NNEBT

MEDICAL BENEFITS

NETWORK BLUE PLAN FEATURES

Network Blue is a health plan administered by Blue Cross and Blue Shield of Massachusetts on behalf of your Northern New England Benefit Trust. Network Blue provides you with comprehensive medical benefits as well as all the resources you need to maintain a healthy lifestyle.

When you join Network Blue, you choose a primary care physician (PCP) who works with you to coordinate all of your care, in sickness and in health. Each member of your family can choose his or her own PCP.

Your Primary Care Physician

Your primary care physician (PCP) is the first person you call when you need medical care. If your PCP determines that you need to see a specialist, you’ll be referred to the appropriate specialist most likely affiliated with your PCP’s hospital, which is also the facility where you’ll receive inpatient care if needed. If the care you need is not available within your PCP’s hospital, your PCP can refer you to one of the many specialists or hospitals in the Network Blue network.

Choosing a Primary Care Physician

When you join Network Blue, you choose a PCP for you and each member of your family. You’ll find a complete listing of our PCP’s in the Network Blue Directory of Providers. In addition to PCPs, the directory lists specialists, hospitals, and multi-service health centers. If you don’t have a copy of the directory, call our Physician Selection Service at 1-800-821-1388 and we’ll send you one right away. If you have trouble choosing a doctor, the Physician Selection Service can help. We can tell you whether a doctor is male or female, the medical school(s) he or she attended, and if any foreign languages are spoken in the office.

Urgent Care

Urgent care is needed to treat an urgent medical condition that can wait for the time it takes to call your PCP for advice. Examples of urgent care are sprains, earaches, and high fever. If you need urgent medical care, call your PCP to arrange where you’ll receive treatment.

Urgent Care Away From Home

If you’re traveling out-of-state and you need urgent care, you may go to the nearest appropriate health care facility. You are covered for the urgent care visit and one follow-up visit. You must call the Plan on the next business day. Any additional follow-up care must be arranged by your PCP.

Emergency Care — Wherever You Are

In a life-threatening emergency, such as heart attack, stroke, or poisoning, you should go directly to the emergency room at your Network Blue hospital or the nearest medical facility. You pay your applicable co-payment for emergency room services. You are covered for the emergency care visit and one follow-up visit. Your co-payment is waived if you’re admitted to the hospital. The Plan should be notified on the next business day. Any additional follow-up care must be arranged by PCP.

NETWORK BLUE BENEFIT PLAN SUMMARY

Benefits outlined below are intended only as a general summary.

TRUST BENEFITS for COVERED SERVICES	YOUR COST
Office visits	$15 per visit
Emergency room visits	$50 per visit (waived if admitted)
Well-baby care	$15 per visit
Routine checkups	$15 per visit
Maternity care	No charge
Allergy injections	No charge
X-rays and laboratory tests	No charge
Short-term rehabilitative therapy — physical, speech/language, or occupational	$15 per visit
Ambulatory surgery	$150* per admission
Home health care agency services, including hospice care	No charge
Durable medical equipment (such as glucometers, wheelchairs, crutches, hospital beds) – must be purchased at an approved Blue Cross Durable Medical Equipment Provider as listed in your Provider Directory	Covered to maximum of $750 per calendar year (waived if provided as part of a home health care program)
INPATIENT CARE (INCLUDING MATERNITY CARE)
Semiprivate room and board	$250* per admission
Surgical services, X-rays and laboratory tests, anesthesia	No charge
Drugs and medications	No charge
Physicians’ services	No charge
Intensive care services	No charge
Care in a designated skilled nursing facility (up to 100 days per calendar year)	No charge
Care in a rehabilitation facility (up to 60 days per calendar year)	No charge
MENTAL HEALTH AND SUBSTANCE ABUSE
Outpatient care for mental health and substance abuse (up to 30 visits in a calendar year)
Visit 1 - 10	$15 per visit
Visit 11 - 30	$25 per visit
Inpatient mental health care (in a psychiatric hospital , 60 days per calendar year)	$250* per admission
Substance abuse rehabilitation (up to 30 days per calendar year)	$250* per admission
CHIROPRACTIC CARE
First three visits —self referral	$15 per visit
Visits 4-20 (when approved in advance by Network Blue)	$15 per visit

* Co-payments for consecutive inpatient admissions (or day surgery followed by inpatient care) within 30 days for the same or related illness will not exceed $500.

Maximum Out-of-Pocket Expenses

The maximum out-of-pocket expense amount for member payments is $1,000 per member in a calendar year, not to exceed $2,000 per family in a calendar year. (This amount does not include payments made for durable medical equipment or to office visit co-payments.)

Lifetime Maximum

All benefits are subject to a lifetime maximum of $2,000,000 for each member.

HEARING BENEFITS

Your health Plan includes a hearing benefit. The hearing benefit is administered by the Trust Office.

Benefit

Your Plan covers hearing evaluations and the purchase of hearing aids. Benefits are paid at 75% of the total charges not to exceed $800.00. Benefits are payable once every five years.

How To Receive The Benefit

You must submit, directly to the Trust Office, itemized bills containing the following information: name of patient, date(s) of service, types of service provided, provider’s name and address and amount charged.

Should you have any questions or require additional information concerning this benefit, please call the Trust Office at 1-800-258-9732.

HEALTH CLUB REIMBURSEMENT

Your health Plan includes a health club cost reimbursement benefit. The health club benefit is administered by the Trust Office.

Benefit

$100.00 payable at the conclusion of each 6-month period

Eligibility

Only members and spouses are eligible for the health club reimbursement benefit. The member or spouse must have been a covered participant during the entire 6-month period for which reimbursement is sought and must engage in physical activity an average of three times per week during the 6-month period.

How To Receive The Benefit

You must obtain from the Trust Office a Health Club Reimbursement form or download a copy by clicking here. The form must be completed and signed by the member or spouse and by an authorized representative of the health club.

NOTE: The Trust reserves the right to review the records of any health club to verify the participant’s attendance.

Should you have any questions or require additional information concerning this benefit, please call the Trust Office at 1-800-258-9732.

MENTAL HEALTH AND SUBSTANCE ABUSE CARE

If you or a family member requires mental health or substance abuse treatment, you must call Magellan at 1-800-444-2426 prior to starting the treatment. You must call seven days prior to the start of care that is not an emergency. If emergency care is necessary, you must notify Magellan within 48 hours following an emergency admission. If Magellan is closed, you must report the admission on the next workday.

After Magellan receives your notice, its specialists will decide if the care being proposed is necessary and appropriate for the patient's condition. Magellan will refer you or your family member to an In-Network provider.

Magellan may conduct concurrent review and re-certify care as needed. When Magellan is notified or becomes aware of an admission after care has begun, concurrent review will begin immediately to determine whether the care is appropriate.

For inpatient care, a $250.00 deductible per admission is applied and then benefits are paid at 100%. If you do not request pre-certification, no benefits are payable.

Outpatient treatment will be covered at 100% of the Usual and Customary Charge, less your co-payment ($15 for visits 1-10; $25 for visits 11-30). You will be eligible for up to 30 outpatient visits per calendar year for mental health and substance abuse services, if such visits are necessary and appropriate. However, if you fail to get pre-certified, benefits will be not be paid.

PLAN DEFINITIONS AND NOTES TO SCHEDULE

Blue Cross and Blue Shield

Blue Cross and Blue Shield of Massachusetts, Inc.

Contract

Your Summary Plan Description, any riders or other amendments, the subscriber’s enrollment application and the agreement that the Plan has with the subscriber’s group to furnish covered services and supplies to the subscriber and his or her covered dependents.

If your contract is changed or clarified, the group will be notified in writing. The notice will describe the change being made and its effective date. For example, the Plan may change the amount you must pay or certain services or change coverage to comply with state or federal law. Oral statements or other written Plan materials (other than riders to be attached to this certificate) do not modify the coverage described in this contract.

Co-payment

The portion of the charge for a certain covered service or supply that you are required to pay. The Plan provider will collect the co-payment from you at the time the provider furnishes the service or supply.

Dependent

The lawful spouse of a member, including a legally separated spouse;

The unmarried child of a member who has not attained his 19th birthday and is primarily dependent upon the member for financial support and maintenance and can be claimed as a dependent for federal income tax purposes. Coverage for the child who has attained age 19 will continue until the end of the calendar year in which the child attains the age of 19.

The unmarried child of a member who is between the ages of 19 and 23; is a full-time student in regular attendance (including customary school or college vacations) at an accredited post-secondary school or college including, but not limited to, a university, college, vocational, nursing, trade or technical school; is fulfilling all course requirements as prescribed by such institution and is working toward a degree or certificate issuable by such institution upon completion of the required courses of study; and is primarily dependent upon the member for financial support and maintenance and can be claimed as a dependent for federal income tax purposes. If the dependent is in such attendance during any of the calendar years from age 19 to age 23, coverage will continue until the end of the calendar year. However, verification of compliance with the foregoing requirements must be provided at the beginning of each calendar year in the form of a paid tuition bill or letter from the institution’s authorized office.

The word “child,” as used above, will include the employee’s own child, a child that is placed for adoption with an employee, a stepchild or a foster child, all of whom are dependent upon the employee for support and maintenance, but excludes a child who is:

a. eligible for Member Coverage under this Plan;
b. eligible for coverage as an employee under another Group Benefit Plan.

Coverage for a dependent child which is placed for adoption will commence on the date of the child’s legal placement for adoption.

If a member has a child covered under the Plan who reaches the age at which the child would otherwise cease to be a Covered Dependent but who is then mentally or physically handicapped and incapable of earning his/her own living, the Plan will continue to consider such child as a covered dependent beyond such age so long as the child remains in such condition and provided that the member has, within 31 days of the date on which the child attained age 19, submitted proof of the child’s incapacity as described above.

The Trust shall have the right to require satisfactory proof of the continuance of such mental or physical incapacity and the right to examine such child at any time or times during the first two years after receiving proof of the child’s incapacity, but not more often than once a year thereafter. Upon failure to submit such required proof or to permit such an examination, or when the child ceases to be so incapacitated, coverage with respect to the child shall cease.

This continuation of coverage shall be subject to all the provisions of the Dependent Coverage - Termination section of this Plan, except as modified in the Plan Document.

Effective Date

The date, as shown on our records, on which your coverage begins under your contract or under an amendment to it.

Emergency Care

Medical, surgical or psychiatric (mental health/substance abuse) care that is needed immediately in order to prevent death or permanent impairment to your health.

Emergency care is usually needed because of an accidental injury or the sudden onset of a medical condition. It cannot be safely postponed for the time it takes to contact your primary care physician or the Plan for instruction. Suspected heart attacks, strokes, poisoning, loss of consciousness and convulsions are examples of conditions that require emergency care.

When reviewing claims for emergency care, the Plan uses its guidelines to determine whether your condition required emergency care.

Enrollment Area

The enrollment area is comprised of those cities and towns described in the Plan’s service area (see your Summary Plan Description), as well as specific additional cities and towns that may be contiguous to the service area. You must be a permanent resident in the enrollment area in order to be eligible for coverage with the Plan. Also, unless you are a full-time student, you must actually live within the enrollment area at least nine months of the year.

Family Membership

A membership that covers the subscriber and one or more of the following members: his or her eligible spouse; and/or other eligible dependent(s).

Group

Any corporation, partnership, individual proprietorship or other organization that has an agreement with the Plan to provide health care coverage for a group of members. The group will make payment to the Plan for covered members and will also deliver to the members all notices from the Plan. The group is the subscriber’s agent and is not the agent of the Plan.

Individual Membership

A membership that covers only the subscriber.

Inpatient

A registered bed patient.

Maternity Care

Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Medically Necessary

Medically necessary means health care that is required to diagnose or treat your illness, injury, symptom or complaint and:

• Is consistent with the diagnosis and treatment of your condition and is in accordance with generally accepted medical practice;
• Is essential to improve your net health outcome and is as beneficial as any established alternatives covered under your contract;
• Is as cost effective as any established alternatives and requires the level of skilled services that are furnished; and
• Is furnished in the least intensive type of medical care setting required by your medical condition.

Medically necessary health care is not a service that is furnished solely for your convenience or religious preference or the convenience of your family or Plan provider, or a service that promotes athletic achievements or a desired lifestyle, or a service that increases or enhances your environmental or personal comfort. The Plan determines if a treatment, service, supply or drug is medically necessary for you.

Member

You, the person who has the right to coverage under this contract. A member may be the subscriber, or his or her enrolled spouse or an enrolled dependent child.

Outpatient

A patient who is not a registered bed patient. For example, a patient at a Plan health center, Plan provider’s private office, surgical day care unit or ambulatory surgical facility is considered an outpatient.

Plan

Network Blue (a line of business of Blue Cross and Blue Shield) licensed by the Commonwealth of Massachusetts as a non-profit health maintenance organization (HMO) to arrange for the coordinated delivery of health care services to its members. “Plan” also means an employee or designee of the Plan who is authorized to make decisions or take action called for within the terms of this contract.

Plan Facility

A Plan physician’s office, Plan health center, Plan hospital or another facility or agency designated by the Plan to furnish health care services to its members.

Plan Health Center

A multi-service outpatient facility that is staffed by physicians and other health professionals who are employed by or under contract with HMO Blue and that is designated by the Plan as a health care center for its members. The names and addresses of the Plan health centers are shown in your Summary Plan Description.

Plan Physician

A licensed doctor of medicine or osteopathy who has a written payment agreement with the Plan to furnish medical services to its members. The Network Blue Directory of Providers lists the Plan physicians.

A licensed acute care, psychiatric or rehabilitation hospital, detoxification facility, skilled nursing facility, ambulatory surgical facility, appliance supplier, home health agency, hospice provider, ambulance service, nurse, physician, dentist, optometrist, podiatrist, paraprofessional, psychologist, nurse midwife, certified registered nurse anesthetist, licensed independent clinical social worker, clinical specialist in psychiatric and mental health nursing, mental health center, physical therapist, dialysis facility or another health care provider that has a written payment agreement with the Plan (or that has been specifically designated by the Plan) to furnish its members the health care services that are covered under your contract.

Plan Sponsor

The plan sponsor is the same as the plan sponsor designated under the Employee Retirement Income Security Act of 1974 (ERISA), as amended. The plan sponsor is the subscriber’s agent and is not the agent of the Plan. The plan sponsor receives all notices from the Plan for you.

Primary Care Physician

The Plan physician that you select to furnish most medical care, arrange and coordinate all other covered health care and make necessary referrals to other Plan providers. The Network Blue Directory of Providers lists the Plan’s primary care physicians.

Reconstructive Surgery following mastectomy

When a person insured for benefits under this certificate receives benefits for a mastectomy and decides to have breast reconstruction, based on consultation between the attending physician and the patient, the following benefits will be subject to the same coinsurance and deductibles which apply to other plan benefits:

a. reconstruction of the breast on which the mastectomy was performed;
b. surgery and reconstruction of the other breast to produce a symmetrical appearance; and
c. prostheses and physical complications in all stages of mastectomy, including lymphedema;

Service Area

The geographic area within which you must receive covered services and supplies, except for: urgent care or emergency care and certain specialty services recommended by your primary care physician and authorized in advance by the Plan.

Subscriber

The eligible employee who signs the enrollment application at the time of initial enrollment for coverage with the Plan and on whose behalf the Plan and the group have entered into the contract.

Urgent Care

Medical, surgical or psychiatric (mental health/substance abuse) care that the Plan determines is needed to prevent serious deterioration of your health, but which can be safely postponed for the time it takes to contact your primary care physician (or, in the case of mental health and substance abuse services, the “MH/SA administrator”). The Plan has guidelines to determine whether your condition requires urgent care. High fever, lacerations requiring stitches, earaches and sprains are examples of problems requiring urgent care.

LIMITATIONS AND EXCLUSIONS

The Network Blue Summary Plan Description is your contract. The Summary Plan Description explains in detail the rights and obligations of Network Blue and those of its members.

Some of the more common limitations and exclusions to your Network Blue coverage are listed here.

Blue Cross and Blue Shield will not pay for the following:

1.  Unless otherwise specified, any service, in or out of the hospital, not performed, prescribed, or authorized in advance by your PCP and approved by Network Blue
2.  Cosmetic surgery, except that which is expressly described in the reconstructive surgery benefit in the Summary Plan Description
3.  Dental care and oral surgery, except that which is expressly described in the Summary Plan Description
4.  Routine foot care such as trimming of corns and calluses (See Summary Plan Description for specifics.)
5.  Exams and tests performed solely to comply with the requirements of a third party, such as your employer, insurance company, school, or camp
6.  Personal comfort items and custodial care
7.  Hearing aids, eyeglasses, and contact lenses and their fitting, unless otherwise specified
8.  Whole blood, packed red blood cells, and blood donor fees, including storage fees
9.  An illness or injury for which benefits are available, in whole or in part, through a government program, or would have been available if you did not have this contract
10. Charges incurred when, for your own convenience, you choose to stay in a covered facility beyond its discharge hour
11. Services or supplies Blue Cross and Blue Shield determines are not medically necessary
12. Services, procedures, supplies, or appliances that are not generally accepted or are experimental, as determined by Blue Cross and Blue Shield
13. An illness or injury that Blue Cross and Blue Shield determines arose out of and in the course of your employment
14. Infertility services
15. Prescription drugs or medications except when administered during a covered inpatient hospital stay

CLAIM FILING AND APPEALS PROCEDURES

If you receive bills for covered services or supplies or if you disagree with a determination made by the Plan, see the applicable section below for further assistance.

CLAIM FILING PROCEDURES

Who Files Your Claim for Services Furnished by Plan Providers

When you receive a covered service or supply from a Plan provider, you will not have to file a claim. Simply identify yourself as a Network Blue member and show your Network Blue identification card to the provider before receiving covered services or supplies. Your provider will ask you to pay the co-payment amount at the time of your visit.

All Plan providers will file claims for you. For covered services and supplies furnished by Plan providers, the Plan will make payment directly to the provider.

Who Files Your Claim for Services Furnished by Non-Plan Providers

When you receive a covered service or supply from a non-Plan provider, you will have to file a claim for reimbursement. You must send your original itemized bill(s) to Blue Cross and Blue Shield of Massachusetts.

You must submit your claim within one year of the date you received the covered service or supply. The Plan does not have to honor claims submitted after this one-year period. When you submit a claim, the Plan will reimburse you directly. Non-Plan providers may ask you to pay the entire charge at the time of the visit. It is up to you to pay your provider. Any co-payment amount will be deducted from the claim payment.

Out-of-Country Claims

When you are traveling outside the country and use the services of a hospital, physician or other covered provider, you will have to pay for the services at the time they are furnished. You must send all bills for these services to your Blue Cross and Blue Shield customer service center. Any bills that you submit must be translated into English and completely itemized stating the date and type of service and the charge for each service. The charge for each service must be converted to the U.S. dollar value in effect on the date the service was finished.

Time Limit for Legal Action

You may not bring legal action against the Plan for any claim under this contract more than two years after the cause of action arises.

Preexisting Medical Condition Limitation

A preexisting medical condition is an illness or injury for which a Covered Person has been diagnosed and treated during the three months before being covered under this Plan.

No benefits will be paid for any preexisting medical condition until the earlier of the following:

a. the Covered Person does not receive any hospital, surgical or medical treatment, services or supplies of any kind including prescription medicines for a period of three consecutive months ending on or after his effective date of coverage; or
b. the Covered Member completes a period of six consecutive months of continuous coverage and substantially active employment on a full-time basis; or
c. the Covered Person has been covered under the Plan for 12 consecutive months, reduced by the length of the periods of prior coverage under a group or other health insurance plan (or certain state or federal health care programs) applicable to the Covered Person. For purposes of determining the length of the periods of prior coverage, a period of coverage shall not be counted if, after such period of coverage and before the enrollment date in this Plan, there was a 63-day period during which the Covered Person was not covered under any group or other health insurance plan.

This limitation does not apply to the first $1,000 of covered medical expenses nor does it apply to pregnancy or to certain newborns. This limitation also does not apply to any dependent child, adopted by a participant or placed with a participant for adoption, provided that the adoption or placement for adoption occurs while the participant is eligible for coverage under the Plan.

NOTE: The preexisting limitation will only apply to new hires. New groups will not be subject to the preexisting limitation.

YOUR RIGHT TO APPEAL

How claim determinations are made and the procedures governing claim appeals is described below . To best understand these procedures, you need to be aware of the definition of certain important terms:

“ Claim involving urgent care” - Any claim for medical care or treatment with respect to which the application of the time periods 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 with 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.

“ Pre-service claim” - Any claim for a benefit under a group health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

“ Post-service claim” - Any claim for a benefit under a group health plan that is not a pre-service claim within the meaning of the regulations.

“ Adverse benefit determination” - Any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

Timing of notification of benefit determinations

The amount of time that the Trust will take in making a medical benefit determination (including mental health benefit determinations) will be governed by the nature of the claim.

Urgent care claims - In the case of a urgent care claim, the Trust will make the benefit determination (whether adverse or not) as soon as possible but not later than 72 hours after receipt of the claim. In the case of requests for additional treatments or periods of time involving urgent care, the Trust will make the benefit determination (whether adverse or not) within 24 hours after receipt of the claim provided that any such claim is made to the Trust at least 24 hours prior to the expiration of the prescribed period of time or number of treatments.

Pre-service non-urgent care claims - In the case of a pre-service, non-urgent care claim, the Trust will notify you of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim. This period may be extended one time by the Trust for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies you, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which the Trust expects to render a decision.

Post-service non-urgent care claims - In the case of a post-service non-urgent care claim, the Trust will notify you of the adverse benefit determination within a reasonable period of time but not later than 30 days after receipt of the claim. This period may be extended one time by the Trust for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies you, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the Trust expects to render a decision.

Manner and content of notification of an adverse benefit determination

You will be furnished with written or electronic notification of any adverse benefit determination. The notification will include the following information:

1. The specific reason or reasons for the adverse determination;
2. Reference to the specific plan provisions upon which the determination is based;
3. If applicable, a description of any additional material or information necessary for the you to perfect the claim and an explanation of why such material or information is necessary;
4. A description of the 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.
5. When applicable, if an internal rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to you upon request.
6. When applicable, if the adverse benefit determination was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination applying the terms of the plan to the your medical circumstances, or a statement that such explanation will be provided free of charge upon request; and
7. When applicable, in the case of an adverse benefit determination concerning a claim involving urgent care, a description of the expedited review process applicable to such a claim.

Appeal of adverse benefit determinations

The Trust has established and maintains a procedure through which you will be afforded a full and fair review of an adverse benefit determination. That procedure:

1. Provides you 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.
2. Provides you the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits.
3. Provides for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual.
4. Provides that, in deciding an appeal of an adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.
5. Provides for the identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination.
6. Provides that the health care professional engaged for purposes of consultation on the appeal shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual; and
7. Provides, in the case of a claim involving urgent care, for an expedited appeal of an adverse benefit determination by which information can be submitted and transmitted orally or by facsimile or other available expeditious methods.

Timing of notification of benefit determinations on review

The timing of notification, by the Trust, of benefit determinations on review varies according to the nature of the underlying claim.

Urgent care claims - In the case of the review of an adverse benefit determination concerning an urgent care claim, the plan administrator will notify you of the results of the review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your request for review.

Pre-service claims - In the case of the review of an adverse benefit determination concerning a pre-service claim, the plan administrator will notify you of the results of the review not later than 30 days after receipt by the plan of your request for review.

Post-service claims - In the case of the review of an adverse benefit determination concerning a post-service claim, the plan administrator will notify you of the results of the review not later than 60 days after receipt by the plan of your request for review.

COORDINATION WITH OTHER PLANS

This Plan coordinates benefits with other group plans so that the total benefits payable from all plans combined does not exceed 100%.

If you (or your spouse or dependent) are covered by two plans, the plan that covers the patient as a member/employee pays first, and the plan that covers the patient as a spouse or dependent is secondary.

Dependent children are covered first by the plan of the parent with a birthday earlier in the calendar year. The other plan is secondary. If a divorce decree indicates which parent's plan pays first, the decree will be honored; otherwise, the plan of the parent with custody will be primary and the other plan will be secondary.

A dependent child may be considered as a dependent of more than one member if both parents are members of the Northern New England Benefit Trust for coordination of benefits purposes.

If a plan has no coordination provision, that plan will be primary.

Special Medicare Rules

If a Covered Member works past age 65 and is covered under this Plan, this Plan will be the primary carrier with respect to Medicare coverage. If the Member chooses Medicare coverage as primary, no coverage is available under this Plan. If a Covered Dependent of any age is eligible for Medicare and is covered as a dependent under this Plan, this Plan will be primary with respect to Medicare coverage. If the Covered Dependent chooses Medicare coverage as primary, no coverage is available under this Plan. For a Covered Member or Covered Dependent under age 65, if Medicare eligibility is due solely to end-stage renal disease (ESRD), the Plan will be primary only during the first 18 months of Medicare coverage. Thereafter, the Plan will be secondary with respect to Medicare coverage. If a Covered Member or Covered Dependent is under age 65 when Medicare eligibility is due solely to ESRD, and he subsequently attains age 65, the Plan will be primary for a full 18 months (or 21 months, depending upon whether a transplant or self-dialysis is involved) from the date of ESRD eligibility. Thereafter, Medicare will be primary and the Plan will be secondary. If a Covered Member or Covered Dependent is age 65 or over, working and develops or is undergoing treatment for ESRD, the Plan will be primary for a full 18 (or 21) months from the date of ESRD eligibility. Thereafter, Medicare will be Primary and the Plan will be secondary.

Exchange of Information

Any person who claims benefits under this Plan must, upon request, provide all information needed to coordinate benefits. In addition, this information may be exchanged with other companies, organizations or persons for the purpose of determining correct benefit payments.

Facility of Payment

Other plans may be reimbursed if benefits were paid by the other plan but should have been paid under this Plan. The reimbursed amounts will be considered benefits paid under this Plan.

Right of Recovery

If it is determined that benefits paid under this Plan should have been paid under another plan, this Plan will have the right to recover those payments.

SUBROGATION

In certain instances, a “third party” may be responsible for the cost of treating an illness or injury incurred by you, your spouse or an eligible dependent. A “third party” means someone other than Northern New England Benefit Trust. It can be a person, a legal entity or some other insurance or benefit plan (e.g., Workers’ Compensation, uninsured motorists’ pool).

If you are entitled to reimbursement from a third party for expenses for an illness or injury, this Plan has the right to recover all amounts paid by this Plan. As a condition to receiving medical or disability benefits under this Plan, covered person(s), including all dependents, agree to transfer to the Plan their rights to make claim, sue and recover medical or disability expenses against any person,an insurance company or business entity from any funds which are paid or payable as a result of a personal injury claim or any reimbursement of medical/disability expenses. Alternatively, if a covered person or a dependent receives any funds, by way of judgment, settlement or otherwise, from any person, an insurance company or business entity, the covered person or dependent agrees to reimburse the Plan in full, in first priority, for any medical or disability expenses incurred by the Plan. In other words, the Plan is entitled to 100% reimbursement andshall be first reimbursed from any monies received, with the balance, if any, to be retained by the Plan member, spouse or dependent.

In the event of an illness or injury which may give rise to a right of recovery by a covered person or dependent from a third party, the right to receive benefits under this Plan shall be conditioned upon the covered person or dependent, or his/her personal representatives delivering to the Plan a signed agreement to fully repay the Plan from amounts recovered from a third party. In the event that an agreement is not signed, the provisions of this section shall remain in effect.

The obligation to reimburse the Plan, in full, in first priority, exists regardless of whether the member, spouse or dependent insured is made whole or the settlement or judgment designates the recovery, or a portion thereof, as including or excluding the Plan’s medical/disability expenses. Where medical expenses incurred by the Plan have been subject to contractual discounts or capitation agreement, the Plan shall be entitled to reimbursement on the basis of the usual, customary and reasonable fees charged by health care providers of such services, without regard to such contractual discounts or capitation.

The Plan’s right of full recovery, either by way of subrogation or right of reimbursement, may be from funds the covered person, dependent or guardian receives or is entitled to receive from the third party, any liability or other insurance covering the third party, any first party benefits such as uninsured motorist insurance, under insured motorist insurance, any medical payments, no-fault or school insurance coverages which are paid or payable. The Plan may enforce its reimbursement or subrogation rights by requiring the dependent or guardian to assert a claim to any of the foregoing coverages to which he/she may be entitled.

A Plan member, spouse or dependent, by receipt of benefits under this Plan, agrees to cooperate fully with the Plan and shall provide any information requested by the Plan within five (5) days of request. The Plan member, spouse or dependent shall within five days give the Plan or its administrator notice in writing of any personal injury claim or any other claim for reimbursement of medical or disability expenses filed with any person, an insurance company or business entity. The Plan member, spouse or dependent shall not settle or compromise any claim unless the Plan or its administrator is notified in writing at least thirty (30) days before such settlement or compromise and agrees thereto in writing. Regardless of whether the settlement or judgment purports to include or exclude medical/disability expenses, the Plan member, spouse or dependent shall immediately repay the amount of any benefits paid under the Plan.

A Plan member, spouse or dependent who waives, abrogates or impairs the Plan's recovery rights or otherwise fails to comply with the obligations specified herein, relieves the Plan from any obligation to pay past or future benefits or expenses of the injured person. If you or your spouse or dependent is obligated to reimburse the Plan under the terms the subrogation provision of the Plan and you do not make the reimbursement, the Plan may, in its discretion, offset the amount of medical/disability expenses related to the subject incident from its obligation to pay any past or future medical/disability expenses of you, your spouse and/or any dependent.

The Plan will not pay attorney’s fees or other costs associated with a Plan member’s (spouse’s or dependent’s) claim or lawsuit. Once the personal injury claim is settled, the Plan will not pay past or future benefits or claims related to that injury or accident without prior written authorization.

COBRA CONTINUATION COVERAGE

All individuals covered by our Health Plan are entitled to elect to remain in the Plan at their own expense and without proof of good health after coverage would otherwise terminate, as follows:

Coverage may be continued for up to 36 months for:

1. surviving spouses and children of deceased members;
2. separated or divorced spouses and children of current members;
3. children of current members who would lose coverage because they are no longer dependents as defined in the Plan; or
4. spouses and children of current members who would lose coverage because the member becomes entitled to Medicare benefits.

Coverage may be continued for up to 18 months for members, spouses and dependents in case of loss of coverage through the member’s:

1. reduction in work hours;
2. voluntary termination of employment or retirement;
3. layoff for economic reasons; or
4. discharge (other than for gross misconduct).

However, if the Social Security Administration determines that the Covered Person was disabled at the time of employment termination or reduction in hours, then the required continuation coverage period is extended from 18 months to 29 months. In order to be eligible for this extension, the Covered Person must notify the Trust within 60 days from the date the Social Security Administration makes the determination that he/she is disabled. The extended coverage for disabled individuals will end earlier than the 29 months, if Social Security determines that he/she is no longer disabled. The Covered Person must notify the Trust within 30 days of the date Social Security determines that he/she is no longer disabled. The disabled individual may be charged 150% of the cost of the coverage for the coverage beyond the 18 months.

In addition, if the spouse or dependent child of a member loses coverage because of the member’s termination of employment or reduction in hours and the member is eligible for Medicare before the termination or hours reduction, then the continuation coverage will last for up to 36 months from the date the member becomes eligible for Medicare.

How Does a Person Continue Coverage?

A Covered Person must notify the Trust when the divorce is finalized or after a dependent child ceases to be an eligible dependent as listed in your Plan.

When the Trust is notified that an event has occurred entitling a person covered by the Plan to continuation coverage, the Trust will notify the Covered Person of his/her right to choose continued coverage. The Covered Person must submit written election of coverage within 60 days of the date of notice from the Trust of his/her rights to continue coverage. Each Covered Person may elect to continue his/her coverage, even if other Covered Persons do not elect to continue their coverage. The coverage must be identical to the coverage provided under the Plan to similarly situated members or family members.

The Trust may terminate coverage prior to the expiration of the 36-month or 18-month period only under the following circumstances:

1. termination of all health plans provided to any member;
2. the Covered Person’s failure to make the required contribution;
3. the Covered Person’s coverage under another group health plan upon employment, remarriage, or otherwise, so long as the group plan does not have a preexisting condition provision or limitation that applies to the Covered Person; or
4. the Covered Person’s entitlement to Medicare benefits.

AMENDMENT PROVISION

Northern New England Benefit Trust has established this Plan for the benefit of its Members and their dependents under the applicable provisions of the Employee Retirement Income Security Act of 1974 (ERISA).

In keeping with the ERISA provisions, Northern New England Benefit Trust anticipates that this Plan is established as a health and welfare benefit plan. Northern New England Benefit Trust, however, reserves the right to amend, modify, suspend or terminate the Plan, or any part of the Plan, by written instrument executed by Northern New England Benefit Trust. This express reservation of right is intended specifically to include any and all retiree welfare benefits provided by the Plan. Any such benefits provided by the Plan at any time shall be deemed not to be vested, nor shall any retiree participant or beneficiary be exempt from this express reservation on the basis of any claim of status as a retiree participant, or entitles to continue welfare benefits of such status. Upon execution of such instrument, such instrument will become effective in accordance with its terms as to all Plan participants and all persons having or claiming any interest hereunder; provided that Northern New England Benefit Trust will not have the power to:

1. amend the Plan in such a manner as would cause or permit any part of the assets of Northern New England Benefit Trust Plan to be diverted to purposes other than for the exclusive benefit of the Plan participants and their covered Dependents; or
2. amend the Plan retroactively in such a manner as would deprive any person of any benefit to which he was entitled to under the Plan prior to the amendment, unless such amendment is permitted by, or necessary to bring the Plan into compliance with any law, governmental regulation or ruling.

The Fund Director of Northern New England Benefit Trust shall have express authority to implement any Plan changes voted on by the Board of Trustees.

Northern New England Benefit Trust will provide Plan participants with notice of any Plan change in writing within 60 days of the change as required under ERISA provisions.

Plan members can find more information about their specific rights under ERISA by referring to the section of this Plan Document, entitled "ERISA Information."

YOUR RIGHTS UNDER ERISA

As a participant in the Plan described in this Summary Plan Description 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 Trust Office and your Union hall, 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 Pension and Welfare Benefit Administration. Obtain, upon written request to the Trust 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 Trust may make a reasonable charge for the copies.

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

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 the 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.

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 Trust 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 Trust. 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 your claim is frivolous.

Assistance with Your Questions

If you have any questions about your Plan, you should contact the Trust 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 Trust, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits 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 Pension and Welfare Benefits Administration.

Notice of Privacy Practices
[Effective April 14, 2003]

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.

This Notice of Privacy Practices describes how the Northern New England Benefit Trust (“Trust”) may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and to control your protected health information.

“Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. The Trust is required by law to maintain the privacy of protected health information and to provide participants with notice of its legal duties and privacy practices with respect to protected health information. The Trust is required to abide by the terms of this Notice of Privacy Practices. The Trust, however, reserves the right to change the terms of this notice at any time and to make new provisions effective for all protected health information (not just for protected health information created or received after the effective date of the revised notice). The Trust will provide you, by mail, with any revised Notice of Privacy Practices upon your telephonic request.

Uses and Disclosures of Protected Health Information

A. For Treatment, Payment and Health Care Operations. The Trust may use and disclose your protected health information, without your authorization or consent, for treatment, payment and health care operations. Your protected health information may be used and disclosed by the Trust, our office staff and others outside of our office, who are involved in your care and treatment, for the purpose of providing managed care services to you. Your protected health information also may be used and disclosed to pay your health care bills and to support the Trust’s operation. The following are examples of the types of uses and disclosures of your protected health care information that the Trust is permitted to make. These examples are not meant to be exhaustive but, rather, merely describe the types of uses and disclosures that may be made by the Trust.

Treatment: The Trust may use and disclose your protected health information to provide, coordinate or manage your health care, including any related services. This includes the coordination or management of your health care with a third party. For example, the Trust may disclose your protected health information, as necessary, to consult with health care providers regarding your treatment and coordinate and manage your health care with others. Your protected health information also may be used or disclosed by the Trust in order to determine whether the Trust will authorize your care under the plan or whether your care will be covered by the plan. In addition, the Trust may use or disclose your protected health information from time-to-time to our physician consultants to review a plan of treatment or to consider an appeal.

Payment: The Trust may use your protected health information to pay and to obtain payment for your health care treatment and services; to fulfill the Trust’s coverage responsibilities; to provide benefits under the Plan; and to obtain or provide reimbursement and/or subrogation for the costs associated with your health care. This may include certain activities that the Plan may undertake before it approves or pays for the health care services provided by the Trust such as making a determination of eligibility or coverage for benefits, claims management, adjudicating claims and reviewing services provided to you for medical necessity, coverage, justification of charges and the like. For example, the Trust may use and disclose your protected health information to a health care provider in order to resolve issues related to the payment of your health care bills. The Trust also may use and disclose protected health information in order to obtain reimbursement for medical or disability payments made under the plan that resulted from injuries caused by a third-party. The Trust, in addition, may use and disclose protected health information to confirm that you are receiving the appropriate amount of care to obtain payment for services.

Health Care Operations: The Trust may use or disclose your protected health information in order to support the activities of the Trust. These activities include, but are not limited to, managing and administering the operation of the Trust and the terms of the plan; determining eligibility; reviewing and improving the quality and cost of care; managing and coordinating care; reviewing and evaluating providers; assisting the Trust in determining future benefits under the plan; quality assessment activities; employee review activities; reviewing services provided to you for medical necessity; reviewing the performance of health care providers; and conducting or arranging for other Trust related activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be used and disclosed by the Trust. The Trust also may use and disclose your protected health information to determine whether your care is medically necessary. The Trust additionally may send you information about the benefits and services provided by the Trust under the plan.

The Trust may share your protected health information with third party “business associates” that perform various activities (e.g., billing, claims review, managed care reviews, legal, accounting, etc.) for the Trust. Whenever an arrangement between the Trust and a business associate involves the use or disclosure of your protected health information, the Trust will have a written contract with the business associate that contains terms that will protect the privacy of your protected health information.

B. Based Upon Your Written Authorization. Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that the Trust has taken an action in reliance on the use or disclosure indicated in the authorization.

C. Made With Your Agreement, Authorization or Opportunity to Object. The Trust may use and disclose your protected health information, if you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information; or if you are not present or able to agree or object to the use or disclosure of the protected health information, the Trust, using professional judgment, may determine whether the disclosure is in your best interest. In such a case, only the protected health information that is relevant to your health care will be disclosed.

Individuals Involved in Your Health Care: Unless you object, the Trust may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are present and able to consent or object, the Trust may only use or disclose protected health information, if you do not object after you have been informed of you opportunity to object. If you are not present or unable to agree or object to such a disclosure, the Trust may disclose such information as necessary if the Trust determines that it is in your best interest based on its professional judgment.

Emergencies: The Trust may use or disclose your protected health information in an emergency treatment situation.

D. Made Without Your Authorization or Opportunity to Object. The Trust may use or disclose your protected health information in the following situations without your authorization.

Required by Law: The Trust may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: The Trust may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability (including communicable diseases).

Health Oversight: The Trust may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. 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 Trust may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, the Trust may disclose to the appropriate governmental entity your protected health information, if the Trust believes that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Legal Proceedings: The Trust may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized) and, under certain conditions, in response to a subpoena, discovery request or other lawful process.

Law Enforcement: The Trust also may disclose protected health information for law enforcement purposes, so long as applicable legal requirements are met. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the Trust, and (6) certain medical emergencies not occurring at the Trust that involve criminal activity.

Threat to Health or Public Safety: Consistent with applicable federal and state laws, the Trust may disclose your protected health information, if the Trust believes that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The Trust also may disclose protected health information, if it is necessary for law enforcement authorities to identify or apprehend an individual.

Workers’ Compensation: Your protected health information may be disclosed by the Trust to comply with workers’ compensation laws and other similar legally-established programs.

Incidental Disclosures: The Trust may use or disclose protected health information incident to a use or disclosure permitted by the HIPAA Privacy Rule so long as the Trust has reasonably safeguarded against such incidental uses and disclosures and has limited them to the minimum necessary information.

Military Activity and National Security: When the appropriate conditions apply, the Trust may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits or (3) to foreign military authority if you are a member of that foreign military services. The Trust also may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized.

Disclosures Required By HIPAA: Under HIPAA, the Trust is required to disclose protected health information when required by the Secretary of the United States Department of Health and Human Services to investigate or determine our compliance with the requirements HIPAA Privacy Rule. The Trust also is required, in certain cases, to disclose protected health information upon your request to access protected health information or for an accounting of certain disclosures of protected health information about you as stated below.

Your Rights

A. Right to Inspect and Copy. You have the right to request the opportunity to inspect and obtain a copy of protected health information about you that is contained in certain records that are maintained by the Trust for as long as the Trust maintains the protected health information. This includes medical and billing records. You, however, may not inspect or copy the following records to the extent that they are in the possession of the Trust: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding and protected health information that is subject to other laws that prohibit access to protected health information. The Trust may deny a request to inspect and copy protected health information. In some circumstances, you may have a right to have this decision reviewed by the Trust. If you request a copy of protected health information about you, the Trust may charge you a reasonable fee for the copying, postage, labor and supplies used in meeting your request. Please contact our Privacy Officer if you have questions about access to your records.

B. Right to Request Restrictions. You may ask the Trust not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You also may request that any part of your protected health information not be disclosed to persons involved in your care as permitted by the Privacy Rule. However, the Trust is not required to agree to a restriction that you may request. If the Trust believes that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If the Trust does agree to the requested restriction, the Trust may not use or disclose your protected health information in violation of that restriction except in certain cases, including where it is needed to provide emergency treatment. You may request a restriction by forwarding a written request for restriction to the Privacy Officer, by United States mail, return receipt requested, postage prepaid, as to the restriction sought. Your request must state the specific information which you want to restrict, how you want to restrict the information and to whom you want the restrictions to apply. Within sixty (60) days following the Trust’s receipt of the written request, the Privacy Officer will notify you whether the Trust agrees or disagrees with the requested restriction.

C. Right to Receive Confidential Communications. You have the right to request that you receive confidential communications regarding your protected health information in a certain manner or at a certain location. The Trust, however, will accommodate only reasonable requests. The Trust will not request an explanation from you as to the basis for the request. All such requests must be made, in writing, to the Trust’s Privacy Officer by forwarding a written request, by United States mail, return receipt requested, postage prepaid.

D. Right to Amend. You have the right to request an amendment to your protected health information for as long as the Trust maintains this information. In certain cases, the Trust may deny your request for an amendment. If the Trust denies your request for amendment, you have the right to file a statement of disagreement with the Trust and the Trust may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. All such requests for amendment must be made in writing to the Trust’s Privacy Officer by United States mail, return receipt requested, postage prepaid.

E. Right to Receive an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures that the Trust has made of protected health information about you. This right applies to disclosures for purposes other than treatment, payment or healthcare operations; to family members or friends involved in your care; to you directly; pursuant to an authorization by you or your personal representative; certain notification purposes; as incidental disclosures that occur as a result of otherwise permitted disclosures; and as part of a limited data set that doesn’t directly identify you. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. You may request a shorter time-frame. The right to receive this information is subject to certain exceptions, restrictions and limitations. All such requests for accounting must be to the Trust’s Privacy Officer by forwarding a written request by United States mail, return receipt requested, postage prepaid.

F. Right to Obtain a Paper Copy of this Notice. You have the right to receive a paper copy of this notice at any time even if you have agreed to accept this notice electronically. All such requests for a paper copy must be made to the Trust’s Privacy Officer.

G. Complaint Procedure. You may complain to us or to the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated by the Trust. To file a complaint with the Trust, please notify the Privacy Officer at the address and number listed below. Complaints also may be filed with the U. S. Department of Health and Human Services, Office for Civil Rights, Medical Privacy, Complaint Division, 200 Independence Avenue, SW, Washington, D.C. 20201; Toll free Phone: 877‑696‑6775; Phone: 866‑627‑7748; e-mail: www.hhs.gov/ocr. The Trust will not retaliate against you for filing a complaint.

Questions

If you have any questions about this notice, please contact the Trust’s Privacy Officer at the following address and following telephone number: Marcia MacGregor, Privacy Officer, Northern New England Benefit Trust, 51 Goffstown Road, P.O. Box 4604, Manchester, New Hampshire 03108; Telephone Number: (800) 258-9732.

This notice was published and first became effective April 14, 2003.

GENERAL INFORMATION

Name and Business Address of the Plan Sponsor:

Board of Trustees, Northern New England Benefit Trust
51 Goffstown Road
P.O. Box 4604
Manchester, NH 03108

Trustee Contacts:
Mr. David Laughton Local 633 P.O. Box 870 Manchester, NH 03105 (603) 625-9731	Mr. Ronald Rabideau Local No. 597 P.O. Box 277 South Barre, VT 05670 (802) 476-4159	Mr. Robert Gibbons NNEBT P.O. Box 4604 Manchester, NH 03108 (603) 669-4771
Mr. Robert Piccone P.O. Box 4604 Manchester, NH 03108 (603) 669-4771	Mr. Robert Holmes P.O. Box 4604 Manchester, NH 03108 (603) 669-4771	Mr. Robert Robichaud P.O. Box 4604 Manchester, NH 03108 (603) 669-4771

Employer Identification Number (E.I.N.) Assigned to Sponsor by IRS: 02-6015031

Plan Name, Plan Number and Type of Plan:

Northern New England Benefit Trust; Plan #501; Group Medical, Dental, Hearing, Vision, Prescription Drug, Weekly Disability Income Benefits and Health Club Reimbursement

Plan Effective Date:

January 1, 1994
Revised September 1, 2002

Name, Address and Telephone Number of the Plan Administrator:

Northern New England Benefit Trust
51 Goffstown Road
P.O. Box 4604
Manchester , NH 03108
(603) 669-4771

The agent for service of legal process is the Plan Administrator and service may be made at the above address.

Type of Administration:

Contract Administration

The Sources of Contribution to the Plan:

Refer to the Eligibility section for details.

The financial records of the Plan are maintained on the basis of a plan year beginning on September 1 and ending on August 31.

Discretionary Authority:

The Plan Administrator shall have full discretionary authority to interpret this Plan and its provisions and regulations with regard to eligibility, benefit determination and general administrative matters. The Plan Administrator’s decisions shall be binding on all Plan participants and conclusive as to all questions of coverage under this Plan

Gentile, Carolyn D. and Kirke M. Hasson. Aftermath of Firestone v. Bruch, or Much Ado About Nothing? Employee Benefits Journal, v. 15, no. 3, September 1990, pp. 10-13.

Revised: October 2005