Page 3 - 2013 Wexford CCU PLAN DOC SPD

Table of Contents

Introduction .............................................................................................................................. 2

Table of Contents ..................................................................................................................... 3
Plan Overview .......................................................................................................................... 6
Your Eligibility ......................................................................................................................... 6
Eligible Dependents ................................................................................................................ 6
When Coverage Begins .......................................................................................................... 7
Proof of Dependent Eligibility .................................................................................................. 7
Your Contribution for Coverage ............................................................................................... 7
Enrolling for Coverage ............................................................................................................ 8
New Hire Enrollment ............................................................................................................ 8
Late Entrant ......................................................................................................................... 8
Annual Open Enrollment Period .............................................................................................. 8
Effect of Section 125 Tax Regulations on this Plan ................................................................. 8
Special Enrollment Rights ....................................................................................................... 9
When Coverage Ends ............................................................................................................. 9
Cancellation of Coverage .......................................................................................................10
Rescission of Coverage .........................................................................................................10
Coverage While Not at Work ..................................................................................................10
If You Take a Leave of Absence (FMLA) ................................................................................10
If You Take a Military Leave of Absence .................................................................................10
Your Health Care Coverage ....................................................................................................12
Participation ...........................................................................................................................12
Benefits Provided ...................................................................................................................12
Source of Payments ...............................................................................................................13
Limitations and Exclusions .....................................................................................................13
Continuation of Health Care Coverage through COBRA ........................................................13
For More Information .............................................................................................................13
Your Life and Accidental Death & Dismemberment (“AD&D”) Coverage ............................14

Participation ...........................................................................................................................14
Benefits Provided ...................................................................................................................14
Source of Payment ................................................................................................................14
Plan Limitations and Exclusions .............................................................................................14
Coverage Continuation ..........................................................................................................14
For More Information .............................................................................................................14
Your Disability Benefits ..........................................................................................................15

Participation ...........................................................................................................................15
Benefits Provided ...................................................................................................................15
Source of Payment ................................................................................................................15
Payment of Benefits ...............................................................................................................16
Offset of Other Benefits..........................................................................................................16

3