Health Summary Plan Description

Total Disability Extension

If you or your eligible dependent are Totally Disabled when Earned Eligibility or self-pay coverage terminates, the disabled individual may be entitled to an extension of coverage for a maximum of 12 months beginning with the first month following the month in which the Earned Eligibility or self-pay coverage ends. The disabled individual must pay the Health Plan premium, as outlined on page 13 . If the disabled individual qualifies for Medicare, he or she must enroll in Parts A and B or Plan benefits will be reduced as described on page 83.

Coverage is available under this provision only if the disabled individual is Totally Disabled as defined by the Health Plan and is not covered by any other group health plan with the exception of Medicare. If you lose Earned Eligibility in Plan I but satisfy one of the Plan II requirements you are not entitled to the Plan I Total Disability Extension (because you are covered under Plan II).

Total Disability Defined

For adult participants and dependents, Total Disability means the disabled individual is prevented, solely because of sickness or accidental bodily injury, from performing the material and substantial duties of their regular occupation. With respect to minor participants and dependents, Total Disability means that the disabled individual is presently suffering from a sickness or accidental bodily injury, the effects of which are likely to be of long or indefinite duration and which will prevent him or her from engaging in most of the normal activities of a person of like age
and gender, in good health.

All requests for the Total Disability Extension are reviewed by the Health Plan's medical consultant.

Benefit Coverage

Only the disabled individual is covered under the Total Disability Extension. Other family members are not covered. However, family members may be entitled to enroll in the Self-Pay Program.

For the most part, the disabled individual will be entitled to the same benefits under the Total Disability Extension that he or she was receiving during their immediately preceding coverage – Plan I or Plan II. However, dental benefits are not included in the Total Disability Extension, nor may they be paid for separately.

Length of Coverage

The Total Disability Extension is available for a maximum of 12 months and will be granted only once for the same disability. If you regain Earned Eligibility during your period of Total Disability Extension, you will be able to use any remaining months of Total Disability Extension when you subsequently lose Earned Eligibility, provided you are still Totally Disabled from
the same disability at that time.

If you recover from one disability, regain Earned Eligibility, and subsequently become Totally Disabled from a new and different disability, you will be entitled to another 12 months of Total Disability Extension for the new disability.

If your Total Disability Extension ends during the middle of the month, as commonly occurs in the case of pregnancy, you must pay the full monthly Health Plan premium. The amount will not be prorated.

Option to Elect Self-Pay Coverage or Total Disability Extension

If you or your dependent are Totally Disabled at the time Earned Eligibility terminates, you are entitled to a choice of 1 or 2 as follows:

  1. Enrolling in the Self-Pay Program. If this option is elected, the disabled individual may continue coverage under the Total Disability Extension when the maximum number of self-pay months have elapsed, provided he or she is still Totally Disabled and is not covered under another group health plan.
  2. Electing coverage under the Total Disability Extension. If this option is elected, the disabled individual may continue coverage under the Self-Pay Program when the maximum number of Total Disability Extension months have elapsed.

If Option 2 is elected and your dependents do not enroll in the Self-Pay Program while you are covered under the Total Disability Extension, they may be added to your self-pay coverage following the Total Disability Extension.

If Option 2 is elected and you first acquire dependents during the 12-month period, you may change from the Total Disability Extension to the Self-Pay Program. However, you will forfeit the remaining months of coverage under the Total Disability Extension and you will not be entitled to return to the Total Disability Extension after the self-pay period ends.

Special Rules for Total Disability Extension

Becoming Totally Disabled While on the Self-Pay Program

If you or your eligible dependent become Totally Disabled while enrolled in the Self-Pay Program, the disabled individual will be eligible for the Total Disability Extension after completion of the applicable maximum number of months of coverage available to the individual under the Self-Pay Program.

Total Disability Extension for Pregnancy

If you, your spouse or your same-sex domestic partner is pregnant at the time of loss of either Earned Eligibility or self-pay coverage, benefits may be provided under the Total Disability Extension but only if the delivery occurs within 31 days of loss of coverage. If this requirement is met coverage will be limited to:

  • Normal Delivery: 31 days before delivery and six weeks following delivery.
  • Cesarean Delivery: 31 days before delivery and eight weeks following delivery.

Children born during the Total Disability Extension are not covered under the extension but they may be covered under any self-pay coverage which is elected immediately following the Total Disability Extension.