laborers health and welfare trust fund

Transcripción

LABORERS
HEALTH AND WELFARE
TRUST FUND
FOR NORTHERN CALIFORNIA
ACTIVE LABORERS PLAN
MARCH 2006
Please disregard the Rules and Regulations section of this booklet which begins on page 66. The
Rules and Regulations have been revised as of January 1, 2016. You may review the revised Rules &
Regulations at the Laborers Trust Funds’ website at www.norcalaborers.org.
LABORERS HEALTH AND WELFARE TRUST FUND
220 Campus Lane
Fairfield, California 94534-1498
TELEPHONE: 707 864 2800 • TOLL-FREE NUMBER: 800 244 4530
WEBSITE: www.norcalaborers.org
EMAIL: [email protected]
BOARD OF TRUSTEES
EMPLOYEE TRUSTEES
EMPLOYER TRUSTEES
José Moreno, Chairman
Doyle Radford
Ron Puls
Mike Muesing
Oscar De la Torre
Larry Totten, Co-Chairman
Terence Street
Claire Koenig
Robert Chrisp
Byron C. Loney
LEGAL COUNSEL
Stanton, Kay & Watson
Weinberg, Roger & Rosenfeld
CONSULTANT AND ACTUARY
The Segal Company
ADMINISTRATIVE OFFICE
Laborers Funds Administrative Office of Northern California, Inc.
Edward J. Smith, Secretary
Active Laborers Plan
To All Active Laborers Covered by the Plan:
We are pleased to provide you with this updated booklet, describing the benefits available from
your Health and Welfare Plan. Though this booklet primarily describes benefits provided by the
Fund’s Direct Payment Plan, it also includes information on dental, vision, and death benefits
which are available to all Active Laborers, regardless of which medical plan you choose.
This booklet explains:
•
how and when you become eligible for benefits,
•
what your benefits are and how to obtain those benefits,
•
how to file a claim and, if your claim is denied, how to file an appeal for benefits,
•
general provisions of the Plan, including limitations and exclusions.
Your benefit booklet is divided into two sections. The first section is a summary of your benefits.
The second section is the complete text of the Rules and Regulations of the Plan, which presents
the provisions of the Plan in detail. In the event of a conflict between the Plan summary and the
Rules and Regulations, the Rules and Regulations will govern.
Be sure to share this booklet with your family, since they too are covered by the Plan. If
you have any questions a�er reading this booklet, or any questions about your benefits in
general, contact the Fund Office at (707) 864-2800 or toll-free at 1-800-244-4530, Monday
through Friday, between the hours of 8:00 AM and 5:00 PM. You can also e-mail questions
to the Fund Office at [email protected].
Sincerely,
BOARD OF TRUSTEES
March 1, 2006
1
Important Information
About Your Plan
Only a summary of the Plan’s benefits appears in the first part of this
booklet. If you are eligible for benefits, your rights can only be determined
by reading the complete Rules and Regulations of the Health and Welfare
Plan printed in the last part of this booklet.
None of the benefits described in this booklet is insured by any contract
of insurance and there is no liability on the part of the Board of Trustees,
any individual, or entity to provide payment in excess of the amounts in
the Trust Fund that have been collected and are available for the payment
of benefits.
Plan benefits for Participants are not guaranteed. The Board of Trustees
has the right to change or discontinue (1) the types and amounts of benefits
under the Plan and (2) the eligibility rules, including those rules providing
extended or accumulated eligibility, even if the extended eligibility has
already been accumulated.
The nature and amount of plan benefits are always subject to the actual
terms of the Plan as it exists at the time the claim occurs.
You should understand that only the Board of Trustees is authorized to
resolve any question in the intepretation of the Plan of benefits described
in this booklet. No employer or union, nor any representative of any
employer or union is authorized to interpret this Plan on behalf of the
Board—nor can any of these persons act as an agent of the Board.
2
Eligibility .......................................................................................................................................... 6
Initial and Continuing Eligibility ..................................................................................................... 6
If You Become Disabled ............................................................................................................... 6
Your Eligible Dependents ............................................................................................................. 6
Qualified Medical Child Support Order (QMCSO) ........................................................................ 7
Enrolling for Benefits .................................................................................................................... 7
When Eligibility Terminates for the Laborer .................................................................................. 7
When Eligibility Terminates for Your Dependents ........................................................................ 8
How to Regain Eligibility ............................................................................................................... 8
What Happens When You Lose Eligibility .................................................................................... 8
COBRA Continuation Coverage .................................................................................................... 10
Qualifying Events ....................................................................................................................... 10
Duration of COBRA Continuation Coverage .............................................................................. 10
Extending COBRA Coverage in Cases of Disability ................................................................... 11
Extending COBRA Coverage When a Second Qualifying Event Occurs ................................... 11
Effect of Medicare Entitlement Before a Termination of Employment or Reduction in Hours .... 11
Benefits Available Under COBRA Continuation Coverage ......................................................... 11
Cost of COBRA Continuation Coverage .................................................................................... 12
Electing COBRA Continuation Coverage ................................................................................... 12
Paying for COBRA Continuation Coverage ................................................................................ 13
How to Obtain COBRA Continuation Coverage ......................................................................... 13
Your Duty to Notify the Fund Office ............................................................................................ 13
How to Notify the Fund Office .................................................................................................... 14
Where to Send Your Notice ........................................................................................................ 14
When to Notify the Fund Office .................................................................................................. 14
Who Can Notify the Fund Office ................................................................................................ 15
Adding New Dependents ........................................................................................................... 15
Changing Medical Plans Under COBRA .................................................................................... 15
Termination of COBRA Continuation Coverage ......................................................................... 16
Post-COBRA Coverage Under an HMO .................................................................................... 16
Conversion to Individual Coverage ............................................................................................ 17
More Information on HMO Options ............................................................................................ 17
Keeping the Fund Office Notified ............................................................................................... 17
Dental and Vision Benefits ............................................................................................................ 18
Delta Dental of California ........................................................................................................... 18
DeltaCare ................................................................................................................................... 18
Bright Now! ................................................................................................................................. 19
Pacific Union Dental ................................................................................................................... 19
Vision Service Plan .................................................................................................................... 19
Resolving Complaints with Dental and Vision Providers ............................................................ 19
Employee Assistance Program (EAP) ........................................................................................... 20
3
Death Benefits ............................................................................................................................... 21
Laborer’s Death Benefit ............................................................................................................. 21
Death Benefit Coverage During Total Disability ......................................................................... 21
Laborer’s Accidental Death and Dismemberment Benefits ........................................................ 21
Naming Your Beneficiary ............................................................................................................ 22
Dependent’s Death Benefit ........................................................................................................ 22
Beneficiary of Dependent’s Death Benefit ................................................................................. 22
Dependent’s Extended Death Benefit ........................................................................................ 23
Choice of Medical Plan .................................................................................................................. 24
Fund’s Direct Payment Plan ....................................................................................................... 24
Kaiser Foundation Health Plan, Inc. ........................................................................................... 24
When You Can Change Plans .................................................................................................... 24
Table of Benefits - Direct Payment Plan ........................................................................................ 26
Hospital and Medical Benefits ....................................................................................................... 28
Hospital Benefits ........................................................................................................................ 28
Preferred Provider Plan Service Area ........................................................................................ 28
Benefits for In-Area Residents ................................................................................................... 29
Benefits for Out-of-Area Residents ............................................................................................ 29
Skilled Nursing Facility (SNF) Benefit ........................................................................................ 29
Combined Maximum Number of Days in Hospital/Skilled Nursing Facility ................................ 29
Period of Disability ..................................................................................................................... 30
Limitations on Hospital and Skilled Nursing Facility Benefits ..................................................... 30
Utilization Review (UR).................................................................................................................. 30
Utilization Review for Elective, Non-Emergency Confinements ................................................. 30
Utilization Review for Emergency Confinements ....................................................................... 31
Out-of-Pocket Cost for Non-Compliance with Utilization Review ............................................... 31
Benefits Required by Law ............................................................................................................. 32
Newborns’ and Mothers’ Health Protection Act .......................................................................... 32
Women’s Health and Cancer Rights Act .................................................................................... 32
Comprehensive Medical Benefits .................................................................................................. 32
Payment ..................................................................................................................................... 32
Lifetime Maximum Benefit .......................................................................................................... 33
Plan Year Deductible .................................................................................................................. 33
Physician Office Visit Copayment .............................................................................................. 34
Hospital Emergency Room Copayment ..................................................................................... 34
Maximum Out-of-Pocket Payment ............................................................................................. 34
Covered Expenses ..................................................................................................................... 34
Case Management Program ......................................................................................................... 37
Annual Physical Examination Benefit ............................................................................................ 37
Prescription Drug Benefit .............................................................................................................. 38
Retail .......................................................................................................................................... 38
Mail Service ................................................................................................................................ 39
Substance Abuse Treatment Benefits ........................................................................................... 40
4
General Exclusions and Limitations .............................................................................................. 42
If You Have Coverage From Another Group Plan ......................................................................... 44
Third Party Liability ........................................................................................................................ 44
Claims and Appeals Procedures for Direct Payment Plan ............................................................ 45
Claims ........................................................................................................................................ 45
How to File a Claim .................................................................................................................... 48
When Must Claims Be Filed ....................................................................................................... 48
Where to File Claims .................................................................................................................. 49
Authorized Representative ......................................................................................................... 49
Notice of Decision on Claim ....................................................................................................... 49
How to Request a Review of a Denied Claim ............................................................................ 50
Review Process ......................................................................................................................... 50
Timing of Notice of Decision on Appeal...................................................................................... 51
Notice of Decision on Review .................................................................................................... 51
Limit on When You May Begin a Lawsuit (Civil Action) .............................................................. 52
Privacy of Your Health Information ................................................................................................ 53
Who Sees Your Health Information? .......................................................................................... 53
The Plan’s Promise to You ......................................................................................................... 53
Other Privacy Notices ................................................................................................................ 54
How the Plan Uses and Discloses Your Health Information ....................................................... 54
Special Situations ....................................................................................................................... 55
Your Rights Regarding the Health Information the Plan Maintains About You ........................... 56
Changes to Privacy Notice ......................................................................................................... 57
Complaints ................................................................................................................................. 57
Other Uses of Medical Information ............................................................................................. 57
Information Required by the Health Insurance Portability and Accountability Act ......................... 58
Information Required by the Employee Retirement Income Security Act of 1974 ......................... 60
Statement of Rights Under the Employee Retirement Income Security Act of 1974 (ERISA) ...... 63
Rules and Regulations - Direct Payment Plan .............................................................................. 66
Article I
Definitions ............................................................................................................... 66
Article II
Eligibility for Benefits ............................................................................................... 72
Article III
Death Benefits for Active Employees ...................................................................... 80
Article IV Death Benefits for Dependents of Active Employees ............................................. 83
Article V
Hospital-Medical Benefits ....................................................................................... 84
Article VI Drug Benefits .......................................................................................................... 93
Article VII Behavioral Health Benefits ..................................................................................... 96
Article VIII Health Insurance Portability and Accountability Act
Protected Health Information ................................................................................ 97
Article IX Exclusions, Limitations, and Reductions .............................................................. 102
Article X
General Provisions ............................................................................................... 106
Ariticle XI Claims and Appeals Procedures ........................................................................... 108
Article XII Amendment and Termination ................................................................................ 117
Article XIII Disclaimer ............................................................................................................. 118
5
Eligibility
Initial and Continuing Eligibility
(Article II, Subsections 2.a.(1) and (2), page 72)
You will become eligible for benefits on the first day of the second calendar month a�er you work
at least 440 hours for contributing employers who have reported and paid contributions on your
behalf for the maintenance of the Health and Welfare Plan.
Your eligibility continues as long as you have at least 440 hours in your Hour Bank before 110 hours
are deducted for the current month’s eligibility. All hours worked for contributing employers that
are reported and paid to the Health and Welfare Trust Fund on your behalf are credited to your
Hour Bank. You can accumulate up to a maximum of 990 hours in your Hour Bank a�er 110 hours
have been deducted for the current month’s eligibility.
ANY HOURS WORKED BUT NOT PAID BY YOUR EMPLOYER INTO
THE HEALTH AND WELFARE FUND ON YOUR BEHALF WILL NOT
BE ADDED TO YOUR HOUR BANK. THIS COULD AFFECT YOUR
ELIGIBILITY ADVERSELY.
If You Become Disabled
(Article II, Subsection 2.a.(3), page 73)
If you become disabled and you have a minimum of 440 hours in your Hour Bank on the date
you become disabled, you will receive credit of 8 hours per day, up to 40 hours per week. No
more than 110 disability hours will be granted in any month. Disability hours are not granted for
Saturday or Sunday, nor will disability hours be granted for more than 6 months during any 12
consecutive-month period.
Remember – To qualify for disability hours, you must have at least 440 hours in your Hour Bank
at the start of your disability.
To obtain disability hours, request a Certification of Disability from your Local Union or the Fund
Office. Ask your doctor to complete his portion. The Certification of Disability must be filed with
the Fund Office within one year from the beginning of your disability; otherwise it will not be
accepted as timely filed.
6
Your Eligible Dependents
(Article I, Section 8, page 67)
Eligible dependents under the Direct Payment Plan include:
•
•
•
•
•
•
your lawful spouse;
your natural or adopted children who are unmarried and younger than age 19. Adopted
children are covered from the date they are placed in your custody;
your stepchildren who are unmarried and younger than age 19, reside in your home, and
are primarily dependent on you for support;
an unmarried child acquired through legal guardianship if the child is primarily dependent
on you for support, resides in your home, and is younger than age 19;
your unmarried children who are 19 but less than age 23 if they are enrolled at an accredited
educational institution for at least 8 units per semester, and are primarily dependent on
you for support;
a child of any age who is unable to earn a living because of a mental or physical handicap,
provided the child was both handicapped and eligible under the Plan prior to age 19, and
is primarily dependent on you for support.
Qualified Medical Child Support Order (QMCSO)
In accordance with ERISA Section 609(a)(2)(A), this Plan will provide coverage for a dependent
child of an Active Employee if required by a Qualified Medical Child Support Order (QMCSO).
Enrolling for Benefits
When you become eligible for benefits, the Trust Fund will send you an information packet,
including an Enrollment Form. Complete the Enrollment Form and include any of the following
documents, as required:
•
•
•
•
To enroll your spouse, include a Certificate of Marriage;
To enroll your natural or stepchildren, include a Certificate of Birth;
To enroll an adopted child, include the Legal Adoption Document and Certificate of
Birth;
To enroll a child acquired through legal guardianship, include court papers indicating
the child’s name and placement date.
As events occur, for example, you marry, you welcome a newborn, or you divorce, contact the
Fund Office to update the information on your Enrollment Form.
7
When Eligibility Terminates for the Laborer
(Article II, Subsection 2.b.(1), page 73)
Coverage for the Laborer terminates at the end of the month:
•
following the month that your Hour Bank balance falls below 440 hours before 110 hours
are deducted for the current month’s eligibility. However, if you retire with a minimum of
440 hours, your eligibility in the Active Plan will continue until the last day of the month
following the month the balance in your Hour Bank falls below 110 hours; or
•
that you enter military service, other than a temporary tour of duty of 30 days or less. If
you lose eligibility as a result of entering military service, special reinstatement rights
apply. Refer to Article II, Section 2.a.(5), page 73 for more information; or
•
that you perform the type of work covered by the collective bargaining agreement for an employer
that is not a contributing employer. (See definition of “Individual Employer,” page 72.)
When Eligibility Terminates for Your Dependents
(Article II, Subsection 2.b.(3), page 74)
Coverage for your dependents will end on the earlier of:
•
the date your eligibility ends. However, in the event you die with at least 440 hours in your
Hour Bank, your Dependents will continue to maintain eligibility until the last day of the
month following the month your Hour Bank falls below 110 hours before a deduction is
made for the current month’s coverage, or
•
the date your dependent no longer meets the definition of a dependent (see Article I,
Section 8, page 67 for the Plan definition of “Dependent”).
How to Regain Eligibility
(Article II, Subsection 2.c., page 74)
Eligibility can be regained on the first day of the second calendar month following the month you
accumulate a minimum of 440 hours in your Hour Bank.
If you do not regain eligibility within 13 months from the date you lost coverage, you will forfeit all
hours in your Hour Bank. If this occurs, you must satisfy the initial work requirements described
above - that is, you must work at least 440 hours for contributing employers. You then become
eligible on the first day of the second calendar month following the satisfaction of the 440-hour
requirement.
If you fail to regain eligibility within 13 months because you are disabled, you may petition the
Board of Trustees to reinstate any hours forfeited.
8
What Happens When You Lose Eligibility
When you lose eligibility under the Plan, the Fund Office provides you and each of your covered
dependents with a Certificate of Coverage. The purpose of the Certificate is to provide evidence of
your prior health coverage under the Active Laborers Plan. If you and your covered dependents
become eligible for coverage under another group health plan, or if you purchase a health
insurance policy for yourself or any of your covered dependents, the Certificate of Coverage may be
necessary to reduce or eliminate the period of time that an exclusion may apply for pre-existing
medical conditions. For example, if you were covered under this Plan for 6 months and your new
health plan has a 12-month waiting period before providing coverage to individuals with preexisting medical conditions, the 6 months coverage you had under this Plan can be applied to
your new plan and shorten the waiting period from 12 months to 6 months.
The Certificate of Coverage is automatically sent to you (or to any of your covered dependents)
shortly a�er coverage under this Plan ends. If you or any of your dependents elect COBRA
Continuation Coverage (discussed in the next section), another Certificate of Coverage is sent to
you (or to your dependents) a�er COBRA Continuation Coverage terminates.
You may also request a Certificate of Coverage, which will be sent to you or any of your covered
dependents, if the request is received by the Fund Office within 2 years a�er the later of:
•
•
the date your eligibility terminated under this Plan; or
the date COBRA Continuation Coverage terminated.
Requests for a Certificate of Coverage should be addressed to the Fund Office at the address shown
on page 60. Certificates of Coverage are provided without charge.
You should be aware that if you have a lapse in coverage of 63 or more days, the Certificate of
Coverage will not be accepted as evidence of previous coverage and cannot be used to offset any
waiting period that may apply to pre-existing medical conditions. In other words, if you do not
enroll in a health plan within 63 days from the date you lost eligibility in this Plan, your next
health insurer is not required to use the Certificate of Coverage to offset a waiting period for preexisting medical conditions.
9
Continuation Coverage Under
Federal Law (COBRA)
(Article II, Section 3., pages 75 - 79)
Qualifying Events
In the event you lose coverage, you and your eligible Dependents have the right to continue
group health coverage under the Active Laborers Plan. If any of the “Qualifying Events” listed
below occurs, Qualified Beneficiaries have the right to continue the Plan’s health benefits that
were in effect on the date the Qualifying Event occurred. To continue the Plan’s health coverage,
you must apply for COBRA Continuation Coverage and make the required monthly premium
payments to the Trust Fund. The following are Qualifying Events:
1.
The work hours reported on your behalf are less than the required monthly minimum
2.
Your divorce
3.
Your death
4.
Your Dependent child loses status as a “Dependent” under the Plan
A “Qualified Beneficiary” is any individual who was covered under the Active Laborers Plan on
the day before a “Qualifying Event” occurred. A Qualified Beneficiary includes the Laborer, his
Spouse, and his Dependent children. A child born to, placed for adoption, or acquired through
legal guardianship while the Laborer has COBRA Continuation Coverage is also a “Qualified
Beneficiary.”
Duration of COBRA Continuation Coverage
You can elect COBRA Continuation Coverage for up to 18, 29, or 36 months, depending on the
Qualifying Event:
•
18 Months - You and your Dependents can continue coverage for up to 18 months from the
date of the Qualifying Event if you would lose coverage because the work hours reported
on your behalf are less than the required monthly minimum.
•
29 Months - You or your Dependent can extend an 18-month period by 11 months, for a
total of 29 months if one of you becomes disabled, as determined by the Social Security
Administration, before or during the first 60 days of COBRA Continuation Coverage. See
“Extending COBRA Coverage in Cases of Disability” on page 11.
•
36 Months - Qualifying Events 2 through 4, as shown above, entitle your Dependents to
up to 36 months of COBRA Continuation Coverage from the date of the Qualifying Event.
(In the case of a child’s losing Dependent status, only the affected child is eligible for 36
months of coverage.)
10
Extending COBRA Coverage in Cases of Disability
If you or one of your eligible Dependents is or becomes totally disabled before or during the
first 60 days of COBRA Continuation Coverage, you may extend COBRA for an additional 11
months, up to 29 months. To qualify for an extension of 11 months, the disabled individual must
be deemed totally disabled by the Social Security Administration and must report the Social
Security disability determination to the Fund Office before the end of the initial 18 months of
COBRA and within 60 days of the Social Security determination. All family members of the
disabled individual are entitled to the additional 11-month extension of COBRA.
Premiums for the additional 11 months will be approximately 50% higher than those charged
during the initial 18-month period.
Extending COBRA Coverage When a Second
Qualifying Event Occurs
If, during an 18-month period of COBRA Continuation Coverage as a result of insufficient work
hours, the Laborer dies, divorces, or a Dependent child loses his “Dependent” status under the
Plan, the maximum period of COBRA Continuation Coverage for the Laborer’s Spouse and
Dependent children can be extended to 36 months from the date of the initial Qualifying Event.
This extended period is not available to an individual who becomes the Laborer’s Spouse a�er the
initial Qualifying Event. However, this extended period is available to children born to, adopted
by, placed for adoption, or acquired through legal guardianship with the Laborer during the 18month period of COBRA Continuation Coverage.
Effect of Medicare Entitlement Before a Termination of
Employment or Reduction in Hours
If you are a Laborer and the reporting of insufficient work hours occurs less than 18 months
a�er the date you became entitled to Medicare (Part A, Part B, or both), the maximum period of
COBRA Continuation Coverage for your Dependents will be 36 months a�er the date of your
Medicare entitlement.
Medicare entitlement is not a Qualifying Event under this Plan. Medicare entitlement a�er a
termination of employment or the reporting of insufficient hours will not extend a Qualified
Beneficiary’s COBRA coverage beyond 18 months.
Benefits Available Under COBRA Continuation Coverage
You may elect to continue hospital/medical and prescription drug coverage only (Core Coverage),
or hospital/medical, prescription drug, vision and dental coverage (Core Plus Coverage). Dental
and vision coverages do not have to be continued; however, you may not continue one of these
benefits without the other. Death and Accidental Death and Dismemberment Benefits are not
available under COBRA Continuation Coverage.
11
Once you or your Dependents select a level of benefits (Core or Core Plus Coverage), you cannot
change while you and your Dependents have COBRA coverage. For example, if you choose Core
Coverage, you cannot later change to Core Plus or vice versa.
Cost of COBRA Continuation Coverage
COBRA Continuation Coverage is available only at your own expense. If you or your Dependents
elect COBRA, the full cost, plus a 2% administrative fee will be charged (in the case of an extension
due to a disability, the charge is the full cost plus 50%). If the cost changes, the Trust Fund will
revise the charge you are required to pay. In addition, if the benefits change for Active Employees,
benefits under COBRA Continuation Coverage will change as well.
Electing COBRA Continuation Coverage
A�er receiving notice of a Qualifying Event, the Fund Office will send you a notice of your right
to choose COBRA Continuation Coverage, along with an election form. If you do not qualify for
COBRA Continuation Coverage, a Notice of Unavailability of COBRA Continuation Coverage
will be sent. These notices will be sent within 14 days from the date the Fund Office receives
notice of a Qualifying Event.
The Fund Office will send you a notice when your Hour Bank falls below 440 hours before a
deduction of 110 hours for the current month’s eligibility. Even if you think you will be returning
to work and will not need COBRA Continuation Coverage, it is important that you return the
election form to the Fund Office within 60 days.
YOU MUST SIGN AND RETURN THE ELECTION FORM TO THE FUND OFFICE NO
LATER THAN 60 DAYS AFTER THE DATE YOU LOSE ELIGIBILITY OR THE DATE OF
THE COBRA NOTICE FROM THE FUND OFFICE, WHICHEVER IS LATER, OR YOU
WILL NOT BE ELIGIBLE FOR COBRA CONTINUATION COVERAGE. IF YOU OR
YOUR DEPENDENTS DO NOT FILE THE COBRA ELECTION FORM WITHIN THIS
60-DAY PERIOD, YOU OR YOUR DEPENDENTS WILL FORFEIT COBRA RIGHTS.
If you do not choose COBRA Continuation Coverage, your health insurance coverage will
end. However, your Spouse and eligible Dependents can elect COBRA, independent of your
rejection.
In deciding whether to elect COBRA Continuation Coverage, you should understand that failure to
continue your group health coverage will affect your future rights under federal law as follows:
•
If you have a gap in health coverage of 63 days or more, you can lose the right to apply
prior health coverage as credit for pre-existing conditions that may be excluded by other
health plans in which you enroll. (Election of COBRA Continuation Coverage may prevent
a gap in coverage.)
•
If you do not obtain COBRA Continuation Coverage for the maximum period available to
you, you will lose the guaranteed right to purchase individual health insurance policies
with no pre-existing condition exclusions.
12
•
You have the right to request special enrollment in another group health plan for which
you are otherwise eligible. Special enrollment under this provision is allowed within 30
days a�er your group health coverage ends because of the Qualifying Events listed on
page 10, or when COBRA Continuation Coverage terminates if you enrolled in COBRA
Continuation Coverage for the maximum period available to you.
Paying for COBRA Continuation Coverage
The Fund Office will notify you of the cost of coverage when you receive your notice of entitlement
to COBRA Continuation Coverage. The cost of COBRA may be subject to future increases during
the period it remains in effect.
There is an initial grace period of 45 days to pay the first premium due, starting with the date
COBRA coverage was elected. If the initial payment is not made when due, COBRA coverage will
not take effect. A�er the first payment, subsequent payments are due on the first day of the month
for which coverage is provided. There is a grace period of 30 days to pay the monthly premiums.
If you do not pay the premium by the end of the grace period, COBRA coverage will terminate.
Your initial payment must cover the period from the date coverage terminated up to the current
month’s coverage. For example, if your coverage terminated on February 28, 2005 and you are
sending your election form on April 29, 2005, and you are making your initial payment on June 10,
2005, you must pay for the months of March, April and May 2005. In addition, if you are paying for
June 2005 coverage, your premium must be received by no later than June 30, which is the end of the
grace period.
How to Obtain COBRA Continuation Coverage
Your Employer is responsible for notifying the Fund Office within 30 days of the date coverage
would otherwise terminate for one of the following reasons:
•
•
your death or
termination of employment
The Fund Office will determine when your Employer reports less than the minimum required
work hours on your behalf. Your Dependents should also notify the Fund Office of these events
so that your COBRA rights are not adversely affected. The Fund Office then has 14 days to notify
you of your rights to continue coverage.
Your Duty to Notify the Fund Office
You and your Dependents are responsible for providing the Fund Office with timely notice of the
following Qualifying Events:
•
•
•
your (the Laborer’s) divorce from your Spouse,
your child’s loss of “Dependent” status under the Plan, or
the occurrence of a second Qualifying Event while your Dependents are in an 18-month
COBRA Continuation period (see “Extending COBRA Coverage When a Second Qualifying
Event Occurs” on page 11).
13
You must also provide timely notice to the Fund Office when:
•
•
you and your Dependents have a Qualifying Event that entitles you to COBRA Continuation
Coverage with a maximum duration of 18 months and the Social Security Administration
determines that one of you is disabled, or
the Social Security Administration determines that the individual is no longer disabled.
Make sure you or your Dependents notify the Fund Office of any of the 5 events listed above.
Failure to provide this notice within the time frames described below may prevent you or your
Dependents from obtaining or extending COBRA Continuation Coverage.
How to Notify the Fund Office
You must notify the Fund Office of any of the 5 events listed above, by sending a le�er to the Fund
Office, containing the following information:
•
•
•
•
•
name of the Qualified Beneficiary
the Laborer’s name and social security number
the event for which you are providing notice and the date of the event (for example, the
date of a Dependent child’s 19th birthday), or
a copy of the final marital dissolution if the event is a divorce
if your child is no longer a full time student, the date he or she last a�ended school
If you have any questions as to how to notify the Fund Office of one of these events, call (707) 8642800 or toll-free at 1-800-244-4530 and ask for the COBRA Department.
Where to Send Your Notice
Notice of a Qualifying Event should be sent to the Fund Office at the following address:
Laborers Health and Welfare Trust Fund for Northern California
220 Campus Lane
Fairfield, California 94534-1498
A�ention: COBRA Department
When to Notify the Fund Office
If you are providing notice of a divorce, a Dependent child losing eligibility, or a second Qualifying
Event, you must send the notice no later than 60 days a�er the date of the Qualifying Event. If you
are providing notice of a Social Security Administration determination of disability, notice must
be sent no later than the end of the first 18 months of COBRA Continuation Coverage. If you are
providing notice of a Social Security Administration determination that you or your Dependent is
no longer disabled, notice must be sent no later than 30 days from the date of the determination by
the Social Security Administration. IF YOU DO NOT NOTIFY THE FUND OFFICE WITHIN
THESE TIME FRAMES, YOU WILL FORFEIT YOUR COBRA RIGHTS.
14
Who Can Notify the Fund Office
Notice may be provided by you or your Dependents or any representative acting on behalf of you
or your Dependents.
Notice from one individual will satisfy the notice requirement for all related Qualified Beneficiaries
affected by the same Qualifying Event. For example, if your Spouse notifies the Fund Office that
your child no longer meets the definition of “Dependent” under the Plan, the single notice would
satisfy the notification requirement.
Adding New Dependents
If, while you are covered under COBRA Continuation Coverage, you marry, have a newborn
child, have a child placed with you for adoption, or assume legal guardianship of a child, you may
enroll your new Spouse or child for the remainder of the period of your COBRA Continuation
Coverage by sending a completed enrollment form to the Fund Office within 30 days a�er the
birth, marriage, placement for adoption, or legal guardianship.
Any Qualified Beneficiary can add a new Spouse or child to his COBRA Continuation Coverage,
but the only family members who are newly added that have the rights of a Qualified Beneficiary,
such as the right to extend COBRA if a second Qualifying Event occurs, are natural, adopted, or
legal guardianship children of the former Laborer.
Special enrollment for the balance of your COBRA period is also allowed for Dependents who
lose other coverage. For this to occur,
•
Your Dependent must have been eligible for COBRA Continuation Coverage on the date of
the Qualifying Event but declined when enrollment was offered because he had coverage
under another group health plan or had other health insurance coverage,
•
Your Dependent must exhaust the other coverage, lose eligibility for it, or lose employer
contributions to it, and
•
You must enroll that Dependent by sending an enrollment form to the Fund Office within
30 days a�er the termination of the other coverage or contributions.
Changing Medical Plans Under COBRA
If you wish to change your health plan, you may do so up to 2 times a year. To change your health
plan, contact the Fund Office for a Benefit Application Form. Complete and submit a new Benefit
Application Form to the Fund Office. The change becomes effective on the first day of the second
calendar month following the date your Benefit Application Form is received by the Fund Office.
15
Termination of COBRA Continuation Coverage
COBRA Continuation Coverage will terminate at the end of the maximum continuation period
allowed (18, 29, or 36 months). COBRA Continuation Coverage will terminate before the end of
the 18, 29, or 36 month period if one of the following events occurs:
1.
You or your Dependents fail to remit the required premium payments in full and on time
(within 45 days following the submission of the initial COBRA election form, including the
cost of coverage retroactive to the first day your coverage would have otherwise terminated,
or within 30 days following the due date for subsequent monthly payments);
2.
You or your Dependents become covered under any other group health plan a�er the date
you elect COBRA coverage; however, if the other group health plan will not cover a preexisting health condition, COBRA Continuation Coverage will not be terminated;
3.
You or your Dependents become entitled to Medicare Part A or Part B a�er the date of
your COBRA election;
4.
Your employer no longer provides group health coverage to any of its employees; or
5.
You or your Dependents have continued coverage for additional months due to a disability
and there has been a final determination by Social Security that you or your Dependents
are no longer disabled.
COBRA Continuation Coverage will terminate on the first day of the month following any of the
events 1 through 5 listed above.
If COBRA coverage is terminated before the end of the maximum period of coverage, the Fund
Office will send you a wri�en notice as soon as practicable following its determination that
continuation coverage will terminate.
Post-COBRA Coverage Under an HMO
California COBRA Law (the following provisions apply only to HMO Participants)
If you are a COBRA Participant enrolled in an HMO, California law has a provision that affects
the length of time you may continue coverage. This law applies only to your HMO medical
coverage, not to the other health care benefits usually available under COBRA. Payments beyond
the federal COBRA period are made directly to the HMO.
•
If your Qualifying Event was termination of your employment or reporting of less than the
minimum required work hours for a month and you exhaust the 18 months of coverage
normally available a�er this type of Qualifying Event (or the 29 months available in the
case of a disability), you may continue your HMO medical coverage an additional 18
months (or an additional 7 months in the case of a disability).
To take advantage of this provision, you must remain in the HMO plan.
16
Conversion to Individual Coverage
At the end of the COBRA Continuation Coverage period, you or your eligible Dependents may
enroll in an individual conversion plan offered by an HMO as described in the HMO’s Evidence
of Coverage (EOC) brochure, provided you were enrolled in the HMO before your continuation
coverage ended.
You also have the option of purchasing individual conversion coverage from the HMO instead
of COBRA coverage, but only if you were enrolled in the HMO when your Trust Fund coverage
ended.
More Information on HMO Options
Check your HMO’s Evidence of Coverage (EOC) for more information on how to elect postCOBRA extended coverage under California law or enroll in an HMO conversion plan. You can
also call Member Service at your HMO.
Keeping the Fund Office Notified
If you have changed marital status, or you or your Spouse or other Dependents have changed
addresses, contact the Fund Office. Notify the Fund Office of any Qualifying Event, even if your
Employer is required to give notice to the Fund Office.
Should federal or state law alter the provisions of COBRA in existence at the time this Summary
Plan Description is printed, Participants will be advised of these modifications, as required.
17
Dental and Vision Benefits
When you become eligible for benefits, you will automatically be enrolled in Delta Dental of
California, the Fund’s flagship dental plan. You may either remain in that plan, or enroll in one
of the optional, HMO-type plans described below. Whichever plan you choose, your eligible
dependents will be covered under the same dental plan. You may not split coverage—that is,
you may not enroll in DeltaCare and one or more of your dependents enroll in Bright Now! Each
March, the Fund holds an open enrollment, at which time you may change dental plans.
Brochures, describing each dental plan and the vision plan are available from the Fund Office or
your Local Union Office.
Delta Dental of California
More than 9,000 dentists in Northern California are Delta dentists. Under Delta Dental, you are
free to choose any dentist you wish, however, it is to your advantage to choose a Delta dentist, as
his fees are approved by Delta in advance. To lower your dental bills even more, you can choose
a dentist who participates in Delta’s preferred provider organization, called DeltaPreferred Option
(DPO). DPO is made up of a select group of Delta dentists who have an agreement with Delta to
provide services at moderate fees. Whether you choose a regular Delta dentist or a DPO dentist,
payment is based on the same Table of Allowances, which assigns a maximum payment for each
dental procedure covered by the plan.
The annual deductible is $100/individual, up to $300/family; the annual maximum benefit is
$1,500/individual; diagnostic and preventive services are paid in full, with the deductible being
waived. All other dental procedures are paid according to the Table of Allowances. Any difference
between the allowance shown in the Table and the dentist’s fee is your responsibility.
DeltaCare
DeltaCare is an HMO dental plan that provides you and your family with quality dental benefits
at an affordable cost. There are no deductibles; out-of-pocket costs are clearly defined; and no
annual dollar maximum (except for treatment of an accidental injury). When you enroll, you select
a contract dentist to provide all dental services. If you require a specialist, your contract dentist
will handle the referral. DeltaCare is administered by PMI Dental Health Plan. For additional
information about this plan, call 1-800 422-4234.
Except for emergency services, any dental services you receive from a dentist other than your
selected contract dentist will not be paid by DeltaCare or the Trust Fund.
18
Bright Now!
Bright Now! is another HMO dental plan that offers quality, affordable family dental care. The
plan covers preventive and basic care in full (at no charge to you). There are no deductibles. The
annual maximum is $2,500 per eligible individual. You are responsible for 20% of the cost for
major dental work. This plan is only available to Laborers who reside within the Bright Now! Service
Area. To find out if this plan is available in your area, contact Bright Now! at 1-888-274-4486.
Except for emergency services, any dental services you receive from a dentist other than your
Bright Now! dentist will not be paid by Bright Now! or the Trust Fund.
Pacific Union Dental
Pacific Union Dental is another HMO dental plan that offers quality dental services at a savings.
Pacific Union contracts with dental professionals to provide services to you and your eligible
dependents at no cost, or with low, fixed copayments. Call 1-800-999-3367 for a Pacific Union
dentist in your area.
There are no deductibles and no annual maximum. You know your exact “out-of-pocket” costs,
if any. You and your family choose your dentist from a network of private dental offices. All your
dental care will be handled by your dental office, including referrals to specialists.
Vision Service Plan
Vision care benefits are provided through a contract with Vision Service Plan (VSP). These benefits
include vision examinations, frames, lenses, and contacts. When you use the services of a VSP
network doctor, you receive the best value from your vision service benefit. You are free to use
the services of an out-of-network doctor, however, you will incur more out-of-pocket expense.
In addition, you will be required to file a claim form for reimbursement when using an out-ofnetwork doctor.
Resolving Complaints with Dental and Vision Providers
Delta Dental, DeltaCare, Bright Now!, Pacific Union Dental and VSP have grievance procedures for
handling Participant complaints. If you have a complaint with one of these service providers, you
should first seek resolution using the service provider’s complaint procedure before appealing to
the Board of Trustees of the Laborers Health and Welfare Trust Fund for Northern California. If
you have issues involving eligibility, contact the Fund Office.
19
Employee Assistance
Program (EAP)
Personal concerns can have a big impact on your work performance and overall functioning.
The Employee Assistance Program (EAP) helps individuals solve personal issues before they
become more serious and difficult to manage. Employees and their family members can receive
professional, confidential counseling at no cost. The EAP also provides access to resources that
can help you address virtually any personal concern or question.
What Can EAP Help With?
•
•
•
•
•
Marital/Relationship Issues
Dependent Care Referrals
Domestic Violence
Anxiety/Depression
Financial Ma�ers
•
•
•
•
•
Work Issues
Parenting Issues
Substance Abuse
Legal Issues
Most Other Personal Concerns
What’s Included?
The EAP offers three, no-fee counseling visits with a participating provider for any personal issue,
including: marital/family conflicts, parenting concerns, substance abuse, work stress, depression,
and other issues that affect your qualify of life.
A�er using your free EAP visits, you can continue to see your counselor on a self-pay basis at a
discounted rate if you are enrolled in the Fund’s Direct Payment Plan. Check your Plan’s mental
health benefits on page 36, #13. (For Kaiser members, arrange continuing counseling through
your Kaiser primary care physician.)
Who Provides the EAP?
Claremont Behavioral Services, a firm of select professionals who can help you with life’s challenges
administers the EAP. You will be referred to a conveniently located counselor or resource with
expertise in your area of concern. Claremont recognizes your need for prompt, helpful assistance.
The EAP is a confidential service. Claremont understands the importance of maintaining your
privacy and everything you tell them will be kept confidential. Your involvement with Claremont
is afforded the maximum confidentiality permi�ed under the law.
What’s the First Step?
Call 1-800-834-3773 to discuss your issue with an experienced resource counselor. He or she will
help you develop an action plan and refer you to resources most appropriate for your needs.
20
Death Benefits
Laborer’s Death Benefit
(Article III, Subsection 1.a., page 80)
The Fund will pay your designated beneficiary $15,000 in the event of your death from any cause
(on the job or off) while you are eligible or within 31 days a�er your eligibility has terminated.
Death Benefit Coverage During Total Disability
(Article III, Subsection 1.c., page 80)
Death Benefit coverage will be continued for you until you are age 65 if you become totally
disabled and:
•
•
are under age 60 when you become totally disabled and
lose your eligibility under the Plan because of your total disability.
In the event of your death, the Fund will pay your designated beneficiary the full amount if your
total disability continues until you reach age 65. Once you become age 65, Death Benefit coverage
will no longer be continued for you. Evidence of your total disability will be required from time
to time while coverage is being continued on your behalf.
Laborer’s Accidental Death and Dismemberment Benefits
(Article III, Section 2, page 81)
You or your designated beneficiary will be paid an amount indicated below if, while eligible and
as a result of an accident, you suffer one of the following losses within one year of the accident:
Accidental Death (in addition to Death Benefit of $15,000)
$15,000
Accidental Dismemberment:
• Loss of one hand, leg, or sight of one eye
• Loss of more than one of these members
$7,500
$15,000
No more than $15,000 will be paid for all losses sustained by the Laborer in one accident. Loss of
hand or foot means dismemberment at or above the wrist or ankle joint. Loss of sight means the
irrevocable loss of sight.
21
Accidental Death and Dismemberment Benefits will not be paid for any loss caused by injuries
sustained as a result of any of the following:
•
•
•
•
•
suicide or self-inflicted injuries;
disease, bodily or mental infirmity, or medical or surgical treatment;
ptomaine or bacterial infections (except infections occurring through an accidental cut or
wound);
war or acts of war or service in any military, naval or air force; or
commission of a felony.
Naming Your Beneficiary
(Article III, Subsections 3.a. and b., page 82)
You may name anyone you wish as your beneficiary and you may change your beneficiary at any
time by filling out a new enrollment form and sending it to the Fund Office. The enrollment form,
naming your beneficiary, must be on file with the Fund Office in order for the Trust Fund to pay
a death benefit to your designated beneficiary.
If no beneficiary has been designated, or if a designated beneficiary dies before the Death Benefit
or Accidental Death Benefit is paid, the Death Benefit or Accidental Death Benefit will be paid to
your lawful spouse if living, or if there is no lawful spouse alive at the time of payment, payment
may be made to one or more of the following surviving relatives: child or children, mother, father,
brothers or sisters, or to your estate, as the Board in its sole discretion may designate.
A designated beneficiary who is found guilty of feloniously and intentionally causing the death
of the Laborer on whose life benefits are being paid will be disqualified from receiving payment
of death benefits which may become payable under the Plan.
Dependent’s Death Benefit
(Article IV, Section 1, page 83)
In the event the Laborer’s legal spouse dies, a death benefit of $7,500 will be paid to the Laborer.
In the event the Laborer’s dependent child dies, a death benefit based on the age of his dependent
child at the time of death will be paid according to the following schedule:
•
•
•
24 hours, but less than 2 years of age
2 years, but less than 5 years of age
5 years, but less than 19 years of age
$500
$750
$1,000
Beneficiary of Dependent’s Death Benefit
The Dependent’s Death Benefit will be paid to the Active Laborer, if living; otherwise, payment
will be made to one or more of the Laborer’s surviving relatives as follows: lawful spouse, child
or children, mother, father, brothers or sisters, or to the Laborer’s estate, as the Board of Trustees,
in its sole discretion, may designate.
22
Dependent’s Extended Death Benefit
If the Laborer’s eligibility terminates because of his death, and his dependent’s death occurs
within 6 months of his (the Laborer’s) termination of eligibility, the benefits described above will
be paid to the Laborer’s beneficiary.
23
Choice of
Medical Plan
When you become eligible for benefits, you are given the opportunity to choose which medical
plan best suits the needs of you and your family. You may enroll in the Fund’s Direct Payment Plan
or Kaiser Permanente, a health maintenance organization (HMO). Your eligible dependents will
be covered under the same medical plan. You may not split coverage—that is, you may not enroll
in the Fund’s Direct Payment Plan and your eligible dependents enroll in Kaiser Permanente.
Regardless of which medical plan you choose, dental, vision, EAP, death, and accidental death
and dismemberment benefits are provided by the Laborers Health and Welfare Trust Fund. These
benefits are described on the preceding pages and in greater detail in separate brochures.
Fund’s Direct Payment Plan
The Fund’s Direct Payment Plan provides traditional, fee-for-service benefits, including hospital,
medical, and prescription drug. Benefits provided through the Fund’s Direct Payment Plan are
described in this booklet.
Under this Plan, you may select any doctor or hospital for your medical care. However, use of
Prudent Buyer Plan participating physicians and hospitals will result in lower out-of-pocket costs
because these providers have agreed to provide services at special, negotiated rates.
When you become eligible for benefits, you will receive a Health Plan Identification Card. Your ID
card serves as both your group health plan card as well as a prescription drug card. You should
retain your ID card, even if you lose eligibility because if you become eligible again, the Trust
Fund reactivates your ID card.
Kaiser Foundation Health Plan, Inc.
Kaiser Permanente provides comprehensive medical care through its physicians and medical
staff at Kaiser facilities. It differs from traditional fee-for-service plans in that you are limited in
your choice of physicians and hospitals. Members must use a Kaiser Permanente physician and
work with that physician in seeking referrals to specialists. Except for emergencies and certain
referrals to outside specialists, all medical care must be received from Kaiser Permanente. To be
eligible to enroll in this plan, you must reside or work within a Kaiser service area.
Kaiser Permanente’s medical plan is described in a separate brochure, which is available from the
Fund Office.
When You Can Change Plans
You are free to change plans at any time during the year. However, you can only change plans
twice in a calendar year. To change medical plans, obtain an application from the Fund Office. If
24
your application is received in the Fund Office by the 15th of the month, your plan change will
become effective on the first day of the following month. If the application is received a�er the 15th
of the month, the change will be effective on the first day of the second month following receipt
of your application.
25
Table of
Direct Pay
This table highlights the benefits provided by the Direct Payment Plan. It is not intended to presen
numbers appearing in this table in the far-left column. These pages will take you to sections in the
Plan’s Rules and Regulations.
Page #
Plan Feature/Benefit
Coverage
33
Plan Year Deductable
$150 per individual, up to $450 per family
34
Out-of-Pocket Maximum
$3,000 per individual, up to $6,000 per family
33
Lifetime Maximum Benefit $1,000,000 per individual
Participating Providers
Non-Participating Providers
70% of first $10,000 of
charges, 100% thereafter
during first 20 days of
confinement per period of
disability
28
Hospital
90% of first $10,000 of
negotiated rate, 100%
thereafter during first 30 days
of confinement per period of
disability
29
Skilled Nursing Facility
Same as Hospital benefit,
except 2 days in SNF count
as one Hospital day
Same as Hospital benefit,
except 2 days in SNF count
as one Hospital day
28 & 29
Combined Maximum
Hospital Days/SNF
30 days (2 days in SNF equal
one Hospital day)
20 days (2 days in SNF equal
one Hospital day)
34 & 35
Surgical & Anesthesiology 90% of negotiated rate
70% of UC&R1
32 & 34
Physician Office Visit
100% of negotiated rate after
$15 copayment
70% of UC&R after $15
copayment
34 & 36
Hospital Emergency
Room
$25 copayment
copayment
35
Diagnostic, X-ray, and
Lab
90% of negotiated rate
70% of UC&R
35
Chiropractic
$40/visit, limit of 20 visits per Plan Year, $100 maximum for
X-rays taken by Chiropractor
35
Durable Medical
Equipment (DME)
90% of negotiated rate
36
Home Health Care
90% of Covered Expenses upon referral by Case
Management
36
Hospice
90% of Covered Expenses upon referral by Case
Management
28
Mental Health-Inpatient
Same as Hospital benefit
34
Mental Health-Outpatient
50% of negotiated rate, limit
40 visits per Plan Year
70% of UC&R
50% of UC&R, limit 40 visits
per Plan Year
UC&R means Usual, Customary and Reasonable (definition, Article I., Section 37., page 71).
1.
26
Benefits
yment Plan
nt a detailed explanation of the Plan’s benefits. For a more complete presentation, refer to the page
booklet that explain more fully the benefits and, if necessary, will refer you to the actual text of the
Page #
Plan Feature/Benefit
Coverage
40
Substance Abuse Treatment
MUST BE PROVIDED BY CLAREMONT BEHAVIORAL SERVICES
40
Adult Inpatient
100% of contracted rate for 1st course of treatment, not to
exceed 30 days; 50% of contracted rate for 2nd course of
treatment, not to exceed 30 days
40
Adult Lifetime Maximum
Benefit
$10,000 per individual
40
Adolescent Inpatient
100% of contracted rate for one course of treatment, not to
exceed 45 days
40
Adolescent Lifetime
Maximum Benefit
$12,500 per individual
40
Substance Abuse
Treatment - Outpatient
Visits 1-10 100% of contracted rate
37
Routine Physical Exam
$200 for Laborer or Spouse
(one exam per Plan Year) $100 for each dependent child over 24 months of age
Participating Providers
Non-Participating Providers
35
Well Baby Care
$15 copayment
37
Hearing Aid
$750 per device for each ear, once every 36 months
Prescription Drug
(Purchased through Contracting Pharmacies)
38
Retail Pharmacy
30-Day Supply
$10 copayment for Generic Drugs
$20 copayment for Formulary Brand Name Drugs
$30 copayment for Non-Formulary Brand Name Drugs
39
Mail Service Pharmacy
90-Day Supply
$20 copayment for Generic Drugs
$40 copayment for Formulary Brand Name Drugs
$60 copayment for Non-Formulary Brand Name Drugs
33
Podiatry
PPOC Network Podiatrist
$15 copayment
27
copayment
Non-PPOC
Network Podiatrist
copayment
Hospital and
Medical Benefits
The Fund’s Direct Payment Plan contracts with Blue Cross’ Prudent Buyer Plan to provide a
network of participating hospitals, physicians, and ancillary medical providers. Though you are
free to choose any medical provider you wish, it is to your advantage to use Prudent Buyer Plan
providers, since they have agreed to accept a reduced, pre-negotiated rate for services covered
by the Active Laborers Plan. If you use the services of non-Prudent Buyer Plan providers, you will
incur more out-of-pocket expense.
Ideally, Prudent Buyer Plan providers will refer you to other providers in the network, such as a
“participating hospital,” or a “specialist,” however, it is not a requirement. Therefore, to maximize
your health care dollars, it is up to you to request to be admi�ed to a Prudent Buyer Plan hospital
and to be referred to specialists and other health care providers who are part of the Prudent Buyer
Plan network.
For a current Prudent Buyer Plan directory of participating hospitals, physicians, and ancillary
medical providers, contact the Fund Office or your Local Union Office. You can also find Prudent
Buyer Plan providers through the Trust Fund’s Web site by clicking on “Links to Other Sites.” Once
there, click on the “Blue Cross of California” logo and follow the prompts. Since the network of
providers changes frequently, always ask whether your provider is still in the Prudent Buyer Plan
network when making your appointment.
Hospital Benefits
In determining the level of hospital benefits payable, the Plan takes into account your place of
residence and whether your confinement is of an elective, non-emergency nature or an emergency.
For example, if you reside within the “Preferred Provider Plan Service Area,” defined below, the
Plan will pay a higher level of benefits if you are confined in a Prudent Buyer Plan hospital and
you have obtained authorization from the Professional Review Organization (PRO) prior to your
confinement.
Preferred Provider Plan Service Area
The “Preferred Provider Plan Service Area” includes all 46 Northern California Counties. This
means that if you reside within the 46 Northern California Counties and you or your dependent
requires hospitalization, the Plan will pay the level of benefits described under the section entitled
“Benefits for In-Area-Residents.”
28
Benefits for In-Area Residents
(Article V, Subsections 1.a. and b. and 1.c.(2), page 84)
If you or your dependent reside within the Preferred Provider Plan Service Area and you
require hospitalization, the Plan will pay 90% of the first $10,000 of the negotiated rates and
100% therea�er for medically necessary hospital services received at any participating hospital
during the first 30 days of confinement during any one period of disability. If you do not use a
participating hospital, the Plan will pay 70% of the first $10,000 of Covered Charges incurred
and 100% therea�er during the first 20 days of confinement during any one period of disability.
Covered Charges are described under “Benefits for Out-of-Area Residents” below.
If you or your dependent resides within the Preferred Provider Plan Service Area and are admi�ed
by a physician to a non-participating hospital due to a serious or life-threatening emergency, the
Plan will pay the “Out-of-Area Residents” benefits described below. The Fund may, however,
require that the eligible individual be transferred to a participating hospital upon the advice of a
physician that it is medically safe to make the transfer.
(Article V, Subsection 1.c.(1), page 84)
If you or your dependent reside outside the Preferred Provider Plan Service Area and require
hospitalization, the Plan will pay 90% of the first $10,000 of Covered Charges incurred and 100%
therea�er during the first 20 days of confinement during any one period of disability.
Covered Charges include the hospital’s lowest rate charged for semi-private room accommodations
or 80% of the lowest rate charged for private room accommodations, if used, for each day you or
your dependents are confined in the hospital. If care is received in an intensive care unit, covered
expenses will include the hospital’s lowest rate charged for that unit.
Skilled Nursing Facility (SNF) Benefit
(Article V, Section 2, page 87)
If you or your dependent are admi�ed to a Skilled Nursing Facility (SNF), you will be reimbursed
for the amount charged by the SNF for room and board, not to exceed the SNF’s lowest rate
charged for semi-private room accommodations, or 80% of the lowest rate charged for private
room accommodations.
Combined Maximum Number of Days in
Hospital/Skilled Nursing Facility
(Article V, Subsections 1.a. and b. and Section 2, pages 84 and 87)
The Plan counts one hospital day for every 2 days you are confined in a skilled nursing facility.
For example, if you are confined in a hospital for 2 days and then transferred to an SNF for 10
days, you will have used 7 hospital days during that period of disability (2 hospital days and 10
SNF days [10 SNF days = 5 hospital days]).
29
Period of Disability
(Article V, Subsection 1.e., page 86)
All confinements in a hospital or SNF are considered to have occurred during one period of
disability, unless the confinements are due to entirely unrelated causes or unless (1) in the case of
the Laborer, the confinements are separated by a return to work or availability for work, or (2) in
the case of a dependent, the confinements are separated by 3 or more months.
If you exhaust your Hospital/Skilled Nursing Facility Benefit during one period of disability, you
and your eligible dependents may have additional hospital/SNF benefits under the Comprehensive
Medical Benefits, see item 3 under “Covered Expenses,” page 35.
Limitations on Hospital and Skilled Nursing Facility Benefits
(Article V, Subsection 1.f., page 87)
Benefits are not payable for any day of confinement beyond the period of hospitalization approved
by the Professional Review Organization (PRO) or for any day of confinement, which is solely for
the convenience of the individual.
Utilization Review
(Article V, Subsection 1.d., pages 85-86)
Utilization Review (UR) is required of every hospital confinement. The purpose of UR is to
determine the number of medically necessary days for a hospital confinement. There are 3 types
of UR:
1.
If the hospital confinement is for an elective, non-emergency medical procedure, PreAdmission Review is required. The Professional Review Organization (PRO) will
review your case and authorize a number of medically necessary days for your hospital
confinement.
2.
While you are in the hospital, the PRO will review your case to determine whether the
number of inpatient days authorized under Pre-Admission Review is still appropriate.
This level is referred to as Concurrent Review. Concurrent Review is also performed if
your confinement is due to an emergency admission.
3.
If neither Pre-Admission nor Concurrent Review is performed by the PRO, a Retrospective
Review will be conducted. This is performed a�er you are discharged from the hospital.
It is important to understand what is required when you are to be admi�ed to a hospital or already
confined in the hospital. If you do not comply with the requirements of UR, you will not receive
the maximum benefit for your hospital stay. Be sure to review the penalties for non-compliance of
UR explained under “Out-of-Pocket Costs for Non-Compliance With Utilization Review.”
Utilization Review for Elective, Non-Emergency Confinements
The Plan requires the PRO to perform Pre-Admission Review on all elective, non-emergency
confinements to determine the number of inpatient days that is medically necessary. If you are
30
scheduled for admission to a participating hospital, Blue Cross, the Plan’s PRO, will arrange
Utilization Review. You must, however, follow through with your physician to make sure he has
arranged Pre-Admission Review; otherwise, you will be responsible for the additional copayment
described below. If you are to be admi�ed to a non-participating hospital, request your physician
to arrange Utilization Review by calling Blue Cross of California at 1-800-274-7767. If you do
not obtain Utilization Review, you will be responsible for the additional copayment described
below.
Concurrent Review is performed while you are confined in the hospital as the result of an elective
non-emergency procedure.
Utilization Review for Emergency Confinements
Emergency confinements do not require Pre-Admission Review but are subject to Concurrent
Review to determine the number of medically necessary days of confinement. In most cases, if
you are admi�ed to a participating hospital, the hospital arranges Concurrent Review through
the Plan’s PRO, Blue Cross. However, you should follow through with the hospital to make sure
Concurrent Review has been arranged. If you or your dependent is admi�ed to a non-participating
hospital on an emergency basis, you or a family member must notify Blue Cross of California at
1-800-274-7767 within 24 hours a�er your being admi�ed. Blue Cross will perform Concurrent
Review to determine the number of days of confinement that are medically necessary.
Out-of-Pocket Cost for Non-Compliance With Utilization Review
If you do not obtain Pre-Admission Review prior to any elective, non-emergency hospital
admission, you will be responsible for payment of 30% (10% co-insurance, plus 20% penalty
for non-compliance) of the first $10,000 of Plan benefits if you are confined in a participating
hospital, or 50% (30% co-insurance, plus 20% penalty for non-compliance) of the first $10,000
of Plan benefits if you are confined in a non-participating hospital. If Concurrent Review is not
obtained on an emergency hospital admission, you will be responsible for payment of 30% of the
first $10,000 of Plan benefits.
On any hospital admission (whether elective, non-emergency or emergency), if Utilization Review
determines that all or part of a hospital confinement is not medically necessary and you or your
dependent is nevertheless hospitalized during a period not authorized by the PRO, no hospital
benefits will be payable.
Any payment you are required to make for non-compliance with Utilization Review will not
be applied to the Out-of-Pocket Maximum, see page 34.
Utilization Review is not required for maternity admissions where the length of stay is not in
excess of 48 hours for a normal delivery or 96 hours for a cesarean section.
31
Benefits Required by Law
Newborns’ and Mothers’ Health Protection Act
Under federal law, group health plans and health insurers may not restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a normal delivery, or to less than 96 hours following a cesarean section. However, federal
law does not prohibit the mother’s or newborn’s a�ending provider, a�er consulting with the
mother, from discharging the mother or her newborn earlier than the 48 hours, or 96 hours as
applicable.
Women’s Health and Cancer Rights Act
Under federal law, group health plans, insurers, and HMOs that provide medical and surgical
benefits in connection with a mastectomy must also provide benefits for reconstructive surgery,
in a manner determined in consultation with the a�ending physician and the patient, for:
•
•
•
reconstruction of the breast on which the mastectomy was performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance;
and
prostheses and treatment of physical complications at all stages of the mastectomy,
including lymphedemas.
This coverage is subject to the Plan’s deductible, copayment and coinsurance provisions.
In addition to the information concerning Women’s Health and Cancer Rights Act appearing
in this booklet, the Plan is required to mail an annual notice to remind you that breast cancer
patients who elect to have reconstructive surgery in connection with a mastectomy have certain
protections under federal law.
Comprehensive Medical Benefits
Payment
(Article V., Section 3.e., page 88)
If you or one of your dependents incurs Covered Expenses as described on pages 34 through
37 in connection with the treatment of an illness or injury, the Plan will pay 90% of the contract
rates negotiated for Prudent Buyer Plan participating providers, or 70% of Usual, Customary,
and Reasonable charges (UC&R) for non-participating providers a�er you and your eligible
dependents have satisfied the Plan Year deductible and any required copayment. The following
are exceptions to the Plan’s reimbursement provision:
•
Routine Office Visit - If you or your dependent uses the services of a Prudent Buyer Plan
provider for a Routine Office Visit, the Plan will pay 100% of the contract rate a�er you
have satisfied the Plan Year Deductible and required copayment.
32
•
Emergency Room Services - If you or your dependent receives treatment in a participating
hospital’s emergency room from an a�ending physician that is not a participating provider,
the Plan will pay 90% of UC&R charges for the professional services provided by that
a�ending physician.
•
Podiatry Treatment - If you or your dependent requires the services of a Podiatrist (DPM),
you must use the services of a Podiatrist in the Podiatry Plan of California (PPOC) network
to receive the greatest benefit for your medical care. When you use the services of a PPOC
network Podiatrist, the Plan will pay 90% of the negotiated rate. If you do not use a PPOC
network Podiatrist, the Plan will pay 70% of UC&R.
CALL 1-800-367-7762 FOR A REFERRAL
TO A PPOC NETWORK PODIATRIST
•
Professional Ambulance Service - If you or your dependent requires Emergency Services
for a life threatening illness or injury, the Plan will pay 90% of billed charges or UC&R
charges, whichever are less, for transportation by a non-participating professional
ambulance service, if requested by a hospital or paramedic personnel.
Lifetime Maximum Benefit
(Article V., Section 3.e., page 88)
Each Eligible Individual has a $1,000,000 lifetime maximum benefit. On March 1 of each Plan
Year, up to $2,000 is reinstated to your lifetime maximum benefit. However, the amount reinstated
cannot increase the total Comprehensive Medical Benefit payable during any one Plan Year to
more than $1,000,000 for each eligible individual.
Plan Year Deductible
(Article V., Section 3.b., page 87)
The Plan Year Deductible is the amount of Covered Expenses you and your eligible dependents
pay each Plan Year before Comprehensive Medical Benefits become payable. The Plan Year
Deductible is $150 per person, up to a maximum deductible of $450 per family. The Plan Year
begins on March 1 of each year and ends the last day of February of the following year.
So that you will not have to satisfy a deductible late in one Plan Year and soon again the following
year, any expenses incurred and applied against the deductible in the last 3 months of a Plan Year
(December, January, and February) will be applied against the deductible for the following Plan
Year.
33
If 2 Active Employees can claim one another as a Dependent, (see Article I, Section 8, page 67 for
the definition of “Dependent”), then Plan Year deductibles that would normally apply will be
waived. However, if either Active Employee subsequently loses eligibility, all deductibles that
were waived during that Plan Year will be reinstated.
Physician Office Visit Copayment
(Article V., Section 3.c., page 88)
You pay a $15 copayment for each visit to a Physician, except for the following:
•
•
•
•
visits to a chiropractor;
visits in connection with the treatment of mental disorders;
visits for a routine physical examination;
visits for consultations upon the referral of your primary care physician.
Hospital Emergency Room Copayment
(Article V., Section 3.d., page 88)
You pay a $25 copayment for each visit to a participating hospital emergency room or a $50
copayment for each visit to a non-participating hospital emergency room.
The hospital emergency room copayment will be waived under the following circumstances:
•
•
•
the emergency room visit results in an overnight hospital stay of the patient;
the emergency room services are provided as a result of paramedic intervention;
the patient was dead on arrival, or dies while receiving services in the emergency room.
Maximum Out-of-Pocket Payment
(Article V., Section 3.f., page 89)
The maximum out-of-pocket payment is the total amount of out-of-pocket expense for which
you are responsible each Plan Year. The maximum out-of-pocket payment is $3,000 per Eligible
Individual, up to $6,000 per family. All out-of-pocket expense will apply toward satisfying your
out-of-pocket maximum, with the exception of the following charges:
•
•
•
•
•
Physician Office Visit Copayments
Hospital Emergency Room Copayments
Coinsurance payment made to a non-Prudent Buyer Plan provider
Charges for any medical services or supplies that are excluded or limited under the Plan
Penalties for non-compliance with the Plan’s Utilization Review Program
Covered Expenses
(Article V., Section 3.g., pages 89-92)
1.
Charges for medical or surgical services provided by a Physician except that:
• benefit payments for outpatient care of mental disorders are payable at 50% of the
negotiated rates for participating providers, or 50% of Usual, Customary, and Reasonable
34
(UC&R) for non-participating providers, up to 40 visits per Plan Year and
• treatment by a chiropractor is limited to a maximum payment of $40.00 per visit and 20
visits per Plan Year.
2.
Charges for nursing services of a registered graduate nurse, or licensed vocational nurse.
3.
Charges made by a Hospital for room and board that do not exceed the Hospital’s lowest
rate charged for semi-private room accommodations, or 80% of the lowest rate charged
for private room accommodations, if used or, if care is received in an intensive care unit,
the lowest rate charged for that unit.
4.
Charges made by a licensed occupational, physical, or speech therapist not related to the
Eligible Individual by blood or marriage.
5.
Charges for the following medical services and supplies:
a.
Anesthesia and its administration.
b.
Blood and blood products.
c.
Surgical dressings, splints, casts and other devices for the treatment of burns or the
reduction of fractures and dislocations.
d.
Diagnostic tests, X-rays and laboratory services performed in connection with
the therapeutic treatment of the Eligible Individual. X-rays by a chiropractor are
limited to $100.00 per Plan Year.
e.
Radiation therapy.
f.
Durable medical equipment (DME) including, but not limited to, apnea monitors,
commodes, hospital beds, electric and manual wheelchairs, nebulizers and oxygen.
DME includes prosthetic devices, such as artificial limbs, heart pacemakers, or
corrective lenses required a�er cataract surgery. DME also includes orthotic
devices, such as specially designed corsets, leg braces, or extremity splints.
g.
Professional ambulance service when used to transport the Eligible Individual,
but only if the Eligible Individual requires paramedic support:
1)
2)
3)
h.
directly from the place where he is injured by an accident or stricken by an
illness to a Physician’s office; or
to or from a Hospital; or
by a licensed air ambulance if the charges do not exceed UC&R and if the
Fund determines, based on the location and nature of the illness or injury,
that air transportation is cost effective or medically necessary to avoid the
possibility of serious complications or loss of life.
Newborn and well child visits, including routine immunizations from birth through
24 months of age, according to the schedule of the American Academy of Pediatrics.
35
i.
Outpatient intravenous therapy when authorized by and under the supervision
of a Physician, for the treatment of an illness that would otherwise require
hospitalization (therapy includes the administration of cancer chemotherapy
drugs and any other drugs that require administration under the supervision of a
Physician).
6.
Charges made by a licensed Ambulatory Surgical Facility.
7.
Charges made by the emergency room of a Hospital.
8.
Charges made by a licensed Hospice upon a referral by the Plan’s Case Management
Program.
9.
Charges made for a licensed Home Health Care Agency upon a referral by the Plan’s Case
Management Program.
10.
Charges made by a Physician for contraceptive services and supplies, including
examinations, injections, implants, and devices (except diaphragms which are covered
under the Prescription Drug Benefit, page 95), or for a surgical procedure resulting in
voluntary infertility.
11.
Charges in connection with a mastectomy, including reconstruction of the breast on which
the mastectomy was performed, surgery on the other breast to produce a symmetrical
appearance, and prostheses and treatment of physical complications of all stages of
mastectomy, including lymphedemas.
12.
Charges in connection with the surgical treatment of morbid obesity if the Eligible
Individual’s Body Mass Index (BMI) is greater than 35 and complicated by any of the
following:
•
•
•
•
•
•
•
life-threatening cardiopulmonary conditions;
difficulty controlling diabetes mellitus or hypertension;
end stage renal disease with difficulty dialyzing;
severe sleep apnea documented by a sleep study performed by a certified sleep
clinic;
severe lower extremity edema with ulceration;
symptomatic degenerative joint disease, resulting in ambulatory difficulties (cane
walker, wheelchair); or
stress incontinence with gynecologic abnormalities.
Only one of the following bariatric surgical procedures will be covered in a lifetime—Rouxen Y gastric bypass, gastric stapling or banding, or biliopancreatic bypass. Prior approval
is required by a Medical Consultant selected by the Fund, which includes a review of
the individual’s medical record for the past 2 years, assessment of a Registered Dietician
that the individual is ready and able to comply with post surgical dietary restrictions and
documentation of failed a�empts at weight loss by other conservative measures.
13.
Charges for outpatient treatment of mental or psychiatric disorders including, but
not limited to, psychotherapy and psychological testing provided by a psychiatrist,
36
psychologist, or licensed clinical social worker, up to 50% of the negotiated rates for
participating providers or 50% of UC&R for non-participating providers, not to exceed 40
visits in a Plan Year.
14.
Expenses in connection with the purchase of a hearing aid device prescribed by a Physician,
up to a maximum of $750 for each hearing aid device for each ear once every 36 months.
The Plan will pay the charges for a hearing test a�er payment of the Physician Office Visit
Copayment.
15.
Charges of a Dentist for the following:
(a)
(b)
Treatment necessary to alleviate the damage to broken or injured teeth as a result
of an accidental bodily injury (no payment will be made for replacement of teeth,
in whole or in part) and
Medically necessary surgery not covered under the Fund’s dental benefits.
Case Management Program
Case Management is a program designed to assist the patient in making important decisions
concerning his or her health care, and in dealing with the health care system. Blue Cross of
California, the organization currently performing Utilization Review, also provides Case
Management for the Plan.
Case Management can involve the patient, family, health care providers, the employer and the
Trust Fund in assessing and coordinating the best possible care in each situation and can help
return the patient from the acute care facility to an alternate, more comfortable and efficient
se�ing as soon as it is medically safe to do so. Case Management professionals can arrange for
the patient’s care, nursing and equipment needs at the time of discharge from the acute care
facility because Blue Cross of California has the ability to select cases that may benefit from case
management, since its staff reviews and monitors hospital admissions through the Pre-Admission
and Concurrent Hospital Utilization Review Program.
Annual Physical Examination Benefit
The Plan will pay the amount actually charged by the Physician for a physical examination and
any X-ray and laboratory tests performed in connection with the physical examination up to the
maximums shown below during each Plan Year:
•
$200 for you or your spouse, and
•
$100 for each of your dependent children over 24 months of age.
37
Prescription Drug Benefit
(Article VI, pages 93-95)
The Plan contracts with a Pharmacy Benefit Manager (PBM) to provide prescription drugs through
retail contracting pharmacies and a mail-service pharmacy. The amount you pay is determined
by where you purchase your prescriptions and whether you request generics, formulary, or nonformulary brand-name drugs. You pay less out-of-pocket expense by requesting generic drugs. If
a generic equivalent is not available, requesting a brand-name that is on the PBM’s formulary list
will cost less out-of-pocket than a brand-name that is designated as “non-formulary.”
You save even more when you have your prescriptions filled through the mail-service pharmacy.
If you are taking maintenance medication, that is, medication that you take on a regular, longterm basis, your out-of-pocket costs are less when you use the mail-service pharmacy.
Here’s how it works:
Retail
Have your prescriptions filled at any contracting pharmacy by presenting your Health Plan ID
card. Copayments for a 30-day supply are:
Drug
Copayment
$10/prescription
$20/prescription
$30/prescription
Generic
Formulary Brand Name
Non-Formulary Brand Name
Though you can have your prescriptions filled at a retail pharmacy, you will pay a higher
copayment if you are taking a maintenance medication, which is a medication taken daily to treat
a chronic, long-term condition. Your copayment will be higher because the 4th time you have
your maintenance medication filled at a retail pharmacy, you will be charged double the usual
copayment for only a 30-day supply.
Instead, consider obtaining drugs from a retail pharmacy only for temporary illnesses, or when
your physician writes a new prescription for a medication you will be taking long term. In that
case, ask your physician to write two prescriptions—one for up to 30 days that can be filled at your
retail pharmacy and one for 90 days plus refills that you will send to the mail-service pharmacy.
If you obtain prescriptions from a non-contracting pharmacy, you will be responsible for payment
at the time your prescription is filled. Request reimbursement by submi�ing a claim form to the
Plan’s PBM. Reimbursement will be based on the amount the Plan would have paid had you had
your prescription filled at a contracting pharmacy. In other words, you may incur more out-ofpocket expense if the non-contracting pharmacy charges more for a medication than does the
contracting pharmacy. Claim forms are available from the Fund Office or your Local Union.
38
Mail Service
The first time you use the mail-service pharmacy, include the “Confidential Patient Profile” with
your prescription. This alerts the PBM to any allergies or health conditions you or an eligible
dependent may have. You only need to complete the profile once. Copayments for a 90-day
supply are:
Drug
Copayment
$20/prescription
$40/prescription
$60/prescription
Generic
Formulary Brand Name
Non-Formulary Brand Name
If you are taking a maintenance medication, mail service saves you money over having your
prescription filled at a retail pharmacy. You receive a 90-day supply for the equivalent of two retail
copayments. Also, you are not penalized with a double copayment as you would be at a retail
pharmacy. Remember, if you are on a maintenance medication, you pay a regular copayment
until the 3rd refill at a retail pharmacy, at which time you pay double the retail copayment for
only a 30-day supply.
For both retail and mail-service prescription drugs, if you or your physician chooses a brand
name when a generic drug is available, you will be responsible for the difference in cost between
the generic and brand name, in addition to the appropriate copayment.
Brochures, describing how to use your prescription drug benefit, are available from the Fund
Office or your Local Union.
39
Substance Abuse
Treatment Benefits
(Article VII, pages 96)
The Plan contracts with Claremont Behavioral Services to provide substance abuse treatment
for Active Laborers and their eligible dependents. This program is designed to provide strong
financial incentives for you and your eligible dependents to only use participating facilities and
providers contracted with Claremont Behavioral Services. If you or your eligible dependents
use a substance abuse treatment facility not contracted with Claremont Behavioral Services,
the Plan will not pay for any of the charges. You will be responsible for the entire cost.
When you make the decision to seek treatment for substance abuse, contact Claremont Behavioral
Services at its toll-free number 1-800-834-3773 for authorization and a referral to a participating
facility or provider in your area.
Below is a description of the Substance Abuse Treatment Benefits available to you and your
eligible dependents:
Adult Inpatient Benefit
If you or your spouse use a participating substance abuse treatment facility, the Plan will pay
100% of the contracted rate for the first course of treatment, not to exceed 30 days. If you enter
the program for a second course of treatment, the Plan will pay 50% of the contracted rate, not to
exceed 30 days. You will be responsible for a 50% copayment. The Plan will only cover 2 courses
of treatment in a lifetime, up to a maximum of $10,000.
Adolescent Inpatient Benefit
If your dependent child uses a participating substance abuse treatment facility, the Plan will pay
100% of the contracted rate for one course of treatment, not to exceed 45 days. The Plan will only
cover one course of treatment in a lifetime, up to a maximum of $12,500.
Course of Treatment
A course of treatment begins on the first day an eligible individual participates in substance abuse
treatment until 6 months a�er completion of authorized care. If an individual requests additional
treatment within 6 months of previously authorized care, the newly authorized care will be
considered as part of the “First Course of Treatment.” A�er 6 months, any additional authorized
care will be considered the “Second Course of Treatment.”
40
Outpatient Benefits for Adults and Adolescents
If you use the services of a participating substance abuse treatment provider on an outpatient
basis, the Plan will pay each Plan Year according to the following schedule:
•
•
•
•
100% of the contracted rate for the 1st through the 10th visit
85% of the contracted rate for the 11th through the 25th visit
70% of the contracted rate for the 26th through the 40th visit
50% of the contracted rate for the 41st through the 50th visit
IF YOU OR YOUR ELIGIBLE DEPENDENT DO NOT USE
A PARTICIPATING SUBSTANCE ABUSE TREATMENT
FACILITY OR PROVIDER, THE PLAN WILL NOT PAY FOR
ANY CHARGES INCURRED FOR SERVICES PROVIDED
BY A NON-PARTICIPATING SUBSTANCE ABUSE
TREATMENT FACILITY OR PROVIDER.
41
General Exclusions
and Limitations
(Article IX, Sections 1 and 2, pages 102-105)
(These Exclusions and Limitations do not apply to Death and Accidental Death and
Dismemberment Benefits.)
Benefits are not payable for the following:
1.
Disability as a result of an occupational injury or illness covered by the Workers’
Compensation law or similar legislation, regardless of whether a Workers’ Compensation
claim is filed.
2.
Except to the extent a law requires the Fund to pay benefits, charges incurred while confined
or treated in a Veterans Administration Hospital, or for care or treatment obtained from
a federal government agency or from any state or political subdivision where that care or
treatment is available without cost to the person.
3.
Except to the extent a law requires the Fund to pay benefits, hospital or surgical services
or supplies provided by or paid for under any governmental program--national, state,
county or municipal.
4.
Conditions arising out of an act of war, armed invasion or aggression.
5.
A condition for which the person is not under the care of a Physician, or for a period of
confinement beyond that authorized by the Professional Review Organization (PRO).
6.
Eye refractions and eyeglasses.
7.
Callus or corn paring; toenail trimming; treatment of chronic conditions of the foot, such
as weak or fallen arches, flat or pronated foot metatarsalgia, or foot strain.
8.
Services to reverse voluntary surgically induced infertility.
9.
Expenses incurred outside the United States, its Territories or Possessions, except for
Emergency Services.
10.
Substance abuse treatment, except as provided in Article VII.
11.
Any services in connection with breast surgery, unless to treat an abscess, fibrocystic
disease, a tumor (benign or malignant), or as provided in Article V., Section 3.g.(11).
12.
Hospital or medical services or supplies in connection with the treatment of obesity or
weight control, except as provided in Article V., Section 3.g.(12).
42
13.
Hospital or medical services or supplies in connection with the treatment of an
aggressive social, behavioral, or conduct disorder, as defined by the American Psychiatric
Association.
14.
Charges for or in connection with the treatment of infertility as defined by the American
College of Obstetrics and Gynecology including, but not limited to, in vitro fertilization,
artificial insemination, surgery including treatment to alleviate pelvic adhesions (unless
medically necessary), and other infertility related services.
15.
Charges for Experimental or Investigative Procedures.
16.
An injury or illness resulting from participation in, or as a result of participating in the
commission or a�empted commission of an assault or a felony.
17.
Expenses for or in connection with cosmetic surgery, except cosmetic surgery which is
not primarily for beautification but is performed to correct or improve a bodily function,
congenital malformation, or as provided in Article V., Section 3.g.(11).
18.
Medical Treatment received in connection with the pregnancy of a Dependent Child.
19.
Dental appliances, bridges, crowns, caps or other dental prostheses, dental services,
extraction of teeth or treatment to the teeth or gums, except as specially provided in Article
V., Subsection 3.g.(15).
20.
Services and supplies related to sexual reassignment, including medications, implants,
hormone therapy, surgery and medical care.
21.
Expense for travel or transportation, except as provided in Article V., Subsection
3.g.(5)(g).
22.
Services furnished by an institution that is primarily a rest home, a home for the aged,
a nursing home, a convalescent home, or any institution of similar character providing
Custodial Care.
23.
Routine physical examination, except as provided in Article V., Section 4.
24.
Charges for ambulance transportation that is primarily for the convenience of the Eligible
Individual or ambulance transportation by railroad.
43
If You Have Coverage From Another Group Plan
(Article IX, Section 3, page 103-105)
It is to your advantage to inform your medical provider and the Trust Fund if you are covered by
another group plan. Most group plans cooperate with one another to avoid duplicate payments,
while still allowing you to make use of both plans, sometimes paying 100% of expenses. When
determining the amount of benefits payable under this Plan, the Plan considers whether you are
covered by another group plan and takes into account benefits payable under another group
plan supported wholly or in part by employer contributions. For any expense covered under this
Plan, you will receive (1) the full regular benefits, or (2) a reduced amount which, when added to
the benefits available under another group plan, will not exceed 100% of what you would have
received had you not had coverage under another group plan.
Third Party Liability
(Article X, Section 8, page 107)
If you or an eligible dependent suffers an injury or illness that was caused by a third party, you
must agree to pursue a claim for damages from that third party. Before the Plan pays medical
expenses for these injuries or illnesses, you must agree, in writing, to reimburse the Trust Fund
for the benefits paid on your behalf. This reimbursement will come from the money you receive
as a result of pursuing your claim against a third party or any insurance company.
44
Claims and Appeals Procedures
for Direct Payment Plan
(Article XI., pages 108-116)
Claims
This section describes the proper procedures to follow when filing a claim for benefits. These
procedures only apply to the Fund’s Direct Payment Plan. If you are covered under Kaiser
Permanente, you should refer to Kaiser’s Evidence of Coverage (EOC). You can request an EOC
from Kaiser prior to enrolling in that health plan; otherwise, you will receive one once you are
enrolled.
What is a “claim”?
A “claim” is a request for Plan benefits made in accordance with the Plan’s reasonable claims
procedures as described on the following pages.
What is NOT a “claim”?
•
Simple or general inquiries about the Plan’s provisions that are unrelated to any specific
benefit claim.
•
Request for a determination regarding the Plan’s coverage of a medical treatment or
service that your physician has recommended, but that treatment or service has not yet
been provided and the treatment or service is for non-urgent care that does not require
prior authorization from the Plan. In this case, you may request a determination from
the Trust Fund regarding the Plan’s coverage of the treatment or service. However, any
determination from the Trust Fund is not a guarantee of payment because the request is
not a claim and, therefore, is not subject to the requirements and timelines of a “claim.”
•
Request for a prescription to be filled under the terms of the Plan is not a claim under these
procedures. If, however, your request for a prescription to be filled is denied, in whole or
in part, you are entitled to file a claim and appeal the denial by using the procedures
described on the following pages.
Inquiries and questions are NOT claims.
Claims procedures for hospital/medical benefits vary depending on whether your claim is a PreService, an Urgent Care, a Concurrent, or a Post-Service Claim.
45
Pre-Service Claims
A Pre-Service Claim is a claim for benefits that requires approval by the Plan before medical care
is obtained so that you may receive full Plan benefits for the medical services you are requesting.
For example, if you are to be confined in a hospital for elective surgery, you or your physician must
arrange Utilization Review; otherwise; you will be responsible for more out-of-pocket expenses.
Circumstances under which you might submit a Pre-Service Claim are listed below. This is only
a partial list, as there may be other circumstances under which you would submit a Pre-Service
Claim.
•
•
•
•
•
•
Elective, non-emergency hospital confinements
Surgical treatment for morbid obesity
Hospice
Home Health Care
Medical procedures that may be considered cosmetic or procedures that may be
questionable as to medical necessity, or experimental/investigative procedures
Substance Abuse Treatment (call Claremont Behavioral Services at 1-800-834-3773 to
arrange treatment)
Contact the Fund Office at (707) 864-2800 or toll-free at 1-800-244-4530 to confirm that the hospital
or health care provider is a Prudent Buyer Plan provider so that you might receive the highest
reimbursement allowed by your Plan. (For podiatry treatment, contact Podiatry Plan of California
(PPOC) at 1-800-367-7762.)
For properly filed Pre-Service Claims, you and your medical provider will be notified by Blue
Cross of a decision within 15 days from the receipt of the claim, unless additional time is needed
to make a decision. If necessary, an extension of up to 15 days may be required due to ma�ers
beyond the control of the Plan. You will be notified of the circumstances requiring an extension of
time and the date a decision may be made available to you.
If an extension is necessary because Blue Cross requires additional information from you or
your medical provider, the extension will specify the information needed. In this case, you or
your medical provider will have 45 days from receipt of the notification to submit the additional
information. If that information is not provided within 45 days, your claim will be denied. During
the period in which you are allowed to provide additional information, the normal period for
making a decision on the claim will be suspended. The deadline is suspended from the date of
the extension notice either until 45 days have elapsed or the date you respond to the request,
whichever occurs sooner. Once your response is received (within the earlier of 45 days or the date
of your response), Blue Cross has 15 days to make a decision on a Pre-Service Claim.
If your provider does not file a Pre-Service Claim properly, you and your medical provider will
be notified as soon as possible, but not later than 5 days a�er receipt of the claim. This notice will
advise you of the proper procedures for filing the claim. You and your provider will only receive
notice of an improperly filed Pre-Service Claim if the claim includes (i) your name, (ii) your
specific medical condition or symptom, and (iii) a specific treatment, service or product for which
approval is requested. Unless the claim is resubmi�ed properly, it will not constitute a “claim”
and will not be acted on.
46
Urgent Care Claims
An Urgent Care Claim is any claim for medical care or treatment that, if handled within the time
period(s) of a Pre-Service Claim as described above, could seriously jeopardize the life or health
of the individual or his ability to regain maximum function or, in the opinion of the physician
with knowledge of the individual’s medical condition, would subject the individual to severe
pain that cannot be adequately managed without the care or treatment requested in the claim. An
example of an Urgent Care Claim might be a request for prior approval of a diagnostic test for
appendicitis.
Whether your claim is an Urgent Care Claim is determined by Blue Cross by applying the
judgment of a prudent layperson possessing an average knowledge of health and medical claims
processing. Any claim made by a medical provider, who has knowledge of your medical condition
and determines that it is an Urgent Care Claim will be treated as an Urgent Care Claim.
If you are requesting approval of an Urgent Care Claim, the response times differ, depending on
whether your request contains sufficient information for making a determination. If the request
contains sufficient information, Blue Cross will respond to you and your medical provider with
a determination, by telephone, as soon as possible, taking into account the medical urgency of
the patient’s condition, but not later than 72 hours a�er receipt of the claim by Blue Cross. The
determination will be confirmed in writing.
If an Urgent Care Claim is received without sufficient information to determine whether or not
benefits are covered or payable or to what extent benefits are covered or payable, Blue Cross will
notify you and your medical provider as soon as possible, but not later than 24 hours a�er receipt
of the claim, of the specific information necessary to complete the claim. You or your physician
must provide the specified information within 48 hours. Notice of the decision will be provided
no later than 48 hours a�er the Plan receives the specified information, but only if the information
is received within the required time frame. If the information is not provided within that time,
your claim will be denied.
Concurrent Claims
A Concurrent Claim is a claim that is reconsidered a�er an initial approval was made and, a�er
reconsideration, results in a reduction, termination or extension of a benefit. An example of a
Concurrent Claim is an inpatient hospital stay that was originally authorized for 5 days and
is reviewed a�er 3 days to determine if the full 5 days is still appropriate. In this example, a
decision to reduce, terminate or extend the inpatient stay is made concurrently with the provision
of medical treatment. Reconsideration of a benefit with respect to a Concurrent Claim that
involves the termination or reduction of an approved benefit (other than by a Plan amendment or
termination) will be made by the Fund Office or Blue Cross as soon as possible but, in any event,
in time to allow you to appeal the decision before the benefit is reduced or terminated.
Any request by a claimant to extend approved urgent care treatment will be acted upon by Blue
Cross within 24 hours of receipt of the claim, provided the claim is received at least 24 hours
prior to the expiration of the approved treatment. A request to extend approved treatment that
47
does not involve urgent care will be decided according to pre-service or post-service timeframes,
whichever apply.
Post-Service Claims
Claims that are not Pre-Service, Urgent Care, or Concurrent are considered Post-Service Claims.
An example of a Post-Service Claim is any claim submi�ed for payment a�er medical services
or treatment has been obtained.
Usually, you will be notified of the decision on your Post-Service Claim within 30 days from the
date the Plan receives your claim. This period may be extended one time by the Plan for up to
15 days if an extension is necessary due to ma�ers beyond the control of the Plan. If an extension
is necessary, you will be notified before the end of the initial 30-day period of the circumstances
requiring the extension of time and the date by which the Plan expects to make its decision
available.
How to File a Claim
In most cases, your health care provider will submit a claim form on your behalf. If you require a
claim form, you may obtain one from your Local Union or from the Fund Office by calling (707)
864-2800 or toll-free at 1-800-244-4530.
To be considered a “claim,” your request for benefits must include the following information on
the claim form:
•
•
•
•
•
•
•
•
•
•
•
•
•
Laborer’s Name
Patient’s name
Patient’s date of birth
Laborer’s social security number
Date of service
CPT-4 (the code for physician services and other health care services found in the Current
Procedural Terminology, Fourth Edition, as maintained and distributed by the American
Medical Association)
ICD-9 (the diagnosis code found in the International Classification of Diseases, 9th Edition,
Clinical Modification as maintained and distributed by the U.S. Department of Health
and Human Services)
Billed charges (bills must be itemized, showing all dates of visits to the physician)
Number of Units (for example, anesthesia and certain other services)
Federal Taxpayer Identification Number (TIN) of the provider
Provider’s billing name, address, phone number, and professional degrees or license
If treatment is due to an accident, details of the accident must be included
Information of other insurance coverage, if any
When Claims Must Be Filed
All claims should be filed within 90 days following the date charges were incurred (date of service).
Failure to file claims within that time period will not invalidate or reduce your claim if it can be
demonstrated that it was not reasonably possible to file the claim within 90 days. In that case,
48
your claim must be submi�ed as soon as it is reasonably possible, but under no circumstances,
later than one year from the date charges were incurred (date of service).
Where to File Claims
Urgent Care Claims
Urgent Care Claims must be referred to Blue Cross (Prudent Buyer Plan) by calling 1-800-274-7767.
Urgent Care Claims are not to be submi�ed by U.S. Postal Service.
CALL 1-800-274-7767
FOR ALL URGENT CARE CLAIMS
Pre-Service Claims
Pre-Service Claims should be filed with Blue Cross (Prudent Buyer Plan) by calling 1-800-274-7767.
Post-Service Claims
Post-Service Claims are considered filed as soon as they are received at the Fund Office. Hospitals,
contracted with Blue Cross (Prudent Buyer Plan), will file claims directly to Blue Cross. All other
claims should be filed with the Fund Office at the following address:
220 Campus Lane
Fairfield, CA 94534-1498
Authorized Representative
An “authorized representative,” such as your spouse, can complete the claim form on your behalf
if you are unable to complete it yourself, as long as you have designated that individual to act on
your behalf. You can obtain a form from the Fund Office to designate an authorized representative.
The Plan may request additional information to verify that the person you designate is authorized
to act on your behalf. Though you designate an authorized representative to act on your behalf,
you must personally sign a claim form and file it with the Fund Office at least once each year. This
is necessary so that the Fund Office has your current signature on file.
A health care professional, with knowledge of your medical condition, may act as an authorized
representative in connection with an Urgent Care Claim (defined above) without your having to
complete a special authorized representative form.
Notice of Decision on Claim
If your claim for benefits is denied, in whole or in part, you will be provided with a wri�en notice
of denial (adverse benefit determination) of the claim that will state:
•
The specific reason(s) for the determination
49
•
•
•
•
•
•
•
Reference to the specific Plan provision(s) on which the determination is based
A description of any additional material or information necessary to complete your claim
and an explanation of why that material or information is necessary
A description of the appeal procedures and applicable time limits
A statement of your right to bring a civil action under ERISA Section 502(a) following an
adverse benefit determination on review
Any guideline or protocol that was relied upon in deciding your claim. You will receive
a copy of the rule or you will be advised that it is available, upon wri�en request, at no
charge.
If the adverse benefit determination was made because the treatment or service was not
medically necessary or experimental or investigational, or other similar exclusion, you
will receive an explanation of the scientific or clinical judgment for the determination,
applying the terms of the Plan to your claim, or a statement that it is available upon wri�en
request at no charge.
In the case of an Urgent Care Claim, the notice will describe the expedited review process
that applies to Urgent Care Claims. For Urgent Care Claims, the required determination
may be provided orally, followed with a wri�en notification.
For Urgent Care Claims, you will receive notice of the determination even when the claim is
approved.
How to Request a Review of a Denied Claim
If your claim is denied, in whole or in part, or if you disagree with the decision made on your
claim, you may request a review. Your request for review must:
•
•
•
•
be made in writing;
state the reason(s) for disputing the denial (adverse benefit determination);
include any pertinent material not already furnished to the Plan; and
be submi�ed within 180 days from the date you receive the notice of denial.
Failure to file an appeal that meets all of the above will constitute a waiver of your right to a
review of the denial (adverse benefit determination) of your claim.
To appeal an adverse benefit determination of an Urgent Care Claim, call Blue Cross at
1-800-274-7767.
Review Process
The review process is as follows:
You have the right to review documents relevant to your claim. A document, record or other
information is relevant if it was relied upon by the Plan in making the decision; it was submi�ed,
considered, or generated (regardless of whether it was relied upon); it demonstrates compliance
with the Plan’s administrative processes for providing consistent decision making; or it constitutes
a statement of Plan policy regarding the denied treatment or service.
Upon request, you will be provided with the identification of medical or appropriate expert,
50
consultant, or advisor, if any, that gave advice to the Plan on your claim, without regard to whether
the advice of those experts was relied upon in deciding your claim.
A different person will review your claim from the one who originally denied it. The reviewer
will not give deference to the initial adverse benefit determination. The decision will be made on
the basis of the record, including any additional documents and comments that may be submi�ed
by you.
If your claim was denied on the basis of a medical judgment (such as a determination that the
treatment or service was not medically necessary, or was investigational or experimental), a health
care professional with appropriate training and experience in a relevant field of medicine will be
consulted.
Timing of Notice of Decision on Appeal
Pre-Service Claims: Blue Cross will mail you a notice of a decision on review within 30 days of
receipt of the appeal.
Urgent Care Claims: Blue Cross will send you a notice of a decision on review within 72 hours of
receipt of the appeal.
Post-Service Claims: Usually, decisions involving Post-Service Claims will be made at the next
regularly scheduled meeting of the Board of Trustees following receipt of your request for review.
However, if your request for review is received in the Fund Office within 30 days of the next
regularly scheduled meeting, your request for review may be considered at the second regularly
scheduled meeting following receipt of your request. In special circumstances, a delay until the
third regularly scheduled meeting following receipt of your request for review may be necessary.
You will be advised, in writing, in advance if this extension will be necessary. Once a decision on
review of your claim has been reached, you will be notified of the decision as soon as possible, but
no later than 5 days a�er the decision has been made.
Notice of Decision on Review
The decision on any review of your claim will be provided to you in writing. The notice of a
denial of a claim on review will state:
•
•
•
•
•
•
The reason(s) for the determination
Reference to the specific Plan provision(s) on which the determination is based
A statement that you are entitled to receive reasonable access to and copies of all documents
relevant to your claim, upon request and free of charge
A statement of your right to bring a civil action under ERISA Section 502 following an
adverse benefit determination on review
If an internal rule, guideline or protocol was relied upon by the Plan, you will receive either
a copy of the rule or a statement that it is available, upon wri�en request, at no charge
If the determination was based on medical necessity, or because the treatment was
experimental or investigational, or other similar exclusion, you will receive an explanation
of the scientific or clinical judgment for the determination, applying the terms of the Plan to
your claim, or a statement that it is available upon wri�en request, at no charge.
51
The denial of a claim to which the right to review has been waived (that is, you have failed to
file a wri�en request within the required time limit), or the decision of the Board or the Board’s
designated Appeals Commi�ee with respect to a petition for review, is final and binding upon all
parties, including the claimant or petitioner, subject only to any civil action you may bring under
ERISA. Following issuance of the wri�en decision of the Board on an appeal, there is no further
right of appeal to the Board or right to arbitration.
Limit on When You May Begin a Lawsuit (Civil Action)
You may not begin a lawsuit against the Trust Fund to obtain benefits until a�er the following
events have occurred:
•
•
You requested a review of the denial of your claim and the Board has reached and issued
a final decision on your review; or
You requested a review, but have not received either a notice within the time frames
indicated above that a final decision has been reached or a notice that an extension will be
necessary to reach a final decision.
52
Privacy of Your
Health Information
(Article VIII, pages 97-101)
This section describes how your medical information may be used and disclosed and how you
obtain access to this information. Please read this section carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) grants you certain
privacy rights with respect to your Health Information maintained by the Laborers Health and
Welfare Trust Fund For Northern California, Active Laborers Plan (the Plan). In addition, HIPAA
requires that the Plan comply with rules designed to protect this information from improper uses
and disclosures. One of your rights under HIPAA is to know how the Plan handles your Health
Information. This section explains how the Plan uses and discloses your Health Information, and
what rights you have with respect to your Health Information. The Plan may change this Privacy
Notice in the future, but it must always follow the terms of the Privacy Notice in effect. This
Privacy Notice applies to the Active Laborers Plan, which is a member of an “Organized Health
Care Arrangement.” The terms “Plan,” “Plan Administration Team,” and “Team Member” apply
to the Active Laborers Plan in which you are a participant.
If you have any questions about this notice, please contact the HIPAA Compliance Director,
Laborers Funds Administrative Office of Northern California, Inc., 220 Campus Lane, Fairfield,
CA, 94534.
Who Sees Your Health Information?
The Plan Administration Team includes all Individuals who must see Health Information that can
be linked to an Individual (“Protected Health Information”) in order to operate the Plan. Certain
members of the Team are employees of the Laborers Funds Administrative Office of Northern
California, Inc. Other members of the Team are employees of outside organizations that assist
in the operation of the Plan. In order to serve as a Team Member, an Individual must complete
extensive training on privacy and security procedures. The law prohibits Team Members from
using Protected Health Information for improper purposes. Each Team Member understands
that a violation of the Plan’s privacy and security procedures may result in disciplinary action.
Therefore, Team Members take the privacy of your Health Information seriously.
The Plan’s Promise to You
Plan Administration Team Members understand that your health and medical information is
private. Laborers Health and Welfare Trust Fund For Northern California (Active Laborers Plan),
is commi�ed to using your Health Information only for the purposes of treatment, paying benefits,
operating the Plan and, as expressly permi�ed or required by law.
53
Other Privacy Notices
Your doctors, nurses, hospitals and other health care providers may provide you with privacy
notices required by HIPAA. These privacy notices differ from this one because these notices
discuss how your health care providers use your Health Information. This notice applies only to
the Protected Health Information obtained and maintained by the Plan. It describes your rights
with respect to your Health Information maintained by the Plan, and how the Plan may use and
disclose that Health Information.
How the Plan Uses and Discloses Your Health Information
Team Members can only use and disclose Protected Health Information in ways that are expressly
permi�ed by HIPAA. The sections entitled Treatment, Payment and Health Care Operations
describe how the Plan uses and discloses the Health Information obtained about you (your
“Health Information”). Some of these uses and disclosures are routine, and are necessary to
operate the Plan, and to provide assistance to the health care providers who treat you. Others
are not routine, but are required by law or necessary due to special circumstances. The Plan
has developed procedures for all of these uses and disclosures. The Active Laborers Plan is a
member of an “Organized Health Care Arrangement.” Therefore, the Health Plan may share your
information with members for purposes of Treatment, Payment and Health Care Operations.
Treatment. Team Members may use or disclose your Health Information to facilitate medical
Treatment or services by your health care providers such as doctors, nurses, technicians, medical
students, other hospital personnel or pharmacists who are involved in treating you.
Payment. Team Members may use and disclose your Health Information in order to determine
your eligibility for Plan benefits, to process claims for Payment for your Treatment, or to
determine whether any other plan or party might be responsible for payment of your Treatment.
For example, a Team Member might review a bill that contains Health Information about you
in order to determine whether the Treatment is a covered expense under the Plan. Sometimes a
Team Member must obtain information from a health care provider or from your medical record
to determine whether the Treatment provided was medically necessary, or experimental and
investigative. One Team Member may send the information to another Team Member who is a
medical specialist for the purpose of obtaining a medical opinion concerning the nature of the
claim. These are just a few examples of how Team Members may use and disclose your Health
Information in order to make sure the Plan pays benefits properly.
Health Care Operations. Team Members may use and disclose your Health Information in order
to conduct Plan operations. For example, Team Members may review your Health Information
in order to:
1.
2.
3.
4.
5.
6.
Conduct quality assessment and improvement activities;
Perform underwriting, premium rating, and other activities relating to Plan coverage;
Submit claims for stop-loss (or excess loss) coverage;
Conduct or arrange for medical review, legal services, audit services, and fraud and
abuse detection programs;
Learn about ways to manage costs; and
Manage the business of the Plan, to make sure it is administered properly and
effectively.
54
Required By Law. Team Members will disclose your Health Information when required to do
so by federal, state or local law. For example, a Team Member will disclose information about
medical bills submi�ed by your health care provider in response to a court order in a litigation
proceeding that alleges the provider is involved in fraudulent billing practices.
To Prevent Serious Threats to Health or Safety. Team Members may use and disclose your Health
Information in order to prevent a serious threat to your health and safety or the health and safety
of the public or another person. Any disclosure of this nature would only be made to a person
who is able to help prevent the threat.
Laborers Funds Administrative Office of Northern California, Inc., Employee Team Members.
As mentioned above, certain employees of Laborers Funds Administrative Office of Northern
California, Inc. serve as Plan Administration Team Members. Your Protected Health Information
will only be used and disclosed by these employees for Plan administrative purposes.
Special Situations
Organ and Tissue Donation. If you are an organ donor, Team Members may release your Health
Information to organizations that handle organ procurement or organ, eye or tissue transplantation
or to an organ donation bank, in order to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces of the United States or any
other country, Team Members may release your Health Information if the Active Laborers Plan is
required to do so by the appropriate military command authorities.
Workers’ Compensation. Team Members may release your Health Information if required to in
order to comply with workers’ compensation laws.
Health Oversight Activities. Team Members may disclose your Health Information to a Health
Oversight Agency for activities authorized by law. These oversight activities may include audits,
investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, Team Members may disclose
your Health Information in response to a court or administrative order. Team Members may also
disclose your Health Information in response to a subpoena, discovery request, or other legal
process by someone involved in the dispute, but only if efforts have been made to inform you of
the request or to obtain an order protecting the information requested.
Law Enforcement. If requested to do so by a Law Enforcement Official, a Team Member may
release your Health Information in response to a court order, subpoena, warrant, summons or
similar process.
Coroners, Medical Examiners and Funeral Directors. Team Members may release your Health
Information to a coroner or medical examiner. This may be necessary, for example, to identify you
if you die or to determine the cause of your death. Team Members may also release your Health
Information to funeral directors as necessary to carry out their duties.
55
Your Rights Regarding Health Information the Plan Maintains About You
You have the following rights regarding the Health Information the Plan maintains about you:
Right to Inspect and Copy. You have the right to inspect and copy your Health Information that
may be used to make decisions about your Plan benefits. To inspect and copy medical information
that may be used to make decisions about you, you must complete the Form entitled “Request
for Access to Protected Health Information” and submit the Form to the HIPAA Compliance
Director, Laborers Funds Administrative Office of Northern California, Inc., 220 Campus Lane,
Fairfield, CA, 94534. If you request a copy of the information, you may be charged for the cost of
copying, mailing and for any supplies associated with your request.
Right to Amend. If you feel the Plan has medical information about you that is incorrect or
incomplete, you may ask the Plan to amend the information. You have the right to request an
amendment for as long as the information is retained by or for the Plan.
To request an amendment, you must complete a Form entitled “Request for Amendment of
Protected Health Information.” This Form is available, upon request, from the HIPAA Compliance
Director, Laborers Funds Administrative Office of Northern California, Inc., 220 Campus Lane,
Fairfield, CA, 94534. Your request for an amendment may be denied if you do not complete this
Form. In addition, your request may be denied if you ask the Plan to amend information that:
1.
2.
3.
4.
Is not part of the medical information retained by or for the Plan;
Was not created by the Plan;
Is not part of the information which you would be permi�ed to inspect and copy;
or
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures” where disclosures were made for any purpose other than Treatment, Payment, or
Health Care Operations.
To request a list or accounting of disclosures, you must complete the Form entitled “Request
for an Accounting of Disclosures of Protected Health Information” and submit the Form to the
HIPAA Compliance Director, Laborers Funds Administrative Office of Northern California, Inc.,
220 Campus Lane, Fairfield, CA, 94534. Your request must state a period within which you are
requesting an accounting of disclosures. This period may not be longer than 6 years and may not
include dates before April 14, 2003. Your request should indicate in what form you want the list
(for example, paper or electronic). The first list you request within a 12-month period will be free.
If you request any additional lists, the Plan may charge you for the cost of providing the lists. You
will be notified of the cost in advance and you may choose to withdraw or modify your request
at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical
information the Plan uses or discloses about you for Treatment, Payment or Health Care Operations. You
also have the right to request a limit on the medical information the Plan discloses about you to someone
who is involved in your care or the Payment for your care, such as a family member or friend. For example,
you could request that the Plan not use or disclose to your spouse information about a surgery you had.
To request restrictions, you must complete the Form entitled “Request for Restriction of Protected Health
56
Information” and submit it to the HIPAA Compliance Director, Laborers Funds Administrative Office of
Northern California, Inc., 220 Campus Lane, Fairfield, CA, 94534. You should understand that the HIPAA
Compliance Director is not obligated to comply with your request.
Right to Request Confidential Communications. If you believe that the normal form of
communications of benefit information could compromise you, you have the right to request that
the Plan communicate with you about medical ma�ers in a certain way or at a certain location.
For example, you can request that the Plan only contact you at work or by mail.
To request confidential communications, you must complete the Form entitled “Request for
Confidential Communications of Protected Health Information” and submit it to the HIPAA
Compliance Director, Laborers Funds Administrative Office of Northern California, Inc., 220
Campus Lane, Fairfield, CA, 94534. The Plan will not ask the reason for your request and will
accommodate all reasonable requests. Your request must specify how or where you wish to be
contacted.
You may obtain copies of the request forms on our Web site, www.norcalaborers.org, or obtain a
paper copy by contacting the HIPAA Compliance Director, Laborers Funds Administrative Office
of Northern California, Inc., 220 Campus Lane, Fairfield, CA, 94534.
Changes to Privacy Notice
The Plan reserves the right to change this notice.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Laborers
Health and Welfare Trust Fund for Northern California (Active Laborers Plan) or with the Secretary
of the Department of Health and Human Services. To file a complaint with the Plan, contact the
HIPAA Compliance Director, Laborers Funds Administrative Office of Northern California, Inc.,
220 Campus Lane, Fairfield, CA, 94534. All complaints must be submi�ed in writing.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or any
law that applies to the Plan will be made only with your wri�en authorization. If you
provide the Plan authorization to use or disclose medical information about you, you
may revoke that authorization, in writing, at any time. If you revoke your authorization,
the Plan will no longer use or disclose medical information about you for the reasons
covered by your wri�en authorization. You understand that the Plan is unable to take
back any disclosures already made with your authorization. To request authorization
for use or disclosure of your Protected Health Information, you must complete the Form
entitled “Authorization for Use or Disclosure of Protected Health Information” and
submit the Form to the HIPAA Compliance Director, Laborers Funds Administrative
Office of Northern California, Inc., 220 Campus Lane, Fairfield, CA, 94534.
57
Information Required by the
Health Insurance Portability
and Accountability Act
In accordance with disclosure requirements of the Health Insurance Portability and Accountability
Act of 1996, listed below are the names and addresses of all Health Providers for the Active
Laborers Plan.
Blue Cross of California
21555 Oxnard Street, M/S 10-H2
Woodland Hills, CA 91367
Provides utilization review, provider network
services and case management.
Kaiser Foundation Health Plan Northern
California Region
1950 Franklin Street
Oakland, CA 94612
Provides prepaid medical plan for
Active Laborers.
Bright Now! Newport Dental Plan
201 E. Sandpointe #200
Santa Ana, CA 92707
Provides fully insured dental plan for Active
Laborers.
Claremont Behavioral Services
1050 Marina Village Parkway Suite 203
Alameda, CA 94501
Provides substance abuse treatment for Active
Laborers.
Delta Dental of California
100 First Street
San Francisco, CA 94105
Administers dental plan for Active Laborers.
Prescription Solutions
3515 Harbor Blvd.
Costa Mesa, CA 92626
Administers retail and mail-service prescription
drug benefit.
Private Medical Care, Inc. (PMI)
DeltaCare Group Dental Service
12898 Towne Center Drive
Cerritos, CA 90703
Provides fully insured dental plan for Active
Laborers.
Vision Service Plan
3333 Quality Drive
Rancho Cordova, CA 95670
Administers vision plan for Active Laborers.
Pacific Union Dental
1390 Willow Pass Road
Concord, CA 94520-5240
Provides fully insured dental plan for
Active Laborers.
Podiatry Plan Organization of California
203 Willow Street Suite 204
Provides podiatry network services.
The Act also requires that we inform you of the Department of Labor address in Washington,
D.C. Therefore, if you have any questions about your rights under ERISA, you should contact
58
the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of
Labor, or write to Employee Benefits Security Administration, U.S. Department of Labor, 200
Constitution Avenue, N.W., Washington, D.C. 20210. Additional information regarding your
ERISA rights is located in this booklet on pages 63 through 65.
59
Information Required by the
Employee Retirement Income
Security Act of 1974
1.
The Plan is administered and maintained by a Joint Board of Trustees at the following
address.
Board of Trustees
220 Campus Lane
(707) 864-2800
The above is the name, address and telephone number of the Plan Administrator.
2.
The Fund Office will provide any Plan participant or beneficiary, upon wri�en request,
information as to whether a particular employer is contributing to this Fund with respect
to the work of participants in the Fund and if the employer is a contributor, the employer’s
address.
3.
The Employer Identification Number (EIN) issued to the Board of Trustees by the Internal
Revenue Service is 94-1235152.
4.
Plan Number: 501
5.
This is a Welfare Plan which provides, hospital, medical, drug, dental, vision care and
death and accidental death and dismemberment benefits.
6.
The person designated as agent for the service of legal process is:
Mr. Edward J. Smith, Secretary
220 Campus Lane
The service of legal process may also be made upon a Plan Trustee or the Plan
Administrator.
60
7.
The names, titles and business addresses of the Trustees are:
EMPLOYEE TRUSTEES
EMPLOYER TRUSTEES
Mr. José Moreno, Chairman
Northern California District
Council of Laborers
4780 Chabot Drive Suite #200
Pleasanton, CA 94588-3322
Mr. Larry To�en, Co-Chairman
Johnson Western Gunite Co.
940 Dooli�le Drive
San Leandro, CA 94577-1021
Mr. Terence Street
Roebbelen Contracting, Inc.
1241 Hawks Flight Court
El Dorado Hills, CA 95762-9648
Mr. Doyle Radford
Laborers Local Union No. 185
1320 West National Drive
Sacramento, CA 95834-1908
Ms. Claire Koenig
McNely Construction Co.
2081 Adams Avenue
San Leandro, CA 94577-1074
Mr. Ron Puls
2920 Sonoma Blvd Suite B
Vallejo, CA 94590-3800
Mr. Robert Chrisp
Chrisp Company
43650 Osgood Road
Fremont, CA 94539-5631
Mr. Mike Muesing
5431 East Hedges Avenue
Fresno, CA 93727-2296
Mr.. Bryon C. Loney
Teichert Construction Company
P. O. Box 15002
Sacramento, CA 95851-1002
Mr. Oscar De La Torre
3271 - 18th Street
8.
This program is maintained pursuant to various collective bargaining agreements. Copies
of the collective bargaining agreements are available for inspection at the Fund Office
during regular business hours and, upon wri�en request, will be furnished by mail. A
copy of any collective bargaining agreement which provides for contributions to this
Fund will also be available for inspection within 10 calendar days a�er wri�en request
at any of the Local Union offices or at the office of any contributing employer to which at
least 50 Plan participants report each day.
9.
The requirements for eligibility for benefits are set forth on pages 6 through 8 of this
booklet and in Article II of the Plan Rules and Regulations.
10.
The circumstances which may result in disqualification, ineligibility, or denial, loss,
forfeiture or suspension of benefits are set forth on pages 7 and 8 of this booklet and in
Article II of the Plan Rules and Regulations.
11.
All contributions to the Fund are made by individual employers in accordance with
collective bargaining agreements in force with the Northern California District Council of
Laborers, affiliated Local Union, or other entity related to the Fund, with respect to certain
of their employees pursuant to Board regulations.
61
12.
Benefits are provided from a trust fund and insurance contracts through Kaiser Foundation
Health Plan, Newport Dental Plan (Bright Now!) Private Medical Care, Inc. (PMI), and
Pacific Union Dental.
13.
The end of the year for purposes of maintaining the Fund’s fiscal records is May 31.
14.
The procedure for filing claims is set forth on pages 45 through 52 of this booklet.
62
Statement of Rights Under the
Employee Retirement Income
Security Act of 1974 (ERISA)
As a participant in the Laborers Health and Welfare Trust Fund for Northern California, you are
entitled to certain rights and protections under the Employee Retirement Income Security Act of
1974 (ERISA). ERISA provides that all Plan participants are entitled to the following rights::
Receive Information About Your Plan and Benefits
•
Examine, without charge, at the Plan Administrator’s office and at other specified
locations, such as work sites and union halls, all Plan documents governing the Plan. These
documents include insurance contracts and collective bargaining agreements and a copy
of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department
of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration (formerly the Pension and Welfare Benefits Administration).
•
Obtain, upon wri�en request to the Plan Administrator, copies of documents governing
the operation of the Plan. These include insurance contracts and collective bargaining
agreements and copies of the latest annual report (Form 5500 Series) and updated summary
plan description. The administrator may make a reasonable charge for the copies.
•
Receive a summary of the Plan’s annual financial report. The Plan Administrator is
required by law to furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage
•
Continue health care coverage for yourself, Spouse, or Dependent children if there is a loss
of coverage under the Plan as a result of a qualifying event. You or your Dependents may
have to pay for such coverage. Review this Summary Plan Description and the documents
governing the Plan on the rules of your COBRA Continuation Coverage rights.
•
Reduction or elimination of exclusionary periods of coverage for pre-existing conditions
under your group health plan, if you have creditable coverage from another plan. You
should be provided a certificate of creditable coverage, free of charge, from your group
health plan or health insurance issuer when you lose coverage under the plan, when
you become entitled to elect COBRA Continuation Coverage, or when your COBRA
Continuation Coverage ceases, if you request it before losing coverage or if you request
it up to 24 months a�er losing coverage. Without evidence of creditable coverage, you
may be subject to a pre-existing condition exclusion for 12 months (18 months for late
enrollees) a�er your enrollment date in your coverage.
63
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who
are responsible for the operation of the employee benefit plan. The people who operate your Plan,
called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and
other Plan participants and beneficiaries. No one, including your employer, your union, or any
other person, may fire you or otherwise discriminate against you in any way to prevent you from
obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied, in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request
a copy of Plan documents or the latest annual report from the Plan and do not receive them
within 30 days, you may file suit in a federal court. In such a case, the court may require the
Plan Administrator to provide the materials and pay you up to $110 a day until you receive
the materials, unless the materials were not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits, which is denied or ignored, in whole or in part, you
may file suit in a state or federal court, once you have exhausted the appeals process described
in “Claims and Appeals Procedures” in this booklet. In addition, if you disagree with the Plan’s
decision or lack thereof concerning the qualified status of a medical child support order, you may
file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if
you are discriminated against for asserting your rights, you may seek assistance from the U.S.
Department of Labor, or you may file suit in a federal court. The court will decide who should
pay court costs and legal fees. If you are successful, the court may order the person you have sued
to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for
example, if it finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you have
any questions about this statement or about your rights under ERISA, or if you need assistance
in obtaining documents from the Plan Administrator, you should contact the nearest office of the
Employee Benefits Security Administration (EBSA) (formerly the Pension and Welfare Benefits
Administration), U.S. Department of Labor, listed in your telephone directory. Alternatively,
you may obtain assistance by calling EBSA toll-free at 1-866-444-EBSA (3272) or writing to the
following address:
Division of Technical Assistance and Inquires
Employee Benefits Security Administration
U.S. Department of Labor
200 Constitution Avenue N.W.
Washington, D.C. 20210
64
You may obtain certain publications about your rights and responsibilities under ERISA by calling
the publications hotline of EBSA. For single copies of publications, contact the EBSA brochure
request line at 1-800-998-7542 or contact the EBSA field office nearest you.
You may also find answers to your plan questions and a list of EBSA field offices at the Web site
of EBSA at www.dol.gov/ebsa.
65
LABORERS HEALTH AND WELFARE TRUST FUND
RULES AND REGULATIONS
DIRECT PAYMENT PLAN
FOR
ACTIVE EMPLOYEES
AMENDED AND RESTATED EFFECTIVE MARCH 1, 2006
ARTICLE I.
DEFINITIONS
Section 1.
The term “Active Employee” means any person who meets the eligibility rules in
Article II, Section 2.
Section 2.
The term “Ambulatory Surgical Facility” means a free standing surgical facility
which is licensed under any applicable state statute or, in the absence of any state licensing
statute, conforms with any other requirements imposed on free standing surgical facilities within
that jurisdiction.
Section 3.
The term “Board of Trustees” or “Board” means the Board of Trustees established
by the Trust Agreement.
Section 4.
The term “Collective Bargaining Agreement” means (a) the Laborers’ Master
Agreement between Employers and the Union for the 46 Northern California Counties dated June
4, 1952, including any amendment, extension or renewal of that Agreement and the Tunnel Master
Agreement between Employers and the Union dated June 18, 1952, including any amendment,
extension or renewal of that Agreement, and (b) any other collective bargaining agreement
between the Union or any of its affiliated local unions, and any employer organization or Individual
Employer which provides for the making of Contributions to the Health and Welfare Fund.
Section 5.
The term “Concurrent Review” means the process through which the Professional
Review Organization (PRO) determines the number of authorized days considered Medically
Necessary that are eligible for Hospital Benefits according to the Plan provisions once an Eligible
Individual has been confined in a Hospital on the recommendation of the Professional Review
Organization (PRO).
Section 6.
The term “Custodial Care” means general assistance in performing the activities
of daily living, which include but are not limited to, bathing, dressing, toileting, meal preparation,
eating, housekeeping, board, room and other services provided on a long-term basis, but that do
not include medical care or treatment.
66
Section 7.
•
•
The term “Dentist” means:
A legally qualified Dentist, or
A physician authorized by his license to perform, at the time and place involved, the
particular dental procedure performed by him.
Section 8.
The term “Dependent” means:
a.
The Active Employee’s lawful spouse.
b.
The Active Employee’s unmarried children, if they are:
(1) natural or adopted children (adopted children are covered from the date they are placed
in the Active Employee’s custody) younger than age 19; or
(2) stepchildren younger than age 19, provided these children are primarily dependent on
the Active Employee and reside in the Active Employee’s home; or
(3) acquired through legal guardianship and are younger than age 19, provided these
children are primarily dependent on the Active Employee and reside in the Active
Employee’s home; or
(4) 19 but less than age 23, provided these children are students at an accredited educational
institution and enrolled for at least 8 units of credit per semester (or equivalent credits),
and are primarily dependent upon the Active Employee for support; or
(5) older than age 19 and prevented from earning a living because of a mental or physical
handicap, (provided the disabled child was handicapped and eligible as a Dependent
prior to age 19) and is primarily dependent upon the Active Employee for support.
In accordance with ERISA Section 609(a)(2)(A), this Plan will provide coverage for a
Dependent child of an Active Employee if required by a Qualified Medical Child Support
Order.
Section 9.
The term “Drugs” means any item, which is lawfully dispensed, as required
under the federal Food, Drug and Cosmetic Act, including any amendments, only upon a written
prescription of a physician or dentist licensed by law to prescribe it.
Section 10. The term “Durable Medical Equipment (DME)” means medical equipment that
can withstand repeated use, is not disposable, and is only related to care for a medical condition.
Examples of DME include, but are not limited to, apnea monitors, wheelchairs, hospital beds, and
oxygen.
Section 11. The term “Eligible Individual” means each Active Employee and each of his
eligible Dependents.
Section 12. The term “Emergency Services” means Medically Necessary treatment required
as the result of a life threatening condition which, without immediate intervention, would result
in placing the Eligible Individual’s health in serious jeopardy, or serious impairment to bodily
67
functions, or serious dysfunction of any bodily part. Some examples of life threatening conditions
requiring Emergency Services include, but are not limited to, heart attacks, strokes, poisonings
and appendicitis.
Section 13. The term “Experimental or Investigative Procedures” means a drug, device,
medical treatment or procedure if:
a. the drug or device cannot be lawfully marketed without the approval of the Food and Drug
Administration (FDA) and
(1) approval for marketing has not been given at the time the drug or device is prescribed
or provided, or
(2) approval has not been given by the FDA for the specific diagnosis, illness, or condition
for which the drug or device is prescribed or provided; or
b. the drug, device, medical treatment or procedure, or the patient’s informed consent document
utilized with the drug, device, treatment or procedure, was reviewed and approved by the
treating facility’s Institutional Review Board or other body serving a similar function, or if
federal law requires a review or approval; or
c. Reliable Evidence shows that the drug, device, medical treatment or procedure is the
subject of on-going phase I or phase II clinical trials, is the research, experimental, study
or investigational arm of on-going phase III clinical trials, or is otherwise under study to
determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as
compared with a standard means of treatment or diagnosis; or
d. Reliable Evidence shows that the prevailing opinion among experts regarding the drug,
device, medical treatment or procedure is that further studies or clinical trials are necessary
to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as
compared with a standard means of treatment or diagnosis.
For purposes of this Section, “Reliable Evidence” means only published reports and articles
in peer reviewed authoritative medical and scientific literature; the written protocol or protocols
used by the treating facility or the protocol(s) of another facility studying substantially the same
drug, device, medical treatment or procedure; or the written informed consent used by the treating
facility or by another facility studying substantially the same drug, device, medical treatment or
procedure.
Section 14. The term “Federal Medicare” or “Medicare” means the benefits provided under
Title XVIII of the Social Security Amendments of 1965.
Section 15.
California.
The term “Fund” means the Laborers Health and Welfare Trust Fund for Northern
Section 16. The term “Group Plan” means any plan providing benefits of the type provided by
this Plan which is supported wholly or in part by employer payments.
68
Section 17. The term “Home Health Care” means skilled nursing care services provided by
a Home Health Care Agency, which is an organization that provides a program of home health
care, approved by Medicare, or that is licensed as a Home Health Care Agency by the regulatory
authority having responsibility for the licensing under the laws of the jurisdiction in which it is
located.
Section 18. The term “Hospice” means an organization that administers a program of palliative
and supportive health care services for terminally ill individuals assessed to have a life expectancy
of 6 months or less and is approved by Medicare or is licensed as a Hospice by the regulatory
authority having responsibility for the licensing under the jurisdiction in which it is located.
Section 19. The term “Hospital” means any general acute care hospital which is licensed
under any applicable state statute and must provide: (a) 24-hour inpatient care, and (b) the
following basic services on the premises: medical, surgical, anesthesia, laboratory, radiology,
pharmacy and dietary services. The term “Hospital” also includes a free-standing psychiatric
facility, but only if the facility is a Participating Hospital in the Prudent Buyer Plan network.
Section 20. The term “Licensed Pharmacist” means a person who is licensed to practice
pharmacy by the governmental authority having jurisdiction over the licensing and practice of
pharmacy.
Section 21. The term “Medically Necessary,” as it applies to services and supplies received
for the treatment of an illness or injury, and for the purpose of determining eligibility for Plan
benefits, means those services and supplies considered to be:
a. Appropriate and necessary for the symptoms, diagnosis, or treatment of the illness or injury;
and
b. Provided for the diagnosis or direct care and treatment of the illness or injury; and
c. Within standards of good medical practice within the organized medical community; and
d. Not primarily for the personal comfort or convenience of the patient, the patient’s family,
any person who cares for the patient, any Physician or other health care practitioner, or any
Hospital or specialized health care facility. The fact that a Physician may provide, order,
recommend, or approve a service or supply does not mean that the service or supply will be
considered Medically Necessary for medical coverage provided by the Plan, and
e. The most appropriate supply or level or service that can safely be provided. For Hospital
confinement, this means that acute care as a bed patient is needed due to the kind of
services the patient is receiving or the severity of the patient’s condition, and that safe and
adequate care cannot be received as an outpatient or in a less intensified medical setting.
Section 22. The term “Non-Participating Hospital” means a Hospital, which is not part of the
Fund’s Preferred Provider Plan.
Section 23. The term “Non-Participating Provider” means a Laboratory or Radiology Facility,
Physician, Ambulatory Surgical Facility, or licensed health care provider, which is not part of the
69
Section 24.
The term “Normal Retirement Age” means age 65.
Section 25. The term “Participating Hospital” means a Hospital, which is part of the Fund’s
Preferred Provider Plan.
Section 26. The term “Participating Provider” means a Laboratory or Radiology Facility,
Physician, Ambulatory Surgical Facility, or licensed health care provider, which is part of the
Section 27.
The term “Physician” means:
a. A physician or surgeon (M.D.) licensed to practice medicine in the state in which he
practices.
b. Any other practitioner of the healing arts who provides care or treatment within the limits set
forth in the license issued to him by the applicable agency of the state in which he provides
care or treatment.
Section 28.
The term “Plan Year” means March 1 of any year to March 1 of the following year.
Section 29. The term “Pre-Admission Review” means the process through which the
Professional Review Organization (PRO) determines the medical necessity of an Eligible
Individual’s elective confinement in a Hospital prior to the elective confinement occurring and, if
Medically Necessary, the number of pre-authorized days eligible for unreduced benefit coverage
according to the Plan provisions.
Section 30. The term “Preferred Provider Plan” means a program through which Hospitals,
Laboratory and Radiology Facilities, Physicians and Ambulatory Surgical Facilities provide any
and all necessary hospitalization and medical services to Eligible Individuals payable on the basis
of contract rates.
Section 31. The term “Preferred Provider Plan Service Area” means the aggregate list of zip
codes in the 46 Northern California Counties in which Eligible Individuals reside and are subject
to the reimbursement provisions of the Preferred Provider Plan.
Section 32. The term “Professional Review Organization (PRO)” means an organization,
under contract with the Fund, which is responsible for determining whether the confinement
of an Eligible Individual in a Hospital is Medically Necessary. If Medically Necessary, the PRO
determines the number of Medically Necessary days for the confinement.
Section 33. The term “Rehabilitation Therapy” means physical, occupational, or speech
therapy that is prescribed by a Physician to improve or restore bodily function that has been
restricted or diminished as a result of an illness, injury, or surgery and that is performed by a
licensed therapist acting within the scope of his license.
70
Section 34. The term “Retrospective Review” means the process through which the
Professional Review Organization (PRO) determines the number of authorized days considered
Medically Necessary and eligible for Hospital Benefits coverage. This review occurs after the
Eligible Individual has been discharged from the Hospital with the approval of a Physician.
Section 35. The term “Skilled Nursing Facility” means an institution, which is primarily
engaged in providing inpatients with skilled nursing care and related services for patients who
require rehabilitation services for recovery from an injury, disability, or illness, and which meets all
of the following requirements:
•
•
•
•
•
•
it is regularly engaged in providing skilled nursing care for sick and injured persons under
24-hours-a-day supervision of a Physician (M.D.) or a graduate Registered Nurse (R.N.);
it has available at all times the services of a Physician (M.D.) who is a staff member of a
general Hospital;
it has on duty, 24 hours a day, a graduate Registered Nurse (R.N.), Licensed Vocational
Nurse (L.V.N.), or skilled practical nurse, and it has a graduate Registered Nurse (R.N.)
on duty at least 8 hours per day;
it maintains a clinical record for each patient;
it is not, other than incidentally, a place for rest, a place for custodial care, a place for the
aged, a place for drug addicts, a place for alcoholics, a hotel, or a similar institution;
it complies with all licensing and other legal requirements, and is recognized as a “skilled
nursing facility” by the Department of Health and Human Services pursuant to Title XVIII
of the Social Security Amendments of 1965.
Section 36. The term “Trust Agreement” means the Trust Agreement establishing the Laborers
Health and Welfare Trust Fund for Northern California, including any amendment, extension or
renewal.
Section 37. The term “Usual, Customary and Reasonable (UC&R) Fee or Charge”
means the usual or customary fee charged by a Hospital, Physician, Dentist, or other licensed
professional providing medical services, treatments or supplies which do not exceed the general
level of charges made by others providing similar services, treatments, or supplies within the
same service area. The charges incurred must be comparable, based on the severity and nature
of the bodily injury, illness, or dental condition treated. Billed charges are not always the same
as Usual, Customary and Reasonable fees or charges.
Section 38. The term “Utilization Review (UR) Program” means a program that requires an
Eligible Individual who is admitted or scheduled to be admitted to a Hospital have his Physician
obtain the opinion of the Professional Review Organization (PRO) as to the Medical Necessity of
the confinement, in order to receive the maximum Hospital Benefits.
71
ARTICLE II.
ELIGIBILITY FOR BENEFITS
Section 1.
Definitions. The following definitions will govern in this Article:
a. The term “Hour Bank” means the account established for an employee of an Individual
Employer(s). All hours for which an Individual Employer(s) makes contributions to the Fund
with respect to the employee’s work are credited to the account.
b. The term “Individual Employer” means any employer who is required by a collective
bargaining agreement with the Union to make contributions to the Fund.
c. The term “Union” means the Northern California District Council of Laborers of the Laborers’
International Union of North America, AFL-CIO and its affiliated local unions.
Section 2.
Eligibility Rules for Active Employees
a. Establishment and Maintenance of Eligibility
(1) A person who is an employee of an Individual Employer on whose behalf contributions
are made to the Fund will be eligible for Fund benefits on the first day of the second
calendar month after he works 440 hours for one or more Individual Employers. A person
will continue to be eligible during any subsequent month for which the appropriate
deduction has been made from his Hour Bank as described in Subsection a.(2).
Exception: In cases where a new signatory employer had been providing health
coverage to its employees immediately prior to signing a collective bargaining agreement,
each employee who had coverage under the new employer’s prior plan, in the month
immediately preceding transition to this Plan, will have coverage in this Plan beginning
on the first day of the month immediately following the new employer’s transition to this
Plan. The intention of this exception is to provide uninterrupted coverage for employees
transitioning to this Plan by way of their current employer signing a collective bargaining
agreement requiring contributions to be paid to this Trust Fund. This uninterrupted
transition will only apply in cases where: (1) the new signatory employer had provided
coverage immediately prior to joining this Plan, and (2) the employee had coverage
under that plan during the month immediately preceding the first month of coverage
under this Plan. Following this transition month, coverage will continue for each month
in which he works a minimum of 160 hours for one or more Individual Employers, for
which contributions were made on his behalf. 110 hours are to be used for the current
month’s eligibility and the remaining hours are to be placed in the employee’s Hour Bank.
Once the employee accumulates 440 hours in his Hour Bank, the appropriate deduction
will be made from his Hour Bank as described in Subsection a.(2). This exception is
effective, October 1, 2004 through May 31, 2006, unless extended by the Trustees.
(2) Hour Bank Deductions. 110 hours will be deducted from the Active Employee’s Hour
Bank for each month of eligibility. The maximum hours in an Active Employee’s Hour
Bank cannot exceed 990 hours after deducting 110 hours for the current month’s
eligibility.
72
(3) Disability Credit. If an Active Employee has met the work-hour requirements of
Subsections a.(1) and (2) above and becomes disabled and unable to perform any
and every duty of his occupation, he will receive disability credit at the rate of 8 hours
per day up to 40 hours in one week not to exceed 110 disability hours in any month.
Disability credit is not given for Saturdays and Sundays. Disability credit will not be
granted for more than 6 months during any consecutive 12-month period.
In order to obtain disability credit, a Physician’s certification must be filed with the Fund
Office on a form approved by the Board of Trustees within one year from the start of
disability.
(4) Reciprocity Credit. Hours credited by another welfare trust fund with which the Board
of Trustees has entered into a Reciprocity Agreement may be used to satisfy the
requirements of Subsections a.(1) and (2) of this Article if the person would otherwise
be ineligible for the benefits. However, an Active Employee may qualify for eligibility
under this Subsection only for the month for which he files the required notification
under the terms prescribed by the Reciprocity Agreement.
(5) Credit While Serving in Military. If an Active Employee enters military service (other
than a temporary tour of duty not exceeding 30 days) under circumstances which entitle
him to re-employment rights under federal law and subsequently returns to work or
makes himself available for work as a Laborer within the jurisdiction of the Fund for an
Individual Employer and within the period during which he has re-employment rights
under federal law, he will have his Hour Bank and eligibility reinstated to the same level
as of the date he entered military service.
The Active Employee must file a written notice of his return to or availability for work
with the Fund Office on a form approved by the Board of Trustees. Depending on the
time spent in military service, the Active Employee must provide written notice by the
deadlines shown below:
(a) For service of more than 30 days but less than 181 days, written notice must be
provided within 30 days of release from military duty; or
(b) For service of more than 180 days, written notice must be provided within 90 days
of release from military duty.
(6) A person who is a Dependent of an Active Employee will be eligible for Fund benefits
on the date the Active Employee becomes eligible or on the date the person becomes
a Dependent, whichever is later.
b. Termination of Eligibility
(1) An Active Employee’s eligibility will terminate on the earliest of the following dates:
(a) The last day of the month following the month in which his Hour Bank balance falls
below 440 hours before the deduction is made for the current month’s coverage.
Exception: An Active Employee who retires and who has at least 440 hours in his
Hour Bank on the date of his retirement will continue his eligibility until the last day of
73
the month following the month in which his Hour Bank falls below 110 hours before the
deduction is made for the current month’s coverage.
(b) The last day of the month following entry into military service (other than a temporary
tour of duty not exceeding 30 days).
(c)
At the end of the calendar month in which he performs work of the type covered
by the collective bargaining agreement, for an employer that is not an Individual
Employer as defined in Section 1.b. of this Article.
(2) If an Active Employee dies, his eligibility will terminate on the last day of the month for
which he qualified for coverage under Subsections 2.a.(1), (2) and (3) of this Article.
However, the Dependents of an Active Employee who dies with at least 440 hours in his
Hour Bank on the date of his death will continue to maintain eligibility until the last day
of the month following the month in which the deceased Active Employee’s Hour Bank
falls below 110 hours before the deduction is made for the current month’s coverage.
(3) The eligibility of a Dependent of an Active Employee will terminate on the earliest of the
following dates:
(a) On the date the Active Employee’s eligibility terminates, except as provided for in
Subsection 2.b.(2) above.
(b) On the date he no longer qualifies as a Dependent, as defined in Article I,
Section 8.
c. Reinstatement of Eligibility
(1) If an Active Employee’s eligibility has terminated, his eligibility will be reinstated on the
first day of the second calendar month following the month in which the hours in his
Hour Bank total a minimum of 440, provided eligibility is regained within 13 months of
the loss of eligibility.
(2) If an Active Employee fails to regain his eligibility within 13 months, he will forfeit all hours
in his Hour Bank and will again become eligible only upon meeting the requirements of
Subsection 2.a.(1).
Exception: If an Active Employee fails to regain his eligibility within 13 months because
he was disabled and unable to perform any and every duty of his occupation, he may
petition the Board of Trustees to reinstate any hours that were forfeited. The petition
must include competent medical evidence that the Active Employee was unable to
engage in or perform work in the Building and Construction Industry. Evidence may
include proof of continuous coverage under State Disability Insurance or Workers’
Compensation. The Trustees will not reinstate the Hour Bank of a Participant whose
disability was due to an injury or illness not covered by the Plan, or whose disability is
due to non-physical causes including, but not limited to, abuse of chemical substances.
The Trustees may require the Participant to sign a HIPAA compliant authorization for
the release of medical records related to the disability.
74
Section 3.
Continuation Coverage under COBRA
The health care continuation coverage provisions of the Employee Retirement Income Security
Act, Section 601 et seq., as amended, require that when coverage terminates under certain
circumstances, health plan benefits must be made available to Eligible Individuals through self
payment. To the extent that COBRA applies to any Eligible Individual under this Plan, these
benefits will be offered in accordance with this Section.
a. General. Active Employees or their Dependents who lose eligibility under the Plan may
continue Plan coverage subject to the terms of this Section. This Section is intended to
comply with the health care continuation provisions of COBRA, including any regulations
which are incorporated by reference and will be controlling in the event of any conflict
between those provisions and the terms of this Section.
b. Continuation Coverage. Active Employees or their Dependents whose eligibility terminates
may continue coverage (except Death, Accidental Death and Dismemberment Benefits),
under COBRA upon the occurrence of a “Qualifying Event.”
A “Qualifying Event” is defined as any of the following:
(1) The Active Employee’s Employer(s) reports less than the minimum required hours as
shown in Section 2.a.(1);
(2) the Active Employee’s death;
(3) divorce of the Active Employee from his Dependent spouse;
(4) cessation of a Dependent child’s dependent status.
c. Qualified Beneficiary. A Qualified Beneficiary is defined under COBRA as an individual who
on the day before a Qualifying Event was covered under this Plan as an Active Employee,
the spouse of an Active Employee, or a Dependent child of an Active Employee. A child born
to or placed for adoption with an Active Employee during a period of COBRA Continuation
Coverage will also be a Qualified Beneficiary.
d. Duration of Coverage.
(1) Qualified Beneficiary whose coverage terminated because of a Qualifying Event as
described in this Subsection 3.b.(1) may elect continuation coverage for up to 18
months from the date of termination of eligibility. This 18-month period will expand to
a maximum of 36 months from the date of the Qualifying Event if a second Qualifying
Event (other than a Qualifying Event described in Subsection b.(1) of this Section)
occurs with respect to that Qualified Beneficiary during the original 18-month period and
while the Qualified Beneficiary is covered under the Plan.
(2) If coverage is terminated due to a Qualifying Event described in Section 3.b.(1), the 18month period may be extended up to a total of 29 months for any Qualified Beneficiary
who is determined by Social Security to be totally disabled any time before or during
the first 60 days of COBRA Continuation Coverage, the disabled person and family may
extend COBRA Continuation Coverage beyond the original 18 months up to 29 months.
To qualify for the additional 11 months, a Qualified Beneficiary must report the Social
Security disability determination to the Fund Office in writing before the original 18-
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month period expires and within 60 days after the date of the determination. Premiums
charged for the additional 11-month period will be approximately 50% higher than the
premium for the initial 18-month period.
(3) If the Qualifying Event described in Section 3.b.(1) occurs less than 18 months after the
date the Active Employee becomes eligible for Medicare (Part A, Part B or both), the
maximum period of continuation coverage for the Dependents of the Active Employee
will be 36 months from the date of the Active Employee’s Medicare entitlement.
(4) Medicare entitlement is not a Qualifying Event under the Plan. Medicare entitlement
following an Active Employee’s termination of employment or reduction in hours will not
extend a Dependent Qualified Beneficiary’s COBRA coverage beyond the 18-month
period allowed for the Qualifying Event described in Section 3.b.(1).
(5) A Qualified Beneficiary whose coverage would otherwise terminate because of a
Qualifying Event other than one described in Section 3.b.(1), may elect continuation
coverage for up to 36 months from the date of the Qualifying Event.
e. Termination of Continuation Coverage. Notwithstanding the maximum duration of coverage
described in the above paragraphs, a Qualified Beneficiary’s continuation coverage will end
on the earlier of the date on which:
(1) the employer of the Qualified Beneficiary ceases to provide group health coverage to
any Active Employee;
(2) the premium described in Subsection g. below is not timely paid;
(3) the Qualified Beneficiary becomes covered under another Group Plan after electing
COBRA Continuation Coverage (as an employee or otherwise) which does not contain
any exclusion or limitation with respect to any pre-existing condition;
(4) the Qualified Beneficiary (after the Qualifying Event), enrolls in either Part A or Part B of
Medicare;
(5) the Participant or Dependent has continued coverage for additional months due to a
disability and there has been a final determination by Social Security that the individual
is no longer disabled.
f. Types of Benefits Provided. A Qualified Beneficiary will be provided health coverage under
the Plan which is identical to the health coverage that is provided to other Eligible Individuals
who have not experienced a Qualifying Event. A Qualified Beneficiary will have the option of
taking “Core Coverage” only instead of full coverage. “Core Coverage” refers to the health
benefits the Qualified Beneficiary was receiving immediately before the Qualifying Event,
except dental, vision, and death, accidental death and dismemberment benefits.
g. Premiums. A premium for continuation coverage will be charged to Qualified Beneficiaries
in amounts established by the Board of Trustees. The premium will be payable in monthly
installments. The first installment of the premium must be paid within 45 days of the date the
Qualified Beneficiary elects continuation coverage and must include payment for all months
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of COBRA coverage to date. Thereafter, monthly premium payments are due on the first day
of the month for which continuation coverage is elected. There will be a grace period of 30
days to pay the monthly premium payments. If payment of the amount due is not made by
the end of the applicable grace period, COBRA Continuation Coverage will terminate. The
Board of Trustees may, upon good cause shown, extend the premium payment due date.
h. Notice Requirements for Qualified Beneficiaries.
(1) The Qualified Beneficiary is responsible for providing the Fund Office with timely written
notice of any of the following events:
(a) The divorce of a Participant from his Spouse.
(b) A child losing Dependent status under the Plan.
(c)
If a second Qualifying Event occurs after a Qualified Beneficiary has become
entitled to COBRA with a maximum of 18 (or 29) months.
In the case of any of the events described in Subsections (a), (b) and (c) above, the
Qualified Beneficiary must notify the Fund Office in writing no later than 60 days after
the date of the Qualifying Event.
(d) When a Qualified Beneficiary entitled to receive COBRA Coverage with a maximum
of 18 months has been determined by the Social Security Administration to be
disabled, the Qualified Beneficiary must provide written notice to the Fund Office
of the disability determination before the end of the initial 18-month continuation
coverage period and within 60 days after the date of the determination.
(e) When the Social Security Administration determines that a Qualified Beneficiary is
no longer disabled, written notice must be provided to the Fund Office no later than
30 days after the date of the determination by the Social Security Administration
that the person is no longer disabled.
(2) The written notice must contain the following information: name of Qualified Beneficiary,
Participant’s name and identification number, the Qualifying Event for which notice is
being given, date of the Qualifying Event, copy of the final marital dissolution if the event
is a divorce.
(3) Notice may be provided by the Participant, Qualified Beneficiary with respect to the
Qualifying Event, or any representative acting on behalf of the Participant or Qualified
Beneficiary. Notice from one individual will satisfy the notice requirement for all Qualified
Beneficiaries affected by the same Qualifying Event.
(4) Failure to provide the Fund Office with written notice of the occurrences described in
Subsection (1) above, and within the required time frames, will prevent the individual
from obtaining or extending COBRA Continuation Coverage.
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i. Notice Requirements for Employers and the Plan.
(1) If the Qualifying Event is the death of the Participant, the Employer must notify the Fund
Office in writing of the Qualifying Event within 30 days after the Qualifying Event.
(2) If the Qualifying Event is a reduction in hours, the determination that a Participant’s
Employer(s) has reported less than the minimum required hours referenced in Section
3.b.(1) on the Participant’s behalf will be made by the Fund Office.
(3) No later than 14 days after the date on which the Fund Office receives written notification
from the Qualified Beneficiary or Employer, or after the Fund Office has determined that
less than the minimum required hours have been reported by the Employer, the Plan
will send a written notice to the Qualified Beneficiary affected by the Qualifying Event of
his rights to continuation coverage.
Notwithstanding the immediately preceding paragraph, the Plan’s written notification to a
Qualified Beneficiary who is a Dependent spouse will be treated as notification to all other
Qualified Beneficiaries residing with that person at the time notification is made.
j. Election Procedure.
(1) A Qualified Beneficiary must elect continuation coverage within 60 days after the later
of:
(a) the date on which the Qualified Beneficiary loses coverage under the Plan as a
result of a Qualifying Event; or
(b) the date on which the Qualified Beneficiary receives notice of COBRA Continuation
Coverage from the Fund Office.
(2) Any election made by a Qualified Beneficiary who is an Active Employee or Dependent
spouse on behalf of any other Qualified Beneficiary will be binding. However, each
individual who is a Qualified Beneficiary with respect to the Qualifying Event has an
independent right to elect COBRA coverage. The failure to elect COBRA by an Active
Employee or Dependent spouse will not prevent any other Qualified Beneficiary from
being given the same 60-day period to elect or reject the coverage.
k. Types of Benefits Provided. A Qualified Beneficiary will be provided health coverage under
the Plan which is identical to the health coverage he had on the day before the Qualifying
Event and is offered to other Beneficiaries who have not experienced a Qualifying Event.
l. Addition of New Dependents.
(1) If, while enrolled for COBRA Continuation Coverage, a Qualified Beneficiary marries, has
a newborn child, has a child placed for adoption or assumes legal guardianship of a child,
he may enroll the new spouse or child for coverage for the balance of the period of COBRA
Continuation Coverage by doing so within 30 days after the birth, marriage, placement
for adoption or assumption of legal guardianship. Adding a child or spouse may cause an
increase in the amount that must be paid for COBRA Continuation Coverage.
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(2) Any Qualified Beneficiary may add a new spouse or child to his or her COBRA
Continuation Coverage. The only newly added family members who have the rights
of a Qualified Beneficiary, such as the right to stay on COBRA coverage longer in the
event of a second Qualifying Event, are the natural or adopted children of the former
Participant or children for whom the former Participant is legal guardian.
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ARTICLE III.
DEATH BENEFITS FOR ACTIVE EMPLOYEES
Section 1.
Death Benefit
a. If an Active Employee dies while eligible or within 31 days following the termination
of his eligibility, the Fund will, subject to all other Plan provisions, pay a Death Benefit
of $15,000.
b. Facility of Payment
(1) If any beneficiary is a minor or is legally incompetent or incapable of handling his
own affairs, the Fund reserves the right to make payment in monthly installments not
exceeding $100 to the person or persons, or institution, who had been caring for or
supporting the beneficiary, until a claim is made for the remainder by a duly appointed
guardian, conservator or other legal representative of the beneficiary.
(2) The Fund may, at its option, pay an amount not to exceed $250 of the Death Benefit
to any person who has incurred expenses in connection with the burial of the Active
Employee.
(3) Any payment made under this Subsection will discharge the obligation of the Fund to
the extent of that payment.
c. Payment of Death Benefit of Totally Disabled Former Active Employee
The Death Benefit amount payable under Subsection 1.a. above on the date eligibility
terminated will be payable to the beneficiary of a totally disabled former Active Employee
under the following circumstances:
(1) He must, while eligible and prior to age 60, have become totally disabled so as not to
have been able to engage in any occupation for compensation or profit; and
(2) If the former Active Employee dies within one year following the date his eligibility
would have otherwise terminated under Article II, Subsection 2.b., and evidence of the
uninterrupted existence of total disability was furnished to the Board of Trustees within
one year following his death; or
(3) If the former Active Employee dies one year or more following the date his eligibility would
have otherwise terminated under Article II, Subsection 2.b., and proof of uninterrupted
total disability was submitted to the Board of Trustees within one year after that date
and annually thereafter; and
(4) If the former Active Employee was totally disabled for 2 full years, he submitted to a
medical examination by a Physician, but not more often than once a year if he was
required to do so by the Board of Trustees.
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(5) For Active Employees who become totally disabled on or after June 1, 1994, a Death
Benefit will not be payable under any circumstances once the former Active Employee
reaches Normal Retirement Age (age 65).
Section 2.
Accidental Death and Dismemberment Benefits
a. Accidental Death Benefit
If an Active Employee sustains bodily injuries solely through external, violent and accidental
means, and dies as a result of those injuries within one year following the accident in which the
injuries were sustained, the Fund will, subject to all other Plan provisions, pay an Accidental
Death Benefit of $15,000.
b. Accidental Dismemberment Benefits
If an Active Employee sustains bodily injuries solely through external, violent and accidental
means, and within one year following the accident in which the injuries were sustained suffers
one of the losses enumerated below, the Fund will, subject to all other Plan provisions, pay
to the Active Employee a Dismemberment Benefit in the following amount:
(1) $7,500 for (a) the loss of a hand by severance at or above the wrist, (b) the loss of a foot
by severance at or above the ankle, or (c) the irrecoverable loss of sight of an eye.
(2) $15,000 for the loss of more than one of the members identified in Subsection b.(1).
c. Limitations
(1) Not more than $15,000 is payable under Subsections a. and b. above as a result of any
one accident.
(2) No benefits are payable for any loss resulting from bodily injuries sustained as a result
of:
(a) disease or bodily or mental infirmity, or medical or surgical treatment, ptomaine
or bacterial infections (except infections occurring through an accidental cut or
wound); or
(b) suicide, attempted suicide, or self-inflicted injury; or
(c)
war or an act of war, or service in any military, naval or air force of any country
engaged in war, or police duty as a member of any military, naval or air organization;
or
(d) participation in, or as the consequence of having participated in, the commission
of a felony.
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Section 3.
Beneficiaries
a. Designation of Beneficiary
An Active Employee may designate a beneficiary or beneficiaries to receive the Death Benefit
or Accidental Death Benefit payable under this Article by forwarding the designation on a form
acceptable to the Board of Trustees to the Fund Office. An Active Employee has the right
to change his beneficiary designation without the consent of the beneficiary, but no change
will be effective or binding on the Fund unless the Fund Office receives the designation
prior to the time any payments are made to the beneficiary whose designation is on file with
the Fund. If more than one beneficiary is designated, and their respective interests are not
specified, they will share equally.
If a designated beneficiary is found guilty of feloniously and intentionally causing the death
of the Active Employee, that beneficiary will be disqualified from receiving payment of death
benefits which may be payable under this Article. If no other beneficiary has been designated,
then any death benefits payable will be paid in accordance with Section 3.b. below.
b. Lack of Designated Beneficiary
If no beneficiary has been designated, or if a designated beneficiary dies before the Death
Benefit or Accidental Death Benefit is paid, the Death Benefit or Accidental Death Benefit will
be paid to the lawful spouse of the Active Employee if living, or if there is no lawful spouse
alive at the time of payment, payment may be made to one or more of the following surviving
relatives of the Active Employee: child or children, mother, father, brothers or sisters, or to
the Active Employee’s estate, as the Board of Trustees in its sole discretion may designate.
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ARTICLE IV.
DEATH BENEFITS FOR DEPENDENTS
OF ACTIVE EMPLOYEES
Section 1.
Dependents’ Death Benefit
Upon the death of a Dependent of an Active Employee, the Fund will, subject to all other Plan
provisions, pay the Dependents’ Death Benefit to the Active Employee or the beneficiary, whichever
is applicable, in accordance with the following schedule:
Dependent
Spouse
Children:
• 24 hours, but less than 2 years of age
• 2 years, but less than 5 years of age
• 5 years, but less than 19 years of age
Section 2.
Amount of
Dependent’s
Death Benefit
$7,500
$500
$750
$1,000
Beneficiaries
The Dependents’ Death Benefit will be paid to the Active Employee, if living. Otherwise, the
Dependents’ Death Benefit will be paid to one or more of the following surviving relatives of the
Active Employee: lawful spouse, child or children, mother, father, brothers or sisters, or to the
Active Employee’s estate, as the Board of Trustees in its sole discretion may designate.
Section 3.
Extended Benefits
If the Dependent of a deceased Active Employee dies within 6 months following the date the
Active Employee would have no longer been eligible for benefits, the Fund will, subject to all other
Plan provisions, pay to the beneficiary the applicable Dependents’ Death Benefits set forth in
Section 1. of this Article.
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ARTICLE V.
HOSPITAL-MEDICALBENEFITS
Section 1.
Hospital Benefits
a. Benefits for Confinement in a Participating Hospital
If an Eligible Individual is confined in a Participating Hospital with the approval of the
Professional Review Organization (PRO), the Fund will, subject to all other Plan provisions,
pay the Participating Hospital 90% of the first $10,000 of the negotiated contract rate under
the Fund’s Preferred Provider Plan and 100% thereafter for all necessary services provided
during the first 30 days of confinement during one period of disability, including but not limited
to, room and board and routine nursing care.
b. Benefits for Confinement in a Non-Participating Hospital
If an Eligible Individual is confined in a Non-Participating Hospital with the approval of
the PRO, the Fund will, subject to all other Plan provisions, pay the Employee 70% of the
first $10,000 of Covered Charges incurred and 100% thereafter during the first 20 days of
confinement during any one period of disability.
For purposes of this Article V., Section 1., “Covered Charges” are defined as: Room and board
and routine nursing charges up to an amount equal to the Non-Participating Hospital’s lowest
rate charged for semi-private room accommodations, or 80% of the lowest rate charged for
private room accommodations. If the Eligible Individual receives care in an Intensive Care
Unit, the full cost, based on the lowest rate charged for care in that unit, will be paid.
c. Exceptions to Preferred Provider Plan
(1) If an Eligible Individual who does not reside within the Fund’s Preferred Provider Plan
Service Area is confined in a Non-Participating Hospital with the approval of the PRO,
the Fund will pay the Active Employee 90% of the first $10,000 of Covered Charges
incurred and 100% thereafter, during the first 20 days of confinement for any one period
of disability.
(2) If an Eligible Individual who resides within the Fund’s Preferred Provider Plan Service
Area is confined in a Non-Participating Hospital due to a serious or life threatening
emergency, the Fund will pay the Active Employee Covered Charges incurred as
provided in Subsection c.(1) above. However, the Fund may require the transfer of the
Eligible Individual to a Participating Hospital, upon the advice of a Physician that it is
medically safe to make the transfer.
84
d. Utilization Review
(1) If an Eligible Individual is to be confined in a Hospital on an elective, non-emergency
basis, the admitting Physician must obtain Pre-Admission Review by the Professional
Review Organization (PRO) to determine prior to the admission, the medical necessity
of the Hospital confinement, and the number of pre-authorized days, if any, determined
by the PRO to be Medically Necessary for the confinement.
(a) If an Eligible Individual’s Physician does not obtain Pre-Admission Review by the
PRO, and the Eligible Individual is confined in a Participating Hospital, the Fund
will, subject to all other Plan provisions, pay 70% of the first $10,000 of benefits
and 100% of benefits thereafter.
(b) If an Eligible Individual’s Physician does not obtain Pre-Admission Review by the
PRO, and the Eligible Individual is confined in a Non-Participating Hospital, the
Fund will, subject to all other Plan provisions, pay 50% of the first $10,000 of
benefits and 100% of benefits thereafter.
(c)
If an Eligible Individual’s Physician does not obtain Pre-Admission Review by
the PRO, and PRO determines that confinement in a Hospital is not Medically
Necessary, and the Eligible Individual is nevertheless confined in a Hospital, the
Fund will not be obligated to provide benefits for medical services or supplies not
reasonably necessary for the care or treatment of bodily injuries or illness.
(d) If an Eligible Individual’s Physician obtains Pre-Admission Review by the PRO, and
the PRO pre-authorizes a specified number of days as Medically Necessary for the
confinement, and the Eligible Individual is nevertheless confined in a Hospital for a
greater number of days than pre-authorized by the PRO, the Fund will, subject to
all other Plan provisions, pay the benefits otherwise payable for the number of days
pre-authorized by the PRO for confinement in a Participating or Non-Participating
Hospital, as described in Subsections 1a. and 1b. However, the Fund will not be
obligated to pay for medical services or supplies provided for any days in excess
of those authorized by the PRO.
(2) If an Eligible Individual is confined in a Hospital on an elective, non-emergency basis,
the admitting Physician must obtain Concurrent Review by the PRO once the Eligible
Individual has been admitted to the Hospital, to determine the number of days authorized
by the PRO as Medically Necessary, or any change in the number of days authorized as
Medically Necessary by the PRO if Pre-Admission Review has taken place previously.
(a) If an Eligible Individual is confined in a Hospital, and the admitting Physician does
not obtain Concurrent Review by the PRO, the Fund will, subject to all other Plan
provisions, pay the reduced benefits described in Subsection d.(1)(a) or d.(1)(b)
if Pre-Admission Review was not performed. Further, in order to determine
the number of days authorized as Medically Necessary in the absence of PreAdmission and Concurrent Reviews, the Fund will request that the PRO conduct a
Retrospective Review. If the Retrospective Review determines that any days of the
confinement are not Medically Necessary, the Fund will not be obligated to provide
benefits for medical services or supplies not reasonably necessary for the care or
85
treatment of bodily injuries or illness for any days in excess of those authorized by
the PRO’s Retrospective Review.
(b) If an Eligible Individual is confined in a Hospital and the admitting Physician obtains
Concurrent Review by the PRO which determines a greater or lesser number of
days of confinement as Medically Necessary than were previously determined by
Pre-Admission Review, the Fund will, subject to all other Plan provisions, pay the
benefits otherwise payable for the number of days determined by the PRO to be
Medically Necessary by Concurrent Review for confinement in a Participating or
Non-Participating Hospital, as described in Subsections 1a. and 1b. However, the
reasonably necessary for the care or treatment of bodily injuries or illness for any
days in excess of those authorized by the PRO’s Concurrent Review.
(3) If an Eligible Individual is confined in a Hospital on an emergency basis, the admitting
Physician must obtain Concurrent Review by the PRO once the Eligible Individual has
been admitted to the Hospital to determine the number of days authorized by the PRO
as Medically Necessary.
(a) If an Eligible Individual is confined in a Participating Hospital and the admitting
Physician does not obtain Concurrent Review by the PRO, the Fund will, subject
to all other Plan provisions, pay 70% of the first $10,000 of benefits and 100% of
benefits thereafter. Further, in order to determine the number of days authorized as
Medically Necessary in the absence of Concurrent Review, the Fund will request
that the PRO conduct a Retrospective Review. If the Retrospective Review
determines that any days of the confinement are not Medically Necessary, the
Fund will not be obligated to pay for medical services or supplies provided for any
days in excess of those authorized by the PRO’s Retrospective Review.
(b) If an Eligible Individual is confined in a Non-Participating Hospital and the admitting
Physician does not obtain Concurrent Review by the PRO, the Fund will, subject
to all other Plan provisions, pay 50% of the first $10,000 of benefits and 100% of
benefits thereafter. Further, in order to determine the number of days authorized as
Medically Necessary in the absence of Concurrent Review, the Fund will request
that the PRO conduct a Retrospective Review. If the Retrospective Review
determines that any days of the confinement are not Medically Necessary, the
reasonably necessary for the care or treatment of bodily injuries or illness for any
days in excess of those authorized by the PRO’s Retrospective Review.
e. Period of Disability
All confinements in a Hospital or Skilled Nursing Facility will be considered to have occurred
during one period of disability unless the confinements were due to entirely unrelated causes
or unless: (1) in the case of an Active Employee, they are separated by a return to work or
the status of availability for work, or (2) in the case of a Dependent, they are separated by 3
or more months.
86
f. Limitation
No benefits are payable for any period of confinement which extends beyond the period
approved by the PRO or for any period of confinement which is solely for the convenience
of the Eligible Individual.
Section 2.
Skilled Nursing Facility Benefits
If an Eligible Individual is confined in a Skilled Nursing Facility with the approval of the PRO, the
Fund will, subject to all other Plan provisions, pay the Active Employee the amount of expenses
incurred up to the maximum number days of confinement allowed during any one period of
disability for:
a. Room and board and routine nursing charges up to an amount equal to the Skilled Nursing
Facility’s lowest rate charged for semi-private room accommodations, or 80% of the lowest
rate charged for private room accommodations, if used.
(1) Each 2 days of confinement in a Skilled Nursing Facility is equal to one day of confinement
in a Hospital and is included in the maximum number of days allowed for Hospital
Benefits.
A “period of disability” is defined in Subsection 1.e. of this Article.
Section 3.
Comprehensive Medical Benefits
a. Covered Expense. The term “Covered Expense” refers to the items of medical expense
described in this Section that may be payable under the Plan’s Comprehensive Medical
Benefits, subject to all other Plan provisions.
b. Deductible
(1) Each Eligible Individual is responsible for the first $150 of Covered Expense. This
Deductible is an out-of-pocket cost for Covered Expenses incurred during any one Plan
Year before Comprehensive Medical Benefits become payable. When a total of $450
in Deductible Covered Expenses has been satisfied by covered family members during
any one Plan Year, the Plan will waive any further Deductible amount for that family
during the remainder of the Plan Year.
Deductibles that would normally apply for claims incurred in a month in which 2 Active
Employees can claim each other as a Dependent, as defined in Article I. Section 8.a.,
will be waived while both Active Employees remain eligible for benefits under the Plan. If
either Active Employee subsequently loses eligibility under this Plan, the Deductible for
the former Active Employee and any Dependent will be reinstated, less any Deductible
amounts previously satisfied during the Plan Year.
(2) If a Covered Expense is incurred during the last 3 months of a Plan Year (December,
January, February) and applied against the Deductible amount for that Plan Year, the
expense will be carried forward to apply against the Deductible amount for the following
Plan Year.
87
c. Physician Office Visit Copayment. Except as provided below, a $15.00 copayment is
required for every visit to a Physician’s office before Comprehensive Medical Benefits are
payable. The exceptions to this requirement are as follows:
(1) Visits to a chiropractor.
(2) Visits for treatment of mental or nervous disorders.
(3) Visits for consultation, upon the referral of the Eligible Individual’s primary Physician.
The $15.00 Physician Office Visit Copayment is in addition to the Deductible described in
Subsection 3.b. above.
d. Hospital Emergency Room Copayment. If an Eligible Individual incurs expenses in
the emergency room of a Hospital, a $25.00 copayment will be required if a Participating
Hospital is used or a $50.00 copayment will be required if a Non-Participating Hospital is
used, before Comprehensive Medical Benefits are payable. The copayment will be waived
under any of the following circumstances:
(1) The emergency room visit results in the overnight confinement of the Eligible
Individual.
(2) The emergency room services are provided as a result of paramedic intervention.
(3) The Eligible Individual is dead on arrival at the emergency room or dies while receiving
services in the emergency room.
The Hospital Emergency Room Copayment is in addition to the Deductible described in
Subsection 3.b. above.
e. Payment. If an Eligible Individual receives therapeutic treatment for an illness, injury or
pregnancy, the Fund will, subject to all other Plan provisions, pay for the Covered Expenses
indicated below, up to a Plan maximum of $1,000,000. The treatment, services or supplies
must be certified by a Physician as being required for treatment of the illness, injury or
pregnancy.
If Comprehensive Medical Benefits have been paid for an Eligible Individual, an amount equal
to the benefits paid up to $2,000 will automatically be reinstated on March 1 of each Plan
Year, but the total amount reinstated in any Plan Year may not increase the Comprehensive
Medical Benefits payable during any Plan Year to more than $1,000,000.
(1) For Covered Expenses incurred at a Participating Provider, the Fund will pay 90% of
the negotiated contract rate. For Routine Office Visits at a Participating Provider, the
Fund will pay 100% of the negotiated rate after payment of the $15 Physician Office
Visit Copayment.
(2) For Covered Expenses incurred at a Non-Participating Provider, the Fund will pay the
lesser of the amount actually charged or 70% of Usual, Customary and Reasonable
Charges (UC&R).
88
Exceptions:
• Emergency Room Services - If an Eligible Individual receives treatment at a
Participating Hospital’s Emergency Room from an attending Physician that is not a
Participating Provider, the Plan will pay 90% of UC&R charges for the professional
services provided by that attending Physician.
• Podiatry Treatment - If an Eligible Individual requires the services of a Podiatrist
(DPM), the Fund will pay 90% of the contract rate negotiated by the Podiatry Plan
Organization of California (PPOC). If an Eligible Individual uses the services of
a Podiatrist that is not in the PPOC network, the Plan will pay 70% of the UC&R
charges.
• Professional Ambulance Service - If an Eligible Individual requires Emergency
Services for a life threatening illness or injury, the Fund will pay 90% of the amount
actually charged or Usual, Customary, and Reasonable (UC&R), whichever is less,
for transportation by a Non-Participating professional ambulance service if requested
by a Hospital or by paramedic personnel.
f.
Plan Year Out-of-Pocket Maximum
The maximum out-of-pocket expense for Active Employees and their Dependents under this
Article will be $3,000 per Eligible Individual, up to $6,000 per family. The following charges
incurred by Eligible Individuals will not be applied toward the Out-of-Pocket Maximum:
(1) Physician Office Visit Copayment
(2) Hospital Emergency Room Copayment
(3) Co-insurance payment for Hospital confinements when the Eligible Individual resides
within the Fund’s Preferred Provider Service Area and uses the services of a NonParticipating Hospital, except in cases of serious or life threatening emergencies
(4) Co-insurance payment to a Non-Participating Provider
(5) Charges for any medical services or supplies excluded or limited by the Plan
(6) Penalties for non-compliance with the Plan’s Utilization Review Program
g.
Included in Covered Expenses are:
(1) Charges for medical or surgical services by a Physician, except:
(a) charges made by a chiropractor are limited to $40.00 per visit and 20 visits during
each Plan Year;
(b) charges made by a chiropractor for X-rays are limited to $100.00 each Plan Year.
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(2)
Charges for nursing services provided by a registered graduate nurse, or licensed vocational
nurse.
(3)
Charges made by a Hospital on its own behalf, except room and board charges in excess
of the Hospital’s lowest rate charged for semi-private room accommodations, or 80% of the
lowest rate charged for private room accommodations, if used, or if care is received in an
intensive care unit, the lowest rate charged for that unit.
(4)
Charges made for Rehabilitation Therapy performed by a licensed therapist, not related to the
Eligible Individual by blood or marriage. Covered services include short term active, progressive
occupational or physical therapy. Speech therapy is covered if it is to restore normal speech or
correct dysphagic or swallowing defects due to an illness, injury, or a surgical procedure.
(5)
Charges for the following medical services and supplies:
(a)
Anesthesia and its administration.
(b)
Blood and blood products.
(c)
Surgical dressings, splints, casts and other devices for the treatment of burns and
reduction of fractures and dislocations.
(d)
Diagnostic tests, X-ray and laboratory examinations made for diagnostic purposes in
connection with the therapeutic treatment of the Eligible Individual.
(e)
Radiation therapy.
(f)
Durable Medical Equipment (DME). DME includes, but is not limited to, apnea monitors,
commodes, hospital beds, electric and manual wheelchairs, nebulizers, and oxygen.
DME also includes Prosthetic devices designed to replace all or part of a missing body
part including, but not limited to, artificial limbs, heart pacemakers, or corrective lenses
required after cataract surgery. DME also includes Orthotic devices designed to support
a weakened body part including, but not limited to, specially designed corsets, leg braces,
or extremity splints.
(g)
Professional ambulance service when used to transport the Eligible Individual in need of
paramedic assistance:
(i)
directly from the place where he is injured by an accident or stricken by an illness
to a Physician;
(ii)
to or from a Hospital; or
(iii) by a licensed air ambulance if the charges do not exceed Usual, Customary, and
Reasonable Charge and if the Fund determines that the location and nature of the
illness or injury made air transportation cost effective or Medically Necessary to
avoid the possibility of serious complications or loss of life.
(h) Newborn and well child visits, including routine immunizations from birth through
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24 months of age, in accordance with the recommended schedule of the American
Academy of Pediatrics.
(i)
Outpatient intravenous therapy when authorized by and under the supervision of
a Physician for treatment of an illness that would otherwise require hospitalization.
Therapy includes the administration of cancer chemotherapy drugs and any other
drugs that require administration under the supervision of a Physician.
(6) Charges made by an Ambulatory Surgical Facility.
(7) Charges made by the emergency room of a Hospital.
(8) Charges made by a Hospice, upon referral by the Plan’s Case Management Program.
(9) Charges made for Home Health Care, upon referral by the Plan’s Case Management
Program.
(10) Charges made by a Physician for services and supplies related to administrating
contraceptive implants, injections, devices, or surgical procedure resulting in voluntary
infertility.
(11) Charges in connection with a mastectomy, including reconstruction of the breast on
which the mastectomy was performed, surgery on the other breast to produce a
symmetrical appearance, and prostheses and treatment of physical complications of all
stages of mastectomy, including lymphedemas.
(12) Charges in connection with Medically Necessary surgical treatment of morbid obesity
when the Eligible Individual’s Body Mass Index (BMI) is greater than 35 and complicated
by any of the following:
(a)
(b)
(c)
(d)
life-threatening cardiopulmonary conditions;
difficulty controlling diabetes mellitus or hypertension;
end stage renal disease with difficulty dialyzing;
severe sleep apnea documented by a sleep study performed by a certified sleep
clinic;
(e) severe lower extremity edema with ulceration;
(f) symptomatic degenerative joint disease, resulting in ambulatory difficulties (cane,
walker, wheelchair); or
(g) stress incontinence and gynecologic abnormalities.
Only one of the following bariatric surgical procedures will be covered in a lifetime:
Roux-en-Y gastric bypass, gastric stapling, or biliopancreatic bypass. Prior approval
by an independent Medical Consultant selected by the Fund is required which includes
a review of the Eligible Individual’s primary care medical record for the past 2 years,
assessment by a Registered Dietician confirming the readiness and ability of the Eligible
Individual to comply with post surgical dietary restrictions, and clear documentation of
the Eligible Individual’s failed attempts at weight loss by other conservative measures.
(13) Outpatient treatment of mental or psychiatric disorders including, but not limited to,
91
psychotherapy and psychological testing provided by a psychiatrist, psychologist, or
licensed clinical social worker is limited to 50% of the negotiated rates for Participating
Providers or 50% of Usual, Customary, and Reasonable (UC&R) for Non-Participating
Providers, not to exceed 40 visits per Plan Year.
(14) Expenses incurred for a hearing aid device prescribed by a Physician. The Fund will pay
up to $750 per device for each ear once every 36 months. Hearing tests are covered
after payment of the Physician Office Visit Copayment. Repairs to or replacement of a
hearing aid device that is lost, broken, or stolen are not covered.
(15) Charges of a Dentist for the following:
(a) the treatment necessary to alleviate the damage to broken or injured teeth as
a result of an accidental bodily injury (no payment is made under this Article for
replacement of teeth, in whole or in part) and
(b) Medically Necessary surgery not covered under the Fund’s Dental Benefits.
Section 4.
Physical Examination Benefit
If an Eligible Individual undergoes a routine physical examination by a Physician, the Fund will,
subject to all other Plan provisions, pay to the Active Employee the amount actually charged the
Active Employee for the examination and any X-ray and Laboratory examinations:
a. up to a maximum of $200 per Plan Year for each Active Employee or Dependent spouse of
an Active Employee; or
b. up to a maximum of $100 per Plan Year for each Dependent child of an Active Employee
who is over 24 months of age.
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ARTICLE VI.
DRUG BENEFITS
Section 1.
Definitions
a. Contracting Pharmacy. The term “Contracting Pharmacy” means a pharmacy which has
a contract to provide prescription Drug services to Eligible Individuals.
b. Formulary. The term “Formulary” means a preferred list of quality, cost effective medications
established by the Pharmacy Benefit Manager. Use of Formulary medications results in a
lower copayment.
c. Non-Contracting Pharmacy. The term “Non-Contracting Pharmacy” means a pharmacy
which has no contract to provide prescription Drug services to Eligible Individuals.
d. Pharmacy Benefit Manager. The term “Pharmacy Benefit Manager (PBM)” means an
organization under contract with the Fund to administer drug benefits for Active Laborers
and their Dependents.
Section 2.
Benefits. If an Eligible Individual obtains any of the items listed under “Covered
Charges” in Section 3. of this Article, the Fund will, subject to all other Plan provisions, pay the
applicable amount as set forth below:
a. If the item is obtained in accordance with established procedures at a retail Contracting
Pharmacy, the Fund will pay the Contracting Pharmacy as follows:
(1) for generic Drugs, the amount of expense incurred for the item less a copayment of
$10.00 for up to a 30-day supply per prescription, which is payable by the Eligible
Individual to the Contracting Pharmacy;
(2) for Formulary brand name drugs, the amount of expense incurred for the item less a
copayment of $20.00 for up to a 30-day supply per prescription, which is payable by the
Eligible Individual to the Contracting Pharmacy;
(3) for non-formulary brand name drugs, the amount of expense incurred for the item less
a copayment of $30 for up to a 30-day supply per prescription, which is payable by the
Eligible Individual to the Contracting Pharmacy.
If the prescription drug is a maintenance medication, that is, a medication the Eligible
Individual is taking to treat a long-term, chronic condition, and the Eligible Individual has had
the prescription filled 3 times at a retail Contracting Pharmacy, the copayment for the 4th refill
will be double the copayments listed above.
b. If the item is obtained at a Non-Contracting Pharmacy, the Eligible Individual will be
responsible for payment to the Non-Contracting Pharmacy for the full cost of the item. The
Eligible Individual will be reimbursed in accordance with the benefits payable in a.(1), (2), or
(3) above upon submission of a claim to the PBM.
93
c. If the item is obtained in accordance with established procedures through the Fund’s mailservice Contracting Pharmacy, the Fund will pay the Contracting Pharmacy as follows:
(1) for generic Drugs, the amount of expense incurred for the item less a copayment of
$20.00 for up to a 90-day supply per prescription, which is payable by the Eligible
Individual to the Contracting Pharmacy.
(2) for Formulary brand name Drugs, the amount of expense incurred for the item less a
copayment of $40.00 for up to a 90-day supply per prescription, which is payable by the
(3) for non-formulary brand name Drugs, the amount of expense incurred for the item less
a copayment of $60 for up to a 90-day supply per prescription, which is payable by the
Whether prescription drugs are obtained through retail or mail-service, if the Eligible Individual or
his Physician request a brand-name drug when a generic drug is available, the Eligible Individual
will be responsible for the difference in cost between the generic and brand name, in addition to
payment of the appropriate copayment.
Section 3.
Covered Charges. Included in Covered Charges are:
a. Charges made by a Licensed Pharmacist for Drugs prescribed by a Physician licensed by
law to administer or prescribe Drugs.
b. Charges made by a Licensed Pharmacist for insulin or insulin injection kits.
c. Charges made by a Physician licensed by law to administer Drugs, or insulin or insulin
injection kits:
(1) which are supplied to the patient in the Physician’s office, and
(2) for which a charge is made separately from the charge for any other item of expense.
d. Charges made by a Hospital for Drugs, or for insulin injection kits, which are for use
outside the Hospital in connection with treatment received in the Hospital, provided that
with respect to Drugs, they are prescribed by a Physician licensed by law to administer or
prescribe Drugs.
e. Charges made by a Licensed Pharmacist for compounding dermatological preparations
prescribed by a Physician.
f. Charges made by a Licensed Pharmacist for therapeutic vitamins, cough mixtures, antacids,
eye and ear medications prescribed by a Physician for the treatment of a specific illness or
complaint.
g. Charges made by a Licensed Pharmacist for self-administered injectables as recommended
by the Fund’s Pharmacy Benefit Manager and as, periodically, reviewed and verified by the
Board of Trustees.
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h. Charges made by a Licensed Pharmacist for contraceptives which have been prescribed by
a Physician.
Section 4.
Exclusions. No benefits are payable for:
a. Drugs taken or administered while a patient is in the Hospital.
b. Patent or proprietary medicines not requiring a prescription, except insulin.
c. Appliances, devices, bandages, heat lamps, braces, or splints.
d. Multiple and nontherapeutic vitamins, cosmetics, dietary supplements, health and beauty
aids.
e. Injectable Drugs (except insulin and injection kits, or as provided in connection with outpatient
intravenous therapy as described in Section 3.g.(5)(i) of Article V, or as provided in Section
3.g of this Article) and blood and blood products.
f. Drugs for which reimbursement is provided by any federal, state, local governmental agency
or programs.
g. Charges for prescription Drugs containing in excess of a 30-day supply if obtained through
a retail Contracting or Non-Contracting Pharmacy or a 90-day supply if obtained through the
mail-service Contracting Pharmacy.
95
ARTICLE VII.
BEHAVIORAL HEALTH BENEFITS
Section 1.
only)
Inpatient Substance Abuse Benefits. (Participants in the Direct Payment Plan
a. Adult Benefits
(1) If an Active Employee or his Dependent spouse is undergoing inpatient treatment
in a participating substance abuse treatment facility with the approval of Claremont
Behavioral Services, the Fund will, subject to all other Plan provisions pay:
(a) 100% of the contracted rate for the first course of treatment, not to exceed 30 days,
and
(b) 50% of the contracted rate for the second course of treatment, not to exceed 30
days.
The maximum lifetime benefit under this Subsection is $10,000. Benefits are not payable for
more than 2 courses of treatment in a lifetime or for charges incurred for treatment from a
facility which is not a participating substance abuse facility.
b. Adolescent Benefits
If a Dependent child is undergoing inpatient treatment in a participating substance abuse
treatment facility with the approval of Claremont Behavioral Services, the Fund will, subject
to all other Plan provisions, pay 100% of the contracted rate for one course of treatment, not
to exceed 45 days.
The maximum lifetime benefit under this Subsection is $12,500. The Fund will not pay for
more than one course of treatment for each Dependent child.
Section 2.
only)
Outpatient Substance Abuse Benefits. (Participants in the Direct Payment Plan
If an Eligible Individual uses the services of a Claremont Behavioral Services participating provider
for the treatment of substance abuse, the Fund will, subject to all other Plan provisions, pay
according to the following schedule in a Plan Year:
100% of the contracted rate for the 1st through the 10th Visit
85% of the contracted rate for the 11th through the 25th Visit
70% of the contracted rate for the 26th through the 40th Visit
50% of the contracted rate for the 41st through the 50th Visit
96
ARTICLE VIII.
HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT
PROTECTED HEALTH INFORMATION
Section 1.
Definitions.
The following definitions will govern in this Article:
a. The term “Covered Entity” means (1) a Health Plan; (2) a health care clearinghouse; or (3)
a health care provider who transmits any Health Information in electronic form in connection
with a Transaction.
b. The term “Health Information” means any information, whether oral or recorded in any
form or medium that: (1) is created or received by a health care provider, Health Plan, public
health authority, employer, life insurer, school or university, or health care clearinghouse;
and (2) relates to the past, present or future physical or mental health or condition of an
individual; the provision of health care to an individual; or the past, present or future payment
for the provision of health care to an individual.
c. The term “Health Plan” means any individual or group plan that provides or pays the
cost of medical care (as defined in Section 28/79(1)(2) of the PHS Act, 42 U.S.C. §300gg91(a)(2)).
d. The term “Individually Identifiable Health Information” means a subset of Health
Information, including demographic information collected from an individual, and: (1)
is created or received by a health care provider, Health Plan, employer or health care
clearinghouse; and (2) relates to the past, present or future physical or mental health or
condition of an individual; the provision of health care to an individual; or the past, present
or future payment for the provision of health care to an individual; and (i) that identifies the
individual; or (ii) there exists a reasonable basis to believe the information can be used to
identify the individual.
e. The term “Plan Administration Function” means administration functions performed by
the Plan Sponsor on behalf of the Plan, excluding functions performed by the Plan Sponsor
in connection with any other benefit or benefit plan of the Plan Sponsor.
f. The term “Protected Health Information” means Individually Identifiable Health Information
that is transmitted by electronic media; maintained in any media described in the definition
of electronic media at 42 CFR §16.103; or transmitted or maintained in any other form or
medium. Protected Health Information excludes Individually Identifiable Health Information
in: (i) Education records covered by the Family Education Rights and Privacy Act, as
amended, 20 U.S.C. §1232g; (ii) records described at 20 U.S.C. §1232g(a)(4)(B)(iv); and
(iii) employment records held by a Covered Entity in its role as employer.
g. The term “Summary Health Information” means information that (1) summarizes the
claims history, claims expenses or types of claims of individuals for whom a plan sponsor had
provided health benefits under a Health Plan; and (2) from which the information described
at 42 CFR §164.514(b)(2)(i) has been removed.
97
h. The term “Transaction” means the transmission of information between two parties to
carry out financial or administrative activities related to health care.
Section 2.
Use and Disclosure of Protected Health Information:
Payment and Plan Operations
a. The Plan will use Protected Health Information (PHI) to the extent and in accordance with
the uses and disclosures permitted by the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). Specifically, the Plan will use and disclose PHI for purposes related to
health care treatment, payment of health care, and health care operations.
“Payment” includes activities undertaken by the Plan to obtain premiums, to determine or
fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual
being provided health care. Activities include, but are not limited to, the following:
(1) Determine eligibility, coverage, and cost sharing amounts (e.g. cost of a benefit, Plan
maximums, and copayments for an individual’s claim),
(2) Coordinate benefits,
(3) Adjudicate health benefit claims (includes appeals and payment disputes),
(4) Subrogate health benefit claims,
(5) Establish employee contributions,
(6) Calculate risk adjustment amounts based on enrollee health status and demographic
characteristics,
(7) Bill, collect, and related health care data processing,
(8) Handle claims management and related health care data processing, includes payment
audits, investigation and resolution of payment disputes, and responses to participant
inquiries concerning payments,
(9) Obtain payment under a reinsurance contract (including stop-loss and excess of loss
insurance),
(10) Review claims for medical necessity, appropriateness of care, or justification of
charges,
(11) Conduct utilization review, including precertification, preauthorization, concurrent and
retrospective reviews,
(12) Disclose to consumer reporting agencies information related to the collection of premiums
or reimbursement (for payment purposes, the following PHI can be disclosed: name
and address, date of birth, social security number, payment history, account number,
and name and address of provider or Health Plan), and
98
(13) Reimburse the Plan.
b. Health Care Operations include, but are not limited to, the following activities:
(1) Performing quality assessment,
(2) Conducting population-based activities related to improving health or reducing health
care costs, developing protocol, case management and care coordination, disease
management, contacting health care providers and patients with information concerning
treatment alternatives and related functions,
(3) Rating provider and Plan performance, including accreditation, certification, licensing,
or credentialing activities,
(4) Underwriting, premium rating, and other activities relating to the creation, renewal or
replacement of a contract for health insurance or health benefits, and ceding, securing,
or placing a contract for reinsurance of risk relating to claims for health care (including
stop-loss insurance and excess of loss insurance),
(5) Conducting or arranging for a medical review, legal services and auditing functions,
including fraud and abuse detection and compliance programs,
(6) Business planning and development, such as conducting cost-management and
planning analyses related to managing and operating the entity, including formulary
development and administration, development or improvement of methods of payment
or coverage policies,
(7) Managing and administering the activities of the entity including, but not limited to:
(a) Implementation of and compliance with the requirements of HIPAA Administrative
Simplification,
(b) Customer service, including the provision of data analyses for policyholders, Plan
sponsors, or other customers,
(c)
Resolution of internal grievances, and
(d) Due diligence in connection with the sale or transfer of assets to a potential
successor in interest, if that successor is a Covered Entity or, following completion
of the sale or transfer, will become a Covered Entity.
(8) Compliance with and preparation of all documents required by the Employee
Retirement Income Security Act of 1974 (ERISA), including Form 5500, SAR, and other
documents.
99
Section 3.
Use and Disclosure of PHI: Required by Law or Permitted by Authorization
The Plan will only use and disclose PHI for Treatment, Payment and Operations (TPO) purposes;
or as required by law and as permitted by authorization of the participant or beneficiary. The Plan
will disclose PHI to the individuals or organizations, as identified under the Plan Administration
Team Member Roster, as amended and updated from time to time, for purposes related to the
administration of the Plan.
Section 4.
Use and Disclosure of PHI:
To the Plan Sponsor
For purposes of this Article, the Board of Trustees of the Laborers Health and Welfare Trust Fund
for Northern California is the “Plan Sponsor.” The Plan will disclose PHI to the Plan Sponsor,
only upon receipt of a certification from the Plan Sponsor, that the Plan Rules and Regulations
have been amended to incorporate the following provisions. With respect to Protected Health
Information (PHI), the Plan Sponsor agrees to:
(1) Not use or further disclose the information other than as permitted or required by the
Plan Rules and Regulations or as required by law,
(2) Insure that any agents, including a subcontractor, to whom the Plan Sponsor provides
PHI it receives from the Plan, agree to the same restrictions and conditions that apply
to the Plan Sponsor with respect to PHI,
(3) Not use or disclose the information for employment related actions and decisions,
unless authorized by the individual,
(4) Not use or disclose the information in connection with any other benefit or employee
benefit plan of the Plan Sponsor, unless authorized by the individual,
(5) Report to the Plan, as it becomes known, any use or disclosure of PHI that is not
consistent with the uses or disclosures provided for by HIPAA,
(6) Make PHI available to the individual in accordance with the access requirements of
HIPAA,
(7) Make PHI available for amendment and incorporate any amendments to PHI in
accordance with HIPAA,
(8) Make available the information required to provide an accounting of disclosures,
(9) Make internal practices, books, and records relating to the use and disclosure of PHI
received from the group Health Plan available to the Secretary of HHS for the purposes
of determining compliance by the Plan with HIPAA, and
(10) Return or destroy (if feasible) all PHI received from the Plan that the Plan Sponsor still
maintains in any form and retain no copies of that information when no longer required
for the purpose for which the disclosure was made. If the return or destruction is not
feasible, limit further uses and disclosures only to those purposes that make the return
or destruction not feasible.
100
Section 5.
Fund Staff Access to PHI
a. Adequate separation between the Plan and the Plan Sponsor must be maintained. Therefore,
in accordance with HIPAA, only the following employees or classes of employees may be
given access to PHI:
(1) The Plan Administrator,
(2) Staff designated by the Plan Administrator, as identified under the Plan Administration
Team Member Roster,
(3) The persons described in this Section may only have access to use and disclosure of
PHI for Plan Administration Functions that the Plan Sponsor performs for the Plan.
b. If the persons described in this Section do not comply with the provisions of this Article, the
Plan Sponsor will provide a mechanism for resolving issues of noncompliance, including
disciplinary sanctions.
c. For purposes of complying with the HIPAA privacy rules, this Plan is a “Hybrid Entity”
because it has both Health Plan and non-Health Plan functions. Non-Health Plan functions
include administration of a death and dismemberment benefit for employees and eligible
dependents. The Plan designates that its health care components that are covered by the
privacy rules include only health benefits and not other Plan functions or benefits.
Section 6.
Plan Sponsor Protection of Electronic PHI
The Board of Trustees of the Laborers Health and Welfare Trust Fund for Northern Califonria, who
is the Plan Sponsor:
(1) Implements administrative, physical and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity and availability of electronic PHI that it
creates, receives, maintains, or transmits on behalf of the health plan;
(2) Ensures that the adequate separation discussed in Section 5., specific to electronic
PHI, is supported by reasonable and appropriate security measures;
(3) Ensures that any agent, including a subcontractor, to whom it provides electronic PHI
agrees to implement reasonable and appropriate security measures to protect the
electronic PHI; and
(4) Reports to the Plan any security incident of which it becomes aware concerning
electronic PHI.
101
ARTICLE IX
EXCLUSIONS, LIMITATIONS, AND REDUCTIONS
(Not applicable to the Death Benefit, Accidental Death and Dismemberment Benefit or the
Dependents’ Death Benefit.)
Section 1.
Exclusions
The Fund will not provide benefits for:
a. Any accidental bodily injury arising out of, or in the course of, the Eligible Individual’s
employment or in connection with an illness for which the Eligible Individual is entitled to
indemnity under the provisions of any Workers’ Compensation or similar law.
b. Charges incurred while confined or treated in a Veterans Administration Hospital, or for
care or treatment obtained from any federal, state or local governmental agency or program
where the care or treatment is available without cost to the Eligible Individual, except to the
extent the law requires benefits to be paid by the Fund.
c. Confinement or care obtained in a Hospital owned or operated by any federal, state or
local governmental agency or program, unless there is an unconditional requirement that
the Eligible Individual pay for the confinement or care, without regard to any rights against
others, contractual or otherwise.
d. Conditions caused by or arising out of an act of war, armed invasion or aggression.
e. A condition for which the Eligible Individual is not under the care of a Physician, or for a period
of confinement beyond that authorized by the Professional Review Organization (PRO).
f. Eye refractions and eyeglasses.
g. Callus or corn paring; toenail trimming; treatment of chronic conditions of the foot, such as
weak or fallen arches, flat or pronated foot metatarsalgia, or foot strain.
h. Services to reverse voluntary surgically induced infertility.
i.
Expenses incurred outside the United States and its Territories and Possessions, except for
Emergency Services.
j.
Substance abuse treatment, except as provided in Article VII.
k. Any services in connection with breast surgery, unless in connection with the treatment
of abscess, fibrocystic disease, tumor (benign or malignant), or as provided in Article V.
Section 3.g.(11).
l.
Hospital or medical services or supplies in connection with the treatment of obesity or
weight control, except as provided in Article V., Section 3.g.(12).
102
m. Hospital or medical services or supplies in connection with the treatment of an aggressive
social, behavioral or conduct disorder, as defined by the American Psychiatric Association.
n. Charges for or in connection with the treatment of infertility as defined by the American
College of Obstetrics and Gynecology, including but not limited to, in vitro fertilization, artificial
insemination, surgery including treatment to alleviate pelvic adhesions (unless determined
to be Medically Necessary), and other infertility related services.
o. Charges for Experimental or Investigative Procedures.
p. Injury or illness resulting from participation in, or in consequence of having participated in,
the commission or attempted commission of an assault or felony.
q. Expenses for or in connection with cosmetic surgery, except cosmetic surgery which is not
primarily for beautification but is performed to correct or improve a bodily function, congenital
malformation, or as provided in Article V., Subsection 3.g.(11).
r. Medical treatment received in connection with the pregnancy of a Dependent Child.
s. Dental appliances, bridges, crowns, caps or other dental prostheses, dental services,
extraction of teeth or treatment to the teeth or gums, except as specifically provided under
Article V., Subsection 3.g. (15).
t. Services and supplies related to sexual reassignment, including medications, implants,
hormone therapy, surgery and medical care.
u. Expense for travel or transportation, except as provided in Article V., Subsection 3.g.(5)(g).
v. Services furnished by an institution that is primarily a rest home, a home for the aged,
a nursing home, a convalescent home, or any institution of similar character providing
Custodial Care.
w. Routine physical examination, except as provided in Article V., Section 4.
x. Charges for ambulance transportation that is primarily for the convenience of the Eligible
Individual or ambulance transportation by railroad.
Section 2.
Limitations
The Fund does not provide benefits for medical services or supplies that are not Medically
Necessary for the care or treatment of a bodily injury or illness. Furthermore, the Fund will not
provide benefits for medical services or supplies for the care or treatment of a bodily injury or
illness that are in excess of Usual, Customary and Reasonable Charges as would have been
made for care or treatment in the absence of the benefits provided by the Fund.
Section 3.
Coordination of Benefits
If an Eligible Individual is entitled to benefits from another Group Plan for hospital, medical, dental
or health care expenses for which benefits are also due from this Plan, then the benefits provided
103
by this Plan will be paid according to the following provisions, not to exceed 100% of the Usual,
Customary and Reasonable expenses actually incurred by the Eligible Individual.
a. If the Eligible Individual is an Active Employee, Plan benefits will be provided without
reduction.
b. The benefits of a Group Plan which covers the Eligible Individual as other than a Dependent
will be determined before the benefits of a Group Plan which covers that person as a
Dependent.
c. If the Eligible Individual for whom claim is made is a Dependent child whose parents are not
separated or divorced, the benefits of a Group Plan which covers the Eligible Individual as a
Dependent of an Active Employee whose date of birth, excluding year of birth, occurs earlier
in a calendar year, will be determined before the benefits of a Group Plan which covers that
Eligible Individual as a Dependent of an Active Employee whose date of birth, excluding year
of birth, occurs later in a calendar year. If either Group Plan does not have the provisions
of this rule c. regarding Dependents, which results either in each Group Plan determining
its benefits before the other or in each Group Plan determining its benefits after the other,
the provisions of this paragraph will not apply, and the rule set forth in the Group Plan which
does not have the provisions of this paragraph will determine the order of benefits.
d. In the case of an Eligible Individual for whom claim is made as a Dependent child whose
parents are separated or divorced and the parent with custody of the child has not remarried,
the benefits of a Group Plan which covers the child as a Dependent of the parent with
custody of the child will be determined before the benefits of a Group Plan which covers the
child as a Dependent of the parent without custody.
e. In the case of an Eligible Individual for whom claim is made as a Dependent child whose
parents are divorced and the parent with custody of the child has remarried, the benefits
of a Group Plan which covers the child as a Dependent of the parent with custody will be
determined before the benefits of a Group Plan which covers that child as a Dependent of
the stepparent, and the benefits of a Group Plan which covers that child as a Dependent of
the stepparent will be determined before the benefits of a Group Plan which covers that child
as a Dependent of the parent without custody.
f. In the case of an Eligible Individual for whom claim is made as a Dependent child whose
parents are separated or divorced, where there is a court decree which would otherwise
establish financial responsibility for the medical, dental or other health care expenses with
respect to the child, then, notwithstanding paragraphs d. and e. above, the benefits of a
Group Plan which covers the child as a Dependent of the parent with financial responsibility
will be determined before the benefits of any other Group Plan which covers the child as a
Dependent child.
g. When rules a., b., c., d., e., or f. do not establish an order of benefit determination, the
benefits of a Group Plan which has covered the person for the longer period of time will be
determined before the benefits of a Group Plan which has covered the Eligible Individual the
shorter period of time, provided that:
(1) the benefits of a Group Plan covering the Eligible Individual as a laid-off or retired
104
employee, or Dependent of the person, will be determined after the benefits of any
other Group Plan covering the person as an employee, other than a laid-off or retired
employee, or Dependent of the Active Employee; and
(2) if either Group Plan does not have a provision regarding laid-off or retired employees,
which results in each Group Plan determining its benefits after the other, then the
provision (1) above will not apply.
For purposes of this Section only, the terms “laid off” or “retired employee” will also include
employees covered by COBRA.
Section 4.
Coordination with Medicaid
Payments by this Plan for benefits with respect to an Eligible Individual will be made in compliance
with any assignment of rights made by or on behalf of the Eligible Individual as required by
California’s plan for medical assistance approved under Title XIX, Section 1912(a)(1)(A) of the
Social Security Act (Medicaid).
Where payment has been made by the State under Medicaid for medical assistance in any case
where this Plan has a legal liability to make payment for that assistance, payment for the benefits
will be made in accordance with State law which provides that the State has acquired the rights
with respect to an Eligible Individual to payment for that assistance, but in no event, more than
one year from the date expenses were incurred. Reimbursement to the State, like any other entity
which has made payment for medical assistance where this Plan has a legal liability to make
payment, will be equal to Plan benefits or the amount actually paid, whichever is less.
105
ARTICLE X.
GENERAL PROVISIONS
Section 1.
Payment of Benefits
Except as provided in Subsection 1.a. of Article V, all benefits will be paid by the Fund to the Active
Employee as they accrue upon receipt of written proof, satisfactory to the Fund, covering the
occurrence, character and extent of the event for which the claim is paid. (See also Article XI.)
Section 2.
Benefits May Not Be Alienated
Benefits payable may not be subject in any manner to anticipation, alienation, sale, transfer,
assignment, pledge, encumbrance or charge by any person. However, any Active Employee may
direct that benefits due him be paid to an institution in which he or his Dependent is hospitalized,
to any provider of medical or dental services or supplies for those services or supplies, or to any
other person or agency that may have provided or paid for or agreed to provide or pay for any
benefits.
Section 3.
Notice of Claims Required
Benefits will be paid by the Fund only if notice of claim is made within 90 days from the date on
which covered expenses were first incurred unless it is shown by the Active Employee not to
have been reasonably possible to give notice within that time limit, but in no event will benefits
be allowed if notice of claim is made beyond one year from the date on which expenses were
incurred. (See also Article XI.) Proof of claim forms, as well as other forms, and methods of
administration and procedure will be solely determined by the Fund.
Section 4.
Offset and Recoupment
In the event that it is determined that due to either a mistake of fact or law or to any other
circumstance, an Active Employee has been paid more than he is entitled to under the terms of the
Plan or under the law, the Board may offset, recoup and recover the amount of the overpayment
from payments due or becoming due to the Active Employee or his beneficiary in installments and
to the extent the Board determines.
Section 5.
Payment in Event of Incompetency or Lack of Address
In the event the Fund determines that the Active Employee is incompetent or incapable of
executing a valid receipt and no guardian has been appointed, or in the event the Active
Employee has not provided the Fund with an address at which he can be located for payment,
the Fund may, during the lifetime of the Active Employee, pay any amount otherwise payable
to the Active Employee to the husband or wife or relative by blood of the Active Employee, or to
any other person or institution determined by the Fund to be equitably entitled. In the case of the
death of the Active Employee and before all amounts payable under Articles V, VI, and VII, have
been paid, the Fund may pay any amount payable to any person or institution determined by the
Fund to be equitably entitled. The remainder of the amount will be paid to one or more of the
following surviving relatives of the Active Employee: lawful spouse, child or children, mother,
father, brothers or sisters, or to the Active Employee’s estate, as the Board of Trustees in its sole
106
discretion may designate. Any payment made in accordance with this provision will discharge the
obligation of the Fund to the extent of that payment.
Section 6.
Physical Examination or Autopsy
The Fund, at its own expense, has the right and opportunity to examine the person of any Eligible
Individual when and so often as it may reasonably require during the pendency of any claim, and
also the right and opportunity to make an autopsy in case of death where it is not forbidden by
law.
Section 7.
Benefits Not in Lieu of Workers’ Compensation
The benefits provided by this Fund are not in lieu of and do not affect any requirement for coverage
by Workers’ Compensation Insurance laws or similar legislation.
Section 8.
Rights Against Third Parties
If an Eligible Individual has an illness, injury, disease or other condition for which a third party
may be liable or legally responsible by reason of an act or omission, or insurance coverage of
that third party, the Fund will have an automatic lien upon any recovery against the third party
for benefits paid by the Fund as a result of that illness, injury, disease or other condition. All
Eligible Individuals, as a condition precedent to entitlement to benefits from the Fund, must agree
in writing to reimburse the Fund for any payments made by the Fund on account of hospital,
medical or other expenses in connection with, or arising out of, that injury, illness, disease or other
condition. The reimbursement will be made out of any proceeds received by way of judgement,
arbitration award, settlement or otherwise in connection with, or arising out of, any claim for or
right to damages by the Eligible Individual against the third party, his insurance carrier, guarantor
or other indemnitor, or by reason of uninsured or under-insured motorist coverage of the Eligible
Individual, or any other source of third party recovery. The agreement will require all Eligible
Individuals to prosecute the claim for damages diligently; to give priority to the reimbursement
of the Fund in the allocation of the proceeds of any recovery; to cooperate and assist the Fund
in obtaining reimbursement for the payments; to execute any documents necessary to secure
reimbursement; and to refrain from any act or omission that might hinder reimbursement, and
may contain any other provisions the Fund may reasonably require.
Section 9.
Gender
Wherever any words are used in this Plan in the masculine gender, they should be construed
as though they were also used in the feminine gender in all situations where they would apply;
wherever any words are used in this Plan in the singular form, they should be construed as though
they were also in the plural form in all situations where they would apply, and vice versa.
Section 10.
Trust Agreement Governs
The provisions of these Rules and Regulations are subject to and controlled by the provisions of the
Trust Agreement, and in the event of any conflict between the provisions of these Rules and Regulations
and the provisions of the Trust Agreement, the provisions of the Trust Agreement will prevail.
107
ARTICLE XI.
CLAIMS AND APPEALS PROCEDURES
Section 1.
Definitions.
The following definitions will govern in this Article:
a. An “Adverse Benefit Determination” is any denial, reduction, or termination of a benefit
or failure to provide or make payment for a benefit, in whole or in part under the Plan. Each
of the following is an example of an Adverse Benefit Determination:
(1) a payment of less than 100% of a Claim for benefits (including coinsurance or copayment
amounts of less than 100% and amounts applied to the deductible);
(2) a denial, reduction, termination of a benefit or failure to provide or make payment for a
benefit, in whole or in part, resulting from any utilization review decision;
(3) failure to cover an item or service because the Plan considers it to be experimental,
investigational, not Medically Necessary, or not medically appropriate;
(4) a restriction on reimbursement for particular services because the services are classified
as treatment of a mental or nervous condition, rather than a physical condition; and
(5) a decision that denies a benefit based on a determination that a claimant is not eligible
to participate in the Plan.
A pharmacy’s refusal to fill a prescription order, unless the Participant pays the entire cost of
the prescription, is not considered an Adverse Benefit Determination if the refusal is based
on Plan Rules and Regulations. Similarly, a Participating Provider’s (Physician or Hospital)
refusal to provide services to a Participant, unless the Participant pays the entire cost of
the services, is not considered an Adverse Benefit Determination if the refusal to provide
services is based on the Plan Rules and Regulations.
b. A “Claim” is a request for a benefit made by a claimant in accordance with the Plan’s
reasonable procedures.
Casual inquiries concerning benefits or under which circumstances benefits might be paid
are not considered Claims. A request for a determination as to whether an individual is
eligible for benefits under the Plan is not considered to be a Claim. However, if a claimant
files a Claim for specific benefits and the Claim is denied because the individual is not eligible
for benefits under the Plan, the coverage determination is considered a Claim.
The presentation of a prescription order at a pharmacy does not constitute a Claim if the
pharmacy follows rules established by the Plan and has no discretion to act on behalf of the
Plan. Similarly, interactions between Participants and Participating Providers (Physicians
and Hospitals) do not constitute Claims in cases where the providers exercise no discretion
on behalf of the Plan. If a Physician, Hospital or pharmacy declines to provide services
or refuses to fill a prescription unless the Participant pays the entire cost, the Participant
may submit a Post-Service Claim for the services or prescription, as described under Claim
Procedures, below.
108
A request for pre-certification or prior authorization of a benefit that does not require precertification or prior authorization by the Plan is not considered a Claim. However, requests
for pre-certification or prior authorization of a benefit where the Plan does require precertification or prior authorization are considered Claims and should be submitted as PreService Claims (or Urgent Care Claims, if applicable), as described under Claim Procedures,
below.
c. A “Concurrent Claim” is a Claim that is reconsidered after an initial approval has been
made that results in a reduction, termination or extension of a benefit.
d. A “Post-Service Claim” is a Claim for benefits that is not a Pre-Service, Urgent Care or
Concurrent Claim.
e. A “Pre-Service Claim” is a Claim for a benefit that requires pre-certification or prior
authorization by the Plan before medical care is obtained.
f. “Relevant Documents” include documents pertaining to a Claim if those documents
were relied upon in making the benefit determination, were submitted, considered or
generated in the course of making the benefit determination, demonstrate compliance with
the administrative processes and safeguards required by the regulations, or constitute the
Plan’s policy or guidance with respect to the denied treatment option or benefit. Relevant
Documents could also include Plan rules, protocols, criteria, rate tables, fee schedules
or checklists and administrative procedures that demonstrate that the Plan’s rules were
appropriately applied to a Claim.
g. An “Urgent Care Claim” is a Claim for medical care or treatment that, if Pre-Service Claim
standards were applied, would seriously jeopardize the life or health of the Participant or the
ability of the Participant to regain maximum function or, in the opinion of a Physician with
knowledge of the Participant’s medical condition, would subject the Participant to severe
pain that could not be adequately managed without the care or treatment that is the subject
of the Claim.
Section 2.
Claim Procedures
a. Pre-Service Claims
A Pre-Service Claim is a Claim for a benefit that requires pre-certification or prior authorization
by the Plan before medical care is obtained. All elective, non-emergency Hospital admissions
require pre-certification (Pre-Admission Review). Therefore, pre-certification of an elective,
non-emergency Hospital admission is treated as a Pre-Service Claim. Pre-Service Claims
for the pre-certification of Hospital admissions must be arranged by calling Blue Cross.
The Plan requires prior authorization for various services and prescription drugs, as described
in this booklet. Pre-Service Claims for prior authorization for these services and prescription
drugs must be submitted by calling Blue Cross or Prescription Solutions.
If a Pre-Service Claim is properly filed, the claimant will be notified of a decision within 15
days from receipt of the Claim. If additional time is needed, the time for response may be
extended up to 15 days, if necessary, due to matters beyond the control of the Plan. The
109
claimant will be notified of the circumstances requiring the extension of time and the date by
which the Plan expects a decision to be made available.
If an extension of time is necessary because the Plan requires additional information from the
claimant, the claimant will be notified, in writing, before the end of the initial 15-day period,
of the information required. The claimant will have 45 days from receipt of the notification
to provide the additional information. If the information is not provided within 45 days, the
Claim will be denied. During the period that the claimant is allowed to provide additional
information, the normal deadline for making a decision on the Claim will be suspended from
the date of the extension notice until either 45 days or the date the claimant responds to the
request (whichever is sooner). The Plan then has 15 days to make a decision on the Claim
and notify the claimant of the determination.
If a claimant improperly files a Pre-Service Claim with the Laborers Health and Welfare
Trust Fund, the Trust Fund or Blue Cross will notify the claimant as soon as possible but not
later than 5 days after receipt of the claim of the proper procedures to be followed in filing
a Claim. The claimant will only receive notice of an improperly filed Pre-Service Claim if the
claim includes (i) the patient’s name, (ii) the patient’s specific medical condition or symptom,
and (iii) the specific treatment, service or product for which approval is requested. Unless the
claim is properly refiled, it will not constitute a Claim.
b. Urgent Care Claims
An Urgent Care Claim is a Claim for a benefit for which the Plan requires pre-certification or
prior authorization before medical care is obtained and, were normal Pre-Service standards
applied, the life or health of the Participant would be seriously jeopardized.
The Plan will determine whether a Claim is an Urgent Care Claim by applying the judgment
of a prudent layperson that possesses an average knowledge of health and medicine.
Alternatively, if a Physician with knowledge of the patient’s medical condition determines
that the Claim is an Urgent Care Claim and notifies the Plan of this, it will be treated as an
Urgent Care Claim.
Urgent Care Claims, which may include pre-certifications (Pre-Admission Review) of Hospital
admissions and prior authorizations of various services and prescription drugs, must be
submitted in the same manner as Pre-Service Claims by calling Blue Cross or Prescription
Solutions.
For properly filed Urgent Care Claims, the Plan will respond to the claimant with a determination
by telephone as soon as possible, taking into account the medical exigencies, but not later
than 72 hours after receipt of the Claim. The determination will also be confirmed in writing.
If an Urgent Care Claim is received without sufficient information to determine whether, or
to what extent, benefits are covered or payable, the Plan will notify the claimant as soon as
possible, but not later than 24 hours after receipt of the Claim, of the specific information
necessary to complete the Claim. The claimant must provide the specified information within
48 hours. If the information is not provided within 48 hours, the Claim will be denied.
During the period that the claimant is allowed to provide additional information, the normal
110
deadline for making a decision on the Claim will be suspended from the date of the extension
notice until either 48 hours or the date the claimant responds to the request, whichever
occurs first. Notice of the decision will be provided no later than 48 hours after receipt of the
specified information or the end of the 48-hour period allowed for the claimant to provide this
information, whichever is sooner.
If a claimant improperly files an Urgent Care Claim with the Laborers Health and Welfare
Trust Fund, the Trust Fund or Blue Cross will notify the claimant as soon as possible but not
later than 24 hours after receipt of the claim, of the proper procedures to be followed in filing
an Urgent Care Claim. The claimant will only receive notice of an improperly filed Urgent
Care Claim if the claim includes (i) the patient’s name, (ii) the patient’s specific medical
condition or symptom, and (iii) the specific treatment, service or product for which approval
is requested. Unless the claim is properly refiled, it will not constitute a Claim.
c. Concurrent Claims
A reconsideration of a benefit with respect to a concurrent claim that involves the termination
or reduction of a previously approved benefit (other than by plan amendment or termination)
will be made by the Plan as soon as possible. In any event, the Participant will be given
enough time to request an appeal and to have the appeal decided before the benefit is
reduced or terminated.
Any request by a claimant to extend an approved Urgent Care Claim will be acted upon
by the plan within 24 hours of receipt of the Claim, provided the Claim is received at least
24 hours prior to the expiration of the approved Urgent Care Claim. A request to extend
approved treatment that does not involve an Urgent Care Claim will be decided according to
the guidelines for Pre-Service or Post-Service claims, as applicable.
d. Post-Service Claims
A Post-Service Claim must be submitted to the Laborers Health and Welfare Trust Fund
Office in writing, using the appropriate claim form, within 180 days after the expenses were
incurred. A claim form may be obtained by contacting the Laborers Health and Welfare Trust
Fund. Failure to file a Post-Service Claim within the time required will not invalidate or reduce
any Claim if it was not reasonably possible to file the Claim within the time required. However,
in that case, the Claim must be submitted as soon as reasonably possible.
The claim form must be completed in full and an itemized bill(s) attached to the claim form in
order for the request for benefits to be considered a Claim. The claim form and/or itemized
bill(s) must include the following information for the request to be considered a Claim:
•
•
•
•
Patient’s name;
Date of service;
Type of service or CPT-4 code (the code for physician services and other health care
services found in the Current Procedural Terminology, Fourth Edition, as maintained
and distributed by the American Medical Association);
Diagnosis or ICD-9 code (the diagnosis code found in the International Classification of
Diseases, 9th Edition, Clinical Modification as maintained and distributed by the U.S.
Department of Health and Human Services);
111
•
•
•
•
Billed charge(s);
Number of units (for anesthesia and certain other claims);
Provider’s federal taxpayer identification number (TIN); and
Provider’s billing name and address.
A Post-Service Claim is considered filed upon receipt of the Claim by the Laborers Health and
Welfare Trust Fund. Ordinarily, claimants are notified of decisions on Post-Service Claims
within 30 days from the receipt of the Claim by the Laborers Health and Welfare Trust Fund.
The Plan may extend this period one time for up to 15 days if the extension is necessary
due to matters beyond the control of the Plan. If an extension is necessary, the claimant will
be notified, before the end of the initial 30-day period, of the circumstances requiring the
extension and the date by which the Plan expects a decision to be made available.
If an extension is required because the Plan needs additional information from the claimant,
the Plan will issue a Request for Additional Information that specifies the information needed.
The claimant will have 45 days from receipt of the notification to supply the additional
information. If the information is not provided within that period, the Claim will be denied.
During the 45-day period in which the claimant is allowed to provide additional information,
the normal deadline for making a decision on the Claim will be suspended. The deadline is
suspended from the date of the Request for Additional Information until either 45 days or until
the date the claimant responds to the request, whichever is sooner. The Plan then has 15
days to make a decision on the Claim and notify the claimant of the determination.
If the Plan determines that additional information is required from the claimant, it may issue
a combined Request for Additional Information and Notice of Adverse Benefit Determination.
The Notice of Adverse Benefit Determination would only be applicable if the claimant fails
to provide any information within 45 days. In this case, the Plan would not issue a separate
Notice of Adverse Benefit Determination if the claimant failed to submit any information within
45 days. The combined notice will clearly state that the Claim will be denied if the claimant
fails to submit any information in response to the Plan’s request, and will satisfy the content
requirements of both the Request for Additional Information and the Notice of Adverse
Benefit Determination. When the combined notice is used, the time frame for appealing the
Adverse Benefit Determination begins to run at the end of the 45-day period prescribed in
the combined notice for submitting the requested information.
e. Authorized Representatives
An authorized representative, such as a spouse or an adult child, may submit a Claim or
appeal on behalf of a participant if the Participant has previously designated the individual to
act on his behalf. An Appointment of Authorized Representative form, which may be obtained
from the Laborers Health and Welfare Trust Fund, must be used to designate an authorized
representative. The Laborers Trust Fund may request additional information to verify that the
designated person is authorized to act on the Participant’s behalf.
A health care professional with knowledge of the Participant’s medical condition may act as
an authorized representative in connection with an Urgent Care Claim without the Participant
having to complete the Appointment of Authorized Representative form.
112
f.
Notice of Initial Benefit Determination
The claimant will be provided with written notice of the initial benefit determination. If the
determination is an Adverse Benefit Determination, the notice will include:
•
•
•
•
•
•
•
•
the specific reason(s) for the determination;
reference to the specific Plan provision(s) on which the determination is based;
a description of any additional material or information necessary to complete the Claim,
and an explanation of why the material or information is necessary;
a description of the appeal procedures (including voluntary appeals, if any) and
applicable time limits;
a statement of the claimant’s right to bring a civil action under ERISA Section 502(a)
following the appeal of an Adverse Benefit Determination;
if an internal rule, guideline or protocol was relied upon in deciding the Claim, a statement
that a copy is available upon request at no charge;
if the determination was based on the absence of medical necessity, or because the
treatment was experimental or investigational, or other similar exclusion, a statement
that an explanation of the scientific or clinical judgment for the determination is available
upon request at no charge;
for Urgent Care Claims, a description of the expedited review process applicable to
Urgent Care Claims (for Urgent Care Claims, the notice may be provided orally and
followed with written notification).
Section 3.
Appeal Procedures
a. Appealing an Adverse Benefit Determination
If a Claim is denied in whole or in part, or if the claimant disagrees with the decision made on
a Claim, the claimant may appeal the decision.
(1) Pre-Service Claims.
Appeals of Adverse Benefit Determinations regarding Pre-Service Claims must be
made by phoning Blue Cross within 180 days after receipt of the Notice of Adverse
Benefit Determination.
(2) Urgent Care Claims.
Appeals of Adverse Benefit Determinations regarding Urgent Care Claims must be
made by phoning Blue Cross within 180 days after receipt of the Notice of Adverse
Benefit Determination by Blue Cross or by writing the Trust Fund within 180 after receipt
of the Notice of Adverse Benefit Determination from the Trust Fund. If an appeal is
made within 72 hours of receipt of the Notice of Adverse Benefit Determination from the
Trust Fund, it may be made orally by phoning the Trust Fund.
(3) Concurrent Claims.
Appeals of Adverse Benefit Determinations regarding Concurrent Claims must be made
by phoning Blue Cross if Blue Cross issued the Adverse Benefit Determination. For a
113
Concurrent Claim that involves a termination or reduction of previously approved care,
there is no set time frame for appeal; however, the appeal must be completed before
the care is terminated or reduced. For a Concurrent Claim regarding an extension of
care, the appeal time frame will be the time frame for an Urgent, Pre-Service or PostService Claim, whichever category applies to the appeal.
(4) Post-Service Claims.
The appeal of a Post-Service Claim must be submitted in writing to the Laborers Health
and Welfare Trust Fund within 180 days after receipt of the Notice of Adverse Benefit
Determination and must include:
•
•
•
•
•
the patient’s name and address;
the claimant’s name and address, if different;
a statement that this is an appeal of a decision by the Board of Trustees;
the date of the Adverse Benefit Determination; and
the basis of the appeal, i.e., the reason(s) why the Claim should not be denied.
b. The Appeal Process
The claimant must have the opportunity to submit written comments, documents, and other
information for consideration during the appeal, even if the information was submitted or
considered as part of the initial benefit determination. The claimant will be provided, upon
request and free of charge, reasonable access to and copies of all Relevant Documents
pertaining to his or her Claim.
A person different from the person who originally made the initial Adverse Benefit Determination
on the Claim will review the appeal. The reviewer will not give deference to the initial Adverse
Benefit Determination. The decision will be made on the basis of the record, including any
additional documents and comments that may be submitted by the claimant.
If the Claim was denied on the basis of a medical judgment (such as a determination that the
treatment or service was not Medically Necessary, or was investigational or experimental),
a health care professional who has appropriate training and experience in a relevant field of
medicine will be consulted. Upon request, the claimant will be provided with the identification
of medical consultant or adviser, if any, that gave advice on the Claim, without regard to
whether the advice was relied upon in deciding the Claim.
c. Time frames for Sending Notices of Appeal Determination
(1) Pre-Service Claims.
Notice of the appeal determination for Pre-Service Claims will be sent within 30 days of
receipt of the appeal by the Plan.
(2) Urgent Care Claims.
Notice of the appeal determination for Urgent Care Claims will be sent within 72 hours
of receipt of the appeal by the Plan.
114
(3) Concurrent Claims.
Notice of the appeal determination for a Concurrent Claim that involves a termination
or reduction of previously approved care will be sent by the Plan before the care is
terminated or reduced. Notice of the appeal determination for a Concurrent Claim that
involves an extension of care will be sent by the Plan based on the time frames for
an Urgent, Pre-Service or Post-Service Claim, whichever type claim applies to the
appeal.
(4) Post-Service Claims.
Decisions on appeals involving Post-Service Claims will be made by the Trustees no
later than the date of the quarterly meeting of the Board of Trustees that immediately
follows receipt of the request for review, unless the request for review is filed within
30 days preceding the date of the meeting. In that case a decision will be made no
later than the date of the second meeting following receipt of the request for review.
If special circumstances require a further extension of time for processing, a decision
will be made no later than the third meeting following receipt of the request for review.
The Board of Trustees will provide the claimant with a written notice of the extension,
describing the special circumstances and the date by which the benefit determination
will be made, prior to the commencement of the extension. The Board of Trustees will
notify the claimant of the benefit determination as soon as possible, but not later than 5
days after the benefit determination is made.
d. Content of Appeal Determination Notices
The determination of an appeal will be provided to the claimant in writing. The notice of a
denial of an appeal will include:
•
•
•
•
•
•
the specific reason(s) for the determination;
reference to the specific Plan provision(s) on which the determination is based;
a statement that the claimant is entitled to receive reasonable access to and copies of
all documents relevant to the Claim, upon request and free of charge;
a statement of the claimant’s right to bring a civil action under ERISA Section 502(a)
following an adverse benefit determination on appeal;
if an internal rule, guideline or protocol was relied upon, a statement that a copy is
available upon request at no charge; and
if the determination was based on medical necessity, or because the treatment was
experimental or investigational, or other similar exclusion, a statement that an explanation
of the scientific or clinical judgment for the determination is available upon request at
no charge.
115
Section 4.
When A Lawsuit May Be Started
The claimant may not start a lawsuit to obtain benefits until after the claimant has requested an
appeal and a final decision has been reached, or until the appropriate time frame described above
has elapsed since the claimant filed a request for review and has not received a final decision or
notice that an extension will be necessary to reach a final decision. If the claimant is not satisfied
with the final decision, he has the right to bring a civil action to obtain benefits under Section 502
of ERISA.
116
ARTICLE XII.
AMENDMENT AND TERMINATION
In order that the Fund may carry out its obligation to maintain, within the limits of its resources, a
program dedicated to providing the maximum possible benefits for all Active Employees, the Board
of Trustees expressly reserves the right, in its sole discretion at any time on a non-discriminatory
basis:
a. to terminate or amend either the amount or condition with respect to any benefit even though
a termination or an amendment affects claims which have already accrued; and
b. to alter or postpone the method of payment of any benefit; and
c. to amend or rescind any other provisions of these Rules and Regulations.
117
ARTICLE XIII.
DISCLAIMER
None of the benefits provided in these Rules and Regulations is insured by any contract of
insurance and there is no liability on the part of the Board of Trustees or any individual or entity to
provide payment over and beyond the amounts in the Trust Fund collected and available for that
purpose.
118

laborers health and welfare trust fund

Transcripción

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