NNEBT

NORTHERN NEW ENGLAND BENEFIT TRUST POINT OF SERVICE BENEFIT PLAN SUMMARY Benefits outlined below are intended only as a general summary.
TRUST BENEFITS for PLAN A1		COVERAGES
		IN-NETWORK	OUT-OF-NETWORK
		MEMBER / CIGNA PAYS	MEMBER / CIGNA PAYS
ANNUAL DEDUCTIBLE		Does not apply IN-NETWORK	$250 Deductible per individual
			$500 Deductible per family
MAXIMUM OUT-OF-POCKET EXPENSE
	(per calendar year, Deductible and copayments do not apply.)	$1,500 per person, $3,000 per	$2,500 per individual annual
		family annual maximum	Maximum
PREVENTIVE CARE
	Routine Physical Examination	$15 per visit / 100% remaining cost	Preventative Care is Not Covered Out-Of-Network
	Well Baby/Child Care	$15 per visit / 100% remaining cost
	Gyn Services (self-referral - two per year)	$15 per visit / 100% remaining cost
OUTPATIENT CARE
	Office Visits	$15 per visit / 100% remaining cost	(All Outpatient Care is subject to the 30% Coinsurance after the Deductible / Cigna pays 70% of Usual & Customary Charges.)
	Allergy Testing/Treatment	$15 per visit / 100% remaining cost
	Diagnostic X-ray	No charge / 100%
	Laboratory Services	No charge / 100%
	Injections	No charge / 100%
	Immunizations	No charge / 100%
	Office Surgery	$15 per visit / 100% remaining cost
	Gyn Services	$15 per visit / 100% remaining cost
	OB Services/Pre-Natal Examination	$15 (initial visit only) / 100%
	(In-Network- self-referral to Cigna/Healthcare Physician)	remaining cost
HOSPITAL CARE
	Inpatient Services	10% / 90% remaining cost	(All Inpatient Hospital Care must be precertified and is subject to the 30% Coinsurance after the Deductible / Cigna pays 70% of Usual & Customary Charges.)
	Same Day or Outpatient Surgery	10% / 90% remaining cost
	Maternity and Newborn Care	10% / 90% remaining cost
	Physician Visits and Services	10% / 90% remaining cost
	Anesthesiologist Services	10% / 90% remaining cost
	Nursing Care	10% / 90% remaining cost
	Operating Room	10% / 90% remaining cost
	Intensive Care Unit	10% / 90% remaining cost
	X-ray and Laboratory Services	10% / 90% remaining cost
	Medications and Supplies	10% / 90% remaining cost
EMERGENCY ROOM CARE		$25 - waived if admitted	Cigna pays 70% of Usual & Customary
			Charges after the Deductible.
MENTAL HEALTH /SUBSTANCE ABUSE
	OUTPATIENT (In- and Out-of-Network care is	$15 per visit / 100% remaining cost	30% / 70% of contract charges after
	limited to 30 visits per person per calendar year)	(Precertification Required by TBH)	Deductible
	INPATIENT Mental Health (Precertification is required by TBH.)	10% / 90% M/N	30% / 70% of contract charges after
			Deductible
	INPATIENT Substance Abuse (Precertification is required by TBH.)	First Admission covered at 90%	30% / 70% of contract charges after
	Mental Health/Substance Abuse benefits are	Second Admission covered at 50%	Deductible
	limited to 30 days per calendar year	No further Admissions are covered	No further Admissions are covered
OTHER BENEFITS
	Durable Medical Equipment	10% / 90% remaining cost	(All Other Benefits are subject to the 30% Coinsurance after the Deductible / Cigna pays 70% of Usual & Customary Charges.)
	Skilled Nursing Care (combined maximum of 120 days per year.)	10% / 90% remaining cost
	Ambulance (if medically necessary)	10% / 90% remaining cost
	Short-Term Physical and Occupational Therapy (In- and	$15 per visit / 100% remaining cost
	Out-of-Network limited to 30 days in any six month period)
	Home Health Care (Precertification required Out-of-Network)	No Charge / 100%
	Chiropractic Care / Massage Therapy (Does not include lab and X-ray,	N/A	Cigna pays $30 maximum per visit, not
	Combined annual maximum limited to $1,000)		subject to Deductible (not applied to
			Out-of-Pocket Maximum)
LIFETIME MAXIMUM (Combined In- and Out-of-Network)		$2,000,000	$2,000,000

NORTHERN NEW ENGLAND BENEFIT TRUST POINT OF SERVICE BENEFIT PLAN SUMMARY Benefits outlined below are intended only as a general summary.
TRUST BENEFITS for PLAN A2		COVERAGES
		IN-NETWORK	OUT-OF-NETWORK
		MEMBER / CIGNA PAYS	MEMBER / CIGNA PAYS
ANNUAL DEDUCTIBLE		Does not apply IN-NETWORK	$250 Deductible per individual
			$500 Deductible per family
MAXIMUM OUT-OF-POCKET EXPENSE
	(per calendar year, Deductible and copayments do not apply.)	None	$1,500 per individual annual
			Maximum
PREVENTIVE CARE
	Routine Physical Examination	$10 per visit / 100% remaining cost	Preventative Care is Not Covered Out-Of-Network
	Well Baby/Child Care	$10 per visit / 100% remaining cost
	Gyn Services (self-referral - two per year)	$10 per visit / 100% remaining cost
OUTPATIENT CARE
	Office Visits	$10 per visit / 100% remaining cost	(All Outpatient Care is subject to the 20% Coinsurance after the Deductible / Cigna pays 80% of Usual & Customary Charges.)
	Allergy Testing/Treatment	$10 per visit / 100% remaining cost
	Diagnostic X-ray	No charge / 100%
	Laboratory Services	No charge / 100%
	Injections	No charge / 100%
	Immunizations	No charge / 100%
	Office Surgery	$10 per visit / 100% remaining cost
	Gyn Services	$10 per visit / 100% remaining cost
	OB Services/Pre-Natal Examination	$10 (initial visit only) / 100%
	(In-Network- self-referral to Cigna/Healthcare Physician)	remaining cost
HOSPITAL CARE
	Inpatient Services	No charge / 100%	(All Inpatient Hospital Care must be precertified and is subject to the 20% Coinsurance after the Deductible / Cigna pays 80% of Usual & Customary Charges.)
	Same Day or Outpatient Surgery	No charge / 100%
	Maternity and Newborn Care	No charge / 100%
	Physician Visits and Services	No charge / 100%
	Anesthesiologist Services	No charge / 100%
	Nursing Care	No charge / 100%
	Operating Room	No charge / 100%
	Intensive Care Unit	No charge / 100%
	X-ray and Laboratory Services	No charge / 100%
	Medications and Supplies	No charge / 100%
EMERGENCY ROOM CARE		$25 - waived if admitted	Cigna pays 80% of Usual & Customary
			Charges after the Deductible.
MENTAL HEALTH /SUBSTANCE ABUSE
	OUTPATIENT (In- and Out-of-Network care is	$10 per visit / 100% remaining cost	20% / 80% of contract charges after
	limited to 30 visits per person per calendar year)	(Precertification Required by TBH)	Deductible
	INPATIENT Mental Health (Precertification is required by TBH.)	100% M/N	20% / 80% of contract charges after
			Deductible
	INPATIENT Substance Abuse (Precertification is required by TBH.)	First Admission covered at 100%	20% / 80% of contract charges after
	Mental Health/Substance Abuse benefits are	Second Admission covered at 50%	Deductible
	limited to 30 days per calendar year	No further Admissions are covered	No further Admissions are covered
OTHER BENEFITS
	Durable Medical Equipment	100%	(All Other Benefits are subject to the 20% Coinsurance after the Deductible / Cigna pays 80% of Usual & Customary Charges.)
	Skilled Nursing Care (combined maximum of 120 days per year.)	100%
	Ambulance (if medically necessary)	100%
	Short-Term Physical and Occupational Therapy (In- and	$10 per visit / 100% remaining cost
	Out-of-Network limited to 30 days in any six month period)
	Home Health Care (Precertification required Out-of-Network)	No Charge/100%
	Chiropractic Care / Massage Therapy (Does not include lab and X-ray,	N/A	Cigna pays $30 maximum per visit, not
	Combined annual maximum limited to $1,000)		subject to Deductible (not applied to
			Out-of-Pocket Maximum)
LIFETIME MAXIMUM (Combined In- and Out-of-Network)		$2,000,000	$2,000,000

MANAGED CARE PROGRAM

Managed care helps the Trust make sure that the medical care that you and your dependents receive is the best way to treat your condition. The process also helps to ensure that you receive the best possible treatment and services in the most cost-effective manner.

CIGNA HealthCare, Inc. (CIGNA) provides most of the managed care services to the Trust. However, in cases in which you or a family member needs mental health or substance abuse treatment, the Trust provides the managed care services directly through Teamsters Behavioral Health (TBH).

Inpatient Medical Care

Pre-admission Certification

You must notify CIGNA any time you or one of your covered family members are scheduled for inpatient care by calling CIGNA at (800) 531-4009 at least seven days before the admission is scheduled. CIGNA nurses will contact both your physician and the hospital to ensure that the hospital stay is necessary and appropriate for the medical problem. Should you or a family member be admitted to a hospital, on an emergency basis, you must call CIGNA within 48 hours of the admission. If CIGNA is closed, you must report the admission on the next workday; provided however, that notice may be given during non-business hours by leaving a message on CIGNA’s 24-hour answering service.

If you fail to get pre-admission certification, the charges for the hospital stay, as well as any related charges, will be subject to a $150 penalty for each hospital stay; and this penalty will not be applied toward your out-of-pocket maximum. Also, if CIGNA finds that you were hospitalized for days that were not medically necessary for your condition, room and board charges for those days will be denied under the Plan; no benefits will be paid; and the expenses you pay will not be applied toward the out-of-pocket maximum.

Retrospective Review

When you receive hospital services without pre-certification or any notice to CIGNA, a thorough review of your stay will take place. During this review, CIGNA may discover treatment that was not medically necessary or appropriate. Benefits may be reduced or even denied as a result of the review findings. Reviews are conducted on every case of this nature, regardless of whether the Trust was responsible as the primary or secondary payer.

Surgical Review/Second Surgical Opinion

When you or a family member require non-emergency inpatient surgery, you must notify CIGNA prior to treatment. CIGNA will review the surgical plan and may ask you to get a second or third opinion on the surgery. The charges for these opinions will be paid at 100% of the Usual and Customary Charge. These opinions have to be from a board-certified surgeon. The surgeon can be one of your own choice, or CIGNA can recommend a surgeon for you. However, the surgeon giving a second or third opinion cannot be connected with the surgeon who first ordered the surgery. If you fail to go through this process by either not notifying CIGNA or not getting a second opinion when it is requested, you will have to pay a 50% penalty that will be applied to that surgery and all related expenses. The penalty, which you will be responsible for paying, will not be applied toward your out-of-pocket maximum.

Continued Stay Review

While you or your family member is in the hospital, CIGNA will monitor your treatment plan to determine if the services being provided are medically necessary and appropriate. Managed care nurses will either travel directly to the hospital or discuss the case with the staff by phone. The nurse assigned to the case reviews the medical records during the hospital stay and remains in close contact with your family physician, the attending physician and any other medical professionals responsible for the care. The nurse may recommend a different length of stay or level of treatment depending on the results of her conferences with the doctors and staff assigned to the case.

Individual Case Management

If you or one of your family members experiences a medical problem involving a serious, chronic condition or extensive inpatient charges, CIGNA will start special individual case management procedures. This process could involve transfer to an alternate facility, home care treatment or other special arrangements. The process helps patients get the care they need in the setting that is most helpful and cost-effective.

Discharge Planning

When it comes time for you or your family member to leave the hospital, CIGNA will work with your attending physician to develop a treatment plan to be followed after discharge. The nurse will also assist with any special arrangements that may be needed after discharge.

Tertiary Care

Tertiary Care is specialized hospital care. In order to receive such care, CIGNA must pre-certify the stay and authorize the hospital as a preferred provider. You will receive benefits on an In-Network basis when you follow both of these steps. Managed care services, as previously described, are provided to all In-Network patients who follow the process.

Outpatient Medical Care

POS Access Program

You may receive benefits through a network of primary care physicians (PCP) and preferred providers. By using these In-Network providers, you will receive benefit payments at a higher rate. You still have complete choice over where you get medical care, but you will pay more for care when you use an Out-of-Network provider.

In-Network Office Visits

When you visit an In-Network provider, under the A-1 plan you will pay a $15 co-payment and under the A-2 plan you will pay a $10 co-payment to the provider’s office (which will not be applied to your out-of-pocket maximum) and the balance will be paid at 100% of the scheduled fee. All other charges resulting from your office visit will be paid at 100%.

Out-Of Network Services

When you go to an Out-of-Network provider for services, benefits are paid subject to both the Plan Deductible and Plan Co-payment.

Out-of-Area Emergencies

The Trust provides benefits for out-of-area emergencies on an In-Network basis. When you receive emergency care outside of your immediate area, CIGNA will review the emergency care given and determine the benefits you receive based on that review. Each such emergency case is reviewed separately.

Mental Health And Substance Abuse Care

If you or a family member requires mental health or substance abuse treatment, you must call TBH at 1-800-258-9732 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 TBH within 48 hours following an emergency admission. If TBH is closed, you must report the admission on the next workday.

After TBH receives your notice, its specialists will decide if the care being proposed is necessary and appropriate for the patient's condition. TBH will refer you or your family member to either an In-Network provider or to an Out-of-Network provider, as needed. If an Out-of-Network referral is made with TBH's approval, your benefits will be paid on an In-Network basis.

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

Full benefits are paid when you follow the pre-certification process. If you do not request pre-certification, the hospital charges and all related expenses are subject to (1) a $150 penalty, (2) the Out-of-Network Deductible and (3) a reduced Plan Coinsurance of 70% or 80%. In addition, the $150 penalty and the higher deductible amount will not be applied toward the Out-of-Pocket Maximum. Lastly, no subsequent substance abuse admissions are covered if the TBH requirements for the first admission were not followed.

When you follow pre-certification for outpatient treatment, treatment will be covered at 100% of the Usual and Customary Charge, less your $15 co-payment under the A-1 plan or your $10 co-payment under the A-2 plan; and you will be eligible for up to 30 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 paid, if at all, subject to the Out-of-Network Deductible and a reduced Plan Coinsurance of 70% or 80%. The higher deductible that you pay will not apply toward the Out-of-Pocket Maximum.

A Final Note

Please remember that managed care requirements apply regardless of whether you use an In-Network or Out-of-Network provider.

LIMITATIONS AND NOTES TO SCHEDULE

Point Of Service

1. Out-of-Network Deductible and/or Coinsurance Amounts will accumulate toward the Out-of-Pocket Maximum. Penalty amounts for failure to comply with Managed Care rules, In-Network Office Visits, Chiropractic and TMJ care coinsurances will not accumulate toward the Out-of-Pocket Maximum. All Out-of-Network services are subject to Usual and Customary Charges.

NOTE: Benefits for all Out-of-Network services are based on the Usual and Customary Charges or in network contracted rates.

2. Physicians’ Home and Office Visits will be paid as follows:

In-Network - Office Visits will include adult routine physical examinations, well child care visits (including immunizations), consultations and outpatient mental health and substance abuse visits. All these services must be billed as part of the Office Visit to be covered at the $15 co-payment under the A-1 plan or the $10 co-payment under the A-2 plan.
Out-of-Network - Office Visits are subject to the Out-of-Network Plan Deductible and Plan Coinsurance and do not cover adult routine physical examinations, routine Pap smears and well child care. Consultations and outpatient mental health/substance abuse visits will be covered subject to the Plan Deductible and Plan Coinsurance.

3. All In-Network inpatient hospital expenses, including rehabilitative care, skilled nursing, extended care and inpatient mental health and substance abuse care, will be paid at 90% or 100% coverage. All Out-of-Network inpatient hospital expenses will be paid at 70% or 80% Coinsurance, after the Plan Deductible.

4. Ambulance services will always be paid on an In-Network basis, providing the transportation is medically necessary.

5. Rehabilitative care will be paid under the Plan and will include coverage for cardiac and pulmonary rehabilitation programs when such care is authorized by the patient’s Primary Care Physician (PCP) as being medically necessary.

6. Care received in a skilled nursing or extended care facility will be paid at either the In-Network level or Out-of-Network level subject to the Plan Deductible and Plan Coinsurance, up to a maximum of 120 days per confinement. Confinement in a facility must begin within 14 days after a general hospital confinement lasting at least three consecutive days. A physician must then certify this treatment as medically necessary every 30 days thereafter.

7. Hospice care will be paid at the In-Network level, at 100% coverage. Out-of-Network coverage will be subject to the Plan Deductible and Plan Coinsurance.

8. Routine mammograms, which are billed as part of routine physical examinations, will be paid as diagnostic X-ray services at 100%. Coverage for routine mammograms is not available under the Out-of-Network benefits.

9. Surgical Expenses will be paid as follows:

In-Network – Inpatient surgical expenses will be paid subject to the Plan co-payment. Outpatient surgery, same-day surgery or office surgery will be paid at 100% coverage.
Out-of-Network – Inpatient surgery, outpatient surgery or office surgery will be paid subject to the Plan Deductible and Plan Coinsurance. Assistant surgeons will be paid up to 20% of the surgeon’s Usual and Customary Charge for the surgical procedure, subject to the Plan Deductible and Plan Coinsurance.

10. Organ transplant benefits are provided on both an In-Network and Out-of-Network basis. Benefits are payable as follows:

In-Network - Services will be paid at the In-Network level, with no separate $100,000 lifetime maximum, providing the transplant is approved by CIGNA and the services are rendered at a “center of excellence” facility.
Out-of-Network - Services will be paid subject to the Plan Deductible and Plan Coinsurance, up to Usual and Customary Charges. A separate $100,000 lifetime maximum will apply for transplants that are performed Out-of-Network.

11. In-Hospital medical visits In-Network will be paid at 100% coverage and are limited to one visit per day from a physician, and one specialist consultation per period of confinement. Out-of-Network visits are subject to the same limitations and will be covered subject to the Plan Deductible and Plan Coinsurance.

12. Maternity care will be paid for covered members and their covered dependents as follows:

In-Network – A $15 co-payment applies to the first visit under the A-1 plan, and a $10 co-payment applies to the first visit under the A-2 plan, then all subsequent care will be paid at 100% coverage.
Out-of-Network – All maternity care is subject to the Plan Deductible and Plan Coinsurance.

NOTE: Birthing centers are a low-cost alternative to traditional maternity care delivered in the hospital. Birthing centers are covered under both the In-Network and Out-of-Network Plan benefits.

NOTE: 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).

13. Elective Abortions will be covered for both covered members and their covered dependents.

14. Routine In-Hospital Newborn Care will be covered while the mother is confined in the hospital.

15. Well Child Care will be payable in the following manner:

In-Network - There will be a $15 co-payment under the A-1 plan or a $10 co-payment under the A-2 plan per Well Child Care Visit, then benefits will be payable at 100%, including immunizations, up to age 3.
Out-of-Network - Well Child Care is not available under the Out-of-Network benefits.

16. Routine Physical Examinations will be paid as follows for covered members, their covered spouses and covered dependent children from age 3 up to age 19 (and extended to full-time students age 19 to 23 and to handicapped dependent children):

In-Network - There will be a $15 co-payment for each visit under the A-1 plan, or a $10 co-payment for each visit under the A-2 plan, then benefits will be paid at 100%. This will include charges for routine mammograms and Pap smears (including pathology) if the charges are billed as part of the office visit. X-rays and diagnostic tests are payable under Diagnostic Services.
Out-of-Network - Physical Exams are not available under the Out-of-Network benefits.

17. Chiropractic/Osteopathic office visits will be covered. Benefits will be paid up to a $30 per visit maximum with a $1,000 per calendar year maximum. Diagnostic X-ray services rendered by a chiropractor will not be available under the In-Network or the Out-of-Network benefits.

18. Temporomandibular Joint (TMJ) Dysfunction will be covered under the Plan. In-Network there will be a $15 co-payment for each office visit under the A-1 plan, or a $10 co-payment for each office visit under the A-2 plan for TMJ with a $1,000 Lifetime Maximum. Out-of-Network benefits will be subject to at 50% co-payment with a $1,000 Lifetime Maximum. These expenses will not be applied to the Out-of-Pocket Maximum.

19. Prescription Drug Benefits will be available through Prescription Card Services, Inc. (PCS). Maintenance drugs are available by mail order through the TeamstersCare Pharmacy. Please refer to the PCS section for more details on your prescription drug coverage.

20. Mental Health Benefits are paid as follows:

For Care Certified By TBH:

Inpatient-Benefits will be paid subject to the Plan Co-payment up to 30 days maximum per calendar year. Day treatment programs are covered under this benefit.

Outpatient - Benefits will be paid subject to a $15 member co-payment per visit under the A-1 plan or a $10 co-payment under the A-2 plan, then payable at 100%, up to a maximum of 30 visits per calendar year for Mental Health/Substance Abuse treatment.

For Care Not Certified By TBH:

Inpatient - After $150 penalty, subject to the Out-of-Network Plan Deductible and 70% or 80% of the contracted rates up to 30 days per calendar year for Mental Health/Substance Abuse Maximum. Day treatment programs are covered under this benefit.

Outpatient - Subject to the Out-of-Network Plan Deductible and 70% or 80% of the contracted rates up to a maximum of 30 visits per calendar year for Mental Health/Substance Abuse Maximum.

21. Substance Abuse Benefits will be paid as follows:

For Care Certified By TBH:

Inpatient - Benefits will be payable according to the following schedule:
First Admission - Subject to the Plan Coinsurance.
Second Admission - Payable at 50% copayment for hospital charges only.
No further admissions are covered.
Outpatient - Benefits will be paid subject to a $15 member co-payment per visit under the A-1 plan, or a $10 member co-payment under the A-2 plan, then payable at 100%, up to a maximum of 30 visits per calendar year for Mental Health/Substance Abuse Maximum.

For Care Not Certified By TBH:

Inpatient - Benefits will be payable according to the following schedule:
First Admission - After $150 penalty, subject to the Out-of-Network Plan Deductible and 70% or 80% of the contracted rates to 30 days per calendar year for Mental Health/Substance Abuse Maximum.

No further admissions are covered.

Outpatient - Subject to the Out-of-Network Plan Deductible and 70% or 80% of the contracted rates up to a maximum of visits per calendar year for Mental Health/Substance Abuse Maximum.

NOTE: Penalty amounts for failure to comply with Managed Care requirements, Chiropractic, Podiatry and TMJ care co-payments, the $15 per visit member co-payment under the A-1 plan, or the $10 per visit member co-payment under the A-2 plan and co-payments for the second substance abuse admission will not count toward the Out-of-Pocket Maximum.

22. Occupational Therapy, Physical Therapy and Speech Therapy expenses will be paid to a maximum of 30 days within any six month period. Benefits for treatment beyond the 30-day maximum will be considered for payment for certain conditions including, but not limited to, strokes, birth defects or serious injuries. Treatment will be monitored on an on-going basis. The attending physician and the therapist must submit a narrative report outlining the medical necessity of extended treatment. The report will be reviewed by Cigna HealthCare’s Medical Director. If it is determined that the patient has reached a level of maintenance care or if the care is for the comfort of the patient or family, no benefits will be approved. If approved, benefits for occupational therapy, physical therapy or speech therapy beyond the 30-day limitation will be paid subject to the Out-of-Network Deductible and Coinsurance.

23. Other Covered Medical Expenses

a. non-surgical podiatry services (except routine foot care);
b. physical therapist charges;
c. durable medical equipment;
d. diagnostic X-ray services, including radiology (excluding hospital charges);
e. anesthesiologist services (excluding hospital charges);
f. nutritional counseling services, with PCP referral;
g. health education, as approved by Cigna HealthCare, up to $100 maximum.

All these services will be paid at the In-Network level or, when applicable, will be covered subject to the Plan Deductible and Plan Coinsurance.

24. Coverage for 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.

If you have any questions about your benefits under this plan, please call the number on your ID card. If further information is required, call the Trust Office at 1-800-258-9732.

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 COST 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.

Click here to link to your weekly disability plan..

PLAN DEFINITIONS

Anesthesia — is the condition produced by the administration of specific agents to achieve the loss of conscious pain response.

Basic Earnings — is compensation, exclusive of overtime pay, bonuses or any other form of additional compensation.

Cosmetic Surgery — surgical procedures performed to improve appearance or to correct a deformity without restoring the bodily function.

Dependent —

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

2. 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.

3. 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.

Hospital — is an institution which:
1. provides inpatient diagnostic services and treatment of injured or sick persons under continuous physician supervision;
2. has organized departments of medicine and surgery;
3. requires every patient to be under a physician’s care;
4. provides 24-hour nursing care by or under registered graduate nurse (R.N.) supervision;
5. is licensed by the agency responsible for regulating hospitals; and
6. may not be a place of rest; a place primarily for treatment of tuberculosis, mental or emotional disorders; a place for the aged or substance abusers; or a place for custodial care.

In-Network Services — are those services given by a provider specially contracted with Cigna HealthCare.
Injury — is bodily harm, which results from an accident.

Medical Emergency — is a condition considered hazardous to the patient’s life, health or physical well-being, including the sudden, unexpected onset of severe symptoms requiring urgent, immediate medical attention. To qualify as an emergency, care must be received within a reasonable amount of time after the onset and failure to receive immediate treatment might place the patient’s life in jeopardy and/or cause serious impairment to bodily function.

A medical emergency does not exist simply because your private physician may not be available or may refer you to the emergency room.

Some examples of medical emergencies are: threatened abortion, acute abdominal pain, airway obstruction, severe allergic reaction, severe asthma attack, coughing up blood, food poisoning, insulin reaction, loss of consciousness, asphyxia, convulsions, frostbite, hemophilia, hemorrhage, hysteria, uncontrolled nosebleed, poisoning or suspected poisoning, rape victim, sunstroke, uncontrolled vomiting.

Medically Necessary — services and supplies that are determined to be no more than required to meet your essential health needs; consistent with the diagnosis of the condition for which they are required; consistent in type, frequency and duration of treatment with scientifically based guidelines as determined by medical research; required for purposes other than comfort and convenience of the patient or his/her physician; rendered in the least intensive setting that is appropriate for the delivery of health care; and of demonstrated medical value.

Member Copayment — is the dollar amount a Covered Member or Dependent pays when receiving certain medical services under the Plan.

Mental Health Care Facility — is an institution or part thereof which:

1. specializes in the diagnosis and treatment of mental illness or functional nervous disorder;
2. is licensed to give medical treatment;
3. is operated under the supervision of a physician;
4. offers nursing service by registered graduate nurses (R.N.) or licensed practical nurses (L.P.N.);
5. provides on the premises all the necessary facilities for medical treatment;
6. is licensed by the agency responsible for regulating Mental Health Care Facilities; and
7. may not be a place of rest; a place for the aged or substance abusers; or a place for custodial care.

Out-of-Network Services — are those services given by a provider not specially contracted with Cigna HealthCare. The Out-of-Network deductible for Plan A-1 is $250 per individual and $500 per family; and the Maximum Annual Out-of-Pocket Expense is $2,500 per individual. The Out-of-Network deductible for Plan A-2 is $250 per individual and $500 per family; and the Maximum Annual Out-of-Pocket Expense is $1,500 per individual.

Physician — is a Doctor of Medicine (M.D.), a Doctor of Osteopathy (D.O.), a Dentist (D.M.D. or D.D.S.), a Psychologist (Ed.D., Psy.D. or Ph.D.), a Podiatrist (Pod.D., D.S.C. or D.P.M.), a Chiropractor (D.C.), an Optometrist (O.D.), a Pastoral Counselor, a Social Worker (L.C.S.W. or M.S.W.), a Nurse Midwife, a Medical Social Worker, a Psychiatric-Mental Health Clinical Nurse, an Advanced Registered Nurse Practitioner, an Occupational Therapist, a Physical Therapist, a Speech Therapist, an Audiologist, or a Physician’s Assistant. Each must be licensed or certified by the state in which services are rendered and act within the scope of such license. Physician shall include an accredited Christian Science Practitioner listed in the current issue of the Christian Science Journal.

Plan Coinsurance — is the percentage amount paid by the Plan for medical expenses of a Covered Member or Dependent, as stated in the applicable benefit schedule. After the Member’s Out-of-Pocket Maximum is reached, the Plan will pay 100% of the Usual and Customary Charges up to any stated maximums in the Schedule of Benefits, and up to the Lifetime Maximum.

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.

Routine Newborn, Nursery Care Charges — are for care of newborn children including hospital nursery charges for room and board, miscellaneous nursery expenses, pediatrician charges for attendance at a caesarean birth, a physical examination for the newborn child in the hospital and inpatient circumcision if performed at the time of birth.

Substance Abuse Treatment Facility — is a private or public program, institution or portion thereof which:

1. provides services for detoxification or rehabilitation of substance abusers; or
2. furnishes mental health services with the approval of the appropriate governmental authority (such as a comprehensive health service organization, community mental health center, mental health clinic or day treatment center).

Total Disability — is the inability to work for wage or profit at any job for which you are reasonably qualified by education, training or experience.

Usual and Customary Charge — Usual means the provider’s regular fee for the service. Customary means the fee charged by similar providers in the same area, as determined by industry standards. This Plan covers provider fees which are both usual and customary.

GENERAL PLAN EXCLUSIONS

The Northern New England Benefit Trust Plan does not cover expenses for the following:

1. services not directly related to the diagnosis or treatment of an illness or injury (see chart for any exceptions);
2. care, services and supplies not prescribed by a Physician and/or treatment not provided by a Physician;
3. services and supplies that are not medically necessary;
4. charges in excess of Usual and Customary;
5. preexisting medical conditions as defined;
6. eye examination/refractions for the purpose of prescribing corrective lenses or the fitting or actual cost of corrective lenses, except as stated;
7. the fitting or actual cost of hearing aids except as stated;
8. any routine or elective expenses (some examples are: shoe inserts, ankle pads, printed material, arch supports, elastic stockings, nutritional or dietary counseling (except as part of home health care), food supplements and drugs which can be purchased without a prescription);
9. cosmetic surgery, except:
a. expenses to repair or alleviate the damage from an accident which occurred while the Covered Person was covered under this Plan;
b. charges resulting from a birth defect of a dependent who was covered under the Plan from birth; or
c. surgical removal or reconstruction of breast tissue due to an illness occurring while covered under the Plan;
10. sex change operations and related charges before and after the surgery which are for the purpose of changing a person’s sex;
11. artificial insemination, in vitro fertilization or any other procedures which are intended to result in pregnancy;
12. home health care or organ transplant expense for transportation;
13. reverse sterilizations;
14. treatment of temporomandibular joint dysfunction (TMJ) which is considered dental, for example:
a. the service is in conjunction with the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth such as periodontal membrane, cementum and alveolar process,
b. manipulative or operative procedures involve occluded teeth or adjustments of teeth, dental appliances and/or prostheses — for example: biteguards or bruxism appliances; or
c. treatment of syndrome involves malocclusion of the teeth;
15. experimental or investigative medical, surgical or other health care procedures or services;
16. any dental services, except as stated;
17. conditions caused by war (declared or undeclared) or any act of war;
18. services while on full-time active duty in the armed forces of any country, combination of countries or international authority;
19. services provided by or in a hospital owned or operated by a federal government or any agency thereof for service connected disabilities;
20. bodily injuries or illnesses arising out of or in the course of any employment (past or present), or which is payable under any workers’ compensation or occupational disease act or law;
21. services for which there is no legal obligation to pay or for which no charges would be made if the patient had no coverage;
22. ambulance transportation to or from a hospital or medical facility not approved under the Plan;
23. services provided by you or by your spouse, by a parent, son, daughter, brother or sister of you or of your spouse or by a member of your household;
24. services resulting from an attempt by you or your dependents to commit an unlawful act;
25. more than one year of rehabilitative care;
26. a child who is not a dependent as defined under this Plan;
27. services performed by an individual who is not a Physician as defined under this Plan or by an institution which does not meet this Plan’s definition of Hospital, Mental Health Facility or Substance Abuse Treatment Facility;
28. marital counseling;
29. custodial care, which is care designed to help a person in the activities of daily living and which does not require the continuous attention of trained medical or paramedical personnel;
30. radial keratotomy and other forms of eye surgery;
31. services resulting from acts committed while driving under the influence of a chemical;
32. genetic screening and genetic screening procedures, except in women over 35 and where a family history of genetically-linked disorders is present;
33. speech therapy for any condition which does not have its basis in a medically proven organic pathology except as stated;
34. surgical procedures or routine foot care (except for diabetics) by a podiatrist, defined as the preventive maintenance and care (including cutting, debridement, trimming, reduction or removal) of calluses, clavi, corns, dystrophic nails, excrescences, helomas, hyperkeratosis, onychauxis, onychocryptosis and tylomas - except where a systemic condition has resulted in severe circulatory impairment or desensitization in the feet as these conditions make it hazardous for the cutting of nails, corns, etc., to be performed by a nonprofessional person;
35. equipment which has personal use in the absence of the condition for which is prescribed including, but not limited to, air conditioners, air purifiers, dehumidifiers, humidifiers, waterbeds, sunlamps and exercise equipment;
36. diagnostic lab and X-ray services rendered by a chiropractor;
37. any expense for the treatment of nicotine addiction;
38. learning disorders, educational, academic or N.I.Q. testing;
39. room and board charges for any hospital day determined to not be medically necessary by Cigna HealthCare as described in the Managed Care Section;
40. claims submitted more than one year after the expense is incurred; or
41. Covered Medical Expenses after the Annual or Lifetime Maximum Benefit has been exhausted.

FILING CLAIMS

When to File a Medical Claim
You will not have to file a claim if you use the services of an In-Network provider. Claims will be submitted directly to Cigna HealthCare. If you choose to use the services of an Out-of-Network provider or Out-of-Area Provider, the following filing requirements will apply. You should file a claim within 20 days after the beginning of the illness or injury. Claims received more than one year after the loss or expense is incurred will not be covered under the Plan. You should submit the charges even if you are not certain that the expense is covered. Benefits will be determined according to Plan provisions. Submit medical claims to Cigna HealthCare.

How to File a Medical Claim (Out-of-Network)

Send the itemized bill directly to: Cigna HealthCare, PO Box 2041, Concord, NH 03302-2041. Be sure to include the member's name and social security number on the itemized bill. No claim forms are required.
Each provider's bill sent to Cigna HealthCare must be itemized. This means that the bill must show all of the following:
1. provider’s name and address;
2. member’s name and social security number;
3. patient’s name;
4. the diagnosis or the name of the condition being treated; and
5. the date, charge and type of expense for each service billed.

NOTE: Incomplete information will cause a delay in processing your claim. Receipts, balance forward statements or canceled checks cannot be used in place of itemized bills.

How Medical Claims Are Paid

Once complete claim information is received, Cigna HealthCare reviews the claim and pays or denies the claim based on your plan of benefits. Claim payments are made directly to the provider of service unless you submit proof of payment with your claim. When claims are processed, you will be sent a worksheet showing how your benefits were calculated. This is called an "Explanation of Benefits" (EOB).

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 nor to 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.

NOTE: If you or your dependents lose coverage under the Plan, you will receive a certificate of former plan coverage. You may need the certificate if your new plan excludes coverage for Preexisting conditions. If you are entitled to COBRA coverage, the certificate will be mailed when a notice for qualifying event under COBRA is required, and after COBRA coverage stops. You may request another copy of the certificate within 24 months after losing coverage.

Claim Determinations And Claim Appeals

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.

Medical Benefits

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.

Disability Benefits

Timing of notification of benefit determination
In the case of a claim for disability benefits, the Trust will notify you of the adverse benefit determination within a reasonable period of time but not later than 45 days after receipt of your claim by the Trust. This period may be extended, however, two times, for up to 30 days each, provided that the Trust 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 45-day period (or the subsequent 30-day extension period in the case of the need for the second extension), of the circumstances requiring the extension of time and the date by which the Trust expects to render a decision. In the case of any extension, the notice will specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and you will be afforded at least 45 days within which to provide the specified information.

Manner and content of notification of an adverse benefit determination
The notification requirements in the case of an adverse benefit determination by the Trust concerning a claim for disability benefits are the same as the applicable requirements for adverse medical benefit determinations.

Appeal of adverse benefit determinations
The procedure for appealing an adverse disability determination is the same as the appeal procedure for non-urgent medical care claims.

Timing of notification of benefit determination on review
In the case of an appeal taken from an adverse benefit determination concerning a claim for disability benefits, you will be notified of the Trust’s determination on review within 45 days.

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 and shall 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

Revised: January 2004