The following are key terms as used in this Summary Plan Description.
The term “Active Employee” is defined as a person who is employed by an Employer and for whom the Employer is required by a Collective Bargaining Agreement or Participation Agreement to make contributions to the Local 170 Health and Welfare Fund. Active Employees shall also mean employees of the Local 170 Health and Welfare Fund and Employees of the Teamsters Local Union 170, for whom contributions are made to the Fund.
Adverse Benefit Determination
The term “Adverse Benefit Determination” is defined as any of the following: a denial, reduction, termination of, or failure to provide or make payment (in whole or in part) for a benefit, that is based on a determination of a Participant’s, Dependent’s or Beneficiary’s eligibility to participate in a Plan, or for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental, Investigational, or not Medically Necessary or appropriate.
The term “Allowable Charge” is defined as the amount resulting after subtracting the applicable network discount from a charge submitted by an In-Network provider or the appropriate Fee Allowance for charges submitted by an Out-Of-Network provider.
The term “Beneficiary” is defined as any person designated in writing by the Participant or by the terms of the Plan, who is now or may hereafter, become entitled to a benefit from the Plan.
The term “Coinsurance” or “cost sharing percentage” is defined as that portion of an Allowable Charge that is not covered by the Plan and thus payable by the Participant, Dependent or Beneficiary. This means the cost for covered services will be calculated as a percentage. The Schedule of Benefits shows the covered services for which payment of co-insurance is required.
The term “Co-Payment” is defined as a fixed dollar amount payable by the Participant, Dependent, or Beneficiary to a provider upon incurring certain claim types as identified in the applicable Schedule of Benefits.
The term “Contributions” is defined as the amount paid by an Employer to the Fund on behalf of his Employees, on a monthly basis, pursuant to the terms of an applicable Collective Bargaining Agreement or Participation Agreement. The term “Contributions” shall also mean the amounts paid to the Fund on behalf of their Employees by the Local 170 Health and Welfare Fund and Teamsters Union Local 170 that constitute “Employers” within the meaning of this Plan.
The term “Deductible” is defined as the amount which the Participant pays for medical expenses before benefits are paid by the Plan. When your health plan includes a deductible, the amount that is put toward your deductible is calculated based on the health care providers actual charge or allowed charge, whichever is less (unless otherwise required by law). A Schedule of Benefits shows the amount of a member’s deductible, if there is one. Your Schedule of Benefits also shows those covered services for which you must pay the deductible before you receive benefits.
The term “Dependent” is defined as any of the following:
- The Participant’s Spouse;
- The Participant’s children under age 26 (which will be no less than the end of the month when such child attains the age of 26), whether married or unmarried, regardless of his/her student or employment status and regardless of whether your home is his/her principal place of abode or whether you support him/her financially;
The Participant’s children over the age of 26 and are unmarried and (i) primarily dependent on you for support because of mental retardation or physical handicap; and (ii) first became disabled before turning the age of 26 and were covered by this Plan at that time.
A “Child” or “Children” may include the following: a son, daughter, step-son, step-daughter, adopted child, a child placed for adoption, a foster child, a child named in a Qualified Medical Child Support Order, a child for whom you are responsible under court order, a child for whom you are appointed legal guardian.
The term “Employer” is defined as any Employer who has been and remains approved for participation by the Fund’s Board of Trustees and has a Collective Bargaining Agreement in effect with the Union or a Participation Agreement requiring periodic Contributions to the Fund. The term Employer shall also mean the Local 170 Health and Welfare Fund and Teamsters Local Union 170, provided such Employers make contributions to the Local 170 Health and Welfare Fund on behalf of their Employees.
Essential Health Benefit
The term “Essential Health Benefit” includes ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services; chronic disease management; and pediatric services, including oral and vision care.
The term “Fund” is defined as the Local 170 Health and Welfare Fund also known as the Teamsters Local 170 Health & Welfare Fund.
“He, his and him” means she, her or hers, respectively when referring to a female.
The term “In-Network” is defined as the use of a covered primary care provider or other covered provider who participate in the network such that all claims incurred by such a provider will be processed under the “In-Network” benefit level as described in the applicable Schedule of Benefits.
The term “Medical Benefits” is defined as all benefits provided under this Plan, other than the Life Insurance Benefit, Accidental Death and Dismemberment Benefit, Spousal Burial Benefit, Dependent Burial Benefit, Short Term Disability Income Benefit and certain Wellness Benefits or Programs.
The term “Medically Necessary” is defined as services or supplies which the Trustees or their delegate determine, in the exercise of their discretion, are generally acceptable by the national medical professional community as being safe and effective in treating a covered illness or injury, consistent with the symptoms or diagnoses, furnished at the most appropriate medical level and not primarily for the convenience of the patient, a health care provider, or anyone else. Because a health care provider has prescribed, ordered, or recommended a service or supply does not, by itself, mean that it is Medically Necessary.
The term “Out-of-network” is defined as the use of a provider that does not participate in the network such that all claims incurred by such a provider will be processed under the “Out-of-network” benefit levels as described in the applicable Schedule of Benefits.
The term “Participant” is defined as an active Employee, or retired Employee, who has met the necessary requirements to receive benefits from the Fund.
The term “Plan” is defined as this Plan or program of benefits established by the Trustees pursuant to the Agreement and Declaration of Trust.
The term “Qualified Beneficiary” is defined as:
- The Spouse and Qualifying Children of a Participant who, on the day before a Qualifying Event, were eligible for benefits under the Plan;
- Any Qualifying Child who is born to or placed for adoption with a covered Participant during a period of COBRA Continuation Coverage; and
- Any covered Participant who had retired before the date of termination of benefits caused by the bankruptcy of his last regular Employer, his Spouse or Surviving Spouse, and Dependent Children
Schedule of Benefits
The term “Schedule of Benefits” is defined as the benefits listed and described within documents entitled “Schedule of Benefits” available to all Participants and their dependents. It describes the cost share amount a Participant and or dependent must pay for each covered service. It provides deductibles, co-payments, co-insurance, out of pocket maximums, prior authorization limitations, and benefit limits. The term schedule of “Schedule of Benefits” is further defined to include the benefits set forth in the Member Handbook for Participants and their dependents who are enrolled in a Fallon Plan; and to include the benefits set forth in the Benefit Description and Riders for Participants and their dependents who are enrolled in a Blue Cross Blue Shield Plan.
“Spouse” means the individual to whom you are legally married or in the event of a divorce, the participant’s former spouse may remain covered unless:
- The divorce decree does not require (or no longer requires) the participant to maintain coverage for his former Spouse;
- or either the participant or his former Spouse remarries
A participant will be considered totally disabled during any period when as a result of a non-occupational injury or illness, he is unable to perform duties of his occupation, as documented by a treating physician’s orders.
The term “Agreement and Declaration of Trust” or “Trust Agreement” is defined as the Agreement and Declaration of Trust made and entered into on April 14, 1954, and as amended from time to time known as the Local 170 Health and Welfare Fund and/or the Teamsters Local 170 Health & Welfare Fund.
The term “Trustees” as used herein is defined as “Trustees,” “Board of Trustees,” “Board” or “Trustee” or “one of the Trustees,” as the context may require, designated by the Agreement and Declaration of Trust, together with their successors designated and appointed to administer the Fund. The Trustees, collectively, shall be the “Plan Administrator” of this Plan as that term is used in the Employee Retirement Income Security Act, 29 U.S.C. Sections 1001, et seq.
The term “Union” is defined as Teamsters Local Union 170 affiliated with the International Brotherhood of Teamsters, which has Collective Bargaining Agreements with Employers requiring periodic Contributions to the Fund created by the Trust Agreement.