UMWA REPRESENTED EMPLOYEES
[ Name of Employer ]
Effective as of December 16, 1993
This Benefit Plan for United Mine Workers of America Represented Employees of
(Name of Employer) (“the Plan”) has been established pursuant to the provisions of Article
XX of the National Bituminous Coal Wage Agreement of 1993.
The Plan provides health and vision care for Employees and Pensioners and their eligible
Dependents, and life insurance and accidental death and dismemberment insurance for
Employees. These benefits are provided by
(Name of Employer) through insurance carriers or professional contract administrators.
Each eligible Employee and Pensioner will receive an identification card.
ARTICLE I DEFINITIONS
The following terms shall have the meanings herein set forth:
(1) “Employer” means (Insert Employer’s Name) .
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1993, as amended
from time to time and any successor agreement.
(3) “Plan Administrator” shall be the Employer or as designated by the Employer.
(4) “Employee” shall mean a person working in a classified job for the Employer, eligible
to receive benefits hereunder.
(5) “Pensioner” shall mean any person who is receiving a pension, other than (i) a
deferred vested pension based on less than 20 years of credited service, or (ii) a pension
based in whole or in part on years of service credited under the terms of Article II G of
the 1974 Pension Plan, or any corresponding paragraph of any successor thereto, under the
1974 Pension Plan (or any successor thereto), whose last classified signatory employment
was with the Employer, subject to the provisions of Article II B of this Plan. “Pensioner”
shall not mean any individual entitled to benefits under section 9711 of the Internal
Revenue Code of 1986, as amended by the Coal Industry Retiree Health Benefit Act of 1992.
(6) “Beneficiary” shall mean any person who is eligible pursuant to the Plan to receive
health benefits as set forth in Article III hereof.
(7) “Dependent” shall mean any person described in Section D of Article II hereof.
(8) “Attains the age” shall mean on or after 12:01 A.M. of the anniversary date of one’s
(9) “Signatory Service” shall have the meaning assigned to such term in the United Mine
Workers of America 1974 Pension Plan (the “1974 Pension Plan”) or any successor thereto.
(10) “Trustee” or “Trustees” shall mean the Trustees of the United Mine Workers of America
Health and Retirement Funds.
(11) “UMWA” means the United Mine Workers of America.
(12) “BCOA” means the Bituminous Coal Operators’ Association, Inc.
ARTICLE II ELIGIBILITY
The persons eligible to receive the health benefits pursuant to Article III are as follows:
A. Active Employees
Benefits under Article III shall be provided to any Employee who:
(1) is actively at work1
for the Employer on the effective Date of the Wage Agreement; or
(2) is on layoff or disabled from the Employer and had continuing eligibility as of the
Effective Date of the Wage Agreement for coverage under the 1988 Employer’s Benefit Plan
(“prior Plan”) as a laid-off or disabled employee. Coverage for such laid-off or disabled
Employees shall not continue beyond the date when they would no longer have been eligible
for coverage under the provisions of the prior Plan.
(3) is on leave under section 102 of the Family and Medical Leave Act of 1993, subject to
Article III. A (10)(g).
(4) Except as provided in subsection (2) and (3) above, any Employee of the Employer who
is not actively at work1
for the Employer on the Effective Date of the Wage Agreement will
not be eligible for coverage under the Plan until he returns to active employment with the
Any Employee of the Employer who as of February 1, 1993, was eligible for benefits under
the prior Plan who is not scheduled to work within two weeks after the effective date of
the Wage Agreement because of lack of work, will, if eligible under Article III. D (1) (a)
of this Plan, be considered eligible for coverage under this Plan as of the Effective Date
of the Wage Agreement but as an Employee on layoff as of such date.
(5) A new Employee will be eligible for health benefits from the first day worked with the
Health benefits under Article III hereof shall be provided to Pensioners as follows:
(1) Any Pensioner who is not again employed in classified signatory employment subsequent
(a) such Pensioner’s initial date of retirement under the 1974 Pension Plan, and
(b) February 1, 1993, shall be eligible for coverage as a Pensioner under, and subject
to all other provisions of this Plan. Notwithstanding (i) and (ii) of the definition
of Pensioner in Article I(5) of this Plan, any such Pensioner who was eligible for
benefits under the 1974 Benefit Plan as a Pensioner on December 5, 1977, shall be
eligible for such benefits, subject to all other provisions of this Plan.
1 Actively at work includes an Employee of the Employer who was actively at work on February
1, 1993, and who returns to active work with the Employer two weeks after the effective date of
the Wage Agreement.
(2) Any person who
(a) has been covered as a Pensioner under this Plan, and
(b) is again employed in classified signatory employment after February 1, 1993, with
an employer signatory to the Wage Agreement, other than the Employer, shall have
coverage under the Plan suspended during such period of employment. If such person is
credited with at least three or more years of service under the 1974 Pension Plan after
February 1, 1993, while so employed with the same employer, coverage shall be
terminated under this Plan.
(3) Any person who
(a) has been receiving a pension under the 1974 Pension Plan,
(b) has not been previously covered as a Pensioner under this Plan, and
(c) is employed in a classified job by the Employer after February 1, 1993, shall,
upon subsequent retirement, be covered as a Pensioner under this Plan only if such
person is credited with at least three or more years of service under the 1974 Pension
Plan subsequent to the most recent date of employment in a classified job with the
(4) Health benefits shall not be provided during any month in which the Pensioner is
regularly employed at an earnings rate equivalent to at least $1,000 per month.
C. Disabled Employees
In addition to disabled Pensioners who are receiving pension benefits and are therefore
entitled to receive health benefits under section B of this Article II, health benefits under
Article III shall also be provided to any Employee who:
(1) (a) Has completed 20 years of credited service, including the required number of years
of signatory service pursuant to Article IV C(6) of the 1974 Pension Plan or any
corresponding paragraph of any successor thereto, and
(b) has not attained age 55, and
(c) became disabled after December 6, 1974 while in classified employment with the
(d) is eligible for Social Security Disability Insurance Benefits under Title II of
the Social Security Act or its successor;
(2) Becomes totally disabled due to a compensable disability within four years of the date
the Employee would be eligible to receive a pension under the 1974 Pension Plan or any
successor thereto, as long as the Employee continues to be so disabled during the period
for which Workers’ Compensation payments (Workers’ Compensation does not include Federal
Black Lung Benefits) are applicable; or
(3) Is receiving or would, upon proper application, be eligible to receive Sickness and
Accident Benefits pursuant to the Wage Agreement.
Life and accidental death and dismemberment insurance shall also be provided to Employees
described in (3) above.
D. Eligible Dependents
Health benefits under Article III shall be provided to the following members of the family of
any Employee, Pensioner, or disabled Employee receiving health benefits pursuant to sections A,
B, or C of this Article II:
(1) A spouse who is living with or being supported by an eligible Employee or Pensioner;
(2) Unmarried dependent children of an eligible Employee or Pensioner who have not
attained age 22;
(3) A parent of an eligible Employee, Pensioner or spouse, if the parent has been
dependent upon and living in the same household (residence) with the eligible Employee or
Pensioner for a continuous period of at least one year;
(4) Unmarried dependent grandchildren of an eligible Employee, Pensioner or spouse who
have not attained age 22 and are living in the same household (residence) with such
Employee or Pensioner;
(5) Dependent children (of any age), of an eligible Employee, Pensioner or spouse, who are
mentally retarded or who become disabled prior to attaining age 22 and such disability is
continuous and are either living in the same household with such Employee or Pensioner or
are confined to an institution for care or treatment. Health benefits for such children
will continue as long as a surviving parent is eligible for health benefits.
For purposes of this section D, a person shall be considered dependent upon an eligible
Employee, Pensioner or spouse if such Employee, Pensioner or spouse provides over one-half
of the support to such person.
E. Surviving Spouse and Dependents of Deceased Employees or Pensioners
Health benefits under Article III shall be provided to (i) any unmarried surviving spouse (who
was living with or being supported by the Employee or Pensioner immediately prior to the
Employee’s or Pensioner’s death) and (ii) such spouse’s unmarried surviving dependent children
as defined in sub-sections (2) and (5) of section D of an Employee or Pensioner who died:
(1) As a result of a mine accident occurring on or after the effective date of the Plan
while the Employee was working in a classified job for the Employer;
(2) Under conditions which qualify such spouse for a Surviving Spouse benefit under the
1974 Pension Plan or any successor thereto;
(3) At a time when such Employee or Pensioner is entitled to receive health benefits
pursuant to section A, B, or C of this Article II, provided that (i) if such Employee or
Pensioner died prior to the effective date of the Wage Agreement and the spouse is not
eligible for a Surviving Spouse’s benefit, then only for the period that the spouse is
eligible to receive death benefits in installment payments pursuant to section C of Article
III, or (ii) if such Employee or Pensioner died on or after the Effective Date of the Wage
Agreement and the spouse is not eligible for a Surviving Spouse’s benefit and life
insurance benefits or death benefits under any plan maintained pursuant to Article XX of
the National Bituminous Coal Wage Agreement of 1993 are payable in a lump sum, then only
for 60 months following the month of the death of such Employee or only for 22 months
following the month of death of such Pensioner. If life insurance benefits are not
payable, health benefits shall be provided only to the end of the month in which the
Employee or Pensioner died.
Any children who have not attained age 22 shall not be entitled to receive health benefits
under this section E if employed and living outside the household (residence) of the
surviving spouse or the immediate family of the deceased Employee or Pensioner.
Health benefits shall continue for a surviving spouse until remarriage of such spouse, but
if such spouse is entitled to such benefits under subsection (3) above, such health
benefits will continue not longer than for the period specified in subsection (3) above.
Health benefits shall not be provided during any month in which such surviving spouse is
regularly employed at an earnings rate equivalent to at least $1,000 a month.
At the death of an Employee described in subsection (1) above, health benefits will be
continued for the unmarried children until they attain age 22, even if there is no
surviving spouse or if the surviving spouse dies before they attain age 22; provided,
however, health benefits shall not be provided for any child during any month in which such
child is regularly employed at an earnings rate equivalent to at least $1,000 per month,
unless such child is a full-time student.
If at the death of an Employee or pensioner described in subsection (3) above, there is
no surviving spouse, or if the surviving spouse dies during any period in which health
benefits are being continued, such health benefits will be continued for the unmarried
children during the period in which such spouse would have been eligible for health
benefits but in no event beyond their attaining age 22; provided, however, health benefits
shall not be provided for any child during any month in which such child is regularly
employed at an earnings rate equivalent to at least $1,000 per month, unless such child is
a full-time student.
The unmarried, dependent children of a Surviving Spouse eligible under (2) above shall be
eligible for health benefits until they attain age 22, so long as the Surviving Spouse is
eligible for benefits; provided, however, health benefits shall not be provided during any
month in which such child is regularly employed at an earnings rate equivalent to at least
$1,000 per month, unless such child is a full-time student.
ARTICLE III BENEFITS
Effective December 16, 1993, the benefits provided under this Plan are as set forth in this
Article III. Benefit payments are based on negotiated rates applicable to services
provided by hospitals, physicians, pharmacies and other providers on Participating Provider
Lists (PPLs) adopted under Article IV. During any period when PPLs are not in effect, and
for covered services and supplies not offered under a PPL (or otherwise not subject to a
PPL-related benefit limit), benefit payments shall not exceed reasonable and customary
for covered services and supplies. Covered services shall be limited to those
2 The reasonable and customary charge for any service or supply is the usual charge for the
service or supply in the absence of insurance. The usual charge may not be more than the
general level of charges for illness or injury of comparable severity and nature made by other
services which are reasonable and necessary for the diagnosis or treatment of an illness or
injury and which are given at the appropriate level of care, or are otherwise provided for
in the Plan. The fact that a procedure or level of care is prescribed by a physician does
not mean that it is medically reasonable or necessary or that it is covered under this
Plan. In determining questions of reasonableness and necessity, due consideration will be
given to the customary practices of physicians in the community where the service is
provided. Services which are not reasonable and necessary shall include, but are not
limited to the following: procedures which are of unproven value or of questionable current
usefulness; procedures which tend to be redundant when performed in combination with other
procedures; diagnostic procedures which are unlikely to provide a physician with additional
information when they are used repeatedly; procedures which are not ordered by a physician
or which are not documented in timely fashion in the patient’s medical records; procedures
which can be performed with equal efficiency at a lower level of care.
The benefits described in this Article are subject to any precertification and other
utilization review requirements implemented pursuant to Article IV. Covered services that
are medically necessary will continue to be provided, and accordingly, while benefit
payments are subject to prescribed limits, this paragraph shall not be construed to detract
from plan coverage or eligibility as described in this Article III.
A. Health Benefits
(1) Inpatient Hospital Benefits
(a) Semi-private room
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for
treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits
will be provided for semi-private room accommodations (including special diets and
general nursing care) and all medically necessary services provided by the hospital as
set out below for the diagnosis and treatment of the Beneficiary’s condition.
Medically necessary services provided in a hospital include the following:
Operating, recovery, and other treatment rooms
Laboratory tests and x-rays
Diagnostic or therapy items and services
Drugs and medications (including take-home drugs which are limited to a 30-day supply)
Oxygen and its administration
Intravenous injections and solutions
Administration of blood and blood plasma
Blood, if it cannot be replaced by or on behalf of the beneficiary
providers within the geographic area in which the service or supply is provided. This is
determined by the use of prevailing health care charges guides such as that prepared by the
Health Insurance Association of America (HIAA).
(b) Intensive Care Unit – Coronary Care Unit
Benefits will also be provided for treatment rendered in an Intensive Care or Coronary
Care Unit of the hospital, if such treatment is certified as medically necessary by the
(c) Private Room
For confinement in a private room, benefits will be provided for the hospital’s most
common charge for semi-private room accommodations and the Beneficiary shall be
responsible for any excess over such charge except that private room rates will be paid
when (i) the Beneficiary’s condition requires him to be isolated for his own health or
that of others, or (ii) the hospital has semi-private or less expensive accommodations
but they are occupied and the Beneficiary’s condition requires immediate
hospitalization. Semi-private room rates, not private room rates, will be paid beyond
the date a semi-private room first becomes available and the Beneficiary’s condition
permits transfer to those accommodations.
(d) Renal Dialysis
Benefits will be provided for renal dialysis provided that the renal dialysis therapy
is administered in accordance with Federal Medicare regulations as in effect from time
(e) Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined
for mental illness in a hospital by a licensed psychiatrist. When medically necessary,
hospitalization may be extended for a maximum of 30 additional days for confinements
for an acute (short-term) mental illness, per episode of acute illness. (More than 90
days of confinement for mental illness over a two-year period, (dating from the first
day of hospital confinement, even if the first day of confinement occurred during a
prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term)
mental problem for which the Plan will not provide inpatient hospital benefits).
(f) Alcoholism and Drug Abuse
Benefits are provided for a Beneficiary who requires emergency detoxification hospital
care for the treatment of alcoholism or emergency treatment for drug abuse. Such
treatment is limited to 7 calendar days per inpatient hospital admission.
If treatment of a medical or mental condition is necessary following detoxification or
emergency treatment for drug abuse, benefits may be provided under other provisions of
this Plan and are subject to any requirements or limitations in such provisions.
See subsection (7)(f) for information concerning other services related to treatment of
alcoholism and drug abuse.
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral
surgical procedures described in subsection (3)(e) provided hospitalization is
Benefits are also provided for a Beneficiary admitted to a hospital for dental
procedures only if hospitalization is necessary due to a pre-existing medical condition
and prior approval is received from the Plan Administrator.
(h) Maternity Benefits
Benefits are provided for a female Beneficiary who is confined in a hospital for
pregnancy. Such benefits will also be available for services pertaining to termination
of pregnancy but only if medically necessary and is so certified to and such services
are performed by licensed gynecologist or surgeon.
Accredited Hospital is a hospital which is operated primarily for the purpose of
rendering inpatient therapy for the several classifications of medical and surgical
cases and which is approved by the Joint Commission on Accreditation of Hospitals or
which has been approved by the Trustees of the United Mine Workers of America Combined
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical treatment or
medical treatment of an injury as the result of an accident, provided such emergency
medical treatment is rendered within 48 hours following the onset of acute medical
symptoms or the occurrence of the accident.
(b) Surgical Cases
Benefits are provided for a Beneficiary who receives surgical treatment in the
outpatient department of a hospital.
(c) Laboratory Tests and X-rays
Benefits are provided for laboratory tests and x-ray services performed in the
outpatient department of a hospital which provides such services and when they have
been ordered by a physician for diagnosis or treatment of a definite condition, illness
(d) Chemotherapy and Radiation Therapy
Benefits are provided for chemotherapy treatments of a malignant disease or radiation
treatments performed in the outpatient department of a hospital.
Benefits are provided for physiotherapy treatments performed in the outpatient
department of a hospital. Such therapy must be prescribed and supervised by a
(f) Renal Dialysis
Benefits are provided for outpatient renal dialysis treatments rendered in accordance
with Federal Medicare regulations as in effect from time to time.
(3) Physicians’ Services and Other Primary Care
(a) Surgical Benefits
Benefits are provided for surgical services essential to a Beneficiary’s care
consisting of operative and cutting procedure (including the usual and necessary postoperative care) for treatment of illnesses, injuries, fractures or dislocations, which
are performed either in or out of a hospital by a physician.
When surgical services consist of necessary major surgery (primary) and the physician
performs surgery additional to the primary surgery (incidental surgery), benefits
payment for the incidental surgery will be provided but at a rate 50% lower than the
physician’s normal charge had he performed only the incidental surgery.
(b) Assistant Surgeons
If the Beneficiary is an inpatient in a hospital, benefits will also be provided for
the services of a physician who actively assists the operating physician in the
performance of such surgical services when the condition of the Beneficiary and type of
surgical service require such assistance.
(c) Obstetrical Delivery Services
Benefits are provided for a female Beneficiary for obstetrical delivery services
(including pre- and post-natal care) performed by a physician. Benefits will also be
provided if such delivery is performed by a midwife certified by the American College
of Nurse Midwifery and licensed where such licensure is required.
Such benefits will also be provided for termination of pregnancy but only if medically
necessary and is so certified to and such services are performed by a licensed
gynecologist or surgeon.
(d) Anesthesia Services
Benefits are provided for the administration of anesthetics provided either in or out
of the hospital in surgical or obstetrical cases, when administered and billed by a
physician, other than the operating surgeon or his assistant, who is not an employee
of, nor compensated by, a hospital, laboratory or other institution; or by a nurse
(e) Oral Surgery
Benefits are not provided for dental services. However, benefits are provided for the
following limited oral surgical procedures if performed by a dental surgeon or general
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular Joint Dysfunction, only when medically necessary and related to an
oral orthopedic problem.
Biopsy of the oral cavity
Dental services required as a direct result of an accident
(f) Surgical Services Limitations
Benefits are not provided for certain surgical services without prior approval of the
Plan Administrator. Such surgical procedures include, but are not limited to, the
Plastic surgery, including mammoplasty
Intestinal bypass for obesity
Gastric bypass for obesity
Dorsal stimulator implants
Prosthesis for cleft palate if not covered by crippled children services
(g) In-hospital Physicians’ Visits
If a Beneficiary is confined as an inpatient in a hospital because of an illness or
injury, benefits are provided for in-hospital visits by the physician in charge of the
case. Such benefits will also be provided concurrently with benefits for surgical,
obstetrical and radiation therapy services when the Beneficiary has a separate and
complicated condition, the treatment of which requires skills not possessed by the
physician who is rendering the surgical, obstetrical or radiation therapy services.
(h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic
(including the outpatient department of a hospital) or in the physician’s office for
the treatment of illnesses or injuries, if provided by a physician.
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary who receives
outpatient emergency medical treatment or treatment of an injury as the result of an
accident, provided such emergency medical treatment is rendered within 48 hours
following the onset of acute medical symptoms or the occurrence of the accident.
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed
laboratory when ordered by a physician for diagnosis or treatment of a definite
condition, illness or injury.
Such benefits will not cover laboratory tests and x-rays ordered in connection with a
routine physical examination, unless the examination is considered medically necessary
by a physician.
(k) Radiation and Chemotherapy Benefits
Benefits are provided for treatment by x-ray, radium external radiation or radioactive
isotope (including the cost of materials unless supplied by a hospital), provided in or
out of a hospital, when performed and billed by a physician.
When a Beneficiary’s condition requires radiation therapy services in conjunction with
medical, surgical or obstetrical services, benefits will be provided for such radiation
therapy in addition to the payment for such other types of covered services if the
physician performing the radiation therapy services is not the same physician who
performs the medical, surgical or obstetrical services.
Benefits are provided for treatment of malignant diseases by chemotherapy provided in
or out of the hospital when prescribed and billed by a physician.
(l) Medical Consultation
Benefits are provided for services rendered, at the request of the attending physician
in charge of the case, by a physician who is qualified in a medical specialty necessary
in connection with medical treatment required by a Beneficiary.
(m) Specialist Care
Benefits will be provided for treatment prescribed or administered by a specialist if
the treatment is for illness or injury which falls within the specialist’s area of
(n) Primary Care – Podiatrists’ Services
Benefits are provided for minor surgery rendered by a qualified licensed podiatrist.
Routine care of the feet such as trimming of nails, the treatment of corns, bunions
(except capsular or bone surgery therefor) and calluses is excluded.
Covered minor surgery includes surgery for ingrown nails and surgery in connection with
the treatment of flat feet, fallen arches, weak feet, chronic foot strain or
symptomatic complaints of the feet.
Benefits for major surgical procedures rendered by a licensed podiatrist are not
provided, except if such surgery is rendered in a hospital.
(o) Primary Medical Care – Miscellaneous
1. Benefits are provided for care of newborn babies and routine medical care of
children prior to attaining age 6.
2. Benefits are provided for immunizations, allergy desensitization injections, pap
smears, screening for hypertension and diabetes, and examinations for cancer,
blindness, deafness, and other screening and diagnostic procedures when medically
3. Benefits are provided for physical examinations when certified as medically
necessary by a physician. Medically necessary will mean that a Beneficiary (i) has
an existing medical condition under treatment by a physician, (ii) has attained age
55, (iii) is undergoing an annual or semi-annual routine examination by a
gynecologist, or (iv) is undergoing a routine examination prescribed by a specialist
as part of such specialist’s care of a medical condition.
4. Benefits are provided for “physician extender” care or medical treatment
administered by nurse practitioners, physician’s assistants or other certified or
licensed health personnel when such service is rendered under the supervision of a
5. Benefits are provided for a nominal fee covering instruction in preparation for
natural childbirth, if rendered in a hospital or clinic.
6. Benefits are provided for family planning counseling when rendered by a
physician or by other appropriately trained and supervised health care
7. Benefits are provided covering artificial insemination if the service is
provided by a licensed gynecologist.
8. Benefits are provided for sterilization procedures if such procedures are
performed by a physician.
9. Birth control services and medications are not covered under the Plan, except
that benefits are provided for physician services rendered in connection with the
prescription of oral contraceptives, the fitting of a diaphragm or the insertion or
removal of an IUD.
(p) Services Not Covered
1. Services rendered by a chiropractor or naturopathic services.
2. Acupuncture therapy.
3. Home obstetrical delivery.
4. Telephone conversations with a physician in lieu of an office visit.
5. Charges for writing a prescription.
6. Medications dispensed by other than a licensed pharmacist.
7. Charges for medical summaries and medical invoice preparation.
8. Services of any practitioner who is not legally licensed to practice medicine,
surgery, or counseling except as specifically provided herein.
9. Cosmetic surgery, unless pertaining to surgical scars or to correct results of
an accidental injury or birth defects.
10. Physical examinations, except as specifically provided herein.
11. Removal of tonsils or adenoids, unless medically necessary.
(4) Prescription Drugs
(a) Benefits Provided
Benefits are provided for insulin and prescription drugs (only those drugs which by
Federal or State law require a prescription) dispensed by a licensed pharmacist and
prescribed by a (i) physician for treatment or control of an illness or nonoccupational
accident or (ii) licensed dentist for treatment following the performance of those oral
surgical services set forth in (3)(e).
The initial amount dispensed shall not exceed a 30 day supply. Any original
prescription may be refilled for up to six months as directed by the attending
physician. The first such refill may be for an amount up to, but no more than, a 60
day supply. The second such refill may be for an amount up to, but no more than, a 90
day supply. Benefits for refills beyond the initial six months require a new
prescription by the attending physician. Prescriptions filled by the Plan’s mail order
provider, if any, are not subject to the limits on quantity set forth in this
Reasonable charges for prescription drugs or insulin are covered benefits. Reasonable
charges will consist of the lessor of:
(1) The amount actually billed per prescription or refill;
(2) The price of the applicable generic substitution drug, if AB or better-rated,
approved by the federal Food and Drug Administration; or, in the event the
prescribing physician determines that the use of a brand name drug is medically
necessary, the price of such brand name drug; or
(3) The current price paid to participating pharmacies in any prescription drug
program established by the Employer.
However, in no event will a Beneficiary be responsible to pay more for a single
prescription than the appropriate co-payment set forth in this Plan, plus any
difference between the price of the generic and the brand name drug, where applicable.
(b) Benefits Excluded
Benefits shall not be provided under subsection (4)(a) for the following:
1. Medications dispensed in a hospital (including take-home drugs), skilled
nursing facility or physician’s office. (See Article III A (1)(a) and (5)(a) for
benefits provided for drugs and medications during inpatient confinement in a
hospital skilled nursing facility.)
2. Birth control prescriptions.
3. Prescriptions dispensed by other than a licensed pharmacist.
4. Any medication not specifically provided for in (a) above.
(5) Skilled Nursing Care and Extended Care Units
(a) Skilled Nursing Care Facility
Upon determination by the attending physician that confinement in a licensed skilled
is medically necessary, to the extent that benefits are not available
from Medicare or other State or Federal programs, benefits will be provided for:
1. skilled nursing care provided by or under the supervision of a registered nurse;
2. room and board;
3. physical, occupational, inhalation and speech therapy, either provided or
arranged for by the facility;
4. medical social services;
5. drugs, immunizations, supplies, appliances, and equipment ordinarily furnished by
the facility for the care and treatment of inpatients;
6. medical services, including services provided by interns or residents in an
approved, hospital-run training program, as well as other diagnostic and therapeutic
services provided by the hospital; and
7. other health services usually provided by skilled nursing care facilities.
The Plan will not pay for services in a nursing care facility:
1. that is not licensed or approved in accordance with Federal Medicare and state
laws or regulations;
2. unless the service is provided by or under the direct supervision of licensed
nursing personnel and under the general direction of a physician in order to achieve
the medically desired results.
Exclusions: Telephone, T.V., radio, visitor’s meals, private room or private
nursing (unless necessary to preserve life), custodial care, and services not
usually provided in a skilled nursing facility are not covered under the Plan.
(b) Extended Care Units
Benefits are provided for up to two weeks of specialized medical services and daily
treatments by licensed personnel in extended care units. When medically necessary,
benefits may be provided for a longer period of time, subject to approval from the Plan
The Plan will not pay for services in an extended care unit unless, in the case of a
Medicare patient, such extended care has prior approval of Medicare.
3 Skilled nursing care facility is limited to a skilled nursing care
facility which is licensed and approved by Federal Medicare and by any appropriate state law,
regulation or agency.
1. Services, drugs or other items which are not covered for hospital inpatients;
2. Custodial care.
(6) Home Health Services & Equipment
(a) General Provisions
Benefits are provided for home health services, including nursing visits by registered
nurses and home health aides, and various kinds of rehabilitation therapy, subject to
the following conditions and approval of the Plan Administrator.
1. The Beneficiary must be under the care of a physician.
2. The Beneficiary’s medical condition must require skilled nursing care, physical
therapy, or speech therapy at least once in a 60-day period.
3. The physician must initiate a treatment plan and specify a diagnosis, the
Beneficiary’s functional limitations and the type and frequency of skilled services
to be rendered.
4. The Beneficiary must be confined to his home. The services must be provided by a
certified home health agency.
(b) Physical and Speech Therapy
Benefits are provided for physical and speech therapy services at home when prescribed
by a physician to restore functions lost or reduced by illness or injury. Such
services must be performed by qualified personnel. When the Beneficiary has reached
his or her restoration potential, the services required to maintain this level do not
constitute covered care.
(c) Skilled Nursing
Benefits are provided for skilled nursing care rendered by a registered nurse as a home
health service when a Beneficiary’s condition has not stabilized and a physician
concludes that the Beneficiary must be carefully evaluated and observed by a registered
nurse. The Plan Administrator may request an evaluation visit to the Beneficiary’s
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment
suitable for home use when determined to be medically necessary by a physician.
Benefits are provided for oxygen supplied to a Beneficiary subject to the following
conditions when ordered by the attending physician:
1. The patient is referred to a designated pulmonary consultant for testing.
2. Such consultant’s report is submitted to the Plan Administrator with the order
Benefits are also provided for services of inhalation therapists in the home with the
attending physician’s order.
(f) Coal Miners Respiratory Disease Program
Benefits are provided for services or treatments administered by personnel employed by
the Coal Miners Respiratory Disease Program to a Beneficiary in such Beneficiary’s home
when ordered or requested by a physician, except where such benefits are available
under a governmental program and such Beneficiary is eligible, or upon application
would be eligible, under such programs.
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician
when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body
parts, other than dental.
These include artificial eyes, noses, hands (or hooks), feet, arms, legs, and ostomy
bags and supplies.
2. Prosthesis following breast removal.
3. Leg, arm, back, and neck braces.
5. Stump stockings and harnesses when these devices are essential for the effective
use of an artificial limb. An examination and recommendations by an orthopedic
physician is required.
Note: Benefits are provided for repairs and adjustments for braces, trusses, stump
stockings and harnesses as well as replacement of any of those devices which have
been worn out and can no longer be repaired. Benefits will be provided for
replacements for usable appliances and artificial limbs if they are needed because
of a change in the Beneficiary’s condition. Benefits will also be provided to cover
repair and adjustment cost for appliances and artificial limbs.
If replacement of a prosthesis is required, the Beneficiary should in all cases be
reevaluated by an orthopedic physician.
6. Surgical stocking (up to two pairs per prescription with no refills) when
prescribed by a physician for surgical or medical conditions. The Plan will not pay
Beneficiaries for support hose, garter belts, etc.
7. Orthopedic shoes when specifically prescribed by a physician or licensed
podiatrist for a Beneficiary according to orthopedist specifications, including
orthopedic shoes attached to a brace that have to be modified to accommodate the
brace. Benefits will not be provided for stock orthopedic shoes.
8. Orthopedic corrections added to ordinary shoes by a physician or licensed
podiatrist. Benefits are provided for only the correction to the shoe.
(b) Physical Therapy
Benefits are provided for physical therapy in a hospital, skilled nursing facility,
treatment center, or in the Beneficiary’s home. Such therapy must be prescribed and
supervised by a physician and administered by a licensed therapist. The physical
therapy treatment must be justified on the basis of diagnosis, medical recommendation
and attainment of maximum restoration.
(c) Speech Therapy
Benefits are provided for speech therapy rendered by a qualified licensed speech
therapist if the Beneficiary is a stroke patient or has had conditions including
ruptured aneurysm, brain tumors or autism and needs special instruction to restore
technique of sound and to phonate, and needs direction in letter and word exercises in
order to express basic needs. Benefits are also provided for speech therapy for child
Beneficiaries with a speech impediment from a qualified speech therapist provided that
the child cannot receive speech therapy through the public schools.
(d) Hearing Aids
Benefits are provided for hearing aids recommended by a licensed otologist or
otolaryngologist and a certified clinical audiologist. Such hearing aids must be
purchased from a participating vendor. Benefits for necessary repairs and maintenance,
except the replacement of batteries, will be provided after the expiration of the
warranty period. Benefits will be provided for replacement hearing aids only if a new
aid is needed because of a change in the Beneficiary’s condition, or if the aid no
longer functions properly. Benefits will not be provided for any fees for
incorporating hearing aids into eyeglasses.
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a hospital, clinic,
medical center, physician’s office, or skilled nursing care facility, when considered
medically necessary by a physician.
With prior approval from the Plan Administrator benefits will also be provided for
other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the
Beneficiary must be taken to an out-of-area medical center.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s
home and a hospital or clinic for such types of treatment as radiation or physical
therapy or other special treatment which would otherwise require hospitalization,
benefits will be provided for such transportation only when the Beneficiary cannot
receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending
physician must submit satisfactory evidence as to why the Beneficiary needs an
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for: Psychotherapy, psychological testing, counseling, group
therapy and alcoholism or drug rehabilitative programs where free care sources are not
available and when determined to be medically required by a physician.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental deficiencies.
3. School related behavioral problems.
4. Services by private teachers.
5. Alcoholism and drug rehabilitation if an advance determination has not been made
by the rehabilitation team that the Beneficiary is a good candidate for
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
(8) Co-Payments and Deductibles
Effective January 1, 1994, the benefits provided in this Plan shall be subject to the copayments and deductibles set forth below and such co-payments and deductibles shall be the
responsibility of the Beneficiary. The Plan Administrator shall implement such procedures
as deemed appropriate to achieve the intent of these co-payments and deductibles.
Beneficiaries and providers shall provide such information as the Plan Administrator may
require to effectively administer these co-payments and deductibles, or such Beneficiaries
or providers shall not be eligible for benefits or payments under this Plan. Any
overpayments made to a provider who overcharges the Plan in lieu of collecting the
applicable co-payment and/or deductible from a participant or Beneficiary shall be repaid
to the Plan Administrator by such provider.
The Employer shall notify the Trustees of the UMWA 1974 Pension Plan of the names of all
1974 Pension Plan pensioners and surviving spouses who are covered by this Plan and subject
to the deductible requirements.
Co-payments for covered Health Benefits are established below. Co-payments for services or
supplies subject to a deductible only apply after the deductible has been met in full for
Participating Provider Lists (PPLs) implemented by the Employer pursuant to Article IV may
include participating hospitals, physicians, pharmacies and other providers. The Plan
payment for hospitals and related benefits provided from a non-PPL source will be limited
to 90% of the amount that would have been paid by the Plan if the benefit had been provided
by a provider on a PPL (or actual charges, if less). If a provider then bills the
Beneficiary for any remaining amount, the protections of subsection (10) (h) (2) (Hold
Harmless) will not apply until the non-PPL out-of-pocket maximum is reached. In any case
where a non-PPL provider is treated as being within the PPL, pursuant to the provisions of
Article IV.C, the Beneficiary will be responsible for the deductible and co-payment that
would apply to a PPL service. The Plan will pay the provider at no greater than the PPL
rate, and the protections of subsection (10) (h) (2) (Hold Harmless) will apply.
If an employee is covered under an employer Plan (established pursuant to the NBCWA of
1993) by more than one signatory employer during a calendar year, the total deductibles and
co-payments made and documented by the employee during such calendar year shall be counted
toward the deductible and out-of-pocket maximum in the same manner as if they had been made
under a single plan. Notwithstanding any other provision of this Plan, the amount of the
deductible in such a case shall be the same as the deductible that applied to the employee
under the first employer Plan that covered him during the calendar year. No employee
covered under an employer Plan by more than one signatory employer during a calendar year
shall be entitled to more than one Health Care Bonus pursuant to Article XX (General
Description) (10) c of the 1993 NBCWA for such year, and the preceding two sentences shall
not apply in the case of any employee that receives a Health Care Bonus from more than one
signatory employer for the calendar year.
Physician Office Visits:
In PPL: $10.00 per office visit (up to an annual maximum of $200 per family)
Non-PPL: $15.00 per office visit
Hospital and Related Charges:
In PPL: No Co-payment
Non-PPL: Balance of charges after Plan pays 90% of the PPL rate for covered services from
a non-PPL source.
Prescription Drugs (Co-pays do not apply to out-of-pocket maximum):
In PPL: $4.50 per prescription4
Non-PPL: $9.00 per prescription4
Mail Order: No co-payment
Brand name where a generic equivalent is available:
In addition to the co-payment, the Beneficiary is responsible for the additional cost of
the brand name drug over the cost of the generic substitute. A generic drug will not be
considered “available” unless it has been approved by the federal Food and Drug
4 Note: For purposes of this co-payment provision, a prescription or refill shall be deemed
to be each 30 days (or fraction thereof) supply.
Administration. In addition, if the prescribing physician determines that use of a brand
name drug is medically necessary, the generic drug will not be considered “available,” and
there will be no additional payment by the beneficiary for the use of the brand name drug.
Deductibles for covered Health Benefits refer to the first portion of covered benefits that
must be paid by a Beneficiary during a calendar year before any amounts will be paid by the
Plan. The first $1,000 of all covered medical expenses incurred by any covered family
member will be counted toward satisfying the deductible. Vision care and prescription drug
expenses are not subject to the deductible. Any deductible applicable to a covered benefit
must be met before co-pays apply. In no event will the deductible applicable to a family
for a calendar year exceed the gross amount of the Health Care Bonus paid for that year to
that family either from the Employer or from the UMWA 1974 Pension Plan pursuant to Article
XX (General Description) (10) c of the 1993 NBCWA. Deductibles are established as follows:
Physician, hospital or other $1,000 per family
The following payment will be required as an additional deductible, and will apply regardless
of whether the original deductible has been met for the year:
Any specified service obtained $300.00, not applied to the annual
without required precertification out-of-pocket maximum
The following special rules apply to the annual deductible:
(i) The deductible for a laid-off employee or for a surviving spouse for a calendar year
shall be the pro-rata portion of $1,000 that reflects the number of calendar quarters
during which he or she is entitled to Employer-provided health care under the plan during
(ii) The deductible for a pensioner or a surviving spouse for the calendar year in which
he or she will attain age 65 shall be the pro-rata portion of $1,000 that reflects the
number of calendar quarters during such year prior to the month in which he or she attains
age 65. The deductible shall not be applicable to such pensioner or surviving spouse in
succeeding calendar years.
(iii) The deductible for a disabled employee, or a disabled pensioner under age 65, will
cease to be in effect beginning with the first calendar year following his or her
eligibility for Medicare benefits.
(iv) A newly-hired employee or an employee recalled from layoff who commences coverage
after January 1 of any year shall be subject to a deductible that reflects the number of
calendar quarters remaining in the year.
Annual Out-of-Pocket Maximum:
The requirement that co-payments be paid (other than the additional deductible for services
obtained without required precertification and all co-payments relating to prescription drugs)
will be suspended for the remainder of any calendar year during which the following out-ofpocket maximum amounts have been paid:
Benefit Annual Out-of-Pocket Maximum
For services obtained from $1,200.00 per family, including the $1,000 a PPL
provider deductible and $200 in per physician
office visit co-pays
For services obtained from $2,500.00 per family, including the $1,000
a non-PPL provider deductible and $1,500 in physician office visit co-pays
and balance billing after Plan pays 90% of PPL rate
for covered service.
When the non-PPL out-of-pocket maximum has been reached, the Plan will pay at no greater than
the PPL rate for a covered benefit provided from a non-PPL source, but Hold Harmless
protections will apply.
(9) Vision Care Program
Actual Charge Up To
(a) Benefits Maximum Amount Frequency Limits
Vision Examination $24 Once every 24 months
Per Lens (Maximum = 2) Once every 24 months
– Single vision 12
– Bifocal 18
– Trifocal 24
– Lenticular 30
– Contact 18
Frames 17 Once every 24 months
Note: The 24 month period shall be measured from the date the examination is performed or
from the date the lenses or frames are ordered, respectively, even if the last examination
occurred during a prior Wage Agreement.
(b) Lenses will not be covered unless the new prescription differs from the most
recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and
the lenses must improve visual acuity by at least one line on the standard chart.
(c) Exclusions include:
1. sunglasses (other than Tints #1 or #2);
2. extra charges for photosensitive or anti-reflective lenses;
3. drugs or medication (other than for vision examination), medical or surgical
treatment of eyes;
4. special procedures, such as orthoptics, vision training, subnormal vision aids,
aniseikonic lenses and tonography;
5. experimental services or supplies;
6. replacement of lost or broken lenses and/or frames unless replacement is eligible
under the frequency and prescription limitations;
7. services or supplies not prescribed as necessary by a licensed physician,
optometrist or optician;
8. services or supplies for which the insured person is entitled to benefits under
any other provision of the Plan or as provided under a mine safety glass program;
9. any services which are covered by any workers’ compensation laws or employer’s
liability laws, or services which the Employer is required by law to furnish in
whole or in part;
10. services or supplies which are obtained from any governmental agency without
cost by compliance with laws or regulations enacted by any federal, state, municipal
or other governmental body;
11. charges for services or supplies for which no charge is made that the
Beneficiary is legally obligated to pay or for which no charge would be made in the
absence of vision care coverage.
(d) The exclusions in (c) above shall not be read to limit or exclude coverage that
may be contained elsewhere in the Plan.
(10) General Provisions
(a) HMO Election
Any Beneficiary as described in Article II, Sections A, B, C and E may elect coverage
by a certified health maintenance organization (HMO) in lieu of the health benefits
provided under this Plan, in accordance with Federal or State laws governing HMOs;
provided, however, that all Beneficiaries in a family shall be governed by an HMO
If the monthly charge made by the HMO exceeds the monthly cost of this Plan to the
Employer, the excess charge shall be paid by the Beneficiary.
The Plan Administrator is authorized to promulgate rules and regulations to implement
and administer the Plan, and such rules and regulations shall be binding upon all
persons dealing with the Beneficiaries claiming benefits under this Plan. The Trustees
of the UMWA Health and Retirement Funds will resolve any disputes, including excessive
fee disputes, to assure consistent application of the Plan provisions under the 1993
NBCWA. The Trustees shall develop procedures for the resolution of such disputes. In
the event the Trustees decide such dispute, such decision of the Trustees shall be
final and binding on the parties. If the Trustees are unable to resolve the dispute,
such dispute shall be referred to a permanent three-member arbitration panel selected
by mutual agreement of the UMWA and BCOA and maintained by the Trustees. A dispute
referred in this manner shall be decided by one member of the arbitration panel,
determined on a rotating basis, whose decisions shall be final and binding on the
parties. Precedent under the resolution of disputes mechanism previously in place
shall remain in effect, and the panel shall be required to cooperate to assure the
consistent interpretation of provisions under the Employer Plans under the 1993 NBCWA.
The Plan Administrator shall give written notice to each employee of the termination of
extended coverage under the Benefit Plan. Such notice shall explain the conversion
privileges of the Benefit Plan and the enrollment procedures to be followed. Failure
to provide such notice shall not extend coverage beyond the period otherwise provided
in the Benefit Plan.
(c) Services Rendered Outside the United States
Benefits are provided for health care rendered outside of the United States on the same
basis as if such care had been rendered in the United States.
1. For Pensioners, and surviving spouses, the benefits provided under the Plan will
not be paid to a Beneficiary otherwise eligible if such Beneficiary is eligible for
Hospital Insurance coverage (Part A) of Medicare where a premium is not required
and/or Medical Insurance coverage (Part B) of Medicare unless such Beneficiary is
enrolled for each part of Medicare for which such Beneficiary is eligible. Any such
Beneficiary who is enrolled in a Medicare program shall receive the benefits
provided under the Plan only to the extent such benefits are not provided for under
2. For Employees age 65 or older the benefits provided under the Plan will be paid
to a Beneficiary unless the company is furnished written notice of electing coverage
under Medicare rather than coverage under the Plan. Alternatively, the participant
may elect to enroll for Medicare as secondary payor.
The Plan Administrator shall give written notification of the obligation to enroll
with respect to 1. above and of the options to enroll with respect to 2. above. For
active Employees such notice shall be given prior to their 65th birthdays, but
subsequent to their 64th birthdays. Said notice shall explain the limited annual
enrollment period and the effect of failing to enroll if retirement should occur
prior to the next enrollment period. Failure to provide such notification shall not
remove any obligation to enroll.
The Plan does not assume primary responsibility for covered medical expenses which
another party is obligated to pay or which another insurance policy or other medical
plan covers. Where there is a dispute between the carriers, the Plan shall, subject to
provisions 1. and 2. immediately below, pay for such covered expenses but only as a
convenience to the Beneficiary eligible for benefits under the Plan and only upon
receipt of an appropriate indemnification or subrogation agreement; but the primary and
ultimate responsibility for payment shall remain with the other party or carrier.
Obligations to pay benefits on behalf of any Beneficiary shall be conditioned:
1. upon such Beneficiary taking all steps necessary or desirable to recover the
costs thereof from any third party who may be obligated therefore, and
2. upon such Beneficiary executing such documents as are reasonably required by the
Plan Administrator, including, but not limited to, an assignment of rights to
receive such third party payments, in order to protect and perfect the Plan’s right
to reimbursement from any such third party.
The health benefits provided under this Plan are subject to a non-duplication provision
1. Benefits will be reduced by benefits provided under any other group plan,
including a plan of another Employer signatory to the Wage Agreement, if the other
(i) does not include a coordination of benefits or non-duplication provision,
(ii) includes a coordination of benefits or non-duplication provision and is
the primary plan as compared to this Plan.
2. In determining whether this Plan or another group plan is primary, the following
criteria will be applied:
(i) The Plan covering the patient other than as a dependent will be the primary
(ii) Where both plans cover the patient as a dependent, the plan of the parent
or step-parent whose birthday occurs earlier in the calendar year will be the
(iii) Where the determination cannot be made in accordance with (i) or (ii)
above, the plan which has covered the patient the longer period of time will be
the primary plan.
(iv) In the event a Pensioner or surviving spouse is covered under another group
plan by reason of his or her employment, the other group plan shall be the
primary plan for such Pensioner or surviving spouse and their eligible
3. As used herein, “group plan” means (i) any plan covering the individuals as
members of a group and providing hospital or medical care benefits or services
through group insurance or a group prepayment arrangement, or (ii) any plan covering
individuals as employees of an employer and providing such benefits or services,
whether on an insured, prepayment or uninsured basis.
4. If it is determined that benefits under this Plan should have been reduced
because of benefits provided under another group plan, the Plan Administrator shall
have the right to recover any payment already made which is in excess of the Plan’s
liability. Similarly, whenever benefits which are payable under the Plan have been
provided under another group plan, the Plan Administrator may make reimbursement
directly to the insurance company or other organization providing benefits under the
5. For the purpose of this provision the Plan Administrator may, without consent or
notice to any Beneficiary, release to or obtain from any insurance company or other
organization or person any information which may be necessary regarding coverage,
expense and benefits.
6. Any Beneficiary claiming benefits under this Plan must furnish the Plan
Administrator such information as may be necessary for the purpose of administering
(g) Recovery of Family and Medical Leave Act Premium
The Employer may in its sole discretion recover the premium that it paid for maintaining
coverage during a leave under section 102 of the Family and Medical Leave Act of 1993, if:
(a) the Employee fails to return to work after the period of leave to which the Employee
is entitled has expired; and
(b) the Employee fails to return to work for a reason other than
1. the continuation, recurrence, or onset of a serious health condition of the
2. the need of the Employee to care for the Employee’s spouse, son, daughter, or
parent due to the continuation, recurrence, or onset of a serious health condition
of such individual, or
3. other circumstances beyond the control of the Employee.
The Employer may in its sole discretion require a certification of a health provider
attesting to the existence of the factors set forth in 1 or 2, above.
(h) Explanation of Benefits (EOB) and Hold Harmless
1. Each Beneficiary shall receive an explanation of billing and payment rendered on
behalf of such Beneficiary. Should full payment for a service be denied because of
a charge that has been determined by the Plan Administrator to be in excess of the
reasonable and customary charge, the UMWA may request that a copy of such EOB shall
be forwarded to the UMWA (International Headquarters, Attention: Benefits
2. The Employer and the UMWA agree that excessive charges and escalating health
costs are a joint problem requiring a mutual effort for solution. In any case in
which a provider attempts to collect excessive charges or charges for services not
medically necessary, as defined in the Plan, from a Beneficiary, the Plan
Administrator or his agent shall, with the written consent of the Beneficiary,
attempt to resolve the matter, either by negotiating a resolution or defending any
legal action commenced by the provider. Whether the Plan Administrator or his agent
negotiates a resolution of a matter or defends a legal action on a Beneficiary’s
behalf, the Beneficiary shall not be responsible for any legal fees, settlements,
judgements or other expenses in connection with the case, but may be liable for any
services of the provider which are not provided under the Plan. The Plan
Administrator or his agent shall have sole control over the conduct of the defense,
including the determination of whether the claim should be settled or an adverse
determination should be appealed. The “hold harmless” protections available under
this subparagraph do not apply until the deductible is met in full for the year, and
shall not apply in the case of any service or supply obtained from a non-PPL source
until the non-PPL out-of-pocket maximum is reached.
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits
are also not provided for the following:
1. Cases covered by workers’ compensation laws or employer’s liability acts or
services for which an employer is required by law to furnish in whole or in part.
2. Services rendered
(i) prior to the effective date of a Beneficiary’s eligibility under the Plan;
(ii) subsequent to the period after which a Beneficiary is no longer eligible
for benefits under the Plan; or
(iii) in a non-accredited hospital, other than for emergency services as set
forth in A(2)(a) and (3)(i).
3. Services furnished by any governmental agency, including benefits provided under
Medicaid, Federal Medicare and Federal and State Black Lung Legislation for which a
beneficiary is eligible or upon proper application would be eligible.
4. Services furnished by tax-supported or voluntary agencies.
5. Immunizations provided by local health agencies.
6. Evaluation procedures such as x-rays and pulmonary function tests, in connection
with applications for black lung benefits, or required by Federal or State Black
7. Private duty nursing. If necessary to preserve life and certified as medically
necessary by the attending physician and an Intensive Care Unit is unavailable,
benefits are provided for private duty nursing services for up to 72 hours per
inpatient hospital admission. In no event will payment be made for private duty
nursing during a period of confinement in the Intensive Care Unit of a hospital.
8. Custodial care, convalescent or rest cures.
9. Personal services such as barber services, guest meals and cots, telephone or
rental of radio or television and personal comfort items not necessary to the
treatment of an illness or injury.
10. Charges for private room confinement, except as specifically described in the
11. Services for which a Beneficiary is not required to make payment.
12. Excessive charges.
13. Charges related to sex transformation.
14. Charges for reversal of sterilization procedures.
15. Charges in connection with a general physical examination, other than as
specified in this Plan.
16. Inpatient confinements solely for diagnostic evaluations which can be provided
on an outpatient basis.
17. Charges for medical services for inpatient or outpatient treatment for mental
retardation and other mental deficiencies.
18. Finance charges in connection with a medical bill.
19. Dental services.
20. Birth control devices and medications.
21. Abortion, except as specifically described in the Plan.
22. Eyeglasses or lenses, except when medically required because of surgically
caused refractive errors or as otherwise provided in section A(9).
23. Exercise equipment.
24. Charges for treatment with new technological medical devices, therapy which are
experimental in nature.
25. Charges for treatment of obesity, except for pathological, morbid forms of
severe obesity (200% or more of desirable weight) when prior approval is obtained
from the Plan Administrator.
26. Charges for an autopsy or post-mortem surgery.
27. Any types of services, supplies or treatments not specifically provided by the
B. Life and Accidental Death and Dismemberment Insurance for Active Employees
Life and accidental death and dismemberment insurance will be provided for Employees, as
described in Article II, Sections A and C(3), in accordance with the following schedule:
1. Upon the death of an Employee (including an Employee on authorized strike against an
Employer following expiration of the 1988 NBCWA) due to other than violent, external and
accidental means prior to the Effective Date of the 1993 NBCWA, life insurance in the
amount of $35,000 will be paid to the Employee’s named beneficiary. Upon the death of an
Employee due to other than violent, external and accidental means on or after the Effective
Date of the 1993 NBCWA, life insurance in the amount of $50,000 will be paid to the
Employee’s named beneficiary.
2. Subject to (4) below, upon the death of an Employee (including an Employee on
authorized strike against the Employer following expiration of the 1988 NBCWA) due solely
to violent, external and accidental means as the result of an injury occurring while
insured and prior to the Effective Date of the 1993 NBCWA, life insurance in the amount of
$70,000 will be paid to the Employee’s named beneficiary. Subject to (4) below, upon the
death of an Employee due solely to violent, external and accidental means as the result of
an injury occurring while insured and on or after the Effective Date of the 1993 NBCWA,
life insurance in the amount of $100,000 will be paid to the Employee’s named beneficiary.
(3) If an Employee (including an Employee on authorized strike against the Employer
following expiration of the 1988 NBCWA) shall lose two or more members due to violent,
external and accidental means as the result of an injury occurring while insured and prior
to the Effective Date of the 1993 NBCWA, such Employee shall receive a $35,000
dismemberment benefit. If an Employee shall lose two or more members due to violent,
external and accidental means as the result of an injury occurring while insured and on or
after the Effective Date of the 1993 NBCWA, such Employee shall receive a $50,000
dismemberment benefit. If an Employee (including an Employee on authorized strike against
the Employer following expiration of the 1988 NBCWA) shall lose one member due to violent,
external and accidental means as the result of an injury occurring while insured and prior
to the Effective Date of the 1993 NBCWA, such Employee shall receive a $17,500
dismemberment benefit. If an Employee shall lose one member due solely to violent,
external and accidental means as the result of an injury occurring while insured and on or
after the Effective Date of the 1993 NBCWA, such Employee shall receive a $25,000
dismemberment benefit. A member for the purpose of the above is (i) a hand at or above the
wrist, (ii) a foot at or above the ankle or (iii) total loss of vision of one eye.
(4) Accidental death or dismemberment benefits are not payable if caused in whole or in
part by disease, bodily or mental infirmity, ptomaine or bacterial infection, hernia,
suicide, intentional self-inflicted injury, insurrection, or acts of war, whether declared
or not, or is caused by or results from committing a felony.
C. Death Benefits
(1) Deaths Prior to December 6, 1977
Death benefit payments shall be continued in those cases which were in pay status as of
December 5, 1977, under the 1974 Benefit Plan, for deceased Employees and Pensioners, whose
last classified employment was with the Employer, in the same manner and the same amounts,
as previously provided for in the 1974 Benefit Plan.
(2) Deaths after December 5, 1977 and Prior to March 27, 1978
Death benefit payments shall be made for deaths occurring between and including December 6,
1977, and immediately prior to March 27, 1978, for Employees and Pensioners whose last
classified employment was with the Employer, and who were participants in the 1974 Benefit
Plan as of December 5, 1977, in the same manner and in the same amounts, as previously
provided for in the 1974 Benefit Plan.
D. General Provisions
(1) Continuation of Coverage
If an Employee ceases work because of layoff, continuation of health, life and
accidental death and dismemberment insurance coverage is as follows:
Number of Hours Worked for
the Employer in 24
Consecutive Calendar Month
Period Immediately Prior to Period of Coverage
the Employee’s Date Continuation from the
Last Worked Date Last Worked
2,000 or more hours Balance of month plus
500 or more but less than Balance of month plus
2,000 hours 6 months
Less than 500 hours 30 days
Except as otherwise provided in Article II, section C, if an Employee ceases work
because of disability, the Employee will be eligible to continue health, life and
accidental death and dismemberment insurance coverage while disabled for the greater of
(i) the period of eligibility for Sickness and Accident benefits, or (ii) the period as
set forth in the schedule in (a) above.
(c) Leave of Absence
1. During any period for which an employee is granted an approved leave of absence
for the purpose of accepting temporary employment with the United Mine Workers of
America (UMWA) such Employee shall be eligible to continue health, life and
accidental death and dismemberment insurance coverage for a period not to exceed 120
calendar days within any 12-month period.
2. During any period for which an Employee is granted an approved leave of absence
for any other reason, such Employee’s eligibility for health, life and accidental
death and dismemberment insurance coverage shall be terminated as of the day last
worked and shall not be reinstated until the Employee returns to active work except
as provided in subparagraph 3 below.
3. If an Employee who is on approved leave of absence is placed on lay-off status,
or would have been placed on lay-off status had the Employee been actively at work,
health, life and accidental death and dismemberment coverage shall be reinstated as
of the effective date of lay-off. Such coverage shall continue for a period
determined pursuant to the provisions of paragraph (a) above using the commencement
date of the leave of absence in place of the date last worked for purpose of
determining the number of hours worked. In no event shall coverage under this
paragraph continue beyond the balance of the month plus 12 months from the effective
date of the lay-off. An Employee who returns to work after having been on leave of
absence shall not have the period for which such Employee was on leave of absence
included in the 24-calendar-month period as used in paragraph (a) for determining
eligibility for continuation of coverage.
(d) Maximum Continuation of Coverage
In no event shall any combination of the provisions of (a), (b), (c), (e) or (g) above
result in continuation of coverage beyond the balance of the month plus 12 months from
the date last worked.
(e) Quit or Discharge
If an Employee quits (for any reason) or is discharged, health, life and accidental
death and dismemberment insurance coverage will terminate as of the date last worked.
An Employee who ceases work and is determined to be eligible for health benefits as a
retiree on the first of the month subsequent to the date on which he last worked shall
be eligible for benefits without interruption as provided by the Plan from the date he
(f) Other Employment
Notwithstanding the forgoing, in the event an Employee accepts employment during a
period of continued coverage under paragraph (a) health, life and accidental death and
dismemberment insurance coverage will terminate as of the date of such employment. If,
however, such employment subsequently terminates prior to the date the Employee’s
coverage under paragraph (a) otherwise terminates, such Employee’s health, life and
accidental death and dismemberment insurance coverage will be reinstated following the
later of (i) termination of such employment or (ii) any continued health coverage
resulting therefrom, and will continue to the date such coverage under paragraph (a)
would have otherwise terminated. It is the obligation of the Employee to notify the
Employer within 10 days by certified mail of both acceptance and termination of such
employment; failure to provide such notice will result in permanent termination of
coverage. Nothing in this paragraph shall extend coverage beyond the date determined
pursuant to paragraph (a).
(g) Article III (j) – Wage Agreement
An Employee terminated under the provisions of Article III (j) of the Wage Agreement
shall not be treated as a quit or discharge for purposes of continuation of coverage.
Such an Employee shall be entitled to continuation of coverage on the same basis as
provided in paragraph (b) above; provided, however, hours worked and the period of
continuation of coverage shall be determined as of the date last worked.
(h) COBRA Continuation Coverage
Notwithstanding the foregoing, this Plan shall comply with the health care continuation
coverage provisions of Sections 601-608 of ERISA and Section 4980B of the Internal
Revenue Code. The Plan Administrator shall include appropriate language explaining the
Employees’, Beneficiaries’ and Pensioners’ rights under COBRA in the next Summary Plan
description booklet distributed.
(2) Advanced Insurance Premiums
In the event of an economic strike at the expiration of the 1993 Bituminous Coal Wage
Agreement, the Employer will advance the premiums for its health, vision care, and life and
accidental death and dismemberment insurance coverage for the first 30 days of such strike.
Such advanced premiums shall be repaid to the Employer by such Employees through a checkoff deduction upon their return to work. Should a strike continue beyond 30 days, the
Union or such Employees may elect to pay premiums themselves.
(3) Conversion Privilege
(a) Life Insurance
Upon application to the insurance carrier within 31 days after life insurance coverage
terminates, the Employee may, subject to applicable state insurance laws, arrange to
continue life insurance protection under an individual policy, for an amount not
greater than $50,000 without evidence of insurability. Such individual policy may be
on any one of the forms of policy then customarily issued by the insurance company,
other than a policy of term insurance or one which provides disability benefits in the
event of accidental death, and will be issued at the rate applicable to the Employee’s
age and class of risk at the time.
(b) Health Benefits
When health benefits coverage terminates, a Beneficiary may, upon application, convert,
without medical examination, to a policy issued by the claims administrator, provided
such application is made to the claims administrator within 31 days after the date
coverage terminates. The type of policy, coverage and premiums therefor are subject to
the terms and conditions set forth by the claims administrator.
(4) Qualified Medical Child Support Orders
The Plan shall comply with the provisions of Section 609 of ERISA as amended by the Omnibus
Budget Reconciliation Act of 1993 (“OBRA 1993”).
ARTICLE IV MANAGED CARE, COST CONTAINMENT
A. (1) Effective six months after the Effective Date of the 1993 NBCWA, the Employer may adopt
Participating Provider Lists (PPLs) of physicians, hospitals, pharmacies and other
providers, subject to the requirements set forth in C., below.
(2) In addition, the Employer may implement certain other managed care and cost containment
rules, which may apply to benefits provided both by PPL providers and by non-PPL sources,
but which (except for the deductibles and co-payments specifically provided for in the
Plan) will not result in a reduction of benefits or additional costs for covered services
provided under the Plan.
B. The Employer will comply with any UMWA-BCOA agreed-upon procedure for determining whether a
PPL satisfies appropriate criteria, and for identifying specific procedures subject to
precertification. The Employer shall not in any way be responsible for the failure of a
physician, health care facility, or other provider to satisfy any criteria, where any agreedupon procedure has been followed. Further, notwithstanding the implementation of any PPL or
other managed care or cost containment rule or procedure, the Employer shall not in any way be
responsible for the outcome of any medical treatment or health care (or lack of such treatment
C. The following requirements apply to a PPL implemented under this Plan:
1. Initial Certification and recertification — All Participating Provider Lists (PPLs)
must be certified prior to their implementation to ensure that they meet the required
standards, and recertified at least once during the term of this Agreement, in accordance
with a procedure to be agreed-to between the UMWA and the BCOA.
The costs of certification and recertification will be borne by the Employer.
2. Ongoing review — Continued compliance of each PPL with the required standards will be
the subject of ongoing review.
3. Criteria — A PPL established by an Employer must meet the necessary criteria. The
following is a general statement of the required elements:
4. Choice — Each covered individual will have the freedom to select any provider within
the PPL, regardless of whether that provider is a generalist or specialist.
5. Reduction of Paperwork and Prohibition on Prepayment — Eligible individuals utilizing
PPL providers shall, to the extent possible, not be required to fill out or submit claims
forms. In addition, such individuals shall not be required to pay a PPL provider any
amount other than the copayment and any outstanding annual deductible permitted under this
6. Quality Certification — All providers must meet quality standards.
a. Providers will be available within a reasonable distance. Where possible, this
means that a covered individual will not have to travel more than 20 to 30 minutes
to receive general medical care.
b. There will be adequate numbers of providers in the different specialties to
ensure that each member will have a sufficient choice.
c. Providers must be available to see covered individuals within a reasonable
period, depending upon the nature of the problem.
8. Breadth of Scope — The PPL shall include adequate diversification of specialties and
9. Additional Specialties — The program must have provision for going outside the PPL for
necessary specialties and/or facilities that are not contained within the PPL, at no
additional cost to the covered individual.
10. Other Outside Referrals — The program must have provision for referral outside the PPL
where particular medical services can be better provided elsewhere in the opinion of the
referring PPL provider, at no additional cost to the covered individual.
11. Emergencies — Emergency treatment is covered in full (subject to applicable
deductibles and copayments) whether or not provided within the PPL.
12. Beneficiaries Outside PPL Area — A Beneficiary who lives outside an area served by the
PPL shall be permitted to utilize non-PPL providers without incurring additional
deductibles and copayments. For purposes of determining the Beneficiary’s deductibles and
copayments, utilization of such non-PPL providers shall be considered to be within the PPL.
13. Transition — Out of PPL — If a beneficiary has begun to undergo a course of treatment
with a non-PPL provider prior to the establishment of the PPL (or with a PPL provider that
leaves the PPL) completion of that course of treatment will not be considered “out of PPL”
a. for an acute condition (including pregnancy, treatment for cancer, etc.), for
the duration of the specific course of treatment.
b. for a chronic condition, for up to six months.
14. Viability — A PPL must be viable, both financially and otherwise, in order to ensure
that it will continue to be able to appropriately serve the participant population.
15. Internal Review — Each PPL must have internal mechanisms (including physician peer
review) to resolve member complaints and to ensure that the highest quality standards are
16. Percertification — Precertification for services (including hospitalization) performed
by PPL providers is the responsibility of the provider, and not the covered individual. In
addition, precertification in the event a covered individual is referred to a provider
outside the PPL is the responsibility of the PPL provider making the referral.
Failure to precertify a non-emergency hospital admission to a non-PPL hospital (other than
by referral from a PPL provider) or certain other specified inpatient and out-patient
procedures performed by a non-PPL provider, will subject the Beneficiary to an additional
ARTICLE V AMENDMENT AND TERMINATION
A. Mid-Term Amendments. The UMWA and BCOA (and its successors or assigns) reserve the
right at any time and from time to time to modify or amend in whole or in part any or all of
the provisions of this Plan, or to terminate this Plan, by written instrument between the UMWA
and BCOA, without reopening or otherwise affecting the integrity of any other provision of the
B. Post-Termination Amendments. Subject to section C, following termination of the 1993
NBCWA, this Plan may be modified, amended, or terminated by BCOA and the UMWA, or by BCOA or
the Employer as permitted by law.
C. Special Rule for Certain Pensioners. The Employer will provide, for life, only the
benefits of its own eligible Pensioners who retired between February 1, 1993 and December 16,
1993, or who retire during the term of the 1993 NBCWA. The benefits and benefit levels
provided by the Employer under this Plan are established for the term of the 1993 NBCWA only,
and may be jointly amended or modified in any manner at any time after the expiration or
termination of the 1993 NBCWA.
D. Procedural Requirements. Any written instrument executed by BCOA and UMWA shall be
signed by the President of BCOA and by the International President of the UMWA. In the event
BCOA ceases to exist and there is no successor or assign, then the Employer, acting through its
____________, shall have the rights of the BCOA under this Article.
IN WITNESS WHEREOF, BCOA and the Union, pursuant to proper authority, have caused this
model plan, established under Article XX of the National Bituminous Coal Wage Agreement of 1993
and Effective December 16, 1993, to be signed by their proper officers or representatives in
Washington, D.C. on this 22nd day of July, 1994
UNITED MINE WORKERS OF AMERICA
/s/ Richard L. Trumka
BITUMINOUS COAL OPERATORS’ ASSOCIATION, INC.
/s/ Joseph P. Brennan