Health and Welfare Summary Plan Description

Table of Contents - Effective as of February 1, 2023

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• LETTER TO PARTICIPANTS
• ARTICLE I - DEFINITIONS
• ARTICLE II – OVERVIEW AND ADMINISTRATION
  2.1 Establishment and Continuation
  2.2 Board Composition
  2.3 Board Responsibilities
  2.4 Plan Office Responsibilities
  2.5 Employer Contributions
  2.6 Plan Amendment and Termination
  2.7 Benefits Conditioned on Availability of Funds
  2.8 Special Exclusion for Fraud
  2.9 Information You Must Provide the Plan
  2.10 HIPAA Privacy
• ARTICLE III – EMPLOYEE ELIGIBILITY
  3.1 Hour Bank
  3.2 Hours Required for Initial Coverage
  3.3 Hours Required to Maintain Coverage
  3.4 Limited Coverage Rule for Delinquent Contributions
  3.5 Reciprocity
  3.6 No Cost Disability and Reduced-Cost COBRA Coverage
• ARTICLE IV – RETIREE ELIGIBILITY
  4.1 Regular Retiree Eligibility
  4.2 Disability Retiree Eligibility
  4.3 Early Retiree Eligibility
  4.4 Retiree Monthly Coverage Payments
  4.5 Medicare
  4.6 Supplemental Benefits Available Even if No Major Medical Coverage
  4.7 Suspension/Cancelation of Retiree Benefits
• ARTICLE V – DEPENDENT ELIGIBILITY
  5.1 Dependent Coverage
  5.2 Dependent Coverage upon Death of Participant
  5.3 Qualified Medical Child Support Orders
  5.4 Establishing Tax Dependent Status
  5.5 Imputed Income for Certain Dependents
• ARTICLE VI – ENROLLMENT AND TERMINATION OF COVERAGE
  6.1 Benefit Options
  6.2 Initial Enrollment
  6.3 Rolling Open Enrollment
  6.4 Special Enrollment
  6.5 Retiree's and Retiree Dependents' One Time Opt-Out and Re-Enrollment Right
  6.6 Termination of Coverage
  6.7 Family and Medical Leave Act
  6.8 Military Service
• ARTICLE VII – COBRA COVERAGE
  7.1 General Rules
  7.2 COBRA Events, Beneficiaries and Maximum Coverage Periods
  7.3 COBRA and Medicare
  7.4 Separate Notice Required by Dependent
  7.5 COBRA Notice Procedures
  7.6 Early Termination of COBRA Coverage
  7.7 Coverage Options
  7.8 California COBRA
• ARTICLE VIII – SELF FUNDED PPO OPTION
  8.1 In General
  8.2 Blue Shield California PPO Network
  8.3 Blue Shield Out of State Programs
  8.4 No Surprises Act: Certain Out-of-Network Charges Cost-Sharing Same As In-Network/PPO
  8.5 Prescription Drug Card Program
  8.6 Limits on Covered Charges
  8.7 Early Medical Assessment and Case Management
  8.8 Life Referrals 24/7 Program
  8.9 Covered Charges
  8.10 Exclusions
  8.11 Federal Mandates
  8.12 Coordination of Benefits
8.13 Subrogation and Reimbursement
• ARTICLE IX – HMO Options
  9.1 General Rules
  9.2 Enrollees Must Live in Service Area
  9.3 Incorporation of HMO Contract Into Plan
• ARTICLE X – HEALTH REIMBURSEMENT ARRANGMENT (HRA)
  10.1 General Rules and Eligibility
  10.2 Qualified Expenses
  10.3 Submitting Claims
  10.4 Statements
  10.5 Unused Account Balances and Forfeiture
• ARTICLE XI – SUPPLEMENTAL BENEFITS
  11.1 Dental Benefits
  11.2 Vision Benefits
  11.3 Long-Term Disability Benefits
  11.4 Supplemental Parental Leave Benefit
  11.5 Pregnancy Leave Benefit
  11.6 Emergency Leave Benefit
  11.7 Death Benefit
• ARTICLE XII – CLAIM AND APPEAL PROCEDURES
  12.1 Claims and Appeals for Self-Funded PPO, Dental, Vision, LTD and Other Noninsured Benefits
  12.2 Claims and Appeals for HMO Benefits
  12.3 Eligibility Determinations
• ARTICLE XIII – MISCELLANEOUS PROVISIONS
  13.1 Basic Plan Information
  13.2 Construction
  13.3 No Vested Right
  13.4 Facility of Payment
  13.5 Available Assets for Benefits
  13.6 Incompetence and Incapacity
  13.7 Gender and Number
  13.8 Mistaken Payments
  13.9 Loss of Benefits and Other Consequences
  13.10 Organizations that Receive Premiums
  13.11 Method of Funding
  13.12 Rescission of Plan Coverage
  13.13 Temporary Releif Provisions
• ARTICLE XIV – STATEMENT OF ERISA RIGHTS
  14.1 Your Rights Under ERISA
  14.2 Prudent Actions by Plan Fiduciaries
  14.3 Enforcing Your Rights
  14.4 Assistance with Your Questions
• Appendix A: List of Contribution Agreements and other Agreements
• Appendix B: Monthly Coverage Payment Schedules
• Appendix C: Claim and Appeal Procedures for Non-HMO Benefits
• Appendix D: Blue Shield Out-of-Area-Services
• Appendix E: List of Trustees and Plan Service Providers

This is the San Francisco Electrical Workers Health & Welfare Plan, as maintained pursuant to a Collective Bargaining Agreement and Declaration of Trust negotiated by the International Brotherhood of Electrical Workers, Local 6 ("Local 6"), and the San Francisco Electrical Contractors Association, Inc. ("SFECA"). This document constitutes both the Plan's plan document and its summary plan description. You should review this document to understand your rights under the Plan.