Wednesday, May 29, 2024

Frequently Asked Health Care Questions


Q.

Who is eligible to become a Participant in the Plan?

A.

To participate in this Plan, you must (1) work within the jurisdiction of Local 5 of the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry of the United States and Canada, (2) be a full-time officer or Employee of Local 5 or of the Plumbers and Pipefitters Apprenticeship Fund, or (3) otherwise satisfy the requirements established by the Trustees.  Initial Eligibility

You are eligible for Plan benefits on the first day of the second month after you have worked 750 hours in Covered Employment. These hours must be worked within no more than a nine (9) consecutive month period.  You are then eligible for at least three months before you must satisfy additional employment requirements for continued coverage.  There are also special eligibility rules for participants who are working under a Newly Organized Group classification. Please refer to the SPD or contact the Fund Office for the Newly Organized Group rules.

Q.

What if I don’t work enough hours to gain eligibility for the month?

A.

If you do not work for at least 300 hours in Covered Employment during a Work Quarter, coverage for you and your Dependents under this Plan automatically terminates at the end of the current Eligibility Quarter. If you were previously eligible, the Fund provides a Reserve Account (hours bank), Unemployment Set-Aside Account, and special coverage provisions if you are Disabled. Self-pay and COBRA options are also offered. Please refer to the SPD or contact the Fund Office at 800-741-9249 for more information.  

Q.

How do I maintain my monthly Health Care coverage?

A.

After you become eligible under the Plan’s regular rules for eligibility, your continued coverage depends upon your working for a minimum number of hours in each Work (calendar year) Quarter. Your eligibility for benefits will continue during the periods shown below, which are referred to as Eligibility Quarters, if you worked in Covered Employment for at least 300 hours in the corresponding Work Quarter.

Q.

How do I make a payment towards the continuation of my Health Care coverage?

A.

This Plan allows you to make self-payments on behalf of yourself and your Dependents in order to maintain your coverage if you become ineligible during periods of unemployment or Disability.  If you leave the geographic area covered by the Local 5 Agreement or leave the unionized plumbing and or pipefitting industry, you are not permitted to make self-payments except under COBRA Continuation Coverage.  Payments can be made by check or money order.

Q.

Whom should I call if I have questions about my Health Care eligibility?

A.

Contact the Fund Office at 800-741-9249.

Q.

Who are my eligible dependents?

A.

Your legal Spouse, Biological children, Step-Children, and Adopted Children . 

Q.

Will my child(ren) who is/are age 19 through age 26 be covered under the Plan?

A.

Yes. 

Q.

How do I add my new baby or spouse to my insurance plan?

A.

Complete a new Enrollment Card and provide your Marriage Certificate and/or Birth Certificate. A proof of birth can be provided for an infant to add for an initial 90-day period until the Birth Certificate is received.

Q.

Whom should I contact if I'm getting a divorce and what documents do I need to submit?

A.

Contact the Fund Office at 800-741-9249.  You must provide a copy of your Divorce Decree, when available.

Q.

How do I obtain a replacement Medical and Prescription Card?

A.

A new or replacement card can be requested from the Fund Office at 800-741-9249.

Q.

How do I inquire about the status of my medical claim?

A.

Contact the Fund Office at 800-741-9249 and ask for the Claims Department.

Q.

Who is the Prescription Drug Benefit Manager?

A.

CVS Caremark

Q.

How can I contact the Prescription Drug Benefit Manager?

A.

CVS Caremark at 866-282-8503

Q.

If a service I need requires Prior Authorization, who do I (or my provider) contact?

A.

American Health Holdings at 800-641-5566

Q.

If I need to utilize Mental Health or Substance Abuse benefits, who do I contact?

A.

Contact the Fund Office at 800-741-9249.

Q.

How do I find a dentist or find out if my dentist participates with the Plumbers Dental PPO?

A.

Contact the Fund Office at 800-741-9249 and ask for the Claims Department.

Q.

If I have Medicare, who does my provider submit the claim to?

A.

Your Provider should submit your claim to Medicare first. The Fund has a program in place with Medicare to electronically submit your claim to the Fund for coordination of benefits. 

Q.

Who are my Vision benefits through and how can I contact them?

A.

Vision is provided through Vision Service Plan (VSP). They can be contacted at 800-877-7195. 

Q.

How do I become eligible for Disability Benefits?

A.

Benefits are provided for non-work related injuries or illnesses for members that have completed 300 or more hours of Covered Employment in a 3 month period immediately preceding the month the disability occurs
OR
At the time disability occurs you are currently employed, actively seeking employment in the industry during the preceding 3 month period, and you worked at least 3,400 hours during the preceding 3 years. The Fund also offers a Supplemental Workers' Compensation Benefit that is offset by Workers' Compensation Disability benefits and varies depending on the State where you filed. Contact the Fund Office at 800-841-9249 for more information about this benefit or refer to the SPD.

Q.

How much does the Disability Benefit Pay per week? 

A.

$350.00 per week for non-occupational disability.

Q.

How long can I collect a Disability Benefit? 

A.

13 weeks per calendar year.

Q.

 Are there any Death Benefits Available?  How do I qualify for Death Benefits?

A.

Yes. A Death Benefit is provided to Active Eligible Employees and Retirees. This Benefit is not provided to dependents/spouses.

Q.

Is there a filing limit for Death Benefits?

A.

Request must be made within 1 year from date of death.

Q.

Who is Eligible for the Death Benefit? 

A.

It is available for Active Employees and eligible Retirees ONLY.

Q.

How Much Does the Benefit Pay?

A.

Covered Active Employees:

Basic Death Benefit = $ 10,000 (If death is accidental, benefit is doubled)

Supplemental Insured Occupational Accident Benefits: (Governed by an outside insurance policy) (refer to the SPD for the details concerning coverage under the Supplemental Insured Occupational Accident Benefit)                   

Covered Retirees Only:

Death Benefit = $ 3,000 (If death is accidental, benefit is doubled)

Q.

How are benefits paid out, who receives the benefits when I pass? 

A.

The benefit is paid out as a paper check. It is paid to the beneficiary named on the most recent enrollment card on file at the Fund Office.