Medical Plan - General Information

Despite our best efforts to maintain good health, some medical expenses are inevitable for most families. Since these expenses can be costly, most employees rank health care coverage as their most important employer-sponsored benefit. This section gives you a detailed explanation of the AUI OAP Medical Plan. Here is a brief overview of how the Plan works: If you elect coverage in the AUI Medical Plan, you will be enrolled in CIGNA Health Care’s Open Access Plus (OAP) network. The CIGNA OAP network provides care through a carefully selected network of doctors and hospitals who agree to treat AUI employees at negotiated contract rates. Each doctor and hospital must meet strict criteria for delivering quality and efficient health care. You have the freedom to choose any provider you want. Each time you need care, you decide whether to use a OAP network provider or an out-of-network provider. If you select an out-of-network provider, your eligible expenses will be covered, but at a lower coinsurance level, and after applicable deductibles, than if you use network providers.

Eligibility and Enrollment

Who Is Eligible? - If you are employed on a regular basis, working at least 20 hours per week, you are eligible for medical coverage for yourself as of your first day of active employment. You may also enroll your eligible dependents for coverage.

Coverage for Your Dependents - Dependents that are eligible for medical coverage include your spouse and children as defined below:

Legally married spouse.

Dependent children under the age of 26 regardless of marital, student or residency status.
Unmarried mentally or physically disabled children age 26 or over who were disabled before age 26, provided they depend on you for their principal financial support and maintenance and provided they remain continuously disabled. Coverage may be continued beyond age 26 if, within 31 days after he or she has reached the age limit, you submit proof of the child’s incapacity to the Connecticut General Life Insurance Company.

Children Include - Your natural children, legally adopted children (coverage is provided during the adoption proceedings), and stepchildren.

In addition, if a divorce decree or Qualified Medical Child Support court order requires you to provide coverage, the term “children” also includes children who do not live with you and children for whom you do not provide principal support. A Qualified Medical Child Support court order is any judgment, decree, or order issued by a court requiring you to provide child support or health care coverage for a child. Dependents will not be eligible if they are in the armed forces of any country. Dependent children will not be eligible if they are covered as an employee under this or another AUI Plan.

If You Are On Leave of Absence - Except under certain conditions (see the following paragraph), you may continue your group medical insurance coverage for up to one year from the starting date of a leave of absence provided you pay the required employee premium contribution.

Continuation of insurance while you are on leave from AUI is not allowed when (1) you are employed by another organization which offers equivalent coverage or (2) you are employed by an agency or prime contractor of the federal government that will cover you under its insurance program.

Dependents of Deceased Employees - If you die while employed by AUI or while receiving Long Term Disability Insurance benefits, and while medical coverage for your eligible dependents is in effect, your spouse and other eligible dependents may continue in the plan, for one year following the date of your death, provided they pay the required employee premium contribution.

After one year, if you had three (3) but less than fifteen (15) years of employment with AUI, your surviving spouse and other eligible dependents may elect to continue in the plan. To do so, they must pay the full cost of the plan. See “Continued Health Care Coverage Through COBRA.”

If you die during or after the calendar year of your 58th birthday with at least three (3) years of employment or after fifteen (15) or more years of employment with AUI, your surviving spouse and other eligible dependents may continue to be covered by the plan, until they are no longer qualified as eligible dependents, provided they pay the required employee premium contribution.

These provisions will not apply in the case of a surviving spouse if the spouse is eligible for comparable coverage, at comparable premium rates, under another group medical insurance plan. Coverage will terminate with respect to the surviving spouse on the date he or she remarries.

Retired Employees - If you terminate employment after attaining age 55, you will be eligible to continue your insurance coverage for yourself and your eligible dependents indefinitely as a retired employee if you satisfy each of the following conditions:

Coverage for you and your dependents was in force on the date of your termination.
You had at least 5 continuous years of service immediately prior to termination.
Your age and years of service totals 70 or more.

You must continue paying the employee premium that was in force on the date of your termination until you and your eligible dependents each become eligible for Medicare. Retiree premiums are adjusted each year as active employee premiums are adjusted. Your AUI coverage is provided at no cost to you once you and your dependents reach Medicare eligibility.

When Coverage Begins - Your health care coverage does not begin automatically; you must complete an enrollment form and list all dependents you want covered. By completing the form you will authorize the necessary premium payment for the coverage you select. The coverages available are:

Employee only
Employee plus one dependent
Employee plus two or more dependents

Coverage begins on your date of hire if you complete all enrollment forms within 30 days of your date of hire.

Dependent insurance for any one of your dependents who is a patient in a hospital on the date his or her insurance would otherwise become effective will be postponed until the day after he or she is discharged. If you do not enroll in the Plan within 30 days after the date you are hired, or if you do not enroll a dependent within 30 days after the date he or she becomes eligible, and you later decide to enroll yourself or a dependent, you must wait until the next enrollment period. Enrollment periods are held during November of each year, with coverage becoming effective on January 1 of the following year.

It will not be necessary to wait until an enrollment period if you or your dependents did not elect coverage under this plan because of coverage provided by your spouse’s plan, and you lose coverage under your spouse’s plan due to termination of your spouse’s employment. In such cases, you may enroll yourself and your dependents immediately, provided you do so within 30 days of losing your other coverage.

Changing Your Coverage - It is your responsibility to notify the Human Resources Office of any changes in your family status which would affect your insurance coverage under this plan. Newly acquired family members will not be covered until you complete the forms adding them as dependents under your insurance. (Exception: Newborn children may be added for up to 30 days after their birth with coverage retroactive to the date of birth.) You must promptly notify the Human Resources Office whenever any of the following events occur:

Marriage or divorce/legal separation (must have signed papers indicating estranged spouse can be removed).
Birth or adoption of a child.
Death of a spouse or child.
A change in you or your spouse’s employment that affects health care coverage (such as changing from full-time to part-time or terminating employment).

Employees will not be entitled to a refund of premiums in cases where they have failed to drop coverage on family members who are no longer eligible for medical insurance.

Modified on Thursday, 24-Feb-2011 11:44:05 EST by Denise Utley