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Termination of Coverage

In document Clergy. Group Number (Page 55-57)

How and When Your Coverage Stops

Your coverage under the terms and conditions, as described in this Book, stops:

• By termination of the Agreement with Medical Mutual including termination for non-payment. This automatically ends all of your coverage and you are not offered a conversion privilege. It is the responsibility of your Group to notify you of such termination.

• On the date that a Card Holder becomes ineligible.

• At the end of the period for which payment was made when a Covered Person does not pay the required contribution. • Immediately upon notice if:

• a Covered Person allows a non-Covered Person to use his/her identification card to obtain or attempt to obtain benefits; or

• a Covered Person materially misrepresents a material fact provided to the Group or Medical Mutual or commits fraud or forgery.

Continuation of Coverage During Military Service

If your coverage would otherwise terminate due to a call to active duty from reserve status, you are entitled to continue coverage. Your group shall notify you of your right to continue coverage at the time you notify the group of your call to active duty. You must file a written election of continuation with the group and pay the first contribution for continued coverage no later than 31 days after the date on which your coverage would otherwise terminate. Continuation coverage will end on the earliest of the following dates:

• the date you return to reserve status from active military duty;

• the date coverage terminates under the Benefit Book for failure to make timely payment of a required contribution; • the date the entire Benefit Book ends; or

• the date the coverage would otherwise terminate under the Benefit Book. Benefits After Termination of Coverage

If you are an Inpatient of a Hospital or Skilled Nursing Facility on the day your coverage stops, only the benefits listed in the Inpatient Hospital Services section under bed, board and general nursing services and ancillary services will continue. These benefits will end when any of the following occurs:

• the Plan provides your maximum benefits; • you leave the Hospital or Skilled Nursing Facility;

• the Benefit Period in which your coverage stopped, comes to an end; or • you have other health care coverage.

This provision applies only to the Covered Services specifically listed in these two subnamed sections. No other services will be provided once your coverage stops.

Rescission of Coverage

A rescission of coverage means that your coverage is retroactively terminated to a particular date, as if you never had coverage under the Plan after the date of termination. Your coverage can only be rescinded if you (or a person seeking coverage on your behalf) performs an act, practice, or omission that constitutes fraud; or unless you (or a person seeking coverage on your behalf) makes an intentional misrepresentation of material fact, as prohibited by the terms of your Plan. Your coverage may also be rescinded for any period of time for which you did not pay the required contribution to coverage. You will be provided with thirty (30) calendar days' advance notice before your coverage is rescinded. You have the right to request an internal appeal of a rescission of your coverage.

Extended Coverage

If a Card Holder ceases to be an active Priest or Seminarian of the Diocese, and thereby ceases to be eligible for coverage, such Card Holder may be eligible to continue health coverage under this program for a period of 18 months after the date of termination of his service with the Diocese if the following requirements are met:

• The Card Holder was covered under this program during the entire three (3) month period preceding the termination of employment;

• The Card Holder is not covered by nor eligible for benefits under Medicare;

• The Card Holder is not covered by nor eligible for coverage under any other group health plan, as an employee or otherwise; and

• The Card Holder was not terminated as a result of any gross misconduct.

In order to extend coverage in accordance with the provisions of this Section, the Covered Person will be required to make the full monthly required contributions.

If a terminated Card Holder elects extended coverage, such coverage will cease upon the occurrence of any of the following events:

• becoming eligible for benefits under Medicare;

• become eligible and covered under any other group health plan, as an employee or otherwise; • failing to make a timely payment of a required contribution;

• the Diocese ceases to sponsor any group health plan for its priests and seminarians. Benefits for Retirees

Upon retirement, you may elect to continue coverage under the Program if you have been insured at least five years immediately preceding your retirement, and have attained age 55.

The coverage provided to retirees will be the same coverage which was provided to them when they were an active priest. However, once retirees become eligible for Medicare, the Program will assume they are enrolled for both Medicare Part A and Medicare Part B, and any benefits payable under this Program will first be reduced by any such benefits they are eligible to receive from Medicare, as described under "Coordination of Benefits."

Authorized Leaves of Absence

If a Card Holder takes an authorized leave of absence, coverage under the program may be continued, at his own expense, for up to one (1) year following such leave.

In document Clergy. Group Number (Page 55-57)

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