1 BOWDOIN COLLEGE EMPLOYEE WELFARE BENEFIT PLAN (Plan #516) Summary Plan Description Effective January 1, 2015
2 TABLE OF CONTENTS Page PART I INTRODUCTION...1 Purpose of This Booklet...1 PART II ELIGIBLITY AND PARTICIPATION REQUIREMENTS...1 Eligibility and Participation...1 Need for Enrollment: Time Limits...2 Special Enrollment Rights...2 When Participation Begins...2 Termination of Participation...2 Continuation Coverage Under COBRA and USERRA...3 PART III SUMMARY OF PLAN BENEFITS...3 Available Benefits and Contributions...3 Qualified Medical Child Support Orders...4 Circumstances That May Affect Benefits...4 Administrative Requirements and Timelines...4 PART IV PLAN ADMINISTRATION...5 Plan Operations...5 Plan Administration...5 Your Questions...5 PART V CLAIMS PROCEDURES...6 Claims for Fully Insured Benefits...6 Claims for Self-Funded Benefits...6 Exhaustion...6 PART VI PLAN INFORMATION...7 Your ERISA Rights...7 Plan Amendment and Termination...8 General Information About the Plan...8 Funding Medium and Type of Plan Administration...9 No Contract of Employment...10 Electronic Forms...10 LIST OF ATTACHMENTS
3 PART I INTRODUCTION The Bowdoin College established the Bowdoin College Employee Welfare Benefit Plan, effective January 1, 2012, for the exclusive benefit of eligible employees and their eligible family members. The Plan provides certain health and welfare benefits through the Component Benefit Programs listed on Schedule A, each of which is described in the separate Attachments. Some of these Component Benefit Programs require completion of application forms, annual elections, and/or other administrative forms. The details of these administrative requirements are described in the Attachments. Eligible Employees may pay for their share of the cost of certain of these Component Benefit Programs on a pre-tax basis. The details about pre-tax contributions are described in the Flexible Benefits Plan (Attachment #1). Each of the Component Benefit Programs is summarized in a separate written plan document, insurance certificate or contract, benefit summary, or other written governing document. A copy of each plan document, insurance certificate or contract, summary, or other governing document is attached to this booklet in Attachments #1 through #8. In the event that the terms of this booklet conflict with the terms of the written plan document, insurance certificate or contract, benefit summary, or other written governing document, then the terms of the such document will control, rather than this booklet, unless otherwise required by law. Purpose of This Booklet This booklet provides an overview of the Plan and addresses certain information that may not be addressed in the Attachments. This booklet is not intended to give you any substantive rights to benefits that are not already provided by the Attachments. If you have not received a copy of the Attachments, contact the Director of Human Resources. You should read the Attachments and this booklet carefully to understand your benefits. This booklet, together with the Attachments, is the summary plan description required by Section 102 of the Employee Retirement Income Security Act of 1974 ( ERISA ). Note that not all of the Component Benefit Programs are subject to ERISA. They are described as part of the Plan for purposes of convenience and because there may be other applicable laws (for example, the Internal Revenue Code) that require a written document. The following Component Benefit Programs are not subject to the requirements of ERISA: the Bowdoin College Flexible Benefits Plan and the Dependent Care Reimbursement Plan. PART II ELIGIBLITY AND PARTICIPATION REQUIREMENTS Eligibility and Participation An eligible employee with respect to the Plan is any common-law employee of the College who is eligible to participate in and receive benefits under one or more of the Component Benefit Programs. In general, employees who are regularly scheduled to work at least 20 hours per week are eligible to participate in the Component Benefit Programs subject to the following exceptions:
4 The Aetna Life Insurance Company Long Term Disability Insurance Plan (Attachment #7) is only available to Hourly Paid, Non-Exempt Employees who are regularly scheduled to work at least 30 hours per week, Monthly Paid, Exempt Employees who are regularly scheduled to work at least 30 hours per week, and regular benefits-eligible Faculty who work at least 50 percent of the normal Faculty course load. The Aetna Life Insurance Company Short Term Disability Insurance Plan (Attachment #7) is only available to Hourly Paid, Non-Exempt Employees who are regularly scheduled to work at least 30 hours per week. The eligibility and participation requirements may vary depending on the particular Component Benefit Program. You must satisfy the eligibility requirements under a particular Component Benefit Program in order to receive benefits under that Program. To determine whether you or your family members are eligible to participate in a Component Benefit Program, please read the eligibility information contained in the applicable Attachment. Need for Enrollment: Time Limits In general, eligible employees must complete an application form (available through Human Resources) to enroll themselves and/or their eligible spouses or domestic partners and dependents. New employees must generally enroll within certain time periods after being hired, as described in the Attachments. Thereafter, enrollment is generally limited to the annual open enrollment period that occurs before January 1 of each year. Special Enrollment Rights In certain circumstances and with respect to particular Component Benefit Programs, enrollment may occur at times outside the open enrollment period (this is referred to as special enrollment ), as explained in the summary plan description for the Bowdoin College Flexible Benefits Plan (Attachment #1). When Participation Begins Once you, as an eligible employee, have completed the necessary enrollment paperwork, your coverage under the Plan may begin. Requirements may vary depending on the Component Benefit Program. For information about when coverage begins, please read the eligibility and participation information contained in the Attachments. Termination of Participation In general, your coverage under this Plan terminates when you terminate employment with the College. Coverage also terminates if you fail to pay your share of the premium, if your hours drop below the required eligibility threshold, if you submit false claims, and for certain other reasons described in the Attachments. Coverage for your spouse or domestic partner and dependents stops when your coverage stops, if you fail to provide proof of continued eligibility as may be required by the Plan Administrator, -2-
5 and for other reasons specified in the Attachments (for example, divorce, dissolution of domestic partnership, or a dependent s attaining age limit). Coverage also ceases for employees, spouses, domestic partners, and dependents upon termination of the Plan. Coverage under a particular Component Benefit Program stops according to the terms and conditions reflected in the Attachments. Note that termination of coverage under a particular Component Benefit Program does not necessarily mean your coverage under the Plan in general terminates. You should consult the applicable Attachments for specific information. Continuation Coverage Under COBRA and USERRA There are several types of continuation coverage that may apply to particular Component Benefit Programs, as highlighted below. For more information, see the Attachments for the particular Component Benefit Programs. If medical, dental, or vision coverage for you or your eligible family members ceases because of certain qualifying events specified in COBRA (for example, termination of employment, reduction in hours, divorce, death, or a child s ceasing to meet the definition of dependent), then you and your eligible family members may have the right to purchase continuation coverage for a temporary period of time. Please note, by law COBRA continuation coverage does not apply to your domestic partner or to the child of your domestic partner who is not your dependent for federal income tax purposes. The College has, however, chosen to extend continuation coverage to domestic partners and the child of domestic partners who are covered by the medical, dental, or vision plan and who would lose their coverage due to a COBRA qualifying event. If you have any questions about your COBRA rights, please read the COBRA Continuation Coverage section in Part V of the Bowdoin College Flexible Benefits Plan Summary Plan Description, a copy of which has been previously furnished to you and your spouse (if covered). Please contact the Plan Administrator if you need another copy. Continuation and reinstatement rights may also be available if you are absent from employment due to service in the uniformed services pursuant to the Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA ). More information about coverage available pursuant to USERRA is included in the Attachments. Note also that state law may provide continuation and/or conversion coverage. Available Benefits and Contributions PART III SUMMARY OF PLAN BENEFITS The Plan provides you and your eligible spouse, domestic partner, and/or dependents with medical, dental, vision, health reimbursement account, short- and long-term disability, accidental death and dismemberment insurance, and life insurance benefits. The Plan also provides you with the opportunity to participate in the Health Care Reimbursement Plan and Dependent Care Reimbursement Plan. A summary of each Component Benefit Program provided under the Plan -3-
6 is set forth in the Attachments. The Component Benefit Programs under the Plan may change from time to time, and not all benefits may be offered to all participants in this Plan. In general, the cost of the benefits provided through the Component Benefit Programs will be funded in part by contributions made by the College and in part by employee contributions, which may be pre-tax contributions under the Flexible Benefits Plan. The College will determine and periodically communicate your share of the cost of the benefits provided through each Component Benefit Program, and it may change that determination at any time. The College will make its contributions in an amount that (in the College s sole discretion) is at least sufficient to fund the benefits or a portion of the benefits that are not otherwise funded by your contributions. With respect to the insured Component Benefit Programs, the College will pay its contribution and your contributions to the insurer. With respect to benefits that are selffunded, the College will use these contributions to pay benefits directly to (or on behalf of) you or your eligible family members from the College s general assets. Your contributions toward the cost of a particular benefit will be used in their entirety prior to using College contributions to pay for the cost of such benefit. Qualified Medical Child Support Orders The Plan extends benefits under the Component Benefit Programs to an employee s noncustodial child, as required by any qualified medical child support order (QMCSO), under ERISA Section 609(a). The Plan has procedures for determining whether an order qualifies as a QMSCO. Participants and beneficiaries can obtain, without charge, a copy of such procedures from the Director of Human Resources. Circumstances That May Affect Benefits Your benefits (and the benefits of your eligible family members) will cease when your participation in the Plan terminates. See the Section entitled Termination of Participation in Part II above. Benefits will also cease upon termination of the Plan. Benefits under a particular Component Benefit Program will cease for you or your eligible family member when you or your family member ceases to be eligible for the particular Component Benefit Program. Other circumstances can result in the termination, reduction, recovery (through subrogation or reimbursement), or denial of benefits. For example, if any benefit under the Plan is erroneously paid or exceeds the amount payable to you then you may be responsible for refunding the overpayment to the Plan. Consult the Attachments for additional information. Administrative Requirements and Timelines As described in the Attachments, there may be other reasons that a claim for benefits is not paid, or is not paid in full. For example, claims must generally be submitted for payment within a certain period of time, and failure to submit within that time period may result in the claim being denied. In this regard, please consult the Attachments. -4-
7 PART IV PLAN ADMINISTRATION Plan Operations Because benefits under the Plan are provided both through insurance contracts and on a selffunded basis, the Plan is administered by the College and the insurance companies. Plan Administration The Director of Human Resources is the Plan Administrator. The principal duty of the Plan Administrator is to see that the Plan functions according to its terms, and for the exclusive benefit of persons entitled to participate in the Plan. The administrative duties of the Plan Administrator include, but are not limited to, interpreting the Plan, prescribing applicable procedures, determining eligibility for and the amount of benefits, authorizing benefit payments, and gathering information necessary for administering the Plan. The Plan Administrator may delegate any of these administrative duties among one or more persons or entities, provided that such delegation is in writing, expressly identifies the delegate(s), and expressly describes the nature and scope of the delegated responsibility. The Plan Administrator has delegated its responsibilities for deciding claims for benefits under the Component Benefit Programs to certain insurance companies and third-party administrators who serve as the named fiduciaries (or claims fiduciaries ) for their respective Component Benefit Programs. (See the Section entitled Insurance Companies and Third Party Administrators on Schedule A.) The insurance companies and third-party administrators are responsible for (a) determining eligibility for a benefit and the amount of any benefits payable under the Plan; and (b) providing the claims procedures to be followed and the claims forms to be used by eligible individuals pursuant to the Plan. As claims fiduciaries, the insurance companies and third party administrators have the discretionary authority to interpret the Plan in order to make benefit determinations. They also have the authority to require eligible individuals to furnish them with such information as they determine necessary for the proper administration of the Plan. The Plan Administrator has the discretionary authority to interpret the Plan to make eligibility and benefit determinations as it may determine in its sole discretion. The Plan Administrator also has the discretionary authority to make factual determinations as to whether any individual is entitled to receive any benefits under the Plan. The College will bear its incidental costs of administering the Plan. Your Questions If you have any general questions regarding the Plan (including, for example, whether you are eligible to participate in the Plan or a particular Component Benefit Program offered through the Plan), please contact Human Resources. If you have any question regarding your eligibility for, or the amount of, any benefit payable under the Component Benefit Programs, please contact the appropriate insurance company or third party administrator identified in Schedule A. -5-
8 PART V CLAIMS PROCEDURES Claims for Fully Insured or Capitated Benefits For purposes of determining the amount of, and entitlement to, benefits of the Component Benefit Programs provided under insurance or contracts, the respective insurer is the named fiduciary under the Plan, with the full power to interpret and apply the terms of the Plan as they relate to the benefits provided under the applicable insurance contract. To obtain benefits from the insurer of a Component Benefit Program, you must follow the claims procedures under the applicable insurance contract, which may require you to complete, sign, and submit a written claim on the insurer s form. (See the Attachments for more information.) The insurer will decide your claim in accordance with its reasonable claims procedures, as required by ERISA and other applicable law. If your claim is denied, you may appeal to the insurer for a review of the denied claim. The insurer will decide your appeal in accordance with reasonable claims procedures, as required by ERISA and other applicable law. Claims for Self-Funded Benefits For purposes of determining the amount of, and entitlement to, benefits under the Component Benefit Programs provided through the College s general assets, the respective third party administrator is the named fiduciary under the Plan, with the full power to make factual determinations and to interpret and apply the terms of the Plan as they relate to the benefits provided through a self-funded arrangement. To obtain benefits from a self-funded arrangement, you must complete, execute, and submit to the third party administrator a written claim on the form available from Human Resources. (See the Attachments for more information.) The third party administrator will decide your claim in accordance with reasonable claims procedures, as required by ERISA (if ERISA applies) and other applicable law. If your claim is denied, you may appeal to the third party administrator for a review of the denied claim. The third party administrator will decide your appeal in accordance with reasonable claims procedures, as required by ERISA (if ERISA applies). Exhaustion If you do not appeal within the timeframe set forth in the applicable Component Benefit Program, you will lose your right to file suit in a state or federal court, because you will not have exhausted your internal administrative appeal rights (which generally is a prerequisite to bringing suit in state or federal court). See the Attachments for information. -6-
9 PART VI PLAN INFORMATION Your ERISA Rights Note that the Bowdon College Flexible Benefits Plan and Dependent Care Reimbursement Plan are not covered by ERISA and this Statement of ERISA Rights does not apply to them. As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ( ERISA ). ERISA provides that all plan participants shall be entitled to: Examine, without charge, at the Plan Administrator s office and at other specified locations (such as worksites) all documents governing the Plan, including insurance contracts, and a copy of the latest annual report (Form 5500 series), if any, filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report, if any is required to be prepared, in which case the Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Under certain circumstances, continue health care coverage for yourself, your spouse, or your dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the Attachments for the rules governing your COBRA continuation coverage rights. In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a Plan benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps that you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report (Form 5500), if any, from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 per day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored in whole or in part, and if you have exhausted the claims procedures available to you under the Plan (discussed in -7-
10 Part V), you may file suit in a state or federal court. In addition, if you disagree with the Plan Administrator s decision (or lack thereof) concerning the qualified status of a medical child support order, then you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about your Plan, you should contact Human Resources. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor (listed in your telephone directory) or contact the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Plan Amendment and Termination The College may amend, discontinue, or terminate the Plan or any Component Benefit Program, in whole or in part, at any time or from time to time as it deems necessary or desirable with or without retroactive effect, to the extent permitted by law, by any means permitted under the its by-laws. If the College terminates a Component Benefit Program, plan assets will be allocated and distributed in accordance with the terms of the Component Benefit Program. General Information About the Plan Plan Name: Bowdoin College Welfare Benefit Plan Plan Number: 516 Plan Type: Welfare benefit plan providing medical, dental, vision, health care reimbursement, health reimbursement account, short- and long-term disability, accidental death and dismemberment insurance, and life insurance benefits. The Plan also includes a cafeteria plan under Internal Revenue Code Section 125 and a dependent care reimbursement plan under Internal Revenue Code Section 129; neither is subject to ERISA. Plan Year: January 1 to December 31-8-
11 General Information About the Plan Plan Sponsor: Tax Identification Number for Bowdoin College: Plan Administrator and Named Fiduciary: Claims Fiduciary: Agent for Service of Legal Process: The President and Trustees of Bowdoin College 1 College Street, Hawthorne-Longfellow Hall Brunswick, Maine (207) Director of Human Resources Bowdoin College 3500 College Station Brunswick, Maine (207) The insurance company or third party administrator of each Component Benefit Program is the named fiduciary for and has the authority to decide claims for benefits and appeals under its respective Component Benefit Program. Director of Human Resources Bowdoin College 3500 College Station Brunswick, Maine (207) Funding Medium and Type of Plan Administration Some benefits under the Plan are self-funded, and other benefits are fully insured. As discussed above in the Section entitled Plan Administration, the College, insurance companies, and third party administrators share responsibility for administering the Component Benefit Programs under the Plan. The medical, dental, health care reimbursement, health reimbursement account, and dependent care reimbursement Component Benefit Programs are self-funded by the College. The vision, long-term disability, life insurance, and accidental death and dismemberment Component Benefit Programs are fully insured. The College is responsible for paying claims with respect to the selffunded Component Benefit Programs. The insurance companies, not the College, are responsible for paying claims with respect to the insured Component Benefit Programs. Insurance premiums for employees and their eligible family members are paid in part by the College out of its general assets and in part by employees. Contributions for the self-funded Component Benefit Programs are made by employees. Employee contributions may be made on a pre-tax basis under the Bowdoin College Flexible Benefits Plan. Human Resources provides a -9-
12 schedule of the applicable premiums during the initial and subsequent open enrollment periods and upon request for each of the Component Benefit Programs, as applicable. Neither the Plan nor any of the Component Benefit Programs offered through it have a trust. No Contract of Employment The Plan is not intended to be, and may not be construed as constituting, a contract or other arrangement between you and the College to the effect that you will be employed for any specific period of time. Electronic Forms To facilitate efficient operation of the Plan, the Plan may allow forms (including, for example, election forms and notices), whether required or permissive, to be sent and/or made by electronic means _1.DOCX -10-
13 SCHEDULE A Component Benefit Programs Bowdoin College Flexible Benefits Plan, including Health Care Reimbursement Plan and Dependent Care Reimbursement Plan (Attachment #1); Bowdoin College Out-of-Pocket Expenses Reimbursement Plan (HRA) (Attachment #2); Bowdoin College Preferred Provider Organization Health Plan (Attachment #3); Bowdoin College Preferred Provider Organization Health Savings Account Plan (Attachment #4) Bowdoin College Dental Plan (Attachment #5); Bowdoin College Vision Plan (Attachment #6); Aetna Life Insurance Company Short and Long Term Disability Insurance Plans (Attachment #7); and Aetna Life Insurance Company Life Insurance, Supplemental Life Insurance, Accidental Death and Dismemberment Insurance, and Supplemental Dependent Life Insurance (Attachment #8). Insurance Companies and Third Party Administrators Combined Services LLC (Flexible Benefits Plan) P.O. Box 1320 Concord, New Hampshire ext Employee Benefit Plan Administration, Inc. (HRA Plan) P.O. Box 1140 Exeter, New Hampshire Anthem Blue Cross and Blue Shield (Health Plan) 2 Gannett Drive South Portland, Maine Northeast Delta Dental (Dental Plan) One Delta Drive P.O. Box 2002 Concord, New Hampshire EyeMed Vision Care (Vision Plan) 4000 Luxottica Place Mason, Ohio EYEMED
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