COORDINATION OF BENEFITS

• Qualified Medical Child Support Orders (QMCSOs)

• Claims and appeals procedures

• Factors that could affect your receipt of benefits

• General exclusions, limits, and reductions

• Your rights under ERISA

• General Plan information

• Plan facts

COORDINATION OF BENEFITS

NOTE: This discussion deals only with health care benefits paid directly by the Fund. If you elected Kaiser coverage instead of the Plan’s comprehensive medical benefits, see the materials provided by Kaiser for information regarding how your medical benefits are coordinated.

The benefits provided by the Fund are “coordinated” with any benefits under any other group plan that covers you or your dependents.

Coordination of benefits means that one plan pays benefits first (the primary payer) and one pays second (the secondary payer), with the combined total of benefits not to exceed 100% of the covered expenses incurred.

If the Fund is the primary payer, it pays its benefits first, without regard to any other plan. If the Fund is the secondary payer, it will pay the amount of covered charges not covered by the primary plan (subject to coinsurance, copayment, benefit and lifetime maximum, and other provisions described in this booklet).

If contract providers are involved, the covered expense will not exceed whichever of the following is lowest: this Plan’s contractual rate (if the provider is a contract provider under this Plan), the contractual rate under the other plan, or the normal charge billed by the provider for the expense.

If non-contract providers are used, the covered expenses will not exceed usual, customary and reasonable charges that are covered in whole or in part by either plan.

ORDER OF PAYMENT

NOTE: This order of payment applies only if your other plan has a coordination-of-benefits provision. If it does not, your other plan will always be primary.

The provisions for coordination with Medicare, Medicaid, and HMO plans are different and are explained later below. Otherwise, primary and secondary payers are as follows:

Chapter 14

OTHER IMPORTANT

PLAN INFORMATION

• Employees: A plan covering you as an active employee is primary. A plan covering you as a laid-off or retired employee is secondary, provided both plans have this rule.

NOTE: If you are available for work but ineligible for coverage because your hours were worked under two or more of the funds signatory to the reciprocity agreements described in chapter 2 of this booklet, responsibility for your coverage will be determined in accordance with the administrative procedures outlined in the Reciprocity Agreement.

• Spouses: The plan covering the spouse directly, as a nondependent rather than as an employee’s dependent, is the primary plan. The plan covering the spouse as a dependent is the secondary plan.

• Children: If the parents are not separated or divorced, the primary plan is usually the plan of the parent whose birthday falls earlier in the calendar year. If the other plan does not have this “birthday rule,” then the rules of the other plan will determine the order of benefits.

If the parents are separated or divorced and two or more plans cover a child as a dependent, benefit payments are first determined in accordance with any court decree. Otherwise, the plans pay benefits for the child in the following order:

• the plan of the parent with custody pays first,

• the plan of the stepparent—the spouse of the parent with custody, if he or she has remarried—pays second, and

• the plan of the parent without custody pays last.

If none of the rules outlined here apply, the plan that has covered someone for a longer period will pay first.

COORDINATION WITH MEDICARE

If an active employee has coverage under the Plan’s comprehensive medical benefits and is eligible for Medicare, the following special rules apply:

• Employees: If you are an active employee covered under this Plan and you are age 65 or older, you have the option of selecting either this Plan or Medicare as your primary coverage.

This Plan will automatically provide you with primary coverage unless you notify the Trust Fund Office in writing that you wish to select Medicare as your primary coverage.

If you choose to have this Plan as your primary plan, this Plan will pay its regular benefits without regard to Medicare. If you select Medicare as your primary plan, Medicare will be your only medical coverage. (However, your other Fund coverage will remain in effect as long as you meet the eligibility rules.)

• Dependent spouse: If your spouse is age 65 or older, she/he will be eligible for the same benefits as you. If you select Medicare as your primary coverage, your spouse’s coverage will also be provided by Medicare. If you do not select Medicare as your primary coverage, your spouse’s primary coverage will be provided under this Plan.

• Totally disabled participants: If you or your dependent become totally disabled, as determined by the Social Security Administration, and you are eligible for Medicare, this Plan will still be primary.

• Participants with End-Stage Renal Disease: If you or any of your covered dependents become eligible for Medicare on the basis of end-stage renal disease (ESRD) while you are an active employee, benefits for the individual with ESRD will be coordinated with

Medicare. This Plan will be the primary plan and Medicare will be secondary for 30 months

in most cases; after that, Medicare will be primary. The 30 months begin the month in which Medicare ESRD coverage begins.

COORDINATION WITH MEDICAID

Payments by this Plan will be made in compliance with any assignment of rights as required by California’s (or any other state’s) plan for medical assistance approved under Title XIX, Section 1912(a)(1)(A) of the Social Security Act (Medicaid).

If the state has paid for medical assistance under Medicaid in any case where this Plan has a legal liability to make payment for such assistance, payment for the benefits will be made in

accordance with any state law giving the state rights to such payment with respect to an eligible individual. The Plan’s reimbursement to the state will be for the amount of Plan benefits or the amount actually paid, whichever is less. The Plan will not pay benefits in such a case for any claim submitted more than 1 year from the date expenses were incurred.

COORDINATION WITH HMOS

If your other coverage is an HMO (or similar prepaid plan, such as an individual practice association), the HMO’s benefits are typically available only if you use the HMO’s providers. If you use the HMO’s providers, benefits payable by the Fund will be limited to reimbursement of the standard copayment you are required to make when you use the HMO’s providers.

Third-Party Payments

If you are injured or made ill by the act or failure to act of another person (called a “third party”), the Fund will pay benefits only if you agree to repay the benefits if you later recover damages or receive reimbursement from the third party or an insurance company. You must also agree to help the Fund recover those benefits.

Before accepting any benefits from the Fund, you and your covered dependents must agree in writing to reimburse the Fund for any payments made by the Fund for hospital, medical, or other expenses in connection with, or arising out of, any injury, illness, disease, or other condition. The Fund will have an automatic lien upon any recovery against the third party for benefits paid by the Fund as a result of such illness, injury, disease, or other condition.

You can reimburse the Fund with

• proceeds received by way of judgment, arbitration award, settlement, or otherwise from a claim against the third party, his insurance carrier, guarantor, or other indemnitor,

• any payments you receive under “no fault” (uninsured or underinsured) motorist coverage, or

• proceeds from any other source of third-party recovery.

You are required to

• prosecute a claim for damages diligently,

• give priority to the reimbursement of the Fund in the allocation of the proceeds of any recovery,

• cooperate with and assist the Fund in obtaining reimbursement for such payments,

• execute any documents necessary to secure the reimbursement, and

• refrain from any act or omission that might hinder any reimbursement.