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:

Qualifying Schedule

The following table defines the work quarters and corresponding eligibility quarters.

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”.

Any hours worked and reported in excess of the required 375 hours in a Work Quarter are permitted to be carried over to the next Eligibility Quarter.  You are permitted to carryover hours from the previous three (3) work quarters.

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 seventy-five (375) 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, adoption papers and/or verification of full-time student status.

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 seventy-five (375) 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 (62^nd) 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.