How do I become eligible?

Initial eligibility begins when an employee works at least 400 hours in a four consecutive month period. The employee will become initially eligible for Benefits on the first day of the third month following the month in which the 400 hours were accumulated.

 

Once an employee has satisfied the Initial Eligibility requirements, he will remain eligible for Benefits for the duration of that Benefit Period. Thereafter, to remain eligible an employee must be credited with at least 350 hours in a four- month period or 700 hours in an eight- month period.

 

To be eligible for coverage during the Benefit Period	You must have worked	During the work period
April 1 thru July 31	At least 350 hours or A least 750 hours	October 1 – January 1 or June 1 – January 1
August 1 thru November 30	At least 350 hours or at least 700 hours	February 1 – May 31 or October 1 – May 31
December 1 thru March 31	At least 350 hours or at least 700 hours	June 1 – September 30 or February 1 – September 30

 

How can I add or remove my dependents to this Plan?

You must submit the appropriate legal documents to The Fund Office. For example: birth certificate, marriage certificate, divorce decree, custody agreement, and decree of adoption or a Qualified Medical Child Support Order.

 

How long will my dependent children be covered by this Plan?

Unmarried, natural or adopted children or stepchildren of the Covered Employee will be covered if they are under the age of 19 or under the age of 24 if they remain a full-time college student or are Totally Disabled. (Refer to the Summary Plan Description, page 82, letter J, Eligible Dependent, for more details.)

 

Can I continue my coverage when I retire?

Yes, provided you meet the retiree requirements for maintaining coverage.

 

What do I do if I am injured or become ill and am unable to work?

If an active eligible employee becomes totally disabled from a sickness or accidental bodily injury which prevents the employee from engaging in any occupation or employment for wage or profit, the employee will receive credit for 30 hours worked per week for a maximum of 13 weeks. These disability credit hours may help continue your coverage for health care benefits. You must request a claim form from The Fund Office and have it completed by a Physician certifying the dates of disability. A new claim form is required for each new period of disability.  Disabled employees receiving Workman’s Compensation must submit proof of compensation.

 

What are the health care benefits?

The fund has contracted with Freedom Network Select to provide participants and the fund with discounts on medical services.  By choosing an in-network provider for your health care needs, you will save money for yourself and the fund.  The deductible is $300 per individual vs. the out- of – network deductible of $500 per individual.  The benefit provided by using the in- network provider is 90% vs. the out-of-network benefit of 70%.  (For further details regarding the medical benefits available, please refer to the Summary Plan Description).

 

Description of Covered Benefit	In-PPO-Network	Out-of-Network
Major Medical Benefit (Hospital, ER, Doctor etc.)	90%	70%
Executive Physical Examination Benefit (Active Eligible Employee and Spouse Only) Coordinates with Routine Care Benefit	100% provided through Concentra*Services only (*see page 4 for more detail)	100% provided through Concentra*Services only (*see page 4 for more detail)
Routine Care Benefit (In or Out- of- Network) See Benefit Description for Specific Limitations Coordinates with Executive Physical Exam Benefit	100% up to $315 per Calendar Year	100% up to $315 per Calendar Year
Emergency Room Co-Payment	$75 per visit (waived if admitted)	$75 per visit (waived if admitted)
Mental Health Benefit See Benefit Description for Specific Limitations	90%	70%
Alcohol & Drug Treatment Benefit See Benefit Description for Specific Limitations	90%	70%
Chiropractic Expense Benefit See Benefit Description for Specific Limitations	90%	70%
Maternity Benefit (Employee or Dependent Spouse Only)	90%	70%
Surgery – Second Surgical Opinion	100%	100%
Well Child Benefit (Eligible Dependents of Active Employees Only) See Benefit Description for Specific Limitations	100%	100%

 

What Vision Benefits are available?

The plan will pay 80% of the amount charged up to $200.00 towards exams, lenses, contact lenses and frames every calendar year.

 

What Dental Benefits are available?

The plan will pay 80% of the amount charged up to $1,500.00 towards exams, cleanings, x-rays and other services and supplies provided by a dentist in a calendar year.  (Please refer to the Summary Plan Description for more detail).

 

Orthodontia benefits are available for eligible dependent children of eligible Active Members.  The benefit applies only for eligible dependent children age 18 and under.  There is a $1,000 lifetime maximum.  (Please refer to the SPD for more detail).

 

Is there a well child benefit?

Yes, for age 0 up to age 1 year all visits are covered at 100% with no deductible.  For age 1 year up to age 3 years up to five (5) visits per year paid at 100% with no deductible.  Age 3 years up to age 7 years – one (1) visit per year paid at 100% with no deductible.  Age 7 and older would fall under the Routine Care Benefit Section 4, page 27 of the Summary Plan Description.

 

I need to add my newborn; spouse; step-child.  How do I go about this? 

Just give The Fund Office a call and request a new Enrollment Card.  You will need to provide a birth certificate; marriage certificate; divorce decree, whichever applies to your situation.

 

I want my spouse off of my coverage.

Before a spouse can be terminated from the Plan, The Fund Office would need a copy of the divorce decree or the court document showing you are legally separated.

 

What happens if I loose my eligibility because of a reduction in hours, termination of employment, or certain other events?

You will be notified by The Fund Office that your Health Care Coverage has terminated and will be given the opportunity to elect COBRA Continuation Coverage.

 

What is COBRA Continuation Coverage?

Federal law requires that sponsors of group health plans offer Covered Employees and their families

a temporary extension of their health care coverage under the Plan in exchange for self-contribution payments to the Plan. (Find detailed information regarding COBRA in the Summary Plan Description on page 18, letter K, Section Two)

 

Concentra- (Employer Health Services)

The Executive Physical Examination Benefit is provided through a contract with Concentra, which has agreed to provide physical examination services at a contracted fee.  The physical examinations are provided without cost (no employee co-payment) to eligible Active Employees and spouses.  All eligible retirees and their spouses are also provided this benefit with a co-payment of $50 per examination.

 

Frequency of Exam

Eligible Employee and Spouse under age 50…………………….1 exam every 2 years

Eligible Employee and Spouse over age 50……………………………1 exam per year

 

The physical includes:

 

1. Lab work which includes:

q       Lipid Profile (includes cholesterol, HDL, LDL, and triglycerides)

q       Glucose (blood sugar)

q       Complete blood count (CBC)

q       Chemistry profile

q       TSH (thyroid) for females

q       PSA (prostate) for males and

q       Colorectal cancer screen hemoccult kit (on request)

2. History and physical examination including medical history, body composition,   resting blood pressure and heart rate.
3. Cardiovascular stress test including resting EKG, exercise stress EKG and individual consultation with Physician.  Or in lieu of the exercise stress EKG, females can choose to have a pelvic/pap exam and screening mammogram.
4. Strength and flexibility test.
5. Education including coronary risk factor analysis, goal setting and individualized wellness education and instruction.

 

For more information about this benefit or to set up an appointment, you may contact Concentra at 913-894-6600 ext 233 or ask for Judy.