2015/2016 benefits enrollment guide

IBEW LOCAL UNION 716
ELECTRICAL MEDICAL TRUST
2015/2016
BENEFITS ENROLLMENT GUIDE
ELIGIBILITY AND ENROLLMENT
Initial Eligibility
▪ 375 hours during a period of 3 consecutive
months, eligible for benefits the 1st day of the
2nd calendar month following that 3-month
period; or
▪ Total of at least 500 hours are contributed during
a period of 6 consecutive months, eligible 1st day
of the 2nd calendar month following that 6month period.
▪ You and your eligible dependents will become
initially eligible on the 1st day of the 2nd month
following any 3 consecutive calendar months in
which you have worked at least 375 hours for
Contributing Employers.
▪ You must enroll your dependents or they will
lose their eligibility to participate in the health
plan.
Maintenance of Eligibility
Reserve Account (Hour Bank) – hours worked in
excess of 140 per month will be credited to the
Reserve Account with a maximum of 560 Reserve
hours.
Monthly Deductions from Reserve Account
140 hours are deducted from the Active Member’s
Reserve Account for each month of coverage. A
lag month will be used in determining continuing
eligibility, i.e., June hours are worked for August
eligibility.
Termination for Active Members
▪ Last day of the month member has less than 140
hours in Reserve Account
▪ 31st day Collective Bargaining Agreement no
longer provides continued remittance of
employer contributions
Reinstatement
Member must post 140 hours within a 6-month
period immediately following such termination.
Reinstatement will take place on the 1st day of the
month following the month requirement is met. If
Reserve Account does not show 140 hours within
such 6-month period all hours will be forfeited
unless coverage is continued through selfpayment. Once a Reserve Account has been
forfeited for this reason Active Member will have
to meet the Initial Eligibility requirements again.
Continuation During Total Disability
With prior approval total disability continuing for
30 days or more will not have any hours deducted
from the Member’s Reserve Account from the 1st
day of the month disability commences. Coverage
will be continued up to 3 consecutive months.
After that 3 month period the Reserve Account will
be used. Once the Reserve Account is depleted,
the Member may then continue coverage through
self-pay provisions.
Eligibility for Dependents
Your lawful spouse and eligible children up to age
26.
Non-Bargaining Employees
Employer must contribute 173 hours per month for
each Non–Bargaining Employee.
Non-Bargaining Employees Loss of Eligibility for
Insufficient Hours
Once a Non-Bargaining Employee loses eligibility
due to a reduction or insufficient hours, coverage
may be continued through the self-pay provisions
of COBRA.
Enrollment for the Newly Eligible:
▪ You will need Social Security Number and Date of
Birth for all covered family members.
▪ You should confirm your health care providers
participate in the insurance plan before making
an appointment.
▪ You will receive a detailed benefit booklet and ID
card at your home after you have enrolled.
▪ If you have become eligible for the first time and
are enrolling in the medical plan, you may be
asked to send a HIPAA Certificate of Creditable
Coverage to Cigna from your prior insurance
carrier. The plan may impose a pre-existing
condition limitation if there is more than a 63day gap from your prior carrier or if you have not
had coverage previously for 12 consecutive
months.
▪ Member will automatically receive the option to
choose between any of the 2 lower deductible
plans highlighted in red until they are given the
opportunity to participate in the wellness
program. Members who completed both the
biometric screening as well as the Health
Assessment during the Spring of 2015 will
receive the option to choose between any of the
2 plans marked "Wellness Participant." Those
who did not complete both portions will choose
between the plans listed as "Non-Wellness
Participant. Any newly eligible member who
does not make their plan election will be
automatically placed into the “Kelsey Care HMO”
plan based on their wellness participation.
*At time of hire, or if you are already employed, please notify your employer of your plan election.*
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MEDICAL
GROUP #3335042
800-CIGNA24
WWW.MYCIGNA.COM
Those who participated in and completed the Health Assessment and biometric screening are eligible to elect one of the two
enhanced benefit options, indicated as “Wellness Participant” plans. Those who did not complete both portions may select from the
“Non-Wellness Participant” plans.
Lifetime Maximum
Annual Deductible
Individual
Family
Out of Pocket Maximum
Individual
Family
Hospital Services
Inpatient
Outpatient
Emergency Room
Physician Services
Primary Care Physician
Specialist
Urgent Care
Diagnostic X-Ray & Lab
Physician’s Office
Facility
Maternity
Initial OB visit
Hospital, OB visits
Wellness Participant
Non-Wellness Participant
KELSEY HMO - $500 DED
KELSEY HMO - $750 DED
coverage is effective 8/1/2015
coverage is effective 8/1/2015
In Network
In Network
Unlimited
Unlimited
$500
$1,500
$750
$2,250
$5,000
$10,000
$5,000
$10,000
90% after deductible
90% after deductible
90% after deductible
90% after deductible
$150 copay
$200 copay
$25 copay
$35 copay
$50 copay
$25 copay
$35 copay
$75 copay
No charge
100%
No charge
100%
$35 copay
90% after deductible
$35 copay
90% after deductible
Therapy Services
Speech, Physical, Occupational - 60
visit limit combined;
Primary Care Physician
$25 copay
Specialist
$35 copay
Chiropractic - 20 visit limit
$35 copay
Mental Health and Chemical
Dependency
Inpatient
90% after deductible - unlimited visits
Outpatient
$35 copay - unlimited visits
Participating Pharmacies Only
Prescription Drugs
$15
Generic Drugs
Brand Name
$35
Non-Formulary
$55
1.5x applicable copay
Mail Order
Pharmacy Out of Pocket Maximum
Individual
$1,350
Family
$2,700
Eye Exam
$35 copay*
1 per calendar year
Hearing Test
$35 copay
1 per calendar year
* Routine eye exams available through Cigna providers - see www.cigna.com. No referral needed.
$25 copay
$35 copay
$35 copay
90% after deductible - unlimited visits
$35 copay - unlimited visits
Participating Pharmacies Only
$20
$40
$70
1.5x applicable copay
$1,350
$2,700
$35 copay
$35 copay
This is a partial comparison of plan benefits. Refer to the Master Contract/Summary Plan Description for plan details.
3
MEDICAL
GROUP #3335042
1-800-CIGNA24
WWW.MYCIGNA.COM
Those who participated in and completed the Health Assessment and biometric screening are eligible to elect one of the two
enhanced benefit options, indicated as “Wellness Participant” plans. Those who did not complete both portions may select from the
“Non-Wellness Participant” plans.
Wellness Participant
Non-Wellness Participant
CIGNA OAP - $750 DED
CIGNA OAP - $1,250 DED
coverage is effective 08/01/2015
coverage is effective 08/01/2015
In Network
Lifetime Maximum
Annual Deductible
Individual
Family
Out of Pocket Maximum
Individual
Family
Hospital Services
Inpatient
Outpatient
Emergency Room
Physician Services
Primary Care Physician
Specialist
Urgent Care
Diagnostic X-Ray & Lab
Physician’s Office
Facility
Maternity
Initial OB visit
Hospital, OB visits
Therapy Services
Speech, Physical, Occupational60 visit limit combined;
Chiropractic - 20 visit limit
Mental Health and Chemical
Dependency
Inpatient
Outpatient
Prescription Drugs
Generic Drugs
Brand Name
Non-Formulary
Mail Order
Pharmacy Out of Pocket
Maximum
Individual
Family
Eye Exam
1 per calendar year
Hearing Test
1 per calendar year
Out of Network
In Network
Unlimited
Out of Network
Unlimited
$750
$2,250
$2,000
$6,000
$1,250
$3,750
$3,000
$9,000
$5,000
$10,000
$10,000
$20,000
$5,000
$10,000
$10,000
$20,000
75% after deductible
50% after deductible
75% after deductible
50% after deductible
$150 copay
75% after deductible
50% after deductible
75% after deductible
50% after deductible
$200 copay
$35 copay
$45 copay
50% after deductible
50% after deductible
$50 copay
$45 copay
$55 copay
50% after deductible
50% after deductible
$75 copay
OV copay
100%
50% after deductible
50% after deductible
OV copay
100%
50% after deductible
50% after deductible
$45 copay
75% after deductible
50% after deductible
50% after deductible
$55 copay
75% after deductible
50% after deductible
50% after deductible
75% after deductible
50% after deductible
75% after deductible
50% after deductible
$45 copay
50% after deductible
$55 copay
50% after deductible
75% after deductible
50% after deductible
unlimited visits
unlimited visits
$45 copay
50% after deductible
unlimited visits
unlimited visits
Participating Pharmacies Only
$15
$35
$55
1.5x applicable copay
75% after deductible
50% after deductible
unlimited visits
unlimited visits
$55 copay
50% after deductible
unlimited visits
unlimited visits
Participating Pharmacies Only
$20
$40
$70
1.5x applicable copay
$1,350
$2,700
$45 copay
$1,350
$2,700
50% after deductible
$1,350
$2,700
$55 copay
$1,350
$2,700
50% after deductible
$45 copay
50% after deductible
$55 copay
50% after deductible
This is a partial comparison of plan benefits. Refer to the Master Contract/Summary Plan Description for plan details.
4
HAVE YOU MET BEN-IQ?
Inside the Ben-IQ™ app
24/7 access to your health plan highlights
Store and organize your plan ID cards
Nurse line numbers an helpful contact
information
Cost of care info at your fingertips
Get Ben-IQ today!
Download the free app with your Android or
iPhone.
Enter this username:
EMT IBEW 716
Read the Terms and Conditions, then tap the
Sign In button.
PUT BEN-IQ TO WORK
FOR YOU. SMARTER IS
BETTER.
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USE YOUR CIGNA ID CARD FOR DISCOUNTS ON SERVICES
AND PRODUCTS
24/7 Hour Customer Service
We have extended Customer Service hours to include
Weekdays, Saturdays, Sundays and holidays, 24 hours a day, 7
days a week.
Convenience Care Clinics
When you need treatment for common ailments and injuries, you have more
choices. Open 7 days a week with evening weekday hours, the clinics offer
convenient, professional walk-in care for common ailments. You can get highquality, affordable services for a wide variety of routine medical conditions
through Convenience Care Clinics located throughout the country. You can
find locations near you by going to myCIGNA.com or calling the number on
your ID card.
24 Hour Health Information Line – Call a nurse anytime. Day or Night.
The 24 hr Health information line assists individuals in understanding the right
level of treatment at the right time. Trained nurses are available 24 hours a
day, 7 days a week, 365 days a year to provide health and medical
information and direction to the most appropriate resource for you. Just call
the number on your ID card.
CIGNA Healthy Rewards® Member Discounts
Just Walk 10,000 Steps-A-Day Walking Program
8-week online program allows you to log your daily steps, track your
progress and receive coaching tips and fun facts. Members receive
pedometer and related materials ($23.95). Option to extend online program
by purchasing the 52-week step-up maintenance program.
Weight Management Discount Programs
On-line, at home, telephone-based & traditional meeting options
Fitness Club Memberships
American Specialty Health Networks and ChooseHealthy provide access to
over 15,000 fitness clubs, including Yoga and Pilates studios
Tobacco Cessation Discounts
Telephonic based Employee-pay cessation program. Other discounts through
drugstore.com,
Eyeglasses & Contacts
Reduced rates at over 15,000 participating retailers and providers.
Discounts on eyeglasses, contact lenses, prescription sunglasses and vision
exams.
Complementary & Alternative Medicine
Reduced rates from over 22,000 participating providers including
chiropractics, acupuncturists, massage therapists & registered dieticians.
Health & Wellness Products
5% off every order at drugstore.com, including weight management scales
and blood pressure monitors. And the ChooseHealthy Store offers discounts
on vitamins & supplements, herbal products, dental products, homeopathic
remedies, natural products, diet & sports nutrition, yoga & fitness activities,
personal body care, books, audio, video & DVDs.
Laser Vision Correction (LASIK)
Reduced rates at over 240 participating facilities
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RETIREE MEDICAL
Retiree Rates:
Please call the Trust
Office at 713-869-8900
for information
regarding retiree rates.
SHORT TERM DISABILITY COVERAGE
877-672-1648
WWW.AGEMPLOYEEBENEFITS.COM
Once you have met your initial eligibility requirements you will automatically be enrolled in the Short Term
Disability program. In order to maintain your coverage under the Short Term Disability program, all members
must work 140 hours or more per month. After being totally disabled for 7 days due to a non-work related
covered accident or sickness, and if your disability is approved by the insurance company, you will be eligible to
receive a weekly benefit of up to $250, (not to exceed 70% of weekly salary). This benefit could last for up to 26
weeks as long as you continue to meet the definition of disabled. The benefit reduces to 50% at age 70. You may
be considered totally disabled if you are unable to perform each of your main duties of your occupation. If you
are unable to perform one or more of your main full-time duties, you may be eligible for a partial disability
benefit.
Short Term Disability is not available to Retirees.
Disability Claims Address:
Disability Claims Phone:
AG Benefit Solutions Connecticut Claims Center
P.O. Box 387
Farmington, CT 26034
888-762-2250
13
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No. 1210-0149
(expires 1-31-2017)
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employment­based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for
a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax
basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact
.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs cove red
by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
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PART B: Information About Health Coverage Offered by Your
Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for
coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the
Marketplace application.
Employer Name
Electrical Medical Trust Local 716
Employer Address
1475 North Loop West
City
Houston
Who can we contact about employee health coverage at this job?
Benefit Resources, Inc.
Phone number (if different from above)
(713) 643-9300
Employer Identification Number (EIN)
74-1621269
Employer phone number
State
TX
ZIP Code
77008
Email address
Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to:
All employees. Eligible employees are:
x Some employees. Eligible employees are:
Have worked 375 hours during 3 consecutive months are eligible for benefits the 1 st day of the 2nd calendar month
following that 3 month period. OR If at least 500 hours are contributed during a period of 6 consecutive months, they are
eligible the 1st day of the 2nd calendar month following that 6 month period.
With respect to dependents:
x We do offer coverage. Eligible dependents are:
Your lawful spouse and eligible children to age 26.
We do not offer coverage.
x If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable,
based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through
the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether
you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an
hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other
income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer
information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but
will help ensure employees understand their coverage choices.
11. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee
eligible for coverage? __________________ (mm/dd/yyyy) (Continue)
No (STOP and return this form to employee)
12 Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 13)
No (STOP and return form to employee)
For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum
discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.
How much would the employee have to pay in premiums for this plan? $_____________________
How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and
return form to employee.
14. What change will the employer make for the new plan year? _____________
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question
15.)
a. How much would the employee have to pay in premiums for this plan? $ ___________
b. How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
15
MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM
(CHIP)
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer,
your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid
or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these
premium assistance programs but you may be able to buy individual insurance coverage through the Health
Insurance Marketplace. For more information, visit healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the following
page, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 877KIDS NOW or insurekidsnow.gov to find out how to apply. If you qualify, ask your State if it has a program that
might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your
employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is
called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined
eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the
Department of Labor at askebsa.dol.gov or call 866-444-EBSA (3272).
If you live in one of the States listed on the following page, you may be eligible for assistance paying your
employer health plan premiums. The following list of States is current as of January 31, 2015. Contact your State
for more information on eligibility.
To see if any other States have added a premium assistance program since January 31, 2015, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor
U.S. Department of Health and Human Services
Employee Benefits Security Administration
Centers for Medicare & Medicaid Services
dol.gov/ebsa
cms.hhs.gov
866-444-EBSA (3272)
877-267-2323, Menu Option 4, Ext. 61565
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ALABAMA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs > Medicaid > Health Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-435-7414
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care > Medical Assistance
Phone: 1-800-657-3739
MISSOURI – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Phone: 573-751-2005
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
MONTANA – Medicaid
WASHINGTON – Medicaid
Website: http://medicaid.mt.gov/member
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx
Phone: 1-800-694-3084
Phone: 1-800-562-3022 ext. 15473
NEBRASKA – Medicaid
WEST VIRGINIA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Website: www.dhhr.wv.gov/bms/
Phone: 1-855-632-7633
Phone: 1-877-598-5820, HMS Third Party Liability
NEVADA – Medicaid
WISCONSIN – Medicaid and CHIP
Medicaid Website: http://dwss.nv.gov/
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Medicaid Phone: 1-800-992-0900
Phone: 1-800-362-3002
NEW HAMPSHIRE – Medicaid
WYOMING – Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 603-271-5218
Phone: 307-777-7531
effective: January 31, 2015
17
Important Notice from Electrical Medical Trust About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage with Electrical Medical Trust and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not you want to join a
Medicare drug plan. If you are considering joining, you should compare your current coverage, including
which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare
prescription drug coverage in your area. Information about where you can get help to make decisions
about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get
this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO
or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Electrical Medical Trust has determined that the prescription drug coverage offered by the Express
Scripts Pharmacy Plan is, on average for all plan participants, expected to pay out as much as standard
Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your
existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a
penalty) if you later decide to join a Medicare drug plan.
______________________________________________________________________________
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October
15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you
will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your Electrical Medical Trust coverage will not be affected. See
below for more information about what happens to your current coverage if you join a Medicare drug plan.
Since the existing prescription drug coverage under Express Scripts Pharmacy Plan is creditable (e.g. as good
as Medicare coverage), you can retain your existing prescription drug coverage and choose not to enroll in a
Part D plan; or you can enroll in a Part D plan as a supplement to, or in lieu of, your existing prescription drug
coverage.
If you do decide to join a Medicare drug plan and drop your Electrical Medical Trust prescription drug
coverage, be aware that you and your dependents may not be able to get this coverage back.
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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Electrical Medical Trust and don’t
join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium
may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did
not have that coverage. For example, if you go nineteen months without creditable coverage, your premium
may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay
this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you
may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also
get it before the next period you can join a Medicare drug plan, and if this coverage through Electrical
Medical Trust changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be
contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or
call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
drug plans, you may be required to provide a copy of this notice when you join to show
whether or not you have maintained creditable coverage and, therefore, whether or not you
are required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
08/01/2015
Electrical Medical Trust Local 716
Cory Crandell – Benefit Resources, Inc.
8441 Gulf Freeway, Suite 304, Houston, TX 77017
(713) 643-9300
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NOTICES
Women’s Health and Cancer Rights Act Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s
Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage
will be provided in a manner determined in consultation with the attending physician and the patient, for:
▪ All stages of reconstruction of the breast on which the mastectomy was performed;
▪ Surgery and reconstruction of the other breast to produce a symmetrical appearance;
▪ Prostheses; and
▪ Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply.
Continuation Required by Federal Law for You and Your Dependents
The Continuation Required by Federal Law does not apply to any benefits for loss of life, dismemberment or loss
of income.
Federal law enables you or your Dependent to continue health insurance if coverage would cease due to a
reduction of your work hours or your termination of employment (other than for gross misconduct). Federal law
also enables your Dependents to continue health insurance if their coverage ceases due to your death, divorce or
legal separation, or with respect to a Dependent child, failure to continue to qualify as a Dependent. Continuation
must be elected in accordance with the rules of your Employer’s group health plan(s) and is subject to federal law,
regulations and interpretations.
Newborns’ and Mothers’ Health Protection Act Notice
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following
a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not
prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not,
under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing
a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on maternity benefits,
call your plan administrator.
Health Insurance Portability and Accountability Act (HIPAA)
IBEW Union 716 Electrical Medical Trust, in accordance with HIPAA, protects your Protected Health Information
(PHI). IBEW Union 716 Electrical Medical Trust will only discuss your PHI with medical providers and third party
administrators when necessary to administer the plan that provides you your medical, dental, and vision benefits or
as mandated by law. A copy of the IBEW Union 716 Electrical Medical Trust Notice of Privacy Practices is available
upon request in the Human Resources department.
Summary of Material Modification (SMM)
This enrollment guide constitutes a Summary of Material Modifications (SMM) to the Electrical Medical Trust
Health & Welfare Fund 2015-2016 summary plan description (SPD). It is meant to supplement and/or replace
certain information in the SPD, so retain it for future reference along with your SPD. Please share these materials
with your covered family members.
This brochure summarizes the health care and income protection benefits that are available to IBEW Union 716 Electrical
Medical Trust members and their eligible dependents. Official plan documents, policies, and certificates of insurance contain
the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program.
If there is any conflict, the official documents prevail. These documents are available upon request through the Human Re­
sources Department.
Information provided in this brochure is not a guarantee of benefits.
© 2015 Alliant Insurance Services, Inc. All rights reserved. Alliant Employee Benefits, a division of Alliant Insurance
Services, Inc. CA License No. 0C36861
Rev. 7-15-15 Alliant Insurance Services