INDIANA UNIVERSITY HEALTH Health and Welfare Benefit Plan ...

INDIANA UNIVERSITY HEALTH Health and Welfare Benefit Plan

Summary Plan Description

Administered by IU Health Plans

Indiana University Health Employee Benefits Plan ? 2017

Summary Plan Description

Your Guide to Quality Healthcare Services and Healthier Living. As an employee of Indiana University Health, this document is to help you understand the healthcare services and benefits available to you and your dependents and will be updated as necessary.

This Summary Plan Description is a SPD. We encourage you to take the time to read it carefully and to access it for future reference. Plan information is available on the IU Health Plans website: You will find helpful information about:

? Network Providers; ? Covered benefits and services, limitations and exclusions; ? Administrative and enrollment procedures; ? The medical benefits administrator and coordination of benefits; ? Medical Management services to ensure quality care; ? The Prescription Drug benefit and eligibility; ? Pharmacy and benefits management programs; and ? Member services. Refer to this document for detailed information and definitions of the terms used throughout the Plan. Be sure to bookmark this document for quick reference when you need it. If you have any questions, contact IU Health Plans Member Services for information: 800.873.2022 or 317.816.5170, 7 a.m.-7 p.m. Eastern Time, Monday-Friday or visit our website at: . This is your guide to quality healthcare services and healthier living. Quality healthcare is everybody's responsibility. We encourage you to pursue a lifestyle of healthy living. IU Health Plans looks forward to assisting you with your healthcare needs.

Indiana University Health Employee Benefits Plan ? 2017

Table of Contents

Section One:............................................................................................................................................................. 1 ESTABLISHMENT OF THE PLAN: ADOPTION OF THE SUMMARY PLAN DESCRIPTION .... 1

Section Two:............................................................................................................................................................ 2 INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION.............................................. 2

Section Three:......................................................................................................................................................... 5 PLAN CHOICES AND NETWORKS .............................................................................................................. 5

Section Four: ........................................................................................................................................................... 8 HEALTHCARE COVERAGE ............................................................................................................................ 8

Section Five: ......................................................................................................................................................... 62 ELIGIBILITY, CONTINUATION OF COVERAGE, AND TERMINATION PROVISIONS ............ 62

Section Six:............................................................................................................................................................ 76 MEDICAL BENEFITS ADMINISTRATOR FOR THE PLAN ............................................................... 76

Section Seven:...................................................................................................................................................... 82 CLAIM PROCEDURES; GRIEVANCE and APPEAL RIGHTS............................................................. 82

Section Eight: ....................................................................................................................................................... 95 EMPLOYEE'S RIGHTS AND RESPONSIBILITIES ................................................................................ 95

Section Nine: ......................................................................................................................................................122 MISCELLANEOUS PROVISIONS..............................................................................................................122

Section Ten:........................................................................................................................................................127 DEFINITION OF TERMS ............................................................................................................................127

Indiana University Health Employee Benefits Plan ? 2017

Section One:

ESTABLISHMENT OF THE PLAN: ADOPTION OF THE SUMMARY PLAN DESCRIPTION

THIS SUMMARY PLAN DESCRIPTION ("SPD"), made by Indiana University Health, Inc. (the "Company" or the "Plan Sponsor") as of January 1, 2017, hereby sets forth the provisions of the Indiana, Inc. Health and Welfare Benefit Plan (the "Plan"). Any wording which may be contrary to Federal Laws or Statutes is hereby understood to meet the standards set forth in such. Also, any changes in Federal Laws or Statutes which could affect the Plan are also automatically a part of the Plan, if required.

THIS SUMMARY PLAN DESCRIPTION ("SPD"), made by Indiana University Health, Inc. (the "Company" or the "Plan Sponsor") as of January 1, 2017, hereby amends and restates the Indiana University Health, Inc. Health and Welfare Benefit Plan (the "Plan"), which was originally adopted by the Company to be effective January 1, 2017. Any wording which may be contrary to Federal Laws or Statutes is hereby understood to meet the standards set forth in such. Also, any changes in Federal Laws or Statutes which could affect the Plan are also automatically a part of the Plan, if required.

Effective Date

The SPD is effective as of the date first set forth above, and each amendment is effective as of the date set forth therein, (the "Effective Date").

Adoption of the SPD

The Plan Sponsor, as the settlor of the Plan, hereby adopts this SPD as the written description of the Plan. This SPD represents the Summary Plan Description, which is required by the Employee Retirement Income Security Act of 1974, 29 U.S.C. et seq. ("ERISA"). This SPD amends and replaces any prior statement of the health care coverage contained in the Plan or any predecessor to the Plan.

IN WITNESS WHEREOF, the Plan Sponsor has caused this SPD to be executed.

Date:

Indiana University Health, Inc. By: _____________________________________ Name: __________________________________ Title: ___________________________________

Indiana University Health, Inc. Health and Welfare Benefit Plan ? 2017

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Section Two:

INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION

Introduction and Purpose

The Plan Sponsor has established the Plan for the benefit of eligible Employees and their eligible Dependents, in accordance with the terms and conditions described herein. Plan benefits are self-funded through a benefit fund or a trust established by the Plan Sponsor and self-funded with contributions from Covered Persons and/or the Plan Sponsor, or are funded solely from the general assets of the Plan Sponsor. The Plan's benefits and administration expenses are paid directly from the Employer's general assets. Covered Persons in the Plan may be required to contribute toward their benefits. Contributions received from Covered Persons are used to cover Plan costs and are expended immediately.

The Plan Sponsor's purpose in establishing the Plan is to protect eligible Employees and their Dependents against certain health expenses and to help defray the financial effects arising from Injury or Sickness. To accomplish this purpose, the Plan Sponsor must be mindful of the need to control and minimize health care costs through innovative and efficient plan design and cost containment provisions, and of abiding by the terms of the SPD, to allow the Plan Sponsor to effectively assign the resources available to help Covered Persons in the Plan to the maximum feasible extent.

The Plan Sponsor is required under ERISA to provide to Covered Persons a Summary Plan Description. The Plan Sponsor has adopted this SPD as the written description of the Plan to set forth the terms and provisions of the Plan that provide for the payment or reimbursement of all or a portion of certain expenses for eligible benefits. The SPD is maintained by the Indiana University Health, Inc. and may be reviewed at any time during normal working hours by any Covered Person.

General Plan Information

Name of Plan: Plan Sponsor:

Indiana University Health, Inc. Health and Welfare Benefit Plan

Indiana University Health, Inc. 340 W. 10th Street Indianapolis, Indiana 46202

Indiana University Health, Inc. Health and Welfare Benefit Plan ? 2017

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