UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS
                                   HEALTH and WELFARE FUND
 

Who is Eligible?

You and your dependents are eligible to participate in the Plan if you are an active, full-time employee, as provided in your collective bargaining agreement. (Refer to your collective bargaining agreement to determine your eligibility for benefits.) You and your dependents are entitled to all benefits discussed in this booklet. Your dependents include your spouse and your unmarried children who are under the age of 19. Children include your natural children, legally adopted children or children legally placed for adoption, foster children, and stepchildren. (Stepchildren must live with you and you must claim them as dependents on your federal income tax return.) You may also claim other children if they live with you, you claim them as dependents on your federal income tax return and you are their legal guardian.

In addition, unmarried children who are physically or mentally disabled are covered under the Plan if they were disabled before the age of 19, and if you provide their support. To be eligible, they must be covered under the Plan as your dependent before they reach age 19.

IMPORTANT: Whenever you or a dependent has a change in status, such as a marriage, birth of a child, divorce, change of address, etc., you must notify the Fund office immediately. If you fail to notify the Fund office of a change, and the Fund pays benefits to your former spouse or dependent, the Fund may sue you for reimbursement or instead may deny you future benefits until the amount owed is recouped.

Qualified Medical Child Support Orders

Your child may be covered under the Plan even though he or she is not your federal income tax dependent or does not reside with you. The child must be your biological or adopted child. However, it does not matter if the child was born out of wedlock, is not a dependent for federal income tax purposes or does not live with you. The Plan will provide such coverage if it receives a "qualified medical child support order" (QMCSO). A QMCSO is a court or administrative order which provides for child support, is made under the state domestic relations law, and relates to medical benefits. Generally, these orders are obtained by the custodial parent in connection with divorce or separation. However, they may also be obtained by the government. In order for the Fund to honor a QMCSO, the order must specifically refer to the UFCW Local 1776 and Participating Employers Health and Welfare Fund and must contain the following information:

  The name and last known mailing address of the participant and of each child covered by the order.

  A description of the coverage to be provided, or the manner in which coverage is to be determined.

   The period to which the order applies (i.e., start and stop dates).

 The order cannot require the Plan to provide any type or form of benefit that is not available under the Plan, except as required under the law relating to medical child support in section 1908 of the Social Security Act. When the Fund receives a medical child support order, it will send the participant and each child covered under the order (or the child's parent or legal guardian) notification of the order's receipt and a copy of the Plan's procedures for determining whether the order is "qualified." A copy of these procedures will be furnished to you without charge upon request at any time.) Each child covered under the order (or the child's parent or legal guardian) may designate a representative to receive notices on his or her behalf. If the Plan Administrator rules that an order is not a QMCSO, this determination can be appealed under the Plan's claims review procedure. If the Plan Administrator determines that an order is a QMCSO, it will enroll the child (or children) for group health benefits. The Plan will reimburse any reimbursable payments made by the child (or the child's parent or legal guardian) directly to that person. Benefit payments will be made in accordance with any assignment of rights made by or on behalf of the child (or beneficiary of the child) as required by a state plan for medical assistance approved under Title XIX of the Social Security Act.

Eligibility for Medicaid or any other state medical assistance plan is not relevant to benefit eligibility or payments. The Plan will reimburse the state for any payments made under a state plan for medical assistance if the state has been assigned the rights of the participant for payment.