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Summary Plan Description and Plan Document PIPE FITTERS’ WELFARE FUND">
Summary Plan Description and Plan Document PIPE FITTERS’ WELFARE FUND, LOCAL 597
Fund Office BOARD of TRUSTEES Union Trustees Employer Trustees
Mr. James Buchanan
Mr. Frederick S. Oyer FUND OFFICE MANAGER and AGENT for the
SERVICE of LEGAL PROCESS FUND COUNSEL CONSULTANT CERTIFIED PUBLIC ACCOUNTANTS A Message from the Board of Trustees We are pleased to provide
you with this updated booklet describing your health benefits under
the Pipe Fitters' Welfare Fund Local 597, effective January 1, 2005
unless otherwise indicated. Although this booklet is meant to be an
easy-to-understand description of your Plan benefits, it also serves
as the Plan Document, which is the Plan’s official Rules and
Regulations. This booklet describes the
benefits and the Plan’s eligibility rules. The following are the
significant changes that were made to your Plan of Benefits since
the booklet was last printed:
1.
The Plan’s claims and appeals rules (Sec.
18) and privacy procedures (Sec. 20.14) have been revised in keeping
with recent legislation.
2. The Death Benefit and the Accidental Death
and Dismemberment Benefit for Active Employees have been raised to a
maximum of $10,000 per benefit. (Sec. 4)
3. The Weekly Accident and Sickness
Disability Benefit has been increased from $100 per week to $350 per
week. There is a limit of two periods of disability during any 60
month period. (Sec. 6)
4. The maximum Comprehensive Major Medical
Expense benefit per disability has been increased to $1,000,000.
(Sec. 2)
5. The hours required for quarterly
eligibility increased to 375 hours effective October 31, 2005. (Sec.
3.01D)
6. Retirees who are otherwise eligible, are
now charged a self-pay amount for Retired Employee coverage called
the Standard Retiree Premium. (Sec. 3.02 B)
7. The Standard Retiree Premium applies to
disability pensioners except substantially employed disability
pensioners ($24,000 per year) who will be charged a higher premium.
(Sec. 3.02 C)
8. Effective January 1, 2006, a subsidized
COBRA premium (50% of the regular COBRA premium) will be available
for up to six months for an Employee who is available for work in
the industry. (Sec. 3.03 E)
9. The calendar year deductible for active
employees is now $300 per person with a maximum 3 deductibles per
family. (Sec.2.01)
10.
The Plan co-pay for PPO fees is 85% and
for Non-PPO fees the Plan co-pay is 75%. (Sec. 2.01 and Sec. 2.02)
11.
Out-of-pocket maximum per calendar year is
$1,000.00 per person for non-PPO expenses. (Sec. 2.01 & Sec. 2.02)
12.
The participant co-pay for Prescription
Drug Benefits is 20% with certain minimums that apply to the retail
and mail order programs. (Sec. 2.04)
13. Certain Specialty injectable prescription
drugs are now covered exclusively through Curascript, under a
contract with Express Scripts. There is now a separate injectable
specialty drug benefit. (Sec. 2.04 and Sec. 9.06)
14.
Coverage has been expanded to add medical
care and treatment by a surgical assistant or surgical technician
who assists a Surgeon in performing surgical procedures covered by
the Plan. (Sec. 7.08 A 24)
15.
Licensed Clinical Professional Counselors
and Licensed Clinical Social Workers have been added to the list of
professionals (Physician, psychiatrist, and licensed psychologist)
whose services are covered for the outpatient treatment of mental
and nervous disorders and chemical dependency. (Sec. 7.08 A 15)
16. The Plan has also adopted a Dental PPO
(Sec. 10) and an Employee Assistance Program (Sec. 12) and
clarified coverage of Hospice (Sec. 14), Home Birth (Sec. 2.01 and
Sec. 2.02), and Hearing Aid Benefits (Sec. 13).
17. Effective January 1, 2005, the limiting
age for a dependent child has been changed from 19 to the end of the
calendar year in which the child attains age 18. This change was
required by the Working Families Tax Relief Act of 2004. (Sec. 19.01
G).
18.
The Plan has also been clarified to limit
coverage of dependent children to your natural children, legally
adopted children, and step children when certain conditions are met.
(Sec. 19.01 G). Important terms used
throughout this booklet are initial upper cased and defined in the
Plan. Please keep this booklet with your other important papers and
share this information with your family. If you have questions
about information in this booklet, you should contact the Fund
Office. This booklet replaces and
supersedes any previous written explanation of the Plan.
IMPORTANT REMINDER
Tell your family, particularly your spouse, about this
booklet and where it is located. Please notify the Fund
Office promptly if you change your address. Only the full
Board of Trustees is authorized to interpret the benefits
described in this booklet. No Employer, the Union, nor any
representative of any Employer or Union, in such capacity,
is authorized to interpret this Plan, nor can any such
person act as agent of the Trustees.
The
Trustees reserve the right to amend, modify or discontinue
all or part of this Plan whenever, in their judgment,
conditions so warrant. You will be notified in writing of
any plan changes. At some point in your life,
you will experience a life event that impacts health care coverage
for you and your Dependents. You may have experienced some of these
life events already. Life events such as these can affect your
benefit coverage:
·
Marriage
· Birth or adoption of a child
·
Divorce or legal separation
· Your child reaches the maximum age
for coverage
·
Your spouse loses a job or starts
a new job
· Medical leave
·
Military duty
· You become disabled
·
Your death
· Retirement
·
You stop working
Your benefits are
designed to adapt to your needs at different stages of your life.
This section describes how your coverage is affected when these
different events occur. Your natural born child will
be eligible for coverage on the date of birth. If you adopt a child
or have a child placed with you for adoption, coverage will become
effective on the date of placement as long as you are responsible
for health care coverage and your child meets the Plan’s definition
of a Dependent child. Stepchildren who live in your home are
eligible for coverage on the date of your marriage, provided that
you can provide satisfactory proof that: a) they are living in your
home and b) they are financially dependent on you for support and c)
another party is not responsible for providing health coverage.
If you and your spouse
obtain a legal separation or divorce, your spouse will no longer be
eligible for coverage as a Dependent under the Plan. However, your
spouse may elect to continue coverage under COBRA for up to 36
months. See Section 3.03 for additional information and the
requirements for electing COBRA Continuation Coverage. You should contact the Fund
Office if a Qualified Medical Child Support Order (QMCSO) has been
issued as a result of your divorce or legal separation. A QMCSO may
affect benefit coverage for your Dependents. Therefore, it is
important to notify the Fund Office immediately to avoid unnecessary
delays in claim payments or denial of benefits. When your spouse loses
employer-provided insurance due to the loss of employment, you
should contact the Fund Office to let them know that this Plan’s
coverage will be primary. Please provide a copy of the letter from
your spouse’s insurance carrier advising as to the date of
termination. If your spouse takes a new
job and enrolls in the coverage offered by your spouse’s employer,
then this Plan will cover your spouse’s medical expenses as the
secondary plan under the coordination of benefits provisions. If you take maternity or
paternity leave, a leave of absence under the Family and Medical
Leave Act (FMLA) or if you take military leave under the Uniformed
Services Employment and Reemployment Rights Act (USERRA), your
eligibility under this Plan may be affected. You should refer to the
explanation of these types of leave in Section 3.01(I) and Section
3.01(J). If you become disabled
because of a certified disability, you will be eligible for Weekly
Accident and Sickness Disability Benefits for a maximum of 26
weeks. During that time, you will be credited with disability hours
to help maintain your eligibility under the Plan. When your coverage
ends, you may elect COBRA coverage as explained in Section 3.03. If you
are eligible for Active Employee Benefits, coverage for
you and your Dependents will end on the last day of any
benefit quarter for which you do not have the required
hours of contributions in your Accumulation Account. You
may elect COBRA Continuation Coverage when your coverage
ends, as explained beginning in Section 3.03.
When you retire, if
you are not yet eligible for Medicare, you may continue coverage if
you meet the Plan’s requirements for Retiree coverage. If you
retired and are eligible for Medicare, the Plan provides a
Supplemental Medical Benefit that supplements the benefits you
receive from Medicare. See the Schedule of Benefits in Section 2 and
Section 3.02 regarding Retired Employee Eligibility.
Section 2: Schedules of Benefits A Schedule of Benefits is a
list of benefit amounts and exclusions that apply to the plan of
benefits. Each specific benefit is described in more detail in the
section concerning that particular benefit. When reading the
specific benefit section you should reference the applicable
Schedule of Benefits and vice versa. If there is a discrepancy
between the Schedule and a specific Plan section, the specific Plan
section will usually govern. However, the Board has discretionary
decision making authority to interpret the terms of the Plan. This Section provides
information for each type of participant under the Plan. Section
2.01 provides a Schedule for Active Employees. Section 2.02 provides
a Schedule for Retired Employees not yet eligible for Medicare.
Section 2.03 provides a Schedule for Retired Employees who are
eligible for Medicare. Section 2.04 provides Schedules for
Prescription and Specialty Drug Benefits for Active and Retired
Employees The following Schedule
provides an overview of the benefits that apply to each type of
participant. Benefit
Active Employees
Retired Not Yet Eligible for Medicare*
Retired Eligible for Medicare* Major Medical;
Section 7
x
x
Supplemental
Medical; Section 8
x Prescription Drug;
Section 9
x
x
x Dental; Section 10
x
Vision; Section 11
x
Employee Assistance
Plan; Section 12
x
x
Hearing Aid Benefit;
Section 13
x
x
Hospice Benefits;
Section 14
x
x
* When you retire; if you
meet the eligibility requirements for retiree medical benefits,
those benefits will commence after eligibility for active Employee
benefits ceases due to the exhaustion of your Accumulation Account. Benefit Benefit Amount or Limitation Death Benefit
for Active Employees Only $10,000 Accidental
Death and Dismemberment Benefit for Active Employees Only For loss of: Life $10,000 Both
hands, both feet, or sight of both eyes $10,000 One hand
and one foot, one hand and sight of $10,000 One
hand, one foot, or sight of one eye $5,000 Weekly
Accident and Sickness Disability Benefit for Active
Employees Only
Weekly
Benefit Amount $350 Maximum
Number of Weeks of Benefit 26 Medical
Expense Benefits for Active Employees and Dependents Calendar Year
Deductible
$300 per Person
Maximum 3 deductibles per Family Maximum
Benefit Maximum
per Disability $1,000,000 per
Person Spinal
Manipulation Maximum $1,000 per Calendar
Year (for covered individuals age 16 and older)
Confinement in a Skilled Nursing Care Facility 60 Days per
Confinement Covered Expenses
Payable by the Fund up to the
Usual and Customary Fees PPO Charges Non-PPO
Charges
Physician,
Hospital/Facility (inpatient and
outpatient) 85% 75% Skilled
Nursing Care
60 days per confinement; See Sec. 7.08
(A) (11) Out-of-Pocket
Maximum per Calendar Year Out-of-Pocket
Maximum Does Not Include:
· Deductible Amount
· Prescription Drug Copayments
· Dental Expense Payments
· Vision Care Expense Payments
· Copayments for Outpatient
Treatment of Mental and Nervous Disorders, or Chemical
Dependency $1,000 per Person
for PPO expenses $2,500 per Person
for Non-PPO expenses Once you reach the
Out-of-Pocket Maximum, the Plan pays 100% of allowable
expenses for the calendar year up to the Maximum Benefit
listed above. Expenses that apply towards the Non-PPO
out-of-pocket limits apply towards the PPO out-of-pocket
limits and vice versa. Note: Durable
Medical Equipment and Local Ambulance Service for which PPO
services are not available will be covered the same as PPO
charges
Mental and Nervous Disorders
PPO Charges Non-PPO
Charges
Outpatient
50%
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