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Clallam

HEALTHCARE PLAN

 

 

 

 

 

 

 

January 1, 2014

 


To:       Plan Participants

 

Welcome to the Clallam County Public Utility District Healthcare Plan. This Healthcare Plan was established for the benefit of Clallam County Public Utility District, their eligible employees, retirees, and dependents.  The purpose of the Plan is to reimburse covered healthcare expenses, and it is designed to provide comprehensive protection for you and your dependents. We sincerely wish that you and your dependents enjoy good health, but in the event you need to use the Plan, we know that you'll be happy to have the service and security of the Clallam County Public Utility District Healthcare Plan.

Please take time to become familiar with the benefits that the Plan offers. Many terms have specific meanings as used throughout the booklet. Please refer to the definitions section on page 36 for clarification. We suggest you review the booklet carefully. If you have questions regarding coverage or how benefits have been paid, we encourage you to contact our claims administrator, Pacific Underwriters, using the phone numbers given at the end of the booklet.

The District expects to continue the Plan indefinitely. Healthcare coverage is an element of the Collective Bargaining Agreement with IBEW Local 997. The District reserves the right to propose amendments to the Plan at any time. Subject to the Collective Bargaining Agreement, the District also has the right to terminate the Plan. The District's amendment and termination powers may be carried out by the General Manager of the District in accordance with authorization by the District's Board of Commissioners.

Clallam County Public Utility District has full power and authority to control and manage the operation and administration of the Plan and to construe and apply all of its provisions including the specific power and authority to interpret the Plan and to remedy or resolve ambiguities, inconsistencies, or omissions.  This specifically includes the power to decide any eligibility and the approval of benefits under the Plan.  Any action taken in good faith by the Plan Administrator shall be conclusive and binding upon the participants and the beneficiaries.  The District’s Health Committee and General Manager will communicate with the claims administrator as to any ambiguities, inconsistencies, or omissions.

This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 

 

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 360-452-9771.

Heal

 

Sincerely,

 

 

 

Clallam County Public Utility District


 

 



The following pages contain the Healthcare Plan Description.

This Plan Description replaces any Plan Description, booklet or certificate previously issued by us and makes such document void.

Throughout this Plan Description, the terms “you” and “your” refer to the covered participant. The terms “we,” “us,” and “our” refer to the Clallam County Public Utility District Healthcare Plan.  The term “Plan Administrator” refers to Clallam County Public Utility District.  The term “Claims Administrator” refers to Pacific Underwriters.

PREFERRED PROVIDER BENEFITS

This Plan includes preferred provider benefits for medical expenses through First Choice Health Network Preferred Provider Organization (PPO). Covered individuals always have the freedom to choose either a First Choice Health Network Preferred Provider (hospitals, facilities and physicians) or a non-preferred provider each time medical care is needed. However, First Choice Health Network Preferred Provider fees will be discounted to you (or your covered dependents) and the Clallam County Public Utility District Healthcare Plan. When seeking medical care, we encourage you to use First Choice Health Network Preferred Providers whenever possible.

You will receive a directory of First Choice Health Network Preferred Providers as part of your enrollment material. The directory will list preferred hospitals and healthcare providers.

NON-PREFERRED PROVIDER BENEFITS

This Plan includes non-preferred provider benefits for medical expenses. If you choose the services of a non-preferred provider, your benefits will be reduced by 20% (in most cases) compared to preferred providers.   You maximum out-of-pocket expenses will also increase from $400 to $1,250.


This section will describe who is eligible to enroll under the Plan. Please be aware that the date you or your dependent becomes eligible may be different from the date coverage begins. See the sections entitled “How to Enroll” and “When Coverage Begins.”

“Replacement Benefits” Upon the original enrollment of the employer, this Plan will extend benefits as provided in this Plan to all eligible employees and dependents if there has been continuous coverage with the prior carrier up to the enrollment date in the Clallam County Public Utility District Healthcare Plan.

Eligible Individuals

Active employees - You are eligible if you are an active employee of Clallam County Public Utility District No. 1 and have worked long enough to satisfy any required waiting period.  A Commissioner of Clallam County Public Utility District No. 1 will also be considered an active employee while serving his/her term as Commissioner.

Retirees - Employees who retire from active employment with the District and are qualified under the Public Employees' Retirement System, Plans I, II, and III, may continue under the District's medical and dental plans, provided that the employee/retiree pays the contributions for the plans.  If a retired employee's coverage is terminated for any reason, the retired employee is not eligible for reinstatement of coverage.  Coverage for the retired employee must be continuous from his/her active employment to retirement.  Subsequent employment by the employee after retirement from the District will terminate the availability of coverage for that employee, provided provisions of the Continuation Omnibus Budget Reconciliation Act of 1985 (COBRA) are met.  Spouse employment which provides health coverage for a District retiree will also terminate the availability of coverage under the District's health plans for the retiree, consistent with COBRA.

Eligible Dependents

Dependents include your:

·       Spouse, if not legally separated; and

  • Child, including a legally adopted child, child legally placed in your home for adoption, or a step child:
    • Who is less than age 26.

 

·       A developmentally or physically disabled child:

·        Who has reached age 26 and is dependent on you for support and maintenance; and

·        Who is, and continues to be, incapable of self-support due to developmental or physical disability; and:

·        Who was disabled prior to reaching age 26; and

·        For whom the Plan Administrator receives proof of disability within 31 days of the effective date of the dependent’s coverage.

A dependent does not include any person who is residing outside the United States or who is on active duty in the Armed Forces.

The following section explains how to enroll yourself and your eligible dependents.

When You First Become Eligible

You must file an enrollment form with the Human Resources Dept. for yourself and any dependent you want covered within 31 days following the completion of your waiting period.

Active employees - Coverage becomes effective on the 1st day of the month following or coinciding with your date of hire.

Open Enrollment

If you or your eligible dependents elect not to enroll when originally eligible, you may only enroll during Open Enrollment (the month of December, for coverage effective January 1), or under the Special Enrollment section, if applicable.

Special Enrollment

If you or your dependents decline coverage, there are two situations in which you or your dependents will be allowed to enroll without having to wait until the Plan's next open enrollment period.

·                  Individuals Losing Other Coverage

If you decline 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 this Plan, provided that you request enrollment within 30 days after your other coverage ends. To enroll during this special enrollment period, you and your dependents must otherwise be eligible for coverage under the terms of the Plan. This special enrollment period is available if you or your dependents were covered under another group health plan or had other health insurance coverage at the time you declined coverage under this Plan.

You may enroll during this special enrollment period if you lose the other coverage. Your dependents may enroll during this special enrollment period if your dependents lose the other coverage and you are already enrolled in the Plan. Finally, both you and your dependents may enroll together during this special enrollment period if either of you lose the other coverage.

Special enrollment may be requested only if the other coverage ends because you or your dependents lost eligibility for the other coverage (including a loss of coverage due to legal separation, divorce, death, termination of employment or reduction in hours) or employer contributions for the other coverage terminated. If the other coverage is COBRA continuation coverage, special enrollment may only be requested after you or your dependents have exhausted the continuation coverage. Special enrollment is not available if you or your dependents lost the other coverage because of failure to pay premiums or for cause.

 

·                  Dependent Beneficiaries

If you are a participant under this Plan (or have met the waiting period applicable to becoming a participant under this Plan and are eligible to be enrolled under this Plan but for a failure to enroll during a previous enrollment period), and a person becomes your dependent through marriage, birth, adoption or placement for adoption then the dependent (and if not otherwise enrolled) may be enrolled under this Plan as a covered dependent or employee. In the case of the birth or adoption of a child, your spouse may be enrolled as a dependent if your spouse is otherwise eligible for coverage.

The Dependent Special Enrollment Period is a period of 31 days and begins on the date of marriage, birth, adoption, or placement for adoption.

Coverage under this special enrollment is effective the first day of the month after you request the enrollment for yourself or your dependent. Coverage in the case of a dependent's birth is effective as of the date of birth; or in the case of adoption or placement for adoption, the date of the adoption or placement for adoption.

There are a variety of circumstances in which coverage for you and/or your covered dependents will end. These are described in the following paragraphs.

Plan Termination

The District may at any time terminate this Plan at its discretion. If the Plan is terminated, coverage ends for you and your covered dependents on the date the Plan ends.

Termination Date for an Employee

The coverage of any employee under this Plan will terminate on the earliest occurrence of any of the following dates:

·                  The date on which termination of the Plan occurs;

·                  The last day of the month in which you fail to meet the minimum eligibility requirements;

·                  The last day of the month in which your employment with Clallam County Public Utility District No. 1 is terminated;

·                  The date you begin active duty in the armed forces;

·                  The last day of the month for which there is failure to make any required contributions; or

·                  The last day of the month in which your approved Leave of Absence terminates unless you immediately return to work.

Termination Date for a Dependent

A dependent's coverage will terminate on the earliest occurrence of any of the following dates:

·                  The date on which termination of the Plan occurs;

·                  The last day of the month in which the employee's coverage under whom the dependent is covered terminates;

·                  The date the dependent begins active duty in the armed forces;

·                  The last day of the month in which the dependent fails to meet this Plan's definition of an eligible dependent;

·                  The last day of the month for which there is failure to make any required contributions; or

·                  The last day of the month in which the employee becomes ineligible.

Family Medical Leave Act

If you have worked more than 1,250 hours in the 12-month period immediately preceding the leave, you may be eligible to take up to 12 weeks of unpaid leave for any of the following reasons:

·                  A child's birth, adoption or foster-care arrival;

·                  To care for a spouse, parent or child with a “serious health condition”;

·                  The employee's “serious health condition.”

“Serious Health Condition” is defined as any illness, injury, impairment or physical or mental condition that involves (i) inpatient care, (ii) continuing treatment by a health care provider, or (iii) substance abuse, all as defined by federal law.

Employees on a qualified leave are allowed to:

·                  continue group health coverage (medical, dental, vision, prescription drug) during leave the same as if continually employed, including making required contributions; and,

·                  return to prior job or equivalent one in terms of salary, accrued benefits and other job conditions if returning within the 12-week period. If the employee does not choose to continue coverage, he or she may re-enroll within 31 days of returning to work without penalty if returning within the 12-week period. If on leave more than 12 weeks, he or she will be treated as a re-hire and be subject to normal waiting periods.

An employee not returning to work will be offered COBRA continuation of coverage (see the following section). The date COBRA coverage begins will be the date the employer learns the employee will not be returning, or the date the leave period ends, whichever comes first.

Continuation of Coverage

Under certain circumstances, called Qualifying Events, you and your covered Dependents (Qualified Beneficiaries) have the right to continue coverage beyond the time coverage would ordinarily have ended. The rights and obligations regarding continuation of coverage are explained below.

Qualified Beneficiaries may continue medical, dental, prescription drug and vision coverages provided by this Plan. Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and subsequent amendments, coverage may continue on a self-pay basis when any of the following Qualifying Events occurs:

Qualifying Event

Qualified Beneficiaries

(Who May Elect to Continue Coverage)

Maximum Period of Continued Coverage

Employee separated from employment for reasons other than gross misconduct

Employee, spouse and dependent children

18 months*

Reduction in hours of Covered Employee

Employee, spouse and dependent children

18 months*

Death of Covered Employee

Spouse and dependent children

36 months

Divorce or legal separation

Spouse and dependent children

36 months

Employee or Retiree becomes entitled to Medicare

Spouse and dependent children

36 months

Dependent child becomes ineligible

Dependent children

36 months

 

*NOTE: The maximum period of coverage may be extended from 18 months to 29 months if during the 18-month self-pay period you or your Dependent receives a determination from the Social Security Administration that he or she was disabled at the time of the Qualifying Event or any time within the first 60 days of COBRA continuation coverage. The Qualified Beneficiary must give the Plan Administrator notice of the determination of disability from the Social Security Administration within 60 days of the date of the determination letter and prior to the date the original 18-month continuation would have expired. The Plan is allowed to increase the cost of coverage for the additional 11 months of coverage, up to 150% of the full cost of the coverage. The maximum period of coverage will be extended to 36 months from the date of the termination or reduction in hours if, within the 18-month self-pay period, one of the 36-month Qualifying Events occurs. In addition, if your Medicare entitlement is followed by a termination of employment or reduction in hours, the maximum period of COBRA coverage available to your covered Dependents must not end before 36 months after the date you became entitled to Medicare.

Continued coverage will be at the same level as this coverage under the group Plan when the Qualifying Event occurred. However, any benefit changes that apply to active employees also apply to anyone continuing coverage. All Qualified Beneficiaries covered under this Plan at the time of the Qualifying Event have a separate option to continue coverage.

If you are entitled to COBRA because you are a current or former employee and you give birth or adopt a child while you are on COBRA continuation coverage, you can enroll your new child for COBRA continuation coverage immediately. Also, your newborn and adopted child will obtain qualified beneficiary status. In other words, they will have independent election rights and second qualifying event rights.

If coverage is lost due to termination, reduction in hours, your death, or Title XI Bankruptcy within one year of the filing, Pacific Underwriters will notify Qualified Beneficiaries of their right to continue coverage, including the cost. The Plan is permitted, by law, to charge up to 102% of the full cost of the Plan.

If a Dependent loses coverage for any of the following reasons (divorce, legal separation or Dependent ineligibility), you or your Dependent must notify the Plan Administrator in writing, as soon as possible, but no later than 60 days from the date of this event. Within 14 days after receiving this notice, Pacific Underwriters will notify Qualified Beneficiaries of their right to continue coverage.

A Qualified Beneficiary will have 60 days from receiving that notice or from the date coverage would otherwise be lost, whichever is later, to elect continued coverage. If continued coverage is not requested in writing within 60 days, coverage will end on the last day of the month in which the Qualifying Event occurred. Only one notification will be provided to a family. A Qualified Beneficiary does not have to show proof of insurability to continue coverage.

The Qualified Beneficiary must pay the full contribution for continued coverage.  The Plan Administrator must receive the first payment within 45 days after continued coverage is first elected.  Monthly payments thereafter are due on the first of each month and must be received on or before the 30th day of each month, unless otherwise determined by the Plan Administrator when circumstances warrant.

Continued coverage under COBRA will end on the last day of the month in which any of the following occurs, whichever is first:

·                  The Qualified Beneficiary fails to pay the required monthly contribution on time;

·                  The first day on which the Qualified Beneficiary becomes covered under another group health plan, but only if the new group health plan does not contain any exclusions or limitations for preexisting conditions of that Qualified Beneficiary. If you do become covered under another group health plan and are affected by a preexisting condition limitation, COBRA coverage may be cut off as soon as that preexisting condition limitation is satisfied due to the new plan's crediting toward the limitation of any prior coverage you had.

·                  The date the Qualified Beneficiary becomes entitled to Medicare, except when the Qualifying Event is due to a Title XI Bankruptcy;

·                  The date the Plan discontinues group coverage;

·                  The date the Qualified Beneficiary's employer no longer participates in this Plan;

·                  The maximum period of continuation of coverage ends; or

·                  For disabled Qualified Beneficiaries, the first of the month following the date of the final Social Security determination letter stating that the Qualified Beneficiary is no longer disabled.

 

If a Qualified Beneficiary is eligible for the other “continuation of coverage privileges” required by state law or as provided by this Plan, these extensions will run concurrently with continued coverage under COBRA.

In all cases, the Plan will provide continuation coverage as federally mandated by COBRA, subsequent COBRA amendments, and proposed regulations.


ARTICLE II

MEDICAL PLAN BENEFITS

 

SUMMARY OF MEDICAL PLAN BENEFITS

This section is only a summary and schedule of the benefits of the Plan. The text of your Healthcare Plan Description spells out the actual benefits and the conditions, limitations and exclusions.

The Clallam County Public Utility District Healthcare Plan has preferred provider arrangements based on agreements that these providers have made with this Plan. It is to your and our financial advantage to obtain services from a preferred provider. Medical expenses are limited to the usual, customary and reasonable charges as determined by the Clallam County Public Utility District Healthcare Plan.

 

IN THE PPO

OUT OF THE PPO

LIFETIME MAXIMUM MEDICAL BENEFIT

ANNUAL MAXIMUM MEDICAL BENEFIT

UNLIMITED

UNLIMITED

UNLIMITED

UNLIMITED

DEDUCTIBLES

NONE

NONE

MEDICAL OUT-OF-POCKET MAXIMUM

After an individual has incurred the maximum amount of eligible out-of-pocket PPO medical expenses or eligible out-of-pocket non-PPO medical expenses in a calendar year, the Plan pays 100% of eligible charges subsequently incurred by that individual in that calendar year.  The maximum eligible out-of-pocket medical expenses is $1,250 (combination of PPO and non-PPO eligible expenses) in a calendar year.  Eligible expenses do not include copayments associated with hospital and physician visits, prescription drug copayments, vision, or dental expenses.

$400

$1,250