ORCHARD HEIGHTS, INC.
HEALTH AND LIFE INSURANCE
BENEFITS PLAN
Please note that this information is only a summary of the health
plans, including applicable medical, dental and life insurance benefits. The plan described herein is governed by its
plan documents, including any contracts with insurance companies and other
providers of benefits. If there are any
discrepancies between the information included herein and the plan documents,
the plan documents will govern.
PLAN ADMINISTRATION
Plan
Name
Orchard
Heights, Inc.
Health
and Life Insurance Benefits Plan
Plan
Administrator
Orchard
Heights, Inc.
5200
Chestnut Ridge Road
Orchard
Park, New York 14127
(716)
662-0651
The
administration of the plan will be under the supervision of the Plan
Administrator. To the fullest extent
permitted by law, the Plan Administrator will have the discretion to determine
all matters relating to eligibility, coverage and benefits under the Plan. The Plan Administrator will also have the
discretion to determine all matters relating to interpretation and operation of
the plan and to make factual determinations.
Any determination by the Plan Administrator, or any authorized delegate,
shall be final and binding.
Employer
Identification Number
16-1520691
Plan
Number
501
Type
of Plan
Group
Health Plan
Type
of Administration
Insurer
Name
and Addresses of Insurers
Univera
Healthcare
205
Park Club Lane
Buffalo,
New York 14221
Independent
Health Association
511
Farber Lakes Drive
Buffalo,
New York 14221
CIGNA
(Dental)
499
Washington Boulevard, 526
4th
Floor
Jersey
City, New Jersey 07310
Continental
Assurance Company (Life Insurance)
CNA
Plaza
Chicago,
Illinois 60685
Agent
for Service of Legal Process
If,
for any reason, you wish to seek legal action, you may serve legal process on
the Plan Administrator to the Agent for Service of Legal Process at the
following address:
CSC
P.O.
Box 13397
Philadelphia,
PA 19101
Service
of legal papers also may be made upon the Plan Administrator.
Plan
Year
For
governmental filing and reporting purposes, the official plan year for the
Orchard Heights, Inc. Health and Life Insurance Benefits Plan is January 1
through December 31.
WHO IS ELIGIBLE
Full-time Co-workers
You
are generally eligible to participate in the Orchard Heights, Inc. Health and
Life Insurance Benefits Plan if you are a full-time co-worker. A full time co-worker is an co-worker who
works at least 68 hours each two week pay period on a continuing basis. Eligible co-workers acquire time credits
toward benefits beginning the date of hire.
If you are a new co-worker you are eligible to participate in the plan
on the first day of the month 90 days after your date of hire. Time spent on a leave of absence is subtracted
from time periods necessary to earn benefits.
Leaves of absence exceeding six (6) months cause you to start anew the
earning of all benefits upon your return as if you were a new co-worker. An inactive co-worker (not working for a
period of two (2) months) is terminated unless on worker’s compensation, Family
Medial leave or disability. In that case the co-worker would be responsible for
any premiums due to applicable insurance.
Eligibility
for enrollment and re-enrollment is not based on health status, medical
condition (including both physical and mental illness), claims experience,
receipt of health care services, medical history, genetic information, or
evidence of insurability or disability if not otherwise specified by the Plan.
If
you do not elect group coverage at the time of initial eligibility, you may
only enter the plan at the next open enrollment. Life insurance coverage is effective the 1st day of
the month following receipt of completed enrollment/beneficiary forms.
Dependents
Please
see the definition of dependents in your enrollment booklet.
WHEN
COVERAGE BEGINS
If
you are a new co-worker enrolling in the health and/or dental insurance during
the year, coverage for you and your eligible dependents will begin on the 1st
of the next month 90 days following the date you start work, provided you have
elected coverage within 60 days of your start date. If you do not enroll when you are first eligible, restrictions
may apply for health plan elections.
If
you enroll or change coverage during the open enrollment period each year,
coverage for you and your dependents will begin on the effective date of the
change and remain in effect as long as you are still eligible for coverage.
MAKING
CHANGES
You
may make changes to your medical coverage once each year during annual
enrollment or when you experience a qualified life status change. A life status change is a change in your job
or family status that justifies a change in your medical elections during the
plan year. Qualified changes in job or
family status include:
·
Marriage, divorce, legal
separation
·
A change in the number
of dependents either through birth, death, adoption or placement for adoption
·
Employment or
termination of employment for your spouse or dependent
·
A change in employment
status, including a switch from full-time to part-time status or vice versa or
the beginning or end of an unpaid leave of absence for you, your spouse, or
dependent
·
A significant change in
medical coverage under your spouse’s health plan for you or your spouse
·
Your spouse or dependent
satisfying or failing to satisfy a medical plan’s coverage requirements due to
age, student status, or similar circumstances
·
A change of residence or
work site for you, your spouse, or dependent
·
You or one of your
covered dependents becomes entitled to Medicare or Medicaid
·
A judgment, decree, or
order resulting from a divorce, legal separation, annulment, or change in legal
custody (including a Qualified Medical Child Support Order) is issued requiring
health coverage for your child.
Please
note that even with a qualified life status change you can only make changes to
your benefit election that are consistent with your life status change. For example, if you have a child, you can
add the child to your medical plan, but you would not be able to change from
one medical plan to another. Changes
must be made within 30 days of the life status change. After your request is received, the benefit
change you request will go into effect as of the date the qualified event
occurred. Adding dependents with exception of birth need to be done at open
enrollment and you must notify the Employer thirty (30) days in advance.
WHEN
COVERAGE ENDS
Your
benefits coverage ends on the last day of the month in which you or the company
terminates your employment. Coverage
under this plan also ends if:
·
Orchard Heights, Inc.
terminates the plan
·
You are no longer
eligible for benefits
·
You fail to make a
required contribution
Your
dependent’s coverage ends if:
·
Orchard Heights, Inc.
terminates all dependent coverage under the plan
·
Your dependent becomes
covered as a co-worker
·
Your dependent is no
longer eligible for benefits
·
You fail to make any
required contributions
·
Your coverage terminates
You
may be eligible to continue coverage under the Consolidated Omnibus Budget
Reconciliation Act (COBRA). You may
also be able to continue coverage if you are on an approved leave.
CONTINUATION
OF COVERAGE (COBRA)
According
to the Consolidated Omnibus Budget Reconciliation Act (COBRA), you, your
spouse, and your dependent child(ren) may elect to temporarily continue group
medical coverage if you lose your benefits under certain circumstances. You will be required to pay the full cost of
coverage plus an administrative fee.
Individuals
entitled to COBRA continuation are called qualified beneficiaries. They include you, your spouse, and your
dependent child(ren) who are covered at the time of the qualifying event. In addition, a child who is born to you,
adopted, or placed with you for adoption during the COBRA coverage period is
also a qualified beneficiary and eligible for coverage.
COBRA
continuation is available for a maximum of 18, 29, or 36 months, depending on
the “qualifying events” under which you are eligible for the continuation. The maximum continuation period, if multiple
circumstances should occur, is a total of 36 months. This means, if your dependents experience a second qualifying
event within the original 18-month or 29-month period, they (but not you) may
extend the COBRA continuation period for up to an additional 18 months (for a
total of up to 36 months from the original qualifying event).
|
Qualifying Events that Result in Loss of Coverage |
Maximum Continuation Period |
||
|
|
Co-worker |
Spouse |
Child |
|
Co-worker’s
work hours are reduced and results in loss of coverage |
18
months |
18
months |
18
months |
|
Co-worker
terminates for any reason (other than gross misconduct) |
18
months |
18
months |
18
months |
|
Co-worker
becomes entitled to Medicare as a retiree · |
N/A |
36
months |
36
months |
|
Co-worker
or dependent is disabled (as defined by Title II or XVI of the Social
Security Act) at the time of the qualifying event or becomes disabled within
the first 60 days of COBRA continuation that begins as a result of
termination or reduction in work hours |
29
months |
29
months |
29
months |
|
Co-worker
dies |
N/A |
36
months |
36
months |
|
Co-worker
and spouse legally separate or divorce |
N/A |
36
months |
36
months |
|
Co-worker
becomes eligible for Medicare within 18 months prior to termination of
employment or reduction in work hours · |
N/A |
36
months |
36
months |
|
Child
no longer qualifies as a dependent |
N/A |
N/A |
36
months |
·
36-month period is
counted from the date you become entitled to Medicare
Electing
COBRA Continuation Coverage
You
and your covered dependents must choose to continue coverage within 60 days
after the later of the following dates:
·
The date you and your
covered dependents would lose coverage as a result of the qualifying event; or
·
The date Orchard
Heights, Inc. notifies you and your covered dependents of your right to choose
to continue coverage as a result of the qualifying event
Paying
for COBRA Continuation Coverage
If
you elect COBRA continuation coverage, you must pay the initial premium plus 2%
administrative fee (including all premiums due but not paid) within 45 days
after your election. Thereafter, COBRA
premiums must be paid monthly on the first day of each month. You are responsible for making payments each
month in a timely manner. If you elect
COBRA continuation coverage, but then fail to pay any of the premiums due
within the initial 45-day grace period, or you fail to pay any subsequent
premium, your coverage will be terminated retroactively to the last day for
which timely payment was made.
Cost
of COBRA Coverage
The
cost of COBRA medical is the full group cost of plan coverage per covered
person plus a 2% administrative fee. (A
spouse or dependent making a separate election will be charged the same rate as
a single co-worker.)
Cost
for Disabled Beneficiaries
If
you become disabled and receive long-term disability benefits, you may continue
medical coverage provided you continue to make contributions toward the cost of
coverage. However, the cost of medical
coverage for your dependents under COBRA for the 19th through 29th
months of coverage under the disability extension will be:
·
102% for any dependent
participating in a different coverage option than you are.
If
you have a second qualifying event while you are receiving COBRA continuation
for a disability the rate for your dependents will depend on when the second
qualifying event occurs:
·
If a second qualifying
event occurs during the first 18 months of coverage, then the 102% rate applies
to the full 36 months, but
·
If a second qualifying
event occurs during the 19th through 29th month, then the
rate for the 19th through 36th months of COBRA
continuation is:
o The 102% rate for any family members in a different
coverage option than you.
Changes
in Coverage During the Continuation Period
If
coverage under the plan is changed for active co-workers, the same changes will
be provided to individuals on COBRA continuation. Qualified beneficiaries also may change their coverage elections
during annual enrollment, if a qualified change in status occurs, or at other
times under the plan to the same extent that active co-workers may do so.
When
COBRA Continuation Coverage Ends
COBRA
continuation coverage for medical coverage will end when the first of the
following occurs:
·
The applicable
continuation period ends
·
The initial premium for
continued coverage is not paid within 45 days after the date COBRA is elected,
or any subsequent premium is not paid
·
After the date COBRA is
elected, the qualified beneficiary first becomes covered (as an co-worker or
otherwise under another group medical plan not offered by Orchard Heights,
Inc., which does not contain an exclusion or limitation affecting the person’s
pre-existing condition, or if the other plan does contain a pre-existing
condition limit or exclusion, it does not apply, due to rules under the Health Insurance
Portability and Accountability Act.
·
After the date COBRA is
elected, the qualified beneficiary first becomes entitled to Medicare (this
does not apply to other qualified beneficiaries who are not entitled to
Medicare)
·
In the case of the
extended coverage period due to a disability, there has been a final
determination, under the Social Security Act, that the qualified beneficiary is
no longer disabled. In such a case, the
COBRA coverage ends on the first day of the month at least 31 days from the
date the final determination is issued.
However, if a second qualifying event has occurred during the first 18
months, COBRA may continue based on that second qualifying event
·
For newborns and
children adopted or placed for adoption with you (the co-worker) during your
COBRA continuation period, the date your COBRA continuation period ends, unless
a second qualifying event has occurred
·
Orchard Heights, Inc.
terminates all group medical coverage for all co-workers.
YOUR MEDICAL OPTIONS
BREAST
RECONSTRUCTION BENEFITS
The
medical options provide benefits related to breast reconstruction in compliance
with the Women’s Health and Cancer Rights Act of 1998. This Federal law states that group health
plans provide medical and surgical benefits for mastectomy and must provide
certain additional benefits related to breast reconstruction
If
you (or a covered dependent) are receiving mastectomy benefits and elect breast
reconstruction in connection with the mastectomy, the medical plans will
provide coverage for:
·
Reconstruction of the
breast on which the mastectomy has been performed
·
Surgery and
reconstruction of the other breast to produce a symmetrical appearance
·
Prostheses and physical
complications of mastectomy, including lymphedrmas.
Benefits
will be provided as they would for any other surgical expense.
MATERNITY
Your
health plan and/or group health insurance insurer may not, under federal law,
restrict benefits for any hospital stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal delivery, or
less than 96 hours following a cesarean section. However, the mother’s or the newborn’s attending provider, after
consulting with the mother, may discharge the mother or her newborn earlier
than 48 hours (or 96 hours as applicable).
In any case, no pre-authorization from your health plan or the group
health insurance insurer is needed for a stay of up to 48 hours (or 96 hours).
QUALIFIED
MEDICAL CHILD SUPPORT ORDER
A
Qualified Medical Child Support Order is an order or judgment from a court or
administrative body, which directs the plan to cover a child as a participant
under the health plan. Federal law
provides that a medical child support order must meet certain form and content
requirements in order to be a Qualified Medical Child Support Order. When an order is received, each affected
participant and each child (or the child’s representative) covered by the order
will be given notice of the receipt of the order and a copy of the plan’s
procedure for determining if the order is valid. Coverage under the plan pursuant to a Qualified Medical Child
Support Order will not become effective until the Plan Administrator determines
that the order is a Qualified Medical Child Support Order. If you have any questions or would like to
receive a copy of the written procedure for determining whether a Qualified
Medical Child Support Order is valid, please contact the Plan Administrator.
COORDINATION
OF BENEFITS
Coordination
of Benefits is a method of paying benefits when more than one medical plan
covers you or a family member. It
determines how much each plan pays toward expenses. The contract or agreement
with the insurer or HMO, which is provided to each participant in the option
that has been selected, describes the terms and conditions regarding
coordination of benefits and subrogation (collecting from third parties who may
be liable for paying some of the health expenses).
MEDICARE
You
and your dependents may be eligible for Medicare at age 65, or after 24 months
of receiving Social Security Disability Income benefits, whichever comes first.
Medicare
consists of hospital insurance benefits (Part A) and Supplemental Medical
Insurance benefits (Part B). Generally,
you do not have to pay a premium for Part A; however, you are required to pay a
premium for Part B coverage. About
three months before your 65th birthday, you will receive an Initial
Enrollment Package from the Federal government, which includes information
about Medicare, a questionnaire, and your Medicare card. At this time, you can choose whether you
want to participate in Medicare Part B.
Co-workers have the option of choosing plan coverage or Medicare Part B,
or both, if they are Medicare eligible.
For more information on Medicare, visit the Medicare website at
www-medicare.gov or call the Social Security Administration at 1-800-772-1213.
GROUP
LIFE INSURANCE
Following
one year of continuous service, Orchard Heights, Inc. shall provide and pay for
a term life insurance policy. Please
refer to you life insurance packet for your eligible class.
FUNDING
MEDIUM
The HMOs and dental plans are fully insured
plans, which means the plan carriers assume financial responsibility for paying
claims.
CLAIMS
AND APPEALS PROCESS
Claims are processed according to the claims procedures described in the insurance documents provided by the applicable insurance carrier, or if the insurance documents do not provide a procedure, according to the rules described below.
A
person who files a claim for benefits under the Plan is called a
“claimant”. The insurance claims
administrator or other person authorized to review claims is called the “claims
reviewer.”
A claimant can be you, your beneficiary or a representative you authorize to act on your behalf. To authorize a representative, you and the representative must sign a statement to that effect. You must print your name and provide your social security number or plan identification number under your signature. Written designation of an authorized representative protects against disclosure of information about you except to your authorized representative.
Each health care claim will be classified as one of the following types of claim:
· Urgent care claims-any claim for medical care where:
o The claimant’s life or health, or the claimant’s ability to gain maximum function, is in jeopardy or
o The care is either reduced or terminated by the Plan, or
o The claimant request that the care be extended.
· Pre-service claims-any claim for non-urgent medical care that must be decided before the claimant will be given access to the care (that is, pre-authorization of the claim). A pre-service claim may also be classified as urgent care claim and, if so, the rules applicable to urgent care claims supercede the rules applicable to pre-service claims.
· Post-service claims-any claim for non-urgent medical care that has already been provided involving the payment or reimbursement of costs for the care.
A claims reviewer who has to make a decision whether to approve or deny a health care claim has to do so within the following time frames, depending on the claim’s classification:
· For urgent care claims-as soon as possible, taking into account the medical circumstances, but not later than 72 hours after the claims reviewer receives the claim, unless more information is needed to process the claim. If more information is needed, the claims reviewer has 24 hours to notify the claimant of the specific information needed, the claimant has 48 hours from receipt of the notice to provide the information, and the claims reviewer must make a decision within 48 hours after the earlier of the receipt of the needed information or the end of the claimant’s 48-hour period to provide the information.
· For concurrent care clams –as soon as possible, taking into account the medical circumstances, but not later than within 24 hours of a claimant’s request for an extension of care if the request was made at least 24 hours before the treatment is to end. A claimant must be given sufficient advance notice of any premature reduction or termination of an ongoing treatment by the Plan to permit the claimant to appeal and obtain a determination on review before the reduction or termination goes into effect.
· For pre-service claims-within a reasonable period of time appropriate to the medical circumstance, but not later than 15 days after the claims reviewer receives the claim, except that an extension of an additional 15 days may be taken in circumstances beyond control of the claims reviewer with notice to the claimant before the initial 15-day period expires. If the circumstances involve the need for more information, the claimant has 45 days from receipt of notice to provide the information, and the claims reviewer must make a decision within 15 days after the earlier of the receipt of the needed information or the end of the claimant’s 45-day period to provide the information.
· For post-service claims-within a reasonable period of time, but not later than 30 days after the claims reviewer receives the claim, except that an extension of an additional 15 days may be taken in circumstances beyond control of the claims reviewer with notice to the claimant before the initial 30-day period expires. If the circumstances involve the need for more information, the claimant has 45 days from receipt of notice to provide the information, and the claims reviewer has to make a decision within 15 days after the earlier of the receipt of the needed information or the end of the claimant’s 45-day period to provide the information.
Whenever an urgent or concurrent claim is approved, the claims reviewer must give verbal notice of the approval to the claimant followed within three days by written or electronic notice.
Whenever a claim is denied, the claims reviewer must give notice of the denial to the claimant in writing or electronically. The denial notice will include the specific reason(s) for the denial (including an explanation of the scientific or clinical basis used to support a finding that the proposed care is not medically necessary or experimental), specific reference to applicable Plan provisions on which the denial was based (including disclosure of any internal rule, guideline or protocol relied on in making the determination), a description of any additional information needed to complete the claim with an explanation of why it is necessary, instructions to be followed if the claimant wishes to appeal the denial (including how to appeal on an expedited basis if the denial pertains to an urgent or concurrent care claim), and a statement about the claimant’s right to bring a civil suit under ERISA following the appeal.
NOTE: State laws generally have special rules governing the processing of claims for insured health care benefits. These laws usually include claim determination processes similar to the procedures described in this section. However, if a rule described in this section is more favorable to a claimant than the rule under state law, this section’s rule may supercede the rule required by state law. As a result, the rules used to process an insured health care claim should be determined at the time that the claim is
Filed.
An appeal of the denied claim will be processed according to the procedures described in the insurance documents or, if the insurance documents do not described the appeal procedures used, according to the procedures described below.
To appeal a denied claim, the claimant must write a letter (as described below) to the plan’s claims reviewer authorized to review appeals within 180 days following the claimant’s receipt of the denial notice pertaining to the claim. If the denial notice pertains to a urgent or concurrent care claim, an expedited appeals process is available upon oral or written request of the claimant. All necessary information, including the decision on appeal, will be transmitted between the administrator reviewing the appeal and the claimant by telephone, facsimile or another method which is similarly expeditious.
No form of communication other than a letter (for example, telephone or e-mail) will constitute an appeal. The appeal letter should include the reasons why the claimant believes the claim was improperly denied, as well as any other data, questions or comments the claimant believes the claimant deems appropriate. The appeal letter also must be in the form directed by the claims reviewer and include all information required by the claims reviewer. If the claimant has any questions about how to file an appeal with a claims reviewer, he or she should call the claims reviewer directly.
When a denied claim is appealed the claimant has the right to submit written comments, documents, records, and other information relating the denied claim. The claimant also can access or obtain copies of any documents, records and other information relevant to the denied claim upon request and without charge.
The claims reviewer authorized to review a claimant’s appeal will be someone other than the decision maker of the initial claim determination. In making a decision, the claims reviewer will not defer to the findings and conclusions made with respect to the initial clams determination. If the denied claim being appealed is based in whole or in part on a medical judgment (including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate), the claims reviewer must consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved with the initial claims determination. The carrier or claims administrator making the initial claim determination must identify the medical and vocational experts whose advise was obtained on behalf of the Plan in connection with that determination, regardless of whether the advice was relied upon in making the determination.
The claims reviewer must decide upon the appeal within the applicable timeframes described below:
· For urgent and concurrent care claims-as soon as possible, taking into account the medical circumstances, but not later than 72 hours after receipt of the claimant’s appeal.
· For pre-service claims-within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the claimant’s appeal.
· For post-service claims-within a reasonable period of time, but not later than 60 days after receipt of the claimant’s appeal.
When
a decision regarding an appeal is made, the claimant will receive written or
electronic notice from the claims reviewer.
If the decision upholds the initial claim denial (that is, if an adverse
determination is made on appeal), the notice will include:
· The specific reason(s) for the adverse determination (including an explanation of the scientific or clinical basis used to support a finding that the proposed care is not medically necessary or experimental);
· Specific reference to applicable plan provisions on which the decision was based (including disclosure of any internal rule, guideline or protocol relied on in making the determination);
· A statement that the claimant is entitled to receive, upon request and free of charge; reasonable access to and copies of all documents, records and other information relevant to the denied claim;
· A statement regarding any voluntary appeal procedures offered by the plan and how to obtain information about those procedures;
· A statement about your right to bring a civil suit under ERISA; and
· If applicable, a statement about other voluntary alternative dispute resolution options available.
If the claimant decides to start a legal action regarding the denied claim, he or she must first follow the claim and appeal procedures applicable to the denied claim and comply with the time limits for taking legal action that are described in the applicable insurance documents, if any.
NOTE: State laws generally have special rules governing the review of denied claims for insured health care benefits. These laws usually include appeal processes similar to the appeal procedures described in this summary. However, if a rule described in this summary is more favorable to a claimant than the rule under state law, this summary’s rule may supercede the rule required by state law. As a result, the rules used to appeal a denied insured health care claim should be determined at the time that the appeal is filed.
STATEMENT
OF ERISA RIGHTS
As
a participant in the Orchard Heights, Inc. Co-worker Benefits Plan you are
entitled to certain rights and protections under the Co-worker Retirement
Income Security Act of 1974 (ERISA).
ERISA provides that all plan participants shall be entitled to:
·
Examine, without charge,
at the plan administrator’s office and at other specified locations, such as
worksites, all documents governing the plan, including insurance contracts and
collective bargaining agreements, 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 Pension and Welfare Benefit
Administration.
·
Obtain, upon written
request to the plan administrator, copies of documents governing the operation
of the plan, including insurance contracts and collective bargaining agreements
and a copy of the latest annual report (Form 5500 Series) and updated summary
plan description. The administrator may
make a reasonable charge for the copies.
·
Receive a summary of the
plan’s annual financial report. The
plan administrator is required by law to furnish each participant with a copy
of his or her summary annual report.
·
Continue health care
coverage for yourself, spouse, or dependent if there is a loss of coverage
under the plan as a result of a qualifying event. You or your dependents may have to pay for this coverage. Review this summary plan description and the
documents governing the plan on the rules governing your COBRA continuation
coverage rights.