Page 59 - 2023 Hickory Crawdads - Benefits Guide_Neat

Notwithstanding the above, the Board may, in its sole discretion, terminate your, your
spouse’s, your domestic partner’s, or your dependent’s coverage under the Plan if you, your
spouse, your domestic partner, or your dependent provides false information or makes
misrepresentations in connection with a claim for benefits; permits a non-participant to use a
membership or other identification card for the purpose of wrongfully obtaining benefits; or
obtains or attempts to obtain benefits by means of false, misleading or fraudulent
information, acts or omissions. Please see the Special Rules Relating to Rescissions of
Coverage subsection in the section of this booklet entitled BENEFITS for additional details.

ELECTIONS AND CONTRIBUTIONS

As an eligible employee under the Plan, you may enroll in a medical benefit option available
through Highmark Blue Cross Blue Shield and offered by your Employer. Your Employer
may offer one or more options.

Under the Plan, there are two types of coverage: (1) individual coverage; and (2) family
coverage. If you have individual coverage, only your expenses are covered, not those of
other members of your family. If you have family coverage, only the expenses of you, your
enrolled spouse, and enrolled dependent children are covered.

To receive benefits under the Plan, you must elect coverage for you, your spouse, and your
eligible dependent children by completing and returning the necessary forms identifying your
spouse and any eligible dependent children in accordance with the rules established by your
Employer. You must also pay the portion of the premium designated by your Employer.

Special Enrollment Rights

You may be able to enroll or make an election change pursuant to a special enrollment right.
The following describes your special enrollment rights:

If you decide not to enroll yourself, your spouse, or your dependent child(ren) in medical
coverage under the Plan because the individual has other health insurance or group health
plan coverage, and either (1) the individual has a loss of eligibility for that other coverage, or
(2) the prior coverage was continuation coverage and the continuation period has been
exhausted, you will be able to enroll in medical coverage under the Plan, as applicable, if you
enroll within 31 days after losing or exhausting the prior coverage.

If you have a new spouse or dependent child as a result of marriage, birth, adoption, or
placement for adoption, you will be able to enroll yourself, your spouse and (if applicable)
your eligible newborn or new adoptive dependent child in medical coverage under the Plan,
if you do so within 31 days after the marriage, birth, adoption, or placement for adoption
provided you make a timely election to add coverage.

In addition, if you, your spouse, or your dependent child(ren) lose coverage or gain eligibility
for coverage under Medicaid or CHIP, you will be able to enroll you, your spouse, and your
dependent child(ren) in medical coverage under the Plan if you, your spouse, and your
dependent child(ren) are eligible but not enrolled provided that you make an election to add
coverage not later than 60 days after you, your spouse, or your dependent child(ren) loses or
gains coverage under Medicaid or CHIP.

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