Page 73 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Section 3: When Coverage Begins

How Do You Enroll?

Eligible Persons must complete the proper enrollment process communicated by the Plan Sponsor. The
Plan Sponsor will submit your completed enrollment to the Claims Administrator, along with any required
contribution. The Plan will not provide Benefits for health care services that you receive before your
effective date of coverage.
To enroll, complete the Plan Sponsor’s proper enrollment process within 31 days of the date you first
become eligible for medical Plan coverage. If you do not enroll within 31 days, you will need to wait until
the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical
election. If you wish to change your benefit elections due to your marriage, birth, adoption of a child,
placement for adoption of a child or other family status change, you must complete the Plan Sponsor’s
proper enrollment process within 31 days of the event. Otherwise, you will need to wait until the next
annual Open Enrollment to change your elections.

Cost of Coverage
You and the Plan Sponsor share in the cost of the Plan. Your contribution amount depends on the Plan
you select and the family members you choose to enroll.
Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out
of your pay before federal income and Social Security taxes are withheld. In most states, before state and
local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost
to you.
Your contributions are subject to review and the Plan Sponsor reserves the right to change your
contribution amount from time to time.

You can obtain current contribution rates by calling the Plan Sponsor.

What If You Are Hospitalized When Your Coverage Begins?

The Plan will pay Benefits for Covered Health Care Services when all of the following apply:

• You are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the
day your coverage begins.

• You receive Covered Health Care Services on or after your first day of coverage related to that
Inpatient Stay.

• You receive Covered Health Care Services in accordance with the terms of the Plan.
These Benefits are subject to your previous carrier's obligations under state law or contract.

You should notify the Claims Administrator of your hospitalization within 48 hours of the day your
coverage begins, or as soon as reasonably possible. For plans that have a Network Benefit level,
Network Benefits are available only if you receive Covered Health Care Services from Network providers.

What If You Are Eligible for Medicare?

Your Benefits may be reduced if you are eligible for Medicare but do not enroll in and maintain coverage
under both Medicare Part A and Part B.

70 Section 3: When Coverage Begins