Nebraska Farm Bureau Member Health Plan Summary Plan Description

This document, together with the Medica Insurance Company (“Medica”) Certificate of Coverage (the “Certificate”), constitutes the Summary Plan Description for the Nebraska Farm Bureau Member Health Plan (the “Plan”). You can obtain a copy of the Certificate at www.nefbhealth.org/certificateofcoverage. The Certificate is a summary of the benefits. If the provisions of this document or the Certificate conflict with the provisions of the actual policy, the provisions of the policy control.

General Plan Information

1. Name of Plan and Plan Number: Nebraska Farm Bureau Member Health Plan
Plan Number 501
2. Plan Sponsor/Administrator and EIN: Nebraska Farm Bureau Employer Insurance Consortium (“NFBEIC”)
5225 S. 16th Street, Lincoln, NE 68512
(402) 421-4466
EIN: 83-1687593
3. Type of Plan: The Plan is a group health plan. Refer to the Certificate for a full summary of benefits.
4. Funding and Administration: The Plan is fully insured. Benefits are paid pursuant to the terms of a group health policy issued and insured by:

Medica Insurance Company (the “Insurer”)
401 Carlson Parkway, Minnetonka, MN 55305
(952) 992-2900

The Insurer administers claims, and the Plan Sponsor maintains a contract with respect to administration with the Insurer.
5. Plan Year, Fiscal Year, and Records: The Plan Year and the Plan’s fiscal year is January 1 – December 31. The Plan keeps its records on a fiscal year basis.
6. Participating Employers: NFBEIC is an association of employers who are members of the Nebraska Farm Bureau Federation. You may obtain information whether a particular employer participates in the Plan and if so, its address, by submitting a written request to the Plan Administrator.
7. Agent for Service of Legal Process: Attn: President, NFBEIC
635 South 14th Street, Ste. 200, Lincoln, NE 68508
Service of legal process may also be made on the Plan Administrator.
8. Who is Eligible: Only persons who are employed by employers who participate in the Plan under a membership agreement with NFBEIC (“Participating Employers”) are eligible for the Plan.

A person employed by a Participating Employer must be employed on average at least 30 hours per week by an employer and complete the 60 day waiting period to enter the Plan. However, a person who works on a temporary, or seasonal, or substitute basis will not be considered an eligible employee. The Plan Administrator has discretion to determine whether a person and his or her dependents are eligible for coverage.
9. Commencement of Participation: You become a participant in the Plan on the first day of the month following completion of a 60 day waiting period. The waiting period begins upon the date you meet the Plan’s eligibility criteria. Refer to the Certificate for information about Initial Enrollment Periods, Special Enrollment Periods, and Qualified Medical Child Support Orders. You may obtain a copy of the Plan’s procedures for determining whether an order constitutes a Qualified Medical Child Support Order at no charge by contacting the Plan Administrator.
10. Termination of Participation: Refer to the Certificate for events that may cause termination of participation and the effective date of termination. Your coverage will also terminate if your employer ceases to participate in the Plan.
11. Contributions: Employer and Employee. Your employer will contribute the amount it has agreed to contribute. You must contribute an amount that, together with employer contributions, equals the premium for the coverage option you have elected. Refer to the Certificate for information about cost sharing payments that may apply.

If the Plan and/or the Insurer overpay or mistakenly pay benefits to which you are not entitled under the terms of the Plan, the Plan and/or the Insurer may seek recovery of those payments from you and/or the recipient.
12. Network Providers: Your network name is shown on the identification card furnished to you by the Insurer. To obtain a list of network providers, visit www.medica.com/FarmBureauLogin or contact the Insurer at the number listed on your identification card. Medica will furnish a copy to you at no charge.
13. Amendment or Termination: NFBEIC, as Plan Sponsor, has the right to amend or terminate the Plan at any time. You may not receive benefits if the Plan is amended or terminated. Your employer may also cease participating in the Plan.
Statement of Rights under the Family Medical Leave Act of 1993
The Family Medical Leave Act of 1993, as amended, generally requires that most employers of 50 or more persons must offer continued coverage to eligible employees and their covered dependents while an employee is on an approved FMLA leave of absence. In addition, an employee of an FMLA-covered employer who has terminated his/her coverage while on an approved FMLA leave is entitled to reenroll for group health coverage upon return to work. Please check with your employer for details regarding your eligibility.
Statement of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stopped contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If you or your dependents lose eligibility for Medicaid coverage or coverage under a state children’s health insurance program, you may be able to enroll yourself and your dependents in this Plan. However, you must request enrollment within 60 days after your or your dependent’s coverage under your or your dependents’ Medicaid coverage or coverage under a state children’s health insurance program.

Finally, or if you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this Plan, you may be able to enroll yourself and your dependents in this Plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact the Plan Administrator at the address and phone number shown above.

Consolidated Omnibus Budget Reconciliation Act (“COBRA”) Initial Notice

The Plan provides continuation coverage in compliance with federal law. The provisions in this section apply to the extent that COBRA rights are not set forth in the policy. Contact the Plan Administrator if you have any questions.

Qualifying Events. Certain individuals may be eligible for COBRA if coverage is lost for any of the following reasons, called Qualifying Events:

  • Your employment with all Participating Employers ends for any reason (including retirement and layoffs) other than gross misconduct;
  • Your scheduled hours of work are reduced;
  • You die while employed and your dependents are covered by one or more of the Plans;
  • You and spouse legally separate or divorce, causing your spouse and/or children to lose coverage under the Plan;
  • You become entitled to Medicare (date of enrollment in Part A or Part B, whichever occurs earlier). This allows eligible dependents to elect COBRA coverage for up to 36 months from the date you enroll in Medicare.
  • Your dependent children no longer meet the Plan’s eligibility requirements.
  • In certain circumstances, a proceeding in bankruptcy under Title 11. Special rules apply to this type of event governing who may elect to continue coverage and how long that coverage lasts.

A loss of coverage occurs when coverage ceases to be available under the same terms and conditions that applied immediately before the Qualifying Event. If one of the above events occurs, eligible individuals may continue the same coverage they had when the event occurred, subject to any future Plan changes.

Qualified Beneficiaries. Only Qualified Beneficiaries may elect continued coverage. Qualified Beneficiaries include you (for termination of employment and reduction of hours), your spouse and any dependent children who are enrolled in the Plan at the time of the Qualifying Event in addition to any children who are born to or placed for adoption with you if you are participating in COBRA during the COBRA continuation period, provided they are enrolled within 60 days of the date of birth or date of placement.

A domestic partner is not eligible to elect COBRA as a Qualified Beneficiary unless he or she qualifies as a tax dependent within the meaning of Internal Revenue Code Section 152 (determined without regard to sections 152(b)(1), (b)(2), or (d)(1)(B)). However, if you and a domestic partner have coverage under the Plan and together lose coverage due to a Qualifying Event, the Qualified Beneficiary may elect COBRA for himself or herself and the domestic partner.

Qualified Beneficiaries have the same right to change coverage under any Plan for which coverage has been continued and add or drop dependents as active employees.

COBRA Coverage—Time Limits. Continued coverage is limited to the following specific periods of time:

  • You and your dependents may continue coverage for up to 18 months, if:
    • Your employment with all Participating Employers is terminated (including retirement and layoff); or
    • Your regularly scheduled work hours are reduced.
  • A spouse and dependent children may continue coverage for up to 36 months, if they lose coverage:
    • Because of your death, divorce or legal separation or because you become entitled to Medicare; or
    • Because a dependent child no longer meets the Plan’s eligibility requirements.

If you become entitled to Medicare before retirement, your entitlement to Medicare is not a Qualifying Event unless your spouse or dependent child loses coverage as a result. If no such loss of coverage occurs (before retirement), at retirement, the maximum COBRA coverage period for your spouse and dependent children ends on the later of these two dates:

  • 18 months from your date of retirement
  • 36 months from the date you became covered by Medicare.

For Qualified Beneficiaries who are determined to be disabled by the Social Security Administration or who are dependents of a disabled Qualified Beneficiary at the time employment ends (or hours are reduced), or become disabled during the first 60 days of continuation of coverage, coverage may continue for up to 29 months. Each Qualified Beneficiary may separately elect the additional continuation coverage for up to 29 months. You must notify the Plan Administrator of a Social Security award or appeal notice within 60 days of the Social Security determination but no later than the end of the 18th month of COBRA coverage. If you or your family member received a determination of disability before COBRA continuation coverage began and did not receive a subsequent determination that you are no longer disabled, a copy of the determination of disability must be furnished within 60 days of the loss of coverage.

A Qualified Beneficiary may be subject to more than one Qualifying Event. For example, subsequent Qualifying Events may occur as the result of death, divorce, legal separation, or a child losing Plan eligibility. A second Qualifying Event may extend coverage for your dependents to a maximum of 36 months from the date of the original Qualifying Event.

A Qualified Beneficiary’s COBRA continuation coverage will end before the maximum time period is reached if:

  • Payments are not made on a timely basis (within the 30-day grace period);
  • The Qualified Beneficiary becomes entitled to Medicare after COBRA continuation coverage is elected;
  • In the case of an 11-month extension (up to a total of 29 months) due to certain disabilities, a final determination is made that the individual is no longer disabled (after the first 18 months);
  • After the COBRA continuation coverage is elected, the Qualified Beneficiary who elects COBRA coverage under this Plan becomes covered under another group health plan, unless the other plan contains a pre-existing condition exclusion or limitation applicable to the Qualified Beneficiary. COBRA coverage will not terminate unless or until the individual is not or is no longer affected by the pre-existing condition exclusion or limitation under the other plan (for example, if the new plan gives credit for prior coverage, it may eliminate all or part of the pre-existing condition exclusion period and COBRA coverage may be terminated);
  • Your employer ends all group health plan coverage for all active employees;
  • Coverage ceases for any other generally applicable reason under the Plan.

COBRA Notification/Cost. The Plan Administrator will provide enrollment information for COBRA continuation coverage at the time of a Qualifying Event. It is the enrolled participant’s responsibility to provide an accurate address for mailing purposes. It is also the enrolled participant’s responsibility to notify the Plan Administrator of a loss of health coverage as a result of a divorce, legal separation, or child’s loss of dependent status under a health plan. This notice must be provided within 60 days of the date of the event (or, if later, the date the dependent would lose coverage because of the event).

The Plan Administrator must also be notified if:

  • A dependent has a second Qualifying Event that would allow coverage to be extended to a total maximum of 36 months. This notice must be provided within 60 days of the second Qualifying Event (or the date it would have resulted in a loss of coverage if it had been the first Qualifying Event).
  • An enrolled participant is determined by the Social Security Administration to have a disability that would allow the extension of coverage from 18 months to a total maximum of 29 months. This notice must include a copy of the Social Security Administration’s determination letter and be provided within 60 days of that determination and no later than the end of the original 18-month of COBRA continuation coverage.
  • The Social Security Administration has determined that an enrolled individual is no longer disabled, ending entitlement to continue coverage. This notice must be provided within 30 days of the Social Security Administration’s determination.

All of the notices provided under COBRA must include: the name of the employee, the name of each affected dependent, the Qualifying Event, and the date of the Qualifying Event. If an individual fails to provide an appropriate notice on time, the right to COBRA continuation coverage will be lost.

The cost of continued coverage is 102% of the total cost for the coverage, including the employer and employee contributions. For disabled Qualified Beneficiaries and their family members who have elected COBRA who are continuing coverage beyond 18 months, the monthly cost will be increased to 150% of the cost for the remaining 11 months. The cost will be adjusted annually each January 1 to reflect any changes in the total cost.

To elect COBRA continuation coverage, Qualified Beneficiaries are given 60 days after they receive the election form or, if later, 60 days after coverage under the Plan would otherwise end if COBRA coverage is not elected. Each Qualified Beneficiary is entitled to make his or her own coverage election. When coverage is elected, there is 45 days from the date of election to make the initial payment. After that, payments must be made monthly and there is a 30-day grace period.

Under the Health Insurance Portability and Accountability Act (HIPAA) and certain state laws, participants may be entitled to purchase medical coverage under an individual health insurance policy when coverage terminates under the medical plan.

Keep the Plan Administrator and your Employer Informed of Address Changes. You must notify the Plan Administrator and your Employer in the event your or your family members’ mailing address changes. You are responsible to provide an accurate address. Failure to provide a correct and current address could mean that you do not receive important Plan information, such as information about your claims or your right to continue coverage.

Statement of Rights under ERISA

The Employee Retirement Income Security Act of 1974 (“ERISA”) grants certain rights to participants. ERISA entitles all Plan participants to the following:

  1. You may examine documents governing the Plan without charge. This includes a copy of the latest annual report (Form 5500 series) filed with the U.S. Department of Labor. It also includes the updated Summary Plan Description. The Plan Administrator will make the documents available at its office. They may also be available at other specified locations.
  2. You may obtain copies of all Plan documents and other Plan information. The Plan Administrator will provide them upon written request. It may charge a reasonable amount for the copies.
  3. You will receive a summary of the Plan’s annual financial report from the Plan Administrator.

ERISA also imposes duties upon the people responsible for the operation of the Plan. These individuals are called “fiduciaries” of the Plan. Fiduciaries have a duty to act prudently. They must act in the interest of you, other Participants, and Beneficiaries. No one may fire you or otherwise discriminate against you in any way to prevent you from obtaining a retirement benefit or from exercising your rights under ERISA. You have the right to have the Plan review and reconsider your claim.

ERISA provides several steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials. It may also order the Plan Administrator to pay you up to $110 a day until you receive the materials. The court may decide not to enforce a penalty if the Plan Administrator did not send the materials because of reasons beyond its control. You may file suit in state or federal court if you have a claim for benefits that is wholly or partially denied or ignored. You may file suit in federal court if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic relations order. The Plan fiduciaries may not misuse the Plan’s money or discriminate against you for asserting your rights. If they do, you may seek assistance from the U.S. Department of Labor. You may also file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor. Your telephone directory should list the address. You may also ask the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration

Notice Regarding Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW (7669) or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2018. Contact your State for more information on eligibility –

ALABAMA Medicaid
Website: myalhipp.com
Phone: 1-855-692-5447

ALASKA Medicaid
The AK Health Insurance Premium Payment Program
Website: myakhipp.com
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: View Eligibility

Website: myarhipp.com
Phone: 1-855-MyARHIPP (855-692-7447)

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)
Health First Colorado Website: www.healthfirstcolorado.com
Health First Colorado Member Contact Center: 1-800-221-3943 State Relay 711
CHP+: Colorado.gov/HCPF/
CHP+ Customer Service: 1-800-359-1991 State Relay 711

FLORIDA Medicaid
Website: flmedicaidtplrecovery.com/hipp
Phone: 1-877-357-3268

GEORGIA Medicaid
Website: dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507

INDIANA Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: www.in.gov/fssa/hip
Phone: 1-877-438-4479
All other Medicaid
Website: www.indianamedicaid.com
Phone: 1-800-403-0864

IOWA Medicaid
Website: dhs.iowa.gov/hawk-i
Phone: 1-800-257-8563

KANSAS Medicaid
Website: www.kdheks.gov/hcf
Phone: 1-785-296-3512

Website: chfs.ky.gov
Phone: 1-800-635-2570

Website: dhh.louisiana.gov
Phone: 1-888-695-2447

MAINE Medicaid
Website: www.maine.gov/dhhs
Phone: 1-800-442-6003
TTY: Maine relay 711

Website: www.mass.gov/eohhs/gov
Phone: 1-800-862-4840

Website: mn.gov/dhs/people-we-serve
Phone: 1-800-657-3739

Website: www.dss.mo.gov/mhd/participants
Phone: 573-751-2005

MONTANA Medicaid
Website: dphhs.mt.gov/MontanaHealthcarePrograms
Phone: 1-800-694-3084

Website: www.ACCESSNebraska.ne.gov
Phone: 855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178

NEVADA Medicaid
Medica Website: dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900

Website: www.dhhs.nh.gov/ombp
Phone: 603-271-5218
Hotline: NH Medicaid Service Center at 1-888-901-4999

NEW JERSEY Medicaid and CHIP
Medicaid Website: www.state.nj.us
Phone: 609-631-2392
CHIP Website: www.njfamilycare.org
CHIP Phone: 1-800-701-0710

NEW YORK Medicaid
Website: www.health.ny.gov/health_care/medicaid
Phone: 1-800-541-2831

Website: dma.ncdhhs.gov
Phone: 919-855-4100

Website: www.nd.gov/dhs
Phone: 1-844-854-4825

OKLAHOMA Medicaid and CHIP
Website: www.insureoklahoma.org
Phone: 1-888-365-3742

OREGON Medicaid
Website: healthcare.oregon.gov
Phone: 1-800-699-9075

Website: www.dhs.pa.gov
Phone: 1-800-692-7462

Website: www.eohhs.ri.gov
Phone: 855-697-4347

Website: www.scdhhs.gov
Phone: 1-888-549-0820

Website: dss.sd.gov
Phone: 1-888-828-0059

TEXAS Medicaid
Website: gethipptexas.com
Phone: 1-800-440-0493

UTAH Medicaid and CHIP
Medicaid Website: medicaid.utah.gov
CHIP Website: health.utah.gov/chip
Phone: 1-877-543-7669

VERMONT Medicaid
Website: www.greenmountaincare.org
Phone: 1-800-250-8427

VIRGINIA Medicaid and CHIP
Medicaid and Chip Website: www.coverva.org
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-855-242-8282

Website: www.hca.wa.gov
Phone: 1-800-562-3022 Ext. 15473

Website: mywvhipp.com
Toll-Free Phone: 1-855-MyWVHIPP (1-855-699-8447)

Website: www.dhs.wisconsin.gov
Phone: 1-800-362-3002

WYOMING Medicaid
Website: wyequalitycare.acs-inc.com
Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either: