CITY OF CHICAGO GROUP HEALTH PLAN: MEDICAL PPO OPTION ( MEDICAL PPO PLAN )

Transcription

1 CITY OF CHICAGO GROUP HEALTH PLAN: MEDICAL PPO OPTION ( MEDICAL PPO PLAN ) Effective January 1, 2014 Fr nn-represented Emplyees, and fr Emplyees cvered under the City's cllective bargaining agreements with: AFSCME, Calitin f Uninized Public Emplyees (Chicag Building Trades Calitin), INA, Unit II, Plice Captains Assciatin, and the Plice Lieutenants Assciatin; plice sergeants represented by the Plicemen s Benevlent & Prtective Assciatin f Illinis (PB&PA); supervising plice cmmunicatins peratrs represented by Teamsters Lcal 700; aviatin security sergeants represented by the Illinis Cuncil f Plice; public health nurse III's and IV's represented by Teamsters Lcal 743; and unifrmed firefighters and paramedics represented by the Chicag Fire Fighters Unin, Lcal N. 2.

2 TABLE OF CONTENTS I. INTRODUCTION... 1 II. QUICK GUIDE... 3 III. LIFE EVENTS... 4 Page A. Marriage, Civil Unin, r Dmestic Partnership... 4 B. Adding a Child... 4 C. Getting Divrced, Disslving a Civil Unin r Dmestic Partnership... 4 D. Child Lsing Eligibility... 5 E. Taking a Family Medical Leave f Absence... 5 F. Military Leave... 5 G. In the Event f Death... 5 H. Returning t Wrk after a Leave f Absence... 5 IV. PPO PLAN SCHEDULE OF BENEFITS... 6 V. IMPORTANT CONTACT INFORMATION VI. ELIGIBILITY, ENROLLMENT, AND TERMINATION OF COVERAGE A. Eligibility B. Enrlling C. Cverage Under Mre than One Plan - N Dual Cverage D. When Cverage Begins E. Chse A Plan Once a Year F. When Cverage Ends G. Family and Medical Leave Act (FMLA) H. Military Leave/USERRA I. Reinstating Cverage J. Cntinuatin f Cverage after Terminatin - Public Health Service Act PHSA (COBRA) K. Fraudulent Cverage/Nn-Transfer/Failure t Ntify VII. MEDICAL ADVISOR REVIEW PROGRAM VIII. HOW THE MEDICAL PLAN WORKS A. PPO Prviders B. Usual and Custmary Charges i

3 C. Yur Share f Expenses IX. COVERED EXPENSES X. MEDICAL PLAN EXCLUSIONS: WHAT'S NOT COVERED BY THE PLAN XI. PRESCRIPTION DRUG COVERAGE XII. PRESCRIPTION DRUG EXCLUSIONS: WHAT'S NOT COVERED BY THE PLAN XIII. CLAIM FILING PROCEDURES XIV. CLAIM AND APPEAL DETERMINATION PROCEDURES XV. COORDINATION OF PLAN BENEFITS WITH MEDICARE FOR MEDICARE ELIGIBLE PARTICIPANTS XVI. COORDINATION OF BENEFITS XVII. THIRD PARTY RECOVERY AND REIMBURSEMENT PROVISION XVIII. HOW YOU CAN HELP CONTROL COSTS XIX. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) INFORMATION A. HIPAA Privacy B. HIPAA Security XX. PLAN FINANCING/COST OF COVERAGE XXI. PLAN ADMINISTRATOR AND ADMINISTRATION/PLAN AMENDMENT AND TERMINATION XXII. DEFINITIONS A. Fr Prviders Other than Prfessinal Prviders B. Fr Prfessinal Prviders ii

4 I. INTRODUCTION Please read this entire PPO bklet at least nce. It will help yu t be generally familiar with the medical Preferred Prvider Organizatin (PPO) Plan benefits ffered by the City. If yu knw the rules and fllw them, yu may be able t reduce yur ut-f-pcket csts fr health care. Fllwing this page is a Quick Guide t this PPO bklet, which prvides a list f the typical questins asked abut the medical PPO Plan and where t find answers. The Quick Guide is nt intended t be a substitute fr reading the PPO bklet; it is intended t help yu lcate answers t yur mst imprtant questins quickly. Fllwing the Quick Guide is the Life Events (als knwn as Family Status Changes) sectin, which prvides guidance n what t d when certain life events ccur. It's just ne mre way t find infrmatin quickly in the PPO bklet. The Definitins sectin is in the back f this bklet (starting n 113). Defined terms are capitalized thrughut the PPO bklet. T lk up a definitin, g t the Definitins sectin and search alphabetically. The City prvides cmprehensive health care prtectin fr yu and yur Family. Under the City s grup health plan, yu have the ptin t select between an HMO ptin and a PPO ptin. This dcument prvides infrmatin abut the City s Medical PPO ptin (the Plan ). Additinal infrmatin abut ther ptins under the grup health plan and ther benefits prvided by the City may be fund n the City s website at The Plan features: Access t the PPO netwrk, which cnsists f Dctrs and Hspitals natinwide (Plan benefits are higher if yu use the PPO netwrk); Preventive care benefits; and Prescriptin drug benefits. Limitatins apply t yur cverage fr speech and ccupatinal therapy, and Certificatin by the Medical Advisr is required fr MRI, PET scans, and CAT scans. Mre infrmatin is prvided later in this dcument regarding the services that require precertificatin and the applicable limitatins. In additin, the Plan s Medical Advisr Review Prgram must be ntified 24 hurs befre an elective Hspital admissin r within tw business days after an emergency admissin. There is a financial penalty applied t yur Hspital bill fr failure t call, s cntact the Medical Advisr, tll-free, at the number listed in Sectin V. These are just a few examples f the prcedures and services required t be pre-certified by the Medical Advisr, fr further infrmatin, it is imprtant that yu review the sectin entitled Medical Advisr Review Prgram. It is imprtant that yu keep the Plan Administratr (the City f Chicag) infrmed abut changes in yur status r in the status f a Dependent that is cvered by the Plan. Fr example, yu must ntify the Plan abut a change in a Dependent's status r the death r divrce f a Dependent. Nte that yu must ntify the City's Human Resurces Department f any change in address. Keep in mind that many changes can have an impact n yur mnthly cntributin rate fr cverage, hw yur claims are paid, r wh is respnsible fr the payment f the claim. If 1

5 yu fail t infrm the Plan Administratr abut certain events, yu may lse the right t cntinuatin cverage under the Public Health Services Act (see page 31). In additin, if yu r yur Dependent deliberately defraud r mislead the Plan Administratr abut yur eligibility r that f yur Dependents, yu and yur Dependents will becme ineligible fr benefits effective immediately and pssibly retractively. The City adpted this restatement f the Plan effective January 1, The Plan has been established t prvide health care benefits t Emplyees and their Dependents. The benefits described n the fllwing pages are spnsred by the City (Plan Spnsr). Please take sme time t review this PPO bklet, and share the infrmatin in this PPO bklet with yur cvered adult Dependents. Cntact the Benefits Service Center by phne at , if yu have any questins abut the benefits described in this PPO bklet. A list f infrmatin resurces is prvided with this PPO bklet in the Imprtant Cntact Infrmatin sectin n page 11. 2

6 II. QUICK GUIDE If I want t knw... See Page: Hw d I enrll fr cverage? 17 What des the Plan cver (the big picture)? 6 Hw des the Plan cver Prescriptin Drugs? 67 Hw des the Plan cver Hspital stays? 53 Hw des the Plan cver Outpatient Hspital expenses? 58 Hw des the Plan cver Skilled Nursing Facility expenses? 60 Hw des the Plan cver Dctr expenses? 59 Hw des the Plan cver Durable Medical Equipment? 49 D I have t call anyne befre I seek medical services? 36 Hw are Occupatinal and Speech Therapy cvered? 58 Hw are ther medical expenses cvered? 45 Hw d I file a claim? 76 Hw d I appeal a decisin n a claim? 80 Wh must I ntify abut Family Status Changes? 4 What des cverage cst? 6 Wh can answer questins n Plan cverage? 11 Wh can answer questins n enrllment and eligibility? 11 Wh can answer questins n the claim appeal prcess? 11 Wh can answer questins n the deductin frm my check fr medical 11 cverage? Wh d I call t find ut if my Prvider is in the netwrk? 11 What if I have cverage under mre than ne plan? 20 3

7 III. LIFE EVENTS Nte: This Life Events Sectin applies t bth participants in this Plan (the PPO Plan) and als t participants in the HMO Plan. Accrdingly, there may be references t the HMO r t HMO/insurance law requirements that d nt apply t this Plan. Different life events can affect yur benefits cverage. This article describes very generally hw yur cverage may be affected and what yu may need t d when different events ccur. Additinal detail is prvided in Article VI. Eligibility, Enrllment, and Terminatin f Cverage, and the prvisins in this Article III are subject t the mre detailed requirements set frth in Article VI. Fr mre infrmatin, please cntact the Benefits Service Center at , r by at benefitshelp@cityfchicag.rg. A. Marriage, Civil Unin, r Dmestic Partnership When yu marry, enter int a civil unin r dmestic partnership, yur Spuse, Civil Unin Spuse r Dmestic Partner is eligible fr medical cverage, including prescriptin drug cverage, as f the date f yur marriage, civil unin r satisfactin f Dmestic Partner requirements. Hwever, the Plan will nt pay any benefits n behalf f yur Spuse, Civil Unin Spuse, r Dmestic Partner until yu enrll yur Spuse, Civil Unin Spuse, r Dmestic Partner fr cverage. Yu must enrll yur Spuse r Civil Unin Spuse within 30 days f yur marriage r civil unin and supply Prf f Dependency. Yu must enrll yur Dmestic Partner within 30 days f certificatin f the partnership. See page 14 fr mre infrmatin n adding yur Spuse, Civil Unin r Dmestic Partner Spuse t yur cverage. B. Adding a Child Yur natural child will be eligible fr cverage n the date f birth. If yu adpt a child, have a child placed with yu fr adptin r becme a legal guardian fr a child, he r she may be eligible fr cverage n the date f placement s lng as the child therwise meets the Plan's definitin f a Dependent child. Stepchildren may be eligible fr cverage n the date f yur marriage. See page 14. Hwever, yu must enrll yur child fr cverage within 30 days f acquiring that child and prvide a certified birth certificate and ther dcumentatin f dependency within the required time frames befre the Plan pays any benefits fr that child. See Prf f Dependency n page 19 fr mre infrmatin n adding yur child t yur cverage. C. Getting Divrced, Disslving a Civil Unin r Dmestic Partnership If yu and yur Spuse get a divrce r if yu and yur Civil Unin Spuse r Dmestic Partner disslve yur civil unin r dmestic partnership, yur Spuse, Civil Unin Spuse r Dmestic Partner will n lnger be eligible fr cverage. Yu must ntify the City immediately f a divrce r disslutin. Hwever, a divrced Spuse may elect t cntinue cverage under the Public Health Service Act (PHSA) COBRA fr up t 36 mnths as set frth n page 31. Yu r yur ex-spuse must ntify the Benefits Service Center within 60 days f the divrce fr yur spuse t btain this cntinuatin cverage fr up t 36 mnths. Dmestic Partners and Civil Unin Spuses (except thse wh are legally married in a state that recgnizes such marriages 4

8 in which case, they wuld be simply cnsidered Spuses ) may nt be eligible fr cntinuatin. See page 31 fr mre infrmatin. If yur ex-spuse, ex-civil Unin Spuse, r ex-dmestic Partner has claims paid after the effective date f the divrce r disslutin, yu will be respnsible fr reimbursing the City fr either the claims (fr PPO Plan participants) r premiums (fr HMO participants) paid n behalf f the ex-spuse. D. Child Lsing Eligibility In general, yur Dependent child is n lnger eligible fr cverage when he r she reaches the limiting age r n lnger meets the definitin f Dependent under the Plan. See page 117. Yu shuld ntify the Benefits Service Center when ne f these events ccurs. Yur child may elect t cntinue cverage under PHSA COBRA fr up t 36 mnths. Yu r yur child must ntify the Benefits Service Center within 60 days f the date yur child n lnger meets the eligibility requirements in rder t btain this cntinuatin cverage. E. Taking a Family Medical Leave f Absence The Family and Medical Leave Act (FMLA) allws yu t take a certain amunt f unpaid leave during any 12-mnth perid, if yu qualify, due t specific reasns. Emplyees n FMLA leave are entitled t the same health benefits cverage frm the City during the leave under the same cnditins is if they were wrking. F. Military Leave Under the Unifrmed Services Emplyment and Reemplyment Rights Act ( USERRA ), yu may cntinue cverage fr up t 24 mnths if yu are absent frm wrk due t qualified military service. G. In the Event f Death In the event f yur death, yur Spuse and eligible Dependent children may cntinue cverage fr up t 36 mnths by electing cntinuatin cverage thrugh PHSA COBRA (see page 31). H. Returning t Wrk after a Leave f Absence When yu return t wrk after an apprved leave f absence, yu must cmplete enrllment by calling the Benefits Service Center t reinstate yur cverage. Yu have 30 days frm the date yu return t wrk t cmplete enrllment; therwise yu will have t wait until the next pen enrllment perid t enrll fr cverage fr the next January 1. 5

9 IV. PPO PLAN SCHEDULE OF BENEFITS The fllwing chart highlights key features f the Plan. These benefits are described in detail in this PPO bklet. The Plan pays the fllwing percentage f Allwable Charges after yu meet the Deductible. Medical Benefits PPO Prvider Nn-PPO Prvider Deductible Each Year Individual Family Out-f-Pcket Limit Each Year Individual Family $350 $1,050 $1,500 $3,000 $1,500 $3,500 $3,000 $7,000 Netwrk and Nn-PPO Prvider benefits cannt be cmbined; Deductible des nt include any Cpayments; Out-f- Pcket Limit des nt include Prescriptin Drug Cpayments Preventive Service Benefits - Certain Cntraceptive Medicatins and Devices (e.g., IUD, diaphragm) if prescribed - Certain Smking Cessatin Medicatins - Additinal Recmmended Preventive Services t the extent required t be cvered under the Affrdable Care Act f 2010 (als knwn as the health care refrm legislatin); fr a list f ther cvered preventive services, please visit 100% f Allwable Charges Nt Cvered 6

10 Outpatient Services PPO Prvider Nn-PPO Prvider - Diagnstic Testing (e.g., X-ray, lab, etc.) (5) - Outpatient Surgery - Physical Therapy - MRI Scans, PET Scans, CAT Scans (1)(5) - Durable Medical Equipment (if ver $500, subject t Pre-Certificatin (1) ) - Prsthetic Appliances, such as artificial limbs r eyes - Skilled Hme Health Care and Hspice Care (1) - Infertility Treatment (1) - Ambulance Transprtatin between Hspitals (1) 90% 90% 90% 90% 90% 60% 60% 60% 60% 60% 90% 90% 90% 90% 90% 60% 60% 60% 60% 90% - Physician Office Visit - Occupatinal and Speech Therapy (2) - Chirpractic ffice visits fr manipulatin (maximum 20 per year; three Mdalities per visit) $25 Cpayment fr Primary Care visit $35 Cpayment fr Specialist visit $20 Cpayment per visit (annual 60 visit maximum fr each) $35 Cpayment per visit 60% 60% 60% Organ Transplants PPO- Apprved Transplant Center Nn-Apprved Transplant Center The fllwing rgan transplants must be perfrmed at an apprved transplant center r they are nt cvered. Yu must call the Medical Advisr fr Pre-Certificatin. - Heart (1)(4) - Cmbinatin Heart/Bilateral Lung (1)(4) - Simultaneus Pancreas Kidney (1)(4) - Kidney nly in cnjunctin with SPK/PAK (1)(4) - Bne Marrw (1)(4) - Stem Cell (autlgus and allgeneic) (1)(4) - Lung (1)(4) - Liver (1)(4) - Pancreas (PAK/PAT) (1)(4) 90% 90% 90% 90% 90% 90% 90% 90% 90% Nt Cvered Nt Cvered Nt Cvered Nt Cvered Nt Cvered Nt Cvered Nt Cvered Nt Cvered Nt Cvered - All Other Organ Transplants (1) 90% 60% 7

11 (1) These services require Pre-Certificatin by Medical Advisr. Call (2) After 10 therapy visits, Pre-Certificatin by Medical Advisr is required. Call All speech and ccupatinal therapy visits have a $20 Cpayment (therapy nly) per visit. Cpayment des nt apply tward Deductible r Out-f-Pcket Limit. Maximum f 60 visits annually fr speech therapy. Maximum f 60 visits annually fr ccupatinal therapy. (3) These services require Pre-Certificatin by Medical Advisr after the first seven sessins in any ne year with ne r mre Prviders. (4) These services must be perfrmed at an apprved transplant r bariatric center. (5) Plan will pay 100% fr certain PPO Prvider diagnstic testing and MRI/CAT/PET scans if Participant meets the requirements f the Diagnstic Testing Incentive Prgram as set frth under Diagnstic Testing in Article VIII Hw the Medical Plan Wrks. 8

12 Hspital PPO Prvider Nn-PPO Prvider - Rm and Bard (private rm cvered if Medically Necessary) (1) - Inpatient Hspital Services (1) 1 - Outpatient Hspital Services - Skilled Nursing Facility (1) 90% 90% 90% 90% 90% 60% 60% 60% 60% 60% Bariatric Surgery PPO-Apprved Bariatric Prvider Nn-Apprved Bariatric Prvider Bariatric surgery must be perfrmed at an apprved bariatric center. Otherwise, the surgery is nt cvered. Yu must call the Medical Advisr fr Pre-Certificatin. - Bariatric Surgery (1)(3) 90% Nt Cvered Maternity PPO Prvider Nn-PPO Prvider - Maternity (delivery (1), prenatal visits, and pstnatal visit) Emergency 90% 60% - Emergency Rm Cpayment $100 per visit; waived if admitted as an inpatient. The Cpayment des nt apply tward the Deductible r Nn-PPO Prvider Out-f- Pcket Limit, but it des apply tward the PPO Prvider Out-f-Pcket Limit. - Emergency Medical r Emergency Accident 90% 90% Care Mental Health and Substance Abuse Treatment PPO Prvider Nn-PPO Prvider - Outpatient Mental Health and Substance $25 Cpayment 60% Abuse (2) treatment by a Behaviral Health Specialist - Inpatient Mental Health and Substance Abuse Treatment) (1) 90% 60% (1) These services require Pre-Certificatin by Medical Advisr. Call (2) These services require Pre-Certificatin by Medical Advisr after the first seven sessins each year with ne r mre Prviders. (3) These services must be perfrmed at an apprved transplant r bariatric center. 9

13 Prescriptin Drug Benefits At a Participating Pharmacy: - Retail (Shrt term medicatins; Maintenance/ Lng Term Medicatins less than 4 refills; 34-day supply r 100 units, whichever is less) - Retail (Maintenance/Lng Term medicatins 4 th refill and any additinal refills; 34-day supply r 100 units, whichever is less) - Mail Order (Maintenance/Lng Term Medicatins fr chrnic cnditins; 90 day supply) Generic: $10 cpay Brand Name (Frmulary) $30 cpay* ** Brand Name (Nn-Frmulary) $45 cpay* ** Generic: $20 cpay Brand Name (Frmulary) $60 cpay* Brand Name (Nn-Frmulary) $90 cpay* Generic: $20 cpay Brand Name (Frmulary) $60 cpay* Brand Name (Nn-Frmulary) $100 cpay* *If the member chses a brand name drug when a direct generic equivalent is available, member pays the cst difference between the brand name and the generic drug PLUS the generic Cpayment. **Where there is n direct generic equivalent available, but there are generic r preferred specialty drugs in the same class, the Generic Step Therapy/Specialty Drug Preferred Therapy Prgram applies. Under this prgram yu may be required t try an available generic r a preferred frmulary specialty drug in the same class f drugs; if yu d nt try the generic r preferred frmulary specialty drug as required, yu will pay the full cst f the brand name drug. If yu d try the drug and yur Physician finds that it is nt effective, yu then may receive cverage fr the brand drug based n the schedule set frth here. At a Nn-Participating Pharmacy: If yu btain prescriptins frm a nn-participating pharmacy, benefits will be paid at: - 60% f the Plan s cst fr generic drugs and fr brand name drugs when a generic equivalent is nt available, and - 60% f the Plan s generic drug cst when yu get a brand name drug that has a generic equivalent available. 10

14 V. IMPORTANT CONTACT INFORMATION Belw is cntact infrmatin fr the varius rganizatins that prvide services and/r insurance under the grup health plan spnsred by the City, including under this Plan (the PPO Plan), and under ther City plans, as identified. Cntact infrmatin als will be available at and will be included with annual pen enrllment materials. IMPORTANT WEB SITES, TELEPHONE NUMBERS, AND ADDRESSES City f Chicag Plan Eligibility Benefits Service and Enrllment Center Medical Plans PPO Plan Claims Administratr Blue Advantage HMO Blue Crss and Blue Shield f Illinis Fax: S. State Street, Rm 400 Chicag, IL (Fr Claim Prcessing) 300 East Randlph Street Chicag, IL Medical Plan Prescriptins PPO Plan Prescriptin Benefit Manager and Specialty Pharmacy Blue Advantage HMO Medical Plan Advisr PPO Plan Dental Plan Dental HMO Dental PPO Visin Care Benefits PPO Plan Blue Advantage HMO CVS Caremark Blue Crss and Blue Shield f Illinis Telligen (frmerly Encmpass) Blue Crss and Blue Shield f Illinis Fax: (Specialty Rx) Fax: Davis Visin (Fr Mail Order Prescriptins) P.O. Bx Palatine, IL (Fr Paper Claims) P.O. Bx Phenix, AZ (Fr Claim Submissins) 300 East Randlph Street Chicag, IL Westlakes Parkway West Des Mines, IA (Fr Claim Prcessing) P.O. Bx Belleville, Il Express Street Plainview, NY

15 IMPORTANT WEB SITES, TELEPHONE NUMBERS, AND ADDRESSES Flexible Spending Accunt Wellness Prgram Administratr Taking Cntrl f Yur Health Diabetes Management Prgram Life Insurance Plans Term Life Insurance Universal Life Insurance Lng Term Disability Deferred Cmpensatin PayFlex (FSA) Healthways Health Advisrs TCOYH Prgram Prudential Insurance Cmpany f America cm MetLife Underwritten by TexasLife Prudential Insurance Cmpany f America Natinwide Retirement Slutins L.cm m Transit Benefit Wagewrks Pensin Funds Unifrmed Firefighters Swrn Plice Municipal Emplyees Labrer Emplyees Firemen s Annuity and Benefit Fund f Chicag Plicemen s Annuity and Benefit Fund f Chicag Municipal Emplyees and Annuity and Benefit Fund f Chicag (M.E.A./B.F.C.) Labrers and Retirement Bard Emplyee Annuity Benefit Fund f Chicag Flex Dept. P.O. Bx 3039 Omaha, NE P.O. Bx Philadelphia, PA Attn: Rebecca Wanner 2650 Warrenville Rd, Suite 100 Dwners Grve, IL P.O. Bx Philadelphia, PA ATTN: Rebecca Wanner 205 W. Randlph, Suite 1540 Chicag, IL Park Place San Mate, CA S. Clark, Rm 1400 Chicag, IL N. LaSalle, Suite 1626 Chicag, IL N. Clark St., Suite 700 Chicag, IL N. Clark St., Suite 1300 Chicag, IL

16 VI. ELIGIBILITY, ENROLLMENT, AND TERMINATION OF COVERAGE Nte: This Sectin applies t participants in this Plan (the PPO Plan) and als t participants in the HMO Plan (bth f which are ptins ffered under the City s grup health plan). Accrdingly, there may be references t the HMO r t HMO/insurance law requirements that d nt apply t this Plan. A. Eligibility Yu are eligible t participate in the City s medical plans if yu are: A crssing guard hired prir t January 1, 2006; A full-time salaried Emplyee; A full-time Emplyee cmpensated at an hurly r daily rate; A part-time Emplyee regularly scheduled t wrk at least 84 hurs a mnth, except library pages; A regularly scheduled part-time Schl Dentist r a City Cuncil Investigatr if earning at least a Grade 1, Step 1 Salary frm Schedule B f the Salary Reslutin issued, by the City's Department f Human Resurces; An individual classified by the City as a fster grandparent and cvered under this Plan n May 31, A seasnal Emplyee wh is scheduled t wrk full-time. Yu are nt eligible t participate if yu are: A swrn plice fficer belw the rank f sergeant and represented by the Fraternal Order f Plice (their benefits are described in a separate dcument); A crssing guard hired n r after January 1, 2006; A seasnal Emplyee wh is nt scheduled t wrk full-time (in ther wrds, a seasnal Emplyee scheduled t wrk part-time); An individual hired fr a temprary prgram; An emergency appintment Emplyee; An individual paid by vucher; A library page, an aldermanic aide, r a traffic aide; A part-time Emplyee regularly scheduled t wrk less than 84 hurs a mnth; 13

17 An Emplyee earning less than a Grade 1, Step 1 Salary frm Schedule B f the Salary Reslutin issued by the City's Department f Human Resurces; An Emplyee wh has received a lifetime award frm the Illinis Wrkers Cmpensatin Cmmissin; An independent cntractr. Dependents Dependents that may be enrlled are an Emplyee's Spuse, Dmestic Partner, Civil Unin Spuse, and child(ren). Emplyees wh enrll a Spuse, Dmestic Partner, Civil Unin Spuse, r child as a Dependent are respnsible fr ntifying the Benefits Service Center f any change in circumstances, including death r terminatin f the relatinship that wuld disqualify the Dependent frm further benefits. Failure t prvide this required ntice may lead t suspensin r terminatin f the Emplyee's r Dependent s health benefits. Further, the Emplyee must reimburse the City fr any claims paid in errr n behalf f the ineligible Dependent. An Emplyee s Child is cvered if: The child is: under age 26, r 26 r lder, unmarried, mentally r physically disabled prir t reaching age 26, cvered by the Plan as f the day befre his/her 26 th birthday and dependent upn the Emplyee fr supprt and maintenance, fr the duratin f the incapacity, prvided the cverage des nt therwise terminate fr any ther reasn and all ther eligibility requirements are met. Prf f mental r physical incapacity and supprt is needed annually. In additin, fr an extra cst per child, yu may enrll unmarried children wh are between the ages f 26 and 30, if such child received a discharge (ther than a dishnrable discharge) frm the U. S. military as lng as the child is an Illinis resident and is dependent n yu fr financial supprt. "Children" means individuals wh are the Emplyee's: Natural children; Stepchildren; Dmestic Partner s children; Civil Unin Spuse s children; Children placed in the Emplyee's hme fr adptin; 14

18 Legally adpted children; and Children under legal guardianship fr whm the Emplyee is a legal guardian pursuant t an rder f a curt r administrative tribunal with apprpriate jurisdictin. Any Dependent wh is in the military service f any cuntry is nt eligible fr benefits. A Dependent wh lses cverage due t lss f dependent eligibility thrugh ne f the City s medical, dental r visin plans, may within 60 days f the date cverage was lst, elect t cntinue cverage thrugh PHSA COBRA. The Emplyee r Dependent must cntact the PHSA COBRA Administratr t receive PHSA COBRA infrmatin and an enrllment applicatin. (Refer t the When Cverage Ends sectin f this bklet fr mre details.) There may be tax cnsequences fr receiving benefits with respect t Dependents. In particular, if benefits are prvided t persns wh d nt qualify as dependents under the Internal Revenue Cde, such benefits may be taxable t the Emplyee. The fair market value f the benefits will be imputed as incme fr tax reprting and withhlding purpses. Emplyees and their Dependents shuld cnsult a tax adviser t understand these cnsequences further. Parties t a Civil Unin If yu enrll r are enrlled in the Plan, yu may als enrll a Civil Unin Spuse (same r ppsite sex) fr Plan benefits by calling the Benefits Service Center r visiting and prviding the dcuments listed belw t the Benefits Service Center within the related timeframes: Cmplete enrllment with the Benefits Service Center within 30 days f the ceremny r at the time f yur enrllment r the annual pen enrllment perid if the Civil Unin already is in effect at that time (cntact the Benefit Management Office r yur department's benefits liaisn fr a frm), A certified civil unin certificate (frm any Illinis cunty clerk) within 60 days f the ceremny, AND Statement f Tax Cde Sectin 152 Dependence (if yu are claiming yur Civil Unin Spuse as a tax-qualified dependent as defined by Sectin 152 f the Internal Revenue Cde (nt applicable with respect t Civil Unin Spuses wh are legally married in a state that recgnizes such marriages; such partners are cnsidered t be Spuses). Cverage fr a Civil Unin Spuse wh is legally married t the Emplyee in a state that recgnizes such marriages will terminate in the event f the Emplyee s death r divrce, but cntinuatin cverage under PHSA COBRA will be available. Hwever, cverage fr any ther Civil Unin Spuse will terminate and cntinuatin cverage benefits under PHSA COBRA will nt be available in the event f the death f the Emplyee r disslutin f the Civil Unin. 15

19 Dmestic Partners The City has extended health benefits t same sex Dmestic Partners f Emplyees enrlled in the Plan. Yur Dmestic Partner is eligible fr cverage at the same time yu are, if yu submit the required dcuments t the Benefits Service Center. Prf f dmestic partnership is required. T determine if yur Dmestic Partner qualifies fr enrllment, the fllwing eligibility requirements must be met: First yu, the Emplyee, must be enrlled in the PPO Plan r an HMO ffered by the City. Then, yu must btain a Certificate f Partnership frm the Department f Human Resurces. T btain a certificate yu must submit a cmpleted Affidavit f Dmestic Partnership and meet the eligibility requirements fr a Dmestic Partner. The Department f Human Resurces will review yur affidavit t determine if yu meet the minimum eligibility requirements listed belw: Yu may enrll yur Dmestic Partner if: Yu and yur Dmestic Partner are each ther's sle Dmestic Partner, respnsible fr each ther's cmmn welfare; and Neither yu nr yur Dmestic Partner are married r in a Civil Unin with smene else (if yu r yur partner were previusly married r in a Civil Unin, prf f disslutin is required), and Yu and yur Dmestic Partner are nt related by bld clser than wuld bar marriage in the State f Illinis, and Yu and yur Dmestic Partner are at least 18 years f age, are the same sex, and reside at the same residence, and At least tw f the fllwing fur cnditins must apply: 1. Yu and yur Dmestic Partner have been residing tgether fr at least twelve (12) mnths prir t filing the Affidavit f Dmestic Partnership. 2. Yu and yur Dmestic Partner have cmmn r jint wnership f a residence. 3. Yu and yur Dmestic Partner have at least tw f the fllwing arrangements: a. Jint wnership f a mtr vehicle; 16

20 b. A jint credit accunt; c. A jint checking accunt; r d. A lease fr residence identifying bth yu and yur partner as tenants. 4. Yu declare yur Dmestic Partner as a primary beneficiary in yur will. If the Department f Human Resurces issues yu a Certificate f Partnership, yu must cmplete a health cverage enrllment by: 1. Submitting a Certificate f Partnership within 60 days f certificatin; and 2. Submitting a Statement f Tax Cde Sectin 152 Dependence (if yu are claiming yur partner as a dependent as defined by Sectin 152 f the Internal Revenue Cde). T enrll yur Dmestic Partner, yu must call the Benefits Service Center at r visit the website at within 30 days f the date f certificatin and submit the Certificate f Partnership t the Benefits Service Center within 60 days f certificatin. If yu submit all the required dcumentatin within the stated timelines, cverage will be effective as f the date f certificatin by the Department f Human Resurces. If yu enrll after 30 days r yu submit the Certificate f Partnership after 60 days, cverage will nt be effective until the next January 1st. Fllwing the terminatin f a dmestic partnership, a minimum f twelve (12) mnths must elapse befre a new Dmestic Partner may be designated. Hwever, cntinuatin benefits that might therwise be available t frmer Spuses, such as PHSA COBRA benefits, are nt available t Dmestic Partners. The decisin f the City Benefits Manager n terminatin f Dmestic Partner eligibility may be reviewed nly by the Benefits Cmmittee. The premium deductin fr yur Dmestic Partner r same sex Civil Unin Spuse is taken after tax unless yur same sex Civil Unin Spuse is legally married t yu in a state that recgnizes such marriages r a Statement f Tax Cde Sectin 152 Dependence has been submitted. There may be ther tax cnsequences fr the receipt f Dmestic Partner r same sex Civil Unin Spuse benefits (unless the same sex Civil Unin Spuse is legally married t yu); Emplyees and their Dmestic Partners r Civil Unin Spuse shuld cnsult a tax adviser t understand these cnsequences. B. Enrlling T enrll fr health benefit cverage, each Emplyee wh meets eligibility requirements must enrll n line at r by calling the Benefits Service Center at within 30 days f his r her hire date, reinstatement, r Family Status Change. 17

21 The City spnsrs an Internal Revenue Cde Sectin 125 Cafeteria Plan that allws yu t pay fr yur share f cverage n a pre-tax basis. Enrllment must be cmpleted within 30 days f a Family Status Change in rder t add yurself and/r an eligible Spuse and/r eligible Dependents. Family Status Changes fr purpses f adding new Dependents include marriage, creatin f a civil unin, creatin f a dmestic partnership, birth r adptin f a child, and the lss f ther health cverage maintained by yu and/r an eligible Spuse due t a lss f eligibility fr such ther cverage (including the exhaustin f COBRA cverage). If yu add a Spuse r Dependent as a result f a Family Status Change, yur payrll deductins will include an amunt t pay fr such additinal cverage retractive t the date that the cverage began. S, fr example, if yu are married July 1 st, apply t enrll yur spuse n July 10 th, and prvide the required dcumentatin n August 1, yur payrll deductins thereafter will be adjusted t include whatever deductins were missed fr yu and/r yur spuse. If yu enrll mre than 30 days after yur hire date, reinstatement, lss f ther cverage r Family Status Change, n cverage will be available. The next pprtunity t enrll fr Plan cverage in that case will be the next annual pen enrllment perid. Yu may either cmplete enrllment nline r call the Benefits Service Center at T cmplete the nline enrllment, g t and fllw these steps: Register as a user at Lg in; and Click the link in the upper left crner titled Select Yur Benefits in rder t begin the enrllment prcess fr yu and yur Dependents. Please keep in mind that the initial enrllment prcess and the dcumentatin t establish eligibility are separate phases - each has a different due date, and bth must be cmpleted n time. If yu r yur Dependent experience (1) a lss f eligibility fr Medicaid r a state children s health insurance prgram, r (2) becme eligible t participate in a premium assistance prgram under Medicaid r a state children s health insurance prgram, yu and/r yur Dependent will be entitled t receive cverage under the Plan. Yu must ntify the Benefits Service Center within 60 days f either event described in this paragraph in rder t be enrlled in the Plan. Enrllment will begin retractive t the date f such event. Please nte that all newly hired Emplyees are eligible t participate nly in the PPO ptin fr the first 18 mnths f their emplyment, nt the HMO ptin. Emplyees may enrll in the HMO effective as f the January 1 st next fllwing the date that is 18 mnths after their date f hire. An electin t switch must be made during the pen enrllment perid immediately preceding that January 1st. 18

22 Prf f Dependency fr Spuses and Children Yu must enrll a Dependent within 30 days f the acquisitin f the Dependent. Yu then must prvide ne r mre f the fllwing dcuments as prf f dependency within 60 days f the date yur cverage is effective. T enrll a Dependent fr cverage, the Emplyee is required t prvide prf f Dependent status, such as, but nt limited t the fllwing (as applicable and determined by the City): Certified marriage certificate; Certified birth certificate fr each child yu claim as a Dependent. (The birth certificate must cntain the names f the child and the Emplyee, Emplyee s Spuse, r Civil Unin Spuse r Dmestic Partner, parent r parents.) Fr newbrns nly, yu will be affrded up t 180 days t prvide a birth certificate; Adptin papers fr legally adpted children nce yu have btained legal custdy and have brught the child hme. Yu will als need t submit a certified birth certificate and certified adptin papers within 60 days f the effective date f cverage. Please have freign dcument(s) translated prir t submissin t avid a delay in prcessing. An rder regarding legal guardianship r placement fr adptin; Curt rders if yu are required t prvide medical cverage fr ther children; r Prf f mental r physical incapacity and supprt fr a disabled child n a frm prvided each year by the Benefits Service Center if incapacity is the basis fr cntinued eligibility. If any such dcuments are required as determined by the City in its sle discretin, all certificates, curt rders, and divrce decrees must be certified. Nn-certified dcuments r cpies f certified dcuments will nt be accepted. The certified dcuments will be returned s lng as a self-addressed envelpe, with sufficient pstage, is prvided t the Benefits Service Center alng with the dcuments. If yu submit the required prf f dependency within 60 days f the date yur cverage first begins, cverage fr yur Dependents will begin when yur cverage begins. Yur payrll deductins will include an amunt t pay fr such Dependent cverage retractive t the date that the cverage began. If yu d nt submit prf within 60 days, yu will nt be able t add yur Dependents until the next pen enrllment perid fr the fllwing January 1 (unless yu acquire a new Dependent thrugh marriage, civil unin, birth, r adptin). Fr mre infrmatin r fr thse wh may have difficulty prviding prf f dependency, cntact the Benefits Service Center. 19

23 C. Cverage Under Mre than One Plan - N Dual Cverage Yu may be cvered under the Plan as either an Emplyee r as a Dependent; yu may nt be cvered as bth. A Dependent can nly be cvered by ne City Emplyee. If yu have a child wh is a full-time City Emplyee, he r she must be cvered as an Emplyee, nt as a Dependent under yur cverage. If yu are married r in a civil unin r dmestic partnership t anther City Emplyee with wh is participating as an Emplyee in a medical Plan ffered by the City, yu may elect t: Be cvered as an Emplyee and pay the required premium. Fr example, yur Spuse may want HMO cverage and yu may nt want HMO cverage. If yu and yur Spuse maintain separate cverage, yu can each select a plan; Cver yur Spuse, Civil Unin Spuse, r Dmestic Partner as yur Dependent and the premium yu pay will be based n yur salary; r Be cvered as a Dependent and yur Spuse, Civil Unin Spuse, r Dmestic Partner will pay premiums based n his r her salary. D. When Cverage Begins Cverage fr Yu and Yur Dependents Yu must enrll in the Plan befre yur cverage is effective. Yur cverage will be effective n the first day f the mnth after yur hire date if: Yu enrll within 30 days f yur hire date; and The City begins the required payrll deductin. Fr example, if yu are hired n March 5, yur cverage will begin n April 1 if yu enrll by April 4 (30 days frm March 5) and yur payrll deductins begin. Payrll deductins will include an amunt t pay fr cverage retractive t April 1 and ging frward even thugh the first deductin actually may nt ccur until later. Yur Dependents are eligible fr cverage at the same time yu are, if yu submit the required dcuments t the Benefits Service Center. Enrllment may be dne n line at r by calling Required dcumentatin fr Dependents includes prf f dependency (as described n page 19). Yu must cmplete enrllment if yu want cverage fr yur Dependents. Yur enrllment must be cmpleted befre the effective date f yur cverage, but nt later than 30 days frm yur hire date. If yu wait mre than 30 days t apply fr dependent cverage, yu will nt be able t add yur Dependents until the next pen enrllment perid fr cverage beginning the fllwing January 1. T enrll n-line, fllw these steps: Register as a user at 20

24 Lg in; Click the link in the upper left crner titled Select Yur Benefits in rder t begin the enrllment prcess fr yu and yur Dependents. Newbrn Cverage: Tw Step Prcess Ntwithstanding anything cntained herein t the cntrary, newbrns are eligible fr cverage as f the date f birth, prvided that the Emplyee is enrlled r enrlls fr cverage effective as f that date and cmpletes the fllwing steps: Step One: The Emplyee must cmplete enrllment n-line at r by calling the Benefits Service Center at fr cverage fr the newbrn within 30 days f the date f birth f the newbrn. Step Tw: The Emplyee must als submit a certified birth certificate t the Benefits Service Center within 180 days f the child's date f birth. If the Emplyee cmpletes the enrllment fr cverage within 30 days and submits the certified birth certificate within 180 days, cverage is retractive t the date f birth. If the nline r telephne applicatin fr cverage is nt made within 30 days r the certified birth certificate is nt received within the required 180 days, cverage will be effective as f the first day f the next Plan Year, prvided the enrllment is cmpleted and the birth certificate is received by that date. The enrllment and the certified birth certificate t establish eligibility can be dne separately as each has a different due date. Hwever, each frm must be submitted n time. Yu will nt need the newbrn s scial security number t enrll newbrns fr cverage, but yu will be required t prvide the number at a later date. Alternative Cverage If yu applied fr cverage fr yurself r an therwise eligible Dependent and were denied cverage because f failure t meet the enrllment r dcumentatin deadlines f the Plan, yu will be ntified f the denial by the Benefits Service Center. The ntice will infrm yu f the availability f Alternative Cverage. Alternative Cverage is identical t regular cverage except that yu will be required t pay a higher premium. If yu wish t enrll in the Alternative Cverage prgram yu must cmplete an Alternative Cverage Enrllment Frm (available frm the Benefits Service Center) and submit it t the Benefits Service Center within 30 days f the date f the denial ntice. If yu submit the Alternative Cverage Enrllment Frm after 30 days frm the date f ntice, yu may nt enrll in the Alternative Cverage prgram. Alternative Cverage will be ffered t an individual wh: Wuld therwise be eligible under the Plan, Has submitted all necessary dcuments, 21

25 Has been denied cverage under the Plan because he r she failed t cmply with the Plan's enrllment requirements, First became eligible fr cverage subsequent t the clse f the mst recent pen enrllment perid, and Agrees t pay the required premium. Persns wh are entitled t cverage as the Spuse, Civil Unin Spuse, r Dmestic Partner f an eligible Emplyee and wh have been denied cverage under the Plan because the Emplyee failed t cmply with the Plan's enrllment requirements will nt be eligible fr Alternative Cverage if such persn is currently cvered by ther medical cverage. Yu must indicate n the Alternative Cverage Enrllment Frm the type f cverage yu are requesting. The tw types f cverage available are: Retractive cverage. If yu elect retractive cverage, cverage will be effective as f the date yu and r yur dependent(s) wuld have been eligible fr cverage if yu had cmpleted enrllment in a timely manner. Yu will be required t pay the Alternative Cverage premium frm the date yu wuld have been eligible. Premium payments fr Alternative Cverage are due at the time f applicatin fr the perid f retractive cverage. Premiums shall be due thereafter n later than the first day f the mnth fr which the cverage is effective. Prspective cverage. If yu elect prspective cverage, cverage will be effective n the first day f the mnth fllwing the mnth in which yu submit the required premium. Premiums are due thereafter n later than the first day f the mnth fr which cverage is effective. In any event, Alternative Cverage will end the next December 31st r fr thse wh missed pen enrllment, the December 31st f the fllwing year, at which time thse persns receiving Alternative Cverage will be eligible fr and enrlled in regular cverage under the Plan during the applicable pen enrllment perid. Examples f cverage: Example 1 - Yu have a new baby n June 1, 2010 and apply fr cverage fr the baby n August 10, Yu wuld receive a denial ntice frm the Benefits Service Center because yu failed t apply fr cverage within 30 days f the Family Status Change, which in this case is the birth f yur child. Yu wuld have 30 days frm the date f the denial ntice t apply fr Alternative Cverage fr yur newbrn. If yu apply fr Retractive cverage, cverage is effective frm the date f birth f the child and yu wuld be required t pay premiums frm June 1, 2010, until December 31, Example 2 - Yu are married n February 14, 2010, and apply fr cverage fr yur spuse n May 1, Yu wuld receive a denial ntice frm the Benefits Service Center because yu failed t apply within 30 days f the Family Status Change, yur marriage. Yu wuld have 30 days frm the date f the denial ntice t apply fr 22

26 Alternative Cverage fr yur spuse. If yu cmplete enrllment fr Prspective cverage n May 15, 2010, cverage will be effective June 1, 2010 if yu pay the required premium. Yu wuld pay premiums frm June 1, 2010, until December 31, Example 3 - Yu are hired and fail t apply fr cverage within 30 days f yur date f hire. Several mnths later yu cmplete enrllment and the required dcumentatin. If an pen enrllment perid has nt ccurred between yur hire date and the time yu apply, yu may apply fr Alternative Cverage. Hwever, if an pen enrllment perid ccurred yu wuld nt be eligible fr Alternative Cverage because yu had the pprtunity t enrll during the pen enrllment perid. Yu will be eligible t enrll during the next pen enrllment perid fr the fllwing January 1st. Alternative Cverage fr Dependents will be prvided under the plan in which the Emplyee is enrlled. All relevant plan terms will apply. Cvered expenses will be included in any calculatin f deductibles and ut-f-pcket expenses in accrdance with the applicable plan. Premiums are subject t change each January 1st Premiums fr Alternative Cverage must be paid directly t the Benefits Service Center by check r mney rder n an after-tax basis. N deductin can be taken frm an Emplyee's check. In the event an Emplyee submits a check that is returned frm the bank because f nnsufficient funds (NSF), the Alternative Cverage shall be terminated as f the last day f the mnth fr which premium payments were received. Cverage can be terminated fr failure t make required payments in a timely manner. N ne whse Alternative Cverage is terminated can be enrlled until the Plan s pen enrllment perid fr the fllwing January 1st. E. Chse A Plan Once a Year Each year, yu will have the pprtunity t enrll r change the level f yur cverage during the pen enrllment perid. Limited Changes During The Year Yu will be able t change yur level f cverage during the year nly if yu have a Family Status Change, such as: Yur marriage r divrce, Frmatin r disslutin f a civil unin r Dmestic Partnership, Birth r adptin r placement fr adptin f a child, Death f an eligible Dependent, 23

27 A cvered Dependent child reaching the age limit, r A lss f health insurance maintained by yu and/r an eligible spuse due t a lss f eligibility fr such ther cverage (including the exhaustin f COBRA cverage). Yu must ntify the Benefits Service Center f a Family Status Change and submit dcumentatin t supprt the change with yur request. This means yu cannt drp r add Dependents during the year unless yu: Experience a Family Status Change as described abve, and Ntify the Benefits Service Center within 30 days f the change. Payrll deductins cannt be changed unless the Benefits Service Center is ntified within 30 days f the Family Status Change. The change in deductin must be cnsistent with the Family Status Change and will be retractive t the effective date f any change in cverage. Enrllment. Yu must ntify the Benefits Service Center within 30 days f a Family Status Change. In the case f Family Status Change that justifies enrllment in the Plan, cverage will be effective n the date f the Family Status Change, assuming yu als submit prf f the change in the required time perid (see belw). If yur enrllment frm indicating yur request fr a change in cverage is nt submitted within 30 days, yu will nt be able t make the change until the next pen enrllment perid fr the fllwing January 1st. Prf f Change. Yu must als submit dcumentatin t supprt the change in cverage. This dcumentatin must be submitted within 60 days f an eligible Family Status Change. If yu dn't submit the required dcuments within 60 days, yu will nt be able t make the change until the next pen enrllment perid fr the fllwing January 1st. Examples f Mid-Year Changes Any mid-year change must be cnsistent with yur status change. Example 1 - If yu have cverage fr yurself and then get married, yu'll be able t add medical cverage fr yur Spuse. Example 2 - If yu adpt r give birth t a child, yu can add yur new child t yur cverage. Example 3 - If yur Spuse lses medical cverage because he r she is laid ff frm his r her jb, yu can add yur spuse t yur medical cverage. Example 4 - Yu currently cver yur Dependents under this Plan and yur Spuse decides t elect cverage at wrk during his r her emplyer's pen enrllment perid. Yu can drp yurself, yur Spuse and/r yur Dependent children, and change yur level f cverage. This change must be requested within 30 days f yur new cverage. 24

28 Nte: If yu are nt currently enrlled in the Plan, yu will have an pprtunity t enrll yurself (alng with yur new Spuse r Dependent) when yu gain a dependent thrugh marriage, birth, adptin r placement fr adptin. Here are sme examples f changes nt cnsidered Family Status Changes: Example 1 - Yu get married but yu dn't ntify the Benefits Service Center fr six mnths. Since yu did nt request cverage fr yur spuse within 30 days f yur marriage, yu will have t wait until the next pen enrllment perid t add this cverage. (Hwever, Alternative Cverage may be available; see page 21.) Example 2 - Yu decide that yu n lnger want cverage fr yur children. Since this is nt a Family Status Change, yu'll have t wait until the next pen enrllment perid t drp cverage fr yur children. F. When Cverage Ends end: Benefits will n lnger be available fr the Emplyee and Dependents, and cverage will After the fifth cnsecutive wrking day that the Emplyee is absent withut pay, (hwever, if the Emplyee is an hurly Emplyee and n a medical leave f absence in the Labr and Trades Calitin Bargaining Grup and makes the required Emplyee cntributin, cverage will cntinue thrugh the end f the current mnth and als cntinues fr ne additinal mnth); On the 31st day f a suspensin lasting lnger than 30 days; If the Plan is discntinued; When an Emplyee is n lnger part f an Emplyee grup cvered by this Plan; The date the Emplyee ceases active emplyment with the City fr any reasn ther than disability r death; If the Emplyee takes an unpaid leave f absence, except as therwise required by the Family Medical Leave Act; On the date it is determined that the Emplyee knwingly presented bills fr services that were nt received r submits bills fr a Dependent wh is nt eligible; When the Emplyee fails t make required cntributins; If the Emplyee receives a lifetime award frm the Illinis Wrkers Cmpensatin Cmmissin; 25