Introduction
Summary Plan Description Introduction
Your Benefit Materials
Your benefit materials include this introduction document
your Certificate of Coverage, any riders that amend it and
your Summary of Benefits and Coverage, which gives
you information about your costs when you receive
care. You or your dependent may obtain a Summary
of Benefits and Coverage at no cost upon request.
You may have received these benefit materials
electronically or on paper with this introduction. You
may request copies at any time without cost to you.
Open Enrollment
Your employer may have an open enrollment period.
If so, you may make changes to your existing Plan
during the open enrollment period. The date for
your open enrollment, if you have one, appears
above. Changes to your enrollment will be effective
on the first of the month following BCBSVT’s
receipt of the change during open enrollment.
At open enrollment, you may only make changes
as otherwise described in this section.
When Coverage Ends
In general, your Plan Coverage will end
for you and your Dependents:
the end of the month in which your employment ends;
when you stop making required
contributions to your Plan;
when you or your Dependents are no longer
eligible to participate in your Plan; or
when your Plan is terminated.
NAME OF PLAN: PLAN NUMBER:
COMMON NAME OF PLAN (if dierent): TYPE OF PLAN:
PLAN SPONSOR: PLAN ADMINISTRATOR:
ADDRESS OF PLAN SPONSOR: ADDRESS OF PLAN ADMINISTRATOR:
AGENT FOR SERVICE OF LEGAL PROCESS (service can also be made on a
Plan trustee or Plan administrator):
BUSINESS PHONE NUMBER OF PLAN ADMINISTRATOR:
ADDRESS FOR SERVICE OF LEGAL PROCESS: INSURER (a nonprot hospital/medical service corp.):
TRUSTEE (if more than one, please see attached list to this document):
EMPLOYER IDENTIFICATION NUMBER:
If checked, this Plan is maintained pursuant to a collective
bargaining agreement. You may obtain and examine a copy
of this agreement by writing to the Plan administrator.
CONTRACT NUMBER: OPEN ENROLLMENT PERIOD:
YOUR CONTRIBUTION TO THE COST OF THIS PLAN: ELIGIBILITY you are eligible for coverage after complete the following):
TYPE OF ADMINISTRATION the Plan is administered by a nonprot hospi-
tal service corporation on a fully insured basis):
PLAN YEAR:
Marlboro College Group Health Plan
507
same
Employee Health &Welfare Benefit Plan
Corporation of Marlboro College
Corporation of Marlboro College
2582 South Road
Marlboro, Vermont 05344
2582 South Road
Marlboro, Vermont 05344
Corporation of Marlboro College
802-257-4333
Blue Cross Blue Shield of VT
Corporation of Marlboro College
2582 South Road
Marlboro , VT 05344
03-0179593
81243
To be determined by the employer
see attached rate sheet
30 days from hire date
1/1-12/31
Blue Cross and Blue Shield of Vermont
You may be eligible for benefits after termination of
Coverage. See the “Membership” section of your Summary
Plan Description. You may also be able to continue your
Plan Coverage under The Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) or Vermont Statute.
Resuming Participation
If you are rehired or if you return from a leave of absence
or furlough, you will become eligible to participate in your
Plan on the date you are rehired, recalled or return to work.
If you are rehired, recalled or return to work,
and resume participation in your Plan, you must
select new benefits for you and your eligible
Dependents by re-enrolling in the Plan.
If you are rehired, recalled or return to work during
the same Plan Year in which you were terminated,
took leave or were furloughed, your prior enrollment
election will be reinstated for the balance of the
Plan Year. You can make changes within 31 days
of the date of your rehire or return to work.
If You Go To Work for another Employer
The Health Insurance Portability and Accountability
Act of1996 (HIPAA) defines eligibility for
medical Coverage and may be limited based
on a pre-existing medical condition.
If you leave your employer and go to work for
another employer whose medical plan includes a
pre-existing condition exclusion from Coverage,
the HIPAA “prior creditable Coverage” may
help protect you from any such exclusion.
When you leave your employer, you and your Covered
Dependents will automatically receive a certificate of
creditable Coverage from your employer. This certificate
will document that you (and any of your eligible, enrolled
Dependents) had medical Coverage under the Plan.
If your new employer’s medical plan includes a
pre-existing condition clause, you can use your
certificate(s) of creditable Coverage to shorten or
eliminate any applicable waiting period for full
medical benefits under the new employer’s plan.
You can request a certificate of creditable Coverage
by calling the appropriate medical carrier.
Note: If your new employer benefits has a
pre-existing condition clause, a certificate of
creditable Coverage will not be effective to shorten
or eliminate any applicable waiting period.
Paying for Coverage
You and your employer share in the cost of your medical
Coverage. In general, your employer determines your
portion of the contribution costs prior to the beginning of
each Plan Year. (Your Plan Year appears on your Summary
of Benefits and Coverage.) Your current contribution
appears on the first page of this introduction. Each year,
before the annual enrollment period, your employer will
give you information about your Coverage options.
If you are on an unpaid leave of absence or furlough,
your payment will be made to Blue Cross and
Blue Shield of Vermont on an after-tax basis.
Continuation of Coverage
COBRA Eligibility
If you face losing health insurance Coverage, COBRA
may apply. COBRA doesn’t apply if you are fired for gross
misconduct. COBRA requires your employer to keep
you and/or your Dependents on the group plan for a
certain period of time. You must pay for your Coverage.
You could lose Coverage under your Plan because:
you quit your job;
you are laid off;
you enter active military service;
your job status changes;
you are fired; or
your company goes bankrupt but does
not cancel the group policy.
In the cases above, your employer must allow
you to stay on the Plan for 18 months.
Your employer must tell you of your COBRA rights
when you become eligible. To continue your
Coverage, you must tell your employer you elect
COBRA. You must do so within 60 days after one of
the events above (or after your employer tells you
of your COBRA rights). You must then pay the cost
of Coverage, plus up to 2 percent in a service fee.
If you or a Dependent are disabled or become disabled
within 60 days of the COBRA event (see event list above),
you can keep Coverage longer. You and your Covered
Dependents may continue for up to 29 months. You
must pay a 50 percent service fee for months 19 to 29.
In other cases (such as divorce or death of the
subscriber), you may keep your Coverage for up
to 36 months. Please check with your employer
or an attorney for more information.
Introduction
Vermont Continuation of Coverage
Vermont law requires your employer
to keep you on your Plan after:
Loss of employment, including a reduction
of hours resulting in ineligibility for
employer-sponsored Coverage;
Divorce, civil union dissolution, or legal
separation resulting in a loss of Coverage for a
Covered employee’s spouse, civil union partner
or domestic partner if domestic partners are
Covered under your employer’s plan;
A child no longer qualifying as a Dependent child
under the plan rules (e.g.—due to the child’s age), or
Death of the Covered employee, which
causes Dependents to lose Coverage.
Generally, continuation of Coverage lasts for 18 months.
Continuation of Coverage could end sooner,
under the following circumstances:
You don’t pay your premiums on a timely basis.
Your employer ceases to maintain any
group health insurance plan.
You obtain Coverage with another employer’s group
health insurance plan that does not contain any
exclusion or limitation for pre-existing conditions.
You become entitled to Medicare benefits.
Continuation of Coverage for Employees
in the Uniformed Services
The Uniformed Services Employment and Reemployment
Rights Act of 1994 (USERRA) guarantees certain rights
to eligible employees who enter military service. Upon
reinstatement, eligible employees are entitled to
the seniority, rights and benefits associated with the
position held at the time employment was interrupted
due to military service, plus additional seniority,
rights and benefits that the employee would have
attained if he or she had not left employment.
You may continue your medical Coverage for a period
of time by paying premiums as stated per company
policy or your collectively bargained agreement.
If you choose not to continue your medical
Coverage while on military leave, you may reinstate
Coverage with no waiting periods or exclusions
(exception the exclusion that applies to service-
related disabilities) when you return from leave.
In general, to be eligible for the rights
guaranteed by USERRA, you must:
Return to work on the first full, regularly scheduled
workday following your leave, safe transport
home, and an eight-hour rest period if you are
on a military leave of less than 31 days;
Return to or re-apply for re-employment within
14days of completion of such period of duty, if your
absence from employment is from 31 to 180 days; or
Return to or re-apply for re-employment within
90 days of completion of your period of duty, if
your military service lasts more than 180 days.
Continuation of Coverage while on
a Family and Medical Leave
Under the Family and Medical Leave Act (FMLA), eligible
employees may generally take up to 12 weeks of
unpaid leave for certain family and medical situations
and continue their elected medical Coverage benefits
during this time. If you take this unpaid leave and wish
to continue your medical Coverage under the Plan, you
will be billed directly on a monthly basis, at the same
rates applicable before the unpaid leave began.
If you are eligible, you can take up to 12 weeks of unpaid
leave in a 12-month period for the following reasons:
For the birth and care of your newborn child or a child
that is placed with you for adoption or foster care;
To care for a Spouse, child, or parent who
has a serious health condition; or
For your own serious health condition.
The number of weeks of unpaid leave available to
you for family and medical reasons may vary based
on the applicable state law requirements.
Statement of ERISA Rights
As a participant in the Plan you are entitled to certain
rights and protections under the Employee Retirement
Income Security Act of 1974 (ERISA). ERISA provides
that all Plan participants shall be entitled to:
Examine, without charge, at the Plan administrators
office and at other specified locations, such as
worksites and union halls, all documents governing
the Plan, including insurance contracts and
collective bargaining agreements, and a copy of
the latest annual report (Form 5500 Series) filed
by the Plan with the U.S. Department of Labor
and available at the Public Disclosure Room of the
Employee Benefits Security Administration.
Obtain, upon written request to the Plan administrator,
copies of documents governing the operation of the
Plan, including insurance contracts and collective
bargaining agreements, and copies of the latest
annual report (Form 5500 Series) and updated
summary plan description. 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.
Continue health care Coverage for yourself, spouse
or Dependents if there is a loss of Coverage under
the Plan as a result of a qualifying event. You or your
Dependents may have to pay for such Coverage.
Review this summary plan description and the
documents governing the Plan on the rules governing
your COBRA continuation Coverage rights.
Prudent Actions by Plan Fiduciaries
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 any way to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored,
in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating
to the decision without charge, and to appeal
any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce
the above rights. For instance, if you request a copy of
Plan documents or the latest annual report 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 $110 a day until you receive the
materials, unless the materials were not sent because
of reasons beyond the control of the administrator.
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.
Assistance with Your Questions
If you have any questions about your Plan, you should
contact the Plan administrator. If you have any questions
about this statement or about your rights under ERISA,
or if you need assistance in obtaining documents from
the Plan administrator, you should contact the nearest
office of the Employee Benefits Security Administration,
U.S. Department of Labor, listed in your telephone
directory or the Division of Technical Assistance and
Inquiries, Employee Benefits Security Administration,
U.S. Department of Labor, 200 Constitution Avenue N.W.,
Washington, D.C. 20210. You may also obtain certain
publications about your rights and responsibilities
under ERISA by calling the publications hotline of
the Employee Benefits Security Administration.
Your Plan is administered by your Plan administrator,
which has the authority to delegate the day-to-
day administrative duties to a third party. Here,
your Plan administrator has delegated such duties
to Blue Cross and Blue Shield of Vermont.
Blue Cross and Blue Shield of Vermont, as delegated by
your Plan administrator, shall have complete discretion to
interpret and construe the provisions of the Plan options,
programs and policies described in this Benefits Booklet,
to determine eligibility for participation and for benefits,
make findings of fact, correct errors and supply omissions.
All decisions and interpretations Blue Cross and Blue Shield
of Vermont made pursuant to the Plan options, programs
and policies described in this Benefits Booklet shall be
final, conclusive and binding on all persons and may not
be overturned unless found by a court to be arbitrary
and capricious, or unless found by an independent
medical review organization, after external review, to
be made in error. Your Plan administrator may delegate
this discretionary authority to select service providers.
If you have questions or comments regarding the
Plan’s administration, contact customer service
at Blue Cross and Blue Shield of Vermont.
Qualified Medical Child Support Orders (QMCSO)
The Omnibus Budget Reconciliation Act of 1993 (OBRA
‘93) mandates that group health plans provide benefits
according to qualified medical child support order
requirements. Contact your plan administrator to obtain,
without charge, a copy of the QMCSO procedures.
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