Active employees covered under the Western States Health & Welfare Trust Fund of the OPEIU have family coverage at no additional cost. A covered dependent is outlined below:
The enrolled employee's legal spouse and his or her children under 26 years of age, and who are enrolled under the Plan.
The following are considered children:
- the enrolled employee's or enrolled domestic partner's natural child;
- the enrolled employee's enrolled domestic partner's adopted child, a child placed for adoption with the enrolled employee or domestic partner, a stepchild living in the enrolled employee's home or a nonresident stepchild if there is a qualified medical child support order that requires the spouse to provide health insurance coverage; and
- children related to the enrolled employee or enrolled domestic partner by blood or marriage, which may include grandchildren if the natural mother or father are an eligible family dependent and enrolled in this plan or for whom the employee is the legal guardian (the enrolled employee will need to give us a court order showing legal guardianship).
The newborn child of an enrolled employee, or an enrolled employee's domestic partner, or of an enrolled dependent will be covered for 31 days after it is born. We must have notice of the birth and in the case of a newborn of a male dependent, proof of paternity. To continue the newborn's coverage beyond this 31-day period, the child must be eligible under the terms of the Plan and the enrolled employee must sign a new application within 60 days listing the child as a dependent. Be sure to send a copy of the child's birth certificate along with your application. this is not done, coverage for the child will lapse at the end of 31 days.
In addition, incapacitated children can remain enrolled past the age of 26. An incapacitated child is an unmarried child who is incapable of self-support because of a physical handicap or mental retardation. The incapacitating condition must have existed before the child's 23rd birthday. In order to obtain continued coverage for an incapacitated child, the enrolled employee must complete a special application and have it approved by us before the child's 26th birthday.
Newly Acquired Dependents
If an enrolled employee marries while he or she is enrolled under the Plan, his or her spouse and the spouse's children become eligible to apply for coverage on the date of the marriage. The new stepchildren must meet the eligibility requirements for all children in order to be enrolled.
An enrolled employee's or an enrolled female dependent's newborn child will automatically be enrolled for 31 days after it is born. To continue the newborn's coverage beyond this 31-day period, the child must be eligible under the terms of the Plan.
A child will be enrolled as an enrolled employee's dependent child for 31 days after the date the child is placed with the enrolled employee for the purpose of adoption. "Placement" means the enrolled employee has assumed and retained a legal obligation for full or partial support of the child in anticipation of adoption.
In order to continue this coverage beyond the first 31 days, the enrolled employee must sign a new application within the first 31 days listing the child as a dependent, along with proof of placement. Be sure to send a copy of the child's birth certificate or adoption papers. If this is not done, coverage for the child will terminate at the end of the 31st day after placement.
An eligible individual will not be considered a late enrollee in the following situations:
If you and/or your eligible dependents lose coverage under another group or individual health benefit plan due to:
the exhaustion of federal COBRA or Oregon state continuation;
- the loss of eligibility due to legal separation, divorce, death, termination of employment or reduction in hours; or the employer contributions were terminated; or
involuntary loss of coverage under Medicaid, Medicare, CHAMPUS/Tricare, Indian Health Service, or a publicly sponsored or subsidized health plan, like Oregon Health Plan.
In all of the above situations, you and/or your eligible dependents become eligible for coverage under this Plan on the date the other coverage ends. Note that loss of eligibility does not include a voluntary termination of coverage, a loss because premiums were not paid in time, or termination of coverage because of fraud.
- If you declined coverage when you were first eligible and you subsequently marry, you become eligible for coverage under this Plan on behalf of yourself, your spouse, and any eligible dependent children on the date of marriage.
If you declined coverage when you were first eligible and you subsequently acquire a new dependent child by birth, adoption, or placement for adoption, you become eligible for coverage under this Plan along with your eligible spouse and eligible dependent children including the newly acquired child on date of the birth, adoption, or placement.
A spouse and/or dependent child for whom you declined coverage becomes eligible for coverage under this Plan on the date a court has issued an order for you to provide such coverage.
If you and/or your eligible dependents enroll during an open enrollment period under the Plan, if any. Contact the Administrator to find out if you have an open enrollment period.
If you and/or your eligible dependents are employed by an employer who offers multiple health benefit plans and you and/or your eligible dependents enroll during an open enrollment period under the Plan, if any. Contact the Administrator to find out if you have an open enrollment period.
When you receive care, your doctor's office usually takes care of filing your claim. However, to ensure your claim is sent to the proper address you must show your doctor's receptionist or billing department your ID card.
It is important that you ask that they update their computer records with the claim address information shown on the back of the card. The address to submit claims is found in the Contacts Section.
If your provider bills you directly for services under the Trust Dental Plan, you'll need to submit that bill for processing. For your convenience in sending in provider bills you can print a claim form from this web site. The proper mailing address is shown on the claim form.
| A.|| Yes,
hearing aids are covered. The Trust provides hearing aid benefits for Regence
BlueCross BlueShield of Oregon and Kaiser Permanente medical plan members. This
benefit is available for all active employees and their dependents. It is not
available to retirees.|
Plan will pay 80% of usual and customary charges (UCR) up to a maximum of $400
in a period of three (3) consecutive calendar years for a hearing evaluation,
examination, and hearing aid device. A Physician examination and written
certificate must be provided prior to obtaining a hearing aid in order for the
device to be covered.
Plan does not pay benefits for certain services such as repairs, servicing, or
alteration of hearing aid equipment.
see Attachment #4 of the Summary Plan Description for a complete summary of
benefits located in the Health Documents tab of the website.