This Summary Plan Description describes the Employee Assistance Program benefit available under the Franklin & Marshall College Group Long-term Disability Insurance Plan (the Employee Assistance Program benefit is described herein as the "Employee Assistance Program", the "Program", or the ”Plan”), effective as of July 1, 2013. This Summary Plan Description is required by The Employee Retirement Income Security Act (ERISA) of 1974, as amended. The purpose of this Summary Plan Description is to acquaint employees with the provisions of the Employee Assistance Program, the way in which it is administered, and participants' rights under the federal law which applies to employee benefit plans. Every effort has been made to make this Summary Plan Description as accurate as possible, however, in the event of a discrepancy between this Summary Plan Description and the Plan Document, the Plan Document shall control. The Plan Document can be viewed by contacting Human Resources. The Plan is established for the benefit of employees, their covered dependents, and their beneficiaries, and is administered impartially for the benefit of all eligible participants.
Facts About the Plan
Plan Name: Franklin & Marshall College Group Long-term Disability Insurance Plan (the"Employee Assistance Program")
Plan Number: 503 - Plan 503 also includes the Franklin & Marshall College Group Long-term Disability Insurance Plan and the Group Business Travel Accident Insurance Plan, which are each described in separate Summary Plan Descriptions.
Name, Address, and Telephone Number of Employer/Sponsor: Franklin & Marshall College, Lancaster, PA 17604-3003, (717) 291-3995. Employer shall also include the Lancaster City Alliance (effective February 25, 2003).
Plan Sponsor's Employer Identification Number: 23-1352635
Plan Year: July 1 through June 30
Type of Plan: Welfare Plan (Plan)
Plan Administrator: Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003
Plan Benefits Provided By: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company, 1777 Sentry Park West, Gwynedd Hall, Suite 100, Blue Bell, PA 19422, (215) 283-3947; administrative responsibilities assigned to Cigna Behavioral Health.
Agent for Service of Legal Process: Same as Plan Administrator
Funding: Fees for coverage through the Employee Assistance Program are paid by Franklin & Marshall College, through general employer assets. Enrolled "COBRA" participants pay fees.
Assessment, Counseling, and Referral
An eligible employee, and family members regularly residing in his/her household, may participate in up to three (3) phone or in-person sessions through the Employee Assistance Program per Plan Year, per issue. Services provided through the Employee Assistance Program include confidential assessment, and if deemed necessary by a Program counselor, counseling and referral services. Employees and/or eligible family members residing in the employee's household may contact the Employee Assistance Program provider, Cigna, to seek assessment, counseling, and/or referral services with regard to a personal, marital, or family-related concern; work-related concern; school-related concern; substance abuse issue; or any other concern for which the employee or family member would like assistance through the Program. There are no pre-existing condition exclusions. Use of the Employee Assistance Program is optional.
Assessment, counseling, and referral services are provided by counselors employed by Cigna, or by Cigna' contracted providers. Eligible employees and family members regularly residing in the employee's household must contact Cigna, at (877) 622-4327, in advance to access services provided through the Employee Assistance Program.
Assessment or counseling beyond three (3) sessions per Plan Year, per issue; psychological testing; career aptitude and placement services; outplacement counseling and services; and psychiatric services are services which are excluded under the Employee Assistance Program.
Employees and their dependents enrolled in the Franklin & Marshall Group Health & Prescription Drug Plan may be eligible for mental health treatment through that plan. The Summary Plan Description for the Group Health & Prescription Drug Plan and the Schedule of Benefits, available from Human Resources, contain details about mental health benefits.
Eligibility for Coverage
The following employees are eligible to participate in the Employee Assistance Program:
• full-time faculty and professional staff employees: Franklin & Marshall College employees who are scheduled to work at least 30 hours per week for wages on a regular basis, including visiting, tenured, non-tenured, and tenure-track faculty; full-time employees of the Lancaster City Alliance; and full-time employees of the Centennial Conference who: (1) are regularly scheduled to work on the Franklin & Marshall College campus and (2) are paid through the College's payroll system, as long as otherwise eligible
• full-time faculty and professional staff employees who are scheduled to work at least 30 hours per week for wages on an approved 9, 10, or 11 month per year appointment
• faculty on an approved joint appointment: one full-time position shared by two College faculty members each working at least 1040 hours annually
• full-time faculty working a reduced schedule under an approved Phased Retirement Agreement
• full-time faculty on an approved paid sabbatical or paid Junior Faculty Leave
• full-time faculty and professional staff employees on an approved paid or unpaid Family & Medical Leave as provided for in the Family & Medical Leave Act, or other approved leave of absence which provides for continued coverage
Independent contractors, contracted employees, adjunct faculty, individuals who volunteer their services without compensation, students, student employees, retired College employees, and those not in a covered class are not eligible to participate in the Employee Assistance Program.
Eligible Dependents for Purposes of the Employee Assistance Program
An eligible employee's family members who regularly reside with the employee in the employee's household are eligible to participate in the Employee Assistance Program. For purposes of the Program, eligible family members will typically include an employee's spouse or same-sex domestic partner, and children. Children include biological or legally adopted children, foster children, step-children, children for whom the employee is the legal guardian, and children of an employee's same-sex domestic partner who regularly reside with the employee, and/or who are claimed by the employee as legal dependents. An employee's dependent children who attend school or college, and as a result do not reside with the employee during the academic year, continue to be eligible to participate in the Program if they reside with the employee while school/college is not in session. Solely for purposes of the Employee Assistance Program, eligible dependents may include other members of an eligible employee's family, such as an opposite-sex domestic partner, parent, or sibling, if such family members regularly reside with the employee in the employee's household. Upon seeking benefits through the Program, the benefit provider, Cigna, may require verification of eligibility.
Eligibility for participation through the Employee Assistance Program is effective immediately upon appointment to a full-time position as a member of an eligible class. Eligible employees and their eligible dependents (family members regularly residing in the employee's household) are automatically enrolled in the Employee Assistance Program; there are no enrollment forms required. Eligible employees are not required to notify the Plan Administrator of their eligible dependents, however, when seeking benefits, the benefit provider, Cigna, may require verification of eligibility.
Eligibility for participation through the Program continues until an employee is no longer a member of an eligible class or until terminated as outlined below.
Employee Assistance Program costs are paid by Franklin & Marshall College from general employer assets. There are no fees or premiums required from eligible employees or their dependents.
Termination of Coverage
An eligible employee, and his/her eligible dependents, will cease to be eligible to participate in the Employee Assistance Program effective on the date one or more of the following events occurs:
1) employment termination, including retirement
2) loss of full-time employment status or other event which causes an employee to no longer be a member of an eligible class
3) death of an eligible employee
4) during a medical leave of absence: expiration of employer-paid sick leave benefits (salary continuation) or expiration of eligibility for Family & Medical Leave, whichever occurs later
5) an eligible employee's last work day prior to commencement of an unpaid leave of absence, including disability leave, other than an approved Family & Medical Leave or other approved leave of absence which provides for continued coverage
6) expiration of a leave of absence which provided for continued participation
Coverage will also end if Franklin & Marshall College fails to pay the required premium or terminates the Program.
Please see the “COBRA” section below for important information about optional, temporary continuation of coverage through the Plan following a “Qualifying Event” that leads to loss of coverage.
Benefit Denials and Claims Procedures
The Employee Assistance Program provider, Cigna, determines the level of assessment and counseling necessary for a participant, and when a referral for further treatment is necessary.
The Plan Administrator shall have the responsibility and authority, in its sole discretion, to decide eligibility for participation in the Employee Assistance Program. If the Administrator denies a claim for participation or benefits through this Program, the Administrator promptly and in writing shall notify the individual of such denial. The notification of denial will be made not later than within thirty (30) days of receipt of the individual's claim. This 30 day period may be extended for an additional 15 days due to circumstances beyond the control of the Plan Administrator, including cases in which a claim is incomplete. The individual will receive written notice of any such extension, including the reason for the extension and the date by which a decision by the Administrator can be expected. The Plan Administrator may secure independent information or other advice and require such other evidence as deemed necessary to decide a claim. A written notice of adverse benefit determination will be provided to the individual, and will include:
(1) the specific reason(s) for the denial of benefits,
(2) the specific Plan provision on which the denial is based,
(3) a description of any additional material or information necessary for the individual to complete a claim and an explanation of why such information is necessary, and
(4) an explanation of the right of appeal and the process to appeal the adverse benefit determination, including an explanation of the individual's right to review relevant documents and information, and his/her right to file suit under the Employee Retirement Income Security Act (ERISA) with respect to any adverse determination after appeal of a claim.
If a claim is denied in whole or in part, the individual may appeal to the Plan Administrator for review of the claim. The appeal must be made within one hundred, eighty (180) days of the Plan Administrator's initial notice of adverse benefit determination. If the appeal is not made within 180 days, the individual will lose his/her right to appeal and to file suit in court. The individual's written appeal should state the reasons that he/she believes the claim should not have been denied. It should include any relevant facts and/or documents to support the claim. The individual may ask additional questions of the Plan Administrator, make written comments, and may review (on request and at no charge) documents and other information relevant to the appeal. The Plan Administrator will review and decide the individual's appeal within a reasonable time and, within sixty (60) days after receiving the written appeal, shall render, in writing, a decision. The individual who reviews and decides the appeal will not be the same individual who originally denied the claim for benefits, or that individual's subordinate. The Plan Administrator may require additional relevant information to decide the claim. If the decision on appeal affirms the initial denial of the individual's claim for benefits under the Plan, he/she will be furnished with a notice of adverse benefit determination on review, which includes the following:
(1) the specific reason(s) for the denial,
(2) the specific Plan provision(s) on which the denial is based,
(3) a statement of the individual's right to review (on request and at no charge) relevant documents and other information,
(4) a description of any internal rule, guideline, or protocol, if applicable, used to make the benefit determination and a statement that such rule, guideline, or protocol will be provided to the claimant upon request at no charge, and
(5) a statement of the individual's right to bring suit under ERISA. Claims and appeals of adverse benefit determinations are to be addressed to Human Resources, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003, fax (717) 291-3969.
Plan Amendment, Modification, and Termination
The Employee Assistance Program may be amended or terminated by Franklin & Marshall College at any time. Termination will also occur if the College fails to pay the required fees to the benefits provider. No consent of any employee, participant, or beneficiary is required to terminate, modify, amend, or change the Employee Assistance Program.
Health Insurance Portability and Accountability Act of 1996
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before a participant enrolls in a group health insurance plan ("pre-existing conditions"). In addition, HIPAA prevents discrimination against individuals based on their health status, and allows for special enrollment periods under certain circumstances. HIPAA also regulates the use and disclosure of "Protected Health Information".
Pre-existing Condition Exclusions— Under the law, a pre-existing condition exclusion generally may not be imposed for more than 12 months (18 months for a late enrollee). The 12 month exclusion period is reduced by an individual's prior health coverage. If, at the time an employee enrolls in a new employer's health plan, he/she already has had 12 months of continuous health coverage, without a break in coverage of 63 days or more, the employee will not have to start over with a new 12 month exclusion for any preexisting medical conditions. If an individual was previously covered, he/she is entitled to a certificate of prior coverage from the third party administrator. A "Certificate of Creditable Coverage" must be provided to the individual by the plan when coverage is lost. Under HIPAA, pre-existing condition exclusions may not be applied to pregnancy. In addition, pre-existing condition exclusions may not be applied to a newborn, an adopted child, or a child placed for adoption who is under age 18 as long as the child becomes covered under the health plan within 31 calendar days of birth, adoption, or placement for adoption, and provided the child does not incur a subsequent 63 day or more break in coverage. The Plan includes no pre-existing condition exclusions.
Health Status Discrimination— HIPAA prohibits group health plans from establishing eligibility rules based on health status-related factors (such as medical condition, claims experience, medical history, genetic information, or disability). Plans may not require individuals to pay a greater premium based on a health status-related factor. However, plans may establish limits or restrictions on benefits or coverage for similarly situated individuals.
Special Enrollment Provisions— HIPAA provides for special enrollment periods under certain circumstances. If an employee or retiree declines coverage under the Shared Services Health Plan for him/herself and/or eligible dependents because of other coverage, the individual may be able to enroll him/herself and/or eligible dependents in the Plan, providing the appropriate enrollment form is completed and submitted within 31 calendar days after other coverage, including "COBRA", terminates due to loss of eligibility for such coverage. Under HIPAA, special enrollment rights are also granted when an employer's contributions toward an individual's other health insurance coverage ceases. In addition, if an employee or retiree acquires a new eligible dependent(s) through marriage, birth, adoption, or placement for adoption, such dependent may be enrolled in the Shared Services Health Plan within 31 days of the birth, adoption, or placement for adoption, or in the case of marriage, within 31 days of the 1st of the calendar month after the date of marriage. Under these circumstances, it is not necessary to wait until the annual Open Enrollment period to enroll in the Plan. The maximum pre-existing condition exclusion period for special enrollees is 12 months, reduced by the special enrollee's creditable coverage. No pre-existing condition exclusions may apply to a child if enrolled within 31 days of birth, adoption, or placement for adoption.
Coverage During Family & Medical Leave
If a covered College employee takes a qualifying leave under the Family & Medical Leave Act of 1993, as amended (FMLA), then to the extent required by the FMLA, the College will continue to maintain the employee's coverage through the Employee Assistance Program on the same terms and conditions as if the employee were still an active employee.
Continuation of Coverage under USERRA
The Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA") requires employers to provide coverage during qualified service of an employee in the Uniformed Services. This continued coverage, although similar to COBRA, may in certain circumstances provide rights in addition to those under COBRA. If an employee is on a qualified leave of absence under USERRA, when making an election to continue coverage under COBRA, the employee will also be making an election under USERRA. Where COBRA and USERRA provide different benefit protections, the law that provides greater protection will apply. For example, under USERRA if an employee is on a qualified leave of absence that lasts less than 31 days, the employee cannot be required to pay an insurance premium greater than what he/she would have paid if the employee had remained at work during this period. During a Service leave, a full-time College employee will be eligible for coverage through the Plan for him/herself and covered dependents, at active employee rates, for up to 30 calendar days. In the case of Service leave exceeding 30 calendar days, USERRA requires the College to extend coverage to the employee and his/her covered dependents, at 102% of the full premium, until the lesser of 24 months from the date the employee's civilian employment ended, or until the end of the period allowed for the individual to apply for reemployment. COBRA rights also apply to the employee and each of his/her covered dependents.
Statement of ERISA Rights
Participants in the Plan are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA). ERISA provides that all Plan participants are entitled to the following rights:
Receive information about the Plan and benefits-- Examine, without charge, at the Plan Administrator's office and at other specified locations, all documents governing the Plan (including, if applicable, insurance contracts and collective bargaining agreements), and a copy of the latest annual report (Form 5500 Series) filed by the Plan, if the Plan is required to do so, with the U.S. Department of Labor and available at the Public
Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, (including, if applicable, insurance contracts and collective bargaining agreements), and copies of the latest annual report (Form 5500 Series), if the Plan is required to file such form, and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report, if the Plan is required to
Prepare such a report— The Plan Administrator is required by law to furnish each participant with a copy of any summary annual report.
Continue Plan coverage— Continue health coverage for self, and dependent spouse or dependent children if applicable, if there is a loss of coverage under the Plan as a result of a Qualifying Event. A participant and his/her dependents will be required to pay for such coverage. This Summary Plan Description includes rules governing COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under the Plan, if you have Creditable Coverage for another plan— You should be provided a Certificate of Creditable Coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under a health insurance plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of Creditable Coverage, an individual may be subject to a preexisting condition exclusion for 12 months (up to 18 months for late enrollees) after enrolling in a health insurance plan.
Prudent action by Plan Fiduciaries— In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of an employee benefit plan. The people who operate this 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 or any other person, may terminate your employment 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 a 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 participants can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest annual report (if applicable) 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 Plan Administrator 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 Plan Administrator. 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 Questions
If you have any questions about the Program, you should contact the Plan Administrator, via Franklin & Marshall College's Human Resources department. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security 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 Employee Benefits Security Administration.
In no case will a Program participant, or anyone acting on a participant's behalf, be entitled to challenge a decision of the Plan Administrator in court or in any other administrative proceeding unless and until the claim and appeal procedures described in this Summary Plan Description have been complied with and exhausted.