Vision Care Plan Summary

 

Important Information

The information in this document is a summary of the major provisions of this benefit plan, and constitutes the summary plan description as governed by the Employee Retirement Income Security Act of 1974 (ERISA). Benefits under the plan are determined by the terms of the underlying plan document and contracts. In the case of any inconsistency between this document and the plan document or contract, the plan document or contract will govern your rights and benefits.

RIT intends to continue the benefit plans indefinitely, but reserves the right to modify or terminate all or any portion of the employee benefits package at any time with or without notice. Such changes automatically will apply to you and your employment relationship at RIT. Participation in this plan is provided to eligible employees and does not constitute a guarantee of employment, requires continued employment and eligibility and is subject to the terms and conditions of the underlying plan document and insurance contracts.

Table of Contents

Plan Number: 514 
Plan Year: January 1 – December 31 
Plan Established: 01/01/2008

Introduction

The RIT Vision Care Plan is designed to cover much of the cost of prescription eyeglasses and contact lenses. There is also coverage for eye exams. This plan is administered by VSP.

General Information

Who is Covered and When

Regular full-time and extended part-time employees are eligible to participate in the Vision Plan. If you elect vision coverage, it can begin on the first day of the month on or after your date of employment. You need to enroll, however, and authorize the payroll deductions to pay your share of the cost before coverage can begin. If you are not at work on the day coverage is supposed to start, coverage will become effective on the day you return to active employment.

You also may obtain coverage for your spouse or domestic partner and/or eligible children by enrolling in two person or family coverage and authorizing payroll deductions to pay your share of the cost. You may not cover your spouse/domestic partner as a dependent if your spouse is enrolled for coverage as an employee. No dependent child may be covered by more than one employee in the plan. No dependent child can be covered as both an employee and a dependent.

Please refer to the Domestic Partner section of this handbook for more information on covering a domestic partner.

The eligibility rules for children are as follows:

The natural or adopted child of the employee or the employee’s opposite gender legal spouse

  • who is under age 26, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.

 

The natural or adopted child of the employee’s domestic partner or same gender spouse*

  • who is under age 26, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.
  •  
  • *if the child is not claimed as a depending on the employee’s federal income tax return, this benefit will be taxable.

 

Any other child

  • who is under age 26, and
  • for whom the employee is the legal guardian, and
  • who resides in the employee’s home, and
  • who is claimed as a tax dependent on the employee’s federal income tax return, and
  • who does not have access to employer-sponsored coverage from someone other than a parent.

 

Coverage for an unmarried dependent child who is physically or mentally disabled may be continued beyond the age limits of the Plan. Contact the Human Resources Department for further details.

Coverage for your dependents usually begins when your coverage begins. However, if your spouse/partner or a dependent child is confined in an institution or at home for medical reasons when coverage is supposed to begin, coverage will become effective on the first day the person is no longer confined.

A spouse/partner who is divorced from you is not eligible for coverage under the Plan. If you have an eligible dependent who is also an RIT employee, he or she may be covered either as an employee or as a dependent, but not both.

You Need to Enroll

Vision Care Plan coverage is not automatic; you need to complete an enrollment form for coverage to take effect. On the form you indicate your election of vision care coverage, and whether you want individual, two person, or family coverage.

It is important for you to return the completed enrollment form within 30 days after you first become eligible for coverage. If you wait beyond 30 days to enroll, you will not have another opportunity to enroll until the Plan's next open enrollment.

You may have a different level of coverage than you do for your medical and/or dental coverage (e.g., you can have family medical and two person vision care).

Open Enrollment

Because vision care needs change from time to time, you have the opportunity once each year – effective as of January 1 - to make a change in your Vision Care Plan election. You can enroll in or cancel coverage or change your coverage level (i.e., change from individual to two person). If you do not make a change during an open enrollment period, you will have to wait until the next open enrollment period to make a change unless you experience a qualified change in status that permits changes in your election. Information regarding qualified change in status events is found in the Medical Care Plan section of this handbook.

Election Changes During the Plan Year

In general, once you have enrolled in the Plan, you cannot change your elections or withdraw from the Plan until the beginning of the next plan year. However, pursuant to federal regulations, you may be able to make mid-year election changes if you meet certain criteria, as explained in the Election Changes During the Plan Year section of the Medical Care Plan section of this handbook. Your requested election change must be consistent with the reason for the change. For example, it would be consistent for an employee with two-person coverage that adopts a child during the year to change his or her election to family coverage. It would not be consistent to move from a family contract to a single contract. Changes must be made within 31 days of the event that gives you the right to make a new election. The Administrator may require you to submit certain documentation related to your reason for making a mid-year election change. New elections will become effective as soon as administratively possible.

For more details on mid-year changes, please refer to the Medical Care Plan section of this handbook.

Who Pays For This Protection

This is a voluntary plan, with the employee paying the full premium by pre-tax payroll deduction. Your cost will be based on whether you choose individual, two person or family coverage.

Rates for vision care coverage are provided annually by the Human Resources Department. These rates are subject to change. You will be notified in the event of any change in rates.

Coordination of Benefits

If you have vision care coverage under another group plan in addition to this one - through that of a spouse/partner, for example - the total benefits you are eligible to receive could be greater than your actual expenses. To help eliminate this duplicate spending, our Plan's coverage is coordinated with other group plans with which you have coverage. This means that when the RIT Plan pays second, benefits will be adjusted so that the total payments from both plans won't be more than 100% of total covered charges.

For your own claims and those of your spouse/partner, the plan that pays first is the one that covers you, your spouse or partner as an employee. If your children are covered by more than one plan, the plan of the parent whose birthday occurs earliest in the year will pay benefits first. However, if you are separated or divorced, the plan of the parent who has financial responsibility for the child's medical care expenses will pay first. If there is no court decree for medical care coverage, then the plan of the parent who has custody of the child will pay first. Where none of these situations apply, the plan that you're covered under the longest will pay first.

What the Vision Care Plan Covers

Benefits are available under this plan if you receive services from a participating provider. You can find VSP providers on their website at http://www.vsp.com or by calling them at (800) 877-7195/v and (800) 428-4833/TTY Monday – Friday 8 a.m. to 10 p.m., Eastern Time.

You will not receive an ID card from VSP. And, when you go to a VSP provider, you simply let them know you are a VSP member and they will take care of the rest (no claim forms to file!). For employees, your ID number is your University ID (UID); for retirees, your ID number is your Social Security Number.

If you or a covered family members receives coverage from a non-VSP provider, you should pay the provider's full fee at the time of service and then submit an itemized bill to VSP for reimbursement according to the schedule of allowances. Discounts do not apply for vision care benefits obtained from Non-VSP Providers.

If you go to a VSP provider, the coverage is as follows:

Eye Exam: An eye exam is covered once per calendar year with a $15 copayment.

Lenses: VSP's standard lenses are covered in full, every calendar year, after a $20 copayment, including glass or plastic single vision, bifocal, trifocal, progressive, or other more complex lenses necessary for the patient's visual welfare. There is an additional cost for various coatings (e.g., anti-reflective, scratch, etc.), but VSP does provide a discount on these optional items.

Frames: $120 allowance toward frames, every calendar year. If you select a frame that costs more than $120, VSP offers a 20% discount off the amount over the retail allowance.

Contact Lenses: You may choose contacts instead of glasses (lenses and frame). There is a $120 allowance applied to the contact lens exam (fitting & evaluation) and the contact lenses. You also receive a 15% discount off the contact lens exam before the allowance is applied.

Some important notes:

  • You can enroll in the RIT Vision Care Plan whether or not you have RIT medical coverage – they are two separate enrollments; you can have the Vision Care Plan without having RIT's medical coverage;
  • If you have RIT medical coverage, your coverage level under the RIT Vision Care Plan can be different (i.e., you can have family medical coverage and two person Vision Care coverage); this gives you flexibility if some family members don't wear glasses. However, the employee needs to be covered in order to cover other family members;

Exclusions And Limitations Of Benefits

Patient Options

This Plan is designed to cover visual needs rather than cosmetic materials. If you or a covered family member selects any of the following extras, the Plan will pay the basic cost of the allowed lenses, and you will pay the additional costs for the options.

  • Optional cosmetic processes.
  • Anti-reflective coating.
  • Color coating.
  • Mirror coating.
  • Scratch coating.
  • Cosmetic lenses.
  • Laminated lenses.
  • Oversize lenses.
  • Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
  • UV (ultraviolet) protected lenses.
  • Certain limitations on low vision care.

Not Covered

There are no benefits for professional services or materials connected with:

  • Orthoptics or vision training and any associated supplemental testing.
  • Plano lenses (less than a ±.50 diopter power).
  • Two pair of glasses in lieu of bifocals.
  • Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are otherwise available.
  • Medical or surgical treatment of the eyes.
  • Corrective vision treatment of an Experimental Nature, unless approved by an external appeal agent.
  • Plano contact lenses to change eye color cosmetically.
  • Artistically-painted contact lenses.
  • Contact lens insurance policies or service contracts.
  • Additional office visits associated with contact lens pathology.
  • Contact lens modification, polishing, or cleaning.
  • Costs for services and/or materials above Plan Benefit allowances.
  • Services or materials of a cosmetic nature.
  • Services and/or materials not indicated on this Schedule as covered Plan Benefits.

Liability In Event Of Non-Payment

In the event VSP fails to pay the provider, you will not be held liable for any sums owed by VSP other than those not covered by the plan.

Complaints And Grievances

If you have a question or problem, your first step is to call VSP's Customer Service Department. The Customer Service Department will make every effort to answer your question and/or resolve the matter informally. If a matter is not initially resolved to your satisfaction, you may communicate a complaint or grievance to VSP orally or in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. You also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP's review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty (120) days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty (30) days, a letter will be sent to you to indicate VSP's expected resolution date. Upon final resolution, you will be notified of the outcome in writing.

Claims Payments And Denials

Initial Determination: VSP will pay or deny claims within thirty (30) calendar days of the receipt of the claim from you or your authorized representative. In the event that a claim cannot be resolved within the time indicated, VSP may, if necessary, extend the time for decision by no more than fifteen (15) calendar days.

Request for Appeals: If a claim for benefits is denied by VSP in whole or in part, VSP will notify you in writing of the reason or reasons for the denial. Within one hundred eighty (180) days after receipt of such notice of denial of a claim, you may make an oral or written request to VSP for a full review of such denial. The request should contain sufficient information to identify the the person for whom a claim for benefits was denied, including the name of the VSP enrollee, Member Identification Number of the VSP enrollee, your name and date of birth, the name of the provider of services and the claim number. You may state the reasons you believe that the claim denial was in error. You may also provide any pertinent documents to be reviewed. VSP will review the claim and give you the opportunity to review pertinent documents, submit any statements, documents or written arguments in support of the claim, and appear personally to present materials or arguments. You or your authorized representative should submit all requests for appeals to:

VSP
Member Appeals
3333 Quality Drive
Rancho Cordova, CA 95670
(800) 877-7195

VSP's determination, including specific reasons for the decision, shall be provided and communicated to you within thirty (30) calendar days after receipt of a request for appeal from the you or your authorized representative.

If you disagree with VSP's determination, you may request a second level appeal within sixty (60) calendar days from the date of the determination. VSP shall resolve any second level appeal within fifteen (15) calendar days.

If Plan benefits have been denied or reduced because the requested services or materials were considered by VSP to not be medically necessary, or to be experimental or investigational, you or your authorized representative also have the right to request an external appeal. The appeal must be submitted in writing to the New York State Insurance Department. An external appeal may be requested after receiving a denial from VSP following either an initial or second level appeal. There is no cost to you for an external appeal.

When you have completed all appeals mandated by the Employee Retirement Income Security Act of 1974 ("ERISA"), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. You should contact the U. S. Department of Labor or the state insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], you have the right to bring a civil (court) action when all available levels of review of denied claims, including the appeals process, have been completed, the claims were not approved in whole or in part, and you disagree with the outcome.

When Coverage Ends

Your vision care coverage ends when

  • Your employment ends;
  • You retire, unless for retirement, you are eligible for continued coverage;
  • You no longer meet the Plan's eligibility requirements; this includes transfer to an employment category that is not eligible for coverage under the Plan, such as part-time employees and adjunct faculty; coverage for a faculty member with a 10-month contract ending in June of the academic year, which is not being renewed for the following academic year, will end on June 30, even if the person is teaching in an adjunct capacity during the summer (adjunct faculty are not eligible); a faculty member with a 9½-month contract which is being renewed for the following academic year will continue to have coverage during the summer between the two academic years;
  • You stop making required contributions;
  • You die; or
  • RIT discontinues the Plan.

Generally, your dependent's coverage ends when your coverage ends. However, a dependent's coverage also will end on the last day of the month in which;

  • He or she no longer meets the Plan's dependent eligibility requirements ; or
  • You stop making required contributions.

If you or a dependent submit a fraudulent claim under a medical, prescription drug, vision care or dental plan, you and all your dependents will be permanently ineligible for coverage under all RIT health care options (medical, prescription drug, dental and vision care).

Coverage May Be Continued

In certain circumstances, your coverage and that of your dependents may be continued beyond the date it normally would end. Coverage may continue as shown below, provided you make any required premium contributions.

  • For a Disabled Child - Coverage for an unmarried child who is physically or mentally incapable of self-support may be continued beyond the age limit of the plan provided the disability occurred before that age and family coverage was in effect before the disability occurred.
  • For a Personal Leave of Absence – Coverage may continue while on a personal leave of absence of up to three months. For leaves of absence beyond three months, coverage is not continued.
  • For a Professional Leave of Absence (including sabbaticals)– Coverage is continued for up to two years while on an approved professional leave of absence, including a sabbatical.
  • For Long-Term Disability – Coverage is continued during long term disability in the same manner as it was during active employment. Coverage will end when benefits under RIT's long term disability plan end.

When You Are Eligible for COBRA

See the Medical Care Plan section of this handbook for information on COBRA continuation of coverage. There is no conversion option under this Plan.

Your Rights under ERISA

[The U.S. Department of Labor requires that the following notice be included in all Summary Plan Descriptions.]

As a participant in Rochester Institute of Technology benefit plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites, all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual report. The Plan Administrator is required by law to furnish each Participant with a copy of this summary financial report.

Continue Group Health Care Coverage

Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. [NOTE: None of the health insurance options presently offered by RIT include a pre-existing condition exclusion.]

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "Fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

Your Rights under the Newborns' and Mothers' Health Protection Act

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Qualified Medical Child Support Orders ("QMCSOS")

A medical child support order shall be filed with the plan administrator as soon as reasonably possible after it has been filed promptly upon the receipt of such order, the plan administrator shall notify the participant and each person eligible to receive benefits under the terms of the order ("alternate recipients") of its receipt and of the procedures set forth in this section 14.04.

The Participant and the alternate recipients may provide comments to the Plan Administrator with respect to the order during the 30 day period commencing as of the date the Plan Administrator sends them notice of receipt of the order. The Plan Administrator shall, within the 60 day period commencing as of the expiration of the 30 day comment period specified in the preceding sentence, determine whether the order is qualified and shall so notify the participant and the alternate recipients in writing of its decision. The parties may waive the 30 day comment period. If they do so, the 60 day period shall commence as of the date all parties have waived their rights to submit comments. The Plan Administrator's determination on the qualified status of an order is final. As soon as reasonably practicable following its notification that an order is "qualified," the Plan Administrator shall take such steps it deems appropriate to implement the order.

The Plan Administrator encourages parties to submit draft orders for "pre-approval" of their qualified status prior to their being submitted to a court for signature as such pre-approval will expedite approval procedures.

An alternate recipient may designate a representative for receipt of copies of notices that are sent to an alternate recipient with respect to a medical child support order.

Claim Procedures

A decision will be made by the Plan Administrator no more than sixty (60) days after receipt of the request for review, except in special circumstances (such as the need to hold a hearing), but in no case more than one hundred twenty (120) days after the request for review is received. The written decision will include specific reasons for the decision and specific references to the Plan provisions on which the decision is based.

Additional information about claims submitted and review procedures may be obtained by contacting the Plan Administrator.

If you have any questions about your Plan, you should contact the Human Resources Department. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U.S. Labor Management Services Administration, Department of Labor.

Additional Information

Employer: Rochester Institute of Technology
Employer Identification Number: 16-0743140
Plan Sponsor: Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604
Plan Administrator: Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604
Business Telephone Number: (585) 475-2424 (voice)
Agent for Service of Legal Process: Associate Director, Human Resources
Benefits, Health and Wellness 
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604
  1. Claims for Benefits – An Employee wishing to present a claim for benefits for himself or his Dependents should obtain a claim form or forms from his Employer or Plan Administrator. The applicable section of such form or forms should be completed by (1) Employee, (2) Employer or Plan Administrator, and (3) attending Physician or Hospital. Claims will only be processed if received within a reasonable time following the date the expense to which the claim relates arises.

    Following completion, the claim form or forms should be submitted to the Plan's representative as indicated on the reverse side of the Employee's Benefit Plan Identification Card. The organization that is authorized by the Plan to process and pay claims (the Plan's Claims Administrator) will compute benefits due, and cause proper claims to be paid. Unless the Employee assigns benefits to a doctor or to a Hospital, draft(s) will be made payable to the Employee.

    A decision will be made by the Claims Administrator no more than ninety (90) days after receipt of due proof of loss, except in special circumstances (such as the need to obtain further information), but in no case more than one hundred eighty (180) days after the due proof of loss is received. The written decision will include specific reasons for the decisions and specific references to the Plan provisions on which the decision is based.

  2. Appealing Denial of Claims – If a claim for benefits is wholly or partially denied, notice of the decision shall be furnished to the Employee. This written decision will:
    1. Give the specific reason or reasons for denial;
    2. Make specific reference to the Plan provisions on which the denial is based;
    3. Provide a description of any additional information necessary to perfect the claim, if possible, and an explanation of why it is necessary; and
    4. Provide an explanation of the review procedure.

    On any denied claim an Employee or his representative may appeal to the Plan Administrator for a full and fair review. The claimant may:

    1. Request a review upon written application within sixty (60) days of receipt of claim denial;
    2. Review pertinent documents; and
    3. Submit issues and comments in writing.