Laborers Health & Welfare Bulletin

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1 What Is An EOB Notice? An Explanation of Benefits notice (EOB) is a summary of your recent medical benefit claim that has been processed for payment. The notice will show the dates and what types of services were performed by your medical provider, as well as the amounts billed and paid by the trust fund. Additionally, the notice will inform the participant of his financial responsibility for the claim after taking into consideration copayments, deductible, and coinsurance. It is very important that participants save their EOB and compare the information provided with the bill they receive from their medical provider. This quick comparison helps to ensure that the provider is not overcharging for services, or charging for services that were never performed. If you discover any information on your EOB that you do not recognize or know is incorrect, contact the Health & Welfare Dept. I Need Help With My Benefits. Who Can I Talk To? All Participants The best answer is, your benefit representative at the Trust Fund Office. We realize that your employee benefits are complex and very difficult to understand. However, our benefit representatives have all the necessary information and tools to help guide you through this process. Even though your employer, labor officials and fellow laborers may be somewhat knowledgeable about our benefits, it is always advisable to talk with representatives at the Trust Fund Office. They are the only source that has the most recent and accurate information regarding your benefits. Please remember to save all the benefit information that we send you during the year. It is very important information and can be referred to when you have questions about your benefits. In addition, our website is a great tool for benefit information. EyeMed Vision Care Network Select Plan H To save yourself money, you should always use the EyeMed Vision Care network. Remember, if you use a vision care professional that is not part of the EyeMed Select Plan H network, you will pay more. Keep your identification card and the vision care benefit summary including the list of names of local vision care professionals in a handy location. Present your identification card to your EyeMed Vision Care provider at the time of service. For more information, call EyeMed: Physical Examination Benefit Participants who undergo routine physical examinations by a physician are allowed $300 for the exams, X-rays or laboratory tests. Plan Year Deductible A deductible is the dollar amount you must pay each plan year before benefits are paid by your plan. Direct Payment Plan $150 per person/$450 per family Plan Year: March 1 - February 28 Kaiser Permanente $150 per person/$450 per family Plan Year: January 1 - December 31 November 2012

2 Divorce and Health and Welfare Coverage If you divorce, your former spouse is no longer eligible to be covered under the Health and Welfare Plan. It is important to remove your spouse from the Plan as soon as the divorce is final. To remove a former spouse, complete a new Enrollment Form and provide a copy of the Final Dissolution of Marriage to the Trust Fund Office. Soon after, you or your former spouse will receive a COBRA notification letter as required by law. Your former spouse has the option to continue Plan coverage for up to 36 months by making self payments. If payments are made on any claims for your former spouse after the divorce is final, you will be held responsible for repayment of those claims. For more information, contact the Health & Welfare Dept. Use Your Mail Service Pharmacy Use the OPTUMRx Mail Service Pharmacy to refill prescriptions you take on a continuous basis. Ordering is convenient and easy. This method reduces your costs on copayments and you will receive a 90-day supply of your medication. First, tell your physician to call or fax your prescription for a 90-day supply with as many refills as the physician determines necessary to OPTUMRx. Second, place an order for your prescriptions by calling the Mail Service Pharmacy, where an OPTUMRx representative will talk you through the process. Your prescriptions will arrive by mail in about 7-14 working days. For more information about the Mail Service Pharmacy, call OPTUMRx at: , 24 hours a day, 7 days a week. I m Having General Surgery. How Can I Reduce My Medical and Hospital Costs? To save on non-emergency medical and hospital costs, remember the following tips: 1. Confirm that the surgeons, assistants and hospital are part of the Anthem Blue Cross Prudent Buyer Plan Network. 2. If the medical procedure requires an overnight stay, your physician must request pre-authorization through Anthem Blue Cross. If you spend the night without preauthorization, you will pay additional medical and hospital costs. For more information, contact the Health & Welfare Dept. Generic Drugs Save Money Generic drugs have the same active ingredients as their brand-name counterparts and are required to pass strict testing to make sure that they react the same as brand-name drugs. Each year, more generic drugs are approved and become available. Save money on your drug costs by asking your physician to prescribe a generic drug. DISCLAIMER The is published with the intent of providing information about the various benefits available to eligible participants and how to effectively use those benefits. There are exclusions and limitations in all benefit plans, so carefully read our various plan Rules and Regulations. Health & Welfare Plan rules should be reviewed before seeking medical care. Your rights as a plan participant are ultimately determined by the Rules and Regulations of the various benefit plans. DELTA DENTAL DELTACARE USA BRIGHT NOW! DENTAL PACIFIC UNION DENTAL BENEFIT CONTACT DIRECTORY KAISER PERMANENTE OPTUMRx (PRESCRIPTIONS SOLUTIONS) CLAREMONT EAP HEALTHWAYS Health Improvement Program EYEMED VISION CARE ANTHEM BLUE CROSS PPO Find a Doctor Search for an Urgent Care Center Trust Fund Office Hours: 8:00AM thru 5:00PM Monday thru Friday 220 Campus Lane Fairfield, CA

3 Laborers Health and Welfare Trust Fund for Northern California 220 Campus Lane Fairfield, California Telephone: (707) or Toll Free (800) Women s Health and Cancer Rights Act of 1998 Annual Notice Insert with the November Active Health and Welfare Bulletin To: Covered under the Active, Special Active and Retired Plans Annually, the Laborers Health and Welfare Trust Fund is required to provide Plan Participants with notification that applies to breast cancer patients who elect to have reconstructive surgery in connection with a mastectomy. Under Federal Law, group health plans, insurers, and HMO s, that provide medical and surgical benefits in connection with a mastectomy, must provide benefits for reconstructive surgery, in consultation with the attending physician for: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to provide symmetrical appearance and; Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymphedemas. This coverage is subject to the Plan s deductible, coinsurance, and copayment provisions. If you have questions, contact the Trust Fund Office. You may also the Trust Fund Office at Sincerely, Board of Trustees November 2012

4 Complaint Procedure If you are dissatisfied with an EyeMed Provider s quality of care, services, materials or facility or with EyeMed s Benefit administration, you should first call EyeMed Customer Care Center at to request resolution. The EyeMed Customer Care Center will make every effort to resolve your matter informally. If you are not satisfied with the resolution from the Customer Care Center service representative, you may file a formal complaint with EyeMed s Quality Assurance Department at the address noted above. You may also include written comments or supporting documentation. The EyeMed Quality Assurance Department will resolve your complaint within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty (120) days after EyeMed s receipt of your complaint. Upon final resolution, EyeMed will notify you in writing of its decision. ERISA As a participant in the Laborers Health & Welfare Trust Fund Benefit, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ( ERISA ). For a detailed description of your rights, please refer to the Summary Benefit Description ( SPD ) document provided by your employer. Enforce Your Rights If your claim for vision benefits is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. When you have completed all appeals mandated by ERISA, additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. You should contact the U. S. Department of Labor or the state insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)), see, 29 U.S.C. 1132(a)(1)(B), you have the right to bring a civil (court) action when all available levels of review of denied claims, including the appeals process, have been completed, the claims were not approved in whole or in part, and you disagree with the outcome. Assistance with Your Questions If you have any questions about your Benefit, you should contact the Benefit Administrator. Your Human Resources Department should be able to provide you with the name and contact information of your Benefit Administrator. If you have any questions about this summary of vision care services or about your rights under ERISA, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration. Grievance System - November 2012 Page 1

5 Claims & Claims Appeals Time Frames for Processing Claims FAA will generally decide claims within the time permitted by applicable state law, but generally no longer than 30 days after receipt. If FAA needs additional time to decide a claim, it will send you a written notice of the extension, which will not exceed 15 days. If FAA needs additional information from you in order to decide the claim, FAA will send you a written notice explaining the information needed. You will have 45 days to provide the information to FAA. If your claim is denied, in whole or in part, FAA will inform you of the denial in writing. Time Frames for Appealing Claims If your claim is denied, in whole or in part, you may appeal. The appeal must be in writing and received by FAA within 180 days of your notice of the denial. If you do not receive an EOB within 30 days of submission of your claim, you may submit an appeal within 180 days after this 30-day period has expired. Your appeal will be decided within 60 days after receipt. Your written letter of appeal should include the following: The applicable claim number or a copy of the FAA denial information or Explanation of Benefits, if applicable. The item of your vision coverage that the member feels was misinterpreted or inaccurately applied. Additional information from the member s eye care provider that will assist FAA in completing its review of the member s appeal, such as documents, records, questions or comments. You may authorize someone else to file and pursue a complaint or appeal on your behalf. If you do so, you must notify EyeMed Vision Care in writing of your choice of an authorized representative. Your notice must include the representative s name, address, phone number, and a statement indicating the extent to which he or she is authorized to pursue the complaint and/or appeal on your behalf. A consent form that you may use for this purpose will be provided to you upon request. The appeal should be mailed or faxed to the following address: FAA/EyeMed Vision Care, LLC Attn: Quality Assurance Dept Luxottica Place Mason, OH Fax: FAA/EyeMed will review your appeal for benefits and notify you in writing of its decision. Grievance System - November 2012 Page 2

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