KANE FURNITURE CORPORATION - Explain My Benefits

PLAN DOCUMENT SUMMARY PLAN DESCRIPTION

for the

KANE FURNITURE CORPORATION HEALTH PLAN

This booklet describes the Plan Benefits in effect as of September 1, 2017

The Plan has been established for the benefit of eligible Employees and their Dependents of:

KANE FURNITURE CORPORATION

Claims Processed By:

ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC.

2806 South Garfield Street PO Box 3018

Missoula, MT 59806-3018

Missoula Area Phone Number: (406) 721-2222 Toll-Free Number: (800) 877-1122

Kane Furniture Corporation - Group #2003015

Plan Document / SPD - Effective 9/1/2017

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NETWORK PROVIDER BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 OAP LOW AND OAP HIGH OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 OAP HIGH DEDUCTIBLE HEALTH PLAN OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 TRANSITION OF CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

SCHEDULE OF MEDICAL BENEFITS - OAP LOW OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

SCHEDULE OF MEDICAL BENEFITS - OAP HIGH OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

SCHEDULE OF MEDICAL BENEFITS - OAP HIGH DEDUCTIBLE HEALTH PLAN (HDHP) OPTION . 24

PHARMACY BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 COST SHARING PROVISIONS - OAP LOW OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 COST SHARING PROVISIONS - OAP HIGH OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 COST SHARING PROVISIONS - OAP HIGH DEDUCTIBLE HEALTH PLAN (HDHP) OPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 SERVICE OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 DRUG OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 COPAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 SUPPLY LIMITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 PRIOR AUTHORIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

MEDICAL BENEFIT DETERMINATION REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 DEDUCTIBLE - OAP LOW AND OAP HIGH OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 DEDUCTIBLE - OAP HIGH DEDUCTIBLE HEALTH PLAN (HDHP) OPTION . . . . . . . . . . . . . . 40 BENEFIT PERCENTAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 OUT-OF-POCKET MAXIMUM - OAP LOW AND OAP HIGH OPTIONS . . . . . . . . . . . . . . . . . . 41 OUT-OF-POCKET MAXIMUM - OAP HIGH DEDUCTIBLE HEALTH PLAN (HDHP) OPTION . 41 COPAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 MAXIMUM BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 PRIOR PLAN DEDUCTIBLE CREDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 PRIOR PLAN COINSURANCE CREDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT . . . . . . . . . . . . . . . . 42 CHANGES IN COVERAGE CLASSIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 NEW YORK STATE EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

MEDICAL BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 ADVANCED RADIOLOGY IMAGING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 ALCOHOLISM AND/OR CHEMICAL DEPENDENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 AMBULATORY SURGICAL CENTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 CARDIAC REHABILITATION THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 CHIROPRACTIC CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 COLONOSCOPY BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 DENTAL SERVICES (COVERED UNDER MEDICAL BENEFITS) . . . . . . . . . . . . . . . . . . . . . . 47 DIABETIC NUTRITIONAL COUNSELING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 DIALYSIS TREATMENTS - OUTPATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 HOME HEALTH CARE BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 HOSPICE CARE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 HOSPITAL SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

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INBORN ERRORS OF METABOLISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 INFERTILITY TREATMENT BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 INFUSION SERVICES - OUTPATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 MAMMOGRAM BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 MEDICAL EQUIPMENT/SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 MENTAL ILLNESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 OCCUPATIONAL THERAPY - OUTPATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 ORGAN AND TISSUE TRANSPLANT SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 PHYSICAL THERAPY - OUTPATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 PREVENTIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 RECONSTRUCTIVE BREAST SURGERY/NON-SURGICAL AFTER CARE BENEFIT . . . . . . 54 RESIDENTIAL TREATMENT FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 ROUTINE NEWBORN INPATIENT NURSERY/PHYSICIAN CARE . . . . . . . . . . . . . . . . . . . . . 54 SKILLED NURSING FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 SPEECH THERAPY - OUTPATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 SURGICAL PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 URGENT CARE FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

EXPERIMENTAL COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

HOSPITAL ADMISSION CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 PRE-ADMISSION CERTIFICATION REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 CONTINUED STAY CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 EMERGENCY NOTIFICATION/CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

PRE-TREATMENT REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

MEDICAL BENEFIT EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

GENERAL PLAN EXCLUSIONS AND LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

COORDINATION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 ORDER OF BENEFIT DETERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Non-Dependent/Dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Child Covered Under More Than One Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Active or Inactive Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Longer or Shorter Length of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 No Rules Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 COORDINATION WITH MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 For Working Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 For Covered Persons who are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 For Covered Persons with End Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 71 COORDINATION WITH MEDICAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 COORDINATION WITH TRICARE/CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

PROCEDURES FOR CLAIMING BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Urgent Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Pre-Service Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Post-Service Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Concurrent Care Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 APPEALING AN UN-REIMBURSED PRE-SERVICE CLAIM . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 First Level of Benefit Determination Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Second Level of Benefit Determination Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 INDEPENDENT EXTERNAL REVIEW FOR A PRE-SERVICE CLAIM . . . . . . . . . . . . . . . . . . . 75 APPEALING AN UN-REIMBURSED POST-SERVICE CLAIM . . . . . . . . . . . . . . . . . . . . . . . . . . 75 First Level of Benefit Determination Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

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Second Level of Benefit Determination Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 INDEPENDENT EXTERNAL REVIEW FOR A POST-SERVICE CLAIM . . . . . . . . . . . . . . . . . . 76

ELIGIBILITY PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 EMPLOYEE ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 WAITING PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 DEPENDENT ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . 78 DECLINING COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

EFFECTIVE DATE OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 PARTICIPANT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 DEPENDENT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 OPEN ENROLLMENT PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 SPECIAL ENROLLMENT PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 CHANGE IN STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER . . . . . . . . . . . . . . . . . . . 83 PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS . . . . . . . . . . . . . . . . . . . . . . 84 ERISA REPORTING AND DISCLOSURE REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 84 NATIONAL MEDICAL SUPPORT NOTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

FAMILY AND MEDICAL LEAVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 EMPLOYERS SUBJECT TO FMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ELIGIBLE EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 REASONS FOR TAKING LEAVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ADVANCE NOTICE AND MEDICAL CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 PROTECTION OF JOB BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 UNLAWFUL ACTS BY EMPLOYERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ENFORCEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

TERMINATION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 PARTICIPANT TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 REINSTATEMENT OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 DEPENDENT TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 RESCISSION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

CONTINUATION COVERAGE AFTER TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 NOTIFICATION RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 ELECTION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 MONTHLY PREMIUM PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE . . . . . . 91 SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 WHEN COBRA CONTINUATION COVERAGE ENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 INFORM THE PLAN OF ADDRESS CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

COVERAGE FOR A MILITARY RESERVIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

FRAUD AND ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 MISSTATEMENT OF AGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

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MISREPRESENTATION OF ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 MISUSE OF IDENTIFICATION CARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 REIMBURSEMENT TO PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 RESCISSION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

RECOVERY/REIMBURSEMENT/SUBROGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 RIGHT TO RECOVER BENEFITS PAID IN ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 REIMBURSEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 SUBROGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 RIGHT OF OFF-SET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

PLAN ADMINISTRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 EFFECTIVE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 PLAN YEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 PLAN SPONSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 PLAN SUPERVISOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 NAMED FIDUCIARY AND PLAN ADMINISTRATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 PLAN INTERPRETATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 CONTRIBUTIONS TO THE PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 PLAN AMENDMENTS/MODIFICATION/TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 TERMINATION OF PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 SUMMARY PLAN DESCRIPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 PAYMENT OF CLAIMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 LEGAL PROCEEDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 NO WAIVER OR ESTOPPEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 VERBAL STATEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 FREE CHOICE OF PHYSICIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 WORKERS' COMPENSATION NOT AFFECTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 CONFORMITY WITH LAW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 FACILITY OF PAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 PROTECTION AGAINST CREDITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 PLAN IS NOT A CONTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

GENERAL DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

ERISA STATEMENT OF RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

HIPAA PRIVACY AND SECURITY STANDARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 PRIVACY CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 SECURITY CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

PLAN SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

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INTRODUCTION

Effective August 1, 2016, as restated September 1, 2017, Kane Furniture Corporation, hereinafter referred to as the "Company" or "Employer", reinstates the benefits, rights and privileges which will pertain to participating Employees, referred to as "Participants," and the eligible Dependents of such Participants, as defined, and which benefits are provided through a fund established by the Company and referred to as the "Plan." This booklet describes the Plan in effect as of September 1, 2017.

Coverage provided under this Plan for Employees and their Dependents will be in accordance with the Eligibility, Effective Date, Qualified Medical Child Support Order, Termination, Family and Medical Leave Act and other applicable provisions as stated in this Plan.

Kane Furniture Corporation (the Plan Sponsor) has retained the services of an independent Plan Supervisor, experienced in claims processing, to handle health claims. The Plan Supervisor for the Plan is:

Allegiance Benefit Plan Management, Inc. P.O. Box 3018

Missoula, MT 59806-3018

Please read this booklet carefully before incurring any medical expenses. For specific questions regarding coverage or benefits, please refer to the Plan Document which is available for review in the Personnel Office, at the office of the Plan Supervisor, or call or write to Allegiance Benefit Plan Management, Inc. regarding any detailed questions concerning the Plan.

This Plan is not intended to, and cannot be used as workers compensation coverage for any Employee or any covered Dependent of an Employee. Therefore, this Plan generally excludes claims related to any activity engaged in for wage or profit including, but not limited to, farming, ranching, part-time and seasonal activities. See Plan Exclusions for specific information.

The information contained in this Plan Document/Summary Plan Description is only a general statement regarding FMLA, COBRA, USERRA, and QMCSO's. It is not intended to be and should not be relied upon as complete legal information about those subjects. Covered Persons and Employers should consult their own legal counsel regarding these matters.

Pre-certification or Pre-treatment Review by the Plan is strongly recommended for certain services. If Pre-certification or Pre-treatment Review is not obtained, the charge could be denied if the service, treatment or supply is not found to be Medically Necessary or found to be otherwise excluded by the Plan when the claim is submitted.

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NETWORK PROVIDER BENEFIT

OAP LOW AND OAP HIGH OPTIONS

This Plan provides benefits for Network Providers only, except as stated below. A "Network Provider" means a provider that agrees to provide services as part of an agreement. Using Network Providers offers costsaving advantages because a Covered Person pays only a percentage of the scheduled fee for services provided.

Charges billed by a Non-Network Provider are not covered, except as stated below. Non-Network Provider means a provider who is not a Network Provider. A Covered Person who uses a Non-Network Provider may result in balance billing.

When a covered service is rendered by a Non-Network Provider, charges will be paid as if the service were rendered by a Network Provider under any of the following circumstances:

1.

Charges for an Emergency as defined by this Plan, limited to only those emergency medical

procedures necessary to treat and stabilize an eligible Injury or Illness and then only to the extent that

the same are necessary in order for the Covered Person to be transported, at the earliest medically

appropriate time to a Network Hospital, clinic or other facility, or discharged.

2.

Charges which are incurred as a result of and related to confinement in or use of a Network Hospital,

clinic or other facility only for Non-Network services and providers over whom or which the Covered

Person does not have any choice in or ability to select.

OAP HIGH DEDUCTIBLE HEALTH PLAN OPTION

This Plan provides benefits through a group of contracted providers (Network Provider). A "Network Provider" means a provider that agrees to provide services as part of an agreement. Using Network Providers offers cost-saving advantages because a Covered Person pays only a percentage of the scheduled fee for services provided.

Non-Network Provider means a provider who is not a Network Provider. A Covered Person who uses a NonNetwork Provider will pay more and may result in balance billing.

To determine if a provider qualifies as a Network Provider under this Plan, please consult Allegiance's website at to access links for directories of Network Providers.

The Benefit Percentages for benefits may vary depending on the type of service and provider rendering the service or treatment. If a Non-Network Provider is chosen over a Network Provider, the Benefit Percentage will be lower (as stated in the following Schedule of Medical Benefits), except as stated below.

When a covered service is rendered by a Non-Network Provider, charges will be paid as if the service were rendered by a Network Provider under any of the following circumstances:

1.

Charges for an Emergency as defined by this Plan, limited to only those emergency medical

procedures necessary to treat and stabilize an eligible Injury or Illness and then only to the extent that

the same are necessary in order for the Covered Person to be transported, at the earliest medically

appropriate time to a Network Hospital, clinic or other facility, or discharged.

2.

Charges which are incurred as a result of and related to confinement in or use of a Network Hospital,

clinic or other facility only for Non-Network services and providers over whom or which the Covered

Person does not have any choice in or ability to select.

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