Health and Welfare Summary Plan Description

About this Booklet

Amendment and Interpretation of the Plan
Upon Becoming a Participant

Your Health and Welfare Benefits

At a Glance
Schedule of Benefits
Eligibility
Initial Eligibility by Hours
Initial Eligibility by Self Contributions
Qualifying Schedule
Coverage Effective Date
Continuation of Eligibility
Coverage Termination Date
Coverage for Your Dependents
Medical Child Support Orders
Coordination of Benefits
Reinstatement of Coverage
Self-Contribution Provisions
For Active Participants
For Non-Medicare Retirees
For Retirees Eligible for Medicare
COBRA

Comprehensive Major Medical Benefit

Your Benefits
The Deductible
Common Accident
Maximum Benefits
Automatic Reinstatement
Maximum Benefit Reinstatement
Eligible Medical Expenses

Ineligible Medical Expenses
Subrogation
Fund’s Right of Recovery

Prescription Drugs and Medicines Benefit

Covered Prescription Expenses
Deductible and Co-Payment Amounts
Limitations

Claims Procedures

Definition of a Claim
Assignment
Submitting Claims
Timely Filing Limit
Payment of Claim
Not in Lieu of Workers’ Compensation
Plan Change or Termination

Benefit Appeal Procedures

Initial Claim Determination
Definitions
Time Limits
Concurrent Care Decisions
Claim Denial Procedures
Claim Review Procedures
Filing an Appeal
Decision on Review

Life Insurance Benefit

Beneficiary
Conversion Privilege
Accidental Death and Dismemberment Benefit
Who Will Receive Benefits
Definitions
The Benefits
Beneficiary
Losses that are Not Covered
Dependents’ Life Insurance Benefit
Effective Date of Dependents’ Life Insurance
Termination of Dependents’ Life Insurance
Conversion Privilege
General Provisions
How to Appeal a Life Insurance Claim
Facility of Payment
Examinations
Legal Actions
Change of Beneficiary
Conformity with State Laws

Medicare and Your Plan Coverage

When will you become entitled to Medicare Benefits
Life Insurance Conversion Privilege
Eligibility Requirements for the Medicare Supplemental Plan
Payment of Claim
How Your Claim is Processed
Your Prescription Drug Coverage and Medicare

Key Terms and Definitions

Notice of Privacy Practices

Rights and Protections Under ERISA

Important Information Required by ERISA


About this Booklet

We are pleased to provide you with this updated International Union of Operating Engineers Local 132 Health and Welfare Fund Summary Plan Description.  This booklet defines and describes the Health and Welfare Fund benefits.  This booklet cancels and replaces all previous booklets and related material which you have been previously issued.

The Plan Year commences on July 1st and ends on June 30th, and consists of an entire twelve (12) month period for the purposes of accounting and all reports to the United States Department of Labor and other regulatory bodies.

The Plan benefits are based on a calendar year.

Collective Bargaining Agreements, and the names of the parties thereto and their expiration dates, may be reviewed at the Fund Office.  The Collective Bargaining Agreements are between the International Union of Operating Engineers Local 132 and various Employers that have entered into labor contracts with the Union.

A list of the Employers who participate in the Fund may be obtained either by writing to the Administrator or examined at the Fund Office by participants and their beneficiaries during normal business hours.  Upon written request, the Administrator will furnish you with information as to whether a particular Employer participates in the Plan, and if so, their address.

Amendment and Interpretation of the Plan

The Trustees are empowered to amend the Plan and the benefits provided hereunder from time to time as they in their sole discretion determine appropriate.  Participants will be advised of any material modification to the Plan by notice forwarded to their last known address by first class mail, postage prepaid.

The Trustees are empowered to construe and interpret the Plan and this Summary Plan Description, and any such construction and interpretation adopted by the Trustees in good faith shall be binding upon the Union, Employers, Employees and Participants.

Upon Becoming a Participant

When becoming a participant in the Plan, you will be provided an enrollment packet.  It is important that you complete the Enrollment Form and return the requested information to the Fund Office so that we may update our records with the most complete and accurate information available.  When you enroll a dependent, you will be required to provide proof of their dependent status.

You should contact the Fund Office any time you experience a life change, such as moving and changing your place of residence, getting married, the birth of a child, the adoption of a child, a legal separation from your spouse, or a divorce.

Should you have any questions or need assistance with your enrollment packet or any information regarding the Plan, feel free to contact the Fund Office.

At a Glance

The following Schedule of Benefits briefly highlights the benefits available through the Plan and shows the payment percentages for both In-Network and Out-of-Network expenses.  By utilizing providers which are In-Network, you will have lower out-of-pocket expenses as the Plan will process eligible expenses at a higher payment percentage.  In-Network providers have also agreed to accept the allowable charges for eligible expenses, therefore you will not be responsible for the difference between the actual charge and the allowable charge.

As this schedule is only a summary, please refer to the appropriate sections of this booklet for more detailed information including any requirements for eligible expenses, as well as any limitations or exclusions from coverage.  Benefits are subject to change.  Please contact your Fund Office for the most up to date information regarding eligibility and covered expenses.

Schedule of Benefits

Comprehensive Major Medical

Annual Deductible
Individual
Family
$250
$500
Annual Maximum for all Covered Expenses
Effective July 1, 2014 there is no limit
Maximum Out of Pocket Expenses
The Plan’s payment factor will be increased to 100% for Covered Expenses in excess of $20,000 per calendar year (does not include the annual deductible).

Annual

 

$3,000
to
$6,000
Oral/Vision Care Benefit Maximum Reimbursement
100% Payment Factor
$750
Pediatric Oral/Vision Care Benefit
(eligible children age 19 or less)
The first $750 is reimbursed at 100%,
50% reimbursement factor thereafter.
Preventive Care Benefit The first $1,000 is reimbursed at 100%,
50% reimbursement factor thereafter.

 

Annual Co-Insurance Factor Summary

In-Network Out-of-Network
Physician, Hospital and Other Medical Services    
Payment Factor for first $20,000 per calendar year 85% 70%
Payment Factor for charges over $20,000 100% 100%

Benefits and Payment Factors

In-Network Out-of-Network
Hospital In-Patient Charges
Room & Board charges
Miscellaneous charges
85% of allowable
charge
70%
Hospital Out-Patient Charges
Pre-Admission Testing, Anesthesiologist, Laboratory, Pathology, Radiology, Surgery and Testing charges
85% of allowable
charge
70%
Emergency and Urgent Care Services
Hospital Emergency Room
Physicians Office
Urgent Care facility
85% of allowable
charge
70%

Ambulance Fees

Durable Medical Equipment

Orthotic and Prosthetic Devices

85% of allowable
charge
70%
Physician Services
Allergy Treatments
Emergency and Urgent Care
Mammograms
Office Visits
Pre-Admission Testing
Second Opinions
Specialists
85% of allowable
charge
70%
Laboratory Services
BC/BS network free-standing Laboratory facility
100% of allowable
charge
n/a
Laboratory Services
Other laboratory services billed through an independent facility
85% of allowable charge 70%
Radiology Services
X-Rays, MRIs, MRAs, CAT Scans and PET Scans (billed through an independent facility)
85% of allowable
charge
70%
Chiropractic Treatment
Limited to twenty (20) visits or a maximum of
$1,000 per calendar year  (including x-rays)
85% of allowable
charge
70%
Physical Therapy and Speech Therapy
Limited to a maximum of twenty (20) visits per
calendar year and must be medically necessary
and not for developmental or educational expenses
85% of allowable
charge
70%
Alcohol and Substance Abuse Treatment
85% of allowable
charge
70%
Mental Health Care Treatment
Inpatient Expenses
85% of allowable
charge
No coverage
Mental Health Care Treatment
Outpatient Expenses
85% of allowable
charge
70%
Maternity Care
Physician charges
All prenatal and postnatal visits
Delivery charges
85% of allowable
charge
70%

Weekly Disability Benefit

Weekly Disability Benefit
Waiting period for injury
Waiting period for illness
Maximum Benefit Period
$350 per week
0 days
7 days
26 weeks
 

No benefits are payable for a work related injury or illness.  This benefit is subject to FICA and Medicare taxes.  A Form W-2 will be provided annually for all benefits paid.

The weekly disability benefit is for active participants only and does not apply to a retiree, spouse or an eligible dependent.

 

Prescription Drugs and Medicines Benefit

Annual Deductible $100 per individual
Retail Drug Program 30 Day Supply per fill of a prescription
Generic
Preferred Brand Name
Non-Preferred Brand Name
10% of cost or minimum co-pay of $  7.50
20% of cost or minimum co-pay of $20.00
30% of cost or minimum co-pay of $35.00
  The maximum co-payment for any one (1) prescription is $100
Mail Order Drug Program 90 Day Supply per fill of a prescription
Generic
Preferred Brand Name
Non-Preferred Brand Name
$20 per prescription
$40 per prescription
$80 per prescription

Please refer to the Prescription Managers booklet for a listing of the Preferred Brand Name Drugs.

Should you receive a Brand Name drug when a Generic equivalent is available, you will be required to pay the difference between the cost of the Brand Name and the cost of the Generic.

 

Life Insurance Schedule of Benefits

Participant
Life Insurance Benefits $25,000
Accidental Death and Dismemberment (AD&D) Benefit $25,000
   
Dismemberment and Loss of Sight  
Loss of two arms or legs or sight in both eyes $25,000
Loss of one arm or leg and sight of one eye $25,000
Loss of one arm, one leg, or sight of one eye $12,500
   
Dependents
Spouse $10,000
Children
24 hours after live delivery but less than 19 years of age
(to age 23 if continuing to meet the dependent definition)
$5,000
   
The Life Insurance, AD&D and Dependent Life Insurance Benefits are underwritten by an insurance company.  The current underwriter is Dearborn National Life Insurance.

Eligibility

Initial Eligibility by Hours

Each person employed by an employer participating in the International Union of Operating Engineers Local 132 Health & Welfare Fund and is covered by a collective bargaining agreement between his employer and the International Union of Operating Engineers Local 132, AFL-CIO (Union) shall become eligible for benefits in accordance with the “Qualifying Schedule”, provided appropriate monthly contributions have been made to the Fund on his account by a Participating Employer or Employers.

Initial Eligibility by Self Contributions

A new employee or a participant who has not been eligible for twenty-four (24) or more months who works 120 hours with a Participating Employer during not more than the preceding twelve (12) months may make a self-contribution to initially become eligible for benefits in accordance with the following schedule:

If you work 120 or more credited hours
with Participating Employers during the
12 month period ending:
Will be permitted to make the appropriate
self contribution for coverage for the
months of:
January 31
February 28 (29)
March 31
April 30
May 31
June 30
July 31
August 31
September 30
October 31
November 30
December 31
March and April
April
May, June and July
June and July
July
August, September and October
September and October
October
November, December and January
December and January
January
February, March and April

Qualifying Schedule

Eligibility for benefits is based upon the satisfaction of minimum contribution credits during a Work Quarter (or Work Quarters, in some cases).  Coverage is provided for the associated Benefit Quarter.  Benefit Quarters are three-month periods beginning on:

February 1st               For coverage from February 1st through April 30th
May 1st                        For coverage from May 1st through July 31st
August 1st                   For coverage from August 1st through October 31st
November 1st             For coverage from November 1st through January 31st

Benefit Quarter Beginning

Work Quarters
 February 1st 325 hrs during the previous October thru December; or, if not,
Then 650 hrs during the previous July thru December; or, if not,
Then 975 hrs during the previous April thru December; or, if not,
Then 1,300 hrs during the previous January thru December.
 May 1st 325 hrs during the previous January thru March; or, if not,
Then 650 hrs during the previous October thru March; or, if not,
Then 975 hrs during the previous July thru March; or, if not,
Then 1,300 hrs during the previous April thru March.
 August 1st 325 hrs during the previous April thru June; or, if not,
Then 650 hrs during the previous January thru June; or, if not,
Then 975 hrs during the previous October thru June; or, if not,
Then 1,300 hrs during the previous July thru June.
 November 1st 325 hrs during the previous July thru September; or, if not,
Then 650 hrs during the previous April thru September; or, if not,
Then 975 hrs during the previous January thru September; or, if not,
Then 1,300 hrs during the previous October thru September.

Coverage Effective Date

You will become covered for benefits on the date you meet the Initial Eligibility requirements or the Qualifying Schedule requirements.

Continuation of Eligibility

Once having become eligible, you shall remain eligible for a full quarter (three consecutive months).  Thereafter, to remain eligible, an employee must be credited with contributions for the work hours specified in the “Qualifying Schedule”.

Should you have been eligible for the previous quarter and not reach the required hours for coverage in the following quarter, you will be permitted to self-pay for the shortage of hours required to maintain your eligibility in the Plan determined by deducting the hours worked from the required three hundred and twenty-five (325) hours.  The deficit hours are paid at the current contractual contribution rate.

Coverage Termination Date

Your coverage under the Plan will terminate on the earliest of the following:

  • The date the Plan terminates;
  • The date you are no longer a member of an eligible class;
  • The date on which a self-contribution is due and unpaid;
  • The date on which a self-contribution payment is rejected by a bank for insufficient funds; or
  • The date a change is made in the Plan to terminate benefits for your class.

Your Dependents’ Benefits will terminate on the earliest of the following:

  • The date your coverage terminates;
  • The date a change in the Plan terminates dependents’ benefits;
  • The date a dependent is no longer an Eligible Dependent, as defined.

Your continued eligibility for benefits will cease immediately if you become employed without the Union’s consent by an employer who is not required to make contributions to the Fund or if you become employed outside the Fund’s jurisdiction by any employer for whom you perform work commensurate with that considered to be in the same industry, trade or craft as you performed while working in this Fund’s jurisdiction.

Coverage for Your Dependents

Your dependents will become eligible for coverage when you become eligible, or when they become a dependent, if later.

When you become eligible for coverage, you will be provided an enrollment package and you will need to complete the required Enrollment forms.  For a dependent spouse, you will need to provide a marriage certificate and birth certificate and for each dependent child, you will need to provide a birth certificate and/or adoption papers.

Medical Child Support Orders

A Qualified Medical Child Support Order (QMCSO) is an order issued by a state court that requires an employee to provide coverage for a child under a group health plan.  A QMCSO is generally the result of a legal separation or a divorce.  In the event of a Qualified Medical Child Support Order, you are required to provide for dependent coverage.

A National Medical Support Notice is an order also issued by a state court or Child Support Agency.  Receipt of this type of notice constitutes a Medical Child Support Order and requires the Fund to add a dependent child to your coverage.

Coordination of Benefits

When there is coverage under more than one group plan, the plan that determines benefits first is called the primary plan, and allows for benefits as provided under the plan.  The plan that determines benefits after the first plan is called the secondary plan and benefits are limited so that the total amount from all the group plans will not be more than the actual amount of covered expenses incurred.

The rules for which the Health and Welfare Fund will follow for determining which plan is the primary plan are as follows:

  • A plan without a coordination clause will always pay first.
  • The plan covering the patient as an employee is primary and the plan covering the patient as a dependent is secondary.
  • For a dependent child that is covered under both parent’s plans, the plan of the parent whose birthday is earlier in the year is primary and the other parent’s plan is secondary.  (Should both parents have the same birthday, then the plan that has covered the parent longer will be primary.)
  • The plan that covers an individual as an active employee is primary and the plan that covers the individual as an inactive employee is secondary. (A participant who is retired or self-paying for COBRA coverage is considered an inactive employee.)
  • The plan that covers an individual as an active employee is primary to the plan covering the individual as a self-pay participant.
  • The plan covering the individual as other than a COBRA continue pays first. (If both plans do not have this rule, it is ignored.)

In the case of divorced parents, the following line of benefit determination is applied:

  • The plan of the parent with custody of the dependent child pays benefits first.
  • The plan of the spouse of the parent with custody of the child pays second.
  • The plan of the parent without custody of the dependent child pays last.

If none of the above situations apply, the plan which has had the individual covered the longest period of time is primary.

If there is a court decree which would otherwise establish financial responsibility for the health care expenses with respect to the child, the benefits of a plan which covers the child as a dependent of the parent with such financial responsibility shall be primary and any other plan which covers the child as a dependent will be secondary.

In applying the rules for determining which plan is the primary carrier, the provisions of any plan which would attempt to shift the status of this Plan from secondary to primary by excluding from coverage under such other Plan, any participant or dependent eligible under this Plan, shall not be considered.

In the event another plan is determined to be primary and such other plan is either not financially able or refuses to discharge its responsibility such action shall not cause this plan to assume the primary status.

In the event an employee or dependent fails or refuses to comply with the terms and conditions of another plan, thereby resulting in that other plan reducing or denying benefits, this Plan will only provide benefits under the coordination of benefits provision based upon the benefits which the other plan would have provided if the employee or dependent had fully and properly complied with the terms and conditions of the other plan.

Reinstatement of Coverage

A participant having lost eligibility for a period of not more than eighteen (18) months may once again become eligible for benefits after having contributions paid on his or her behalf by a contributing employer for at least two hundred (200) hours in any work quarter, and self-paying the deficit hours determined by deducting the hours worked from the three hundred twenty-five (325) hours required.  The deficit hours shall be paid at the current contractual contribution rate.

If your Dependents’ benefits would otherwise terminate due to your death, your Dependents’ benefits will continue until the end of the Eligibility Quarter for which you would have been eligible.

A Surviving Spouse may continue benefits on a monthly basis by paying the self-contribution established by the Fund until such time as they become entitled to benefits under Medicare at which time they will be permitted to purchase a Medicare supplement benefit package through self-contributions on a monthly basis.  Failure to make any necessary self-contribution when due will result in a forfeiture of the right to make future self-contributions.

In order to continue eligibility in this manner the Surviving Spouse must reject the COBRA continuance option.

Self-Contribution Provisions

For Active Participants

Participants whose benefits would otherwise terminate due to insufficient hours may elect to continue to be eligible under the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) as further explained later in this booklet.

Such participants may also elect to continue to be eligible on a self-pay basis provided they self-pay the necessary contributions to the Fund and during such period do not accept employment in the construction industry with an employer who is not obligated to make contributions on their behalf to the Fund or to another Health and Welfare Fund maintained by any other International Union of Operating Engineers Local Union, subject to the following:

  • If you work at least one (1) hour during any Work Period, you may self-pay for the corresponding Eligibility Quarter.
  • If you work zero (0) hours, you may self-pay for a maximum of four (4) consecutive Eligibility Quarters.

Once you have made the maximum of four (4) consecutive full self-contributions on a quarterly basis you will be permitted to maintain your eligibility for benefits on a monthly basis.  You will be permitted to continue eligibility on a monthly basis through self-pay for a maximum period of twelve (12) consecutive months.

Any period of eligibility maintained through self-payment will be considered as part of the coverage period mandated by COBRA.

If the participant fails to make any necessary self-pay contribution when due, they will lose their right to make future payments.

For Non-Medicare Retirees

If you retire under a qualified pension plan prior to age sixty-five (65) and if you were eligible for benefits under this plan at the time of your retirement and for a total of sixty (60) Eligibility Quarters over your working lifetime, you will be permitted to continue your eligibility for benefits, except Weekly Disability and AD & D Benefits, through self-contributions.  You must complete an application for continued benefits and make continuous payments.  If your benefits terminate for failure to make a payment when due, you will not be permitted to reinstate benefits unless the initial eligibility requirements are again met.

Upon attaining Medicare age or qualifying for Medicare due to disability, you will be permitted to purchase the Medicare Supplement benefits described in the “For Retirees Eligible for Medicare” section.

If you work in a jurisdiction outside the Fund’s area and elect to authorize the transfer of reciprocal hours to this Fund, your hours earned will be credited based upon the Work Quarter and eligibility will be granted for the ensuing Benefit Quarter.  If necessary for you to maintain coverage, you will be permitted to make a self-contribution in an amount equal to the difference between the required hours for eligibility and the number of hours credited times the prevailing building trades contribution rate applicable under the terms of the IUOE Local 132 Collective Bargaining Agreement in effect at the time.

Upon the cessation of active employment and the payment of the final partial self-contribution as an active employee, you will be permitted to reinstate coverage as a retiree by paying the required self-contribution amount, provided there is no break in the continuity of coverage periods.

Participants in the Fund who retire after their sixty-second (62nd) birthday, continue eligibility in the Fund and who were unmarried at the time of retirement but subsequently marry may apply within sixty (60) days of marriage for coverage of their spouse.  Such coverage will exclude expenses for any condition for which the spouse has been diagnosed or received medical treatment (including prescription medicines) within one (1) year prior to the marriage and will be contingent upon payment of the required contribution.

For Retirees Eligible for Medicare

If you retire under a qualified pension plan at age sixty-five (65) or after (when eligible for benefits through Medicare) and if you were eligible for benefits under this plan at the time of your retirement and for a total of sixty (60) Eligibility Quarters over your working lifetime, you will be permitted to purchase coverage by self-contribution to supplement benefits under Medicare.  Life Insurance, AD & D, Weekly Disability and Dependent Life Insurance benefits are not provided with the Medicare supplemental benefits program.  You must complete an application for continued benefits and make continuous payments.  If your benefits terminate for failure to make a payment when due, you will not be permitted to reinstate benefits unless the initial eligibility requirements are again met.

If you work in a jurisdiction outside the Fund’s area and elect to authorize the transfer of reciprocal hours to this Fund, your hours earned will be credited based upon the Work Quarter and eligibility will be granted for the ensuing Benefit Quarter.  If necessary for you to maintain coverage, you will be permitted to make a self-contribution in an amount equal to the difference between the required hours for eligibility and the number of hours credited times the prevailing building trades contribution rate applicable under the terms of the IUOE Local 132 Collective Bargaining Agreement in effect at the time.

Upon the cessation of active employment and the payment of the final partial self-contribution as an active employee, you will be permitted to reinstate coverage as a retiree by paying the required self-contribution amount, provided there is no break in the continuity of coverage periods.
h1>Consolidated Omnibus Budget Reconciliation Act (COBRA)

Medical Benefits Continuance Provisions

Medical Benefits as used in this provision means major medical and prescription drug benefits provided under the Plan on an expense-incurred basis.

Continuation of Group Medical Benefits

  1. You may elect to continue medical benefits for yourself and your eligible dependents for as long as eighteen (18) months from the day your eligibility ends because:
  1. your employer terminates (other than due to gross misconduct) or
  2. you no longer satisfy the requirements for hours worked.
  1. You or your dependents may elect to continue medical benefits for yourself and/or your dependents for an additional eleven (11) months following the original eighteen (18) month period if eligibility ends due to total disability on the date of or within sixty (60) days of the Qualifying Event and Social Security Disability Benefits have been awarded.  Proof of total disability must be provided to the Fund Office prior to the expiration of the eighteen (18) month continuation period described above.
  1. Your eligible spouse and/or any eligible dependent children may elect to continue medical benefits for as long as thirty-six (36) months from the day eligibility ends because:
  1. you die;
  2. you become entitled to Medicare benefits;
  3. you and your spouse are legally separated;
  4. your marriage is ended by divorce; or
  5. a child is no longer an eligible dependent.

You are responsible for notifying the Fund Office when medical benefits end in accordance with 3(c), 3(d) or 3(e) above.

The Fund Office will send you or your dependent written notice of the right to continue medical benefits.  The Fund Office must receive you or your dependent’s written request to continue medical benefits by the later of:

  1. Sixty (60) days after the day medical benefits end; or
  2. Sixty (60) days after the notice is received.

Continued coverage may only begin on the day after medical benefits under the Plan ends.  You or your dependents must pay the required premium, including any retroactive premium, from the day the coverage would have otherwise ended.  The premiums must be paid to the Fund Office within the forty-five (45) days after the day continued coverage is elected.  The Fund Office will inform you or your dependent of the monthly premium to be paid.

  1. Continued medical benefits will end at midnight on the earliest of:
  1. the day the Fund ceases to provide any group health plan;
  2. the day premium is due and unpaid;
  3. the day the covered person, after the date of the COBRA election, first becomes covered under another group plan that does not contain a pre-existing conditions limitation or such limitation is not applicable to the covered person due to the absence of a pre-existing condition.  (A plan’s pre-existing conditions limitation period will be reduced by each month that you or your family had continuous health coverage (including COBRA) with no break in coverage greater than sixty-three (63) days.  When your coverage ends, you will receive certification of the duration of your COBRA coverage.  This provision applies individually to each COBRA beneficiary.);
  4. the day a covered person again becomes covered under the Plan;
  5. the day a covered person, after the date of the COBRA election, is entitled to benefits under Medicare;
  6. the day medical benefits have been continued for the period of time provided in 1, 2 or 3 above;
  7. the date the Social Security Disability Award is revoked (which entitled the person to continue coverage beyond the eighteen (18) month continuance period); or
  8. the first of the month for which the premium payment is rejected by that person’s bank for insufficient funds.

NOTES:  In the event more than one (1) continuation provision applies, the periods of continued coverage will run concurrently up to a maximum of thirty-six (36) months.

Any period of continued eligibility for surviving spouses of deceased participants provided by the Plan will not reduce the period of continuation mandated under this provision.

Comprehensive Major Medical Benefit

This benefit will be payable if you or your dependents, while covered, incur Covered Charges which exceed the Deductible Amount.  This Benefit provides you with coverage of any illness or injury that is not employment related.

Your Benefits

Benefits are payable, as shown in the Schedule of Benefits, for Covered Charges that you, or one of your Dependents, incur within a calendar year, which are in excess of the Deductible.

The Deductible

The Deductible is an “out-of-pocket” expense which you and your Dependents are required to pay before you are entitled to the Comprehensive Major Medical Benefit.  The Deductible Amount per individual is shown in the Schedule of Benefits.

The Deductible applies only once in the calendar year.  Any expenses incurred in the last three (3) months of a calendar year which are used to satisfy the Deductible, in part of in full, will also be applied to reduce the Deductible for the following calendar year.

Common Accident

If two (2) or more covered members in a family are injured in the same accident, only one Deductible has to be met during that calendar year and the following calendar year for Covered Charges which are incurred as a result of the common accident.  Separate Deductibles will still apply to charges not related to the common accident.

Automatic Reinstatement

Major Medical benefit payments made on you or your dependent’s behalf reduce the lifetime Maximum Benefit amount.  Each January 1st, the Plan will automatically reinstate the amount of Comprehensive Major Medical Benefits which have been paid during the preceding calendar year, up to a maximum of one thousand dollars ($1,000).  The reinstatement is made without any action required on your part.  However, in no event will the total benefit, including any amount reinstated, exceed the original lifetime maximum at any one time.

Maximum Benefit

The annual maximum amount payable with respect to all illnesses or injuries is shown below:

  • Effective July 1, 2011          $750,000 per individual;
  • Effective July 1, 2012          $1,250,000 per individual;
  • Effective July 1, 2013          $2,000,000 per individual;
  • Effective July 1, 2014          No annual limit per individual.

Eligible Medical Expenses

Benefits are payable for the Reasonable and Customary charges incurred for treatment, services and supplies ordered by a Physician for care and treatment of an injury or illness covered under the Plan.  The level of reimbursement depends on if you utilize In-Network or Out-of-Network providers (refer to the Schedule of Benefits).  Eligible medical expenses are as follows:

Ambulance Service

  • Charges for a licensed professional ambulance service for transportation to or from a hospital.

Pre-Admission Testing

  • Charges for tests required before a hospital admission performed in a physician’s office or outpatient facility.

Hospital

  • Inpatient Hospital charges for the first one hundred and eighty (180) days for inpatient treatment per confinement.  Covered room and board charges may not exceed the hospital’s average rate for semi-private rooms.  If a private room is used, covered room and board charges may not exceed the Hospital’s average rate for semi-private rooms.  If a hospital does not have semi-private rooms, the coverage charges may not exceed the average rate for such rooms charged by the hospitals located in the surrounding geographical area.
  • Critical Care Units (CCU) and Intensive Care Units (ICU)
  • Pre-Admission tests required before a hospital admission
  • Routine nursery care or maternity care of a newborn child during the mother’s inpatient hospital stay
  • Staff physician visits and treatment of a medical condition and inpatient nursing services by a registered graduate nurse (RN)
  • Services provided by anesthesiologists, pathologists, radiologists, surgeons and other physicians who visit or treat you while in the hospital
  • Charges for blood and blood plasma, and the administration thereof
  • Prescribed drugs, medications, intravenous injections and solutions
  • Any miscellaneous charges which are customarily provided to treat a medical condition that resulted in the hospitalization
  • Charges by a Hospital for outpatient treatment
  • Charges by a Hospital or licensed rehabilitation facility for treatment of alcoholism or drug addiction upon the recommendation and approval of a licensed Physician

Emergency and Urgent Care

The Plan provides coverage for emergency and urgent care services provided in a physician office, hospital emergency room or urgent care facility.

Preventive Care

Benefits for preventive care, as detailed below, will be paid at 100%, then 50% thereafter per covered individual, without application of the calendar year deductible.  Covered services include:

  • Mammogram, limited to one exam per calendar year
  • Pap smear and related office visit, limited to one such exam per calendar year
  • HPV testing and vaccination, limited to one exam per calendar year
  • Immunizations, including vaccines and flu shots
  • Routine physical exam, limited to one exam per calendar year
  • Prostate exam, limited to one exam per calendar year
  • Colonoscopy exam for screening purposes, limited to:
    • One exam every ten (10) years, if under age fifty (50)
    • One exam every five (5) years, if age fifty (50) and over

Benefits will not be provided under this Preventive Care Benefit for treatment, including diagnostic testing, of any illness or injury.  Charges for treatment of an illness or injury will be considered under the Comprehensive Major Medical Benefit as detailed in this booklet.

Laboratory Benefit

The Plan will pay 100% of covered charges submitted by a free-standing Blue Cross Blue Shield network laboratory facility for outpatient laboratory testing, without application of a calendar year deductible.  This benefit will not apply to laboratory charges submitted by a hospital, whether the patient is confined or not confined.

Charges submitted by an out-of-network provider will be covered at 70% and subject to the calendar year deductible.

Should Medicare be your primary insurance, or should you be a dependent with another primary insurance carrier, your LabOne claim will need to be processed by Medicare, or your primary insurance carrier, before this Plan can process your claim and coordinate benefits.

Office Visits

The Plan provides coverage for office visits to a physician and specialist and for surgery performed in the physician’s office.  Typical types of charges included:

  • Physician and specialist charges for diagnosis, treatment and surgery
  • Charges related to providing a second opinion
  • Drugs and medicine which, by law, require a Physician’s written prescription
  • Services by a physiotherapist under the supervision of a Physician

Surgery

  • Surgical procedures performed on both an inpatient and outpatient basis
  • Cosmetic surgery required by an accidental bodily injury which occurred while covered by the Plan
  • Reconstructive surgery due to a congenital disease or anomaly of a dependent child which has resulted in a functional defect
  • Gastric By-Pass or Gastric Banding up to a maximum of $25,000
  • Mastectomy, including:
  • Reconstruction of the breast on which the mastectomy has been performed
  • Surgery and reconstruction of either or both breasts to produce a symmetrical appearance
  • Prostheses and treatment of physical complications in all stages of mastectomy, including lymph edemas

Should your physician recommend an elective surgery, the Plan also provides coverage for a second opinion.

Facility Fees

The Plan provides coverage for surgical or outpatient procedures and treatments performed at a free-standing facility.

Mental Nervous

Charges for Day Treatment Program expenses for the outpatient treatment of substance abuse and psychiatric counseling, including pain management, provided the day treatment care meets all of the following requirements:

  • Follows an inpatient confinement of at least three (3) days;
  • Commences within three (3) days of the hospital discharge;
  • Is recommended by a physician; and
  • Is rendered by a provider licensed for such treatment by the state of domicile.

Oral/Vision Care Benefit

If while covered, you or an eligible dependent incur expenses for dental services which are not covered under the Major Medical Benefit, such expenses will be reimbursed at 100%.  The maximum benefit which will be paid on behalf of any covered individual is $750 for expenses incurred in a calendar year.

In regards to pediatric oral/vision care, if an eligible minor child(ren), age 19 or less, incurs expenses for oral or vision care services which are not covered under the Major Medical Benefit, such expenses will be reimbursed at 100% of the first $750, then 50% thereafter.

Please note, Orthodontics are not considered as an “essential health benefit”, and are not covered under the Oral Care Benefit.

This benefit is intended to be a reimbursement arrangement where you pay the service provider’s bill and submit a receipt to the Fund Office for reimbursement.  If you and the service provider can reach an agreement where the service provider will accept payment from the Fund, with you responsible for the difference, you can instruct the service provider to submit his bill directly to the Fund Office and the Fund’s check will be made payable to the service provider.

Dental Work or Treatment

The Plan provides coverage for dental work, surgery or treatment required to repair, replace, restore or reposition sound natural teeth or other body tissues as a result of an injury that occurred while the patient was covered under the Plan.  Coverage is also provided for:

  • Charges for the treatment of a cleft lip or palate;
  • Charges for the treatment of temporomandibular joint disease (TMJ), including office visits and bite splints; excluding orthodontic treatment and retainers;
  • Charges for the treatment of cysts or tumors; and
  • Charges for the treatment of cancer of the jaw or mouth.

Eye Care or Treatment

The Plan provides coverage for the treatment of glaucoma and cataracts, and also for charges related to an accidental eye injury occurring while eligible for benefits.  The Comprehensive Major Medical Plan does not provide coverage for routine eye refractions, eyeglasses, contact lenses or charges for eye surgery or treatment primarily to correct refractions.

Chiropractic Care

The Plan provides coverage for chiropractic care provided by a chiropractor, limited to either a maximum of twenty (20) visits per calendar year or a total of $1,000, whichever occurs first.  Charges for x-rays are included in this benefit.

Physical Therapy and Speech Therapy

The Plan provides coverage for physical therapy, limited to a maximum of twenty (20) visits per condition per calendar year.  The therapy must be medically necessary and not for developmental or educational purposes.

Charges related to speech therapy must be medically necessary, require a treatment plan and may initially be approved for twenty-four (24) visits.  Additional visits may be permitted after the review of therapist’s documentation and progression.  Speech therapy is limited to a maximum of forty-eight (48) visits.

Maternity Care

The Plan provides coverage for physician charges for all obstetrical care, including the initial visit and all prenatal and postnatal visits, and delivery in a hospital or birthing center.  Newborn benefits include the hospital’s nursery charges incurred during the mother’s confinement.

Also covered are services rendered by a birthing center (as defined by State Law) including any charges for care rendered by a licensed nurse-midwife (or by a midwife as defined by State Law) providing services within the scope of his license as permitted by State Law.

You must enroll a newborn within thirty (30) days after birth in order for the Plan to identify the dependent on future claims.

Premature Birth and Congenital Malformation

Medical expenses incurred while you are covered with respect to a dependent child for treatment of a child’s premature birth or congenital malformation will be considered for benefits as though such expenses were due to a disease of the child.  Premature birth will be deemed to have occurred only if a doctor certifies to such prematurity and the child requires confinement in an incubator or the premature baby room of a hospital.

Abortions

The Plan covers both elective and therapeutic procedures for participants and covered dependents.

Weekly Disability Benefits

The Plan provides coverage should you become totally disabled due to a non-occupational accidental bodily injury or disease.  Benefits will begin on the day of disability following the applicable waiting period specified in the Schedule of Benefits and will continue during the continuance of total disability for up to twenty-six (26) weeks.  The amount of the benefit is shown in the Schedule of Benefits.

If while covered, you become totally disabled due to pregnancy, you will be eligible for this benefit, subject to the same provisions regarding commencement and duration of benefits as would be applicable to any disease.

Successive periods of disability separated by less than two (2) weeks of continuous full-time active work shall be considered as one period in determining the benefits available to you, unless the subsequent disability is due to an injury or disease entirely unrelated to the cause of the previous disability and commences after your return to full-time active work.

This benefit will not be payable for a disability due to injury or disease for which you are not under regular treatment by a physician.

Skilled Nursing Facility

A Skilled Nursing Facility provides for a level of services that are often essential after a hospital stay, such as rehabilitation, physical, speech, or occupational therapy.  The Plan provides coverage for room and board charges and requires the attending physician to certify the admission to the facility is medically necessary as a substitute for hospital confinement.  Skilled nursing is limited to coverage for up to sixty (60) days and must be for patient rehabilitation.  A Skilled Nursing Facility must meet the following requirements:

  • Licensed physician on call 24 hours a day;
  • Registered Nurse (RN) on duty 24 hours a day;
  • Each patient must be under the care of a physician; and
  • Skilled Nursing Facility must be licensed by the State

The Plan does not provide coverage for charges related to a convalescent nursing home, rest facility or facility for the aged that furnishes primarily Custodial Care, including training in routines of daily living.

Home Health Care

Home Health Care is generally for the treatment of an illness or injury in the patient’s home and begins immediately following an inpatient hospital stay.  The Plan provides coverage only for medically necessary services and supplies which are rendered to a patient at home by a licensed agency or individual, excluding a family member or resident of the household.  No coverage is provided for custodial care, housekeeping services, child care, cooking, bathing or laundry services.  Home Health Care coverage must meet the following requirements:

  • Condition calls for intermittent (part-time) Registered Nurse (RN) care, physical, speech, or occupational therapy;
  • Individual is confined to the home; and
  • A physician determines home health care is needed and sets up the home health care plan

Hospice Care

Hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management, and support services to terminally ill patients and their families.  The Plan provides coverage for the following:

  • Outpatient medical and support services from an approved Hospice
  • Outpatient nursing care provided by a Registered Nurse (RN)
  • Physical or occupational therapy or speech language pathology

The Plan does not provide coverage for Hospice charges for an inpatient hospital environment.

Diabetic Services and Supplies

The Plan provides coverage for services and supplies related to the care and treatment of diabetes.  Coverage is also provided for glucometers, blood glucose monitors and infusion devices, including charges for insulin needles and syringes, visual reading strips, urine test strips and injection aids such as lancets and alcohol swabs.

No coverage is provided for outpatient educational or training charges by a certified nutritionist or licensed dietitian.

Durable Medical Equipment

The Plan provides for monthly rental to the purchase price of durable medical equipment (DME) when prescribed by a physician.  Charges for repair are covered due to reasonable wear and tear usage.  Replacement costs are covered only if the durable medical equipment is unable to be repaired or due to the patient’s growth or anatomical changes.

Durable medical equipment must be medically necessary and some equipment requires specific criteria to be met before being approved for coverage.  Typical types of durable medical equipment are as follows:

  • Wheelchairs
  • Hospital type beds
  • Iron lungs
  • Dialysis machines
  • Kangaroo Pumps
  • Nebulizers
  • Oxygen concentrators
  • C-Pap or Bi-Pap  (for moderate to severe sleep apnea)

The Plan provides coverage for the supplies required for the administration of covered durable medical equipment.

No benefits are payable for items which are not medically necessary and are considered as convenience items.  Typical types of equipment which are ineligible expenses include, but are not limited to:

  • Air purifiers, humidifiers and vaporizers
  • Bed related items such as mattresses, pillows and tables
  • Bath related items such as grab bars, rails, raised toilet seats and bath benches
  • Heat lamps, sun lamps, heating pads or any form of ultraviolet beds or cabinets
  • Pools No benefits are payable for the for spas for aqua therapy

Orthotics

The Plan provides coverage for orthotic devices which are medically necessary to support or aid in the treatment of an injury or illness and prescribed by a physician.  Coverage is also provided for all medically necessary supplies, adjustments, repairs or replacement of covered orthotic devices.  Replacement of orthotics is generally provided following a malfunction of the device, for growth adjustments, or after the device’s normal life span.  Typical types of orthotics are:

  • Splints and Trusses
  • Braces for the arm, back, leg, neck or shoulder
  • Custom molded foot orthotics

The Plan provides coverage for foot orthotics if they are custom molded from a mold of the patient’s foot and prescribed by a physician.  Orthopedic shoes are not eligible for coverage unless one or both of the shoes are an integral part of a leg brace.

Over the counter support devices are not eligible for coverage.

Prosthetics

The Plan provides coverage for prosthetic devices such as artificial limbs or eyes, which are prescribed by a physician as a replacement of a natural limb or eye lost while a covered individual and must be medically necessary for the correction of an injury, illness or congenital defect.

The Plan provides coverage for the initial purchase and fitting of the device.  Coverage is also provided for repairs and replacements which are due to reasonable wear and tear or anatomical changes that are not otherwise provided under the manufacturer’s warranty or purchase agreement.  No coverage is provided for repairs or replacements that are the result of a covered individual’s misuse.

A prosthetic device requires a Letter of Medical Necessity from the physician.  Typical types of prosthetics are as follows:

  • Basic limb prosthetic
  • Eye prosthetic
  • Breast prosthetic
  • Penile prosthetic
  • Bra
  • Wig

Ineligible Medical Expenses

No benefits are payable for the following expenses:

  • Services, supplies and treatment that are not medically necessary, as defined by the Plan;
  • Charges which are in excess of the Reasonable and Customary charges (as defined) for services, supplies and treatment;
  • Charges which are in excess of the contracted allowable charge for In-Network benefits;
  • Expenses for work related injuries, illnesses or medical expenses covered under Workers’ Compensation or any state or Federal Law (unless benefits are denied and the appeal process has been exhausted);
  • Hospital charges for personal or comfort items such as personal care kits and other items which are not for the specific treatment of an injury or illness;
  • Services rendered during confinement in a hospital owned or operated by the Federal Government, unless you would be required to pay such charges in the absence of coverage;
  • Loss due to war, either declared or undeclared, or loss suffered while engaged in military service;
  • Expenses which were incurred before you became eligible for benefits and expenses which were incurred after your coverage terminated;
  • Expenses you or your dependents are not required to pay;
  • Expenses in excess of the Plan’s annual limits;
  • Expenses for eyeglasses or contact lenses and charges for eye surgery or treatment primarily to correct refractions;
  • Dental work or treatment, except for the accidental injury to sound natural teeth occurring while covered or for the treatment of cysts and tumors or cancer of the jaw or mouth;
  • Charges for hearing aids or any device which assists in hearing;
  • Charges related to cosmetic surgery unless caused by an accidental bodily injury occurring while covered or reconstructive surgery due to congenital disease or anomaly of a dependent child which has resulted in a functional defect;
  • Charges related to breast augmentation for cosmetic purposes;
  • Routine physical examinations, except as provided for elsewhere;
  • Transportation, except for licensed professional ambulance services;
  • Expenses related to an injury sustained when it is determined the covered individual was intoxicated under the laws of the state where the accident occurred or the result of being under the influence of a drug, unless the drug was prescribed by a physician and used strictly as prescribed;
  • Intentionally self-inflicted injury or injury sustained in the commission of a felony, unless the injury is the direct result of a medical condition (such as mental illness or depression);
  • Expenses for any services provided by an out-of-network residential treatment facility, including but not limited to services for inpatient or residential skilled nursing, alcohol and/or drug dependence rehabilitation.
  • Expenses for outpatient treatment of Mental and Nervous disorders unless provided by a licensed clinical psychologist or psychiatrist;
  • Charges for preparing medical reports, itemized bills or claim forms, handling, mailing, shipping expenses or sales tax;
  • Charges for missed appointments or “no show” fees;
  • Membership fees or costs associated with health clubs, weight loss programs and smoking cessation programs
  • Infertility treatment and services including In Vitro Fertilization (IVF), Gamete Intra Fallopian Transfer (GIFT) or any other variations of these types of procedures;
  • Charges associated with the collection, washing, preparation or storage of sperm for artificial insemination and charges for cryopreservation of donor sperm and eggs;
  • Charges for a reversal of a voluntary sterilization;
  • Charges for routine foot care, including service for calluses, corns or toenails, unless medically necessary;
  • Convalescent care or nursing homes; and
  • Experimental treatments or services.

The Plan benefits outlined in this booklet are subject to change.  Contact the Fund Office to confirm whether a service or procedure is an Eligible Medical Expense or an Ineligible Medical Expense.

Subrogation

If the Fund makes a payment under the terms of this Plan and the individual to or for whom the payment was made has a right to recover damages from another, the Fund shall be subrogated to that right to the extent of the payment of benefits made by this Plan.  The recipient of benefit shall do whatever is required to enable the Fund to exercise this right and shall do nothing to prejudice this right.  Should a recipient of benefits recover damages from another the recipient shall hold the proceeds in trust for the Fund to the extent of the Fund’s payment.

Once a Third-Party’s liability is resolved the individual will be required to reimburse the Fund up to the full amount of the recovery for the full amount of benefits received.  In such cases, the acceptance of benefits constitutes an agreement to reimburse the Fund for benefits paid up to the full amount of recovery.  By accepting benefits from the Fund, the injured party agrees that any amounts recovered by the injured party by judgment, settlement or otherwise will be applied first to reimburse the Fund.

Fund’s Right of Recovery

The Fund has the right to recovery from any Participant, or any other individual or recipient of Plan benefits, any payments made as a result of misrepresentation, mistake or error, irrespective of the party causing such mistake or error.

Prescription Drugs and Medicines Benefit

The Plan provides benefits for Covered Prescription Expenses in excess of the Deductible and Co-payment amounts.  These benefits are provided through an independent Prescription Benefit Manager.

Covered Prescription Expenses

Covered Prescription Expenses are necessary and reasonable expenses incurred for drugs and medicines which require a doctor’s prescription, and injectible insulin prescribed by a physician, which are necessary in the treatment of an illness.

Deductible and Co-Payment Amounts

The Deductible amount is an expense which you or your dependents are required to pay before you are entitled to prescription benefits.  The Co-Payment is the amount you must pay for each prescription before a benefit is payable by the Plan.  The calendar year deductible and the co-payment factors are shown in the Schedule of Benefits.

Limitations

The Plan does not provide coverage for any of the following types of expenses:

  • Drugs or medicines lawfully obtained without a doctor’s prescription
  • Refills of any prescription in excess of the number of refills specified by the doctor, or any drugs or medicines dispensed more than one year following the date of the doctor’s prescription order
  • Any quantity of drugs or medicines dispensed which exceed a thirty-four (34) day supply or one hundred (100) unit doses, whichever is greater, when taken in accordance with the directions of the prescriber, except if provided under the mail service program
  • Prescription drugs which may be properly received without charge under local, state or federal programs
  • Drugs labeled “Caution – limited by federal law to investigational use”, or experimental drugs, even though a charge is made to the Covered Individual
  • Drugs prescribed for indications not approved by the Food and Drug Administration (FDA)
  • Drugs or medicines in whole or in part, to be taken by, or administered to a Covered Individual during confinement in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution
  • Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substance, regardless of there intended use
  • Any charges for immunization agents, biological sera, blood or blood plasma, including the administration thereof
  • Any charges for contraceptives, contraceptive materials, contraceptive devices or infertility medication
  • A.D.D. / Narcolepsy medications for individuals twenty-four (24) years of age and older
  • Anabolic steroids
  • Anti-wrinkle agents (i.e.: Renova)
  • Any drugs used for cosmetic purposes
  • Dermatologicals and hair stimulants
  • Erectile dysfunciton medications
  • Fluoride supplements
  • Growth hormones
  • Hemantinics
  • Immunization agents, blood and blood plasma
  • Impotence medications
  • Infertility medications
  • Interferon (Avonex)
  • Isotretinoin (Accutane)
  • Levonorgestrel (Norplant)
  • Mineral and nutrient supplements
  • Non-legend drugs other than insulin
  • Pigmenting and depigmenting agents
  • Tretinoin topical (i.e.: Retin-A)
  • Vitamins, singly or in combination

The following types of expenses require a 100% co-payment from the participant:

  • Non-sedating antihistamines
  • Allegra, Clarinex, Zyrtec and any similar types
  • Proton Pump Inhibitors
  • Aciphex, Nexium, Omeprazole, Prevacid, Prilosec, Protonix and any similar types

Important Notice:  Although the prescription drugs and medicines outlined in the Limitations may appear in the Prescription Benefit Managers listings of “Preferred Drugs” or “Primary Drugs”, they are specifically excluded from coverage by the Plan.

Claims Procedures

Definition of a Claim

A claim is a request for Plan benefits made in accordance with the Plan’s claims procedures.  Should you be required to file the claim yourself, you will need to complete a Claim Form and attach an itemized statement from your provider which includes your name, identification number, the date of service, procedure code or description and diagnosis code.

When you go to a physician’s office, hospital or any provider of medical services, you should present your medical identification card.  The provider of services can use this ID card to contact the Fund Office and inquire as to your eligibility for coverage and the Plan’s benefits.

In verifying eligibility and Plan benefits, the Fund Office staff will use the information which is currently available; however, this verification is not a guarantee of eligibility or benefits.  When the Fund Office receives claims for benefits, the claims are processed in accordance with the Plan’s provisions and the Fund’s records regarding eligibility.

Assignment

In most cases, your physician’s office, the hospital or provider of services will allow you to assign benefits so any payments made for expenses due to medical care and treatment by the Plan can be issued directly to the provider of services.

Submitting Claims

Your claim will be considered to have been filed as soon as it is received by the Fund Office.  The Plan will accept a paper claim (mailed or delivered to the Fund Office) or an electronic claim.

The submission of a provider’s claim to the provider’s billing agent or clearinghouse does not constitute receipt of a claim by the Plan.

Timely Filing Limit

Your claim must be submitted within twelve (12) months of the date of service to be eligible for reimbursement under the Plan.  Failure to submit a claim within the one year timely filing limit will result in the claim being denied with no benefits payable.

As a participant in the Plan, you are responsible for verifying the provider has submitted your claim.  When the claim is processed by the Plan, both you and the provider will receive an Explanation of Benefits (also known as an EOB) explaining how the claim was processed.

Should a claim be submitted and not have the required information or documentation, both you and the provider will be notified that your claim has been received and is pending additional information or clarification before the benefit processing can be completed.

Payment of Claim

Payment of benefits will be made at regular intervals occurring at least once every thirty (30) days.  When payment is made, you will receive an Explanation of Benefits (EOB) which will explain how the claim was processed.  Included on this EOB is the provider’s original charge, the allowable amount, any deductible amount and Plan payment.  This EOB will also show your member liability.  You may receive a bill from the provider for any remaining expense, which will be your responsibility to pay.  Should there be no member liability, you will also receive an EOB showing the allowable amount was paid in full.  You should always retain all EOBs and notices from the Plan for your records.

If you pay an In-Network provider at the time of service, you may need to contact the provider about any refund should your member liability be less than your payment after the Plan processes your claim.

If your claim for benefits is denied, you have the right to file an appeal.

Not in Lieu of Workers’ Compensation

The provisions of the Plan are not in lieu of, and shall not affect any requirements for coverage by Workers’ Compensation insurance.

Plan Change or Termination

The Trustees reserve the right to change or discontinue the type and amounts of benefits under the Plan and the eligibility rules for extended or accumulated eligibility, even if extended eligibility has already been accumulated.

Plan Benefits and eligibility rules for active, retired or disabled participants:

  • Are not guaranteed;
  • May be changed or discontinued by the Board of Trustees;
  • Are subject to the rules and regulations adopted by the Board of Trustees;
  • Are subject to the Trust Agreement which establishes and governs the Fund’s operations; and
  • Are subject to the provisions of any group insurance policy purchased by the Board of Trustees.

The nature and amount of Plan benefits are always subject to the actual terms of the Plan as it exists at the time the claim occurs.

If the Plan is changed or discontinued, it will not affect your or your beneficiary’s right to any insured benefit to which you have already become entitled.

Benefit Appeal Procedures

Initial Claim Determination

Definitions

  1. Urgent claims are requests for eligibility status or for medical care or treatment of an emergency nature, which could seriously jeopardize the life or health of the claimant or would subject the claimant to severe pain.
  1. A pre-service claim is a request for eligibility status or for benefits for which a Plan requires pre-approval, such as predetermination of benefits for major surgery.
  1. A post-service claim is a request for a benefit following the claimant’s receipt of services.

Time Limits

  1. A decision with respect to an urgent care claim will be made within seventy-two (72) hours.  If the claim is not complete, the Plan will notify you of the additional information required within twenty-four (24) hours.
  1. A decision on a pre-service claim will be made within fifteen (15) days.  The Plan will advise of a defective or incomplete filing of a pre-service claim within five (5) days of receipt.  The Plan may take an additional fifteen (15) days, if it is determined an extension is necessary due to matters beyond the control of the Plan and you are advised of the need for the extension.
  1. A decision on a post-service claim will be made within thirty (30) days.  The Plan will advise of a defective or incomplete filing of a post-service claim within thirty (30) days of receipt.  You will have forty-five (45) days to provide the required information.  The Plan may take an additional fifteen (15) days, if it is necessary due to matters beyond the control of the Plan and you are advised of the need for the extension.

Concurrent Care Decisions

  1. If the Plan has approved an ongoing course of treatment to be provided over a period of time or a number of treatments, any reduction or termination by the Plan or such course of treatment before the end of the period or number of treatments previously agreed will be considered a denial.  The Plan will notify you of this action in advance of the application of the reduction or termination and advise of the appeal rights to permit a review prior to the date the benefit is reduced or terminated.
  1. A decision with respect to extend the previously agreed to course of treatment for an urgent care claim will be acted upon as soon as possible.  The Plan will notify you of the determination within twenty-four (24) hours of receipt, provided the claim is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number of treatments.

Claim Denial Procedures

If your claim is denied or partially denied, you will be notified in writing and provided an opportunity for a review.

The written notice of denial will provide:

  1. The specific reason(s) for the denial;
  1. The specific Plan provision on which the determination is based;
  1. A description of additional information or information necessary for you to perfect the claim and an explanation of why this additional information is necessary;
  1. A statement that the specific rule, guideline, protocol or other criterion relied upon in making the determination, if applicable, will be provided at no cost upon request;
  1. A statement that an explanation of the scientific or clinical judgment relied upon and the names of the individuals from whom opinion(s) were secured, if a determination is based upon medical necessity or experimental treatment, or similar exclusion or limit, will be provided at no cost; and
  1. A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement regarding your right to bring a civil action under section 502(a) of ERISA.

Claim Review Procedures

Filing an Appeal

If your claim has either been denied or partially denied and you are not satisfied with the decision, you may appeal the decision and request a review of the claim.  The appeal must include all of the following:

  • Be in writing and can be made by you or your duly authorized representative;
  • Should be mailed or delivered to the Fund address shown in the Summary Plan Description;
  • Should state the reasons you believe the initial determination was incorrect;
  • Should include any written comments, documents, records and other information relating to the claim for benefits; and
  • Be submitted within one hundred eighty (180) days of the date you receive the notice of denial or partial denial.

You will be provided access to and copies of, at a reasonable charge, all documents, records, and other information relevant to your claim.

Decision on Review

  • A decision on review of an urgent care claim will be made within seventy-two (72) hours after receipt of your request for review.
  • A decision on review of a pre-service claim will be made within thirty (30) days of receipt of your request for review.
  • A decision on review of a post-service claim will be made during the course of the regular quarterly Trustees’ meeting following receipt of the request for review and you will be notified of the decision within five (5) days of the date of such meeting.  (If the request for review is received within thirty (30) days of the next regular quarterly Trustees’ meeting, the decision on review will be made no later than the date of the second meeting following the Plan’s receipt of the request for review.)  If special circumstances require an extension of time, a decision will be rendered no later than the next following quarterly Trustees’ meeting.  You will be advised of the special circumstances and the date the decision is expected to be made.

The decision of the Trustees on review will be made in good faith and will be final and binding on all issues.  The claimant or claimant’s duly authorized representative will be required to exhaust the entire claim review procedure before instituting any other form of action.

Life Insurance Benefit

If you die from any cause while you are insured, the proceeds will be paid to your beneficiary.  The proceeds may be paid in monthly or annual installments or as a lump sum.

Beneficiary

You may name anyone you wish as your beneficiary.  You may change your beneficiary at any time by completing the proper form.  The change will be effective when the IUOE Local 132 Health and Welfare Fund receives the completed form at its office.

Conversion Privilege

If you are no longer eligible for group life insurance due to your ceasing to belong to an eligible insured class or if you terminate your employment, you may convert that benefit to any form of individual life insurance usually offered by the Insurance Company, except for term.

You will not need a medical examination, but you must complete the application form and send it with the first premium payment to the Insurance Company no later than thirty-one (31) days after your group life insurance has terminated.

The face value of your new policy cannot be more than the amount you had under the group plan.  The rate you pay will depend upon your age (at the nearest birthday to the date of issue of the individual policy) and your class of risk at the time of your conversion.

You may also convert if your life insurance benefits terminate because the policy terminates, or because life insurance benefits for your class terminate.  In this case, however, you must have been covered under the group plan for at least five (5) years.  You may convert the lesser of the following amounts:

  • The amount of life insurance you have under this Plan, less any new amount you may have or for which you may become eligible under another group plan within thirty-one (31) days of termination; or
  • Two thousand dollars ($2,000)

If you should die during the thirty-one (31) day period after your group life insurance has terminated, the Insurance Company will pay the group life insurance benefits to the last beneficiary you named, whether or not you applied for an individual life insurance policy.

Accidental Death and Dismemberment Benefit
(24 Hour Coverage)

This benefit will be payable if you, while insured, sustain any of the losses mentioned below as a result of purely accidental means.  The loss must take place within ninety (90) days from the date of the accident for the benefits to be payable.  This benefit is in addition to your other benefits under this Plan.

Who Will Receive Benefits

For loss of life, benefits will be paid to the beneficiary you name.  For any other loss, the benefits will be paid to you.

Definitions

  • Principal Sum is the benefit amount shown in the Schedule of Benefits.
  • Loss of hand or foot means that the limb is severed at or above the wrist or ankle joint.
  • Loss of sight means the total and irrecoverable loss of sight.

The Benefits

FOR LOSS OF: AMOUNT:
Life
Two Hands
Two Feet
Sight of Two Eyes
One Hand and One Foot
One Hand and Sight of One Eye
One Foot and Sight of One Eye
One Hand or One Foot
Sight of One Eye
The Principal Sum
The Principal Sum
The Principal Sum
The Principal Sum
The Principal Sum
The Principal Sum
The Principal Sum
One-Half the Principal Sum
One-Half the Principal Sum

If you suffer more than one loss in any one accident, no more than the full amount of your benefit will be paid.  The full amount is the principal sum.

Beneficiary

You may name anyone your wish as your beneficiary.  You may change your beneficiary at any time by completing the proper form.  The change will be effective when the form is received by the IUOE Local 132 Health and Welfare Fund at its office.

Losses that are Not Covered

No benefit is payable under this section if your death or any loss is caused directly or indirectly, in whole or in part, by:

  • Bodily or mental illness or disease of any kind;
  • Ptomaines or bacterial infection (except infections caused by pyogenic organisms which occur with and through an accidental cut or wound);
  • Suicide or intentional self-inflicted injury;
  • Participation in the commission of a felony; or
  • Any act of war, whether declared or undeclared.

Dependents’ Life Insurance Benefits

Life insurance is provided for your eligible dependents in the amounts shown in the Schedule of Benefits.  If one of your dependents dies, the life insurance proceeds will be payable to you.  However, if you die before your dependent, you dependent’s life insurance proceeds will be payable upon his death to the executor or administrator of the estate or, at the Company’s option, to any one or more of his or her surviving relatives; mother, father, child or children, brothers or sisters.

Effective Date of Dependents’ Life Insurance

Coverage for your dependents starts on the date your coverage starts or, if your coverage is already in effect, on the date he acquires the status of an eligible dependent.

Termination of Dependents’ Life Insurance

The dependents’ life insurance shall terminate on the earliest of the following:

  • The date your insurance as an employee terminates;
  • The date a change is made in the Plan to terminate dependents’ coverage; or
  • The date a dependent is no longer an eligible dependent, as defined above.

Exception:  If your dependents’ life insurance would otherwise terminate due to your death, such dependent will continue to be eligible for the rest of the Benefit Quarter for which you would have been otherwise eligible.

Conversion Privilege

If your dependents’ life insurance terminates because your coverage terminates or because his eligibility terminates, he may convert that benefit to any form of life insurance, except term, usually offered by the Company.

A medical examination will not be required.  However, the application form and the first premium payments must be sent to the Company no later than thirty-one (31) days after the life insurance coverage has terminated.

The face value of the new policy cannot be more than the amount under the group plan.  The rate charged will depend upon your Dependents’ age and class of risk at the time of conversion.

The converted policy will become effective on the thirty-second (32) day following the date his or her life insurance coverage terminated.

Your dependent may also convert if his life insurance benefits terminate because the policy terminates, or because life insurance benefits or dependent status terminates.  In this case, however, he must have been covered under the group plan for at least three (3) years.  He may convert the lesser of the following amounts:

  • The amount of life insurance he had under this Plan, less any amount of group life insurance for which he may become eligible under a group plan issued or reinstated within thirty-one (31) days of such termination; or
  • Two thousand dollars ($2,000)

If your dependent dies during the thirty-one (31) day period after his group life insurance terminated, the Company will pay the life insurance benefit, as specified in the provision, whether or not your dependent had applied for an individual life insurance conversion policy.

General Provisions

How to Appeal a Life Insurance Claim

If you do not agree with a claim denial, you may request that a review be made of your claim.  The claim denial will tell you the name and address of the person to whom you may send a written request.

You may submit additional information with your request for review.  You may request and receive copies of pertinent documents, although in some cases approval may be needed for the release of confidential information, such as medical records.  You may submit issues and comments in writing.

A decision will be made within sixty (60) days following the date the Insurance Company received your request for review or the date the Insurance Company received all information required of you, whichever date is later.  You will be notified of the decision in writing and you will be given clear and specific reasons for the decision.

Facility of Payment

If you or your Dependent are not legally capable of giving a valid receipt for a benefit payment, the Insurance Company has the right (if there is no legal guardian) to pay the party it believes is entitled to such payment.  Once such a payment is made, the Insurance Company has no further obligation with respect to the amount so paid.  If you name more than one (1) Beneficiary, but do not say how much each Beneficiary should receive, the total amount will be shared equally by all surviving Beneficiaries.  If there is no living Beneficiary when you die, the Insurance Company will make the payment to your spouse; if none, to your children; if none, to your parents; if none, to your brothers and sisters.  However, the Insurance Company has the option to make the payment to your estate.

Examinations

The Insurance Company shall have the right and opportunity through its medical representative to examine any living insured during the pendency of a claim and so often as it may reasonably require.

The Insurance Company shall also have the right to make an autopsy in the case of death, where it is not forbidden by law.

Legal Actions

No action at law or in equity shall be brought to recover on the policy prior to the expiration of sixty (60) days after written Proof of Loss has been furnished.  No action shall be brought after the expiration of three (3) years from the time Proof of Loss is required.

Change of Beneficiary

The right to change of beneficiary is reserved to the insured.  The consent of the beneficiary or beneficiaries is not required for any change in beneficiary requested by the insured.

Conformity with State Laws

Where required by law, limitations will be extended to comply with the minimum requirements of the state in which the insured resides or works.

Medicare and Your Plan Coverage

When will you become entitled to Medicare Benefits

You will become entitled to Medicare Benefits when you reach age sixty-five (65).  Should you be found Totally and Permanently Disabled through the Social Security Administration, you may become entitled to Medicare Benefits twenty-four (24) months from the date you were found disabled.

You or your eligible dependents may also become entitled to Medicare Benefits after the first eighteen (18) months of end-stage renal disease.

Medicare consists of two types of coverage:

  • Medicare Part A       hospital insurance for hospital in-patient stays, skilled nursing facilities, home health and hospice care
  • Medicare Part B       medical insurance for doctors, outpatient hospital care and other medical services

Medicare Part A benefits are automatically provided to you when you reach age sixty-five (65) and for disabled participants under age sixty-five (65) if:

  • You are already receiving retirement benefits from Social Security;
  • You are eligible to receive Social Security benefits but have not yet filed for them; or
  • You or your spouse had Medicare covered employment.

Medicare Part B benefits must be elected and require you to pay a monthly premium.  Any entitled to Medicare Part A benefits can enroll for Medicare Part B coverage.

You may be entitled to Medicare benefits even though you may still be an active participant still working.  If you are eligible for coverage through the Health and Welfare Fund by hours worked or even by self-paying for a deficit or shortage of hours, the Fund will be your primary insurance carrier.  If you have enrolled for Medicare benefits, Medicare would be your secondary insurance carrier.  In this case, you would need to submit all claims to the Health and Welfare Fund, and after the Fund processes your claims, you can then submit your claims to Medicare.

After becoming entitled to Medicare benefits, when you have retired or stop working and you are no longer eligible for coverage by hours worked and are making a monthly self-pay premium to the Fund, Medicare will become your primary insurance carrier.

You will then need to submit all claims to Medicare first.  Once Medicare has processed your benefits, they will then need to be sent to the Health and Welfare Fund to be processed.  The Fund will consider all charges which Medicare allows but does not pay, such as deductibles and co-payments.

The total benefits paid under Medicare and the Health and Welfare Fund cannot exceed the expenses incurred.

Should you be entitled to Medicare benefits and not enroll for coverage, the Health and Welfare Fund will not pay any claims submitted to the Fund as the primary insurance carrier.  When you become entitled to Medicare benefits, you must enroll for both Medicare Part A and Medicare Part B coverage.

If you did not enroll for Medicare benefits when you were initially entitled, you may sign up during the general enrollment period, which runs from January 1st through March 31st each year.

Should you have any questions concerning Medicare enrollment and coverage benefits, you should contact a Social Security Administration office or you may contact Medicare at 1-800-772-1213 or online at www.Medicare.gov.

International Union of Operating Engineers Local 132 retirees, under the condition they continued their Health and Welfare coverage at the time of retirement, are permitted to continue their coverage when they become entitled to Medicare benefits.  Each participant must realize when they begin Medicare coverage, they must enroll in both Part A (Hospital Benefits) and Part B (Medical Benefits) in order for the Health and Welfare Fund to continue their coverage.  In converting to the Medicare Supplemental Plan, the retirees will receive the same prescription coverage they had through the Fund while they were active employees or making the required self-contributions for full coverage.

Life Insurance Conversion Privilege

Upon becoming entitled to Medicare Benefits, the retirees eligible for coverage and were covered for the Life Insurance benefits under the group plan must convert this policy to an Individual Policy.  The Fund Office will provide you with the proper forms to convert your life insurance and the instructions for completing.  Please note, once you convert your life insurance to an individual policy, the Fund Office will no longer be able to provide information regarding coverage and your premiums, you will need to contact the Life Insurance carrier directly.

Eligibility Requirements for the Medicare Supplemental Plan

In order for you to participate in the Medicare Supplemental Plan you must:

  • Be eligible for benefits on the date you retire, been covered under the Fund for at least sixty (60) benefit quarters over your working lifetime, and be eligible for Medicare benefits on that date; or
  • Maintain your eligibility with the Fund by self-contribution from the date of your retirement until the date you become entitled to Medicare benefits and been eligible for at least sixty (60) benefit quarters over your working lifetime; and
  • Complete an application for the Medicare Supplemental Plan; and
  • Pay the required self-contribution each month.

In order for your spouse to participate in the Medicare Supplemental Benefit Plan you must:

  • Have maintained eligibility for your spouse under the Fund on a continuous basis from the date of your retirement until your spouse becomes eligible for Medicare, if not eligible for Medicare benefits on the date of your retirement; and
  • Complete an application for Family Medicare Supplemental Benefits; and
  • Pay the required self-contribution amount each month.

Spouses of deceased employees or retirees will be permitted to continue the Medicare Supplemental Plan if benefit eligibility was maintained from the date of the spouse’s death until eligible for Medicare or if eligible for Medicare at the spouse’s death.

You will not be permitted to reinstate your eligibility under the Fund in order to purchase the Medicare Supplemental Plan.

Eligibility under the Medicare Supplemental Plan will continue for you and your spouse, if applicable, until the earliest of the following dates:

  • The date the required self-contribution premium is due and unpaid;
  • The date on which a self-contribution payment is rejected by a bank for insufficient funds;
  • The date the Medicare Retirees Benefit Plan is terminated; or
  • The date the IUOE Local 132 Health and Welfare Fund terminates.

Payment of Claim

Payment of benefits will be made at regular intervals occurring at least once every thirty (30) days.  When payment is made, you will receive an Explanation of Benefits (also known as an EOB) which will explain how the claim was processed.  Included on this EOB is the provider’s original charge, the allowable amount, any deductible amount and Plan payment.  This EOB will also show your member liability, or the amount which you are required to pay directly to the provider.  Should there be no member liability, you will still receive an EOB showing the allowable amount was paid in full.  You should always retain all EOBs and notices from the Plan for your records.

How Your Claim is Processed

After you have met your calendar year deductible with the Fund, the Medicare Supplemental Plan will process all covered charges at 80% of the Medicare deductibles or the co-insurance amounts.

Shown below are two simple examples of how a claim would be processed, assuming you have already met your calendar year deductible with the Plan:

Physician Charges
Medicare Allows
Medicare Pays
Balance
$100
$100
$80
$20
  Hospital Inpatient Stay
Medicare Allows
Medicare Pays
Inpatient Deductible
$22,329
$8,359
$5,714
$1,216
Fund Pays
You Pay
$16
$4
  Fund Pays
You Pay
$973
$243

Your Prescription Drug Coverage and Medicare

Medicare prescription drug coverage became available in 2006 to everyone with Medicare, and was provided through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage.  All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare.  Some plans may also offer more coverage for a higher monthly premium.

The IUOE Local 132 Health and Welfare Fund has determined that the prescription drug coverage offered by the Health and Welfare Fund is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage and is considered Creditable Coverage.

Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage.

Individual’s can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15th through December 31st.  Beneficiary’s leaving employer/union coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan.

You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area.

If you do decide to enroll in a Medicare prescription drug plan and drop your IUOE Local 132 Health and Welfare coverage, be aware that you and your dependents cannot get this coverage back.  Please contact the Fund Office for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan.

The Medicare Supplemental Plan pays for other health expenses in addition to prescription drugs.  If you enroll in a Medicare prescription drug plan, you and your eligible dependents will not be eligible to receive all of your current health and prescription drug benefits.

You should also know that if you drop or lose your coverage through the IUOE Local 132 Health and Welfare Fund and do not enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later.

If you go sixty-three (63) days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage.  For example, if you go nineteen (19) months without coverage, your premium will always be at least 19% higher than what many other people pay.  You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage.  In addition, you may have to wait until the following November to enroll.

You will receive a Notice annually from the Fund Office regarding Medicare prescription drug coverage, as well as other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage.  You can also contact the Fund Office and request that a copy of the most recent notice be sent to you.

If you enroll in one of the plans approved by Medicare which offers prescription drug coverage, you may be required to provide a notice, verifying your coverage through the Health and Welfare Fund, when you join to show that you are not required to pay a higher premium amount.

More detailed information about Medicare plans that offer prescription drug coverage are in the “Medicare & You” handbook.  You’ll get a copy of the handbook in the mail every year from Medicare.  You may also be contacted directly by Medicare prescription drug plans.  For more information about Medicare prescription drug plans:

  • Visit www.medicare.gov
  • Call your State Health Insurance Assistance Program (see your copy of the “Medicare & You” handbook for their telephone number) for personalized help
  • Call 1-800-MEDICARE (1-800-633-4227).  TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available.  Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778).

Key Terms and Definitions

These are some of the terms used in your booklet.  Some other terms are described where they are used.  Please read them carefully.  It can help you to better understand your benefits.

Whenever a personal pronoun in the masculine gender is used, it includes the feminine, unless the context clearly indicates otherwise.

Covered Charges” means the reasonable and customary charges which are incurred for the medically necessary treatment of conditions that are covered under this Plan.

Day of Hospital Confinement” means a period of twenty-four (24) hours or less for which the hospital makes a full daily room and board charge.

Dependent” means your spouse, and each of your unmarried children less than nineteen (19) years of age, excluding individual who is a full-time military, naval or air service.  A child who has attained age nineteen (19) will continue to be eligible as a dependent until the child’s twenty-third (23rd) birthday if unmarried, a full-time student at an accredited college or technical school, and not eligible under any other plan.

The word “child” includes the following:

  1. Your biological child;
  2. A legally adopted child, including a child placed with you for the duration of the probationary period, without regard to whether the adoption becomes final;
  3. A stepchild residing with you for whom you provide sole support (evidenced by federal income tax returns) where the applicable divorce decree does not obligate the other biological or legal parent to provide health care or health insurance coverage;
  4. A child permanently residing in your household for whom you provide sole support, provided you are related to the child by blood or marriage and you have been granted legal custody by a court of record; and
  5. Any child named in a Qualified Medical Child Support order satisfying all conditions outlined in the Omnibus Budget Reconciliation Act of 1993.

While your Dependent Coverage is in affect, newly acquired dependents automatically become Covered Individuals on the date they meet this definition of “dependent,” subject to the effective date.  If you die, the eligibility of your dependents shall continue to the end of the normal termination date, as outlined in “Termination of Coverage”.

Dependent Coverage” means coverage under the Plan with respect to your dependents.

Hospital” means an institution which:

  1. is primarily engaged in providing, by or under the supervision of Physicians, inpatient diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation of injured, disabled or sick persons; and
  2. maintains clinical records on all patients; and
  3. has bylaws in effect with respect to its staff of Physicians; and
  4. has a requirement that every patient be under the care of a Physician; and
  5. provides twenty-four (24) hour nursing service rendered or supervised by a registered professional nurse; and
  6. has in effect a hospital utilization review plan; and
  7. is licensed pursuant to any state or agency of the state responsible for licensing Hospitals; and
  8. has accreditation under on of the programs of the Joint Commission on Accreditation of Hospitals.

Hospital” does NOT mean any institution, or part thereof, which is used principally as a rest facility, nursing facility, convalescent facility or facility for the aged.  It does NOT mean any institution that makes a charge that you or your dependents are not required to pay.  However, the term shall include any rehabilitative facility which is licensed by the state for the treatment of alcoholism or drug abuse.

Illness” means a bodily sickness, disorder or disease.  The Plan treats pregnancy as if it were an illness for you or your eligible dependents.

Injury” means all damage to you or your eligible dependent’s body which is caused by an accident while this Plan is in force and which results directly and independently of all other causes in a loss covered under this Plan.

Inpatient” is a Covered Individual who incurs a hospital charge for a day of hospital confinement in other than the outpatient department of the hospital.

Medically Necessary” means the services, supplies, treatment and confinement must be generally recognized in the physician’s profession as effective and essential for treatment of the injury or illness for which it is ordered and that they must be rendered at the appropriate level of care in the most appropriate setting based on diagnosis.  To be considered “Medically Necessary”, the care must be based on generally recognized and accepted standards of medical practice in the United States and it must be the type of care that could not have been omitted without an adverse effect on the patient’s condition or the quality of medical care.  In addition, services, treatment, supplies or confinement shall not be considered “Medically Necessary” if they are an Experimental Procedure, or if investigational or primarily limited to research in their application to the injury or illness; or if primarily for scholastic, educational, vocational or developmental training; or if primarily for the comfort, convenience or administrative ease of the provider or the patient or his or her family or caretaker.

The definition and determination of Medically Necessary shall not apply to any services which are covered under the Plan as preventive services.  Preventive services means those services and supplies used for routine physical examinations and any such other services which are not for the treatment of an injury or illness, but which are for prevention of disease and for maintenance of good health which may otherwise be covered under the Plan.

Participant Coverage” means coverage under the Plan with respect to yourself.

Physician” means a duly licensed doctor of medicine authorized to perform medical or surgical service within a lawful scope of his practice, and shall also include any other health care provider or allied practitioner as mandated by State Law.

Totally Disabled” when used in reference to the Health coverage means, with respect to you, that you, due solely to Injury or Illness, are prevented from engaging in your regular or customary occupation and you receive no remuneration for any other work or service.  With respect to a dependent, this means that he, due solely to Injury or Illness, is prevented from engaging in substantially all of the normal activities of a person of like age and like sex who is in good health.  This definition does NOT apply to Life Insurance.

Usual, Reasonable and Customary” means the usual charge made by a person, a group or an entity which renders or furnishes the services, treatment or supplies that are covered under this Plan.  In no event does it mean a charge in excess of the general level of charges made by others who render or furnish such services, treatments or supplies to persons; (a) who reside in the same area and (b) whose illness is comparable in nature and severity.  The term “area” means a county or such greater area that is necessary to obtain a representative cross section of the usual charges made.

Notice of Privacy Practices

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

 

Effective Date of Notice:  September 2013

 

The IUOE Local 132 Health and Welfare Fund is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:

  • the Plan’s uses and disclosures of Protected Health Information (PHI);
  • your privacy rights with respect to your PHI;
  • the Plan’s duties with respect to your PHI;
  • your right to file a complaint with the Plan and to the Secretary of the US Department of Health and Human Services; and
  • the person or office to contact for further information about the Plan’s privacy practices.

The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic.) and when applicable includes “genetic information.” PHI is protected for 50 years after the death of a participant or beneficiary after which it is no longer PHI.

 

Section 1.  Notice of PHI uses and Disclosures

Upon your request, the Plan is required to give you access to certain PHI in order to inspect and copy it.

Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations.

 

Uses and disclosures to carry out treatment, payment and health care operations

 

The Plan and its business associates will use PHI without your consent, authorization or opportunity to agree or object to carry out treatment, payment and health care operations.  The Plan also will disclose PHI to the Plan Sponsor (Trustees of the IUOE Local 132 Health and Welfare Fund) for purposes related to treatment, payment and health care operations.  The Plan Sponsor has amended its plan documents to protect your PHI as required by federal law.

 

Treatment is the provision, coordination or management of health care and related services.  It also includes but is not limited to consultations and referrals between one or more of your providers.

 

For example, the Plan may disclose to a medical specialist the name of your primary doctor so that the specialist may ask questions or receive historical medical information in order to make treatment decisions.

 

Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims management, subrogation, plan reimbursement, reviews for medical necessity and appropriateness of care and utilization review and pre-authorizations.)

 

For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.

 

Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts.  It also includes disease management, case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities.  The disclosure of PHI that is genetic information for underwriting purposes is prohibited.
For example, the Plan may use information about your claims to refer you to a disease management program, project future benefit costs or audit the accuracy of its claims processing functions.

 

Uses and disclosures that require your written authorization

 

Your written authorization generally will be obtained before the Plan will use or disclose psychotherapy notes about you from your psychotherapist.  Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session.  They do not include summary information about your mental health treatment. The Plan may use and disclose such notes when needed by the Plan to defend against litigation filed by you. Your written authorization is also required before the Plan could sell PHI or use it for marketing.

Use and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release

Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if:

  • the information is directly relevant to the family or friend’s involvement with your care or payment for that care; and
  • you have either agreed to the disclosure or have been given an opportunity to object and have not objected.

Uses and disclosures for which consent, authorization or opportunity to object is not required

 

Use and disclosure of your PHI is allowed without your consent, authorization or request under the following circumstances:

  1. When required by law.
  2. When permitted for purposes or public health activities, including when necessary to report product defects, to permit product recalls and to conduct post-marketing surveillance.  PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if authorized by law.
  3. When authorized by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence.  In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm.  For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made.  Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI.
  4. To a public health oversight agency for oversight activities authorized by law.  This includes uses or disclosures in civil, administrative or criminal investigation; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud.)
  5. When required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request provided certain conditions are met.  One such condition is that satisfactory assurances be given to the Plan that the requesting party has made a good faith attempt to provide written notice to you, and the notice provided sufficient information about the proceeding to permit you to raise an objection and no objections were raised or were resolved in favor of disclosure by the court or tribunal.
  6. When required for law enforcement purposes (for example, to report certain types of wounds.
  7. To organ procurement organizations for cadaveric organ, eye, or tissue donation purposes.
  8. If you are in the Armed Forces and your PHI is needed by military command authorities.  The Fund may also disclose your PHI for the conduct of national security and intelligence activities and for other specialized government functions such as protective services for the President, Medical suitability determinations, correctional institutions and other law enforcement custodial situations.
  1. For law enforcement purposes, including the purpose of identifying or locating a suspect, fugitive, material witness or missing person.  Also, when disclosing information about an individual who is or is suspected to be a victim of a crime but only if the individual agrees to the disclosure or the covered entity is unable to obtain the individual’s agreement because of emergency circumstances.  Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of the Plan’s best judgment.
  2. When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law.  Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.
  3. For medical research subject to conditions.
  4. When consistent with applicable law and standards of ethical conduct if the Plan, in good faith believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
  5. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
  6. To disclose proof of immunization to schools in States that have school entry or similar laws.

 

Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization.

 

Section 2.  Rights of Individuals

 

Right to Request Restrictions on PHI Uses and Disclosures

You may request the Plan to restrict uses and disclosures of your PHI to carry out treatment, payment or health care operations, or to restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care.  However, the Plan is not required to agree to your request.  The Plan is required to grant a requested restriction if: (1) the disclosure is to a health plan for purposes of carrying out payment or health care operations and is not for purposes of carrying out treatment; and (2) the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full.

 

The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations.

 

You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your PHI.

 

Such requests should be made to the privacy officer, Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

Right to Inspect and Copy PHI

 

You have the right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the Plan uses or maintains your PHI in an electronic health record, you have a right to obtain a copy of this information in an electronic format.

 

“Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written electronic) and when applicable includes genetic information.

 

“Designated Record Set” includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for a health plan; or other information used in whole or in part by or for the covered entity to make decisions about individuals.  Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set.

 

The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite.  A single 30-day extension is allowed if the Plan is unable to comply with the deadline.

 

You or your personal representative will be required to complete a form to request access to the PHI in your designated record set.  Requests for access to PHI should be made to the privacy officer, Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise those review rights and a description of how you may complain to the Secretary of the US Department of Health and Human Services.

 

Right to Amend PHI

 

You have the right to request the Plan to amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set.

 

The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.  If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial.  You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI.

 

Requests for amendment of PHI in a designated record set should be made to the privacy officer, Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

You or your personal representative will be required to complete a form to request amendment of the PHI in your designated record set.

 

The Right to Receive an Accounting of PHI Disclosures

 

At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request.  However, such accounting need not include PHI disclosures made: 1) to carry out treatment, payment or health care operations; 2) to individuals about their own PHI; or 3) prior to the compliance date.  However, electronic health records disclosed for purposes of payment or health care operations are subject to your right to an accounting for disclosures made up to three years before the date of your request.

 

If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided.

If you request more than one accounting within a 12 month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting.

 

The Right to Receive a Paper Copy of This Notice Upon Request

 

To obtain a paper copy of this notice contact the privacy officer,  Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

A Note About Personal Representatives

 

You may exercise your rights through a personal representative.  Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you.  Proof of such authority may take on of the following forms:

  • a power of attorney for health care purposes, notarized by a notary public;
  • a court order of appointment of the person as the conservator or guardian of the individual; or
  • an individual who is the parent of a minor child.

The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.  This also applies to personal representatives of minors.

 

Section 3.  The Plan’s Duties

 

The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of its legal duties and privacy practices.  If your PHI is improperly accessed, acquired, used, or disclosed, the Plan will notify you, as required by law.  That notification may include a description of what happened, the information involved, and the steps you can take to protect yourself.

 

This notice is effective beginning April 1, 2013 and the Plan is required to comply with the terms of this notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date.  If a privacy practice is changed, a revised version of this notice will be provided in writing to all past and present participants and beneficiaries for whom the Plan still maintains PHI.

 

Any revised version of this notice will be distributed within 60 days of the effective date of any material change to the uses or disclosures, the individual’s rights, the duties of the Plan or other privacy practices stated in this notice.

 

Minimum Necessary Standard

 

When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.

However, the minimum necessary standard will not apply in the following situations:

  • disclosures to or requests by a health care provider for treatment;
  • uses or disclosures made to the individual;
  • disclosures made to the Secretary of the US Department of Health and Human Services;
  • uses or disclosures that are required by law; and
  • uses or disclosures that are required for the Plan’s compliance with legal regulations.

This notice does not apply to information that has been de-identified.  De-identified information does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual and is therefore not considered to be individually identifiable health information.

 

In addition, the Plan may use or disclose “summary health information” to the Plan sponsor for obtaining premium bids or modifying, amending or terminating the group health plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor has provided health benefits under a group health plan; and from which identifying information has been deleted in accordance with HIPAA.

 

Section 4.  Your Right to File a Complaint with the Plan or the HHS Secretary

 

If you believe that your privacy rights have been violated, you may complain to the Plan in care of the privacy officer, Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

You may file a complaint with the Secretary of the US Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201.  The Plan will not retaliate against you for filing a complaint.

 

Section 5.  Whom to Contact at the Plan for More Information

 

If you have any questions regarding this notice or the subjects addressed in it, you may contact the privacy officer, Mr. Jerry Moore, IUOE Local 132 Health and Welfare Fund, 636 Fourth Avenue, Second Floor, Huntington, WV 25701 (telephone 304-525-0482 or 800-642-3525).

 

Conclusion

 

PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act.)  You may find these rules at 45 Code of Federal Regulations Parts 160 and 164.  This notice attempts to summarize the regulations.  The regulations will supersede any discrepancy between the information in this notice and the regulations.

 

Rights and Protections Under ERISA

As a Participant in the Fund 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:

  1. Examine, without charge, at the plan administrator’s office and at other specified locations, such as worksites and union halls, all plan documents including insurance contracts, collective bargaining agreements and copies of all documents filed by the plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions.
  2. Obtain copies of all plan documents and other plan information upon written request to the plan administrator.  The administrator may make a reasonable charge for the copies.
  3. 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 the summary annual report.

In addition to creating rights for plan participants, ERISA imposes duties on the people who are responsible for the operation of the employee benefit plan.  The people who operate your plan, called “Fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries.  No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit under this plan or exercising your rights under ERISA.  If your claim for a benefit under this plan is denied in whole or in part you must receive a written explanation of the reason for the denial.  You have a right to have the plan review and reconsider your claim.

Under ERISA, there are steps you can take to enforce the above rights.  For Instance, if you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court.  In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.  If you have a claim for benefits which is denied or ignored in whole or in part, you may file suit in a state or federal court.  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.

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, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

Important Information Required by ERISA

This is your Summary Plan Description.  Contributions to this Plan are made by Participating Employers based on the negotiated contribution rates set forth in Collective Bargaining Agreements.

PLAN SPONSOR AND ADMINISTRATOR

Trustees of the International Union of Operating
Engineers Local No. 132 Health and Welfare Fund
PO Box 2626
Huntington, WV  25726-2626
(304) 525-0482

E.I.N. 55-0455491   |   Plan Number:  501

Plan Administrator
The Plan is administered by the Board of Trustees

Trustees of the Plan


Union Trustees


Employer Trustees


Charles A. Parker, Business Manager
IUOE Local 132, AFL-CIO
606 Tennessee Avenue
Charleston, WV  25362-0770


D.W. “Bud” Daniel, Jr.
Wayne Concrete Company, Inc.
PO Box 342
Barboursville, WV  25504-0342


Rodney Marsh
IUOE Local 132, AFL-CIO
PO Box 796
Pineville, WV  24874-0796


John M. Farley, II
Triton Construction Company
PO Box 908
Nitro, WV  25143-0908


AGENT FOR SERVICE OF LEGAL PROCESS

Lawrence B. Lowry, Esquire
Barrett, Chafin, Lowry & Amos
PO Box 402
Huntington, WV  25708-0402

(Legal Process may also be served upon a Trustee)

The Plan Year starts on July 1st and ends on June 30th, and consists of an entire twelve (12) month period for the purposes of accounting and all reports to the United States Department of Labor and other regulatory bodies.

Collective Bargaining Agreements, and names of the parties thereto and their expiration dates, may be reviewed at the Fund Office.

The Collective Bargaining Agreements are between the International Union of Operating Engineers Local No. 132 and various Employers who have entered into labor contracts with the Union.

Upon written request, the Administrator will furnish you with information as to whether a particular Employer participates in the Plan, and if so, his address.