Health and Welfare Plan

Health and Welfare Plan

Plan H002 Active and Retiree Plan For Employees and Retirees of

SAMPLE SPD BOOKLET

NATIONAL IAM BENEFIT TRUST FUND HEALTH AND WELFARE PLAN

To all Participating Employees:

On September 6, 1966, the Executive Council of The International Association of Machinists and Aerospace Workers established a nationwide Trust Fund known as the I.A.M. National Health and Welfare Plan. On October 1, 1979, the Plan became a part of the National IAM Benefit Trust Fund.

The purpose of the Fund is to provide health and welfare benefits to participants and their families. Medical coverage is self-funded through contributions paid by employers and employees participating in the Plan. Life insurance and Accidental Death and Dismemberment Benefits are insured through a contract with a life insurance company.

Medical benefits are provided only to the extent permitted by the contributions. Should contributions not provide sufficient funding to maintain benefits, the Trustees reserve the right to change the eligibility rules, reduce or change the benefits, or eliminate the Plan, in whole or in part.

Please read this booklet carefully and keep it in a safe place for future reference.

EMPLOYER TRUSTEES

Thomas Mitchell David R. Dietly Marie Underwood

UNION TRUSTEES

James Conigliaro Dora H. Cervantes Philip J. Gruber

TABLE OF CONTENTS

PAGE

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

SCHEDULE OF BENEFITS .....................................................................................................2

COVERED CHARGE LIMITS .................................................................................................6

PREFERRED PROVIDER ORGANIZATION (Cigna Open Access Plus Network) ..............7

Applicability of In-Network Benefits ........................................................................................7 Opportunity to Select a Primary Care Physician .......................................................................8 Cigna's Toll-Free Care Line ......................................................................................................9 Access to Cigna Participating Providers While Traveling ........................................................9 Case Management ......................................................................................................................9 When You Have a Complaint About Cigna ..............................................................................9

DISEASE MANAGEMENT PROGRAM (Cigna "Your Health First") ................................11

DEFINITIONS .........................................................................................................................12

ELIGIBILITY PROVISIONS .................................................................................................20

Active Employee Eligibility ....................................................................................................20 Retiree Eligibility.....................................................................................................................20 Surviving Spouse Eligibility ....................................................................................................20 Dependent Eligibility ...............................................................................................................21 Disabled Dependents ...............................................................................................................21 Qualified Medical Child Support Orders .................................................................................21 Enrollment................................................................................................................................22 Special Enrollment...................................................................................................................22 Effective Date ..........................................................................................................................22 Limitations ...............................................................................................................................23

TERMINATION AND CONTINUATION OF COVERAGE................................................24

Termination of Coverage for Employees.................................................................................24 Termination of Coverage for Dependents................................................................................24 Spouse's Termination of Coverage..........................................................................................24 Family and Medical Leaves of Absence ..................................................................................25 Coverage During Military Service...........................................................................................26 Extension of Benefits for Total Disability ...............................................................................26 Medically Necessary Student Leave of Absence.....................................................................27 Reinstatement of Coverage ......................................................................................................27

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Continuation of Health Coverage (COBRA) ...........................................................................27 Continuation Coverage Rules for Employees....................................................................28 Continuation Coverage Rules for Dependents...................................................................28 Disability and Continuation Coverage...............................................................................29 Application of Continuation Coverage to Retirees ............................................................30 Multiple Qualifying Events While on Continuation Coverage..........................................30 Summary of Periods of Continuation Coverage ................................................................31 Loss of Other Group Health Plan Coverage or Other Health Insurance Coverage ...........32 Benefits While on Continuation Coverage ........................................................................32 Notification Requirements for Continuation Coverage .....................................................32 Election of Continuation Coverage....................................................................................33 Cost of Continuation Coverage..........................................................................................33 Termination of Continuation Coverage .............................................................................34 Continuation Coverage and Other Extensions of Coverage ..............................................34 Health Insurance Portability and Accountability Act of 1996 (HIPAA) .................................35

COMPREHENSIVE MEDICAL COVERAGE ......................................................................36

Medical Benefits and Covered Charges...................................................................................36 Medical Benefit........................................................................................................................36 Covered Medical Charge .........................................................................................................36 Covered Charge Limits ............................................................................................................37 Deductible ................................................................................................................................37 Family Deductible Maximum ..................................................................................................37 Deductible Carry-Over.............................................................................................................37 Common Accident ...................................................................................................................37 Percentage Payable ..................................................................................................................37 Percentage Payable Increase ....................................................................................................38 Out-of-Pocket Maximum .........................................................................................................38 Accumulation of Deductibles and Out-of-Pocket....................................................................39 Lifetime Maximum ..................................................................................................................39

COVERED MEDICAL CHARGES LIST ..............................................................................40

Facility Charges .......................................................................................................................40 Practitioner Charges.................................................................................................................41 Medical Support Charges.........................................................................................................42

AREAS OF LIMITED COVERAGE ......................................................................................44

Acupuncture .............................................................................................................................44 Allergy Testing and Treatment ................................................................................................44 Bariatric Surgery......................................................................................................................44 Chiropractic Care .....................................................................................................................46 Clinical Trials...........................................................................................................................46 Erectile Dysfunction ................................................................................................................47 Genetic Testing ........................................................................................................................47 Home Health Care....................................................................................................................47

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