Saturday, September 19, 2020

Frequently Asked Health Care Questions


Q.

Who is eligible to become a Participant in the Plan?

A.

This Plan covers employees working under collective bargaining agreements in positions for which contributions are required to be made to this Plan (also known as bargaining unit employees or Class A participants). The following other people may also participate:

  • Qualified contributing employers, partners, self-employed contractors and proprietors (also known as Class B participants) who are signatory to a collective bargaining agreement with the Local Union and pay the required monthly charge, and their enrolled non-bargaining unit employees (also known as Class D participants).
  • Full-time officials and full-time employees of participating local unions, qualified active trustees of the Welfare Fund and their surviving spouses, and qualified retired trustees (also known as Class C participants).
  • Retired employees and retired employers who satisfy the appropriate eligibility rules for retiree coverage and who pay the required monthly charge which applies to their coverage. Eligible dependents of all of the above, including your lawful spouse or registered domestic partner; and your natural children, adopted children, foster children and stepchildren, until age 26 for medical benefits.
Q.

If I am a bargaining unit employee, how do I become eligible for coverage under the Plan?

A.

Eligibility is based on your reserve account of hours which are reported and credited on your behalf for each hour of covered employment. A month of coverage under the Plan for Shop/Regular Status Employees "costs" 125 Hours, and for Installers "costs" 85 hours.

To qualify for coverage, Shop/Regular Status Employees must be credited with a total of 250 hours within two consecutive months. Installers must be credited with a total of 170 hours within two consecutive months.

This Plan uses a "double skip month" eligibility system. Hours worked in Month One are reported by the employer in Month Two, and provide health coverage for Month Four.

For example, let's say you are a Regular Employee and work at least 250 hours in January and February. Your work hours in January and February will be reported to the Plan in February and March. When the total of the hours reported to the Plan on your behalf reaches 250 in March, you will be covered under the Plan starting on May 1.

Q.

How do I maintain monthly eligibility?

A.

Shop/Regular Status employees maintain eligibility by having a reserve account of at least 125 covered hours at the beginning of each month. Installers maintain eligibility by having a reserve account of at least 85 covered hours at the beginning of each month. See pages 6-7 and Appendix 1, pages 47-48 of the SPD, for more details. The Plan's "double skip month" eligibility system also applies to maintaining monthly eligibility: hours worked in Month One are reported by the employer in Month Two, and provide health coverage for Month Four.

Q.

What benefits are provided?

A.

There are currently two options for medical, surgical, and hospital benefits:

  • The Self-Funded PPO Plan (a "preferred provider organization," or PPO); and
  • Kaiser Foundation Health Plan (a "health maintenance organization," or HMO).
The Self-Funded PPO Plan pays benefits to you, or directly to your provider, for health care which is medically necessary and prescribed by a licensed provider. The PPO Plan pays benefits for most types of care, regardless of whom you use as providers, but you will pay significantly less if you use PPO providers. The Plan's current PPO for medical benefits is Blue Shield of California. Medical benefits under the Self-Funded PPO Plan are no longer subject to a calendar year deductible, effective for services provided on January 1, 2015 and after. Under Kaiser, you pay a fixed fee for each covered visit, which may vary with the type of service. However, Kaiser requires that you use only their doctors and facilities, and have all your health care handled through a primary care physician.

The Plan provides a variety of other benefits:

  • Dental benefits are provided by the Self-Funded PPO Plan for active bargaining unit participants.
  • Prescription benefits are provided by the medical option in which you enroll: either the Self-Funded PPO Plan or Kaiser.
  • Vision care benefits are provided through Vision Service Plan for active bargaining unit participants. Life insurance is provided through United of Omaha for active bargaining unit participants. Fill out a beneficiary card and keep it current.
  • Help with personal and work-related problems and issues, including drug and/or alcohol dependence, is coordinated by the Claremont Employee Assistance Program for bargaining unit participants and their dependents.
  • The Plan also provides an orthotics benefit and a smoking cessation benefit.
All of these benefits are summarized in this booklet beginning on page 19 of the SPD.

Q.

Are my dependents covered?

A.

Your eligible dependents are covered when you are covered and have enrolled them. Be sure to inform the Plan Administration Office immediately if you get married, register a domestic partnership, have a child, or if a child is placed with you for adoption. Enroll new dependents within 30 days of the birth, marriage, or other event which makes them eligible, or you may have to wait until the next open enrollment period. Your eligible dependents lose coverage when you lose coverage, or, in the case of your children, when they reach the Plan's age limitations. Dependents who lose coverage are eligible for the Plan's COBRA continuation coverage. See page 13 and Appendix 1, pages 52-55 of the SPD, for Dependent Eligibility for Health Coverage. See page 15 and Appendix 1, pages 61-63 of the SPD, for COBRA continuation coverage.

Q.

What happens if I am disabled?

A.

Bargaining unit participants who become disabled due to an occupational or nonoccupational disability may receive coverage at no charge for up to six months. See pages 7-8 and Appendix 1, pages 49-50 of the SPD, for more details.

Q.

What happens if I am out of work?

A.

Reserve Account: Hours credited on your behalf which exceed those needed for current eligibility are reserved in your account to allow coverage in periods of unemployment. The maximum reserve you may accumulate is 4 full months of coverage: 500 hours for Shop/Regular Status Employees and 340 hours for Installers. Self-Pay: Shop/Regular Status employees who are credited with a minimum of 90 hours in a month may make a short payment to bring the total up to 125. Installers who are credited with a minimum of 60 hours in a month may make a short payment to bring the total up to 85.

Q.

What happens if I am hospitalized?

A.

Self-Funded PPO Plan: If you are going to be hospitalized, utilization review is required for most services, except for emergency admissions. See Appendix 1, pages 83 and 92-93 for details. Approved hospital charges are paid at 90% at PPOcontracted facilities, without a deductible for claims for services provided January 1, 2015 and after. At non-contracted facilities, approved hospital charges are paid at 70% after a $200 deductible. Kaiser: There are no charges at a Kaiser hospital.

Q.

What happens if I have surgery?

A.

Self-Funded PPO Plan: Surgeon's fees and facility charges are paid at 90% for PPO providers, without a deductible for claims for services provided January 1, 2015 and after. For non-PPO providers, surgeon's fees and facility charges are paid at 70%, after a $200 deductible applied to the facility charge. Kaiser: There are no surgeon charges at a Kaiser hospital.

Q.

What happens if I go to a hospital emergency room?

A.

Self-Funded PPO Plan: If you have an accident and go to a hospital emergency room, you will be responsible for the first $50 of covered charges. If you go to a hospital emergency room for an illness, you will be responsible for the first $100 of covered charges. Kaiser: If you go to a Kaiser emergency room, you are responsible for a $35 copay.

Q.

How do life insurance benefits get paid?

A.

The life insurance benefit will be paid to the person you have named on your beneficiary designation form. Be sure to fill one out and keep it updated.