Welfare Fund Announcement Letters
 

1. 

Summary of Material Modification - December 2006

Unless otherwise stated herein, all the changes summarized in this notice are effective January 1, 2007.

1.  New Vision Care Network for Active Employees. 

Effective January 1, 2007, vision care benefits are provided exclusively through a contract with EyeMed Vision Care.  Under the previous vision benefit you submitted your bills to the Fund Office and the Fund reimbursed you up to a maximum of $150 per person per calendar year.  

By using the EyeMed network you can receive substantially greater benefits than previously.  Under the new contract, EyeMed handles both the In-Network and Out-of-Network benefits. This means that you will no longer send vision claims to the Fund Office. 

We encourage you to get the most out of your new benefit by using the EyeMed network.  The In-Network Benefits described below are available for one set of contact lenses or one set of frames and lenses per person per calendar year: 

 If you don’t use the EyeMed network, the benefits provided are substantially less. If you don’t use the network, you should still submit your claims to EyeMed.

Under the previous benefit, it didn’t matter what type of vision expense you submitted for the $150 reimbursement. Under the new benefit, you are reimbursed for Out-of-Network benefits according to a schedule. The Out-of-Network Benefit payable per person per calendar year is limited to the following:  

 Each year you can receive the Out-of-Network benefit up to the stated amount. For instance, if you go out of network and are charged $70 for an eye examination, EyeMed will pay the Out-of-Network benefit of $40. No further benefit is payable for a vision examination for that person for the remainder of the calendar year.    

Similarly, if you go Out-of-Network and are charged $200 for frames, EyeMed will pay the Out-of Network Benefit of $110. No further benefit is payable for the remainder of the calendar year for frames and lenses or contact lenses. 

Information describing the EyeMed network and EyeMed I.D. cards will be distributed before the January 1, 2007 effective date. The network includes most of the major vision care chain stores. 

2.  Improved Dental and Orthodontia Benefits for Active Employees. 

Effective January 1, 2007, the dental benefit maximum is increased from $1,000 to $1,250 per person per calendar year and the orthodontia benefit maximum has increased from $1,000 to $1,500 per person per lifetime. 

In addition, the Plan has been amended effective January 1, 2006 to make clear that coverage for dental benefits ends when Active Employee benefits terminate.                 

3.  Satisfying the maximum deductible for families made easier effective January 1, 2007 for Active Employees.  

Each eligible person is required to satisfy the individual deductible each calendar year. However, once the family deductible is reached no further deductibles are applied to any members of that family. 

Previously a family reached the maximum deductible when three family members met the $300 per person deductible.    

Effective January 1, 2007, a family is no longer required to have three members reach the $300 per person deductible. The family deductible is now satisfied when the family reaches $900 even if more than three family members incurred the expenses to meet the $900 family deductible. 

4.  New Wellness Expense Benefit covers Routine Physical Exams and Weight Watchers®.  

Effective January 1, 2007, the Plan provides for a new Wellness Benefit that consists of a Routine Physical Exam Benefit and a Weight-Loss Program. 

Routine Physical Exam Benefit. 

The Routine Physical Exam Benefit applies to active and retired employees and their dependent spouses, except persons with Retired Employee coverage who are Medicare eligible.  Persons with Retired Employee coverage who are Medicare eligible are already covered by most of these services and lab tests through Medicare and the Fund’s Supplement to Medicare. 

Under the Routine Physical Exam Benefit, the Fund will pay the full Usual and Customary Fee for the covered service.  If you go to an out of network provider, this amount may be substantially less than the amount charged by your provider.  Under the Routine Physical Exam Benefit you can receive the following services once per calendar year: 

1. Routine physical examination by a licensed M.D. or D.O.

2. Wellness laboratory tests as follows:
   1. Comprehensive metabolic panel (organ function)

2. Lipid panel and total cholesterol

3. Occult blood over age 35 (gastrointestinal)

4. Complete blood count with differential WBC (diseases)

5. Complete urinalysis (infections, diseases)

6. Blood glucose (diabetes)

3. PSA screen (prostrate) for men over 40 and Mammogram for women over 40.

No deductible or co-payments will need to be paid for the above services.  Any other medically necessary tests and services ordered by the physician are covered under the Comprehensive Major Medical benefit and subject to deductible and co-payments. 

To take full advantage of the new Wellness Benefit, detach the postcard inserted in this brochure and present it at your Doctor’s office when scheduling or undergoing the exam. 

Weight-Loss Program 

If you feel that you need an organized, well rounded approach to healthy eating and living and perhaps shedding a few pounds, beginning January 1, 2007 you can enroll in Weight Watchers® 13 week program at no charge.  The Welfare Fund will pay the full cost of the program ($142.35) on a once per lifetime basis for you and/or your dependent spouse.   

If you decide that you want to enroll in a more extended program with Weight Watchers®, the Fund will pay $142.35 towards the extended program and you will be charged a reduced rate for the additional weekly sessions. 

You may contact Weight Watchers® at a special toll free number (1-866-204-1141) after January 1, 2007 to enroll. 

All eligible active and retired employees and their dependent spouses are eligible for the Fund’s program with Weight Watchers®.   

5.  Retired Employees have access to discounts effective January 1, 2007 under the Blue Cross Dental PPO. 

Retired Employee Coverage now includes access to discounts under the Blue Cross Blue Shield Dental PPO network. The Fund does not pay for the services provided by your dentist. The Fund pays a fee so that Retired Employees will have access to discounts under the Dental PPO network.  The participant pays the full cost of the discounted dental services directly to the provider.  

Brochures describing the Dental PPO network and I.D. cards will be distributed to retirees before the January 1, 2007 effective date. 

6.  Retired Employees to pay less to satisfy the annual deductible.   

Previously, Retired Employees Not Yet Eligible for Medicare had a $500 per person calendar year deductible. Effective January 1, 2007, the calendar year deductible is reduced to $300 per person and $900 per family. 

7.   Improved Supplemental Benefits for Retired Employees Eligible For Medicare. 

Effective January 1, 2007, the Trustees increased the amount the Fund pays towards the Part A Medicare deductibles for hospital confinements and skilled nursing facility charges for Retired Employees Eligible For Medicare as described in the chart below.  The amount paid by the Fund for Part B Medicare benefits has not been changed.  

 In addition, the exclusion in Plan Section 8.03(1) related to Major Medical benefits has been removed so that the Supplemental Medical Benefit more closely matches Medicare. This means that if Medicare covers a service or supply it will also be covered by the Fund. 

8.  Medicare Crossover. 

In September, the Fund became the first Building Trades Health and Welfare Fund in the Chicagoland area to contract directly with Medicare to receive supplement to Medicare claims electronically from Medicare. 

This process is known as Medicare Crossover and it works this way:  Your health care provider files his bill with Medicare.  Medicare processes the bill, paying its share to the provider.  Medicare then electronically transmits the charge and payment information directly to the Fund.  The Fund then pays the provider the supplemental amount due under the Plan and sends you an explanation of benefits at the same time. 

This all means that Retired Employees eligible for Medicare will no longer have to file a claim for their supplemental benefits with the Fund Office. 

9.   Coverage for Outpatient Speech, Occupational, and Physical Therapy updated; Exclusions Eliminated and Definition of Mental Nervous Disorder Expanded. 

A.        Special Rules for Outpatient Speech, Occupational, and Physical Therapy 

Depending on the circumstances, outpatient speech therapy, occupational therapy, and physical therapy, can be 1) covered under the Medical Expense schedule of benefits, 2) covered under the Mental and Nervous Disorder schedule of benefits, or 3) excluded from coverage.  

Outpatient speech therapy and physical therapy are covered up to a combined maximum of $3,500 per person per calendar year. Outpatient occupational therapy is covered up to a separate maximum of $3,500 per person per calendar year. These limits apply regardless of whether the service is covered under the Medical Expense schedule of benefits or the Mental and Nervous Schedule of benefits. 

After the $3,500 outpatient maximum is reached, no other payment is made under the Plan with one exception.  If $3,500 is reached for the outpatient treatment of cerebral palsy, then the Plan pays 75% and the Participant co-pay is 25%.  The 25% participant co-pay in excess of $3,500 does not count towards the Out-of-Pocket Maximum.  Regardless of whether the person otherwise meets the Out-of-Pocket Maximum, the 25% Participant co-pay continues to apply for outpatient physical, speech, and occupational therapy. 

Additionally, services provided by a duly licensed Physical Therapist Assistant or a duly licensed Occupational Therapy Assistant are now covered.  

            Please note that no change has been made to the Plan’s Chiropractic limit. 

            i.          Medical Expense Schedule of Benefits 

Speech, occupational, and physical therapy services designed and adapted to promote the restoration of a useful physical function are covered under the Medical Expense schedule of benefits. Educational or training services to develop a physical function are not covered under the Medical Expense schedule of benefits except for a developmental delay related to the treatment of cerebral palsy.  

The Medical Expense schedule applies to a person who previously developed, but no longer has use of a physical function, so that expenses to restore such function are covered under the Medical Expense schedule. If a physical function did not develop in the first place, the Medical Expense schedule does not apply to expenses to develop this physical function.                       

            ii.         Mental and Nervous Schedule of Benefits 

The Mental and Nervous Disorders schedule of benefits pays for some services that are not covered under the Medical Expense schedule. The Mental and Nervous schedule will cover services to develop a useful physical function if the condition results from a Mental Illness.

Mental Illness means those illnesses classified as a disorder in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. 

 
Please note that the Plan’s Out of Pocket Maximum does not apply to outpatient treatment for Mental and Nervous Disorders. 

            iii.        Excluded from Coverage 

If the Speech, Occupation or Physical Therapy is provided to develop a useful physical function but the condition does not result from a Mental Illness or a developmental delay related to cerebral palsy, then the therapy is not covered under the Plan.  The Plan also excludes any expense that is determined to be related to behavioral problems, conduct disorders, learning disabilities, or developmental delays that are not the result of a Mental Illness. 

            iv.        Examples 

                        Example 1:       Restoration of a physical function.

Mary suffers a stroke and receives speech, occupational, and physical therapy to restore certain physical functions at an outpatient PPO facility. These expenses are covered under Medical Expense schedule because these services are to restore such physical functions. Because these services are provided at an outpatient PPO facility, these expenses are covered at 85%. Outpatient speech and physical therapy are subject to a combined maximum of $3,500 per person per calendar year. Outpatient occupational therapy is subject to a separate maximum of $3,500 per person per calendar year. 

                        Example 2:       Development of a physical function.   

John has autism and has not developed certain physical functions. Expenses for speech, occupational, and physical therapy are not covered under Major Medical because these physical functions did not develop previously so that coverage to restore such physical function does not apply.

However, John’s expenses for speech, occupational, and physical therapy may be covered under the Mental and Nervous schedule of benefits if such expenses are provided in conjunction with the treatment of a condition that is the result of a mental illness. Autism is classified as a disorder in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Because they are provided in conjunction with the treatment of a mental and nervous disorder, John’s expenses for speech, occupational, and physical therapy are covered under the Mental and Nervous schedule of benefits at 50%. Outpatient speech and physical therapy are subject to combined maximum of $3,500 per person per calendar year. Outpatient occupational therapy is subject to a separate maximum of $3,500 per person per calendar year. 

                        Example 3:       Developmental Delay Related to Cerebral Palsy. 

                        Tom has cerebral palsy and has not developed certain physical functions.  Expenses for speech, occupational, and physical therapy would generally be excluded under Major Medical, except when the developmental delay is related to cerebral palsy. 

                        Because these services are provided at an outpatient PPO facility, these expenses are covered at 85%.  Outpatient speech and physical therapy are subject to combined maximum of $3,500 per person per calendar year.  Outpatient occupational therapy is subject to a separate maximum of $3,500 per person per calendar year. 

                        When the maximum is reached for treatment related to cerebral palsy, the Plan pays 75% and the participant co-pay is 25%.  The 25% participant co-pay in excess of $3,500 does not count towards the Out-of-Pocket Maximum.  Even if Tom otherwise meets the Out-of-Pocket Maximum, the 25% participant co-pay continues to apply for his outpatient physical, speech, and occupational therapy. 

                        Example 4:   Exclusion for behavioral problems.   

Sue is regularly disciplined at school for being disruptive and failing to follow instructions in class. Unless such behavior can be classified as a mental and nervous disorder, such expenses resulting from behavioral problems, conduct disorders, learning disabilities, and developmental delays are excluded. 

B.      Exclusions Eliminated and Definition of Mental Nervous Disorder Expanded 

Diabetes self-management training, education, and medical nutrition therapy rendered by a Physician, or duly certified, registered, or licensed healthcare professional with expertise in diabetes management is now covered. 

Genetic testing for the existence of inherited mutations related to thyroid, colon, breast, and ovarian cancer are covered when medically necessary effective February 16, 2006. 

Family therapy is now a covered expense under the Mental and Nervous Disorder schedule of benefits, however, marriage counseling is still excluded. Short term marriage counseling is available through the Employee Assistance Plan.  

Previously, the Plan limited coverage for one office visit for the diagnosis of Attention Deficit Disorder (ADD) and Attention Deficit Hyperactive Disorder (ADHD). Treatment for these conditions will now be covered under the Mental and Nervous Disorder schedule of benefits.  

The Fund has adopted a broader definition of Mental and Nervous Disorder.  Mental or Nervous Disorder now means 1) a Mental Illness, or 2) a neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind, regardless of whether such disease or disorder has causes or origins which are organic, physiological, traumatic or functional. 

10.   Prescription Drug Benefit updated. 

The Prescription Drug Benefit currently covers oral contraceptives.  Effective February 16, 2006 the Prescription Drug Benefit has been updated to include coverage for the following non-oral contraceptives: Ortho Evra Patch, Nuvaring Vaginal Ring, Depo-Provera 150 mg/ml syrn, and Depo-Provera 150 mg/ml vial. 

11.  Coordination of Benefits rules updated for Non-Medicare Eligible Retired Employees covered by actively employed spouse. 

Your benefits under the Welfare Plan are coordinated when you are also covered by another plan. The Coordination of Benefits rules have been updated based on rules established by the insurance industry. Previously, when a retired pipe fitter was covered by the plan of his working spouse, and also covered under the Pipe Fitters’ Retiree Medical Benefits, our rules provided that the spouse’s plan paid first. The Welfare Plan has been amended so that the plan that covers the person as an employee (active or retired) pays before the plan that covers the person as a dependent. This rule was administratively implemented for claims processed after September 1, 2006. 

12.  Appeal procedure time limits modified effective January 1, 2007. 

Effective January 1, 2007, Section 18.17 is restated as follows:

18.17          Exhaustion of Your Remedies.

You must exhaust all of the claims and appeals procedures of the Plan before you bring any action in court or administrative action for benefits.  After you have exhausted all of the procedures in this section and if you are dissatisfied with the written decision of the Board of Trustees on review, you may institute legal action.

However, if your appeal is denied, no legal action can be brought with respect to a claim under the Plan after 90 days from the decision on appeal.  

13.  Participants entering the military have expanded eligibility options effective January 1, 2006. 

The Plan provides benefits as described below that comply with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).  

If you enter active service, your coverage under the Plan will not be affected during the initial 31 day period. Your coverage under the Plan will be suspended at the end of this initial 31 day period under Option 1 below (the default option), unless you elect otherwise.

In order to exercise your options, you must notify the Fund Office when you are called to active service. You will have three options regarding your Plan benefits as follows: 

Option 1:    Suspend all coverage under the Plan and rely on military coverage for you and your Dependents. This is the DEFAULT OPTION. 

Option 2:    Suspend active coverage and elect COBRA coverage for up to 24 months.

Option 3:    Continue active coverage for as long as the Plan’s eligibility rules permit, and then elect COBRA coverage for up to 24 months.  

If your failure to provide advance notice when called to active service is excused under USERRA because of military necessity, then you can make a retroactive election to continue coverage, provided you pay any unpaid amounts that are due.

Option 1 

If you elect Option 1 (suspend eligibility and rely on military coverage), your eligibility and Accumulation Account will be frozen until you are discharged from active military service.  In order to reinstate active eligibility, you must provide the Fund Office with a copy of your discharge papers within the time periods provided under USERRA as described in the following chart.  

Once you provide the Fund Office with your discharge papers, your Accumulation Account, as of the end of the initial 31 day period, will be reinstated effective as of your date of discharge, or a later date as agreed to by the Fund, for the balance of the current Benefit Quarter. Your eligibility for subsequent Benefit Quarters will be determined under the Plan’s Eligibility Requirements. 

Option 2 

If you elect Option 2 (suspend active coverage and elect COBRA), your eligibility and Accumulation Account will be frozen until you are discharged from active military service.  Under this Option, you and your Dependents can pay the monthly COBRA premium for up to 24 months of COBRA coverage. The standard election and payment deadlines under COBRA apply. 

In order to reinstate active eligibility upon discharge, you must provide the Fund Office with a copy of your discharge papers within time periods provided under USERRA as described in the above chart.  

Once you provide the Fund Office with your discharge papers, your Accumulation Account, as of the end of the initial 31 day period, will be reinstated effective as of your date of discharge, or a later date as agreed to by the Fund. Your eligibility for subsequent Benefit Quarters will be determined under the Plan’s Eligibility Requirements.    

Option 3 

If you elect Option 3 (continue active coverage), you and your Dependents will receive active coverage for as long as your Accumulation Account permits. Thereafter you will be offered COBRA coverage for up to 24 months. The standard election and payment deadlines under COBRA apply. 

Under USERRA, you must provide the Fund Office with a copy of your discharge papers within time periods provided as described in the above chart. 

If active eligibility has been exhausted under Option 3, then upon discharge you will not qualify for active eligibility until you satisfy the requirements for Initial Eligibility.  

In the meantime, you will have the opportunity to pay for COBRA coverage as of the date of discharge, or a later date as agreed to by the Fund. Upon discharge, you can pay for COBRA coverage until the later of 1) the end of six months of payments, or 2) the end of the original 24 month period. 

14.  Usual and Customary Fee Clarified effective January 1, 2007. 

Effective January 1, 2007, Section 19.01(S) is restated as follows: 

S.                  Usual and Customary Fee means the following: 

1.      For service or supply covered under a Plan PPO or similar organization contract, the fee shall be the contracted amount. 

2.      For service or supply where the fee is not determined under (1) above, the amount the Fund would have paid if the item had been covered under any such Plan PPO contract. 

3.      For service or supply where the fee cannot be determined under (1) or (2) above, the fee shall be based on 125% of the amount that would be allowed by Medicare, except as described in (4) below. 

4.      For outpatient facility charges and ambulatory surgical center charges where the fee cannot be determined under (1) or (2) above, the fee shall be based on 150% of the Medicare grouper rate. 

The Board of Trustees reserves the right under extenuating circumstances to pay an amount greater than the fee determined under subsections (1), (2), (3) and (4) above.