ibew local no. 461 welfare fund summary plan description

Transcription

IBEW LOCAL NO. 461
WELFARE FUND
SUMMARY PLAN DESCRIPTION
BENEFITS AND ELIGIBILITY RULES
AUGUST 2014
IBEW Local No. 461 Welfare Fund
Summary Plan Description
________________________________
PAGE
INTRODUCTION
SECTION I - SCHEDULE OF BENEFITS
CLASS A
Active Members & Their Dependents...................................................................... A-E
CLASS B
Retired Or Disabled Members And Their Eligible Dependents Who are not
Eligible For Medicare................................................................................................... F
CLASS C
Retired Or Disabled Members And Their Eligible Dependents Who are
Eligible For Medicare...................................................................................................G
SECTION II - ELIGIBILITY RULES
Disqualifying Employment .......................................................................................... 1
Initial Eligibility (Bargaining Unit Employees............................................................. 1
Continuation of Eligibility – Employer Contributions ................................................. 2
Reserve Accumulation Account “Hour Bank” ............................................................. 2
Self-Payment of Contributions ................................................................................... 2
Participation Agreements for Non-Bargaining Unit Participants ............................... 3
Self-Pay When Disabled .............................................................................................. 4
Continuation of Eligibility During Disability ............................................................... 4
Total and Permanent Disability .................................................................................. 5
Self-Payment............................................................................................................... 5
Work Outside Trust Fund Jurisdiction - Reciprocity................................................... 5
Termination of Eligibility for Employees and their Dependents When Entering
Military Service.......................................................................................................... 6
Reinstatement of Eligibility ........................................................................................ 6
Employees ................................................................................................................... 6
RETIREE PROGRAM
Coverage Classifications Defined................................................................................ 7
Class B ......................................................................................................................... 7
Class C ......................................................................................................................... 7
General Eligibility Requirements ................................................................................ 7
Self-Payment of Contributions ................................................................................... 8
Benefit Limitations...................................................................................................... 8
Effective Dates Of Coverage ....................................................................................... 9
Employee..................................................................................................................... 9
Dependents ................................................................................................................. 9
Termination Dates of Coverage .................................................................................. 9
Employee..................................................................................................................... 9
Dependents ................................................................................................................. 9
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General Provisions .................................................................................................... 10
Change of Eligibility Rules ........................................................................................ 10
A Note of Explanation ............................................................................................... 10
Health Insurance Portability and Accountability...................................................... 11
Family and Medical Leave ......................................................................................... 11
Cobra Continuation Coverage ................................................................................... 12
Employee................................................................................................................... 12
Spouse....................................................................................................................... 13
Dependent Children .................................................................................................. 14
Disabled Eligible Employee ....................................................................................... 14
Employee Obligations to Notify the Fund Office of a Qualifying Event.................... 15
Second Qualifying Event ........................................................................................... 16
Proof of Insurability is not Necessary to Elect Continuation Coverage ................... 17
Procedure for Obtaining Continuation Coverage ..................................................... 17
Termination of Continuation Coverage..................................................................... 17
Qualified Medical Child Support Orders.................................................................... 18
Receipt of Order ........................................................................................................ 18
Determination of Qualification ................................................................................. 18
Effect of National Medical Support Notices .............................................................. 18
Status of Alternate Recipients .................................................................................. 18
Direct Payments........................................................................................................ 18
Notification Issues .................................................................................................... 18
General Definitions ................................................................................................... 20
SECTION III - MAJOR MEDICAL BENEFITS
Introduction .............................................................................................................. 33
Preferred Provider Organization (PPO) .................................................................... 33
Non-Preferred Provider Organization (PPO) ............................................................ 33
The Deductible Amount ............................................................................................ 33
Maximum Deductible Amount for Families.............................................................. 33
Co-Payment.............................................................................................................. 34
The Maximum Amount ............................................................................................. 34
Co-Payment Limit for Individuals ............................................................................ 34
Hospital Expense Benefits ....................................................................................... 34
Daily Room Benefit .................................................................................................. 34
Miscellaneous Charges While Confined ................................................................... 35
Out-Patient Hospital Treatment .............................................................................. 35
Charges Related to Hospital Treatment................................................................... 35
Limitations ............................................................................................................... 35
Hospital Pre-Admission Testing ................................................................................ 36
Surgical Expense Benefit .......................................................................................... 37
Limitations................................................................................................................ 37
Second Surgical Opinion Benefits ............................................................................. 38
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Diagnostic X-Ray and Lab Benefits........................................................................... 38
Limitations ................................................................................................................ 39
In-Hospital Physician Benefits.................................................................................. 39
Covered Expenses ..................................................................................................... 40
Limitations ................................................................................................................ 41
Pregnancy Expense Benefits..................................................................................... 42
Limitations ................................................................................................................ 43
Statement of Rights Under the Mother’s and Newborn’s Health Protection Act ..... 43
Newborn Dependent Child Benefits.......................................................................... 43
Crib Care.................................................................................................................... 44
Newborn Examination .............................................................................................. 44
Newborn Circumcision .............................................................................................. 44
Birth Coverage ............................................................................................................ 44
Limitations ................................................................................................................ 44
SECTION IV – BENEFITS WITH SPECIAL LIMITATIONS
Weekly Accident and Sickness Benefits (Loss of Time) ........................................... 47
Active Employees Only.............................................................................................. 47
Application for Loss of Time Benefits ....................................................................... 47
Period of Disability.................................................................................................... 47
Limitations ................................................................................................................ 47
Chiropractic Expense Benefits ...................................................................................... 48
Limitations ................................................................................................................ 48
Physical Therapy Expense Benefits ......................................................................... 49
Home Health Care Benefits....................................................................................... 49
Limitations ................................................................................................................ 49
Elective Sterilization Benefit (Employee or Spouse Only)........................................ 50
Limitations ................................................................................................................ 50
Mental Health and Substance Abuse Benefits .......................................................... 50
In-Patient Treatment ................................................................................................ 50
Out-Patient Treatment.............................................................................................. 51
Limitations ................................................................................................................ 51
Co-Payment............................................................................................................... 51
Maximum amount Payable ....................................................................................... 52
In-Patient Benefits.................................................................................................... 52
Out-Patient Benefits ................................................................................................. 52
Limitations ................................................................................................................ 53
Well Child Care Benefits and Routine Physical Examination Benefit ....................... 54
Limitations ................................................................................................................ 54
Prescription Drug Benefits........................................................................................ 54
Hearing Care Benefits ............................................................................................... 55
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Eligibility ................................................................................................................... 55
The Deductible Amount ............................................................................................ 55
Co-Payment............................................................................................................... 55
The Maximum Amount .............................................................................................. 55
Limitations ................................................................................................................ 56
Organ Transplant Benefit.......................................................................................... 56
Eligibility ................................................................................................................... 56
Co-Payment - PPO..................................................................................................... 56
Co-Payment – Non-PPO ............................................................................................ 57
Limitations ............................................................................................................... 57
SECTION V – DENTAL CARE BENEFITS
Predetermination of Benefits.................................................................................... 59
Expense Incurred ...................................................................................................... 61
Treatment in Progress When Eligibility Terminates ................................................. 62
Limitations ................................................................................................................ 62
SECTION VI – VISION CARE BENEFITS
Covered Expense....................................................................................................... 65
Limitations ................................................................................................................ 66
Surgery to Correct Vision Deficiencies ..................................................................... 66
Vision Therapy........................................................................................................... 67
SECTION VII – DEATH AND DISMEMBERMENT BENEFITS
Death Benefits........................................................................................................... 69
Beneficiary Designation ............................................................................................ 69
Notice of Claim .......................................................................................................... 69
SECTION VIII – MEDICAL SAVINGS BENEFIT
How the Medical Savings Benefit Works .................................................................. 71
What the Money Can Be Used For............................................................................. 71
How to Use the Medical Savings Plan ....................................................................... 71
Medical Savings Benefit and Supplemental Benefit Account ................................... 72
Eligible Healthcare Expenses .................................................................................... 72
Eligible Medical Expenses ......................................................................................... 72
Eligible OTC Expenses – Without a Prescription....................................................... 73
Eligible OTC Expenses – With a Prescription ............................................................ 73
Ineligible Medical Expenses...................................................................................... 73
SECTION IX – SUPPLEMENTAL BENEFIT ACCOUNT
Funding ..................................................................................................................... 75
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Participation.............................................................................................................. 75
Eligibility ................................................................................................................... 75
Reimbursable Benefits .............................................................................................. 75
Reimbursement......................................................................................................... 75
Accruing Account Balances ....................................................................................... 76
Non Covered Expenses.............................................................................................. 76
Work in an area outside of the jurisdiction of the Fund........................................... 76
SECTION X – GENERAL PLAN EXCLUSIONS AND LIMITATIONS
Routine Care and Elective Procedures...................................................................... 77
Medical Necessity...................................................................................................... 77
Work Related Disabilities.......................................................................................... 77
Organ Transplants..................................................................................................... 78
Reasonable and Customary Charges ........................................................................ 78
Treatment Sponsored by Governmental Units ......................................................... 78
Treatment Without Charge ....................................................................................... 79
Illegal Occupation or Commission of Felony ............................................................ 79
Experimental Treatment of Procedures.................................................................... 79
Liability for Accidental Injuries ................................................................................ 79
General Limitations................................................................................................... 80
SECTION XI – OTHER GENERAL PLAN PROVISIONS
Physical or Dental Examination and Autopsy ........................................................... 85
Free Choice of Physician ........................................................................................... 85
Workers' Compensation Not Affected....................................................................... 85
Time Limits for Filing Claims..................................................................................... 85
Circumstances That May Result in Loss of Eligibility of Benefits ............................. 86
Claims Review and Appeal Procedures..................................................................... 86
Coordination of Benefits With Other Group Plans.................................................... 90
Benefit Determination .............................................................................................. 91
Claim for a Covered Employee .................................................................................. 91
When Claim is on the Dependent Spouse ................................................................. 92
When Claim is for a Dependent Child ....................................................................... 94
Coordination of Benefits with Medicare ................................................................... 94
Active Employees and/or Their Spouses Who are Eligible for Medicare.................. 95
Active Employees with Dependents Eligible for Medicare........................................ 96
HIPAA- CONFIDENTIAL INFORMATION ............................................................................. 97
SECTION XII - STATEMENT OF PARTICIPANT’S RIGHTS
Information Required by the Employee Retirement Income Security Act (ERISA). 99
Introduction .............................................................................................................. 99
Your Rights as a Participant ..................................................................................... 99
SECTION XIII - OTHER IMPORTANT INFORMATION
The Trustees Interpret the Plan ............................................................................. 105
The Plan Can be Changed ....................................................................................... 105
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Your Plan is Tax Exempt ...................................................................................... 106
Right to Receive and Release Necessary Information ........................................ 106
Facility of Payment............................................................................................... 106
Right of Recovery................................................................................................. 107
Payment of Claims ............................................................................................... 107
Name of the Plan.................................................................................................. 107
Type of Plan.......................................................................................................... 108
Type of Plan Administration................................................................................. 108
Name and Address of Administrator .................................................................... 108
Name and Address of the Agent for Service of Legal Process ............................. 108
Name and Address of Claims Agent ..................................................................... 109
Name and Address of Investment Consultant ..................................................... 109
Name and Address of Member Assistance Program (MAP) ................................. 109
Name and Address of Preferred Provider Organization (PPO) ............................ 109
Name and Address of Prescription Drug Vendor ................................................. 109
Name and Title of Each Trustee ........................................................................... 110
Name and Address of Local Union Office ............................................................. 110
Parties to the Collective Bargaining Agreement.................................................. 110
Internal Revenue Service Employer and Plan Identification Numbers............... 110
Eligibility Requirements ....................................................................................... 111
Sources of Trust Fund Income ............................................................................. 111
Method of Funding Benefits ................................................................................. 111
Fiscal Year of the Plan.......................................................................................... 111
The Plan May be Terminated................................................................................ 111
August 2014
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IBEW LOCAL NO. 461 WELFARE FUND
TO:
ALL PARTICIPANTS
We are pleased to distribute this new Summary Plan Description (SPD) which
explains the benefits available under your Welfare Plan, summarizes the eligibility rules
for participation in the Fund, and presents your rights as a participant. You should take
time to read this new SPD so that you are up-to-date on the protection provided.
The Trustees have elected to provide many of the plan benefits directly from the
assets of the Trust Fund. The Trustees have also elected to use the services of the Blue
Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Network, and purchased
insurance for catastrophic loss. This arrangement is expected to result in cost savings
which will contribute to greater financial security for the Plan, and which may also allow
the Trustees to improve benefits more frequently.
From time to time, changes and improvements in your Plan will be made. We
will keep you fully informed about any changes as they occur.
After you read it, keep this SPD in a convenient place. If you have questions
about your benefits, please call or write the Fund Office for assistance, and have your
SPD available for reference. We encourage each eligible person to use medical care and
these benefits wisely and only when genuinely necessary.
Sincerely,
THE BOARD OF TRUSTEES
Management Trustees
Bruce Anderson, Chairman
Paul Hopkins
Craig Martin
Adam Mata
Union Trustees
Joel Pyle, II, Secretary
Michael Angelo
Steve Musich
Mark Seppelfrick
The Union Administrative Office is open:
Monday, through Friday from 8:00 a.m. to 4:30 p.m.
591 Sullivan Road, Suite 100
Aurora, IL 60506
(630) 897-0461
(630) 897-7605 FAX
August 2014
Introduction Letter
_____________________________________________
THIS PAGE LEFT INTENTIONALLY BLANK
August 2014
Introduction Letter
SECTION I
SCHEDULE OF BENEFITS – CLASS A
ACTIVE EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS
Deductible
Co-pay Dollar
Maximum
Lifetime Maximum
Preventive Services
Health Maintenance
Exam – includes chest xray, EKG, annual
OBGYN exam,
mammogram & select lab
procedures
Well Child & Infant care
– (Birth to age 18)
Immunizations
Fecal Occult Blood
Screening
Flexible Sigmoidoscopy
Exam
Prostate Specific Antigen
(PSA) Screening
In-Network BCBSIL
$100 per person
$300 per family (per
calendar year, combined
with out-of-network
deductible)
$1,600 per person
$3,300 per family (per
calendar year)
None
Out-of-Network
$100 per person
$300 per family (per
calendar year, combined
with out-of-network
deductible)
$3,100 per person
$6,300 per family (per
calendar year)
None
Covered at 100% (no
deductible, no co-pay;
one per person per
calendar year)
Covered at 80% of R&C
(no deductible, no copay; one per person per
calendar year)
Covered at 100%
no deductible, no co-pay
Covered at 100%
Covered at 100%
Covered at 100%
Covered at 100%
Patient is Responsible for any Charges over Reasonable & Customary
August 2014
Section I - Schedule of Benefits
Page A
Major Medical
Hospital Confinement,
Surgery & Physician
Services
Physician Office Services
Office Visits
Outpatient & Home visits
Office Consultations
Urgent Care visits
Emergency Medical Care
Hospital Emergency
Room – medically
necessary
Ambulance Services –
medically necessary
Diagnostic Services
Laboratory & Pathology
Testing
Diagnostic Tests & Xrays
Radiation Therapy
Maternity Services
Pre-natal & Post-natal
care (by a physician)
Delivery & Nursery care
(by a physician)
Hospital Care
Semi-private room, Inpatient
Inpatient Consultations
Chemotherapy
In-Network BCBSIL
Out-of-Network
Covered at 80% of the
first $15,000 after the
deductible then 100%
thereafter
Covered at 65% of the
first $15,000 after the
deductible then 100%
thereafter
Covered at 80% after the
deductible
deductible
deductible
deductible
after the deductible
deductible
deductible
Covered at 80%
deductible
deductible
deductible
deductible
deductible
deductible
deductible
deductible
August 2014
Page B
In-Network BCBSIL
Out-of-Network
Inpatient: 80% after
deductible
Outpatient: paid as Home
Health Care
Inpatient: paid as Major
Medical 80% after the
deductible
Health Care Benefit
Maximum 4 hours/day
up to 30 days/calendar
year – maximum
$100/hour – 80% after
the deductible
Inpatient: 65% of the
R&C after deductible
Health Care
Inpatient: paid as Major
Medical 65% of R&C
Health Care Benefit
Maximum 4 hours/day
up to 30 days/calendar
year – maximum
$100/hour – 65% of
R&C after the deductible
deductible
deductible
Alternatives to hospital care
Skilled nursing care
Hospice Care
Home Health care
Surgical Services
Surgery – includes related
surgical services
Voluntary sterilization
Human Organ Transplants
Specified Organ
Transplants
deductible
Bone marrow
deductible
Kidney, Cornea & Skin
deductible
Mental Health & Substance Abuse Treatment
In-patient Mental Health
Care
deductible
In-patient Substance
Abuse Care
deductible
Out-patient Mental
Health Care
deductible
Out-patient Substance
Abuse Care
deductible
August 2014
Page C
Benefits paid under this section are not eligible for and do not
contribute to the Co-Payment Limit which allows for 100% payment
under the Major Medical Expenses
Other Services
Outpatient Diabetes
Management Program
Chiropractic Spinal
Manipulation
Chiropractic Diagnostic
X-ray & Laboratory
Outpatient Physical &
Occupational Therapy
(Facility, Clinic &
Physicians Office)
Durable Medical
Equipment
Prosthetic & Orthotic
Appliances
Private Duty Nursing
Vision (no PPO
network)
Laser Eye surgery
(Lasik)
Hearing Aid
In-Network BCBSIL
Out-of-Network
Covered at 80% after
the deductible
Covered at 65% of
R&C after the
deductible
Not Covered if Out-ofNetwork
the deductible
– Maximum 24 visits
per person, per calendar
year
Not Covered if Out-ofthe deductible
Network
$200 per person, per
calendar year
maximum
Not Covered if Out-ofthe deductible
Network
$1,500 maximum per
calendar year
Covered at 65% of
the deductible
R&C after the
Rental up to purchase
deductible
price covered under
Major Medical
Covered at 65% of
the deductible
R&C after the
1 per person, per year,
deductible
per diagnosis
Not covered
$600 per person, per benefit period (benefit period is
two years)
50% of R&C after the deductible. Lifetime
maximum of $2,000 per eye
50% of R&C after the deductible. Maximum
payable $2,500 per ear, per person every 5 years
August 2014
Page D
Other Services
Dental
(no PPO network)
TMJ
Prescription Drugs
(including contraceptive
medications paid by
Citizens-Rx)
Preventive – No deductible. Covered at 100%
(exam, cleaning & x-rays)
Restorative & Routine Care – Covered at 80% (Xrays, restorative care, extractions, periodontics &
implants) No deductible.
Orthodontics – (Dependent children only) Maximum
36 month treatment. Covered at 80%.
All Dental (preventive, restorative, routine care &
orthodontics) have a combined maximum of $1,500
per person, per calendar year for members 19 &
older.
Covered at 50% of the R&C up to a lifetime
maximum of $3,000 for both In-network & Out-ofnetwork
Coverage is through Citizens-Rx: Generic is covered
at 80% and Brand Name is covered at 70%. No
Prescriptions are covered when filled at a WalMart. Note: If a Brand Name is available as a
Generic but elected to be filled as a Brand Name,
the Participant will be responsible for all costs
above the 80% coverage of the Generic cost.
Life Insurance – Death
(All causes) Participant
only
Weekly Loss of Time
Benefits
$1,000
Non-Occupational Injury or Illness Benefit –
Payment Begins – For accident 1st day disabled and
For sickness 8th day disabled
Weekly Payment Rate - $400
Maximum Payment Period – 18 weeks
Occupational Injury or Illness Benefit – Not
Covered.
August 2014
Page E
SCHEDULE OF BENEFITS – CLASS B
RETIRED EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS
WHO ARE NOT ELIGIBLE FOR MEDICARE
Your benefits are the same as those listed for Class A except as noted
below:
Death Benefit – All
causes (Retirees
ONLY)
Weekly Loss of Time
Benefit
Comprehensive Major
Medical Benefits
Dental Care Benefit
Vision Care Benefit
$500
Non-Occupational or Occupational – Not Covered
Generally the same as Class A Benefits except:
Excludes Elective Sterilization
Excludes Pregnancy Expense Benefits & Newborn
Child Benefits
Same as Class A
Same as Class A
Patient Is Responsible For All Charges Over Reasonable and
Customary
August 2014
Page F
SCHEDULE OF BENEFITS – CLASS C
RETIRED EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS
WHO ARE ELIGIBLE FOR MEDICARE
Maximum Benefit (All
Plan Benefits,
Including Prescription
Drugs)
Death Benefit – All
causes, Retiree only
Weekly Loss of Time
Benefit
Major Medical Benefits
Medicare Hospital (Part
A)
Medicare Professional
Services (Part B)
Prescription Drug
Benefits – Citizens-Rx
Dental Care Benefit
Vision Care Benefit
Maximum per person, per calendar year
(includes prescriptions purchased through
Citizens-Rx) - $3,000
$500
Non-Occupational or Occupational – Not Covered
Generally the same as Class A Benefits except:
Excludes Elective Sterilization
Excludes Pregnancy Expense Benefits & Newborn
Child Benefits
Deductible – Not covered
Deductible – Not covered
Plan Pays 100% of patient’s 20% of Medicare’s
Allowable
Amounts in Excess of Medicare’s Allowable – Not
covered (subject to yearly maximum
Coverage is through Citizens-Rx: Generic is covered
at 80% and Brand Name is covered at 70%. No
Prescriptions are covered when filled at a WalMart. Note: If a Brand Name is available as a
Generic but elected to be filled as a Brand Name,
the Participant will be responsible for all costs
above the 80% coverage of the Generic cost.
Not Covered
Not Covered
August 2014
Page G
August 2014
Page H
SECTION II
ELIGIBILITY RULES – BARGAINING UNIT EMPLOYEES
Disqualifying Employment
Effective October 21, 2002, the Trustees have amended the Plan to
provide that a Participant who works in Disqualifying Employment shall forfeit all
of the unused accumulated hours in his/her hour bank.
“Disqualifying Employment” has three (3) components:
1.
employment for a non-contributing employer, or self-employment
as a non-contributing employer,
2.
in a position as an electrician or a supervisor in the electrical industry,
3.
within the geographical area that includes the State of Illinois plus
the remainder of any Standard Metropolitan Statistical Area which
falls in part within the State of Illinois.
A Participant who engages in any Disqualifying Employment will forfeit
the accumulated unused hours in his/her hour bank irrespective of
whether the Participant has also performed work for a Contributing
Employer during the same time period.
All Employees working for a Contributing Employer or Employers within
the jurisdiction of the Fund shall be eligible to receive benefits after meeting the
following eligibility requirements. Eligibility is based on Work Month and
Eligibility Month.
Initial Eligibility (Bargaining Unit Employees)
You will become initially eligible on the first day of the month following a
two-month accounting period if you have been employed by a contributing
Employer or Employers and those Employers have made contributions to the
Fund on your behalf for at least 300 hours worked within a period of
twelve (12) consecutive calendar months or less. Your initial period of
eligibility continues for the remainder of that “Eligibility Month”.
August 2014
Section II - Eligibility Rules
Page 1
Continuation of Eligibility – Employer Contributions
After your period of initial eligibility, you continue to be eligible so long as
you are working for a contributing Employer or Employers and those Employers
made contributions on your behalf for at least one hundred fifteen (115) hours in
one month. You are then eligible the first day of the month following a twomonth accounting period in which the hours were worked.
For example, because the contributions for hours worked in any month
are not made to the Plan until the following month, your current work earns
future eligibility as follows:
Contribution Month
Work Performed During…..
Eligibility Month
Determines Eligibility For…..
January
February
March
April
May
June
July
August
September
October
November
December
April
May
June
July
August
September
October
November
December
January
February
March
Reserve Accumulation Account “Hour Bank”
After initial eligibility all hours worked in excess of the one hundred fifteen
(115) credited hours per month required thereafter for continued monthly
eligibility will be credited to your individual Hour Bank. Accumulated hours in
your Hour Bank allow you to continue your eligibility during periods of
unemployment and underemployment. The Hour Bank maximum can afford you
up to six (6) months of eligibility. If you become ineligible for more than thirtysix (36) months any accumulated bank hours will become forfeit.
Self-Payment of Contributions
After becoming initially eligible, you may be allowed to make selfpayments of contributions if you are in danger of losing eligibility due to a period
of unemployment. To be eligible to make self-payments, you must be available
August 2014
Page 2
for work at covered employment in the Industry with an Employer who
participates in this Fund.
If your monthly contributions are less than the required one hundred
fifteen (115) any available hours in your hour bank are utilized and then you can
self-pay the difference based on the number of hours short at the current
contribution rate.
Self-payments must be received at the Fund Office within ten (10) days of
the date the Termination Notice is received by you. All Notices are sent by first
class mail to the last known address on file at the Fund Office so it is important
that any address changes are reported immediately.
Eligibility by means of self-payments can be continued for no more than
twelve (12) consecutive Benefit Months, whether or not the self-payment is full
or partial.
After your right to make self-contributions is exhausted, you may be able
to elect COBRA Continuation Coverage at a self-contribution level based on the
actual cost of coverage to the Plan. This is allowed for a maximum of twentyfour (24) months.
When you are eligible by self-payments, you and your eligible Dependents
are covered by the same benefits as all other Employees; all normal Plan
provisions apply.
Participation Agreements for Non-Bargaining Unit Participants
Employers, that have executed a Participation Agreement, must contribute
at the prescribed rate as determined by the Board of Trustees for all full time (as
defined in their Participation Agreement) Non-Bargaining Unit Employees
regardless of the number of actual hours worked by such Employees. Employers
are required to remit fringe benefit contributions by the fifteenth (15th) of the
month with all regular Monthly Payroll Reports.
Eligibility will begin on the first day of the second calendar month after the
employer has contributed the required contributions on the Participant’s behalf.
The participant will remain eligible so long as the employer continues to remit
the required contributions per month for all applicable employees in accordance
with payment requirements.
August 2014
Page 3
Delinquent contributions for all non-bargained employees must be
received prior to the first day of the month for which all such coverage is being
provided or coverage will cease and will not be reinstated.
Eligibility ceases on the first day of the calendar month following the last
month for which coverage was provided by the contribution received from the
Employer.
Non-Bargaining Unit Participants are not eligible for Loss of Time Benefits.
Self-Pay When Disabled
If a Participant is prevented from engaging in covered employment by
total disability, he will be allowed to make self-payment of contributions for up to
twelve (12) consecutive Benefit Months. The self-payment amount is determined
by the Board of Trustees.
Continuation of Eligibility During Disability
If you become disabled and are unable to perform covered employment
while you are eligible in this Plan, you must either utilize your banked
contributions or remit self-payments to maintain eligibility.
All disability absences will be considered a single disability unless:
1.
You return to active covered employment for at least one day and
you submit evidence satisfactory to the Trustees that the cause(s)
of the latest disability absence cannot be connected with the
cause(s) of any prior disability absences, or
2.
You return to active covered employment for at least two weeks
even though a connection can be established between the cause(s)
of two successive disability absences.
The Trustees retain the right to have you medically examined by a
physician of their own choice at the Plan’s expense to determine whether a
disability qualifies under this Rule.
August 2014
Page 4
Total and Permanent Disability
In order for you to be eligible to make self-payments when totally and
permanently disabled, you must:
1. Be totally and permanently disabled on or after January 1, 1992, and so
unable to perform any work for remuneration or profit on the date you
would otherwise lose eligibility under these Rules, and
2. Be awarded a disability benefit from the Social Security Administration,
and
3. Have a minimum of five (5) years of continuous eligibility in this Plan prior
to the disability.
This self-payment provision applies to the Employee coverage and your
Dependents (if any) until the earlier of:
1. The date you are eligible in any other group health care plan; or
2. The date you are no longer totally disabled, or
3. The date you become eligible for Medicare,
When you are covered by a total and permanent disability self-payment, you
are not covered by Weekly Accident and Sickness (Loss of Time) Benefits.
Self-Payment
You will be required to make self-payments in the amount equal to the
self-payment rate(s) established for active participants.
Work Outside Trust Fund Jurisdiction - Reciprocity
Once you are eligible in this Fund, the Trustees of this Fund have entered
into contracts known as Reciprocity Agreements with the Trustees of similar
IBEW Welfare Funds which, once you are eligible in this Fund, may allow
contributions you earn for work in IBEW jurisdictions outside the jurisdiction of
this Trust Fund to be transferred for eligibility credit in this Fund. If you plan to
work at covered employment outside the jurisdiction of this Fund, you should
contact the IBEW Local 461 Union Office to ask whether you would be allowed to
transfer contributions for that work. All reciprocity transfers are processed
through the Electronic Reciprocal Transfer System (ERTS). All participants are
required to file a reciprocity form through the Internet via their Local Union.
Please contact the Local Union for more information.
August 2014
Page 5
You are not allowed to transfer contributions to establish initial eligibility
under this Plan unless you are a Local 461 member.
TERMINATION OF ELIGIBILITY FOR EMPLOYEES
DEPENDENTS WHEN ENTERING MILITARY SERVICE
AND
THEIR
An Employee’s or Dependent’s eligibility ceases the date he is inducted
into the Armed Forces of the United States. When you are inducted, your
Dependents’ eligibility terminates on the last day of the Benefit Month in which
the induction occurs.
You and your dependents may be eligible to remit up to 18 months of
COBRA payments to maintain your coverage under the Fund, (please contact the
Fund Office for more information).
Your accumulated eligibility, if any, will be kept on the records of the
Fund, provided you notify the Fund Office in writing that you are entering the
Armed Forces of the United States. Such accumulated eligibility will be made
available to you upon discharge and return to work for a contributing Employer.
If covered employment is available and you are physically fit, you must return to
work for a contributing Employer within ninety (90) days after a discharge to
retain your rights to your eligibility; then your eligibility and that of your
Dependents, if any, is then reinstated on the day you return to work for a
contributing Employer.
If you fail to return to work for a contributing Employer within ninety (90)
days from the date you are discharged, you must again satisfy the Initial
Eligibility requirements of these Rules.
Reinstatement of Eligibility
Employees
If you once establish eligibility under this Plan and lose that eligibility at a
later date, you will be reinstated when you meet the requirements under
“Continuation of Eligibility” (page 1) in these Rules, provided you remain
ineligible for at least one month. If you remain ineligible more than thirty-six
(36) months, you must meet the requirements under “Initial Eligibility” in these
Rules to become eligible again.
August 2014
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RETIREE PROGRAM
Coverage Classifications Defined
Employees eligible to participate in the Retiree Program and their eligible
Dependents, if any, are covered under one of two benefit classes, depending on
whether the covered person is also eligible for Medicare.
Class B:
Coverage for Employees and/or eligible Dependents who are NOT eligible
for Medicare
Class C:
Coverage for Employees and/or eligible Dependents who ARE eligible for
Medicare (Medicare coverage includes both Part A & B)
For example, you and your spouse would both be covered under Class B if
neither of you are eligible for Medicare. If you are eligible for Medicare and your
Spouse is not, you would be eligible in Class C and your spouse would be eligible
in Class B.
General Eligibility Requirements
Each normal or early retired Employee may continue coverage for himself
and his Dependents through this Plan under the Retiree Program provided he
meets all of the following requirements:
1.
He is at least fifty-five (55) years old; and
2.
He has been eligible in this Plan at least sixty-four (64) of the
eighty (80) coverage months immediately prior to his request for
coverage under this Retiree Program; and
3.
He is eligible in this Plan at the time of his retirement.
If you are eligible to participate in the Retiree Program, you must exercise that
option when first eligible to do so. If you do not exercise your option to
participate in the Retiree Program immediately upon retirement, you will not be
allowed to begin participation at a later date.
The rate of self-payment for retirees between ages fifty-five (55) and
sixty-two (62) will be based upon one hundred fifteen (115) hours per month at
the current contribution rate.
August 2014
Page 7
The rate of self-payments for retirees over age sixty-two (62) will be determined
by the Board of Trustees. Please contact the Fund Office for the applicable rate.
Self-Payment of Contribution
If the participant is age sixty-two (62) to sixty-five (65) in Class B
coverage, the rate established by the Board of Trustees will provide coverage for
the participant and his dependents. If the participant is eligible for Medicare and
his spouse is sixty-two (62) to sixty-five (65), the participant has no self-payment
and is in Class C coverage; however, the spouse must pay the rate established
by the Board of Trustees to maintain coverage. If the participant is eligible for
Medicare but the spouse is not yet sixty-two (62), the participant has no selfpayment for Class C coverage but for coverage for the spouse must pay the full
self-payment rate of one hundred (115) hours per month at the current collective
bargaining rate to maintain continuous coverage.
The self-payment amounts required for eligibility in the Retiree Program
are those determined by the Trustees to be necessary to run the Plan. Selfpayments must be received at the Fund Office on or before the first day of the
coverage month for which the payment is due. You will receive only one Notice
describing the self-payment procedure; you are responsible for making
subsequent monthly payments on time and without further Notice. All Notices
are sent by mail to the last known address on file at the Fund Office so it is
important that any address changes are reported immediately.
Self-payments are required on a monthly basis. A change in coverage
circumstances (such as eligibility for Medicare) will re-determine the covered
person’s Coverage Class effective the first day of the calendar month co-incident
with or next following the date the change in circumstance occurs.
Benefit Limitations
All normal Plan provisions apply to Retiree Program coverages.
Employees and their Dependents eligible in Class B are not covered for:
1.
Weekly Accident and Sickness Benefits (Loss of Time Benefits)
Employees and their Dependents eligible in Class C are not covered for:
1.
Weekly Accident and Sickness Benefits (Loss of Time); or
2.
Dental Care or Vision Care Benefits
August 2014
Page 8
3.
Excess Risk Insurance (stop loss).
Please see the Schedule of Benefits and the Benefits Section as described
for more information.
EFFECTIVE DATES OF COVERAGE
Employees
Your effective date of coverage as an Employee will normally be the date
you satisfy the requirements of the Eligibility Rules.
Dependents
Your effective date of coverage as a Dependent will be the date the
Employee who sponsors you becomes eligible or the date you first satisfy the
definition of Dependent, whichever is later.
TERMINATION DATES OF COVERAGE
Employees
Your coverage as an Employee under all benefit provisions of the Plan
terminates when the earliest of the following events occurs:
1.
Failure to meet the requirements for continuing eligibility as shown
in the Eligibility Rules, including a failure to make any selfpayments of contributions in a timely manner;
2.
Termination of the coverage classification under which you were
continuing your eligibility;
3.
Induction into the Armed Forces of the United States, except for
temporary duty of thirty (30) days or less;
4.
Termination of the Plan itself.
Dependents
Your coverage as a Dependent under all benefit provisions of the Plan
terminates when the earliest of the following events occurs:
1.
Termination of eligibility for the Employee who sponsors you (for
reasons other than the receipt of a Maximum Amount Payable);
August 2014
Page 9
2.
On the first of the month next following the date you fail to meet
the definition of Dependent;
3.
Induction into the Armed Forces of the United States, except for
temporary duty of thirty (30) days or less;
The surviving spouse of an eligible retiree will be eligible under the same
provisions as his/her spouse until he/she either remarries, or becomes eligible for
Medicare, or is covered under another Plan.
General Provisions
Change of Eligibility Rules
The Trustees, at their discretion, are empowered to change or to amend these
Eligibility Rules at any time.
A Note of Explanation
The Eligibility Rules represent the requirements which must be satisfied
for you and your dependents to become and to remain eligible for benefits
from this Plan. In the event the requirements are not satisfied, eligibility
is lost and benefits are not payable. The Trustees reserve the right to
deny benefits to any claimant who is, in their opinion, attempting to
subvert the purpose of the Plan or who does not present a bona fide
claim.
Remember: Changes in employment may have an effect on Employer
contributions paid on your behalf. For example, Employer contributions may
cease in the event you:
1.
Change job classifications from covered to non-covered
employment, even if that employment is with the same
employer; or
2.
Change employment from a participating to a non-participating
Employer.
You and your dependents may obtain, upon written request to the Union Office,
information as to the address of a particular Employer and whether that
Employer is required to pay contributions to the Plan.
August 2014
Page 10
Health Insurance Portability and Accountability
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits
the circumstances under which coverage may be excluded for medical conditions
present before you enroll. Under the law, a pre-existing condition exclusion
generally may not be imposed for more than twelve (12) months (eighteen [18]
months for late enrollees). The twelve (12) month (or eighteen [18] month)
exclusion period is reduced by your prior health coverage. You are entitled to a
certificate that will show evidence of your prior health coverage. If you buy
health insurance other than through an employer group health plan or other
source, a certificate of proof of coverage may help you obtain coverage without
a pre-existing condition exclusion. If you have questions 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.
You have a right to receive a certificate of prior health coverage since July 1,
1996. You may need to provide other documentation for earlier periods of
health care coverage. Check with your new Plan Administrator to see if your
new Plan excludes coverage for pre-existing conditions and if you need to
provide a certificate or documentation of your previous coverage. To receive a
certificate, please contact the Fund Office.
Family and Medical Leave
You may be eligible for up to twelve (12) weeks of unpaid, job protected leave
for certain family and medical reasons under the Family and Medical Leave Act of
1993. You are eligible under the Act if:
1. You are employed by an employer with at least fifty (50) employees at
your work site or with at least fifty (50) employees within a seventyfive (75) mile radius of your work site; and
2. You have been employed by the employer at least twelve (12) months;
and
3. You have worked at least one thousand, two hundred fifty (1,250)
hours for the employer during the twelve (12) months immediately
before the requested leave.
Your employer determines whether you are eligible for family or medical leave
under the Act, not this Plan or its Trustees.
August 2014
Page 11
Both you and your employer are required to notify the Fund Office if you take a
family or medical leave and to provide certain other information as required by
the Trustees. Your coverage in the Plan will continue during the period of your
family or medical leave, provided self-payments are made or your employer
makes contributions to the Plan at the same rate and in the same amount as if
you were continuously employed during the period of your leave and fully
complies with all requirements established by the Trustees.
Cobra Continuation Coverage
This section is intended to explain to you and your eligible dependents, in a
summary fashion, about rights and obligations under the Continuation Coverage
provisions of the Consolidated Omnibus Budget Reconciliation Act, or “COBRA.”
You, your spouse (if any), and your dependents (if any) should take time to read
this section carefully.
Certain terms are used in this section and are defined as follows:
Continuation Coverage – the coverage available to you and your family in the
event you lose eligibility due to a Qualifying Event. If you elect Continuation
Coverage, the Plan must provide coverage which, as of the time such coverage is
provided, is identical to the coverage provided for other similarly situated
beneficiaries for basic hospital, medical, and surgical benefits. Burial Benefits and
Accidental Death and Dismemberment Benefits are not provided.
Qualified Beneficiary – an individual who is covered under the Plan on the day
before a Qualifying Event, as well as a newborn child or child placed for adoption
with you during the period of Continuation Coverage. Qualified Beneficiaries are
you, your spouse or your dependant child(ren).
Qualifying Event – an event that causes you and/or your family to lose
coverage under the Plan. The specific events which are Qualifying Events for
you, your spouse and/or your children are explained in detail in the following
sections. Depending on the Qualifying Event, Continuation Coverage is available
for eighteen (18), twenty-nine (29) or thirty-six (36) months.
Employee Right to Elect Continuation Coverage
You, as a Qualified Beneficiary, have the right to choose Continuation Coverage if
you lose eligibility for coverage under the Plan due to a reduction in the amount
of employer contributions remitted or termination of employment for any reason,
unless termination is due to gross misconduct on your part. Either of those
circumstances is what is known as a “Qualifying Event” for you, as an employee.
These Qualifying Events entitle you and/or your family to elect eighteen (18)
months of Continuation Coverage.
August 2014
Page 12
The Trustees, through the Fund Office, determine when a Qualifying Event
occurs as a result of a reduction of employer contributions or a termination of
employment based on information contained on submitted employer contribution
forms. The Fund Office will determine when the COBRA Qualifying Event has
occurred within one hundred twenty (120) days following receipt of the employer
contribution form. The Fund Office will mail the COBRA election notice within
sixty (60) days after it has determined that you or a qualified beneficiary has lost
eligibility for coverage. You have sixty (60) days from the date you receive the
election notice to elect to receive Continuation Coverage. If you do not make an
election for coverage within sixty (60) days, you no longer have a right to receive
Continuation Coverage.
If you qualify for Continuation Coverage under COBRA but do not elect such
coverage for your entire family, your spouse and/or dependent children are still
entitled to elect Continuation Coverage for themselves.
Your Spouse’s Right to Elect Continuation Coverage
Spouses of employees or Retired Participants covered under the Plan, as
Qualified Beneficiaries, have the right to choose Continuation Coverage for
themselves if they lose their group health care coverage under the Plan for any
of the following reasons:

Termination of your employment (for reasons other than gross
misconduct), or a reduction in the hours worked by you which results in
your losing eligibility under the Fund;

Your death if you are a participant in the Plan;

Divorce or legal separation from you; or

You become entitled to Medicare and are not eligible to continue coverage
for your spouse under another portion of the Plan or choose not to
continue such coverage.
These reasons are known as Qualifying Events for your spouse. The first
Qualifying Event entitles your spouse to elect eighteen (18) months of
Continuation Coverage. The other Qualifying Events would entitle your spouse to
elect thirty-six (36) months of Continuation Coverage.
August 2014
Page 13
Your Dependent Children’s Right to Elect Continuation Coverage
All of your dependent children covered under the Plan, as Qualified Beneficiaries,
have the right to Continuation Coverage if they lose their eligibility for coverage
under the Plan for any of the following five reasons:

Termination of their parent’s employment (for reasons other than gross
misconduct) or a reduction in the number of hours worked by their
parent, who is the covered Employee under the Plan;

Death of the parent, who is the covered employee under the Plan:

Divorce or legal separation of their parents;

You become entitled to Medicare and either are not eligible to continue
coverage for the children or choose not to continue such coverage; or

The child or children cease to satisfy the Plan’s definition of a “dependent
child.”
These reasons are known as Qualifying Events for your dependent children. The
first Qualifying Event entitles your dependant child (ren) to elect eighteen (18)
months of Continuation Coverage. The other Qualifying Events would entitle your
dependant children to elect thirty-six (36) months of Continuation Coverage.
A newborn or adopted child will automatically be extended COBRA coverage if
the parents already have COBRA coverage. This may involve an increase in the
COBRA premium charged. A newborn child or an adopted child (or the child’s
custodian or guardian) has a right; separate from his or her parents to elect
Continuation Coverage for eighteen (18) or thirty-six (36) months, depending on
the Qualifying Event, even if the child’s parent(s) do not elect Continuation
Coverage.
Continuation Coverage for Disabled Persons
If you, as a covered employee, your spouse, or any dependent child, as Qualified
Beneficiaries, qualify for Social Security disability benefits at the time of a
Qualifying Event that entitles the Qualified Beneficiary to elect eighteen (18)
months of Continuation Coverage (or any time during the first sixty (60) days
after you lose coverage due to a Qualifying Event), you may purchase up to an
additional eleven (11) months of Continuation Coverage (or a total of twentynine [29] months).
August 2014
Page 14
This additional Continuation Coverage may be purchased not only for the
disabled person but also for other eligible family members who are not disabled
(subject to the applicable premium).
To obtain this additional Continuation Coverage, the Qualified Beneficiary must
be determined eligible for Social Security disability benefits before the end of the
eighteen (18)-month Continuation Coverage period and must notify the Fund
Office during the eighteen (18) month period and within sixty (60) days after the
Social Security Administration awards Social Security benefits to the disabled
person.
The Fund is permitted to charge a higher premium (up to one hundred fifty
percent [150%] of the regular COBRA premium) for the additional eleven (11)
months of Continuation Coverage available to disabled persons and their
families. The higher premium applies to the disabled person and for other family
members who opt for additional COBRA coverage.
Eligibility for extended Continuation Coverage because of disability ends the first
day of the month that is more than thirty (30) days after the date that the
person is determined under the Social Security Administration to be no longer
disabled. Federal law requires a disabled person to notify the Fund within thirty
(30) days of a final Social Security Administration determination that they no
longer are disabled.
Employee Obligations to Notify the Fund Office of a
Qualifying Event
Under COBRA, you or a family member must notify the Fund Office immediately
about a divorce, legal separation, or a child losing dependent status under the
Plan. If such an event is not reported to the Fund Office within sixty (60) days
after it occurs, Continuation Coverage will not be permitted.
Your surviving spouse (or dependent child) should contact the Fund Office
immediately after your death. This assures that Continuation Coverage is offered
to your surviving spouse and children at the earliest possible date.
The law requires the COBRA election notice to be sent to the last known address
on file at the Fund Office. If the election notice is sent to the wrong address due
to your failure to notify the Fund Office about a change in address, the sixty (60)
day time limit will not be extended and you may lose the opportunity to elect
COBRA.
August 2014
Page 15
You are also required to notify the Fund Office if you or any family members are
covered under another group health care plan at the time you received a COBRA
election notice (e.g., if you are covered as a dependent under your spouse’s
plan) or if you elect Continuation Coverage, at any time you or a family member
later becomes covered under another group health care plan, including Medicare.
The Fund Office may require you to provide information about your coverage
under another group health care plan. The Fund may seek reimbursement
directly from you if medical expenses are paid by the IBEW Local 461 Welfare
Fund through Blue Cross Blue Shield of Illinois because you or your dependents
do not notify the Fund of other health care coverage.
Second Qualifying Events
The following rules concerning the occurrence of a second Qualifying Event only
apply if the original Qualifying Event was termination of the employee's
employment (for reasons other than gross misconduct) or reduction in the
number of hours worked by the employee. If a second Qualifying Event should
occur during the eighteen (18) months of coverage available as a result of the
first Qualifying Event [or, twenty-nine [29] months if the eleven (11) month
extension due to disability applies], then you may purchase additional
Continuation Coverage for up to a total of thirty-six (36) months. An example of
a second Qualifying Event would be:

Death of the employee, if he or she is a covered employee under the Plan;

Divorce or legal separation of the employee and his/her spouse;

The employee, if a covered employee under the Plan, becomes enrolled in
by Medicare (Part A, Part B, or both); or

For dependent children, the dependent child ceases to satisfy the Plan's
definition of a "dependent child” (The rules for second qualifying events
also apply to newborn or adopted children.)
This thirty-six (36) months total of Continuation Coverage available when a second
Qualifying Event occurs includes the number of months you have already been
covered under Continuation Coverage because the first Qualifying Event. The
thirty-six (36) month total is not in addition to any months of Continuation
Coverage you have already had because of the first Qualifying Event. The Plan
Administrator must be notified within sixty (60) days of the second Qualifying Event
or the additional extended coverage will not be allowed.
August 2014
Page 16
Proof of Insurability is Not Necessary to Elect Continuation
Coverage
You and your family members do not have to show that you are insurable to
purchase Continuation Coverage; however, you must make the required selfpayment(s) for such coverage in accordance with specific due dates. The
amount(s) and the due date(s) will be shown on the COBRA election notice.
Procedure for Obtaining Continuation Coverage
Once the Fund Office knows that an event has occurred which qualifies you or
other family members for Continuation Coverage, the Fund Office will attempt to
notify you or your family member of their rights to elect Continuation Coverage.
Once you receive this election notice, you will have sixty (60) days after the date
on the election notice within which to notify the Fund Office whether or not you
want the Continuation Coverage. If you do not elect the coverage within the
sixty (60) day time period, your right to continue your continuation coverage will
end.
Termination of Continuation Coverage
The law provides that Continuation Coverage may be cancelled by the Fund for
any of the following reasons:
1. The Fund no longer provides group health care coverage to any Employees
2. The required self-payment for Continuation Coverage is not paid on time
3. The person remitting Continuation Coverage payments becomes covered
under any group health care plan, after the Qualifying Event, that does not
include a pre-existing condition exclusion
4. The person remitting Continuation Coverage payments becomes entitled to
Medicare.
Although your Continuation Coverage may be canceled as soon as you are
covered by Medicare, a spouse or dependent child receiving Continuation
Coverage at that time may continue purchasing such coverage for up to eighteen
(18) or thirty-six (36) months minus any months of Continuation coverage
received immediately prior to your coverage under Medicare. This option applies
only if a spouse or dependent child is not also covered by Medicare.
August 2014
Page 17
QUALIFIED MEDICAL CHILD SUPPORT ORDERS
The Omnibus Budget Reconciliation Act of 1993 requires that group health
plans recognize and comply with “Qualified Medical Child Support Orders.” This
document sets forth the Fund’s procedure for processing medical child support
orders that are claimed to be Qualified Medical Child Support Orders.
Receipt of Order
The Fund Office shall promptly notify the participant and each alternate
recipient (i.e., a person to receive benefits according to the Order) of the Order’s
receipt and the Fund’s procedures for determining whether a medical child
support order is a Qualified Medical Child Support Order. The Fund Office shall
forward a copy of the order to Fund Counsel.
Determination of Qualification
Within a reasonable period after receipt of such Order, the Plan
Administrator, with the assistance of the Fund Counsel, shall determine whether
such order is a qualified medical child support order and notify the participant
and each alternate recipient of such determination.
The procedures to determine whether medical child support orders are
qualified medical child support orders shall follow the criteria established by
Section 609 of the Employee Retirement Income Security Act of 1974, as
amended and any applicable regulation and administration actions by agencies
charged to enforce Section 609. Those criteria include:
1. Inclusion of the order in a judgment order or decree made pursuant to
state domestic relations law or is made pursuant to state domestic
relations law or made pursuant to a law relating to medical child
support described in 42 U.S.C. 1396g issued by a court of competent
jurisdiction or administrative process that has the force or effect of law
in the state issuing the order.
2. Creation, assignment or recognition of the right of an alternate
recipient to receive Fund benefits to which a participant or a
beneficiary is entitled.
3. Whether the alternate recipient is a child of the participant or a child
adopted by or placed for adoption with a participant.
August 2014
Page 18
4. Inclusion of the name and last known mailing address of the affected
participant and the name and last known mailing address of the
alternate recipient.
5. Inclusion of a description of the type of coverage to be provided by the
Fund or the manner in which such coverage is to be determined.
6. Identification of the period for which the order applies.
7. Identification of the Fund as the plan to which the order supplies.
8. Verification that the order does not require the Fund to provide
benefits or a form of benefits other than one provided by the Fund,
provided that the Fund shall satisfy requirements of applicable laws
relating to medical child support described in 42 U.S.C. 1908.
Effect of National Medical Support Notices
The Fund shall recognize as Qualified Medical Child Support Orders
“National Medical Support Notices” that comply with the provisions of applicable
final regulations effective March 27, 2001.
Status of Alternate Recipients
Alternate Recipients shall be deemed Fund participants for purposes of
applicable reporting and disclosure requirements and shall be treated as Fund
beneficiaries for all other purposes.
Direct Payments
Payments for benefits or claims for reimbursements made by Alternate
Recipients under Qualified Domestic Child Support Orders shall be made to the
Alternate Recipients or their legal guardians as applicable.
Notification Issues
The Fund Office shall notify an Alternate Recipient or the Alternate
Recipient’s legal guardian of its determination concerning a medical child support
order which is claimed to be a Qualified Medical Child Support Order within a
reasonable time after receipt. Alternate Recipients shall be entitled to designate
a representative for the receipt of copies of notices that are sent to the Alternate
Recipient with respect to a medical child support order. The custodial parents or
guardians of minor Alternate Recipients shall be considered their designated
representatives absent an express written request of other representatives.
August 2014
Page 19
GENERAL DEFINITIONS
Accident
An Accident must contain some degree of unexpected violence, such as a fall,
blow, laceration, contusion, or abrasion.
Accidental Bodily Injury and Sickness
Accidental Bodily Injury and Sickness, with respect to a covered person, does not
include accidental bodily injury or sickness which arises out of or in the course of
employment, except that this provision shall not apply to the Death Benefit.
Ambulatory Surgical Center
An Ambulatory Surgical Center is a free standing facility, which is wholly owned
and operated by a hospital on the same basis as the outpatient department of its
main facility or a legally constituted institution, which meets all of the following
requirements:
1.
Is established, equipped and operated primarily for the
purpose of performing surgical procedures; and
2.
Operates under the supervision of one or more physicians as
defined by the Plan; and
3.
Is equipped with at least two operating rooms, at least one
post-anesthesia recovery room, and has the ability to
perform diagnostic X-ray and laboratory procedures as
required in conjunction with the surgery to be performed;
and
4.
Continually provides nursing services by registered nurses
for patient care in the operating rooms and the postanesthesia recovery room(s); and
5.
Is licensed by the appropriate State agency and is
recognized by the local medical society.
Behavioral Disorders
Behavioral Disorders include but are not limited to:

Attention Deficit Disorder
August 2014
General Definitions
Page 20




Childhood Disorders-treatment of reading or learning disorders or
developmental disability
Counseling for adoption, custody, family planning, pregnancy, or
catastrophic illness diagnosis in the absence of psychiatric diagnosis
generally recognized and accepted by the medical profession such
as the American Psychiatric Association’s Diagnostic and Statistical
Manual of psychiatric diagnosis.
Court-Ordered Confinement – Any confinement of a Covered
Person in a public or private institution as the result of a court
order.
Educational or Vocational Testing or Training – Testing and/or
training for educational purposes or to assist an individual in
pursuing a trade or occupation.
Custodial Care
Custodial Care means care, services or supplies, which are furnished mainly to
train or to assist in personal hygiene or other activities of daily living, rather than
to provide therapeutic treatment. Care, services or supplies will also be
considered “custodial” if they can be safely and adequately provided by persons
who do not have the technical skills of a covered health care provider.
Dental Hygienist
Dental Hygienist means a person who is currently licensed (if licensing is
required in the State) to practice dental hygiene by the governmental authority
having jurisdiction over the licensing and practice of dental hygiene and who
works under the supervision of a Dentist.
Dentist
Dentist means a person who is currently licensed to practice dentistry by the
governmental authority having jurisdiction over the licensing and practice of
dentistry.
Diagnosis
Diagnosis refers to the statement of the medical condition requiring the care of a
physician.
August 2014
General Definitions
Page 21
Elective or Voluntary Sterilization
Elective Sterilization is sterilization not medically required but requested by the
patient and will include among others, vasoligation, vasectomy, salpingectomy,
and tubal ligation.
Eligibility Rules
The Eligibility Rules shall apply to Active Employees and their Dependents,
Totally and Permanently Disabled Employees and their Dependents, and Self-Pay
Employees and their Dependents and Retirees and their Dependents.
Eligible Dependents
Eligible Dependents are the following:
1.
The legal spouse of the eligible Employee provided he/she is
not legally separated from the eligible Employee; or
2.
Any natural child of the eligible Employee and the legal
spouse if:
a.
the child is less than nineteen (19) years old,
excluding a person who would otherwise be entitled
to benefits under this Plan as an Employee; or
b.
the child is less than twenty-six (26) years of age, will
be considered an Adult ; or
c.
the child is over twenty-six (26) years of age and
he/she is totally and permanently disabled because of
a qualifying physical handicap or mental retardation.
To be considered a qualified physical handicap or
mental retardation under this definition, it must:
1)
occur before the child reaches age twenty-six
(26); and
2)
be certified by a Physician; and
3)
render the child incapable of self-sustaining
employment so as to make the child dependent
upon the parents for financial support and
maintenance.
Initial proof of such disability and financial
dependency must be furnished to the Trustees
August 2014
General Definitions
Page 22
within sixty (60) days of the child's reaching
twenty-six (26) years of age. Subsequent
proofs may be required by the Trustees after
the child reaches twenty-six (26), but not more
frequently than annually.
3.
Your natural child, provided the child's surname is the same
as the eligible employee; a legally adopted child; including
the legally required trial period prior to the approval of the
adoption by a court.
In order to qualify under the definition of an eligible
dependent the following conditions must be met:
a.
the Employee contributes more than fifty percent
(50%) toward the maintenance and support of the
child; and
b.
legal documentation is presented, upon request,
supporting the Dependent's status.
It is understood that coverage of a dependent child
may also be established in those cases where the
Welfare Fund has received a "Qualified Medical Child
Support Order" (QMCSO) entered by an appropriate
court as defined under applicable federal law.
Normally, such an order will be issued in a divorce or
other family law action, which recognizes the child's
right to health benefits under the Plan.
The term Eligible Dependent does not include a child delivered by a
female other than the eligible employee or the eligible employee’s legal spouse,
unless:
a.
A blood test is performed to prove that the child was
actually fathered by the member, and a certified
copy of the birth certificate or
b.
The Fund is provided with a Qualified Medical Child
Support Order (QMCSO) which indicates the member
is to maintain health coverage for the dependent.
Dependent coverage terminates on the date:
1.
The qualifying disability ceases; or
2.
The QMCSO terminates; or
August 2014
General Definitions
Page 23
3.
The Employee's coverage is terminated; or
4.
The first day of the following the month in which the
dependent reaches the age twenty-six (26).
If one spouse is covered under the Plan pursuant to the terms of a
Collective Bargaining Agreement and one spouse is covered under the terms of a
Participation Agreement:
1.
Their children may be covered as Dependents of the
husband or the wife; but not both
2.
Neither may be covered as the Dependent of the other at
the same time.
If both the husband and the wife are covered under the Plan pursuant to
the terms of a Collective Bargaining Agreement:
1.
Their children may be covered as Dependents of the
husband and
the wife;
2.
One spouse may also be covered as the Dependent of the
other
spouse.
The term Eligible Dependent does not include a child fathered by a
Dependent child or delivered by a female other than the eligible Employee or the
Employee's legal spouse except as previously indicated.
Eligible Member
An Eligible Member means any person who: (1) is working within the jurisdiction
of and covered under the terms of the Collective Bargaining Agreement or NonBargaining Unit Participation Agreement entered into between the Trustees and
the Employer, and (2) is eligible for benefits as set forth in the IBEW Local No.
461 Welfare Eligibility Rules.
Eligible Person
An Eligible Person means either the eligible Employee or such employee’s eligible
Dependents.
August 2014
General Definitions
Page 24
Employee
An Employee means a person, actively employed by an Employer, on whose
behalf Employer contributions are required to be made.
Employer
Employer or Contributing Employer means any association or individual employer
who has duly executed a collective bargaining agreement with the Union or a
Welfare Fund participation agreement, and is required to make contributions to
this Fund on behalf of its Employees.
Expense Incurred
Expense Incurred includes only those charges made for services and supplies,
which are reasonably priced and reasonably necessary for treatment of the injury
or sickness.
Family Medical Leave
Unpaid job protected leave of absence.
Health Insurance Portability and Accountability Act
Law, which limited the circumstances under which coverage may be excluded for
medical conditions before your enroll.
Hines & Associates
Provides Case Management and Utilization Review services related to inpatient
hospital admissions.
Hospital
A Hospital is any legally constituted institution, which meets all the following
requirements:
1.
Maintains permanent and full time facilities for bed care of
five (5) or more resident patients; and
2.
Has a doctor in regular attendance; and
3.
Continually provides a twenty-four (24) hour-a-day nursing
service by registered nurses; and
August 2014
General Definitions
Page 25
4.
Is primarily engaged in providing diagnostic and therapeutic
facilities for medical and surgical care of injured and sick
persons on a basis other than as a rest home, nursing home,
convalescent home, a place for the aged, a place for drug
addicts, or a place for alcoholics; and
5.
Is operating lawfully in the jurisdiction where it is located.
In-patient
In-patient means a person who is a resident patient using and being charged for
the room and board facilities of the hospital.
Intensive Care Unit
Intensive Care Unit means a special area of a hospital, exclusively reserved for
critically ill patients requiring constant observation, which in its normal course of
operation provides:
1.
Personal care by specialized registered professional nurses
and other nursing care on a twenty-four (24) hour per day
basis;
2.
Special equipment and supplies which are immediately
available on a stand-by basis; and
3.
Care required, but not rendered, in the general surgical or
medical nursing units of the hospital. The term “Intensive
Care Unit” shall also include an area of the hospital
designated and operated exclusively as a Coronary Care Unit
or as a Cardiac Care Unit.
Medicare
Government Health Insurance Program for people sixty-five (65) or older, certain
disabled people under sixty-five (65), and people who have permanent kidney
failure. As referred to in this document, Medicare means both Parts A & B of
Medicare.
Medical Equipment
Medical Equipment means equipment, which meets all of the following
requirements:
August 2014
General Definitions
Page 26
1.
Is primarily and customarily used to serve a medical
purpose; and
2.
Is generally not useful to a person in the absence of illness
or injury; and
3.
Is necessary and reasonable for the treatment of an illness
or injury, which is covered by the terms of this Plan.
To be considered “medical equipment,” a device must make a meaningful
contribution to the treatment of a patient’s illness or injury or to the improved
functioning of a malformed or damaged body member. Equipment, which
primarily serves a comfort or convenience function for the patient or the patient’s
caretaker (such as a wheelchair ramp or a vehicle lift device), is not considered
“medical equipment.”
N.E.C.A.
National Electrical Contractors Association
Optician, Optometrist and Ophthalmologist
Optician, Optometrist and Ophthalmologist means any person who is qualified
and currently licensed (if licensing is required in the State) to practice each such
profession by the appropriate government agency or authority having jurisdiction
over the licensing and practice of such a profession, and who is acting within the
usual scope of his practice.
Out-patient
Out-patient means a person who receives hospital services and treatments, but
is not an in-patient.
Period of Disability Confinement
Successive periods of disability or hospital confinement are considered one
continuous disability and period of confinement for the purpose of determining
maximum benefits payable unless:
1.
The later treatment period is due to causes entirely
unrelated to the causes of the prior treatment; or
2.
The periods of treatment are separated by ninety (90)
calendar days; or
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General Definitions
Page 27
3.
For an Employee, a return to covered employment for at
least two (2) weeks.
Physician, Doctor, or Surgeon (M.D.)
Physician, Doctor, or Surgeon (M.D.) includes Osteopaths, Dentists, and
Podiatrists or Chiropodists when practicing within the scope of their respective
licenses. A Chiropractor is not considered to be a Physician for most benefits
under this Plan. A naprapath is not considered to be a Physician for benefits
under this Plan.
Pregnancy
Pregnancy includes resulting childbirth, miscarriage, and any complications of
pregnancy.
Protected Health Information
Information maintained by a health care provider, health plan, employer,
health care clearinghouse which relates to past, present, or future physical
mental health or condition of an individual that identifies the individual or
which there is a reasonable basis to believe the information can be used
identify an individual.
or
or
to
to
Reasonable and Customary Charge
Reasonable and Customary Charge is determined by uniform reference standards
as adopted by the Board of Trustees. To be considered reasonable and
customary, the charge by any provider for a service must be similar to the
charges generally incurred for cases of comparable nature and severity by a
physician of similar training and experience in that geographical area. Area
means a metropolitan area, county or such greater area as is necessary to obtain
a representative cross-section of providers rendering such service or furnishing
such supplies.
With respect to medical equipment, a charge will be considered "reasonable"
only if the following requirements are met:
1.
The expense of the equipment must be clearly proportionate
to the therapeutic benefits ordinarily derived from its use;
and
August 2014
General Definitions
Page 28
2.
The equipment may not be substantially more costly than a
medically appropriate and realistically feasible alternative
pattern of care; and
3.
The equipment may not serve essentially the same purpose
as equipment already available to the patient.
Routine Physical Examination
A Route Physical Examination is an examination done by a physician for
screening purposes. If there is no diagnosis or symptoms presented on a claim
form or itemized bill by the physician, the care will be considered routine.
Sickness
Sickness means a deviation from a healthy condition which:
1.
Alters the state of the body; and
2.
Interrupts or disturbs the performance of vital functions; and
3.
Tends to undermine or weaken the constitution.
Sickness does not include a limitation on or a loss of body function or a
temporary indisposition, which does not progressively undermine or weaken the
constitution. Sickness caused or contributed by self-abuse, such as alcoholism or
intentional overdose of drugs, are generally subject to special limitations and
may be excluded from coverage entirely.
Skilled Nursing Care Facility
Skilled nursing care facility means an institution or that part of any institution,
which operates to provide convalescent or nursing care and:
1.
2.
Is primarily engaged in providing to inpatients:
a.
skilled nursing care and related services for patients
who require medical or nursing care; or
b.
rehabilitation services for the rehabilitation of injured,
disabled or sick persons; and
Has a requirement that the health care of every patient be
under the supervision of a physician; and
August 2014
General Definitions
Page 29
3.
Has a physician available to furnish necessary medical care
in case of emergency; and
4.
Has policies, which are developed with the advice (and with
provision for review of such policies from time to time) by a
group of professional personnel, including one (1) or more
physicians and one (1) or more registered professional
nurses, to govern the skilled nursing care and related
medical or other services it provides; and
5.
Has a physician, a registered professional nurse or a medical
staff responsible for the execution of such policies; and
6.
Maintains clinical records on all patients; and
7.
Provides twenty-four hour nursing services which is
sufficient to meet nursing needs in accordance with the
policies developed as provided in paragraph two (2), and
has at least one (1) registered professional nurse employed
full time; and
8.
Provides appropriate methods and procedures for the
dispensing and administering of drugs and biologicals; and
9.
In the case of an institution in any state in which state or
applicable local law provides for the licensing of institutions
of this nature; and
10.
a.
is licensed pursuant to such law; or
b.
is approved by the agency of the state or locality
responsible for licensing institutions of this nature as
meeting the standards established for such licensing;
and
Meets any other conditions relating to the health and safety
of individuals who are furnished services in such institution
or relating to the physical facilities thereof.
Surgical Procedure
Surgical procedure means certain invasive procedures, including the reduction of
fractures or dislocations, in addition to recognized cutting procedures.
August 2014
General Definitions
Page 30
Totally Disabled and Total Disability
Totally Disabled and Total Disability, unless otherwise specifically defined, refer
to disability resulting solely from a sickness or accidental bodily injury which
prevents an Employee from engaging in any occupation or employment for
compensation or profit or prevents a Dependent from engaging in substantially
all the normal activities of a person of like age and sex in good health and the
person is eligible for Social Security Disability Benefits. A copy of the Social
Security Administration Award Letter is required for proof of total disability.
Trust Agreement
Trust Agreement means the Agreement and Declaration of Trust establishing the
IBEW Local No. 461 Welfare Fund and that instrument as may be amended from
time to time.
Trust Fund
Trust Fund or Fund means the IBEW Local No. 461 Welfare Fund.
Trustees
Trustee means the Employer Trustees and the Union Trustees, collectively, as
selected under the Trust Agreement, and as constituted from time to time in
accordance with the provisions of the Trust Agreement.
Union
Union means those Unions, which have executed an Agreement of Collective
Bargaining with an Employer who, in accordance with such Agreement of
Collective Bargaining, participates in and contributes to the IBEW Local No. 461
Welfare Fund.
August 2014
General Definitions
Page 31
August 2014
General Definitions
Page 32
SECTION III
MAJOR MEDICAL BENEFITS
Introduction
When you or your Dependent require hospital confinement, surgery or
other eligible medical treatment, most covered expenses will be paid according
to a single benefit formula known as "Major Medical Benefits". There may be
some other expenses that have other benefit levels. "Treatment with Special
Limitations" is explained in a separate Section of this booklet. You must contact
Hines and Associates at (888) 236-2652 to pre-certify all hospital admissions.
The telephone number for Hines and Associates is also on the back of your Fund
ID Card.
Preferred Provider Organization (PPO)
This plan uses a “Preferred Provider Organization” or “PPO” known as Blue
Cross Blue Shield of Illinois or “BCBSIL” to obtain medical treatment on a
discounted basis. Using a PPO hospital or doctor is voluntary, but the Trustees
encourage you to do so if possible because it will save money for both you and
the Plan. To qualify for the discount, you must identify yourself as a PPO
member, so be sure to carry and to present the Identification Card which is
issued to you when you become initially eligible.
Non-Preferred Provider Organization (PPO)
The Plan pays sixty-five percent (65%) of the first fifteen thousand dollars
($15,000) of covered reasonable and customary expenses incurred after the
deductible and one hundred percent (100%) thereafter with no overall
maximum.
The Deductible Amount
The deductible amount is the amount that you have to pay from your own
pocket before any benefits are payable. That amount, as shown in the Schedule
of Benefits, generally applies to each individual person each calendar year.
Maximum Deductible Amount for Families
When three (3) or more people of the same family satisfy the family
deductible in the same calendar year, a deductible is not required for other
family members in that year. This is called the “family limit” on the deductible
amount.
August 2014
Section III - Major Medical Benefits
Page 33
Co-Payment
The Major Medical Benefits do not pay covered expenses in full; the
amount you or your Dependent has to pay depends on the type of treatment.
The Maximum Amount
All payments under Major Medical Benefits are limited to the maximum
amount shown in the Schedule of Benefits. The maximum amount applies to
you and each of your Dependents separate on a Lifetime basis unless the
Trustees grant a reinstatement of the maximum.
The maximum amount paid in Major Medical Benefits by the Plan is one
hundred fifty thousand dollars ($150,000) per person, per calendar year. After
this point, the benefits are paid by an “Excess Risk” insurance carrier. You may
be asked to re-submit medical evidence at your own expense which satisfies the
Excess Risk Carrier that you or your Dependent’s claim is payable under the Plan.
Co-Payment Limit for Individuals
The Plan limits the out-of-pocket expense due to the co-payment
requirement for most (not all) conditions per person, per calendar year. When an
individual reaches the co-payment limit of one thousand, six hundred dollars
($1,600) per person and three thousand, three hundred dollars ($3,300) per
family for in-network services and three thousand, one hundred dollars ($3,100)
per person and six thousand, three hundred dollars ($6,300) per family for outof-network services in a calendar year, the Plan will pay one hundred percent
(100%) of such person's covered expenses incurred in the rest of the year. This
amount is based on eligible expenses only; it does not apply to expenses applied
toward any deductibles or "Treatment With Special Limitations".
THE PLAN WILL NOT CONSIDER ANY AMOUNT OVER WHAT IS
CONSIDERED TO BE A REASONABLE OR CUSTOMARY CHARGE FOR ANY
SERVICES RENDERED.
HOSPITAL EXPENSE BENEFITS
Daily Room Benefit
When the Eligible Person is hospital confined, the Plan pays for each day's
room and board charges up to the semi-private room rate and the reasonable
and customary amount charged in the area.
August 2014
Page 34
Miscellaneous Charges While Confined
The Plan pays for miscellaneous charges made by the hospital during the
Eligible Person’s confinement. Examples of eligible miscellaneous items include:
the use of an operating room, X-rays, laboratory tests, blood, drugs and
medications prescribed by a physician and used while confined.
Out-Patient Hospital Treatment
The Plan pays for hospital charges due to treatment when the Eligible
Person is not charged for a room under certain circumstances:
1.
When surgery is performed at the hospital on an out-patient
basis; or;
2.
For emergency treatment of a non-occupational accidental
bodily injury on the day of the accident or the next two
following days; or
3.
Tests required by the hospital prior to admission.
Charges Related to Hospital Treatment
The Plan pays for certain charges which are not billed by the hospital but
are related to hospital treatment eligible under the Plan. Examples of related
charges include:
1.
Charges for professional local ambulance services for
transportation to or from the hospital; and
2.
Charges made by a physician, other than the operating
physician or his assistant, for the administration of
anesthesia by other than local infiltration; and
3.
Charges made by a radiologist or pathologist.
Limitations
Hospital Expense Benefits are not payable for:
1.
Personal conveniences or grooming items such as guest tray
meals, television rental, barber or beautician services or
admission kits;
2.
Confinement, which is not medically necessary, including
early admission or late discharge and confinement related to
August 2014
Page 35
elective surgical procedures such as sterilization reversal
procedures or cosmetic surgery.
Hospital Expense Benefits may be subject to additional exclusions and
limitations for some conditions; see the Treatment with Special Limitations
section.
Hospital Expense Benefits are also subject to all General Plan Exclusions and
Limitations.
HOSPITAL PRE-ADMISSION TESTING
Benefits will be payable if you or your eligible Dependent undergoes
diagnostic tests and X-rays in a hospital's out-patient department prior to actual
admission to the hospital for treatment of the condition which makes the tests
necessary provided:
1.
The tests or x-rays are otherwise eligible expense under the
Hospital Expense Benefit; and
2.
The patient is scheduled for subsequent admission to the
hospital for treatment of the condition which makes the tests
necessary, and
3.
The tests are ordered by a physician.
Amounts paid for Pre-Admission Testing will be applied to the maximum
Hospital Miscellaneous charges for that confinement.
However, in the event that the scheduled admission does not take place,
the testing may still be covered if the admission is postponed or canceled for one
or more of the following reasons:
1.
The tests show a condition requiring medical treatment prior
to admission; or
2.
A medical condition is developed that delays the admission;
or
3.
A hospital bed is not available on the scheduled date of
admission; or
4.
The tests indicate that, contrary to the attending physician's
expectation, the admission is not necessary.
August 2014
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Pre-Admission Testing Benefits are also subject to all General Plan
Exclusions and Limitations.
SURGICAL EXPENSE BENEFITS
When a surgical procedure is performed on you or your Dependent for
treatment of a non-occupational sickness or accidental bodily injury, the Plan will
pay the surgical fee charged by a physician up to the reasonable and customary
amount charged in the area and as described in this section.
"Surgical procedure" means certain invasive procedures, including the
reduction of fractures or dislocations, in addition to recognized cutting
procedures. Surgical procedures may be performed in a hospital, physician's
office or elsewhere. Surgical benefits include charges for necessary and related
pre- and post-operative care and any anesthetic customarily administered by the
surgeon.
When a mastectomy is considered an eligible surgical procedure under the
Plan, the Plan will also provide benefits for:
1.
reconstruction of the breast on which the mastectomy has
been performed;
2.
reconstruction of the other breast to produce a symmetrical
appearance; and
3.
prostheses and treatment of physical complications of
mastectomy, including lymphedemas (swelling of the lymph
vessels or lymph nodes).
Limitations
Surgical Expense Benefits are not payable for:
1.
Dental work or treatment, except as specifically provided; or
2.
Elective cosmetic or plastic surgery procedure such as
rhinoplasty or breast augmentation. Breast reduction
(reduction mammoplasty) may be considered an eligible
expense in certain cases which are determined to be
"medically necessary. Examples of medical necessity include:
severe skin disorder (such as rash or ulceration under the
breast) and/or severe musculoskeletal symptoms (such as
back pain or shoulder disfiguration) which generally requires
that no less than five hundred fifty (550) grams of tissue be
August 2014
Page 37
removed from each breast; breast reconstructive
surgery in connection with a mastectomy is covered
for reconstruction of the breast on which the
mastectomy has been performed, surgery and
reconstruction of the other breast to produce a
symmetrical appearance and prostheses and physical
complications for all stages of mastectomy; or
3.
Cosmetic or reconstructive surgery which is not necessary
for prompt repair of an accidental bodily injury, which occurs
while the patient is eligible.
Charges by an assistant surgeon will be considered as a covered expense
provided his assistance is considered medically necessary.
Surgical Expense Benefits are also subject to all General Plan Exclusions
and Limitations.
SECOND SURGICAL OPINION BENEFITS
When you or your Dependent wishes to secure a second opinion regarding
the medical necessity or an in-patient surgical procedure of a non-emergency
nature, the Plan will pay the physician's fee and related expenses provided:
1.
You or your Dependent is examined in person by a board
certified specialist; and
2.
The specialist submits a written report of his findings and
recommendation; and
3.
The specialist physician who renders the second surgical
opinion does not also perform the recommended surgical
procedure.
Second Surgical Opinion Benefits are also subject to all General Plan
DIAGNOSTIC X-RAY AND LAB BENEFITS
When you or your Dependent incurs out-patient expense for examination
by X-ray or laboratory testing to aid in diagnosis of non-occupational sickness or
accidental bodily injury, the Plan will pay those expenses up to the reasonable
and customary amount charged in the area and as described in this section.
August 2014
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Diagnostic Benefits are payable for examination and testing in a
physician's office, clinic or hospital out-patient department.
Limitations
Diagnostic X-Ray and Lab Benefits are not payable for:
1.
Testing or examination not recommended as medically
necessary to diagnose sickness or injury (e.g., marital or
employment examinations, research studies, camp or school
admission);
2.
X-ray or testing related to dental care or treatment;
3.
Eye examination for prescribing corrective lenses, including
contact lenses; or
4.
Testing or examination performed while the Eligible Person
is hospital confined.
Diagnostic X-ray and Lab Benefits are also subject to all General Plan
IN-HOSPITAL PHYSICIAN BENEFITS
When you or your Dependent requires non-surgical treatment by a
physician for non-occupational sickness or accidental bodily injury while confined
in a hospital, the Plan will pay the reasonable and customary medical fee
charged by the physician.
Benefits may be paid for medical treatment rendered during a period of
confinement when a surgical procedure is also performed.
In-Hospital Physician Benefits pay for one physician’s visit per day when
you are confined in a hospital for reasons other than surgery. If surgery is
recommended and performed, these benefits are not paid on or after the day of
surgery unless you are seen by a physician, other than the one who performed
the surgery, for a co-existent medical condition.
August 2014
Page 39
COVERED EXPENSES
The following hospital, medical and other expenses are covered by the
Comprehensive Major Medical Benefits:
1.
Daily hospital charges for ward or semi-private room and
general nursing services;
2.
Daily hospital charges for treatment at an intensive or
coronary care unit;
3.
Other medically necessary services and supplies furnished by
the hospital;
4.
The services of a legally qualified physician;
5.
The services of a graduate registered nurse (R.N.) or legally
licensed physiotherapist, provided those services are not
rendered by someone who ordinarily resides in your home or
by a member of your or your spouse's family;
6.
Diagnostic laboratory and x-ray examinations, x-ray or
radium therapy treatment;
7.
Casts, splints, trusses, braces and crutches and artificial
limbs and eyes replacing limbs or eyes which are lost while a
person is eligible for these benefits;
8.
Whole blood or blood plasma, including the cost of their
administration, other than those charges for "elective”
testing and donation. Autologous transfusion procedures
will be considered if medically necessary due to surgery and
only those pints used as a result of the surgery will be
considered an eligible expense;
9.
Anesthetics and oxygen, including their administration, or
rental of equipment;
10.
Rental, up to the purchase price, of durable medical
equipment (such as wheel chair, hospital bed, or braces)
based on at least one (1) purchase estimate for such
equipment;
11.
Medically necessary professional local ambulance service to
and from a hospital or between hospitals if necessary for
more highly specialized care;
August 2014
Page 40
12.
Drugs and medicines which require a physician's prescription
and are legally obtained from a licensed pharmacist that are
not vitamins, minerals, food supplements or substitutes;
13.
Cardiac rehabilitation (not to exceed six [6] weeks unless
medically necessary) following a heart attack or surgery;
14.
Physical therapy, only when prescribed by a medical doctor
and performed by a licensed physical therapist. Physical
therapy charges for conditions or diagnosis generally
covered under the Chiropractic Benefit are not eligible under
the Major Medical Benefit if the Trustees determine such
treatment is of the type customarily rendered by a
Chiropractor (refer to Section II, Benefits with Special
Limitations “Physical Therapy Expense Benefit” for a more
detailed description of coverage).
15.
Treatment for allergies such as allergy therapy and/or
allergy extract.
Limitations
Major Medical Benefits are not payable for:
1.
Eye refraction (for fitting glasses only), eyeglasses, lasik
surgery, hearing aids or dental prosthetic appliances or
charges for the fitting of any of these applications, unless
such appliances are required due to accidental injury:
2.
Cosmetic or reconstructive surgery which is not necessary
for the prompt repair of an accidental bodily injury, which
occurs while the patient is eligible;
3.
Dental care or treatment except as specifically provided;
4.
Rest cures or custodial care;
5.
Ambulance service or transportation between cities, such as
by air ambulance, railroad or bus;
6.
Maintenance or repairs of durable medical equipment;
7.
Shoes or shoe inserts for treatment of the feet, unless
prescribed by a physician and custom-fitted for the patient;
8.
Orthoptics or aniseikonia;
August 2014
Page 41
9.
Testing or examination not recommended as medically
necessary to diagnose sickness or injury (e.g., pre-marital or
employment examination or research studies); or
10.
Experimental or investigational procedures.
11.
Vitamins, supplements, including pre-natal vitamins.
12.
Lifestyle drugs, for example: Viagra, diet drugs, or drugs for
smoking cessation.
13.
Acupuncture
14.
Massage
15.
Naprapath
In-Hospital Medical Expense Benefits are subject to additional exclusion
and limitations for some conditions; see Treatment with Special Limitations
Section for additional information when treatment is related to drug abuse or
overdose or alcoholism or alcohol abuse and treatment or evaluation of nervous
or mental disorders.
The Major Medical Benefits are also subject to all General Plan Exclusions
and Limitations.
All benefits are subject to additional exclusions and limitations for some
conditions. Refer to the Treatment with Special Limitations Section for additional
information.
In-Hospital Medical Expense Benefits are also subject to all General Plan
PREGNANCY EXPENSE BENEFITS
When you or your Dependent Spouse incurs expense for hospital
confinement or treatment by a physician due to pregnancy, including normal
childbirth, Caesarean section or miscarriage, the plan will pay those expenses on
the same basis as any sickness or injury, up to the reasonable and customary
amount charged in the area and as described in this section. Obstetrical
procedures are eligible under the Surgical Expense Benefits of the Plan.
Benefits for pregnancy are effective immediately for expenses incurred on
or after the Eligible person's individual effective date of coverage. Pregnancy is
not considered a pre-existing condition.
August 2014
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The Fund also covers maternity care benefits when provided by a certified
nurse midwife. Delivery must be in an approved hospital or birthing center.
Limitations
Pregnancy Expense Benefits are not payable for pregnancy expenses
incurred by a Dependent child. The newborn of a dependent child is not
considered eligible for any benefit under the Plan.
Pregnancy Expense Benefits are subject to all the limitations which apply
to individual benefits payable for any sickness or injury, including the General
Plan Exclusions and Limitations.
Statement of Rights Under the Newborn’s and Mother’s Health
Protection Act
Under federal law, group health plans and health insurance issuers offering
group health insurance coverage generally may not restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn
child to less than forty-eight (48) hours following a vaginal delivery, or less than
ninety-six (96) hours following a delivery by cesarean section. However, the
plan or issuer may pay for a shorter stay if the attending provider (e.g., your
physician, nurse midwife, or physician assistant), after consultation with the
mother, discharges the mother or newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or
out-of-pocket cost so that any later portion of the forty-eight (48) hour (or
ninety-six [96] hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician
or other health care provider obtain authorization of prescribing a length of stay
of up to forty-eight (48) hours (or ninety-six [96] hours). However, to use
certain providers or facilities, or to reduce your out-of-pocket costs, you may be
required to obtain precertification. For information on precertification, contact
the Fund Office.
NEWBORN DEPENDENT CHILD BENEFITS
When a female Employee or the Dependent wife of a male Employee
delivers a child or children while eligible under the Plan, benefits are payable for
the newborn, up to the reasonable and customary amount charged in the area
and as described in this section.
August 2014
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Crib Care
Benefits for the care of each newborn Dependent child are payable in the
same manner as hospital room and board and miscellaneous charges are paid
under Hospital Expense Benefits. Crib care is payable during the period the
mother of the child is hospital confined as a result of giving birth to the child.
Newborn Examination
Benefits for medical examination and care of a newborn Dependent, while
hospital confined, by a physician specializing in pediatrics are payable for the day
of birth or the next following day.
Newborn Circumcision
Benefits for circumcision of a newborn Dependent male child by a
physician are payable in the same manner as Surgical Expense Benefits.
Birth Coverage
Benefits for special care and treatment medically required by a newborn
Dependent child as a result of:
1.
Sickness contracted or injury suffered; or
2.
Congenital defect; or
3.
Premature birth.
Benefits are payable in the same manner as any other disability, up to the
reasonable and customary amount charged in the area.
Limitations
Crib care, Newborn Examination and Newborn Circumcision Benefits are
not payable for expenses incurred:
1.
After the mother of the child is no longer hospital confined
as a result of giving birth to such child unless the child
requires extended confinement; except however,
2.
During a period of confinement for the mother which is
longer than that for a normal delivery.
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Newborn Dependent Child Benefits are not payable for expense incurred
by the newborn child or children of an Eligible Person's Dependent child.
Newborn Dependent Child Benefits are also subject to all General Plan
August 2014
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August 2014
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SECTION IV
BENEFITS WITH SPECIAL LIMITATIONS
WEEKLY ACCIDENT AND SICKNESS BENEFITS (LOSS OF TIME)
If you become totally disabled from non-occupational accidental bodily
injury or sickness, the Plan will pay the Weekly Benefit shown in the schedule of
Benefits.
Active Employees Only
Application for Loss of Time Benefits
For the Fund to consider Loss of Time, you must submit a fully completed
claim form.
1.
Both you and the physician must complete the form.
2.
The Fund must receive a "Return to Work Notice" completed
by your physician.
Period of Disability
All disability absences will be considered as having occurred during a
single period of disability unless evidence acceptable to the Trustees is furnished
that:
1.
The cause of the latest disability absence cannot be
connected with the causes of any prior disability absences,
and the latest disability absence occurs after return to active
work for at least one day; or
2.
The causes of the latest disability absence can be connected
with the causes of a prior disability, but the two were
separated by a return to active work for at least two weeks.
Limitations
No benefits are payable under this benefit provision for any period or day
of disability for which the Employee is not under the regular care and attendance
of a physician. A Chiropractor is not considered a physician for the purposes of
disability benefits.
August 2014
Section IV - Benefits With Special Limitations
Page 47
No benefits are payable under this benefit provision for any period on or
after the date an Employee retires, even if such Employee would normally be
considered eligible based on Employer contributions for hours worked before
retirement.
The benefits provided under this provision are not assignable.
Weekly Accident and Sickness Benefits are also subject to all General Plan
Exclusions and Limitations
Benefits paid under this Section are not eligible for and do not contribute
to the Co-payment Limit which allows for one hundred percent (100%) payment
under the Major Medical Expense Benefits.
CHIROPRACTIC EXPENSE BENEFITS
When you or your Dependent is treated by a Chiropractor in connection
with the detection, treatment and correction of structural imbalance, subluxation
or misalignment of the vertebral column for the purposes of alleviating pressure
or spinal nerves, benefits for all related services, supplies and procedures will be
paid as described in this section.
After satisfying the calendar year deductible, chiropractic treatment
charges are payable at fifty percent (50%) of the BCBSIL approved amount after
the deductible for In-Network providers and not covered for Out-of-Network
providers.
Covered services include office visits, manipulations, adjustments and
diagnostic x-ray or laboratory services. The benefit maximum is twenty-four (24)
visits per person per calendar year. Chiropractic x-rays are paid at fifty percent
(50%) of the approved for in-network services and not covered for out of
network services after the applicable deductible. The maximum benefit payable
per person, per calendar year for chiropractic x-rays is two hundred dollars
($200).
Limitations
This Plan does not provide benefits for:
1.
More than one treatment per day;
2.
Services or conditions other than those indicated above.
August 2014
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Expenses related to chiropractic treatment, other than the Chiropractic
Services specified above are not eligible under the Major Medical Expense
Benefits.
Benefits for or related to treatment by a Chiropractor are subject to all
General Plan Exclusions and Limitations.
to the Co-Payment Limit which allows for one hundred (100%) percent payment
under the Major Medical Expense Benefit.
PHYSICAL THERAPY EXPENSE BENEFIT
When you or your dependents undergo physical therapy that is prescribed
by a medical doctor and performed by a licensed physical therapist, reasonable
and customary charges will be considered as described in the schedule of
benefits. Charges for treatment by a medical doctor or licensed physical
therapist that is normally performed by a chiropractor will be considered under
the chiropractic benefit.
Benefits for or related to Physical Therapy are subject to all
general plan exclusions and limitations allowing for fifty percent
(50%) payment after the deductible and subject to a maximum
payable of one thousand, five hundred dollars ($1,500) per person, per
calendar year.
*Physical Therapy Benefits prescribed for surgical procedures and
commencing within six (6) weeks of a covered surgery are considered under the
Major Medical Benefit.
HOME HEALTH CARE BENEFITS
When you or your dependents incur expenses for Home Health Care, and
when such expenses are deemed medically necessary, the Fund will reimburse
those expenses as follows:
1.
Part-time intermediate skilled nursing care up to a maximum
of four (4) hours of reasonable and necessary care per day.
2.
A maximum of thirty (30) days per calendar year.
3.
A maximum of one hundred dollars ($100) per hour.
August 2014
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Limitations
Services must be rendered by a registered nurse.
Benefits are subject to the Plan co-payment inclusive of the calendar year
deductible.
Home Health Care Benefits are also subject to all General Plan Exclusions
and Limitations.
ELECTIVE STERILIZATION BENEFIT (EMPLOYEE OR SPOUSE ONLY)
Charges in connection with an elective sterilization are paid under the
Plan’s Major Medical Benefit.
Limitations
Elective Sterilization Benefits are not payable for:
1.
Expense incurred by a Dependent other than an eligible
dependent spouse;
2.
More than one sterilization procedure per Eligible Family;
and
3.
Expense incurred for the purpose of reversing a sterilization
procedure.
Elective Sterilization Benefits are also subject to all General Plan
MENTAL HEALTH & SUBSTANCE ABUSE BENEFITS
All treatment in-patient or out-patient should be pre-certified by
the Member Assistance Program (MAP).
In-Patient Treatment
Treatment rendered by a certified, registered psychologist (PhD) on the
referral of a physician (MD) will be considered an eligible expense on the same
basis as a physician only if such treatment was recommended by that MD.
No benefits are payable for any portion of a course of inpatient treatment
that is terminated against the medical advice of the MD of record.
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Treatment must be provided by a state licensed facility or provider.
Benefits are paid under the Plan’s Major Medical Provisions: eighty percent
(80%) of the charges for in-network treatment and 65% of reasonable and
customary charges for out-of-network treatment.
Yearly major medical
deductibles apply to this benefit.
Out-Patient Treatment
Treatment rendered by a certified, registered psychologist (PhD) on the
referral of a physician (MD) will be considered an eligible expense on the same
basis as a physician only if such treatment was recommended by that MD.
No benefits are payable for any portion of an intensive outpatient
treatment that is terminated against the advice of the MD of record.
Benefits are paid under the Plan’s Major Medical Provisions: eighty percent
(80%) of the charges for in-network treatment and sixty-five percent (65%) of
reasonable and customary charges for out-of-network treatment. Yearly major
medical deductibles apply to this benefit.
Attention Deficit Disorder (ADD) is considered an eligible diagnosis under
this Benefit. Prescriptions for ADD will be eligible for payment under the
Comprehensive Major Medical Expense Benefit provision of the Plan.
Limitations
Benefits for treatment of mental and nervous disorders are not payable for:
1.
Behavioral disorders (see definition);
2.
Charges related to primal therapy, rolfing, psychodrama,
megavitamin therapy, vision perception training, or carbon
dioxide training.
3.
Charges related to marriage, family, parental, child career,
social adjustment, pastoral or financial counseling services.
4.
Counseling for adoption, custody, family planning,
pregnancy, or catastrophic illness diagnosis in the absence
of psychiatric diagnosis generally recognized and accepted
by the medical profession such as the American Psychiatric
Association’s Diagnostic and Statistical Manual of psychiatric
diagnosis.
August 2014
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5.
Court-Ordered Confinement – Any confinement of a Covered
Person in a public or private institution as the result of a
court order.
6.
Educational or Vocational Testing or Training – Testing
and/or training for educational purposes or to assist an
individual in pursuing a trade or occupation.
7.
Biofeedback, Recreational or Educational Therapy, or other
forms of self-care or self-help training or any related
diagnostic testing.
Treatment of Mental and Nervous Disorders are also subject to
General Plan Exclusions and Limitations.
Co-Payment
Mental Health and Substance Abuse Benefits do not pay covered expenses
in full, so you will share in the cost of your treatment. The Plan pays covered
expenses for in-patient or out-patient rehabilitation programs up to a maximum
lifetime benefit as outlined in the Schedule of Benefits.
Maximum Amount Payable
Aggregate benefits for treatment of alcoholism and substance abuse will
not exceed the maximum amount payable as stated in the Schedule of Benefits.
In-Patient Benefits
1.
one hundred dollars ($100) deductible per person, three
hundred dollars ($300) per family annual deductible applies;
and
2.
Payment at eighty percent (80%) for In-Network Services;
and
3.
Payment at sixty-five percent (65%) for Out-of-Network
Services.
Out-Patient Benefits
1.
one hundred dollars ($100) per person, three hundred
dollars ($300) per family annual deductible applies; and
August 2014
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2.
No more than fifty dollars ($50) paid by the Plan per day for
out of network services; and
3.
Payment at eighty percent (80%) for In-Network Services;
and
4.
Payment at sixty-five percent (65%) for Out-of-Network
Services.
Covered Expenses
Only expenses considered eligible under the Major Medical Expense
Benefits are covered under this Section. Recognized facilities may include nonhospital facilities specializing in substance abuse treatment as well as normal
hospital in-patient facilities.
Limitations
Benefits for treatment of alcoholism and substance abuse will not be paid
if the patient does not complete the full course of treatment prescribed by the
approved program, including initial confinement and/or all group or individual
counseling sessions during the customary treatment program.
Benefits for treatment of alcoholism and substance abuse are not
payable for:
1.
Treatment programs for which the patient does not
complete the full course of treatment prescribed by the
approved program, including initial confinement and/or all
group or individual counseling sessions during or after
confinement.
2.
Treatment programs, which are not conducted by a state
licensed facility.
Benefits for treatment of alcoholism and substance abuse are subject to
the same terms, conditions and limitations governing individual benefits for any
other illness or injury under this Plan.
Benefits paid under this Section are eligible for and do contribute to the
Co-Payment Limit which allows for one hundred (100%) payment under the
Major Medical Expense Benefit.
August 2014
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WELL CHILD CARE BENEFITS AND ROUTINE PHYSICAL EXAMINATION BENEFIT
(WELLNESS BENEFITS)
When you, your Dependent spouse, or your Dependent child (up to the
age of nineteen [19]) incurs eligible expenses for a routine physical examination
performed by a physician, the Plan will pay those reasonable expenses up to the
amounts shown in the Schedule of Benefits Section and as described in this
Section.
Eligible expenses include the physician's professional fees, immunizations
and diagnostic x-ray or laboratory charges. The examination may be performed
in a physician's office, clinic or hospital out-patient department.
Limitations
Routine Physical Examination Benefits are not payable for:
1.
Testing or examination related to accidental bodily injury,
sickness or pregnancy (including resulting child birth or
complications);
2.
Testing or examination related to or as a condition of
employment or to the issuance of any insurance policy;
3.
Expense incurred by a Dependent other than the Employee's
spouse (except for children up to the age of nineteen [19]).
Routine Physical Examination Benefits are also subject to all General Plan
Benefits paid under this Section are eligible for and do contribute to the
Co-Payment Limit which allows for one hundred percent (100%) payment under
the Comprehensive Major Medical Expense Benefit. Benefits are also not payable
under any other benefit.
PRESCRIPTION DRUG BENEFITS
The Plan will pay for Prescription Drugs, in generic or brand form, when
prescribed by a physician, and after applicable co-payments have been satisfied.
Benefits for Active Participants are provided through the Citizens-Rx
Prescription Drug Program. You should automatically receive a prescription drug
card when you become eligible under the Plan. Benefits are paid based upon the
Schedule of Benefits on Pages A-G.
August 2014
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HEARING CARE BENEFITS
When you or your Dependent incurs expenses for hearing care, the Plan
will pay those expenses up to the amount shown in the Schedule of Benefits and
as described in this Section.
Eligibility
The benefit is available to all eligible members and their Dependents on a
recurring basis each five years.
The Deductible Amount
There is no deductible.
Co-Payment
Hearing Care Benefits are paid at fifty percent (50%) of the usual,
reasonable, and customary covered expenses for eligible hearing care treatment
expenses.
The Maximum Amount
All payments under Hearing Care Benefits are limited to the maximum
amount shown in the Schedule of Benefits. The maximum amount applies to you
and each of your Dependents separately. The maximum amount cannot be
reinstated and is not renewed if eligibility is lost and then regained at a later
date.
Covered Expenses
Hearing Care Benefits are divided into three main parts: a physical
examination by a specialist physician (otologist or otorhinolaryngolist); a test of
hearing ability and condition by a specialist physician or a licensed audiologist;
and the purchase of a hearing aid, if required.
Fitting and purchase of a hearing aid includes the reasonable charges for
the manufacture of ear molds by a specialist physician or licensed audiologist;
and the purchase of a hearing aid, including hearing aid rental and audiologist
consultation fees during an evaluation period (whether or not a hearing aid is
found to be satisfactory and is purchased).
August 2014
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Limitations
Hearing Care Benefits are not payable for:
1.
Examination or testing by other than an otologist,
otorilinolaryngolist or licensed audiologist;
2.
Services or supplies provided by an audiologist, which are
not prescribed by a specialist physician;
3.
Charges for hygienic cleaning of the hearing aid;
4.
Batteries and their installation;
5.
Charges for repair due to accidental damage or for
replacement of a lost hearing aid.
Hearing Care Benefits are also subject to all General Plan Exclusions and
Limitations.
to the Co-Payment Limit, which allows for one hundred (100%) percent payment
under the Major Medical Expense Benefit.
Organ Transplant Benefit
When you or your Dependent require organ transplant procedures (as
approved by Medicare), benefit payments by the Plan are subject to the rules
described in this section in addition to those governing individual benefits.
Eligibility
To be considered eligible for benefits under this section, the patient must
have been continuously eligible in the Plan for at least twelve (12) calendar
months immediately before covered expense is incurred.
Co-Payment - PPO
The Plan pays eighty percent (80%) of covered expenses based upon the
BCBSIL approved amounts in lieu of benefit amounts or payment formulas
applicable to any other sickness or accidental bodily injury.
August 2014
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Co-Payment – Non-PPO
The Plan pays sixty-five percent (65%) of covered expenses in lieu of
benefit amounts or payment formulas applicable to any other sickness or
accidental bodily injury.
The Maximum Amount
The maximum amount is the same as any other illness or injury as
described in the Schedule of Benefits. Payments made by the Plan shall be
applied to the Transplant Benefit as the expense is incurred on and after the
date a transplant is determined to be medically necessary.
Limitations
Transplant Benefits are not payable for:
1.
Expense incurred by any person other than an Eligible
Person as determined by the Eligibility Rules, including but
not limited to a living tissue or organ donor, and
2.
Transplants other than those approved by Medicare, and
3.
Treatment employing experimental or investigational medical
or surgical procedures, and
4.
Participation in study Programs.
“Experimental” or “Investigative” means the use of any treatment,
procedure, facility, equipment, drugs, devices or supplies not yet recognized as
acceptable general medical practice and any such items requiring federal or
governmental agency approval for which such approval has not been granted at
the time the service was provided. The Trustees have the sole authority to
determine whether the treatment shall be considered “experimental or
investigational” for the purposes of this Plan.
Transplant Benefits are also subject to all General Plan Exclusions and
Limitations.
August 2014
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August 2014
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SECTION V
Dental Care Benefits
When you or your Dependent incurs expenses for dental care, the Plan
will pay those expenses to a maximum amount as shown in the Schedule of
Benefits and as described in this Section. The Plan also requires co-payments for
eligible types of care so you will share the cost of your treatment. Co-payment
levels are specified for each group of eligible expenses. The annual deductible
does not apply to dental benefits.
Predetermination of Benefits
You are not required to have the dentist submit an estimate of charges
before work begins. However, the Trustees recommend that the dentist give the
Claims Office a description of the procedures to be performed and the estimated
fees before treatment starts if the total charges will be over two hundred dollars
($200). This will let you and your dentist know if the treatment plan is
considered reasonable and what benefits will be paid.
The Maximum Amount
All payments under Dental Care Benefits are limited to the maximum
amount shown in the Schedule of Benefits for the type of care involved. The
maximum amount applies to you and each of your eligible Dependents
separately for all covered expenses.
Covered Expenses
Dental Care Benefits are divided into four main parts: preventive; diagnostic
expenses; restorative expenses (such as most fillings and extractions);
prosthodontics expenses (such as gold work and dentures or orthodontics). The
percentage payable by the Plan is determined separately for each type of
treatment group.
1.
Preventive Expense.
The Plan pays one-hundred percent
(100%) of the reasonable expense for the following dental care:

Oral Examinations, twice (2) per calendar year;

Preventive treatment consisting of:
(1)
Oral prophylaxis (cleaning and scaling of teeth)
but not more than twice (2) in a calendar year;
August 2014
Section V -Dental Care Benefits
Page 59
(2)

Topical sodium and stannous fluoride treatment
or sealants are available only to eligible persons
under age nineteen (19), but not more than one
treatment per tooth in a calendar year; and
Space Maintainers for replacement of deciduous prematurely
lost teeth for an eligible person under age nineteen (19).
Diagnostic Expense. The Plan pays one hundred percent
(100%) of the reasonable and customary expenses for x-rays,
consisting of:
2.

Bitewing x-rays, not more than twice in a calendar year; and

Full mouth x-rays, once in a thirty-six (36) consecutive
month period.
All Other Dental Expenses
Restorative Expenses. The Plan pays eighty percent (80%) of
the reasonable and customary expenses for the following dental
care:

Extractions not related to orthodontics;

Oral surgery, including medically necessary administration of
local or general anesthetics;

Fillings, other than gold;

Periodontal treatment (diseases of gums);

Endodontic
therapy);

Injections of antibiotic drugs;
treatment (pulp
infection
and root canal
Prosthodontics Expenses. The Plan pays eighty percent (80%)
of the reasonable expense for the following dental care:

Initial installation of complete or partial bridgework fixed or
removable;

Initial installation of gold fillings or crowns as abutments,
provided that amalgam, silicate, plastic or other materials
will not adequately restore the teeth;
August 2014
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

Replacement of
provided that:
previously
existing
gold
restorations
(1)
Amalgam, silicate, plastic or other materials will
not adequately restore the tooth, and
(2)
The previous restoration was installed five (5) or
more years prior to this replacement.
Replacement of previously existing complete or partial
removable dentures or fixed bridgework provided that:
(1)
the previous denture or bridgework was
installed three or more years prior to its
replacement.

Dental implants.

Orthodontic Expense. When a dependent child through the
age of eighteen (18) (through the age of twenty-two [22] if
dependent is a full-time student) undergoes Orthodontic
Treatment, the Plan pays eighty percent (80%) of the
reasonable and customary expense for the following services
and supplies during the first thirty-six (36) months of
treatment:

diagnostic procedures, including cephalometric xrays;

surgical therapy, including repositioning of the jaw
or facial bones or teeth to correct malocclusion;

appliance therapy (braces), including related
periodic oral exams, surgery and extractions.
Expense Incurred
Expense Incurred means the date a dental service or treatment is performed,
except for the following services or treatments:
1.
Dentures or bridgework – the date the impressions are taken.
2.
Crowns, in-lays, on-lays – the date the teeth are first prepared.
3.
Root canal therapy – the date the pulp chamber is opened.
August 2014
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The Maximum Amount
The maximum amount for all other Covered Expenses applies to payments
for treatment each calendar year and so is renewed each January 1st. Benefits
not used in a prior year cannot be carried forward to increase the maximum
amount for the next calendar year.
Treatment in Progress When Eligibility Terminates
The Plan will generally not pay for services or supplies furnished after the
date you or your Dependent’s eligibility terminates, even if the Claims Office has
predetermined the payments for a treatment plan submitted before the
termination date.
The Plan will pay for services or supplies related to the following covered
expenses if the treatment is rendered and delivered to the patient within ninety
(90) days after the termination date and the following conditions are met:
1.
A prosthetic device (such as full or partial dentures) if the
dentist took the impressions and prepared the abutment
teeth while the patient was covered under the Plan;
2.
A crown if the dentist prepared the tooth for the crown while
the patient was covered under the Plan; and
3.
Root canal therapy if the dentist opened the tooth while the
patient was covered under the Plan.
LIMITATIONS
Dental Care Benefits are not payable for:
1.
Any service rendered, supply ordered or treatment plan
begun before coverage became effective;
2.
Treatment other than by a licensed dentist or licensed
physician, except that scaling or cleaning of teeth and
topical application of fluoride may be performed by a
licensed dental hygienist if the treatment is rendered under
the supervision and guidance of and billed for by the dentist;
3.
Services or supplies that are primarily cosmetic in nature,
including charges for personalization or characterization of
dentures;
August 2014
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4.
Replacement of a lost, missing or stolen prosthetic device;
5.
Services rendered through a medical department, clinic or
similar facility provided or maintained by the patient’s
employer or governmental agency;
6.
Services or supplies which do not meet accepted standards
of dental practice, including charges for services or supplies
which are experimental in nature;
7.
Any duplicate appliance or prosthetic device;
8.
Athletic mouth guards;
9.
A plaque control program (a series of instructions on the
care of the teeth);
10.
Periodontal splinting;
11.
Services which are provided under other sections of this
Plan;
12.
Myofunctional therapy (correction of harmful habits);
13.
Sealants and fluorides painted on the teeth in an attempt to
prevent further decay (more than once a year);
14.
Services or supplies which are not necessary according to
accepted standards of dental practice;
15.
Oral hygiene or dietary instructions.
16.
Occusual guards or bite splints.
Limitations
for:
Dental Care Benefits for Orthodontic Treatment are not payable
1.
a Dependent other than a Dependent child;
2.
any orthodontic treatment program begun on or after the
Dependent child’s nineteenth (19th) birthday, (or twentythird [23rd] birthday if a full-time student);
3.
any orthodontic treatment procedures performed after the
first thirty-six (36) months of treatment.
Dental Care Benefits are also subject to all General Plan Exclusions and
Limitations.
August 2014
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August 2014
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SECTION VI
VISION CARE BENEFITS
When you or your Dependent incurs expense for vision care, the Plan will
pay those expenses up to the maximum amount shown in the Schedule of
Benefits and as described in this Section. There is no deductible required by
the Plan before Vision Care Benefits become payable. Vision Benefits renew
every even calendar year.
The Maximum Amount
Payments under the Vision Care Benefits are limited to the individual
maximum as shown in the Schedule of Benefits and renew every other calendar
year. For example, the benefit periods January 1, 2012 through December 31,
2013 and January 1, 2014 through December 31, 2015.
Covered Expense
Services or supplies must be provided by an Optician, Optometrist, or
Ophthalmologist to be considered Covered Expenses. Typical services are shown
below.
1.
2.
Vision Examination - A vision screening includes:
a.
a check of principle vision functions, and;
b.
determination of vision ability and condition.
Vision analysis may be done. Vision analysis includes:
a.
complete case history;
b.
measuring and recording of visual acuity, corrected
and uncorrected;
c.
examination of fundus, media, crystalline lens, optic
disc and pupil reflex for pathology, anomalies or
injury, corneal curvature measurements, retinoscopy;
d.
fusion determination, distance and near, subjective
determination, distance and near, and stereopsis
determination, distance and near;
e.
color discrimination and amplitude or accommodation;
August 2014
Section VI –Vision Care Benefits
Page 65
3.
f.
analysis of findings, lens prescription (if needed); and
g.
measuring and recording of visual acuity, distance
and near, with new prescription if required.
Contact Lenses or Lenses and Frames. Related services and
supplies include:
a.
professional advice on frame selection;
b.
facial measurement, and preparation of specifications
for optical laboratory and verifying and fitting of
prescription glasses or contact lenses;
c.
re-evaluation and progress report after fitting new
prescription and subsequent servicing.
Limitations
Vision Care Benefits are not payable for:
1. Examinations or materials more frequently than specifically
provided;
2. Lenses, frames or contact lenses which are lost or broken
except at the normal intervals when benefits are available;
3. Special procedures such as orthoptics, vision training or
aniseikonia;
4. Non-Prescription sun glasses or tinted glasses;
5. Services or supplies not listed as covered vision expenses;
6. Services, treatment or supplies, related to medical or surgical
treatment of the eyes;
7. Services, treatment or supplies which are rendered or finished
before the date a person becomes initially eligible or after the
date a person's eligibility terminates;
Surgery to correct vision deficiencies
a.
Radial Keratotomy’s Surgery (RK);
b.
Lasik Surgery;
August 2014
Page 66
The Plan will pay the covered amount at 50% after the applicable
deductible up to a maximum of two thousand dollars ($2,000) per eye per
lifetime.
Vision Care Benefits are also subject to all General Plan Exclusions and
Limitations.
Vision Therapy
Vision Training/Therapy is a separate benefit and must be performed by
an optometrist, an opthamologist, or an MD trained in vision therapy. The benefit
is paid at 100% and has a maximum allowable expense of $400 per person per
year. Coverage is for Class A and Class B participants and their eligible
dependents.
August 2014
Page 67
August 2014
Page 68
SECTION VII
EMPLOYEES ONLY
DEATH AND DISMEMBERMENT BENEFITS
Death Benefits
If you die from any cause, a Death Benefit is payable in the amount
specified in the Schedule of Benefits. The Fund Office must be provided with
acceptable proof of death on forms provided by the Trustees.
Beneficiary Designation
You must file a written designation of Beneficiary with the Fund Office on
a properly completed form. If you have not made an irrevocable designation of
Beneficiary, you may name a new Beneficiary without your prior Beneficiary's
consent, by filing a new form with the Fund Office. The change of Beneficiary
will be effective retroactively to the date you sign the form, whether or not you
are living when the Fund Office receives it. The Plan is not responsible for any
payments made before the change of Beneficiary form is received. If you do not
designate a Beneficiary or if your Beneficiary does not outlive you, the Death
Benefit will be paid to the living in the following order:
1.
Spouse;
2.
Children, including legally adopted children;
3.
Parents;
4.
Brothers and sisters; or
5.
Executor or administrator of the Employee's estate.
If two (2) or more persons are entitled to the Death Benefit, they will
share equally.
Notice of Claim
Written notice of the death of an Employee whose coverage has been
continued under this provision must be given to the Fund Office within twelve
(12) months of the date of death. If written notice is not given within such
twelve (12) month period, the Plan will not be liable for any person on account
of that death.
August 2014
Section VII - Death and Dismemberment Benefits
Page 69
August 2014
Section VII - Death and Dismemberment Benefits
Page 70
SECTION VIII
MEDICAL SAVINGS BENEFIT
The Medical Savings Benefit is currently five hundred dollars ($500) per
participant. Each year the Trustees will determine whether an allocation to the
Medical Savings Benefit will be made and if so, the amount of the allocation.
How the Medical Savings Benefit Works
As of January 1, each year, the Trustees will determine the amount that
will be allocated to the Medical Savings Benefit. This is the total amount payable
per calendar year for the participant and their eligible dependents.
In order to qualify for the Medical Savings Benefits, you must be eligible
on the date services were incurred.
What the Money Can Be Used For
The Medical Savings Plan can be used to pay for certain eligible health
care expenses NOT reimbursed by the IBEW Local 461 Welfare Fund or any
other benefit or insurance plan under which you or your dependents are eligible.
Among the eligible items are:
a.
Your medical deductibles;
b.
The medical, dental or vision care co-payments;
c.
Federally recognized covered Medical, dental or vision care
expenses not eligible for payment under this or any other
Plan;
How to Use the Medical Savings Plan
To receive payment from your Medical Savings Plan:
a.
You should accumulate at least twenty-five dollars ($25) in
reimbursable expenses before you file a claim for payment
from your Medical Savings Plan.
b.
Fill out a request form, provided by the Administration
Office, indicating which expenses you want reimbursed from
your Medical Savings Plan.
c.
Submit, along with the form, itemized bills or Explanation of
Benefits forms.
August 2014
Section VIII – Medical Savings Benefit
Page 71
d.
Send the above items to IBEW Local 461 Welfare Fund
Medical Savings Plan, 6525 Centurion Drive, Lansing, MI
48917.
e.
You must apply for Medical Savings Benefits within 90 days
of the end of the calendar year for which your medical
savings apply. For example, claims for calendar year 2014
should be submitted by March 31, 2015.
MEDICAL SAVINGS BENEFIT AND SUPPLEMENTAL BENEFIT ACCOUNT
Eligible Healthcare Expenses
There are a wide range of eligible healthcare expenses for your Medical Savings
Benefit and Supplemental Benefit Account, including prescriptions, over-thecounter medications, medical co-payments, and health insurance deductibles, for
you, your spouse, and your eligible children.
The tables below provide examples of eligible medical expenses, eligible overthe-counter (OTC) expenses, OTC expenses that are eligible only with a
prescription, and ineligible expenses. You must be eligible in the Welfare
Plan on the date of purchase.
ELIGIBLE MEDICAL EXPENSES



















Acupuncture
Alcoholism treatment
Ambulance services
Artificial limbs & teeth
Automobile modified for
physically handicapped
Birth control pills
Blood pressure monitoring
Braille publications (above
regular printed cost)
Breast pumps and lactation
devices
Chiropractic care
Christian Science
practitioners
COBRA premiums
Contact lenses
Crutches
Dental treatment
Dentures
Diagnostic services
Disability care expenses
Drug addiction treatment



















Eye examination & glasses
Fertility treatments or
abortions
Flu shot
Guide dog or animal aides
Hearing aids & batteries
Hospital services
Immunization
Insulin
Insurance premiums
Laboratory fees
Laser eye surgery
Lodging & meals for
medical care
Long-term care premiums
or expenses
Medical & testing devices
Medicare premiums
Nursing services
Obstetrical expenses
Organ transplant
Orthodontia (not for
cosmetic reasons)
















Oxygen
Physical exam
Physical therapy
Prescription drugs
Psychiatric care
Retiree medical insurance
premiums
Special schooling for disabilities
Speech therapy, lip reading
Smoking cessation
programs
Sunscreen (SPF 15+ broad
spectrum)
Surgery
Telephone & TV for deaf
Transportation & travel exp
for medical care
Weight loss program to
treat obesity
Wheelchairs
X-rays and body scans
August 2014
Page 72
ELIGIBLE OTC EXPENSES - WITHOUT A PRESCRIPTION









Bandages
Braces & supports
Catheters
Contact lens supplies &
solutions
Denture adhesives
Diagnostic tests & monitors
Family planning items
First aid supplies
Insulin & diabetic supplies



Ostomy products
Reading glasses
Wheelchairs, walkers,
canes
ELIGIBLE OTC EXPENSES - WITH A PRESCRIPTION













Acid controllers
Allergy & sinus medicine
Antibiotics
Anti-diarrheals
Anti-gas products
Anti-itch & anti-fungal
Anti-parasitic treatments
Arthritis creams
Baby rash ointments
Cold sore remedies
Cough, cold & flu
treatments
Digestive aids










Dietary and weight loss
supplements*
Electrolysis, hair removal*
Feminine creams
Fiber supplements*
Hemorrhoidal preps
Incontinence pads, diapers
Laxatives
Lead paint removal*
Legal healthcare orders*
Motion sickness
Nutritional supplements











Orthopedic shoes and
inserts*
Pain relievers
Respiratory treatments
Shampoo psoriasis or lice
Sleep aids & sedatives
Snoring cessation aids*
Stomach remedies
Vaporizers & humidifiers
Veterinary fees
Vitamins and herbal
supplements*
Wigs & hair transplant*
Prescription means a written or electronic order for a medicine or drug that meets
the legal requirements of a prescription in the state in which the medical expense is
incurred and that is issued by an individual who is legally authorized to issue a
prescription in that state. The items marked with an * are eligible with a
prescription, a doctor’s directive, or letter of medical necessity.
INELIGIBLE MEDICAL EXPENSES
(The expenses below are never eligible for reimbursement)















Childcare regular services
Cosmetics
Cosmetic surgery
Dance or swim lessons
Deodorant
Diaper services
Exercise equipment
Fitness programs, dues
Funeral expenses
Hair transplants
Healthcare tax exp
Household help
Illegal substances,
treatments, or operations
Moisturizers and wrinkle
creams
Maternity clothes


Teeth whitening services &
products
Toothpaste & mouth wash
August 2014
Page 73
DRAFT COPY - July 9, 2014
August 2014
Page 74
SECTION IX
SUPPLEMENTAL BENEFIT ACCOUNT
The Supplemental Benefit Account (SBA) provides for coverage of
deductibles, co-payments and other benefits under the plan (please refer to the
“Covered Benefits” in this section for a detailed listing of the covered benefits.
Funding
For every hour worked, employer contributions are placed into the
individuals Supplemental Benefit Account (SBA).
These are not vested benefits; the Trustees have the legal right to use any or all
of your SBA balance for any Plan purposes or obligations.
Participation
Contributions are required from the employers for Active participants
working within the jurisdiction of and covered under the terms of the Collective
Bargaining Agreement and Non-Bargaining Unit (NBU) participants employed by
Local Union 461 or the Joint Apprenticeship and Training Fund.
Eligibility
The participant must be eligible based upon the Plans regular active
participant eligibility provisions or self-payments on the date services are
rendered.
The participant may continue to utilize the SBA provided he/she is eligible
by way of employer contributions, the hour bank or retiree self-payments.
Reimbursable Benefits
Eligible expenses include reimbursement of self-payments and those
defined by the Internal Revenue Service (IRS) which are listed under Covered
Benefits in this section.
Reimbursement
Participants must submit an itemized bill, for dental and vision services.
For all other services the participant must submit the appropriate payment
voucher or rejection from Blue Cross Blue Shield of Illinois to the Fund Office.
August 2014
Section IX – Supplemental Benefit Account
Page 75
Claims will be reimbursed on a weekly basis however; participants can
submit claims as frequently as they want. The Fund Office will hold the claims
until the next reimbursement period.
Please refer to Section VIII under the Medical Savings Benefit for a
complete list of Eligible Health Care Expenses
Accruing Account Balances
The account balance will continue to grow each year if the participant
does not use it. If however the participant has an account balance which is less
than one hundred dollars ($100) and he/she has had no contributions to the
account for more than twenty-four (24) months, the account will be closed and
the monies will be utilized by the Fund.
Non Covered Expenses
●
Expenses incurred prior to May 1, 2014
●
Expenses for which you are eligible to receive reimbursement from
another source
●
Occupational Injuries
●
Non-eligible expenses
For a more complete listing of expenses not covered, please refer to
section for “Examples of Non-Eligible Health Care Expenses”.
Work in an area outside of the jurisdiction of the Fund
Contributions be remitted at the current contribution rate which includes
the SB allocation at the IBEW Local 461 Collective Bargaining Agreement (CBA)
rate. If contributions are reciprocated that are less than the current contribution
rate but in excess of the amount determined by the Board of Trustees (currently
ten dollars and eleven cents [$10.11]) then that excess amount will be credited.
August 2014
Section IX – Supplemental Benefit Account
Page 76
SECTION X
GENERAL PLAN EXCLUSIONS AND LIMITATIONS
The following exclusions and general limitations apply to all benefits
provided by the IBEW Local No. 461 Welfare Fund unless specifically waived by a
particular benefit section.
Routine Care and Elective Procedures
Benefits under this Plan are for the treatment of sickness or accidental
bodily injury when rendered by hospitals and physicians. Routine care, cosmetic
surgery, diet medication or supplements, which are not medically necessary to
correct a condition which threatens the health of an Eligible person are not
eligible for Benefits from this Plan unless specifically provided for. The Trustees
reserve the right to have an Eligible Person examined by a physician of their own
choice and at their own expense to make their determination regarding any
benefit payable or eligibility rule of this Plan.
Treatment designed to merely improve bodily functions is not considered
medically necessary or an eligible expense for benefits.
Medical Necessity
Benefits under this Plan are payable only for services and supplies which
are considered by the Trustees to be medically necessary in view of the patient's
condition and diagnosis. For example, non-emergency hospital admission and
confinement over a weekend will be presumed not medically necessary and not
an eligible expense incurred. Hospital admission for surgery which is generally
performed on an out-patient basis will not be considered eligible for benefits
unless such admission is medically necessary due, for example, to a co-existent
medical condition.
Work Related Disabilities
Payment will not be made by the Plan for expenses incurred because of
disease, defect or accidental injury which occurs during, or arises out of, any
occupation for wage or profit. Occupational refers to any activity involving
wages or profit, not simply collective bargaining employment. If the Eligible
Person’s claim under Workers’ Compensation or any Occupational Disease Law is
rejected, the illness or injury will not be considered work-related and payment
will be made.
August 2014
Section X - General Plan Exclusions and Limitations
Page 77
1.
A claim under Workers’ Compensation will be considered to
have been rejected under the following circumstances:
a. when, after a hearing in the Illinois Industrial
Commission (or a corresponding agency in another
state), there has been a final administrative
determination denying the claim and no lawsuit seeking
court review of the decision has been filed; or
b. when a decision has been rendered by the Illinois
Industrial Commission (or corresponding agency in
another state), a party has sought court review of the
decision and a final court determination has been made
rejecting the claim.
Occupational injury and illness claims are not subject to
subrogation/repayment agreements, and as such no coverage for occupational
injuries or illnesses can be accessed through any subrogation or repayment
agreement.
Organ Transplants
Payment will be limited to the usual, customary and reasonable fee
schedule incurred as a result of any type of organ transplants, such as, but not
limited to the liver, lung, heart, kidney or cornea.
Reasonable and Customary Charges
Payment will not be made by this Plan for any expense incurred or charge
made, which the Trustees determine is not reasonable or customary as defined
herein.
Treatment Sponsored by Governmental Units
Payment will not be made by the Plan for expenses incurred:
1.
While confined in a hospital owned or operated by the
Federal Government or other government unit; or
2.
For treatment by a physician employed by the Federal
Government or other governmental unit; or
3.
For services or supplies furnished by or at the request or
direction of the Federal Government, any of its agencies, or
August 2014
Page 78
other government unit unless the Eligible person is legally
required to pay.
This exclusion will not prevent coordination of benefits with a plan
specifically established by a governmental unit for its own civilian employees and
their dependents.
Treatment Without Charge
Payment will not be made for confinement in any hospital or treatment by
a physician when the hospital or physician makes no charge that the Eligible
Person is legally required to pay or would not be charged in the absence of these
benefits.
Illegal Occupation or Act or Commission of Felony
Any condition, disability, or expense resulting from or sustained as a result
of being engaged in: 1) an illegal act or occupation which is considered to be a
felony in the jurisdiction in which the act occurred, regardless of whether
charged or convicted; 2) commission or attempted commission of assault,
battery, criminal trespass, criminal damage to property, theft, robbery, burglary,
or arson, regardless of whether charged with or convicted of a felony; or 3)
participation in civil insurrection or riot; provided, however, that this exclusion
shall not apply if the condition, disability or expense resulted from a medical
condition.
Experimental Treatment of Procedures
Benefits under this Plan are for the treatment of accidental bodily injury or
sickness by generally recognized medicines, surgery and other techniques or
devices. Medicines, treatment techniques and devices which are not generally
recognized by professional peer groups (such as the American Medical
Association) or by regulatory governmental authorities (such as the Food and
Drug Administration) will be considered experimental and will not be considered
eligible expenses under this Plan. For the purposes of this provision, recognized
treatment or medicines used in a non-routine manner (frequency or dosage) will
be considered experimental.
Liability for Accidental Injuries
Benefits under this Plan are considered secondary and excess coverage,
including but not limited to, any automobile insurance or individual common
carrier's liability (such as bus or commercial airline). No payment shall be made
August 2014
Page 79
until proof is submitted to and judged acceptable by the Trustees that a proper
claim has been made for other coverage. Normal Plan benefits shall be paid if
other coverage has been denied or shall be coordinated with other coverage
payments, if any.
General Limitations
Benefits of this Plan do not cover any loss caused by, incurred for or
resulting from:
1.
Declared or undeclared war, or any act thereof, or military or
naval services of any country;
2.
Services, treatment or supplies received from a dental or
medical department maintained by a mutual benefit
association of this or another employee benefit plan or labor
union;
3.
Services, treatment or supplies, which are payable or
furnished under any policy of insurance or other medical
benefit plan or service plan for which the Trustees shall,
directly or indirectly, have paid for all or a portion of the
cost;
4.
Services or treatment rendered or supplies furnished
primarily for cosmetic purposes;
a)
Unless necessary for the prompt repair of an
accidental bodily injury or sickness or disease; and
b)
Performed within two (2) years of a covered event.
5.
Expenses incurred for services performed or supplies
furnished by other than a physician;
6.
Services, treatment or supplies rendered or furnished:
7.
a.
Before the individual concerned became an Eligible
Person; or
b.
Without the recommendation and approval of a
legally qualified physician;
Services related to obesity, diet or weight control, including
but not limited to: exercise programs, surgery, special diet
or diet supplements, smoking cessation programs and drugs,
amphetamines, or any form of diet medication whether or
not recommended or supervised by a physician, including
August 2014
Page 80
dietary or nutritional counseling, books, pamphlets or
classes;
8.
Mental counseling, physical therapy, supplies or prosthesis
for sexual dysfunction or inadequacies;
9.
Implantation within the human body of artificial mechanical
devices designed to replace human organs other than
pacemakers or similar such devices which merely assist
rather than replace the function of the organ;
10.
Ambulance service or transportation between cities or states
(such as by ambulance, air ambulance, railroad or bus)
unless judged by the Trustees as essential for treatment of a
life-threatening illness or injury;
11.
Growth hormones;(testing covered if medically necessary)
12.
Expenses incurred for the purpose of reversing tubal
ligations, vasectomies or other sterilization procedures;
13.
Special home construction to accommodate a disabled
person;
14.
Education, special education, job training or work hardening
whether or not given in a facility that also provides medical
or psychiatric treatment beyond the first medically necessary
visit. Special education or like services, regardless of: the
type of education, the purpose of the education, their
recommendation of the attending physician or the
qualification of the individual rendering the educational
services;
15.
Rest cures or custodial care;
16.
Speech therapy, other than charges for speech therapy that
is expected to restore speech to a person who has lost
existing speech function (the ability to express thoughts,
speak words and form sentences) while eligible in the Plan
and as the result of a disease or accidental injury. Speech
therapy to improve speech in the absence of disease or
accidental injury (such as for a learning disability or speech
delay) is considered special education and is not covered;
17.
Supplies or equipment for personal hygiene, comfort or
convenience;
August 2014
Page 81
18.
Services, treatment or care rendered by a member of the
Eligible Member's family;
19.
Treatment or services for or in connection with marriage,
family, child, career, social adjustment, pastoral, or financial
counseling;
20.
Treatment or services for primal therapy, rolfing,
psychodrama, megavitamin therapy, bioenergetic therapy,
vision perception training, or carbon dioxide therapy except
as previously provided for;
21.
Dietary or nutritional counseling, books, pamphlets or
classes;
22.
Charges incurred for travel, whether or not recommended by
a physician.
23.
Treatment to improve fertility such as artificial insemination,
invitro fertilization, or embryo transfer process or infertility.
24
Expenses for services related to sex transformations or
sexual dysfunctions or inadequacies (including impotency),
other than diagnosis and treatment of organic impotency.
25
Voluntary acceptance of extraordinary risks such as speed
contests or fighting.
26.
Programs or prescription medications for the purpose of
smoking cessation.
27.
Pre-natal vitamins.
28.
Charges incurred for any abortion procedure except where
the pregnancy is the result of rape as evidenced by a Police
Report.
29.
Accidental Injuries For Which a Third Party May Be Liable
No benefits will be paid to you or your eligible
dependent for expenses incurred due to an accidental injury
for which a third-party may be liable. The Trustees, in their
sole discretion, may agree to pay such benefits provided that
you
and/or
your
eligible
dependent
sign
a
Repayment/Subrogation agreement in a form approved by
the Trustees. In this Repayment/Subrogation agreement
you and/or your eligible dependent must agree to the
following:
August 2014
Page 82
1. That if there is any recovery from a third-party
relating to the accidental injury you will repay the
Fund the benefits which have been paid without
deduction for expenses or attorneys fees.
2. That you will only hire an attorney who
agrees, in writing, to waive the common
fund doctrine and agrees to remit to the Fund
from any settlement or judgment the gross
amount of benefits paid by the Fund without any
claim for legal fees.
3. That, if the Fund receives from any settlement or
judgment less than full re-payment of the benefits
which it paid, you will be personally liable for
all amounts required to make the Fund
whole.
This provision will not apply if the
judgment in the case establishes that the third
party was not liable for the accident.
4. That, if you do not prosecute a claim against a
third-party to recover for the injuries, then you
must agree to authorize the Fund, at its option, to
bring a claim in your name against the third-party,
including the filing of a lawsuit in court.
5. That, you will cooperate fully with the Fund in any
action which the Fund may take.
6. That, you will not take any action, or sign any
document which impairs the Fund’s right to
recover the benefits paid.
If you or an eligible dependent accept a
settlement or receive an award or judgment, future
medical expense for any injury or illness that has
been caused by the third-party will not be considered
eligible expenses under this Plan.
August 2014
Page 83
August 2014
Page 84
SECTION XI
OTHER GENERAL PLAN PROVISIONS
Physical or Dental Examination and Autopsy
The Trustees at their own expense have the right and opportunity to
examine the person of any individual whose injury or sickness is the basis of a
claim when and as often as it may reasonably require during pendency of claim
under the Plan, and to make an autopsy in case of death, where it is not
forbidden by law.
Free Choice of Physician
The covered person has free choice of any physician and the physicianpatient relationship will be maintained.
Workers' Compensation Not Affected
The Plan is not in lieu of and does not affect any requirement for coverage
of Workers' Compensation insurance.
Time Limits for Filing Claims
The Fund will furnish to the claimant, on request, the forms approved by
the Trustees for filing proof of loss covered under this Plan. The Trustees may
accept other written forms as proofs of loss, if in their sole judgement; the
written proofs contain complete and credible information as to the occurrence,
character and extent of the loss for which the claim is made.
Written proof of expense incurred due to hospital confinement or due to
total disability must be furnished to the Fund within ninety (90) days after the
termination of the period for which the claim is made. Written proof of other
covered expense incurred must be furnished within ninety (90) days of the date
the expense is incurred. Failure to furnish notice or proof of loss within the time
period provided in the Plan will not invalidate or reduce any claim:
1.
if it was not reasonably possible to give proof within that
time; and
2.
if proof is furnished as soon as reasonably possible; and
August 2014
Section XI - Other General Plan Provisions
Page 85
3.
no later than one (1) year from the time proof is otherwise
required (except this time limit will not apply to a claimant
who is legally incapacitated).
4.
Medical Savings Benefits must be filed within ninety (90)
days of the end of the calendar year.
Benefits payable under the Plan for any loss other than Weekly Accident
and Sickness Benefits will be paid as they accrue and upon receipt of due written
proof of loss. Subject to due written proof of loss, Weekly Accident and Sickness
Benefits will be paid at the times set forth in the applicable benefit provision.
CIRCUMSTANCES THAT MAY RESULT IN LOSS OF ELIGIBILITY OF BENEFITS
Throughout this booklet the Trustees have tried to bring to your attention
those circumstances which might lead to a loss of eligibility and to describe any
limitations, exclusions, or restrictions applicable to specified benefits.
The Trustees urge you to familiarize yourself with this information,
especially as it relates to the requirements which must be met in order to
maintain your eligibility for benefits.
REMEMBER: You must work the required number of hours or make
timely self-payments in order to maintain your eligibility.
If at any time you are uncertain about how a specific circumstance might
affect your eligibility or benefit coverage, please contact the Fund Office and, if
possible, try to do so before any circumstance arises.
Claims Review & Appeal Procedures
Your Right to Receive an Explanation of and to Ask for Review of an
Adverse Benefit Determination
You or your provider must file claims for Fund Benefits with Blue Cross Blue
Shield of Illinois or the Claim processor, TIC International Corporation.
If you have questions about decisions made on claims or requests for Medical
benefits, you can address them by telephone to the Claims processor. Their
telephone number is in the top right hand corner of the first page of the
Explanation of Benefits sent to you by the Claims processor and on the denial
letter notifying you that your claim for benefits has not been approved.
August 2014
Page 86
If you are not satisfied that the Claims processor’s denial of your request for
benefits was proper, the Employee Retirement Income Security Act of 1974, as
amended (“ERISA”) requires that you can ask for review or appeal that “adverse
benefit determination.”
An adverse benefit determination is a denial, reduction or termination of, or a
failure to provide or make payment (in whole or in part) for a benefit, including
any denial based on your eligibility to participate in the Plan. You may ask for
review of or appeal an adverse benefit determination on a pre-service claim, an
urgent care claim, or a post-service claim.
A “pre-service claim” is a claim for a benefit conditioned, in whole or in part, on
obtaining advance approval of medical care.
An “urgent care claim” is a claim for medical care or treatment where applying
the normal time periods for claims determination could seriously jeopardize your
life or health or your ability to regain maximum function, or in the opinion of a
physician who knows your medical condition, would subject you to severe pain
that cannot be adequately managed without the care or treatment that you are
seeking.
A claim will be found to be an urgent care claim if either (1) a physician with
knowledge of your medical condition determines that the claim is an urgent care
claim or (2) the Plan using the judgment of a prudent layperson with average
knowledge of health and medicine determines that it is an urgent care claim.
A “post-service claim” is any claim that is not a pre-service claim or an urgent
care claim.
You must follow the review procedure set forth below to appeal or obtain review
of an adverse benefit determination on pre-service, post-service and urgent care
claims.
Except for appeals or requests for review of adverse benefit
determinations involving urgent care claims, all appeals or requests for review
must be in writing. You normally must follow these review procedures before
you can file a civil lawsuit under ERISA to get a court to order the Plan to provide
you with the benefits that you have requested.
Medical Benefit Claim Review Procedure
A.
Review Procedure – Post-service claims
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The review procedure is triggered when the Plan provides you with a written
adverse benefit determination, which must be done within thirty (30) days of the
Plan’s receipt of your claim.
To start the review, you, or your authorized representative, must send a written
statement to the Fund Office explaining why you disagree with the Plan’s
adverse benefit determination to the following address:
6525 Centurion Drive
Lansing, MI 48917
The mailing address also is found at the top of the first page of your Explanation
of Benefits form and in the letter we send notifying you that the Plan has not
approved a benefit or service that you have requested.
You must include in your request all documents, records or comments that you
believe support your position. You must request review no later than one
hundred eighty (180) calendar days after you receive the Plan’s decision on your
claim for benefits.
You will receive a written determination of your request for review by the later of
(a) the Plan’s next regularly scheduled meeting which is at least thirty (30) days
after the date of your appeal request for review or (b) thirty (30) days following
your request for review unless the Trustees tell you that they need more time.
The written determination that you receive as a result of your appeal request for
review will be the final determination involving your claim for benefits.
If you disagree with the Plan’s determination, or a determination is not issued by
the time required, or the procedures for a review are not followed by the Plan,
you have the right to bring a civil lawsuit under ERISA Section 502 (a) to try to
obtain the benefits that you have requested.
B.
Review Procedure – Pre-service claims
The review procedure for pre-service claims is identical to the review procedure
for post-service claims, except that the Claims processor must provide you with
written determinations within shorter time frames. A determination of preservice claims will be issued within fifteen (15) calendar days of receipt of your
request for a review.
If you disagree with the final determination, or if the determination is not issued
within the fifteen (15) day time frame or the review procedures are otherwise
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not complied with, you have the right to bring a civil action under section 502(a)
of ERISA to obtain your benefits.
C. Review Procedure – Urgent care claims
The review procedure for urgent care claims is as follows:
1.
You or your physician may submit your request for an internal
review orally or in writing. If you choose to submit your request
for review orally, please call: (866) 461-4329.
2.
The Claims Processor must provide you with their decision as soon
as possible, taking into account the medical exigencies, but not
later than seventy-two (72) hours after receipt of your request for
review. All necessary information, including the Claims processor
decision on review, will be transmitted to you or to your authorized
representative by telephone, facsimile, or other available similarly
expeditious method. If the decision is communicated orally, they
must provide you or your authorized representative with written
confirmation of their decision within two (2) business days.
3.
If you disagree with the final determination or if the Claims
processor fails to issue the determination within seventy-two (72)
hours, or otherwise fail to comply with the review procedures, you
have the option to bring a civil action under section 502(a) of
ERISA to obtain your benefits. In addition to the information found
above, the following requirements apply to review of pre-service,
post-service, and urgent care claims.
a.
You may authorize in writing another person, including, but
not limited to, a physician, to act on your behalf at any stage
in the standard internal review procedure.’
b.
No fees or costs may be imposed as a condition to
requesting review.
c.
Although there are set timeframes within which you must
receive the final determination on all three types of claims,
you have the right to allow additional time if you wish.
d.
You will be provided, upon request and free of charge,
reasonable access to, and copies of, all documents, records,
and other information relevant to your claims for benefits.
e.
You may submit written comments, documents, records, and
other information relating to your claim for benefits, and this
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information will be considered even if it was not submitted
or considered in the initial benefit determination.
f.
The person who reviews your adverse benefit determination
will be someone other than the person who issued the initial
adverse benefit determination. The determination on review
will be a new determination; the initial determination on
your claim will not be afforded deference on review.
g.
If your request for review involves an adverse benefit
determination that is based in whole or in part on a medical
judgment, including whether a particular treatment, drug or
other item is experimental, investigational, or not medically
necessary or appropriate, a health care professional who has
appropriate training and experience in the field of medicine
involved in the medical judgment will be consulted.
h.
Upon request, the medical experts whose advice was
obtained in connection with the adverse benefit
determination will be identified, even if their advice was not
relied upon in making the determination.
i.
On review, you will be advised of the specific reason for an
adverse determination with reference to the specific plan
provisions on which the determination is based.
j.
If an internal rule, guideline, protocol, or other similar
criterion is relied upon in making the adverse determination,
you will be advised and provided a copy of the rule,
guideline, protocol, or other similar criterion free of charge
upon request.
k.
If the adverse benefit determination is based on a medical
necessity or experimental treatment or similar exclusion or
limit, you will be advised and provided an explanation of the
scientific or clinical judgment free of charge upon request.
Coordination of Benefits With Other Group Plans - How Benefits Are Reduced
To alleviate the problem of excess coverage, which needlessly increases
the costs of protection, all the Plan benefits will be coordinated with the following
coverage:
1.
Individual, group, blanket, franchise,
common carrier insurance coverage; or
general
liability,
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2.
Hospital or medical service organizations, group practice,
and other prepayment coverage; or
3.
Any coverage under any labor-management trusted plans,
union welfare plans, employer organization plans or
Employee benefit organization plans; or
4.
Any coverage under governmental programs
coverage required or provided by any statute.
or
any
Benefits will be reduced under certain circumstances when an individual is
covered under this Plan and under one or more other plans, but it is intended
that the individual will be fully reimbursed for allowable expenses under the
various plans to the extent combined benefits equal one hundred (100%)
percent of the total allowable expenses.
Benefit Determination
As stated above, the Plan will coordinate benefits with all group programs
providing coverage to the Employee or his dependent for all claims.
1.
When the other group plan does not have a provision for
Coordination of Benefits, they must be considered the
primary carrier and must make benefit payment first before
this Fund will consider payment.
2.
When the other group plan does have a provision for
Coordination of Benefits, the order of benefit payments will
be determined by the Industry Standard Provision of the
birth date rule.
3.
If you elect to make COBRA self-payments under this Plan
while you are also covered by another Plan, the other Plan
will pay first and this Plan’s COBRA coverage will pay
second.
Claim for a Covered Employee
The covered employee must first submit all charges to the group with the
earliest effective date. After the charges have been considered, copies of all
charges and payment statements should then be submitted to the secondary
plan for consideration.
The eligible person must claim benefits due from the "primary" plan
determined by these rules for its share of eligible expenses, including benefits or
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services available from prepayment coverage programs such as Health
Maintenance Organizations. When this Plan is "secondary" according to the
established order of benefit determination, the term "benefits payable under
another Plan" will include the benefits that would have been paid if the eligible
person made a proper claim on that Plan or used its services. This Plan's liability
and its benefit payments will not increase simply because the eligible person
elects not to use the "primary" coverage.
When Claim is on the Dependent Spouse
Effective January 1, 2012 the IBEW Local No. 461 Welfare Fund (“Fund”)
implemented a Working Spouse Rule requiring that working spouses of
participants enroll in their employers’ health plans. Spouses that do not enroll in
their employers’ health plans will have their coverage reduced to twenty percent
(20%) of allowable charges rather than eighty percent (80%) of the BCBSIL
approved amount for in-network services and sixty-five percent (65%) of the
BCBSIL approved amount for out of network services unless they qualify for the
HARDSHIP EXEMPTION as explained below.
The participant must provide information regarding their marital
status and the spouse’s employment status (if they are married) on an
annual basis.
THE BASIC “WORKING SPOUSE RULE”
If the participant’s spouse works and is eligible for coverage through
his or her employer (a plan in which the employer contributes some or all of the
premiums), then his or her plan is primary and the Fund will be secondary for all
the spouse’s medical claims. The Fund will only pay twenty percent (20%) of the
allowable charges rather than eighty percent (80%) of the BCBSIL approved.
Below is the HARDSHIP EXEMPTION for the Working Spouse Rule:
HARDSHIP EXEMPTION – the Working Spouse Rule will not apply if your spouse:
1. Has gross annual wages of less than twenty thousand dollars
($20,000), or
2. Has gross annual wages greater than or equal to twenty thousand
dollars ($20,000) but less than thirty thousand dollars ($30,000)
and must pay more than one hundred dollars ($100) per month
toward the cost of the least expensive health plan offered by his or
her employer.
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You are responsible for demonstrating your spouse’s entitlement to a
hardship exemption by submitting a letter to the Fund Office attesting to your
spouse’s wages and cost of coverage from your spouse’s employer on company
letterhead. The Fund Office will determine whether a spouse with variable wages
qualifies for the hardship exemption by looking at the spouse’s average wages
over the past twelve (12) months.
Dual Coverage Saves you Money – When your spouse is covered by his or
her employer’s plan and this Plan at the same time, the two plans together will
usually pay one hundred percent (100%) of his or her covered claims under the
coordination of benefits rules. If your spouse requires a hospitalization or
surgery, you will generally come out ahead financially from the dual coverage,
even after your spouse’s premiums are taken into account.
Additional provisions and exceptions to the Working Spouse Rule:
1. The Working Spouse Rule only applies to your spouse’s claims, not to claims
incurred by your children.
2. It applies to retirees as well as active employees, but only if the retiree’s
spouse is till actively employed.
3. It does not apply to COBRA coverage, meaning that if your spouse terminates
employment and declines COBRA, this Plan will pay its normal benefits.
4. The Working Spouse Rule only applies to medical and drug expenses.
5. The Rule applies without regard to whether or not your spouse’s employer
requires its employees to pay for part of the premium, whether or not the
employer offers an incentive to induce employees not to enroll, and whether
or not the employer offers a single-only coverage option. It also applies if the
employer only offers medical coverage as an option under a cafeteria plan.
6. No reductions will apply to a particular claim if you can demonstrate that your
spouse’s claim would have been denied under the employer’s plan (for
example, if the claim was for a pre-existing condition incurred during the preexisting waiting period).
7.
The provision will also be waived if the only health plan offered by your
spouse’s employer is an HMO plan, and your residence is more than twentyfive (25) miles outside the HMO service area.
8. If your spouse is covered under his or her employer’s plan, then your spouse
must receive his or her medical care in accordance with that plan’s rules. This
Fund will not cover the amount of the other plan’s noncompliance penalties,
or any charges incurred because of failure to follow the other plan’s rules,
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including failure to use HMO providers or follow the HMO’s referral
procedures. (This is not a new rule, and it also applies to claims for your
children when your spouse’s plan is primary).
9.
You are required to provide accurate and timely information to the Fund
about your spouse’s employment status and benefit entitlement, and the
Fund Office may require verification of this information from your spouse’s
employer.
When Claim is for a Dependent Child
The Trustees have adopted, in principle, the coordination provision known
as the "birthday rule" effective July 1, 1985. The "birthday rule" provides that:
In claims involving children, the order of benefit payments will be as
follows:
1.
The plan covering the parent whose birthday occurs earliest
in the calendar year will pay first.
2.
The plan covering the parent whose birthday occurs later in
the calendar year, and having a provision for Coordination of
Benefits, will pay second.
Special Note: If an Employee covered under this Plan has two types of
group coverage, the plan with the earliest effective date must pay first. The Plan
covering the Employee for the shortest period of time will consider the balance
due upon receipt of:
1.
A copy of itemized bills; and
2.
A copy of the payment statement.
If there is a divorce and/or remarriage, the financial and medical
responsibility is generally stipulated by court decree. Members are required to
submit legal documents that are requested by the Fund Office so that the order
of benefit determination can be established. Contact the Fund Office for further
information.
Coordination of Benefits with Medicare
If you are not active under Class A or Class B eligibility when you or your
Dependent becomes eligible for Medicare (officially known as Title XVII of the
Social Security Amendments of 1954, amended effective July 1, 1973, and as
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thereafter may be amended) in addition to this Plan, the Trustees require that
you enroll in Medicare Part A & B. This applies when you are retired due to
attained age or to a qualifying disability.
Effect on Benefits
When a person is eligible in this Plan and eligible for Medicare, Medicare
generally is required to pay first. Benefits payable by this Plan may be reduced
by the amount Medicare pays, but only if the total of this Plan's normal benefits
and Medicare's payment will be more than one hundred (100%) percent of
eligible expenses.
Once retired, you or your Dependent will be considered to be currently
eligible and covered by Medicare as soon as you would be eligible to enroll
whether or not you actually enroll as you should.
The Plan will remain the primary payer of benefits to the end of the
quarter of Medicare entitlement.
Limitations
To comply with Federal regulations, the provision will not apply to an
Employee who is still eligible in this Plan due to Employer contributions or to the
spouse of such an Employee.
Medicare will always be required to pay first when eligible expenses are
incurred by:
1.
Retired Employees and their Dependents (except for the end
of the quarter of entitlement); or
2.
Employees eligible for Medicare on the basis of permanent
kidney failure, after the first thirty (30) months of treatment.
Active Employees and/or Their Spouses Who Are Age 65 or Older
If you are an Active Employee and continue to work, or remain eligible via
banked contributions or self-contributions, beyond the date you or your spouse
become eligible for Medicare at age sixty-five (65), you have the option to have
either the Fund or Medicare as your primary payer of benefits. If you elect
Medicare as the primary payer of benefits, your out-of-pocket expenses will
generally be greater than they would be if the Fund is the primary payer.
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Because of the additional costs to you if Medicare is the primary payer of
benefits, the Trustees have decided that the Fund should be the primary payer of
benefits for all Active Employees and Their Spouses who are over age sixtyfive (65) and entitled to Medicare. What this means is that in those cases where
Medicare and the Fund cover the same items or services, the Fund will pay first
and then Medicare will supplement the Fund’s coverage up to the Medicare limit.
In most cases, the Fund’s benefits are more generous than those provided
under Medicare. Where they are not, you retain the right to file your claim with
Medicare for whatever supplemental coverage is available. Your combined
benefits from Medicare and the Fund will remain unchanged.
Any time after the age of sixty-five (65) that you cease to meet the
definition of an Active Employee, Medicare automatically becomes the primary
payer.
If for some reason you or your spouse would rather have Medicare as the
primary payer, you must state this preference in writing to the Fund Office when
you become eligible for Medicare. Regardless of your election, you should not
forget to pay the Part B Medicare premium for medical services for your own
protection. Failure to pay the Part B premium on time will result in the loss of
Medicare protection for medical services. You are considered active until you
retire with the Social Security Administration, or cease to apply for active
employment.
Active Employees with Dependents Eligible for Medicare
The Fund must act as the primary payer of benefits for any Active
Employee and/or your covered family members who are eligible for Medicare due
to a disability. This requirement ends when you cease to meet the definition of
an Active Employee.
Claims for the Covered Persons affected by this provision are considered
primary to the Fund first. Any portions not paid should then be submitted to
Medicare for payment. In those cases where Medicare and the Fund cover the
same items or services, the Fund will pay first up to its limits and then Medicare
will supplement the Fund’s coverage up to the Medicare limits. In some
instances, only the Fund will provide coverage for some items.
Covered persons affected by this provision are advised to pay the
premium for Part B (Medical) coverage through Medicare. This assures the most
complete coverage for medical expenses and is required to qualify for
participation in certain programs available through the Fund.
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HIPAA Privacy - Confidential Information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides
stringent requirements for the Fund, its Trustees, and its service vendors
concerning the use and disclosure of Participants’ personally identifiable
‘Protected Health Information’ (PHI).
Broadly speaking, PHI includes
demographic information about you and/or your dependents, such as your name,
address, telephone number and Social Security Number, in conjunction with
information concerning you and/or your dependents, such as: (1) eligibility for
Benefits, (2) medical treatment provided or (3) payment for such medical
treatment. Specifically, the Plan will use and disclose PHI only for purposes
related to health care treatment, payment for health care and health care
operations or otherwise allowed or required by law.
The Plan’s use and disclosures of PHI is set out in detail in the Privacy Notice
previously mailed to you. If you would like another copy of this notice, please
contact the Fund Office.
The Plan and the Trustees are committed to observing these privacy rules and in
ensuring the confidentiality of your PHI. Your cooperation and understanding in
working with the Plan to achieve compliance with these federal requirements is
appreciated.
August 2014
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SECTION XII
STATEMENT OF PARTICIPANT’S RIGHTS
Information Required by the Employee Retirement Income Security Act
(ERISA)
Introduction
You have probably heard about ERISA. ERISA stands for the Employee
Retirement Income Security Act, which was signed into law in 1974.
This federal law establishes certain minimum standards for the operation
of employee benefits plans including the IBEW Local No. 461 Welfare Fund. The
Trustees of your Fund, in consultation with their professional advisors, have
reviewed these standards carefully and have taken the steps necessary to assure
full compliance with ERISA.
ERISA requires that Plan participants and beneficiaries be provided with
certain information about their benefits, how they may qualify for benefits, and
the procedures to follow when filing a claim for benefits. This information has
already been presented in the preceding pages of this Summary Plan
Description.
ERISA also requires that participants and beneficiaries be furnished with
certain information about the operation of the Plan and about their rights under
the Plan. This information follows:
READ THIS SECTION CAREFULLY. Only by doing so can you be sure
that you have the information you need to protect your rights and your best
interests under this Plan.
Your Rights as a Participant
As a participant in the IBEW Local No. 461 Welfare Plan:
1. You will automatically receive a Summary Plan Description (this
booklet). The purpose of this booklet is to describe all pertinent
information about the Plan.
2. If any substantial changes are made in the Plan, you will be
notified within the time limits required by ERISA.
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Section XII - Statement of Participants Rights
Page 99
3. Each year you will automatically receive a summary of the
Plan’s latest annual financial report. A copy of the full report is
also available upon written request. You will also receive a copy
of the Summary of Benefits and Coverage each year or more
frequently if requested.
4. You may examine, without charge, all documents relating to this
Plan. These documents include: the legal Plan Document,
collective bargaining agreements, and copies of all documents
filed by the Plan with the Department of Labor or the Internal
Revenue Service, such as annual reports and Plan descriptions.
Such documents may be examined at the Fund Office (or at
other required locations such as work sites or union halls)
during normal business hours.
To assure that your request is handled promptly and that you are
given the information you want, the Trustees have adopted certain
procedures which you should follow:
-
Your request should be in writing;
It should specify what materials you wish to look at; and
It should be received at the Fund Office at least three
days before you want to review the materials at the Fund
Office.
Although all pertinent Plan documents are on file at the Fund Office,
arrangements can be made upon written request to make the documents you
want available at any work site or union location at which fifty (50) or more
participants report to work. Allow ten days for delivery.
5. You may obtain copies of any Plan document upon written
request to the Trustees, addressed to the Fund Office. ERISA
provides that the Trustees may make a reasonable charge for
the actual cost of reproducing any documents you request.
You are entitled to know, however, what the charge will be in
advance. Just ask the Fund Office.
6. No one may take any action which would prevent you from
obtaining a benefit to which you may be entitled or from
exercising any of your rights under ERISA.
7. In accordance with Section 503 of ERISA and related
regulations, the Trustees have adopted certain procedures to
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protect your rights if you are not satisfied with the action taken
on your claim.
8. These procedures appear in the Appeal section of this booklet.
Basically they provide that:
-
If your claim for a welfare benefit is denied in whole
or in part, you will receive a written explanation of
the reason(s) for the denial.
-
Then, if you are still not satisfied with the action on
your claim, you have the right to have the Plan review
and reconsider your claim in accordance with the
Plan’s claims review procedures.
-
These procedures are designed to give you a full and
fair review and to provide maximum opportunity for
all the pertinent facts to be presented on your behalf.
9. In addition to creating rights for Plan participants, ERISA also
defines the obligations of people involved in operating employee
benefit plans.
These persons are known as “fiduciaries”. They have the duty
to operate your Plan with reasonable care and with your best
interests in mind as a participant under the Plan.
Be assured that the Trustees of this Plan will do their best to
know what is required of them as “fiduciaries” and to take
whatever actions are necessary to assure full compliance with
all state and federal laws applicable to the Plan.
10.Under ERISA, you may make certain actions to enforce the
rights listed above.
a. For instance, if you request materials from the Plan and
do not receive them within thirty (30) days, you may file
suit in federal court.
Of course, before taking such action, you will no doubt
want to check again with the Fund Office to make sure
that:
(1) the request was actually received, and
(2) the material was mailed to the right address, or
(3) the failure to send the material was not due to
circumstances beyond the Trustees’ control
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If you are still not able to get the information you want,
you may wish to take legal action. The Court may
require the Trustees to provide the materials promptly
and/or pay you a fine until you actually receive the
materials (unless the delay was caused by reasons
beyond the Trustees’ control).
b. Although the Trustees will make every effort to settle any
disputed claims with participants fairly and promptly, in
accordance with the Fund’s rules, there is always the
possibility that differences can not be resolved to
everyone’s satisfaction.
For this reason, you may file suit in a state or federal
court if you feel that you have been improperly denied a
benefit.
Before exercising this right, however, you will normally
find it advisable to exhaust all the claim review
procedures available under your Plan and then proceed
only upon the advice of your attorney.
c. If it should happen that Plan fiduciaries misuse the Plan’s
money or
discriminate against you 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 the court finds your claim is
frivolous, you may be required to pay court costs and
legal fees.
We trust this Summary Plan Description has provided you with most
important information about your Plan and your rights under ERISA.
If you have any questions about your Plan, you should contact the Fund
Office by writing to: IBEW Local No. 461, 6525 Centurion Drive, Lansing,
Michigan, 48917 or by telephone: (630) 897-0461.
If you have any questions about this Statement or about your rights under
ERISA which have not been answered in this Summary Plan Description or by the
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Fund Office, you should contact the nearest Area Office of the U.S. Department
of Labor. The Fund Office will be glad to furnish the address.
Nothing in this statement is meant to interpret or extend or change in any
way the provisions expressed in the Plan. The Trustees reserve the right to
amend, modify or discontinue all or part of this Plan whenever, in their
judgment, conditions so warrant. Participants will be notified of any plan
changes.
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SECTION XIII
OTHER IMPORTANT INFORMATION
The Trustees Interpret the Plan
Under the Trust Agreement creating the Welfare Fund, and the terms of
this Plan, the Board of Trustees have the sole authority to make final
determinations regarding any application for benefits and the interpretation of
the Plan and any administrative rules adopted by the Trustees. The Trustees
have full discretionary authority to interpret and construe the Plan, all Plan
Documents, the Trust Agreement, and all Plan rules and procedures. The
Trustees interpretation will be given the maximum deference permitted by law
for the exercise of such full discretionary authority. The Trustees’ decisions in
such matters are final and binding on all persons dealing with the Plan or
claiming a benefit from the Plan. If a decision of the Trustees is challenged in
court, it is the intention of the parties to the Plan, and the Welfare Plan provides,
that such decision is to be upheld unless it is determined to be arbitrary or
capricious.
Any interpretation of the Plan’s provisions rests with the Board of
Trustees. No employer or union, nor any representative of any employer or
union, is authorized to interpret this Plan on behalf of the Board nor can an
employer or union act as an agent of the Board of Trustees.
However, the Board of Trustees has authorized the Administrative
Manager and the Fund Office staff to handle routine requests from participants
regarding eligibility rules, benefits, and claims procedures. But, if there are any
questions involving interpretation of any Plan provisions, the Administrative
Manager will ask the Board of Trustees for a final determination.
The Plan Can Be Changed
The Trustees have the legal right to change the Plan, subject to any
collective bargaining agreement that applies to it.
Although the Trustees hope to maintain the present level of benefits and
to improve upon them if possible, a primary concern of the Trustees is to protect
the financial soundness of the Plan at all times. To do so may require Plan
changes from time to time.
Changes in the Plan may also be required in order to preserve the Fund’s
tax exempt status under Internal Revenue Service rules and regulations. These
August 2014
Section XIII - Other Important Information
Page 105
rules and regulations may change and as a result, Trustees may find it necessary
to change Plan provisions so that the Trust does not lose its tax exempt status.
Your Plan is Tax Exempt
Your Welfare Plan is classified by the Internal Revenue Service as a 501(c)
(9) Trust. This means that the employers contributions to the Trust are tax
deductible and are not included as part of your income. Also, in most cases, the
benefits paid on your behalf are not taxable as personal income and investment
earnings on Plan assets are excluded as taxable income of the Trust since they
are specifically set aside for the purpose of providing benefits to participants.
Obviously, such tax exemption works to the benefit of both employer and
employee. In effect, it means that money which otherwise might be payable as
taxes can be used to purchase benefits and to cover administrative expenses.
The Trustees are well aware of these advantages and will take whatever
steps are necessary to keep your Plan “Qualified” as a tax exempt Trust under
Internal Revenue Service rules.
Right to Receive and Release Necessary Information
To determine the applicability of and to implement the terms of this Plan
or the similar terms of any other plan, the Fund will not, without consent, notice
and signed authorization to any covered person, release to or obtain from any
insurance company or other organization or individual, any information, with
respect to any covered person which is considered individually identifiable
protected health information unless such information is deemed necessary for
payment of medical claims.
Facility of Payment
Whenever payments which should have been made under this Plan in
accordance with its provision have been made under any other plans, the Fund
shall have the right, exercisably alone and at its sole discretion, to pay any
organization making such other payments any amounts it shall determine to be
warranted.
If any Plan benefits become payable to the estate of an eligible person or
to an eligible person or Beneficiary who is a minor or otherwise not competent to
give a valid release, the Plan may pay up to one thousand dollars ($1,000) in
benefits to that person’s relative by blood or connection by marriage who the
Trustees find is equally entitled thereto.
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Any payment made by the plan in good faith under this provision shall
fully discharge the Plan to the extent of such payment.
Right of Recovery
Whenever payments have been made by the Fund with respect to
allowable expenses in excess of the maximum amount of payment necessary at
the time to satisfy its provisions, the Fund shall have the right to recover such
payments, to the extent of such excess, from among one or more of the
following as the Fund shall determine:
1.
Any individual to whom or from whom such payments were made;
or
2.
Any insurance
organization.
company,
hospital,
physician
or
any
other
The Fund may also recover such excess payments by reducing future
benefit payments, if any, which become due a Participant, Dependent or
Beneficiary.
Payment of Claims
Indemnity for loss of life will be payable in accordance with the
beneficiary designation and the provisions respecting such payment which are
prescribed herein effective at the time of payment. If no such designation or
provision is then effective, the indemnity will be payable as described on Page
sixty-nine (69) “Beneficiary Designation”. Any other accrued indemnities unpaid
at the Employee’s death may, at the option of the Trustees, be paid either to the
beneficiary or to the estate.
Subject to any written direction of the Employee, all or a portion of any
indemnities provided by the Fund for services rendered by a hospital, nursing,
medical, surgical, dental or vision service may, at the Trustees’ option, and
unless the Employee requests otherwise in writing no later than the time for
filing proof of loss, be paid directly to the hospital or provider of services.
Name of the Plan
The Plan is the IBEW Local No. 461 Welfare Fund.
August 2014
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Type of Plan
This Plan provides Health Care Benefits for expenses due to
hospitalization, surgery, medical treatment, vision or dental care. This Plan also
provides benefits for Death, and Weekly Accident and Sickness (Loss of Time).
Type of Plan Administration
The Administrator is responsible for carrying out the Trustees’ policy
decisions, record keeping, and accounting.
The Trustees have also selected a professional Third Party Administrator,
TIC International Corporation to process the payment of medical, dental, vision
and disability benefits. TIC International is responsible for the payment of
claims, coordination of benefits, maintains participant census information and
performs other routine activities under the direction of the Trustees.
Name and Address of the Administrative Manager
The Administrative Manager selected by the Trustees is:
Joel Pyle II, Administrative Manager
Aurora, IL 60506
Telephone: (630) 897-0461
Facsimile:
(630) 897-7605 FAX
Agent for Service of Legal Process
Roger Gold
James Neuman
Baum Sigman Auerbach & Neuman, Ltd.
200 West Adams Street, Suite 2200
Chicago, IL 60606
(312) 236-4316
(312) 236-0214 FAX
Service of legal process may also be made upon any Plan Trustee.
August 2014
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Name and Address of Claims Agent (Claims Inquiries)
TIC International Corporation
6525 Centurion Drive
Lansing, MI 48917-9275
(517) 321-7502
(866) 461-4329 (IBEW)
(517) 321-7508 FAX
Name and Address of Investment Consultant
Ted Disabato
Disabato Advisers
525 West Monroe Street, Suite 560
Chicago, IL 60661
(312) 474-0900 Main
(312) 474-0905 Direct
Name and Address of Member Assistance Program (MAP)
Employee Resource Systems, Inc.
29 East Madison Street, Suite 1600
Chicago, IL 60602
(800) 292-2780
Name and Address of Preferred Provider Organization
Blue Cross Blue Shield of Illinois
PO Box 1364
Chicago, IL 60601
Claim Inquiry (800) 571-1043
www.bcbsil.com
Name and Address of Prescription Drug Vendor
Citizens-Rx
103 Vandalia
Edwardsville, IL 62025
(888) 545-1120
www.citizensrx.com
August 2014
Page 109
Name and Title of Each Trustee
The Trustees of this Fund are:
Union Trustees
Management Trustees
Joel Pyle, II, Secretary
Michael Angelo
Steve Musich
Mark Seppelfrick
Bruce Anderson, Chairman
Paul Hopkins
Craig Martin
Adam Mata
Name and Address of Local Union Office
Aurora, IL 60506
Telephone: (630) 897-0461
Facsimile:
(630) 897-7605 FAX
Parties to the Collective Bargaining Agreement
The Fund is established and maintained under the terms of a collective
bargaining agreement. This agreement sets forth the conditions under which
participating Employers are required to contribute to your Fund.
The parties to the collective bargaining agreement are:
Local Union Number 461,
International Brotherhood of Electrical Workers
And
Northeastern Illinois Chapter of the National Electrical Contractors Associations,
Inc.;
Internal Revenue Service
Employer and Plan Identification Numbers
The Employer Identification Number (EIN) issued to the Board of Trustees is 362514448 the Plan Number is 501.
August 2014
Page 110
Eligibility Requirements
The Plan’s requirements with respect to eligibility for benefits are shown in
the Eligibility Rules in the Eligibility Section of this Document. Circumstances
which may cause you to lose eligibility are explained in the Eligibility Rules in the
Eligibility Section of this Document.
Sources of Trust Fund Income
Sources of Trust Fund income include Employer contributions, Employee
self-payment of contributions and investment earnings.
All Employer
contributions paid to the Trust Fund are subject to the provisions in the collective
bargaining agreement between the Union and the Employer Association; or are
subject to a separate individual collective bargaining agreement with the Union;
or are subject to a Fund Participation Agreement for contributions for noncollectively bargained employees.
The agreements specify the amount of contribution, due date of Employer
contributions, type of work for which contributions are payable and the
geographic area covered by the labor contract.
Method of Funding Benefits
Benefits payable under this Plan are self-funded and paid directly from the
accumulated assets of the Trust Fund. A portion of Fund assets are also
allocated for reserves to meet future liabilities and to carry out the objectives of
the Plan.
Fiscal Year of the Plan
The financial records of this Plan are based on a fiscal year which begins
June 1 and ends May 31.
The Plan May be Terminated
Although the Trustees do not foresee that the Plan will be terminated, the
Trust Agreement provides that termination may occur when:
1. The Trustees determine that the Trust Fund assets are not
adequate to carry out the purpose for which the Welfare Fund is
intended; or
August 2014
Page 111
2. There is no longer a collective bargaining agreement or other
written agreement in effect that requires Employer contributions
to be made to the Trust Fund and negotiations for extension
thereof have ceased.
The Trustees are obligated to use the Trust Assets for payment of
expenses incurred up to the date of termination and expenses related to the
termination as their first priority. Remaining assets, if any, must be used to
continue Plan benefits after the Plan termination date for those persons eligible
when the Plan was terminated.
Upon written request, you may examine the agreement at the
Administration Office or other specified locations. Or you may request of a copy
of the agreement which will be provided for a reasonable charge.
August 2014
Page 112

ibew local no. 461 welfare fund summary plan description

Transcription

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