2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 23
HEALTH CARE PLAN ADMINISTRATION
Delegation of Responsibility
The Health Care Plan Sponsor has full discretionary authority for the control and management of the operation and
administration of the Health Care Plan. The Health Care Plan Sponsor may delegate any duties and other
responsibilities to any individual or entity. Any person to whom any responsibility is delegated may serve in more
than one capacity with respect to the Health Care Plan and may be a participant in the Health Care Plan.
Authority to Make Decisions
The Health Care Plan is administered by the Employer. The Employer has retained the services of the Claims
Administrator to provide certain claims processing and other ministerial services. The Claims Administrator
adjudicates claims in accordance with provisions of the Health Care Plan and Employer’s claim guidelines.
The Employer will administer this Health Care Plan in accordance with its terms and establish its policies,
interpretations, practices and procedures. It is the express intent of this Health Care Plan that the Employer will
have maximum legal discretionary authority to construe and interpret the terms and provisions of the Health Care
Plan, to make determinations regarding issues which relate to eligibility for benefits (including the determination of
what services, supplies, care and treatments are Experimental and/or Investigational), to decide disputes which
may arise relative to you and/or your Dependent’s rights and to decide questions of Health Care Plan interpretation
and those of fact and law relating to the Health Care Plan. The decisions of the Employer as to the facts related to
any claim for benefits and the meaning and intent of any provision of the Health Care Plan or its application to any
claim, shall receive the maximum deference provided by law and will be final and binding on all interested parties.
Benefits under this Health Care Plan will be paid only if the Employer decides, in its discretion, that you and/or your
Dependent (as applicable) are entitled to them.
The duties of the Employer include the following:
(1)
To administer the Health Care Plan in accordance with its terms;
(2)
To determine all questions of eligibility, status and coverage under the Health Care Plan;
(3)
To interpret the Health Care Plan, including the authority to construe possible ambiguities, inconsistencies,
omissions and disputed terms;
(4)
To make factual findings;
(5)
To decide disputes which may arise relative to a Covered Person’s rights;
(6)
To prescribe procedures for filing a claim for benefits, to review claim denials and appeals relating to them
and to uphold or reverse such denials; or alternatively, to appoint a qualified administrator to carry out these
functions on the Employer’s behalf.
(7)
To keep and maintain the Health Care Plan documents and all other records pertaining to the Health Care
Plan;
(8)
To appoint and supervise a Contract Administrator to pay claims;
(9)
To perform all necessary reporting as required by Federal or State law;
(10) To establish and communicate procedures to determine whether a child support order or decree is a QMCSO;
(11) To delegate to any person or entity such powers, duties and responsibilities as it deems appropriate; and
(12) To perform each and every function necessary for or related to the Health Care Plan’s administration.
Amendment or Termination of Health Care Plan
The Health Care Plan Sponsor may amend or terminate this Health Care Plan at any time without prior notice. It is
the intent of the Health Care Plan Sponsor to comply with all applicable laws.
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