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 Long Term Disability Income Plan |
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COLBY COLLEGE SUMMARY PLAN DESCRIPTION COLBY COLLEGE HEALTH PLAN I. PLAN INFORMATION (1) Name of Plan: Colby College Health Plan (2) Name and address of Plan sponsor: (3) Employer Identification Number of Plan sponsor: 01-0211497 (4) Plan number: 501 (5) Type of plan: Group Health Plan (6) Plan year: January 1 through December 31 (7) Type of administration: The Plan is administered under contracts with the following insurance carriers: Anthem Blue Cross Blue Shield of Maine
Maine Partners Health Plan
HMO Maine
CIGNA Behavioral Health
(8) Name, business address and business telephone number of Plan Administrator: Colby College
(9) Name and address of agent for service of legal process: Director of Personnel
(10) Eligibility requirements and description of benefits: For eligibility conditions and requirements, please refer to the benefit booklet(s) prepared by the applicable insurance provider. (11) Loss of benefits: Your coverage and/or your eligible dependent’s coverage under the Plan will terminate as of the earlier of (1) the date the Plan terminates or (2) the date on which coverage, or your election to receive coverage, is terminated under (a) the Colby College Cafeteria Plan, (b) coverage provided the applicable group insurance company or (c) a Qualified Medical Support Order (see 14 below). For a description of circumstances which may result in disqualification, ineligibility, denial, loss, forfeiture or suspension of any benefits, please refer to the benefit booklet(s) prepared by the applicable insurance provider. (12) Source of contributions: Employees are required to make contributions as described in the Colby College Staff Handbook, the Colby College Faculty Handbook and enrollment materials which are available in the Personnel Office. (13) Funding Medium: The insurance carriers listed in (7) above provide benefits under insurance policies or contracts issued to Colby College. These vendors are solely responsible for financing and providing the benefits due under the insurance policies and contracts. Colby College has no liability for any benefits due, or alleged to be due, under any such insurance policies or contracts. (14) Support order procedures: Upon request, copies of the procedures for Qualified Medical Child Support Orders (QMCSOs) may be obtained from the Administrator free of charge. (15) Special Enrollment Periods: 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 one of the health care options offered by the Plan Sponsor, provided that you request enrollment within 30 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. (16) Provider Lists or Directories: Provider lists or directors will be provided, without charge, for the applicable health care provider networks utilized by the Plan. (17) Maternity stays: Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of 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, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). (18) Reconstructive Surgery Following Mastectomies: A federal law known as the Women’s Health & Cancer Rights Act of 1998 requires group health plans that provide coverage for mastectomies to provide mastectomy-related benefits to plan participants: Specifically, the legislation requires that when a covered individual receives benefits for a mastectomy and decides to have breast reconstructive surgery, the plan and its insurance companies and HMOs must provide coverage in a manner determined in consultation with the attending physician and the patient, for:
Coverage for the procedures will be the same as that for any other medical/surgical benefit under the medical plan you have elected, and certain general coverage limitations may apply including, but not limited to, deductibles, co-insurance, co-payments and reasonable and customary charges. Please refer to the description of your medical plan coverage in the schedule of benefits or other description for the medical plan you have elected. (19) Amendment and Termination of Plan: As sponsor of the Plan, Colby College reserves the right to amend or terminate the Plan, at any time and for any reason whatsoever. Any modification, amendment or termination of the Plan will be by written instrument signed by an officer of the Plan Sponsor and delivered to the Plan Administrator. No vested rights of any nature are provided under the Plan. II. CLAIMS AND APPEALS PROCEDURE A claim for benefits is a request for a Plan benefit or benefits, made by a claimant or dependent or their representative, that complies with the Plan’s reasonable procedure for making benefit claims. A claim for benefits includes a request for a coverage determination, for pre-authorization or approval of a Plan benefit, or for a utilization review determination in accordance with the terms of the Plan. A claim for benefits should be filed with the applicable insurance carrier in accordance with the insurance carrier’s procedures, as set forth in the benefit booklet(s) prepared by the applicable insurance provider. If you have any questions about a claim payment, contact the insurance carrier. If you do not agree with the reason why your claim was denied, in whole or in part, you should write to the insurance company that denied your claim. An appeal of a claim which was denied should be filed in accordance with the applicable insurance carrier’s procedures, as set forth in the benefit booklet(s) prepared by the applicable insurance provider. III. CONTINUATION OF MEDICAL COVERAGE UNDER COBRA A federal law known as "COBRA" requires that most employers sponsoring group health plans offer employees and their families ("qualified beneficiaries") the opportunity to elect and pay for a temporary extension of health coverage called "continuation coverage" at group rates in certain instances ("qualifying events") where coverage under the Plan would otherwise end. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of that law. (Both you and your spouse should take the time to read this notice carefully.) If you are an employee of Colby College covered by the Plan, you have a right to choose this continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). If you are the spouse of any employee covered by the Plan, you have the right to choose continuation coverage for yourself if you lose group health coverage under the Plan for any of the following four reasons:
In the case of a dependent child of an employee covered by the Plan, he or she has the right to choose continuation coverage if group health coverage under the Plan is lost for any of the following five reasons:
Rights similar to those described above may, in certain instances, apply to retirees, retirees’ spouses and retirees’ dependents if Colby College is involved in a proceeding under Title 11, United States Code, and those individuals lose health coverage as a result of that proceeding. Under the law, the employee or a family member has the responsibility to inform Colby College of a divorce, legal separation or a child losing dependent status under the Plan within 60 days of the later of the date of such event or the date on which coverage would be lost because of such event. Failure to Colby College has the responsibility to notify the Plan Administrator of the employee's death, termination of employment, reduction in hours, commencement of a proceeding in bankruptcy with respect to Colby College or Medicare entitlement. Under the law, you have at least 60 days from the date you would lose coverage because of one of the events described above to inform Colby College that you want to elect continuation coverage. If you do not elect continuation coverage on a timely basis, your group health coverage will end. If you elect continuation coverage, Colby College is required to permit you to elect and purchase coverage which, as of the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated employees or family members. The law requires that you be afforded the opportunity to maintain continuation coverage for 36-months unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, the required continuation coverage period is 18 months. For spouses or dependent children of employees covered by the Plan, this 18-months may be extended to 36-months from the date employment terminated or hours were reduced if a second event entitling you to choose continuation coverage (such as death, divorce, legal separation, ceasing to be a dependent child, or Medicare entitlement) occurs within the 18-month period. If a second qualifying event entitles you to extend your period of continuation coverage to 36 months, you must notify the Plan Administrator of the second qualifying event within 60 days of the second qualifying event. The 18-months may be extended to 29-months if a qualified beneficiary is determined by the Social security Administration (for purposes of Title II (OASDI) or Title XVI (SSI) of the Social Security Act) to have been disabled at any time during the first 60 days of COBRA continuation coverage. This 11-month extension is available to all individuals who are qualified beneficiaries due to a termination in employment or reduction in hours. To benefit from this extension, the qualified beneficiary must notify Colby College of the Social Security Administration's determination within 60 days of such a determination and before the end of the original 18-month period of continuation coverage. The qualified beneficiary must also notify Colby College within 30 days of the date of any final determination by the Social Security Administration that the individual is no longer disabled. Furthermore, the monthly premium cost to such a qualified beneficiary during the 11-month extension will be increased to 150% of the applicable premium relating to continuation coverage. A child who is born to or placed for adoption with the covered employee during a period of COBRA continuation coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the Plan and the requirements of federal law, these qualified beneficiaries can be added to COBRA continuation coverage upon proper notification to Anthem Blue Cross Blue Shield of Maine of the birth or adoption. However, the law also provides that your continuation coverage may be cut short for any of the following five reasons:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts the extent to which group health plans may impose preexisting condition limitations. These rules are generally effective for plan years beginning after June 30, 1997. HIPAA coordinates COBRA's other coverage cut-off rule in (3) above with these new limits as follows: If you become covered by another group health plan after the date of your COBRA election, and that plan contains a preexisting limitation that affects you, your COBRA coverage cannot be terminated. However, if the other plan's preexisting condition does not apply to you by reason of HIPAA's restrictions on preexisting condition clauses, Colby College may terminate your COBRA coverage. Failure to pay any required premium on a timely basis will result in the permanent termination of continuation coverage. You do not have to show that you are insurable to choose continuation coverage. However, as discussed above, you will have to pay all the required premiums for your continuation coverage. The law also says that, at the end of the 18-month, 29-month or 36- month continuation coverage period, you must be allowed to enroll in an individual conversion Medical Benefits Plan if such an individual conversion Medical Benefits Plan is otherwise generally available under the Plan. Continuation coverage under COBRA is provided subject to the qualified beneficiary's eligibility for coverage. The Administrator reserves the right to terminate your COBRA continuation coverage retroactively if you are determined to be ineligible. Continuation coverage is administered by the Anthem Blue Cross Blue Shield of Maine. Please send all required notices to Anthem at the following address: Anthem Blue Cross Blue Shield of Maine
If you have any questions about COBRA, please contact the Personnel Office]. If you have changed marital status, or you or your spouse have changed addresses, please notify the Personnel Office as well. IV. STATEMENT OF ERISA RIGHTS 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 provides that all Plan participants shall be entitled to: RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS • Examine, without charge, at the Administrator's office and at other specified locations, all Plan documents, including insurance contracts 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 copies of all documents governing the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and an updated summary plan description, upon written request to the Administrator. The Administrator may make a reasonable charge for the copies. • Receive a summary of the Plan's annual financial report. The Administrator is required by law to furnish each participant with a copy of this summary annual report. CONTINUE GROUP HEALTH PLAN COVERAGE • Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. • Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. PRUDENT ACTIONS BY PLAN FIDUCIARIES In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the 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 your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. ENFORCE YOUR RIGHTS If your claim for a 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 time 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 latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the 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 Administrator. If you have a claim for benefits which 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 medical child support order, you may file 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 from 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 legal 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. ASSISTANCE WITH YOUR QUESTIONS 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 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, Employee Benefits Security 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. V. HEALTH BENEFITS FOR RETIRED EMPLOYEES UNDER THE PLAN The College currently makes postretirement health coverage available to any employee who was a Plan participant immediately preceding his or her retirement, or an individual covered as an eligible dependent of the employee on the date of the employee’s death, where on the date of the employee’s retirement or death, the employee (i) had completed ten or more years of continuous service with Colby after age 40 and attained age 60, (ii) had received or begun receiving retirement benefits from a retirement plan sponsored by Colby immediately after retirement from Colby or was receiving medical benefits under the Plan prior to his or her death, (iii) was employed by Colby during the year just prior to his or her retirement date or death, and (iv) if covered by a collective bargaining agreement at retirement, was entitled to retiree health coverage under that agreement. An eligible dependent is an individual who meets the eligibility requirements for dependent coverage provided by the applicable insurance carrier and who is either (1) the spouse of the employee (or if no spouse, domestic partner of the employee) or (2) the unmarried dependent child of the employee. Coverage for an eligible dependent will cease when the individual is no longer an eligible dependent or when the employee’s coverage ceases. A retiree (or an eligible dependent) will become a participant on the first day of the month following (1) the date of enrollment or (2) the date COBRA coverage ends (whichever is later), so long as the retiree or eligible dependent enrolls in the manner specified by the Administrator. Under the terms of the Plan, retirees or eligible dependents will contribute towards the cost of coverage as follows:
A Retiree pays the full cost of any dependent coverage. Eligible dependents who are covered under the Plan at the time of a retiree’s death, may continue to participate in the Plan, subject to eligibility requirements and payment of the full cost of coverage. Retiree contributions toward the cost of coverage are determined at the sole discretion of the Plan Sponsor. The Plan Sponsor may amend the Plan, at any time or times, to change contribution rates for retirees. In accordance with the provisions of the Plan, medical benefits provided to retired employees or eligible dependents under the Plan will be secondary to the benefits for which the participant is eligible, upon timely application, under Medicare (Part A and Part B). Eligibility for post-retirement coverage requires continuous participation in the Plan subsequent to retirement. VI. HEALTH BENEFITS FOR DISABLED EMPLOYEES UNDER THE PLAN The College currently makes health coverage available to any disabled employee, or an individual covered as an eligible dependent of a disabled employee as of the disabled employee’s death, if the disabled employee (i) had, at disability, completed two or more years of continuous service as an employee with the College (ii) receives (or was at death receiving) disability benefits from a College-sponsored disability plan beginning immediately after completion of the applicable waiting or elimination period and (iii) was employed by Colby during the year just prior to receiving disability benefits. Such individuals will be considered retired employees for purposes of the health coverage made available to them and required contributions, if any, for coverage. In accordance with the provisions of the Plan, medical benefits provided to retired employees under the Plan will be secondary to the benefits for which the participant is eligible, upon timely application, under Medicare (Part A and Part B). Eligibility for post-retirement coverage requires continuous participation in the Plan subsequent to retirement. VII. POWERS OF THE ADMINISTRATOR The Administrator shall have the discretion, to the fullest extent permitted by law, to determine all matters relating to eligibility, coverage or benefits under the Plan. The Administrator shall also have the discretion to decide all matters relating to the interpretation and operation of the Plan. Any determination by the Administrator shall be final and binding, in the absence of clear and convincing evidence that the Administrator acted arbitrarily and capriciously. July, 2003 |
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