This document is a sample only. As the plan administrator, the Company has the obligation to provide participants with the summary plan description and/or plan document. Vitable is not a legal advisor. Vitable recommends that the Company’s counsel reviews and edits this document. Instead of the plan document, you may need an amendment to any existing wrap plan document to include the plan in your consolidated health plan Form 5500.
Health Plan
Plan Document
Amended and Restated Effective [the date on the contract]
ARTICLE 1. Definitions
1.1 Definitions
"COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
"Code" means the Internal Revenue Code of 1986, as amended.
"Company" means [Company.Name] , or any successor thereto.
"Effective Date" means, for this amendment and restatement,
"Eligible Employee" means an Employee who satisfies the eligibility provisions of Article 3.
"Employee" means any common-law employee of the Company. The determination of whether an individual is an Employee, an independent contractor or any other classification of worker or service provider, and the determination of whether an individual is classified as a member of any particular classification of employees shall be made solely in accordance with the classifications used by the Company and shall not be dependent on, or change due to, the treatment of the individual for any purposes under the Code, common law or any other law, or any determination made by any court or government agency.
"ERISA" means the Employee Retirement Income Security Act of 1974, as amended.
"Participant" means an Eligible Employee or the covered eligible dependent of an Eligible Employee.
"Plan" means the [Company.Name] Health Plan.
"Plan Administrator" means the Company.
"Plan Sponsor" means the Company.
ARTICLE 2. Introduction
2.1 Introduction
The Company, as Plan Sponsor, hereby establishes the Plan to provide health benefits to its eligible employees, and their eligible spouses and eligible dependents. The Plan is effective [per the date on the contract] . The Plan is a group health plan (a type of welfare benefit plan that is subject to the provisions of ERISA).
The Plan is paid from the general assets of the Company, which may fund a general claims account.
2.2 Purpose of This Plan Document
This document constitutes the written document as required by ERISA §402.
ARTICLE 3. Eligibility and Participation Requirements
3.1 Eligibility and Participation
An Eligible Employee is any Employee who is eligible to participate in and receive benefits under the Plan. Employees who work [ as stated in the contract] or more hours per week and have been employed by the Employer for a period of at least [as stated in the contract] consecutive calendar days are Eligible Employees and may become Participants in the Plan.
3.2 Qualified Medical Child Support Orders
The Plan will extend benefits to an Eligible Employee's non-custodial child, as required by any qualified medical child support order (QMCSO), under ERISA §609(a), including a National Medical Support Notice. The Plan has procedures for determining whether an order qualifies as a QMCSO. Participants and beneficiaries can obtain, without charge, a copy of such procedures from the designated HR representative of the Company.
3.3 Enrollment
Eligible Employees must complete an online application form (available through Vitable) to enroll themselves and/or their eligible spouses and dependents. New employees must enroll within certain time periods after being hired. Otherwise, enrollment generally is limited to the annual open enrollment period that occurs at renewal each year or in the event of a qualifying life event (QLE). If an Eligible Employee fails to make an election during a renewal annual open enrollment period the Eligible Employee will be deemed to continue their benefits in effect as of their last election. For clarity, if an Eligible Employee elects to receive coverage in an open enrollment period and then fails to make an election in the next open enrollment period the Eligible Employee will continue on the same level of coverage.
3.4 Special Enrollment Rights
In certain circumstances, enrollment may occur outside the open enrollment period. The Plan's "Special Enrollment Notice" contains information about the special enrollment rights.
3.5 Termination of Participation
An employee's coverage (and the coverage of his or her eligible family members) will cease when the employee's participation in the Plan terminates. (This may occur, for example, when an employee no longer meets the definition of Eligible Employee.) Coverage will also cease upon termination of the Plan. Other circumstances, such as misrepresentations to the Plan, may result in the termination, reduction, or denial of benefits.
3.6 Continuation Coverage Under COBRA
If the health coverage for an Eligible Employee or his or her covered 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 the Eligible Employee or his or her covered eligible family members may have the right to purchase continuation coverage for a temporary period of time. More information about COBRA rights is included in the "Summary of Rights and Obligations Regarding Continuation of Group Health Plan Coverage." Continuation of coverage will also, or alternatively, be made available as required by applicable state law.
ARTICLE 4. Plan Benefits
4.1 Benefits Provided
The MEC Plan covers only routine preventative Medical Care Expenses for Eligible Employees and their eligible Spouses and Dependents. The Plan does not cover medical illness or accidental injury claims.
The MEC Plus Plan covers routine preventative medical care expenses for Eligible Employees and their eligible Spouses and Dependents, as well as additional medical care expenses as described in Appendix B.
4.2 Funding
The Plan is self-funded. All reimbursements are paid from the general assets of the Company, which may fund a general claims account.
4.3 Timely Payments
A request for payment should be received by the Claims Administrator within 90 days from the date charges for the services were incurred. Benefits are based on the Plan's provisions in effect at the time the charges were Incurred. Claims received later than that date will be denied.
4.4 Right to Recover Benefit Overpayments and Other Erroneous Payments
If, for any reason, any benefit under the Plan is erroneously paid or exceeds the amount appropriately payable under the Plan to a Participant, the Participant shall be responsible for refunding the overpayment to the Plan to the fullest extent permitted by law. The Plan reserves the right to be made whole without offsets for attorney's fees, to the extent permitted by law. In addition, if the Plan makes any payment that, according to the terms of the Plan, should not have been made, the Plan Administrator (or designee) may, to the fullest extent permitted by law, recover that incorrect payment, whether or not it was made due to the Plan Administrator's (or its designee's) own error, from the person to whom it was made or from any other appropriate party.
As may be permitted in the sole discretion of the Plan Administrator, the refund or repayment may be made in one or a combination of the following methods: (a) as a single lump-sum payment, (b) as a reduction of the amount of future benefits otherwise payable under the Plan, (c) as automatic deductions from pay, or (d) any other method as may be required or permitted in the sole discretion of the Plan Administrator. The Plan may also seek recovery of the erroneous payment or benefit overpayment from any other appropriate party.
4.5 Participant's Responsibilities
Each Participant shall be responsible for providing the Plan Administrator with his or her current address. If required by the Plan Administrator, each employee who is a Participant shall be responsible for providing the Plan Administrator with the address of a covered spouse and each of his or her covered eligible dependents. Any notices required or permitted to be given to a Participant hereunder shall be deemed given if directed to the address most recently provided by the Participant and mailed by first class United States mail. The Plan Administrator shall have no obligation or duty to locate a Participant.
4.6 Right to Information and Fraudulent Claims
Any person claiming benefits under the Plan shall furnish the Plan Administrator with such information and documentation as may be necessary to verify eligibility for and/or entitlement to benefits under the Plan.
If a person is found to have falsified any document in support of coverage or a claim for benefits under the Plan, or failed to have corrected information which such person knows or should have known to be incorrect, or failed to bring such misinformation to the attention of the Plan Administrator, the Plan Administrator may, without the consent of any person, and to the fullest extent permitted by applicable law, terminate the person's Plan coverage, including retroactively (such as in situations involving fraud or material misstatement of fact). In addition, the Plan Administrator may refuse to honor any claim for benefits under the Plan for the Participant related to the person submitting the falsified information. Such person shall be responsible, to the fullest extent permitted by applicable law, to provide restitution, including monetary repayment to the Plan, with respect to any overpayment or ineligible payment of benefits.
ARTICLE 5. Plan Administration
5.1 Plan Administration
The Plan is administered by the Company, as Plan Administrator. The designated HR person of the Company is the person who has been designated to act on behalf of the Plan Administrator and the Company. The Company has agreed to indemnify the designated HR person for any liability that he or she incurs as a result of acting on behalf of the Plan Administrator, unless such liability is due to his or her gross negligence or misconduct, and such indemnity is permitted under the Company's fiduciary liability coverage policies.
ARTICLE 6. Circumstances That May Affect Benefits
6.1 Denial or Loss of Benefits
An Eligible Employee's benefits (and the benefits of his or her eligible spouses and dependents) will cease when the employee's participation in the Plan terminates (that is, when coverage ends). Benefits also cease upon termination of the Plan. In both instances, expenses incurred before coverage ended generally remain payable.
6.2 Other Circumstances
Other circumstances can result in the termination, reduction, recovery (through subrogation or reimbursement), or denial of benefits. For example, benefits may be denied based on lack of medical necessity.
ARTICLE 7. Amendment or Termination of the Plan
7.1 Amendment or Termination
The Company, as Plan Sponsor, has the right to amend or terminate the Plan at any time. The Plan may be amended or terminated by a written instrument duly adopted by the Company or any of its delegates.
ARTICLE 8. Claims Procedures
8.1 General
All claims for benefits under the Plan will be submitted to and decided by such persons or organizations as the Plan Administrator may from time to time designate, in the form and within the time specified by the Administrator, as set forth in the Summary Plan Description. Claims shall be administered in accordance with all relevant law. The Plan Administrator has sole discretionary authority to grant or deny benefits under the Plan and has discretion to interpret the terms of the Plan, determine facts, and determine whether benefits are due. Benefits under the Plan will be paid only if the Plan Administrator decides in its sole discretion that the claimant is entitled to them. The Plan Administrator’s decisions made pursuant to this Section are intended to be final and binding on Participants, beneficiaries and others.
Claims Administrator:
TrueClaim Technologies, Inc.
2261 Market Street STE 85063
San Francisco, CA 94114
(415) 612-8388
8.2 Exhaustion of Administrative Remedies
Claimants will not be entitled to challenge the Plan Administrator’s determinations in judicial or administrative proceedings without first complying with the administrative claims procedures set forth in the Summary Plan Description. The decisions made pursuant to applicable administrative claims procedures are final and binding on the claimant and any other party. The Plan may also permit an external review.
8.3 Limitations Period
If the claimant has complied with and exhausted the appropriate claims procedures and intends to exercise his or her right to bring civil action under ERISA Section 502(a), the claimant must bring such action within 6 months following the date on which he or she submitted the last required appeal (or voluntary appeal, if offered and the claimant files a voluntary appeal) under such procedures. If the claimant does not bring such action within such 6-month period, the claimant will be barred from bringing an action under ERISA related to his or her claim. In addition, all claims for benefits must be submitted within 12 months of the date of service or the date on which the claim was incurred.
8.4 Incompetency
If any person entitled to payments under the Plan is a minor or under other legal disability or otherwise incapacitated so as to be unable to manage his or her financial affairs, or is otherwise incapable of giving a valid receipt and discharge for any payment, the following provision will apply. The Plan Administrator, in its discretion, may direct that all or any portion of such payment be made:
to such person;
to such person’s legal guardian or conservator;
to such person’s spouse or to any other person; or
in any manner the Plan Administrator considers advisable, to be expended for his or her benefit.
The decision of the Plan Administrator will, in each case, be final and binding upon all persons. Any payment made pursuant to the power herein conferred will operate as a complete discharge of the obligations of the Plan Administrator with respect to such payment.
ARTICLE 9. General Information About the Plan
9.1 No Contract of Employment
The Plan is not intended to be, and may not be construed as constituting, a contract or other arrangement between any individual and the Company to the effect that the individual will be employed for any specific period of time.
IN WITNESS WHEREOF, [Company.Name] has caused this Plan to be executed, effective as of .
By: ___________________________________
Title: ___________________________________
Signature:_____________________________________________
Appendix B
MEC Summary of Benefits
Important Questions | Answers | Why This Matters: |
What is the overall deductible? | $0 | See the Common Medical Events chart below for your costs for services this Plan covers. If you have other family members on the plan, each family member must meet their own individual deductible. |
Are there services covered before you meet your deductible? | Yes. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. |
Are there other deductibles for specific services? | No. | You don’t have to meet deductibles for specific services. |
What is the out-of-pocket limit for this plan? | Not applicable. | This plan does not have an out-of-pocket limit on your expenses. |
What is not included in the out-of-pocket limit? | Not applicable. | This plan does not have an out-of-pocket limit on your expenses. |
Will you pay less if you use a network provider? | Yes. See www.myfirsthealth.com or call 1-800-226-5116 for a list of network providers. Contact Vitable Health Customer Support at 484-416-0769 for questions about the network. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
Do you need a referral to see a specialist? | No. | You can see the specialist you choose without a referral. |
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. |
Common | Services You May Need | What You Will Pay | What You Will Pay | Limitations, Exceptions, & Other Important Information |
Common | Services You May Need | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, & Other Important Information |
If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | Not Covered | Not Covered | None |
If you visit a health care provider’s office or clinic | Specialist visit | Not Covered | Not Covered | None |
If you visit a health care provider’s office or clinic | immunization | No Charge | No Charge | No charge up to Usual, customary and reasonable (UCR) rates for out-of-network provider. Out-of-network will be processed through reimbursement. |
If you have a test | (blood work) | Not Covered | Not Covered | Diagnostic test related to Preventive care is covered at no charge. |
If you have a test | X-Rays | Not Covered | Not Covered | None |
If you have a test | Imaging (CT/PET scans, MRIs) | Not Covered | Not Covered | Imaging related to Preventive care is covered at no charge. |
If you need drugs to treat your illness or condition | Generic drugs (Tier 1) | Not Covered | Not Covered | None |
If you need drugs to treat your illness or condition | Preferred brand drugs (Tier 2) | Not Covered | Not Covered | None |
If you need drugs to treat your illness or condition | Non-preferred brand drugs (Tier 3) | Not Covered | Not Covered | None |
If you need drugs to treat your illness or condition | Specialty drugs (Tier 4) | Not Covered | Not Covered | None |
If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | Not Covered | Not Covered | None |
If you have outpatient surgery | Physician/surgeon fees | Not Covered | Not Covered | None |
If you need immediate medical attention | Not Covered | Not Covered | None | |
If you need immediate medical attention | Not Covered | Not Covered | None | |
If you need immediate medical attention | Not Covered | Not Covered | None | |
If you have a hospital stay | Facility fee (e.g., hospital room) | Not Covered | Not Covered | None |
If you have a hospital stay | Physician/surgeon fees | Not Covered | Not Covered | None |
If you need mental health, behavioral health, or substance abuse services | Outpatient services | Not Covered | Not Covered | None |
If you need mental health, behavioral health, or substance abuse services | Inpatient services | Not Covered | Not Covered | None |
If you are pregnant | Office visits | Not Covered | Not Covered | None |
If you are pregnant | Childbirth/delivery professional services | Not Covered | Not Covered | None |
If you are pregnant | Childbirth/delivery facility services | Not Covered | Not Covered | None |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If your child needs dental or eye care | Children’s eye exam | Not Covered | Not Covered | None |
If your child needs dental or eye care | Children’s glasses | Not Covered | Not Covered | None |
If your child needs dental or eye care | Children’s dental check-up | Not Covered | Not Covered | None |
MEC Plus Summary of Benefits
Important Questions | Answers | Why This Matters: |
What is the overall deductible? | $0 | See the Common Medical Events chart below for your costs for services this Plan covers. If you have other family members on the plan, each family member must meet their own individual deductible.If you have other family members on the plan, each family member must meet their own individual deductible. |
Are there services covered before you meet your deductible? | Yes. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. |
Are there other deductibles for specific services? | No. | You don’t have to meet deductibles for specific services. |
What is the out-of-pocket limit for this plan? | Not applicable. | This plan does not have an out-of-pocket limit on your expenses. |
What is not included in the out-of-pocket limit? | Not applicable. | This plan does not have an out-of-pocket limit on your expenses. |
Will you pay less if you use a network provider? | Yes. See www.myfirsthealth.com or call 1-800-226-5116 for a list of network providers. Contact Vitable Health Customer Support at 484-416-0769 for questions about the network. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
Do you need a referral to see a specialist? | No. | You can see the specialist you choose without a referral. |
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. |
Common | Services You May Need | What You Will Pay | What You Will Pay | Limitations, Exceptions, & Other Important Information |
Common | Services You May Need | Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions, & Other Important Information |
If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | $15 copayment/visit | Not Covered | Limited to 5 visits per year. Limited to $200 maximum cost per visit. $0 copayment when using Vitable Primary Care. |
If you visit a health care provider’s office or clinic | Specialist visit | $25 copayment/visit | Not Covered | Limited to 2 visits per year. Limited to $200 maximum cost per visit. |
If you visit a health care provider’s office or clinic | immunization | No Charge | No Charge | No charge up to Usual, customary and reasonable (UCR) rates for out-of-network provider. Out-of-network will be processed through reimbursement. |
If you have a test | Diagnostic test (blood work) | Not Covered | Not Covered | Diagnostic test related to Preventive care is covered at no charge. |
If you have a test | X-Rays | $50 copayment/visit | Not Covered | Limited to 3 visits per year. Limited to $200 maximum cost per visit. |
If you have a test | Imaging (CT/PET scans, MRIs) | Not Covered | Not Covered | Imaging related to Preventive care is covered at no charge. |
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.vitablehealth.com | Generic drugs (Tier 1) | $0 copayment | Not Covered | Prescription drug coverage is offered through Vitable Health. |
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.vitablehealth.com | Preferred brand drugs (Tier 2) | Not Covered | Not Covered | Prescription drug coverage is offered through Vitable Health. |
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.vitablehealth.com | Non-preferred brand drugs (Tier 3) | Not Covered | Not Covered | Prescription drug coverage is offered through Vitable Health. |
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.vitablehealth.com | Specialty drugs (Tier 4) | Not Covered | Not Covered | Prescription drug coverage is offered through Vitable Health. |
If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | Not Covered | Not Covered | None |
If you have outpatient surgery | Physician/surgeon fees | Not Covered | Not Covered | None |
If you need immediate medical attention | Not Covered | Not Covered | None | |
If you need immediate medical attention | Not Covered | Not Covered | None | |
If you need immediate medical attention | $25 copayment/visit | Not Covered | Limited to 2 visits per year. Limited to $200 maximum cost per visit. | |
If you have a hospital stay | Facility fee (e.g., hospital room) | Not Covered | Not Covered | None |
If you have a hospital stay | Physician/surgeon fees | Not Covered | Not Covered | None |
If you need mental health, behavioral health, or substance abuse services | Outpatient services | $0 copayment/visit | Not Covered | Mental health services offered through Vitable Health. Limited to 10 visits. |
If you need mental health, behavioral health, or substance abuse services | Inpatient services | Not Covered | Not Covered | Mental health services offered through Vitable Health. Limited to 10 visits. |
If you are pregnant | Office visits | Not Covered | Not Covered | None |
If you are pregnant | Childbirth/delivery professional services | Not Covered | Not Covered | None |
If you are pregnant | Childbirth/delivery facility services | Not Covered | Not Covered | None |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If you need help recovering or have other special health needs | Not Covered | Not Covered | None | |
If your child needs dental or eye care | Children’s eye exam | Not Covered | Not Covered | None |
If your child needs dental or eye care | Children’s glasses | Not Covered | Not Covered | None |
If your child needs dental or eye care | Children’s dental check-up | Not Covered | Not Covered | None |