General Health Care Facts

This section is a summary of provisions that specifically apply to the medical (including prescription drug), dental, and vision plans. Here you'll find rules about eligibility, when coverage begins and ends, and other information that applies to your benefits. To view a complete description of these provisions, please reference the CMSU Wrap SPD.

If you live in Hawaii and are covered by a health care plan offered through HMSA, please refer to your HMSA materials that were provided to you.

  

  

Who's Eligible

Dependent definitions
Special rules about children's coverage

  

You are eligible to enroll in the plan if you are an active, full-time employee working on a full-time basis (20 hours per week or more). You are not eligible for coverage if you are a temporary, leased, or seasonal employee, or an independent contractor, consultant, or individual who is not on the company payroll.

You may enroll your eligible family members under the plan at the same time you enroll yourself. Dependents may not be covered by the plan if you, the employee, are not enrolled or if they are enrolled as employees.

The Company reserves the right to request proof of marriage, dissolution of marriage, proof of partnership, dissolution, termination of partnership, birth, adoption, disability, or any other documentation that demonstrates eligibility for benefits.

For medical coverage, eligible family members include:

• Your legally married spouse or qualified domestic partner.
• Your or your spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption, or a child for whom you or your spouse are the legal guardian. Children for whom you are required to provide health coverage under a qualified medical child support order are also considered eligible—see Qualified Medical Child Support Order.
• An unmarried child age 26 or over who is or becomes disabled and dependent upon you (periodic proof of their handicap may be required); see Special Rules Regarding Your Children's Coverage. 

For dental and vision coverage, eligible family members include:

• Your legally married spouse or qualified domestic partner.
• Your unmarried children who rely on you for more than 50% of their financial support. Such children include a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your spouse/domestic partner are the legal guardian who meet the following criteria:
  • Children under age 19.
  • Children ages 19 up to 25, provided they are full-time students taking 12 or more units at an accredited school (9 units for graduate school).
  • Children who are physically or mentally incapacitated regardless of age (periodic proof of their handicap may be required); see Special Rules Regarding Your Children's Coverage. For new hires, your unmarried mentally or physically disabled children are eligible, provided these children were covered under the coverage you had immediately before your date of hire and you enroll yourself and these children in the plan within 30 days of your date of hire.

  

Dependent Definitions

Children

Children include your natural children, stepchildren, legally adopted children (including pre-adoptive children from date of placement in your home), and children for whom you or your spouse/domestic partner are the legal guardian. 

  

Domestic Partner

A domestic partner is an individual of the same or opposite sex with whom you have established a domestic partnership as described below.

A domestic partnership is a relationship between an employee and one other person of the same or opposite sex. Both persons must:

• Not be so closely related that marriage would otherwise be prohibited;
• Not be legally married to, or the domestic partner of, another person under either statutory or common law;
• Be at least 18 years old;
• Live together and share the common necessities of life;
• Be mentally competent to enter into a contract; and
• Be financially interdependent

The Employee and domestic partner must jointly sign an affidavit of domestic partnership provided by Human Resources upon your request.

  

Special Rules About Children's Coverage

Disabled Children

If you have a dependent child who is physically or mentally disabled, his or her health care coverage may continue beyond the maximum age for coverage, as long as you continue to pay the required contributions and you provide the Plan Administrator with proof that your child is:

• Unable to earn a living because of a physical or mental disability,
• Dependent on you for support and maintenance, and
• Unmarried.

You must provide such proof within 31 days of the date your child reaches the maximum age of coverage, and then each year thereafter for as long as your child's disability continues. The Plan Administrator may also require doctor examinations. Note that to be eligible for this coverage, your child must meet the applicable medical plan's definition of disability.

Under this situation, your child's coverage will continue until any of the following occur:

• The child is no longer disabled as determined by the Plan Administrator,
• You do not provide proof to the Plan Administrator of your child's disability when requested to do so, or
• Your eligibility for coverage under this plan ends.

Depending on the circumstances, coverage for your child may be available through COBRA (see Continuation of Coverage).

  

Qualified Medical Child Support Order

A qualified medical child support order (QMCSO) is a judgment, decree, or order issued by a court that requires a parent to provide medical coverage, regardless of with whom the child resides.

Child support orders should be sent to the Plan Administrator. Upon receipt, the Plan Administrator will review it to determine if it meets the requirements of a QMCSO. If the order is qualified, you may cover your children under the plan. 

You may obtain, without charge, a copy of the procedures governing QMCSOs from the Plan Administrator.

Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the requirements of a QMCSO. 

  

Enrollment

Declining medical coverage
Cost of coverage
When coverage begins and ends
Certificate of creditable coverage
If you are not actively at work
Making changes

  

Health care coverage is not automatic—you must enroll to cover yourself and your dependents. Medical, dental and vision coverages require separate elections. You will have the ability to enroll through the online New Hire Onboarding system within 30 days of the date you first become eligible for medical plan coverage. If you do not enroll within 30 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.

If you participate in a Company medical plan, you may print a temporary medical ID card by logging on to Anthem's website.

After you enroll, you will receive ID cards for the medical and dental plans. Your ID cards include important phone numbers. Please replace any old ID cards with the new ones you receive. You will need to show your ID card each time you or your covered dependents receive care from network providers. Other health care providers may also ask to see your ID card. You should carry your ID cards at all times.

The Company wants you to have at least a basic level of protection. If you don't enroll within the first 30 days of your hire date, you will be covered by the following default health care coverages:

DEFAULT HEALTH CARE COVERAGE	WHO PAYS THE COST
The CDHP Basic (this includes coverage for prescription drugs and mental health/substance abuse services)—single coverage only	The Company and you
The Vision Plan—single coverage only	The Company and you
The Dental Plan—single coverage only	The Company and you
WorkLife Services and EAP (Consultation, Referrals, and the EAP)-all eligible family members	The Company

If you do not elect coverage for yourself or your eligible dependents within 30 days after your eligibility date, you may enroll only during a future Open Enrollment period, unless you have a status change during the year. For a description of status changes, please see Making Changes. Your coverage will be effective from the date of acceptance.

  

Declining Medical Coverage

To decline medical coverage, you must have coverage through another source, such as your spouse's employer's plan. If you are declining medical coverage, you must sign a waiver stating that you have other coverage.

You may in the future be able to enroll yourself or your dependents in this plan, provided you request enrollment within 31 days after your other coverage ends.

If you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you enroll within 31 days after the marriage, birth or adoption (or placement for adoption).

  

Cost of Coverage

You and the Company share the cost of health care coverage; however, the Company pays the major portion of the cost. Your share of the cost for prescription drug and mental health/substance abuse coverage are automatically included in your medical plan contribution. Dental and vision are deducted separately. Your contribution is made through automatic payroll deductions. Any changes in the cost will be communicated to you before they are made.

In general, your contributions are made on a before-tax basis. That means they will be deducted from your regular paycheck before federal and Social Security taxes are taken—so, you pay lower taxes. In many cases, you also pay no state or local taxes on your contribution.

  

Imputed Income for Non-Tax Dependents

The Internal Revenue Code provides that only individuals who qualify as a tax dependent be provided-tax-favored benefits. If you cover a domestic partner or child who does not meet IRS criteria for tax-favored benefits, you will be taxed on the value of the benefits provided by the Company to these dependents. This means your taxable pay will be increased by the estimated value of your domestic partner’s coverage, less the amount you pay in premiums. Your taxable income will be higher than your real cash wages, and all income-based taxes will be due on the whole amount. The amount of the imputed income can be substantial and will vary by the plan you select and the number of dependents you cover. In addition, your contributions for their benefits must be paid on an after-tax basis.  

If your domestic partner qualifies for tax-favored benefits under state or federal guidelines, you must provide a completed Declaration of Domestic Partnership or Civil Union and a Declaration of Same-Sex Spouse, Domestic Partner, or Civil Union Partner’s Tax Status, if applicable to receive favorable tax treatment. 

Depending upon state law, the value of coverage for adult children who are not your federal tax dependents may be taxable to you as imputed income under state tax rules.  

  

When Coverage Begins and Ends

Once Human Resources receives your properly completed enrollment through the online New Hire Onboarding system, coverage will begin on your date of hire. A newly eligible spouse/domestic partner is effective on the date you enroll him or her for coverage, provided you enroll your spouse/domestic partner within 31 days of his or her eligibility.

A newborn is covered from birth if you enroll the baby within 31 days after the date he or she is born. An adopted child is covered from the date the child is placed with you for adoption, provided you request coverage within 31 days of the adoption. If you request coverage for a child as a result of a Qualified Medical Child Support Order (QMCSO), coverage will begin on the effective date of the court order, as long as you have notified the Company in writing of the court order and enrolled within 31 days of receiving the QMCSO.

Coverage for you and your dependents under the Company benefits program generally ends on the latest of:

• The last day of the month in which your employment ends
• The last day of the month in which you retire (if you retire before you are eligible for Medicare benefits, you may elect to continue coverage under your Company health benefits for a specified period, at your own expense (see Continuation of Coverage)
• The last day of the month in which you or your dependents no longer meet the eligibility requirements as described in Who's Eligible
• The last day of the month Anthem receives written notice from the Company to end your coverage, or the date requested in the notice if later
• The date the group plan terminates
• The date the plan determines that you committed a fraudulent act or intentional misrepresentation of a material fact including, but not limited to, false information relating to another person's eligibility or status as a dependent
• The date the plan determines that there is a material violation of the terms of the plan
• The date the plan determines that you fail to make any required contribution
• The date the plan determines you permit an unauthorized person to use your ID card or you use another person's ID card
• The date the plan determines that you physically or verbally threaten representatives of the Company or Anthem, a provider, or other persons who are covered by the plan

If you die while you are an active employee, or while receiving Short Term or Long Term Disability benefits, coverage for your dependents may continue free of charge to the last day of the month following the date of your death. After this period, your eligible dependents may elect to continue coverage at their own expense for a specified period of time (see Continuation of Coverage).

  

Extended Coverage for Full-Time Students

Coverage for an enrolled dependent child who is a full-time student at a post-secondary school and who needs a medically necessary leave of absence will be extended until the earlier of the following:

• One year after the medically necessary leave of absence begins
• The date coverage would otherwise terminate under the plan

Coverage will be extended only when the enrolled dependent is covered under the plan because of full-time student status at a post-secondary school immediately before the medically necessary leave of absence begins.

Coverage will be extended only when the enrolled dependent's change in full-time student status meets all of the following requirements:

• The enrolled dependent is suffering from a serious sickness or injury
• The leave of absence from the post-secondary school is medically necessary, as determined by the enrolled dependent's treating physician
• The medically necessary leave of absence causes the enrolled dependent to lose full-time student status for purposes of coverage under the plan

A written certification by the treating physician is required. The certification must state that the enrolled dependent child is suffering from a serious sickness or injury and that the leave of absence is medically necessary.

For purposes of this extended provision, the term "leave of absence" shall include any change in enrollment at the post-secondary school that causes the loss of full-time student status.

  

Certificate of Creditable Coverage

If your coverage under this plan stops, you and your covered dependents will receive a certificate of creditable coverage that shows your period of coverage under the plan. You may need to furnish the certificate if you become eligible under another group health plan if it excludes coverage for pre-existing conditions. You may also need the certificate to buy, for yourself or your family, an individual insurance policy that excludes pre-existing conditions. You and your dependents may also request a certificate within 24 months of losing coverage under this plan. 

  

If You Are Not Actively at Work

There may be times when your coverage may continue even if you are not actively at work.

If a you have a total disability on the date your coverage under the plan ends, your benefits will not end automatically. The plan will temporarily extend coverage, only for treatment of the condition causing the total disability. Benefits will be paid until the earlier of:

• The total disability ends; or
• Twelve months from the date coverage would have ended.

If you are on an approved leave of absence, coverage for you and your dependents may continue for the approved period, as long as you make the required contribution. (When a leave qualifies as a family or medical leave, the plan will be administered under the provisions of the Family and Medical Leave Act.) When coverage stops, you and any eligible dependents may elect to continue health care coverage for a specified period, provided you make the required contribution (see Continuation of Coverage).

  

Making Changes

Each year during the Open Enrollment period, you will be able to change coverage, including adding or dropping dependents and changing between medical plans.

You may generally change your health care coverage during the year only if you have a change in your status as defined by federal regulations. The following events qualify as a change in your status:

• Marriage, divorce, legal separation, or annulment
• Formation or dissolution of a domestic partnership
• Birth, adoption, placement for adoption, or legal guardianship of a child
• A change in your spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan
• Loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis 
• Death of a dependent
• Your dependent child no longer qualifying as an eligible dependent
• A change in your or your spouse's position or work schedule that impacts eligibility for health coverage
• Employer contributions for coverage have stopped
• You move out of an HMO's service area that you are enrolled in and no other benefit option is available
• Benefits are no longer offered for a class of individuals that include you and your dependents
• Termination of your or your dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact Human Resources within 60 days of termination)
• You or your dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact Human Resources within 60 days of determination of subsidy eligibility)
• A strike or lockout involving you or your spouse/domestic partner
• A court or administrative order

Unless otherwise noted above, all changes must be made within 31 days of the event and supporting documentation is required. Your coverage change will be effective on the date you notify the Plan Administrator, unless your status change is a birth, adoption, or placement for adoption of a dependent child, in which case coverage will be effective retroactive to the date of the event. Any change you make must be consistent with the change in your status. For example, if you get married, you may add your spouse to your coverage. However, you may not switch from one medical plan to another until the annual enrollment period.

  

Your Special Enrollment Rights

In certain situations, you may be eligible to enroll in a health care plan during the plan year, even if you previously declined coverage. This right extends to you and all eligible family members if you notify the Benefits Department within 31 days of the event or unless otherwise noted below:

You will be eligible to enroll yourself and eligible dependents in a health care plan if:

• You or your dependents have lost coverage under another plan because:
  • Employer contributions to the plan stopped,
  • The plan was terminated or was amended to exclude all members of a specific class,
  • Coverage ended due to divorce or termination of a domestic partner relationship, legal separation, death, termination of employment, or a reduction in hours to part-time status,
  • You or your dependent incurred claim expenses that exceeded your plan's lifetime maximum, or
  • Your dependent child has reached the plan's maximum age limit.
• A court has ordered you to provide coverage for a dependent.
• COBRA coverage under another plan ends involuntarily.
• Individuals who lose Medicaid or CHIP coverage due to ineligibility
• Gain eligibility for a state's employer-plan premium assistance program
• Termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact the Benefits Department within 60 days of termination).
• You or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact the Benefits Department within 60 days of determination of subsidy eligibility)

In addition, if you gain a new dependent during the year, you may enroll that dependent, as well as yourself and any other eligible dependents, for health care coverage—even if you previously declined health care coverage.

  

If You Have Other Coverage

Definitions
Determining which plan pays first
Coordination with Medicare
Third party liability and subrogation
Overpayment and underpayment of benefits

  

Most insurance companies and providers cooperate with each other to avoid duplicate payments. If you or your dependents have medical or dental coverage in addition to your Canon Medical Systems coverage, one of the plans will pay the benefits first and that plan is considered primary. Secondary plans pay benefits after the primary plan, and coordinate their benefits based on what the primary plan paid.

When a Company medical or dental plan is the secondary plan, the Company plan will pay only up to the amount that it would have paid if it were the primary payer. For example, if the primary plan pays 70% and the Company (secondary) plan normally pays 80%, the Company plan will pay 10%. If the primary plan pays 80% and the Company plan normally pays 80%, the Company plan will pay 0%.

The plan has the right to obtain any benefit information necessary to determine whether the coordination provision applies and release it to any insurance company, claims administrator, organization, or person.

  

Definitions

Allowable expense. When this plan is secondary, the allowable expense is the primary plan's network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan's reasonable and customary charge. If both the primary plan and this plan do not have a contracted rate, the allowable expense will be the greater of the two plans' reasonable and customary charges.

Custodial parent. The custodial parent is the parent who is awarded custody by a court decree. If there is no court decree, the custodial parent is the parent with whom the child resides for more than half of the calendar year regardless of visitation rights.

Health care plan. Health care plan means medical (including integrated mental health and substance abuse), dental, prescription drug, or vision coverage under the following types of plans:

• Another employer-sponsored health care plan
• Medical care components of a group long-term care plan, such as skilled nursing care
• Medical benefits under a group or individual automobile contract
• Medical payments under a premises liability or other types of liability coverage
• Medicare or other governmental benefits, as permitted by law

The plan will not coordinate with the following types of health care plans:

• Any type of individual or family insurance health care program
• School accident coverage
• Benefits for the non-medical components of a group long-term care plan
• Medicare supplement policies, Medicaid policies, and coverage under other governmental plans unless permitted by law

To obtain all the benefits for which you are eligible, claims should be filed with each of your sources of coverage.

Primary Plan. The primary plan pays benefits without regard to any other benefit program.

Secondary Plan. The secondary plan pays benefits after the primary plan has paid benefits. The secondary plan benefits are reduced by what the primary plan has paid.

  

Determining Which Plan Pays First

When a claim is made, the primary plan pays its benefits as if the secondary plan did not exist. Then, the secondary plan reduces its benefits by what the primary health plan has paid. When determining whether this plan or another group plan is the primary payer, one of the following coordination rules will apply:

• This plan 
• If the other plan does not have a coordination of benefits provision or one that is consistent with this plan's provision, it will be primary. (It will not be primary if other coverage is obtained through a group membership and is a plan that supplements a larger overall program of benefits.)
• The plan that covers the person as an employee pays benefits before the plan that covers the person as a dependent (however, special provisions may apply if the person is also a Medicare beneficiary—see the following section Coordination with Medicare for details).
• The plan that covers the person as an active employee pays benefits before the plan that covers the person as a laid off or retired employee. 
• The plan that covers the person as an employee pays benefits before the plan that covers the person under a state or federal continuation provision. 
• The plan that covered the person the longest is primary.
• If the preceding rules do not determine which plan pays first, the allowable expenses will be shared equally between the health care plans. This plan will not pay more than it would have had it been primary.

In addition to the preceding rules, the following guidelines apply to eligible dependent children:

• When the parents are married, not legally separated, or have joint custody:
  • If neither parent has responsibility to provide health care coverage, the plan of the parent whose birthday (month and day) occurs earlier in the calendar year will pay first. When parents have the same birthday (month and day), the plan of the parent who has been covered longer will pay first.
  • If one of the parents has responsibility to provide health care coverage and the parent's plan is aware of the court decree, that plan is primary.
• When the parents are divorced or legally separated (even if they have never been married) and there is no court decree specifying which parent has responsibility for providing health care coverage, the order of benefits is:
  • The plan of the parent with custody
  • The plan of the spouse of the parent with custody
  • The plan of the parent without custody
  • The plan of the spouse of the parent without custody
• When parents are separated/divorced, have joint custody, and the court decree does not specify who has financial responsibility for the dependents' health care coverage, the plan will follow the birthday rule outlined earlier to determine which plan pays first. If a court decree specifies that one parent has financial responsibility for providing health care coverage, the plan of that parent will be primary.
• The plan that covers a person as an employee, or as that employee's dependent, will determine its benefits before those of a plan covering a person as a laid off or retired employee, or as that employee's dependent.
• If none of these rules decide which plan's benefits are payable first, the plan that has covered the person for the longest time will be primary.

  

Coordination With Medicare

At Age 65—As an active employee or covered spouse/domestic partner age 65 or older, you may be eligible to enroll for Medicare. As long as you are covered under a Company medical plan for active employees and you and/or your spouse/domestic partner has enrolled for Medicare, your Company plan coverage will be the primary payer of benefits. If you elect in writing to terminate coverage under a Company medical plan, then Medicare will be primary. 

Upon Disability—If you or a covered dependent become eligible for Medicare Disability benefits, Medicare will be the primary payer of benefits. This plan will be secondary and will coordinate its benefit with the full amount of estimated Medicare benefits—even if you are not enrolled in Medicare or certain services or facilities are not eligible for Medicare reimbursement.

  

Third Party Liability and Subrogation

There may be circumstances when Anthem pays benefits that should legally be paid by a third party. For example, if you are involved in a car accident, Anthem may pay benefits before issues of liability are worked out. In those types of situations, subrogation means that Anthem has the right to recover any money it has paid when a third party is legally responsible. Recovery of payments include reimbursements from a third party who has not yet made a payment, or from you if you have already received a payment from a third party.

The following information is Anthem's own language about this provision. If a third party is responsible for your medical expenses, you may request a copy of the official plan documents from the Benefits Department. 

 

Subrogation and reimbursement

These provisions apply when the plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a recovery or have received a recovery from any source. A “recovery” includes, but is not limited to, monies received from any person or party, any person’s or party’s liability insurance, uninsured/underinsured motorist proceeds, worker’s compensation insurance or fund, “no-fault” insurance and/or automobile medical payments coverage, whether by lawsuit, settlement or otherwise. Regardless of how you or your representative or any agreements characterize the money you receive as a recovery, it shall be subject to these provisions.

 

Subrogation

The plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries. The following apply:

• The plan has first priority from any recovery for the full amount of benefits it has paid regardless of whether you are fully compensated, and regardless of whether the payments you receive make you whole for your losses, illnesses and/or injuries.
• You and your legal representative must do whatever is necessary to enable the plan to exercise the plan's rights and do nothing to prejudice those rights.
• In the event that you or your legal representative fails to do whatever is necessary to enable the plan to exercise its subrogation rights, the plan shall be entitled to deduct the amount the plan paid from any future benefits under the plan.
• The plan has the right to take whatever legal action it sees fit against any person, party or entity to recover the benefits paid under the plan.
• To the extent that the total assets from which a recovery is available are insufficient to satisfy in full the plan's subrogation claim and any claim held by you, the plan's subrogation claim shall be first satisfied before any part of a recovery is applied to your claim, your attorney fees, other expenses or costs.
• The plan is not responsible for any attorney fees, attorney liens, other expenses or costs you incur. The ''common fund'' doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the plan.

 

Reimbursement

If you obtain a recovery and the plan has not been repaid for the benefits the plan paid on your behalf, the plan shall have a right to be repaid from the recovery in the amount of the benefits paid on your behalf and the following provisions will apply:

• You must reimburse the plan from any recovery to the extent of benefits the plan paid on your behalf regardless of whether the payments you receive make you whole for your losses, illnesses and/or injuries.
• Notwithstanding any allocation or designation of your recovery (e.g., pain and suffering) made in a settlement agreement or court order, the plan shall have a right of full recovery, in first priority, against any recovery. Further, the plan’s rights will not be reduced due to your negligence.
• You and your legal representative must hold in trust for the plan the proceeds of the gross recovery (i.e., the total amount of your recovery before attorney fees, other expenses or costs) to be paid to the plan immediately upon your receipt of the recovery. You and your legal representative acknowledge that the portion of the recovery to which the plan’s equitable lien applies is a plan asset
• Any recovery you obtain must not be dissipated or disbursed until such time as the plan has been repaid in accordance with these provisions.
• You must reimburse the plan, in first priority and without any set-off or reduction for attorney fees, other expenses or costs. The ''common fund'' doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the plan.
• If you fail to repay the plan, the plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the plan has paid or the amount of your recovery whichever is less, from any future benefit under the plan if:
  • The amount the plan paid on your behalf is not repaid or otherwise recovered by the plan; or
  • You fail to cooperate.
• In the event that you fail to disclose the amount of your settlement to the plan, the plan shall be entitled to deduct the amount of the plan’s lien from any future benefit under the plan.
• The plan shall also be entitled to recover any of the unsatisfied portions of the amount the plan has paid or the amount of your recovery, whichever is less, directly from the providers to whom the plan has made payments on your behalf. In such a circumstance, it may then be your obligation to pay the provider the full billed amount, and the plan will not have any obligation to pay the provider or reimburse you.
• The plan is entitled to reimbursement from any recovery, in first priority, even if the recovery does not fully satisfy the judgment, settlement or underlying claim for damages or fully compensate you or make you whole.

 

Your duties

• You must promptly notify the plan of how, when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved and any other information requested by the plan.
• You must cooperate with the plan in the investigation, settlement and protection of the plan's rights. In the event that you or your legal representative fails to do whatever is necessary to enable the plan to exercise its subrogation or reimbursement rights, the plan shall be entitled to deduct the amount the plan paid from any future benefits under the plan.
• You must not do anything to prejudice the plan's rights.
• You must send the plan copies of all police reports, notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you.
• You must promptly notify the plan if you retain an attorney or if a lawsuit is filed on your behalf.
• You must immediately notify the plan if a trial is commenced, if a settlement occurs or if potentially dispositive motions are filed in a case.

The plan administrator has sole discretion to interpret the terms of the subrogation and reimbursement provision of this plan in its entirety and reserves the right to make changes as it deems necessary.

If the covered person is a minor, any amount recovered by the minor, the minor’s trustee, guardian, parent, or other representative, shall be subject to this provision. Likewise, if the covered person’s relatives, heirs, and/or assignees make any recovery because of injuries sustained by the covered person, that recovery shall be subject to this provision.

The plan is entitled to recover its attorney’s fees and costs incurred in enforcing this provision.

The plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary. The plan shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.

 

  

 

Overpayment and Underpayment of Benefits

 

Whenever payment has been made in error, the claims administrator will have the right to make appropriate adjustment to claims, recover such payment from you or, if applicable, the provider, in accordance with applicable laws and regulations. In the event the claims administrator recovers a payment made in error from the provider, except in cases of fraud or misrepresentation on the part of the provider, they will only recover such payment from the provider within 365 days of the date the payment was made on a claim submitted by the provider. The claims administrator reserves the right to deduct or offset any amounts paid in error from any pending or future claim.

Under certain circumstances, if the claims administrator pays your healthcare provider amounts that are your responsibility, such as deductibles, copayments, or coinsurance, they may collect such amounts directly from you. You agree that the claims administrator has the right to recover such amounts from you.

The claims administrator has oversight responsibility for compliance with provider and vendor and subcontractor contracts. The claims administrator may enter into a settlement or compromise regarding enforcement of these contracts and may retain any recoveries made from a provider, vendor, or subcontractor resulting from these audits if the return of the overpayment is not feasible.

The claims administrator has established recovery policies to determine which recoveries are to be pursued, when to incur costs and expenses, and whether to settle or compromise recovery amounts. The claims administrator will not pursue recoveries for overpayments if the cost of collection exceeds the overpayment amount. The claims administrator may not provide you with notice of overpayments made by them or you if the recovery method makes providing such notice administratively burdensome.

 

  

Continuation of Coverage

Applying for COBRA coverage
Disability continuation
The cost of COBRA coverage
Address changes
When COBRA coverage begins and ends
For more information

  

COBRA (the Consolidated Omnibus Budget Reconciliation Act) is a federal law that allows you to continue group health care coverage at your own expense for a period of time after employer-provided coverage ends. If you and/or your dependents experience one of the qualifying events below, you or your dependents can elect to continue coverage for the corresponding time. Such coverage includes medical, dental, prescription drug, vision, mental health/substance abuse coverage, and the Health Care Reimbursement Account. All coverages you continue during COBRA, including the Health Care Reimbursement Account, will be paid for on an after-tax basis.

The coverage provided under COBRA is the same as that offered to active employees, including the right to change medical plan options at annual enrollment. Additionally, any coordination of benefit provisions of the health care plans will also apply to continued coverage under COBRA. Continued coverage may be extended if another qualifying event occurs during that time. However, no one may extend coverage for more than 36 months. The 36-month period is counted from the first event.

QUALIFYING EVENT	WHO MAY CONTINUE	HOW LONG
Your employment stops for any reason other than gross misconduct or you have a reduction in hours	You and your dependents	18 months
Divorce, legal separation, or termination of Domestic Partnership and you stop coverage for your spouse or children	Ex-spouse, legally separated spouse, domestic partner and/or your dependent children and domestic partner children	36 months
You or a family member become eligible for Social Security disabiltiy benefits within the first 60 days of losing coverage	You and your dependents	29 months
Dependent child no longer eligible	Dependent child	36 months
You become entitled to Medicare and experience a second qualifying event, or you experience a qualifying event and then become entitled to Medicare	Dependent spouse/DP, children & DP children	36 months
Your death	Dependent spouse/DP, children & DP children	36 months

  

Applying for COBRA Coverage

In most cases, you will be notified if you are eligible to continue coverage. However, you or your dependents must notify the Plan Administrator in the event of divorce, legal separation, termination of Domestic Partnership or when a dependent child is no longer eligible for coverage. You will then receive notice of eligibility for continuation of health care coverage under the plan.

You or your dependents will have 60 days to elect to continue coverage from the later of the date your coverage would end or the date your employer notifies you of your continuation rights. You will then have an additional 45 days to pay the cost of your COBRA coverage, retroactive to the date your plan coverage ended.

Voya is responsible for administering COBRA continuation coverage. This means that Voya will be your primary contact for premium and COBRA-related matters. You may contact Voya at 888-401-3539 if you have any questions or if need to request forms.

No "evidence of insurability" (proof of good health) is required to continue coverage under COBRA.

You and your dependents ("qualified beneficiaries") have the right to elect COBRA even if you have other coverage before you elect COBRA coverage (for example, if you have coverage under your spouse or domestic partner's plan at the time your coverage under your Company plans end). However, if you obtain other coverage after electing COBRA, your COBRA coverage will end, as specified in the table above.

Each qualified beneficiary has an independent right to elect continuation coverage. For example, both the employee and the employee's spouse/domestic partner may elect continuation coverage, or only one of them. Parents may elect to continue coverage on behalf of their dependent children. A qualified beneficiary may change a prior rejection of continuation coverage any time up until the 60-day notification date. If you or your dependents do not elect COBRA continuation coverage, coverage will end on the date explained under When Coverage Begins and Ends.

  

Your Coverage Options

At the time your active coverage ends, you may...

• Only elect COBRA coverage under those plans in which you are already enrolled, and
• Not add previously eligible but currently uncovered dependents through COBRA.

However once you elect COBRA coverage, you are entitled to participate in the plans' Open Enrollment as long as you are still eligible for and participating in COBRA coverage at that time. During Open Enrollment you may...

• Add previously uncovered (but eligible) dependents to your coverage,
• Change your plan election(s) - for example, you may switch from the CDHP Premier to the CDHP Basic, and
• Drop any coverages you no longer want.

Keep in mind that if you declined a particular coverage (either for yourself or your dependents) at the time you became eligible for COBRA coverage or you drop a particular coverage during Open Enrollment, you (or your dependents) may never reenroll in that coverage for the remainder of your COBRA coverage period.

  

If Your Family Situation Changes

If while covered under COBRA (as a former employee) you gain a child, either through birth or adoption, you may enroll the child and coverage will be effective immediately as long as you enroll the child within 31 calendar days of the birth or placement.

Dependents enrolled in COBRA under such circumstances may continue COBRA coverage for the maximum period allowed.

  

Disability Continuation

If you or a dependent is disabled before or within 60 days of when you become eligible to continue your coverage, you and your covered dependents may extend coverage for 29 months (rather than 18 months). To extend coverage, the disabled person must:

• Be entitled to receive Social Security disability benefits, and
• Notify Voya, the COBRA Administrator, within 60 days of the latest of: (1) the date of Social Security's disability determination; (2) the date of the qualifying event; (3) the date on which the qualified beneficiary loses coverage due to the qualifying event; or (4) the date on which the qualified beneficiary is informed of the obligation to provide the notice of disability.

Additionally, if Social Security determines that the disabled person is no longer disabled, he or she must notify the Plan Administrator within 31 days of the final determination.

  

The Cost of COBRA Coverage

You (or your covered dependents) must pay a premium for COBRA continuation coverage. The monthly cost is the full cost, including both employer and employee costs, plus a 2% administrative fee as permitted by law.

The premium will not exceed 102% of the rate that would apply for an active plan member with similar coverage on the date this premium was due. However, the amount charged to disabled individuals, will be increased to 150% of the current active rate for the 19th through the 29th month.

If you have a Health Care Reimbursement Account (HRA) at the time you elect COBRA coverage, the HRA will automatically continue with Anthem until the HRA balance is exhausted.

The premium rate will be determined at the beginning of the Plan Year and will apply to anyone who elects to continue coverage during that period. The premium rate will not change during the Plan Year, unless the Company revises the group health care program for all members, or continuing dependent coverage is terminated because there are no longer any eligible dependents under COBRA coverage.

  

Address Changes

You should keep Voya, the COBRA administrator, informed of any change of address for you or your family members. You should also keep a copy of any notices you send to Voya.

  

When COBRA Coverage Begins and Ends

COBRA coverage will begin on the first of the month following the date your active coverage ends. There should be no lapse in coverage since active coverage generally ends the last day of month following the date you or your dependents are no longer eligible, except in certain cases as described under When Coverage Begins and Ends.

An individual's continued coverage will end for any of the following reasons when:

• The cost of continued coverage is not paid on or before the date it is due,
• That person becomes entitled to, and enrolls in, Medicare after electing COBRA,
• That person becomes covered under another group health care plan (unless the individual would lose coverage due to a pre-existing condition), or
• The Company terminates all like coverage for all employees.

  

For More Information

Further information about COBRA coverage will be provided to you and/or your dependents when you or your dependents become eligible as explained previously.

If you have questions about your COBRA continuation coverage, you should contact Voya at 888-401-3539 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.