To maintain continuous coverage, you must be credited with 140 work hours each month. If you are credited with 140 work hours each month, you will be given eligibility for the 3rd month following that work month. For example, if you have the necessary hours of contributions in the work month of April you will be eligible in July. May earns eligibility for August - and so on.                                     

Work hours in excess of those needed to maintain eligibility will be added to your hour bank. If you work less than the monthly requirement of 140 hours in a month, the difference is taken from your hour bank and you are made eligible for the month. On the other hand, if you work 170 hours in a month, 30 hours will be added to your hour bank. If, the following month you work only 115 hours, the 25-hour shortage will be deducted from your hour bank to make you eligible. You can build up to 3 months of eligibility with your hour bank for a total hour bank balance of 420 hours.                  

Any time the Fund has not received enough employer contributions based on hours you worked for you to continue your eligibility for coverage, you will receive a Self-Payment Notice. In order for you to continue eligibility, you will be required to make a self-payment to the Insurance Fund. For example, the eligibility requirement is 140 work hours per month. Your employer reports that you worked 100 hours, leaving you 40 hours short of the requirement. In order to continue your healthcare coverage, you must submit a payment to the Fund Office for difference in the shortage of hours.                     

Eligibility with the Fund is completely determined by employer contributions received. If your employer reports late or fails to remit contributions, you will not receive credit and your eligibility may be lost. Therefore, in order to avoid a lapse in your health care coverage, you will have to pay your self-payment even if you worked enough hours to be eligible but your employer is late submitting the contributions, or does not pay them at all. In the event the late contributions are received, or if the Fund is able to collect the money owed, you will be refunded any excess self-payment amount that you paid. You can help the Insurance Fund collect late payments by keeping records of all hours worked and notifying the Fund Office immediately if your employer is late in paying the contributions.                 

If your full self-payment is not received by the date on which it is due, your coverage will be canceled. You will be offered the opportunity to continue your and your dependents' coverage under the Plan's COBRA provisions, but you should know that the monthly premiums you will have to pay if you elect COBRA coverage owe are much higher than the Fund's regular self-payments amounts.

The Consolidated Omnibus Reconciliation Act of 1985 provides that all employers who sponsor group health plans must permit covered individuals who lose coverage under the plan as a result of certain events to elect to continue their coverage under the plan for a prescribed period of time on a self-pay basis.                 

If you become disabled when you are eligible for benefits, your eligibility will be continued for the balance of the month in which you become disable and thereafter for up to a total of 18 consecutive months without cost to you. In order to qualify for this eligibility, you must be under the treatment of a physician, file a claim form and submit satisfactory written medical evidence of your disability to the Fund Office. Upon approval of your application, your disability eligibility will be retroactive to the date your disability commenced.

You may be entitled to Weekly Disability Benefits for loss of wages, if you are unable to work because of an accident occurring off the job, an accident not involving an automobile or other motor vehicle licensed to be on the road, or any illness not connected with employment. The Weekly Disability benefit is $250 for journeymen and $175 for allied tradesmen for a maximum of 26 weeks or the period of disability, whichever is shorter. You must file a Weekly Disability Benefits claim form with the Fund Office within 20 days after the first day of disability and submit written proof that you are disabled before benefits will be paid.

Whether your new child or spouse is eligible for coverage depends on whether they meet the Fund's requirements. In order to begin this process, you must complete a Vital Information form and return it to the Fund Office with a copy of the birth certificate, adoption papers or marriage certificate within 30 days of the event. A Coordination of Benefits Inquiry must be completed when adding a spouse.                 

Your spouse's eligibility for coverage ends on the date of your divorce. You must notify the Fund Office immediately and send a copy of the divorce decree to the Fund office, P.O. Box 966, Troy, Michigan 48099-0966. If you do not notify the Fund Office immediately and any benefits are paid on behalf of your former spouse after the date of divorce, you will be responsible for paying those benefits back to the Insurance Fund. Also, your former spouse has the right to elect COBRA continuation coverage, but only if the Fund Office receives notice of the divorce within 60 days of the entry of the Judgment. Therefore, for your protection and for exercising COBRA rights, you must notify the Fund as soon as you are divorced.                      

If you are appealing a matter about eligibility (such as dependent coverage, self-payment assessments, etc.), you should send a letter to the Board of Trustees, P.O. Box 966, Troy, Michigan 48099-0966, within 180 days of whatever it is that you are appealing. You also have a right to submit information relating to your appeal and you have a right to reasonable and free access to and copies of information relevant to the claim denial. (Please make requests for documents relevant to your appeal through the Fund Office.) Your letter should include your name, and describe in detail what it is you are appealing and the basis for your appeal. Your appeal will be reviewed by the Board at their next meeting (or if it is received too close to that meeting, at the next meeting). When the Board decides your appeal, you will be notified in writing.

If you are appealing a denial of benefits or the imposition of co-pays or deductibles by Blue Cross, you must first submit an appeal to that organization and complete that process under the rules set out by that organization. Please refer to the "Explanation of Benefits" from that organization regarding its appeal process. If that organization denies your appeal, you may then appeal to the Board of Trustees, P.O. Box 966, Troy, Michigan 48099-0966, within 180 days of whatever it is that you are appealing. You also have a right to submit information relating to your appeal and you have a right to reasonable and free access to and copies of information relevant to the claim denial. (Please make requests for documents relevant to your appeal through the Fund Office.) Your letter should include your name, and describe in detail what it is you are appealing and the basis for your appeal. Your appeal will be reviewed by the Board at their next meeting (or if it is received too close to that meeting, at the next meeting). When the Board decides your appeal, you will be notified in writing.