Responsibilities For Plan Administration
The Plan Administrator has (i) the power and authority in its sole, absolute and uncontrolled discretion to control and manage the operation and administration of the Plan and (ii) all powers necessary to accomplish these purposes.
The Plan Administrator will administer the Plan in accordance with established policies, interpretations, practices, and procedures and in accordance with the requirements of ERISA and other applicable laws. With respect to the Plan, the Plan Administrator has discretion (i) to interpret the terms of the Plan, (ii) to determine factual questions that arise in the course of administering the Plan, (iii) to adopt rules and regulations regarding the administration of the Plan, (iv) to determine the conditions under which benefits become payable under the Plan, and (v) to make any other determinations that the Plan Administrator believes are necessary and advisable for the administration of the Plan. Subject to any applicable claims procedure, any determination made by the Plan Administrator will be final, conclusive and binding on all parties. The Plan Administrator may establish minimum contribution rates and the Plan Administrator may, at its discretion permit a deviation from a minimum contribution rate. The Plan Administrator may delegate all or any portion of its authority to any person or entity. A claims administrator may, at the discretion of the Plan Administrator, have the authority to administer, apply, and interpret Plan provisions. All claims should be directed to the applicable administrator (either the Claims Administrator or the Plan Administrator).
Under the terms of any insurance contracts issued for Life Insurance and/or the AD&D benefit, the insurance company issuing the contract has full discretionary authority to make all benefit decisions concerning eligibility for benefits under the contract, payment of claims or benefits, and interpretation of the terms and provisions of the insurance contract. Only the insurance company can resolve insurance contract ambiguities, correct errors or omissions in the contract, and interpret contract terms. The insurance company has the full discretionary authority to interpret, construe and administer the terms of such policies, and its decisions are final and binding on all parties. The Plan Administrator does not guarantee the payment of any benefit described in an insurance coverage contract and you must look solely to the insurance carrier for the payment of benefits.
Duties of the Plan Administrator
The Plan Administrator will (i) administer the Plan in accordance with its terms, (ii) decide disputes which may arise relative to a Plan participant’s rights, (iii) keep and maintain the Plan documents and all other records pertaining to the Plan, (iv) pay or arrange for the payment of claims, (v) establish and communicate procedures to determine whether a medical child support order is qualified under Section 609 of ERISA, and (vi) perform all necessary reporting as required by ERISA.
Plan Administrator Compensation
While the Plan Administrator serves without compensation, all expenses for administration, including compensation for hired services, will be paid by the Plan.
A fiduciary must carry out his or her duties and responsibilities for the purpose of providing benefits to eligible employees and their eligible dependents and defraying reasonable expenses of Plan administration. These duties must be carried out with care, skill, prudence and diligence under the given circumstances that a prudent person, acting in a like capacity and familiar with such matters, would use in a similar situation and in accordance with Plan documents to the extent that they are consistent with ERISA.
The Named Fiduciary
The Plan Administrator is a “named fiduciary” with respect to the Plan. A named fiduciary can appoint others to carry out fiduciary responsibilities (other than as a trustee) under the Plan. The Plan Administrator has delegated certain day-to-day administration of the Plan and claims fiduciary responsibility for the processing and review of claims for benefits under the Plan. These other persons become fiduciaries themselves and are responsible for their acts under the Plan. To the extent that the named fiduciary allocates its responsibility to other persons, the named fiduciary will not be liable for any act or omission of such person unless either (i) the named fiduciary has violated its duties under ERISA in appointing the fiduciary, establishing the procedures to appoint the fiduciary or continuing either the appointment or the procedures or (ii) the named fiduciary breached its fiduciary responsibility under ERISA Section 405(a).
Certificate of Coverage Under a Group Health Plan
Certificates of coverage are written documents provided by a group health plan to show the type of health care coverage a person had (e.g., employee only, employee plus spouse, etc.) and how long the coverage lasted. Most group health plans provide these certificates automatically when a person’s coverage terminates. If you do not receive a certificate, however, you have the right to request one. Certificates apply to you and your eligible dependents. The primary purpose of the certificates is to show the amount of “Creditable Coverage” that you had under a group health plan or other health insurance coverage, because this can reduce or eliminate the length of time that any preexisting condition clause in a new plan otherwise might apply to you. Upon request the Fund Office will provide a Certificate of Coverage.
Coordination of Benefits
If you or your Eligible Dependent has or is entitled to benefits under another health plan, you are subject to a coordination of benefits process. Coordination of benefits is designed to prevent the payment of benefits from exceeding 100% of any allowable expenses that have been incurred. The Plan Administrator may request an Explanation of Benefits (EOB) which provides detailed claim reimbursement information from any other plans under which you are insured. If any of these plans provide coverage for services that are also covered under the Plan, the carrier will determine which plan is considered primary before any payments are made. The certificates of coverage and/or benefit booklets attached hereto provide more detailed information on how your benefits under this Plan will be coordinated with other coverage you may have.
To determine how the plans coordinate benefits, one plan is considered “primary” and the other is considered “secondary”. The primary plan pays benefits first, up to that plan’s limits. The secondary plan will not pay benefits until the primary plan pays or denies a claim. In no instance will the primary and secondary plans pay, in total, more than the actual cost of the healthcare services.
If the other plan does not include a coordination of benefits or non-duplication provision, that plan will be primary.
The following are the provisions for determining which plan will be “primary”:
|Active Employee Note: If employee is covered as an “employee” under two plans, the plan covering the employee for the longest period of time is considered the primary plan.||Teamsters Local 170 Health and Welfare Fund||Other Health Plan|
|Dependent spouse with other coverage as “active employee”||Other Health Plan||Teamsters Local 170 Health and Welfare Fund|
|Active Employee & Spouse with children: both parents’ health plans cover children||Follow birthday rule*||Follow birthday rule*|
|Active Employee, divorced or separated, both parents’ health plans cover children with court order||Follow court decree||Follow court decree|
*Under the birthday rule, the plan of the parent whose birthday falls earliest in the calendar year is the child’s primary plan. If both parents have the same birthday, the parent who has been covered longer has the primary plan. If the other plan does not have the birthday rule, then the rule in the other plan will determine which is primary.
- If parents are divorced or separated and both parents’ plans cover a dependent child, benefits for the child are determined in this order:
- First, the plan of the parent with custody;
- Then, the plan of the stepparent (spouse of the parent with custody of the child); and
- Finally, the plan of the parent not having custody of the child.
The benefits of a plan, which covers a person as an employee who is neither laid off nor retired, are determined before those of a plan which covers that person as a laid off or retired employee. The same would hold true if a person is a dependent of a person covered as a retired employee and an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine which plan is primary.
Where the determination cannot be made in accordance with other provisions in this section, the plan that has covered the Plan participant for the longer period of time will be primary.
The term “plan” as used in this section means any of the following that provide benefits for services, for or by reason of, medical or dental care or treatment:
- Any health plan which provides services, supplies, or equipment for hospital, surgical, medical, or dental care or treatment, or prescription drug coverage, including, but not limited to, coverage under group or individual insurance policies, non-profit health service plans, health maintenance organizations, self-insured group plans, pre-payment plans, and Medicare as permitted by federal law. This does not include hospital daily indemnity plans, specified diseases-only policies, or limited occurrence policies that provide only for intensive care or coronary care in the hospital.
- Coverage under a governmental plan or coverage required or provided by law. This does not include a state plan under SCHIP Title XXI or Medicaid Title XIX (grants to States for Medical Assistance Programs of the United States Social Security Act as amended). It also does not include any law or plan when, by law, its benefits are in excess to those of any private insurance program or other non-governmental program.
- Any individual automobile no-fault insurance plan.
- Any labor-management trusted plan, union welfare plan, employer organization plan, or employee benefit organization plan.
Each plan or other arrangement for coverage outlined immediately above is a separate plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan.
For the purpose of this provision, BCBSMA, Fallon Health, or Davis Vision may, without consent or notice to any person, release to or obtain from any insurance company or other organization or person any information that may be necessary regarding coverage, expenses, and benefits.
Participants claiming benefits under the Plan must furnish BCBSMA, Fallon Health and Davis Vision such information as may be necessary for the purpose of administering this provision.
Where any medical payment sums are applicable under any coverage, including but not limited to, automobile and premises liability policies, the limits of any such coverage must be applied to related claims before any benefits will be provided under this Plan.
The Plan is the primary payer for an active employee, active employee’s spouse, and active employee’s dependent child that is also covered by Medicare.
Medicare is the primary payer for a retired employee, surviving spouse, or dependent of a retired employee or surviving spouse who is:
- Age 65 or older
- Under age 65 with Social Security disability; or
- Under age 65 with end-stage renal disease after the first 30 months of Medicare eligibility
If the participant does not elect Medicare Part A or B, benefits will be reduced as though Medicare is the primary payer. The Plan will calculate the benefits assuming the participant has Medicare A and B.
A surviving spouse or dependent of a retired employee or surviving spouse age 65 or older is assumed to have Medicare Part A and B regardless of that participant’s Medicare eligibility. The Plan will calculate benefits assuming the participant has Medicare Part A and B.
If a retiree is retroactively approved for Medicare due to Social Security disability, the Plan will update their records to reflect Medicare as the primary coverage effective the date of Medicare eligibility. The Plan will also refund any overpayment of premiums and reprocess claims to calculate the benefit as secondary to Medicare.
Medicare Coordination – End-Stage Renal Disease
The Plan is the primary payer for:
- An active employee or employee’s dependent spouse or child with end-stage renal disease during the first thirty (30) months of Medicare eligibility solely by reason of end-stage renal disease (Medicare is primary after the first 30 months).
- A retired employee, surviving spouse, or retired employee’s or surviving spouse’s dependent spouse or child under age 65 with end-stage renal disease during the first 30 months of Medicare eligibility.
Medicare is the primary payer for:
- An active employee or employee’s dependent spouse or child with end-stage renal disease after the first 30 months of Medicare eligibility solely by reason of end-stage renal disease
- A retired employee, surviving spouse, or dependent of a retired employee or surviving spouse who is under age 65 with end-stage renal disease after the first 30 months of Medicare eligibility.
- If the participant does not elect Medicare Part A, B, or D, benefits will be reduced as though Medicare is the primary payer. The Plan will calculate benefits assuming the participant has Medicare A, B, and D.
Uniformed Services Reemployment Rights
Your right to continued participation in a group health plan during leaves of absence for active military duty is protected by the Uniformed Services Employment and Reemployment Rights Act (USERRA). Accordingly, if you are absent from work due to a period of active duty in the military for less than 31 days, your Plan participation will not be interrupted. If the absence is for more than 31 days and not more than 12 weeks, you may continue to maintain your coverage under the Plan by paying premiums in the manner specified by the Plan Sponsor.
If you do not elect to continue to participate in a group health plan during an absence for military duty that is more than 31 days, or if you revoke a prior election to continue to participate for up to 12 weeks after your military leave began, you and your covered family members will have the opportunity to elect COBRA Continuation Coverage for the 18-month period that begins on the first day of your leave of absence. You must pay the premiums for continuation coverage with after-tax funds, subject to the rules that are set out in the Plan.
USERRA continuation coverage is considered alternative coverage for purposes of COBRA. Therefore, if you elect USERRA continuation coverage, COBRA coverage will generally not be available.
Family Medical Leave Act (“FMLA”)
If you take a leave of absence (i) for your own serious health condition, (ii) to care for family members with a serious health condition, (iii) to care for a newborn or adopted child, (iv) to care for an injured or ill covered service member of the Armed Forces, or (v) due to a qualifying exigency arising out of a covered service member’s active duty, you may be able to continue your health coverage under the Plan. If you drop your health coverage during the leave, you can also have your health coverage reinstated on the date you return to work assuming you pay any contributions required for the coverage.