Sunday, November 29, 2020

Frequently Asked Health Care Questions


Q. Why do I owe money for my health care coverage?
A.

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. If the Fund receives contributions for at least one hour of work in the month for which you are short, you can choose to make a self-payment either equal to the number of hours multiplied by the contribution rate needed to bring your total up to the eligibility requirement (in which case you will receive credit toward eligibility for the hours of work as if an employer had remitted the contribution), or equal to the subsidized self-payment amount set by the Trustees (in which case you will not receive credit as if an employer had paid the contributions). If the Fund did not receive contributions for even one hour for the month you are short, you must pay the subsidized self-payment amount set by the Trustees (and you will not receive credit as if an employer had paid the contributions).

Q. What if I worked enough hours to be eligible, but my employer reports the hours late, or does not pay contributions?
A.

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.

Q. What happens if I do not pay my self-payment?
A.

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.

Q. What is COBRA coverage?
A.

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.

Q. Who should I call if I have questions about my eligibility, my coverage or a claim?
A.

Eligibility questions (such as whether you are covered, whether dependents are covered, added and removing dependents, etc.) should be directed to the Fund Office at 248-641-4980.

If your question is regarding your prescription, vision or dental coverage you should call the Fund Office at 248-641-4980.

If the question is regarding a medical claim, you should contact your medical carrier: 
Blue Cross
1-877-474-5834
Blue Care Network
1-888-662-6667 

Q. How do I add a new child or spouse as a dependent?
A.

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.

Q. What happens when I get divorced?
A.

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, 700 Tower Drive, Suite 300 Troy, Michigan 48098. 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.

Q. How do I appeal?
A.

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, 700 Tower Drive, Suite 300 Troy, Michigan 48098, 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, Blue Care Network, 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, 700 Tower Drive, Suite 300 Troy, Michigan 48098, 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 Claimspro, your dental or vision provider or the Fund Office, you should send a letter to the Board of Trustees, 700 Tower Drive, Suite 300 Troy, Michigan 48098, 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.