1
The Heritage Group Health Plan
Plan Document and Summary Plan Description
January 1, 2024
This document, together with the Anthem, Delta Dental and UNUM certificates of coverage,
constitutes the plan document and summary plan description required by ERISA § 102.
1
TABLE OF CONTENTS
I. INTRODUCTION .................................................................................................. 1
II. GENERAL INFORMATION ABOUT THE PLAN ............................................. 1
III. ELIGIBILITY AND PARTICIPATION REQUIREMENTS ................................ 3
IV. SUMMARY OF PLAN BENEFITS ...................................................................... 4
V. CIRCUMSTANCES THAT MAY AFFECT BENEFITS ..................................... 4
VI. HOW THE PLAN IS ADMINISTERED ............................................................... 5
VII. AMENDMENT OR TERMINATION OF THE PLAN ........................................ 6
VIII. NO CONTRACT OF EMPLOYMENT ................................................................. 6
IX. CLAIMS FOR BENEFITS .................................................................................... 6
X. STATEMENT OF ERISA RIGHTS ...................................................................... 7
1
I. INTRODUCTION
Introduction: The Heritage Group Health Plan (the “Plan”) provides fully
insured medical, dental, vision, life, accident, critical illness, and
disability benefits to eligible employees of those employers who
participate in this Plan (“Participating Employers”), as well as
their eligible spouses and eligible dependents. The current
Participating Employers are listed in Supplement A.
The fully insured medical and vision benefits are described in the
medical and vision certificate of coverages issued by Anthem
Insurance Company (“Anthem”). The fully insured dental benefits
are described in the dental certificate of coverage issued by Delta
Dental. The life, accident, critical illness, and disability products
are described in the certificate of coverages issued by UNUM.
The certificates of coverage are intended to be read in conjunction
with this document.
Document Purpose: You are being provided this document to give you an overview of
the Plan and to address certain information that may not be
addressed in the certificates of coverage. This document, together
with the certificates of coverage, is the plan document and
summary plan description (“SPD”) required by ERISA § 102.
This document is not intended to give you any substantive rights
to benefits that are not already provided by the certificates of
coverage. If you have not received a copy of the certificates of
coverage, please contact the Plan Administrator at 800-303-0408.
You must read the entire SPD, including certificates of coverage
and this document, to understand your benefits.
Electronic Forms To facilitate efficient operation of the Plan, the Plan may allow
forms (including, for example, election forms and notices),
whether required or permissive, to be sent and/or made by
electronic means.
II. GENERAL INFORMATION ABOUT THE PLAN
Plan Name: The Heritage Group Health Plan
Type of Plan: The Plan is a welfare plan that provides fully insured medical and
vision benefits through Anthem. The Plan provides fully insured
dental benefits through Delta Dental. The Plan provides fully
insured life insurance, critical illness, accident, and disability
benefits through UNUM.
2
Plan Year: January 1 – December 31
Plan Number: 601
Effective Date: The effective date of the SPD is January 1, 2024.
Funding Medium
And Type of Plan
Administration: The benefits offered through the Plan are fully insured. Anthem is
responsible for paying claims with respect to the medical and
vision plans. Delta Dental is responsible for paying claims with
respect to the dental plan. UNUM is responsible for paying claims
with respect to life, critical illness, accident, and disability
products.
Plan Sponsor: The Heritage Group Health Plan Benefits Committee
6510 Telecom Drive, Suite 180
Indianapolis, IN 46278
Phone: 800-303-0408
Fax: 317-228-8424
Plan Sponsor’s
Employer
Identification
Number: 35-1448549
Plan Administrator: The Heritage Group Health Plan Benefits Committee
6510 Telecom Drive, Suite 180
Indianapolis, IN 46278
Phone: 800-303-0408
Fax: 317-228-8424
Named Fiduciary: The Heritage Group Health Plan Benefits Committee
6510 Telecom Drive, Suite 180
Indianapolis, IN 46278
Phone: 800-303-0408
Fax: 317-228-8424
Members of Benefits
Committee: Sharon Barclay
David L. Franz
Kierstin Janik
Elizabeth McCaw
Jeff Waeger
3
Agent for Service
of Legal Process: The Heritage Group Health Plan Benefits Committee
6510 Telecom Drive, Suite 180
Indianapolis, IN 46278
Phone: 800-303-0408
Fax: 317-228-8424
E-mail: [email protected]
The benefit program may require completion of application forms,
annual elections, and/or other administrative forms. The details of
these administrative requirements are described in the certificates
of coverage.
Important
Disclaimer: Benefits hereunder are provided pursuant to certificates of
coverage. If the terms of this wrap document conflict with the
terms of such certificates of coverage, then the terms of the
certificates of coverage control, rather than this wrap document,
unless otherwise required by law.
III. ELIGIBILITY AND PARTICIPATION REQUIREMENTS
Eligibility: To be eligible for coverage under the Plan, an eligible individual
must meet the requirements set forth by the Participating
Employer. The eligibility requirements for the Plan are set forth in
Supplement B. If you have additional questions relating to
eligibility, please contact the Plan Administrator at 800-303-0408.
Need for
Enrollment: In general, eligible individuals must complete an application form
to enroll themselves and/or their eligible spouses and dependents.
When Participation
Begins: Once you, as an eligible individual, have completed the
enrollment paperwork, your coverage under the Plan may begin.
For information about when coverage begins, please read the
eligibility and participation information contained in Supplement
B.
Termination of
Coverage: Your coverage terminates as outlined in Supplement B. Coverage
also terminates if you cease to contribute towards the cost of a
coverage as required by the Plan Administrator and for other
reasons specified certificates of coverage booklets (for example,
divorce or a dependent’s attaining age limit). Coverage also ends
for eligible individuals, spouses, and dependents upon termination
of the Plan.
4
Continuation
Coverage Under
USERRA: Continuation and reinstatement rights may be available if you are
absent from employment due to service in the uniformed services
pursuant to USERRA.
IV. SUMMARY OF PLAN BENEFITS
Benefits Provided: The Plan provides you and your eligible spouse and/or dependents
with medical, dental, vision, life, accident, critical illness, and
disability coverage. A summary of the benefits provided by the
Plan is set forth in certificates of coverage booklets. The
certificates of coverage describe the types of benefits, scope of
coverage, prerequisites to being covered, and other details
regarding the benefits. As noted above, you must read the
certificate to understand your benefits.
Qualified Medical
Child Support
Orders: The Plan will also provide benefits as required by any qualified
medical child support order (“QMCSO”) (defined in ERISA §
609(a)). The Plan has procedures for determining whether an
order qualifies as a QMCSO. Participants and beneficiaries can
obtain, without charge, a copy of such procedures from the Plan
Administrator.
Administrative
Requirements and
Timelines: As described in the certificates of coverage, there may be other
reasons that a claim for benefits is not paid or is not paid in full.
For example, claims must generally be submitted for payment
within a certain period of time, and failure to submit within that
time period may result in the claim being denied. In this regard,
please consult certificates of coverage.
V. CIRCUMSTANCES THAT MAY AFFECT BENEFITS
Denial, Loss, or
Recovery of
Benefits: Your benefits (and the benefits of your eligible family members)
will cease when your participation in the Plan terminates.
Your benefits will also cease upon termination of the Plan.
Other circumstances can result in the termination, reduction,
recovery (through subrogation or reimbursement), or denial of
5
benefits. See the certificates of coverage booklets for additional
information.
VI. HOW THE PLAN IS ADMINISTERED
Plan
Administration: The Plan provides fully insured medical, dental, vision, life,
accident, critical illness, and disability benefits. Medical and
vision benefits are provided through insurance policies issued by
Anthem. Dental benefits are provided through an insurance policy
issued by Delta Dental. Life, accident, critical illness, and
disability benefits are provided through insurance policies issued
by UNUM. Claims for medical and vision benefits must be sent to
Anthem, claims for dental benefits must be sent to Delta Dental,
and claims for life, accident, critical illness, and disability benefits
must be sent to UNUM. Anthem, Delta Dental and UNUM (not
the Plan Administrator) are responsible for paying claims
associated with their policies under the Plan. Insurance premiums
are paid in part by the Participating Employers and in part through
contributions made by employees through the cafeteria plan
maintained each Participating Employer.
Duties of Plan
Administrator: The principal duty of the Plan Administrator is to see that the Plan
functions according to its terms, and for the exclusive benefit of
persons entitled to participate in the Plan. The Plan Administrator
may delegate any of these administrative duties among one or
more persons or entities, provided that such delegation is in
writing, expressly identifies the delegate(s), and expressly
describes the nature and scope of the delegated responsibility.
The Plan Administrator or its delegate will administer the Plan on
a reasonable and non-discriminatory basis and will apply uniform
rules to all persons similarly situated.
Anthem, Delta Dental, and UNUM are solely responsible for
paying claims associated with their policies under the Plan.
Questions: If you have any questions regarding the Plan or regarding your
eligibility for or the amount of any benefit payable under the Plan,
please contact the Plan Administrator. You may also direct any
questions relating to the medical or vision plan to Anthem by
calling the number listed on your card. Any questions relating to
the dental plan should be directed to Delta Dental. Any questions
relating to life, critical illness, accident, and disability to UNUM.
6
VII. AMENDMENT OR TERMINATION OF THE PLAN
Amendment or
Termination: The Plan Administrator may amend all or any part of the Plan at
any time in its sole discretion. The Plan Administrator or its
delegate may also remove or change any insurance company or
any other vendor at any time or from time to time.
VIII. NO CONTRACT OF EMPLOYMENT
No Contract of
Employment: The Plan is not intended to be, and may not be construed as
constituting, a contract or other arrangement between you and the
Heritage Group or a Participating Employer to the effect that you
will be employed for any specific period of time.
IX. CLAIMS FOR BENEFITS
Benefit Claims: All medical and vision benefit claims must be directed to Anthem.
If you receive care through a provider in the Anthem network,
you will not be required to file a claim for payment of medical
services provided to you. If you do not receive care from a
provider in the Anthem network, please speak with your provider
to see if the provider will submit a claim on your behalf. If your
provider will not submit a claim on your behalf, it is the
participant’s responsibility to file a claim with Anthem.
All dental benefit claims must be directed to Delta Dental. If you
receive care through a provider in the Delta Dental network, you
will not be required to file a claim for payment of medical
services provided to you. If you do not receive care from a
provider in the Delta Dental network, please speak with your
provider to see if the provider will submit a claim on your behalf.
If your provider will not submit a claim on your behalf, it is the
participant’s responsibility to file a claim with Delta Dental.
All life, accident, critical illness, and disability claims must be
directed to UNUM.
Appealing Denied
Claim: If your medical or vision claim is denied (that is, not paid in part
or in full), you will be notified, and you may appeal to the
Anthem for a review of the denied claim. Anthem will decide
your appeal on behalf of the Plan in accordance with its
7
reasonable claims procedures, as required by ERISA (if
applicable) and other applicable law.
If your dental claim is denied (that is, not paid in part or in full),
you will be notified, and you may appeal to Delta Dental for a
review of the denied claim. Delta Dental will decide your appeal
on behalf of the Plan in accordance with its reasonable claims
procedures, as required by ERISA (if applicable) and other
applicable law.
If your life, accident, critical illness, or disability claim is denied
(that is, not paid in part or in full), you will be notified, and you
may appeal to UNUM for a review of the denied claim within 180
days of receiving your written notice. UNUM will decide your
appeal on behalf of the Plan in accordance with its reasonable
claims procedures, as required by ERISA (if applicable) and other
applicable law.
Important Appeal
Deadlines: If you do not appeal on time, you will lose your right to file suit in
a state or federal court, as you will not have exhausted your
internal administrative appeal rights (which is a condition for
bringing suit in court).
See the certificates of coverage booklets for information about
how to appeal a denied claim, and for details regarding the Plan’s
appeals procedures.
External Review: Under certain circumstances, you may have the right to obtain
external review (that is, review outside of the Plan). The
certificates of coverage booklets provide additional details
regarding this right to external review.
X. STATEMENT OF ERISA RIGHTS
Your Rights: As a participant in the Plan, you are entitled to certain rights and
protections under ERISA. ERISA provides that all plan
participants shall be entitled to:
Receive Information
About Your Plan
and Benefits: Examine, without charge, at the Plan Administrator’s office and at
other specified locations, all documents governing the Plan,
including insurance contracts, a copy of the latest annual report
(“Form 5500 Series”), if any, filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room
of the Employee Benefits Security Administration.
8
Obtain, upon written request to the Plan Administrator, copies of
the documents governing the operation of the Plan, including
insurance contracts and copies of the latest Form 5500 Series and
updated SPD. The Plan Administrator may make a reasonable
charge for the copies.
Receive a summary of the Plan’s annual Form 5500, if any is
required by ERISA to be prepared in which case the Plan
Administrator is required by law to furnish each participant with a
copy of this summary annual report.
COBRA and
HIPAA Rights: Continue health care coverage under certain component benefit
programs for yourself, your eligible and enrolled spouse, or your
eligible and enrolled dependents if there is a loss of coverage
under the Plan because of a qualifying event. You or your
dependents may have to pay for such coverage. Review this SPD
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 participants, ERISA imposes
duties on 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 or any other person, may fire you or
discriminate against you in any way to prevent you from
obtaining a Plan benefit or exercising your rights under ERISA.
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 that you can take to enforce the above
rights. For instance, if you request a copy of the Plan documents
or latest Form 5500 Series, if any, from the Plan and do not
receive them within 30 days, you may file suit in federal court. In
such a case, the court may require the Plan Administrator to
provide the materials and pay you up to $110 per day until you
receive the materials, unless the materials were not sent because
of reasons beyond the control of the administrator. If you have a
claim for benefits which is denied or ignored in whole or in part,
and if you have exhausted the claims procedures available to you
under the Plan (discussed above), you may file suit in state or
9
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 your claim is frivolous.
Assistance With
Your Questions: If you have any questions about your Plan, you should contact the
Plan Administrator. 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.
4690498v3
10
MEDICAL CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY ANTHEM INSURANCE COMPANY
You will be provided with a copy of the medical certificate of coverage booklet issued by
Anthem Insurance Company. The medical certificate describes the types of benefits,
scope of coverage, prerequisites to being covered, and other details regarding the
benefits. If you have not received a copy of the medical certificate of coverage, please
contact the Plan Administrator at 800-303-0408. You must read the entire SPD, including
the medical certificate of coverage and this document, to understand your benefits.
11
DENTAL CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY DELTA DENTAL
You will be provided with a copy of the dental certificate of coverage booklet issued by
Delta Dental. The dental certificate of coverage describes the types of benefits, scope of
coverage, prerequisites to being covered, and other details regarding the benefits. If you
have not received a copy of the dental certificate of coverage, please contact the Plan
Administrator at 800-303-0408. You must read the entire SPD, including the dental
certificate of coverage and this document, to understand your benefits.
12
VISION CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY ANTHEM INSURANCE COMPANY
You will be provided with a copy of the vision certificate of coverage booklet issued by
Anthem Insurance Company. The vision certificate of coverage describes the types of
benefits, scope of coverage, prerequisites to being covered, and other details regarding
the benefits. If you have not received a copy of the vision certificate of coverage, please
contact the Plan Administrator at 800-303-0408. You must read the entire SPD, including
the vision certificate of coverage and this document, to understand your benefits.
13
BASIC AND VOLUNTARY GROUP LIFE AND ACCIDENTAL DEATH AND
DISMEMBERMENT PLAN CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group life and accidental death and
dismemberment plan certificate of coverage booklet issued by UNUM Life Insurance
Company. The certificate of coverage describes the types of benefits, scope of coverage,
prerequisites to being covered, and other details regarding the benefits. If you have not
received a copy of the certificate of coverage, please contact the Plan Administrator at
800-303-0408. You must read the entire SPD, including the certificate of coverage and
this document, to understand your benefits.
14
BASIC GROUP CRITICAL ILLNESS INSURANCE
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group critical illness insurance certificate of
coverage booklet issued by UNUM Life Insurance Company. The certificate of coverage
describes the types of benefits, scope of coverage, prerequisites to being covered, and
other details regarding the benefits. If you have not received a copy of the certificate of
coverage, please contact the Plan Administrator at 800-303-0408. You must read the
entire SPD, including the certificate of coverage and this document, to understand your
benefits.
15
VOLUNTARY GROUP CRITICAL ILLNESS INSURANCE
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group critical illness insurance certificate of
coverage booklet issued by UNUM Life Insurance Company. The certificate of coverage
describes the types of benefits, scope of coverage, prerequisites to being covered, and
other details regarding the benefits. If you have not received a copy of the certificate of
coverage, please contact the Plan Administrator at 800-303-0408. You must read the
entire SPD, including the certificate of coverage and this document, to understand your
benefits.
16
VOLUNTARY GROUP ACCIDENT INSURANCE
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group accident insurance certificate of coverage
booklet issued by UNUM Life Insurance Company. The certificate of coverage describes
the types of benefits, scope of coverage, prerequisites to being covered, and other details
regarding the benefits. If you have not received a copy of the certificate of coverage,
please contact the Plan Administrator at 800-303-0408. You must read the entire SPD,
including the certificate of coverage and this document, to understand your benefits.
17
GROUP LONG TERM DISABILITY INSURANCE
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group long term disability insurance certificate
of coverage booklet issued by UNUM Life Insurance Company. The certificate of
coverage describes the types of benefits, scope of coverage, prerequisites to being
covered, and other details regarding the benefits. If you have not received a copy of the
certificate of coverage, please contact the Plan Administrator at 800-303-0408. You must
read the entire SPD, including the certificate of coverage and this document, to
understand your benefits.
18
GROUP SHORT TERM DISABILITY INSURANCE (HOURLY EMPLOYEES)
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the group short term disability insurance certificate
of coverage booklet issued by UNUM Life Insurance Company. The certificate of
coverage describes the types of benefits, scope of coverage, prerequisites to being
covered, and other details regarding the benefits. If you have not received a copy of the
certificate of coverage, please contact the Plan Administrator at 800-303-0408. You must
read the entire SPD, including the certificate of coverage and this document, to
understand your benefits.
19
GROUP SHORT TERM DISABILITY INSURANCE
(BRANDENBURG UNION EMPLOYEES)
CERTIFICATE OF COVERAGE BOOKLET
ISSUED BY UNUM LIFE INSURANCE COMPANY OF AMERICA
You will be provided with a copy of the short-term disability insurance certificate of
coverage booklet issued by UNUM Life Insurance Company. The certificate of coverage
describes the types of benefits, scope of coverage, prerequisites to being covered, and
other details regarding the benefits. If you have not received a copy of the certificate of
coverage, please contact the Plan Administrator at 800-303-0408. You must read the
entire SPD, including the certificate of coverage and this document, to understand your
benefits.
20
SUPPLEMENT A
Participating Employers
The Plan provides coverage to the following Participating Employers:
1. Asphalt Materials Inc.
2. Avenew Roads Inc.
3. Bituminous Materials and Supply, LP
4. Emulsicoat, Inc.
5. Heritage Aggregates, LLC
6. Heritage Environmental Services, LCC
7. Envita Solutions, LLC
8. Heritage Thermal Services, LLC
9. Heritage Transport, LLC
10. Laketon Refining Corporation
11. Milestone Contractors, LP
12. Monument Chemical, Inc.
13. Monument Chemical Bayport, LLC
14. Johann Haltermann Inc.
15. Monument Chemical Kentucky, LLC
16. Pavement Maintenance Systems LLC
17. Real Estate Recovery Capital, LLC
18. Rineco Chemical Industries, Inc.
19. Rineco Transportation, LLC
20. U.S. Aggregates, Inc.
21
SUPPLEMENT B
Commencement of Participation.
(a) Subject to the conditions and limitations of the Plan, an employee who is
eligible for coverage under a certificate of coverage will be eligible to
participate in the Plan. An employee will become a “Participant” in the
Plan on the later of (a) the Effective Date or (b) the date participant
becomes covered under a certificate of coverage, as described in this
Supplement B. A dependent of a Participant will become covered under
the Plan when participant becomes covered under a certificate of
coverage, in accordance with Supplement B. An employee, and any
eligible dependent, will become covered and will remain covered under a
certificate of coverage at the times, for the periods and under the
conditions specified in that policy or arrangement.
(b) For purposes of the Medical Plan, the following terms will have the following
meaning:
• “Full-time Employee” means a common law employee of an Employer
who completes, on average, 30 or more hours of service per week or is
scheduled to work 30 or more hours of service per week.
• “Initial Measurement Period” means the period beginning on the first
day of the month following the employee’s date of hire and ending the
twelve months immediately following.
• “Ongoing Employee” means any employee who has been employed
for at least one Standard Measurement Period.
• “Standard Measurement Period” means, with respect to determining
eligibility for subsequent Plan Years, a twelve-month period defined
by the Participating Employer in its administrative records in
accordance with the regulatory requirements of the Affordable Care
Act.
• “Administrative Period” means the period beginning at the end of the
Standard Measurement Period of each year and ending on the final day
of each plan year.
(c)Notwithstanding the foregoing, all employees of an Employer who are Full-
time Employees, as defined in subsection (c) below, and their spouses and
dependents will be eligible for coverage under the medical certificate of coverage
in accordance with the Affordable Care Act. For purposes of determining if an
22
employee is a Full-time Employee for purposes of eligibility under the medical
certificate of coverage, the following will apply:
• If a new employee hired on or after January 1, 2015 is scheduled to
work a consistent schedule upon his date of hire, which schedule is
anticipated to result in the employee working, on average, 30 or more
hours per week, such employee will be treated as a Full-time
Employee on his date of hire and will be offered coverage under the
medical certificate of coverage as of the date specified in the
applicable arrangement, which date will not be later than 90 days after
the employee’s date of hire.
• If a new employee hired on or after January 1, 2015, is not scheduled
to work a consistent schedule through his Initial Measurement Period,
his actual hours of service per week will be determined by averaging
his hours worked per week during his Initial Measurement Period. If
his average hours of service per week during his Initial Measurement
Period is 30 or more, will be offered coverage during the 45-day
period following the end of his Initial Measurement Period, which
coverage will be effective no later than the first day of the month that
begins on or immediately after the 13-month anniversary of his date of
hire which eligibility will continue for the 12-month period beginning
on and immediately following his first day of eligibility for coverage,
regardless of his actual hours of service during such 12-month period,
so long as employee remains employed during that period.
• If an Ongoing Employee works, on average, 30 or more hours per
week during the Standard Measurement Period, employee will be
offered coverage under the medical certificate of coverage during the
Administrative Period which coverage will be effective as of the first
day of the Plan Year which begins immediately following the Standard
Measurement Period and employee will remain so eligible for such
Plan Year, regardless of his actual hours of service during such Plan
Year, so long as employee remains employed during that Plan Year.
It is the intention of the Participating Employers that the provisions of this
Supplement B shall operate to allow all employees to be eligible for coverage
under the medical certificate of coverage so as to avoid any penalty for failure to
provide such coverage as mandated under the Patient Protection and Affordable
Care Act and the Health Care Education and Reconciliation Act (collectively
“PPACA”), and all regulations promulgated thereunder by the Departments of
Health and Human Services, Labor and Treasury. The Plan Administrator may
make such rules and decisions with respect to the operation of this Supplement B
as may be necessary to avoid such penalties based upon the then current
regulations implementing such penalty.
23
Eligibility
Provisions
Benefit
Who is Eligible
When Benefit Begins
Initial
Enrollment
Window
Benefit
Termination
Contributions
Medical
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; ACA
Eligible; benefit
eligible seasonal
employees; Early
Retirees*
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days
Medicaid/CHIP
gain/loss)
Last day of
month in
which your
active
employment
ended; the
date of end of
your ACA
stability
period; as
outlined in
certificate;
Benefit is
COBRA
eligible.
Employee and
Employer paid
Base Dental
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; ACA
Eligible; benefit
eligible seasonal
employees; Early
Retirees*
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days or
Medicaid/CHIP
gain/loss)
Last day of
month in
which your
active
employment
ended; the
date of end of
your ACA
stability
period; cease
payment; as
outlined in
certificate;
Benefit is
COBRA
eligible.
100%
Employer paid
for those
enrolled in
medical
Enhanced
Dental
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees; Early
Retirees*
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days or
Medicaid/CHIP
gain/loss)
Last day of
month in
which active
employment
occurred;
cease
payment; as
outlined in
certificate
Benefit is
COBRA
eligible
100%
employee paid
regardless of
medical plan
enrollment
24
Vision
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees; Early
Retirees*
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days
Medicaid/CHIP
gain/loss)divor
ce/separation or
Medicaid/CHIP
gain/loss)
Last day of
month in
which active
employment
occurred;
cease
payment; as
outlined in
certificate;
Benefit is
COBRA
eligible
100%
employee paid
Basic Life
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees;
Department of
Corrections Workers
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
Automatic
Enrollment
Last day of
active
employment
100%
Company paid
Voluntary
Life
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days or
Medicaid/CHIP
gain/loss)
Last day of
active
employment
100%
Employee Paid
Short Term
Disability
(Hourly)
Benefit Eligible
Employees Scheduled
30 or more
hours/week; benefit
eligible seasonal
employees/Brandenbu
rg Union;
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
Automatic
Enrollment/
Brandenburg
Union are not
auto enrolled
Last day of
active
employment
100%
Company paid/
Brandenburg
union 100%
employee paid
25
days;
Qualifying Life Event
Effective Date;
Short Term
Disability
(Salary)
Benefit Eligible
Employees Scheduled
30 or more
hours/week and ACA
Eligible; benefit
eligible seasonal
employees
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
Automatic
Enrollment
Last day of
active
employment
100%
Company paid
Basic
Critical
Illness
Employees and
dependents enrolled in
medical plan
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
Automatic
Enrollment
Last day of
active
employment
100%
Company paid
Voluntary
Critical
Illness
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days
Medicaid/CHIP
gain/loss)
Last day of
active
employment
100%
Employee Paid
Long Term
Disability
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Automatic
Enrollment
Last day of
active
employment
100%
Company paid
26
Effective Date;
Voluntary
Accident
Benefit Eligible
Employees Scheduled
to work 30+
hours/week; benefit
eligible seasonal
employees
New Hires: 1st of the
month following date of
hire;
Rehires: If after 31+
days treated as new
hire; reinstated on rehire
date if less than 31
days;
Qualifying Life Event
Effective Date;
New Hires:
Within 30 days
of hire date
Qualifying Life
Event: Within
31 days of
effective date
of coverage (60
days
Medicaid/CHIP
gain/loss)
Last day of
active
employment
100%
Employee Paid
“Benefit Eligible” active, full-time regular employees scheduled to work at least 30 hours
per week.
“Benefit Eligible Seasonal Employees” – Asphalt Materials Inc. employees who work at
least 1200 hours per year between October-September unless covered by another policy
as outlined in employment agreement.
“Union Employees” refer to your union contracts or contract your HR business partner
for eligibility questions.
“Early Retirees” -- Employees who are at least 60 years of age but younger than sixty-
five and have been employed by the Participating Employer for a minimum of 5 years are
eligible for Early Retiree Benefits. Benefits for which Early Retirees are eligible include
medical, dental, vision coverage. Early Retirees are charged the full COBRA rates for
coverage (without the 2% administrative markup). The Early Retiree’s lawful spouse,
domestic partner and eligible dependents are also eligible for coverage as long as their
spouse remains covered. Coverage for Early Retirees and their covered spouse, domestic
partner and dependents will terminate at the end of the month in which the Early Retiree
turns sixty-five. The participant can drop the coverage at any time by contacting iSolved.
Participants are required to complete the annual election period as directed to maintain
coverage.
“Default Elections”
• (A) Annual Election Period means the period preceding the first day of each
Plan Year during which all Participants are eligible to make a Plan Election
hereunder for the upcoming Plan Year. If a Participant fails to file a Plan
Election during an Annual Election Period, participant will be deemed to have
elected not to be covered under any benefit programs other than those that are
100% Employer paid.
27
• (B) Initial Election Period means the period established by the Plan Sponsor
during which an Employee is eligible to make a Plan Election hereunder upon
entering or reentering service as an Eligible Employee. If a Participant fails to
file a Plan Election during an Initial Election Period, participant will be deemed
to have elected not to be covered under any benefit programs other than those that
are 100% Employer paid.
• (C) Other Election Periods. If a Participant fails to file a Plan Election during any
other Election Period, participant will be deemed to have made the same Plan
Elections as were in effect for participant before the Election Period. In any case
in which there was no prior benefit election in effect for a Participant, participant
will be deemed to have elected not to receive non-taxable benefits through the
Plan.
Leaves of Absence: Coverage during an employer-approved leave of absence will be
determined in accordance with the employer’s leave of absence and benefits policies.
