Michelin Health and Welfare Plan (Union Free) Summary Plan

03/05/2021

Michelin Health and Welfare Plan (Union Free)

Summary Plan Description

Effective January 1, 2020

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Table of Contents Introduction.................................................................................................................................................... 1

How this SPD Works ................................................................................................................................. 1 Coverage Documents and Plan Contact Information ................................................................................ 1 Cafeteria Plan Benefits .............................................................................................................................. 2

Eligibility ........................................................................................................................................................ 3 Your Eligibility ............................................................................................................................................ 3 Dependent Eligibility .................................................................................................................................. 3 Proof of Documentation for Expatriates Returning to the U.S................................................................... 4 Certifying Dependent Eligibility .................................................................................................................. 4 Proof of Dependent Eligibility .................................................................................................................... 5 Qualified Medical Child Support Orders .................................................................................................... 5 If Both You and Your Spouse/Domestic Partner are Employees of Michelin ........................................... 5 If Both You and Your Dependent Child are Employees of Michelin .......................................................... 6 Who Is Not Eligible .................................................................................................................................... 6 Coverage Levels ........................................................................................................................................ 6

Enrolling for Coverage .................................................................................................................................. 8 Enrolling When You are Hired ................................................................................................................... 8 Enrolling During Annual Enrollment .......................................................................................................... 8

If You Don’t Enroll During Annual Enrollment ........................................................................................ 8 Opting Out of Company Coverage ............................................................................................................ 9 Enrollment and Rehired Employees .......................................................................................................... 9 Cost of Health and Welfare Benefits/Funding/Contributions ..................................................................... 9

Stopping Contributions......................................................................................................................... 10 Federal Tax Implications for Dependent Coverage ................................................................................. 10

State Tax Implications for Dependent Coverage ................................................................................. 10 Enrollment Effective Date ............................................................................................................................ 11

Initial Enrollment ...................................................................................................................................... 11 Annual Enrollment ................................................................................................................................... 11 Effective Date of Your Coverage ............................................................................................................. 11

New Employees ................................................................................................................................... 11 Current Employees .............................................................................................................................. 11

Your Health and Welfare Benefits ............................................................................................................... 12 Cost of Coverage ..................................................................................................................................... 12 Participating Provider Networks and Directories ..................................................................................... 12

Your Health Care Flexible Spending Account ............................................................................................. 13 Eligibility ................................................................................................................................................... 13 Contributions ........................................................................................................................................... 13 Claims Reimbursement ........................................................................................................................... 13 Eligible Expenses .................................................................................................................................... 14

Qualified Health Care Expenses .......................................................................................................... 15

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Health Care Expenses for Your Dependents ...................................................................................... 15 Claims Procedures .................................................................................................................................. 15 Qualified Reservist Distribution ............................................................................................................... 16 Nondiscrimination Testing ....................................................................................................................... 16

Your Dependent Care Flexible Spending Account ..................................................................................... 17 Eligibility ................................................................................................................................................... 17 Contributions ........................................................................................................................................... 17 Amounts Available for Reimbursement ................................................................................................... 17 Qualified Dependent Care Expenses ...................................................................................................... 17

Non-Qualified Dependent Care Expenses .......................................................................................... 18 Claims Procedures .................................................................................................................................. 18 Nondiscrimination Testing ....................................................................................................................... 19

Your Health Savings Account (HSA) .......................................................................................................... 20 Eligibility ................................................................................................................................................... 20

If You Participated in a Health Care FSA or HRA ............................................................................... 20 Enrollment in Medicare ........................................................................................................................ 20

Contributions ........................................................................................................................................... 21 Company Contributions ....................................................................................................................... 21 Contributions from Retirement Accounts ............................................................................................. 21

Using Your Account ................................................................................................................................. 21 How to Open Your HSA ........................................................................................................................... 22

HSA Debit Card ................................................................................................................................... 22 Management of Your HSA and Additional Information ........................................................................ 22

Changing Your Coverage During the Year ................................................................................................. 23 Qualifying Life Event ................................................................................................................................ 23

Domestic Partners ............................................................................................................................... 24 Cost or Coverage Changes ..................................................................................................................... 24 HIPAA Special Enrollment Rights ........................................................................................................... 25

Effective Date of Coverage Under Special Enrollment ........................................................................ 25 Revocation of Election due to Enrollment in Qualified Health Plan ........................................................ 26 Other Changes in Circumstance ............................................................................................................. 26 How to Make Changes During the Plan Year.......................................................................................... 26

Important Medical Plan Notices and Protections ........................................................................................ 27 Patient Protection Statement Regarding Provider Designation .............................................................. 27 Consumer Protections Under the Affordable Care Act ........................................................................... 27 Standards for Mothers and Newborns ..................................................................................................... 29 Your Rights Following a Mastectomy ...................................................................................................... 29

Coordination of Benefits .............................................................................................................................. 31 Order of Payment Determination Rules .................................................................................................. 31 When this Plan Is Secondary .................................................................................................................. 32

Determining the Allowable Expense When this Plan Is Secondary .................................................... 32

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Recovery of Excess Payments ................................................................................................................ 32 Right to Receive and Release Information .............................................................................................. 32 Coordination of Benefits for Medicare Eligible Individuals ...................................................................... 32 Right to Receive and Release Needed Information ................................................................................ 33

Continuing Participation .............................................................................................................................. 34 Leaves of Absence .................................................................................................................................. 34 Uniformed Services Employment and Reemployment Rights Act .......................................................... 34

Continuation of Health Benefit Coverage ............................................................................................ 34 Reinstatement of Health Benefit Coverage ......................................................................................... 34

Family and Medical Leave Act................................................................................................................. 34 Benefit Coverage While on FMLA Leave............................................................................................. 35 Reinstatement of Canceled Health Benefit Coverage Following FMLA Leave ................................... 35 State Family and Medical Leave Laws ................................................................................................ 35 If Company Changes Benefits ............................................................................................................. 35

Termination of Plan Participation ................................................................................................................ 36 Employees ............................................................................................................................................... 36

Continuing Coverage ........................................................................................................................... 36 Dependents ............................................................................................................................................. 36

Surviving Dependents .......................................................................................................................... 36 Other Circumstances ............................................................................................................................... 37

COBRA Continuation Rights ....................................................................................................................... 38 Qualified Beneficiaries and Qualifying Events ........................................................................................ 38

Covered Employee or Eligible Retiree ................................................................................................. 38 Spouse/Domestic Partner of Covered Employee or Covered Eligible Retiree .................................... 38 Dependent Children ............................................................................................................................. 39

Notification of Qualifying Events .............................................................................................................. 39 You Must Give Your Plan Administrator Notice of Some Qualifying Events ....................................... 39

How COBRA Continuation Coverage is Offered ..................................................................................... 39 Special Considerations in Deciding Whether to Elect COBRA ........................................................... 39

Effective Date of COBRA Continuation Coverage .................................................................................. 40 How Long COBRA Continuation Coverage Lasts ................................................................................... 40

Disability Extension of 18-Month Period of COBRA Continuation Coverage ...................................... 40 Second Qualifying Event Extension of 18-Month Period of COBRA Continuation Coverage ............. 41 Medicare Extension for Your Dependents ........................................................................................... 41 Special Rule for the Health Care Flexible Spending Account ............................................................. 41

Enrolling in Medicare Instead of COBRA Continuation Coverage .......................................................... 41 What COBRA Continuation Coverage Costs .......................................................................................... 42 General Provisions .................................................................................................................................. 42 When COBRA Continuation Coverage Ends .......................................................................................... 42 If You Have Questions ............................................................................................................................. 43

Claim and Appeals Procedures .................................................................................................................. 44

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Deadlines for Filing Claims ...................................................................................................................... 44 Filing an ERISA Claim or Appeal ............................................................................................................ 44 Eligibility Claims and Appeals for All Benefit Options ............................................................................. 44 Benefits Claims and Appeals Process .................................................................................................... 45 Medical and Prescription Drug Benefit Claims and Appeals ................................................................... 47 Health Care FSA, Dental, Vision, and EAP Benefits Claims and Appeals ............................................. 53 Disability, AD&D, Life, and Other ERISA-Covered Insurance Claims and Appeals ............................... 57 Federal External Review Program .......................................................................................................... 59

HIPAA Privacy Rights ................................................................................................................................. 60 Administrative Information ........................................................................................................................... 68

Plan Name/Identification .......................................................................................................................... 68 Plan Information ...................................................................................................................................... 68 Plan Administration Information .............................................................................................................. 69 Funding and Source of Contributions ...................................................................................................... 69

Self-Insured Plans ................................................................................................................................ 69 Fully-Insured Plans .............................................................................................................................. 70

Claims Administrator and its Authority to Review Claims ....................................................................... 70 Your Relationship with the Claims Administrator and the Company ................................................... 70

No Employment Rights or Guarantee of Benefits ................................................................................... 70 Misrepresentation or Fraud ..................................................................................................................... 71 Amendment/Termination ......................................................................................................................... 71 Company’s Right to Use Social Security Numbers for Administration of Benefits .................................. 71 Outcome of Covered Services and Supplies........................................................................................... 71 Unclaimed Funds ..................................................................................................................................... 72 Non-Assignment of Benefits .................................................................................................................... 72 Right of Recovery .................................................................................................................................... 72 Reimbursement ....................................................................................................................................... 72 Subrogation ............................................................................................................................................. 73 Your Rights Under ERISA ....................................................................................................................... 74

Receive Information About Your Plan and Benefits ............................................................................ 74 Continue Group Health Plan Coverage ............................................................................................... 74 Prudent Actions by Plan Fiduciaries .................................................................................................... 74 Enforce Your Rights ............................................................................................................................. 74 Assistance with Your Questions .......................................................................................................... 75

Important Notice Regarding this Plan and COVID-19 ................................................................................ 76 Certain Benefits Coverage for COVID-19 ............................................................................................... 76 Plan Deadlines Extended During National Emergency ........................................................................... 76

HIPAA Special Enrollment Rights ........................................................................................................ 76 COBRA Continuation Rights ................................................................................................................ 76 Claims and Appeals Procedures ......................................................................................................... 76

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Michelin Health and Welfare Plan Union Free SPD 1 Introduction

Introduction

This Summary Plan Description (“SPD”) describes the health and welfare benefits available to eligible Union Free Employees of Michelin and certain of its subsidiaries and other affiliated companies (the “Company”) and their eligible Dependents, effective as of January 1, 2020. These benefits are governed by the official plan document, the Michelin Health and Welfare Plan (the “Plan”). See the “Administrative Information” section for plan document information.

This SPD can help you better understand your health and welfare benefits, replaces previous SPDs, and is intended to comply with the disclosure requirements of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”). It is to your advantage to read through this SPD, learn how the benefits work, and share this information with your family.

How this SPD Works Certain subsidiaries and affiliated companies of Michelin participate in the Plan. The Employees of each of these entities receive with this SPD a supplement, the Adoption Agreement, that specifies the Benefit Options that cover the Employees of that specific Participating Employer and the exceptions and modifications to this SPD that apply to the Employees of that specific Participating Employer.

Coverage Documents and Plan Contact Information This SPD incorporates by reference the following documents—

• The documents that describe the health and welfare benefits offered under the Plan o These are listed in the “Your Plan Choices and Contacts” section of your Adoption

Agreement. • Certificates of insurance issued by insurers • Administrative services agreements from Plan service providers • Summary plan descriptions issued by the insurers and plan service providers • Benefits guides • Annual Enrollment materials • Summaries of benefits and coverage • Other governing documents referenced herein and other general communications identified by the

Plan Administrator that contain information about health and welfare benefits offered under the Plan

These are the Plan “Coverage Documents”. These Coverage Documents describing the health and welfare benefits are incorporated into this document and serve as the source of specific information relating to these benefits. This SPD document, the Adoption Agreement that applies to you, and these separately written documents combined together serve as one SPD to summarize these benefits.

While the SPD describes your health and welfare benefits, if there is any inconsistency or discrepancy among the provisions of the SPD and the official Plan document, your rights and benefits are determined under the official Plan document for the Plan.

In addition, if there is any inconsistency or discrepancy among the provisions of this document and the Coverage Documents, this document will determine your eligibility and rights for the self- funded benefits under the Plan, while the Coverage Documents will provide the specifics of your benefits for self-funded benefits under the Plan and your eligibility, rights and benefits for the fully-insured benefits under the Plan. For example, the eligibility provisions outlined in this document will prevail over any eligibility provisions outlined in a Coverage Document for self-funded benefits.

Please refer to the Adoption Agreement for your Employer to review your Benefit Options and the terms that affect your benefits and coverage.

Michelin Health and Welfare Plan Union Free SPD 2 Introduction

Cafeteria Plan Benefits The Company’s benefit program includes a cafeteria plan, referred to as the Michelin Cafeteria Plan (“Cafeteria Plan”), that qualifies under Internal Revenue Code Section 125. This allows you to pay your premium contributions for these health and welfare benefits, when applicable, on a pre-tax basis and describes the Health Care Flexible Spending Account, Dependent Care Flexible Spending Account, and the Health Savings Account (“HSA”). It also requires that the Company adhere to Internal Revenue Code Section 125 regulations concerning such terms as when you may make changes to your elections each year. In addition, this means you may have to make new elections every year for the pre-tax benefits. The Cafeteria Plan is part of the Michelin Health and Welfare Plan with respect to the Health Care Flexible Spending Account since the Health Care Flexible Spending Account is subject to ERISA.

Michelin Health and Welfare Plan Union Free SPD 3 Eligibility

Eligibility

You and your eligible Dependents are eligible for the health and welfare benefits under the Plan as described below and further provided in your Adoption Agreement. Please contact the Plan Administrator if you have any questions about your eligibility.

Your Eligibility In general, you are eligible to participate in the benefits described in this SPD if you are a regular, full-time, Union Free employee, or a retirement eligible, part-time, Union Free employee (“Employee”) of Michelin North America, Inc. or a Participating Employer that has adopted the Plan. You may also enroll your eligible family members (“Dependents”) under some of the benefit plans, such as the medical, dental and Dependent life insurance plans. Your Participating Employer, as Plan Administrator, has the sole discretionary authority to determine benefit eligibility and to construe Plan provisions for all benefit plans it offers to its employees.

Your Adoption Agreement may have more details regarding your eligibility and the requirements for your dependents’ eligibility.

Please Note: Employees acquired by the Company as a result of a merger or acquisition will be eligible to participate in the Plan as outlined and agreed to in the Company’s merger or acquisition agreement, except to the extent required by law.

Dependent Eligibility In general, your eligible Dependents include:

Your legal Spouse (includes only common law spouses who were covered before January 1, 1994).

Your registered Domestic Partner. For more information about Domestic Partner eligibility and how to register a Domestic Partner, refer to the Company’s domestic partner benefits policy.

Your or your registered Domestic Partner’s Dependent Child until the end of the month in which he or she turns 26. This coverage is allowed for Employees and COBRA-qualified beneficiaries with qualified Dependents regardless of whether:

– The Dependent is a full-time student;

– The Dependent is married;

– The Dependent lives away from the parent’s home;

– The Dependent is not a dependent on your tax return; or

– The Dependent is not dependent on you financially.

Your or your registered Domestic Partner’s unmarried Dependent Child, regardless of age, who is physically or mentally handicapped, depends on you for support and became disabled before age 26. You must provide supporting medical information to certify your Child’s disability.

Important: The value of the Health Care coverage for your Domestic Partner may be subject to federal and state taxes. In addition, please note that Domestic Partner health care expenses are not eligible for reimbursement through your Flexible Spending Account (FSA) or Health Savings Account (HSA) unless your Domestic Partner qualifies as your legal tax dependent.

Important: The coverage provided is Dependent coverage; therefore, the Spouse, Domestic Partner and/or Children of the eligible Dependent are not covered directly. Your Dependents are eligible for health and welfare benefits only if you are enrolled in the Plan.


The term “Child” includes your:

– Natural child;

– Natural child of your Domestic Partner;

– Stepchild;

– Legally adopted children of your own or your Spouse or registered Domestic Partner (the child becomes eligible on the effective date the child is placed in the home for adoption); and

– Child for whom you or your Spouse or registered Domestic Partner has been granted permanent legal guardianship by a court. The court must have awarded full responsibility and control (the child becomes eligible on the date a judge appoints the guardian of the child).

Eligible Child includes a child for whom you are required to provide health coverage under a Qualified Medical Child Support Order (QMCSO).

The Plan will not cover a child who is temporarily living in the home or a foster child. The Plan will not cover a child whose natural parent is in a position to exercise and share parental responsibility and control.

You must be older than your child in order for that child to be eligible for coverage under the Plan.

If you have any questions about your child’s eligibility for coverage, please contact your Plan Administrator.

Proof of Documentation for Expatriates Returning to the U.S. Different rules may apply for the documentation required of expatriates returning to the U.S. Please review your Adoption Agreement to see if other rules apply to you.

Employees who have a child while working outside of the U.S. on an expatriate assignment should contact the nearest U.S. embassy or consulate to apply for a Consular Report of Birth Abroad of a Citizen of the United States of America (CRBA) to document that the child is a U.S. citizen. This document, or a notarized English version of the birth certificate, can be used to add the child to the Company medical plan upon the Employee’s return to the U.S.

For marriages that occur outside of the U.S., please provide a notarized English version of the marriage certificate.

For more information on how to obtain certified documents while working outside of the U.S., please visit www.travel.state.gov. To have proof documentation validated, contact your Plan Administrator. You have 60 days from your official start date in the U.S. to provide your Plan Administrator with proof documentation required to cover your Dependents.

Certifying Dependent Eligibility Upon initial enrollment and at each Annual Enrollment period, you will be asked to certify that the Dependents you claim for coverage meet the requirements for eligibility under the terms of the Plan. Additionally, the Plan retains the right to conduct periodic internal or external audits of Dependent eligibility at any time to validate any Spouse, Domestic Partner or child you have listed is an eligible Dependent. In the event of an audit, you must provide your most recent federal tax return if you are married and filing jointly, OR a Marriage Certificate (State issued, received after the date of the ceremony with recorded file date) AND one form of Proof of Joint Ownership OR Domestic Partner affidavit or registration. For a child, you must provide a long form birth certificate, adoption or guardianship papers, or QMCSO. Providing false or misleading information to the Plan with respect to enrollment eligibility, or with respect to any claim for benefits, will result in disciplinary action up to and including termination of employment and repayment of any benefits paid for ineligible dependents.

Important: Power of attorney granting such power to a non-parent or an award of temporary custody to a non-parent is not considered the equivalent of permanent legal guardianship and will not qualify.

http://www.travel.state.gov/


Proof of Dependent Eligibility If you wish to add a Dependent Spouse, Domestic Partner or child to the Plan, you must provide proof to your Plan Administrator that the Dependent is eligible for coverage. The following chart shows documents that are acceptable as proof and which must be supplied to your Plan Administrator within 60 days of any qualifying event, in order for coverage to become effective. If you cannot provide the requested documents, please contact your Plan Administrator for additional guidance.

Dependent Type Proof Spouse Copy of marriage certificate

Copy of current tax form Copy of official court documentation

Domestic Partner Complete a Domestic Partner affidavit or proof of Domestic Partner registration For information, contact your Plan Administrator

Child

Copy of birth certificate with parent’s name listed* Copy of adoption certificate Copy of official court documentation Copy of current tax form Qualified Medical Child Support Order (QMCSO) Copy of legal guardianship order

Disabled Child Copy of medical certification Child of Domestic Partner

Completed Domestic Partner affidavit or registration and one of the following: • Copy of birth certificate with parent’s name listed • Copy of adoption certificate • Copy of official court documentation • Copy of current tax form • Qualified Medical Child Support Order (QMCSO) • Copy of legal guardianship order

* If you have a newborn, please call your Plan Administrator if you are approaching the 60-day deadline but have not yet received the official long-form birth certificate.

Qualified Medical Child Support Orders If you are divorced or separated, a court order could require you to provide health coverage for your child under the Plan. If the court order satisfies all of the applicable legal requirements and is determined by the Plan to be a qualified medical child support order (“QMCSO”), the Plan will provide coverage to the child to the extent required by law. The change in coverage takes effect as of the date the QMCSO is processed. Your share of the cost of the health benefit coverage provided pursuant to the QMCSO will be automatically withheld from your pay, subject to any limits set by state or federal law.

Federal law requires that a medical child support order must meet certain form and content requirements to be “qualified”. For example, a QMCSO cannot require the Plan to provide any type or form of benefit coverage not otherwise offered. You may request, without charge, a copy of the Plan’s administrative procedures from the Plan Administrator. If you become subject to an order, you will receive a copy of the QMCSO administrative procedures, free of charge, from the Plan Administrator.

Please Note: The Plan Administrator has the sole right to determine who is eligible for health and welfare benefits under the Plan and may require documentation proving a Dependent’s status. If you are unable to provide the required documentation, your Dependent will not be eligible for benefits under the Plan. In addition, you may be required to reimburse the Plan for any costs associated with covering an individual who is not an eligible Dependent, and your participation in the benefits, as well as that of your Dependents, may be terminated.

If Both You and Your Spouse/Domestic Partner are Employees of Michelin If both you and your Spouse/Domestic Partner work for the Company, special rules apply:

Only one of you may elect medical, dental and supplemental vision coverage for eligible family members.


You may both elect Dependent life insurance coverage for eligible children.

For medical, dental and supplemental vision, you cannot carry the Company’s insurance and be a Spouse/Domestic Partner under another Company Employee’s coverage.

All eligible family members must be covered under the same benefit options.

If the Employee who has elected medical, dental and supplemental vision coverage terminates employment with the Company, coverage and deductions can be moved to the remaining Employee and will be in effect until the next enrollment period, or you may choose to be covered under the Spouse’s or Domestic Partner’s coverage at the new employer.

If you and your Spouse/Domestic Partner work for Michelin, contact your Plan Administrator for more information before you make your elections.

If you and your Spouse or Domestic Partner are employees of a different Participating Employer, please review your Adoption Agreement for any specific rules that may apply to you.

If Both You and Your Dependent Child are Employees of Michelin If both you and your Dependent child work for the Company, your child may choose:

To be covered as a Dependent child under your medical, dental and supplemental vision plan, or

To enroll in his or her own coverage for medical, dental and supplemental vision benefits.

If your child is eligible for life insurance as an Employee, s/he cannot be insured as a Dependent child.

If you and your Dependent Child are employees of a different Participating Employer, please review your Adoption Agreement for any specific rules that may apply to you.

Who Is Not Eligible Employees classified by the Company as apprentices, supplemental interim employees, employees of other companies or independent contractors do not qualify for benefits. Employees whose employment is governed by the terms of a collective bargaining agreement between employee representatives and the Company under which health and/or welfare benefits were the subject of good faith bargaining between the parties shall not be considered eligible employees under the Plan, unless such agreement expressly provides for coverage by this Plan.

Please Note: Only common law employees are eligible to participate in the Plan. This excludes the following individuals as not eligible to participate in the Plan:

Leased employees (under Code Section 414(n)).

Individuals who are classified as special status employees or independent contractors because their employment status is inconsistent with common law employee status.

Individuals who perform services for the Company whose wages are not initially reported by the Company on IRS Form W-2.

Individuals employed through a temporary or staffing agency.

If you are excluded from the Company’s definition of an eligible common law employee, you will not be eligible for benefits under the Plan, even if a court, the Internal Revenue Service (“IRS”), or any other enforcement authority finds that you should be considered an eligible employee unless approved by the Plan Administrator.

Coverage Levels When you enroll for coverage under the medical, dental and vision plans, choose the coverage level that’s right for you and your family:

Employee;


Employee + Spouse or Domestic Partner;

Employee + child(ren); or

Family.

You will also have the option to purchase certain other coverages for yourself and your eligible Dependents. Refer to “Your Plan Choices and Contacts” section of your Adoption Agreement for more information about your coverage options.

Michelin Health and Welfare Plan Union Free SPD 8 Enrolling for Coverage

Enrolling for Coverage

The Company offers a variety of benefits for you and your Dependents. Some of these benefits are provided automatically to you if you are eligible for the Plan. Other benefits that you are eligible for require you to enroll during the open enrollment period or during a midyear enrollment period if you have a Qualifying Life Event. See the “Changing Your Coverage During the Plan Year” section.

Enrolling When You are Hired You and your eligible Dependents may begin participating in the Plan on your date of hire as a full-time Employee (or on the first day you otherwise become an eligible Employee). To participate, however, you must complete the required enrollment process within 60 days of your hire date. If you do not make an election for yourself and your eligible Dependents in the Plan within this period, you will default to Employee only Medical coverage under the option designated by the Company.

As part of health care reform, we also provide a concise statement of your coverage in a Summary of Benefits and Coverage (SBC) document. You can use this document to compare the Company’s coverage with other employer coverage that you may have access to as you decide which plan to enroll in as a new hire. A copy of this document is available from your Plan Administrator or the Medical Plan Claims Administrator.

If you are designated by the Company as a regular part-time Employee, co-op, intern or technical scholar, you may be eligible only for certain Medical Plan options. You must make an election for yourself and your eligible Dependents in one of these options within this 60-day period if you wish to enroll in the health plan. If you do not do so, you will have no coverage.

Please review your Adoption Agreement for further information. It may specify modifications to the enrollment period or procedures for newly-hired Employees.

Enrolling During Annual Enrollment Each year, the Company will conduct Annual Enrollment for benefits. This gives you the opportunity to examine your coverage to see if you need to make any changes for the coming year. Coverage changes made during Annual Enrollment become effective on January 1 of the next year.

The Company provides a Summary of Benefits and Coverage (SBC) document, or information on how to receive it, in the Annual Enrollment packet each year. You can use this document to compare the Company’s coverage with other employer coverage that you may have access to as you decide which plan to enroll in for the coming year. A copy of this document is also available from your Plan Administrator or the Medical Plan Claims Administrator.

If You Don’t Enroll During Annual Enrollment If you don’t enroll for benefits during Annual Enrollment, you may not get the coverage you desire, especially if you intend to cover your eligible Dependents. Your default coverage depends on the coverage you currently have. See your Annual Enrollment materials to determine what your benefits will be if you do not enroll according to a method provided by your Plan Administrator.

Your next opportunity to change your benefit coverage will be during the next Annual Enrollment, unless you experience a Qualifying Life Event or are eligible for special enrollment under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). See the section on “Changing Your Coverage During the Year”.

Important: Default coverage if you fail to enroll is without the non-tobacco user’s credit and includes the spousal surcharge for Employee plus Spouse or Domestic Partner and Employee plus Family coverage tiers.


Important: In general, the elections you make during the Annual Enrollment period take effect January 1 of the following year and remain in effect for the rest of the calendar year. And, if you do not enroll during the Annual Enrollment period you will default to the coverage specified in your Annual Enrollment materials. However, in certain instances you may be able to correct an enrollment error. Any request to make an enrollment correction, or to appeal your failure to enroll during the Annual Enrollment period, must be made in writing to your Plan Administrator as soon as possible.

Opting Out of Company Coverage You may choose to opt out of Company medical coverage when you enroll in benefits as a new hire and each year during the Annual Enrollment period and receive your medical coverage elsewhere. If your Spouse or Domestic Partner works for another employer and has medical coverage available at work, or if you have another source for medical coverage, you may not want or need medical coverage through the Company Medical and Prescription Drug Plan. In this case, you may choose the “No Coverage” option when you enroll. By choosing the No Coverage option, you are confirming that you have coverage elsewhere. You may be required to provide the name of the employer or insurer of your other coverage to the Company during Annual Enrollment.

Enrollment and Rehired Employees If you terminate your employment and are rehired by the Company during the same Plan Year and within 30 days of your prior termination of employment, you will continue to be eligible for (and enrolled in) the same pre-tax benefits in which you participated prior to your termination of employment unless your eligibility status changes. If you are rehired more than 30 days after your prior termination of employment or during a subsequent Plan Year, you must enroll again in the Plan to participate in benefits for which enrollment is required.

Cost of Health and Welfare Benefits/Funding/Contributions The Company determines the amount of your Employee contributions prior to each enrollment period and will provide you with this information in your enrollment materials. You may also contact your Plan Administrator to receive information about your Employee contributions. The Company reserves the right to change the amount of required Employee contributions for the health and welfare benefits at any time, with or without advance notice to Participants.

The cost of your health and welfare benefits depends on the level of coverage you choose under the Plan. Your Employee contributions may be deducted from your paycheck on a pre-tax basis or paid with after-tax dollars.

The amount of your contributions for benefits may be further affected by:

The options you elect;

The Dependents you cover (if coverage is available for Dependents);

Your age;

Submission of all five certified biometrics by you and your covered Spouse or Domestic Partner;

You and your covered Spouse’s or Domestic Partner’s non-tobacco user status; and

Your decision to cover a Spouse or Domestic Partner who has access to another employer’s health coverage.

In the case of Flexible Spending Accounts and a Health Savings Account, your cost to participate is the amount you elect to contribute to the accounts. For more information on how those amounts may be used, see the “Federal Tax Implications for Dependent Coverage” section below.

When you enroll for medical coverage, you authorize the Company to deduct your contributions for benefits on a pre-tax basis. The effect is to lower the amount of your pay that is subject to income taxes. However, some of your benefits are deducted on an after-tax basis. For example, by law, life insurance greater than $50,000 is paid on an after-tax basis.


The cost of health benefit coverage does not include your payments for any applicable deductibles, copays, coinsurance, out-of-network charges, or non-covered items.

If you terminate employment, your benefits coverage will continue through the end of the month during which you terminate your employment unless a different rule is specified in the Coverage Documents or your Adoption Agreement. You will be charged for the appropriate payroll deductions to cover these benefits on your final paycheck.

Stopping Contributions To conform with IRS regulations, once you have enrolled in the benefits program for the year, you may not stop contributions or drop coverage for the remainder of the Plan Year, unless you:

Experience a Qualifying Life Event, as described in the section “Changing Your Coverage During the Year”; and

The coverage change is consistent with the Qualifying Life Event.

Federal Tax Implications for Dependent Coverage Most Dependents are considered IRS Tax Dependents; the value of Dependent coverage is usually exempt from federal income tax.

Generally, if you can claim an individual as a Dependent for federal income tax purposes, then the value of that Dependent’s coverage will not be taxable to you as income. If you enroll an individual in the Plan who is not an IRS tax Dependent, your Participating Employer is required to report income for you that reflects the value of that individual’s coverage for tax-reporting purposes; this is referred to as “imputed income.” Your IRS Form W-2 will reflect any additional income if you cover an individual who does not meet the definition of an IRS tax Dependent.

The Company assumes all Dependents are IRS tax Dependents, except Domestic Partners and the Children of Domestic Partners. You must contact the Plan Administrator if your Domestic Partner and his or her Children are your IRS tax Dependents or if you enroll other individuals who are not IRS Tax Dependents.

If you have questions concerning your specific situation, you should consult your own tax advisor or attorney.

State Tax Implications for Dependent Coverage If you enroll an individual in the Plan who does not meet the state definition of a tax dependent in the state in which you reside (for example, a Domestic Partner), the value of that individual’s coverage may be taxable to you as income for state income tax purposes.

If you have questions concerning your specific situation, you should consult your own tax advisor or attorney.

Michelin Health and Welfare Plan Union Free SPD 11 Enrollment Effective Date

Enrollment Effective Date

The Plan Year runs from January 1 through December 31.

Generally, you can participate in the Plan on the first day of the month on or following your first day of employment. You must notify the Plan Administrator in a timely manner of your intent to enroll in the Plan. The Plan Administrator will provide the appropriate information for your enrollment in the Plan.

Initial Enrollment Some health and welfare benefits are automatically provided to you under the Plan at no cost to you. Please refer to the Annual Enrollment materials to determine which benefits are automatically provided to you when you become an eligible Employee.

You need to enroll in the Plan to be covered by the health benefits and certain other benefits as specified in the Annual Enrollment materials. To enroll yourself and/or your eligible Dependents, you must enroll within 60 days of your first day of employment. If you do not enroll at this time, you may enroll during the next Annual Enrollment period, a special enrollment period, or if you have a Qualifying Life Event. See the “Changing Your Coverage During the Year” section.

Annual Enrollment If you choose to change your benefit elections during the open enrollment period, your new elections will become effective on January 1 of the following Plan Year. If you do not enroll during open enrollment, your participation in elective benefit package options may be terminated, including your participation in the Health Care Flexible Spending Account Benefits, Dependent Care Assistance Flexible Spending Benefits, and HSA contributions through the Plan. Your Annual Enrollment materials will describe what happens if you do not enroll or what default options may be available. If you need to make an election change after the open enrollment period, you may change your elections during the next open enrollment period, a special enrollment period under HIPAA, or if you have a qualified change in status. See the “Changing Your Coverage During the Year” section.

Information regarding enrollment procedures will be provided to you by your Plan Administrator. When you enroll your eligible Dependents you will need to provide relevant documentation as requested by your Plan Administrator.

Effective Date of Your Coverage

New Employees Generally, you and your Dependents will become covered under the Plan on the date set forth above, if you are actively employed on that date. If you are not actively employed on that date, your enrollment will become effective on the first day that you are actively at work. If you are not actively at work on that date due to your health status, your coverage for each benefit will become effective on the date determined by under the Coverage Documents. However, you will not be denied Medical Plan coverage due to your health status.

Current Employees If you enroll or make an election change during the Annual Enrollment period, participation for you and your Dependents begins on the next January 1.

Michelin Health and Welfare Plan Union Free SPD 12 Your Health and Welfare Benefits

Your Health and Welfare Benefits

Eligible Employees may participate in the health and welfare benefits under the Plan listed in the section “Your Plan Choices and Contacts” of your Adoption Agreement. The details of each of these health and welfare benefits are described in the incorporated Coverage Documents.

The Employer may provide certain benefit programs, employee incentives or fringe benefits outside of the Plan. These benefit programs are not subject to ERISA and are not covered benefits under the Michelin Health and Welfare Plan. If you want further information about these benefit programs, you should contact the Plan Administrator.

Cost of Coverage The Company may pay the entire premium for certain coverages, while the payment of premiums for other coverages are shared between you and the Company. Certain elective coverages will be your responsibility if you choose those benefits. Depending on the particular benefits selected, your Employee contributions may be deducted from your paycheck on a pre-tax basis or paid with after-tax dollars.

The Company determines the amount of your Employee contributions prior to each Annual Enrollment period. See your Annual Enrollment materials for more information about paying for your benefits. You may also contact the Plan Administrator to receive information about your Employee contributions.

Participating Provider Networks and Directories You may, without charge, obtain the participating provider directories from the Claims Administrator for a particular benefit. See the “Your Plan Choices and Contacts” section of your Adoption Agreement for contact information.

Michelin Health and Welfare Plan Union Free SPD 13 Your Health Care Flexible Spending Account

Your Health Care Flexible Spending Account

The Health Care Flexible Spending Account (“Health Care FSA”) is used for reimbursement of eligible Health Care FSA expenses for you and your eligible Dependents. Each Plan Year, you can contribute to your Health Care FSA, and then during the Plan Year, you can receive reimbursement for eligible Health Care FSA expenses that are not otherwise reimbursed by the Company or other coverage. Contribution levels are set forth below.

Eligibility To participate in the Health Care FSA, you must be eligible for Medical and Prescription Drug Plan coverage and enroll in the Health Care FSA. See the “Eligibility” and “Enrolling for Coverage” sections of this SPD and your Adoption Agreement for more information.

Contributions Each year, you must decide on the amount of pre-tax dollars you want to contribute to the Health Care FSA. Please note that this account is merely a recordkeeping account with the purpose of keeping track of contributions and determining forfeitures. The Health Care FSA does not constitute a separate fund or entity. Rather, the amount you elect to “contribute” remains in the employer’s general assets until claims are reimbursed. There is no interest credited to this account.

The IRS sets the maximum amount that you can contribute to the Health Care FSA for each Plan Year, as described in the Annual Enrollment materials. The amount is adjusted each year for cost-of-living increases, but the Plan may apply the prior Plan Year or other specified amount. The least amount you can contribute is $120 for the Plan Year. Please check you Annual Enrollment materials for the maximum that you may elect to contribute each year.

You cannot change or stop contributions to the Health Care FSA unless you experience a Qualifying Life Event. See the “Eligibility” and “Changing Your Coverage During the Year” sections of this SPD. It’s important that you carefully estimate the amount that you contribute to the Health Care FSA, since you cannot use amounts in the Health Care FSA to reimburse expenses under the Dependent Care FSA (or vice-versa) and are not permitted to receive a refund of such amounts under IRS rules if you do not use the balance of your account – this is often referred to as the “use it or lose it” rule.

Claims Reimbursement You have until March 31st of the next year to request reimbursement for eligible expenses incurred during the Plan Year and the corresponding grace period (the “run-out period”). If any balance remains in your account after the run-out period, then you will forfeit your rights to any remaining balance. Forfeitures will first be used to defray the administrative costs of the Plan and if any amounts remain, will then be retained by the Company.

Special Grace Period Rule for the Health Care FSA Reimbursements are based on the dates of service, and services must be provided within the Plan Year (January 1 - December 31), or between January 1 and March 15 of the following Plan Year. You have until March 31 after the end of the Plan Year to file your claims.

If you file a claim for an eligible expense for a date of service between January 1 and March 15 and you were a Participant in the previous Plan Year, you will be reimbursed from the previous year’s account first. Once your account balance from the previous Plan Year is exhausted, you will be reimbursed from your current Plan Year account.


You can submit a reimbursement form as often as weekly. You will be reimbursed for eligible expenses as long as the amount requested from either account is at least $25, except for reimbursement with respect to the last month of the Plan Year. Amounts below $25 will be accumulated and processed with future payments.

If you have established a Health Care FSA, your total annual contribution amount is available immediately. You can request reimbursement for eligible expenses up to your annual contribution amount as soon as such eligible expenses have been incurred.

Mid-Year Termination If you leave Michelin, your last deduction will be taken from your final paycheck. If you stop contributing to the Health Care FSA due to a change in status, you may submit claims for eligible expenses that you incurred during the period in which you were actively contributing to the Health Care FSA. If you leave Michelin, you may file claims for services you received before your termination date. Each year, you will have until March 31 to file claims for services you received during the prior year and until March 15 of the current year. After March 31, any remaining balance in your prior benefit year account will be forfeited. If you work for a different Participating Employer, refer to your Adoption Agreement for the terms that apply to you.

You may be eligible to elect COBRA continuation coverage for your Health Care FSA to the end of the current calendar year if your Health Care FSA is “underspent.” “Underspent” means that your account balance on the date of the COBRA qualifying event, equals or exceeds the premiums you would pay for COBRA coverage for the rest of the Plan Year.

If your coverage under your Health Care FSA ends due to your death, then your beneficiary or the representative of your estate may submit claims for expenses incurred prior to your death by the earlier of the end of the Plan Year in which you die or until amounts remaining in your account are exhausted. If no such beneficiary is specified, the Plan Administrator may designate your Spouse, one of your Dependents, or the representative of your estate for this purpose.

Coordination with Health Savings Account If you are enrolled in an HSA-coordinated medical plan, and you have unspent dollars in your Health Care FSA from the prior Plan Year, you will not be eligible for incentive dollars (if available) or to make pre-tax payroll contributions to your HSA until your FSA dollars are depleted, or until April 1 of that year, whichever comes first.

Eligible Expenses To be eligible for reimbursement from your Health Care FSA, the medical expenses must be incurred (i.e., medical care or service is provided and giving rise to the expense) while you are participating in the Health Care FSA. Any reimbursement you receive through your Health Care FSA cannot be reimbursed under any other plan covering health benefits, including a Spouse’s or Dependent’s plan. At any time during the Plan Year, you may seek reimbursement for eligible Health Care FSA expenses up to the amount you have elected to contribute for the Plan Year, less prior reimbursements for that Plan Year.

For purposes of your general-purpose Health FSA, an eligible Health Care FSA expense includes medical, prescription drug, dental, and vision expenses incurred for “medical care” as described under Code Section 213(d) and the IRS Regulations issued under that Code Section for your Spouse or Dependents. Examples of these expenses include deductibles and copayments as well as physicals, well care and vision-related expenses. “Medical care” now includes over-the-counter medicines and drugs sold lawfully without a prescription or menstrual care products.

Important Note: To use up any remaining funds from your previous Plan Year’s Health FSA, you must submit a reimbursement form between January 1 and March 31 instead of swiping your Health FSA card. This will ensure that claims for services provided in the previous Plan Year get reimbursed using that Plan Year’s remaining funds.


Qualified Health Care Expenses You may use your Health Care FSA to be reimbursed for health care expenses not covered by the Company’s benefits plans or your Spouse’s benefits plans, such as:

Deductibles and copayments; Charges for medical, prescription, dental and vision services that exceed limits under the Company’s

plans; Routine physicals; Well-baby care; Vaccinations and immunizations; Hearing exams and hearing aids; Prescription contraceptives; Menstrual supplies; Smoking cessation prescription drugs (requires physicians’ statement of medical necessity with

diagnosis); Smoking cessation program costs; Weight-loss prescription drugs only for treatment of morbid obesity (requires physicians’ statement of

medical necessity with diagnosis); Transportation necessary to obtain certain health care services; also transportation expenses of a

parent (only one) accompanying a child who needs medical care; Radial keratotomy, LASIK or surgery to correct vision acuity; Cleaning solutions for contact lenses; Dental implants; Medical expenses of a dependent parent; and Over-the-counter medicines and drugs used for treatment of injury or illness.

For a complete listing of qualified and non-qualified expenses, refer to IRS Publication 502 (available at www.irs.gov) or call an Internal Revenue Service office. A full list of eligible medical expenses under your general-purpose Health Care FSA can also be obtained from your FSA Claims Administrator. See the “Your Plan Choices and Contacts” section of your Adoption Agreement.

Eligible Health Care FSA expenses do not include expenses incurred for the payment of premiums under a health plan, expenses which are reimbursable through insurance or otherwise (other than this Plan) or expenses for which you are not obligated to pay. Other exclusions include (but are not limited to) long-term care services, cosmetic surgery (unless medically necessary), funeral and burial expenses, and custodial care.

Please keep receipts and other supporting documentation related to your expenses and reimbursement requests. The IRS may request itemized receipts to verify select expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Health Care Expenses for Your Dependents For purposes of Health FSA reimbursements, “dependent” includes anyone who is your dependent for federal income tax purposes, as well as your biological, adopted or step-child or your eligible foster child if the child will be younger than 27 on the last day of the calendar year, even if the child is not a dependent for federal income tax purposes. If you are divorced or separated, you may still submit eligible expenses for your Child(ren). A Domestic Partner or a Child of a Domestic Partner must be an IRS tax dependent for expenses for that individual to be covered.

Claims Procedures When you incur an eligible Health Care FSA expense, you may have a choice as to how to submit your eligible claims. You may be able to use a debit card, to file a claim online with the Claims Administrator or to submit a Health FSA claim form. See the Health FSA Coverage Documents for more information.

Under ERISA, specific procedures apply for the review of claims under your Health Care FSA. While this section explains some of these procedures, please refer to the “Claims and Appeals Procedures” section for

http://www.irs.gov/


additional details. If there is any discrepancy between the information provided in this section and the “Claims and Appeals Procedures” section, the information in that section will control.

Please note that amounts held in your Health Care FSA for which a valid request for reimbursement has not been received by the deadline described above will be forfeited.

Qualified Reservist Distribution In accordance with the Heroes Earning Assistance and Relief Tax Act of 2008 (HEART Act), a qualified reservist distribution (QRD) is permitted for all or part of any unused Health Care FSA amounts if you are a reservist called to active duty, provided that: You are called up for a period of 180 days or more or for an indefinite period of time; and The request for a distribution is made during the period of time between when the order or call is made

and the last day that a reimbursement could be made from the Health Care FSA for that Plan Year.

To receive a QRD of all or part of any unused Health Care FSA amounts, you must give notice by contacting your Personnel Manager or Human Resource representative at your facility as soon as you receive your orders or are called to active duty, and also contact the Claims Administrator to obtain the appropriate form.

Nondiscrimination Testing Under the Code and related federal regulations, Health Care FSAs are subject to nondiscrimination testing each year to ensure the Plan does not provide disproportionate tax benefits to highly compensated employees. You will be notified if results of this nondiscrimination testing performed on behalf of the Company affects you.

Michelin Health and Welfare Plan Union Free SPD 17 Your Dependent Care Flexible Spending Account

Your Dependent Care Flexible Spending Account

The Dependent Care Flexible Spending Account (“Dependent Care FSA”) is used for reimbursement of eligible dependent care expenses such as daycare. Each Plan Year, you can contribute to your Dependent Care FSA, and then, during the Plan Year, you can receive reimbursement for eligible dependent care expenses that are not otherwise reimbursed. Contribution levels are set forth below.

Eligibility To participate in the Dependent Care FSA, you must be eligible and enroll in the Dependent Care FSA. See the “Eligibility” and “Enrolling for Coverage” sections of this SPD and your Adoption Agreement for more information.

Contributions Each year, you must decide on the amount of pre-tax dollars you want to contribute to the Dependent Care FSA. Please note that this account is merely a recordkeeping account with the purpose of keeping track of contributions and determining forfeitures. The Dependent Care FSA does not constitute a separate fund or entity. Rather, the amount you elect to “contribute” remains in the employer’s general assets until claims are reimbursed. There is no interest credited to this account.

For the Dependent Care FSA, the IRS limit that may be contributed is $5,000, or if you are married and filing separately for federal income tax purposes, $2,500 per Plan Year. This limit applies to all contributions, including any Company contributions and deductions your Spouse may make through a similar program. If you or your Spouse’s earned income is less than $5,000 per year, the amount that can be contributed is reduced to the amount of your or your Spouse’s earned income. It is your responsibility to calculate your allowable deduction. Any amounts deducted above the legal limits established by the IRS may subject you to tax penalties. Any change in the maximum amount will be communicated to you, as described in the Annual Enrollment materials.

The most you can have deducted for the Dependent Care FSA is $4,500 per year. The least you can have deducted for a Dependent Care FSA is $120 per year. The Company will match 25% of your contributions to the Dependent Care FSA, up to a maximum

match of $500 per year. You pay no taxes on these contributions.

Amounts Available for Reimbursement Your contributions to your Dependent Care FSA are made available for use as they are deducted from your paycheck. The 25% Company matching contribution to the Dependent Care FSA is available for use beginning with your first pay cycle of the Plan Year. For those who become newly eligible during the Plan Year, the full Company matching contribution becomes available once you have elected Dependent Care FSA contributions and your first deduction is taken.

Your reimbursement is based on when dependent care services are received, not when you pay for the services. If you pay your dependent care expenses in advance, you will be reimbursed only after you actually receive those services.

Qualified Dependent Care Expenses You may use the Dependent Care FSA to pay certain dependent care expenses of a qualifying child or relative, as defined in Internal Revenue Code Section 152, that are necessary to allow you – and your Spouse, if you are married – to work or attend school full-time.

Generally, a qualifying child or relative is:

Your child under the age of 13; or Your Spouse, adult relative or adult child who is physically or mentally incapable of self-care.


Examples of expenses that are eligible for reimbursement through the Dependent Care FSA include:

Babysitters or companions inside or outside your home; Licensed day care centers that comply with state and local laws and regulations; Housekeepers in your home, if part of their work is to provide for the well-being and protection of your

eligible dependents; Licensed disabled care centers that comply with state and local laws and regulations, provide care for

more than six non-resident people, and receive a fee for such services, whether or not for profit (in order for these expenses to qualify, the disabled dependent must regularly spend at least eight hours per day in your home); and

Federal and state taxes (i.e., Medicare/Social Security and unemployment) that you pay for providers of dependent care.

For a complete listing of qualified and non-qualified expenses, refer to IRS Publication 503 (available at www.irs.gov) or call an Internal Revenue Service office.

Non-Qualified Dependent Care Expenses The following expenses do not qualify for reimbursement from your Dependent Care FSA, including charges for:

Days when you are not working (such as sick or vacation days) or days when you do not meet the eligibility requirements;

Dependents who do not qualify as eligible dependents; Care provided by an individual who could be claimed as a dependent on your or your Spouse’s federal

tax return; Services that are eligible for reimbursement under any other plan or program; Transportation to and from the day care center location; Clothing, education or food, unless food and education are provided by the nursery school or day care

center as part of its prescribed care services. Food and education expenses are not covered for kindergarten or higher;

Tuition; Overnight camp expenses; and Child support payments.

You cannot participate in the Dependent Care FSA if your Spouse is unemployed, or employed in a non-paying capacity, unless your Spouse is disabled or a full-time student for at least five months during the year. The Dependent Care FSA can be used if your Spouse is looking for work.

Claims Procedures You have until March 31 of the next year to request reimbursement for eligible expenses incurred during the Plan Year and the corresponding grace period. After March 31, any remaining balance in your account will be forfeited.

If you file a claim for an eligible expense for a date of service between January 1 and March 15 and you were a Participant in the previous Plan Year, you will be reimbursed from the previous year’s account first. Once your account balance from the previous Plan Year is exhausted, you will be reimbursed from your current Plan Year account.

You must provide the name, address and Taxpayer Identification Number (or Social Security number) of your provider in order to take advantage of the tax-free feature of this account. You must include this information on the FSA claim form.

http://www.irs.gov/


Important Note: Careful planning is necessary:

If you contribute to your FSA and you do not file claims for all of your money by March 31, you will forfeit any remaining balance that is not used by March 15 and claimed by March 31. This forfeiture is required by federal law.

Under the Internal Revenue Code, you may instead reduce your taxes by taking a dependent care tax credit. However, any amounts which you exclude from income under the Dependent Care FSA will reduce, dollar for dollar, the tax credit available.

Dependent Care FSA benefits are not subject to the federal law known as ERISA, so the “Your Rights under ERISA” section does not apply to these benefits.

Nondiscrimination Testing Under the Code and related federal regulations, Dependent Care FSAs are subject to nondiscrimination testing each year to ensure the Plan does not provide disproportionate tax benefits to highly compensated employees. You will be notified if results of this nondiscrimination testing performed on behalf of the Company affects you.

Michelin Health and Welfare Plan Union Free SPD 20 Your Health Savings Account

Your Health Savings Account (HSA)

An HSA is an individual account used in conjunction with an HSA-eligible, high-deductible health plan to cover out-of-pocket Qualified Medical Expenses on a tax-advantaged basis. Your HSA belongs entirely to you and can be used to pay for both current and future HSA Qualified Medical Expenses for you and your eligible Dependents. You can contribute to your account, withdraw contributions to pay for current Qualified Medical Expenses, and potentially grow your account on a tax-free basis by investing your savings in a wide array of investment options.

Any unused balance in your account will automatically carry over from year to year so you can begin to build your savings for future Qualified Medical Expenses. Your HSA always belongs to you, even if you change jobs or become unemployed, change your medical coverage, move to another state, or change your marital status.

Eligibility You must meet several IRS eligibility requirements in order to establish and contribute to an HSA. It is your responsibility to determine if you are eligible. To be an “eligible individual” for this purpose, you must meet the following criteria.

You must be enrolled in an HSA-eligible, high-deductible health plan (HDHP) on the first day of the month. For example, if your coverage is effective on May 15, you are not eligible to contribute to or take a distribution from your HSA until June 1.

You cannot be covered by any other health plan that is not an HSA-eligible health plan; otherwise, it will disqualify your ability to contribute to the HSA on a tax-favored basis). Participation in a general-purpose Health Care FSA will disqualify your ability to contribute to an HSA.

You cannot currently be enrolled in Medicare Part A or Part B.

You cannot be claimed as a dependent on another person’s tax return.

If you are eligible to receive VA medical benefits, you must not have received such benefits during the preceding three months.

Additionally, in order to open and contribute to an HSA, you must have a valid U.S. address, other than in Puerto Rico or Hawaii.

If you open an HSA and do not meet the above criteria, your contributions, any investment earnings, and distributions may be subject to income taxes, penalties, and/or excise taxes.

If You Participated in a Health Care FSA or HRA If you participated in the Health Care FSA during the prior year, and you have a Health Care FSA balance as of December 31 (even as little as one penny), you cannot contribute to the HSA until April 1 of the following year, and any Company contributions will not be deposited into your HSA bank account until April 1.

Note that if you have a zero balance in your Health Care FSA as of December 31, your HSA contributions can begin immediately on January 1 of the following year and you will also receive Company contributions in January, if you are eligible.

If you were a participant in an HRA in the prior year, and have a balance in your HRA on December 31, your Plan Administrator may arrange to roll over those dollars into a post-deductible HRA account with the HRA Claims Administrator. That would allow you to use those funds to pay for any expenses after you’ve met the deductible, such as coinsurance.

Enrollment in Medicare If you are enrolled in Medicare, you cannot contribute to an HSA. This means that some individuals upon reaching age 65 will no longer be eligible to contribute to an HSA. Please consult a tax advisor about tax


consequences if you apply for Social Security benefits or are beyond your full Social Security retirement age.

Contributions The maximum annual contribution limit is set by federal regulations and is based on your age and coverage tier, as well as on when you become enrolled in an HSA‑eligible, high deductible health plan. These amounts may be adjusted for cost-of-living increases from year to year. You will be notified of the maximum annual contribution limit at the time of enrollment.

Note: Payroll does not monitor your contributions; all contributions are handled by your HSA Claims Administrator. It is your responsibility to monitor your HSA and ensure contributions are correct.

If you enroll in the HSA-eligible, high-deductible health plan (HDHP) as of the first of the Plan Year, the HSA contribution is prorated based on the number of months during the year a person is covered by an HSA-eligible plan as of the first day of the month. If you enroll in an HSA‑eligible HDHP later, then you may contribute up to the statutory maximum annual contribution as long as you are an eligible individual in December of that tax year and remain eligible for a full 12-month period following such month. If you fail to meet these criteria, the maximum annual contribution must be prorated based on the number of months you are an eligible individual, and any amount above that prorated amount is includible in your gross income and subject to a 10% tax.

You may increase, decrease or revoke your contribution elections once a month during the Plan Year. Your election changes only affect your future contributions and will become effective no later than the first day of the next calendar month following the date your election change was made.

Company Contributions The Company may provide wellness incentive dollars you can earn by participating in certain wellness activities. These will be directly deposited into your HSA bank account in early January as long as your account has been approved by your HSA Claims Administrator and you do not have any unspent prior year Health Care FSA dollars. You are not required to contribute to an HSA to receive contributions from the Company, if applicable.

Contributions from Retirement Accounts You can make a one-time contribution to an HSA from an IRA or Roth IRA, tax-free. The amount transferred counts as part of your maximum contribution limit for that calendar year. Both accounts must be in your name, and the transferred amount may be subject to an IRS testing period. Contact your financial advisor for details.

Using Your Account In general, to access your HSA funds, you pay for the health care product or service up front and reimburse yourself later. HSA distributions are tax-free if they are used to pay for Qualified Medical Expenses incurred by:

You or your Spouse. Any dependent you claim on your tax return. Any person you could have claimed as a dependent on your return except that

– The person filed a joint return, – You, or your spouse if filing jointly, could be claimed as a dependent on someone else's return.

Note that you may not use your HSA for expenses incurred by your Domestic Partner unless he or she is an IRS tax dependent.

Qualified medical expenses include:

Medical, dental, vision and prescription drug expenses not covered by the Plan or other insurance;


Medicare premiums (including Part A, Part B, Part C, Medicare Prescription Drug Coverage) or employer- or Plan-sponsored health coverage premiums or self-payments once you retire (when you are age 65 or older);

COBRA continuation coverage premiums (but not active Employee Plan premiums); Coverage you have while you are receiving unemployment compensation benefits; Qualified long-term care insurance contract; and Health plan coverage during a period in which you are receiving unemployment compensation under

any federal or state law.

For further information please refer to IRS Publication 502 for information on eligible HSA expenses and IRS Publication 969 for general HSA information at www.irs.gov, or consult your tax advisor.

You are responsible for determining if an expense is eligible for payment from your HSA. Your HSA Claims Administrator will not review expenses and cannot offer you advice. You should keep detailed records of your expenses and payments from your HSA to demonstrate to the IRS that you used the money to pay for eligible expenses.

Any distribution taken from your HSA to pay for a nonqualified medical expense must be included in your gross income for tax purposes and may be subject to an additional 20% penalty.

How to Open Your HSA You can open your HSA with the HSA Claims Administrator listed in the “Your Plan Choices and Contacts” section of your Adoption Agreement. Additional information is available in the Annual Enrollment materials. If you previously opened your HSA with the HSA Claims Administrator, there is no need to so again. If you fail to complete the administrative process required by your HSA Claims Administrator, you will not be eligible to make pre-tax contributions through payroll deductions.

HSA Debit Card Your HSA Claims Administrator may issue an HSA debit card that can be used to pay for known Qualified Medical Expenses at the point of sale (such as pharmacy prescriptions). Many providers will also accept HSA debit cards for payment of invoices received in the mail. For convenience, you may be able to request debit card(s) for your Spouse and eligible Dependents too. See your HSA Claims Administrator for other options such as online bill paying for medical services.

Management of Your HSA and Additional Information The recordkeeping of your HSA is up to you, and it is important to hold on to all receipts, records, and other documentation as proof that the expenses you pay from your HSA are for Qualified Medical Expenses. You may use the tools available from your HSA Claims Administrator to manage claims, account statements and tax forms, beneficiary information and contact information. You may have opportunity to invest or accrue interest on your HSA balance. There are also tax considerations associated with an HSA, such as completing and returning IRS form 8899 each year with your tax return. Check with a tax advisor for more information. You can also contact your HSA Claims Administrator listed in the “Your Plan Choices and Contacts” section of your Adoption Agreement.

http://www.irs.gov/

Michelin Health and Welfare Plan Union Free SPD 23 Changing Your Coverage During the Year

Changing Your Coverage During the Year

Once you enroll in or decline pre-tax health and welfare benefits under the Plan, your election generally stays in effect for the Plan Year. However, you can make changes to your election during the Plan Year if:

You experience a Qualifying Life Event, have a special enrollment right, or experience another change in circumstance.

That event or other change affects the eligibility for benefits under the Plan for either you or your Dependents, as determined by your Plan Administrator.

The modification in your election is due to and consistent with the event or other change, as determined by your Plan Administrator.

Note: Your Plan Administrator has determined that it will also administer election changes for post-tax benefits following these same rules.

Note: While your contributions to the HSA are made on a pre-tax basis, the IRS has made an exception and you can typically change your HSA elections at any time during the year as long as it is on a prospective basis. The Company generally allows you to change your HSA, as needed, subject to reasonable administrative limitations. Contact your Plan Administrator for details.

Qualifying Life Event A Qualifying Life Event, or a qualified change in status, is a specific change in circumstance that affects your eligibility for benefits, including the Health Care Flexible Spending Account and Dependent Care Flexible Spending Account, under the Plan for either you or your Dependents, which is any of the following:

Your Spouse or Domestic Partner elects to take coverage through his or her employer during the course of the Company’s Plan Year instead of paying the monthly spousal/Domestic Partner surcharge to stay on the Company Medical Plan;

Your legal marital status changes (e.g., marriage, divorce, death of Spouse or Domestic Partner, legal separation or annulment);

The number of your Dependents changes (e.g., through birth, adoption, placement for adoption or death);

You or your Dependent has a change in employment status that affects benefit eligibility, such as:

– Beginning or ending employment (this provision does not apply if rehired within 30 days).

– Experiencing work schedule changes, resulting in an increase or reduction in hours of employment.

– Experiencing a strike or a lockout.

– Commencing or returning from an unpaid leave of absence. [Note: This change is only permitted if there is a change in eligibility. So, an unpaid Leave of Absence will not allow for a change to the Health Care Flexible Spending Account, because you remain eligible.]

– Changing your worksite or residence.

– Experiencing any other change in employment status that affects eligibility for benefits.

Your Dependent meets (or ceases to meet) the Plan’s Dependent eligibility rules on account of age or similar circumstances (e.g., Dependent child reaching age 13 for Dependent Care FSA);

You receive an approved qualified medical child support order (QMCSO);

Your Spouse or Domestic Partner or Dependent starts or stops working, or reduces or increases work hours to the extent that the change affects your Dependent’s plan eligibility (either the Company’s or another employer’s plan);

You, your Spouse or Domestic Partner or Dependent gains or loses group health plan coverage;


Your or your eligible Dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage terminates as a result of loss of eligibility;

You or your eligible Dependent becomes eligible for a premium assistance subsidy under Medicaid or CHIP; or

You, your Spouse or Domestic Partner or Dependent child becomes enrolled in Medicare or Medicaid or loses the right to enroll in either.

If your Spouse or Domestic Partner elects to take coverage through his or her employer during the course of the Company’s Plan Year, contact your Plan Administrator to modify your coverage. The surcharge covering a Spouse or Domestic Partner who had access to other employer coverage will be removed and your premium rates modified effective the next payroll after processing. Due to payroll cutoff timing, you may experience a delay of up to one pay period.

Any other election changes due to a Qualifying Life Event noted above will be effective on the date of the change, if reported to your Plan Administrator within 60 days. If reported after this timeframe, you will be required to wait until the next Annual Enrollment to make changes, except in the case of a child’s birth, adoption or placement for adoption (in this case, the child will be added on the date the proof document(s) is supplied to your Plan Administrator). If you work for a Participating Employer other than Michelin, please check your Adoption Agreement for the applicable timeframe that applies to you.

If you have a Qualifying Life Event, you may change your election only if your requested change is consistent with the event. For example, if you get married, you can drop your health coverage only if you enroll for coverage under your Spouse’s plan. The Plan will determine, based on prevailing Internal Revenue Service (IRS) guidelines, whether a requested change is consistent with your Qualifying Life Event.

If you enroll in coverage because of a Qualifying Life Event, the Plan will only cover expenses incurred after your coverage begins.

Domestic Partners Please note that in general, the changes listed above relating to a Spouse refers to a spouse recognized for federal tax purposes, and the changes relating to a Dependent refer to a dependent who is your federal tax dependent for health insurance purposes. Different rules may apply if the Qualifying Life Event relates to coverage for a Domestic Partner (or his or her children) if your relationship is not recognized as a marriage by federal law. In most cases, if you experience a Qualifying Life Event related to such a family member, under IRS regulations you can only add or drop coverage for that person—you cannot make any changes to your own benefits or those of your other Dependents. Call your Plan Administrator for more information.

Cost or Coverage Changes The IRS allows you to make a change to the Dependent Care Flexible Spending Account if you have a cost change imposed by your dependent care provider who is not a relative, if your dependent care provider is no longer available, or if you make a change in your dependent care provider. For example, if your child attends a child care center at an annual cost of $3,000 (and you make your election before the beginning of the Plan Year under this assumption), but later want to revoke, because you locate a different health care provider with a different cost (whether the new provider is a household employee, family member, or a person who is independent of you such as a day care center), this will be permitted on a prospective basis.

The IRS does not allow you to make a change to your Health Care Flexible Spending Account as a result of a significant cost or coverage change.


HIPAA Special Enrollment Rights The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides the following special enrollment rights. If you or your Dependents (including your Spouse or Domestic Partner) are otherwise eligible, but do not enroll for medical coverage because of other health insurance coverage, you may be able to enroll yourself or your Dependents in the Company Plan mid-year or change your Medical Plan option, if you experience a special enrollment event under HIPAA (described below), as long as you request enrollment within 60 days of your special enrollment event and then coverage becomes effective on the first of the month following the date of your request. These special enrollment events are described below:

Loss of Other Coverage/Employee – If you are eligible but not enrolled in the Plan and had previously declined coverage because you had other health coverage (including COBRA), you may enroll yourself, your Spouse or Domestic Partner and your eligible Dependents in the Plan if you lost that other coverage for any reason listed below:

– Loss of eligibility for other coverage as a result of death, divorce, legal separation, termination of employment or reduction in hours;

– Termination of employer contributions toward other coverage;

– COBRA coverage has been exhausted;

– Loss of coverage* under an HMO or other arrangement because you no longer reside, live or work in the service area of the HMO and no other benefit package is available;

• *Loss of other coverage does not include a loss of coverage due to a failure to pay premiums or a loss of coverage for cause.

– Termination of your or your Dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage as a result of loss of eligibility;

– You or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP; or

– The plan under which you were covered no longer offers any benefits to the group of individuals of which you were a participant.

Other Coverage/Dependent – If you did not enroll your Dependent Child, Spouse or Domestic Partner during the last Annual Enrollment because of other coverage, and that coverage is lost for any of the reasons listed above, you may enroll that Dependent and/or change your Medical Plan option (and enroll yourself if you are eligible but not covered).

Gaining a New Dependent – If you gain a new Dependent through marriage, birth, adoption or placement for adoption, you may enroll yourself and your new Dependent (and/or your Spouse or Domestic Partner, if the new Dependent was gained through birth, adoption or placement for adoption), or change your medical plan option if you are already enrolled.

Effective Date of Coverage Under Special Enrollment Loss of Other Coverage/Employee or Dependent – Coverage will be effective for all individuals covered because of a loss of other coverage effective the date of loss of coverage if reported to your Plan Administrator within 60 days. If loss of coverage is reported after 60 days, you must wait until the next Annual Enrollment period to make any changes.

Gaining a New Dependent – Coverage for your new Dependent will be effective on the date of the marriage, birth, adoption or placement for adoption if reported to your Plan Administrator within 60 days and Dependent eligibility documentation is received by your Plan Administrator within 60 days. If a new Dependent is reported after 60 days, you must wait until the next Annual Enrollment period to make any changes except in the case of a child’s birth, adoption or placement for adoption (in this case, the child will be added on the date the proof document(s) is supplied to your Plan Administrator).


Revocation of Election due to Enrollment in Qualified Health Plan You can revoke a coverage election with respect to coverage under the Plan’s medical benefits due to enrollment in a Qualified Health Plan through an Affordable Care Act government exchange if you satisfy the following conditions:

You are eligible for a Special Enrollment Period to enroll in a Qualified Health Plan through a government exchange pursuant to guidance issued by the Department of Health and Human Services and any other applicable guidance, or you seek to enroll in a Qualified Health Plan through a government exchange during the exchange’s annual open enrollment period; and

The revocation of the election of coverage under the Plan’s medical benefits corresponds to your intended enrollment for yourself and any related individuals who cease coverage due to the revocation in a Qualified Health Plan through a government exchange for new coverage that is effective beginning no later than the day immediately following the last day of the original coverage that is revoked.

Other Changes in Circumstance Certain other events also permit you to change your elections during the Plan Year. The change you make must be consistent with the event:

A QMCSO requires you or another individual to provide health benefit coverage for a Dependent.

You or your Dependent either becomes enrolled in or loses eligibility for Medicare or Medicaid coverage.

Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”) continuation coverage from another employer for you or your Dependent is exhausted.

You experience a change permitted under the Family and Medical Leave Act of 1993, as amended.

How to Make Changes During the Plan Year You can report your mid-Plan Year change to your Plan Administrator. However, you must complete the appropriate election change process within 60 days after the date of the event in order to make the election change effective. If you do not report your mid-Plan Year change and complete the required process within the required period, you will not be able to make any election changes until the next Annual Enrollment, unless you again meet one of the conditions for a change during the Plan Year.

As long as you notify your Plan Administrator within the required time period, election changes will be effective either (a) on the date of the birth, adoption, or placement for adoption or date of hire for new hires; or (b) for all other events, on the first day of the calendar month following your request for the election change.

Michelin Health and Welfare Plan Union Free SPD 27 Important Medical Plan Notices and Protections

Important Medical Plan Notices and Protections

Patient Protection Statement Regarding Provider Designation For purposes of the Plan’s medical coverage, you (or your covered family members) generally may be required or permitted to designate a primary care provider. If that is the case, you have the right to designate any primary care provider in the network and who is available to accept you or your family members. For your covered Child, you may designate a pediatrician as the primary care provider.

For information on how to select a primary care provider and for a list of the participating primary care providers, contact your medical claims administrator. See the “Your Plan Choices and Contacts” section in your Adoption Agreement for contact information.

For purposes of the Plan’s medical coverage, if the Plan requires the designation of a primary care provider, you (or your covered family member) do not need prior authorization from the Plan or from any other person (including a primary care provider) to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact medical claims administrator. See the “Your Plan Choices and Contacts” section in your Adoption Agreement for contact information.

Consumer Protections Under the Affordable Care Act The Company’s medical and prescription drug plan benefits provide you with certain protections—sometimes referred to as “group market reforms” or “consumer protections” under the Affordable Care Act, including:

Prohibition of preexisting condition exclusions

– The Company does not impose any preexisting condition exclusions.

Prohibiting discrimination against participants and beneficiaries based on a health factor

– The Company does not discriminate against participants and beneficiaries based on a health factor.

Prohibition on waiting periods that exceed 90 days

– Any Plan waiting period will comply. See the “Eligibility” section of this SPD and your Adoption Agreement for more details.

Prohibition on lifetime or annual dollar limits on essential health benefits

– The Company does not impose any lifetime or annual dollar limit on essential health benefits.

Prohibition on rescissions

– The Plan will not retroactively rescind your coverage except in the case of fraud or an intentional misrepresentation of a material fact. A rescission is defined as a retroactive cancellation or discontinuance of coverage. If coverage is cancelled or discontinued prospectively, that is not considered a rescission. It is also not a rescission if you do not pay your required premium and your coverage is cancelled or discontinued back to the date that the premium was not paid. The Plan will provide you with at least 30 calendar days’ advance notice before your coverage is rescinded. If your coverage is or will be rescinded, you have the right to file an appeal.

Eligibility of Children until at least age 26

– The Company extends coverage to adult Children until the end of the month in which a Child attains age 26.


Summary of benefits and coverage and uniform glossary

– Choosing a health coverage option is an important decision. To help you make an informed choice, the Plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. SBCs are available by contacting your Plan Administrator. You may request a paper copy free of charge.

Medical loss ratio requirements with respect to insured medical benefit options only

Accommodations in connection with coverage of preventive health services

– The Company’s medical and prescription drug plan options provide preventive care benefits in-network without cost-sharing. See the summary of your medical plan benefits for more details on what constitutes preventive care for this purpose; the list changes periodically. Preventive care generally includes items and services with a rating of “A” or “B” under the United States Preventive Services Task Force, immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the CDC; and with respect to children and women, certain preventive care and screenings based on guidelines supported by the Health Resources and Services Administration.

• General information pertaining to other preventive services and a prescription drug list is available at https://www.healthcare.gov/preventive-care-benefits/. The list of in-network preventive care items and services with no cost sharing includes: A number of screenings (e.g., blood pressure, cholesterol, diabetes and lung cancer screenings), immunizations, counseling (e.g., alcohol misuse, obesity and tobacco use counseling), colonoscopies (including many related items and services, such as bowel preparation medications, anesthesia, and polyp testing) and other items and services that are designed to detect and treat medical conditions to prevent avoidable illness and premature death.

• For women, the medical and prescription drug options also will cover an annual well-woman visit (and additional visits in certain cases); screening for gestational diabetes; testing for the human papilloma virus; counseling for sexually transmitted diseases; counseling and screening for human immunodeficiency virus (HIV); FDA-approved contraceptive methods and counseling as prescribed for women; breastfeeding support, supplies and counseling (including lactation counseling services); and screening and counseling for interpersonal and domestic violence. In addition, a woman who is at increased risk for breast cancer may be eligible for screening, testing and counseling and if at low risk for adverse medication effects may be eligible to receive risk-reducing medications, such as tamoxifen or raloxifene, in-network, without cost sharing. If your Physician prescribes this type of medication to reduce your risk of breast cancer, contact your medical claims administrator to ensure that you satisfy the administrative requirements necessary to receive this benefit. You may be required to meet requirements beyond just submitting the prescription. For example, you and/or your physician may need to demonstrate that you are at an increased risk for breast cancer.

NOTE: The Plan generally may use reasonable medical management techniques to determine frequency, method, treatment, age, setting and other limitations for a recommended preventive care service. When preventive and non-preventive care is provided during the same office visit, special rules apply regarding whether or not cost sharing will be imposed.

Internal claims and appeals and external review process

– See the Claims and Appeals Procedures section of this SPD for more information.

Consumer patient protections (choice of health care professional and coverage of emergency services)

– If you need “emergency services,” the medical options offered by the Company will provide you with coverage regardless of whether the provider for such “emergency” services is in-network or out-of-network. Also, “emergency services” are subject to special cost-sharing rules that require non-grandfathered group health plans (like the Company’s) to not impose a higher copayment or coinsurance, for example, for out-of-network emergency services than for in-network emergencies

https://www.healthcare.gov/preventive-care-benefits/


services, but in certain circumstances you may be “balance billed.” For details on this requirement, including what constitutes an emergency service, contact your medical claims administrator.

The medical and prescription drug options offered to you will not discriminate against an eligible health care provider based on his or her license or certification to the extent the provider is acting within the scope of his or her license or certification under state law. This rule is subject to certain limitations and does not require the medical options to accept all types of providers into a network.

Limitations on cost sharing (i.e., the out-of-pocket expense maximum requirements)

– As required by the Affordable Care Act, your total in-network out-of-pocket costs are limited every year to a dollar amount specified by the IRS. The Plan’s limit includes copayments and prescription drug expenses under the medical options available to you, and will not exceed the specified amount for individual coverage or all other coverage tiers (family), as adjusted from year to year. The Affordable Care Act’s individual out-of-pocket expense maximum applies to each covered individual, whether the individual has self-only, family, or another coverage tier. So, it’s possible that this limit will result in payment for an individual before the family out-of-pocket expense maximum is hit for a High Deductible Health Plan (HDHP) if the HDHP has a family out-of-pocket that is more than the self-only limit under the Affordable Care Act.

• Note for HDHP: With respect to an HSA compatible HDHP, your total out-of-pocket costs will not exceed the annual limit set for individual coverage and all other coverage tiers (family). These amounts may be adjusted each year by the government.

– The maximum imposed by the Affordable Care Act creates a separate, legally required limit on in-network out-of-pocket costs, which requires that additional costs count toward these limits even if they do not apply toward your medical option’s out-of-pocket maximum. Costs that apply toward your total in-network out-of-pocket maximum include, for example, deductibles, copayments, coinsurance, and eligible prescription drug expenses. Out-of-pocket expenses that do not apply toward your in-network out-of-pocket maximums include, for example, premium contributions, spending for non-covered items and services, out-of-network items and services, and the additional cost if you purchase a brand-name prescription drug in a situation where a generic drug was available and medically appropriate as determined by your physician, if specified by your Medical Coverage Documents.

– The actual out-of-pocket expense maximums under the medical/Rx option that you elect may be lower than the legal maximums. Contact your Medical Claims Administrator listed in the “Your Plan Choices and Contacts” section in your Adoption Agreement for more information.

Coverage for individuals participating in approved clinical trials

– You are eligible for coverage of routine costs for items and services furnished in connection with your participation in an approved clinical trial. The clinical trial must relate to the treatment of cancer or another life-threatening disease or condition. Contact your Medical Claims Administrator listed in the “Your Plan Choices and Contacts” section in your Adoption Agreement for more information.

Standards for Mothers and Newborns The Plan 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, the Plan and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Your Rights Following a Mastectomy The Plan includes health benefits for a medically necessary mastectomy and patient-elected reconstruction after the mastectomy. Specifically, for you or your covered Dependent who is receiving


mastectomy-related benefits, benefits will be provided in a manner determined in consultation with the attending physician and the patient for:

All stages of reconstruction of the breast on which the mastectomy was performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications at all stages of mastectomy, including lymphedema.

These benefits will be subject to the same annual deductibles, copays, and coinsurance provisions that apply for all other medically necessary procedures under the Plan.

Michelin Health and Welfare Plan Union Free SPD 31 Coordination of Benefits

Coordination of Benefits

Coordination of benefits procedures will be as described in the Coverage Documents. To the extent that the Coverage Documents do not have any provisions for coordination of benefits, the procedures described below shall govern.

If you or your Dependent(s) is covered by more than one health plan (for example, this Plan and your Spouse’s/Domestic Partner’s plan), you should understand how the plans work together to pay for covered expenses. The coordination of benefits provision is designed to prevent duplicate payments for the same covered expenses.

You should file all health claims with each plan. However, a claim will not be paid twice if the expense is covered by both plans. Claims are coordinated so that you or your providers will receive no more than the benefit payments allowable under this Plan. This Plan is not designed to bring you up to 100% reimbursement (unless you have met your out-of-pocket maximum).

Order of Payment Determination Rules The primary plan is the plan that determines and provides health benefits or makes payments without taking into consideration the existence of any other plan. The secondary plan is the plan that can reduce its payments after taking into consideration the health benefits and payments provided by the primary plan.

A plan that does not have a coordination of benefits rule consistent with this section will always be the primary plan. If the other plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use:

The plan that covers a person as an employee shall be the primary plan and the plan that covers that person as a Dependent will be the secondary plan.

For a Dependent Child whose parents are not divorced or legally separated, the primary plan will be the plan that covers the parent whose birthday falls first in the calendar year:

– This Plan pays first if your birthday (month/day) comes before your Spouse’s/Domestic Partner’s birthday in the calendar year (for example, if your birthday is March 1 and your Spouse’s/Domestic Partner’s birthday is June 1).

– If you and your Spouse/Domestic Partner have the same birthday, the plan covering you or your Spouse/Domestic Partner longer pays first.

– If your Spouse’s/Domestic Partner’s plan does not use the birthday rule, the rules of that plan determine which plan pays first.

For the Dependent Child of divorced or separated parents, the coordination of benefits for the Dependent will be determined in the following order:

– First, according to the provisions of a qualified medical child support order (“QMCSO”) or other court decree, if the court decree states that one parent is responsible for the Child’s health benefit coverage and the plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge.

– Then, the plan of the parent with custody of the Child.

– Then, the plan of the Spouse of the parent with custody of the Child.

– Then, the plan of the noncustodial parent of the Child.

– Finally, the plan of the Spouse of the noncustodial parent.

If none of the above rules determines the order of benefit payments, the plan that has covered you for the longer period of time will be the primary plan.


Benefits and payments under this Plan will be secondary to benefits and payments provided or required by any group or individual automobile, homeowner’s, or premises insurance, including medical payments, personal injury protection, or no-fault coverage, regardless of any provision to the contrary in any other policy of insurance.

When this Plan Is Secondary If this Plan is secondary, it determines the amount it will pay for a covered health service according to the following rules:

The Plan determines the amount it would have paid if it were primary;

If this Plan would have paid less than the primary plan paid, the Plan pays no benefits; and

If this Plan would have paid more than the primary plan paid, the Plan will pay the difference.

Any benefits paid under the Plan are limited to the difference between what the Plan would normally pay if there were no other coverage, and the amount paid by the other plan.

Important: If you are enrolled in a Health Reimbursement Account (HRA), eligible expenses not reimbursed through the primary plan will first coordinate with your HRA. If your HRA balance isn’t enough to cover those expenses, the remaining expenses will be submitted to the medical plan. Also, please note that if you are subject to an annual deductible, you must first meet the applicable deductible requirement before the Plan will pay benefits.

Determining the Allowable Expense When this Plan Is Secondary When this Plan is secondary, the allowable expense is the primary plan’s network rate. If the primary plan bases its reimbursement on reasonable and customary charges, the allowable expense is the primary plan’s reasonable and customary charge. If both the primary plan and this Plan do not have a contracted rate, the allowable expense will be the greater of the two plans’ reasonable and customary charges.

Recovery of Excess Payments If this Plan pays for covered expenses that should have been paid by the primary plan, this Plan will have the right to recover such payments. The Company may recover the amount in the form of salary, wages or benefits payable under any Company-sponsored benefit plans, including this Plan. The Company also reserves the right to recover any overpayment by legal action or offset payments on future eligible expenses.

This Plan will have sole discretion to seek such recovery from any person to whom, or for whom, or with respect to whom, such benefits were provided, or such payments were made by any other plan. If your Plan Administrator requests, you must execute and deliver such instruments and documents as your Plan Administrator determines are necessary to secure the right of recovery for this Plan.

Right to Receive and Release Information Unless prohibited under HIPAA, the Plan Administrator, without consent or notice to you, may obtain information from and release information to any other plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide the Plan Administrator with any information it requests in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the “other coverage” information (including an Explanation of Benefits (“EOB”) paid under the primary plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.

Coordination of Benefits for Medicare Eligible Individuals If you continue to be actively employed by the Company after you reach age 65, your health benefits remain in effect even though you are eligible for Medicare. Your Spouse/Domestic Partner may also continue to be covered under this Plan if he or she reaches age 65 and is eligible for Medicare.


If you or your Spouse/Domestic Partner is enrolled in Medicare because of your age, this Plan pays first, and Medicare pays second, as long as you remain actively employed by the Company.

If you, your Spouse/Domestic Partner, or your Dependent Child is enrolled in Medicare because of a disability, this Plan pays first, and Medicare pays second, as long as you remain actively employed by the Company.

If you, your Spouse/Domestic Partner, or your Dependent Child is enrolled in Medicare because of end stage renal disease (“ESRD”), this Plan pays first for the first 30 months that Medicare benefits are available because of ESRD, and Medicare pays second for that 30-month period. However, after the end of the 30-month period, Medicare will pay first, and this Plan will pay second.

When Medicare is primary (for example, after 30-month ESRD period), the Plan Administrator or Claims Administrator will give consideration to the benefits available under Medicare when determining this Plan’s payments for your covered expenses. As a result, it’s important to enroll in Medicare Part A and Part B, if you and/or your Dependent(s) are eligible, because the Company pays benefits “as if” you are enrolled in Part A and Part B when the Company pays second, even if you are not; this rule applies even if you are required to pay a premium for Medicare benefits. The process used in determining payments under this Plan for your covered expenses is as follows:

This Plan will determine what the payment for a covered expense would be without regard to the coordination of benefits provisions of this Plan.

This Plan will deduct from this amount the amount paid or payable by Medicare. The amount payable by Medicare will be deducted whether or not you have enrolled in and/or received payment from Medicare.

The difference, if any, is the amount that will be paid under this Plan.

Right to Receive and Release Needed Information Certain facts about health care coverage and services are needed to apply these maintenance of benefits rules and to determine benefits payable under this Plan and other plans. The Plan Administrator may get the facts needed from, or give them to, other organizations or persons for the purpose of applying these rules and determining benefits payable under this Plan and other plans covering the person claiming benefits.

The Plan Administrator does not need to tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must give the Claims Administrator any facts needed to apply those rules and determine benefits payable. If you do not provide the Claims Administrator the information needed to apply these rules and determine the benefits payable, your claim for benefits will be denied.

Michelin Health and Welfare Plan Union Free SPD 34 Continuing Participation

Continuing Participation

Leaves of Absence Generally, participation in the Plan’s health and welfare benefits continues while you are on a paid leave of absence, but you must continue to make Employee contributions for your participation to continue. Contact your Plan Administrator for additional payment details.

Participation in the Plan’s health and welfare benefits might also continue while you are on an unpaid leave of absence if you continue to make Employee contributions, as applicable. For more information, please contact your Plan Administrator.

Uniformed Services Employment and Reemployment Rights Act The Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (“USERRA”), sets requirements for the continuation of health benefit coverage under the Plan in the event of an Employee’s military leave of absence. These requirements apply to health benefit coverage for you and your Dependents.

Continuation of Health Benefit Coverage You may elect to continue your health benefit coverage for yourself and your Dependents. For military leaves of less than 31 days, you will make Employee contributions for your health benefit coverage as if you were still an active Employee. For military leaves of 31 days or more, the following applies:

Your health benefit coverage will last up to the earliest of the following:

– 24 months from the last day of employment with the Company.

– The day after you fail to return to work.

– The day the Plan terminates.

The Company may charge you and your Dependents up to 102% of the full cost of the health benefit coverage.

Reinstatement of Health Benefit Coverage If your health benefit coverage ends during the military leave because you do not elect coverage under USERRA and you are reemployed by the Company, the health benefit coverage for you and your Dependents may be reinstated if:

You gave the Company advanced written or verbal notice of your military leave.

The duration of all military leaves while you are employed with the Company does not exceed five (5) years.

You and your Dependents will be subject to only the balance of a waiting period, if appropriate, that was not yet satisfied before the military leave began. However, if an injury or illness occurs or is aggravated during the military leave, full Plan and USERRA limitations will apply.

If your health benefit coverage under the Plan terminates as a result of your eligibility for military health benefits and your order to active duty is canceled before your active duty service commences, these reinstatement rights will continue to apply.

Family and Medical Leave Act Your health benefit coverage will be continued during a leave of absence under the Family and Medical Leave Act of 1993, as amended (“FMLA”). The Plan Administrator will give you more detailed information about the FMLA. The FMLA allows eligible Employees to take an unpaid leave for up to a total of 12 work weeks in a 12-month period for one or more of the following reasons:

The birth of your Child and to care for the newborn Child.

Michelin Health and Welfare Plan Union Free SPD 35 Continuing Participation

The placement of a Child with you for adoption or foster care.

To care for a family member (Child, Spouse, or parent) with a serious health condition.

Your own serious health condition that makes you unable to perform the functions of your job.

Any qualifying exigency arising out of the fact that your Spouse, Child, or parent is a covered member in the Armed Forces on active duty (or has been notified of an impending call or order to active duty) in support of a contingency operation.

If eligible, you may also take a leave for up to a total of 26 work weeks in a single 12-month period to care for a family member who is a covered member of the Armed Forces with a serious injury or illness if you are the Spouse, son, daughter, parent or next of kin of the covered service member.

Benefit Coverage While on FMLA Leave The Company will continue your benefit coverage under the Plan during your FMLA leave just as if you were still employed. The cost of your benefit coverage during an FMLA leave must be paid, and you must make all required Employee contributions in accordance with the agreement reached between you and your Plan Administrator prior to your FMLA leave becoming effective. However, you are required to continue to pay for such benefits during your leave for coverage to remain in effect.

A newly acquired Dependent is eligible for benefit coverage while your participation in the Plan is continued during an FMLA leave.

Continued benefit coverage ends on the earliest date that you:

Terminate employment.

Do not make required Employee contributions.

Exhaust your approved period of FMLA leave and do not return to work from your FMLA leave.

If your employment does not terminate during your FMLA leave, but you do not return to work once your FMLA leave ends, you can choose to continue your health benefit coverage under the COBRA rules at the end of your FMLA leave. See the “COBRA Continuation Rights” section for more details.

Reinstatement of Canceled Health Benefit Coverage Following FMLA Leave Upon your return to your employment following an FMLA leave, any terminated benefit coverage will be reinstated as of the date of your return. You will not be required to satisfy any waiting period, if appropriate, to the extent that it had been satisfied prior to the start of the FMLA leave.

State Family and Medical Leave Laws The Company’s FMLA policy also complies with any state law that provides greater family or medical leave rights than those provided under its FMLA policy. If your leave qualifies under the FMLA and under a state law, you will receive the greater benefit.

If Company Changes Benefits If the Company offers new benefits or changes its benefits while you are on an FMLA leave, you are eligible for the new or changed benefits, but your required Employee contributions for the new benefit coverage may increase.

Michelin Health and Welfare Plan Union Free SPD 36 Termination of Plan Participation

Termination of Plan Participation

Employees Your coverage under the Medical Care and Prescription Drug Plan will end on the earliest of the:

Date you are no longer eligible for coverage (see the “Eligibility” section); Last day of the month in which you terminate or retire from active service; Last day of the Plan Year if you drop coverage during Annual Enrollment; Date you drop coverage due to a Qualifying Life Event; Last day for which you have timely paid required premiums; or Date the Plan ends or is modified to change coverage rules.

Your coverage under other Benefit Options will continue through the end of the month during which you terminate your employment unless otherwise provided in your Adoption Agreement or the Coverage Documents. You will be charged for the appropriate payroll deductions to cover these benefits on your final paycheck.

Continuing Coverage When coverage ends, you may be eligible to continue health care coverage under COBRA (see the “COBRA Continuation Rights” section). You also may be eligible to convert a particular benefit when coverage ends.

If you become disabled, you may be eligible to continue your coverage under the Company Medical Plan and/or Dental Plan. Refer to the Coverage Documents for more information.

If you are eligible for a retiree medical plan, your Plan Administrator will provide you with separate materials.

Dependents Coverage for your Dependents will end on the earliest of the:

Date your Dependent is no longer eligible for coverage as a Dependent, other than due to age; Last day of month in which the Dependent Child turns age 26, if you are still eligible in that month. Last day of the month in which you terminate active service; Last day of the Plan Year if you drop your Dependent from coverage during Annual Enrollment; Date you drop your Dependent from coverage due to a Qualifying Life Event; Date your coverage ends, except for the extension of coverage for Dependents of deceased

Employees; Last day for which you have timely paid required premiums for your Dependent; or Date the Plan or Benefit Option ends or is modified to change coverage rules.

Surviving Dependents If you die while an active Employee and you have medical coverage for Dependents, your Dependents will be covered under your current plan until the earliest of the:

End of 12 months of Company-paid COBRA (additional 24 months available under participant-paid COBRA rates in effect at that time), if your Dependents elect COBRA;

Date your dependents are no longer eligible for coverage as Dependents; or Date the Plan or Benefit Option ends or is modified to change coverage rules.

Your Dependents must continue the same Medical Plan coverage in effect before your death to be eligible for Company-paid COBRA. Refer to the “COBRA Continuation Rights” section for more information. You can contact your Claims Administrator listed in the “Your Plan Choices and Contacts” section in your Adoption Agreement for more details.

Michelin Health and Welfare Plan Union Free SPD 37 Termination of Plan Participation

Other Circumstances If your coverage is rescinded (that is, cancelled because you intentionally misrepresented a material fact, or committed fraud), you will be notified at least 30 calendar days in advance. In some instances, you may be able to convert your coverage to an individual policy of insurance.

If you or your dependent lose coverage under a group health plan, you may be eligible for to continue coverage under COBRA. See the Continuation Coverage Rights under COBRA section.

Michelin Health and Welfare Plan Union Free SPD 38 COBRA Continuation Rights

COBRA Continuation Rights

A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”), offers you the opportunity to continue health benefit coverage under the Plan in certain circumstances. This section of the SPD is a notice that explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. For additional information about your rights and obligations under the Plan and under federal law, contact your Plan Administrator.

COBRA continuation coverage is a temporary continuation of health benefit coverage (i.e., medical and prescription drug, dental, vision, Health Care Flexible Spending Account, and the EAP) under the Plan when it otherwise would end because of a COBRA “qualifying event.” After a qualifying event, COBRA continuation coverage is offered to each “qualified beneficiary.” You, your Spouse, and/or your Dependent children could become qualified beneficiaries if you, your Spouse, or your Dependent Child is enrolled in health benefits under the Plan on the day before a qualifying event occurs and that health benefit coverage is terminated because of the qualifying event. Qualified beneficiaries also include any Children born to you or placed for adoption with you during the COBRA continuation period.

While not legally considered a “qualified beneficiary,” your Domestic Partner and Children of your Domestic Partner also will be offered COBRA-like coverage and will be included in the term “qualified beneficiary” for purposes of this section of the SPD.

Please Note: Qualified beneficiaries may have other options available when they lose Plan coverage. For example, they may be eligible to buy an individual plan through the Health Insurance Marketplace (www.healthcare.gov). By enrolling in coverage through the Marketplace, they may qualify for lower costs on their monthly premiums and lower out-of-pocket costs. Additionally, they may qualify for a 30-day special enrollment period for another group health plan for which they are eligible (such as a Spouse’s plan), even if that plan generally does not accept late enrollees. They may also have other coverage options through Medicare, Medicaid, and the Children’s Health Insurance Program (“CHIP”). Some of these options may cost less than COBRA continuation coverage.

Qualified Beneficiaries and Qualifying Events

Covered Employee or Eligible Retiree You’ll become a qualified beneficiary and eligible for COBRA continuation coverage if you lose your health benefit coverage under the Plan because of one of the following qualifying events:

Your hours of employment are reduced. Your employment ends for any reason other than your gross misconduct. You are a covered Eligible Retiree and a bankruptcy proceeding is commenced with respect to the

Company.

Spouse/Domestic Partner of Covered Employee or Covered Eligible Retiree Your Spouse/Domestic Partner will become a qualified beneficiary and eligible for COBRA continuation coverage if he/she loses health benefit coverage under the Plan because of one of the following qualifying events:

Your hours of employment are reduced. Your employment ends for any reason other than your gross misconduct. You die. You become divorced or legally separated from your Spouse. Your Domestic Partnership ends.


Dependent Children Your Dependent children will become qualified beneficiaries and eligible for COBRA continuation coverage if they lose health benefit coverage under the Plan because of one of the following qualifying events:

Your hours of employment are reduced. Your employment ends for any reason other than your gross misconduct. You die. You become divorced or legally separated from your Spouse. Your Domestic Partnership ends. Your Child loses eligibility as a “Dependent Child” under the Plan.

Notification of Qualifying Events The Plan offers COBRA continuation coverage to qualified beneficiaries only after your Plan Administrator has been notified that a qualifying event has occurred. See the “Your Plan Choices and Contacts” section in your Adoption Agreement for contact information.

When the qualifying event is the end of your employment, the reduction in your work hours, your death, or your entitlement (as a covered Eligible Retiree) to Medicare, the Company will notify your Plan Administrator of the qualifying event.

You Must Give Your Plan Administrator Notice of Some Qualifying Events For other qualifying events (your divorce or legal separation, ending of a Domestic Partnership, or a Dependent Child losing eligibility as a Dependent Child) or the occurrence of a second qualifying event, you or the qualified beneficiary must notify your Plan Administrator or specified COBRA Administrator within 60 days after the later of the date the qualifying event occurs or the day the qualified beneficiary loses health benefit coverage under the Plan because of the qualifying event. If you or your qualified beneficiary fails to notify the Plan Administrator or specified COBRA Administrator within this 60-day period, your Dependent will not be entitled to elect COBRA continuation coverage. In addition, if any benefit claims are mistakenly paid for expenses incurred after the date health benefit coverage under the Plan would normally be lost because of the qualifying event, you will be required to reimburse the Plan for any payments mistakenly made.

How COBRA Continuation Coverage is Offered After the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage is offered to each qualified beneficiary.

The Plan Administrator or COBRA Administrator provides a COBRA enrollment form by mail within 14 days after receiving notice of the qualifying event, and each qualified beneficiary has an independent right to elect COBRA continuation coverage.

You may elect COBRA continuation coverage on behalf of your Spouse/Domestic Partner, and parents may elect COBRA continuation coverage on behalf of their Children. It is critical that you (or anyone who may become a qualified beneficiary) maintain a current address with the Plan Administrator to ensure that you receive a COBRA enrollment form following a qualifying event.

Qualified beneficiaries have 60 days from the date health benefit coverage under the Plan ends due to a qualifying event or from the date of the COBRA notice, whichever is later, to elect COBRA continuation coverage. If the qualified beneficiary fails to elect COBRA continuation coverage within the applicable timeframe, the opportunity to continue coverage under COBRA will be forfeited.

Special Considerations in Deciding Whether to Elect COBRA When deciding whether to elect COBRA, you should consider that a failure to elect COBRA will affect your future rights under federal law.


You can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage. Election of COBRA under the Plan may help you to avoid such a gap.

You will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions if you do not elect and receive COBRA coverage for the maximum time available to you.

There may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a Spouse or Domestic Partner’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

You should consider that you have special enrollment rights under federal law. You have the right to request special enrollment under another group health plan for which you are otherwise eligible (such as a plan sponsored by your Spouse or Domestic Partner’s employer) within 30 days after your Plan coverage ends because of one of the qualifying events listed above. You will also have this same special enrollment right under another group health plan at the end of your COBRA coverage period if you receive COBRA coverage under the Plan for the maximum time available to you.

Effective Date of COBRA Continuation Coverage If elected within the period allowed for the election, COBRA continuation coverage is effective retroactively to the date health benefit coverage under the Plan would otherwise have terminated due to the qualifying event, and the qualified beneficiary will be charged for COBRA continuation coverage in this retroactive period. However, if the qualified beneficiary waives COBRA continuation coverage and then revokes the waiver within the 60-day election period, elected COBRA continuation coverage begins on the date the waiver is revoked.

How Long COBRA Continuation Coverage Lasts COBRA continuation coverage is a temporary continuation of health benefit coverage under the Plan. COBRA continuation coverage generally lasts for up to a total of 18 months when the qualifying event is the end of your employment or reduction of your work hours.

Certain qualifying events may permit coverage to last for up to a total of 36 months when the qualifying event is:

Your death. Your divorce or legal separation. Your Domestic Partnership ending. Your Dependent Child losing eligibility as a Dependent Child.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability Extension of 18-Month Period of COBRA Continuation Coverage If you or a qualified beneficiary in your family is determined by the Social Security Administration to be disabled, and you notify your Plan Administrator in a timely fashion, you and all other qualified beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months, if all of the following conditions are met:

The COBRA qualifying event was your termination of employment or reduction in work hours.

The qualified beneficiary is determined by the Social Security Administration to have been disabled at any time during the first 60 days of COBRA continuation coverage, and the disability lasts at least until the end of the 18-month period of COBRA continuation coverage.


A copy of the Notice of Award from the Social Security Administration is provided to the Plan Administrator within 60 days of receipt of the notice and before the end of the initial 18 months of COBRA continuation coverage.

An increased premium of 150% of the monthly cost of health benefit coverage is paid, beginning with the 19th month of COBRA continuation coverage.

Second Qualifying Event Extension of 18-Month Period of COBRA Continuation Coverage If another qualifying event occurs during the first 18 months of COBRA continuation coverage, your Spouse/Domestic Partner and Dependent children can receive up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan Administrator.

This extension may be available to your Spouse/Domestic Partner and any Dependent Children receiving COBRA continuation coverage if you die, you become entitled to Medicare benefits (under Part A, Part B, or both), get divorced or legally separated, end your Domestic Partnership, or your Dependent Child is no longer eligible under the Plan as a Dependent Child, but only if the event would have caused your Spouse/Domestic Partner or Dependent Child to lose health benefit coverage under the Plan had the first qualifying event not occurred.

Medicare Extension for Your Dependents If the qualifying event is your termination of employment or reduction in work hours and you became enrolled in Medicare (Part A, Part B, or both) within the 18 months before the qualifying event, COBRA continuation coverage for your Dependents will last until the later of: (a) 36 months after the date you became enrolled in Medicare or (b) 18 months (29 if disability extension) after the date of your termination of employment. Your COBRA continuation coverage will last for 18 months from the date of your termination of employment or reduction in work hours.

Special Rule for the Health Care Flexible Spending Account You may be eligible to continue participation in the Health Care Flexible Spending Account for the remainder of the calendar year in which participation otherwise would end due to a COBRA qualifying event. You will be given the opportunity to continue the same coverage you had in effect the day before the qualifying event on a self-pay basis.

COBRA coverage will be available to you only if you have a positive Health Care Flexible Spending Account balance at the time you become eligible for COBRA (considering all claims submitted by you before the date of the qualifying event). Coverage will cease at the end of the calendar year and will not be continued thereafter. However, you will be permitted to request reimbursement for Eligible Expenses incurred during the calendar year as provided by the “run-out period.” Any Health Care Flexible Spending Account amounts left over after the calendar year will be forfeited.

Enrolling in Medicare Instead of COBRA Continuation Coverage In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or • The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA

1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.

https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods


continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

What COBRA Continuation Coverage Costs Qualified beneficiaries must pay monthly premiums for COBRA continuation coverage. Premiums are based on the full cost of health benefit coverage under the Plan for a covered person set at the beginning of the Plan Year, plus 2% for administrative costs. Dependents making separate elections are charged the same rate as a single Employee. An increased premium of 150% of the full cost of health benefit coverage under the Plan must be paid in the case of a disability extension, beginning with the 19th month of COBRA continuation coverage.

Payment is due at enrollment, but there is a 45-day grace period from the date the qualified beneficiary mails his COBRA enrollment form to make the initial payment. The initial payment includes COBRA continuation coverage for the current month, plus any previous month(s). Note that COBRA continuation coverage will not be effective until the COBRA premium is actually paid; if payment is not made with enrollment, COBRA continuation coverage will be retroactively activated back to the date of enrollment upon receipt of payment.

Ongoing monthly payments are due on the first of each month, but there is a 30-day grace period (for example, June payment is due June 1, but will be accepted if postmarked by June 30).

General Provisions If you, your Spouse/Domestic Partner, and/or Dependent Child(ren) elect COBRA continuation coverage:

You or your Dependent can keep the same health benefit coverage under the Plan that you had as an active Employee or choose a lower level of coverage.

You or your Dependent may change health benefit coverage:

– During the annual open enrollment period. – Upon a qualified change in status. – For any change in circumstance recognized by the Internal Revenue Service (“IRS”).

You may enroll any newly-eligible Spouse/Domestic Partner or Dependent Child under Plan rules.

When COBRA Continuation Coverage Ends COBRA continuation coverage ends when the first of the following events occurs:

The qualified beneficiary reaches the maximum COBRA continuation period. COBRA continuation coverage for a newly-acquired Dependent who has been added for the balance of a COBRA continuation period would end at the same time that your COBRA continuation period ends.

The qualified beneficiary becomes covered under another group health plan not offered by the Company.

The qualified beneficiary fails to pay the COBRA premiums by the due date as required.

The Company stops offering any health benefit coverage to any employee or retiree.

The qualified beneficiary dies.

https://www.medicare.gov/medicare-and-you


Any reason the Plan would terminate the health benefit coverage of a participant or beneficiary who is not receiving COBRA continuation coverage (such as fraud).

The Social Security Administration determines that the qualified beneficiary is no longer disabled (if entitled to 29 months of COBRA continuation coverage under the special disability rule), in which case the extended portion of the COBRA continuation coverage will end with the month that begins more than 30 days after the Social Security Administration’s determination.

As a result of the COVID-19 National Emergency, various COBRA deadlines have been extended. See the “Important Notice Regarding this Plan and COVID-19” in the “Administrative Information” section of this SPD.

If You Have Questions See the “Your Rights Under ERISA” section for contact information if you have questions about your rights under COBRA.

Michelin Health and Welfare Plan Union Free SPD 44 Claims and Appeals Procedures

Claim and Appeals Procedures

Deadlines for Filing Claims Each Benefit Option may have deadlines for the filing of claims, described in the Coverage Documents. For Medical Plan claims, the claim must be submitted by March 31 of the following year for services you received during the previous Plan Year. This requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of the service is the date your inpatient stay ends.

Filing an ERISA Claim or Appeal Disagreements about benefit eligibility or benefit amounts can arise. If the Claims Administrator is unable to resolve the disagreement, there is a formal appeals procedure in place for ERISA-covered benefits, such as medical. This section explains the steps you or your authorized representative is required to take to file an ERISA claim or appeal. You must request your benefits or file a claim within one year (or as such shorter time specified in the applicable Coverage Document) of the receipt of service or onset of illness or injury, whichever is later, or your claim will be denied. If you intend to file a civil action under Section 502(a) of ERISA, any such legal action must be commenced within one (1) year of a final determination on appeal, and the failure of an individual to commence legal action within such one (1) year period shall be deemed to be an irrevocable waiver of such claim (unless specified otherwise in the Coverage Documents).

The claims and appeals procedures are slightly different, depending on whether you have an “eligibility” claim or a “benefit” claim. An eligibility claim is a claim to participate in the Plan or a Benefit Option or to change an election to participate during the year. A benefit claim is a claim for a particular benefit under a plan. It typically will include your initial request for benefits.

Eligibility Claims and Appeals for All Benefit Options An eligibility claim is a claim to participate in a Benefit Option offered under the Plan or to change an election to participate during the year. Examples of eligibility claims include claims regarding whether you are enrolled in the correct benefit option, or claims related to whether you properly enrolled a Dependent. Eligibility claims do not address whether a particular treatment or benefit is covered under the Plan.

For each Benefit Option, the Claims Administrator is listed in “Your Plan Choices and Contacts” section of your Adoption Agreement. To file an eligibility claim, you must file a request with your Participating Employer.

You will be notified of the decision within the time periods below:

For medical (including prescription drug), Health Care Flexible Spending Account, dental, vision, and EAP within 30 days or within 72 hours (if you specify that it is an urgent care claim) of the Claim Administrator’s receipt of your Claim;

For disability benefits, within 45 days of the Claim Administrator’s receipt of your Claim; or

For all other ERISA benefits, within 90 days the Claim Administrator’s receipt of your Claim.

If additional information is needed to process your eligibility claim, you will be notified within that initial period. The Plan may request an extension, not longer than:

For medical (including prescription drug), Health Care Flexible Spending Account, dental, vision, and EAP benefits, an additional 15 days;

For disability benefits, up to two additional 30-day periods; or

For all other claims (e.g., life), 90 days.

The Plan Administrator/Participating Employer will notify you of the deadline to submit additional information, if applicable. If your claim is approved, the Claim Administrator will notify you in writing.


If your claim is denied, in whole or in part, your written denial notice will contain:

The specific reason(s) for the denial.

The Plan provisions on which the denial was based.

Any additional material or information you may need to submit to complete the claim and an explanation as to why it is necessary.

A description of the Plan’s appeals procedures and applicable time limits, including a statement of your right to bring a civil action under Section 502(a) of ERISA following your appeal.

With respect to medical including prescription drug and disability,

– Any internal procedures or protocols on which the denial was based (or a statement that this information will be provided free of charge, upon request).

– Information sufficient to identify the claim involved.

Depending on where you live, you may be able to receive a medical, prescription drug or disability denial notice in Spanish, Tagalog, Chinese, or Navajo.

Before you can bring any legal action to recover Plan benefits, you must exhaust this process. Specifically, you must file an appeal as explained in this section and your appeal must be finally decided by the Claims Administrator. For eligibility claims for all Benefit Options, the Claims Administrator fiduciary (appeals) is your Plan Administrator. All decisions by the Plan Administrator are final and binding on all parties.

If your claim is denied and you want to appeal it, you must file your appeal within 180 days (for Medical including Prescription Drug, Health Care Flexible Spending Account, Dental, Vision, and Disability) or otherwise 60 days from the date you receive written notice of your denied claim. You may request access, free of charge, to all documents relating to your appeal. To file your appeal, write to your Plan Administrator for the Plan (see “Your Plan Choices and Contacts” section in your Adoption Agreement) and include:

A copy of your claim denial notice.

The reason(s) for the appeal.

Relevant documentation.

You will be notified of the decision within 60 days for medical (including prescription drug), Health Care Flexible Spending Account, dental, vision, and EAP (unless it is an urgent care claim, in which case you will be notified within 72 hours) of the Administrative Committee’s receipt of your appeal, 45 days for disability (90 days when special circumstances apply), or 60 days (120 days when special circumstances apply) for all other ERISA-covered Benefit Options.

Benefits Claims and Appeals Process The following is a summary of the benefits claims and appeals procedure.

The Claims Administrator/fiduciary must comply with this process or you must verify that the process has been exhausted. If you believe that the Claims Administrator/fiduciary has violated this process, you may write to your Plan Administrator.

References to “you” refer to the claimant, including his or her authorized representative.

Benefit claims and appeals are divided into four categories.

Post-service: A claim for reimbursement of services already received. This is the most common type of claim.

Pre-service: A claim for a benefit for which prior authorization is required by the Plan.


Concurrent care: A claim for ongoing treatment over a period of time or a number of additional treatments that have been approved.

Urgent care: A claim for medical care or treatment that, if the longer time frames for non-urgent care were applied, the delay: (1) could seriously jeopardize the health of the claimant or his or her ability to regain maximum function; or (2) in the opinion of a Physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that could not be managed without the care or treatment that is the subject of the claim.

Fully-Insured Benefits. For purposes of determining the amount of, and entitlement to, benefits of the Benefit Options provided under insurance or contracts, the respective insurer is the named fiduciary under the Plan, with the full power to interpret and apply the terms of the Plan as they relate to the benefits provided under the applicable insurance contract.

To obtain benefits from the insurer of a Benefit Option, you must follow the claims procedures under the applicable insurance contract (Coverage Document), which may require that a written claim be completed, signed and submitted on the insurer’s form. Please contact the Claims Administrator/insurer for details.

The insurance company will decide claims in accordance with its reasonable claims procedures, as required by ERISA. The procedures outlined here align with ERISA. The insurer, as the claims fiduciary may have slightly different procedures. The insurance company has the right to secure independent medical advice and to require such other evidence as it deems necessary in order to decide submitted claims. If the insurance company denies a claim in whole or in part, then you will receive a written notification setting forth the reason(s) for the denial.

If a claim is denied, you may appeal to the insurance company for a review of the denied claim. The insurance company will decide the appeal in accordance with its reasonable claims procedures, as required by ERISA. Failure to timely file a claim may cause you to lose your right to file suit in a state or federal court, based on a failure to exhaust internal administrative appeal rights (which generally is a prerequisite to bringing suit in state or federal court).

See the Benefit Option’s claims filing instructions in the Coverage Documents for more information about how to file a claim and for details regarding each insurance company’s claims procedures.

Self-Funded Benefits. For purposes of determining the amount of, and entitlement to, benefits under the Benefit Options provided through the Company’s general assets, the Plan Administrator is the named fiduciary under the Plan, with the full power to make factual determinations and to interpret and apply the terms of the Plan as they relate to the benefits provided through a self-funded arrangement. The Plan Administrator has delegated its authority for Participating Employer Benefit Options to the Participating Employer maintaining such Benefit Options for its eligible Employees (see your Plan Administrator as listed in the “Your Plan Choices and Contacts” section in your Adoption Agreement). The Plan Administrator may delegate its authority to finally determine claims to the Claims Administrator.

To obtain benefits from a self-funded arrangement, you must complete, execute, and submit to the Claims Administrator a written claim as directed by the Claims Administrator. The Claims Administrator has the right to secure independent medical advice and to require such other evidence as it deems necessary to decide the claim.

The Claims Administrator will decide your claim in accordance with reasonable claims procedures, as required by ERISA. If the Claims Administrator denies a claim in whole or in part, then the Eligible Employee will receive a written notification setting forth the reason(s) for the denial.

If a claim is denied, the denial may be appealed to the Claims Fiduciary. The Claims Fiduciary will decide the appeal in accordance with reasonable claims procedures, as required by ERISA. If the appeal is untimely, the right to file suit in a state or federal court may be lost, because internal administrative appeal rights have not been exhausted (which generally is a prerequisite to bringing a suit in state or federal court).


Medical and Prescription Drug Benefit Claims and Appeals To file a benefit claim, write to the medical and prescription drug Claims Administrator.

Post-Service Claim

Pre-Service Claim

Concurrent Care Claim

Urgent Care Claim

Internal Claims (Internal Benefit Determination) Misdirected Claim Not applicable.

Response time frame does not begin until claim is properly filed.

5 days. Not applicable. Response time frame does not begin until claim is properly filed. If claim involves urgent care, 24 hours.

24 hours.

When You Will Be Notified of Claim Decision Within the time frame indicated in the columns to the right after receipt

30 days. This period may be extended for 15 days. Claimant must be notified within the initial 30-day period.

15 days. This period may be extended for an additional 15 days. Claimant must be notified within the initial 15-day period.

A time period sufficiently in advance of the reduction or termination of coverage to allow appeal and obtain a response to that appeal before coverage is reduced or terminated. For concurrent care that is urgent, within 24 hours (provided that claim is submitted at least 24 hours in advance of reduction or termination of coverage); otherwise, within 72 hours.

72 hours.

Failure to Provide Sufficient Information Procedure Claim may be decided based on the information provided. If Claims Administrator decides to request additional information before deciding claim, you will be notified within these time frames.

30 days. 15 days. Decision will be based on information provided unless the concurrent care claim involved urgent care; see urgent care time frame.

24 hours.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

You must provide additional information within the time frames provided in the columns to the right. Otherwise, the claim will be decided based on information originally provided.

45 days. 45 days. 48 hours.

If claimant provides additional information, notification of the decision must be sent within the time frames provided in the columns to the right.

The time period remaining for the initial claim.

The time period remaining for the initial claim.

48 hours.

How You Will Be Notified of the Claim Decision

If the claim (benefit determination) is approved, you will be notified in writing; commonly referred to as an explanation of benefits (“EOB”).

If claim is denied (adverse benefit determination), in whole or in part, the denial notice must contain: The specific reason(s) for the denial. The Plan provisions on which the denial was based. Information sufficient to identify the claim involved (date

of service, the health care provider, claim amount [if applicable], and upon request the availability of the diagnosis and treatment codes and their corresponding meanings).

Any additional material or information you may need to submit to complete the claim.

Any internal procedures or clinical information on which the denial was based (or a statement that this information will be provided free of charge upon request).

If based on medical necessity or experimental treatment, an explanation of the scientific or clinical judgment for the determination (or a statement that such explanation will be provided free of charge upon request).

The Plan’s appeal procedures. The availability of and contact information for any office

of health insurance consumer assistance or ombudsman available to assist with the appeals process.

If the Claims Administrator relies on new evidence to deny your claim, you will be notified in advance, free of charge, of the rationale so that you can respond in advance of the final internal adverse benefit determination.

You have a right to review your claim file.

If your claim is denied, claimant will be notified by phone. Within 3 days of the oral denial, claimant must receive a written denial notice, as explained under the general procedure. The denial notice must explain the expedited review process.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

Internal Appeals (Benefit Determinations on Review)—Step 2: Before you can bring any action at law or in equity to recover Plan benefits, you must exhaust this process. Specifically, you must file an appeal or appeals, as explained in this Step 2, and the appeal(s) must be finally decided by the Claims Fiduciary.

The Plan Administrator or its delegate has delegated its authority to finally determine claims to the Claims Administrators for benefit claims.

The Claims Fiduciary is authorized to finally determine appeals and interpret the terms of the Plan in its sole discretion. All decisions by the Claims Fiduciary are final and binding on all parties.

How to File an Appeal If your claim is denied and you want to appeal it, you must file your appeal within (see columns to the right) from the date you receive notice of your denied claim (adverse benefit determination). You may request access, free of charge, to all documents relating to your appeal. You should write to the party identified in your claim denial notice (adverse benefit determination) and include: A copy of your

claim denial notice.



180 days. 180 days. 180 days. 180 days. You may orally file your appeal with the Claims Fiduciary for urgent care claims. At the time your claim is denied, the Claims Administrator will give you instructions about how to file your appeal. You must identify that you are appealing an urgent care claim.

The individual/committee (and any medical expert) reviewing your appeal will be independent from the individual/committee who reviewed your initial claim. In addition, if your appeal involves a medical judgment, the Claims Fiduciary will consult with a health care professional who has appropriate relevant experience. You are entitled to learn the identity of such an expert, upon request.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

When You Will Be Notified of Appeal Decision (Can require one or two level(s) of appeal(s))

One level of appeal: within 60 days. Two levels of appeals: within 30 days at each appeal level.


Before a reduction or termination of benefits occurs. If involves urgent care, 72 hours.

Within 72 hours.

If Appeal is Denied in Whole or in Part, the Adverse Benefit Determination on Review Must Contain

The specific reason(s) for the denial. The Plan provisions on which the denial was based. A description of any additional information or material needed from the

claimant to “perfect the claim” and an explanation of why such additional information or material is necessary.

A statement regarding the documents to which the claimant is entitled. An explanation of the voluntary or mandatory appeal procedures, if any. Any internal procedures or clinical information on which the denial was based

(or a statement that this information will be provided free of charge, upon request).


The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency.” – NOTE: In lieu of including the above statement regarding “voluntary

alternative dispute resolution options” in the appeal denial letter, the Plan or insurer may include any specific voluntary appeal procedures offered by the Plan along with a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA.

Sufficient information to identify the claim involved (e.g., date of the service, the health care provider, claim amount (if applicable), a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning).

The reason(s) for an adverse benefit determination, including the denial code and its corresponding meaning, as well as a description of the Plan’s or issuer’s standard, if any, that was used in denying the claim.

A description of available internal appeals and external review processes. The availability of and contact information for any office of health insurance

consumer assistance or ombudsman available to assist with the appeals process.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

External Appeals (IRO)—Step 3 Under the Affordable Care Act, medical benefit claims (not eligibility claims) and rescissions under a non-grandfathered health plan are eligible for an external review (Step 3 of the claims and appeals process) by an independent review organization (IRO). To be eligible for the external review, the medical benefit claim must involve medical judgment, excluding claims that involve only contractual or legal interpretation without any use of medical judgment as determined by the external reviewer. You will be provided with information regarding this new external review if you receive a final internal adverse benefit determination (i.e., your claim is denied after completing Step 2 of the claims and appeals process). You cannot request an external review unless you have exhausted the internal claims and appeals process and receive a final adverse benefit determination.

Filing an Appeal 4 months after date of receipt of notice final adverse benefit determination.

4 months after date of receipt of notice final adverse benefit determination.

4 months after date of receipt of notice final adverse benefit determination. Expedited appeal can be requested: (1) if the time frame for completion of a standard external review would seriously jeopardize life or health or ability to regain maximum function; or (2) if it concerns an admission, availability of care, continued stay, or health care item or service for emergency services, but have not been discharged from a facility.

4 months after date of receipt of notice final adverse benefit determination. Expedited appeal can be requested: (1) if the time frame for completion of a standard external review would seriously jeopardize life or health or ability to regain maximum function; or (2) if it concerns an admission, availability of care, continued stay, or health care item or service for emergency services, but have not been discharged from a facility.

Claims Administrator’s Preliminary Review

5 business days. 5 business days. 5 business days. If involves urgent care, immediately.

Immediately.

Time to Notify Claimant of Preliminary Review If request is incomplete, claimant must provide required information.

1 business day. Within the 4-month appeal filing deadline or 48 hours (whichever is later).

1 business day. Within the 4-month appeal filing deadline or 48 hours (whichever is later).

1 business day. If involves urgent care, immediately. Immediately if the concurrent care claim involves urgent care.

Immediately.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

Claims Administrator Provides IRO with Documentation

5 business days. 5 business days. 5 business days.

Immediately.

IRO Notifies Claimant of Acceptance of External Review Request

Timely. Timely. Timely, expedited if it involves urgent care.

N/A.

Claims Administrator’s Notice of Reversal of Adverse Benefit Determination (if applicable)

1 business day following decision.



N/A.

When You Will Be Notified of External Appeal Decision

Within 45 days. Within 45 days. Within 45 days. If involves urgent care, oral notice within 72 hours.

IRO must provide written confirmation of decision to the claimant and the Claims Administrator within 48 hours.

Oral notice within 72 hours. IRO must provide written confirmation of decision to the claimant and the Claims Administrator within 48 hours.

IRO external review decision notice content

General description of the reason for the request for external review, including information to identify claim (i.e., date[s] of service, health care provider, claim amount [if applicable], diagnosis, and treatment codes and their meaning, and the reason for the previous denial);

Date IRO received the assignment to conduct the external review and date of IRO decision;

References to evidence or documentation, including specific coverage provisions and evidence-based standards considered;

Discussion of the principal reason(s) for its decision, including rationale and any evidence-based standards relied upon;

Statement that the determination is binding except to the extent other remedies may be available under state or federal law to either the medical plan or to the claimant;

Statement that judicial review may be available to the claimant; and Current contact information, including phone number, for any applicable office

of health insurance consumer assistance or ombudsman.

If IRO reverses Claims Administrator’s decision, the Claims Administrator must provide coverage or payment for the claim immediately.


Health Care FSA, Dental, Vision, and EAP Benefits Claims and Appeals To file a benefit claim, write to the applicable Claims Administrator. Generally, these types of claims are post-service.

Post-Service Claim

Pre-Service Claim


Urgent Care Claim

Internal Claims (Internal Benefit Determination) Misdirected Claim Not applicable.

Response time frame does not begin until claim is properly filed.

5 days. Not applicable. Response time frame does not begin until claim is properly filed. If claim involves urgent care, 24 hours.

24 hours.


30 days. This period may be extended for 15 days. Claimant must be notified within the initial 30-day period.

15 days. This period may be extended for an additional 15 days. Claimant must be notified within the initial 15-day period.

A time period sufficiently in advance of the reduction or termination of coverage to allow appeal and obtain a response to that appeal before coverage is reduced or terminated. For concurrent care that is urgent, within 24 hours (provided that claim is submitted at least 24 hours in advance of reduction or termination of coverage); otherwise, within 72 hours.

72 hours.

Failure to Provide Sufficient Information Procedure Claim may be decided based on the information provided if Claims Administrator decides to request additional information before deciding claim, you will be notified within time frames provided in the columns to the right.

30 days.

15 days.

Decision will be based on information provided, unless the concurrent care claim involved urgent care; see urgent care time frame.

24 hours.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

You must provide additional information within the time frames provided in the columns to the right. Otherwise, the claim will be decided based on information originally provided. If claimant provides additional information, notification of the decision must be sent within the time frames provided in the columns to the right.

45 days. The time period remaining for the initial claim.

45 days. The time period remaining for the initial claim.

48 hours. 48 hours.

How to Notify Claimants of Decision

If the claim (benefit determination) is approved notification is provided in writing; commonly referred to as an explanation of benefits or EOB. If claim is denied (adverse benefit determination), in whole or in part, the denial notice must contain: The specific reason(s) for the denial. The Plan provisions on which the denial was based. Any additional material or information you may need to

submit to complete the claim. Any internal procedures or clinical information on which

the denial was based (or a statement that this information will be provided free of charge, upon request).


The Plan’s appeal procedures.

If your claim is denied, you will be notified by phone. Within 3 days of the oral denial, claimant must receive a written denial notice, as explained under the general procedure. The denial notice must explain the expedited review process.

Internal Appeals (Benefit Determinations on Review)—Step 2: About the Claims Fiduciary Before you can bring any action at law or in equity to recover Plan benefits, you must exhaust this process. Specifically, you must file an appeal or appeals, as explained in this Step 2, and the appeal(s) must be finally decided by the Claims Fiduciary. The Plan Administrator or its delegate has delegated its authority to finally determine claims to the Claims Administrators for benefit claims. The Claims Fiduciary is authorized to finally determine appeals and interpret the terms of the Plan in its sole discretion. All decisions by the Claims Fiduciary are final and binding on all parties.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

How to File an Appeal If your claim is denied and you want to appeal it, you must file your appeal within (see columns to the right) from the date you receive notice of your denied claim (adverse benefit determination). You may request access, free of charge, to all documents relating to your appeal. You should write to the party identified in your claim denial notice (adverse benefit determination) and include: A copy of your

claim denial notice.



180 days. 180 days. 180 days. 180 days. You may orally file your appeal with the Claims Fiduciary for urgent care claims. At the time your claim is denied, the Claims Administrator, as applicable, will give you instructions about how to file your appeal. You must identify that you are appealing an urgent care claim.

The individual/committee (and any medical expert) reviewing your appeal will be independent from the individual/committee who reviewed your initial claim. In addition, if your appeal involves a medical judgment, the Claims Administrator will consult with a health care professional who has appropriate relevant experience. You are entitled to learn the identity of such an expert, upon request. When You Will Be Notified of Appeal Decision (Can require one or two level(s) of appeal(s))



Before a reduction or termination of benefits occurs. If involves urgent care, 72 hours.

Within 72 hours.


Post-Service Claim

Pre-Service Claim


Urgent Care Claim

If appeal is denied in whole or in part, the adverse benefit determination on review must contain

The specific reason(s) for the denial. The Plan provisions on which the denial was based. A statement regarding the documents to which the claimant is entitled. An explanation of the voluntary or mandatory appeal procedures, if any. Any internal procedures or clinical information on which the denial was based (or

a statement that this information will be provided free of charge, upon request). If based on medical necessity or experimental treatment, an explanation of the

scientific or clinical judgment for the determination (or a statement that such explanation will be provided free of charge upon request).

The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency.” – NOTE: In lieu of including the above statement regarding “voluntary

alternative dispute resolution options” in the appeal denial letter, the Plan or insurer may include any specific voluntary appeal procedures offered by the Plan along with a statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA.


Disability, AD&D, Life, and Other ERISA-Covered Insurance Claims and Appeals To file a benefit claim, write to the applicable Claims Administrator.

Disability Insurance Subject to ERISA *

AD&D, Life, and Other ERISA Insurance Subject to ERISA

Misdirected Claim Response time frame begins even if claim is not properly filed.

Response time frame begins even if claim is not properly filed.


Within 45 days of receipt. Two 30-day extensions are available. Claimant must be notified within the initial 45-day period, and if extended for a second time, within the first 30-day extension period.

Within 90 days of receipt. This period may be extended for an additional 90 days. Claimant must be notified within the initial 90-day period.

Failure to provide sufficient information procedure Claim may be decided based on the information provided if Claims Administrator decides to request additional information before deciding claim, you will be notified within time frames provided in the columns to the right. You must provide additional information within the time frames provided in the columns to the right. Otherwise, the claim will be decided based on information originally provided. If claimant provides additional information, notification of the decision must be sent within the time frames provided in the columns to the right.

Within 45 days of receipt. (If the original 45-day period is extended due to a request for additional information, the deadline time frame is tolled or suspended.) Within 45 days. Within 30 days after receipt of additional information.

Within 90 days of receipt.

N/A N/A


Disability Insurance Subject to ERISA *

AD&D, Life, and Other ERISA Insurance Subject to ERISA

How You Will Be Notified of Decision

If your claim is approved, you generally will be notified in writing. If your claim is denied, in whole or in part, you will be notified in writing. Your denial notice will contain: Specific reason for denial; Reference to specific plan

provisions on which the decision is based; Description of any additional

information needed to perfect the claim and why such information is necessary; Description of appeal procedures

(e.g., time limits); Specific rule, guideline, protocol

relied upon in making the determination and that a copy is available free of charge; and An explanation of the scientific or

clinical judgments for the determination, applying the terms of the Plan (or that the explanation will be provided free of charge).

If your claim is approved, you generally will be notified in writing. If your claim is denied, in whole or in part, you will be notified in writing. Your denial notice will contain: Specific reason for denial; Reference to specific plan

provisions on which the decision is based; Description of any additional

information needed to perfect the claim and why such information is necessary; and Describe appeal procedures (e.g.,

time limits).

Internal Appeals (Benefit Determinations on Review) *Claimant must exhaust this process before bringing any action at law or in equity* How to File an Appeal If your claim is denied and you want to appeal it, you must file your appeal within these specified periods from the date you receive notice of your denied claim (adverse benefit determination). You may request access, free of charge, to all documents relating to your appeal. Write to the party identified in your claim denial notice (adverse benefit determination) and include: A copy of your claim denial

notice. The reason(s) for the

appeal. Relevant documentation.

Within 180 days.

Within 60 days.

When You Will Be Notified of Appeal Decision (Can require one or two level(s) of appeal(s))

Within 45 days. This period may be extended for an additional 45 days. Claimant must be notified within the initial 45-day period.

Within 60 days. This period may be extended for an additional 60 days. Claimant must be notified within the initial 60-day period.


In addition, the following provisions apply to disability claims and appeals:

Disclosure requirements: Disability denial notices will need a more complete discussion of why the Plan denied a clam and the standards it used to make the decision (e.g., explain why a denial occurred if it disagreed with a disability determination made by the Social Security Administration).

Claim file and internal protocols: Disability claim denial notice must offer that the claimant is entitled to receive the claim file and other relevant documents as part of the claim (not just the appeal).

Review and respond to new information: Plans may not deny benefits on appeal based on new or additional evidence or rationales that were not included when the benefit was denied at the claims stage, unless the claimant is given a fair opportunity to respond.

Conflicts of interest: For example, a claims adjudicator or medical expert cannot be hired, promoted or compensated based on the likelihood of such individual denying benefit claims.

Coverage rescissions: Certain rescissions (retroactive termination) of disability benefits due to alleged misrepresentation of fact (e.g., errors in the application for coverage) must be treated as an adverse benefit determination (i.e., claim denial) which would trigger the Plan’s appeal procedures.

Communication requirements in non-English languages: Adverse benefit determinations of disability benefits must be provided in a “culturally and linguistically appropriate manner.” Depending on what county you live in, you may be able to receive such information in Spanish, Chinese, Tagalog, and Navajo.

Federal External Review Program If, after exhausting the applicable levels of appeal for a medical or prescription drug claim, you are not satisfied with the final decision, you may choose to participate in the voluntary external review program that is described in the applicable Coverage Documents.

Michelin Health and Welfare Plan Union Free SPD 60 HIPAA Privacy Rights

HIPAA Privacy Rights

NOTICE OF PRIVACY PRACTICES Effective: January 1, 2021

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Michelin, as well as any Participating Employer acting on behalf of Michelin or in the role of Plan sponsor (“Michelin”), is required by law to take steps to ensure and maintain the privacy of your personally identifiable health information and to provide you with this Notice of Privacy Practices (“Privacy Notice”). This Privacy Notice is provided to you as a covered person under the Michelin Health and Welfare Plan (medical, prescription drug, dental and medical flexible spending account benefits only), which is referred to in this Privacy Notice as the “Health Plan.”

If you are enrolled in a health benefit that is fully-insured with an insurance company or that is provided through a health maintenance organization (“HMO”), you should receive a Notice of Privacy Practices from the insurance company or HMO with respect to the privacy practices of those entities.

A federal law, known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), requires the Health Plan to maintain the privacy of your protected health information (“PHI”). PHI encompasses substantially all “individually identifiable health information” that is transmitted or maintained by the Health Plan, regardless of its form. PHI includes medical information relating to your past, present or future physical or mental health or condition, the provision of health care to you, or the past, present, or future payment for health care provided to you.

PHI does not include all health information that may be maintained by Michelin or the Health Plan. For example, PHI does not include health information maintained by Michelin in its capacity as an employer, such as drug testing results, sick leave requests and related physician notes and medical information used for processing Family and Medical Leave Act (“FMLA”) requests. Further, PHI does not include health information that is used or maintained by Michelin’s non-health benefit plans, such as workers’ compensation, life insurance, accidental death and dismemberment (“AD&D”) and short- and long-term disability benefits. If health information is not PHI, then the health information is not protected by HIPAA and is not covered by this Privacy Notice.

Michelin and the Health Plan understand that your PHI is personal and private, and both are committed to maintaining the privacy of your PHI. This Privacy Notice summarizes the Health Plan’s legal duties and privacy practices with respect to PHI. In particular, this Privacy Notice describes the ways in which the Health Plan may use or disclose your PHI. It also describes the Health Plan’s obligations to you and your individual rights regarding the use and disclosure of your PHI. HIPAA requires the Health Plan to provide this Privacy Notice to you and to comply with its terms currently in effect.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION

The following categories describe different ways that the Health Plan may use and disclose your health information without your authorization. For each category, the Privacy Notice will outline the uses or disclosures included in the category, but it does not list every use or disclosure within a category.

For Treatment. The Health Plan may use and disclose your PHI to provide, coordinate or manage your health care treatment and any related services provided to you by health care providers. This includes the coordination or management of your health care by a health care provider.

Example: The Health Plan may use and disclose your PHI in order to describe or recommend treatment alternatives to you or to provide information about health-related benefits and services that may be of interest to you.

For Payment. The Health Plan may use and disclose your PHI to make coverage determinations and provide payment for health care services you have received. These activities may include determining your eligibility for benefits or coverage under the Health Plan (including coordination of benefits or the


determination of cost sharing amounts); processing your claims for benefits under the Health Plan; resolving subrogation rights under the Health Plan; billing, claims management and collection activities; obtaining payment under stop-loss and excess loss insurance policies; reviewing health care services you receive for Health Plan coverage, medical necessity and appropriateness; and conducting utilization review activities (including precertification, preauthorization, concurrent review and retrospective review activities).

Example: The Health Plan may disclose your health information to a third party (for instance, a medical reviewer) when necessary to resolve the payment of a claim for health care services that have been provided to you.

For Health Care Operations. The Health Plan may use and disclose your PHI for administration and operations, including quality assessment and quality improvement activities; underwriting, enrollment, premium rating and other activities related to the creation, renewal, or replacement of a health insurance or health benefits contract or a stop-loss or excess loss insurance contract; conducting or arranging for medical assessments, legal services and auditing functions (including fraud and abuse detection and compliance programs), population-based activities relating to improving health or reducing health care costs, business planning and development, and other business management and general administrative activities such as customer service and HIPAA compliance. The Health Plan will not use genetic information for underwriting purposes.

Example: The Health Plan may disclose your health information to potential health insurance carriers in order to obtain a premium bid from the carrier.

Each of the Health Plans which are subject to this Privacy Notice may share health information between them to carry out Treatment, Payment or Health Care Operations.

Note: The Health Plan does not use or disclose PHI that is genetic information for underwriting purposes. Underwriting purposes means: (1) rules for, or determination of, eligibility (including enrollment and continued eligibility) for, or determination of, benefits under the plan (including changes in deductibles or other cost-sharing mechanisms in return for activities such as completing a health risk assessment or participating in a wellness program); (2) the computation of premium or contribution amounts under the plan (including discounts, rebates, payments in kind, or other premium differential mechanisms in return for activities such as completing a health risk assessment or participating in a wellness program); (3) the application of any pre-existing condition exclusion under the plan, coverage, or policy; and (4) other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits. However, underwriting purposes does not include determinations of medical appropriateness where an individual seeks a benefit under the plan.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION IN SPECIAL SITUATIONS

Outlined below are situations in which the Health Plan may use and disclose your PHI without your authorization.

Disclosure to Michelin, as Plan Sponsor. The Health Plan, or an insurer of benefits provided under the Health Plan, may disclose your PHI without your written authorization to Michelin, as plan sponsor, for plan administration purposes. Michelin agrees not to use or disclose your health information other than as permitted or required by the plan documents for the Health Plan and by applicable law. In particular, your health information will not be used for employment decisions.

The Health Plan also may provide summary health information to Michelin, as plan sponsor, so that Michelin may obtain premium bids or may modify, amend, or terminate the Health Plan. Summary health information does not directly identify you, but summarizes claims history, claims expenses, or types of claims experienced. Finally, the Health Plan may disclose your enrollment and disenrollment information to Michelin, as plan sponsor.

Disclosure to You or Your Personal Representative. The Health Plan may disclose your PHI to you or your personal representative.

Disclosure to the Health Plan’s Business Associates. A Business Associate is a person or entity (such as a third-party administrator) that provides certain services to or on behalf of the Health Plan, and


such services involve the use and disclosure of PHI. The Health Plan may disclose PHI to a Business Associate, for such Business Associate’s use or disclosure in connection with providing services to or on behalf of the Health Plan or as required by law. The Health Plan will require its Business Associates to enter into written contracts obligating them to appropriately safeguard your PHI.

Public Health Activities. The Health Plan may use or disclose your PHI for public health activities. Permitted disclosures include:

• Disclosure to a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) in connection with activities related to the quality, safety or effectiveness of FDA-regulated products or activities.

• Disclosure to report births and deaths.

• Disclosure to report reactions to medications, problems with health-related products or to notify a person of recalls of medications or products the person may be using.

• Disclosure to a public health authority for the purpose of preventing or controlling disease, injury, or disability, or to report child abuse or neglect.

• Disclosure, if authorized by law, to a person who may have been exposed to or be at risk of contracting or spreading a communicable disease.

Abuse or Neglect. The Health Plan may disclose your PHI to an appropriate government authority that is authorized by law to receive reports of child abuse, neglect or domestic violence, including a social services or protective services agency, if the Health Plan reasonably believes you to be a victim of abuse, neglect or domestic violence. However, the Health Plan will only disclose your PHI in these situations, if (1) the disclosure is required by law; (2) you agree to the disclosure; or (3) the disclosure is expressly authorized by statute or regulation and the Health Plan reasonably believes that the disclosure is necessary to prevent serious harm to you or other potential victims. The Health Plan will notify you of a disclosure for abuse or neglect purposes if doing so will not place you at further risk of serious harm.

Health Oversight Activities. The Health Plan may disclose your PHI to a health oversight agency for certain activities authorized by law including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions, or other activities necessary for appropriate oversight of the health care system.

Judicial and Administrative Proceedings. In certain limited situations, the Health Plan may disclose your PHI in response to a valid court or administrative order. The Health Plan may also disclose your PHI in response to a subpoena, discovery request or other lawful process, but only if the Health Plan receives satisfactory assurances that the party seeking the information has tried to inform you of the request or to obtain a qualified protective order to safeguard the information requested.

Required by Law. The Health Plan will use or disclose your PHI to the extent required by federal, state or local law, and the use or disclosure complies with the law and is limited to the relevant requirements of such law. The Health Plan may also disclose your PHI to the Department of Health and Human Services (“HHS”) regarding HIPAA compliance matters.

Coroners, Medical Examiners and Funeral Directors. The Health Plan may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. The Health Plan may also disclose PHI to a funeral director, as necessary to allow the funeral director to carry out his or her duties consistent with applicable law.

Organ and Tissue Donation. If you are an organ donor, the Health Plan may disclose your PHI as necessary to facilitate organ or tissue donation, including transplantation.

Research. The Health Plan may disclose your PHI to researchers without your authorization if an alteration to or waiver of the individual authorization requirement has been approved by either an Institutional Review Board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI and the researchers have provided certain necessary representations regarding the research.


Serious Threat to Health or Safety. The Health Plan may use or disclose your PHI, consistent with applicable law and standards of ethical conduct, if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or, in certain cases, when the information is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security. When the appropriate conditions apply and if you are a member of the armed forces, the Health Plan may disclose your PHI (1) for activities deemed necessary by appropriate military command authorities, or (2) to a foreign military authority if you are a member of that foreign military service. The Health Plan may also disclose your PHI to authorized federal officials for the conduct of lawful intelligence, counter-intelligence and national security activities. The Health Plan may also disclose PHI to authorized Federal officials for the provision of protective services to the President or others that are authorized by law.

Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, the Health Plan may disclose your PHI to the institution or official if the information is necessary for (1) the provision of health care to you, (2) your health and safety or the health and safety of other inmates, the officers, employees, or others at the correctional institution, (3) law enforcement on the premises of the correctional institution, or (4) the safety and security of the correctional institution.

Workers’ Compensation. The Health Plan may disclose your PHI as authorized by and to the extent necessary to comply with workers’ compensation laws and other similar legally established programs that provide benefits for work-related injuries or illness without regard to fault.

Law Enforcement Purposes. The Health Plan may disclose your PHI, in certain situations, to law enforcement officials, including: (1) when directed by a court order, subpoena, warrant, summons or similar process or administrative request; (2) if necessary to identify or locate a suspect, fugitive, material witness or missing person; (3) as required by law; and (4) certain information about a victim of a crime.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

For Involvement In, and Notification of, Your Care. The Health Plan may use or disclose to your family member, other relative, your close personal friend, or other person you identify, PHI directly relevant to such person’s involvement in your health care or payment related to your care. The Health Plan may use or disclose your PHI to notify a family member, your personal representative, or another person responsible for your care, about your location, condition, or death. In these situations, when you are present and not incapacitated, the Health Plan will either (1) obtain your agreement; (2) provide you with an opportunity to disagree to the use or disclosure; or (3) using reasonable judgment, infer from the circumstances that you do not object to the disclosure. If you are not present, or you cannot agree or disagree to the use or disclosure due to incapacity or emergency circumstances, the Health Plan may use professional judgment to determine that the disclosure is in your best interests and disclose PHI relevant to such person’s involvement in your care, payment related to your health care, or notification purposes. If you are deceased, the Health Plan may disclose to such individuals involved in your care or payment for your health care prior to your death the PHI that is relevant the individual’s involvement, unless you have previously instructed the Health Plan otherwise.

In order to use or disclose your PHI for any reason other than those described in this Privacy Notice, the Health Plan must obtain your written authorization. Your written authorization is also required for

• Most uses or disclosures of psychotherapy notes (where appropriate);

• Uses or disclosures of your PHI for marketing purposes. Marketing does not include communications, involving no financial remuneration, for certain treatment or health care operations purposes, such as communications about entities that participate in a health plan network, health plan enhancements or replacements, case management or care coordination, or contacting individuals about treatment alternatives; and

• Disclosures of PHI that are considered a sale of PHI under the HIPAA Privacy Rule.

If you sign an authorization form, you may revoke your authorization at any time by submitting a request in writing to Michelin Privacy Officer (see CONTACT INFORMATION). If you revoke your authorization, the Health Plan will no longer use or disclose your PHI for the reasons covered by the authorization.


However, the Health Plan is unable to retract or invalidate any uses or disclosures that were already made with your permission prior to your revocation of the authorization.

REQUIRED NOTICE OF BREACH OF UNSECURED PHI Overview: The Health Plan and its business associates are required to provide certain notifications in the event of a breach of unsecured PHI, with respect to breaches of unsecured PHI occurring on or after September 23, 2009. Specifically, if a breach of unsecured PHI is discovered, the Health Plan must provide notice of the breach to the affected individual(s) as well as to the Secretary of HHS. In some cases, notice must also be provided to the media. If the breach occurs by a business associate under HIPAA, that business associate must promptly notify the Health Plan of the breach. Finally, the Secretary of HHS must post on the HHS website a list of HIPAA-covered entities that experience breaches of unsecured protected health information involving more than 500 individuals.

Definition of Breach: A breach is the unauthorized acquisition, access, use or disclosure of PHI which compromises the security or privacy of such PHI. The Health Plan is responsible for determining whether a breach has occurred.

Definition of Unsecured PHI: Unsecured PHI is PHI that has not been protected by specific technologies or methodologies specified by HHS that makes the PHI unusable, unreadable, or indecipherable to unauthorized individuals. HHS has stated that only PHI protected through encryption and destruction methodologies is deemed secured PHI. For more information about the encryption and destruction methodologies that render PHI secured, see www.hhs.gov/ocr/privacy. Only breaches of “unsecured” PHI must be reported.

Notices to Individuals: Affected individuals must receive notice of a breach without unreasonable delay, but no later than 60 calendar days after the discovery of the breach. The notice of breach must be written in plain language and must include: a brief description of the breach, a description of the type(s) of unsecured PHI involved in the breach, steps the individual(s) should take to protect from potential harm resulting from the breach, a summary of what the Health Plan is doing to investigate and correct the breach, and contact information for additional information.

Notice to HHS: Information regarding breaches involving 500 or more individuals (regardless of location) must be submitted to HHS at the same time that notices are sent to the impacted individuals. If a single breach involves less than 500 individuals, the Health Plan or business associate must record the breach on a log and notify HHS within 60 days of the end of each calendar year.

Notice to the Media: If a breach involves more than 500 residents of a state (or smaller jurisdiction therein, like a county or town), the Health Plan or business associate must notify a prominent media outlet in that location.

Notice by Business Associates to the Health Plan: Business associates of the Health Plan must notify the Health Plan if the business associate has a breach of unsecured PHI. Notice must be given without unreasonable delay and no later than 60 days after the discovery of the breach.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have several important rights with regard to your PHI, which are summarized below. Please contact the Communications Official at the address and phone number shown on the last page of this Privacy Notice if you need additional information or to exercise any of these rights.

Right to Inspect and Copy. With certain exceptions described below, you have the right to inspect and copy your PHI if it is part of a “designated record set” or “DRS.” The DRS is the group of records maintained by or on behalf of the Health Plan and contained in the enrollment, payment, claims adjudication, and case or medical management record systems of the Health Plan, and any other records which are used by the Health Plan to make decisions about individuals. This right to request access does not extend to psychotherapy notes, information gathered for certain civil, criminal or administrative proceedings, and information maintained by Michelin that duplicates information maintained by a Health Plan third-party administrator in its DRS. To inspect and obtain a copy of your PHI that is part of a DRS, you must submit your request in writing to the contact person identified in the “Contact Information”


section below. In most cases, you must use a specific form, which you can request directly from the Communications Official.

If you exercise your right to access your PHI, the Health Plan will respond to your request within 30 days after receipt of the request. If the Health Plan is unable to respond within this time period, it may have a one-time 30-day extension by providing you with a written explanation for the delay and the date by which it will respond to your request.

If your request for access is granted, then the Health Plan will provide you with access to PHI in the form and format you requested, if it is readily producible in such form or format; if it is not readily producible, then access will be provided in a mutually agreed upon form and format. If your PHI is maintained in an electronic DRS and if you request an electronic copy of your PHI, then the Health Plan will provide access in the electronic form and format you requested, if it is readily producible in that form and format; if it is not readily producible, then access will be provided in a readable electronic form and format that is mutually agreed upon.

You may request that the Health Plan provide a copy of your PHI to another person that you designate. Your request must be in writing, be signed by you, and clearly identify the designated person and where to send the PHI copy.

The Health Plan may deny your request to inspect and copy your PHI in certain limited situations. If you are denied access to your PHI, you will be notified in writing. The notice of denial will include the basis for the denial, and a description of any appeal rights you may have and the right to file a complaint with the Health Plan or with HHS. If the Health Plan does not maintain the PHI that you are seeking but knows where it is maintained, the Health Plan will notify you of where to direct your request.

If you request a copy of your PHI contained in a DRS, the Health Plan may charge you a reasonable, cost-based fee that includes the costs of labor for copying, mailing and/or other supplies associated with your request.

Right to Amend. If you believe that your PHI in a DRS is incorrect or incomplete, you may request that the Health Plan amend the PHI. You have the right to request amendment of your PHI or a record about you in a DRS for as long as the PHI is maintained in the DRS. Any such request must be made in writing to the contact person identified in the “Contact Information” section below, and must include a reason that supports your requested amendment. In most cases, you must use a specific form, which you can request directly from the Communications Official. The Health Plan must respond to your request within 60 days. If the Health Plan is not able to respond within this 60-day period, it may have a one-time 30-day extension by providing you with a written explanation for the delay and the date by which it will respond to your request.

In limited situations, the Health Plan may deny your request to amend your PHI. For example, the Health Plan may deny your request if (1) the PHI was not created by the Health Plan (unless the person who created the information is no longer available to make the amendment); (2) the Health Plan determines the information to be accurate or complete; (3) the information is not part of the DRS; or (4) the information is not part of the information which you would be permitted to inspect and copy, such as psychotherapy notes. If your request is denied, you will be notified in writing. The notice of denial will include the basis for the denial, and a description of your right to submit a written statement of disagreement and the right to file a complaint with the Health Plan or with HHS.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain types of disclosures of your PHI made by the Health Plan during a specified period of time. You do not have the right to request an accounting of all disclosures of your PHI. For example, you do not have the right to receive an accounting of (1) disclosures for purposes of Treatment, Payment or Health Care Operations; (2) disclosures to you or your personal representative regarding your own PHI; (3) disclosures pursuant to an authorization; (4) disclosures incident to a use or disclosure otherwise permitted or required by the HIPAA Privacy Rule; (5) disclosures for national security or intelligence purposes, or to correctional institutions or law enforcement officials; (6) disclosures as part of a limited data set; or (7) disclosures prior to April 14, 2004.


Your request must be made in writing to the contact person identified in the “Contact Information” section below, and must indicate the time period for which you are seeking the accounting, such as a single month, six months or two calendar years. This time period may not be longer than six years prior to the date of the request and may not include any disclosures of PHI made before April 14, 2004. The Health Plan must respond to your request within 60 days. If the Health Plan is not able to respond within this 60-day period, it may have a one-time 30-day extension by providing you with a written explanation for the delay and the date by which it will respond to your request.

The Health Plan will provide the first accounting you request in any 12-month period free of charge. The Health Plan may impose a reasonable, cost-based fee for each subsequent accounting request within the 12-month period. The Health Plan will notify you in advance of the fee and provide you with an opportunity to withdraw or modify your request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI that the Health Plan uses or discloses about you in certain situations. For example, you can request that the Health Plan restrict the PHI that the Health Plan uses or discloses about you for Treatment, Payment or Health Care Operations, or for disaster relief and other notification purposes and for involvement in your care. However, the Health Plan is not required to agree to your request.

If you wish to make a request for a restriction, please make a request in writing to the contact person identified in the “Contact Information” section below. Your request should include the following: (1) what uses and/or disclosures you want to limit; and (2) to whom you want the restriction to apply (for example, disclosures to your spouse).

The Health Plan has determined that approving these requests would generally interfere with the resolution of benefit claims and, therefore, a restriction request will only be approved in special and compelling circumstances in the sole discretion of the Health Plan.

Right to Request Confidential Communications. You have the right to request that the Health Plan communicate with you about health matters in a specific manner or specific location. To request confidential communications, please make your request to the contact person identified in the “Contact Information” section below. You must make your request in writing and must specify how and/or where you wish to be contacted, for example, by mailings to a post office box, and your request must state that disclosure of all or part of the information to which the request pertains could endanger you. In most cases, you must use a specific form, which you can request directly from the Communications Official. The Health Plan will accommodate all reasonable requests.

Right to a Paper Copy of this Notice. You have the right to request a paper copy of this Privacy Notice, even if you previously agreed to receive this Privacy Notice electronically. Any such request should be submitted to the Communications Official. You may also view this Privacy Notice on the Personnel Service Center website at www.personnelservicecenter.com.

Personal Representatives. You may exercise your rights though a personal representative. The representative must produce appropriate evidence of his or her authority to act on your behalf. Examples of acceptable authority include (1) a power of attorney, notarized by a notary public, (2) a court order of appointment as conservator or guardian, and (3) a parent of an unemancipated minor. The Health Plan may deny access to PHI to a personal representative, including a parent of an unemancipated minor, if:

• You have been, or may be, subjected to domestic violence, abuse or neglect by such person;

• Treating such person as your personal representative could endanger you; and

• In the exercise of professional judgment, the denial is in your best interest.

The Health Plan may also deny access to PHI to a parent of an unemancipated minor if prohibited by state or other law.

CHANGES TO THIS PRIVACY NOTICE The Health Plan reserves the right to change, at any time, its privacy practices and this Privacy Notice. The revised Privacy Notice will be effective for all PHI that the Health Plan maintains at the time of the revision, as well as PHI the Health Plan receives in the future. If this Privacy Notice is materially revised, a


revised copy of the Privacy Notice will be posted on the website and the revised Notice, or information about the material change and how to obtain a copy of the Notice, will be provided to you in the plan’s next annual mailing.

COMPLAINTS If you believe your privacy rights have been violated, you may submit a complaint to the Health Plan or the Secretary of HHS. To submit a complaint to the Health Plan, you must submit the complaint in writing to the Michelin Privacy Officer at the address shown below. Information about how to submit a complaint to HHS is available on the website for the Office for Civil Rights of HHS at www.hhs.gov/ocr/hipaa.

Michelin will not retaliate against you for filing a complaint with the Health Plan or with HHS.

CONTACT INFORMATION In some cases, your PHI may be held internally at Michelin by workforce members who perform functions on behalf of the Health Plan. In most cases, however, your PHI will be held by privacy contacts, such as a health insurer, HMO, or Health Plan third-party administrator who pays claims on behalf of the Health Plan.

Contact Information If you have a question, concern, complaint, or individual rights request regarding your PHI, please contact:

Michelin Privacy Officer Michelin North America, Inc. P.O. Box 19001 Greenville, SC 29602-9001 Telephone: 864-458-6692 Fax: 864-458-6110

Michelin Health and Welfare Plan Union Free SPD 68 Administrative Information

Administrative Information

This section contains important information about how your health and welfare benefits are administered and funded. It also contains information about your rights and responsibilities as a participant and steps you can take if certain situations arise.

Plan Name/Identification The benefits described in this SPD are governed by the following Plan documents, which are governed by the Employee Retirement Income Security Act of 1974 (ERISA) and subject to the reporting and disclosure requirements of this law:

The official Plan document for the Benefit Options governed by ERISA and described in this Summary Plan Description (SPD) is the Michelin Health and Welfare Plan. The Benefit Options governed by ERISA and covered by this SPD are those listed in your Adoption Agreement.

The official Plan document for the “cafeteria” plan provisions described in this SPD is the Michelin Cafeteria Plan, which is incorporated into the Michelin Health and Welfare Plan as applicable. The “cafeteria” plan document applies to your ability to pay for these benefits on a pre-tax basis, including the ability to contribute to a Health Care Flexible Spending Account, Dependent Care Flexible Spending Account, and Health Savings Account on a pre-tax basis, and the requirements that apply to that ability, such as the mid-year change in status rules (Qualifying Life Events). The Health Care Flexible Spending Account is subject to ERISA, while the Dependent Care Flexible Spending Account and Health Savings Account are not subject to ERISA.

Michelin Health and Welfare Plan is sponsored by Michelin North America, Inc. and is filed with the U.S. Department of Labor under the Company’s employer identification number 11-1724631 and the Plan number 550.

Plan Information The Plan documents consist of:

The official Plan documents referenced above.

This document, which is the Summary Plan Description (SPD) for the ERISA-governed plans, and the Adoption Agreements.

Coverage Documents for the Plan Benefit Options (See the “Your Plan Choices and Contacts” section in your Adoption Agreement).

Applicable Summaries of Material Modifications (SMMs).

“Plan materials,” which means summary plan descriptions and updates to a Plan Benefit Option, including those issued by a third-party administrator or insurer, whether through an online benefit description or booklet.

Insurance contract(s).


Plan Administration Information Plan Sponsor/Employer Michelin North America, Inc.

P.O. Box 19001, One Parkway South Greenville, SC 29602-9001 (864) 458-5000

Participating Employers Michelin Retread Technologies, Inc. (EIN: 58-2323280) American Industrial Plastics, LLC (EIN: 45-4917252) CDI Energy Products (EIN: 76-0375113) Fenner Inc. (EIN: 36-2646332) Fenner Dunlop Americas, LLC (EIN: 58-0255700) Fenner Dunlop (Port Clinton), LLC (EIN: 31-1151108) Fenner Dunlop (Toledo), LLC (EIN: 34-1964081) Fenner Dunlop Conveyor Systems and Services, LLC (EIN: 68-0674791) Oliver Rubber Company, LLC (EIN: 26-1467411) NexTraq, LLC (EIN: 58-2545554) Solesis Inc. (EIN: 36-4819459) Charter Medical Ltd. (EIN: 56-2070359) The Secant Group, LLC (EIN: 23-1944905) Hallite Seals Americas, LLC (EIN: 38-3324987)

Plan Administrator Michelin North America, Inc. Michelin Pension and Benefits Board P.O. Box 19001, One Parkway South Greenville, SC 29602-9001 (864) 458-5000 Each Participating Employer is delegated to act in the place of the Plan Administrator with respect to its Eligible Employees.

Claims Administrators See “Your Plan Choices and Contacts” section in your Adoption Agreement

Agent for Service of Legal Process

Michelin North America, Inc. P.O. Box 19001, One Parkway South Greenville, SC 29602-9001 (864) 458-5000

Plan Year January 1–December 31

Funding and Source of Contributions Each Benefit Option may be either self-insured or fully-insured, and may require Participating Employer contributions, Employee contributions, or both. See “Your Plan Choices and Contacts” section in your Adoption Agreement for this information.

Self-Insured Plans The Company pays a fee to an outside organization to process claims for the self-insured plans (i.e., contract administration). The fees and all benefit payments are paid from Company assets. None of the self-insured benefit plans guarantee benefits under a contract or policy of insurance. The administrators of self-insured options administer the benefits under the options.


Fully-Insured Plans The Company pays an insurance company or other provider a premium for providing coverage under the fully insured plans (i.e., insurer administration). The insurance company or other provider processes claims and makes all benefit payments from a policy of insurance.

Claims Administrator and its Authority to Review Claims The Plan Administrator has delegated its authority to finally determine claims and appeals to the Claims Administrators. In some cases, the Plan Administrator delegates the authority to finally determine claims to certain other organizations on behalf of Company; the organizations listed as the Claims Administrators are the claims and appeals fiduciaries with respect to ERISA-covered benefits, as noted. Benefits under the Plan are paid only if the Plan Administrator, or its delegate, decides in its discretion that the applicant is entitled to them.

The Claims Administrators have—

The authority to make final determinations regarding eligibility and benefit claims under the Plan.

Discretionary authority to:

– Interpret the Plan based on provisions and applicable law and make factual determinations about claims arising under the Plan.

– Determine whether a claimant is eligible for benefits.

– Decide the amount, form and timing of benefits.

– Resolve any other matter under the Plan that is raised by a participant or a beneficiary or that is identified by the Claims Administrator.

In case of an appeal, the Claims Administrators’ decisions are final and binding on all parties to the full extent permitted under applicable law, unless the participant or beneficiary later proves that a Claims Administrator’s decision was an abuse of administrator discretion.

Your Relationship with the Claims Administrator and the Company The Company believes that it is important for you to understand how the Claims Administrators interact with the Company’s Benefit Options under the Plan and how it may affect you. A Claims Administrator helps administer the Benefit Option in which you are enrolled. The Claims Administrator does not provide medical services or make treatment decisions. This means:

The Company and the Claims Administrator do not decide what care you need or will receive. You and your physician or other health care provider make those decisions;

The Claims Administrator communicates to you decisions about whether the Plan will cover or pay for the health care that you may receive (the Plan pays for covered health services, described in this SPD and the Coverage Documents); and

The Plan may not pay for all treatments you or your physician may believe are necessary. If the Plan does not pay, you will be responsible for the cost.

The Company and the Claims Administrator may use individually identifiable information about you to identify for you (and you alone) the procedures, products or services that you may find valuable. The Company and the Claims Administrator will use individually identifiable information about you as permitted or required by law, including in operations and in research. The Company and the Claims Administrator will use de-identified data for commercial purposes including research.

No Employment Rights or Guarantee of Benefits All terms of the Plan are legally enforceable. However, neither the Plan nor this SPD constitutes a contract of employment or guarantee of any particular benefit.


Misrepresentation or Fraud If you or your Dependent makes a false or misleading statement that is material to your claim for benefits, you must repay all amounts paid by the Plan and will be liable for all costs of collection, including attorneys’ fees. Alternatively, the Plan Administrator may offset against future benefit payments any amount paid to you to which you were not entitled. It is the Plan Administrator’s sole decision on whether to demand repayment or offset future payments, and you agree to abide by that decision. The Plan Administrator has the authority to take any additional action as may be deemed necessary to make the Plan whole, in accordance with the law. The Plan Administrator reserves the right to rescind your participation in the Plan if you or your Dependent performs an act, practice, or omission that constitutes fraud or if you or your Dependent makes an intentional misrepresentation of material fact. However, any retroactive cancellation of group health benefits subject to the Affordable Care Act will comply with the Affordable Care Act’s limitations and requirements for rescission of coverage.

Amendment/Termination Although the Company presently intends to continue the Plan, it reserves the right to, at any time, amend or terminate any and all health and welfare benefits under the Plan, to amend or terminate the eligibility of classes of Employees and/or Dependents to be covered by the Plan, to amend or eliminate any other term or condition of the Plan, and to terminate the entire Plan, or any part, subject to applicable law. The procedures by which these actions may be taken are contained in the legal Plan document, which is available for inspection and copying from the Plan Administrator.

No consent of any participant is required to amend or terminate the Plan.

Termination of the Plan will have no adverse effect on any benefit payments to be made under the Plan for any covered expenses incurred prior to the date that the Plan terminates. Likewise, any extension of benefits under the Plan due to your or your Dependent’s total disability which began prior to and has continued beyond the date the Plan terminates will not be affected by the Plan’s termination. No extension of benefits or rights will be available solely because the Plan terminates.

Company’s Right to Use Social Security Numbers for Administration of Benefits The Company will require that you and your Dependents provide Social Security numbers at the time of enrollment so that the Company can comply with various governmental reporting requirements.

The Company retains the right to use your Social Security number for benefit administration purposes, including tax reporting. If a state law restricts the use of Social Security numbers for benefit administration purposes, the Company generally takes the position that ERISA preempts such state laws.

Outcome of Covered Services and Supplies The Company is not responsible for, and makes no guarantees concerning, the outcome of the covered services or supplies for which you receive benefit payments under the Plan.

You are solely responsible for your choice of health care providers, services, and/or supplies. Obtaining health care and determining which provider, service, and/or supply to use shall not be construed, interpreted, or deemed as resulting from the Plan or any Coverage Document.

You must make a decision as to your health care independent of any determinations to whether benefit payments will or will not be made under the Plan for that health care. The determination of whether or not health care is medically necessary is made solely for purposes of determining whether benefit payments will be made under the Plan and is not intended to be advice to you about your health care.


Unclaimed Funds If you fail to file a claim using the Plan’s procedures, or you fail to accept or cash a claim reimbursement check within 120 days after the reimbursement check has been issued, and the Plan Administrator has made a reasonable attempt to reimburse you, the funds will be considered unclaimed and will be treated as Plan forfeitures. However, if you should later renew your written claim for reimbursement of the forfeited amount, the Company will reimburse that amount to you within 90 days of the renewed claim.

However, for an insured benefit, the applicable Coverage Document will govern the handling of any unclaimed funds.

Non-Assignment of Benefits You cannot assign, pledge, borrow against, or otherwise promise any benefit payment provided by the Plan before receipt of that benefit payment. However, benefits will be provided to your Child if required by a Qualified Medical Child Support Order. In addition, subject to your written direction, all or a portion of benefit payments provided by the Plan may, at the option of the Plan, and unless you request otherwise in writing, be paid directly to the provider rendering a service to you. Any benefit payment made by the Plan in good faith pursuant to this provision shall fully discharge the Plan and the Company to the extent of such payment.

In addition, you may not assign your rights to bring a lawsuit under the Plan to any providers or other persons who may provide or render any treatment or services to you or your Dependents.

Right of Recovery If, for some reason, a benefit payment is larger than the amount allowed by the Plan, the Plan has a right to recover the excess amount from the person or agency that received or holds this benefit payment. This excess amount is subject to a constructive trust in favor of the Plan. The person receiving or holding benefit payments must produce any instruments or papers necessary to ensure this right of recovery.

Reimbursement This section applies when you recover damages (by settlement, verdict, or otherwise) for an injury, illness, or other condition, including death. If you have received, or in the future may receive, such a recovery, including a recovery from any insurance carrier, the Plan will not cover either the reasonable value of the services to treat the injury or illness or the treatment of the injury or illness. These benefits are specifically excluded.

If the Plan does advance moneys or provide care for the injury, illness, or other condition, you must promptly send to the Plan the moneys or other property that you receive from any settlement, arbitration award, verdict, insurance proceeds, or monetary recovery from any party for the reasonable value of the health benefits advanced or provided to you by the Plan, regardless of whether or not:

You have been fully compensated or made whole for your loss.

You or any other party admits to liability.

The recovery is itemized or called anything other than a recovery for medical expenses incurred.

If a recovery is made, the Plan has first priority to receive reimbursement for any payments made on your behalf, before payment is made to you or any other party. This reimbursement is required from any recovery you make, including uninsured and underinsured motorist coverage; any no-fault insurance; medical payment coverage (auto, homeowners, or otherwise); workers’ compensation settlements, compromises, or awards; other group insurance (including student plans); and direct recoveries from liable parties.


In order to secure the Plan’s rights when it makes benefit payments in these situations, you must acknowledge and agree to the following when you accept benefit payments from the Plan:

Acknowledge that the Plan has first priority against the proceeds of any such settlement, arbitration award, verdict, or other amounts you receive.

Acknowledge that any proceeds of settlement or judgment, including your claim to such proceeds held by you or any other person, are being held for the benefit of the Plan.

Assign to the Plan any benefits you may have under any automobile policy or other coverage, to the extent of the Plan’s claim for reimbursement.

Cooperate with the Plan and its agents, provide relevant information, and take actions that the Plan or its agents reasonably request to assist the Plan in making a full recovery of the value of benefit payments made.

Consent to the Plan’s right to impress an equitable lien or constructive trust on the proceeds of any settlement to enforce the Plan’s rights under this section.

Consent to the Plan’s right to deduct from any future benefit amounts otherwise payable under the Plan the value of benefit payments advanced under this section to the extent not recovered by the Plan.

Agree to not take any action that prejudices the Plan’s rights of reimbursement.

The Plan is responsible only for those legal fees and expenses to which it agrees in writing. You cannot incur any expenses on behalf of the Plan in pursuit of the Plan’s rights under this section. Specifically, no court costs or attorney’s fees can be deducted from the Plan’s recovery without the express written consent of the Plan. Any so-called “Fund Doctrine” or “Common Fund Doctrine” or “Attorney’s Fund Doctrine” shall not defeat this right.

In cases of occupational illness or injury, the Plan’s recovery rights shall apply to all sums recovered, regardless of whether the illness or injury is deemed compensable under any workers’ compensation or other coverage. Any award or compromise settlement, including any lump-sum settlement, shall be deemed to include the Plan’s interest, and the Plan shall be reimbursed in first priority from any such award or settlement.

The Plan shall recover the full amount of benefit payments advanced and paid hereunder, without regard to any claim or fault on the part of any beneficiary or covered person, whether under comparative negligence or otherwise.

Subrogation This section applies when another party (including insurance carriers who are financially liable) is, or may be considered, liable for your injury, illness, or other condition, including death, and the Plan has advanced benefit payments. Subrogation is similar to reimbursement but allows the Plan to “step into your shoes” and obtain a payment from a third party who was negligent or responsible for your injury or illness. This occurs when the Plan has to make a benefit payment due to your injury, illness, or other condition, but would not have owed the payment if the third party had not caused the problem.

In consideration for the advancement of benefit payments, the Plan is subrogated to all of your rights against any party liable for your injury, illness, or other condition, including death, or which is or may be liable for the payment for the medical treatment of the injury or occupational illness (including any insurance carrier), to the extent of the value of the health benefit payments advanced to you under the Plan. The Plan may assert this right independently of you. This right includes, but is not limited to, the covered person’s rights under uninsured and underinsured motorist coverage, any no-fault insurance, medical payment coverage (auto, homeowners, or otherwise), workers’ compensation coverage, or other insurance, as well as your rights under the Plan to bring an action to clarify your rights under the Plan. The Plan is not obligated in any way to pursue this right independently or on your behalf but may choose to pursue its rights to reimbursement under the Plan, at its sole discretion.


You are obligated to cooperate with the Plan and its agents in order to protect the Plan’s subrogation rights. Cooperation means providing the Plan or its agents with any relevant information requested by them, signing and delivering such documents as the Plan or its agents reasonably request to secure the Plan’s subrogation claim, and obtaining the consent of the Plan or its agents before releasing any party from liability for payment of medical expenses.

If you enter into litigation or settlement negotiations regarding the obligations of other parties, you must not prejudice, in any way, the subrogation rights of the Plan under this section. In the event that you fail to cooperate with this provision, including executing any documents required herein, the Plan will, in addition to remedies provided elsewhere in the Plan and/or under the law, offset from any future benefit payments otherwise payable under the Plan the value of benefit payments advanced under this section to the extent not recovered by the Plan.

The Plan’s subrogation right is a first priority right and must be satisfied in full prior to any of your or your representative’s other claims, regardless of whether you are fully compensated for your damages. The costs of legal representation of the Plan in matters related to subrogation shall be borne solely by the Plan. The costs of your legal representation are borne solely by you.

Your Rights Under ERISA As a participant in the Plan, 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 Employee Benefits Security Administration.

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

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

Continue Group Health Plan 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 SPD, the Adoption Agreement for your Participating Employer, and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

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 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, your union, 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 (as indexed) until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits which is denied or ignored, in whole or in part, and you have exhausted the internal claims and appeals procedures available under the Plan, you may file suit in a state or federal court.

If you disagree with the Plan’s decision or lack thereof concerning the qualified status of 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 Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or write to:

Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue N.W. Washington, DC 20210

You also may obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Michelin Health and Welfare Plan Union Free SPD 76 Important Notice Regarding this Plan and COVID-19

Important Notice Regarding this Plan and COVID-19

The federal government has declared a national emergency due to the coronavirus pandemic. During this period of national emergency, and for as long as legally required, the following provisions apply to the benefits under the Plan and administration of the Plan. These provisions shall terminate automatically upon the earlier of the provision being no longer required under applicable law (“Public Health Emergency Period”) or no longer permitted under applicable law. They may be otherwise terminated by the Participating Employer as permitted under applicable law.

Certain Benefits Coverage for COVID-19 The Plan will provide coverage for testing to determine if you have been infected with SARS-CoV-2 or the diagnosis of COVID-19, including tests that detect antibodies against SARS-CoV-2 virus, at no cost to you (i.e., no deductible, copayment or coinsurance) when medically appropriate, as determined by your attending health care provider. This coverage is provided in accordance with the Families First Coronavirus Response Act (FFCRA) as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act only during the applicable Public Health Emergency Period. This “cost of testing” includes the cost of health care provider office visits (including in-person and telehealth visits), urgent care center visits, and emergency room visits that result in an order for or administration of a test for the detection of SARS-CoV-2 or the diagnosis of COVID-19, but only to the extent the items and services relate to the furnishing or administration of the test or your evaluation for purposes of determining if you need a diagnostic test.

The Plan will cover testing at no cost sharing only as required by FFCRA and the CARES Act and related federal guidance. For example, the cost of testing does not include testing conducted for general work place health and safety or public health surveillance.

If you are diagnosed with COVID-19, the Plan will provide coverage for COVID-19 treatment, to the extent medically necessary, as described in the Medical Coverage Documents.

Plan Deadlines Extended During National Emergency Throughout this SPD, various deadlines are mentioned that have been affected by guidance released by the federal government in light of the COVID-19 public health emergency. Under this guidance, you now have additional time (an “Extension”) to exercise the following rights under this Plan:

HIPAA Special Enrollment Rights Enroll yourself, your Spouse or your child in the Medical and Prescription Drug Plan in connection

with a HIPAA special enrollment event, such as due to birth, adoption, placement for adoption, marriage or loss of other coverage (see the “Changing Your Coverage During the Year” section);

COBRA Continuation Rights Notify the Company of a COBRA qualifying event or of a qualified beneficiary’s determination of

disability by the Social Security Administration;

Elect COBRA continuation coverage;

Pay your initial, or monthly, premium for COBRA continuation coverage (see the “COBRA Continuation Rights” section);

Claims and Appeals Procedures File a claim for benefits under this Plan and any of the Benefit Options hereunder that are governed

by ERISA;

File an appeal with respect to a denied benefit claim governed by ERISA; and

Michelin Health and Welfare Plan Union Free SPD 77 Important Notice Regarding this Plan and COVID-19

File a request under the Medical and Prescription Drug Plan for, and provide information needed to obtain, an independent external review with respect to certain claim denials (see the “Claims and Appeals Procedures” section).

To determine the impact of this Extension, first ignore the “Outbreak Period” when determining the time periods during which you may exercise the rights listed above. The Outbreak Period began on March 1, 2020 and will end 60 days after the announced end of the COVID-19 National Emergency (unless another date is specified by the Internal Revenue Service and Department of Labor).

For example, if a deadline listed above occurred on March 15, 2020, then the new deadline is 15 days following the end of the Outbreak Period.

As another example, if you have a 60-day period of time that occurs during the Outbreak Period to take an action listed above, then that period is extended until 60 days after the end of the Outbreak Period.

For additional information about the Extensions, please refer to the Joint Notice and final regulations issued by the Internal Revenue Service and the Department of Labor, which can be found on the Department of Labor’s website at www.dol.gov. You can also refer to COVID-19 FAQs issued by the Department of Labor, available on their website.

If you have a question about whether an Extension applies to your particular situation, please call the relevant Claims Administrator for the Benefit Option (if you have a question about a claim or appeal) or your Plan Administrator (if you have a question about HIPAA special enrollment rights or COBRA).

These Extensions apply to the deadlines described throughout this document and any applicable Coverage Documents, even if standard deadlines are referenced in this document or the Coverage Documents. In addition, some future standard communications may contain generally-applicable information that includes the usual deadlines (which are now temporarily subject to an Extension). Consequently, you are responsible for understanding what Extension may apply to your particular situation.

http://www.dol.gov/