The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 – your/your domestic partner’s foster children; – children/grandchildren for whom you or your spouse/domestic partner have legal guardianship****; – children/grandchildren legally adopted by you or your spouse/domestic partner or placed with you or your spouse/domestic partner for adoption****; and – grandchildren who are eligible to be claimed as an exemption on you or your spouse/domestic partner’s federal income tax return. • Disabled children age 26 and older who otherwise meet the dependent children definition may be covered as long as ALL of the following requirements are met: – the child is severely disabled by prolonged physical or mental incapacity; – the child became disabled prior to reaching age 26; – the child was covered by the plan prior to reaching age 26, or, if older than age 26, loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of prior coverage must be provided; – the child remains unmarried and you/your domestic partner provide more than 50% of his or her support because he or she is unable to earn a living; and – disabled dependent status is approved by a medical Claims Administrator for U.S. Bank. * Eligible dependents of retirees of the former Mercantile only (at the time the retiree terminated employment) will be allowed to enroll in the Program at a later date as long as the retiree enrolled at termination. ** Even though some localities may recognize same-sex marriages, the U.S. Bank Benefits Program is governed by federal regulations which require that coverage for partners must be paid for on an after-tax basis, and the cost of coverage be considered imputed income. Therefore, even in the event of marriage or civil union, if you are enrolling your same-sex spouse you must designate him/her as a domestic partner. *** For health care coverage, a newborn is not considered a dependent until birth. **** Documentation of legal guardianship or adoption is required. Please call the U.S. Bank Employee Service Center for instructions. The dependent cannot be added to your coverage until a copy of the applicable documents are received and verified by the U.S. Bank Employee Service Center. To have the disabled child considered for coverage, you and his or her doctor must complete an application form for the child. The form is available from the applicable medical Claims Administrator. To be considered, the form must be received by the medical Claims Administrator no later than 30 days after the date the child turns age 26. See the “Important Resources” section of this SPD for telephone numbers for the medical Claims Administrators. If coverage for the child is approved, and the child is not considered permanently disabled, periodically you will be asked to submit proof to the medical Claims Administrator that the child continues to meet eligibility requirements. Failure to provide requested information may result in loss of coverage for the dependent. If your disabled dependent loses coverage under another health care plan, please contact the U.S. Bank Employee Service Center for information regarding the procedure for applying for coverage under the U.S. Bank Retiree Health Care Program. Children who become disabled after age 26 are not eligible for coverage. Ineligible Dependents. Ineligible dependents include but are not limited to the following: • Dependents in the Military. Coverage is not available for any dependent on active duty in the uniformed services or armed forces of any country. • Dependent Parents. Coverage is not available for a retiree's or retiree's spouse's/domestic partner’s parents. 168
Retiree Health Care SPD Effective January 1, 2012 • Former Spouses/Domestic Partners. A spouse from whom you are divorced (even if the divorce decree stipulates you will continue health care, pharmacy care, dental care or vision care coverage for your ex-spouse) or legally separated, or a domestic partner or domestic partner’s dependents if your domestic partnership has ended. • Spouse/Domestic Partner of Adult Children/Grandchildren. Coverage is not available for an adult child’s or grandchild’s spouse/domestic partner. Enrolling ineligible dependents is a violation of company policy and will be treated accordingly. If U.S. Bank determines that an ineligible dependent has been enrolled, coverage will be cancelled retroactively. U.S. Bank reserves the right to recover any and all benefit payments made for services received by ineligible dependents. For more information about eligibility, enrollment and coverage for domestic partners and dependents of domestic partners, see the “Domestic Partner Eligibility” section of this SPD. Enrollment Rules You may initiate your enrollment into the Program up to 90 days prior to your termination date by contacting the U.S. Bank Employee Service Center at 1-800-806-7009 or online at www.yourbenefitsresources.com/usbank. If you are eligible to participate in the Program when you terminate from U.S. Bank and have not enrolled prior to your termination date, you will receive enrollment materials that specify an enrollment deadline. You must enroll by the deadline indicated on your election materials; otherwise you will not be covered by the Program. Coverage Levels. For any of the health care options available to you, you can select from two coverage levels: • Individual (yourself — the retiree — only); or • Family (you, and/or any eligible dependents as previously defined in this section). Effective Date. If you elect coverage by your enrollment deadline, and are enrolling yourself and/or your dependents in the Early Retiree Medical or Comprehensive option, coverage is effective the first day of the month after the date your active employee health care ended or if you are involuntarily terminated, coverage is effective the first day of the month after the date your subsidized health care ended. For dependents covered with you as of the date of your termination or the date your subsidized health care coverage ends, coverage will be effective the same date as your coverage is effective, if you enroll them at the same time that you enroll. You will be responsible for the retroactive premiums due for retiree coverage back to the effective date of your retiree health care coverage. If you elect coverage by your enrollment deadline, and are enrolling yourself and/or your dependents in the UnitedHealthcare or Medica Plan option, coverage is generally effective the first day of the month after your application(s) is received and processed. If you will experience a lapse in coverage between your termination of employment and your effective date of coverage, you must call the U.S. Bank Employee Service Center at 1-800-806-7009. You will be responsible for the premiums due for retiree coverage back to the effective date of your retiree health care coverage. Deciding Between Retiree Health Care Coverage and COBRA Health Care Coverage. Separate from the Program enrollment information, you and any other covered dependents will also receive information on continuing the health care coverage you were enrolled in as an active 169
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The eligibility and enrollment rules for the U

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