REG - AT & T Inc. - 3Q16 10-Q <Origin Href="QuoteRef">T.N</Origin> - Part 7
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- Part 7: For the preceding part double click ID:nRSQ5061Pf
minimum length of stay
otherwise required by law. Such coverage shall be subject to all other provisions of this Plan.
9.4 Women's Health and Cancer Rights Act of 1998. To the extent this Plan provides benefits for mastectomies, it will provide, for an individual who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with
such mastectomy, coverage for reconstruction on the breast on which the mastectomy was performed, surgery and reconstruction on the other breast to give a symmetrical appearance, and prosthesis and coverage for physical complications of all stages of the
mastectomy, including lymphedemas. Such coverage shall be subject to all other provisions of this Plan.
9.5 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. To the extent this Plan provides mental health benefits or substance use disorder benefits it will not place annual or lifetime maximums for such benefits that are
lower than the annual and lifetime maximums for physical health benefits. In addition, the financial requirements (e.g., deductibles and co-payments) and treatment limitations (e.g., number of visits or days of coverage) that apply to mental health
benefits or substance use disorder benefits will not be more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits; mental health benefits and substance use disorder
benefits will not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits; if the Plan provides for out of network medical/surgical or substance use disorder benefits, it will provide for out of
network mental health and substance use disorder benefits and standards for medical necessity determinations and reasons for any denial of benefits relating to mental health benefits and substance use disorder benefits will be made available upon request
to plan participants. Such coverage shall be subject to all other provisions of this Plan.
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9.6 Continuation of Coverage During Family or Medical Leave. During any period which an Active Employee Participant is on a family or medical leave as defined in the Family or Medical Leave Act, any benefit elections in force for such Participant shall remain
in effect. While the Participant is on paid leave, contributions shall continue. If the Participant is on an unpaid leave, the Participant may elect to prepay required contributions on a pre-tax basis before the commencement of such unpaid leave.
Alternatively, the Participant may elect to make such payments on an after-tax basis monthly in accordance with an arrangement that the Plan Administrator shall provide. If coverage is not continued during the entire period of the family or medical leave
because the Participant declines to pay the premium, the coverage must be reinstated upon reemployment with no exclusions or waiting periods, notwithstanding any other provision of this Plan to the contrary. If the Participant does not return to work upon
completion of the leave, the Participant must pay the full cost of any health care coverage that was continued on his/her behalf during the leave. These rules apply to the COBRA eligible programs.
9.7 Rights While on Military Leave. Pursuant to the provisions of the Uniformed Services Employment and Reemployment Rights Act of 1994, an Active Employee Participant on military leave will be considered to be on a Leave of Absence and will be entitled
during the leave to the health and welfare benefits that would be made available to other similarly situated employees if they were on a Leave of Absence. This entitlement will end if the individual provides written notice of intent not to return to work
following the completion of the military leave. The individual shall have the right to continue his/her coverage, including any Dependent coverage, for the lesser of the length of the leave or 18 months. If the military leave is for a period of 31 days
or more, the individual may be required to pay 102 percent of the total premium (determined in the same manner as a COBRA continuation coverage premium). If coverage is not continued during the entire period of the military leave because the individual
declines to pay the premium or the leave extends beyond 18 months, the coverage must be reinstated upon reemployment with no pre-existing condition exclusions (other than for service-related illnesses or injuries) or waiting periods (other than those
applicable to all Eligible Employees).
9.8 Qualified Medical Child Support Orders. The Plan will comply with any Qualified Medical Child Support Order issued by a court of competent jurisdiction or administrative body that requires the Plan to provide medical coverage to a Dependent child of an
Active Employee or Retired Employee Participant. The Plan Administrator will establish reasonable procedures for determining whether a court order or administrative decree requiring medical coverage for a Dependent child meets the requirements for a
Qualified Medical Child Support Order. The cost of coverage or any additional cost of such coverage, if any, shall be borne by the Participant.
9.9 Right of Recovery. If the Plan has made an erroneous or excess payment to any Participant, the Plan Administrator shall be entitled to recover such excess from the individual or entity to whom such payments were made. The recovery of such overpayment may be made by offsetting the amount of any other benefit or amount payable by the amount of the overpayment under the Plan.
ARTICLE 10 COBRA
10.1 Continuation of Coverage Under COBRA. Participants shall have all COBRA continuation rights required by federal law and all conversion rights. COBRA continuation coverage shall be continued as provided in this Article 10.
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10.2 COBRA Continuation Coverage for Terminated Participants. A covered Active Employee Participant may elect COBRA continuation coverage, at his/her own expense, if his participation under this Plan would terminate as a result of one of the following Qualifying Events: an Employee's termination of employment or reduction of hours with an Employer.
10.3 COBRA Continuation Coverage for Dependents. A Qualified Dependent may elect COBRA continuation coverage, at his/her own expense, if his/her participation under this Plan would terminate as a result of a Qualifying Event.
10.4 Period of Continuation Coverage for Covered Participants. A covered Active Employee Participant who qualifies for COBRA continuation coverage as a result of a Participant's termination of employment or reduction in hours of employment described in Subsection 10.2 may elect COBRA continuation coverage for up to 18 months measured from the date of the Qualifying Event.
Coverage under this Subsection 10.4 may not continue beyond the:
(1) date on which the Active Employee Participant's Employer ceases to maintain this Plan;
(2) last day of the month for which premium payments have been made with respect to this Plan, if the individual fails to make premium payments on time, in accordance with Subsection 10.6;
(3) date the covered Active Employee Participant becomes entitled to Medicare; or
(4) date the covered Participant is no longer subject to a pre-existing condition exclusion under the Participant's other coverage or new employer plan for the type of coverage available under the COBRA eligible program for which the COBRA election was made.
10.5 Period of COBRA Continuation Coverage for Dependents. If a Qualified Dependent elects COBRA continuation coverage under a COBRA eligible program as a result of the an Active Employee Participant's termination of employment as described in Subsection 10.2, continuation coverage may be continued for up to 18 months measured from the date of the Qualifying Event. COBRA continuation coverage for all other Qualifying Events may continue for up to 36 months.
Continuation coverage under this Subsection 10.5 with respect to a COBRA eligible program may not continue beyond the
date:
(1) on which premium payments have not been made, in accordance with Subsection 10.6 below;
(2) the Qualified Dependent becomes entitled to Medicare;
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(3) on which the Employer ceases to maintain this Plan; or
(4) the Qualified Dependent is no longer subject to a pre-existing condition exclusion under the Participant's other coverage or new employer plan for the type of coverage available under this Plan.
10.6 Contribution Requirements for COBRA Continuation Coverage. Covered Participants and Qualified Dependents who elect COBRA continuation coverage as a result of a Qualifying Event will be required to pay continuation coverage payments. Continuation coverage
payments are the payments required for COBRA continuation coverage that is an amount equal to a reasonable estimate of the cost to this Plan of providing coverage for all covered Participants at the time of the Qualifying Event plus a 2% administrative
expense. In the case of a disabled individual who receives an additional 11-month extended coverage under COBRA, the Employer may assess up to 150% of the cost for this extended coverage period. Such cost shall be determined on an actuarial basis and
take into account such factors as the Secretary of the Treasury may prescribe in regulations.
Covered Participants and Qualified Dependents must make the continuation coverage payment prior to the first day of the
month in which such coverage will take effect. However, a covered Participant or Qualified Dependent has 45 days from the
date of an affirmative election to pay the continuation coverage payment for the first month's payment and the cost for the
period between the date medical coverage would otherwise have terminated due to the Qualifying Event and the date the
covered Participant and/or Qualified Dependent actually elects COBRA continuation coverage.
The covered Participant and/or Qualified Dependent shall have a 30-day grace period to make the continuation coverage
payments due thereafter. Continuation coverage payments must be postmarked on or before the completion of the 30-day grace
period. If continuation coverage payments are not made on a timely basis, COBRA continuation coverage will terminate as of
the last day of the month for which timely premiums were made. The 30-day grace period shall not apply to the 45-day
period for the first month's payment of COBRA premiums as set out in the section above.
If payment is received that is significantly less than the required continuation coverage payment, then continuation
coverage will terminate as of the last day of the month for which premiums were paid. A payment is considered
significantly less than the amount due if it is greater than the lesser of $50 or 10% of the required continuation coverage
payment. Upon receipt of a continuation coverage payment that is insignificantly less than the required amount, the Plan
Administrator must notify the covered Participant or Qualified Dependent of the amount of the shortfall and provide them
with an additional 30-day grace period from the date of the notice for this payment only.
10.7 Limitation on Participant's Rights to COBRA Continuation Coverage.
(1) If a Qualified Dependent loses, or will lose medical coverage under this Plan as a result of divorce, legal separation, entitlement to Medicare, or ceasing to be a Dependent, such Qualified Dependent is responsible for notifying the Plan Administrator in writing within 60 days of the Qualifying Event. Failure to make timely notification will terminate the Qualified Dependent's rights to COBRA continuation coverage under this Article.
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(2) A Participant must complete and return the required enrollment materials within 60 days from the later of (a) the date of loss of coverage, or (b) the date the Plan Administrator sends notice of eligibility for COBRA continuation coverage. Failure to
enroll for COBRA continuation coverage during this 60-day period will terminate all rights to COBRA continuation coverage under this Article. An affirmative election of COBRA continuation coverage by a Participant or his/her spouse shall be deemed to be
an election for that Participant's Dependent(s) who would otherwise lose coverage under the Plan.
10.8 Subsequent Qualifying Event. If a second Qualifying Event occurs during an 18-month extension explained above, coverage may be continued for a maximum of 36 months from the date of the first Qualifying Event. In the event the Dependent loses coverage due
to a Qualifying Event and after such date the Participant becomes entitled to Medicare, the Dependent shall have available up to 36 months of coverage measured from the date of the Qualifying Event that causes the loss of coverage. If the Participant was
entitled to Medicare prior to the Qualifying Event, the Dependent shall have up to 36 months of coverage measured from the date of entitlement to Medicare.
10.9 Extension of COBRA Continuation Period for Disabled Individuals. The period of continuation shall be extended to 29 months in total (measured from the date of the Qualifying Event) in the event the individual is disabled as determined by the Social
Security laws within 60 days of the Qualifying Event. The individual must provide evidence to the Plan Administrator of such Social Security determination prior to the earlier of 60 days after the date of the Social Security determination, or the
expiration of the initial 18 months of COBRA continuation coverage. In such event, the Employer may charge the individual up to 150% of the COBRA cost of the coverage.
ARTICLE 11 PRIVACY OF MEDICAL INFORMATION
11.1 Definitions. For purposes of this Article 11, the following defined terms shall have the meaning assigned to such terms in this subsection:
(1) "Business Associate" shall have the meaning assigned to such phrase at 45 C.F.R. § 160.103;
(2) "Health Care Operations" shall have the meaning assigned to such phrase at 45 C.F.R. § 164.501;
(3) "HIPAA" shall mean Parts 160 ("General Administrative Requirements") and 164 ("Security and Privacy") of Title 45 of
the Code of Federal Regulations as such parts are amended from time to time;
(4) "Payment" shall have the meaning assigned to such phrase at 45 C.F.R § 160.103;
(5) "Protected Health Information" or "PHI" shall have the meaning assigned to such phrase at 45 C.F.R. § 160.103; and
(6) "Treatment" shall have the meaning assigned to such phrase at 45 C.F.R. § 164.501.
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11.2 Privacy Provisions Relating to Protected Health Information ("PHI"). The Plan and its Business Associates shall use and disclose PHI to the extent permitted by, and in accordance with, HIPAA, for purposes of providing benefits under the Plan and for purposes of administering the plan, including, by way of illustration and not by way of limitation, for purposes of Treatment, Payment, and Health Care Operations.
11.3 Disclosure of De-Identified or Summary Health Information. The HIPAA Plan, or, with respect to the HIPAA Plan, a health insurance issuer, may disclose summary health information (as that phrase is defined at 45 C.F.R. § 160.5049a)) to the Plan Sponsor of the HIPAA Plan (and its affiliates) if such entity requests such information for the purpose of:
(1) Obtaining premium bids from health plans for providing health insurance coverage under the HIPAA Plan;
(2) Modifying, amending or terminating the group health benefits under the HIPAA Plan.
In addition, the HIPAA Plan or a health insurance insurer with respect to the HIPAA Plan may disclose to the Plan Sponsor
of the HIPAA Plan (or its affiliates) information on whether an individual is participating in the group health benefits
provided by the HIPAA Plan or is enrolled in, or has ceased enrollment with health insurance offered by the HIPAA Plan.
11.4 The HIPAA Plan Will Use and Disclose PHI as Required by Law or as Permitted by the Authorization of the Participant or Beneficiary .
Upon submission of an authorization signed by a Participant, beneficiary, subscriber or personal representative that meets
HIPAA requirements, the HIPAA Plan will disclose PHI.
In addition, PHI will be disclosed to the extent permitted or required by law, without the submission of an authorization
form.
11.5 Disclosure of PHI to the Plan Sponsor. The HIPAA Plan will disclose information to the Plan Sponsor only upon certification from the Plan Sponsor that the HIPAA Plan documents have been amended to incorporate the assurances provided below.
The Plan Sponsor agrees to:
(1) not use or further disclose PHI other than as permitted or required by the HIPAA Plan document or as required by law;
(2) ensure that any affiliates or agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the HIPAA Plan, agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI;
(3) not use or disclose PHI for employment-related actions and decisions unless authorized by the individual to whom the PHI relates;
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(4) not use or disclose PHI in connection with any other benefits or employee benefit plan of the Plan Sponsor or its affiliates unless permitted by the Plan or authorized by an individual to whom the PHI relates;
(5) report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which it becomes aware;
(6) make PHI available to an individual in accordance with HIPAA's access rules;
(7) make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
(8) make available the information required to provide an accounting of disclosures;
(9) make internal practices, books and records relating to the use and disclosure of PHI received from the HIPAA Plan available to the Secretary of the United States Department of Health and Human Resources for purposes of determining the Plan's compliance with HIPAA; and
(10) if feasible, return or destroy all PHI received from the HIPAA Plan that the Plan Sponsor still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible).
11.6 Separation Between the Plan Sponsor and the HIPAA Plan. In accordance with HIPAA, only the following employees and Business Associate personnel shall be given access to PHI:
(1) employees of the AT&T Benefits and/or AT&T Executive Compensation organizations responsible for administering group health plan benefits under the HIPAA Plan, including those employees whose functions in the regular course of business include Payment, Health Care Operations or other matters pertaining to the health care programs under a HIPAA Plan;
(2) employees who supervise the work of the employees described in (1), above;
(3) support personnel, including other employees outside of the AT&T Benefits or AT&T Executive Compensation organizations whose duties require them to rule on health plan-related appeals or perform functions concerning the HIPAA Plan;
(4) investigatory personnel to the limited extent that such PHI is necessary to conduct investigations of possible fraud;
(5) outside and in-house legal counsel providing counsel to the HIPAA Plan;
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(6) consultants providing advice concerning the administration of the HIPAA Plan; and
(7) the employees of Business Associates charged with providing services to the HIPAA Plan.
The persons identified above shall have access to and use PHI to the extent that such access and use is necessary for the
administration of group health benefits under a HIPAA Plan. If these persons do not comply with this Plan document, the
Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.
11.7 Enforcement. Enforcement of this Article 11 shall be as provided for by HIPAA. In particular, participants and beneficiaries are not authorized to sue with regard to purported breaches of this Article 11 except as explicitly permitted by HIPAA.
ARTICLE 12 CLAIM AND APPEAL PROCESS
12.1 Claims for Benefits under the Plan. - See Appendix B.
12.2 Claims Related to Basic Eligibility for Coverage under the Plan and Claims Related to the Article 8 Loyalty Conditions .
(a) Claims. A person who believes that he or she is being denied a benefit to which he or she is entitled under this Plan (hereinafter referred to as a "Claimant") based on a claim for basic eligibility for coverage under the Plan or a claim related to the Article 8 Loyalty Conditions may file a written request for such benefit with the Executive Compensation Administration Department, setting forth his or her claim. The request must be addressed to the AT&T Executive Compensation Administration Department
at its then principal place of business.
(b) Claim Decision. Upon receipt of a claim, the AT&T Executive Compensation Administration Department shall review the claim and provide the Claimant with a written notice of its decision within a reasonable period of time, not to exceed ninety (90) days,
after the claim is received. If the AT&T Executive Compensation Administration Department determines that special circumstances require an extension of time beyond the initial ninety (90)- day claim review period, the AT&T Executive Compensation
Administration Department shall notify the Claimant in writing within the initial ninety (90)-day period and explain the special circumstances that require the extension and state the date by which the AT&T Executive Compensation Administration Department
expects to render its decision on the claim. If this notice is provided, the AT&T Executive Compensation Administration Department may take up to an additional ninety (90) days (for a total of one hundred eighty (180) days after receipt of the claim) to
render its decision on the claim.
If the claim is denied by the AT&T Executive Compensation Administration Department, in whole or in part, the AT&T Executive Compensation Administration Department shall provide a written decision using language calculated to be understood by the Claimant
and setting forth: (i) the specific reason or reasons for such denial; (ii) specific references to pertinent provisions of this Plan on which such denial is based; (iii) a description of any additional material or information necessary for the Claimant to
perfect his or her claim and an explanation of why such material or such information is necessary; (iv) a description of the Plan's procedures for review of denied claims and the steps to be taken if the Claimant wishes to submit the claim for review; (v)
the time limits for requesting a review of a denied claim under this section and for conducting the review under this section ; and (vi) a statement of the Claimant's right to bring a civil action under Section 502(a) of ERISA if the claim is denied
following review under this section.
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(c) Request for Review. Within sixty (60) days after the receipt by the Claimant of the written decision on the claim provided for in this section, the Claimant may request in writing that the Plan Administrator review the determination of the AT&T Executive
Compensation Administration Department. Such request must be addressed to the Plan Administrator at the address provided in the written decision regarding the claim. To assist the Claimant in deciding whether to request a review of a denied claim or in
preparing a request for review of a denied claim, a Claimant shall be provided, upon written request to the Plan Administrator and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claim. The
Claimant or his or her duly authorized representative may, but need not, submit a statement of the issues and comments in writing, as well as other documents, records or other information relating to the claim for consideration by the Committee. If the
Claimant does not request a review by the Plan Administrator of the AT&T Executive Compensation Administration Department's decision within such sixty (60)-day period, the Claimant shall be barred and estopped from challenging the determination of the AT&T
Executive Compensation Administration Department.
(d) Review of Decision. Within sixty (60) days after the Plan Administrator's receipt of a request for review, the Plan Administrator will review the decision of the AT&T Executive Compensation Administration Department. If the Plan Administrator determines
that special circumstances require an extension of time beyond the initial sixty (60)-day review period, the Plan Administrator shall notify the Claimant in writing within the initial sixty (60)-day period and explain the special circumstances that require
the extension and state the date by which the Plan Administrator expects to render its decision on the review of the claim. If this notice is provided, the Plan Administrator may take up to an additional sixty (60) days (for a total of one hundred twenty
(120) days after receipt of the request for review) to render its decision on the review of the claim
During its review of the claim, the Plan Administrator shall:
(1) Take into account all comments, documents, records, and other information submitted by the Claimant relating to the claim, without regard to whether such information was submitted or considered in the initial review of the claim conducted pursuant to this section;
(2) Follow reasonable procedures to verify that its benefit determination is made in accordance with the applicable Plan documents; and
(3) Follow reasonable procedures to ensure that the applicable Plan provisions are applied to the Participant to whom the claim relates in a manner consistent with how such provisions have been applied to other similarly-situated Participants.
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After considering all materials presented by the Claimant, the Plan Administrator will render a decision, written in a
manner designed to be understood by the Claimant. If the Plan Administrator denies the claim on review, the written
decision will include (i) the specific reasons for the decision; (ii) specific references to the pertinent provisions of
this Plan on which the decision is based; (iii) a statement that the Claimant is entitled to receive, upon request to the
Plan Administrator and free of charge, reasonable access to, and copies of, all documents, records, and other information
relevant to the claim; and (iv) a statement of the Claimant's right to bring a civil action under Section 502(a) of ERISA.
In any case, a Participant or Beneficiary may have further rights under ERISA. The Plan provisions require that
Participants or Beneficiary pursue all claim and appeal rights described in this section before they seek any other legal
recourse regarding claims for benefits.
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Appendix A
AT&T Health Plan
2017 Monthly Contributions, Annual Deductible, Coinsurance Percentages and
Annual Out-of-Pocket Maximum
Active Participants
Monthly Contributions Individual - $74Individual + Spouse - $91Individual + 1 or More Children - $74Individual + Spouse + 1 or More Children - $178
Annual Deductible (combined with group medical plan annual deductible) Individual - $1,500Individual + 1 or More - $3,000
Coinsurance Percentage (Note 1) 10% after the Annual Deductible is met. Coinsurance applies until the Annual Out-of-Pocket Maximum is reached.
Annual Out-of-Pocket Maximum Individual - $5,000Individual + 1 or More - $10,000 (individual amount of $5,000)
Note 1: For prescription pharmacy services, the Coinsurance shall equal the lesser of (i) the Coinsurance Percentage
multiplied by the amount of the Covered Health Services or (ii) the amount payable by the Participant for such services
under the Basic Plan.
Retired Participants - Monthly Contributions
Retired Prior to August 31, 1992 and Surviving Spouses Individual - $200Individual + Spouse - $200Individual + 2 or More - $200
Retired on or after September 1, 1992 and Surviving Spouses Note: The Plan Administrator shall maintain records governing whether a Retired Participant is in Class A, B, C or D. Class A Individual - $507Individual + Spouse - $825Individual + 1 or More Children - $507Individual + Spouse + 1 or More Children - $782
Class B Individual - $620Individual + Spouse - $1,009Individual + 1 or More Children - $620Individual + Spouse + 1 or More Children - $958
Class C Individual - $783Individual + Spouse - $1,261Individual + 1 or More Children - $783Individual + Spouse + 1 or More Children - $1,209
Class D Individual - $954Individual + Spouse - $1,944Individual + 1 or More Children - $954Individual + Spouse + 1 or More Children - $1,920
COBRA Continuation Coverage - Monthly Contributions
Active COBRA Individual - $873Individual + Spouse - $1,788Individual + 1 or More Children - $1,411Individual + Spouse + 1 or More Children - $2,558
Retired Prior to August 31, 1992 and Surviving Spouses COBRA Individual - $1,412Individual + 1 - $2,879Individual + 2 or More - $3,944
Retired on or after September 1, 1992 and Surviving Spouses COBRA Individual - $1,412Individual + Spouse - $2,879Individual + 1 or More Children - $3,832Individual + Spouse + 1 or More Children - $4,112
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Appendix B
Claims Procedure Applicable to Claims for Benefits under the Plan
Claim for Benefits Procedures
You, your covered dependents or a duly authorized person has the right under ERISA and the Plan to file a written claim for
benefits under the Plan. The following describes the procedures used by the Plan to process claims for benefits, along with
your rights and responsibilities. These procedures were designed to comply with the rules of the Department of Labor (DOL)
concerning claims for Benefits. It is important that you follow these procedures to make sure that you receive full
benefits under the Plan.
The Plan is an ERISA plan, and you may file suit in federal court if you are denied benefits you believe are due you under
the Plan. However, you must complete the full claims and appeal process offered under the Plan before filing a lawsuit.
Filing a Claim for Benefits
When filing a claim for benefits, you should file the claim with the Claims Administrator. The Claims Administrator is the
third party to whom claims and appeal responsibility has been delegated as permitted under Section 9.1 of the Plan.
The following are not considered claims for benefits under the Plan:
· A claim related to basic eligibility for coverage under the Plan (See Section 12.2 of the Plan).
· A claim related to the Loyalty Conditions contained in Article 8 of the Plan (See Section 12.2 of the Plan).
Claim Filing Limits
A request for payment of benefits must be submitted within one year after the date of service or the date the prescription
was provided.
Required Information
When you request payment of benefits from the Plan, you must provide certain information as requested by the Claims
Administrator.
Benefit Determinations
Post-Service Claims
Post-service claims are those claims that are filed for payment of benefits after medical care has been received. If your
post-service claim is denied, you will receive a written notice from the Claims Administrator within 30 days of receipt of
the claim, as long as all needed information identified above and any other information that the Claims Administrator may
request in connection with services rendered to you was provided with the claim. The Claims Administrator will notify you
within this 30-day period if additional information is needed to process the Claim and may request a one-time extension not
longer than 15 days and pend your Claim until all information is received.
Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is
received within the 45-day time frame and the claim is denied, the claims Administrator will notify you of the denial
within 15 days after the information is received. If you don't provide the needed information within the 45-day period,
your claim will be denied.
A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide
the claim appeal procedures.
Pre-Service Claims
Pre-service claims are those claims that require notification or approval prior to receiving medical care or require
notification within a specified time period after service begins as required under the Plan provisions. If your claim is a
pre-service claim and is submitted properly with all needed information, you will receive written notice of the claim
decision from the Claims Administrator within 15 days of receipt of the claim. If you file a pre-service claim improperly,
the Claims Administrator will notify you of the improper filing and how to correct it within five days after the
pre-service claim is received. If additional information is needed to process the
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pre-service claim, the Claims Administrator will notify you of the information needed within 15 days after the claim was
received and may request a one-time extension not longer than 15 days and pend your claim until all information is
received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed
information is received within the 45-day time frame, the Claims Administrator will notify you of the determination within
15 days after the information is received. If you don't provide the needed information within the 45-day period, your claim
will be denied. A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is
based, and provide the claim appeal procedures.
Urgent Care Claims That Require Immediate Action
Urgent care claims are those claims that require notification or approval prior to receiving medical care in which a delay
in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of
a physician with knowledge of your medical condition, could cause severe pain. In these situations:
· You will receive notice of the benefit determination in writing or electronically within 72 hours after the Claims Administrator receives all necessary information, taking into account the seriousness of your condition.
· Notice of denial may be oral with a written or electronic confirmation to follow within three days.
If you filed an urgent claim improperly, the Claims Administrator will notify you of the improper filing and how to correct
it within 24 hours after the urgent claim was received. If additional information is needed to process the claim, the
Claims Administrator will notify you of the information needed within 24 hours after the claim was received. You then have
48 hours to provide the requested information.
You will be notified of a determination no later than 48 hours after either:
· The Claims Administrator's receipt of the requested information.
· The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time.
A denial notice will explain the reason for denial, refer to the part of the Plan on which the denial is based, and provide
the claim appeal procedures.
Concurrent Care Claims
If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your
request to extend the treatment is an urgent care claim as defined above, your request will be decided within 24 hours,
provided your request is made at least 24 hours prior to the end of the approved treatment. The Claims Administrator will
make a determination on your request for the extended treatment within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the
request will be treated as an urgent care claim and decided according to the time frames described above. If an ongoing
course of treatment was previously approved for a specific period of time or number of treatments, and you request to
extend treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to
post-service or pre-service timeframes, whichever applies.
How to Appeal a Claim Decision
If you disagree with a pre-service or post-service claim determination after following the above steps, you can contact the
applicable Claims Administrator in writing to formally request an appeal. Your first appeal request must be submitted to
the Claims Administrator within 180 days after you receive the Claim denial.
Appeal Process
A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. The
Claims Administrator may consult with, or seek the participation of, medical experts as part of the appeal resolution
process. You must consent to this referral and the sharing of pertinent medical claim information. Upon written request and
free of charge you have the right to reasonable access to and copies of all documents, records and other information
relevant to your claim for benefits.
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Appeals Determinations
Pre-Service and Post-Service Claim Appeals
You will be provided written or electronic notification of the decision on your appeal as follows:
· For appeals of pre-service claims, the first-level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 15 days from receipt of a request for appeal of a denied Claim. The second-level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 15 days from receipt of a request for review of the first-level appeal decision.
· For appeals of post-service claims, the first-level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 30 days from receipt of a request for appeal of a denied claim. The second-level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 30 days from receipt of a request for review of the first-level appeal decision.
· For procedures associated with urgent Claims, refer to the following "Urgent Claim Appeals That Require Immediate Action" section.
· If you are not satisfied with the first-level appeal decision of the Claims Administrator, you have the right to request a second-level appeal from the Claims Administrator. Your second level appeal request must be submitted to the Claims Administrator in writing within 60 days from receipt of the first-level appeal decision.
· For pre-service and post-service claim appeals, the Plan Administrator has delegated to the Claims Administrator the exclusive right to interpret and administer the provisions of the Plan. The Claims Administrator's decisions are conclusive and binding.
Please note that the Claims Administrator's decision is based only on whether or not benefits are available under the Plan
for the proposed treatment or procedure. The determination as to whether the pending health service is necessary or
appropriate is between you and your physician.
Urgent Claim Appeals That Require Immediate Action
Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or
the ability to regain maximum function or cause severe pain.
In these urgent situations, the appeal does not need to be submitted in writing. You or your physician should call the
Claims Administrator as soon as possible. The Claims Administrator will provide you with a written or electronic
determination within 72 hours following receipt by the Claims Administrator of your request for review of the determination
taking into account the seriousness of your condition.
For urgent claim appeals, the Plan Administrator has delegated to the applicable Claims Administrator the exclusive right
to interpret and administer the provisions of the Plan. The Claims Administrator's decisions are conclusive and binding.
In any case, a Participant or Beneficiary may have further rights under ERISA. The Plan provisions require that
Participants or Beneficiary pursue and exhaust all claim and appeal rights described in this section before they seek any
other legal recourse regarding claims for benefits.
27
APPENDIX C
DISCLOSURE OF GRANDFATHERED STATUS
MODEL NOTICE
AT&T, as plan sponsor, believes this Plan is a "grandfathered health plan" under the Patient Protection and Affordable Care
Act (the "Affordable Care Act"). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain
basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that
the plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example,
the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health
plans must comply with certain other consumer protections of the Affordable Care Act, for example, the elimination of
lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what
might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at P.O. Box
30558, Salt Lake City, Utah 84130-0558 . You may also contact the Employee Benefits Security Administration, U.S.
Department of labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform . This website has a table summarizing which
protections do and do not apply to grandfathered health plans.
28
AGREEMENT AND RELEASE AND WAIVER OF CLAIMS
This Agreement and the Release and Waiver contained herein are made and entered into in Dallas, Texas, by and between AT&T
Services, Inc. (hereinafter "Company") and Mr. James Cicconi (hereinafter "Mr. Cicconi") for and in consideration of the
mutual promises and agreements set forth below and are conditional on performance of such promises and agreements.
WHEREAS, Mr. Cicconi will retire from Company on September 30, 2016; and as a consequence, Mr. Cicconi will be entitled to
receive appropriate, usual and customary benefits and certain other benefits described herein; and
WHEREAS, both parties agree that in connection with Mr. Cicconi's retirement on September 30, 2016, in addition to the
before referenced appropriate, usual and customary benefits, Mr. Cicconi should receive additional benefits and
consideration as set forth herein, and that Mr. Cicconi, among other things, should release and forever discharge Company,
AT&T Inc. ("AT&T"), any and all other subsidiaries (which term when used throughout this document shall include entities,
corporate or otherwise, in which the company referred to owns, directly or indirectly, fifty percent or more of the
outstanding equity interests) of Company and of AT&T, their officers, directors, agents, employees, successors and assigns
and any and all employee benefit plans maintained by AT&T or any subsidiary thereof and/or any and all fiduciaries of any
such plan, from any and all common law and/or statutory claims, causes of action or suits of any kind whatsoever, arising
from or in connection with Mr. Cicconi's employment by Company or any affiliate of AT&T and/or Mr. Cicconi's separation
from Company, all as set forth in more detail in the Release and Waiver contained herein.
WHEREAS, Mr. Cicconi has been employed by Company and/or AT&T's subsidiaries for eighteen (18) years and worked in
significant positions and assignments that required access to and involvement with confidential and proprietary
information, trade secrets and matters of strategic importance to Company, AT&T and/or AT&T's subsidiaries that will
continue beyond Mr. Cicconi's employment with Company. During the term of his longstanding with Company, or an AT&T
subsidiary, Mr. Cicconi has acquired knowledge of all aspects of its business, on a national and regional level, including
but not limited to operations, sales, marketing, advertising, technology, networks, network technology, network development
and strategy, distribution and distribution channels, operations, strategic planning initiatives, new product and services
development, strategic planning, rate information and growth strategies and initiatives. Mr. Cicconi has acquired and
possesses unique skills as a result of employment with Company and/or AT&T subsidiaries. The trade secrets with which Mr.
Cicconi has been involved are critical to Company's, AT&T's, and AT&T's subsidiaries' success. Disclosure of this
information in the performance of services for a subsequent employer engaged in similar businesses would be inevitable and
inherent as part of Mr. Cicconi's performance of services for such an employer. For all of these reasons and due to the
confidential and proprietary information and trade secrets Mr. Cicconi learned in his employment with Company, or an AT&T
subsidiary, Mr. Cicconi acknowledges that it is reasonable for Company to seek the restrictions contained in the subsequent
provisions of this Agreement and that more limited restrictions are neither feasible nor appropriate. Mr. Cicconi
understands and agrees that the consideration provided herein requires Mr. Cicconi to comply strictly with all terms of
this Agreement including, but not limited to, confidentiality, non-compete, non-solicitation of employees and
non-solicitation of customers as set forth below.
NOW, therefore, the parties further agree as follows:
1. Mr. Cicconi will retire from Company effective at the close of business on September 30, 2016, and Mr. Cicconi herewith
resigns all officer and director positions that he may hold in AT&T and in any subsidiary of AT&T effective at the close of
business on September 30, 2016.
2. Company shall propose to the Human Resources Committee of the AT&T Board of Directors or its authorized delegate (the
"Committee") that the AT&T 2011 Incentive Plan provisions requiring (A) the automatic proration of Mr. Cicconi' 2014, 2015,
and 2016 Performance Share Grants shall not apply and Mr. Cicconi shall be eligible for full distribution of such grants
after the applicable three (3) year performance period, subject to adjustment based on achievement of the applicable
performance goals, approval of the Committee and all other terms and conditions of the grant, (B) the automatic forfeiture
of Mr. Cicconi's 2013, 2014, 2015, and 2016 Restricted Stock Units shall not apply and Mr. Cicconi shall be eligible for
full distribution of such Restricted Stock Units, which shall be paid subject to all other terms and conditions of the
Restricted Stock Unit grants, including with respect to timing, and (C) the automatic forfeiture of Mr. Cicconi's 2014
Restricted Stock Award shall not apply and Mr. Cicconi shall be fully vested and such Restricted Stock Award shall be
distributed upon his termination of employment. Notwithstanding the foregoing, none of the consideration described in this
Section 2 shall be made available to Mr. Cicconi (or shall be subject to rescission) should he not timely sign, or should
he revoke, the Release and Wavier contained herein.
3. The consideration described herein shall be in lieu of, and Mr. Cicconi hereby specifically waives any right to any and
all other termination pay allowance resulting from his retirement.
4. This Agreement and the Release and Waiver contained herein do not abrogate any of the usual entitlements that Mr.
Cicconi has or will have, first, while a regular employee and subsequently, upon his retirement, under any AT&T or AT&T
subsidiary sponsored employee benefit plan, program or policy, all of which will be subject to and provided in accordance
with the terms and conditions of the respective benefit plan, program, or policy as applicable to Mr. Cicconi. Further,
AT&T and its subsidiaries have reserved the right to end or amend any or all of the plans, programs, and policies that it
sponsors. Each participating subsidiary, which includes Company, has reserved the right to end its participation in these
plans, programs, and policies and to discontinue providing any and all such benefits. This means, for example, that Mr.
Cicconi will not acquire a lifetime right to any health care plan benefit or to the continuation of any health care plan
merely by reason of the fact that such benefit, plan, program, or policy is in existence at the time of Mr. Cicconi'
retirement or because of this Agreement and the Release and Waiver contained herein. Thus, except as specifically provided
in this Agreement, Mr. Cicconi's rights/entitlements to any benefit under any of the plans, programs, or policies are no
different as a result of entering into this Agreement and the Release and Waiver contained herein than they would have been
in the absence of this Agreement and the Release and Waiver contained herein.
5. At Company's request at any time during the eighteen (18) months immediately following his retirement, Mr. Cicconi will
cooperate with Company, AT&T or any of their respective subsidiaries in any future claims or lawsuits involving any of them
where Mr. Cicconi has knowledge of the underlying facts; provided, however, Mr. Cicconi shall not be required to and shall
not provide such services for more than twenty percent (20%) of the average amount of time he provided bona fide services
over the thirty-six (36) month period immediately preceding September 30, 2016. For the time Mr. Cicconi spends working on
any claims or lawsuits at such request, Mr. Cicconi shall be reimbursed at the equivalent per hour base salary rate at
which Mr. Cicconi was being compensated by Company immediately prior to his retirement; provided, however, that if Mr.
Cicconi is a named party in any claim or lawsuit and Company, in its discretion, determines that Mr. Cicconi's interests
are adverse to Company, AT&T or any of their respective subsidiaries, he will not be entitled to such compensation. Mr.
Cicconi agrees not to voluntarily aid, assist, or cooperate with any claimants or plaintiffs or their attorneys or agents,
whether individually or as part of a class, in any claims or lawsuits commenced in the future against Company, AT&T or any
AT&T subsidiary; provided, however, that nothing in this Agreement shall prohibit Mr. Cicconi from exercising his right to
file a charge of discrimination with, or that would limit his right to testify, assist, or participate in an investigation,
hearing, or proceeding conducted by the Equal Employment Opportunity Commission ("EEOC"), a comparable state or local
agency, or any other governmental agency charged with enforcing anti-discrimination laws; provided, further, however,
nothing in this Agreement will be construed to prevent Mr. Cicconi from testifying at an administrative hearing, a
deposition, or in court in response to a lawful subpoena in any litigation or proceedings involving Company, AT&T or any of
their respective subsidiaries. Notwithstanding the foregoing, Mr. Cicconi acknowledges and agrees that the Release and
Waiver contained herein includes a waiver of his right, if any, to monetary recovery should any party, entity,
administrative agency, or governmental agency (such as the EEOC, the National Labor Relations Board, or any state or local
agencies) pursue any claims on Mr. Cicconi's behalf against the persons or entities covered by the Agreement and the
Release and Waiver contained herein.
1
Company agrees to indemnify Mr. Cicconi if he is a defendant or is threatened to be made a defendant to any action, suit or
proceeding, whether civil, criminal, administrative or investigative that is brought by a third party by reason of the fact
that he was a director, officer, employee or agent of Company, or was serving at the request of Company as a director,
officer, employee or agent of another corporation, partnership, joint venture, trust or other enterprise, against expenses
(including attorneys' fees), judgments, fines and amounts paid in settlement actually and reasonably incurred by him in
connection with such action, suit or proceeding, but in each case only if and to the extent permitted under applicable
state or federal law.
6. Mr. Cicconi acknowledges that, as a result of his employment with Company and/or any AT&T subsidiaries, he has and had
access to certain Trade Secrets and Confidential Information (as these terms are defined below) and the Company will
continue to provide Mr. Cicconi access to such Trade Secrets and Confidential Information through his termination of
employment so that he may continue performing his job responsibilities. Mr. Cicconi acknowledges that AT&T and its
subsidiaries must protect its Trade Secrets and Confidential Information from disclosure or misappropriation, and Mr.
Cicconi further acknowledges that the Trade Secrets and Confidential Information are unique and confidential and are the
proprietary property of AT&T and its subsidiaries. Mr. Cicconi acknowledges that the Trade Secrets and Confidential
Information derive independent, actual and potential commercial value from not being generally known, or readily
ascertainable through independent development. Mr. Cicconi agrees to hold Trade Secrets or Confidential Information in
trust and confidence and to not directly or indirectly disclose or transmit Trade Secrets or Confidential Information to
any third party without prior written consent of AT&T; provided however, nothing in this Agreement shall prohibit Mr.
Cicconi from reporting possible violations of federal law or regulation to any governmental
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