Cement Masons and Plasterers
Health & Welfare Plan
Summary Plan Description
Effective April 1, 2013
#161W
Administered by:
Welfare & Pension Administration Service, Inc.
2815 Second Avenue, Suite 300
Seattle, WA 98121
Mailing Address:
P.O. Box 34203
Seattle, Washington 98124-1203
Administration and Eligibility:
(206) 441-7574
(800) 331-6158
Plan arranged by:
DiMartino Associates, Inc.
and
Gail E. McGinn Insurance, Inc.
4/2013 1,500
Cement Masons and Plasterers
Health & Welfare Plan
Summary Plan Description
Effective April 1, 2013
#161W
Administered by:
Welfare & Pension Administration Service, Inc.
2815 Second Avenue, Suite 300
Seattle, WA 98121
Mailing Address:
P.O. Box 34203
Seattle, Washington 98124-1203
Administration and Eligibility:
(206) 441-7574
(800) 331-6158
Plan arranged by:
DiMartino Associates, Inc.
and
Gail E. McGinn Insurance, Inc.
4/2013 1,500
Cement Masons and Plasterers
Health & Welfare Plan
Summary Plan Description
Effective April 1, 2013
#161W
Administered by:
Welfare & Pension Administration Service, Inc.
2815 Second Avenue, Suite 300
Seattle, WA 98121
Mailing Address:
P.O. Box 34203
Seattle, Washington 98124-1203
Administration and Eligibility:
(206) 441-7574
(800) 331-6158
Plan arranged by:
DiMartino Associates, Inc.
and
Gail E. McGinn Insurance, Inc.
4/2013 1,500
Cement Masons and Plasterers
Health & Welfare Plan
Summary Plan Description
Effective April 1, 2013
#161W
Administered by:
Welfare & Pension Administration Service, Inc.
2815 Second Avenue, Suite 300
Seattle, WA 98121
Mailing Address:
P.O. Box 34203
Seattle, Washington 98124-1203
Administration and Eligibility:
(206) 441-7574
(800) 331-6158
Plan arranged by:
DiMartino Associates, Inc.
and
Gail E. McGinn Insurance, Inc.
Cement Masons & Plasterers Trust Funds
2815 2nd Avenue, Suite 300 • P.O. Box 34203 • Seattle, Washington 98124Phone (206) 441-7574 or (800) 732-1121 • Fax (206) 505-9727 • Website www.cementmasonstrust.com Administered by
Welfare & Pension Administration Service, Inc.
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110.020 mem qb180402.005
February 26, 2015
TO: All Active, Retired and COBRA Participants and Their Dependents Cement Masons and Plasterers Health and Welfare Plan
RE: Summary of Material Modifications
This provides notice of material modifications to the Cement Masons and Plasterers Health and Welfare Plan (“Plan”). This information is VERY IMPORTANT to you and your Dependents. Please read it carefully and keep it with your booklet dated April 1, 2013.
Employer Contribution Rate Under Collective Bargaining Agreements
The employer contribution rate paid for active employees as provided in the collective bargaining agreements increased from $6.93 per hour to $7.08 per hour effective for hours worked on and after June 1, 2014 for Cement Masons and July 1, 2014 for Plasterers.
Plan Changes The Trustees approved the following changes to the Plan:
Monthly Dollar Bank Deduction Rate for Active Participants (refer to page 21 of the April 2013 Plan Booklet)
Under the Dollar Bank eligibility system, contributions reported by your employer are deposited to your Dollar Bank account with the Plan. The amount required for one month’s coverage, called the “monthly Dollar Bank deduction rate,” is withdrawn monthly by the Plan to provide your coverage. Effective for March 2015 coverage, the Dollar Bank deduction rate will increase from $866.00 per month to $885.00 per month. Please note that there was a delay in implementing this change.
Effective with August 2015 coverage for Cement Masons and September 2015 coverage for Plasterers, the Dollar Bank deduction rate will increase from $885.00 to $910.00.
The Administration Office will notify you regarding a partial self-payment and/or a COBRA (continuation coverage) payment if your bank balance falls below the Dollar Bank deduction rate that is required for a month of coverage.
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Amount Required for Initial Eligibility of Active Participants (refer to page 21 of the April 2013 Plan Booklet)
The amount that you must accumulate in your Dollar Bank to receive initial eligibility will increase from $1,732.00 to $1,770.00 (the equivalent of two times the monthly Dollar Bank deduction rate) effective with March 2015 eligibility. The amount required for initial eligibility will increase to $1,820.00 effective with August 2015 eligibility for Cement Masons and September 2015 eligibility for Plasterers.
Changes to Retiree Self-Payment Rates (refer to page 28 of the April 2013 Plan Booklet)
Self payments are required by Retired Participants and their Covered Dependents to maintain Retiree medical coverage. Effective for June 2015 coverage, the self-payment rate will increase by 7.5%. The Trust Administration Office will notify Retired Participants of their new rate at a later date.
Changes to COBRA Self-Payment Rates (refer to pages 35-42 of the April 2013 Plan Booklet)
Self payments are required if you qualify for and elect to continue coverage through COBRA beyond the time coverage would otherwise end. Effective for August 2015 coverage, the new COBRA self-payment rates will be $929.00 per month if you elect to continue all coverage (medical, dental, vision, life, and accidental death and dismemberment) and $852.00 per month if you elect to continue just medical, life, and accidental death and dismemberment. If you qualify for an extension of COBRA due to a disability as determined by the Social Security Administration, the self-payment rate may be 150% of the COBRA self-payment rate. There is no continuation coverage for weekly disability coverage. The Trust Administration Office will notify COBRA beneficiaries of their new rate at a later date.
If you have any questions about these changes, please contact the Administration Office at 1-800-732-1121, option #4.
Sincerely,
Board of Trustees
Cement Masons and Plasterers Health and Welfare Trust
Lmm Opeiu #8
Cement Masons & Plasterers Trust Funds
2815 2nd Avenue, Suite 300 • P.O. Box 34203 • Seattle, Washington 98124
Phone (206) 441-7574 or (800) 732-1121 • Fax (206) 505-9727 • Website www.cementmasonstrust.com Administered by
Welfare & Pension Administration Service, Inc.
February 12, 2015
TO: All Active Employees, Beneficiaries and Retirees of the Cement Masons and Plasterers Health and Welfare Plan RE: Summary of Material Modification
This notice will advise you of certain material modifications that will be made to the Cement Masons and Plasterers Health & Welfare Plan. This information is VERY IMPORTANT for you and your dependents. Please read it carefully and keep it with your Plan Booklet.
ELIMINATION OF LIMITATIONS ON NEURODEVELOPMENTAL BENEFITS
Effective immediately, the Plan will cover medically necessary speech, occupational, physical and other medically necessary therapies to treat developmental conditions identified as mental disorders in the current International Classification of Diseases (“ICD”) and the Diagnostic and Statistical Manual of Mental Disorders (“DSM”). Covered therapies include the services of those authorized and licensed to deliver occupational, speech, physical and other therapies for treatment of mental disorders. The Plan will not impose age, visit or dollar limits on coverage for these therapies when provided to treat a covered mental disorder. The Plan will continue to impose its current limits on coverage for these therapies when provided for rehabilitative treatment.
If you have questions regarding this notice, contact the Administration Office at (800) 331-6158, option 0, or visit the Trust website at www.cementmasonstrust.com for additional benefit information.
Sincerely,
Board of Trustees
Cement Masons and Plasterers Health and Welfare Plan
CJ:lmm opeiu#8
S:\Mailings\Individual Trust Fund Mailings (SMM, Benefit Changes, etc.)\F16\F16-02 - Mailings - 2015 - 02.12 - SMM - Neurodevelopmental.docx
Please read this notice carefully and keep it with your benefit booklet or insurance records for future reference.
Cement Masons & Plasterers Trust Funds
2815 2nd Avenue, Suite 300 • P.O. Box 34203 • Seattle, Washington 98124
Phone (206) 441-7574 or (800) 732-1121 • Fax (206) 505-9727 • Website www.cementmasonstrust.com
Administered by
Welfare & Pension Administration Service, Inc.
SUMMARY OF MATERIAL MODIFICATION
October 29, 2014
TO: All Active Employees, Beneficiaries and Retirees of the
Cement Masons and Plasterers Health and Welfare Plan
RE: Summary of Material Modifications
This notice will advise you of certain material modifications that will be made to the Cement Masons and Plasterers Health & Welfare Trust. This information is VERY IMPORTANT for you and your dependents. Please read it carefully and keep it with your Plan Booklet.
CHANGES TO YOUR MEDICAL AND PRESCRIPTION DRUG PLAN
Out-of-Pocket Maximum for Medical Plan - (Applies to in-network preferred providers only):
Currently, the Medical Plan has an overall annual maximum out-of-pocket (MOOP) of $3,300 per individual, which includes deductibles, copayments and coinsurance. Effective January 1, 2015, the Plan is implementing a calendar year overall maximum out-of-pocket (MOOP) of $3,300 per individual and $6,600 per family for the Medical Plan. Your in-network (preferred provider) coinsurance, annual deductible, emergency room copayment, and any other in-network copayments will count toward your annual maximum out-of-pocket. Any penalties, fees or out-of-network (non-preferred provider) coinsurance will not count toward your annual pocket maximum. Once the maximum out-of-pocket (MOOP) is reached, no additional cost sharing will be required under the Plan for Covered Service provided by in-network providers for the balance of the calendar year.
Prescription Drug Maximum Coinsurance: Currently, the Plan’s maximum coinsurance for
Prescription Drugs is $6,350 per individual and $12,700 for family for Tiers 1 and 2 drugs (Generics and Preferred Brand Names, respectively). Effective January 1, 2015, the Plan will reduce the maximum coinsurance to $3,300 per individual and $6,600 per family for Tiers 1 and 2 drugs. The maximum coinsurance per individual or family does not apply for Tier 3 drugs (Non-Preferred Brand Name Drugs).
If you have questions regarding the above changes, please contact the Trust Office. Sincerely,
Board of Trustees
Cement Masons and Plasterers Health and Welfare Trust Opeiu#8
S:\Mailings\Individual Trust Fund Mailings (SMM, Benefit Changes, etc.)\F16\F16-02 - Mailings - 2014 - 10.29 - MOOP SMM - Eff 01.01.2015.docx
Please read this notice carefully and keep it with your benefit booklet or insurance records for future reference.
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CEMENT MASONS & PLASTERERS HEALTH AND WELFARE TRUST NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Pursuant to regulations issued by the federal government, the Trust is providing you this Notice about the possible uses and disclosures of your health information. Your health information is information that constitutes PHI as defined in the Privacy Rules of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). As required by law, the Trust has established a policy to guard against unnecessary disclosure of your health information. This Notice describes the circumstances under which and the purposes for which your health information may be used and disclosed and your rights in regard to such information.
PROTECTED HEALTH INFORMATION
PHI generally means information that: (1) is created or received by a health care provider, health plan, employer, or health care clearing house; 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 (3) identifies the individual, or there is a reasonable basis to believe the information can be used to identify the individual.
USE AND DISCLOSURE OF HEALTH INFORMATION
Your health information may be used and disclosed without an authorization for the purposes listed below. The health information used or disclosed will be limited to the “minimum necessary,” as defined under the Privacy Rules.
To Make or Obtain Payment: The Trust may use or disclose your health information to make
payment to or collect payment from third parties, such as other health plans or providers, for the care you receive, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, the Trust may use health information to pay your claims or share information regarding your coverage or health care treatment with other health plans to coordinate payment of benefits. The Trust may also share your protected health information with another entity to assist in the adjudication of reimbursement of your health claims.
To Facilitate Treatment: The Trust may disclose information to facilitate treatment which
involves providing, coordinating or managing health care or related services. For example, the Trust may disclose the name of your treating Physician to another Physician so that the Physician may ask for your x-rays.
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To Conduct Health Care Operations: The Trust may use or disclose health information for its
own operations, to facilitate the administration of the Trust and as necessary to provide coverage and services to all of the Trust’s Participants.
Health care operations include: making eligibility determinations; contacting health care providers; providing Participants with information about health-related issues or treatment alternatives; developing clinical guidelines and protocols; conducting case management; medical review and care coordination; handling claim appeals; reviewing health information to improve health or reduce health care costs; participating in drug or disease management activities; conducting underwriting; premium rating or related functions to create, renew or replace health insurance or health benefits; and performing the general administrative activities of the Trust (such as providing customer service, conducting compliance reviews and auditing, responding to legal matters and compliance inquiries, handling quality assessment and improvement activities, business planning and development including cost management and planning-related analyses and formulary development, and accreditation, certification, licensing or credentialing activities). For example, the Trust may use your health information to conduct case management of ongoing care or to resolve a claim appeal you file.
For Disclosure to the Plan Trustees: The Trust may disclose your health information to the
Board of Trustees (which is the Plan sponsor) and to necessary advisors which assist the Board of Trustees in performing Plan administration functions, such as handling claim appeals. The Trust also may provide Summary Health Information to the Board of Trustees so that it may solicit bids for services or evaluate its benefit plans.
Summary Health Information is information which summarizes Participants’ claims information but from which names and other identifying information have been removed. The Trust may also disclose information about whether you are participating in the Trust or one of its available options.
For Disclosure to You or Your Personal Representative: When you request, the Trust is
required to disclose to you or your personal representative your protected health information that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. Your personal representative is an individual designated by you in writing as your personal representative, attorney-in-fact. The Trust may request proof of this designation prior to the disclosure. Also, absent special circumstances, the Trust will send all mail from the Trust to the individual’s address on file with the Trust Administration Office. You are responsible for ensuring that your address with the Trust Administration Office is current. Although mail is normally addressed to the individual to whom the mail pertains, the Trust cannot guarantee that other individuals with the same address will not intercept the mail. You have the right to request restrictions on where your mail is sent as set forth in the request restrictions section below.
Disclosure Where Required By Law: In addition, the Trust will disclose your health
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1. In Connection With Judicial and Administrative Proceedings. The Trust may disclose your health information to a health oversight agency for authorized activities (including audits; civil; administrative or criminal investigations; inspections; licensure or disciplinary action); government benefit programs for which health information is relevant; or to government agencies authorized by law to receive reports of abuse, neglect or domestic violence as required by law. The Trust, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits. The Trust will make reasonable efforts to either notify you about the request or to obtain an order protecting your health information. 2. When Legally Required and For Law Enforcement Purposes. The Trust will disclose your
protected health information when it is required to do so by any federal, state or local law. Additionally, as permitted or required by state law, the Trust may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if the Trust has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
3. To Conduct Public Health and Health Oversight Activities. The Trust may disclose your protected health information to a health oversight agency for authorized activities (including audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary action), government benefit programs for which health information is relevant, or to government agencies authorized by law to receive reports of abuse, neglect or domestic violence as required by law.
The Trust, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits.
4. In the Event of a Serious Threat to Health or Safety. The Trust may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Trust, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For example, the Trust may disclose evidence of a threat to harm another person to the appropriate authority.
5. For Specified Government Functions. In certain circumstances, federal regulations require the Trust to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the President and others, and correctional institutions and inmates. 6. For Workers’ Compensation. The Trust may release your health information to the extent
necessary to comply with laws related to workers’ compensation or similar programs.
7. To Business Associates. The Trust may disclose your health information to its Business Associates, which are entities or individuals not employed by the Trust, but which perform functions for the Trust involving protected health information, such as claims processing,
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utilization review, or legal, consulting, accounting or administrative services. The Trust’s Business Associates are required to safeguard the confidentiality of your health information.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, the Trust will not disclose your health information without your written authorization.
Generally, you will need to submit an Authorization if you wish the Trust to disclose your health information to someone other than yourself. Authorization forms are available from the Privacy Contact Person listed below.
If you have authorized the Trust to use or disclose your health information, you may revoke that Authorization in writing at any time. The revocation should be in writing, include a copy of or reference to your Authorization and be sent to the Privacy Contact Person listed below.
Special rules apply about disclosure of psychotherapy notes. Your written Authorization generally will be required before the Trust will use or disclose psychotherapy notes. Psychotherapy notes are a mental health professional’s separately filed notes which document or analyze the contents of a counseling session. Psychotherapy notes do not include summary information about your mental health treatment or information about medications, session stop and start times, the diagnosis and other basic information. The Trust may use and disclose psychotherapy notes when needed to defend against litigation filed by you or as necessary to conduct Treatment, Payment and Health Care Operations.
Additionally, your written authorization will be required for any disclosure of your health information that involves marketing, the sale of your health information, or any disclosure involving direct or indirect remuneration to the Trust.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Trust maintains:
Right to Request Restrictions: You may request restrictions on certain uses and disclosures of
your health information. You have the right to request a limit on the Trust’s disclosure of your health information to someone involved in payment for your care. However, the Trust is not required to agree to your request unless the disclosure at issue is to another health plan for the purpose of carrying out payment or health care operations and your health care provider has been paid by you out-of-pocket and in full. However, the Trust is not required to agree to your request. If you wish to request restrictions, please make the request in writing to the Trust’s Privacy Contact Person listed below.
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Right to Inspect and Copy Your Health Information: You have the right to inspect and copy
your health information. This right, however, does not extend to psychotherapy notes or information compiled for civil, criminal or administrative proceeding. The Trust may deny your request in certain situations subject to your right to request review of the denial. A request to inspect and copy records containing your health information must be made in writing to the Privacy Contact Person listed below. If you request a copy of your health information, the Trust may charge a reasonable fee for copying, assembling costs and postage, if applicable, associated with your request. Notwithstanding the foregoing, the fee for a copy of your health information in electronic format shall not be greater than the Trust’s labor costs in responding to the request.
Right to Receive Confidential Communications: You have the right to request that the Trust
communicate with you in a certain way if you feel the disclosure of your health information through regular procedures could endanger you. For example, you may ask that the Trust only communicate with you at a certain telephone number or by e-mail. If you wish to receive confidential communications, please make your request in writing to the Privacy Contact Person listed below. The Trust will attempt to honor reasonable requests for confidential communications.
Right to Amend Your Health Information: If you believe that your health information records
are inaccurate or incomplete, you may request that the Trust amend the records. That request may be made as long as the information is maintained by the Trust. A request for an amendment of records must be made in writing to the Trust’s Privacy Contact Person listed below. The Trust may deny the request if it does not include a reasonable reason to support the amendment.
The request also may be denied if your health information records were not created by the Trust, if the health information you are requesting to amend is not part of the Trust’s records, if the health information you wish to amend falls within an exception to the health information you are permitted to inspect and copy, or if the Trust determines the records containing your health information are accurate and complete.
If the Trust denies a request for amendment, you may write a statement of disagreement. The Trust may write a rebuttal statement and provide you with a copy. If you write a statement of disagreement, then your request for amendment, your statement of disagreement, and the trust’s rebuttal will be included with any future release of the disputed health information.
Right to an Accounting: You have the right to request a list of disclosures of your health
information made by the Trust. The request must be made in writing to the Privacy Contact Person. The request should specify the time period for which you are requesting the information. No accounting will be given of disclosures made: to you or any one authorized by you; for treatment, payment or health care operations; disclosures that were incident to a use or disclosure that is otherwise permitted by the Privacy Rules; disclosures made pursuant to an authorization; disclosures made before April 14, 2003; disclosures for periods of time going back more than six years; or in other limited situations. The Trust will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Trust will inform you in advance of the fee, if applicable.
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Right to Opt Out of Fundraising Communications. If the Trust participates in fundraising,
you have the right to opt-out of all fundraising communications.
Right to a Paper Copy of this Notice: You have a right to request and receive a paper copy of
this Notice at any time, even if you have received this Notice previously or agreed to receive the Notice electronically. To obtain a paper copy, please contact the Privacy Contact Person listed below. You will also be able to obtain a copy of the current version of the Trust’s Notice at its
web sit
Privacy Contact Person/Privacy Official: To exercise any of these rights related to your health information you should contact the Privacy Contact Person listed below. The Trust has also designated a Privacy Official to oversee its compliance with the Privacy Rules who is also listed below.
Privacy Contact Person Claims Manager
c/o Welfare & Pension Administration Service, Inc. P.O. Box 34203 Seattle, WA 98124-1203 Toll Free: 800-331-6158 Fax No: 206-441-9110 Privacy Official C. Gilbert Lynn
c/o Welfare & Pension Administration Service, Inc. P.O. Box 34203
Seattle, WA 98124 Toll Free: 800-331-6158
Fax No: 206-441-9110
DUTIES OF THE TRUST
The Trust is required by law to maintain the privacy of your health information as set forth in this Notice, to provide to you this Notice of its duties and privacy practices, and to notify you following a breach of unsecured protected health information. The Trust is required to abide by the terms of this Notice, which may be amended from time to time. The Trust reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If the Trust changes its policies and procedures, the Trust will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to the Trust and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to the Trust should be made in writing to the Privacy Contact Person identified above. The Trust encourages you to express any concerns you may have regarding the privacy of your health information. You will not be retaliated against in any way for filing a complaint.
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The Trust is prohibited by law from using or disclosing genetic health information for underwriting purposes.
EFFECTIVE DATE
This Notice was originally effective April 14, 2003, as amended September 3, 2013.
CR:lmm opeiu#8
1
Updated to April 1, 2013
To All Participants and Covered Dependents:
We are pleased to present this revised Plan Booklet which describes the benefits provided by the Cement Masons and Plasterers Health and Welfare Plan. This Plan booklet is the Plan document, and it supersedes all previous versions of the Plan booklet or Plan document.
This Plan is a non-grandfathered health plan under the Patient Protection and Affordable Care Act (“PPACA”).
FUNDING
Medical, Prescription Drug, dental, vision and weekly disability benefits are paid directly through the Trust. The Trust is also insured with stop-loss coverage through Transamerica Life Insurance Company. The stop-loss coverage presently provides coverage when either 1) a Participant’s individual medical claims exceed $200,000 in any Plan Year and the Trust has paid the first $135,000 combined for all Participants who have claims exceeding $200,000 during a Plan year; or 2) the claims exposure of the Trust in the aggregate exceeds 125% of expected medical claims. Life, dependent life, and accidental death and dismemberment are insured by LifeMap Assurance Company.
HOW TO OBTAIN PLAN BENEFITS
Welfare & Pension Administration Service, Inc. (“WPAS”), processes claims on behalf of the Board of Trustees. To obtain information about your benefits, request forms, or if you need assistance with filing your claim, contact WPAS at (206) 441-7574, or (800) 331-6158. Forward your completed claim forms to the Trust Administration Office at:
Cement Masons and Plasterers Health and Welfare Plan P.O. Box 34964
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AUTHORITY TO INTERPRET AND CHANGE THE PLAN
The Board of Trustees has the exclusive authority to interpret the provisions of the Plan, to determine eligibility for an entitlement to Plan benefits or to amend the Plan. Any interpretation or determination by the Trustees made in good faith which is not contrary to law is conclusive on all persons affected. The Board of Trustees has delegated to the Trust Administration Office the authority to administer the Plan and provide information relating to the amount of benefits, eligibility, and other Plan provisions. In administering the Plan, the Trust Administration Office and any medical review organization used by the Trust may utilize its internal guidelines and medical protocols in determining whether or not specific services or supplies are covered under the terms of the Plan. The Trust Administration Office does not have the authority to change the provisions of the Plan. An interpretation of the Plan by the Trust Administration Office is subject to review by the Board of Trustees. No individual trustee, Employer, Employer association, labor organization, or any individual employed by an Employer or labor organization, has any authority to interpret or change the Plan.
The Trustees reserve the right to make any changes they deem necessary to promote efficiency, economy and better service for the Participants and their Covered Dependents. The Trustees have no obligation to furnish benefits beyond those that can be provided by the Trust Fund. The Plan, including Retiree benefits, is provided to the extent that money is currently available to pay the cost of such programs.
IMPORTANT NOTICE
The Plan contains certain cost containment features, Medical Review and Authorization requirements, which could affect the way benefits are paid to you. It is important that you refer to your Plan booklet for the details of these requirements.
The Plan includes a medical Preferred Provider Organization (PPO) through First Choice Health Network, Inc., and an extended
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medical PPO through First Health Network, for out of area Participants, a managed care (HMO) dental option through Willamette Dental of Washington, a managed care vision option through National Vision, Inc., and outpatient prescription drug benefits through Sav-RX Prescription Services which reduce your costs as well as the costs of the Plan.
The Plan has an annual maximum benefit limit of $1,250,000 per insured person for all essential medical and prescription drug benefits combined. Unless there are any changes to the Patient Protection and Affordable Care Act (PPACA), the annual limit will increase $2,000,000 effective April 1, 2013; and will be eliminated effective April 1, 2014.
When the Covered Person’s annual maximum limit is exceeded, the Plan is no longer obligated to pay medical or prescription benefits for that person for the balance of the Plan Year (April 1st – March 31st). The Plan also contains specific limits for certain types of treatment. For other limitations, see the Plan booklet.
The Plan incorporates a number of amendments that have occurred since the Plan was last issued in 2003. The Plan also contains a number of changes, including, but not limited to, updates and clarification of benefits and eligibility required by PPACA, Qualified Medical Child Support Orders, COBRA continuation coverage, continuation coverage while on active military duty, coordination of benefits, and the Plan’s right of recovery.
You and your spouse should read this booklet carefully. Keep it with your other important papers so that you can refer to it when you terminate employment, change jobs or retire. If you lose your copy, you may obtain another from the Trust Administration Office or view on-line at www.cementmasonstrust.com.
We urge you to use your benefits wisely to assure the success of the Plan.
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PARTICIPANT REWARDS PROGRAM
The Board of Trustees has adopted a reward program for vigilant Plan members. If you find an error on a medical or dental provider’s bill that has been paid by the Trust, the Plan will pay you 50% of the overcharged amount (based on the Plan’s payment provisions) up to a maximum of $5,000 per occurrence.
Provider fraud is one example where careful attention to your Explanation of Benefits pays off, for example, if a provider submits a claim to the Plan for services that were never rendered. There are also lesser instances where you may be the only one to know that you did not receive the service being billed. Sometimes the billing office reads the doctor’s notes incorrectly and bills for services you did not receive. It might be that your doctor or hospital accidentally bills for the wrong services, or for another individual who shares your name but is not covered by this Plan. Whatever the case, you can save the Plan money and earn a bonus by looking over every Explanation of Benefits you receive.
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CONTACT INFORMATION
Eligibility for Benefits WPAS, Inc.
(206) 441-7574
(800) 732-1121
www.cementmasonstrust.com
Benefits and Claims: Medical, Dental, WPAS, Inc.
Vision, Time Loss (206) 441-7574
Life /AD&D (800) 331-6158 (206) 441-7574
(800) 732-1121
Prescription Drugs Sav-RX
Customer Service (800) 228-3108
www.savrx .com
Hospital Utilization Review UR Coordinator
(for Hospital or surgical pre-authorization) First Choice Health Network
(206) 292-8255 (800) 231-6935 Medical – Primary Preferred Provider Network First Choice Health Network In the states of WA, OR, ID, MT and AK (206) 292-8255
(800) 231-6935 Medical – Extended Network
Outside of WA, OR, ID, MT or AK
www.fchn.com First Health (800) 226-5116 www.firsthealth.com
Managed Vision Care National Vision, Inc. (888) 822-6901
www.nationalvision.com Willamette Dental – Customer Service (855) 433-6825 www.willamettedental.com
Privacy Contact/Officer WPAS, Inc.
206-441-7574 800-331-6158
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Trust Fund Website
The Cement Masons and Plasterers Trust Funds have established a website to provide you with immediate access to your Plan
information. The web site is www.cementmasonstrust.com and
includes the following Trust Fund related material:
Forms – Claim Forms, Legal Documents, and Notices
Plan Booklets
Links to Carriers, Preferred Provider Organizations, and other
useful sites
This site will also provide a link to “My Personal Benefits” information, which may be viewed through a secure location requiring the entry of a personal identification number (PIN) and your social security number or member identification number. A PIN will be assigned and mailed to you upon your written request. To request a PIN, please complete a PIN Request Form which can be printed from the website. Please note that a PIN will be assigned; for security purposes you may not choose your own PIN. “My Personal Benefits” information includes the following data:
Personal Information – Name, address, gender, birth date,
marital status, etc.
Hours/Contributions – A statement showing recent Employers
who have reported hours and contributions to the Trust on your behalf.
Claims Summary – A detailed summary of paid claims
information. Note participants only have access to their own personal paid claims history and that of dependents under the age of 13. Dependents age 13 and over must request their own PIN.
7
SUMMARY OF BENEFITS
The following chart provides a brief summary of your benefits. For a complete description of the benefits listed below, refer to the appropriate section of this booklet.
Medical Benefits
Preferred Providers
Non-Preferred Providers Deductible(per calendar year)
Individual Family $300 $600 $600 $1,200 Maximum Coinsurance
(per individual per calendar year) $3,000 $12,500
Your annual out-of-pocket maximum coinsurance equals the maximum annual coinsurance based on provider category. Your deductible does not count toward your annual out-of-pocket maximum coinsurance.
Annual Maximum $1,250,000 4/01/2012 – 3/31/2013 $2,000,000 4/01/2013 – 3/31/2014 Hospital Care 80% 60%
Emergency Room Copayment $200 $200
Inpatient care must be preauthorized by First Choice or benefits may be reduced or denied. Emergency Room Copayment is waived if directly admitted to hospital, or accidental injury.
Physician Visits
Home and Office Visits 80% 60%
X-ray and Lab 80% 60%
Hospital Visits 80% 60%
Inpatient/Outpatient Surgery 80% 60%
Inpatient care or surgical care not performed in a doctor’s office must be preauthorized by First Choice or benefits may be reduced or denied. Preventive Care
Routine Visits 100% 60%
Immunizations/Vaccinations 100% 60%
8 Medical Benefits Preferred Providers Non-Preferred Providers Spinal Treatment 80% 60%
Maximum benefit is $25 per visit/25 visits each calendar year.
Chemical Dependency 80% 60%
Limited to a maximum of 20 outpatient visits and 10 inpatient days per calendar year. Inpatient care must be preauthorized by First Choice.
Maternity Benefits 80% 60%
Benefits for Covered Participants or spouses only. Benefits processed the same as any other condition.
Mental and Nervous Inpatient 80% 60%
Inpatient limited to 10 days per calendar year, 30 days lifetime. Inpatient care must be preauthorized by First Choice.
Mental and Nervous Outpatient 50% 50%
Outpatient limited to 20 visits per calendar year. Balance does not apply towards your out-of-pocket maximum coinsurance.
Ambulance 80% 60%
Outpatient Rehabilitation 80% 60%
Limited to a maximum of 40 treatments per calendar year.
Alternative Care 80% 60%
Maximum combined benefit of $500 per calendar year. Prescription Drug Program – Sav-Rx Maximum Coinsurance
(per individual per calendar year) $7,000
The coinsurance you pay for Tier 1 and Tier 2 drugs will accumulate towards the prescription out-of-pocket maximum coinsurance, which is separate from the Medical Benefits Maximum Coinsurance. Coinsurance paid towards Tier 3 drugs does not count toward the out-of-pocket maximum coinsurance.
Tier Formulary Status Copayment
1 All Generic Drugs 20% coinsurance
2 Preferred Brand Name Drugs (on the Formulary) 30% coinsurance 3 Non-Preferred Brand Name Drugs (NOT on the Formulary) 40% coinsurance
9 Prescription Drug Program – Sav-RX
Days Supply Participating Retail Pharmacy 34 days
Mail Order 90 days Specialty Drugs 30 days
Self-Insured Traditional Dental Plan
Allowances shown below do not apply to Willamette Dental, for more information about Willamette Dental see page 88.
Calendar Year Deductible $25 per person (waived for Class A Preventive Services)
Calendar Year Maximum $2,000 per person
Does not apply to Covered Dependent children up to the age of 18 for necessary Class A and Class B pediatric Treatment
Co-payment Percentage
Preventive and Routine
(Class A & B Services) 70%; 80%; 90%; 100% of the Allowable Charge
Major Services
(Class C Services) 50% of Allowable Charge
Treatment of
Temporomandibular Joint Disease or Disorder
$750 per Covered Person Cumulative Lifetime Benefit
10 Self-Insured Scheduled Vision Plan
Allowances shown below do not apply to the National Vision Inc. option or to Covered Dependent children under age 18.
For National Vision allowances, see page 91.
For benefits available to your Covered Dependent children under age 18, see page 90.
Vision Service Allowed Amount
Complete Examination $90
Lenses (per pair)
Single vision lens $90 Bifocal lens $110 Trifocal lens $130 Lenticular lens $190 Frames $100 Contact Lens Medically Necessary $215 Not Medically Necessary $150
Weekly Disability Benefits for Active Participants
Weekly Income for Disability
(Non-Occupational) Maximum Benefit per week
$250
Maximum Weeks Payable 26 weeks
Chemical Dependency 12 weeks
11
Life, Accidental Death and Dismemberment, Dependent Life Insurance
For Active, COBRA, and Associate Participants
Life Insurance $25,000 Accidental Death and Dismemberment $25,000 Covered Spouse $ 7,500 Covered Child (age 14 days to age 26 ) $ 5,000
For Retired Participants
Life Insurance $5,000 Accidental Death and Dismemberment None
Covered Spouse $5,000 Covered Child (age 14 days to age 26) $5,000
For Widows/Widowers
Life Insurance $5,000 Accidental Death and Dismemberment None
13 TABLE OF CONTENTS
Medical Preferred Provider Organizations . ...16 Medical Review and Surgical Authorization ...17 Dollar Bank Eligibility ...21 Initial Eligibility ...21 Continuing Coverage ...22 Dollar Bank Maximum ...22 Reciprocity ...22 Termination, Self-Payment and Reinstatement of Eligibility ... 23 Dependent Eligibility and Coverage ...24 When Dependents Coverage Begins ...25 When Dependent Coverage Ends ...25 Qualified Medical Child Support Orders ...26 Run Out of Active Coverage and Waiver of Contributions .…28 Surviving Spouse and Dependent Self-Payment ...29 Coverage for Retired Participants and Their Dependents ...29 Medicare Enrollment ...30 Medicare Part D Prescription Drug Plans ...33 COBRA Continuation of Coverage ...35 COBRA Quick Reference Chart ...45 Continuation of Coverage Beyond COBRA ...46 Family and Medical Leave ...46 Benefit Portability ...46 Military Service ...47 Major Medical Benefits ...52 Cumulative Annual Maximum Benefit Limit ...52 Calendar Year Deductible ...53 Coinsurance Payment Level ...54 Covered Services for Major Medical ...55 Air Transportation/Air Ambulance ...58 Ambulance ...59
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Diabetic Self-Management ...59 Organ Transplant ...60 Preventive Care ...61 Covered Services with Limited Benefit Levels ...63 Alternative Care ...63 Birthing Center...63 Chemical Dependency ...64 Durable Medical Equipment ...64 Home Health Care, Hospice Care, and Bereavement
Counseling ...65 Mental and Nervous ...67 Neurodevelopmental ...67 Private Duty Nursing (Home) ...68 Skilled Nursing Care Facility...68 Spinal Treatment (non-surgical) ...68 Medical Exclusions ...69 Prescription Drug Benefits Program ...73 Dental Care Benefits ...81 Vision Care Benefits ...89 Weekly Disability Benefits ...94 General Exclusions ...96 Coordination of Benefits ...100 Right to Reimbursement ...105 Definitions...110 Schedule of Life, Accidental Death and Dismemberment
and Dependent Life Benefits ...120 Life, Accidental Death & Dismemberment, & Dependent Life ..121 Claims Procedures ...131 Your Privacy ...147 Summary Plan Description ...160 Name of Plan...160 Board of Trustees - Plan Administrator ...160
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Identification Number ...160 Type of Plan ...160 Legal Process ...161 Plan Year ...162 Description of Collective Bargaining Agreements ...162 Eligibility ...163 Termination of Eligibility ...163 Funding Medium ...163 Availability of Information ...164 This Program is Not Guaranteed ...164 Claims and Appeals Procedures ...164 Statement of Rights Under ERISA ...164
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MEDICAL PREFERRED PROVIDER ORGANIZATION FIRST CHOICE HEALTH NETWORK, INC. (For services delivered in the service area which includes
Washington, Oregon, Idaho, Alaska, and Montana)
The Trustees of the Plan have entered into an agreement with First Choice Health Network, Inc. (referred to as “FCHN”) to provide you and your Covered Dependents with all necessary medical services inside the FCHN service area at "preferred rates" that help to reduce your costs and the costs to the Plan. Although you may receive care from any licensed health care provider or facility when inside the FCHN service area, you receive the highest level of benefits when you obtain care from a Preferred Provider. The FCHN service area includes Washington, Oregon, Idaho, Montana and Alaska. When you use non-Preferred Providers while inside the FCHN service area, your deductible and coinsurance will increase, and penalties may apply to hospitalization for other than medical emergencies. Preferred Provider information is available online at www.fchn.com. Provider participation in the FCHN network is subject to change. It is your responsibility to assure that your provider is a Preferred Provider at the time services are rendered.
FIRST HEALTH NETWORK
(for services delivered outside the FCHN service area) Effective January 1, 2012, First Health Network will provide Preferred Provider access to those Participants who do not live in the FCHN service area or are traveling outside Washington, Oregon, Idaho, Montana or Alaska. You will receive the highest level of benefits when you obtain care through a Preferred Provider contracting with First Health Network. To find a Preferred Provider if you live or are traveling outside Washington, Oregon, Idaho, Montana and Alaska, go to www.firsthealth.com, or contact First Health customer service at (800) 226-5116 for assistance. Although you may receive care from any licensed health care facility covered by this Plan, a $500 penalty, not to exceed 50% of
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the expense incurred in excess of the major medical deductible, will be assessed for any treatment provided by a non-preferred Hospital while you are in the FCHN service area. The penalty does not apply to services provided outside the FCHN service area or to Emergency treatment or Emergency admissions, or when Medicare has the primary responsibility for your or your Covered Dependent's claims.
All surgeries or hospitalizations, except Emergency services or maternity admissions, are subject to prior authorization and review, as outlined in the section below.
MEDICAL REVIEW, SURGICAL AUTHORIZATION AND INDIVIDUAL CASE MANAGEMENT FIRST CHOICE HEALTH NETWORK, INC. (“FCHN”)
While Hospital stays and surgeries are sometimes unavoidable, there are times when Medically Necessary care can be provided appropriately in an alternate, less costly setting. Regardless of whether your care is received inside the FCHN network or outside the network, to help you assure that you and your family are hospitalized or has surgery only when necessary, FCHN will review all inpatient Hospital admissions and all surgeries, except maternity, for Medical Necessity. Anytime your doctor recommends admission to the Hospital or a surgery that will be performed in a setting other than the doctor's office, you or your doctor should contact the Plan's Utilization Review (“UR”) Coordinator at FCHN to request an authorization. For all Hospital admissions (excluding maternity and medical emergencies), you must obtain authorization from the UR Coordinator prior to admission. Emergency Hospital admissions or Emergency surgeries must be authorized by the Plan's UR Coordinator within 48 hours of the time you are admitted to the Hospital or the surgery is performed, or as soon as reasonably possible. Failure to do so will result in a $250 reduction (but not to exceed 50% of the expense incurred in excess of the deductible) in benefits for each surgery or hospitalization that is not pre-authorized.
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The pretreatment review by the UR Coordinator is performed by trained medical personnel and is intended to improve the quality of the medical care you receive while controlling the costs to you and the Plan. The UR Coordinator may be contacted at any of the following telephone numbers:
FIRST CHOICE HEALTH NETWORK, INC. (206) 292-8255 or (800) 231-6935 The UR Coordinator will need the following information:
(1) The name of the patient.
(2) The name of the Hospital, admitting Physician or surgeon, and telephone number
(3) The expected date of admission or surgery.
The UR Coordinator, together with your Physician, will then:
(1) Review the reason for admission or surgery and the
procedure to be performed;
(2) Discuss any appropriate optional treatment setting;
(3) Determine the number of days needed for any Hospital
admission.
During any Hospital stay, the UR Coordinator is in contact with the Hospital and Physician to assure that the prescribed care is being administered and that the patient is released from any Hospital stay when hospitalization is no longer needed.
Since most health care plans already include these requirements, your doctor will be able to assist you in seeking the pre-authorization for any admission or surgery. However, it is your responsibility to assure that the appropriate preauthorization is obtained.
In addition to review for Medical Necessity, you should contact the Trust Administration Office to confirm eligibility for coverage.
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INDIVIDUAL CASE MANAGEMENT
Under special circumstances, First Choice Health Network nurses act as patient advocates to help meet the needs of patients with catastrophic or chronic medical problems. They work with you, your family and your physician to help you assess, plan and coordinate all of your health care options and find the most appropriate care for your condition. This is a voluntary program available at no cost to you.
Catastrophic/Chronic Illness
The case management program can help patients with long-term, high-cost illnesses and injuries to obtain needed care. A patient who chooses to participate is assigned a case manager to help coordinate care. Many times case managers identify hospital alternatives, such as home health care or skilled nursing facilities.
Alternative Care and Treatment
Hospital confinement is not always the best environment for treating an illness. For a patient who needs significant long-term medical supervision, case management may recommend alternative care and treatment or facilities that are:
Not normally covered by the Plan
Covered by this Plan, but payable on a different basis from the care and treatment they replace
Payable on the same basis as the care and treatment they
replace, once approved.
In these situations, the Plan may approve coverage for alternative care and treatment that would otherwise not be covered, when Medically Necessary treatment can be delivered most cost-effectively.
Hospital Discharge Planning
Discharge planning helps in situations when you require continued medical care, but not necessarily care that’s as intensive as in an
20
acute setting. Case management nurses will work with you, your physician and the hospital staff to develop a plan that allows for safe release from the hospital. Working with your physician and the hospital staff, the case management nurses can also arrange home health care, skilled nursing facilities and hospice care.
Contact the Trust Administration Office when you need details about how any case management service applies to you.
21
DOLLAR BANK ELIGIBILITY AND COVERAGE FOR ACTIVE PARTICIPANTS AND THEIR COVERED
DEPENDENTS
Employers who have a collective bargaining agreement that provides for contributions to the Cement Masons and Plasterers Health and Welfare Plan will pay the stipulated amount set forth in the labor agreement for each compensable hour. A compensable hour means any straight time or overtime hour worked for which a Participant is paid. Compensable hour includes report time and shift premium hours not worked. Overtime hours are reported as regular hours regardless of the rate of pay.
Employers who have a special Associate agreement may also contribute to the Cement Masons and Plasterers Health and Welfare Plan on behalf of Associate Participants who are not covered by a collective bargaining agreement. The current rate for an Associate Participant is a minimum of 160 times the hourly compensable rate for bargaining unit Participants under the applicable bargaining agreement for each compensable hour, but not less than 160 hours per month.
Initial Eligibility - The Date Your Coverage Begins
Each Participant reported to the Plan is assigned a Dollar Bank Account into which Employer contributions are deposited as they are received from participating Employers. In order to become initially eligible under the Plan, you must accumulate sufficient contributions in your Dollar Bank Account to purchase two months of coverage at the current Dollar Bank deduction rate. The amount of the Dollar Bank deduction rate is $854.00 per month, effective October 1, 2012 and may be revised from time to time by the Board of Trustees. Coverage will commence on the first day of the second month after your Dollar Bank Account has enough funds to purchase two months of coverage. Only Employer contributions may be used to establish initial eligibility.
22 Continuing Coverage
If, after becoming initially eligible, you maintain the required contributions in your account, each month you will have the cost of one month's coverage deducted from your account, for coverage on the first day of the second month following the deduction. For example, if you have sufficient contributions in your Dollar Bank
based on hours you worked in January, the deduction from your
Dollar Bank in January will provide you with coverage in March. Contributions in excess of the required Dollar Bank deduction amount, except those contributions which are identified by the Board of Trustees as a contribution to Trust Fund reserves, will be maintained in your account to be applied towards future eligibility.
Dollar Bank Maximum
Effective August 1, 2005, the Dollar Bank was capped at $10,000 per Participant. Participants may not accumulate dollars in their bank that exceed the cap of $10,000.
Reciprocity
The Cement Masons and Plasterers Health and Welfare Plan is party to the Operative Plasterers and Cements Masons International Association (OPCMIA) Trust Fund Reciprocity Agreement ("Money Follows the Man") and other similar agreements the Trustees may enter into from time to time. The reciprocity agreement allows you to maintain benefit coverage in your home trust if you work outside of the geographic area covered by that home trust. A “home trust” means any trust party to the reciprocity agreement established in the jurisdiction in which the employee maintains his local union membership. A “work trust” means any trust party to the reciprocity agreement, other than the employee’s home trust, in whose jurisdiction the employee happens to be working.
You must work for an Employer whose bargaining agreement requires contributions to another trust, called the work trust that is party to the reciprocity agreement. Contributions received by the
23
work trust on your behalf will be transferred back to your home trust, upon written request.
To qualify for reciprocity transfers of hours and contributions, you must notify the Trust Administration Office of the work trust, in writing and within 60 days after commencing work covered by that trust, that you want your contributions to be transferred to a home trust. If no notice is given, you will be deemed to have elected to be covered by the work trust and will be subject to the eligibility requirements and benefits of that trust. Reciprocity transfers shall take place, when requested in writing, on the first of the month in which the written request is received and which date back no later than 60 days since you commenced work in the work trust.
Termination, Self-Payment and Reinstatement of Eligibility
If your Dollar Bank Account balance is reduced below the cost of one full month of coverage (the current Dollar Bank deduction rate) you will lose eligibility and your coverage will terminate, unless you make a self-payment for the difference between the monthly Dollar Bank deduction and your residual Dollar Bank balance or you elect COBRA continuation of coverage, as described on page 35.
When your coverage is terminated because your Dollar Bank Account has less than the cost of one month's coverage, the balance of your account is carried for twelve (12) months. If sufficient Employer contributions are added to your Dollar Bank Account your eligibility and coverage will be reinstated. If you do not obtain reinstatement of eligibility and coverage during the 12 month period following termination, the balance of your Dollar Bank Account will be forfeited and you will be required to satisfy the initial eligibility rules to again become eligible and covered. Self-payments to make up dollar bank shortages cannot be used to establish initial eligibility.
Refer to the Continuation by Self-Payment Section for your rights to make self-payments to the Plan.
24 Dependent Eligibility and Coverage Who Is Covered:
Your Covered Dependents for medical, prescription drug, dental and vision coverage include:
1. Your lawfully married spouse. The spouse must be legally married to you as determined under federal law, and must be treated as a spouse under the Internal Revenue Code; and 2. Your dependent children. Dependent children include your
natural children, adopted children, stepchildren or children placed with you for adoption who are under age 26. In addition, dependent children include a legally placed foster child who is placed with you by an authorized placement agency or by judgment, decree or other order of any court of competent jurisdiction. Dependent children also include children, other than those mentioned above, for whom you have legal custody or are the legal guardian pursuant to a judgment, decree, or other order of any court of competent jurisdiction and provided they depend upon you for support and live with you in a regular parent-child relationship. 3. In accordance with federal law, the Plan also provides
coverage for certain dependent children (called alternate recipients) if directed to do so by a qualified medical child support order (QMCSO) issued by a court or state agency of competent jurisdiction.
4. Your unmarried, developmentally disabled and physically handicapped dependent child may continue coverage after reaching age 26 if the child is solely dependent upon you for support, not capable of self-sustaining employment by reason of developmental disability or physical handicap and was a dependent child and so handicapped at the time of reaching the limiting age of 26. You must submit written proof of such incapacity to the Trust Administration Office within 31 days of the child's attainment of age 26. The Trust Administration Office, upon receipt of the proof, has the right to have a physician it designates examine the child as it
25
may reasonably require, but not more often than once every two years. Eligibility for disabled or handicapped dependent children will end when the disability no longer exists, or when you fail to submit any required evidence of disability as requested by the Trust Administration Office.
The following are not considered Covered Dependents: 1. Your legally separated or divorced spouse.
2. A child who has been legally adopted by another person. Eligibility ends on the date the adoptive parents assume custody.
3 A child who has attained the maximum limiting age. The maximum limiting age is the child's 26th birthday.
4. Your domestic partner.
When Dependent Coverage Begins
Dependent coverage begins the later of the day you are eligible, or the day you first acquire a Covered Dependent. Coverage for your Covered Dependents continues as long as you and they are eligible.
The Trust Administration Office may request documentation regarding your Covered Dependents’ status. If such documentation is requested, you must provide the documentation to the Trust Administration Office before your Covered Dependents’ claims can be considered. Claims and requested documentation, including eligibility documentation must be received within the timeframes set forth in this booklet section titled Payment of Claims, which begins on page 132.
When Dependent Coverage Ends
Your Covered Dependents’ coverage will end:
on the date your eligibility and coverage ends, or
on the last day of the month that your dependent no longer qualifies as a Covered Dependent, or
26
Qualified Medical Child Support Orders
The Plan recognizes Qualified Medical Child Support Orders (QMCSO) and enrolls dependent children as directed by the Order. A Qualified Medical Child Support Order is any judgment, decree or order (including a domestic relations settlement agreement) issued by a court or by an administrative agency under applicable state law which:
provides child support or health benefit coverage to a
dependent child, or
enforces a state law relating to medical child support
pursuant to Section 1908 of the Social Security Act which provides in part that if the Participant does not enroll the dependent child, then the non-Participant parent or State agency may enroll the child.
To be qualified, a Medical Child Support Order must clearly specify:
the name and last known mailing address of the Participant,
the name and mailing address of each dependent child
covered by the order or the name and mailing address of the State official issuing the order,
a description of the type of coverage to be provided by the Plan to each such dependent child,
the period of coverage to which the order applies, and
the name of each plan to which the order applies.
A Medical Child Support Order will not qualify if it would require the Plan to provide any type or form of benefit or any option not otherwise provided under this Plan, except to the extent necessary to comply with Section 1908 of the Social Security Act.
Payment of benefits by the Plan under a Medical Child Support Order to reimburse expenses claimed by a child or his custodial parent or legal guardian shall be made to the child or his custodial parent or legal guardian if so required by the Medical Child Support Order.
27
No dependent child covered by a Qualified Medical Child Support Order will be denied enrollment on the grounds that the child is not claimed as a dependent on the parent's Federal income tax return or does not reside with the parent.
When a Qualified Medical Child Support Order is Received
If a proposed or final order is received, the Trust Administration Office will notify the Participant and each child named in the order. Each child named in the order may designate a representative to receive copies of notices with respect to the order. The order will then be reviewed to determine if it meets the definition of a "Qualified Medical Child Support Order." A properly completed National Medical Support Notice issued by a state agency shall be deemed to be a Qualified Medical Child Support Order. Within a reasonable time, the Participant and each child named in the order will be notified of the decision. A notice will also be sent to each attorney or other representative named in the order or accompanying correspondence.
If the order is not qualified, the notice will give the specific reason for the decision. The party or parties filing the order will be given an opportunity to correct the order or appeal the decision through the claims review procedures explained in this booklet. If the order is qualified, the notice will give instructions for enrolling each child named in the order. A copy of the entire Qualified Medical Child Support Order and any required self-payments must be received prior to enrollment. Any child or children enrolled pursuant to an order will be subject to all provisions applicable to dependent coverage under the Plan.
Continuing Eligibility for Surviving Spouse and Covered Dependents
If you die while covered, your Covered Dependents that were covered by the Plan at the time of your death may continue coverage in several ways, as follows:
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1. For surviving Covered Dependents of Active Participants, coverage may continue through the run out of your active Dollar Bank coverage;
2. For surviving Covered Dependents of Active or Retired Participants, coverage may continue for up to 12 months through a subsidized waiver of contributions, for medical and Prescription Drug;
3. For surviving Covered Dependents, coverage may continue through self-payment; and
4. Coverage may also continue through COBRA.
Subsidized waiver of contributions and COBRA run concurrently.
Run Out of Active Coverage and Waiver of Contributions
Coverage accumulated in your Dollar Bank Account is available to your surviving Covered Dependents. In this way, benefits shall be continued for your family members until such accumulated coverage is exhausted. Once the coverage in your bank has been exhausted, your surviving Covered Dependents may contact the Trust Administration Office to apply for a waiver of contributions for medical and Prescription Drug coverage, which is subsidized by the Plan. The Plan will pay any premiums required during the period your family is covered by the waiver of contributions. The waiver of contributions may cover only those Covered Dependents that were covered by the Plan at the time of your death. Waiver coverage will cease on the earlier of: (a) 12 months from the date such coverage commenced; (b) on the date the surviving Covered Dependent(s) would cease to qualify as Covered Dependents if you were living; or, (c) the date your widowed spouse remarries, whichever event occurs earlier. The 12 month subsidized waiver of contributions coverage period runs simultaneously with COBRA coverage (See COBRA Continuation of Coverage). The waiver of contribution is subsidized by the Plan and is not guaranteed to continue but may be terminated or modified by the Trustees at any time.
