Page 47 - 2022 MLB Umpire Benefit Guide Flipbook 1

MLB League-Wide Insurance Program
Plan and Summary Plan Description

APPENDIX A

Name of Club/Baseball-Related Entity: Office of the Commissioner of Baseball

Eligible Employees: All full-time, active Employees working at least 30 hours per week, with the
exception of the CFO, unless otherwise modified by the Employer.

Eligible Retirees: All Retired Employees that are not eligible for Medicare, unless otherwise
modified by the Employer. A “Retired Employee” is any former eligible full-time employee,
excluding the CFO, who has terminated active employment (for reasons other than cause, as
determined by the Plan Administrator in its sole discretion) with an Employer at or after age 55 and
who was a full-time employee for at least 10 years.

Eligible Dependents: The following dependents of Eligible Employees are eligible for dependent
coverage under the Plan:
• spouses; or
• same-sex or opposite-sex domestic partners; and
• children (including your legal children, foster children, or step-children) under age 26; and
• unmarried disabled dependent children age 26 and older.

No dependents of Eligible Retirees are eligible for coverage.

Employee/Retiree Contributions: Your Employer (or former Employer) pays the full premium
cost of this coverage. You are not required to contribute towards your or your dependent’s (if
eligible) premium cost.

Insurance Effective Date: January1, 2015.

Effective Date of Coverage: First of the month coincidingwith,or next following, regularfull-time
employment.

Date Coverage Terminates: Last day of the month in which loss of eligibility occurs, the date the
Plan is terminated, or, in the case of an Eligible Retiree, you reach age 65 or otherwise become
eligible for Medicare.

Medical Options Offered:

Non-Grandfathered PPO Option-This program generally provides 70% payment of all reasonable
and customary physician and hospital costs for in-network covered expenses after a $4,500
individual and $9,000family deductible. The program covers100% of all reasonable and customary
costsfor in-network routinepreventative careserviceswith no participant costsharing. The program
also provides50% payment of all reasonable and customary physician and hospital costsfor out-of-
network expenses after a $9,000 individual and $18,000 family deductible. There is an annual
$6,350 individual and $12,700 family out-of-pocket limit for in-network covered services and an

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