Carlson Restaurants Inc. $100K PPO Plan
TABLE OF CONTENTS
SECTION 1 - WELCOME......
SECTION 2 - INTRODUCTION......
Eligibility......
Cost of Coverage......
How to Enroll......
When Coverage Begins......
Changing Your Coverage......
SECTION 3 - HOW THE PLAN WORKS......
Network and Non-Network Benefits......
Eligible Expenses......
Annual Deductible......
Copayment......
Coinsurance......
Annual Maximum Benefit......
SECTION 4 - PERSONAL HEALTH SUPPORT......
Requirements for Notifying Personal Health Support......
Special Note Regarding Mental Health and Substance Use Disorder Treatment.....
Special Note Regarding Medicare......
SECTION 5 - PLAN HIGHLIGHTS......
SECTION 6 - ADDITIONAL COVERAGE DETAILS......
Ambulance Services - Emergency Only......
Congenital Heart Disease (CHD)......
Dental Services - Accident Only......
Diabetes Services......
Durable Medical Equipment (DME)......
Emergency Health Services......
Hearing Care......
Home Health Care......
Hospital - Inpatient Stay......
Injections in a Physician's Office......
Lab, X-Ray and Diagnostics - Outpatient......
Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient
Mental Health Services......
Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders.
Nutritional Counseling......
Ostomy Supplies......
Physician Fees for Surgical and Medical Services......
Physician's Office Services......
Pregnancy - Maternity Services......
Preventive Care......
Prosthetic Devices......
Reconstructive Procedures......
Rehabilitation Services - Outpatient Therapy......
Scopic Procedures - Outpatient Diagnostic and Therapeutic......
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services......
Spinal Treatment......
Substance Use Disorder Services......
Surgery - Outpatient......
Therapeutic Treatments - Outpatient......
Urgent Care Center Services......
Vision Examinations......
Wigs......
SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY......
Optum® NurseLineSM/Connect24......
Live Nurse Chat......
Live Events on myuhc.com......
Healthy Pregnancy Program......
Tobacco Cessation Program (Effective June 1, 2011)......
Disease Management Services......
Treatment Decision Support......
SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER.
Alternative Treatments......
Comfort and Convenience......
Dental......
Drugs......
Experimental or Investigational or Unproven Services......
Foot Care......
Jawbone Surgery......
Medical Supplies and Appliances......
Mental Health/Substance Use Disorder......
Nutrition and Health Education......
Physical Appearance......
Preexisting Conditions......
Pregnancy and Infertility......
Providers......
Services Provided under Another Plan......
Transplants......
Travel......
Vision and Hearing......
All Other Exclusions......
SECTION 9 - CLAIMS PROCEDURES......
Network Benefits......
Non-Network Benefits......
If Your Provider Does Not File Your Claim......
Health Statements......
Explanation of Benefits (EOB)......
Claim Denials and Appeals......
External Review Program......
Limitation of Action......
SECTION 10 - COORDINATION OF BENEFITS (COB)......
Determining Which Plan is Primary......
When This Plan is Secondary......
When a Covered Person Qualifies for Medicare......
Right to Receive and Release Needed Information......
Overpayment and Underpayment of Benefits......
SECTION 11 - SUBROGATION AND REIMBURSEMENT......
Right of Recovery......
Right to Subrogation......
Right to Reimbursement......
Third Parties......
Subrogation and Reimbursement Provisions......
SECTION 12 - WHEN COVERAGE ENDS......
Other Events Ending Your Coverage......
Coverage for a Disabled Child......
Continuing Coverage Through COBRA......
When COBRA Ends......
Uniformed Services Employment and Reemployment Rights Act......
SECTION 13 - OTHER IMPORTANT INFORMATION......
Qualified Medical Child Support Orders (QMCSOs)......
Your Relationship with UnitedHealthcare and Carlson Restaurants Inc......
Relationship with Providers......
Your Relationship with Providers......
Interpretation of Benefits......
Information and Records......
Incentives to Providers......
Incentives to You......
Rebates and Other Payments......
Workers' Compensation Not Affected......
Future of the Plan......
Plan Document......
SECTION 14 - GLOSSARY......
SECTION 15 - PRESCRIPTION DRUGS......
Prescription Drug Coverage Highlights......
Identification Card (ID Card) – Network Pharmacy......
Benefit Levels......
Retail......
Mail Order......
Mandatory Mail Order Program......
Designated Pharmacy......
Assigning Prescription Drugs to the PDL......
Notification Requirements......
Prescription Drug Benefit Claims......
Limitation on Selection of Pharmacies......
Supply Limits......
If a Brand-name Drug Becomes Available as a Generic......
Prescription Drugs that are Chemically Equivalent......
Special Programs......
Step Therapy......
Rebates and Other Discounts......
Coupons, Incentives and Other Communications......
Exclusions - What the Prescription Drug Plan Will Not Cover......
Glossary - Prescription Drugs......
SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA......
ATTACHMENT I -NOTICES......
Patient Protection and Affordable Care Act (“PPACA”)......
Requirements of Medical Leave Act of 1993 (as amended) (FMLA)......
Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)
1Table Of Contents
Carlson Restaurants Inc. $100K PPO Plan
SECTION 1 - WELCOME
Quick Reference Box
■UnitedHealthcare Member services, claim inquiries, Personal Health Support and Mental Health/Substance Use Disorder Administrator: 877-377-2501;
■Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, UT.84130-0555; and
■Online assistance: .
■Team Member Services Phone 1.800.Fridays (1.800.374.3297) Fax 972.307.6069 email .
Carlson Restaurants Inc. is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members under the Carlson, Inc. Employee Welfare Benefit Plan. It includes summaries of:
■who is eligible;
■services that are covered, called Covered Health Services;
■services that are not covered, called Exclusions;
■how Benefits are paid; and
■your rights and responsibilities under the Plan.
This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for this Plan. You must read this SPD in conjunction with the Plan Administration SPD for all information relevant to your plan.
Carlson Restaurants Inc.intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.
UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Carlson, Inc. has delegated to UnitedHealthcare the initial discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.
1Section 1 - Welcome
Carlson Restaurants Inc. $100K PPO Plan
Please read this SPD thoroughly to learn how the Carlson, Inc. Employee Welfare Benefit Plan works. Also read the Plan Administration SPD, which is intended to be read along with the SPD. If you have questions contact Team Member Services or call the number on the back of your ID card.
How To Use This SPD
■Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.
■Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.
■Read the Plan Administration SPD in conjunction with this SPD.
■You can find copies of your SPD and any future amendments at or request printed copies by contacting Team Member Services.
■Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.
■If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.
■Carlson Restaurants Inc. is also referred to as Company.
■If there is a conflict between this SPD and any summaries provided to you, this SPD will control.
1Section 1 - Welcome
Carlson Restaurants Inc. $100K PPO Plan
SECTION 2 - INTRODUCTION
What this section includes:
■Who's eligible for coverage under the Plan;
■The factors that impact your cost for coverage;
■Instructions and timeframes for enrolling yourself and your eligible Dependents;
■When coverage begins; and
■When you can make coverage changes under the Plan.
Eligibility
You are eligible to enroll in the Plan if you are a regular full-time hourly employee as defined in thePlan Administration Manual. Your eligible Dependents may also participate in the Plan. Please refer to the Plan Administration Manual for employee and dependent eligibility requirements.
Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and your Spouse are both covered under the Carlson, Inc. Employee Welfare Benefit Plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Carlson, Inc. Employee Welfare Benefit Plan, only one parent may enroll your child as a Dependent.
A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.
Cost of Coverage
You and Carlson Restaurants Inc. share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.
Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.
Note: The Internal Revenue Service generally does not consider Domestic Partners and their children eligible Dependents. Therefore, the value of Carlson Restaurants Inc. cost in covering a Domestic Partner will be imputed to the Employee as income. In addition, the share of the Employee's contribution that covers a Domestic Partner and their children will be paid using after-tax payroll deductions.
Your contributions are subject to review and Carlson Restaurants Inc. reserves the right to change your contribution amount from time to time.
You can obtain current contribution rates by calling Team Member Servicesor logging onto
How to Enroll
To enroll, call Team Member Services or log onto within 30 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 30 days, you will need to wait until the next Annual Enrollment period to make your benefit elections.
Each year during Annual Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Annual Enrollment will become effective the following January 1.
Important
If you wish to change your benefit elections following your marriage, birth or adoption of a child, or other family status change, you must contact Team Member Services within 30 days of the event. Otherwise, you will need to wait until the next Annual Enrollment period to change your elections.
When Coverage Begins
Once Team Member Services receives your properly completed enrollment, coverage will begin on the first day of eligibility. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.
Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the date of the status change, provided you notify Team Member Services within 30 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided you notify Team Member Services within 30 days of the birth, adoption, or placement.
Changing Your Coverage
Change in Status
You may make coverage changes during the year only if you experience a change in status. A change in status is an event which impacts you, your spouse or your dependent during the plan year and allows you as an employee to make a mid-year change to your current benefit elections.A complete list of change in status events are listed in the Plan Administration Manual and can be found online In addition to the change in status events you may also change your coverage if you or your eligible dependent(s) experience a change listed below under Special Enrollment Rights. You may also contact Team Member Services for more information.
Special Enrollment Rights
Under HIPAA, you have certain special enrollment rights under the Plan. That means there are circumstances where you and/or your dependents can enroll in the Plan outside of the annual enrollment period. If you experience one of these events and wish to enroll in the Plan during the Plan Year, you must notify Team Member Services within 30 days of your special enrollment event. If you do not notify Team Member Services of this event within 30 days, you will lose your right to special enrollment and will have to wait until the next annual enrollment period to enroll in the Plan.
Special enrollment rights provide that, if you, your spouse or your eligible dependent(s) experience one of the events described below, any or all of you may enroll in the Plan. For example, if your spouse experiences an event that triggers a special enrollment right, your spouse may enroll in the Plan. Your eligible dependent(s) that are affected may enroll at the same time. If you are not enrolled in the Plan, you will need to enroll also since your spouse and dependents are not eligible for coverage in the Plan if you are not enrolled. The following paragraphs refer to “you” to describe the events that may trigger special enrollment rights. Unless specifically stated, however, for this purpose “you” refers to you, your spouse and/or your eligible dependent(s).
1. Loss of other coverage: You may be eligible for special enrollment in the Plan if you did not previously enroll in the Plan because you were covered by other health care coverage and you lose eligibility for that coverage. Loss of eligibility under the other coverage includes the following: Exhaustion of COBRA coverage (but not termination before the end of the available period), divorce, death of the employee under whom you were covered, termination or reduction in the number of hours of employment (voluntary or involuntary and with or without electing COBRA), “aging out” under the other parent’s coverage, and moving out of an HMO’s service area.Loss of eligibility does not include cancellation because of a failure to pay premiums, termination of coverage for cause (such as fraud), or failure to elect coverage renewal at a time of year different from when the Plan offers open enrollment.
2. Termination of employer contributions: You may be eligible for special enrollment in the Plan if you did not previously enroll in the Plan because you were covered by another group health plan and that employer terminates all contributions toward that coverage. You may enroll in the Plan in this circumstance even if you do not lose eligibility under the other plan.
3. Marriage: You and/or your new spouse (and any new dependents) may be eligible for special enrollment in the Plan at the time of your marriage.
4. New Dependent: You may be eligible for special enrollment in the Plan, along with your new dependent and your eligible spouse, if you gain a dependent due to birth, adoption or placement for adoption.
When you enroll under these provisions, your coverage will be effective as of the actual date of the event that triggered your special enrollment right.
As of April 1, 2009, you also have certain additional special enrollment rights. You may be eligible for special enrollment in the Plan if (1) you lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or (2) you become eligible for a premium subsidy under Medicaid or CHIP. To enroll in the Plan if one of these events occur, you must notify Team Member Services within 60 days of (1) the loss of eligibility under Medicaid or CHIP or (2) a determination of your eligibility for a premium subsidy under Medicaid or CHIP. For more information on premium subsidy eligibility, please contact your state Medicaid or CHIP office.
While some changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.
Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.
Proof of a change in status or special enrollment right is required for any change in status. You must have a valid change in status event and the change requested must be consistent with the event. You must submit a Benefits Change/Cancellation Form to Team Member Services timely, within 30 days of the event if you wish to add, change, or cancel benefit coverage. DO NOT wait beyond the 30 day timeframe to submit the form if the proof is not available. The Plan Administrator has the sole discretion to determine if a change will be permitted. Remember to update your address on myhr in my Personal Information, if your address changed as a result of the event.