Health & Welfare

Are Claim Forms Necessary?

No. In order for your claims to be processed, a complete itemized bill must be submitted. If you or your dependents have other primary insurance coverage, the Fund requires you submit the other insurance explanation of benefits (EOB) along with the itemized bill.

An itemized bill contains all the details necessary to process a claim. It provides a breakdown of each specific service rendered, the individual price for each service, the diagnosis, the patient’s name as well as the participant’s Social Security Number or HCID# (OE#).

How many types of deductible are there?

For the medical plan, which includes hospital and prescriptions, there are two Calendar Year Deductibles as follows:

  • In-Network (PPO) – $350.00 per individual per calendar year, with a family maximum of $1,050.00 (Applicable with dates of services 01/01/2011 and after).
  • Out-of-Network (F-F-S) – $500.00 per individual per calendar year, with a family maximum of $1,500 (Applicable to dates of services 01/01/2011 and after).

The dental deductible is $25.00 per person with a family maximum of $75.00 during any particular calendar year. The Vision deductibles are $15 for the exam and $25 for materials (frames and/or lenses).

Is the deductible ever waived?

The medical deductibles are waived when an eligible individual files no medical claims for themselves during a calendar year in which he or she is eligible for all four quarters. The following year no medical deductibles apply. If a claim submitted during the previous year was denied for some reason or applied to a deductible, then the deductibles would not be waived the following year.

Does the plan cover on-the-job injuries?

No. The Plan does not pay for on-the-job injuries or illnesses. Even if your employer does not have Workers’ Compensation coverage, a claim for a job-related illness or injury will be denied.

Does the plan pay for medical claims incurred in a foreign country?

Yes. The Fund will cover you anywhere in the world for treatment which is recognized as usual and customary in the United States and is reasonably necessary for treatment. The Fund will not provide coverage for treatment which is not recognized in this country. If you are planning a trip to another country for medical treatment, you should check with the Fund Office to see if the treatment is covered.

If you have Medicare coverage, Medicare will not pay benefits for medical treatment outside the United States. In these cases, Plan benefits are limited to the amount the Fund would have paid as secondary carrier (approximately 20%) and the participant is responsible for the balance of the bill.

In some limited circumstances, Medicare may pay for certain services provided in Canadian or Mexican hospitals or on-board a cruise ship. Contact your Medicare carrier for additional information.

Are hearing aids covered by the plan?

Yes. Eligible participants and their eligible dependents have coverage for hearing aids. The Plan provides for payment at 100% with a $1,000 maximum per ear after satisfaction of the Calendar Year Deductible. Hearing aids cannot be replaced within three years of the original purchase date if this Fund provided benefits.

What happens if I recieve an overpayment on a claim?

If you believe that you have been overpaid, it is your responsibility to notify the Fund Office immediately. When an overpayment is discovered, the Trustees expect immediate repayment. A schedule of installment payments may be acceptable if immediate repayment is not possible. This will require coordination with the Fund Office. If repayment is not made, payment of future claims will be withheld until complete recovery is made.

What happens if I discover that a provider of service has overcharged?

If a provider of service has overcharged, you should notify the Fund Office immediately and the Fund Office will investigate the matter. If, in fact, an error has occurred you may also be entitled to receive 50% of any amounts recovered as a result of that error with a maximum payment of $1,000. If the Fund Office has already discovered and resolved the problem, you will not be entitled to 50% of the amount recovered. This policy does not apply to PPO-contracted hospitals.

Are common-law marrages or domestic partnerships recognized by the plan?

No. Common-law marriages and domestic partnerships are not recognized by the Plan. A common-law spouse or a domestic partner is not a legal spouse as defined by the Board of Trustees and benefits cannot be paid for such an individual even if common-law marriage or domestic partnership is recognized in the State in which the Plan participant resides.

Is the widow or dependent of a deceased participant covered by The Plan?

If the deceased participant was an Active member and eligible for Health & Welfare coverage at the time of death, coverage for his spouse and other dependents will continue, including coverage for all reserve hours plus an additional six months. This coverage is provided at no charge.

After those extensions of eligibility have ceased, a widow who has not remarried or is not eligible for group insurance other than Medicare, or a dependent child without other group insurance, may participate in the Active Health & Welfare Plan as long as the monthly fee required by the Board of Trustees is paid. That fee is subject to change. When the widow reaches age 65, she may be covered by the Retiree Plan and Medicare would be the primary carrier.

If the deceased participant was a Retired member and eligible for Health & Welfare coverage, his spouse and eligible dependents remain covered for the month during which he/she died as well as an additional six months at no charge.

At the end of that period, a widow who has not remarried or is not eligible for group insurance other than Medicare, or a dependent child without other group insurance, may continue coverage as long as the monthly fee required by the Board of Trustees is paid. That fee is subject to change.

What happens if I divorce and remarry?

If the participant has divorced and remarried, the Fund Office will require copies of the Final Decree of Divorce and the certified copy of the Certificate of Marriage to the new spouse, as well as a new Health & Welfare Enrollment Form. Benefits on behalf of a new spouse or step-children will not be available until these documents have been submitted to the Fund Office.

Is retiree health and welfare coverage automatic?

No. Retiree Health & Welfare eligibility is based upon employment for employers who made contributions to the Health & Welfare Fund on behalf of an Active participant. Refer to Retiree Eligibility for the complete rules.

Retirees must pay a fee for coverage. The fees are set by the Trustees of the Health & Welfare Fund and are subject to change from time to time.

If, as an Active employee, you worked at the trade for a non-contributing employer, you will have incurred a Separation from Employment and may not qualify for Retiree Health & Welfare coverage.

If I return to covered employment, will I remain eligible on the retiree plan until I regain active eligibility?

Disability Pensioners who return to covered employment are covered for up to five months under the Retiree Plan. However, you must continue your Retiree self-payments during those five months. After that date Retiree eligibility ceases.

Early and Regular Pensioners who return to covered employment are covered until they regain Active eligibility if they enroll in the COBRA Program and make the monthly payment required.

If you are planning to return to covered employment after retirement, you must make arrangements with the Pension Department to maintain eligibility.