BENEFIT FUND ADMINISTRATION (Employer Plan)
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 1998.
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
1998, 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, (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; or (iii) a special permanent layoff pension under the terms
of Article II.E(4) of the 1974 Pension Plan, during any period prior to the person’s attainment of
age 55. “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
(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
(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
(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 work* 1
for the Employer on the Effective Date of the Wage
(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 1993 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 subsections (2) and (3) above, any Employee of the
Employer who is not actively at work* 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 Employer.
Any Employee of the Employer who as of December 31, 1997, 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 Employer.
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
*Actively at work includes an Employee of the Employer who was actively at work on December 31,
1997, and who returns to active work with the Employer two weeks after the Effective Date of the Wage
(a) such Pensioner’s initial date of retirement under the 1974 Pension Plan,
(b) December 31, 1997, 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.
(2) Any person who
(a) had been covered as a Pensioner under this Plan, and
(b) is again employed in classified signatory employment after December
31, 1997, 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 December
31, 1997, while so employed with the same employer, coverage shall be terminated under this
(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 December 31,
1997, 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 Employer.
(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
success 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
(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 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 subsections (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
1998 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
The benefits provided under this Plan are as set forth in this Article III. Benefits
payments are based on negotiated rates applicable to services provided by hospitals, physicians,
pharmacies and other providers on Participating Provider Lists (PPL’s) adopted under Article IV.
During any period when PPL’s 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 charges2
for covered services and supplies. Covered services
shall be limited to those 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.
The reasonable and customary charge for any service or supply is the usual charge for the service or
supply in 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 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).
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 medication (including take-home drugs which are limited to a 30-day
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
(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’’ 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 to
(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 medically
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 Benefit Fund.
(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 or injury.
(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 physician.
(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 post-operative
care) for the 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
(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 anesthetist.
(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 surgeon.
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 the 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 following:
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
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
(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
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 charged 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 medical
(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 necessary.
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
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 physician.
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 professionals.
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
(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 preparations.
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 scares 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 a nonoccupational) accident or (ii)
licensed dentist for treatment following the performance of those oral surgical services set forth in
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 lesser of :
1. The amount actually billed per prescription or refill;
2. The price of the applicable generic substitution drug, if AB or betterrated, approved by the federal Food and Drug Administration; or, in the event the prescribing
physician determines that 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 nursing care facility3
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
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.
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.
(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.
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 home.
(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 for oxygen.
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
(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
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
(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 escort.
(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
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
(8) Co-Payments and Deductibles
Effective January 1, 1997, 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 requirement.
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 (PPL’s) implemented by the Employer pursuant to Article IV
may include participating hospitals, physicians, pharmacies and other providers. The Plan
payment for hospital 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 benefits 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 1998) 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 payment pursuant to Article XX (General Description)(10)c of the
1998 NBCWA for such year, and the preceding two sentences shall not apply in the case of any
employee that receives a health care payment from more than one signatory employer for the
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 prescription*4
Non-PPL: $9.00 per prescription*
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 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.
Note: For purposes of this co-payment provision, a prescription or refill shall be deemed to be each 30
days (or fraction thereof) supply.
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 $750 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 copays apply. In no event will the deductible applicable to a family for a calendar year exceed the
75 percent of the gross amount of the Health Care payment 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 1998 NBCWA. Deductibles are established as follows:
Physician, hospital or $750.00 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 $300.00, not applied
obtained without required to annual out-of-pocket
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 $750.00 that reflects the number of calendar quarters during
which he or she is entitled to Employer-provided health care under the plan during such year.
(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 $750.00 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
(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
(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 outof-pocket maximum amounts have been paid:
Benefit Annual Out-of-Pocket Maximum
For services obtained $950.00 per family, including
from a PPL provider the $750.00 deductible and
or services obtained $200.00 in per physician
from a non-PPL office visit co-pays
provider $2,250.00 per family,
including the $750.00
deductible and $1,500 in
physician office visit co-pays
and balance billing after Plan
pays 90% of PPL rate for
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 Program
Up to Maximum
(a) Benefits Amount Frequency
Vision Examination $26.40 Once every 24
Per Lens (Maximum = 2) Once every 24
–Single vision 13.20
–Frames 18.70 Once every 24
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, aniseikonia 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 worker’s 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 HMO’s; provided,
however, that all Beneficiaries in a family shall be governed by an HMO election.
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 1998 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 threemember arbitration panel selected by mutual agreement of the UMWA and the 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 decision 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 1998 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
(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
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 Medicare.
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 payer.
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 reasonable 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
The health benefits provided under this Plan are subject to a non-duplication
provision as follows:
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 plan:
(i) does not include a coordination of benefits or non-duplication
(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 spouse or
dependent will be the primary plan.
(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 primary
(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
(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 dependents.
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
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,
when ever 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 other plan.
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 this
(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
(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 Employee,
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 Employee 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 Department).
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,
judgments 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
(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 Lung
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 Plan.
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
26. Charges for an autopsy or post-mortem surgery.
27. Any types of services, supplies or treatments not specifically provided by
B. Life and Accidental Death and Dismemberment Insurance for Active
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
(1) Upon the death of an Employee due to other than violent, external and
accidental means on or after January 1, 1998, life insurance in the amount of $55,000 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 January 1, 2002, life insurance in the amount of
$60,000 will be paid to the Employee’s named beneficiary.
(2) 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 January 1, 1998, life insurance in the amount of $110,000 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
January 1, 2002, life insurance in the amount of $120,000 will be paid to the Employee’s named
(3) If an Employee shall lose two or more members due to violent, external
and accidental means as the result of an injury occurring whole insured and on or after January 1,
1998, such Employee shall receive a $60,000 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 January 1, 2002, such Employee shall receive a $70,000
dismemberment benefit. If an Employee shall lose one member due to violent, external and
accidental means as the result an injury occurring while insured and on or after January 1,1998,
such Employee shall receive a $30,000 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 January 1, 2002, such Employee shall receive a $35,000
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-inflected 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 in
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 Period of Coverage
to the Employee’s Continuation from the
Date Last Worked Date Last Worked
2,000 or more hours Balance of month plus 12 months
500 or more but less 2,000 hours Balance of month plus 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
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
3. If an Employee who is on an approved leave of absence is placed on layoff status, or would have been 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 lay-poof. 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
(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 last worked.
(f) Other Employment
Notwithstanding the foregoing, 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 the 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 for
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 1998 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 check-off
deduction upon their return to work. Should such 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 Consolidated Omnibus Budget Reconciliation Act of 1993 (“COBRA 1993”).
ARTICLE IV MANAGED CARE, COST CONTAINMENT
A. (1) The Employer may adopt Participating Provider Lists (PPL’s) 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 agreed-upon
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 or
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
require 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 subject to 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 Agreement.
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
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” as follows:
a. for an acute condition (including pregnancy, treatment for cancer, etc.),
for duration of the specific course of treatment.
b. for 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. Precertification–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 $300 deductible.
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 Wage Agreement.
B. Post-Termination Amendments. Subject to section C, following
termination of the 1998 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
January 1, 2003. The benefits and benefit levels provided by the Employer under this Plan are
established for the term of the 1998 NBCWA only, and may be jointly amended or modified in
any manner at any time after the expiration or termination of the 1998 NBCWA.
D. Procedural Requirements. Any written instrument executed by BCOA
and the 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 not successor or assign, then the
Employer, acting through its __________, shall have the rights of 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 1998 and effective January 1, 1998, to be signed by their proper officers or
representatives in Washington, D.C. on this ____ day of _______, 1998.