newspaper guild of new york - the new york times ......grant glickson andrew gutterman william baker...

Newspaper Guild of New York - The New York Times Benefits Fund

SUMMARY PLAN DESCRIPTION For Retired Employees Ages 65 and Over

Effective February 1, 2019


TABLE OF CONTENTS

Page Section I Introduction, Benefits at a Glance, and Contact Information .......................... 1 Introduction ............................................................................................................. 2 Benefits at a Glance ................................................................................................ 4 Contact Information ................................................................................................ 5 Section II Eligibility and Continuation of Coverage ........................................................... 7 Eligibility for Benefits ............................................................................................ 8 Enrollment ............................................................................................................... 9 Contributions to the Cost of Coverage .................................................................. 10 If You Continue to Work After Age 65 ................................................................ 11 Life Events ............................................................................................................ 12 When Does Your Coverage End? ......................................................................... 13 Continuation of Coverage – COBRA ................................................................... 14 HIPAA Rights ....................................................................................................... 19 Section III Plan Benefits - Medical and Prescription Drug Benefits ................................. 21 Medical and Prescription Drug Benefits ............................................................... 22 Medicare Supplemental Benefit Plan .................................................................... 23 Prescription Drug Benefit Plan ............................................................................ 28 Section IV Coordination of Benefits, Subrogation, Claims Procedures & Appeals ........ 35 Coordination of Benefits with Medicare ............................................................... 36 Subrogation – Reimbursement Agreement ........................................................... 37 Claims Review and Appeal Procedures ................................................................ 40 Section V ERISA Requirements and Plan Facts ............................................................... 49 Special Rights for Mothers and Newborn Children .............................................. 50 Women’s Health and Cancer Rights Act .............................................................. 51 HIPAA Privacy Practices for Personal Health Information (PHI) ....................... 52 Interpreting the Plan .............................................................................................. 59 If the Plan Ends/Changes in the Plan .................................................................... 60 Misrepresentation and Fraud ................................................................................. 61 Plan Facts .............................................................................................................. 62 Your Rights under ERISA .................................................................................... 65 Definitions ............................................................................................................. 67

Newspaper Guild of New York – The New York Times Benefits Fund Page 1

Section I

Introduction, Benefits at a Glance,

and Contact Information


INTRODUCTION Newspaper Guild of New York – The New York Times Benefits Fund Dear Retiree: The Board of Trustees of the Newspaper Guild of New York – The New York Times Benefits Fund (Guild-Times Benefits Fund) is pleased to provide you with this revised Summary Plan Description (SPD). This SPD has been written to reflect the changes since the last version was printed. This SPD is for the Fund’s plan of benefits for retired employees in Guild jurisdiction who have attained age 65 or are otherwise Medicare-eligible and their eligible spouses, in each case who meet the eligibility requirements. A separate SPD describes the Guild-Times Benefit Fund’s plan of health and welfare benefits for active employees and eligible retirees younger than age 65 (and not otherwise Medicare-eligible). As you look through this SPD, you will learn how you become eligible for retiree benefits, what your retiree benefits are and how you claim them. We urge you to read this SPD with care. This SPD describes the Plan in effect as of February 1, 2019. This SPD has been designed to be easy to read and understand and provide you with a summary of your retiree benefits under the Guild-Times Benefits Fund. This SPD was developed to help you understand your retiree benefits and responsibilities under the health plan. The Trustees may modify or eliminate at any time (without prior notice to you) any benefits and the eligibility requirements for benefits described in this SPD. The Trustees have the authority and discretion to interpret the Plan and make final determinations regarding them. Benefits are not guaranteed. Under no circumstances will any Plan benefits become vested or non-forfeitable with respect to retired employees or their beneficiaries or dependents. This SPD summarizes the key features of the Plan. It also constitutes the Plan document. Details of the Plan are also contained in the other official Plan documents, including the Agreement and Declaration of Trust that created the Fund and any insurance contracts relating to benefits provided under the Plan, which legally govern the operation of the Plan. All other official Plan documents are available for your inspection at the Fund Office during normal business hours, and all statements made in this SPD are subject to the provisions and terms of those documents. In case of a conflict or inconsistency between the other official Plan documents and this SPD, the other official documents will govern in all cases. In addition, this SPD provides the required information about your rights and protection under the law in order to comply with the Employee Retirement Income Security Act of 1974 (ERISA). We encourage you and your family to read this SPD carefully to make the best choices and use of your retiree benefits offered by the Guild-Times Benefits Fund. If you have any questions concerning your retiree benefits or your eligibility, please feel free to contact the Fund Office at (646) 237-1670. Sincerely, The Board of Trustees


BOARD OF TRUSTEES

Union Trustees Employer Trustees Grant Glickson Andrew Gutterman William Baker Andria Greeney Stacy Cowley Christopher Biegner Gwen Knapp Robert Benten

CO-COUNSEL Proskauer Rose LLP Meyer, Suozzi, English & Klein, P.C.

ACTUARIAL CONSULTANT Milliman, Inc.

ACCOUNTANT Novak Francella, LLC

FUND ADMINISTRATOR C&R Consulting, Inc.

For claim forms, beneficiary forms, and other benefit information contact:

Newspaper Guild of New York – The New York Times Benefits Fund 1501 Broadway, Suite 1724

New York, NY 10036

Telephone: (646) 237-1670 Fax: (212) 395-9299

To obtain forms and benefit information online, please visit:

guild.candrdirect.com

www.nyguild.org


BENEFITS AT A GLANCE

Retired Employees Ages 65 and Over MEDICAL & PRESCRIPTION DRUG BENEFITS If you are age 65 or over (or otherwise Medicare-eligible) when you retire and you meet the eligibility requirements described below, this Plan offers eligible retirees a medical program whose benefits are supplementary to Medicare benefits as well as a prescription drug plan. Medicare Supplemental Plan

• The Plan supplements benefits provided by Medicare Part A and Medicare Part B. • The Plan is secondary to Medicare. Prescription Drug Plan • The Plan is administered by Express Scripts, Inc. (ESI). Only medical and prescription drug coverage is available to retirees and their Medicare eligible spouses. HMO coverage (including HMO medical coverage), optical benefits, dental benefits, and life insurance benefits are not available. Please keep in mind that, as with all benefits under the Plan, retiree benefits may be modified or terminated by the Trustees at any time, in their discretion. Those changes can be applied to any individual, whether or not the individual has already retired or satisfied any retiree benefit eligibility requirements and whether or not the individual is a retiree or a spouse. No benefits or rights vest or become non-forfeitable under the Plan.


CONTACT INFORMATION

BENEFIT/PLAN TYPE

VENDOR/ADDRESS

PHONE

NUMBER

WEBSITE

MEDICAL & PRESCRIPTION DRUGS

Medical Benefits Medicare Supplemental

Benefit Plan

Guild-Times Benefits Fund 1501 Broadway, Suite 1724 New York, NY 10036

(646) 237-1670

guild.candrdirect.com

Prescription Drugs Specialty Drugs

Express Scripts, Inc. (ESI) Accredo

(866) 544-2926 (800) 803-2523

www.express-scripts.com


Section II

Eligibility and Continuation of Coverage


ELIGIBILITY FOR BENEFITS Retired Employees You are eligible for medical and prescription drug benefits if: 1. You retire at age 65 or older with 5 years accredited service; or 2. You retire due to a total or permanent disability (i.e. receiving a disability pension benefit under the

frozen Guild-Times Pension Plan or the Guild-Times Adjustable Pension Plan) and you are at least 40 years of age with 10 years of accredited service and are eligible for Medicare benefits at the time of retirement.

In addition, to qualify for these retiree benefits, at the time you lost eligibility for health benefits as an active employee, you must have been an active employee of The New York Times with a right to immediate pension benefits from the frozen Guild-Times Pension Plan or the Guild-Times Adjustable Pension Plan. In order to receive this retiree coverage, you will be required to make monthly contributions. Please see the Contributions to the Cost of Coverage section for more information. Dependents of Retired Employees If you are a retired employee, in order for your spouse to be covered under the health care benefits described in this SPD, he or she must be eligible for Medicare. If your spouse is not eligible for Medicare, please refer to the SPD for active employees and eligible retirees younger than age 65. The Plan offers medical and prescription drug benefits to your Medicare eligible spouse. Domestic partners are not eligible for benefits under this retiree benefit plan and dependent children are not eligible for benefits under this retiree benefit plan.


ENROLLMENT Plan Enrollment At the time of your retirement, the Plan requires that you make an election for your benefits. Plan benefits include medical coverage and prescription drug coverage. You may elect both medical and prescription drug coverage or medical coverage only. Your choices are as follows: 1. Elect Plan benefits and pay monthly contributions directly to the Fund Office; or 2. Elect Plan benefits and pay monthly contributions using deductions from your frozen Guild-Times

Pension Plan (or, if you are not entitled to a benefit from the Guild-Times Pension Plan that covers your monthly contribution, your Guild-Times Adjustable Pension Plan) monthly retirement benefits; or

3. Reject Plan benefits. (If you do not timely elect one of the other choices, you will be treated as having rejected the Plan benefits.)

Important Note: You have 30 days from your retirement to elect to enroll in coverage. If you reject Plan coverage or otherwise do not enroll, neither you nor your dependent spouse will be permitted to enroll in the retiree medical and prescription drug plans in the future. Please keep in mind that you are only eligible for the coverage under this post-Medicare retiree Plan if you were covered under the active plan of the Guild-Times Benefits Fund (either active coverage or pre-Medicare retiree coverage) immediately prior to your otherwise becoming eligible to enroll in the post-Medicare retiree Plan. (There is a special transition rule for certain individuals who were accepted for, and are terminated pursuant to, a group buyout program that was offered in calendar year 2015, 2016, or 2017. Those individuals were notified separately.) Medicare Enrollment The Fund’s medical benefit Plan is a Medicare Supplemental plan. If you are a retiree age 65 or older or a dependent age 65 or older (or otherwise Medicare-eligible) and you have elected to participate in the Fund’s medical Plan, your benefits will be coordinated with Medicare. This Plan requires you to enroll in Medicare Part A and Medicare Part B. There are specific times when you can sign up for Medicare plans. Once you sign up, you do not need to sign up to continue Medicare each year. However, each year you will have a chance to review your coverage and change plans. Please refer to www.Medicare.gov for information concerning the general and special enrollment periods for each Medicare plan. Note: If you do not enroll in Medicare Part A and Part B, your benefits will not be covered under the Medicare Supplemental plan. When Does Coverage Begin? Plan coverage for you and your eligible spouse will begin once you have elected coverage if you have enrolled in Medicare Part A and Medicare Part B.


CONTRIBUTIONS TO THE COST OF COVERAGE You are required to make a monthly contribution (due on the first day of the month) as follows: Medicare Eligible Retirees and their Medicare Eligible Dependent Spouses • 60% of the cost of medical premiums; and • 100% of the cost of prescription drug premiums The cost of these premiums is annually determined by the Trustees in their sole discretion. If the monthly contribution is not received by the Fund (or postmarked) by the 10th day of the month to which it applies, then medical and prescription drug coverage will be terminated retroactive to the last day of the month for which payment was received. Please contact the Fund Office for the current premiums for medical and prescription benefit coverage that apply to you and your eligible spouse.


IF YOU CONTINUE TO WORK AFTER AGE 65 If you continue to work after age 65 (when you become eligible for Medicare), you, your eligible spouse, and your eligible dependent children will not be covered by this Plan, but will continue to be covered by the Fund’s active plan. You can enroll in Medicare at age 65. Medicare Part A hospital coverage is free, but Medicare Part B coverage is not. If you don’t enroll in Medicare Part B because you’re actively employed, make sure you do so prior to enrolling in this Plan. If you don’t enroll in Medicare Part B, you will not be eligible for benefits under this Plan.


LIFE EVENTS You should notify the Fund Office as soon as possible if you experience a life event that may affect your coverage. Changes in Personal Status It is important that you notify the Fund Office promptly if: • You change your address • You change your telephone number Changes in Family Status You must notify the Fund Office as soon as possible, but not more than 30 days, after a change in family status. A change in family status includes: • You get married, divorced, or legally separated • An eligible dependent spouse dies If you have any questions about whether a change in family status requires a new election, please call the Fund Office at (646) 237-1670 as soon as possible.


WHEN DOES YOUR COVERAGE END? Retired Employee Your medical and prescription drug coverage generally ends on the last day of the month in which the earliest of the following events occurs: • You fail to pay any required premium for your coverage; • You cancel your coverage; • You die; or • The Plan terminates or is amended in a manner that makes you ineligible. Medicare Eligible Dependent Spouse Medical and prescription drug coverage for your spouse ends on the last day of the month in which the earliest of the following events occurs: • Your coverage ends; • Your spouse is no longer eligible; • You fail to pay any required dependent spouse premium; • You cancel your spouse’s coverage; • Your spouse dies; or • The Plan no longer covers dependent spouses or is amended in a manner that makes your spouse

ineligible. A spouse of a deceased retired employee who is covered immediately prior to the death of the retired employee may continue to be covered despite the death of the retired employee, as long as the spouse is otherwise eligible, for the 24-month period following death at no cost to the spouse. This coverage is concurrent with COBRA continuation coverage. Thus, after the 24-month period ends, the spouse, if eligible for COBRA continuation coverage, may elect to pay for up to 12 additional months of coverage, adding up to a total of 36 months of continued coverage.


CONTINUATION OF COVERAGE – COBRA Under certain circumstances, your eligible spouse can continue coverage after eligibility ends, but your eligible spouse will have to pay for the cost of this coverage. Read this section carefully. You may contact the Fund Office for further details. Continuation Coverage Rights Under COBRA This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This section generally explains COBRA continuation coverage, when it may become available, and what you need to do to protect the right to receive it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). When you retire, your eligible spouse has the right, under COBRA, to continue group hospital and medical coverage for a limited period of time. For additional information about your rights and obligations under the Plan and under federal law, please contact the Fund Office at (646) 237-1670. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this section. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” Your eligible spouse could become a qualified beneficiary if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are the spouse of a retired employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • Your spouse dies; or • You become divorced or legally separated from your spouse. When Is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the death of the retired employee or commencement of a proceeding in bankruptcy with respect to the employer, the employer or eligible spouse must notify the Fund Office of the qualifying event.


CONTINUATION OF COVERAGE – COBRA (continued) You Must Give Notice of Some Qualifying Events For all other qualifying events (divorce or legal separation of the retired employee and eligible spouse, you (or your eligible spouse) must notify the Fund Office within 60 days after the occurrence of the qualifying event or the date coverage would be lost because of the qualifying event, whichever is later. You (or your eligible spouse) must provide this notice to:


1501 Broadway, Suite 1724 New York, NY 10036

How is COBRA Continuation Coverage Provided? After the Fund Office receives notice that a qualifying event has occurred, the Fund Office will offer COBRA continuation coverage to each of the qualified beneficiaries and will send the materials necessary to make their proper election. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Retired employees may elect COBRA continuation coverage on behalf of their eligible spouses. To elect continuation coverage, you must complete the election form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage. You or your eligible spouse can elect continuation coverage on behalf of all of the qualified beneficiaries. The Fund Office must receive a completed election form from the qualified beneficiary within 63 days of the mailing or 60 days of the date the qualifying event occurred, whichever is later. How Long Does COBRA Continuation Coverage Last? COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the retiree or your divorce or legal separation, COBRA continuation coverage lasts for up to a total of 36 months.

Qualifying Event

Qualified Beneficiary

Eligibility

Notification Requirements

Death of Retiree

Spouse

36 months

Spouse must notify Fund Office of qualifying event.

Retiree is divorced or legally separated from spouse

Spouse

36 months minus the number of months covered since the divorce

Retiree or spouse must notify the Fund Office.


CONTINUATION OF COVERAGE – COBRA (continued) Early Termination of COBRA Continuation Coverage The law provides that continuation coverage may be cut short prior to the expiration of the applicable 36-month period for any of the following four reasons: 1. The group health coverage provided is terminated (and the Plan is not required by COBRA to provide

you with other group health coverage that it maintains, if any); 2. The premium for COBRA continuation coverage is not timely paid in full (within the applicable grace

period); or 3. The qualified beneficiary first becomes, after electing COBRA continuation coverage, covered under

another group health plan (as an employee or otherwise) that does not contain any preexisting condition exclusion or limitation applicable to the qualified beneficiary.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a retired employee or beneficiary not receiving continuation coverage (such as misrepresentation or fraud). How Much Does COBRA Continuation Coverage Cost? Generally, each qualified beneficiary may be required to pay the entire cost of COBRA continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102% of the cost to the group health plan (including both employer and retired employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. When and How Must Payment For COBRA Continuation Coverage Be Made? • First payment for COBRA continuation coverage

If you elect COBRA continuation coverage, you do not have to send any payment with the election form. However, you must make your first payment for continuation coverage no later than 45 days after the date of your election. (The date your election form is postmarked will be used if you decide to mail payment.) If you make your first payment for continuation coverage in full later than 45 days after the date of your election, you will lose all COBRA continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct. You may contact the Fund Office for this information.

Newspaper Guild of New York –

The New York Times Benefits Fund 1501 Broadway, Suite 1724

New York, NY 10036 (646) 237-1670


CONTINUATION OF COVERAGE – COBRA (continued) • Periodic payments for COBRA continuation coverage

After you make your first payment for COBRA continuation coverage, you will be required to make periodic payments for each subsequent coverage period. Information about the amount due for each coverage period for each qualified beneficiary can be obtained from the Fund Office. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due on the first day of the calendar month for that coverage period. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due for these coverage periods.

• Grace periods for periodic payments

Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. Your COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period. However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that coverage period, your COBRA continuation coverage will be terminated and you will lose all rights to COBRA continuation coverage under the Plan. Your first payment and all periodic payments for COBRA continuation coverage should be sent to:

Newspaper Guild of New York – The New York Times Benefits Fund

1501 Broadway, Suite 1724 New York, NY 10036


CONTINUATION OF COVERAGE – COBRA (continued) Other Coverage Options Besides COBRA Continuation Coverage There may also be alternative health insurance coverage options other than purchasing COBRA coverage from this Plan. When key parts of the health care law took effect in 2014, you became entitled to buy coverage through the Health Insurance Marketplace. The Marketplace is designed to help people without employer-sponsored coverage find health insurance that meets their needs and fits their budget. More information about the Health Insurance Marketplace generally is available at www.HealthCare.gov. In addition to the options available from the Marketplace, you may qualify for a special enrollment opportunity to obtain coverage from another group health plan for which you are eligible (such as a spouse’s plan). Even if the other plan generally does not accept late enrollees, you may still qualify if you request enrollment within 30 days through what is called a “special enrollment period.” This option may cost less than COBRA continuation coverage. You should compare your other coverage options with COBRA continuation coverage and choose the coverage that is best for you. For example, if you move to other coverage you may pay more out-of-pocket than you would under COBRA continuation coverage because the new coverage may impose a new deductible. If you would like more information regarding the Marketplace, you should contact the Health Benefit Exchange Marketplace in your state of residence. For example, in New York State, the website for the Marketplace is www.healthbenefitexchange.ny.gov. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at @ www.dol.gov/ebsa (addresses and telephone number of regional and district EBSA offices are available through EBSA’s website).


HIPAA RIGHTS Right to get special enrollment in another plan Under HIPAA, if you lose your group health plan coverage, you may be able to get into another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. (Additional special enrollment rights are triggered by marriage, birth, adoption, and placement for adoption.) • Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a

spouse’s plan), you should request special enrollment as soon as possible. Prohibition against discrimination based on a health factor Under HIPAA, a group health plan may not keep you (or your eligible spouse) out of the plan based on anything related to your health. In addition, a group health plan may not charge you (or your eligible spouse) more for coverage, based on health, than the amount charged a similarly situated individual. For More Information If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (“EBSA”) toll-free at 1-866-444-3272 (for free HIPAA publications ask for publications concerning HPAA). You may also contact the CMS publication hotline at 1-800-633-4227 (ask for “Protecting Your Health Insurance Coverage”). These publications and other useful information are also available at this website: www.dol.gov/ebsa/consumer_info_health.html.


Section III

PLAN BENEFITS

Medical and Prescription Drug Benefits


MEDICAL AND PRESCRIPTION DRUG BENEFITS Retired employees age 65 or older or otherwise Medicare-eligible and dependent spouses age 65 or older or otherwise Medicare-eligible are eligible for a medical program whose benefits are supplementary to Medicare benefits as well as a prescription drug plan. HMO coverage, optical benefits, dental benefits, and life insurance benefits are not available to retired employees or their eligible spouses.


MEDICARE SUPPLEMENTAL BENEFIT PLAN If you are retired and age 65 or over or otherwise Medicare-eligible, Medicare becomes your primary source of coverage. This Plan requires you to enroll in both Medicare Part A and Medicare Part B. Your Medicare Supplemental Benefit Plan provides benefits that are in addition to your Medicare coverage. Benefits for retirees age 65 or older and eligible spouses age 65 or older (or otherwise eligible for Medicare) are coordinated with Medicare. Services are covered under Part A or under Part B. The Medicare Program provides health insurance coverage as follows: • Medicare Part A (hospital insurance) – Covers inpatient care in a hospital, inpatient care in a skilled

nursing facility (not custodial or long-term care), hospice care, home health care, and inpatient care in a religious nonmedical health care institution.

• Medicare Part B (medical insurance) – Covers medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, and other medical services, as well as many preventive services.

The Medicare Supplemental Benefit Plan will not cover benefits for services denied by Medicare. Therefore, if Medicare rejects a claim, then the Medicare Supplemental Benefit Plan will not cover the claim. In addition, the Medicare Supplemental Benefit Plan will not cover charges in excess of the Medicare Allowed Amount. If you do not enroll in Medicare Part A and Part B, your benefits will not be covered under this Medicare Supplemental Benefit Plan.


MEDICARE SUPPLEMENTAL BENEFIT PLAN (continued) The following summary of benefits is an outline of the maximum amounts or specific limits that may apply to benefits payable under the Plan.

Medicare Part A – Hospital Benefits

Medicare Part A Expenses

Medicare Approved Amounts Medicare Pays Plan Pays You Pay

Hospitalization First 60 days per benefit

period

All allowed charges but

the Medicare Part A deductible

Medicare Part A

deductible

$0

61st through 90th day All allowed charges but the Medicare coinsurance

amount

Medicare coinsurance

amount

$0

91st day and after while using 60 lifetime benefit reserve days

All allowed charges but the Medicare coinsurance

amount

Medicare coinsurance amount

$0

Beyond lifetime benefit reserve days

$0

$0

All Costs

Skilled Nursing Facility Care First 20 days

All allowed charges

$0

$0

21st through 100th day All allowed charges but the Medicare coinsurance

amount

Medicare coinsurance amount

$0

101st days and after $0 $0 All Costs Blood First 3 pints (Medicare Part

A & Medicare Part B combined per calendar year)

$0

100% of Medicare eligible expenses

$0

After 3 pints All allowed charges $0 $0 Hospice Care You must meet Medicare’s

requirements, including a doctor’s certification of terminal illness

All but very limited

copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare

copayment/coinsurance

$0

Note: Medicare Part A deductible and coinsurance amounts generally increase each calendar year. Plan payments will be based on the Medicare deductible and coinsurance in effect at the time approved expenses were incurred. Medicare Part A Deductible: The amount the beneficiary must pay each benefit period before Medicare begins to pay. Medicare Coinsurance: The daily amount the beneficiary must pay for each day of inpatient care. Lifetime Benefit Reserve Days: The Medicare coverage that becomes available when the beneficiary has been in a hospital more than 90 days in a benefit period. The 60 reserve days can only be used once during a person’s lifetime. Calendar Year: Twelve consecutive months beginning January 1st and ending December 31st.



Medicare Part B – Medical Benefits

Medicare Part B Expenses Medicare Approved Amounts

Medicare Pays Plan Pays You Pay Medicare Part B Deductible

$0

$0

All Costs

Medicare Supplemental Benefit Plan Part B Deductible

n/a

$0

*

Part B Excess Charges (charges above Medicare approved amounts)

$0

$0

All Costs

Blood (First 3 pints (Medicare Part A & Medicare Part B combined per calendar year)

$0

100% of Medicare eligible expenses

$0

After 3 pints First: $0 until you meet the Medicare Part

B deductible

Then: 80% of allowed charges

First: $0 until you meet the Plan Part

B deductible


First: Plan Part B deductible*

Then: $0

Clinical Lab Services All allowed charges $0 $0 Other Covered Medicare Part B Services

Generally 80% of allowed charges after Medicare

Part B deductible

Generally 20% of allowed charges

$0 (After Plan Part B deductible* is met)

* The Medicare Supplemental Benefit Plan Part B deductible (see page 25) must be satisfied before the Plan pays

any Part B benefits. Payment of the Medicare Part B deductible will be applied towards the Plan’s Part B deductible.

Medicare Part B Deductible: The portion of the Medicare approved amount that the beneficiary must pay each calendar year before Medicare begins to pay (based on the Medicare Part B deductible in effect at the time approved expenses were incurred). This amount is applied to the Medicare Supplemental Benefit Plan Part B deductible. Medicare Supplemental Benefit Plan Part B Deductible: The amount the beneficiary must pay before the Plan begins to pay (based on the Medicare Supplemental Benefit Plan deductible in effect at the time approved expenses were incurred).



Medicare Part A & Medicare Part B – Home Health Care Expenses

Medicare Part A & Medicare Part B

Home Health Care Expenses

Medicare Approved Amounts

Medicare Pays

Plan Pays

You Pay Medicare Approved Services (Medically necessary skilled care services and medical supplies)

100% of Allowed

Charges

$0

$0

Durable Medical Equipment

First: $0 until you meet the Medicare Part B deductible

Then: 80% of

allowed charges

First: $0 until you meet the Plan Part

B deductible*


First: Plan Part

B deductible*

Then: $0

* The Medicare Supplemental Benefit Plan Part B deductible must be satisfied before the Plan pays any Part B

benefits. Payment of the Medicare Part B deductible will be applied towards the Plan’s Part B deductible.

MEDICARE SUPPLEMENTAL BENEFIT PLAN (continued) Medicare Part B Deductibles You are responsible for satisfying the following two deductibles: 1. Medicare Part B deductible – contact Medicare for the current deductible amount –

www.Medicare.gov; and

2. Medicare Supplemental Benefit Plan’s deductible – Contact the Fund Office for the current amount. The amount of the Medicare Part B deductible will be applied towards the Plan deductible.

Therefore, the total amount of both deductibles will equal the Medicare Supplemental Benefit Plan deductible. For example, the Medicare Part B deductible for calendar year 2018 is $183 and the Medicare Supplemental Benefit Plan deductible is $300. You are responsible for a total of $300 before the Plan pays any benefits for Part B services ($183 goes to Medicare and $117 goes to the Fund Office). After the Medicare Part B deductible is satisfied, the Medicare Part B program generally pays 80% of covered charges. Once you have satisfied the Plan’s deductible, the Plan will generally pay 20% of Medicare’s approved charges. In other words, the combination of Medicare Part B and your Medicare Supplemental Benefit Plan will pay Medicare’s approved charge in full. You are responsible for any charges that exceed Medicare’s approved charge.


MEDICARE SUPPLEMENTAL BENEFIT PLAN (continued) Medical Care Outside of the United States Medicare does not cover expenses incurred outside of the United States. Since your Supplemental Benefit Plan does not provide coverage for services denied by Medicare, there are no benefits for medical care provided outside of the United States. Medical Necessity Medicare provides benefits only for covered services that are “medically necessary”. Under the Medicare law, “medically necessary” means services or supplies that: • Are proper and needed for the diagnosis or treatment of your medical condition; • Are provided for the diagnosis, direct care, and treatment of your medical condition; • Meet the standards of good medical practice in the local area; and • Are not mainly for the convenience of you or your doctor. How to File a Medicare Supplemental Claim If you are covered by Medicare, your provider will generally file a claim directly with Medicare. Once Medicare has paid its portion, the claim will normally be forwarded to the Fund Office. However, in the event the claim is not automatically forwarded to the Fund Office and you are “balance billed”, you should submit the bill, along with the Explanation of Benefits (EOB) you receive from Medicare to the Fund Office at:


New York, NY 10036 Additional information for filing claims as well as procedures to follow if your claim is denied in whole or in part and you wish to appeal the decision can be found in the Claims Review and Appeal Procedures section.


PRESCRIPTION DRUG BENEFIT PLAN For Retired Employees Age 65 and Over

Medicare eligible retirees have a choice of prescription drug plans. You may choose the Fund’s prescription drug plan or Medicare Part D. Prescription Drug Benefit Plan The Fund’s prescription drug plan provides the same prescription drug benefits as the plan that is available for active employees and eligible retired employees younger than age 65. Medicare Part D Many insurance carriers make Medicare prescription drug plans available under the “Medicare Part D” program. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium. Your prescription drug coverage with the Guild-Times Benefits Fund is, on average, at least as good as the standard Medicare prescription drug coverage. Medicare eligible retirees are encouraged to compare and contrast the various plans by logging onto the Medicare website at www.medicare.gov and clicking on Medicare Prescription Drug Plans on that page. You can enter information regarding the prescription drugs that you normally take in order to select a program that best meets your needs. You may also contact Medicare at 1-800-MEDICARE (1-800-633-4227) for further information. TTY users may call 1-800-486-2048. You can enroll in a Medicare Part D prescription drug plan during Medicare’s annual open enrollment period (October 15th through December 7th of each calendar year). You do not need to sign up for Medicare each year. However, each year you will have a chance to review your coverage and change plans. Note: If you choose a Medicare Part D prescription drug plan, neither you nor your eligible spouse will be permitted to enroll in the retiree prescription drug plan in the future. You should also know that if you drop or lose your prescription drug coverage with the Guild-Times Benefits Fund and you do not enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later.


PRESCRIPTION DRUG BENEFIT PLAN (continued) For Retired Employees Age 65 and Over

The Fund offers a prescription drug plan to you and your eligible spouse. This Plan is administered by Express Scripts, Inc. (ESI). You may contact ESI at 1-866-544-2926 (toll free) or TDD: (800) 899-2114. Call ESI to: • identify network pharmacies • learn which drugs are currently on the Express Scripts formulary or excluded entirely • find out a prescription drug’s copay before you purchase it • view claims • order ID cards • check the status of a home delivery service order • learn about enrollment in the home delivery service Visit www.express-scripts.com to: • find participating pharmacies in your area (Select Pharmacy Locator) • order home delivery service prescriptions and refills • transfer a prescription to home delivery service • check the status of your order • search the formulary • check drug cost • find information about drugs and health conditions You may also access detailed information about your prescription drug plan by creating a secure account at www.express-scripts.com. There are no claim forms, but you are responsible for a copay or coinsurance amount and a per person annual deductible for retail prescription drug coverage as shown in the chart on the following page.



BENEFIT COVERAGE1

(Provided only through participating pharmacies) Prescription Drug Benefits Retail (up to a 30-day supply) Deductible Generic Formulary Brand2

Non-Formulary Brand2

Mail Order (90-day supply)3

Generic Formulary Brand2

Non-Formulary Brand2

Specialty Drug4

$50 Greater of $10 copay or 25% of drug cost Greater of $15 copay or 25% of drug cost Greater of $40 copay or 40% of drug cost

$20 copay $40 copay $60 copay

Greater of $15 copay or 25% of drug cost

1 Coverage is provided only through participating pharmacies. 2 If a generic drug is available, you must pay 25% of the cost of the drug plus the difference between the cost of the brand and

generic drug. 3 The mail order program is mandatory after two refills of a maintenance drug. Thus, after the two refills, maintenance drugs are

not covered at retail. Retail copay is applied to mail order specialty medications. 4 Must use Accredo Specialty Pharmacy. Retail and mail order are not available.



RETAIL Deductible The retail prescription drug plan has a $50 deductible. The deductible is the amount of charges you have to pay for any covered retail prescription drug, before any retail prescription drug is available to you. Mandatory Generic Policy The Plan requires mandatory dispensing of generic drugs when available. If you elect to fill a brand name prescription and there is a generic alternative, you will be responsible for a greater share of the cost. You must pay the difference in price between the generic and brand name drug, plus 25% of the drug cost. For example, let’s say you purchase a brand-name drug not on the formulary with a cost of $125 that has a generic equivalent that costs $45. Please see the chart below that illustrates the costs associated with a mandatory generic policy. Mandatory Generic Example

Brand Name Chosen

Generic Chosen

Brand Name Drug Cost (not on formulary) $125.00 Generic Equivalent Available Cost -$45.00 $45.00 Difference $80.00 n/a 25% of drug cost $31.25 $11.25 Explanation of Cost Difference +

25% of cost Greater of $10 copay or

25% of cost Your Cost: $111.25 $11.25 MAIL ORDER The Plan also offers a mail order prescription drug plan through ESI. Through this plan, a prescription can be filled up to a 90-day supply. Drugs categorized by ESI as maintenance drugs may only be filled twice at a retail pharmacy. Thereafter, all maintenance drugs must be filled through ESI’s mail order plan. The deductible does not apply to the mail order plan.



SPECIALTY DRUGS Drugs determined by Express Scripts to be specialty drugs are available only through ESI’s specialty pharmacy Accredo. Pre-certification is required. You may call Accredo at (877) 680-4880 or (800) 803-2523 if you have any questions. If you need specialty medications, you must order them through Accredo or, per your Plan, you will be required to pay the entire cost at retail. Specialty medications are generally drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. Whether they are administered by a healthcare professional, self-injected, or taken by mouth, specialty medications generally require an enhanced level of service. Conditions and therapies for which specialty medications are typically used include: Age-related macular degeneration, Hemophilia, Noninfectious uveitis, Alpha-1 antitrypsin deficiency, Hepatitis C, Osteoarthritis, Anemia, Hereditary tyrosinemia, Osteoporosis, Asthma, Homocystinuria, Parkinson’s disease, Cancer, Immune deficiency, Psoriasis, Crohn’s disease, Infertility, Pulmonary arterial hypertension, Cystic fibrosis, Iron chelation therapy, Respiratory syncytial virus, Deep vein thrombosis, Lysosomal storage disorders, Rheumatoid arthritis, End stage renal disease, Multiple sclerosis, Thrombocytopenia, Growth hormone deficiency, and Neutropenia.



UTILIZATION MANAGEMENT PROGRAMS Prior Authorization Most of your prescriptions can be filled without prior authorization at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. Lamisil and Wellbutrin SR are examples of medications that require prior authorization by Express Scripts before they can be covered. If you present a prescription requiring prior authorization, your physician may need to provide additional information before the prescription is covered. When you take a prescription that needs prior authorization to the retail pharmacy, the system will automatically review your file (age, sex and history of prior drug therapies) to determine if the medication can be dispensed. The pharmacy will advise you if additional information is required. Either you or the pharmacy can ask your physician to call Express Scripts at (866) 544-2926 to initiate the prior authorization process. This call will start a review that typically takes two to five business days, unless additional information is required, in which case, the review may take longer. Both you and your physician will be notified in writing of the decision. If the prescription is approved, the letter will tell you the length of your coverage approval. If the prescription is denied, the letter will include the reason for coverage denial and instructions on how to submit an appeal, if you choose to do so. If you want the prescription immediately without waiting for the prior authorization, you will have to pay the full retail price at the pharmacy. If the prescription is approved, your claim should be sent to Express Scripts for reimbursement. Step Therapy For certain prescription drugs to be covered, the Plan requires covered individuals with certain conditions – including, for example, high blood pressure, nasal allergies or acid reflux – to try effective and more affordable prescription drugs first before “stepping up” to more expensive drugs. • Step 1 drugs – These front-line drugs are generic and sometimes lower-cost brand name drugs that

have generally proven to be safe, effective and affordable. In most cases, you should try these drugs first because they usually provide the same health benefit as a more expensive drug, at a lower cost to you and the Plan.

• Step 2 and Step 3 drugs – Second-line drugs are brand name alternative drugs that generally are necessary for only a small number of patients for whom front-line drugs have failed. Third-line drugs are the most expensive option and have not shown greater clinical efficacy than lower cost drugs.

The Plan’s step therapy requirements have been developed and are updated regularly under the guidance and direction of licensed physicians, pharmacists and other medical experts. Together with Express Scripts, they review the most current research on thousands of drugs tested and approved by the FDA for safety and effectiveness. Only some medications are subject to the step therapy requirements, and the prescription drugs that are may change from time to time. Your pharmacist can tell you if your prescription requires step therapy. Or at any time, you can find out yourself by logging in to http://www.express-scripts.com and clicking on “Price a Medication.”



With step therapy, more expensive brand-name drugs are usually covered as second-line alternative drugs if any of the following applies: • You have already tried the generic drugs covered in the step therapy program and they were

unsuccessful. • You cannot take a specific generic drug (for example, because of a documented allergy). • Your physician demonstrates, for medical reasons, that you need a brand-name drug. If one of these situations applies to you, your physician may request an override from Express Scripts, allowing you to take a second-line prescription drug. If the override is approved, you will pay the appropriate copay for the drug. If your physician’s request for an override is denied, you may follow the appeals process. If you choose not to appeal or your appeal is denied, you can talk to your physician again about prescribing one of the front-line drugs covered by the step therapy program. Or you can choose to pay the full price for the drug. Drug Quantity Management The drug quantity management program helps make the use of prescription drugs safer and more affordable by limiting the quantity dispensed for certain medications. This provides the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). For more information or a list of drugs that are subject to quantity limits, you may call Express Scripts at (866) 544-2926. Prescription Drug Benefit Exclusions Expenses for: 1. Pharmaceuticals requiring a prescription that:

• have not been approved by the U.S. Food and Drug Administration (FDA); or • are not approved by the FDA for the condition, dose, routine and frequency for which they are

prescribed; or • are experimental and/or investigational.

2. Nonprescription (or non-legend or over-the-counter) drugs or medicines, except insulin. 3. Foods and nutritional supplements including, but not limited to, home meals, formulas, foods, diets,

vitamins and minerals (whether they can be purchased over-the-counter or require a prescription). 4. Prescription drugs or medicines that are related to, or approved by the FDA for use in connection

with, any procedure, treatment, condition, etc. that is not covered by the Plan.


Section IV

Coordination of Benefits, Subrogation, Claims Procedures & Appeals


COORDINATION OF BENEFITS WITH MEDICARE The medical Plan supplements benefits provided by Medicare. Since Medicare is the primary provider of benefits, all claims must first be submitted to Medicare before the Plan benefits are payable. Your provider will generally file a claim directly with Medicare. Once Medicare has paid its portion, the claim will normally be forwarded to the Fund Office. However, in the event the claim is not automatically forwarded to the Fund Office and you are “balance billed”, you should submit the bill, along with the Explanation of Benefits (EOB) you receive from Medicare to the Fund Office at:


New York, NY 10036 In order to qualify for benefits, a claim must be filed within one year of the date of service. The Plan will not duplicate Medicare’s benefits. Medicare benefits are coordinated with the Plan so that you may receive up to, but not more than, 100% of the usual, customary and reasonable charges for which you submit claims. Medicare has regulations that apply to the maximum amount that a doctor may charge. A doctor can charge more than the Medicare approved amount, up to limits set by law. You are responsible for what the doctor charges above the usual, customary, and reasonable amounts.


SUBROGATION – Reimbursement Agreement Occasionally, a third party may be liable for your medical expenses. This may occur when a third party is responsible for causing your illness or injury or is otherwise responsible for your medical bills. The rules in this section govern how this Plan pays benefits in such situations. These rules have two purposes. First, the rules ensure that your benefits will be paid promptly. Often, where there is a question of third party liability, many months pass before the third party actually pays. These rules permit this Plan to pay your covered expenses until your dispute with the third party is resolved. Second, the rules protect this Plan from bearing the full expense in situations where a third party is liable. Under these rules, once it is determined that a third party is liable in any way for the injury or illness giving rise to these expenses, this Plan shall have a lien for and must be reimbursed for the relevant benefits it has advanced to you out of any recovery whatsoever that you receive that is in any way related to the event which caused you to incur the medical expenses. Benefits payable by the Plan for the treatment of an illness or injury shall be limited in the following ways when the illness or injury is the result of an act or omission of another (including a legal entity) and when the retired employee or eligible spouse pursues or has the right to pursue a recovery for such act or omission. The Plan shall pay benefits for covered expenses related to such illness and injury only to the extent not paid by the third party and only after the retired employee or eligible spouse (and his or her attorneys, if applicable) has entered into a written subrogation and reimbursement agreement with the Plan. Immediately upon paying or providing any benefit under this Plan, the Plan shall be subrogated to all rights of recovery a covered person has against any party potentially responsible for making any payment to a covered person due to a covered person’s injuries or illness, to the full extent of benefits provided or to be provided by the Plan. Covered person includes, for the purposes of this provision, anyone on whose behalf the Plan pays or provides any benefit, including but not limited to the eligible spouse of any retired employee or person entitled to receive any benefits from the Plan. It is the duty of the covered person to notify the Fund within 30 days of the date when any notice is given to any party, including an attorney, of the intention to pursue or investigate a claim to recover damages due to injuries sustained by the covered person. Any and all such funds recovered by the covered person shall remain traceable from the responsible party to the covered person and in the hands of the covered person. A covered person shall not dissipate any such funds received before reimbursing the Plan. By accepting benefits related to such illness or injury, all covered persons (referred to as “you”) agree: • that the Plan has established a lien on any recovery received by you (or your eligible spouse, legal

representative or agent);

• to notify any third party responsible for your illness or injury of the Plan’s right to reimbursement for any claims related to your illness or injury;


SUBROGATION – Reimbursement Agreement (continued) • to hold any reimbursement or recovery received by you (or your eligible spouse, legal representative

or agent) in trust on behalf of the Plan to cover all benefits paid by the Plan with respect to such illness or injury and to reimburse the Plan promptly for the benefits paid, even if you are not fully compensated (“made whole”) for your loss;

• that the Plan has the right of first reimbursement against any recovery or other proceeds of any claim

against the other person (whether or not the retired employee or eligible spouse is made whole) and that the Plan’s claim has first priority over all other claims and rights;

• to reimburse the Plan in full up to the total amount of all benefits paid or to be paid by the Plan in

connection with the illness or injury from any recovery received from a third party, regardless of whether the recovery is specifically identified as a reimbursement of medical expenses, paid and suffering, non-economic damage or otherwise and regardless of whether there is any admission of fault. All recoveries from a third party, whether by lawsuit, settlement, insurance or otherwise, must be turned over to the Plan as reimbursement up to the full amount of the benefits paid;

• that the Plan’s claim is not subject to reduction for attorneys’ fees or costs under the “common fund” doctrine or otherwise;

• that, in the event that you elect not to pursue your claim(s) against a third party, the Plan shall be equitably subrogated to your right of recovery and may pursue your claims;

• to assign, upon the Plan’s request, any right or cause of action to the Plan;

• not to take or omit to take any action to prejudice the Plan’s ability to recover the benefits paid and to cooperate in doing what is reasonably necessary to assist the Plan in obtaining reimbursement;

• to cooperate in doing what is necessary to assist the Plan in recovering the benefits paid or in pursuing any recovery;

• to forward any recovery to the Plan within ten days of disbursement by the third party or to notify the Fund as to why you are unable to do so; and

• to the entry of judgment against you and, if applicable, your eligible spouse, in any court for the amount of benefits paid on your behalf with respect to the illness or injury to the extent of any recovery or proceeds that were not turned over as required and for the cost of collection, including but not limited to the Plan’s attorneys’ fees and costs.

No benefits will be payable for charges and expenses which are excluded from coverage under any other provision of the Plan. The Plan may enforce its right to reimbursement by filing a lawsuit, recouping the amount owed from a retired employee’s or an eligible spouse’s future benefit payments (regardless of whether benefits have been assigned by a retired employee or eligible spouse to the doctor, hospital or other provider), or any other remedy available to the Plan. The Plan may permit you to turn over less than the full amount of benefits paid and recovered as it determines in its sole discretion. Any reduction of the Plan’s claim is subject to prior written approval by the Plan.


SUBROGATION – Reimbursement Agreement (continued) • For example, a retired employee is injured in an accident in a grocery store and the accident was the

store’s fault. If the Plan paid $1,000 in benefits to the retired employee due to injuries resulting from the accident and the retired employee was entitled to recover or did recover, due to a legal suit or settlement, any money from the store, the Plan would be entitled to receive up to $1,000 of such money as reimbursement for the benefits which it provided.


CLAIMS REVIEW AND APPEAL PROCEDURES Filing of Claims All claims for benefits must be submitted on the claim forms made available by the Fund Office or on standardized claim forms provided by providers. Claims submitted must be accompanied by any information or proof requested as reasonably required to process such claims for benefits. In order to qualify for benefits, a claim must be filed within one year of the date of the expense of the incurred claim. For purposes of this provision, the terms “you” and “your” refer to retired employees and their eligible spouses. INITIAL DECISIONS 1. Content of Notification of Initial Adverse Benefit Determination

If an initial notification of adverse benefit determination is needed, the notification shall set forth:

a. The specific reasons for the adverse determination; b. Reference to the specific Plan provisions (including any internal rules, guidelines, protocols,

criteria, etc.) on which the determination is based; c. A description of any additional material or information necessary for you to complete the claim

and an explanation of why such material or information is necessary; d. A description of this Plan’s review procedures and the time limits applicable to such procedures,

including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review;

e. In the case of an adverse determination involving the claim for urgent care, a description of the

expedited review process applicable to such claims; f. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the

adverse benefit determination, the notice will provide either the specific rule, protocol, or other similar criterion that was relied upon in making the adverse benefit determination or a statement that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and

g. If the adverse benefit determination is based on medical necessity or experimental treatment,

either an explanation of the scientific judgment for the determination, applying this Plan’s terms to your medical circumstances, or a statement that such an explanation will be provided free of charge upon request.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued) 2. Time Frames

a. Medical Benefits

• Medical Benefits Not Requiring Pre-Certification: You will be notified of any adverse benefit determination within a reasonable period, but not later than 30 days after receipt of the claim.

The 30-day period may be extended for up to 15 days after receipt of the claim by this Plan. The 15-day period may be extended for up to 15 days for matters beyond this Plan’s control if, before the end of the initial 30-day period, this Plan notifies you of the reasons for the extension and of the date by which this Plan expects to render a decision. If the extension is needed because you did not submit the information necessary to decide the claim, the notice of extension will describe the required information and give you at least 45 days from receipt of the notice to provide it. This Plan then has 15 days to make a decision.

• Medical Benefits Requiring Pre-Certification: You will be notified of this Plan’s benefit determination (whether adverse or not) within a reasonable period, but not later than 15 days after receipt of the claim by this Plan. The 15-day period may be extended for up to 15 days for matters beyond this Plan’s control if, before the end of the initial 15-day period, you are notified of the reasons for the extension and of the date by which this Plan expects to render a decision. If the extension is needed because you did not submit the information necessary to decide the claim, the notice of extension will describe the required information and give you at least 45 days from receipt of the notice to provide it. If the claim is improperly filed, this Plan will provide notice of the failure within 5 days.

• Medical Benefit Claims Requiring Pre-Certification that Involve Urgent Care: An urgent

care claim is a claim for treatment in which application for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or, in the opinion of a physician knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. For urgent care predetermination claims, you will be notified by this Plan regarding the benefit determination (whether adverse or not) as soon as possible, but not later than 72 hours after receipt, unless you fail to provide sufficient information to decide the claim. In the case of a failure to provide sufficient information or to follow filing procedures, you will be notified of the failure as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information needed to complete the claim. Notification of the decision on that claim will then be provided within 48 hours after the earlier of this Plan’s receipt of the specified information or the end of the additional period afforded you to provide such information. Notification can be made orally if a written or electronic communication is provided with 3 days of the oral notification.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued)

With regard to predetermination claims, if this Plan has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination by this Plan of such course of treatment is an adverse benefit determination. You will receive notice of such an adverse determination sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review before the reduction or termination occurs.

Also, for any request to extend an urgent care ongoing course of treatment beyond the initially-prescribed period of time, you will be notified of the determination (whether adverse or not) within 24 hours after receipt of the claim, if the claim is made at least 24 hours before the end of the initially-prescribed period of time or number of treatments.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued) The initial decision timeframes required for claims decisions are listed in the following tables:

MEDICAL CLAIMS DEADLINES*

Medical Claims

Requiring Pre-Certification for

Urgent Care

Medical Claims Requiring

Pre-Certification

Medical Claims Not Requiring

Pre-Certification You must be notified of initial decision within

72 hours

from receipt of claim

15 days


30 days


Are there any extensions?

No

Yes,

one 15-day extension. You will be informed of the extension within the normal

deadline.

Yes,

one 15-day extension. You will be informed of the extension within the normal

deadline.

What is the deadline if additional information is needed?

This Plan will notify you

of need for additional information

within 24 hours of receipt of the claim.

You will be given at least 48 hours to respond. The

normal deadline is suspended for 48 hours or

until information is received.

If extension is necessary

because you failed to provide necessary

information, the notice of extension will specify the

information needed.

You will be given at least 45 days to respond. The

normal deadline is suspended until the end of

this period or until information is received.

This Plan then has 15 days to make a decision.

If extension is necessary

because you failed to provide necessary

information, the notice of extension will specify the

information needed.

You will be given at least 45 days to respond. The

normal deadline is suspended until the end of

this period or until information is received.

This Plan then has 15 days to make a decision.

* The term “days” in the above tables refers to calendar days.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued) APPEALS OF ADVERSE BENEFIT DETERMINATIONS If you are not satisfied with the reason or reasons why your claim was denied, then you may appeal to the Board of Trustees. 1. Timeframes

• Medical Claims To appeal an adverse benefit determination of any benefit claim, you must write to the Trustees within 180 days after you receive this Plan’s initial determination.

For appeals to the Board of Trustees, your correspondence (or your representative’s correspondence) should include the following statement: “I AM WRITING IN ORDER TO APPEAL YOUR DECISION TO DENY ME BENEFITS. YOUR ADVERSE BENEFIT DETERMINATION WAS DATED _________________, 20 .” If this statement is not included, then the Trustees may not understand that you are making an appeal, as opposed to a general inquiry. If you have chosen someone to represent you in making your appeal, then your letter (or your representative’s letter) must state that you have authorized him or her to represent you with respect to your appeal, and you must sign such statement. Otherwise, the Trustees may not be sure that you have actually authorized someone to represent you, and the Trustees do not want to communicate about your situation to someone unless they are sure he or she is your chosen representative. In an appeal from an adverse health insurance benefit expense pre-certification involving urgent care, a health care professional with knowledge of your medical condition shall be permitted to act as your authorized representative. You shall have the opportunity to submit written documents, records, and other information related to the claim for benefits. You shall also be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. The review will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. In addition, in regard to all appeals other than those involving employee life insurance benefits: (1) the review will not afford deference to the initial adverse benefit determination and will be conducted by an appropriate named fiduciary of this Plan who is neither the individual who made the adverse benefit determination nor the subordinate of such individual; (2) insofar as the adverse benefit determination is based on medical judgment, the Board will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment; (3) such health care professional shall not be the individual, if any, who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual; and (4) medical or vocational experts whose advice was obtained on behalf of this Plan, without regard to whether the advice was relied upon in making the adverse benefit determination, will be identified.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued) Special Rule Regarding Urgent Care Claims: For urgent care claims, you may request an expedited appeal, either orally or in writing, and all necessary information, including this Plan’s benefit determination on review, shall be transmitted between you and this Plan by telephone, facsimile, or other similarly expeditious method. DETERMINATIONS ON APPEAL 1. Timeframes

• Medical Benefit Claims Requiring Pre-certification: You will be notified of the decision within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the request for review.

• Medical Benefit Claims Requiring Pre-certification Involving Urgent Care: Appeals of adverse determinations must be decided and communicated to you as soon as possible, taking into account medical exigencies, but not later than 72 hours after receipt of the request for review.

CONTENT OF ADVERSE BENEFIT DETERMINATION ON REVIEW This Plan’s written notice of the Board’s decision will include the following: 1. The specific reasons for the adverse benefit determination; 2. Reference to specific Plan provisions on which the determination is based; 3. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access

to, and copies of, all documents, records, and other information relevant to your claim for benefits; 4. A statement describing any voluntary appeal procedures offered by this Plan and a statement of your

right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA);

5. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the

adverse benefit determination, the notice will provide either the specific rule, protocol, or other similar criterion that was relied upon in making the adverse benefit determination or a statement that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and

6. If the adverse benefit determination is based on medical necessity or experimental treatment, the

written notice shall contain an explanation of the scientific or clinical judgment for the determination, applying the terms of this Plan to the claimant’s medical circumstances, or a statement that such explanation will be provided upon request.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued) The appeals decision timeframes required for claims decisions are listed in the following tables:

MEDICAL CLAIMS APPEALS TIMEFRAMES*

Pre-Certification for Urgent Care

Claims

Medical Claims

Requiring Pre-Certification

Medical Claims Not Requiring

Pre-Certification

Concurrent Claims

How long do you have to appeal?

Within 180 days

following receipt of a notification of adverse benefit determination

Within 180 days


Within 180 days


You will be given the

opportunity to appeal the concurrent review

decision sufficiently in advance to allow an

appeal and determination on the appeal

before termination of the benefit.

Are there any extensions?

No

No

No

No

You must be notified of the decision within

72 hours

from receipt of the appeal

30 days

from receipt of the appeal

At the next regularly

scheduled Trustee meeting. If appeal is received less than 30

days prior to the meeting, the appeal can be reviewed at

the following meeting.

You will be notified within 5 days of the

decision on the appeal.

Prior to termination of the

benefit

* The term “days” in the above table refers to calendar days.


CLAIMS REVIEW AND APPEAL PROCEDURES (continued)

The Trustees’ Decision is Final and Binding The Trustees’ (or their designee’s) final decision with respect to their review of any appeal will be final and binding upon you because the Trustees have exclusive authority and discretion to determine all questions of eligibility and entitlement under this Plan. Limitation on Lawsuits This means that you may not bring any legal or equitable action for benefits under the Plan, to enforce your rights under the Plan, or to clarify your right to future benefits under the Plan unless and until you have followed and exhausted the claims and appeal procedures that are described above and the benefits you requested have been denied in whole or in part, or there is any other adverse benefit determination. In addition, no legal or equitable action for benefits under the Plan, to enforce your rights under the Plan, to clarify your right to future benefits under the Plan, or against the Plan, the Trustees, the Administrator or any other Plan fiduciary or representative may be brought more than 180 days following the earlier of: (i) the date that the statute of limitations period would commence under applicable law, (ii) the date upon which you knew or should have known that you did not receive an amount due under the Plan, or (iii) the date on which you fully exhausted the Plan’s administrative remedies. How to File an Appeal with the Board of Trustees You may file an appeal with the Board of Trustees at the following address:

Board of Trustees Newspaper Guild of New York –


New York, NY 10036 Delayed Benefits If benefit payments are delayed for any reason whatsoever, please be advised that you will not be entitled to interest on these payments as a result of the delay.


Section V

ERISA Requirements and Plan Facts


SPECIAL RIGHTS FOR MOTHERS AND NEWBORN CHILDREN For the mother or newborn child, the Plan will not restrict benefits for any hospital length of stay in connection with childbirth to less than 48 hours following a vaginal delivery, or 96 hours following a Cesarean section. However, the mother’s or newborn’s attending provider, after consulting with the mother, may discharge the mother or her newborn earlier than 48 hours (or 96 hours, as applicable) after the delivery. In any case, no authorization is required from the Plan or an insurance company for a length of stay that does not exceed 48 hours (or 96 hours).


WOMEN’S HEALTH AND CANCER RIGHTS ACT The Plan will provide certain coverage for benefits received in connection with a mastectomy, including reconstructive surgery following a mastectomy. This benefit applies to any retired employee or eligible spouse. If you receive benefits under the Plan in connection with a mastectomy and elect breast reconstruction, the coverage will be provided in a manner determined in consultation with the attending physician and you. Coverage may apply to:

• Reconstruction of the breast on which the mastectomy was performed;

• Surgery and reconstruction of the other breast to produce a symmetrical appearance;

• Prostheses; and

• Treatment of physical complications at all stages of the mastectomy, including lymphedemas.

Benefits for breast reconstruction are subject to the same cost sharing provisions that apply to other medical and surgical benefits covered under the Plan.


HIPAA PRIVACY PRACTICES FOR PERSONAL HEALTH INFORMATION (PHI)

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

PLEASE REVIEW IT CAREFULLY.

Introduction

During the course of providing you with the health coverage, the Fund will have access to information about you that has been deemed to be “protected health information” by the Health Insurance Portability and Accountability Act of 1996, commonly known as “HIPAA”. This Notice describes the medical information privacy practices of the Fund, and explains the Fund’s obligations and your rights regarding the use and disclosure of your protected health information. From time to time, the Fund contracts with individuals or companies to perform various functions on your behalf. HIPAA refers to these persons as “business associates,” and this Notice also applies to the Fund’s business associates. Your personal physician or health care provider, and also HMOs and health insurers, may have different policies or notices regarding their use and disclosure of your protected health information. If you have any questions about this Notice, please contact the Fund’s Privacy Official at (646) 237-1672.

Our Pledge Regarding Health Information The Fund understands that medical information about you and your health is personal information. The Fund is committed to protecting your personal information. Under HIPAA, your protected health information (“Health Information”) includes any individually identifiable information (including your name, address, date of birth, employee ID number, and Social Security number) that is linked to your past, present or future physical or mental health, the health care that you have received or payment for your health care. This Notice covers any such Health Information that is maintained by or on behalf of the Fund. The Fund is required by law to: • Make sure that your Health Information is kept private;

• Provide you with this Notice of the Fund’s legal duties and privacy practices with respect to your

Health Information;

• Notify affected individuals following a breach of unsecured Health Information; and

• Follow the terms of this Notice (as currently in effect or subsequently amended).



How the Fund May Use and Disclose Your Health Information 1. Uses and Disclosures for Treatment, Payment and Health Care Operations

The Fund may use or disclose your Health Information in connection with your receiving treatment from a health care provider, the Fund’s payment for such treatment and for Fund health care operations. • For Treatment: Although the Plan does not provide treatment, the Fund may use or share your

Health Information to support the provision, coordination or management of your health care treatment. For example, the Fund or its business associate may disclose the name of your treating physician to a treating orthopedist so that the orthopedist can obtain your x-rays from your physician.

• For Payment: The Fund may use or disclose Health Information for the Fund’s payment

activities or those payment activities of another health plan or provider. “Payment” includes all activities in connection with processing claims for your health care (including billing, claims management, eligibility, coordination of benefits, adjudication of claims, subrogation, reviews for medical necessity and appropriateness of care and utilization review and pre-authorizations). For example, the Fund may disclose your Health Information to your health care provider to determine whether a particular surgery is medically necessary, or to determine whether the Fund will cover that surgery.

• For Health Care Operations: The Fund may use or disclose your Health Information as part of the general administrative or business functions of the Fund that the Fund must perform in order to function as a health plan, and for certain health care operations of other health plans or providers. Additionally, the Fund may use your Health Information in connection with conducting quality assessment and improvement activities and other activities relating to Fund coverage, submitting claims for stop-loss (or excess loss) coverage, conducting or arranging for medical review, legal services, or audit services. For example, the Fund may need to review your Health Information as a part of the Fund’s efforts to uncover instances of health care provider abuse and fraud.

• Business Associates: In any circumstance where the Fund discloses Health Information to a

business associate to also protect the privacy of your Health Information.

2. Disclosures to the Fund Sponsor and to Your Representatives • Disclosure to the Fund Sponsor: The Fund may disclose your Health Information to the Fund’s

Board of Trustees, which serves as the plan sponsor for the Fund, for purposes related to payment of benefits, Fund operations, and other matters pertaining to Fund administration that involve the Board of Trustees, for example in connection with appeals that you file following a denial of a benefit claim. This includes that the Trustees may receive your Health Information if necessary for them to fulfill their fiduciary duties with respect to the Fund. When disclosing Health Information to the Board of Trustees, the Fund will make reasonable efforts not to disclose more than the minimum necessary amount of Health Information to achieve the particular purpose of the disclosure. In accordance with the Plan documents, the Board of Trustees has agreed that unless it has your written permission, it will not use or disclose your Health Information:



(1) Other than as permitted in this Notice or as required by law, (2) with respect to any employment-related actions or decisions, or (3) with respect to any benefit plan sponsored by or maintained by the Board of Trustees. In addition, the Fund may disclose “summary health information” to the Board of Trustees for obtaining premium bids or modifying, amending or terminating the benefits provided under the Fund. Summary health information summarizes the claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor (such as the Board of Trustees) has provided health benefits under a group health plan. Identifying information will be deleted from summary health information, in accordance with federal privacy rules.

• Disclosure to Your Personal Representatives: The Fund may disclose your Health Information

with your personal representative in accordance with applicable state law and HIPAA (e.g., to parents if you are an unemancipated child under 18, to those people with unlimited powers of attorney, etc.) In addition, you may authorize a personal representative to receive your Health Information and act on your behalf. Contact the Privacy Official to obtain a copy of the appropriate form to authorize the people who may receive this information.

• Individuals Involved in Your Care or Payment for Your Care: Unless you object in writing, the Fund may disclose Health Information to a close friend or family member involved in or who helps pay for your health care, but only to the extent relevant to that friend or family member’s involvement in your care or payment for your care. For example, if a family member or a caregiver calls the Fund with prior knowledge of a claim, the Fund may confirm whether or not the claim has been received and paid. The Fund may also disclose your Health Information to any authorized public or private entities assisting in disaster relief efforts.

3. Other Permitted Uses and Disclosures of Your Health Information

• Required by Law: The Fund may use or disclose your Health Information to the extent that the

Fund is required to do so by applicable law. You will be notified, if required by law, of any such uses or disclosures.

• Public Health: The Fund may disclose your Health Information for public health and safety purposes to a public health authority that is permitted by law to collect or receive the information. Your Health Information may be used or disclosed for the purpose of preventing or controlling disease (including communicable disease), injury or disability. If directed by the public health authority, the Fund may also disclose your Health Information to a foreign government agency that is collaborating with the public health authority.

• Health Oversight: The Fund may disclose your Health Information to a health oversight agency

for activities authorized by law, such as audits, investigations, inspections and legal actions. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

• Abuse or Neglect: The Fund may disclose your Health Information to any public health

authority authorized by law to receive information about abuse, neglect or domestic violence if the Fund reasonably believes that you have been a victim of abuse, neglect or domestic violence. In this case, the Fund will inform you that such a disclosure, however, would only be to someone reasonably able to help prevent or lessen the threat.



• To Avert a Serious Threat to Health or Safety: The Fund may use or disclose your Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone reasonably able to help prevent or lessen the threat.

• Legal Proceedings: The Fund may disclose your Health Information in the course of any

judicial or administrative proceeding, in response to an order of a court or administrative tribunal. In addition, the Fund may disclose your Health Information under certain conditions in response to a subpoena, court-ordered discover request or other lawful process, in which case reasonable efforts must be undertaken by the party seeking the Health Information to notify you and give you an opportunity to object to the disclosure.

• Law Enforcement: The Fund may disclose your Health Information if requested by law

enforcement official as part of certain law enforcement activities.

• Coroners, Funeral Directors, and Organ Donation: The Fund may disclose your Health Information to a coroner or medical examiner for identification purposes, or other duties authorized by law. The Fund may also disclose your Health Information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. The Fund may also disclose such information in reasonable anticipation of death. The Fund may also disclose Health Information for cadaveric organ, eye or tissue donation purposes.

• Research: The Fund is permitted to disclose your Health Information to researchers when their

research has been approved by an institutional review board or privacy board that has established protocols to ensure the privacy of your Health Information.

• Military Activity and National Security: When the appropriate conditions apply, the Plan may

use or share Personal Health Information of individuals who are Armed Forces personnel: (1) for activities deemed necessary by military command authorities; or (2) to a foreign military authority if you are a member of that foreign military service. The Plan may also share your Personal Health Information with authorized federal officials conducting national security and intelligence activities.

• Workers’ Compensation: The Fund may disclose your Health Information to comply with

workers’ compensation laws and other similar legally established programs. • Inmates: If you are inmate of a correctional institution or under the custody of a law

enforcement official, the Fund may disclose your Health Information to the institution or official if the Health Information is necessary for the institution to provide you with health care; to protect you with health care; to protect the health and safety of you or others; or for the security of the correctional institution.

• Required Uses and Disclosures: The Fund must make disclosures of Health Information to the

Secretary of the U.S. Department of Health and Human Services (“HHS”) to investigate or determine the Fund’s compliance with the federal regulations regarding privacy.



Uses and Disclosures of Your Health Information that Require Your Written Authorization The Fund will not use or disclose your Health Information for the following purposes without your prior written authorization: • Psychotherapy Notes: Except for certain narrow exceptions permitted by law (such as legal defense

in a proceeding you bring against the Fund), the Fund will not use or disclose any mental health professional’s psychotherapy notes (discrete notes that document the contents of conversations during counseling sessions) without your prior written authorization.

• Marketing or Sales: Unless you give the Fund your prior written authorization, the Fund will not

use or disclose your Health Information for any paid marketing activities or sell your Health Information.

• Other Uses and Disclosures of Health Information: Other uses and disclosures of your Health

Information not described in this Notice will only be made with your prior written authorization. For example, a written authorization from you would be necessary to disclose your Health Information to a disability insurance company for purposes of obtaining disability benefits, or to a law firm in connection with litigation, unless otherwise permitted or required as outlined above. If you provide the Fund with written authorization to use or disclose your Health Information for purposes other than those set forth in this Notice, you may revoke that authorization in writing at any time. If you revoke your authorization, the Fund will no longer use or disclose your Health Information for the reasons covered by your written authorization. However, you understand that the Fund is unable to take back any disclosures the Fund has already made with your authorization, and that the Fund is required to retain records of the services the Fund provided to you.

No Use or Disclosure of Genetic Information for Underwriting The Fund is prohibited by law from using or disclosing Health Information that is genetic information of an individual for underwriting purposes. Generally, genetic information involves information about differences in a person’s DNA that could increase or decrease his or her change of getting a disease (for example, diabetes, heart disease, cancer or Alzheimer’s disease).

Additional Special Protections Additional special privacy protections, under federal or state law, may apply to certain sensitive information, such as genetic information, HIV-related information, alcohol and substance abuse treatment information, and mental health information. If you have questions, please contact the Privacy Official at (646) 237-1672.



Your Rights with Respect to Your Health Information You have the following rights regarding the Health Information that the Fund maintains:

• Right to Request a Restriction on the Use and Disclosure of Your Health Information: You may ask the Fund to restrict the uses and disclosures of your Health Information to carry out treatment, payment of health care operations. You may also request that the Fund restrict uses and disclosures of your Health Information to family members, relatives, friends, or other persons identified by you who are involved in your care. However, the Fund is not required to agree to a restriction that you request. If the Fund does agree to the request, the Fund will not use or disclose your Health Information in violation of that restriction unless it is needed to provide emergency treatment or the Fund terminates the restriction with or without your agreement. If you do not agree to the termination, the restriction will continue to apply to Health Information created or received prior to the Fund’s notice to you of the Fund’s termination of the restriction. To request a restriction, you must write to the Privacy Official at the address below indicating (1.) what information you want to restrict; (2.) whether you want to restrict use, disclosure, or both, and (3.) to whom you want the restriction to apply.

• Right to Request to Receive Confidential Communications by Alternative Means or at an

Alternative Location: The Fund will accommodate your reasonable request to receive communications of Health Information from the Fund by alternative means or at alternative locations if the request includes a statement that disclosure using the Fund’s regular communications procedures could endanger you. Please direct your written request to the Privacy Official at the address below.

• Right to Inspect and Copy: As long as the Fund maintains it, you may inspect and obtain a copy of

your Health Information that is contained in a “designated record set” – which are records used in making enrollment, payment, claims adjudication, medical management, and other decisions. To request access to inspect and/or obtain a copy of any of your Health Information, you must submit your request in writing to the Privacy Official at the address below indicating the specific information requested, and you may also direct the Fund to transmit the copy of Health Information directly to another person that you designate in writing. If you request a copy of Health Information, please indicate in which form you want to receive it (i.e. paper or electronic). The Fund may impose a fee to cover the cost of producing, copying, and mailing the requested Health Information. The Fund may deny your request inspect and copy your Health Information in certain limited circumstances. For example, under federal law, you may not inspect or copy psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise your review rights and a description of how you may complain to the Fund and to the U.S. Department of Health & Human Services (HHS).

• Right to Amend Your Health Information: If you believe that Health Information that the Fund

has about you is incorrect or incomplete, you may request that it be amended. Your request must be made in writing and submitted to the Privacy Official. In addition, you must provide a reason that supports your request. The Fund may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Fund may deny your request if you ask the Fund to amend information that did not originate with the Fund (unless the person or entity that originated the Health Information is no longer available to make the amendment), is not contained in the records maintained by the Fund, is not part of the information that you would legally be permitted to inspect and copy, or is accurate and complete.



• Right to an Accounting of Disclosures: You have the right to request an accounting (i.e. a list) of certain non-routine disclosures of your Health Information. In general, the list will not include disclosures that were made: in connection with your receiving treatment, payment for such treatment and for certain health care operations; to you regarding your own Health Information; pursuant to your written authorization; to a person involved in your care or for other permitted notification purposes; for national security or intelligence purposes; or to correctional institutions or law enforcement officials. To request a list of disclosures, contact the Privacy Official at the address below. You have the right to receive an accounting of disclosures of Health Information made within six years (or less) of the date on which the accounting is requested. Your request should indicate the form in which you want the list (e.g. paper or electronic). The first accounting you request within a 12-month period will be free of charge. For additional requests within a 12-month period, the Fund will charge you for the costs of providing the accounting. The Fund will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any cost is incurred.

• Right to Obtain a Paper Copy of this Notice: You may request a paper copy of this Privacy

Notice, at any time, even if you have previously agreed to accept the Notice electronically. Requests should be made to the Privacy Official at the address below.

Complaints

If you believe that your privacy rights have been violated, you may file a written complaint with the Fund at the address below or with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The Fund will not retaliate against you for filing a complaint.

Changes to this Notice The Fund reserves the right to change the terms of this or any subsequent notice at any time. If the Fund elects to make a change, the revised notice will be effective for all Health Information that the Fund maintains at that time. If the Fund makes a material change to this notice, and if the Fund posts this notice on its website, the Fund will post the revised notice by the effective date of the material change and also provide the revised notice by mail. If the Fund does not post this notice on its website, the Fund will provide the revised notice to retired employees within 60 days of any material change of this notice.

For Questions or Requests

Privacy Official Newspaper Guild of New York –


New York, NY 10036

(646) 237-1672


INTERPRETING THE PLAN The Board of Trustees, and any person or persons it designates (including, without limitation, any claim or appeal reviewer), has the exclusive right, power, and authority, in its sole discretion, to administer, apply and interpret the Plan, including this SPD and any other Plan documents, and to decide all matters that arise in the operation and administration of the Plan. Without limiting the generality of the foregoing, the Board of Trustees, and its designees, have the sole and absolute authority to: • Take all actions and make all decisions related to eligibility for, and the amount of, benefits under the

Plan; • Formulate, interpret and apply rules, regulations and policies necessary to administer the Fund in

accordance with the terms of the Plan; • Decide questions (both legal and factual) related to eligibility and the calculation and payment of

benefits, and any other issues arising under the Plan; • Resolve and/or clarify any ambiguities, inconsistencies and omissions arising under the official Plan

documents including this SPD or other Plan documents; • Approve or deny benefit claims; and • Determine the standard of proof required in any case. Please note that this list is for illustration purposes only and is not meant to be exhaustive of the types of determinations and interpretations under the control of the Board of Trustees or its designees. Any and all determinations and interpretations made by the Board of Trustees or its designees are final and binding on all retired employees, eligible spouses, and any other individuals claiming benefits under the Plan.


IF THE PLAN ENDS/CHANGES IN THE PLAN The Board of Trustees reserves the right to end the Plan or amend it at any time and for any reason. If the Plan is amended, modified or terminated, in whole or in part, the ability of retired employees and eligible spouses (both present and future) to participate in the Plan and/or to receive benefits thereunder, as well as the type and amount of benefits provided under the Plan, may be modified or terminated. Among other things, the Board of Trustees has the power to do the following: • Change the eligibility rules; • Diminish the amounts of benefits; • Increase deductibles or coinsurance; • Eliminate particular types of benefits; • Substitute certain benefits for others; • Impose or decrease maximums on the amount of benefits payable; and • Change contributions or increase contributions from retired employees and eligible spouses as a

condition of eligibility.

All benefits provided under the Plan and eligibility rules for retired employees and eligible spouses, including without limitation those available to retired employees:

• Are not guaranteed; • May be changed or discontinued by the Board of Trustees at any time, in its sole and absolute

discretion; • Are subject to the rules and regulations adopted by the Board of Trustees; and • Are subject to the Trust Agreement that establishes and governs the Plan’s operations, the collective

bargaining agreements and the Plan’s contracts with the applicable insurance companies or other providers.

• Under no circumstances will any person obtain a vested or non-forfeitable right to receive, directly or indirectly, any benefits provide by, or assets of, the Plan. Without limiting any other Plan provision for the discontinuance of coverage, your coverage under the Plan will be terminated when the Plan terminates or when you are no longer eligible to receive benefits under the Plan, whichever occurs first. If the Plan ends, subject to the Trust Agreement, the Board of Trustees will apply any unused reserves to provide benefits or otherwise carry out the purpose of the Plan in an equitable manner. At no point may your benefits hereunder be pledged to any creditor, third party or otherwise be alienated.


MISREPRESENTATION AND FRAUD If the Board of Trustees (or its designee) determines that you or your spouse is ineligible for coverage under the Plan, coverage will be terminated and the Plan may require you or your spouse to repay amounts incorrectly paid by the Plan. Coverage may also be terminated and you or your spouse will be required to repay amounts incorrectly paid by the Plan where you or your spouse commits fraud or makes an intentional misrepresentation or otherwise provides false information to the Plan. By way of example, fraud includes (among other things) a person’s failure to disclose any other group health coverage under which such person is entitled to receive reimbursement of a claim submitted to the Plan, failure to notify the Plan of life events that render a person ineligible for coverage, such as divorce, and false statements in an application for coverage, a claim or appeal or in response to information requested by the Plan. The Board of Trustees may commence legal action against you or your spouse for restitution and hold them liable for all costs of collection, including interest and attorneys’ fees. The Board of Trustees may also revoke or rescind eligibility and offset future claim payments with respect to you or your spouse to recoup the amount owed. In cases where coverage is terminated, it may also be done retroactively and without advance notice (except where required by law) if it would not be considered a rescission or is considered a permissible rescission under the Affordable Care Act.


PLAN FACTS The following information will help you find answers if you have any questions about your benefits. This is a welfare benefit plan administered by a joint labor-management board of trustees. The Plan Administrator (the Board of Trustees) establishes the Plan’s rules and regulations, interprets the Plan and is otherwise responsible for the Plan’s operation. Certain administrative services with regard to the processing of claims and payment of benefits are provided to the Plan. Medical benefits are self-insured and administered by:

Board of Trustees Newspaper Guild of New York – The New York Times Benefits Fund c/o C&R Consulting 1501 Broadway, Suite 1724 New York, NY 10036 (646) 237-1670

Prescription drug benefits are self-insured and administered by:

Express Scripts, LLC PO Box 66587 St Louis, MO 63166-6587 (877) 680-4880


PLAN FACTS (continued)

Plan Sponsor: Board of Trustees Newspaper Guild of New York – The New York Times Benefits Fund c/o C&R Consulting 1501 Broadway, Suite 1724 New York, NY 10036 Phone: (646) 237-1670

Employer Identification Number: 13-3094045 Plan Number: 501

Type of Plan: Welfare

Plan Administrator: The Board of Trustees

Type of Administration: Benefits are provided on a self-insured basis.

Agent for Service of Legal Process: The Board of Trustees Plan Trustees: Correspondence or inquiries addressed to all Trustees may be sent to: Board of Trustees, Newspaper Guild of New York – The New York Times Benefits Fund 1501 Broadway, Suite 1724 New York, NY 10036 Union Trustees Address Employer Trustees Address Grant Glickson 1500 Broadway, Suite 900 Andrew Gutterman 620 Eighth Avenue Gwen Knapp New York, NY 10036 Andria Greeney New York, NY 10018 William Baker Christopher Biegner Stacy Cowley Robert Benten Plan Year: July 1 to June 30 (Fund’s fiscal year) Legal Co-Counsel: Meyer, Suozzi, English & Klein, PC

1350 Broadway New York, NY 10018 Proskauer Rose LLP Eleven Times Square New York, NY 10036


PLAN FACTS (continued)

Collective Bargaining Agreement and Plan Funding: The Fund is maintained under the terms of one or more collective bargaining agreements between The New York Times and the NewsGuild of New York, Local 31003, Communications Workers of America. These agreements require contributions from the employer to the Fund. You can obtain for yourself or review in person a copy of the agreements by written request to the Plan Administrator at the Fund Office, The New York Times, or the NewsGuild of New York, Local 31003, Communications Workers of America. These contributions are made to a trust fund intended to be tax exempt. This money is reserved for payments on behalf of retired employees and eligible spouses for reasonable administrative expenses. It cannot be used for any other purpose and it cannot be withdrawn by either the employer or the union. The financial activities of the Fund are audited annually by a firm of certified public accountants:

Novak Francella, LLC

450 Seventh Avenue, Suite 3500 New York, NY 10123


YOUR RIGHTS UNDER ERISA As a participant in the Newspaper Guild of New York – Guild-Times Benefits Fund, 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: Receive Information about Your Plan and Benefits • Examine, without charge, at the Fund’s Office and at other specified locations, such as worksites and

union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) 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 collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Fund may make a reasonable charge for the copies.

• Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage • Continue health care coverage for your eligible spouse if there is a loss of coverage under the Plan as

a result of a qualifying event. Your eligible spouse may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

Prudent Actions By Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit 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, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.


YOUR RIGHTS UNDER ERISA (continued) Enforce Your Rights 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 you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report 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 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court, in addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, 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 you claim if frivolous. Assistance With Your Questions If you have any questions about your plans, you should contact the Fund Office. 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 the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.


DEFINITIONS 1. Accepts Assignment: A physician who accepts Medicare assignment agrees to accept no more than

the Medicare-approved amount as total payment for a service.

2. Allowable Charges: Medicare Part A or Medicare Part B approved amount for those covered services billed by a provider. The Medicare approved amount is the amount recognized as reasonable by Medicare for health care expenses.

3. Appeal: A request for your health insurer or plan to review a decision or a grievance again.

4. Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowable amount. For example, if the provider’s charge is $100 and the allowable amount is $70, the provider may bill you for the remaining $30.

5. Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.

6. Claim: A request for payment that you or your health care provider submits to your health insurer or

plan when you get items or services you think are covered.

7. COBRA: A Federal law that may allow you to temporarily keep health coverage if you have a qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.

8. Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowable amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowable amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowable amount.

9. Copays: A fixed amount (for example, $15) you pay for a covered health care service, usually when

you receive the service. The amount can vary by the type of covered health care service.

10. Deductible: The amount you must pay for health care services before Medicare or your Plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

11. Explanation of Benefits (EOB): A statement summarizing charges and payments for medical services including the amount paid by Medicare or the Plan, and amounts remaining to be paid.

12. Excluded Services (Exclusions): Health care services that your health insurance or plan doesn’t pay for or cover.

13. Fee for Service: A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.


DEFINITIONS (continued) 14. Formulary: A list of drugs your insurance plan covers. A formulary may include how much you pay

for each drug. (If the plan uses “tiers,” the formulary may list which drugs are in which tiers.) Formularies may include both generic drugs and brand-name drugs.

15. Hospice Services: Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

16. Home Health Care: Health care services a person receives at home.

17. Lifetime Benefit Reserves Days: The Medicare coverage that becomes available when the

beneficiary has been in a hospital more than 90 days in a benefit period. The 60 reserve days can only be used once during the person’s lifetime.

18. Medicare Part A Deductible: The Medicare approved amount that the Plan pays for Medicare Part A inpatient hospital benefits.

19. Medicare Part B Deductible: The Medicare approved amount that the retiree must pay each calendar year before Medicare begins to pay.

20. Plan: A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

21. Plan Year: A 12-month period of benefits coverage under a group health plan. 22. Preauthorization/Precertification: A decision by your health insurer or plan that a health care service,

treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

newspaper guild of new york - the new york times ......grant glickson andrew gutterman william baker...

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