TO OUR VALUED EMPLOYEES

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1 TO OUR VALUED EMPLOYEES Welcome to the Yakima Valley Memorial Hospital Employee Health Care Plan! We are pleased to provide you with this comprehensive program of medical, prescription drug, and dental coverage. With the exception of very large medical claims from which the Plan is protected by insurance, all Plan expenses are directly paid by the Yakima Valley Memorial Hospital Employee Health Care Plan. The major portion of the Plan cost is provided by Yakima Valley Memorial Hospital and is supplemented by the contributions you make to participate. This means that through careful use of the Plan, you, as a consumer of health care, can have a direct impact on the cost of our Plan which will benefit both you and the Company by allowing us to continue to provide this high quality level of benefits. Please read this booklet carefully and particularly note the special requirements you must follow prior to having surgery or being admitted to a medical facility - this is explained in the IMPORTANT INFORMATION section. We have contracted for Health Services to help assure that you are receiving the best and most appropriate treatment when health care is needed. They are your advocates to help improve the quality of your health care and to lower the cost of health care to you and the Plan. If you have any questions regarding either your Plan's benefits or the procedures necessary to receive these benefits, please call: Healthcare Management Administrators, Inc. at 509/ or toll free at 877/ Washington Dental Service at 206/ or toll free at 800/ We wish you the best of health. Yakima Valley Memorial Hospital Employee Health Care Plan

2 TABLE OF CONTENTS ELIGIBILITY AND ENROLLMENT PROVISIONS 7 ELIGIBILITY... 7 EMPLOYEE ELIGIBILITY... 7 DEPENDENT ELIGIBILITY... 7 ENROLLMENT... 9 REGULAR ENROLLMENT... 9 SPECIAL ENROLLMENT FOR INDIVIDUALS WHO PREVIOUSLY REACHED THE LIFETIME MAXIMUM BENEFITS... 9 SPECIAL ENROLLMENT FOR LOSS OF OTHER COVERAGE... 9 SPECIAL ENROLLMENT FOR LOSS OF ELIGIBILITY DUE TO REACHING LIFETIME MAXIMUM BENEFITS UNDER ANOTHER PLAN SPECIAL ENROLLMENT FOR LOSS OF STATE CHILDREN S HEALTH INSURANCE PROGRAM (SCHIP) OR MEDICAID SPECIAL ENROLLMENT FOR NEW DEPENDENTS SPECIAL ENROLLMENT FOR NEW DEPENDENTS THROUGH QUALIFIED MEDICAL CHILD SUPPORT ORDER OPEN ENROLLMENT CERTIFICATE OF CREDITABLE COVERAGE EFFECTIVE DATE OF COVERAGE EMPLOYEE EFFECTIVE DATE DEPENDENT EFFECTIVE DATE TERMINATION OF COVERAGE EMPLOYEES DEPENDENT(S) OF EMPLOYEES APPROVED FAMILY AND MEDICAL LEAVE MILITARY LEAVE OF ABSENCE REINSTATEMENT OF COVERAGE CONTINUATION COVERAGE RIGHTS UNDER COBRA 16 INTRODUCTION WHAT IS COBRA COVERAGE? WHO IS ENTITLED TO ELECT COBRA? WHEN IS COBRA COVERAGE AVAILABLE? ELECTING COBRA COVERAGE SPECIAL CONSIDERATIONS IN DECIDING WHETHER TO ELECT COBRA LENGTH OF COBRA COVERAGE EXTENSION OF MAXIMUM COVERAGE PERIOD TERMINATION OF COBRA COVERAGE BEFORE THE END OF THE MAXIMUM COVERAGE PERIOD COST OF COBRA COVERAGE PAYMENT FOR COBRA COVERAGE MORE INFORMATION ABOUT INDIVIDUALS WHO MAY BE QUALIFIED BENEFICIARIES 25 IF YOU HAVE QUESTIONS KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES PLAN CONTACT INFORMATION NOTICE PROCEDURES NOTICE PROCEDURES FOR NOTICE OF QUALIFYING EVENT NOTICE PROCEDURES FOR NOTICE OF DISABILITY NOTICE PROCEDURES FOR NOTICE OF SECOND QUALIFYING EVENT NOTICE PROCEDURES FOR NOTICE OF OTHER COVERAGE, MEDICARE ENTITLEMENT, OR CESSATION OF DISABILITY MEDICAL BENEFITS 34 01/01/11 1 GM048 & 00427

3 HEALTHCARE MANAGEMENT ADMINISTRATORS (HMA) 35 PREFERRED PPO 35 SCHEDULE OF MEDICAL BENEFITS 35 SKILLED NURSING FACILITY CARE OUT OF AREA & EMERGENCY SERVICES FOR EMERGENCY SERVICES ONLY FOR NON-EMERGENCY SERVICES MEDICAL BENEFITS CALENDAR YEAR MAXIMUM BENEFITS LIFETIME MAXIMUM BENEFITS IMPORTANT INFORMATION - PLEASE READ 42 MEDICAL FACILITY ADMISSION PRE-AUTHORIZATION CERTIFICATION OF ADDITIONAL DAYS STEPS TO TAKE CASE MANAGEMENT/ALTERNATE TREATMENT HOW TO FILE A CLAIM CONTINUATION OF COVERAGE PROVISIONS (COBRA) CONTACT FOR QUESTIONS ABOUT THE PLAN BENEFITS PRE-EXISTING CONDITIONS LIMITATIONS 46 PRE-EXISTING CONDITIONS PRE-EXISTING CONDITIONS EXCLUSION PLAN PAYMENT PROVISIONS 47 DEDUCTIBLES INDIVIDUAL FAMILY DEDUCTIBLE CARRYOVER AMOUNTS NOT CREDITED TOWARD THE DEDUCTIBLE COINSURANCE PERCENTAGE OUT-OF-POCKET MAXIMUM COMPREHENSIVE MAJOR MEDICAL BENEFITS 49 ELIGIBLE EXPENSES ALLERGY INJECTIONS/TESTING AMBULANCE (AIR AND GROUND) BIOFEEDBACK BIRTH CONTROL DEVICES BLOOD BANK CHEMICAL DEPENDENCY INPATIENT TREATMENT OUTPATIENT TREATMENT CHIROPRACTIC CARE COLONOSCOPY COSMETIC RECONSTRUCTIVE SURGERY DENTAL SERVICES DIABETIC EDUCATION AND COUNSELING DIAGNOSTIC X-RAY AND LABORATORY DURABLE MEDICAL EQUIPMENT EMERGENCY ROOM & SERVICES HEARING BENEFIT HOME HEALTH CARE EXCLUSIONS TO HOME HEALTH CARE GM048 & /01/11

4 HOSPICE CARE EXCLUSIONS TO HOSPICE CARE IMMUNIZATIONS INFUSION THERAPY BENEFIT MAMMOGRAMS MATERNITY SERVICES NEWBORNS AND MOTHERS HEALTH PROTECTION ACT MEDICAL FACILITY SERVICES INPATIENT CARE OUTPATIENT CARE MISCELLANEOUS MEDICAL SUPPLIES MENTAL HEALTH TREATMENT INPATIENT TREATMENT OUTPATIENT TREATMENT NEURODEVELOPMENTAL THERAPY SERVICES NEWBORN NURSERY CARE BENEFIT OUTPATIENT SURGICAL FACILITY PHENYLKETONURIA (PKU) DIETARY FORMULA PHYSICIAN SERVICES PRE-ADMISSION TESTING PRESCRIPTION DRUGS PREVENTIVE MEDICAL CARE PROSTHETIC APPLIANCES RADIATION THERAPY AND CHEMOTHERAPY REHABILITATION BENEFIT INPATIENT TREATMENT SECOND SURGICAL OPINION SKILLED NURSING FACILITY CARE STERILIZATION - ELECTIVE SURGERY AND RELATED SERVICES TRANSPLANTS VISION EXAM GENERAL EXCLUSIONS TO THE MEDICAL PLAN 65 GENERAL MEDICAL DEFINITIONS 70 GENERAL MEDICAL PROVISIONS 79 APPEALING A CLAIM INITIATING A CLAIM URGENT PRE-SERVICE CLAIM PRE-SERVICE CLAIM POST-SERVICE CLAIM AUDIT AND REVIEW FEES MEDICARE DISABLED EMPLOYEES WITH END-STAGE RENAL DISEASE (ESRD) DENTAL BENEFITS 83 MYSMILE PERSONAL BENEFITS CENTER 84 SCHEDULE OF DENTAL BENEFITS 85 HOW TO USE YOUR PROGRAM 86 01/01/11 3 GM048 & 00427

5 CHOOSING A DENTIST DELTA DENTAL PARTICIPATING DENTISTS NONPARTICIPATING DENTISTS IN WASHINGTON STATE OUT-OF-STATE DENTISTS CLAIM FORMS PREDETERMINATION OF BENEFITS BENEFIT PERIOD REIMBURSEMENT LEVELS LIMITATIONS AND EXCLUSIONS COPAYMENTS PROGRAM MAXIMUM PROGRAM DEDUCTIBLE DENTAL BENEFITS COVERED BY YOUR PROGRAM 89 CLASS I DIAGNOSTIC PREVENTIVE PERIODONTICS CLASS II GENERAL ANESTHESIA INTRAVENOUS SEDATION RESTORATIVE ORAL SURGERY PERIODONTICS ENDODONTICS PROSTHODONTICS CLASS III PERIODONTICS RESTORATIVE PROSTHODONTICS ORTHODONTIC BENEFITS FOR ADULTS AND ELIGIBLE CHILDREN TEMPOROMANDIBULAR JOINT BENEFITS GENERAL DENTAL LIMITATIONS 100 GENERAL EXCLUSIONS TO THE DENTAL PLAN 101 IMPORTANT INFORMATION PLEASE READ 102 FREQUENTLY ASKED QUESTIONS ABOUT YOUR DENTAL BENEFITS GENERAL DENTAL DEFINITIONS 104 CLAIM REVIEW AND APPEAL 107 PREDETERMINATION OF BENEFITS URGENT PREDETERMINATION REQUESTS INITIAL BENEFIT DETERMINATIONS APPEALS OF DENIED CLAIMS DISCLOSURE INFORMATION 110 MEDICAL & DENTAL GENERAL PROVISIONS 112 MEDICAL & DENTAL GENERAL PROVISIONS 113 ADMINISTRATION OF THE GROUP MEDICAL PLAN GM048 & /01/11

6 AMENDMENT OF PLAN DOCUMENT APPLICABLE LAW APPLICATION AND IDENTIFICATION CARD ASSIGNMENT OF PAYMENT CANCELLATION CONDITIONS PRECEDENT TO THE PAYMENT OF BENEFITS COORDINATION OF BENEFITS DEFINITIONS APPLICATION CREDIT FOR PRIOR GROUP COVERAGE EFFECT OF TERMINATION OF THE PLAN FACILITY OF PAYMENT FIDUCIARY OPERATION FREE CHOICE OF PHYSICIAN OR DENTAL PROVIDER FUNDING HIPAA PRIVACY AND SECURITY USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION PLAN SPONSOR S CERTIFICATION OF COMPLIANCE RESTRICTIONS ON DISCLOSURE OF PROTECTED HEALTH INFORMATION TO EMPLOYER (PLAN SPONSOR) EMPLOYER (PLAN SPONSOR) OBLIGATIONS REGARDING PROTECTING HEALTH INFORMATION ADEQUATE SEPARATION BETWEEN THE EMPLOYER (PLAN SPONSOR) AND THE PLAN EMPLOYER (PLAN SPONSOR) OBLIGATIONS REGARDING ELECTRONIC PROTECTING HEALTH INFORMATION INADVERTENT ERROR INTERNATIONAL COVERAGE MISREPRESENTATION NOTICE PHOTOCOPIES PLAN ADMINISTRATION PLAN IS NOT A CONTRACT OF EMPLOYMENT PLAN SUPERVISOR NOT A FIDUCIARY PRIVILEGES AS TO DEPENDENTS RIGHT OF RECOVERY SPOUSE SUBROGATION, THIRD-PARTY RECOVERY AND REIMBURSEMENT THE PLANS RIGHT TO RESTITUTION BENEFITS CONDITIONAL UPON COOPERATION RIGHT OF FULL RESTITUTION SURROGACY ARRANGEMENT OR AGREEMENT PAYMENT RECOVERY TO BE HELD IN TRUST SUMMARY PLAN DESCRIPTION TAXES SPECIAL DISCLOSURE INFORMATION (ERISA) 126 STATEMENT OF ERISA RIGHTS RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS CONTINUE GROUP HEALTH PLAN COVERAGE PRUDENT ACTIONS BY PLAN FIDUCIARIES ENFORCE YOUR RIGHTS ASSISTANCE WITH YOUR QUESTIONS PLAN SPECIFICATIONS /01/11 5 GM048 & 00427

7 This booklet is the Master Plan Document and has been prepared in accordance with Public Law , the Employee Retirement Income Security Act of 1974 (ERISA). This booklet and any amendments constitute the plan document for this benefit plan. This Plan is maintained for the exclusive benefit of the Plan Employees and each Participant's rights under this Plan are legally enforceable. The Plan Administrator has the right to amend this Plan at any time. The Plan Administrator will make a good faith effort to communicate to the Plan participants all Plan amendments on a timely basis. For further information, see the section titled Amendment of Plan Document located in the General Provisions section of this Plan. GM048 & /01/11

8 ELIGIBILITY AND ENROLLMENT PROVISIONS ELIGIBILITY Employee Eligibility Employees eligible for coverage under this plan are: All active full-time and part-time employees of Yakima Valley Memorial Hospital who are regularly scheduled to work 20 hours or more per week are eligible for coverage under this Plan. An employee is defined as: an individual directly involved in the regular business of and compensated for services by YVMH, who is regularly scheduled to work as indicated above. Ineligible classes of employees, are: (1) part-time employees who are regularly scheduled to work less than 20 hours per week; (2) temporary employees. In addition to the above, to be eligible for coverage under the Plan, all otherwise eligible employees must provide an accurate social security number to the Plan Administrator at the time of enrollment. Dependent Eligibility Dependents eligible for coverage under this plan are: An employee s legally married spouse (who is neither divorced nor legally separated from the employee.) A domestic partner. Domestic Partners are defined as two adults, of the same or opposite sex, engaged in a spouse-like relationship. To qualify for domestic partners coverage, individuals must meet the following qualifications: 1) Be registered as domestic partners or entered into a civil union in a state where such registration exists; OR 2) Meet all of the following criteria: Both individuals are at least age 18. Neither individual is legally married to another person of the opposite sex or in a domestic partnership with another person. The individuals are not related by blood to a degree of closeness that would prohibit marriage. The individuals are in an exclusive, committed relationship that is intended to be permanent. The individuals share a mutual obligation of support and responsibility for each other s welfare. The individuals currently share a principal residence and we intend to do so permanently Children of domestic partners are not covered. 01/01/11 7 GM048 & 00427

9 An employee must complete a Domestic Partnership Affidavit attesting to the circumstances outlined above. The employee must notify Yakima Valley Memorial Hospital within 30 days of any change in the circumstances attested to in the Affidavit by completing an Affidavit of Termination of Domestic Partnership. Upon termination of a domestic partnership, another Affidavit of Domestic Partnership cannot be filed until the earlier of: six months from the date the last Affidavit of Domestic Partnership was filed; or the date the employee registers a domestic partner or enters into a civil union in a state where such registration exists. Please contact the Yakima Valley Memorial Hospital Human Resources Department to obtain an official Affidavit of Domestic Partnership or for more information on how to qualify for coverage under this provision. An employee s married or unmarried child, under the age of 26, regardless of whether or not the child is eligible for employer sponsored coverage through their own employer, whether or not a full-time student, whether or not claimed as a dependent on the employee s federal income taxes, and whether or not dependent upon the employee for support. A special enrollment period will be held from December 1, 2010 through December 31, 2010 to allow dependent children whose coverage previously ended or were not previously eligible for coverage due to the attainment of age, to now enroll for coverage under the Plan. The dependent (and covered employee) will be eligible to enroll in any benefit package available to other similarly situated individuals. Coverage for eligible dependents that are enrolled during this special enrollment period, will become effective January 1, An employee s unmarried dependent child(ren) who is incapable of self-support because of mental retardation, mental illness or physical incapacity that began prior to the date on which the child's eligibility would have terminated due to age. Proof of incapacity must be received within 120 days after the date on which the maximum age is attained. Subsequent evidence of disability or dependency may be required as often as is reasonably necessary to verify continued eligibility for benefits. An employee s unmarried dependent child(ren) whose coverage is required pursuant to a valid court, administrative order or Qualified Medical Child Support Order (QMCSO). Adopted children are eligible under the same terms and conditions that apply to dependent, natural children of parents covered under this Plan. Any individual who is covered as an employee cannot also be covered as a dependent. No dependent can be covered as a dependent of more than one employee. The term dependent children means any of the employee s natural children, legally adopted children, or children who have been placed for adoption with the employee prior to the age of 18, or step-children who depend on the employee for support, or children who have been placed under the legal guardianship of the employee or the employee s spouse by a court decree or placement by a State agency. Placement for adoption is defined as the assumption and retention of an obligation for total or partial support of a child in anticipation of adoption irrespective of whether the adoption has become final. The child's eligibility terminates upon termination of the legal obligation. A dependent is defined as an individual who is: (1) listed on the employee's application as a dependent of the employee; (2) eligible for dependent coverage (based upon the criteria GM048 & /01/11

10 above); (3) whose application has been accepted by the Plan Administrator; and (4) for whom the applicable rate of coverage has been paid. In addition to the above, to be eligible for coverage under the Plan, all otherwise eligible dependents must provide an accurate social security number to the Plan Administrator at the time of enrollment. ENROLLMENT Regular Enrollment To apply for coverage under this plan, the employee must complete and submit an enrollment form within 31 days of the date the individual first becomes eligible for coverage. The completed enrollment form should list all eligible dependents to be covered. You are required to provide an accurate social security number on the enrollment form, for you and your eligible dependents in order to be covered under the medical plan, newborns within a reasonable period of time following birth.) Individuals who do not enroll when first eligible or do not provide the required social security number(s) will not later be allowed to enroll, unless they become eligible for Special Enrollment or during the annual Open Enrollment period, at which time the social security number will still be required. When the employee acquires a new dependent (birth, marriage, adoption, etc.), the dependents must be enrolled within the enrollment eligibility periods specified below. Domestic partners are eligible for special enrollment to the same extent as a spouse. Newly acquired dependent: A newly acquired dependent (except a newborn child or a child placed for adoption) must be enrolled within 31 days of the date of acquisition. Newborn: A newborn child may be covered from birth provided the child is enrolled within 60 days of the date of birth. Adopted Child: A child placed for adoption may be covered from the date of placement provided the child is enrolled within 60 days of the date of placement. Special Enrollment for Individuals Who Previously Reached the Lifetime Maximum Benefits A special enrollment period will be held from December 1, 2010 through December 31, 2010 to allow individuals whose coverage previously ended due to reaching the lifetime limit for all benefits under the plan to re-enroll for coverage under the Plan. The individual (and employee) will be eligible to enroll in any benefit package available to other similarly situated individuals. Coverage for individuals that are enrolled during this special enrollment period will become effective January 1, Special Enrollment for Loss of Other Coverage A special enrollment period is available for current employees and their dependents who lose coverage under another group health plan or had other health insurance coverage if the following conditions are met: The employee or dependent is eligible for coverage under the terms of the Plan, but not enrolled. Enrollment in the Plan was previously offered to the employee. 01/01/11 9 GM048 & 00427

11 The employee declines the coverage under the Plan because, at the time, the employee and/or dependent was covered by another group health plan or other health insurance coverage. The employee has declared in writing that the reason for the declination was the other coverage. The current employee or dependent may request the special enrollment within 31 days of the loss of other health coverage under the following circumstances. If the other group coverage is not COBRA continuation coverage, special enrollment can only be requested after losing eligibility for the other coverage due to a COBRA qualifying event or after cessation of employer contributions for the other coverage. Loss of eligibility of other coverage does not include a loss due to failure to pay premiums on a timely basis or termination of coverage for cause. COBRA continuation does not have to be elected in order to preserve the right to a special enrollment. If the other group coverage is COBRA continuation coverage, the special enrollment can only be requested after exhausting COBRA continuation coverage. If the other individual or group coverage does not provide benefits to individuals who no longer reside, live, or work in a service area, and in the case of group coverage, no other benefit packages are available. If the other plan no longer offers any benefits to the class of similarly situated individuals. Effective date of coverage will be the first of the month following the date the request is received by the Plan Administrator. Special Enrollment for Loss of Eligibility Due to Reaching Lifetime Maximum Benefits Under Another Plan A special enrollment period is available for current employees and their dependent, if an individual incurs a claim that causes the individual to meet or exceed a lifetime maximum on all benefits. The current employee or dependent may request the special enrollment within 31 days from the date that the claim putting the individual over the lifetime maximum was denied. If the other coverage is COBRA continuation coverage, meeting or exceeding a lifetime maximum on all benefits, shall also result in the exhaustion of COBRA continuation coverage. Special enrollment must be requested within 31 days from the date the claim putting the individual over the lifetime maximum was incurred. Effective date of coverage will be the first of the month following the date the request is received by the Plan Administrator. GM048 & /01/11

12 Special Enrollment for Loss of State Children s Health Insurance Program (SCHIP) or Medicaid A special enrollment period is available for current employees and their dependents who are otherwise eligible for coverage under the Plan, if one of the following events occurs: The employee s or dependent s State Child Health Plan coverage or Medicaid coverage is terminated due to a loss of eligibility. The employee or dependent becomes eligible for State Child Health Plan or Medicaid premium assistance. The current employee or dependent may request the special enrollment within 60 days from the date other coverage is lost or within 60 days from the date that premium assistance eligibility is determined. Effective date of coverage will be the first of the month following the date the request is received by the Plan Administrator. Special Enrollment for New Dependents A special enrollment period is available for current employees who acquire a new dependent by birth, marriage, adoption, or placement for adoption. This special enrollment applies to the following events: When an employee marries, a special enrollment period is available for the employee and newly acquired dependents. The effective date will be the first of the month following or coinciding with the date the completed enrollment material is received by the Plan Administrator, provided the forms are returned within 31 days of the date of marriage. When an employee or spouse acquire a child through birth, adoption, or placement for adoption, a special enrollment period is available for the employee, the spouse and the dependent. As long as the proper enrollment material is received by the Plan within the 60 day enrollment period, the effective date of coverage will be the date of the birth, adoption, or placement of adoption. Special Enrollment for New Dependents through Qualified Medical Child Support Order Section 609(a) of ERISA requires medical benefit plans to honor the terms of a Qualified Medical Child Support Order (QMCSO). The order must be issued as a part of a judgment, order of decree or a divorce settlement agreement related to child support, alimony, or the division of marital property, issued pursuant to state law. Agreements made by the parties, but not formally approved by a court are not acceptable. If the child is enrolled within 31 days of the court or state agency order, the waiting period and pre-existing conditions exclusion period do not apply. If the employee is not covered under the Plan at the time a Qualified Medical Child Support Order is received, the employee and dependent requiring coverage will have the opportunity to enroll in the plan if the request is received by the Plan Administrator, within 31 days of the court, state, or national agency order. If enrollment is not requested within 31 days, the employee must wait until the next annual Open Enrollment period to enroll. 01/01/11 11 GM048 & 00427

13 Open Enrollment An open enrollment period is held once every 12 months to allow eligible employees to change their participation. The open enrollment period will be the month of December for an effective date of January 1. The waiting period for coverage of pre-existing conditions for newly enrolled participants will start on the date the coverage becomes effective. The pre-existing conditions limitation for eligible employees enrolling during open enrollment will be 6 months from the date coverage begins, less any period of creditable coverage. CERTIFICATE OF CREDITABLE COVERAGE Under the Health Insurance Portability and Accountability Act of 1996, former Plan participants and their eligible dependents have the right to request and receive a Certificate of Creditable Coverage for any coverage, including COBRA coverage that was in effect June 1, 1996 or after. The right to receive this certificate continues for 24 months following the date of termination of coverage under this Plan. If a participant loses coverage under this Plan they will be sent a Certificate of Creditable Coverage. This is an important document and should be kept in a safe place. The Certificate of Creditable Coverage will be important proof of coverage under the plan that may be needed to reduce any subsequent health plan's pre-existing condition limitation period which might otherwise apply to plan participants and/or their dependents. When enrolling in this Plan, you must provide a Certificate of Creditable Coverage in order to receive credit towards the pre-existing condition waiting period. EFFECTIVE DATE OF COVERAGE Employee Effective Date The effective date of coverage for eligible employees is the first of the month following the waiting period. The waiting period is the period that must pass before coverage for an employee or dependent, that is otherwise eligible to enroll under the terms of the Plan, can become effective. Periods of employment in an ineligible classification are not part of a waiting period. The waiting period is 3 months. Coverage begins for all eligible employees on the earlier of: (1) the first of the month coinciding with the end of the 3 month wait; or (2) the first of the month following the end of the 3 month wait; or (3) the first of the month following the date the employee becomes eligible, provided the employee has been employed 3 months or more. Dependent Effective Date If the employee elects coverage for dependents during the first 31 days of eligibility, the dependents effective date will be the same as the employee s effective date. If the covered employee marries, the employee must add the newly acquired dependents within 31 days of the date of marriage and the effective date of coverage is the first of the month following or coinciding with the date of marriage; provided the enrollment forms are received within the required time frame. GM048 & /01/11

14 If the covered employee acquires a child through birth, adoption, or placement for adoption, the employee must add the child within 60 days of the date of birth, adoption or placement for adoption and the effective date of coverage for the child is the date of birth, adoption, or placement for adoption. TERMINATION OF COVERAGE Except as provided in the Plan's Continuation of Coverage provisions, coverage will terminate on the earliest of the following occurrences: Employees The last day of the month in which the employee ceases to meet the eligibility requirements of the Plan. The last day of the month in which the employee terminates employment. The last day of the month in which the employee begins active service in the armed forces. The first day of the month in which the employee fails to make any required contribution when coverage is contributory. The last day of the month in which an employee fails to return to work following an approved leave of absence. The last day of the month in which the employee retires. The last day of the month in which the Employer terminates the Plan and offers no other group health plan. Dependent(s) of Employees The last day of the month in which the employee's coverage terminates. The last day of the month in which such individual ceases to meet the eligibility requirements of the Plan. The last day of the month in which the dependent becomes eligible as an employee. The last day of the month in which contributions have been made on their behalf. The last day of the month in which the dependent begins active service in the armed forces of any country. The last day of the month in which dependent coverage is discontinued under the Plan. The last day of the month in which the Employer terminates the Plan and offers no other group health plan. Coverage will not be terminated retroactively except in the case of an employee s failure to remit premiums or contribution in a timely manner or in the case of fraud or intentional misrepresentation. The Plan Administrator will provide 30 days advance written notice to 01/01/11 13 GM048 & 00427

15 covered employees and dependents that will lose coverage retroactively due to an act, practice, or omission that constitutes fraud or the employee or dependent makes an intentional misrepresentation of material fact. APPROVED FAMILY AND MEDICAL LEAVE The Plan will at all times comply with the Family and Medical Leave Act (FMLA) or similar state law that applies to coverage under this group health plan. During any leave taken under FMLA (or applicable state law), you may maintain coverage under this Plan on the same conditions as if you had been continuously employed during the entire leave period. Please contact the YVMH s Human Resources Department for information on how to qualify for a Family/Medical Leave of Absence. MILITARY LEAVE OF ABSENCE Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act of These rights apply only to eligible employees and eligible dependents covered under the Plan before leaving for military service. The maximum period of coverage of a person under such an election shall be the lesser of: a. For elections made before December 10, 2004, the 18 month period beginning on the date that Uniformed Service leave commences; or b. For elections made on or after December 10, 2004, the 24 month period beginning on the date that Uniformed Service leave commences; c. The period beginning on the date that Uniformed Service leave commences and ending on the day after the date on which the person was required to apply for or return to a position of employment and fails to do so. A person who elects to continue Plan coverage may be required to pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the employee s share, if any, for the coverage. A preexisting condition exclusion may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service. However, Plan exclusions and waiting periods may be imposed for any sickness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during military service. Please contact YVMH s Human Resources Department for information concerning your eligibility for USERRA and any requirements of the Plan. GM048 & /01/11

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