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Guild Times Benefit Fund SPD Final

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Guild Times Benefit Fund SPD Final Front Cover.qxp_Layout 1 5/6/16 4:39 PM Page 1 Newspaper Guild of New York - The New York Times Benefits Fund SUMMARY PLAN DESCRIPTION For Active Employees and Eligible Retirees Younger Than Age 65 Effective January 1, 2016 Title Page.qxp_Layout 1 5/9/16 9:34 AM Page 1 Newspaper Guild of New York - The New York Times Benefits Fund SUMMARY PLAN DESCRIPTION For Active Employees and Eligible Retirees Younger Than Age 65 Effective January 1, 2016 Project1_Layout 1 8/27/12 4:47 PM Page 1 Newspaper Guild of New York - The New York Times Benefits Fund TABLE OF CONTENTS Page Section I Introduction, Benefits at a Glance, and Contact Information ......................... 1 Introduction ......................................................................................................... 2 Benefits at a Glance ............................................................................................. 4 Contact Information ............................................................................................. 6 Section II Eligibility and Continuation of Coverage ......................................................... 7 Eligibility for Benefits ......................................................................................... 8 Enrollment ......................................................................................................... 13 Contributions to the Cost of Coverage................................................................ 15 If You Continue to Work After Age 65 .............................................................. 16 Life Events ........................................................................................................ 17 When Does Your Coverage End? ....................................................................... 18 Continuation of Coverage – COBRA ................................................................. 19 Other Ways Your Coverage Can Continue ......................................................... 28 HIPAA Rights ................................................................................................... 31 Section III Plan Benefits - Medical and Prescription Drug Benefits ................................ 32 Summary of Health Plans................................................................................... 33 Preferred Provider Organization (PPO) Plan ................................................ 35 Medical Management Program – PPO Plan ............................................ 40 Medical Benefits – PPO Plan.................................................................. 42 Prescription Drug Benefits – PPO Plan ................................................... 62 PPO Plan Benefit Exclusions .................................................................. 65 Exclusive Provider Organization (EPO) Plan ............................................... 70 United Healthcare Oxford ...................................................................... 71 Health Maintenance Organization (HMO) Plans .......................................... 74 HIP Health Plan of New York - EmblemHealth Company ...................... 75 Empire HealthChoice HMO ................................................................... 78 Global Health Benefits Plan – Cigna for Expatriates .................................... 81 Section IV Additional Benefits – Optical, Dental, and Life Insurance Benefits .............. 88 Summary of Additional Benefits ........................................................................ 89 Optical Benefits ................................................................................................. 90 Dental Benefits .................................................................................................. 92 Life Insurance Benefits .................................................................................... 106 Newspaper Guild of New York - The New York Times Benefits Fund TABLE OF CONTENTS (continued) Page Section V Coordination of Benefits, Subrogation, Claims Procedures & Appeals ...... 112 Coordination of Benefits .................................................................................. 113 Subrogation – Reimbursement Agreement ....................................................... 116 Claims Review and Appeal Procedures ............................................................ 118 Section VI ERISA Requirements and Plan Facts ........................................................... 128 Qualified Medical Child Support Orders (QMCSO) ......................................... 129 Special Rights for Mothers and Newborn Children .......................................... 130 Women’s Health and Cancer Rights Act .......................................................... 131 Grandfathered Plan Status Statement ............................................................... 132 Primary Care Provider (PCP) Designations and Access to OB/GYN Care ........ 133 HIPAA Privacy Practices for Personal Health Information (PHI) ..................... 134 Interpreting the Plan......................................................................................... 141 If the Plan Ends/Changes in the Plan ................................................................ 142 Misrepresentation and Fraud ............................................................................ 143 Plan Facts ........................................................................................................ 144 Your Rights under ERISA ............................................................................... 147 Definitions ....................................................................................................... 149 Section I Introduction, Benefits at a Glance, and Contact Information Newspaper Guild of New York – The New York Times Benefits Fund Page 1 INTRODUCTION Newspaper Guild of New York – The New York Times Benefits Fund Dear Member: The Board of Trustees of the Newspaper Guild of New York – The New York Times Benefits Fund (Guild- Times Benefits Fund) is pleased to provide you with this revised Summary Plan Description (SPD). This SPD has been written to reflect the changes since the last version was printed. This SPD is for active employees and retired employees younger than age 65. A separate SPD describes the plan of health and welfare benefits for eligible retirees or their dependents who have attained age 65. As you look through this SPD, you will learn how you become eligible for benefits, what your benefits are and how you claim them. We urge you to read this SPD with care. Since the last SPD was published, a number of changes in benefits have been implemented, particularly changes related to the Affordable Care Act (ACA), which is the health care reform law, and the Mental Health Parity and Addiction Equity Act of 2008. This SPD describes the Plan in effect as of January 1, 2016. This SPD has been designed to be easy to read and understand and provide you with a summary of your benefits under the Guild-Times Benefits Fund. This SPD was developed to help you understand your benefits and responsibilities under the health plan. The Trustees may modify or eliminate at any time (without prior notice to you) any benefits and the eligibility requirements for benefits described in this SPD. The Trustees have the authority and discretion to interpret the Plan and make final determinations regarding them. Neither employment nor benefits are guaranteed. Under no circumstances will any Plan benefits become vested or non-forfeitable with respect to active or retired employees or their beneficiaries or dependents. This SPD summarizes the key features of the Plan. It also constitutes the Plan document. Details of the Plan are also contained in the other official Plan documents, including the Agreement and Declaration of Trust that created the Fund and any insurance contracts relating to benefits provided under the Plan, which legally govern the operation of the Plan. All other official Plan documents are available for your inspection at the Fund Office during normal business hours, and all statements made in this SPD are subject to the provisions and terms of those documents. In case of a conflict or inconsistency between the other official Plan documents and this SPD, the other official documents will govern in all cases. In addition, this SPD provides the required information about your rights and protection under the law in order to comply with the Employee Retirement Income Security Act of 1974 (ERISA). We encourage you and your family to read this SPD carefully to make the best choices and use of your benefits offered by the Guild-Times Benefits Fund. If you have any questions concerning your benefits or your eligibility, please feel free to contact the Fund Office at (646) 237-1670. Sincerely, The Board of Trustees Newspaper Guild of New York – The New York Times Benefits Fund Page 2 BOARD OF TRUSTEES Union Trustees Employer Trustees Grant Glickson Andrew Gutterman Peter Szekely Charlotte Behrendt Anthony Napoli Christopher Biegner Matthew Seaton Terry L. Hayes CO-COUNSEL Proskauer Rose LLP Meyer, Suozzi, English & Klein, P.C. ACTUARIAL CONSULTANT Milliman, Inc. ACCOUNTANT Novak Francella, LLC FUND ADMINISTRATOR C&R Consulting, Inc. For claim forms, beneficiary forms, and other benefit information contact: Newspaper Guild of New York – The New York Times Benefits Fund 1501 Broadway, Suite 1724 New York, NY 10036 Telephone: (646) 237-1670 Fax: (212) 395-9299 To obtain forms and benefit information
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