. Even if a covered person
waives continuation coverage, but within the 60-day election period revokes the waiver,
continuation coverage will also begin on the date regular Plan coverage ceases. A covered
person may not revoke a waiver after the end of the 60-day election period.
If a covered person does not choose continuation coverage within the 60-day election period,
eligibility for continuation coverage under the Plan ends at the end of that period.
Cost of Continuation Coverage - To receive continuation of coverage, the covered person must
pay the required monthly premium plus a two percent administrative charge. If a covered person
is determined to have been disabled under Title II or XVI of the Social Security Act at the time
of the qualifying event of termination of employment or reduction of hours of employment, then
the cost of continuation coverage will be 150 percent of the normal required monthly premium
for all months after the 18th month of continuation coverage.
Each monthly premium for continuation coverage is due on the first day of the month for which
coverage is being continued. However, the first such monthly premium is not due until 45 days
after the date on which the covered person initially elects continuation coverage.
Benefits Under Continuation Coverage - If a covered person chooses continuation coverage,
the coverage is identical to the coverage then being provided under the Plan to similarly situated
employees, their spouses and their dependent children who have not experienced a qualifying
event. If their coverage changes, continuation coverage will change in the same way.
Payment of Claims - No claim will be payable under this Limited Continuation of Coverage
provision until the Plan Administrator receives the applicable premium.
Termination - A covered person’s coverage under this Limited Continuation of Coverage
provision will terminate on the earliest of:
a.
b.
the date on which the Company ceases to provide a group health plan to any
employee;
the date the covered person first becomes covered under any other group health
plan after electing continuation coverage, provided that applicable law precludes
any pre-existing condition exclusion in the new plan from affecting the covered
person’s coverage under the new plan;
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Plan Document
WHEN COVERAGE ENDS
c.
d.
e.
the date the covered person becomes entitled to Medicare benefits under Title
XVIII of the Social Security Act;
the date the required monthly premium is due, if the covered person fails to make
payment within 30 days after the due date; or
the end of the applicable continuation coverage period described above.
In no case will coverage extend beyond thirty-six months from the original qualifying event,
even if a second qualifying event occurs during the continuation coverage period.
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Plan Document
CONVERSION PRIVILEGE
Conversion Privileges
Life Insurance - When a covered person’s life insurance under this Plan terminates under the
conditions explained in this section, such covered person may obtain a life insurance conversion
policy without evidence of insurability. The conversion privilege is available to:
a.
b.
c.
an employee if coverage terminates because of termination of employment or
transfer to an ineligible class;
an employee’s spouse whose coverage terminates because:
1.
the employee’s employment terminates;
2.
the employee is transferred to an ineligible class;
3.
the employee dies; or
4.
divorce or annulment of marriage.
an employee’s children if their coverage terminates because:
1.
the employee’s employment terminates;
2.
the employee dies; or
3.
the child no longer meets the Plan’s definition of a dependent.
Persons not eligible for conversion policies are:
a.
b.
dependents of employees who are not eligible for conversion; and
persons eligible for Medicare.
The insurance company governs the application procedures, effective dates of coverage, form of
coverage, the benefits, the premium amounts and the terms of payment. The benefits and
amounts may differ from those under this Plan. The amounts of coverage provided may be
subject to and determined by the laws of the state where the policy is issued.
Medical Coverage - Conversion coverage is not available under this Plan.
Accidental Death & Dismemberment Insurance - Conversion coverage is not available under
this Plan.
Short Term Disability Coverage - Conversion coverage is not available under this Plan.
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Plan Document
ELIGIBLE CHARGES
Deductible /Carry Over Deductible - The covered person must meet a new deductible each
calendar year. A calendar year begins on January 1 and ends on December 31 of that same year.
Eligible charges incurred in October, November or December of the preceding year which were
applied to the deductible of the previous calendar year will also be applied to the deductible for
the current calendar year.
The deductible will be applied separately to each covered person except when the family
deductible (shown in “MEDICAL BENEFITS”) has been met by the family. Once the family
deductible is met, no further deductible for any covered person in that family will be required
during that calendar year, except for any inpatient hospital deductible.
Benefits - After a covered person has satisfied any applicable deductible, eligible charges will be
paid subject to exclusions, limitations and other terms of the Plan. The amount payable for any
eligible charge will generally be equal to the percentage of the reasonable and customary charge
as described in “MEDICAL BENEFITS”.
Maximum Benefits - The benefits paid for a covered person’s illnesses and injuries will not
exceed the maximum for a covered person shown in “MEDICAL BENEFITS”.
Only charges incurred by a covered person while covered under this Plan may be considered
“eligible charges”. An eligible charge is considered to be incurred on the date a service is
performed or a purchase is made. Eligible charges are the reasonable and customary charges
incurred for an illness or injury for one or more of the following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
room and board and routine nursing services for each day of confinement in a
hospital;
intensive or cardiac care room and board if medically necessary;
medical services and supplies furnished by a hospital;
anesthetics and their use;
fees of physicians for medical treatment including, but not limited to, fees for
surgical procedures;
services of a Registered Graduate Nurse (R.N. or Licensed Practical Nurse
(L.P.N.) for private duty nursing;
services of a Licensed Physical Therapist;
x-rays (other than dental), laboratory tests, and other diagnostic services which:
1.
are performed as a result of definite symptoms of an injury or illness; or
2.
reveal the need for medical treatment;
x-ray and radiation therapy;
the transport of a covered person:
1.
within the continental United States and Canada;
2.
by means of a professional ambulance service; and
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Plan Document
ELIGIBLE CHARGES
k.
l.
m.
n.
o.
p.
q.
3.
to a hospital for a medical emergency, but not returning from a hospital;
medical supplies as follows:
1.
drugs and medicines (including diabetic supplies);
2.
which are approved by the Food and Drug Administration;
3.
which require the written prescription of a physician;
4.
which must be dispensed by a hospital and are received or obtained while
a covered person is confined in a hospital as a full-time inpatient;
5.
blood, marrow, or other fluids;
6.
artificial limbs and eyes to replace natural limbs and eyes;
7.
repair and adjustment of prosthetic devices, when medically necessary;
8.
contact lenses or lenses for standard glasses only if required promptly
after, and because of, cataract surgery;
9.
casts, splints, trusses, braces, crutches and surgical dressings;
10.
rental or purchase, if less expensive, of hospital-type equipment including,
but not limited to wheelchairs, hospital beds, iron lungs and oxygen
equipment;
charges for services performed in an outpatient surgical center;
room and board charges for each day of confinement in a skilled nursing facility if
the confinement:
1.
follows a hospital confinement for which at least three straight days of
hospital room and board charges were included as eligible charges under
the Plan;
2.
begins within seven days after the covered person is released from such
hospital confinement;
3.
is for treatment of the same illness or injury which resulted in such
hospital confinement; and
4.
is one during which a physician is present and consults with the covered
person at least once every seven days;
room and board charges made by a skilled nursing facility are for the cost of
room, meals and services provided to all inpatients on a routine basis;
second surgical opinion;
routine newborn care for a newborn child up to 14 days old who is either a
covered person at the time of birth or is enrolled in the Plan within 30 days of his
birth. Routine newborn care includes:
1.
hospital charges for room, board, services and supplies;
2.
charges related to circumcision; and
3.
fees of physicians for routine pediatric care;
hospice care for a covered person who is a terminally ill patient and for members
of the covered person’s family who are also covered persons under this Plan.
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Plan Document
ELIGIBLE CHARGES
r.
A terminally ill patient is someone who has a life expectancy of six months or less
as certified in writing by the physician who is in charge of the covered person’s
care and treatment. Hospice care expenses for a covered person will be limited to
the following:
1.
hospice care in a free-standing hospice facility, hospital-based hospice, an
extended care hospice facility or nursing home hospice;
2.
care received from an interdisciplinary team of professionals for hospice
and home care;
3.
pre-bereavement counseling; and
4.
post-bereavement counseling during the 12 months following the death of
the terminally ill patient, up to a limit of six sessions;
home health care provided by a home health care provider if:
1.
on an intermittent basis, the covered person requires nursing services,
therapy or other services provided by a home health care provider;
2.
the covered person is totally disabled and is essentially confined to the
home;
3.
the covered person would otherwise have been confined as an inpatient in
a hospital or skilled nursing facility;
4.
the covered person is examined by the attending physician at least once
every 60 days; and
5.
the plan of treatment including home health care is:
i.
established in writing by the attending physician prior to the
commencement of such treatment; and
ii.
certified by the attending physician at least once every month.
Eligible home health care services will not include:
1.
custodial care;
2.
meals or nutritional services;
3.
housekeeper services;
4.
services or supplies not specified in the home health care plan;
5.
services of a relative of the covered person;
6.
services of any social worker;
7.
transportation services;
8.
care for tuberculosis;
9.
care for chemical dependency;
10.
care for the deaf or blind; or
11.
care for senility, mental deficiency, retardation or mental illness.
s.
for covered persons undergoing mastectomies, and upon consultation with the
covered person’s physician:
1.
reconstruction of the breast on which the mastectomy has been performed;
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Plan Document
ELIGIBLE CHARGES
2.
t.
u.
v.
surgery or reconstruction of the other breast to produce a symmetrical
appearance; and
3.
prostheses and physical complications of all stages of a mastectomy,
including lymphedemas.
services related to organ transplants when the covered person is the recipient for
the following procedures:
1.
cornea;
2.
heart;
3.
lung;
4.
heart/lung;
5.
pancreas;
6.
liver;
7.
kidney; and
8.
bone marrow
services of a licensed speech therapist only for the restoration of speech when
speech loss due to:
1.
cerebral vascular accident (stroke);
2.
cerebral tumor; or
3.
laryngectomy
the Plan will pay accident benefits if a covered person (as a result of an accidental
injury) incurs charges for:
1.
medical, dental or surgical treatment or supplies;
2.
confinement in a hospital;
3.
x-rays and laboratory tests; or
4.
services of a Registered Nurse (R.N.) Or Licensed Practical Nurse
(L.P.N.) for private duty nursing.
Covered expenses must be incurred within three (3) months of the date of the
injury. The amount paid will be the lesser of:
1.
2.
the eligible charges incurred; or
the maximum accident benefit shown on the Schedule of Benefits.
The amount of accident benefit paid may not be used to satisfy the deductible.
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Plan Document
EXCLUSIONS AND LIMITATIONS
Abortion - Benefits will not be paid for any abortion for a dependent child, or for any abortion
which is not medically necessary to preserve the life of a mother or if a fetal chromosomal
abnormality exists which was diagnosed prior to the abortion.
Alcohol - To a Plan Participant, arising from taking part in any activity made illegal due to the
use of alcohol. Expenses will be covered for Injured Plan Participants other than the person
partaking in an activity made illegal due to the use of alcohol, and expenses may be covered for
Substance Abuse treatment as specified in this Plan, if applicable. This exclusion does not apply
(a) if the injury resulted from being the victim of an act of domestic violence, or (b) resulted
from a medical condition (including both physical and mental health conditions).
Breast Surgery - No benefits will be paid for that portion of breast surgery which involves the
implanting or injecting of any substance into the body for restoring breast shape. Charges will,
however, be covered as part of the treatment plan for a medically necessary mastectomy due to
illness, as set forth in the “ELIGIBLE CHARGES” section of the Plan. Charges related to the
removal of a prosthesis due to medical complications will be covered, however, no benefits will
be allowed for the replacement of a prosthesis which was originally inserted as a part of a
voluntary breast augmentation.
Chemical Dependency - No benefits will be paid for services related to drug addiction or
alcoholism.
Cosmetic Surgery - No benefits will be paid for cosmetic treatment, except for that which:
a.
b.
c.
results from an illness or injury which occurs while the covered person is covered
under the Plan and is performed within 12 months of the date of such illness or
injury;
replacement of diseased tissue surgically removed while covered under the Plan;
or
treatment of a birth defect in a child who has been continuously covered under the
Plan since the date of birth.
Court Mandated - No benefits will be paid for services that are provided due to a court order
except as required in the ERISA Requirements section under “MISCELLANEOUS PLAN
PROVISIONS”.
Custodial Care - No benefits will be paid for services which are custodial in nature or primarily
consist of bathing, feeding, homemaking, moving the patient, giving medication or acting as a
companion or sitter.
Drugs - Poison - No benefits will be paid for any illness or injury which is due to:
a.
the voluntary and intentional taking of drugs except those taken as prescribed by a
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Plan Document
EXCLUSIONS AND LIMITATIONS
b.
c.
physician;
the voluntary and intentional taking of poison; or
the voluntary and intentional inhaling of gas.
This exclusion does not apply (a) if the injury resulted from being the victim of an act of
domestic violence, or (b) resulted from a medical condition (including both physical and mental
health conditions).
Educational/Recreational/Biofeedback - No benefits will be paid for any services or supplies
deemed to be educational in nature, or for any services or supplies related to self-care or selfhelp training and any related diagnostic training.
Error - That are required to treat injuries that are sustained or an illness that is contracted,
including infections and complications, while the Plan Participant was under, and due to, the care
of a Provider wherein such illness, injury, infection or complication is not reasonably expected to
occur. This exclusion will apply to expenses directly or indirectly resulting from the
circumstances of the course of treatment that, in the opinion of the Plan Administrator, in its sole
discretion, unreasonably gave rise to the expense.
Excess - That are not payable under the Plan due to application of any Plan maximum or limit or
because the charges are in excess of the Usual and Customary amount, or are for services not
deemed to be Reasonable or Medically Necessary, based upon the Plan Administrator’s
determination as set forth by and within the terms of this document
Experimental/Investigational - Benefits will not be paid for any services or supplies which are:
a.
b.
not provided in accordance with generally accepted professional medical
standards; or
incurred in connection with services and procedures including surgery or drugs
which are considered experimental or research by nature according to the
American Medical Association or the Food and Drug Administration.
Eye Care - Charges for treatment of refractive errors including, but not limited to, routine eye
examinations, eye glasses or contact lenses or the fitting of them (unless for initial replacement
of the lens of the eye following cataract surgery under this Plan), eye exercises, visual therapy,
fusion therapy, visual aids or orthoptics, or any related examination including surgery performed
to eliminate the need for eyeglasses for refractive errors (such as radial keratotomy). This
exclusion does not apply to soft lenses or scleral shells intended for use as corneal bandages;
charges for surgical procedures to correct refraction errors of the eye, including any confinement,
treatment, services or supplies given in connection with or related to the surgery. This exclusion
does not apply to surgery for cataracts.
Food Supplements - No benefits will be paid for food supplements.
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Plan Document
EXCLUSIONS AND LIMITATIONS
Foot Care Limitation - No benefits are payable for any medical services or supplies furnished
for the treatment of (a) weak, strained, flat, unstable or unbalanced feet, metatarsalgia or
bunions, or (b) corns, calluses or toenails, except for surgery performed for a condition listed in
(a) or removal of nail roots, and treatment of a condition listed in (b) because of any metabolic or
peripheral vascular disease.
Foreign Medical Expenses - No benefits will be paid for expenses incurred outside the United
States or Canada, unless the charges are incurred while traveling on business or pleasure.
Government Agencies - No benefits will be paid for hospital confinement, services, treatments
or supplies furnished by the United States or a foreign government or any agency of either for
services related to illness or injury.
Hazardous Activity - To the extent not prohibited by federal law and regulations issued
thereunder, no benefits will be paid for any accident or injury directly or indirectly attributable to
hazardous sporting activities including, but not limited to, motorcycle racing, off-road vehicle
competitions, hang gliding, parasailing, drag racing, motor cross racing, road racing and sporting
stunts. However, this exclusion shall not apply to injuries resulting from an act of domestic
violence or a medical condition (physical or mental).
Hearing Aids - No benefits will be paid for examinations to determine the need for, or for the
fitting or purchase of hearing aids.
Home Medical Supplies - No benefits will be paid for usual and normal home medical supplies
or first aid items.
Hospital Weekend Admissions - No benefits will be paid for the initial Friday, Saturday or
Sunday room and board charges incurred in connection with a hospital confinement which
begins on Friday, Saturday or Sunday except for emergency hospital admissions or scheduled
surgery within the 24 hours immediately following hospital admission.
Illegal Acts - Arising from or caused during the commission of any illegal act for which the
participant could be incarcerated for any period of time. It is not necessary for an arrest to occur,
charges to be filed, incarceration to occur, or a conviction to be had for this exclusion to apply.
This exclusion does not apply (a) if the injury resulted from being the victim of an act of
domestic violence, or (b) resulted from a medical condition (including both physical and mental
health conditions).
Inducement of Pregnancy - No benefits will be paid for expenses related to artificial
insemination, in vitro fertilization or other attempts to induce pregnancy, including drug therapy.
Jaw and Jaw Joints - No benefits will be paid for treatment of the temporomandibular joint (TMJ),
osteotomy, orthognathic surgery or maxillo facial or dental facial orthopedics.
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Plan Document
EXCLUSIONS AND LIMITATIONS
Learning/Behavior Disorders - No benefits will be paid for special education, treatment or training
for learning or behavior disorders.
Legal Duty - Coverage is provided only for services and supplies for which the covered person has a
legal duty to pay.
Limit of Medical Treatment - Benefits will only be paid for charges by a physician who is present
when consulting with the covered person. Benefits will not be paid for charges for services of a
physician or any other provider of services:
a.
b.
who usually resides in the same household with the covered person; or
who is related by blood, marriage or legal adoption to the covered person or to the
covered person’s spouse.
Maternity Expenses - No benefits will be paid for pregnancy expenses incurred by a dependent
child.
Mental or Nervous Disorder - No benefits will be paid for an illness, including, but not limited to,
a neurosis, psychoneurosis, psychopathy, psychosis, personality disorder, or any other illness, the
layman’s understanding of which is a mental or nervous disorder.
Medical Necessary - Benefits are provided only for charges which are:
a.
b.
c.
medically necessary to the treatment of illness or injury;
incurred on the advice of a physician; and
not more than the usual and customary charge.
Just because a service is prescribed by a physician does not make the service medically necessary.
In an effort to make treatment convenient, to follow the wishes of the patient or the patient’s family
to investigate the use of unproven treatment methods, or to comply with local hospital practices, the
physician may suggest or permit a method of providing care that is not medically necessary.
Charges which are determined not to be medically necessary will not be covered and no benefits will
be payable for such charges. This will include, but is not limited to, services which are determined
in a retrospective review and/or audit not to have been medically necessary.
Negligence - For Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or
malpractice on the part of any licensed Physician.
No Legal Obligation - That are provided to a Participant for which the Provider of a service
customarily makes no direct charge, or for which the Participant is not legally obligated to pay, or
for which no charges would be made in the absence of this coverage, including but not limited to
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Plan Document
EXCLUSIONS AND LIMITATIONS
fees, care, supplies, or services for which a person, company or any other entity except the
Participant or this benefit plan, may be liable for necessitating the fees, care, supplies, or services.
Non-Occupation Coverage - No benefits will be provided for an illness or injury:
a.
which arises out of or in the course of employment for any employer which is
eligible to obtain coverage for its employees under workers’ compensation or
occupational disease or similar law; or
b.
for which the covered person is eligible or paid benefits under workers’
compensation or occupational disease or similar law.
Not Acceptable - That are not accepted as standard practice by the AMA, ADA, or the Food and
Drug Administration.
Not Actually Rendered - That are not actually rendered.
Not Specifically Covered - That are not specifically covered under this Plan.
Obesity and Nicotine Addiction - No benefits will be paid for expenses related to the treatment of
nicotine use or addiction, obesity, weight control or diet.
Occupational - For any condition, Illness, Injury or complication thereof arising out of or in the
course of employment, including self-employment, or an activity for wage or profit; If you are
covered as a Dependent under this Plan and you are self-employed or employed by an employer that
does not provide health benefits, make sure that you have other medical benefits to provide for your
medical care in the event that you are hurt on the job. In most cases workers compensation
insurance will cover your costs, but if you do not have such coverage you may end up with no
coverage at all.
Other - Benefits will not be paid for charges not listed under the section entitled eligible charges.
Other than Attending Physician - Other than those certified by a Physician who is attending the
Participant as being required for the treatment of Injury or Disease, and performed by an appropriate
Provider.
Physical Fitness - No benefits will be paid for equipment or supplies made or used for physical
fitness, athletic training or general up-keep of health.
Physician’s Direct Care - Benefits will be paid only for eligible charges incurred by a covered
person under the direct care of a physician.
Pre-Existing Conditions - If charges are incurred as a result of an illness or injury which the Plan
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Plan Document
EXCLUSIONS AND LIMITATIONS
Administrator finds to be pre-existing, payment for such charges will be limited in accordance with
the section of the Plan entitled “PRE-EXISTING CONDITIONS”.
The Pre-existing Condition limitation does not apply to any Participant or Dependent that has not yet
reached age 19.
Prior to Coverage - That are rendered or received prior to or after any period of coverage
hereunder, except as specifically provided herein.
Prohibited by Law - To the extent that payment under this Plan is prohibited by law;
Provider Error - Required as a result of unreasonable provider error;
Radial Keratotomy - No benefits will be paid for radial keratotomy.
Reversal of Sterilization - No benefits will be paid for the reversal of sterilization.
Riot - Crime - No benefits will be paid for any illness or injury which is due to taking part in a riot
or civil disturbance, or while committing or attempting to commit a felony.
Routine Physical Exams - Except as provided in “MEDICAL BENEFITS”, no benefits will be paid
for health exams, tests and immunizations (including newborn care) that are not required for the
treatment for an injury or illness.
Self-Inflicted - To the extent not prohibited by federal law and regulations issued thereunder, no
benefits will be paid for an illness or injury which is intentionally self-induced or self-inflicted. This
exclusion does not apply (a) if the injury resulted from being the victim of an act of domestic
violence, or (b) resulted from a medical condition (including both physical and mental health
conditions).
Sex Change - No benefits will be payable for sex change surgery or any treatment of gender identity
disorders.
Sterilization - No benefits will be paid for sterilization procedures, except for those relating to tubal
ligation or vasectomy.
Subrogation, Reimbursement, and/or Third Party Responsibility - Of an Injury or Sickness not
payable by virtue of the Plan’s subrogation, reimbursement, and/or third party responsibility
provisions.
TMJ - No benefits will be paid for treatment of the temporomandibular joint (TMJ), osteotomy,
orthognathic surgery or maxillo facial or dental facial orthopedics.
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EXCLUSIONS AND LIMITATIONS
Treatment of Teeth and Gums - No benefits will be paid for treatment of teeth, gums, alveolar
process or supplies used in such treatment, or for dental appliances. However, this exclusion does
not apply to:
a.
b.
c.
charges incurred in connection with the treatment of malignant tumors;
the treatment of an injury to sound and natural teeth, including the replacement of
such teeth or setting of a jaw fractured or dislocated in an accident, if such treatment
is necessitated by an accident which occurs while the covered person’s coverage
under the Plan is in effect and is received within 12 months after such accident; or
the removal of impacted teeth.
War - No benefits will be paid for any illness or injury which is due to revolt, war or any act of war,
whether declared or not.
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OUTPATIENT SURGERY
Recommended Outpatient Surgery - Ambulatory (same day/outpatient) surgery is performed for
many types of surgeries. For these procedures, it is recommended that the covered person consult
with a physician regarding the possibility of scheduling surgery on an “outpatient” basis.
The list below is representative of some of the surgeries routinely done on an outpatient basis. In
order to avoid an additional penalty deductible, it is essential that the covered person’s physician
comply with the pre-certification requirements of this Plan.
Procedure
Description
Adenoidectomy
Removal of Adenoids
Arthroscopy
Examination of the interior of a joint, usually the knee, through an
arthroscope
Breast Biopsy
Surgical removal of tissue or lump for diagnosis
Capsulectomy
Removal of a capsule from a joint
Capsuloplasty
Surgical repair of a joint capsule
Carpal Tunnel Release
Removal of fibrous tissue from the tendons and nerves of the wrist to
relieve pressure.
Cataract Extraction
Removal of the lens from the eye
Cystoscopy
Operation or biopsy of the bladder or urinary system through a
cystoscope
Dilation and Curettage
Expansion of the uterus for scraping the uterine wall
Exostectomy
Removal of a bone spur
Gastroscopy
Examination of the interior of the stomach through a gastroscope
Hemorrhoidectomy
Removal of hemorrhoids
Herniorrhaphy
Surgical repair of a hernia
Iridectomy
Removal of part of the iris from the eye
Ligament Repair
Repair of an injured or abnormal collateral ligament
Simple Mastoidectomy
Removal of part of the temporal bone
Meniscectomy
Removal of cartilage from a joint - usually the knee
Myringoplasty
Repair of a perforated eardrum
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OUTPATIENT SURGERY
Procedure
Description
Metatarsal Ostectomy
Repair of a bone or part of a bone from the foot
Pilonidal Cyst Removal
Removal of a cyst from tissue in anal area
Prostate Biopsy
Removal of tissue from prostate
Tonsillectomy
Removal of tonsils
Tubal Ligation
Female sterilization
Varicocele Excision
Removal of a varicose vein from the testicle
Vasectomy
Male sterilization
Outpatient Surgery Benefit - Requires that surgery be performed in an outpatient surgical center as
defined in the “DEFINITIONS” section of this Plan Document.
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MANDATORY SECOND SURGICAL OPINION
If a physician recommends one of the surgeries listed below, the covered person should consult with
another physician as to the necessity of the surgery.
“Second Surgical Opinion” means an evaluation of the need for surgery by a second physician.
Covered persons retain free choice to either have, or not have, the proposed surgery, regardless of
what the consultant recommends. As long as the covered person obtains a second surgical opinion
(and utilizes the Pre-Certification Program), full Plan benefits will be paid.
If a covered person fails to pre-certify or to obtain a second surgical opinion, surgical benefits will
be subject to an additional penalty deductible as shown in “MEDICAL BENEFITS”.
Listed below are the non-emergency (elective) surgeries that require a second surgical opinion:
Procedure
Description
Cataract
Removal of the lens from the eye
Hemorrhoidectomy
Removal of hemorrhoids
Herniorrhaphy
Hernia repair
Hysterectomy
Removal of the uterus
Laminectomy
Back repair
Prostatectomy
Prostate gland removal
Cholecystectomy
Removal of gall bladder
Breast surgery
Excision of cyst, tumor or lesion of the breast
Tonsillectomy & Adenoidectomy
Removal of tonsils and adenoids
The covered person may choose any physician for the second surgical opinion, provided the
physician is a board-certified specialist in treating the covered person’s particular medical condition
and is not financially or professionally associated with the first physician who recommended
surgery. If the first and second opinions differ, the Plan also provides payment of eligible charges
for a third and final surgical opinion from a board-certified specialist. A board-certified specialist is
not required if the physician has been recommended to the covered person by a local medical
society.
Except as stated below, this Plan does not pay benefits for “pre-existing conditions”. A “pre-existing
condition” is any physical condition, regardless of the cause of the condition, for which medical
advice, diagnosis, care or treatment was recommended or received within the six-month period
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MANAGED CARE
Pre-Certification/Continued Stay Review - A covered person must call for pre-certification at least
72 hours prior to hospital admission or surgery, and in case of an emergency hospitalization, must
call by the earlier of 48 hours following, or the next business day following admission. Please refer
to your identification card.
The covered person must provide the name, address and birth dates of the patient, the names,
addresses and telephone numbers of the physician and hospital, and the reason for hospitalization or
surgery. The covered person is responsible for informing the attending physician of the
requirements of the pre-hospitalization review procedures. Continued stay review is also conducted
by the pre-certification provider.
The pre-certification provider’s medical care counselor will contact the physician to discuss the
proposed admission and treatment plan. If the diagnosis and treatment meet the criteria for inpatient
hospital care, the counselor and the physician will discuss the length of time required in the hospital,
as well as any care appropriate for recovery.
If the covered person fails to follow the Plan’s procedures for pre-admission or continued stay
review, the inpatient hospital deductible described in “MEDICAL BENEFITS” will be applicable.
Payment of covered charges will be withheld if pre-certification for treatment is based on a diagnosis
for which treatment is covered, but the treatment is actually undertaken for a condition which is not
covered by the Plan.
Pre-certification does not guarantee coverage or Preferred Provider Organization benefits. It
is the Employee’s responsibility to verify that the medical facility and Physicians are members
of their PPO and that the proposed service is covered by this Plan.
Mothers and Newborns - Notwithstanding any other provision of this “Managed Care Features”
section, the Plan shall not:
a.
b.
restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child following (a) a normal vaginal delivery, to less than 48
hours, or (b) a cesarean section, to less than 96 hours, unless discharged earlier by a
physician after consultation with the mother; or
require any covered person or provider to obtain authorization under the precertification features of this section in conjunction with any such stay that does not
exceed the number of hours set forth in a. above.
Case Management Program - The case management program is a special program designed for
covered persons who are suffering from a complex illness requiring continued medical care.
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MANAGED CARE
Alternate forms of treatment or alternate treatment facilities may be recommended as part of the case
management program. Subject to the administrative service agent’s approval, expenses for such
alternative forms will be payable under this Plan on the same basis as the treatment or facilities for
which they are substituted.
The administrative service agent will have the authority to implement the alternate forms of care and
treatment recommended by the case management program.
Alternative Care - The Plan may elect to offer benefits for services furnished by any provider
pursuant to an alternative treatment plan for a covered person whose condition would otherwise
require hospital care.
The Plan shall provide such alternative benefits at its sole discretion and only when and for so long
as it determines that alternative services are medically necessary and cost effective, and that the total
benefits paid for such services will not exceed the total benefits to which the covered person would
otherwise be entitled under this Plan in the absence of such alternative benefits.
If the Plan elects to provide alternative benefits for a covered person in one instance, it shall not be
obligated to provide the same or similar benefits for other covered persons under this Plan in any
other instance, nor shall it be construed as a waiver of the right to administer this Plan thereafter in
strict accordance with its express terms.
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COORDINATION OF BENEFITS
To prevent duplicate benefit payments if a covered person is covered under more than one plan, the
Coordination of Benefits (COB) provision of this Plan is included to coordinate all the benefits
provided by this Plan with benefits payable under any other medical plan or policy.
Excess Insurance
If at the time of injury, sickness, disease or disability there is available, or potentially available any
Coverage (including but not limited to Coverage resulting from a judgment at law or settlements),
the benefits under this Plan shall apply only as an excess over such other sources of Coverage. The
Plan’s benefits will be excess to, whenever possible:
a) any primary payer besides the Plan;
b) any first party insurance through medical payment coverage, personal injury protection, nofault coverage, uninsured or underinsured motorist coverage;
c) any policy of insurance from any insurance company or guarantor of a third party;
d) worker’s compensation or other liability insurance company; or
e) any other source, including but not limited to crime victim restitution funds, any medical,
disability or other benefit payments, and school insurance coverage
No more than 100% of allowable expenses will be paid by this Plan and all plans together.
“Allowable Expenses” shall mean the Usual and Customary charge for any Medically Necessary,
Reasonable, eligible item of expense, at least a portion of which is covered under this Plan. When
some Other Plan provides benefits in the form of services rather than cash payments, the reasonable
cash value of each service rendered, in the amount that would be payable in accordance with the
terms of the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include
the benefits that would have been payable had claim been duly made therefore.
Vehicle Limitation
When medical payments are available under any vehicle insurance, the Plan shall pay excess
benefits only, without reimbursement for vehicle plan and/or policy deductibles. This Plan shall
always be considered secondary to such plans and/or policies. This applies to all forms of
medical payments under vehicle plans and/or policies regardless of its name, title or
classification.
Coordination Procedures - The procedure hereinafter described will be used to determine the
amount of benefits payable under this Plan for a covered person when the covered person is covered
under any other plan. In that event, one plan is the primary plan, and all the other plans are
secondary, in the order described below. The primary plan pays its benefits first, without taking
other plans into consideration. The secondary plan then pays benefits up to the extent of its liability,
after taking into consideration the benefits provided by the other plan. Benefits under any other plan
include benefits which a covered person could have received if such benefits had been claimed.
a.
b.
If a plan has no COB provision, it is automatically the primary plan.
If all the plans have COB provisions, a plan is primary if it covers the person as an
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c.
d.
e.
f.
employee, and secondary if it covers the person as a dependent.
If a person is covered as a dependent child under more than one plan:
1.
the plan of the parent whose birthday falls earlier in the year is the primary
plan;
2.
if the father and mother share the same birthday, the Plan covering the parent
longer is the primary plan; and
3.
if parents are separated or divorced, the following applies: the plan which
covers a child as a dependent of the parent with legal custody of the child is
the primary plan, unless a court decree outlines the obligation for medical
expenses for the child in which case the plan which covers the child as a
dependent of the parent with such obligation for medical expenses is primary.
If a plan is no fault auto insurance or third party liability insurance, it is the primary
plan.
If the primary plan is still not established by the rules above, then the plan that has
covered such person for the longest continuous period of time will be the primary
plan.
Regardless of (a), (b), (c) or (d) above, the plan which covers the person as an active
employee (or a dependent of an active employee) will be primary to a plan which
covers the person as:
1.
a laid-off or retired employee;
2.
the dependent of a laid-off, retired or deceased employee; or
3.
a COBRA beneficiary who is continuing coverage in accordance with federal
law.
Coordination with Health Maintenance Organization (HMO) or Preferred Provider
Organization (PPO) Plans - This Plan will not consider any charges in excess of what an HMO or
PPO provider has agreed to accept as payment in full. When an HMO is the primary plan and the
covered person did not use the services of an HMO provider, this Plan will not consider as an
allowable charge any charge that would have been covered by the HMO had the covered person used
the services of an HMO provider.
Right to Exchange Data - The Plan Administrator has the right to exchange benefit information
with any plan, insurance company, organization or person to determine benefits payable using this
COB provision. Any such data may be exchanged without the consent of, or notice to, any person.
Any person who claims benefits under this Plan must provide the Plan Administrator with data it
requires to apply this provision. Notwithstanding the preceding, the Plan Administrator will comply
with the applicable federal regulations regarding the privacy of medical information on and after the
effective date of such regulations.
Right of Recovery - In accordance with the Recovery of Payments provision, whenever
payments have been made by this Plan with respect to Allowable Expenses in a total amount,
at any time, in excess of the maximum amount of payment necessary at that time to satisfy the
intent of this Article, the Plan shall have the right to recover such payments, to the extent of
such excess, from any one or more of the following as this Plan shall determine: any person to
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or with respect to whom such payments were made, or such person’s legal representative, any
insurance companies, or any other individuals or organizations which the Plan determines are
responsible for payment of such Allowable Expenses, and any future benefits payable to the
Participant or his or her Dependents. Please see the Recovery of Payments provision for more
details.
Effect of Medicare on Benefits - A covered employee who reaches age 65, and his spouse, may
remain covered by the Plan unless the employee or spouse makes an election to waive coverage
under this Plan and chooses Medicare as the primary payer of benefits.
In the event that an employee or spouse waives coverage under this Plan and thereby elects Medicare
as the primary source of benefits, no benefits will be payable under this Plan.
If an employee or spouse who is eligible for Medicare does not waive coverage under the Plan,
Medicare will be the secondary payer of benefits.
Benefits for covered persons who are eligible for Medicare benefits will be paid and coordinated
according to the rules and regulations of the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA). A participant and/or a dependent spouse may choose this Plan as the primary source of
coverage, with Medicare supplementing that coverage, or Medicare can be chosen as the covered
person’s medical coverage and coverage under this Plan will terminate. Unless an election is made
to choose Medicare as primary, coverage will automatically continue under this Plan, and this Plan’s
benefits will be primary to Medicare.
Notwithstanding the above, if the Plan has less than 100 participants, Medicare shall be primary if
the covered person is eligible for Medicare by reason of disability.
In the case of a participant who is entitled to Medicare benefits by reason of End-Stage Renal
Disease (ESRD), this Plan shall be primary only during the first thirty (30) months of Medicare
coverage. Thereafter, this Plan will be secondary to Medicare coverage.
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Payment Condition
1. The Plan, in its sole discretion, may elect to conditionally advance payment of benefits in those
situations where an injury, sickness, disease or disability is caused in whole or in part by, or
results from the acts or omissions of Plan Participants, and/or their dependents, beneficiaries,
estate, heirs, guardian, personal representative, or assigns (collectively referred to hereinafter in
this section as “Plan Participant(s)”) or a third party, where any party besides the Plan may be
responsible for expenses arising from an incident, and/or other funds are available, including but
not limited to no-fault, uninsured motorist, underinsured motorist, medical payment provisions,
third party assets, third party insurance, and/or grantor(s) of a third party (collectively
“Coverage”).
2. Plan Participant(s), his or her attorney, and/or legal guardian of a minor or incapacitated
individual agrees that acceptance of the Plan’s conditional payment of medical benefits is
constructive notice of these provisions in their entirety and agrees to maintain one hundred
percent (100%) of the Plan’s conditional payment of benefits or the full extent of payment from
any one or combination of first and third party sources in trust, without disruption except for
reimbursement to the Plan or the Plan’s assignee. By accepting benefits the Plan Participant(s)
agrees the Plan shall have an equitable lien on any funds received by the Plan Participant(s)
and/or their attorney from any source and said funds shall be held in trust until such time as the
obligations under this provision are fully satisfied. The Plan Participant(s) agrees to include the
Plan’s name as a co-payee on any and all settlement drafts.
3. In the event a Plan Participant(s) settles, recovers, or is reimbursed by any Coverage, the Plan
Participant(s) agrees to reimburse the Plan for all benefits paid or that will be paid by the Plan on
behalf of the Plan Participant(s). If the Plan Participant(s) fails to reimburse the Plan out of any
judgment or settlement received, the Plan Participant(s) will be responsible for any and all
expenses (fees and costs) associated with the Plan’s attempt to recover such money.
4. If there is more than one party responsible for charges paid by the Plan, or may be responsible
for charges paid by the Plan, the Plan will not be required to select a particular party from whom
reimbursement is due. Furthermore, unallocated settlement funds meant to compensate multiple
injured parties of which the Plan Participant(s) is/are only one or a few, that unallocated
settlement fund is considered designated as an “identifiable” fund from which the plan may seek
reimbursement.
Subrogation
1. As a condition to participating in and receiving benefits under this Plan, the Plan Participant(s)
agrees to assign to the Plan the right to subrogate and pursue any and all claims, causes of action
or rights that may arise against any person, corporation and/or entity and to any Coverage to
which the Plan Participant(s) is entitled, regardless of how classified or characterized, at the
Plan’s discretion.
2. If a Plan Participant(s) receives or becomes entitled to receive benefits, an automatic equitable
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lien attaches in favor of the Plan to any claim, which any Plan Participant(s) may have against
any Coverage and/or party causing the sickness or injury to the extent of such conditional
payment by the Plan plus reasonable costs of collection.
3. The Plan may, at its discretion, in its own name or in the name of the Plan Participant(s)
commence a proceeding or pursue a claim against any party or Coverage for the recovery of all
damages to the full extent of the value of any such benefits or conditional payments advanced by
the Plan.
4. If the Plan Participant(s) fails to file a claim or pursue damages against:
a) the responsible party, its insurer, or any other source on behalf of that party;
b) any first party insurance through medical payment coverage, personal injury protection,
no-fault coverage, uninsured or underinsured motorist coverage;
c) any policy of insurance from any insurance company or guarantor of a third party;
d) worker’s compensation or other liability insurance company; or
e) any other source, including but not limited to crime victim restitution funds, any
medical, disability or other benefit payments, and school insurance coverage.
The Plan Participant(s) authorizes the Plan to pursue, sue, compromise and/or settle any such claims
in the Plan Participant(s)’ and/or the Plan’s name and agrees to fully cooperate with the Plan in the
prosecution of any such claims. The Plan Participant(s) assigns all rights to the Plan or its assignee
to pursue a claim and the recovery of all expenses from any and all sources listed above.
Right of Reimbursement
1. The Plan shall be entitled to recover 100% of the benefits paid, without deduction for attorneys’
fees and costs or application of the common fund doctrine, make whole doctrine, or any other
similar legal theory, without regard to whether the Plan Participant(s) is fully compensated by
his/her recovery from all sources. The Plan shall have an equitable lien which supersedes all
common law or statutory rules, doctrines, and laws of any State prohibiting assignment of rights
which interferes with or compromises in any way the Plan’s equitable lien and right to
reimbursement. The obligation to reimburse the Plan in full exists regardless of how the
judgment or settlement is classified and whether or not the judgment or settlement specifically
designates the recovery or a portion of it as including medical, disability, or other expenses. If
the Plan Participant(s)’ recovery is less than the benefits paid, then the Plan is entitled to be paid
all of the recovery achieved.
2. No court costs, experts’ fees, attorneys’ fees, filing fees, or other costs or expenses of
litigation may be deducted from the Plan’s recovery without the prior, expressed written
consent of the Plan.
3. The Plan’s right of subrogation and reimbursement will not be reduced or affected as a result of
any fault or claim on the part of the Plan Participant(s), whether under the doctrines of causation,
comparative fault or contributory negligence, or other similar doctrine in law. Accordingly, any
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lien reduction statutes, which attempt to apply such laws and reduce a subrogating Plan’s
recovery will not be applicable to the Plan and will not reduce the Plan’s reimbursement rights.
4. These rights of subrogation and reimbursement shall apply without regard to whether any
separate written acknowledgment of these rights is required by the Plan and signed by the Plan
Participant(s).
5. This provision shall not limit any other remedies of the Plan provided by law. These rights of
subrogation and reimbursement shall apply without regard to the location of the event that led to
or caused the applicable sickness, injury, disease or disability.
Excess Insurance
1. If at the time of injury, sickness, disease or disability there is available, or potentially available
any Coverage (including but not limited to Coverage resulting from a judgment at law or
settlements), the benefits under this Plan shall apply only as an excess over such other sources of
Coverage, except as otherwise provided for under the Plan’s Coordination of Benefits section.
The Plan’s benefits shall be excess to:
a) the responsible party, its insurer, or any other source on behalf of that party;
b) any first party insurance through medical payment coverage, personal injury
protection, no-fault coverage, uninsured or underinsured motorist coverage;
c) any policy of insurance from any insurance company or guarantor of a third party;
d) worker’s compensation or other liability insurance company; or
e) any other source, including but not limited to crime victim restitution funds, any
medical, disability or other benefit payments, and school insurance coverage.
Separation of Funds
1. Benefits paid by the Plan, funds recovered by the Plan Participant(s), and funds held in trust
over which the Plan has an equitable lien exist separately from the property and estate of the
Plan Participant(s), such that the death of the Plan Participant(s), or filing of bankruptcy by
the Plan Participant(s), will not affect the Plan’s equitable lien, the funds over which the Plan
has a lien, or the Plan’s right to subrogation and reimbursement.
Wrongful Death
1. In the event that the Plan Participant(s) dies as a result of his or her injuries and a wrongful
death or survivor claim is asserted against a third party or any Coverage, the Plan’s
subrogation and reimbursement rights shall still apply.
Obligations
1. It is the Plan Participant(s)’ obligation at all times, both prior to and after payment of medical
benefits by the Plan:
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a) to cooperate with the Plan, or any representatives of the Plan, in protecting its rights,
including discovery, attending depositions, and/or cooperating in trial to preserve the
Plan’s rights;
b) to provide the Plan with pertinent information regarding the sickness, disease,
disability, or injury, including accident reports, settlement information and any other
requested additional information;
c) to take such action and execute such documents as the Plan may require to facilitate
enforcement of its subrogation and reimbursement rights;
d) to do nothing to prejudice the Plan’s rights of subrogation and reimbursement;
e) to promptly reimburse the Plan when a recovery through settlement, judgment, award
or other payment is received; and
f) to not settle or release, without the prior consent of the Plan, any claim to the extent
that the Plan Participant may have against any responsible party or Coverage.
2. If the Plan Participant(s) and/or his or her attorney fails to reimburse the Plan for all benefits
paid or to be paid, as a result of said injury or condition, out of any proceeds, judgment or
settlement received, the Plan Participant(s) will be responsible for any and all expenses
(whether fees or costs) associated with the Plan’s attempt to recover such money from the
Plan Participant(s).
3. The Plan’s rights to reimbursement and/or subrogation are in no way dependent upon the
Plan Participant(s)’ cooperation or adherence to these terms.
Offset
1. Failure by the Plan Participant(s) and/or his or her attorney to comply with any of these
requirements may, at the Plan’s discretion, result in a forfeiture of payment by the Plan of
medical benefits and any funds or payments due under this Plan on behalf of the Plan
Participant(s) may be withheld until the Plan Participant(s) satisfies his or her obligation.
Minor Status
1. In the event the Plan Participant(s) is a minor as that term is defined by applicable law, the
minor’s parents or court-appointed guardian shall cooperate in any and all actions by the Plan to
seek and obtain requisite court approval to bind the minor and his or her estate insofar as these
subrogation and reimbursement provisions are concerned.
2. If the minor’s parents or court-appointed guardian fail to take such action, the Plan shall have no
obligation to advance payment of medical benefits on behalf of the minor. Any court costs or
legal fees associated with obtaining such approval shall be paid by the minor’s parents or courtappointed guardian.
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Language Interpretation
1. The Plan Administrator retains sole, full and final discretionary authority to construe and
interpret the language of this provision, to determine all questions of fact and law arising under
this provision, and to administer the Plan’s subrogation and reimbursement rights. The Plan
Administrator may amend the Plan at any time without notice.
Severability
1. In the event that any section of this provision is considered invalid or illegal for any reason,
said invalidity or illegality shall not affect the remaining sections of this provision and Plan.
The section shall be fully severable. The Plan shall be construed and enforced as if such
invalid or illegal sections had never been inserted in the Plan.
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FILING A CLAIM FOR BENEFITS
All claims and questions regarding health claims should be directed to the Third Party
Administrator. The Plan Administrator shall be ultimately and finally responsible for adjudicating
such claims and for providing full and fair review of the decision on such claims in accordance with
the following provisions and with ERISA. Benefits under the Plan will be paid only if the Plan
Administrator decides in its discretion that the Participant is entitled to them. The responsibility to
process claims in accordance with the Plan Document may be delegated to the Contract
Administrator; provided, however, that the Contract Administrator is not a fiduciary of the Plan and
does not have the authority to make decisions involving the use of discretion.
Each Participant claiming benefits under the Plan shall be responsible for supplying, at such
times and in such manner as the Plan Administrator in its sole discretion may require, written
proof that the expenses were incurred or that the benefit is covered under the Plan. If the Plan
Administrator in its sole discretion shall determine that the Participant has not incurred a covered
expense or that the benefit is not covered under the Plan, or if the Participant shall fail to furnish
such proof as is requested, no benefits shall be payable under the Plan.
A call from a Provider who wants to know if an individual is covered under the Plan, or if a
certain procedure is covered by the Plan, prior to providing treatment is not a “claim,” since an
actual claim for benefits is not being filed with the Plan. These are simply requests for
information, and any response is not a guarantee of benefits, since payment of benefits is
subject to all Plan provisions, limitations and exclusions. Once treatment is rendered, a Clean
Claim must be filed with the Plan (which will be a “Post-service Claim”). At that time, a
determination will be made as to what benefits are payable under the Plan.
A Participant has the right to request a review of an adverse benefit determination. If the claim is
denied at the end of the appeal process, as described below, the Plan's final decision is known as
a final adverse benefit determination. If the Participant receives notice of a final adverse benefit
determination, or if the Plan does not follow the claims procedures properly, the Participant then
has the right to request an independent external review. The external review procedures are
described below.
The claims procedures are intended to provide a full and fair review. This means, among other
things, that claims and appeals will be decided in a manner designed to ensure the independence
and impartiality of the persons involved in making these decisions.
Benefits will be payable to a Plan Participant, or to a Provider that has accepted an assignment of
benefits as consideration in full for services rendered.
According to Federal regulations which apply to the Plan, there are four types of claims: Preservice (Urgent and Non-urgent), Concurrent Care and Post-service.
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
Pre-service Claims. A “pre-service claim” is a claim for a benefit under the Plan where the
Plan conditions receipt of the benefit, in whole or in part, on approval of the benefit in
advance of obtaining medical care.
A “pre-service urgent care claim” is any claim for medical care or treatment with respect
to which the application of the time periods for making non-urgent care determinations
could seriously jeopardize the life or health of the Participant or the Participant’s ability
to regain maximum function, or, in the opinion of a physician with knowledge of the
Participant’s medical condition, would subject the Participant to severe pain that cannot
be adequately managed without the care or treatment that is the subject of the claim.
If the Plan does not require the Participant to obtain approval of a specific medical
service prior to getting treatment, then there is no pre-service claim. The Participant
simply follows the Plan’s procedures with respect to any notice which may be required
after receipt of treatment, and files the claim as a post-service claim.

Concurrent Claims. A “concurrent claim” arises when the Plan has approved an on-going
course of treatment to be provided over a period of time or number of treatments, and either:

The Plan Administrator determines that the course of treatment should be reduced or
terminated; or

The Participant requests extension of the course of treatment beyond that which the Plan
Administrator has approved.
If the Plan does not require the Participant to obtain approval of a medical service prior to
getting treatment, then there is no need to contact the Plan Administrator to request an
extension of a course of treatment. The Participant simply follows the Plan’s procedures
with respect to any notice which may be required after receipt of treatment, and files the
claim as a post-service claim.

Post-service Claims. A “post-service claim” is a claim for a benefit under the Plan after the
services have been rendered.
When Health Claims Must Be Filed
Post-service health claims must be filed with the Contract Administrator within 180 days of the date
charges for the service were incurred. Benefits are based upon the Plan’s provisions at the time the
charges were incurred. Claims filed later than that date shall be denied.
A pre-service claim (including a concurrent claim that also is a pre-service claim) is considered to be
filed when the request for approval of treatment or services is made and received by the Contract
Administrator in accordance with the Plan’s procedures.
Upon receipt of the required information, the claim will be deemed to be filed with the Plan. The
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Contract Administrator will determine if enough information has been submitted to enable proper
consideration of the claim. If not, more information may be requested as provided herein. This
additional information must be received by the Contract Administrator within 45 days from receipt
by the Participant of the request for additional information. Failure to do so may result in claims
being declined or reduced.
Timing of Claim Decisions
The Plan Administrator shall notify the Participant, in accordance with the provisions set forth
below, of any adverse benefit determination (and, in the case of pre-service claims and concurrent
claims, of decisions that a claim is payable in full) within the following timeframes:

Pre-service Urgent Care Claims:

If the Participant has provided all of the necessary information, as soon as possible,
taking into account the medical exigencies, but not later than 24 hours after receipt of the
claim.

If the Participant has not provided all of the information needed to process the claim,
then the Participant will be notified as to what specific information is needed as soon as
possible, but not later than 24 hours after receipt of the claim.

The Participant will be notified of a determination of benefits as soon as possible, but not
later than 24 hours, taking into account the medical exigencies, after the earliest of:


º
The Plan’s receipt of the specified information; or
º
The end of the period afforded the Participant to provide the information.
If there is an adverse benefit determination, a request for an expedited appeal may be
submitted orally or in writing by the Participant. All necessary information, including
the Plan’s benefit determination on review, may be transmitted between the Plan and the
Participant by telephone, facsimile, or other similarly expeditious method. Alternatively,
the Participant may request an expedited review under the external review process.
Pre-service Non-urgent Care Claims:

If the Participant has provided all of the information needed to process the claim, in a
reasonable period of time appropriate to the medical circumstances, but not later than 15
days after receipt of the claim, unless an extension has been requested, then prior to the
end of the 15-day extension period.

If the Participant has not provided all of the information needed to process the claim,
then the Participant will be notified as to what specific information is needed as soon as
possible, but not later than 5 days after receipt of the claim. The Participant will be
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notified of a determination of benefits in a reasonable period of time appropriate to the
medical circumstances, either prior to the end of the extension period (if additional
information was requested during the initial processing period), or by the date agreed to
by the Plan Administrator and the Participant (if additional information was requested
during the extension period).


Concurrent Claims:

Plan Notice of Reduction or Termination. If the Plan Administrator is notifying the
Participant of a reduction or termination of a course of treatment (other than by Plan
amendment or termination), before the end of such period of time or number of
treatments. The Participant will be notified sufficiently in advance of the reduction or
termination to allow the Participant to appeal and obtain a determination on review of
that adverse benefit determination before the benefit is reduced or terminated. This rule
does not apply if benefits are reduced or eliminated due to plan amendment or
termination. A similar process applies for claims based on a rescission of coverage for
fraud or misrepresentation.

Request by Participant Involving Urgent Care. If the Plan Administrator receives a
request from a Participant to extend the course of treatment beyond the period of time or
number of treatments that is a claim involving urgent care, as soon as possible, taking
into account the medical exigencies, but not later than 24 hours after receipt of the claim,
as long as the Participant makes the request at least 24 hours prior to the expiration of the
prescribed period of time or number of treatments. If the Participant submits the request
with less than 24 hours prior to the expiration of the prescribed period of time or number
of treatments, the request will be treated as a claim involving urgent care and decided
within the urgent care timeframe.

Request by Participant Involving Non-urgent Care. If the Plan Administrator receives a
request from the Participant to extend the course of treatment beyond the period of time
or number of treatments that is a claim not involving urgent care, the request will be
treated as a new benefit claim and decided within the timeframe appropriate to the type
of claim (either as a pre-service non-urgent claim or a post-service claim).

Request by Participant Involving Rescission. With respect to rescissions, the following
timetable applies:
º
Notification to Participant
30 days
º
Notification of adverse benefit determination on appeal
30 days
Post-service Claims:
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
If the Participant has provided all of the information needed to process the claim, in a
reasonable period of time, but not later than 30 days after receipt of the claim, unless an
extension has been requested, then prior to the end of the 15-day extension period.

If the Participant has not provided all of the information needed to process the claim and
additional information is requested during the initial processing period, then the
Participant will be notified of a determination of benefits prior to the end of the extension
period, unless additional information is requested during the extension period, then the
Participant will be notified of the determination by a date agreed to by the Plan
Administrator and the Participant.

Extensions – Pre-service Urgent Care Claims. No extensions are available in connection
with Pre-service urgent care claims.

Extensions – Pre-service Non-urgent Care Claims. This period may be extended by the Plan
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
Participant, prior to the expiration of the initial 15-day processing period, of the
circumstances requiring the extension of time and the date by which the Plan expects to
render a decision.

Extensions – Post-service Claims. This period may be extended by the Plan 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 Participant, prior to
the expiration of the initial 30-day processing period, of the circumstances requiring the
extension of time and the date by which the Plan expects to render a decision.

Calculating Time Periods. The period of time within which a benefit determination is
required to be made shall begin at the time a claim is deemed to be filed in accordance with
the procedures of the Plan.
Notification of an Adverse Benefit Determination
The Plan Administrator shall provide a Participant with a notice, either in writing or electronically
(or, in the case of pre-service urgent care claims, by telephone, facsimile or similar method, with
written or electronic notice). The notice will state in a culturally and linguistically appropriate
manner and in a manner calculated to be understood by the Participant. The notice will contain the
following information:

Information sufficient to allow the Participant to identify the claim involved (including date
of service, the healthcare provider, the claim amount, if applicable, the diagnosis code and its
corresponding meaning, and the treatment code and its corresponding meaning);

A reference to the specific portion(s) of the plan provisions upon which a denial is based;
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
Specific reason(s) for a denial, including the denial code and its corresponding meaning, and
a description of the Plan’s standard, if any, that was used in denying the claim;

A description of any additional information necessary for the Participant to perfect the claim
and an explanation of why such information is necessary;

A description of the Plan’s review procedures and the time limits applicable to the
procedures. This description will include information on how to initiate the appeal and a
statement of the Participant’s right to bring a civil action under section 502(a) of ERISA
following an adverse benefit determination on final review;

A statement that the Participant 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 Participant’s claim for benefits;

The identity of any medical or vocational experts consulted in connection with a claim, even
if the Plan did not rely upon their advice (or a statement that the identity of the expert will be
provided, upon request);

Any rule, guideline, protocol or similar criterion that was relied upon, considered, or
generated in making the determination will be provided free of charge. If this is not
practical, a statement will be included that such a rule, guideline, protocol or similar criterion
was relied upon in making the determination and a copy will be provided to the Participant,
free of charge, upon request;

In the case of denials based upon a medical judgment (such as whether the treatment is
medically necessary or experimental), either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Plan to the Participant’s medical
circumstances, will be provided. If this is not practical, a statement will be included that
such explanation will be provided to the Participant, free of charge, upon request; and

Information about the availability of, and contact information for, an applicable office of
health insurance consumer assistance or ombudsman established under applicable federal
law to assist individuals with the internal claims and appeals and external review processes.

In a claim involving urgent care, a description of the Plan’s expedited review process.
Appeal of Adverse Benefit Determinations
Full and Fair Review of All Claims
In cases where a claim for benefits is denied, in whole or in part, and the Participant believes the
claim has been denied wrongly, the Participant may appeal the denial and review pertinent
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documents. The claims procedures of this Plan provide a Participant with a reasonable opportunity
for a full and fair review of a claim and adverse benefit determination. More specifically, the Plan
provides:

Participants at least 180 days following receipt of a notification of an initial adverse benefit
determination within which to appeal the determination;

Participants the opportunity to submit written comments, documents, records, and other
information relating to the claim for benefits;

For a review that does not afford deference to the previous adverse benefit determination and
that is conducted by an appropriate named fiduciary of the Plan, who shall be neither the
individual who made the adverse benefit determination that is the subject of the appeal, nor
the subordinate of such individual;

For a review that takes into account all comments, documents, records, and other information
submitted by the Participant relating to the claim, without regard to whether such
information was submitted or considered in any prior benefit determination;

That, in deciding an appeal of any adverse benefit determination that is based in whole or in
part upon a medical judgment, the Plan fiduciary shall consult with a health care professional
who has appropriate training and experience in the field of medicine involved in the medical
judgment, who is neither an individual who was consulted in connection with the adverse
benefit determination that is the subject of the appeal, nor the subordinate of any such
individual;

For the identification of medical or vocational experts whose advice was obtained on behalf
of the Plan in connection with a claim, even if the Plan did not rely upon their advice;

That a Participant will be provided, upon request and free of charge, reasonable access to,
and copies of, all documents, records, and other information relevant to the Participant’s
claim for benefits in possession of the Plan Administrator or the Contract Administrator;
information regarding any voluntary appeals procedures offered by the Plan; any internal
rule, guideline, protocol or other similar criterion relied upon, considered or generated in
making the adverse determination; and an explanation of the scientific or clinical judgment
for the determination, applying the terms of the Plan to the Participant’s medical
circumstances; and

In an urgent care claim, for an expedited review process pursuant to which:

A request for an expedited appeal of an adverse benefit determination may be submitted
orally or in writing by the Participant; and
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
All necessary information, including the Plan’s benefit determination on review, shall be
transmitted between the Plan and the Participant by telephone, facsimile or other
available similarly expeditious method.
Requirements for Appeal
The Participant must file the appeal in writing (although oral appeals are permitted for pre-service
urgent care claims) within 180 days following receipt of the notice of an adverse benefit
determination. For pre-service urgent care claims, if the Participant chooses to orally appeal, the
Participant may telephone:
Integrity Benefit Network
P.O. Box 4537
Marietta, GA 30061
Phone: 770-428-1604
Fax: 770-426-0290
To file an appeal in writing, the Participant’s appeal must be addressed as follows and mailed or
faxed as follows:
Integrity Benefit Network
P.O. Box 4537
Marietta, GA 30061
Phone: 770-428-1604
Fax: 770-426-0290
It shall be the responsibility of the Participant to submit proof that the claim for benefits is covered
and payable under the provisions of the Plan. Any appeal must include:

The name of the employee/Participant;

The employee/Participant’s social security number;

The group name or identification number;

All facts and theories supporting the claim for benefits. Failure to include any theories or
facts in the appeal will result in their being deemed waived. In other words, the
Participant will lose the right to raise factual arguments and theories which support
this claim if the Participant fails to include them in the appeal;

A statement in clear and concise terms of the reason or reasons for disagreement with the
handling of the claim; and
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
Any material or information that the Participant has which indicates that the Participant is
entitled to benefits under the Plan.
If the Participant provides all of the required information, it may be that the expenses will be
eligible for payment under the Plan.
Timing of Notification of Benefit Determination on Review
The Plan Administrator shall notify the Participant of the Plan’s benefit determination on review
within the following timeframes:

Pre-service Urgent Care Claims: As soon as possible, taking into account the medical
exigencies, but not later than 24 hours after receipt of the appeal.

Pre-service Non-urgent Care Claims: Within a reasonable period of time appropriate to the
medical circumstances, but not later than 30 days after receipt of the appeal.

Concurrent Claims: The response will be made in the appropriate time period based upon
the type of claim – pre-service urgent, pre-service non-urgent or post-service.

Post-service Claims: Within a reasonable period of time, but not later than 60 days after
receipt of the appeal.

Calculating Time Periods. The period of time within which the Plan’s determination is
required to be made shall begin at the time an appeal is filed in accordance with the
procedures of this Plan, without regard to whether all information necessary to make the
determination accompanies the filing.
Manner and Content of Notification of Adverse Benefit Determination on Review
The Plan Administrator shall provide a Participant with notification, with respect to pre-service
urgent care claims, by telephone, facsimile or similar method, and with respect to all other types
of claims, in writing or electronically, of a Plan’s adverse benefit determination on review,
setting forth:

Information sufficient to allow the Participant to identify the claim involved (including date
of service, the healthcare provider, the claim amount, if applicable, the diagnosis code and its
corresponding meaning, and the treatment code and its corresponding meaning);

A reference to the specific portion(s) of the plan provisions upon which a denial is based;

Specific reason(s) for a denial, including the denial code and its corresponding meaning, and
a description of the Plan’s standard, if any, that was used in denying the claim;
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
A description of any additional information necessary for the Participant to perfect the claim
and an explanation of why such information is necessary;

A description of the Plan’s review procedures and the time limits applicable to the
procedures. This description will include information on how to initiate the appeal and a
statement of the Participant’s right to bring a civil action under section 502(a) of ERISA
following an adverse benefit determination on final review;

A statement that the Participant 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 Participant’s claim for benefits;

The identity of any medical or vocational experts consulted in connection with a claim, even
if the Plan did not rely upon their advice (or a statement that the identity of the expert will be
provided, upon request);

Any rule, guideline, protocol or similar criterion that was relied upon, considered, or
generated in making the determination will be provided free of charge. If this is not
practical, a statement will be included that such a rule, guideline, protocol or similar criterion
was relied upon in making the determination and a copy will be provided to the Participant,
free of charge, upon request;

In the case of denials based upon a medical judgment (such as whether the treatment is
medically necessary or experimental), either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Plan to the Participant’s medical
circumstances, will be provided. If this is not practical, a statement will be included that
such explanation will be provided to the Participant, free of charge, upon request; and

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 U.S. Department of Labor Office and your state insurance regulatory
agency.”
Furnishing Documents in the Event of an Adverse Determination
In the case of an adverse benefit determination on review, the Plan Administrator shall provide such
access to, and copies of, documents, records, and other information described in the section relating
to “Manner and Content of Notification of Adverse Benefit Determination on Review” as
appropriate.
Decision on Review
If, for any reason, the Participant does not receive a written response to the appeal within the
appropriate time period set forth above, the Participant may assume that the appeal has been denied.
The decision by the Plan Administrator or other appropriate named fiduciary of the Plan on review
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will be final, binding and conclusive and will be afforded the maximum deference permitted by law.
All claim review procedures provided for in the Plan must be exhausted before any legal action
is brought.
External Review Process
A. Standard external review
Standard external review is external review that is not considered expedited (as described in
paragraph B of this section).
1. Request for external review. The Plan will allow a claimant to file a request for an external
review with the Plan if 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. If
there is no corresponding date four months after the date of receipt of such a notice, then the
request must be filed by the first day of the fifth month following the receipt of the notice.
For example, if the date of receipt of the notice is October 30, because there is no February
30, the request must be filed by March 1. If the last filing date would fall on a Saturday,
Sunday, or Federal holiday, the last filing date is extended to the next day that is not a
Saturday, Sunday, or Federal holiday.
2. Preliminary review. Within five (5) business days following the date of receipt of the
external review request, the Plan will complete a preliminary review of the request to
determine whether:
(a) 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;
(b) 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);
(c) 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
(d) The claimant has provided all the information and forms required to process an
external review.
Within one (1) business day after completion of the preliminary review, the Plan will
issue a notification in writing to the claimant. If the request is complete but not eligible
for external review, such notification will 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 will describe the
information or materials needed to make the request complete and the Plan will allow a
claimant to perfect the request for external review with the four-month filing period or
within the 48 hour period following the receipt of the notification, whichever is later.
3. Referral to Independent Review Organization. The Plan will assign an independent review
organization (IRO) that is accredited by URAC or by a similar nationally-recognized
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accrediting organization to conduct the external review. Moreover, the Plan will take action
against bias and to ensure independence. Accordingly, the Plan will contract with (or direct
the Claims Processor to contract with, on its behalf) at least three (3) IROs for assignments
under the Plan and rotate claims assignments among them (or incorporate other independent
unbiased method 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.
4. Reversal of Plan’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 immediately will provide coverage or payment (including immediately authorizing
or immediately paying benefits) for the claim.
B. Expedited external review
1. Request for expedited external review. The Plan will allow a claimant to make a request for
an expedited external review with the Plan at the time the claimant receives:
(a) An adverse benefit determination if the adverse benefit determination involves a
medical condition of the claimant for which the timeframe for completion of a
standard 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 claimant has filed a request for an expedited
internal appeal; or
(b) A final internal 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.
2. Preliminary review. Immediately upon receipt of the request for expedited external review,
the Plan will determine whether the request meets the reviewability requirements set forth in
paragraph A.2 above for standard external review. The Plan will immediately send a notice
that meets the requirements set forth in paragraph A.2 above for standard external review to
the claimant of its eligibility determination.
3. Referral to independent review organization. Upon a determination that a request is eligible
for external review following the preliminary review, the Plan will assign an IRO pursuant to
the requirements set forth in paragraph A.3 above for standard review. The Plan will 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.
The assigned IRO, to the extent the information or documents are available and the IRO
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considers them appropriate, will consider the information or documents described above
under the procedures for standard review. In reaching a decision, the assigned IRO will
review the claim de novo and is not bound by any decisions or conclusions reached
during the Plan’s internal claims and appeals process.
4. Notice of final external review decision. The Plan’s (or Claim Processor’s) contract with the
assigned IRO will require the IRO to provide notice of the final external review decision, in
accordance with the requirements set forth in paragraph A.3 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 will provide
written confirmation of the decision to the claimant and the Plan.
Appointment of Authorized Representative
A Participant is permitted to appoint an authorized representative to act on his or her behalf with
respect to a benefit claim or appeal of a denial. An assignment of benefits by a Participant to a
Provider will not constitute appointment of that Provider as an authorized representative. To appoint
such a representative, the Participant must complete a form which can be obtained from the Plan
Administrator or the Third Party Administrator. However, in connection with a claim involving
Urgent Care, the Plan will permit a health care professional with knowledge of the Participant’s
medical condition to act as the Participant’s authorized representative without completion of this
form. In the event a Participant designates an authorized representative, all future communications
from the Plan will be with the representative, rather than the Participant, unless the Participant
directs the Plan Administrator, in writing, to the contrary.
Physical Examinations
The Plan reserves the right to have a Physician of its own choosing examine any Participant whose
condition, Sickness or Injury is the basis of a claim. All such examinations shall be at the expense of
the Plan. This right may be exercised when and as often as the Plan may reasonably require during
the pendency of a claim. The Participant must comply with this requirement as a necessary
condition to coverage.
Autopsy
The Plan reserves the right to have an autopsy performed upon any deceased Participant whose
condition, Sickness, or Injury is the basis of a claim. This right may be exercised only where not
prohibited by law.
Payment of Benefits
All benefits under this Plan are payable, in U.S. Dollars, to the covered Employee whose
Sickness or Injury, or whose covered Dependent’s Sickness or Injury, is the basis of a claim. In
the event of the death or incapacity of a covered Employee and in the absence of written
evidence to this Plan of the qualification of a guardian for his or her estate, this Plan may, in its
sole discretion, make any and all such payments to the individual or institution which, in the
opinion of this Plan, is or was providing the care and support of such Employee.
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Assignments
Benefits for medical expenses covered under this Plan may be assigned by a Participant to the
Provider as consideration in full for services rendered; however, if those benefits are paid
directly to the Employee, the Plan shall be deemed to have fulfilled its obligations with respect to
such benefits. The Plan will not be responsible for determining whether any such assignment is
valid. Payment of benefits which have been assigned will be made directly to the assignee unless
a written request not to honor the assignment, signed by the covered Employee and the assignee,
has been received before the proof of loss is submitted.
No Participant shall at any time, either during the time in which he or she is a Participant in
the Plan, or following his or her termination as a Participant, in any manner, have any right to
assign his or her right to sue to recover benefits under the Plan, to enforce rights due under the
Plan or to any other causes of action which he or she may have against the Plan or its
fiduciaries.
A Provider which accepts an assignment of benefits, in accordance with this Plan as consideration in
full for services rendered, is bound by the rules and provisions set forth within the terms of this
document.
Non U.S. Providers
Medical expenses for care, supplies, or services which are rendered by a Provider whose
principal place of business or address for payment is located outside the United States (a “Non
U.S. Provider”) are payable under the Plan, subject to all Plan exclusions, limitations, maximums
and other provisions, under the following conditions:
1. Benefits may not be assigned to a Non U.S. Provider;
2. The Participant is responsible for making all payments to Non U.S. Providers, and
submitting receipts to the Plan for reimbursement;
3. Benefit payments will be determined by the Plan based upon the exchange rate in effect
on the Incurred Date;
4. The Non U.S. Provider shall be subject to, and in compliance with, all U.S. and other
applicable licensing requirements; and
5. Claims for benefits must be submitted to the Plan in English.
Recovery of Payments
Occasionally, benefits are paid more than once, are paid based upon improper billing or a
misstatement in a proof of loss or enrollment information, are not paid according to the Plan’s
terms, conditions, limitations or exclusions, or should otherwise not have been paid by the Plan.
As such this Plan may pay benefits that are later found to be greater than the Maximum
Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the
source to which it was paid, primary payers, or from the party on whose behalf the charge(s)
were paid. As such, whenever the Plan pays benefits exceeding the amount of benefits payable
under the terms of the Plan, the Plan Administrator has the right to recover any such erroneous
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FILING A CLAIM FOR BENEFITS
payment directly from the person or entity who received such payment and/or from other payers
and/or the Plan Participant or dependent on whose behalf such payment was made.
A Plan Participant, Dependent, Provider, another benefit plan, insurer, or any other person or
entity who receives a payment exceeding the amount of benefits payable under the terms of the
Plan or on whose behalf such payment was made, shall return or refund the amount of such
erroneous payment to the Plan within 30 days of discovery or demand. The Plan Administrator
shall have no obligation to secure payment for the expense for which the erroneous payment was
made or to which it was applied.
The person or entity receiving an erroneous payment may not apply such payment to another
expense. The Plan Administrator shall have the sole discretion to choose who will repay the Plan
for an erroneous payment and whether such payment shall be reimbursed in a lump sum. When
a Plan Participant or other entity does not comply with the provisions of this section, the Plan
Administrator shall have the authority, in its sole discretion, to deny payment of any claims for
benefits by the Plan Participant and to deny or reduce future benefits payable (including payment
of future benefits for other injuries or illnesses) under the Plan by the amount due as
reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or
reduce future benefits (including future benefits for other injuries or illnesses) under any other
group benefits plan maintained by the Plan Sponsor. The reductions will equal the amount of the
required reimbursement.
Providers and any other person or entity accepting payment from the Plan or to whom a right to
benefits has been assigned, in consideration of services rendered, payments and/or rights, agrees
to be bound by the terms of this Plan and agree to submit claims for reimbursement in strict
accordance with their State’s health care practice acts, ICD-9 or CPT standards, Medicare
guidelines, HCPCS standards, or other standards approved by the Plan Administrator or insurer.
Any payments made on claims for reimbursement not in accordance with the above provisions
shall be repaid to the Plan within 30 days of discovery or demand or incur prejudgment interest
of 1.5% per month. If the Plan must bring an action against a Plan Participant, Provider or other
person or entity to enforce the provisions of this section, then that Plan Participant, Provider or
other person or entity agrees to pay the Plan’s attorneys’ fees and costs, regardless of the action’s
outcome.
Further, Plan Participants and/or their dependents, beneficiaries, estate, heirs, guardian, personal
representative, or assigns (Plan Participants) shall assign or be deemed to have assigned to the
Plan their right to recover said payments made by the Plan, from any other party and/or recovery
for which the Plan Participant(s) are entitled, for or in relation to facility-acquired condition(s),
Provider error(s), or damages arising from another party’s act or omission for which the Plan has
not already been refunded.
The Plan reserves the right to deduct from any benefits properly payable under this Plan the
amount of any payment which has been made:
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FILING A CLAIM FOR BENEFITS
1. In error;
2. Pursuant to a misstatement contained in a proof of loss or a fraudulent act;
3. Pursuant to a misstatement made to obtain coverage under this Plan within two years
after the date such coverage commences;
4. With respect to an ineligible person;
5. In anticipation of obtaining a recovery if a Plan Participant fails to comply with the
Plan’s Third Party Recovery, Subrogation and Reimbursement provisions; or
6. Pursuant to a claim for which benefits are recoverable under any policy or act of law
providing for coverage for occupational Injury or disease to the extent that such benefits
are recovered. This provision (6) shall not be deemed to require the Plan to pay benefits
under this Plan in any such instance.
The deduction may be made against any claim for benefits under this Plan by a Plan Participant
or by any of his Covered Dependents if such payment is made with respect to the Plan
Participant or any person covered or asserting coverage as a Dependent of the Plan Participant.
If the Plan seeks to recoup funds from a Provider, due to a claim being made in error, a claim
being fraudulent on the part of the Provider, and/or the claim that is the result of the Provider’s
misstatement, said Provider shall, as part of its assignment to benefits from the Plan, abstain
from billing the plan participant for any outstanding amount(s).
Medicaid Coverage
A Participant’s eligibility for any State Medicaid benefits will not be taken into account in
determining or making any payments for benefits to or on behalf of such Participant. Any such
benefit payments will be subject to the State’s right to reimbursement for benefits it has paid on
behalf of the Participant, as required by the State Medicaid program; and the Plan will honor any
Subrogation rights the State may have with respect to benefits which are payable under the Plan.
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MISC. PLAN PROVISIONS
ERISA Requirements - Notwithstanding anything in the Plan to the contrary, the Plan will comply
with the following requirements of ERISA Section 609:
a.
b.
c.
Medical Child Support Orders. The Plan will comply with the requirements of any
“qualified medical child support order” as defined in ERISA Section 609(a)(2)(a).
The Plan Administrator will develop procedures to determine whether a medical
child support order is qualified and for complying therewith. A covered person may
obtain, without charge, a copy of the procedures upon request to the Plan
Administrator.
Rights of States Where Covered Persons are Eligible for Medical Benefits. The Plan
Administrator will comply with the requirements set forth in ERISA Section 609(b)
regarding:
1.
assignments of rights;
2.
enrollment and provision of benefits without regard to Medicaid eligibility;
and
3.
acquisition by states of rights of third parties.
Coverage of Dependent Children in Cases of Adoption. The Plan Administrator will
comply with the requirements set forth in ERISA Section 609(c) regarding:
1.
the effective date of insurance for adopted dependent children; and
2.
the prohibition of restrictions based on pre-existing conditions at the time of
placement for adoption.
Compliance with Federal Laws - The terms of the Plan shall be construed and administered in a
manner calculated to meet the requirements of the following laws as the laws are applicable to this
Plan:
a.
b.
c.
d.
e.
f.
g.
h.
Americans with Disabilities Act of 1990;
Family and Medical Leave Act of 1993;
Uniformed Services Employment and Reemployment Rights Act of 1994, as
amended;
Health Insurance Portability and Accountability Act of 1996, as amended;
Personal Responsibility and Work Opportunity Reconciliation Act of 1996;
The Newborns’ and Mothers’ Health Protection Act of 1996;
The Mental Health Parity Act of 1996;
Consolidated Omnibus Budget Reconciliation Act of 1985;
i.
j.
Employee Retirement Income Security Act of 1974; and
The Women’s Health and Cancer Rights Act of 1998.
To the extent a Plan provision is contrary to or fails to address the minimum requirements of
these laws, the Plan shall provide the coverage or benefit necessary to comply with the minimum
requirements thereof
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MISC. PLAN PROVISIONS
Non-Discrimination - Notwithstanding anything in the Plan to the contrary, the Plan may not
discriminate against any individual or a dependent of that individual with respect to the health
coverage on the basis of a health factor.
Notification of Material Reduction of Benefits - This Plan shall furnish a summary of a material
reduction in covered services or benefits to covered participants within 60 days after the change has
been adopted by the Plan.
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ERISA
As a participant in the C.W. Matthews Contracting Co., Inc. Employee Health Benefit Plan you
are entitled to certain rights and protection under the Employee Retirement Income Security Act of
1974, as amended (ERISA). ERISA provides that all Plan participants shall be entitled to the
following:
RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS.
-
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 collective bargaining agreements, and a copy of the latest annual report
(Form 5500 Series) filed by the Plan with the U.S. Department of Labor and
available at the Public Disclosure Room of the Pension and Welfare Benefits
Administration.
-
Obtain, upon written request to the Plan Administrator, copies of documents
governing the operation of the Plan, including collective bargaining agreements, and
a copy of the latest annual report (Form 5500 Series) and updated summary plan
description. The Plan Administrator may make a reasonable charge for the copies.
-
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.
CONTINUE GROUP HEALTH PLAN COVERAGE.
-
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 pay for such coverage. Review this summary plan description and the
documents governing the Plan on the rules governing your COBRA continuation
coverage rights.
-
Reduction or elimination of exclusionary periods of coverage for pre-existing
conditions under the Plan, if you have creditable coverage from another health
plan. You should be provided a certificate of creditable coverage, free of charge,
from the Plan or health insurance issuer when you lose coverage under the Plan,
when you become entitled to COBRA continuation coverage, when your COBRA
continuation coverage ceases, if you request it before losing coverage, or if you
request it up to 24 months after losing coverage. Without evidence of creditable
coverage, you may be subject to a pre-existing condition exclusion for 12 months
(18 months for late enrollees) after your enrollment date in your coverage.
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ERISA
PRUDENT ACTIONS BY PLAN FIDUCIARIES. In addition to creating rights for Plan
participants, ERISA imposes duties upon the people who are responsible for the operation of the
Plan. The people who operate the Plan, called "fiduciaries" of the Plan, have a duty to do so
prudently and in the interest of you and other Plan participants and beneficiaries. No one, including
your employer, your union, or any other person, may fire you or otherwise discriminate against you
in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
ENFORCE YOUR RIGHTS. If your claim for a welfare 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 a
copy of Plan documents or the latest annual report from the Plan and do not receive them within 30
days, you may file suit in a Federal court. In such a case, the court may require the Plan
Administrator to provide the materials and pay you up to $110 a day until you receive the materials,
unless the materials were not sent because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a
state or Federal court subsequent to exhausting the Plan’s claims procedures. In addition, if you
disagree with the Plan's decision or lack thereof concerning the qualified status of a medical child
support order, you may file suit in Federal court subsequent to exhausting the Plan’s claim
procedures. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are
discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and
legal fees. If you are successful the court may order the person you have sued to pay these costs and
fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your
claim is frivolous.
ASSISTANCE WITH YOUR QUESTIONS. If you have any questions about the Plan, you
should contact the Plan Administrator. If you have any questions about this statement or about your
rights under ERISA or if you need assistance in obtaining documents from the Plan Administrator,
you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Miscellaneous 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 publications
about your rights and responsibilities under ERISA by calling the publications hotline of Employee
Benefits Security Administration.
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HIPPA PRIVACY
Commitment to Protecting Health Information
The Plan will comply with the Standards for Privacy of Individually Identifiable Health
Information (i.e., the “Privacy Rule”) set forth by the U.S. Department of Health and Human
Services (“HHS”) pursuant to the Health Insurance Portability and Accountability Act
(“HIPAA”). Such standards control the dissemination of “protected health information” (“PHI”)
of Plan Participants. Privacy standards will be implemented and enforced in the offices of the
Employer and Plan Sponsor and any other entity that may assist in the operation of the Plan.
The Plan is required by law to take reasonable steps to ensure the privacy of the Plan
Participant’s PHI, and inform him/her about:
1. The Plan’s disclosures and uses of PHI;
2. The Plan Participant’s privacy rights with respect to his/her PHI;
3. The Plan’s duties with respect to his/her PHI;
4. The Plan Participant’s right to file a complaint with the Plan and with the Secretary of
HHS; and
5. The person or office to contact for further information about the Plan’s privacy practices.
Within this provision capitalized terms may be used, but not otherwise defined. These terms
shall have the same meaning as those terms set forth in 45 CFR Sections 160.103 and 164.501.
Any HIPAA regulation modifications altering a defined HIPAA term or regulatory citation shall
be deemed incorporated into this provision.
How Health Information May be Used and Disclosed
In general, the Privacy Rules permit the Plan to use and disclose an individual’s PHI, without
obtaining authorization, only if the use or disclosure is:
1. To carry out Payment of benefits;
2. For Health Care Operations;
3. For Treatment purposes; or
4. If the use or disclosure falls within one of the limited circumstances described in the
rules (e.g., the disclosure is required by law or for public health activities).
Disclosure of PHI to the Plan Sponsor for Plan Administration Purposes
In order that the Plan Sponsor may receive and use PHI for plan administration purposes, the
Plan Sponsor agrees to:
1. Not use or further disclose PHI other than as permitted or required by the Plan documents or
as required by law (as defined in the privacy standards);
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2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI
received from the Plan, agree to the same restrictions and conditions that apply to the Plan
Sponsor with respect to such PHI;
3. Establish safeguards for information, including security systems for data processing and
storage;
4. Maintain the confidentiality of all PHI, unless an individual gives specific consent or
authorization to disclose such data or unless the data is used for health care payment or Plan
operations;
5. Receive PHI, in the absence of an individual’s express authorization, only to carry out Plan
administration functions;
6. Not use or disclose PHI for employment-related actions and decisions or in connection with
any other benefit or employee benefit plan of the Plan Sponsor, except pursuant to an
authorization which meets the requirements of the privacy standards;
7. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures
provided for of which the Plan Sponsor becomes aware;
8. Make available PHI in accordance with section 164.524 of the privacy standards (45 CFR
164.524);
9. Make available PHI for amendment and incorporate any amendments to PHI in accordance
with section 164.526 of the privacy standards (45 CFR 164.526);
10. Make available the information required to provide an accounting of disclosures in
accordance with section 164.528 of the privacy standards (45 CFR 164.528);
11. Make its internal practices, books and records relating to the use and disclosure of PHI
received from the Plan available to the Secretary of the U.S. Department of Health and
Human Services (“HHS”), or any other officer or employee of HHS to whom the authority
involved has been delegated, for purposes of determining compliance by the Plan with part
164, subpart E, of the privacy standards (45 CFR 164.500 et seq);
12. Report to the Plan any inconsistent uses or disclosures of PHI of which the Plan Sponsor
becomes aware;
13. Train employees in privacy protection requirements and appoint a privacy compliance
coordinator responsible for such protections;
14. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still
maintains in any form and retain no copies of such PHI when no longer needed for the
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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
15. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in
section 164.504(f)(2)(iii) of the privacy standards (45 CFR 164.504(f)(2)(iii)), is
established as follows:
(a) The following employees, or classes of employees, or other persons under
control of the Plan Sponsor, shall be given access to the PHI to be disclosed:
(i) Privacy Officer: The access to and use of PHI by the individuals
described above shall be restricted to the plan administration functions that
the Plan Sponsor performs for the Plan.
(b) In the event any of the individuals described in above do not comply with the
provisions of the Plan documents relating to use and disclosure of PHI, the Plan
Administrator shall impose reasonable sanctions as necessary, in its discretion, to
ensure that no further non-compliance occurs. The Plan Administrator will
promptly report such violation or non-compliance to the Plan, and will cooperate
with the Plan to correct violation or non-compliance to impose appropriate
disciplinary action or sanctions. Such sanctions shall be imposed progressively
(for example, an oral warning, a written warning, time off without pay and
termination), if appropriate, and shall be imposed so that they are commensurate
with the severity of the violation.
Disclosure of Summary Health Information to the Plan Sponsor
The Plan may disclose PHI to the Plan Sponsor of the group health plan for purposes of plan
administration or pursuant to an authorization request signed by the Plan Participant. The Plan
may use or disclose “summary health information” to the Plan Sponsor for obtaining premium
bids or modifying, amending, or terminating the group health plan.
Disclosure of Certain Enrollment Information to the Plan Sponsor
Pursuant to section 164.504(f)(1)(iii) of the privacy standards (45 CFR 164.504(f)(1)(iii)), the
Plan may disclose to the Plan Sponsor information on whether an individual is participating in
the Plan or is enrolled in or has un-enrolled from a health insurance issuer or health maintenance
organization offered by the Plan to the Plan Sponsor.
Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage
The Plan Sponsor may hereby authorize and direct the Plan, through the Plan Administrator or
the third party administrator, to disclose PHI to stop-loss carriers, excess loss carriers or
managing general underwriters (“MGUs”) for underwriting and other purposes in order to obtain
and maintain stop-loss or excess loss coverage related to benefit claims under the Plan. Such
disclosures shall be made in accordance with the privacy standards.
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Other Disclosures and Uses of PHI:
Primary Uses and Disclosures of PHI
1. Treatment, Payment and Health Care Operations: The Plan has the right to use and disclose
a Plan Participant’s PHI for all activities as included within the definitions of Treatment,
Payment, and Health Care Operations and pursuant to the HIPAA Privacy Rule.
2. Business Associates: The Plan contracts with individuals and entities (Business Associates)
to perform various functions on its behalf. In performance of these functions or to provide
services, Business Associates will receive, create, maintain, use, or disclose PHI, but only
after the Plan and the Business Associate agree in writing to contract terms requiring the
Business Associate to appropriately safeguard the Plan Participant’s information.
3. Other Covered Entities: The Plan may disclose PHI to assist health care Providers in
connection with their treatment or payment activities or to assist other covered entities in
connection with payment activities and certain health care operations. For example, the Plan
may disclose PHI to a health care Provider when needed by the Provider to render treatment
to a Plan Participant, and the Plan may disclose PHI to another covered entity to conduct
health care operations. The Plan may also disclose or share PHI with other insurance carriers
(such as Medicare, etc.) in order to coordinate benefits, if a Plan Participant has coverage
through another carrier.
Other Possible Uses and Disclosures of PHI
1. Required by Law: The Plan may use or disclose PHI when required by law, provided the
use or disclosure complies with and is limited to the relevant requirements of such law.
2. Public Health and Safety: The Plan may use or disclose PHI when permitted for purposes
of public health activities, including disclosures to:
(a) a public health authority or other appropriate government authority
authorized by law to receive reports of child abuse or neglect;
(b) report reactions to medications or problems with products or devices
regulated by the Federal Food and Drug Administration or other activities
related to quality, safety, or effectiveness of FDA-regulated products or
activities;
(c) locate and notify persons of recalls of products they may be using; and (d)
a person who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading a disease or condition, if
authorized by law.
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3. The Plan may disclose PHI to a government authority, except for reports of child abuse or
neglect permitted by (5) above, when required or authorized by law, or with the Plan
Participant’s agreement, if the Plan reasonably believes he/she to be a victim of abuse,
neglect, or domestic violence. In such case, the Plan will promptly inform the Plan
Participant that such a disclosure has been or will be made unless the Plan believes that
informing him/her would place him/her at risk of serious harm (but only to someone in a
position to help prevent the threat). Disclosure generally may be made to a minor’s parents
or other representatives although there may be circumstances under Federal or State law
when the parents or other representatives may not be given access to the minor’s PHI.
4. Health Oversight Activities: The Plan may disclose PHI to a health oversight agency for
oversight activities authorized by law. This includes civil, administrative or criminal
investigations; inspections; claim audits; licensure or disciplinary actions; and other activities
necessary for appropriate oversight of a health care system, government health care program,
and compliance with certain laws.
5. Lawsuits and Disputes: The Plan may disclose PHI when required for judicial or
administrative proceedings. For example, the Plan Participant’s PHI may be disclosed in
response to a subpoena, discovery requests, or other required legal processes when the Plan
is given satisfactory assurances that the requesting party has made a good faith attempt to
advise the Plan Participant of the request or to obtain an order protecting such information,
and done in accordance with specified procedural safeguards.
6. Law Enforcement: The Plan may disclose PHI to a law enforcement official when required
for law enforcement purposes concerning identifying or locating a suspect, fugitive, material
witness or missing person. Under certain circumstances, the Plan may disclose the Plan
Participant’s PHI in response to a law enforcement official’s request if he/she is, or are
suspected to be, a victim of a crime and if it believes in good faith that the PHI constitutes
evidence of criminal conduct that occurred on the Sponsor’s or Plan’s premises.
7. Decedents: The Plan may disclose PHI to a coroner, funeral director or medical examiner
for the purpose of identifying a deceased person, determining a cause of death or as
necessary to carry out their duties as authorized by law.
8. Research: The Plan may use or disclose PHI for research, subject to certain
conditions.
limited
9. To Avert a Serious Threat to Health or Safety: The Plan may disclose PHI in accordance
with applicable law and standards of ethical conduct, if the Plan, in good faith, believes the
use or disclosure is necessary to prevent or lessen a threat to health or safety of a person or to
the public.
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10. Workers’ Compensation: The Plan may disclose PHI when authorized by and to the extent
necessary to comply with workers’ compensation or other similar programs established by
law.
11. Military and National Security: The Plan may disclose PHI to military authorities of armed
forces personnel under certain circumstances. As authorized by law, the Plan may disclose
PHI required for intelligence, counter-intelligence, and other national security activities to
authorized Federal officials.
Required Disclosures of PHI
1. Disclosures to Plan Participants: The Plan is required to disclose to a Plan Participant
most of the PHI in a Designated Record Set when the Plan Participant requests access to
this information. The Plan will disclose a Plan Participant’s PHI to an individual who
has been assigned as his/her representative and who has qualified for such designation in
accordance with the relevant State law. Before disclosure to an individual qualified as a
personal representative, the Plan must be given written supporting documentation
establishing the basis of the personal representation.
The Plan may elect not to treat the person as the Plan Participant’s personal
representative if it has a reasonable belief that the Plan Participant has been, or may be,
subjected to domestic violence, abuse, or neglect by such person, it is not in the Plan
Participant’s best interest to treat the person as his/her personal representative, or treating
such person as his/her personal representative could endanger the Plan Participant.
2. Disclosures to the Secretary of the U.S. Dept of Health and Human Services: The Plan is
required to disclose the Plan Participant’s PHI to the Secretary of the U.S. Department of
Health and Human Resources when the Secretary is investigating or determining the
Plan’s compliance with the HIPAA Privacy Rule.
Rights to Individuals
The Plan Participant has the following rights regarding PHI about him/her:
1. Request Restrictions: The Plan Participant has the right to request additional restrictions on
the use or disclosure of PHI for treatment, payment, or health care operations. The Plan
Participant may request the Plan restrict disclosures to family members, relatives, friends or
other persons identified by him/her who are involved in his/her care or payment for his/her
care. The Plan is not required to agree to these requested restrictions.
2. Right to Receive Confidential Communication: The Plan Participant has the right to request
that he/she receive communications regarding PHI in a certain manner or at a certain
location. The request must be made in writing and how the Plan Participant would like to be
contacted. The Plan will accommodate all reasonable requests.
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3. Copy of this Notice: The Plan Participant is entitled to receive a paper copy of this notice at
any time. To obtain a paper copy, contact the Privacy Compliance Coordinator.
4. Accounting of Disclosures: The Plan Participant has the right to request an accounting of
disclosures the Plan has made of his/her PHI. The request must be made in writing and does
not apply to disclosures for treatment, payment, health care operations, and certain other
purposes. The Plan Participant is entitled to such an accounting for the six (6) years prior to
his/her request, though not earlier than April 14, 2003. Except as provided below, for each
disclosure, the accounting will include: (a) the date of the disclosure, (b) the name of the
entity or person who received the PHI and, if known, the address of such entity or person; (c)
a description of the PHI disclosed, (d) a statement of the purpose of the disclosure that
reasonably informs the Plan Participant of the basis of the disclosure, and certain other
information. If the Plan Participant wishes to make a request, please contact the Privacy
Compliance Coordinator.
5. Access: The Plan Participant has the right to request the opportunity to look at or get copies
of PHI maintained by the Plan about him/her in certain records maintained by the Plan. If
the Plan Participant requests copies, he/she may be charged a fee to cover the costs of
copying, mailing, and other supplies. To inspect or copy PHI contact the Privacy
Compliance Coordinator. In very limited circumstances, the Plan may deny the Plan
Participant’s request. If the Plan denies the request, the Plan Participant may be entitled to a
review of that denial.
6. Amendment: The Plan Participant has the right to request that the Plan change or amend
his/her PHI. The Plan reserves the right to require this request be in writing. Submit the
request to the Privacy Compliance Coordinator. The Plan may deny the Plan Participant’s
request in certain cases, including if it is not writing or if he/she does not provide a reason
for the request.
Questions or Complaints
If the Plan Participant wants more information about the Plan’s privacy practices, has questions
or concerns, or believes that the Plan may have violated his/her privacy rights, please contact the
Plan using the following information. The Plan Participant may submit a written complaint to
the U.S. Department of Health and Human Services or with the Plan. The Plan will provide the
Plan Participant with the address to file his/her complaint with the U.S. Department of Health
and Human Services upon request.
The Plan will not retaliate against the Plan Participant for filing a complaint with the Plan or the
U.S. Department of Health and Human Services.
Contact Information:
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Privacy Compliance Coordinator Contact Information:
Ray A. Rodriguez
Division Vice President
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, GA 30061
Phone: 770-422-7520
Fax: 770-423-7529
[email protected]
Additional Contact Information for HIPAA Questions:
Novetta Smith
Medical Benefits Coordinator
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, GA 30061
Phone: 770-422-7520
Fax: 770-423-7529
[email protected]
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Disclosure of Electronic Protected Health Information (“Electronic PHI”) to the Plan Sponsor for
Plan Administration Functions
STANDARDS FOR SECURITY OF INDIVIDUALLY IDENTIFIABLE HEALTH
INFORMATION (“SECURITY RULE”)
The Security Rule imposes regulations for maintaining the integrity, confidentiality and
availability of protected health information that it creates, receives, maintains, or maintains
electronically that is kept in electronic format (ePHI) as required under the Health Insurance
Portability and Accountability Act (HIPAA).
Definitions;
“Electronic Protected Health Information” (ePHI) is defined in Section 160.103 of the Security
Standards (45 C.F.R. 160.103) and means individually identifiable health information
transmitted or maintained in any electronic media.
“Security Incidents” is defined within Section 164.304 of the Security Standards (45 C.F.R.
164.304) and means the attempted or successful unauthorized access, use, disclosure,
modification, or destruction of information or interference with systems operation in an
information system.
Plan Sponsor Obligations
To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions
(as defined in 45 CFR §164.504(a)), the Plan Sponsor agrees to:
1. Implement administrative, physical, and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity and availability of the Electronic PHI
that it creates, receives, maintains, or transmits on behalf of the Plan.
2. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in 45
CFR § 164.504(f)(2)(iii), is supported by reasonable and appropriate Security Measures.
3. Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides
Electronic PHI created, received, maintained, or transmitted on behalf of the Plan, agrees
to implement reasonable and appropriate report to the Plan any security incident of which
it becomes aware.
4. Report to the Plan any security incident of which it becomes aware.
Notification Requirements in the Event of a Breach of Unsecured PHI
The required breach notifications are triggered upon the discovery of a breach of unsecured PHI.
C.W. Matthews Contracting Co., Inc.
Plan Document
103
HIPPA PRIVACY
A breach is discovered as of the first day the breach is known, or reasonably should have been
known.
When a breach of unsecured PHI is discovered, the Plan will:
1. Notify the individual whose PHI has been, or is reasonably believed to have been,
assessed, acquired, used, or disclosed as a result of the breach, in writing, without
unreasonable delay and in no case later than 60 calendar days after discovery of the
breach.
2. Notify the media if the breach affecting more than 500 residents of a State or jurisdiction.
Notice must be provided to prominent media outlets serving the State or jurisdiction
without unreasonable delay and in no case later than 60 calendar days after the date the
breach was discovered.
3. Notify the HHS Secretary if the breach involves 500 or more individuals,
contemporaneously with the notice to the affected individual and in the manner specified
by HHS. If the breach involves less than 500 individuals, an internal log or other
documentation of such breaches must be maintained and annually submitted to HHS
within 60 days after the end of each calendar year.
4. When a Business Associate, which provides services for the Plan and comes in contact
with PHI in connection with those services discovers a breach has occurred, that Business
Associate will notify the Plan without unreasonable delay and in no case later than 60
calendar days after discovery of a breach so that the affected individuals may be notified.
To the extent possible, the Business Associate should identify each individual whose
unsecured PHI has been, or is reasonably believed to have been, breached.
Any terms not otherwise defined in this section shall have the meanings set forth in the Security
Standards.
C.W. Matthews Contracting Co., Inc.
104
Plan Document
CAFETERIA PLAN
PREMIUM REDUCTION OPTION
SUMMARY PLAN DESCRIPTION
AS ADOPTED BY
C. W. MATTHEWS CONTRACTING CO., INC.
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
TABLE OF CONTENTS
PART 1.
PART 2.
Q-1.
Q-2.
Q-3.
Q-4.
Q-5.
Q-6.
Q-7.
Q-8.
Q-9.
Q-10.
Q-11.
Q-12.
Q-13.
1
INTRODUCTION
GENERAL INFORMATION ABOUT THE PLAN
What is the purpose of the Plan?
What benefits are offered through the Plan?
What tax advantages can I gain by participating in the Plan?
Who can participate in the Plan?
How do I become a Participant?
What are the enrollment periods?
How long am I committing to if I elect to be a Participant?
What happens if I fail to return by Benefit Election Form
Can I change my election during the Plan Year?
What happens if I go on leave of absence?
What happens if I go on a Qualified Leave under Family & Medical Leave Act?
What Benefit Package Options are offered under the Plan?
What are the claims procedures under the Plan?
1
1
1
2
2
2
2
2
2
2
2
2
2
1
PART 3.
CASH BENEFITS
2
PART 4.
ERISA RIGHTS
2
PART 5.
PLAN INFORMATION SUMMARY
2
2
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
Section 125 Cafeteria Plan
Part 1. Introduction
Your employer (“Employer”) is pleased to sponsor an employee benefit program known as a Cafeteria Plan (“Plan”) for you and your
fellow employees. It is called a cafeteria plan because you can choose from a selection of different insurance and fringe benefit
programs according to your needs. Your Employer gives you this opportunity to use a salary conversion arrangement through which
you can use pre-tax dollars to pay for your benefits instead of paying for the benefits through after-tax payroll deductions. By paying
for the benefits with pre-tax dollars, you save money by not having to pay social security and income taxes on your salary reduction.
However, you still have the option of paying for your benefits with after-tax dollars.
This Summary Plan Description (“SPD”) describes the basic features of the Plan; how it operates and how you can get the maximum
advantage from it. This SPD only summarizes the Plan’s key parts and briefly describes your rights as a Participant, and is not
designed to be a part of the official plan documents. If a conflict exists between the plan documents and this SPD, the plan documents
will apply.
Part 2. General Information about the Plan
Q-1.
What is the purpose of the Plan?
This Plan is designed to allow eligible employees to choose one or more of the benefits offered through the Plan and, using
funds provided through employee salary reduction, to pay for the selected benefits with pre-tax dollars. It is established for
the exclusive benefit of Participants.
Q-2.
What benefits are offered through the Plan?
The Plan can offer insurance premium benefits for health, group term life, and disability policies. See Part 5 for the specific
benefits offered by your employer.
You will receive information materials before each enrollment period explaining the various benefit options.
Q-3.
What tax advantages can I gain by participating in the Plan?
By participating in the Plan, you will not have to pay income tax or Social Security on your elections. Following is an
illustration of how one employee saved on taxes by participating in his employer’s plan. Let’s assume our hypothetical
employee makes $2,500 each month and has 28% withheld for Federal withholding and 7.65% for FICA. His take-home pay
before participating in the Plan was $1,609 a month. Out of that, he paid $348 a month for his family’s medical premium.
The employee decided to participate in the Cafeteria Plan. By participating in the Plan and pay calculations on a pre-tax
basis, the employee saved $123 a month. Here is a table that better illustrates the example.
NOT PARTICIPATING IN
PARTICIPATING IN
BREAKDOWN OF PAY CHECK
AND DEDUCTIONS
CAFETERIA PLAN
CAFETERIA PLAN
$2,500.00
$2,500.00
Gross Monthly Pay
Less Premium for Major Medical
(348.00)
$2,500.00
$2,152.00
Taxable Income
Less 28% Federal Withholding
(700.00)
(603.00)
Less 7.65% Social Security Tax
(191.00)
(165.00)
Less Premium for Major Medical
(348.00)
$1,261.00
$1,384.00
Spendable Income
The employee saved $123 a month or $1,476 a year by participating in Plan!
This extra spendable income resulted from the employee being able to pay for the premium before the applicable taxes were withheld.
This is just one example of the possible tax savings under the Plan.
3
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
Q-4.
PREMIUM REDUCTION OPTION
Who can participate in the Plan?
Any employee (as defined by the Plan) of the Employer who satisfies the Eligibility Requirements established by the
Employer in the Plan’s Adoption Agreement as summarized in Part 5 below, is eligible to participate in this Plan. An eligible
employee can become a Participant by electing at least one Benefit Package Option offered under the Plan (see Part 2, Q-2
above).
Q-5.
How do I become a Participant?
You become a Participant by signing a Benefit Election Form indicating that you elect one or more of the Benefit Package
Options available under the Plan that are listed in Part 5 below and agree to a salary conversion to pay for your elected
benefits with pre-tax dollars. You will then submit the Benefit Election Form to your Employer during the applicable
Enrollment Period described in Q-6 below, or, if you are a new employee, during the Initial Enrollment Period set for a new
employee.
Q-6.
What are the enrollment periods?
There are three (3) enrollment periods:
1.
Enrollment Period prior to the Effective Date. This is the enrollment period that occurs before the Plan’s Effective
Date (as described in the Adoption Agreement). An Election made during this Enrollment Period is effective on the
Effective Date.
2.
Initial Enrollment Period. The Initial Enrollment Period is the period during which newly eligible employees enroll
in the Plan. The Initial Enrollment Period is described in the enrollment material provided by the Plan
Administrator. An election to participate that is made during this enrollment period will be effective on the Plan
Entry Date.
3.
Annual Enrollment Period. The Annual Enrollment Period is the period each year in which participants may elect to
change and/or continue their elections or eligible employees may elect to participate for the next Plan Year. The
Annual Enrollment Period is described in your enrollment material that you will receive prior to the Annual
Enrollment Period. An election to participate made during this period will be effective on the anniversary date.
Elections that you make or are deemed to make during the Annual Enrollment Period will be effective on the
Anniversary Date, which is identified in Part 5 below. If you have the ability to enroll by phone or Internet, separate
enrollment periods may be set for paper, telephone and Internet. Your employer will tell you what enrollment
periods are established for each.
See Q-8 below for what happens when you fail to return a Benefit Election Form during the enrollment period.
Q-7.
How long am I committing to if I elect to be a participant?
You will be signing up for a Plan Year which is usually 12 months. The first Plan Year and the last Plan Year may be for a
shorter period. See Part 5 below for the exact dates of your Plan.
Q-8.
What happens if I fail to return my Benefit Election Form?
If you are not currently participating in the Plan and fail to return a Benefit Election Form before the end of the applicable
Enrollment Period, it will be assumed that you have elected to receive your full compensation in cash and you cannot elect to
become a Participant until the next Annual Enrollment Period. The only exception to this is if you have experienced one of
the qualifying events listed in Q-9 of Part 2. If so, you must submit a Change of Status form within 30 days of the event to
enroll.
If you are currently participating in the Plan and fail to submit a Benefit Election Form by the end of the Annual Enrollment
Period, it will be assumed that you want to continue your current elections as pre-tax contributions for the next Plan Year.
4
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
Q-9.
PREMIUM REDUCTION OPTION
Can I change my election during the Plan Year?
Generally, you cannot change your election to participate in the Plan or vary the benefits you have selected during the Plan
Year, although your election will terminate if you are no longer working for the Employer. Otherwise, you may change your
elections only during the Annual Enrollment Period, and then the change will not be effective until the beginning of the next
Plan Year.
There are several important exceptions to this general rule. You may change or revoke your previous elections during the
Plan Year if you experience one of the events listed below:
Please refer to the Change of Status Matrix (distributed with this SPD) for a table of the qualifying events, the benefits affected by
each event, and the possible changes in elections that may take place for each benefit. If you have a qualifying event, you must
submit a Employee Statement of Qualifying Event form (stating the event) and a Personal Benefit Election Change Request Form
(stating the changes in elections) within 30 days of the event to enroll.
1.
Change in Status. If one or more of the following Changes in Status occur, your may revoke you old election and
make a new election, provided that both the revocation and new election are on account of and correspond with the
Change in Status (as described below). Those occurrences which qualify as a Change in Status include the events
described below, as well as any other events which the Plan Administrator determines are permitted under
subsequent IRS regulations:
•
•
•
•
•
Change in your legal marital status (such as marriage, legal separation, annulment, divorce or death of your
spouse)
Change in the number of your tax dependents (such as the birth of a child, adoption or placement for
adoption of a dependent, or death of a dependent)
Any of the following events that change the employment status of you, your spouse, or your dependent that
affect benefit eligibility under a cafeteria plan (including this Plan) or other employee benefit plan of yours,
your spouse, or your dependents. Such events include any of the following changes in employment status:
termination or commencement of employment; a strike or lockout; a commencement of or return from an
unpaid leave of absence; a change in worksite; switching from salaried to hourly-paid; or part-time to fulltime; incurring a reduction or increase in hours of employment; or any other similar change which makes
the individual become (or cease to be) eligible for a particular employee benefit.
Event that causes your dependent to satisfy or cease to satisfy an eligibility requirement for a particular
benefit (such as attaining a specified age, getting married, or ceasing to be a student)
Change in your, your spouse’s or your dependent’s place of residence
If a Change in Status occurs, you must inform the Plan Administrator and complete a new election for Pre-Tax Contributions
within 30 days of the occurrence.
If you wish to change your election based on a Change in Status, you must establish that the revocation is on account of and
corresponds with the Change in Status. The Plan Administrator (in its sole discretion) shall determine whether a requested
change is on account of and corresponds with a Change in Status. As a general rule, a desired election change will be found
to be consistent with a Change in Status event if the event affects coverage eligibility (for the Dependent Care FSA, the event
may also affect eligibility for the dependent care exclusion). A Change in Status affects coverage eligibility if it results in an
increase or decrease in the number of dependents who may benefit under the Plan. In addition, you must also satisfy the
following specific requirements in order to alter your election based on that Change in Status:
•
5
Loss of Dependent Eligibility. For accident and health benefits (e.g., health, dental and vision coverage,
accidental death and dismemberment coverage), a special rule governs which type of election changes is
consistent with the Change in Status. For a Change in Status involving your divorce, annulment or legal
separation from your spouse, the death of your spouse or your dependent, or your dependent ceasing to
satisfy the eligibility requirements for coverage, your election to cancel accident or health benefits for any
individual other than your spouse involved in the divorce, annulment, or legal separation, your deceased
spouse or dependent, or your dependent that ceased to satisfy the eligibility requirements, would fail to
correspond with that Change in Status. Hence, you may only cancel accident or health coverage for the
affected spouse or dependent.
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
Example: Employee Mike is married to Sharon, and they have one child. The employer offers a calendar
year cafeteria plan that allows employees to elect no health coverage, employee-only coverage, employeeplus-one-dependent coverage, or family coverage. Before the plan year, Mike elects family coverage for
himself, his wife Sharon and their child. Mike and Sharon subsequently divorce during the plan year.
Sharon loses eligibility for coverage under the plan, while the child is still eligible for coverage under the
plan. Mike now wishes to cancel his previous election and elect no health coverage. The divorce between
Mike and Sharon constitutes a Change in Status. An election to cancel coverage for Sharon is consistent
with this change in Status. However, an election to cancel coverage for Mike and/or the child is not
consistent with this Change in Status. In contrast, an election to change to employee-plus-one-dependent
coverage would be consistent with this Change in Status.
However, if you, your spouse or a dependent elect COBRA continuation coverage under the Employer’s
plan, you may be able to increase your contribution to pay for such coverage.
•
6
Gain of Coverage Eligibility under Another Employer’s Plan. For a Change in Status in which you, your
spouse, or your dependent gain eligibility for coverage under another employer’s cafeteria plan (or
qualified benefit plan) as a result of a change in your marital status or a change in your, your spouse or your
dependent’s employment status, your election to cease or decrease coverage for that individual under the
Plan would correspond with that Change in Status only if coverage for that individual becomes effective or
is increased under the other employer’s plan.
2.
Special Enrollment Rights. If you, your spouse and/or a dependent are entitled to special enrollment rights under a
group health plan, you may change your election to correspond with the special enrollment right. Thus, for
example, if you declined enrollment in medical coverage for yourself or your eligible dependents because of outside
medical coverage and eligibility for such coverage is subsequently lost due to certain reasons (i.e., due to legal
separation, divorce, death, termination of employment, reduction in hours, or exhaustion of COBRA period), you
may be able to elect medical coverage under the Plan for yourself and your eligible dependents who lost such
coverage. Furthermore, if you have a new dependent as a result of marriage, birth, adoption or placement for
adoption, you may also be able to enroll yourself, your spouse and your newly acquired dependents, provided that
you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. An election
change that corresponds with a special enrollment must be prospective, unless the special enrollment is attributable
to the birth, adoption or placement for adoption of a child, which may be retroactive up to 30 days. Please refer to
the group health plan description for an explanation of special enrollment rights.
3.
Certain Judgments, Decrees and Orders. If a judgment, decree, or order from a divorce, separation, annulment,
custody change requires your dependent child (including a foster child who is your tax dependent) to be covered
under this Plan, you may change your election to provide coverage for the dependent child. If the order requires that
another individual (such as your former spouse) cover the dependent child, and such coverage is actually provided,
you may change your election to revoke coverage for the dependent child.
4.
Entitlement to Medicare or Medicaid. If you, your spouse or a dependent becomes entitled to Medicare or
Medicaid, you may cancel that person’s accident or health coverage. Similarly, if you, your spouse or a dependent
who has been entitled to Medicare or Medicaid loses eligibility for such, you may, subject to the terms of the
underlying plan, elect to begin or increase that person’s accident or health coverage.
5.
Change in Cost. If the Plan Administrator notifies you that the cost of your coverage under the Plan significantly
increases or decreases during the Plan Year, regardless of whether the cost change results from action by you (such
as switching from full-time to part-time) or the employer (such as reducing the amount of employer contributions for
a certain class of employees), you may make certain election changes. If the cost significantly increases, you may
choose either to make an increase in your contributions, revoke your election and receive coverage under another
benefit package option which provides similar coverage, or drop coverage altogether if no similar coverage exists.
If the cost significantly decreases, you may revoke your election and elect to receive coverage provided under the
option that decreased in cost. For insignificant increases or decreases in the cost of benefit package options,
however, the Plan Administrator will automatically adjust your election contributions to reflect the minor changes in
cost. The Plan Administrator (in its sole discretion) will determine whether the requirements of this section are met.
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
Example: Employee Mike is covered under an indemnity option of this employer’s accident and health insurance
coverage. If the cost of this option significantly increases during a period of coverage, the employee may make a
corresponding increase in his payments or may instead revoke his election and elect coverage under an HMO option.
6.
Change in Coverage. If the Plan Administrator notifies you that your coverage under the Plan is significantly
curtailed you may revoke election and elect coverage under another benefit package option which provides similar
coverage. If the significant curtailment amounts to a complete loss of coverage, you may also drop coverage if no
other similar coverage is available. Further, if the Plan adds or significantly improves a benefit option during the
Plan Year, you may revoke your election and elect to receive on a prospective basis coverage provided by the
newly-added or significantly improved option, so long as the newly added or significantly improved option provides
similar coverage. Also, you may make an election change that is on account of and corresponds with a change made
under another employer plan (including a plan of the employer or another employer), so long as: (a) the other
employer plan permits its participants to make an election change permitted under the IRS regulations; or (b) this
Plan permits you to make an election for a period of coverage which is different from the period of coverage under
the other employer plan. Finally, you may change your election to add coverage under this Plan for yourself, your
spouse, or your dependent if such individual(s) loses coverage under any group health coverage sponsored by a
governmental or educational institution. The Plan Administrator (in its sole discretion) will determine whether the
requirements of this section are met.
Additionally, the Plan’s Administrator may modify your election(s) downward during the Plan Year if you are a key
employee or highly compensated individual (as defined by the Internal Revenue Code), if necessary to prevent the Plan from
becoming discriminatory within the meaning of the federal income tax law.
Q-10.
What happens if I go on leave of absence?
If you go on leave of absence with pay, your participation in the Plan will continue and your contributions to the Plan will
continue to be deducted from your paycheck.
If you go on leave of absence without pay (LWOP), your participation in the Plan will cease (except as discussed in Q-11
below). The Employer may, on a uniform and non-discriminatory basis, require that employees who return from leave within
30 days and have their elections in effect before the leave, automatically be reinstated (after the employees have satisfied any
applicable eligibility requirements) when they return. If you return after more than 30 days, you can make new elections.
Q-11.
What happens if I go on a Qualified Leave under Family and Medical Leave Act?
(a)
(b)
(c)
(d)
7
If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to the extent
required by the FMLA, the Employer will continue to maintain your Benefit Package Options providing health
coverage (including the Health FSA) on the same terms and conditions as though you were still active (i.e. the
Employer will continue to pay its share of the premium to the extent the Employee opts to continue coverage).
If you opt to continue your group health coverage, you may pay your share of the premium with after-tax dollars
while on leave (pre-tax dollars to the extent you receive compensation during the leave), or you may be given the
option to pre-pay all or a portion of your share of the premium for the expected duration of the leave on a pre-tax
salary reduction basis out of your pre-leave Compensation by making a special election to that effect before the date
such Compensation would normally be made available to you (provided, however, that pre-tax dollars may not be
utilized to fund coverage during the next Plan Year), or by other arrangements agreed upon between you and the
Plan Administrator (e.g. the Plan Administrator may fund coverage during the leave and withhold amounts upon
your return). If the Employer requires all Participants to continue coverage during the leave, you may elect to
discontinue your share of the required contributions until you return from leave. Upon return from such leave, you
will be permitted to reenter the Plan on the same basis you were participating in the Plan before your leave, or as
otherwise required by FMLA. Notwithstanding the preceding sentence, your coverage that is terminated during the
leave may be automatically reinstated provided that health coverage for employees on non-FMLA leave is
automatically reinstated upon return from leave.
The employer may, on a uniform and consistent basis, continue your group health coverage for the duration of the
leave following your failure to pay the required contribution. Upon return from leave, you will be required to repay
the contribution in a manner agreed upon by you and your Employer.
If you are commencing or returning from unpaid FMLA leave, your election under this Plan for Benefit Package
Options providing non-health benefits shall be treated in the same manner that elections for non-health Benefit
Package Options are treated with respect to Participants commencing and returning from an unpaid non-FMLA
leave.
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
Q-12.
PREMIUM REDUCTION OPTION
What Benefit Package Options are offered under the Plan?
Insurance Premium Benefits are offered under the Plan. The specific benefits offered under the Plan are listed in Part 5
below.
For the details of the terms, conditions and limitations of each insurance benefit offered, please refer to plan summaries of
each separate insurance plan referenced in Part 5 below.
Q.13.
What are the claims procedures under the Plan?
If you are denied a benefit under this Plan (such as the ability to pay for premiums on a pre-tax basis) due to an issue
germane to your coverage under this Plan (i.e. such as a determination of: a Change in Status; a “significant” change in
premiums charged; or eligibility and participation matters under the Cafeteria plan document), the claims procedure under
this Plan will apply, and you will be notified in writing by the Plan’s Administrator within 90 days of the date you submitted
your claim if the claim is denied. Such notification will set out the reasons your claim was denied, and further advise you of
what steps, if any, you might take to validate the claim. It will further advise you of your right to request an administrative
review of the denial of the claim; you may request a review any time within the 60 day period after you have received notice
that the claim was denied. You or your authorized representative will have the opportunity to review any important
documents held by the Administrator, and to submit comments and other supporting information. In most cases, a decision
will be reached within 60 days of the date of your request for a review.
Part 3. Cash Benefits
During any one Plan Year, the Maximum Contribution Amount total a Participant can elect cannot exceed the sum of the Benefit
Package Options offered under Part 5 below. Any part of this annual benefit limit you do not apply toward tax-free benefits (or the
remainder of your annul pay if less than the unused portion of the Maximum Contribution Amount) will be paid to you as regular,
taxable salary.
Part 4. ERISA Rights
This Plan is not a welfare benefit plan as defined in the Employee Retirement Income Security Act (ERISA). However, Plan
participation may affect your rights or benefits under the component Benefit Package Options under the Plan. To the limited extent
that the Plan may have an impact on any component welfare benefit plans, we have included the statement of ERISA rights below.
ERISA provides that all plan participants will be entitled to:
1.
2.
8
Receive Information about your Plan and Benefits.
a. Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as work-sites,
and documents governing the Plan, including insurance contracts, collective bargaining agreements and a copy
of the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available
at the Public Disclosure Room of the 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 agreement, and copies of the latest annual report
(Form 5500 series) and updated Summary Plan Description. The Plan Administrator may make a reasonable
charge 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.
Continue Group Health Plan Coverage.
a. Continue health coverage for your self, 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 pay for such coverage. Review this Summary
Plan Description and the documents governing the plan on the rules governing your COBRA continuation
coverage rights.
b. Reduce or eliminate exclusionary periods of coverage for preexisting conditions under your group health plan,
if you have creditable coverage under another plan. You should be provided a certificate of creditable
coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under
the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation
coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing
coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for
12 months (18 months for late enrollees) after your enrollment date in your coverage.
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
3.
Prudent Action by Plan Fiduciaries.
4.
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for
the operation of the Employee Benefit Plan. The people who operate your plan, called “fiduciaries” of the Plan,
have a duty to do so prudently and in the interest of the Plan participants and beneficiaries. 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 welfare benefit from the Plan, or from exercising your rights under ERISA.
Enforcement of Your Rights.
If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive a
written explanation of the reason for the denial. You have the right to have the Plan review and reconsider your
claim. 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 30 days, you may file suit in a federal court. In such a case, the court
may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the
materials, unless the materials were not sent because of reasons beyond the control of the Administrator. If you
have a claim for benefits which is denied or ignored in whole or in party, you may file suit in a state or federal court.
In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic
relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan
fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek
assistance from the U.S. Department of Labor, or you may file a suit in a federal court. The court will decide who
should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay
these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your
claim is frivolous.
5.
Assistance with Your Questions.
If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions
about this statement or about your rights under ERISA, or if you need assistance obtaining documents from the Plan
Administrator, you should contact the nearest office of the U.S. Department of Labor, Pension and Welfare Benefits
Administration listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Pension and Welfare
Benefits Administration, U.S. Department of Labor, 200 Constitution Ave., N.W., Washington, D.C., 20210. You may also
obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the
Pension and Welfare Benefits Administration.
Part 5. Plan Information Summary
Please refer to the Addendum attached to this document for Part 5, the Plan Information Summary.
9
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
C.W. Matthews Contracting Co., Inc.
Section 125 Cafeteria Plan
PLAN INFORMATION SUMMARY
Effective Date: 05/01/2002
Employer Organization
Name of Organization:
Federal Employer ID Number:
Mailing Address:
City, State, Zip:
Street Address:
Street Zip:
Form of Organization:
Organized in the state of:
C.W. Matthews Contracting Co., Inc.
58-0652729
P.O. Drawer 970
Marietta, GA 30061
1600 Kenview Drive
30060
S Corp
Georgia
Plan Design Options
Plan Information
Plan Number
Plan Name:
Original Effective Date:
Plan Year Runs:*
Plan Restated and Amended:
501
Cafeteria Plan
06/01/1994
05/01 – 04/30
07/01/2002
* This Plan is designed to run on a 12-month plan year period as stated above. A Short Plan Year may occur when the Plan is first established,
when the plan year changes, or at the termination of the Plan.
2
Plan Administrator
C.W. Matthews Contracting Co., Inc.
Plan Service Provider
Name
Street Address:
City, State, Zip:
Contact:
Phone:
Flexible Benefit Group, Inc.
P.O. Box 702437
Dallas, TX 75370
Jacquie Whitney
800-249-9970
Benefits Coordinator
Name:
Title:
Phone:
Company Name:
Street Address:
City, State, Zip
Marnie King
Employee Benefits Assistant
770-422-7520
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, Georgia 30061
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
SUMMARY PLAN DESCRIPTION
PREMIUM REDUCTION OPTION
Acceptance of Legal Process
Name:
Title:
Phone:
Company Name:
Street Address:
City, State, Zip:
John H. Ross
Vice President/Corporate Counsel
770-422-7520
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, Georgia 30061
The appointed Plan Service Provider in conjunction with the Administrator will perform the functions of
accounting, record keeping, changes of participant family status, and any election or reporting
requirements of the Internal Revenue Code.
ELIGIBILITY REQUIREMENTS
a)
Except as provided in (b) below, the Classification of eligible employees consists of All employees.
b)
Employees excluded from this classification group are those individual employees who fall into one or more of
the following categories below:
Individuals under 18 years of ege.
Employees who work less than 30.5 hours per week.
Employees who are employed less than 3 months per year.
Service Period Requirement
Incorporated by reference from the underlying benefit policies.
PLAN ENTRY DATE
The Plan Entry Date is the date when an employee who has satisfied the Eligibility Requirements may commence
participation in the Plan. The Plan Entry Date is the later of the date the Employee files a Salary Reduction Agreement
during the applicable Enrollment Period or Date requirements are met.
BENEFIT PACKAGE OPTIONS
The following Benefit Package Options are offered under this Plan:
5.1 Core Health Benefits.
The terms, conditions and limitations of the Core Medical Plan Benefits offered will be as set forth in and
controlled by the Medical Plan Insurance Policy or Policies.
INCORPORATED BY REFERENCE
The actual terms and conditions of the separate benefits offered under this Plan are contained in separate, written
documents governing each respective benefit, and will govern in the event of a conflict between the individual plan
document and the Employer’s Cafeteria Plan adopted through this Agreement as to substantive content. To that end, each
separate document, as amended or subsequently replaced, is hereby incorporated by reference as if fully recited herein.
Signature:___________________________________
Name: John H. Ross
Title:
Vice President/Corporate Counsel
Executed at:
3
Date:______________________
C.W. Matthews Contracting Co., Inc.
P.O. Drawer 970
Marietta, GA 30061
C.W. MATTHEWS CONTRACTING CO., INC.
Nov 2001, V.7.0
LIFE INSURANCE BENEFITS
Schedule of Life and AD&D Benefits
Type Insurance
Amount of Coverage
Employee
Basic Term Life
$5,000
Employee
Basic AD&D (Principal Sum)
up to $5,000
Employee
Supplemental Term Life
Option I
$10,000
Option II
$25,000
Option III
Option IV
$40,000
Additional insurance can be added over
$40,000 in $10,000 increments, up to a
maximum of 4x the employee’s pay, not to
exceed $500,000.
Employee
Extended Term Life
Amount of Coverage: 100 times base weekly
earnings, rounded upward to nearest $100 and
subject to a maximum of $50,000
Employee
Extended AD&D
Amount of Coverage (Principal Sum): up to
the same dollar amount as for Extended Term
Life
Dependent
Term Life
Spouse
Children (less than 6 months of age)
$1,000
None
Children (6 months to 19 years of age)
$1,000
Children (students to age 25)
$1,000
Life Insurance for Employees and Dependents
Insuring Company - The Plan Sponsor/Employer will engage one or more insurance carriers to
provide life insurance benefits for its employees and their dependents. The insurance carrier(s)
will be financially sound, and carry a B+ or better rating as issued by the Best Rating Service.
The employer may from time to time, at its sole discretion, and without notice to its covered
employees, change insurance carriers.
Benefits Payable - Benefits payable are as shown in the Schedule of Life and AD&D Benefits
section of this Plan Document.
LIFE INSURANCE BENEFITS
Available Coverages
a.
Basic Life is group TERM Insurance, and is available to eligible employees as
part of a “basic benefits package”, which also includes medical/health coverage,
Short Term Disability Coverage and Basic AD&D Insurance. Basic Life may not
be purchased separately.
b.
Supplemental Life is group TERM Insurance, and is available to eligible
employees. It may be purchased with or without the basic benefits package.
c.
Extended Life is a group TERM Insurance, and is available to eligible
employees, as explained in the Eligibility section of this Plan Document.
Depending upon a covered employee’s weekly rate of basic earnings and subject
to a maximum of $50,000, the face amount of coverage is adjusted on August 1st
of each calendar year.
d.
Dependent Life is group TERM Insurance, and is available to eligible employees
as a “package” with dependent medical/health coverage. Dependent Life may not
be purchased separately.
Other Policy Provisions - The following provisions of life insurance coverage will be governed
by the terms and specifications of the insurance carrier’s policy contract:










Eligibility for Coverage
Effective Date of Coverage
Evidence of Insurability
Extension of Coverage/Waiver of Premium
Definition of Total Disability
Termination of Coverage
Reductions in Coverage
Claim Procedures
Conversion Privilege
Designation of Beneficiary
In all cases, and where at variance with the Plan Document, the terms of life coverage will be
governed by the life insurance company policy contract.
C.W. Matthews Contracting Co., Inc.
2
Plan Document
AD&D BENEFITS
Employee Accidental Death & Dismemberment Insurance
Insuring Company - The Plan Sponsor/Employer will engage an insurance carrier to provide
accidental death and dismemberment insurance benefits (AD&D) for its employees. The
insurance carrier will be financially sound, and carry a B+ or better rating as issued by the Best
Rating Service. The employer may from time to time, at its sole discretion, and without notice to
its covered employees, change insurance carriers.
Benefits Payable - Benefits payable are shown in the Schedule of Life and AD&D benefits
section of this Plan Document.
Available Coverages
a.
Basic AD&D is group Accidental Death and Dismemberment Insurance, and is
available to eligible employees as part of a “basic benefits package”, which also includes
medical/health coverage, Short Term Disability Coverage and Basic Life Insurance.
Basic AD&D Insurance may not be purchased separately, and it is not available to
dependents of employees.
b.
Extended AD&D is group Accidental Death and Dismemberment Insurance, and is
available to eligible employees, as explained in the Eligibility section of this Plan
Document. Depending upon a covered employee’s weekly rate of base earnings and
subject to a maximum policy limit of $50,000, the Principal Sum is adjusted on August
1st of each calendar year.
Other Policy Provisions - The following provisions of Accidental Death and Dismemberment
Insurance coverage will be governed by the terms and specifications of the insurance carrier’s
policy contract:









Eligibility for Coverage
Effective Dates of Coverage
Evidence of Insurability
Termination of Coverage
Reductions in Coverage
Claim Procedures
Definitions
Limitations & Exclusions
Designation of Beneficiary
In all cases, and where at variance with this Plan Document, the terms of accidental death and
dismemberment coverage will be governed by the life insurance policy contract.
C.W. Matthews Contracting Co., Inc.
3
Plan Document
SHORT TERM DISABILITY
Weekly Indemnity Benefit Payment
Amount of Weekly Benefit Payment
60% of Base Weekly Earnings excluding overtime
Waiting Period for Benefit Payments
14 Days from date of Total Disability
Benefit Payment Period Begins on
15th day of Total Disability
Maximum Weeks Payable
24 Weeks
Taxation of Benefits
Benefit payments are taxable to the employee
Short Term Disability
Weekly Indemnity Benefit Payments
Waiting Period - Except as stated below, the waiting period is the number of continuous and
consecutive days that a covered employee must be away from work before he/she is eligible to
receive benefit payments. During this time the covered employee must be:
1.
unable to work due to sickness or injury;
2.
totally disabled so as to be completely and continuously prevented from
performing any and every duty of his/her employment;
3.
under the direct care of a physician; and
4.
not engaged in any other work for compensation or profit.
Benefits Payable - Benefits are payable in the amount and for the maximum number of weeks, as
stated in the Schedule of Benefits.
Weekly Benefits are payable from the 15th day of any one continuous period of disability up to
the maximum number of weeks. One-seventh of the Weekly Benefit is payable for each full day
of covered disability but no benefit is payable for part of a day. Benefit payments are not
assignable.
Successive periods of disability separated by less than one week of continuous full time work
with the employer will be considered one continuous period of disability, unless the later
disability is due to causes entirely unrelated to the causes of the previous disability and begins
after return to full-time work with the employer for at least one full day.
C.W. Matthews Contracting Co., Inc.
4
Plan Document
SHORT TERM DISABILITY
To receive benefits, a physician must certify in writing the covered person’s disability:
a.
b.
prior to the 15th day of disability; and
thereafter, every 2 weeks during the duration of the disability.
Exclusions - Benefits are not payable for any:
a.
b.
c.
d.
e.
period of disability during which the covered person is not under the direct and
continuous care of a physician;
intentionally self-inflicted injury (while sane or insane);
sickness or injury arising out of employment with the Plan Sponsor, employment
with others, or self-employment, whether or not covered by Workers’
Compensation or any similar act;
sickness or injury or disability to a covered dependent; or
sickness, injury or disability due to a pre-existing condition as defined in the Plan.
Short Term Disability is a group coverage and may not be converted to an individual policy.
Reduction in Benefits - This Plan’s disability payments are secondary to any other indemnity
benefit payments that the covered employee may receive as a result of his/her disability. The
benefits payable under this Plan will be reduced by the amount of other income benefits that are
paid or payable to the covered employee.
Subrogation - Subrogation means our right to recover any benefit payments:
a.
b.
made because of an injury to you caused by a third party’s wrongful act or negligence;
and
which you later recover from the third party of the third party’s insurer.
Third Party means another person or organization.
Subrogation Rights - If you are injured because of a third party’s wrongful act or negligence:
a.
we will pay policy benefits for that injury, subject to the condition that you:
1.
agree in writing to our being subrogated to any recovery or right of
recovery you have against that third party;
2.
will not take any action which would prejudice our subrogation rights; and
3.
will cooperate in doing what is reasonably necessary to assist us in any
recovery.
b.
we will be subrogated only to the extent of the policy benefits paid because of that
injury.
C.W. Matthews Contracting Co., Inc.
5
Plan Document
LONG TERM DISABILITY
Employer Sponsored Long Term Disability
C. W. Matthews Contracting Co., Inc. provides long term disability (LTD) at no cost to all
qualified employees. The purpose of LTD is to ensure that our employees have the financial
support necessary should he/she become permanently disabled and unable to return to work once
Short Term Disability has ended.
Employees qualify in one of three groups:



Group 1-Corporate Officers;
Group 2-Salaried & Office Employees;
Group 3- All other hourly employees with 5 or more years of service.
Must be fulltime employee working a minimum of 30 hours per week.
The benefits for the LTD plan are as follows:
Elimination Period- LTD benefits begin 180 days from the date an employee becomes disabled.
Generally an employee is considered disabled and eligible for long term benefits if, due to
sickness, pregnancy or accidental injury, you are receiving appropriate care and treatment, are
complying with the requirements of the treatment, and you are unable to earn more than 80% of
your pre-disability earnings at your own occupation for any employer in your local economy.
Amount of Monthly Benefit Payment:
60% of pre-disability earnings, excluding overtime
Maximum Monthly Benefit:
Group 1- $10,000
Group 2- $6,000
Group 3- $3,000
Maximum Benefit Period: Maximum benefit period and any limitations are described in the
Certificate of Insurance/Summary Plan Description available through the Human Resources
Department.
Coverage Exclusions
The LTD plan does not cover any disability which results from or is caused or contributed to by:
 War, whether declared or undeclared, or act of war, insurrection, rebellion or terrorist act;
 Active participation in a riot;
 Intentionally self-inflicted injury or attempted suicide; or
 Commission of or attempt to commit a felony.
Coverage Limitations
C.W. Matthews Contracting Co., Inc.
6
Plan Document
LONG TERM DISABILITY
For LTD, limited benefits apply for specific conditions:
If you are disabled due to alcohol, drugs or substance abuse or addiction, the plan will limit your
Disability benefits to one occurrence for a lifetime maximum limit of Disability for 24 months.
During your Disability, we require you to participate in an alcohol, drug or substance or
addiction recovery program recommended by a physician.
Benefit will end at the earliest of:



The date you receive 24 months of disability benefit payments;
The date you cease or refuse to participate in the recovery program referenced above; or
The date you complete such recovery program.
If you are disabled due to mental or nervous disorders or diseases, the plan will limit your
disability benefit to a per occurrence period equal to the lesser of 24 months or the maximum
period.
Your Disability benefits will be limited as stated above for mental or nervous disorder or disease
except if you are disabled due to neuromuscular, musculoskeletal or soft tissue disorder, chronic
fatigue syndrome and related conditions. If you are disabled due to these conditions, the plan
will limit your disability benefits to a per occurrence period equal to the lesser of the Maximum
Benefit Period.
Other limitations or exclusions to coverage may apply. Please review your Certificate of
Insurance/Summary Plan Description provided to you. For specific details contact the Employee
Benefits Department.
Pre-existing Condition Exclusions
The plan will not cover a disability due to sickness or accidental injury for which you received
treatment in the months prior to your participation in the plan. A complete description of the
pre-existing condition exclusion is included in the certificate of Insurance/Summary Plan
Description provided to you. For specific details contact the Employee Benefits Department.
C.W. Matthews Contracting Co., Inc.
7
Plan Document
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