DCCCA,
INC.
GROUP HEALTH CARE PLAN
Restated January 1, 2005
SPD DISCLAIMER:
“Any changes made to this
document must be made with the expressed knowledge of FMH Benefit Services,
Inc.”
TO OUR ELIGIBLE EMPLOYEES:
Welcome. By participating in this Plan, you have put quality, dependability and experience on your side. Benefits are big news these days, especially health care benefits. As health care costs continue to rise, your health care coverage becomes ever more critical. This Plan has been designed to provide you and your family with both comprehensive and affordable coverage.
Please read the following pages carefully. Familiarize yourself with the benefits available, then use the Plan to meet your needs; but use it wisely.
YOUR MEDICAL BENEFITS......WHAT YOU SHOULD KNOW
You have enrolled under the DCCCA, Inc. Group Health Care Plan. The Plan has contracted with a managed care network or networks of medical providers whose members have agreed to charge the Plan reduced or discounted charges for covered services provided to Covered Persons. Although you have the freedom to choose to receive care from any Physician, Hospital, or other medical care provider, as a general rule the amount or percentage of an otherwise Covered Expense payable by the Plan will vary, depending on whether the provider from whom you receive your care is a member of the Plan’s PPO network(s). Generally, the Plan will pay a higher percentage of a Covered Expense if the care is received by a network provider. Thus, in order to receive the highest Benefit level, medical services and supplies should be received from a network provider.
Should the nearest PPO provider be located in excess of thirty-five (35) miles from the employees’ home (determined by zip code), medically necessary services received from the nearest available provider will be payable on the same benefit level as if received from a PPO provider.
Your Group Health Plan ID card contains a toll-free phone number and/or a website you can use to obtain information about the health care providers who are members of the provider network(s).
TABLE OF
CONTENTS
ARTICLE DESCRIPTION PAGE
II. Eligibility
for Coverage.............................................................................. 2
III. Effective
Date of Coverage....................................................................... 3
IV. Termination
of Coverage........................................................................... 5
V. Definitions................................................................................................... 7
VI. Comprehensive
Major Medical Benefits................................................ 17
XII. Participants’ Rights and Claim Appeal Procedures................................ 41
XIII. General
Provisions................................................................................... 46
XIV. HIPAA
Privacy & Security Requirements.............................................. 50
Appendix A Prescription
Drug Legend........................................................................ 52
Schedule of Benefits......................................................................................................... 54
ARTICLE I
INTRODUCTION
This is the DCCCA Inc. Group Health Plan Document. It also represents what is referred to as a Summary Plan Description (SPD). It describes the Benefits to which you and your covered Dependents are entitled, to whom Benefits are payable and other provisions which govern or control the way in which Benefits are provided.
PLAN SPONSOR. The Plan Sponsor is DCCCA, Inc. The Plan Sponsor has the authority to control and manage the operation and administration of the Plan; to establish Plan Benefits and provisions; to amend the Plan; to determine its policies; to appoint and remove the Claim Supervisor, and to exercise general administrative authority over the Supervisor.
CLAIM
SUPERVISOR. The Claim Supervisor of
the Plan is FMH Benefit Services, Inc.
COBRA. Please refer to
the COBRA Continuation Coverage section for information. If you have questions about your COBRA
continuation coverage, you should contact:
DCCCA, Inc.
Human Resources
Department
3312 Clinton
Parkway
Lawrence, KS. 66047
785/841-4138
or you may contact
the nearest Regional or District Office of the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and
District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa.
In order to
protect your family’s rights, you should keep your plan Sponsor or its designee
informed of any changes in the addresses of family members. You should also keep a copy for your records,
of any notices you send to your Plan Sponsor or its designees.
CONTRIBUTIONS TO OR ON BEHALF THE PLAN. The Employer makes contributions to the Plan so that the Plan may make Benefit payments to you and your Dependents. You may also be required to make contributions to the Plan for your coverage or for coverage of your Dependents, or for both you and your Dependents’ coverage. For more information concerning the funding of this Plan, see the section titled General Provisions--Funding Method.
CLAIM PROCEDURES. Claim payments are made based on data furnished by you or your health care provider. In order to collect Benefits under the Plan, you or the provider must first provide information as to the validity of the claim for Benefits. For ease of administration, you may have to file a “claim form” for You and Your Dependents. This form contains essential information necessary for the Claim Supervisor to determine the validity of a claim for Benefits. Occasionally, further information may be necessary and you should provide this information to the Claim Supervisor as requested.
CLAIM DETERMINATION. A determination regarding payment of eligible Benefits will normally be made within 30 days from the Claim Supervisor’s receipt of all necessary information regarding the claim for Benefits. All interpretations of the Plan’s terms regarding Benefits will be made by the Plan Sponsor.
CLAIM FILING DEADLINE. A claim will not be considered unless it is filed within twelve (12) months after the date on which the expense is incurred. Terminated employees (and their Dependents) must file all incurred but unfiled claims within six (6) months after the date of termination of their coverage. In the event of the Plan's termination, you must file all incurred but unfiled claims within six (6) months after the Plan's termination.
See
the section of this SPD titled Participants’
Rights and Claim Appeal Procedures for more information about your rights
with respect to claims and appeals of determinations that are made with respect
to claims.
ARTICLE II
Coverage provided under this Plan for you and your Dependents will be in accordance with the eligibility, effective date and termination provisions that follow below.
EMPLOYEE ELIGIBILITY. In order to be eligible for coverage under this Plan you must be both an Employee and an Eligible Employee. Generally, an Employee is a person employed by the Employer in a classification of employment that qualifies him for participation in the Plan. See the definition of “Employee” in Article V. Generally, an Eligible Employee is an Employee who has met any service requirements that the Employee must meet in order to become eligible. Those service requirements, if they apply, are described in the following paragraph.
An Employee is considered an Eligible Employee when he has completed at least 60 days of continuous employment with the Employer. Note that if an Eligible Employee has a break in continuous employment with the Employer due to a health status condition, the Eligible Employee will be deemed to be in continuous employment with the Employer during the absence that is due to the health status condition. If the Employee is not actively at work on the day coverage would become effective, coverage will become effective when the Employee returns to active work.
DEPENDENT ELIGIBILITY. Your Dependents are eligible for coverage under the Plan on the date you become eligible for Employee coverage, or the date on which the Dependents become your Dependents, whichever occurs last. However, under no circumstances may you enroll your Dependents if you are not also enrolled under the Plan. If both you and your spouse are Employees, and both are eligible for Dependent coverage, either you or your spouse, but not both, may elect Dependent coverage for your other eligible Dependents (e.g., Dependent Children). No person may be covered under this Plan as both an Employee and as a Dependent. Dependent eligibility is also subject to the following rules:
Newborns. Your newborn Children will be eligible as of the moment of birth if you are an Eligible Employee at that time. Generally, coverage of newborn Children includes coverage for care or treatment of medically diagnosed congenital defects, birth abnormalities or prematurity; and for any routine nursery care provided under this Plan. See the description of Covered Expenses in the Article VII of this booklet. An enrollment form must be completed and filed with us within thirty–one (31) days of birth.
New Spouse. Your spouse will be considered an eligible Dependent as of the date of marriage, if you are an Eligible Employee at that time. An enrollment form must be completed and filed with us within thirty-one (31) days of the event.
Other New Dependents. If you acquire a Dependent (other than your spouse) due to marriage, legal adoption or legal guardianship, that Dependent shall be considered an eligible Dependent as of the date of such occurrence, if you are an Eligible Employee at that time. A Child will be considered adopted on the date the Child’s adoption becomes final or on the date the Child is placed for adoption (a Child is considered placed for adoption when you assume and retain a legal obligation for total or partial support of the Child in anticipation of adoption; the Child’s placement terminates upon termination of such legal obligation).
Continuing Coverage for Disabled Dependent Children. An unmarried Child who is a Dependent and who reaches the Plan’s limiting age for Dependent Children while covered under this Plan will remain eligible for coverage to the extent he is at that time incapable of self-sustaining employment and is dependent upon you for support due to a mental or physical illness or handicap. He will remain eligible for coverage under this provision to the extent you remain eligible for Dependent coverage and he remains incapable of self-sustaining employment and dependent upon you for support due to the handicap. Proof of incapacitation must be provided within thirty-one (31) days after the Child attains age 19 and thereafter may be required each year and must be approved by the Plan Sponsor.
Qualified Medical Child Support Orders. The Plan will honor the terms of a Qualified Medical Child Support Order. A Qualified Medical Child Support Order is an order that is typically issued in or after divorce proceedings, and may create or recognize the right of your Child to be covered under this Plan. Such an order must be qualified and issued by a court of competent jurisdiction or authorized state agency in order for this Plan to be bound by it. Please contact your human resources department for more information regarding whether or not a medical child support order is “qualified.” That department will “process” the order as follows:
·
Your Employer,
promptly after receiving a medical child support order, will notify you of each
Child designated in the order. The notification will contain information that
permits the Child to designate a representative for receipt of copies of
notices that are sent to the Child with respect to a medical child support
order.
·
Within forty (40)
business days after receipt of the order (or, in the case of a national medical
support notice, the date of the notice) the Employer will determine whether the
order is a “qualified” medical child support order. Upon determination of whether a medical child
support order is or is not qualified, the Employer will send a written copy of
the determination to you and each Child (or, where an official of the state
agency issuing the order is substituted for the name of the Child, notify such
official).
·
If the Employer
determines that the medical child support order is qualified, you, the Child or
his representative must furnish to the Employer any required enrollment
information. In the case of a national
medical support notice, the Employer will: (i) notify the state agency issuing
the notice whether coverage is available to the Child under the Plan and, if
so, whether such Child is covered under the Plan and either the effective date
of such coverage or any steps to be taken by the Child’s custodial parent or an
official of the state agency that issued the notice to effectuate such
coverage, and (ii) provide the custodial parent (or, where an official of the
state agency issuing the order is substituted for the name of the Child, notify
such official) a description of the coverage available and any forms or
documents necessary to effectuate such coverage.
·
Typically you
must provide such information to the Plan within forty-five (45) days
immediately following the date the determination was made that the order was a
Qualified Medical Child Support Order. In the case of a national medical
support notice, if there are multiple coverage options available to the Child
under the Plan the state agency issuing the notice will select an option, but
if it fails to do so within twenty (20) days after the Employer’s notice
described in the preceding paragraph, the Child will be enrolled under the
Plan’s Base Plan.
·
Unless the
Qualified Medical Child Support Order provides otherwise, you will be
responsible to make any required contribution to pay for such coverage.
·
In no event will
coverage provided under a Qualified Medical Child Support Order become
effective for a Child prior to the date the Order is received by the Plan.
·
If the Employer
determines that the medical child support order is not “qualified,” a written
determination to that effect will be furnished to you and the Child or the
Child’s representative. You or the Child
(or the Child’s representative) may appeal the determination to the
Employer. Any request for review of a
determination must be filed with the Employer within sixty (60) days after the
Employer issues its original determination.
·
Effective date
will be the date that the judicial entity dictates that the Dependent
Child(ren) will be added to the Plan, or if not specified, the first of the
month following initial receipt of the QMCSO from the court or state agency.
EFFECTIVE DATE OF COVERAGE
EMPLOYEE EFFECTIVE DATE. Your coverage is effective as follows:
Enrollment when first eligible: If you complete and file with us the required enrollment forms no later than 31 days after the date you first become eligible, coverage will be effective at 12:01 a.m. on the first day of the month coincident with or first following the date you become eligible. If your coverage effective date is later than the date you became eligible, you must still be eligible on your coverage effective date in order for coverage to begin.
Late Enrollment. If you decline to enroll within the first 31 days after you initially become eligible, you may enroll thereafter only by completing and filing with us the required enrollment forms either: (1) within 30 days after experiencing a special enrollment event (as described below in the section titled Special Enrollment Events), or (2) during the Plan’s annual enrollment period.
If you enroll within 30 days after a special enrollment event, the date your coverage is effective depends on the type of special enrollment event. If the event is your acquisition of a Dependent Child by virtue of birth, adoption or placement for adoption, your coverage is effective as of the date of that event. If the event is loss of other coverage or your acquisition of a Dependent by virtue of marriage, your coverage is effective no later than the first day of the month following the month in which you file the required enrollment forms with us. In either case you must be eligible for coverage on the date your coverage would become effective.
If you enroll during the annual enrollment period, your coverage will be effective on the first day of the first month following the end of the enrollment period (provided you are then still eligible).
DEPENDENT EFFECTIVE DATE.
Enrollment when first eligible: If you are already enrolled for Dependent coverage at the time you acquire a Dependent, coverage of the Dependent is effective on the date the Dependent became an eligible Dependent. In other cases, you must complete and file with us the required enrollment forms no later than 31 days after the date your Dependent first becomes eligible, in which case coverage of the Dependent will be effective at 12:01 a.m. on the date the Dependent became eligible (where the eligible Dependent is a newborn Child, coverage will be effective as of the date of birth, if this date is different than the date described above), provided your coverage is then in effect.
Late Enrollment. If you are not already
enrolled for Dependent coverage at the time you acquire a new Dependent, and
you decline to enroll the Dependent within the first 31 days after the
Dependent initially becomes eligible, you may enroll the Dependent thereafter
by completing and filing with us the required enrollment forms within 30 days
after the Dependent experiences a
special enrollment event which is a loss of other coverage, or within 30 days
after you experience a special
enrollment event which is the acquisition of a Dependent Child by virtue of
birth, adoption or placement for adoption.
Special enrollment events are described below, in the section entitled, Special Enrollment Events.
You may also enroll the Dependent during the Plan’s annual enrollment period. The Plan’s annual enrollment period is determined by DCCCA and held prior to the beginning of the new plan year.
If you enroll the Dependent due to a special enrollment event, the effective date of the Dependent’s coverage depends on the type of special enrollment event. If the event is your acquisition of a Dependent Child by virtue of birth, adoption or placement for adoption, coverage of the Dependent will be effective as of the date of that event. If the event is the loss of other coverage, the Dependent’s coverage is no later than the first day of the month following the month in which you file the required enrollment forms with us. In either case, however, the Dependent’s coverage will not be effective unless you are covered on the date the Dependent’s coverage would become effective.
If coverage of a Dependent Child ceases because the Child is no longer a full-time student, and the Child thereafter becomes a full-time student again (as described in the definition of Dependent), coverage of the Child shall be reinstated effective as of the first of the month the Child is again a full-time student, provided you re-enroll the child within 30 days after such date and the Child otherwise meets the definition of Dependent
In all cases, we may require proof of dependency (and, in the case of an adopted Child or a Child placed with you for adoption, proof of the adoption or placement for adoption) as a condition to enrolling an eligible Dependent.
SPECIAL ENROLLMENT EVENTS. For purposes of the enrollment rules described above, and/or for purposes of the Plan’s Pre-Existing Condition restriction (if any), “special enrollment events” are:
Loss of Other Coverage. You or an eligible Dependent will be considered to have experienced this special enrollment event if:
·
you or the
eligible Dependent declined a previous opportunity to enroll or be enrolled
under the Plan;
·
at the time you
or the eligible Dependent were previously offered the opportunity to enroll or
to be enrolled you declined to enroll yourself (or, in case of an eligible
Dependent, to enroll the eligible Dependent) because you had (or, in the case
of an eligible Dependent, the eligible Dependent had) other health coverage; and
·
that other
coverage was either (1) COBRA Continuation Coverage which is now exhausted
(other than for failure to pay premiums or for fraudulent behavior) or (2)
non-COBRA Continuation Coverage under a group health plan or other health
insurance which has been terminated due to loss of eligibility (other than for
failure to pay premiums or for fraudulent behavior) or termination of employer contributions toward such other
coverage. For this purpose, a “loss of
eligibility” includes (but is not limited to) a loss of eligibility for
coverage as a result of (i) legal separation, (ii) divorce, (iii) cessation of
dependent status, (iv) death of an Employee, (v) termination of employment,
(vi) reduction in hours, (vii) no longer residing or working in a required
service area, (viii) a situation where you incur a claim that would meet or
exceed a lifetime limit on all benefits, or (ix) a situation where a plan no
longer provides any benefits to a class of similarly-situated individuals as
yourself.
For purposes of determining whether you had “non-COBRA Continuation Coverage” as described above, the term “group health plan” means a plan maintained or contributed to by an employer or employee organization (e.g., a union) to provide health care for employees and their families. The term “other health insurance” means benefits consisting of medical care under any Hospital or medical service policy or certificate, Hospital or medical service plan contract, or HMO contract, offered by an insurance company, service, or organization required to be licensed to engage in the business of insurance in a state and that is subject to state insurance law. Specifically, “other health insurance” does not include coverage under Medicare or Medicaid.
Acquisition of a Dependent by Virtue of Marriage, Birth, Adoption or Placement for Adoption. This special enrollment event occurs where you acquire a Dependent spouse or Child by virtue of marriage, or you acquire a Dependent Child by virtue of birth, adoption or placement for adoption.
Note
that, in connection with enrolling under a “special enrollment event,” you may
be able to switch coverage options (such as from an HMO option to a PPO option)
if the Employer offers more than one coverage option to you.
DEFERRED EFFECTIVE DATE PROVISIONS. If you are not actively at work on the date your coverage would otherwise become effective, for reasons other than a health status-related reason, coverage will not become effective until you return to active work, provided you still meet the eligibility requirements at the time you return to active work. Notwithstanding the foregoing, if you have been hired but have never reported for work and are not actively at work due to a health status-related reason or any other reason, your coverage will not become effective prior to the date you report for work, and you will not be treated as having commenced your employment prior to the date you actually report for work.
CHANGES IN COVERAGE. Should you change classifications which results in a coverage change, or should Benefits under this Plan be increased by a Plan change, the effective date of such change shall coincide with the date of the Benefit or classification change.
ARTICLE IV
TERMINATION OF COVERAGE
TERMINATION OF COVERED EMPLOYEE’S COVERAGE. Except as provided in the Plan’s coverage continuation provision, and any extension of Benefits provision in this Plan, your coverage as an Employee will terminate on the earliest of the following dates:
·
If you fail to
remit required contributions for your coverage when due, the date which is the
end of the period for which the last timely contribution was made.
·
The last day of
the month in which you are no longer an Employee.
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