SUMMARY PLAN DESCRIPTION - Playhouse Square
SUMMARY PLAN DESCRIPTION
FOR THE
PLAYHOUSE SQUARE FOUNDATION
MEDICAL AND DENTAL HEALTH PLAN
TABLE OF CONTENTS
Page
INTRODUCTION 1
ELIGIBILITY 1
When Can I Become A Participant In The Plan? 1
What Are The Eligibility Requirements Of Our Plan? 1
When Is My Entry Date? 1
Are There Any Employees Who Are Not Eligible? 2
What Must I Do To Enroll In The Plan? 2
Do I Have Any Special Enrollment Rights? 2
When Does My Participation End In The Plan? 2
COBRA Continuation Coverage 2
THE PLAN'S BENEFITS 5
What Benefits Are Available? 5
BENEFIT PAYMENTS 5
When Will I Receive Payments From This Plan? 5
amendment or termination of the plan 5
No contract of employment 5
ADDITIONAL PLAN INFORMATION 6
Your Rights Under ERISA 6
Claims Process 7
Protection of Health Information 8
Family or Medical Leaves of Absence 8
Statement of Rights Under Newborns' and Mothers' Health Protection Act 9
Notice Regarding Women's Health and Cancer Rights Act 9
Notice of Special Enrollment Rights 9
GENERAL INFORMATION ABOUT OUR PLAN 9
General Plan Information 9
Employer and Plan Sponsor Information 10
Plan Administrator Information 10
Carrier Information 10
Service of Legal Process 10
Type of Administration 11
Funding Medium 11
Important Disclaimer 11
SUMMARY 11
INTRODUCTION
PLAYHOUSE SQUARE FOUNDATION (THE "EMPLOYER") IS PLEASED TO ANNOUNCE THAT WE CONTINUE TO MAINTAIN A HEALTH BENEFIT PLAN FOR YOU AND OTHER ELIGIBLE EMPLOYEES. THIS HEALTH CARE PLAN PROVIDES COVERAGE FOR YOU AND YOUR ELIGIBLE DEPENDENTS FOR MEDICAL AND HOSPITALIZATION TYPE EXPENSES. THE BENEFITS AVAILABLE ARE OUTLINED IN THIS SUMMARY PLAN DESCRIPTION. WE WILL ALSO TELL YOU ABOUT OTHER IMPORTANT INFORMATION CONCERNING THE PLAN, SUCH AS THE LAWS THAT PROTECT YOUR RIGHTS.
Read this Summary Plan Description carefully so that you understand the provisions of our Plan and the benefits you will receive. We want you to be fully informed while you are a participant. You should direct any questions you have to the Administrator.
This Summary Plan Description highlights the important features of the Plan. It is not intended to give all details of the Plan. The Plan, and not this Summary Plan Description, is the official document which controls your rights, benefits and duties under the Plan. Any future revision of the Summary Plan Description shall completely replace and override this Summary Plan Description in all respects. There is a plan document on file that you may review if you desire. In the event there is a conflict between this Summary Plan Description and the Plan document, the Plan document will control.
ELIGIBILITY
WHEN CAN I BECOME A PARTICIPANT IN THE PLAN?
Before you become a member or a "participant" in the Plan, there are certain rules that you must satisfy. First, you must meet the "eligibility requirements." After that, the next step is to actually join the Plan on the "entry date" that we have established for all employees. You will also be required to complete certain application forms before you can enroll in the Plan.
What Are the Eligibility Requirements of Our Plan?
You will be eligible to join the Plan as detailed in the Certificates of Coverage provided by Medical Mutual of Ohio (Health and Prescription) and Ameritas (Dental) which are attached to and hereby made a part of this document.
When Is My Entry Date?
You can join the Plan after you meet the eligibility requirements as provided for in the Certificate of Coverage.
Are There Any Employees Who Are Not Eligible?
Yes, there are certain employees who are not eligible to join the Plan. They are:
Employees who are not eligible for coverage under our group medical plan as provided by the Employer's policy and as detailed in the Certificate of Coverage.
What Must I Do to Enroll in the Plan?
Before you can join the Plan, you must complete an application to participate in the Plan. The Employer will provide you with that application at the appropriate time.
DO I HAVE ANY SPECIAL ENROLLMENT RIGHTS?
In certain circumstances, a special enrollment period may be available for certain eligible persons and/or dependents who did not enroll during the initial or open enrollment periods as explained in the Certificate of Coverage. The Plan's Special Enrollment Notice also contains important information about the special enrollment rights that you may have, a copy of which was previously furnished to you. Contact the Administrator if you need another copy.
When does my participation end in the Plan?
Your coverage under the Plan terminates as provided for in the Certificate of Coverage.
COBRA CONTINUATION COVERAGE
If coverage under the Plan ceases for you, your eligible spouse and your eligible dependents, under certain circumstances you, your eligible spouse and your eligible dependents may be able to continue coverage under this Plan under a federal law called COBRA. COBRA continuation coverage is a continuation of coverage under the Plan when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed below. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happens:
(1) Your hours of employment are reduced, or
(2) Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because of any of the following qualifying events happens:
(1) Your spouse dies;
(2) Your spouse's hours of employment are reduced;
(3) Your spouse's employment ends for any reason other than his or her gross misconduct;
(4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or
(5) You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because of the following qualifying events happens:
(1) The parent-employee dies;
(2) The parent-employee's hours of employment are reduced;
(3) The parent-employee's employment ends for any reason other than his or her gross misconduct;
(4) The parent-employee becomes enrolled in Medicare (Part A, Part B, or both);
(5) The parents become divorced or legally separated; or
(6) The child stops being eligible for coverage under the Plan as a "dependent child."
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the Employer must notify the COBRA Administrator of the qualifying event.
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Administrator within 60 days after the qualifying event occurs. You must send this notice to: Michelle Meers, Director of Human Resources. In addition, if applicable, you must provide a certified copy of the court order granting the divorce or legal separation.
Once the Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare (Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.
Disability Extension of 18-month Period of Continuation Coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Administrator in a timely fashion, you and entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to start at some time before the 60th day of COBRA continuation coverage and last at least until the end of the 18-month period of continuation coverage.
Second Qualifying Event Extension of 18-month Period of Continuation Coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, your spouse and dependent children can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
If You Have Questions About COBRA
Questions concerning your Plan or your COBRA continuation coverage should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health benefits, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.)
In order to protect your family's rights, you should keep the Administrator 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 the Administrator.
THE PLAN'S BENEFITS
WHAT BENEFITS ARE AVAILABLE?
This Plan provides insurance for a number of medical and health care expenses that are incurred by you and your eligible dependents, as detailed in the attached Certificate of Coverage. The specific benefits available to you, including limitations and exclusions, are also detailed in that Certificate of Coverage. You must read the Certificate of Coverage to understand your benefits.
Also, information as to Creditable Coverage, Preexisting Conditions, Coordination of Benefits, Subrogation, and How to File a Claim for Benefits are all addressed in the Certificate of Coverage.
BENEFIT PAYMENTS
WHEN WILL I RECEIVE PAYMENTS FROM THIS PLAN?
Generally, you will not receive payments from the Plan but, instead, the Carrier will make payments directly to the provider for medical and/or hospitalization expenses incurred by you and your dependents.
amendment or termination of the plan
THE EMPLOYER, AS PLAN SPONSOR, HAS THE RIGHT TO AMEND OR TERMINATE THE PLAN AT ANY TIME. IF THE PLAN IS TERMINATED, YOUR COVERAGE UNDER THE PLAN WILL END.
No contract of employment
THE PLAN IS NOT INTENDED TO BE, AND MAY NOT BE CONSTRUED AS CONSTITUTING, AN EMPLOYMENT CONTRACT OR OTHER ARRANGEMENT BETWEEN YOU AND THE EMPLOYER.
ADDITIONAL PLAN INFORMATION
YOUR RIGHTS UNDER ERISA
As a Participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ("ERISA"). ERISA assures that all Plan Participants shall be entitled to:
( Examine, without charge, at the Administrator's office all documents governing the Plan and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
( Obtain, upon the written request to the Administrator, copies of documents governing the operation of the Plan and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Administrator may make reasonable charge for the copies.
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including the Employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain times schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree, with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order, you may file a suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance form the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
If you have any questions about your Plan, you should contact the Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C., 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
Claims Process
You should submit claims during the Plan Year to the Carrier as detailed in the Certificate of Coverage. Claims for benefits that are insured will be reviewed in accordance with procedures contained in that insurance policy.
If you have followed the appropriate submission procedure for the benefits as outlined in the Certificate of Coverage and the Administrator denies all or part of your claim, you will be notified by the Administrator within 30 days (or an additional 15 days, if more time is required and you are provided with a notice of extension within the first 30 day period) of filing your claim. The Notification will state the following: (1) the reason your claim was denied, (2) specific references to the provisions of the Plan upon which the denial is based, (3) a description of any additional information or material necessary to review your claim and an explanation of why such material or information is necessary, (4) the procedures you must take to submit your claim for review, including the applicable time limits, and (5) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion, or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request; or (6) if the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request.
If you decide to appeal your claim, you must ask the Administrator in writing to review the denial of your claim within 180 days after receiving the written notice that your claim was denied. You will be given the opportunity to submit written comments, documents, records, and other information relating to the claim of benefits, and you shall be provided, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to your claim for benefits. The review will take into account all comments, documents, records, and other information submitted by you relating to your claim, without regard to whether such information was submitted or considered in the initial benefit determination.
Within 60 days after the Administrator receives your written appeal, you will be given a written notice of the Administrator's decision. The written response of the Administrator will include (1) the reasons for their decision and references to the Plan's provisions on which the decision is based, (2) a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits, (3) a description of any voluntary appeal procedures offered by the Plan and your right to obtain information about such procedures, (4) a statement of your right to bring action under section 502(a) of ERISA, (5) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline protocol, or other similar criterion, or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline protocol or other similar criterion will be provided free of charge to the claimant upon request, and (6) if the adverse benefit determination is based upon a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provide free of charge upon request. You and your Plan may have other voluntary alternative dispute resolution opportunities, such as mediation. One way to find out what may be available is to contact the U. S. Department of Labor Office and your State insurance regulatory agency. The Administrator has the exclusive right to interpret and administer the Plan.
The exhaustion of the claim appeal procedure is mandatory for resolving every claim and dispute arising under this Plan.
Protection of Health Information
The Plan has committed to complying with the Health Insurance Portability and Accountability Act of 1996 with respect to your health information. This means that there are limited uses and disclosures which will be made of the protected health information that your Employer (and the claims administrator) receive in conjunction with this Plan to be utilized in processing your claims. The Plan will only disclose protected health information as permitted by law, or as may be authorized by you, and will limit access of that protected health information to persons at the Employer who have been designated in the Plan document.
QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO)
As explained in the Certificate of Coverage, an order or judgment may be made by a state court or through an administrative process under state law directing the Administrator to provide coverage for a dependent child under the Employer's Plan. Coverage will be provided according to federal and applicable state law. If the Employer receives such an order, you and your child(ren) will be notified.
A complete description of the Plan’s procedures regarding QMCSOs is available without charge upon request to the Administrator.
Family or Medical Leaves of Absence
A complete description of your rights while on an approved family or medical leave of absence with regard to the Plan can be found in the Certificate of Coverage
Statement of Rights Under Newborns' and Mothers' Health Protection Act
A COMPLETE DESCRIPTION OF YOUR RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT WITH REGARD TO THE PLAN CAN BE FOUND IN THE CERTIFICATE OF COVERAGE.
Notice Regarding Women's Health and Cancer Rights Act
THE NOTICE REGARDING THE WOMEN'S AND HEALTH CANCER RIGHTS ACT WITH REGARD TO THE PLAN CAN BE FOUND IN THE CERTIFICATE OF COVERAGE.
Notice of Special Enrollment Rights
IF YOU ARE DECLINING ENROLLMENT FOR YOURSELF OR YOUR DEPENDENTS (INCLUDING YOUR SPOUSE) BECAUSE OF OTHER HEALTH INSURANCE COVERAGE, YOU MAY IN THE FUTURE BE ABLE TO ENROLL YOURSELF OR YOUR DEPENDENTS IN THIS PLAN, PROVIDED THAT YOU REQUEST ENROLLMENT WITHIN 31 DAYS AFTER YOUR OTHER COVERAGE ENDS. IN ADDITION, IF YOU HAVE 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 REQUEST ENROLLMENT WITHIN 30 DAYS AFTER THE MARRIAGE, BIRTH, ADOPTION OR PLACEMENT FOR ADOPTION.
GENERAL INFORMATION ABOUT OUR PLAN
THIS SECTION CONTAINS CERTAIN GENERAL INFORMATION THAT YOU MAY NEED TO KNOW ABOUT THE PLAN.
General Plan Information
The Playhouse Square Foundation Medical and Dental Health Plan is the name of the Plan.
The Plan Sponsor has assigned Plan Number 510 to your Plan.
The provisions of your Plan become effective July 1, 2009; however, a health and dental plan has been in effect for many years.
Your Plan's records are maintained on a twelve-month period of time. This is known as the Plan Year. The Plan Year begins on July 1 and ends on June 30.
employer and plan sponsor Information
The Employer and the Plan Sponsor's name, address and federal employer identification number are:
Playhouse Square Foundation
1501 Euclid Avenue, Suite 200
Cleveland, OH 44115
23-730-4942
Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator is:
Michelle Meers
Director of Human Resources
1501 Euclid Avenue, Suite 200
Cleveland, OH 44115
(216) 348-5282
The Administrator keeps the records for the Plan and is responsible for the administration of the Plan. The Employer establishes rules and regulations for the administration of the Plan. The decisions regarding any questions involving the Plan will be conclusive to the extent allowed by applicable law. The Administrator will also answer any questions you may have about our Plan. You may contact the Administrator for any further information about the Plan.
CARRIER INFORMATION
The name and address of the Plan's Health Carrier is:
Medical Mutual of Ohio
Group Services, Inc.
P.O. Box 951922
Cleveland, Ohio 44193
The name and address of the Plan's Dental Carrier is:
Ameritas Group
P.O. Box 81889
Lincoln, NE 68501
Service of Legal Process
The name and address of the Plan's agent for service of legal process is:
Patricia Gaul
Vice President of Finance/Administration and Legal Counsel
1501 Euclid Avenue, Suite 200
Cleveland, OH 44115
Service of process may also be made upon the Plan Administrator (if different than listed above).
Type of Administration
The type of Administration is by the Carrier as detailed in the Certificate of Coverage.
FUNDING MEDIUM
The Plan is fully insured. Benefits are provided under a group insurance contract entered into between the Employer and the Carrier. The Carrier is responsible for paying benefits.
Insurance premiums for employees and their families are paid in part by the Employer and in part by employees. The Administrator maintains a schedule of all applicable premiums paid in full by the Employer
IMPORTANT DISCLAIMER
The benefits of the Plan are provided solely pursuant to an insurance contract between the Employer and the Carrier. If the terms of this Summary Plan Description conflict with the terms of the insurance contract, then the terms of the insurance contract will control, unless superseded by applicable law.
SUMMARY
THE MONEY YOU EARN IS IMPORTANT TO YOU AND YOUR FAMILY. YOU NEED IT TO PAY YOUR BILLS, ENJOY RECREATIONAL ACTIVITIES AND SAVE FOR THE FUTURE. OUR HEALTH CARE PLAN WILL HELP YOU KEEP MORE OF THE MONEY YOU EARN BY PROVIDING YOU WITH PROTECTION AS TO CERTAIN COVERED MEDICAL EXPENSES. THE PLAN IS THE RESULT OF OUR CONTINUING EFFORTS TO FIND WAYS TO HELP YOU GET THE MOST FOR YOUR EARNINGS AND PROVIDE YOU WITH A BENEFIT FOR YOU AND YOUR FAMILY.
If you have any questions regarding this document, please contact the Administrator.
The Fedeli Group
HEALTH CARE PLAN DOCUMENT
AND SPD FORM
Name of Employer: Playhouse Square Foundation
Plan Name (from 5500): Playhouse Square Foundation Medical and Dental Health Plan
Name of Carrier Providing Coverage: Medical Mutual of Ohio
Ameritas Group
Plan Year:
a. Begins July 1
b. Ends June 30
Will any affiliated employer be covered by this Plan?
a. No X
b. Yes. following names of affiliated employers:
1)
2)
3)
4)
5)
Employer's Address and Telephone No.: 1501 Euclid Avenue, Suite 200
Cleveland, OH 44115
(216) 771-4444
Employer's Tax ID No: 23-730-4942
Plan No: 510
Plan Administrator shall be:
a) Employer, using employer's address
b) X Other, using following name, address and telephone no:
Michelle Meers
Director of Human Resources
1501 Euclid Avenue, Suite 200
Cleveland, OH 44115
(216) 348-5282
Plan's Agent for service of legal process is:
a) X Employer, using employer's address
b) Other, using following name, address and telephone no:
Service of process may also be made upon the Plan Administrator (if different than listed above).
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