Carlson Restaurants Inc. $100K PPO Plan

Carlson Restaurants Inc. $100K PPO Plan

TABLE OF CONTENTS

SECTION 1 - WELCOME 1

SECTION 2 - INTRODUCTION 2

Eligibility 2

Cost of Coverage 2

How to Enroll 3

When Coverage Begins 3

Changing Your Coverage 3

SECTION 3 - HOW THE PLAN WORKS 6

Network and Non-Network Benefits 6

Eligible Expenses 7

Annual Deductible 7

Copayment 8

Coinsurance 8

Annual Maximum Benefit 8

SECTION 4 - PERSONAL HEALTH SUPPORT 11

Requirements for Notifying Personal Health Support 12

Special Note Regarding Mental Health and Substance Use Disorder Treatment 13

Special Note Regarding Medicare 13

SECTION 5 - PLAN HIGHLIGHTS 14

SECTION 6 - ADDITIONAL COVERAGE DETAILS 21

Ambulance Services - Emergency Only 21

Congenital Heart Disease (CHD) 21

Dental Services - Accident Only 22

Diabetes Services 23

Durable Medical Equipment (DME) 23

Emergency Health Services 25

Hearing Care 25

Home Health Care 25

Hospital - Inpatient Stay 26

Injections in a Physician's Office 26

Lab, X-Ray and Diagnostics - Outpatient 27

Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient 27

Mental Health Services 27

Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders 28

Nutritional Counseling 29

Ostomy Supplies 30

Physician Fees for Surgical and Medical Services 30

Physician's Office Services 30

Pregnancy - Maternity Services 31

Preventive Care 31

Prosthetic Devices 32

Reconstructive Procedures 32

Rehabilitation Services - Outpatient Therapy 33

Scopic Procedures - Outpatient Diagnostic and Therapeutic 34

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services 34

Spinal Treatment 35

Substance Use Disorder Services 36

Surgery - Outpatient 37

Therapeutic Treatments - Outpatient 37

Urgent Care Center Services 37

Vision Examinations 37

Wigs 38

SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY 39

www.myuhc.com 39

Optum® NurseLineSM/Connect24 41

Live Nurse Chat 42

Live Events on myuhc.com 42

Healthy Pregnancy Program 42

Tobacco Cessation Program (Effective June 1, 2011) 43

Disease Management Services 43

Treatment Decision Support 44

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER 45

Alternative Treatments 45

Comfort and Convenience 45

Dental 46

Drugs 47

Experimental or Investigational or Unproven Services 47

Foot Care 47

Jawbone Surgery 48

Medical Supplies and Appliances 48

Mental Health/Substance Use Disorder 48

Nutrition and Health Education 49

Physical Appearance 50

Preexisting Conditions 50

Pregnancy and Infertility 51

Providers 51

Services Provided under Another Plan 52

Transplants 52

Travel 52

Vision and Hearing 53

All Other Exclusions 53

SECTION 9 - CLAIMS PROCEDURES 56

Network Benefits 56

Non-Network Benefits 56

If Your Provider Does Not File Your Claim 56

Health Statements 57

Explanation of Benefits (EOB) 57

Claim Denials and Appeals 58

External Review Program 59

Limitation of Action 63

SECTION 10 - COORDINATION OF BENEFITS (COB) 64

Determining Which Plan is Primary 64

When This Plan is Secondary 65

When a Covered Person Qualifies for Medicare 66

Right to Receive and Release Needed Information 66

Overpayment and Underpayment of Benefits 67

SECTION 11 - SUBROGATION AND REIMBURSEMENT 68

Right of Recovery 68

Right to Subrogation 68

Right to Reimbursement 69

Third Parties 69

Subrogation and Reimbursement Provisions 69

SECTION 12 - WHEN COVERAGE ENDS 71

Other Events Ending Your Coverage 71

Coverage for a Disabled Child 72

Continuing Coverage Through COBRA 72

When COBRA Ends 76

Uniformed Services Employment and Reemployment Rights Act 76

SECTION 13 - OTHER IMPORTANT INFORMATION 78

Qualified Medical Child Support Orders (QMCSOs) 78

Your Relationship with UnitedHealthcare and Carlson Restaurants Inc. 78

Relationship with Providers 79

Your Relationship with Providers 80

Interpretation of Benefits 80

Information and Records 80

Incentives to Providers 81

Incentives to You 82

Rebates and Other Payments 82

Workers' Compensation Not Affected 82

Future of the Plan 82

Plan Document 83

SECTION 14 - GLOSSARY 84

SECTION 15 - PRESCRIPTION DRUGS 97

Prescription Drug Coverage Highlights 97

Identification Card (ID Card) – Network Pharmacy 98

Benefit Levels 98

Retail 99

Mail Order 100

Mandatory Mail Order Program 100

Designated Pharmacy 101

Assigning Prescription Drugs to the PDL 101

Notification Requirements 102

Prescription Drug Benefit Claims 103

Limitation on Selection of Pharmacies 103

Supply Limits 103

If a Brand-name Drug Becomes Available as a Generic 103

Prescription Drugs that are Chemically Equivalent 104

Special Programs 104

Step Therapy 104

Rebates and Other Discounts 104

Coupons, Incentives and Other Communications 104

Exclusions - What the Prescription Drug Plan Will Not Cover 105

Glossary - Prescription Drugs 106

SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA 110

ATTACHMENT I -NOTICES 114

Patient Protection and Affordable Care Act (“PPACA”) 114

Requirements of Medical Leave Act of 1993 (as amended) (FMLA) 115

Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA) 116

5 Table Of Contents

Carlson Restaurants Inc. $100K PPO Plan

SECTION 1 - WELCOME

Quick Reference Box

■  UnitedHealthcare Member services, claim inquiries, Personal Health Support and Mental Health/Substance Use Disorder Administrator: 877-377-2501;

■  Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, UT. 84130-0555; and

■  Online assistance: www.myuhc.com.

■  Team Member Services Phone 1.800.Fridays (1.800.374.3297) Fax 972.307.6069 email .

Carlson Restaurants Inc. is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members under the Carlson, Inc. Employee Welfare Benefit Plan. It includes summaries of:

■  who is eligible;

■  services that are covered, called Covered Health Services;

■  services that are not covered, called Exclusions;

■  how Benefits are paid; and

■  your rights and responsibilities under the Plan.

This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for this Plan. You must read this SPD in conjunction with the Plan Administration SPD for all information relevant to your plan.

Carlson Restaurants Inc.intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.

UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Carlson, Inc. has delegated to UnitedHealthcare the initial discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

1 Section 1 - Welcome

Carlson Restaurants Inc. $100K PPO Plan

Please read this SPD thoroughly to learn how the Carlson, Inc. Employee Welfare Benefit Plan works. Also read the Plan Administration SPD, which is intended to be read along with the SPD. If you have questions contact Team Member Services or call the number on the back of your ID card.

How To Use This SPD

■  Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.

■  Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

■  Read the Plan Administration SPD in conjunction with this SPD.

■  You can find copies of your SPD and any future amendments at www.myhr.carlson.com or request printed copies by contacting Team Member Services.

■  Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.

■  If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.

■  Carlson Restaurants Inc. is also referred to as Company.

■  If there is a conflict between this SPD and any summaries provided to you, this SPD will control.

1 Section 1 - Welcome

Carlson Restaurants Inc. $100K PPO Plan

SECTION 2 - INTRODUCTION

What this section includes:

■  Who's eligible for coverage under the Plan;

■  The factors that impact your cost for coverage;

■  Instructions and timeframes for enrolling yourself and your eligible Dependents;

■  When coverage begins; and

■  When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you are a regular full-time hourly employee as defined in the Plan Administration Manual. Your eligible Dependents may also participate in the Plan. Please refer to the Plan Administration Manual for employee and dependent eligibility requirements.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and your Spouse are both covered under the Carlson, Inc. Employee Welfare Benefit Plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Carlson, Inc. Employee Welfare Benefit Plan, only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

Cost of Coverage

You and Carlson Restaurants Inc. share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

Note: The Internal Revenue Service generally does not consider Domestic Partners and their children eligible Dependents. Therefore, the value of Carlson Restaurants Inc. cost in covering a Domestic Partner will be imputed to the Employee as income. In addition, the share of the Employee's contribution that covers a Domestic Partner and their children will be paid using after-tax payroll deductions.

Your contributions are subject to review and Carlson Restaurants Inc. reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling Team Member Services or logging onto www.myhr.carlson.com.

How to Enroll

To enroll, call Team Member Services or log onto www.myhr.carlson.com within 30 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 30 days, you will need to wait until the next Annual Enrollment period to make your benefit elections.

Each year during Annual Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Annual Enrollment will become effective the following January 1.

Important

If you wish to change your benefit elections following your marriage, birth or adoption of a child, or other family status change, you must contact Team Member Services within 30 days of the event. Otherwise, you will need to wait until the next Annual Enrollment period to change your elections.

When Coverage Begins

Once Team Member Services receives your properly completed enrollment, coverage will begin on the first day of eligibility. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the date of the status change, provided you notify Team Member Services within 30 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided you notify Team Member Services within 30 days of the birth, adoption, or placement.

Changing Your Coverage

Change in Status

You may make coverage changes during the year only if you experience a change in status. A change in status is an event which impacts you, your spouse or your dependent during the plan year and allows you as an employee to make a mid-year change to your current benefit elections.A complete list of change in status events are listed in the Plan Administration Manual and can be found online www.myHR.carlson.com. In addition to the change in status events you may also change your coverage if you or your eligible dependent(s) experience a change listed below under Special Enrollment Rights. You may also contact Team Member Services for more information.

Special Enrollment Rights

Under HIPAA, you have certain special enrollment rights under the Plan. That means there are circumstances where you and/or your dependents can enroll in the Plan outside of the annual enrollment period. If you experience one of these events and wish to enroll in the Plan during the Plan Year, you must notify Team Member Services within 30 days of your special enrollment event. If you do not notify Team Member Services of this event within 30 days, you will lose your right to special enrollment and will have to wait until the next annual enrollment period to enroll in the Plan.

Special enrollment rights provide that, if you, your spouse or your eligible dependent(s) experience one of the events described below, any or all of you may enroll in the Plan. For example, if your spouse experiences an event that triggers a special enrollment right, your spouse may enroll in the Plan. Your eligible dependent(s) that are affected may enroll at the same time. If you are not enrolled in the Plan, you will need to enroll also since your spouse and dependents are not eligible for coverage in the Plan if you are not enrolled. The following paragraphs refer to “you” to describe the events that may trigger special enrollment rights. Unless specifically stated, however, for this purpose “you” refers to you, your spouse and/or your eligible dependent(s).

1. Loss of other coverage: You may be eligible for special enrollment in the Plan if you did not previously enroll in the Plan because you were covered by other health care coverage and you lose eligibility for that coverage. Loss of eligibility under the other coverage includes the following: Exhaustion of COBRA coverage (but not termination before the end of the available period), divorce, death of the employee under whom you were covered, termination or reduction in the number of hours of employment (voluntary or involuntary and with or without electing COBRA), “aging out” under the other parent’s coverage, and moving out of an HMO’s service area. Loss of eligibility does not include cancellation because of a failure to pay premiums, termination of coverage for cause (such as fraud), or failure to elect coverage renewal at a time of year different from when the Plan offers open enrollment.