Welcome to the North Clackamas Vision Plan

Transcription

1 TO OUR VALUED EMPLOYEES Welcome to the North Clackamas Vision Plan If you have any questions regarding either your Plan s benefits or the procedures necessary to receive these benefits, please call the Plan Supervisor Health Management Administrators, Inc. (HMA) at When calling from outside of Seattle, you may call HMA toll free at We are pleased to provide employees and their eligible dependents with this comprehensive vision program. North Clackamas School Board

2 VISION BENEFITS Coinsurance EXAMINATION 100% The Maximum Benefit for services for Vision Exam is Birth to Age 19 One Exam per Calendar Year Paid at 100% Age 19 and Older One Exam Every 24 Months Paid at 100% HARDWARE 100% Birth to age 19 - Limited to $250 per calendar year. Age 19 and older - Limited to $250 every 24 months. NC Vision Plan 1/1/2015 Page 2

3 VISION BENEFITS COVERED SERVICES An eye examination consists of the inspection of internal and external appearance of the eye, eye movement, visual acuity, visual field, color vision, glaucoma, and a refraction test, to assess whether glasses or contact lenses are necessary. An eye examination must be completed by a licensed optometrist or ophthalmologist. Covered vision hardware includes: Single, bifocal and trifocal lenses Frames Contact lenses EXCLUSIONS TO THE VISION PLAN To assure coverage at a reasonable cost, and to prevent unnecessary use of services, the following exclusions have been incorporated: 1. Charges for special procedures, such as orthoptics or vision training, or for special supplies, such as non-prescription sunglasses and subnormal vision aids. 2. Drugs or medications of any kind. 3. Charges for services or supplies which are received while the participant is not covered. 4. Charges for any vision care services or supplies which are included as covered expenses under any other medical or vision care expense benefit plan carried or sponsored by the District, whether benefits are payable as to all or only part of the charges. 5. Charges for vision care services or supplies for which benefits are provided under any worker's compensation law or any other law of similar purpose, whether benefits are payable as to all or only part of the charges. 6. Charges for any eye examination required by an employer as a condition of employment, or which an employer is required to provide under a labor agreement, or which is required by any law or government. 7. Charges for refractive eye surgery including radial keratotomy or Lasik surgery NC Vision Plan 1/1/2015 Page 3

4 ELIGIBILITY AND ENROLLMENT ELIGIBILITY Employee Eligibility Employees eligible for coverage under this plan are: All regular employees of North Clackamas School District No.12, who meet the requirements established by the collective bargaining agreement, are eligible for coverage under this Plan. Ineligible classes of employees, regardless of the number of hours worked, are: (1) those who do not meet the requirements of the collective bargaining agreement; (2) temporary employees. Retiree & Retiree Dependent Eligibility Retired employees and their enrolled dependents are eligible to continue coverage under the North Clackamas Vision Plan as long as the employee applies for coverage 60 days before retirement, and if all the following conditions are met: The employee and their enrolled dependents must have been enrolled under the North Clackamas Vision Plan for at least 24 consecutive months immediately prior to retirement unless otherwise indicated by a management/labor agreement. The employee must be receiving benefits from PERS (Public Employee Retirement System) Only those dependents that were enrolled under the plan for two years at the time the employee retires are eligible to continue coverage under this plan as dependents. At the time of retirement, retirees and their enrolled dependents will have the option of electing COBRA coverage for the Vision 10 or elect retiree coverage for Vision. Additional COBRA rights will not be extended when retiree coverage is exhausted unless the allowed time under COBRA was not satisfied. Please refer to the North Clackamas Retiree Plan Booklet for further details. Dependent Eligibility Dependents eligible for coverage under this plan are: An employee s lawfully married spouse or legally recognized same sex domestic partner. Coverage may continue during a legal separation only if ordered by a court decree. Legally recognized same sex domestic partners with a Certificate of Registered Domestic Partnership as provided under the Oregon Family Fairness Act of Coverage is available to the children of one or both Domestic Partners provided that NC Vision Plan 1/1/2015 Page 4

5 the child meets the eligibility requirements for dependent children provided herein. Upon termination of a domestic partner relationship, an employee must submit a signed Declaration of Termination of Domestic Partnership acknowledging that the relationship has ended. Coverage for domestic partners and their dependent children will cease on the last day of the month the domestic partner relationship has ended. Any enrollment of a new partner after January 1, 2008 will require a Certificate of Registered Domestic Partnership, as provided under the Oregon Family Fairness Act of 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. 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 IRS qualified dependent status verifiable by IRS Form 1040 may be required annually to substantiate continued eligibility for benefits. An employee s 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. 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 above); (3) whose application has been accepted by the Plan Administrator; and (4) for whom the applicable rate of coverage has been paid. Legal documentation will be required for all enrollment of all dependent(s). Documents may include, but not be limited to, marriage licenses, recent tax returns, birth certificates, domestic partner registrations, or court or state placement documents establishing legal guardianship and/or legal placement for adoption. NC Vision Plan 1/1/2015 Page 5

6 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. Individuals not enrolled during the enrollment eligibility period will be required to wait until the next open enrollment period unless they become eligible to enroll as a result of a special enrollment period. When the employee acquires a new dependent (birth, marriage, adoption, etc.), the dependents must be enrolled within 31 days of the date they first become eligible for coverage, in accordance with the Plan's special enrollment provisions. Domestic partners who are not enrolled when the employee is first eligible, must wait until the first open enrollment period following the date they become eligible for coverage. A newborn child of an enrolled employee or spouse will be covered for 31 days following the child s birth. The plan must be notified of the birth. To continue the newborn child s coverage beyond the first 31 days, the child must be eligible under the terms of the Plan and a completed enrollment application, listing the child as a dependent, must be received by the Plan within 31 days from the date of birth. Newborn children of an enrolled dependent child are not eligible for coverage under the plan unless they meet the definition of an eligible dependent. 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 Vision 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. The employee declines the coverage under the Plan because, at the time, the employee and/or dependent was covered by another Group Vision 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 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. NC Vision Plan 1/1/2015 Page 6

7 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 of the loss of other health coverage. 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 a State Child Vision 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. As long as the proper enrollment material is received by the Plan Administrator within the 31 day enrollment period, the effective date of coverage will be the first of the month following 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 31 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 The Plan will 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 a 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 of state agency order, the waiting period and preexisting conditions exclusion period do not apply. NC Vision Plan 1/1/2015 Page 7

8 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 from November 1 st through December 10 th, 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. EFFECTIVE DATE OF COVERAGE Employee Effective Date The effective date of coverage for eligible employees is the first of the month in which they are hired up to the 5 th day of that month. Employees hired after the 5th day will be eligible for coverage the first day of the following month. (Example: Employee hired January 5 would have coverage effective January 1 If hired January 6 coverage would be effective February 1) 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 the date of marriage. If the covered employee acquires a child through birth, adoption, or placement for adoption, the employee must add the child within 31 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: Employee The date the Employer terminates the Plan and offers no other group vision plan. The date the employee ceases to meet the eligibility requirements of the Plan. The last day of the month in which the employee's employment ends. The date the employee begins active service in the armed forces. NC Vision Plan 1/1/2015 Page 8

9 The date the employee fails to make any required contribution when coverage is contributory. The first day an employee fails to return to work following an approved leave of absence. The last day of the month in which the employee retires and does not meet the requirements for continuing retiree coverage, as outlined above. Dependent(s) The date the Employer terminates the Plan and offers no other group vision plan. The date 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 date the dependent becomes eligible as an employee. The last day of the month in which contributions have been made on their behalf. The date the dependent becomes an active, full-time member of the armed forces of any country. The date dependent coverage is discontinued under the 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 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 Vision 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 Group s Human Resources Department for information on how to qualify for a Family/Medical Leave of Absence. NC Vision Plan 1/1/2015 Page 9

10 APPROVED LEAVE OF ABSENCE (OTHER THAN FEDERAL FAMILY AND MEDICAL LEAVE OF ABSENCE) If the employee is granted an approved leave of absence (other than medical/family leave of absence) the employee and their covered dependents are eligible to continue coverage for up to 12 months. The employee is responsible for paying all of the premiums during this 12 month period and all premiums must be receipted by the district by the first of the month in which they are due. Failure to remit premiums in a timely manner will result in termination of benefits. If the leave extends more than 12 months, an employee and their covered dependents may only continue coverage under this plan through Continuation of Coverage (COBRA) An employee and dependents who are being reinstate to an active status after an approved leave of absence do not have to satisfy the initial waiting period again if it was satisfied prior to going out on the approved leave of absence. There will be no lapse of coverage for employees and dependents that have continued coverage while on the approved leave of absence. If the employee did not continue coverage while on the leave of absence, the coverage will be reinstated on the first day of the month following the return to active status. An employee and any dependents that had not satisfied the waiting period prior to the approved leave of absence will receive credit for the portion of the initial waiting period that was satisfied prior to the leave of absence. Coverage will begin on the first of the month following their satisfaction of any remaining eligibility waiting period. Please contact the Human Resource Department for information on how to qualify for an approved 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. NC Vision Plan 1/1/2015 Page 10

11 Please contact the Group s Human Resources Department for information concerning your eligibility for USERRA and any requirements of the Plan. REINSTATEMENT OF COVERAGE If an employee or dependent who was covered under this Plan terminates employment or loses eligibility for coverage and is rehired or again becomes eligible for coverage within 6 months of the date of termination, the waiting period will be waived. An employee will be eligible for reinstatement of coverage on the date he/she returns to work. A dependent will be eligible for reinstatement of coverage the first of the month from the date the application was received. Individuals continuously covered under the COBRA Continuation of Coverage of this Plan will be given credit for the time covered under this Plan toward meeting the pre-existing condition requirement. Individuals not reinstated on the Plan within 6 months and not continuously covered under the COBRA Continuation of Coverage of this Plan will be treated as a new hire. SELF-PAYMENT IN THE EVENT OF A LABOR DISPUTE If a covered employee s compensation is suspended as a result of a strike, lockout, or other labor dispute, the employee may continue coverage for himself or herself and any covered dependents under COBRA. The covered employee must pay the full cost of coverage directly to the Company. GENERAL NOTICE OF YOUR RIGHTS GROUP HEALTH CONTINUATION COVERAGE UNDER COBRA This contains important information about your employee benefits plan(s). Please read the entire notice. On April 7, 1986, a federal law called COBRA was enacted (Public Law , Title X), requiring that most Employers sponsoring Group Vision Plans offer employees and their families (qualified beneficiary/ies) the opportunity for a temporary extension of health coverage at group rates in certain instances where coverage under the plan would otherwise end. This notice is intended to inform you, in a summary fashion, of your rights as a qualified beneficiary and obligations under COBRA. Both you and your spouse, if applicable, should take the time to read this notice carefully. This notice does not fully describe COBRA or other rights under the Employer Group Vision Plan ("Group Vision Plan"). For additional information you should review the Group Vision Plan's "Summary Plan Description" or contact the Employer Plan NC Vision Plan 1/1/2015 Page 11

12 Administrator, Peak1 at (877) Also, you may visit the Department of Labor website ( for more information on COBRA. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. Qualifying Events If you are an employee of North Clackamas School District covered by the Group Vision Plan, you have a right to choose COBRA if you lose your group vision coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). If you are the spouse of an employee covered by the Group Vision Plan, you have the right to choose COBRA for yourself if you lose group health coverage under the Group Vision Plan for any of the following reasons: 1. The death of your spouse; 2. A termination of your spouse's employment (for reasons other than gross misconduct) or reduction in your spouse's hours of employment with North Clackamas School District; 3. Divorce or legal separation from your spouse; or 4. Your spouse becomes entitled to Medicare. In the case of a dependent child of an employee covered by the Group Vision Plan, he or she has the right to choose COBRA if the Group Vision Plan is lost for any of the following reasons: 1. The death of the employee; 2. A termination of the employee's employment (for reasons other than gross misconduct) or reduction in the employee's hours of employment with North Clackamas School District; 3. The employee's divorce or legal separation; 4. The employee became entitled to Medicare prior to his/her qualifying event; or 5. The dependent child ceases to be a dependent child under the Group Vision Plan. Sometimes, filing a bankruptcy under Title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to North Clackamas School District and that bankruptcy results in the loss of any retired employee under the Group Vision Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Group Vision Plan. You may have other options available to you when you lose group health coverage? For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30- day special enrollment period for another Group Vision Plan for which you are eligible (such as a spouse's plan), even if that plan generally doesn't accept late enrollees. NC Vision Plan 1/1/2015 Page 12

13 Coverage Provided Under COBRA, the employee or a family member has the responsibility to inform the North Clackamas School District Plan Administrator of a divorce, legal separation, or a child losing dependent status under the Group Vision Plan within 60 days of the date of the event. North Clackamas School District has the responsibility to notify the administrator of the employee's death, termination, and reduction in hours of employment or Medicare entitlement. When the administrator is notified that one of these events has happened, the administrator will in turn notify you that you have the right to choose COBRA. Under COBRA, you have at least 60 days from the later of the date you would lose coverage because of one of the qualifying events described above or the date of notification of your rights under COBRA, whichever is later, to inform the North Clackamas School District Plan Administrator that you want to continue coverage under COBRA. If you elect COBRA, North Clackamas School District is required to give you and your covered dependents, if any, coverage that is identical to the coverage provided under the plan to similarly situated employees or family members. Under COBRA, you may have to pay all or part of the premium for your continuation coverage. If you do not choose COBRA on a timely basis, your group health insurance coverage will end. Period of Coverage COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. COBRA requires that you be afforded the opportunity to maintain coverage for 36 months unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, the required COBRA period is 18 months. Also, if you or your spouse gives birth to or adopts a child while on COBRA, you will be allowed to change your coverage status to include the child. The 18-month period may be extended to 29 months if an individual is determined by the Social Security Administration (SSA) to be disabled (for Social Security purposes) as of the termination or reduction in hours of employment or within 60 days thereafter. To benefit from this extension, a qualified beneficiary must notify the North Clackamas School District Plan Administrator of that determination within 60 days and before the end of the original 18-month period. The affected individual must also notify the North Clackamas School District Plan Administrator within 30 days of any final determination that the individual is no longer disabled. If the original event causing the loss of coverage was a termination (other than for gross misconduct) or a reduction in hours, another extension of the 18-month continuation period may occur, if during the 18 months of COBRA coverage, a qualified beneficiary experiences certain secondary qualifying events: 1. Divorce or legal separation 2. Death 3. Medicare entitlement 4. Dependent child ceasing to be a dependent If a second qualifying event does take place, COBRA provides that the qualified beneficiary may be eligible to extend COBRA up to 36 months from the date of the original qualifying event. If a second qualifying event occurs, it is the qualified beneficiary's responsibility to inform the North NC Vision Plan 1/1/2015 Page 13

14 Clackamas School District Plan Administrator within 60 days of the event. In no event, however, will COBRA last beyond three years from the date of the event that originally made the qualified beneficiary eligible for COBRA. Alternate Recipients Under QMCSOs A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by North Clackamas School District during the covered employee's period of employment with North Clackamas School District is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee. Are there other coverage options besides COBRA Continuation Coverage Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other Group Vision Plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at Plan Contact Information Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting Group Vision Plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, visit To ensure that all covered individuals receive information properly and timely, it is important that you notify our Benefits Specialist at (503) x of any change in dependent status or any address change of any family member as soon as possible. Certain changes must be submitted to us in writing. Failure on your part to notify us of any changes may result in delayed notification or loss of continuation of coverage options. If you have any questions about COBRA, please contact our Benefit or Human Resource Departments at (503) or Peak1, our COBRA administrators at during business hours. NC Vision Plan 1/1/2015 Page 14

15 GENERAL PLAN INFORMATION NAME OF PLAN North Clackamas Vision Plan NAME & ADDRESS OF EMPLOYER/ North Clackamas School District No. 12 PARTICIPATING GROUP 4444 SE Lake Road Milwaukie, OR EMPLOYER IDENTIFICATION NUMBER TYPE OF PLAN ADMINISTRATION Contract Administration ORIGINAL PLAN EFFECTIVE DATE January 1, 2006 LAST AMENDED DATE January 1, 2011 PLAN YEAR January 1 through December 31 PLAN ADMINISTRATOR/SPONSOR North Clackamas School District No. 12 & NAMED FIDUCIARY 4444 SE Lake Road & DESIGNATED LEGAL AGENT Milwaukie, OR EMPLOYEES Eligible Employees of North Clackamas School District No. 12, when they meet the eligibility requirements GROUP NUMBER CONTRIBUTION REQUIRED PLAN SUPERVISOR FUNDING MEDIUM Employee Coverage - Yes Dependent Coverage - Yes Healthcare Management Administrators, Inc. PO Box Bellevue, Washington Seattle Area All Other Areas Benefits are paid through general assets The Plan shall take effect for each Participating Employer on the Effective Date, unless a different date is set forth above opposite such Participating Employer s name. LEGAL ENTITY; SERVICE OF PROCESS The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator. NC Vision Plan 1/1/2015 Page 15

16 NOT A CONTRACT This Plan Document and any amendments constitute the terms and provisions of coverage under this Plan. The Plan Document shall not be deemed to constitute a contract of any type between the Company and any Participant or to be consideration for, or an inducement or condition of, the employment of any Employee. Nothing in this Plan Document shall be deemed to give any Employee the right to be retained in the service of the Company or to interfere with the right of the Company to discharge any employee at any time; provided, however, that the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be entered into by the Company with the bargaining representatives of any employees. APPLICABLE LAW This is a self-funded benefit plan. The Plan is funded with employee and employer contributions. As such, when applicable, Federal law and jurisdiction preempt State law and jurisdiction. This Plan shall be deemed automatically to be amended to conform as required by any applicable law, regulation or the order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated maximums, exclusions or limitations. DISCRETIONARY AUTHORITY The Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan provisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions in the Plan and related documents; to make determinations in regards to issues relating to eligibility for benefits; to decide disputes that may arise relative to a Plan Participants rights; and to determine all questions of fact and law arising under the Plan. PLAN SUPERVISOR NOT A FIDUCIARY The Plan Supervisor is not a fiduciary with respect to this engagement and shall not exercise any discretionary authority or control over the management or administration of the Plan, or the management or disposition of the Plan's Assets. The Plan Supervisor shall limit its activities to carrying out ministerial acts of notifying Plan Participants and making benefit payments as required by the Plan. Any matters for which discretion is required shall be referred by Plan Supervisor to the Plan Administrator, and Plan Supervisor shall take direction from Plan Administrator in all such matters. The Plan Supervisor shall not be responsible for advising the Company or Plan Administrator with respect to their fiduciary responsibilities under the Plan nor for making any recommendations with respect to the investment of Plan Assets. The Plan Supervisor may rely on all information provided to it by the Company, Plan Administrator, and the Trustees, as well as the Plan's other vendors. The Plan Supervisor shall not be responsible for determining the existence of Plan Assets. North Clackamas School District No. 12, of Milwaukie, Oregon hereby establishes this Plan for the payment of certain expenses for the benefit of its eligible employees to be known as the North Clackamas Vision Plan. North Clackamas School District No. 12 assures its covered employees that during the continuance of the Plan, all benefits herein described shall be paid to or on behalf of the NC Vision Plan 1/1/2015 Page 16

17 employees in the event they become eligible for benefits. The Plan is subject to all the terms, provisions and conditions recited on the preceding pages hereof. This Plan is not in lieu of and does not affect any requirement for coverage by Worker's Compensation Insurance with the terms and conditions described herein. Plan benefits may be self- funded through a benefit fund or a trust established by the Plan Sponsor and self-funded with contributions from Participants and/or the Plan Sponsor, or may be funded solely from the general assets of the Plan Sponsor. Participants in the Plan may be required to contribute toward their benefits. The purpose of this Plan Document is to set forth the terms and provisions of the Plan that provide for the payment or reimbursement of all or a portion of certain vision charges. The Plan Document is maintained by North Clackamas School District No. 12 and may be inspected at any time during normal working hours by any Participant. NC Vision Plan 1/1/2015 Page 17