Blue Cross/Blue
Shield
Indemnity Plan Member Handbook
Section I — Administration of Hospital, Medical-Surgical and
Major Medical Plan
Administration of Hospital, Medical-Surgical and Major
Medical Plan
This booklet describes, in general, the main features
of the Plan. Complete terms and conditions are set forth in the Agreement
between Blue Cross, Blue Shield and your employer. The Plan is self-funded
health plan and the administration is provided through Blue Cross of
Northeastern Pennsylvania and Pennsylvania Blue Shield, 70 North Main Street,
Wilkes-Barre, PA 18711
The funding is derived from the funds of the Employer and
contributions made by employees, if applicable. The plan is not insured.
This booklet has been prepared to meet the summary Plan
description requirements of the Employee Retirement Income Security Act of
1974. The benefits provided under the Plan are subject to the terms and
conditions of the group insurance contract issued by Blue Cross of Northeastern
Pennsylvania and Pennsylvania Blue Shield, 70 North Main Street, Wilkes-Barre,
PA 18711.
Name of
Plan
|
The University of Scranton
|
Employer and
Plan Sponsor
|
The University of
Scranton
Linden and Monroe Ave.
Scranton, PA 18510-4679
Phone: (570) 941-7767
|
Plan
Administrator
|
The University of
Scranton
Linden and Monroe Ave.
Scranton, PA 18510-4679
Phone: (570) 941-7767
|
Employer
Identification Number
|
24-0795495
|
Plan
Number
|
501
|
Participants
|
The benefits in this summary
apply to active employees of the University of Scranton.
|
Contributions
|
The costs for certain
coverage for your benefits under the plan are shared by you and your employer,
if applicable.
|
Plan
Effective Date
|
2-1-99
|
Named
Fiduciary
|
The University of
Scranton
Human Resources Department
Linden and Monroe Ave.
Scranton, PA 18510-4679
Phone: (570) 941-7767
|
Plan
Records
|
The records for the plan are
reported on a calendar year basis beginning each January 1 and ending December
31.
|
Plan/Type
Administration
|
The program described in
this booklet is an employee welfare plan providing Hospital, Medical-Surgical
and Major Medical benefits administered by Blue Cross of Northeastern
Pennsylvania and Pennsylvania Blue Shield.
|
Clerical
Error
|
Any clerical error by the
Plan Administrator or an agent of the Plan Administrator in keeping pertinent
records or a delay in making any changes will not invalidate coverage otherwise
validly in force or continue coverage validly terminated. An equitable
adjustment of contributions will be made when the error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a
Plan reimbursement amount, the Plan retains a contractual right to the
overpayment. The person or institution receiving the overpayment will be
required to return the incorrect amount of money. In the case of Covered
Person, if it is requested, the amount of overpayment will be deducted from
future benefits payable.
|
Responsibilities For Plan Administration
|
Plan Administrator –The
Plan is to be administered by the Plan Administrator in accordance with the
provisions of ERISA. An individual may be appointed by University of Scranton
to be Plan Administrator and serve at the convenience of the Employer. If the
Plan Administrator resigns, dies or is otherwise removed from the position,
University of Scranton shall appoint a new Plan Administrator as soon as
reasonably possible.
The Plan Administrator shall administer this Plan in
accordance with its terms and establish its policies, interpretations,
practices, and procedures. It is the express intent of this Plan that the Plan
Administrator shall have maximum legal discretionary authority to construe and
interpret the terms and provisions of the Plan, to make determinations
regarding issues which relate to eligibility for benefits, to decide disputes
which may arise relative to a Plan Participant’s rights, and to decide
questions of Plan interpretation and those of fact relating to Plan. The
decisions of the Plan Administrator will be final and binding on all interested
parties.
Services of legal process may be made upon the Plan
Administrator.
|
Duties Of The
Plan Administrator
|
- To administer the Plan in accordance with its
terms.
- To interpret the Plan, including the right to
remedy possible ambiguities, inconsistencies or omissions.
- To decide disputes which may arise relative to a
Plan Participant’s rights.
- To prescribe procedures for filing a claim for
benefits and to review claim denials.
- To keep and maintain the Plan documents and all
other records pertaining to the Plan.
- To appoint a Claims Administrator to pay claims.
- To perform all necessary reporting as required by
ERISA.
- To establish and communicate procedures to
determine whether a medical child support order is qualified under ERISA Sec.
609.
- To delegate to any person or entity such powers,
duties and responsibilities as it Deems appropriate.
|
Plan
Administrator Compensation
|
The Plan Administrator
serves without compensation; however, all expenses for plan administration,
including compensation for hired services, will be paid by the Plan.
|
Open
Enrollment
|
During the annual open
enrollment period, benefit eligible Employees and their Dependents will be able
to change health insurance coverage based on which benefits and coverage are
right for them.
Benefit choices made during the open enrollment period
will become effective January 1 and remain in effect unless there is a change
in family status during the year (birth, death, marriage, divorce, adoption) or
loss of coverage due to loss of a Spouse’s employment.
A Covered Person who fails to make an election during open
enrollment will automatically retain his or her present coverage.
Covered Persons will receive detailed information
regarding open enrollment from their Employer.
|
Fiduciary
|
A fiduciary exercises
discretionary authority or control over management of the Plan or the
disposition of its assets, renders investment advice to the Plan or has
discretionary authority or responsibility in the administration of the Plan.
|
Fiduciary
Duties
|
A fiduciary must carry out
his or her duties and responsibilities for the purpose of providing benefits to
the Employees and their Dependent(s), and defraying reasonable expenses of
administering the Plan. These are duties which 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;
- by diversifying the investments of the Plan so as
to minimize the risk of large losses, unless under the circumstances it is
clearly prudent not to do so; and
- in accordance with the Plan documents to the extent
that they agree with ERISA.
|
The Named
Fiduciary
|
A "named
fiduciary" is the one named in the Plan. A named fiduciary can appoint
others to carry out fiduciary responsibilities (other than as a trustee) 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 shall not be liable
for any act or omission of such person unless either:
- the named fiduciary has violated its stated duties
under ERISA in appointing the fiduciary, establishing the procedures to appoint
the fiduciary or continuing either the appointment or the procedures; or
- the named fiduciary breached its fiduciary
responsibility under Section 405(1) of ERISA.
|
Claims
Administrator Is Not A fiduciary
|
A Claims Administrator is
not a fiduciary under the Plan by virtue of paying claims in accordance
with the Plan’s rules as established by the Plan Administrator.
|
Funding the
Plan and Payment of Benefits
|
The cost of the Plan is
funded as follows:
For Employee Coverage: funding is derived
solely from the funds of the Employer.
For Dependent Coverage: Funding is derived from the funds
of the Employer and contributions made by the covered Employees.
The level of any Employee contributions will be set by the
Plan Administrator. These Employee contributions will be used in funding the
cost of the Plan as soon as practicable after they have been received from the
Employee or withheld from the Employee’s pay through payroll deduction.
Benefits are paid directly from the Plan through the
Claims Administrator.
|
Effective
Date
|
Newly hired and rehired
full-time employees and their eligible dependents will be eligible for the
benefits described in this summary plan description on the first of the month
following date of hire by completing an application form.
Persons who become eligible dependents of an enrolled
employee after the effective date of the employee’s enrollment will be
eligible for these benefits upon notification from employee of such additional
dependents and payment of applicable contributions.
|
Statement of
ERISA Rights
|
The following statement of
rights under ERISA is provided as required by regulation issued by the
Department of Labor and is in the form suggested by the Department.
As a participant in your group insurance Plan, you are
entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA provides all Plan participants shall be
entitled to:
Examine, without charge at the Plan
Administrator’s office and at other specified locations, such as work
sites and union halls, all Plan documents including insurance contracts,
collective bargaining arrangements and copies of all documents filed by the
Plan with the U.S. Department of Labor, such as detailed annual reports and
Plan descriptions.
Obtain copies of all documents and other Plan information
upon written request to the Plan Administrator. The Administrator may make a
reasonable charge for the copies.
Receive a summary of the Plan’s annual financial
report. The Plan Administrator is required by law to furnish each participant
with a copy of this summary annual report.
In addition to creating rights for Plan participants,
ERISA imposes duties upon the people who are responsible for the operation of
the Employee Benefit Plan. The people who operate your Plan, called
"fiduciaries" of the Plan, have a duty to do so prudently and in the
interest of you and other Plan participants and beneficiaries. No one,
including your employer, your union or any other person, may fire you or
otherwise discriminate against you in anyway to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA. If your claim for a
welfare benefits is denied in whole or part, you must receive a written
explanation of the reason for denial. You have the right to have the Plan
review and reconsider you claim.
Under ERISA, there are steps you can take to enforce the
above rights. For instance, if you request materials from the Plan and do not
receive them within 30 days, you may file suit in a federal court. In such a
case, the court may require the Plan Administrator to provide the materials and
pay you up to $100 a day until you receive the materials, unless the materials
were not sent because of reasons beyond the control of the Administrator. If
you have a claim for benefits which is denied or ignored, in whole or part, you
may file suit in a state or federal court. If it should happen that Plan
fiduciaries misuse the Plan’s money or if you are discriminated against
for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who
should pay court costs and legal fees. If you are successful, the court may
order the person you have sued to pay these costs and fees.
If you lose, the court may order you to pay these costs
and fees (for example, if it finds your claim is frivolous). If you have any
questions about this statement or about your rights under ERISA, you should
contact the nearest area office of the Pension and Welfare Benefits
Administration, U.S. Department of Labor listed in the telephone director or
the Division of Welfare Benefits Administration, U.S. Department of Labor, 200
Constitution Ave., N.W., Washington, DC 20210.
|
Agent For
Service of Legal Process on the Plan
|
The University of
Scranton
Human Resources
Linden and Monroe Ave.
Scranton, PA 18510-4679
Phone: (570) 941-7767
|
General
Information
No physical or oral examination of any subscriber is
required as a condition of membership.
However, the subscriber agrees that any person or
organization furnishing services or supplies to him is authorized to provide
Blue Cross and/or Blue Shield with requested information and records.
Eligibility: Hospital, Medical-Surgical and Major
Medical
You, your spouse and all unmarried dependent
children under 19 years of age are eligible for enrollment as participants for
the benefits described herein.
Each eligible dependent child is covered from birth until:
(a) the end of the calendar year in which he/she reaches their 19th
birthday, (b) the end of the month in which he/she marries or becomes employed
or (c) the end of any period during which he/she is incapable of self-support
because of a disabling abnormality or condition of illness or injury.
Eligibility for continuation of such disabled children will be determined by
Blue Cross and Blue Shield and such determination shall be conclusive.
The term "dependent child" means any
unmarried child (whether or not adopted) of any enrolled employee or the spouse
of an enrolled employee, or any other unmarried child principally supported by
or living in a parent/child relationship with such employee.
Unmarried dependent students will be covered to age
23 if they are attending on a full time basis an accredited college,
university, technical or specialized school and are pursuing a course of study
requiring at least 2 years which will lead to a degree or certificate upon
completion.
Change in Family Status
It is important that the participant notify
the Plan Administrator and complete a change form for changes in family status;
that is, marriage, marriage of any of the participant’s children, death,
divorce or other change affecting the eligibility of his or her dependents.
Note: A participant’s newborn child
will be considered a dependent under this program for 31 days immediately
following birth. If the employee is not enrolled under a family contract and
wishes to continue coverage of the newborn beyond that date, application must
be made within the 31 day period.
Identification Cards (ID)
Blue Cross and Blue Shield will issue
identification cards. If an identification card is misplaced, request a new one
through your personnel office.
How To File Your Claim For Hospital And
Medical-Surgical Benefits
All claims for benefits covered under your
Plan will be submitted directly to Blue Cross or Blue Shield by the Member
Hospital and all Participating Providers. Be sure to present your Blue Cross
and Blue Shield identification card to the provider or hospital admitting
clerk. They will assist you in completing any forms that my be required.
If the hospital is a Blue Cross Member Hospital or the
provider is a Blue Shield Participating Provider, payment for benefits will be
made directly to the hospital or provider. However, if a Non-Member Hospital or
a Non-Participating Provider provides the services, payment may be made to you.
How to File Your Claim For Major Medical Benefits
Keep a record of expenses covered under the
Major Medical Program incurred by you and each of your eligible dependents.
Complete a Major Medical statement and submit it, together with itemized bills,
to Blue Cross. File your claims throughout the year to expedite processing.
Claims for Major Medical benefits must be submitted no later than 24 months
after the incurred date. Payment for covered medical expenses will be made
directly to the subscriber. Claim forms may be obtained from your Human
Resource Department.
Blue Cross of Northeastern Pennsylvania has contracted
with Express Scripts electronic processing system to communicate with and
receive Major Medical prescription drug claims from Blue Cross of Northeastern
Pennsylvania Member Pharmacies.
When you purchase prescription drugs from a Blue Cross of
Northeastern Pennsylvania Member Pharmacy, it is not necessary for you to
submit a receipt to our office for these charges. The member pharmacy at the
time of dispensing a prescription for you and your dependent(s) will have the
ability to verify member eligibility and submit the prescription claim
electronically. All you need to do is present your Blue Cross identification
card each time a prescription is filled and pay the pharmacy the amount due for
the prescription. Blue Cross will electronically receive the prescription drug
claim; apply the appropriate Major Medical benefits; determine the applicable
deductible and/or co-insurance; calculate the payment due and reimburse you
directly.
If you are outside Blue Cross of Northeastern
Pennsylvania’s service area, you should ask if the pharmacy is a Express
Scripts National Member Pharmacy. If the pharmacy is a member of the National
Network, the claim will be handled as described above. Should the pharmacy not
be a National Member Pharmacy you must submit appropriate receipts along with a
Major Medical claim form to our office.
What To Do If Your Claim For Benefits Is Denied
Should your claim be denied in whole or in
part, you will receive written notification from Blue Cross and/or Blue Shield.
If you have any questions about the payment of your claim,
see your personnel or payroll office for further information.
If you disagree with any part of the Blue Cross or Blue
Shield decision on your claim, you have the right to appeal. If, in preparing
your appeal, you wish to review the documents pertinent to your claim, you
should write to:
Blue Cross of Northeastern Pennsylvania
And Pennsylvania Blue Shield
70 North Main Street
Wilkes-Barre, PA 18711
Your appeal letter should be sent within 60 days of the
denial. In your appeal, you should clearly state your reasons for believing the
claim should be paid, including all pertinent data. You will be sent
notification of their final decision within 60 days of your appeal, unless
special circumstances require an additional 60 days for processing.
Termination and Amendment of Plan
Upon 60 days written notice, the Plan
Administrator may terminate this contract or, subject to Blue Cross and Blue
Shield approval, may modify, amend or change the benefit provisions, terms and
conditions of the contract. No consent of any participant, or any other person
referred to on the contract, shall be required to terminate, modify, amend or
change the contract.
Plans maintained as a result of collective bargaining
Agreements are, of course, subject to change negotiated in the collective
bargaining process.
If you are laid off, resign, or retire, all health care
benefits described herein for you and for your dependents will cease on the
date specified by the plan in writing.
If at the time of termination you are receiving Major
Medical benefits for an injury which occurred or an illness which began prior
to termination, payments will be made for Covered Medical Expenses incurred for
a period not to exceed 12 months from the date of such termination of coverage
on account of that particular accident or illness only. This 12 month extension
applies only to Major Medical benefits.
If the coverage described in this booklet is terminated
because it is being replaced by another carrier, all benefits will cease on the
date when such other coverage becomes effective.
After termination of your coverage under this Plan, you
may arrange to continue your protection under the type coverage for which you
are then eligible by paying the charges for such coverage directly to Blue
Cross and Blue Shield.
Alternative Benefit Provision
The Managed Care Program provided by Blue
Cross directly or through its agent is designed to review a subscriber’s
benefits associated with a proposed or actual course of treatment and recommend
alternative benefits (including benefits not otherwise covered by this
Agreement) which maintain the quality of care, maximize the rate of recovery,
and reduce cost.
The Managed Care Program only involves the review and
recommendation of benefits which may be paid to a participant by Blue
Cross. All decisions with respect to a participant’s proposed or
alternative plan of care shall be the sole responsibility of the
participant’s physician and shall be approved by the subscriber.
Notwithstanding anything in the Plan to the contrary, Blue
Cross may, in its sole discretion, provide such alternative benefits, in lieu
of benefits otherwise payable under the Plan, as it determines to be reasonable
and consistent with the plan of care developed by the participant’s
physician and approved by the participant. Subject to the foregoing, payment of
benefits under the Plan is conditioned upon the participant’s compliance
with all Blue Cross rules and regulations pertaining to the Managed Care
Program, including but not limited to authorizing Member Hospitals, physicians,
providers, employers, unions, family members and public or private agencies, as
necessary and appropriate.
In the event Blue Cross determines in accordance with the
Plan that further treatment or hospitalization associated with the alternative
benefits is no longer medically necessary or cost effective, such alternative
benefits may be terminated and Blue Cross may pay those benefits, if any, which
would otherwise be available to the participant under the provisions of the
Plan.
Payment of benefits under the Managed Care Program is at
all times subject to all other provisions of the Plan except where such other
provisions are inconsistent with this Section in which case this Section shall
control.
Portability
Under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), if you terminate employment and obtain
other health insurance coverage which has a pre-existing condition exclusion,
you may be entitled to receive credit toward the exclusionary period, provided
you have not had a break in coverage of more than 63 days.
At the time you terminate coverage with us, BCNEPA will
issue (upon request) a certificate of coverage showing the period of time
during which you were covered under this program. This new insurer will reduce
its exclusionary period, if any, in accordance with that information.
Coordination of Benefits
In order to avoid duplication of payment for
covered services received by the participant, payment for benefits under this
Plan will be coordinated with other group health Plans.
- In the event a participant is covered under a
Benefit program other than this Plan, which does not contain a provision
coordinating its benefits with those of this Plan, such other Plan will be the
primary Plan and as such shall determine its benefits before benefits are
determined under this Plan. Benefits payable under another Plan include the
benefits that would be payable, whether or not claim is made therefore.
Such other Plan may include any company-sponsored Plan, including any group
Blue Cross/Blue Shield Plan, franchise arrangements, or any company-sponsored
Plan to which any employer contributes or makes payroll deductions. Such other
Plan will not include blanket student accident coverage.
- When a participant is covered under another plan
which contains a provision coordinating its benefit with those of this Plan,
the following rules will establish order of determining liability of this or
any other Plan:
- The Plan covering the patient as a contract Holder
is the primary Plan, which shall determine its benefits before benefits are
determined under any other Plan.
- Except for situations where the parents of a child
are separated or divorced:
- The Plan of the parent whose date of birth (month,
day) falls earlier in the calendar year is the primary Plan. If both parents
have the same birthday, the Plan which covered the parent longer will be the
primary Plan; or
- If this Plan is coordinating with a Plan which uses
a rule based on the gender of the parent, the Plan of the male parent is the
primary Plan.
- In those situations where the parents of the child
are separated of divorced:
- The Plan covering the child as a dependent of the
parent with custody will be the primary Plan;
- If the parent with custody has remarried, the Plan
which covers the child as a dependent of the step-parent with custody will be
the primary Plan;
- Where there is a court decree which establishes
financial responsibility for the health care expenses of the dependent child,
the plan which covers the child as a dependent of the parent with such
financial responsibility will be the primary plan, as long as the Plan of that
parent has actual knowledge of the court decree; or
- If the specific terms of a court decree state that
the parents shall share joint custody, without stating that one of the parents
is responsible for the health care expenses of the child, the Plans covering
the child shall follow the order of benefit determination rules outlined in
paragraph 2.b.
- Where the determination cannot be made in
accordance with the above, the Plan which has covered the participant for the
longer period of time will be considered the primary Plan, except:
- The Plan which covers the participant as an active
employee (or a dependent of such a person) is the primary Plan over a Plan that
covers a participant as laid-off or retired employee (or dependent of such a
person); or
- If either Plan does not have a provision regarding
laid-off or retired employees and as a result, the benefits of each Plan are
determined after the other, then the provisions of a 3.a. above shall not
apply.
- Services provided under any governmental program
for which any periodic payment of rate is made by or for the participant shall
always be the primary Plan, except where prohibited by law.
- Individual Non-Group Health Plans of any kind will
not be coordinated when the participant pays the entire cost.
- When this Plan is determined to be the Primary
Plan, benefits will be paid without regard to coverage under any other Plan.
When this Plan is not the primary Plan and there are remaining covered
services, this Plan will pay its regular benefit up to the amount of such
remaining eligible covered services.
- Facility of Payment – Whenever payments which
should have been made under this Plan in accordance with this provision have
been made under any other Plan, Blue Cross and Blue Shield will have the right,
at their sole discretion, to pay to any organization making such other payments
any amounts they determine to be warranted in order to satisfy the intent of
this provision and amounts so paid will be considered benefits paid under this
Plan and Blue Cross and Blue Shield will be fully discharged from liability.
- Right of Recovery – Whenever payments have
been made by Blue Cross and Blue Shield in excess of the maximum amount of
payment necessary to satisfy the intent of this provision, irrespective of to
whom paid, Blue Cross and Blue Shield will have the right to recover such
payments to the extent of such excess from among one or more of the following,
as Blue Cross and Blue Shield will determine:
- Any persons to or for or with respect to whom such
payments were made (including the participants covered under this Plan);
- Any insurance companies; and
- Any organization.
Blue Cross and Blue Shield may use such reasonable efforts
as deemed suitable to determine the existence of other Plans but will be under
no obligation to do so. Blue Cross and Blue Shield shall not be required to
determine the existence of any contract or amount of benefits under any Plan
except this Plan and the payment of benefits under this Plan shall be affected
by the benefits under any and all other Plans only to the extent that Blue
Cross and Blue Shield are furnished with information relative to such other
Plan by the group or participant or any other organization or person.
When the benefits are reduced under the primary Plan
because a participant does not comply with the Plan provisions, the amount of
such reduction will not be considered covered services. Examples of such
provisions are those related to second surgical opinions, prior certification
of admissions and services and preferred provider arrangements.
This Coordination of Benefits provision does not apply to
individual, non-group or group conversion policies.
Subrogation
- Plan Responsibilities
Plan represents and warrants that the Summary Plan
Description confers on the Plan rights of subrogation and third part recovery.
Plan delegates or assigns these subrogation rights and third party recovery
rights to Blue Cross of Northeastern Pennsylvania as the Plans agent for
purposes of subrogation.
- BCNEPA’s Subrogation Duties
Blue Cross of Northeastern Pennsylvania shall undertake
reasonable steps to identify claims in which the Plan has a subrogation
interest and shall manage subrogation cases on behalf of the Plan. Blue Cross
of Northeastern Pennsylvania shall be subrogated, and succeed to the rights of
recovery of a participant for expenses incurred against any person or
organization except insurers or policies of health insurance issued to and in
the name of participant. In those instances where the subrogation recovery
efforts of the participant’s attorney should, in the opinion of Blue Cross
of Northeastern Pennsylvania, be compensated, the Plan delegates to Blue Cross
of Northeastern Pennsylvania full authority to act on behalf of the Plan to
negotiate reasonable attorney fees not to exceed thirty-three and one-third
percent (33 1/3%) for personal injury cases, up to forty percent (40%) for
medical malpractice cases and twenty percent (20%) for worker’s
compensation cases. Any determination by Blue Cross of Northeastern
Pennsylvania with respect to attorney fees shall be final and conclusive,
unless overturned under a limited arbitrary and capricious standard of review.
Blue Cross of Northeastern Pennsylvania shall provide the participant’s
attorney with updated lien amounts, as requested, and shall work with the
participant’s attorney to recover 100% of the Covered Services paid
(unless such amount is compromised as set forth in Section C). Blue Cross of
Northeastern Pennsylvania shall credit the plan with the amount recovered,
minus, as applicable, a pro-rata share of the costs and the participant’s
attorney fees.
- Authority to Compromise Liens
In those instances where a plan’s subrogation lien
should, in the opinion of Blue Cross of Northeastern Pennsylvania, be
compromised, the plan delegates to Blue Cross of Northeastern Pennsylvania full
authority to act on behalf of the plan to compromise the lien. Any
determination by Blue Cross of Northeastern Pennsylvania with respect to
subrogation liens shall be final and conclusive, unless overturned under a
limited arbitrary and capricious standard of review.
- Participant’s Duties
The participant shall pay to Blue Cross of Northeastern
Pennsylvania all amounts recovered by suit, settlement, or otherwise from any
third party or his insurer to the extent of the benefits provided and paid
under the plan less any attorney’s fees and expenses. The participant
shall take such action, furnish such information and assistance, and execute
such papers as Blue Cross of Northeastern Pennsylvania may require to
facilitate enforcement of its rights and shall take no action prejudicing the
rights and interest of Blue Cross of Northeastern Pennsylvania.
- Prohibited by Law
These provisions shall not apply where subrogation is
specifically prohibited by law.
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA)
Federal law gives certain persons the right to continue
their health care benefits beyond the date that they might otherwise terminate.
The entire cost (plus the administration fee allowed by law) must be paid by
the continuing person. Coverage will end if the covered individual fails to
make timely payment of contributions or premiums (within a maximum of 45 days
during initial premium/contribution and 30 days thereafter). This law is
referred to as "COBRA", which stands for the Consolidated Omnibus
Budget Reconciliation Act of 1985.
Complete instructions on COBRA will be provided by the
Plan Administrator to Covered Persons who become qualified beneficiaries under
COBRA.
Benefits Affected by COBRA:
Federal law gives certain persons the right to
continue their health care benefits beyond the date that they might otherwise
terminate. The entire cost (plus the administration fee allowed by law) must be
paid by the continuing person. Coverage will end if the covered individual
fails to make timely payment of contributions or premiums (within a maximum of
45 days during initial premium/contribution and 30 days thereafter). This law
is referred to as "COBRA", which stands for the Consolidated Omnibus
Budget Reconciliation Act of 1985.
Complete instructions on COBRA will be provided by the
Plan Administrator to Covered Persons who become qualified beneficiaries under
COBRA.
Maximum time Periods.
Continuation will be available for a qualified
beneficiary up to the maximum time period shown in item (1), (2) or (3) below.
Combined qualifying events will not continue a beneficiary’s coverage for
more than 36 months beyond the date of the original qualifying event.
- Up to 18 months for an Employee and his covered
Dependent(s) when coverage terminates due to reduction of hours worked, or
termination of employment for reasons other than gross misconduct.
Note: A qualified beneficiary who is disabled may have
COBRA coverage extended (and an extra fee charged) for himself and the other a
qualified beneficiaries in his or her family from 18 months to 29 months
provided that:
- the individual is determined as being disabled for
Social Security purposes on the date of the qualifying event or within the
first 60 days of COBRA coverage; and
- the individual notifies the Plan Administrator
within 60 days of the Social Security Administration’s determination of
disability and within the original 18-month COBRA period which applies to the
person.
- Up to 36 months for:
- a covered child who ceases to be an eligible
Dependent;
- a covered Dependent of a deceased Employee;
- a former covered Spouse whose coverage ceases due
to divorce or legal separation; or
- a covered dependent when the Employee’s
coverage ceased due to entitlement for Medicare.
- There is a special continuation period for Retired
Employees and their Dependents when the Employer declares bankruptcy under
Title 11 of the United States Code and the Retired Employees and their
Dependents lose substantial coverage within one year before or after the date
that each bankruptcy proceedings commenced. Coverage will be continued for each
person until the date of that person’s death. However, the surviving
Spouse or children or a deceased Retired Employee, may continue coverage for up
to a maximum of 36 months following the Retired Employee’s death. For this
item 3, coverage does not terminate when the person becomes eligible for
Medicare.
Continued coverage may also cease before the end of the
maximum period on the earliest of:
- The date that the Employer ceases to provide a
group health Plan to any Employee; or
- The date that the qualified beneficiary first
becomes, after the date of election, (a) covered under any other group health
Plan (as an Employee or otherwise), or (b) entitled to benefits under Medicare
(except as stated in item 3 above). However, a qualified beneficiary who
becomes covered under a group health Plan which has a Pre-Existing conditions
limit must be allowed to continue COBRA coverage for the length of a
Pre-Existing condition or to the COBRA maximum time period, if less. COBRA
coverage may be terminated if the qualified beneficiary becomes covered under a
group health Plan with a Pre-Existing conditions limit, if the Pre-Existing
conditions limit does not apply to (or is satisfied by) the qualified
beneficiary by reason of the group health Plan portability, access and renew
ability requirements of the Health Insurance Portability and Accountability
Act, or the public Health Services Act.
- The date the cost of continued coverage is not paid
by the due date.
- For an individual who has extended COBRA coverage
of 29 months due to disability, COBRA coverage will end in the month that
begins more than 30 days after a final determination has been made by the
Social Security Administration that the individual is no longer disabled.
Notice Requirements.
When coverage terminates due to an
Employee’s death, termination or eligibility for Medicare, the Employer
has 30 days in which to notify the Plan Administrator of the qualifying event.
When coverage terminates due to divorce, legal separation
or change of Dependent status, the qualified beneficiary has 60 days from the
qualifying event or from the date coverage terminates in which to notify the
Plan Administrator that the qualifying event has occurred.
Complete instruction on how to elect continuation will be
provided by the Plan Administrator within 14 days of receiving notice of the
qualifying event. Covered Persons then have 60 days in which to elect
continuation. The 60 day period is measured from the later of the date coverage
terminates or the date notice of the right to continue is sent. If continuation
is not elected in that 60-day period, then the right to elect continuation
ceases.
Continuation During Family and Medical Leave
This Plan shall at all times comply with the
Family and Medical Leave Act of 1993 as promulgated in regulations issued by
the Department of Labor.
Leave taken under the Family Medical Leave Act shall be
covered under this plan on the same conditions as previously provided, as
though the Employee has been continuously employed up to the 12-week leave
period.
If Plan coverage terminates during the FMLA leave,
coverage will be reinstated for the Employee and his or her covered Dependents
if the Employee returns to work in accordance with the terms of the FMLA leave.
Coverage will be reinstated only if the person(s) had coverage under this Plan
when the FMLA leave started, and will be reinstated to the same extent that it
was in force when the coverage terminated. For example, Pre-Existing conditions
limitations and other Waiting Periods will not be imposed unless they were in
effect for the Employee and/or his or her Dependents when Plan coverage
terminated.
Conversion
If the subscriber ceases to a participant for
this program because of layoff, disability, leave of absence or termination of
employment, arrangements may be made to continue both Blue Cross and Blue
Shield under the direct payment type of participant Agreements. However, if a
participant becomes one of a group having benefits available under a Health
Insurance Program other than Blue Cross, he or she is not entitled to this
conversion privilege.
If the participant dies, the surviving spouse and child
may continue coverage under the direct payment type of subscriber Agreements.
Children who reach the maximum age limit specified in the
program also have the privilege of converting to the direct payment type of
subscriber Agreements.
Misrepresentations
If a false statement is intentionally made by the
subscriber in obtaining coverage or benefits under this Agreement, or if the
subscriber cooperates with a provider of service in the making of a false
statement with the knowledge that such statement is false, this Agreement will
be terminated immediately. Restitution will be sought by Blue Cross for any
amounts paid to the subscriber because of any false statement or
misrepresentation.
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