1199SEIU National Benefit Fund for Home Care Employees Care Home for Fund Benefit National 1199SEIU 1199SEIU National Benefit Fund for Home Care Employees SUMMARY PLAN DESCRIPTION OF YOUR HEALTH AND WELFARE BENEFITS AND WELFARE PLAN DESCRIPTION OF YOUR HEALTH SUMMARY 1199SEIU National Benefit Fund for Home Care Employees Our Benefits 330 West 42nd Street New York, NY 10036-6977 DECEMBER 2012 (646) 473-9200 Summary Plan Description www.1199SEIUBenefits.org of Your Health and Welfare Benefits DECEMBER 2012 HC Benefit SPD Cover 2-Color - DEC2012.indd 1 5/22/13 4:06 PM This booklet serves as both a Summary Plan Description and Plan Document for participants in the 1199SEIU National Benefit Fund for Home Care Employees employed in the metropolitan New York City area and other areas covered by this Fund. The Home Care Plan (the “Plan”) is administered by the Home Care Plan Board of Trustees (the “Trustees”) of the 1199SEIU National Benefit Fund for Home Care Employees (“NBF-Home Care” or “Fund”), a sub-Fund of the 1199SEIU Benefit and Pension Funds, which has established a separate Home Care Trustee board. No individual or entity, other than the Trustees (including any duly authorized board, committee or designee thereof) has any authority to interpret the provisions of this Plan Document or to make any promises to you about the Plan. The Home Care Trustees reserve the right to amend, modify, discontinue or terminate all or part of this Plan for any reason and at any time when, in their judgment, it is appropriate to do so. These changes may be made by formal amendments to the Plan and/or any other methods allowed in the Trust Agreement for Trustee actions. If the Plan is amended or terminated, you and other employees may not receive benefits as described in this Plan Document. This may happen at any time, if the Plan Trustees decide to terminate the Plan or your coverage under the Plan. In no event will any employee become entitled to any vested or otherwise non- forfeitable rights under the Plan. The Trustees themselves (or through any duly authorized designee of the Trustees) reserve the complete authority and discretion to construe the terms of the Plan (and any related Plan documents), including, without limitation, the authority to determine the eligibility for, and the amount of, benefits payable under the Plan. These decisions shall be final and binding upon all parties affected by such decisions. This booklet and any amendments are your source of information on the Plan. You cannot rely on information from co-workers or Union or Employer representatives. If you have any questions about the Plan and how its coverage works, the Fund office staff will be glad to help you. Because telephone conversations and other oral statements can easily be misunderstood, they cannot be relied upon if they are in conflict with what is stated in this Plan Document. 1 HC Benefit SPD Insides - DEC2012.indd 1 5/22/13 4:12 PM The Fund believes it is a “grandfathered health plan” under the Patient Protection and Affordable Care Act, which means that this plan can preserve certain basic health coverage that was already in effect when that law was enacted, and may not include certain new consumer protections that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in the Act, for example, the elimination of lifetime limits on benefits. Questions regarding the Fund’s status as a grandfathered health plan and which protections apply can be directed to the Fund at (646) 473-9200. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor, at (866) 444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. 2 HC Benefit SPD Insides - DEC2012.indd 2 5/22/13 4:12 PM December 1, 2012 Dear 1199SEIU Home Care Member: The Fund cares about you. This Summary Plan Description is a guide to your benefits package. You’ll find information about all the benefits covered under the Fund. The biggest section in the booklet is about health benefits. This booklet will cover the procedures and policies you need to follow. Please remember: If you follow the procedures and policies for getting the most out of your benefits, you will receive comprehensive healthcare at little or no cost to you. Depending on the option you choose, your care may be covered in full when you use doctors, hospitals and other health providers who participate in the Fund’s networks. It is important that you read the entire booklet so that you know: • What benefits you are eligible to receive • What policies and procedures need to be followed to get your benefits; and • How to use your benefits wisely. It is the mission of the 1199SEIU National Benefit Fund for Home Care Employees to provide you with the best benefits possible. That’s what the Fund has been doing for 1199SEIU members for over 50 years, and what you can look forward to as an 1199SEIU member. If you have any questions or concerns about any of your benefits or coverage, call the Member Services Department at (646) 473-9200. Member Services representatives can answer your questions, refer you to another department or take the information and get back to you with an answer. Enjoy the benefits of your new benefit plan. The Board of Trustees 3 HC Benefit SPD Insides - DEC2012.indd 3 5/22/13 4:12 PM NEED HELP WITH THE SUMMARY DESCRIPTION PLAN? This booklet is a summary of your benefits and the policies and procedures for using these benefits with the 1199SEIU National Benefit Fund for Home Care Employees. If the language is not clear to you, you can get assistance by writing the Fund at: 330 West 42nd Street New York, NY 10036 Or calling (646) 473-9200. Office hours for the Fund are 8:00 am to 6:00 pm, Monday through Friday. ¿NECESITA AYUDA CON LA DESCRIPCIÓN ABREVIADA DEL PLAN? Este folleto es un resumen de sus beneficios y de las políticas y procedimientos para utilizar estos beneficios con el Fondo Nacional de Beneficios de 1199SEIU para los Empleados de Cuidados en el Hogar. Si no entiende bien el texto, puede obtener ayuda escribiendo al Fondo al: 330 West 42nd Street New York, NY 10036 O llamando al (646) 473-9200. El horario de oficina para el Fondo es de 8:00 am a 6:00 pm, de lunes a viernes. 4 HC Benefit SPD Insides - DEC2012.indd 4 5/22/13 4:12 PM 你的摘要說明計畫需要幫助嗎？ 這本小冊子是關於1199SEIU國家福利基金會給家庭護理雇員使用這些福 利的政策和程序之摘要。如果你對該語言是不清楚的，你可以透過寫信 至基金會以得到援助： 330 西 42街 紐約，紐約 10036 或請撥打（646）473-9200。 基金會的辦公時間是星期一至星期五上午8點至下午 6點。 ВАМ ЧТО-ТО НЕПОНЯТНО В КРАТКОМ ОПИСАНИИ ПЛАНА? Данная брошюра содержит краткое описание и порядок получения льгот, предоставляемых фондом National Benefit Fund for Home Care Employees профсоюза 1199SEIU. Если вам что-то не совсем ясно в этой брошюре, вы можете обратиться за помощью к специалистам Фонда, отправив письмо по адресу: 330 West 42nd Street New York, NY 10036 или позвонив по телефону: (646) 473-9200. Офис Фонда открыт с 8:00 до 18:00, с понедельника по пятницу. 5 HC Benefit SPD Insides - DEC2012.indd 5 5/22/13 4:12 PM TABLE OF CONTENTS Preface ......................................................1 Letter from the Board of Trustees ..................................3 OVERVIEW OF YOUR BENEFITS . 11 SECTION I – ELIGIBILITY .........................................21 I. A How You Become Eligible ................................23 I. B Your Spouse, Domestic Partner or Children ..................25 I. C Your Health Benefits ID Cards .............................26 I. D Maximum Benefits ......................................27 I. E Coordinating Your Benefits ...............................28 I. F When Others Are Responsible for Your Illness or Injury .........30 I. G When You Are on Workers’ Compensation Leave ..............33 I. H Losing Eligibility ........................................34 I. I Regaining Eligibility .....................................35 I. J How You Can Extend Eligibility ............................36 I. K How to Resolve Questions Concerning Eligibility for Benefits ....44 SECTION II – YOUR HEALTH BENEFITS ............................45 II. A Participating Providers ...................................48 II. B Using Your Benefits Wisely ...............................52 II. C Hospital Care and Hospice Care ...........................56 II. D Emergency Room Visits ..................................60 II. E Program for Behavioral Health: Mental Health and Alcohol/Substance Abuse .................62 II. F Surgery and Anesthesia ..................................64 II. G Maternity Care .........................................67 II. H Medical Services .......................................69 II. I Services Requiring Prior Authorization ......................73 II. J Vision Care and Hearing Aids .............................76 6 HC Benefit SPD Insides - DEC2012.indd 6 5/22/13 4:12 PM II. K Dental Benefits .........................................77 II. L Prescription Drugs ......................................79 SECTION III – DISABILITY BENEFITS ...............................85 SECTION IV – LIFE INSURANCE BENEFIT ...........................87 SECTION V – OTHER BENEFITS ...................................89 V. A Social Services ........................................91 SECTION VI – RETIREE HEALTH BENEFITS .........................93 SECTION VII – GETTING YOUR BENEFITS ..........................95 VII. A Getting Your Healthcare Benefits ...........................97 VII. B Your Rights Are Protected – Appeals Procedure.