Health & Welfare Fund Summary Plan Description (SPD)

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.

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.

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.

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.

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
Loss of one arm or leg and sight of one eye
Loss of one arm, one leg, or sight of one eye
$25,000
$25,000
$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.

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.

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

  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.