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Ilitch Holdings, Inc. Welfare Benefit Plan

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Ilitch Holdings, Inc. Welfare Benefit Plan ILITCH HOLDINGS, INC. WELFARE BENEFIT PLAN Plan No. 501 SUMMARY PLAN DESCRIPTION General Provisions ILITCH HOLDINGS, INC. Fox Office Center 2211 Woodward Avenue Detroit, MI 48201-3467 313.471.6000 2016 18160837v.9 TABLE OF CONTENTS PAGE INTRODUCTION ................................................................................................................................. 1 Benefit Programs ............................................................................................................................. 1 Preferred Providers for Medical, Dental and Vision Benefit Programs ......................................... 2 Funding Arrangements for Benefit Programs ................................................................................. 3 Effective Date .................................................................................................................................. 4 ELIGIBILITY ........................................................................................................................................ 4 Colleague Eligibility........................................................................................................................ 4 Waiting Period .......................................................................................................................... 5 Excluded Colleagues ................................................................................................................. 5 Actively at Work ....................................................................................................................... 6 Rehired Colleague Eligibility .......................................................................................................... 6 Dependent Eligibility ...................................................................................................................... 7 Proof of Dependent Status .............................................................................................................. 8 PARTICIPATION ................................................................................................................................. 8 Initial Enrollment Period ................................................................................................................. 8 Open Enrollment Period .................................................................................................................. 9 Special Enrollment Period ............................................................................................................. 10 Participation During a FMLA Leave of Absence ......................................................................... 11 Qualified Change in Status Events ................................................................................................ 13 Change Events for all Benefit Programs ................................................................................ 13 Additional Change Events for the Medical, Dental, Vision and HFSA Benefit Programs ... 14 Additional Change Event for the Medical Benefit Program .................................................. 15 Additional Change Events for the DFSA Benefit Programs .................................................. 15 Consistency Rule ..................................................................................................................... 16 Procedures for Changing Elections Mid-Year........................................................................ 16 Special Rule for the HFSA and DFSA Benefit Programs ...................................................... 16 End of Participation in the Plan .................................................................................................... 17 COBRA CONTINUATION COVERAGE ........................................................................................ 18 Qualifying Events .......................................................................................................................... 18 Electing COBRA Continuation Coverage .................................................................................... 19 Premium Payments ........................................................................................................................ 20 Duration of Coverage .................................................................................................................... 20 FMLA Leave ................................................................................................................................. 21 Newborns and Adopted Children .................................................................................................. 22 Second Qualifying Event .............................................................................................................. 22 Medicare-Eligible Colleagues ....................................................................................................... 22 Covered Dependents of Medicare-Eligible Colleagues ................................................................ 23 Disabled Individuals ...................................................................................................................... 23 Special Rules for the HFSA Benefit Program .............................................................................. 24 Form and Manner of Notice to the Benefits Department and COBRA Administrator................ 24 i 18160837v.9 Health Care Reform Marketplace ................................................................................................. 25 Questions About COBRA Continuation Coverage ...................................................................... 25 Keep the Plan Informed of Address Changes ............................................................................... 25 MILITARY LEAVE CONTINUATION COVERAGE .................................................................... 25 COORDINATION OF BENEFITS .................................................................................................... 26 Special Rules ................................................................................................................................. 28 Coordination with Medicare ......................................................................................................... 28 Coordination with Motor Vehicle Accident Insurance ................................................................. 28 Coordination Under No-Fault Motor Vehicle Insurance Laws .............................................. 29 Coordination Under Financial Responsibility Law ................................................................ 29 Coordination Under Other Motor Vehicle Liability Insurance .............................................. 29 Coordination with Third Parties .................................................................................................... 29 Facility of Payment ....................................................................................................................... 30 SUBROGATION/RIGHT OF RECOVERY ..................................................................................... 30 Assignment of Rights (Subrogation)............................................................................................. 30 Equitable Lien and Other Equitable Remedies ............................................................................. 31 Obligation to Assist in the Plan’s Reimbursement Activities ...................................................... 31 Payments by Other Sources .......................................................................................................... 32 EAP BENEFIT PROGRAM ............................................................................................................... 32 How the EAP Benefit Program Works ......................................................................................... 32 Benefit Limits ................................................................................................................................ 32 LEGAL BENEFIT PROGRAM ......................................................................................................... 33 PRE-TAX PAYMENT BENEFIT PROGRAM................................................................................. 35 How the Pre-Tax Payment Benefit Program Works .................................................................... 35 Reduction of Compensation .......................................................................................................... 35 Treatment of Benefit Contributions While on Leave ................................................................... 36 HEALTH CARE FLEXIBLE SPENDING ACCOUNT BENEFIT PROGRAM ............................ 36 Amount That You May Contribute to Your Health Care Account .............................................. 36 Amount That Can Be Reimbursed to You .................................................................................... 36 Eligible Health Care Expenses ...................................................................................................... 37 Ineligible Health Care Expenses ................................................................................................... 37 Tax Advantages of Participation in the HFSA Benefit Program.................................................. 38 Federal Itemized Deduction .........................................................................................................
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