2 Carpenters Benefit Funds 350 Fordham Road, Wilmington, MA 01887
3 The New England Carpenters Health Benefits Fund HEALTH FUND BENEFITS GREAT BENEFITS FOR LIFE SUMMARY PLAN DESCRIPTION NEW ENGLAND CARPENTERS
4 GREAT BENEFITS FOR LIFE As a member of the New England Carpenters Health Benefits Fund, you and your family are eligible for a generous benefits package that offers you well-being, security and protection. HEALTH BENEFITS FUND
5 1 Health Benefits Fund The New England Carpenters Health Benefits Fund 350 Fordham Road Wilmington, MA Phone: (800) Fax: (978) August 2005 Dear Participant: The Board of Trustees of the New England Carpenters Health Benefits Fund is pleased to issue this revised Summary Plan Description. This handbook has been written to reflect the changes in the Health Benefits Fund since the last version was printed. As your Board of Trustees, we continually evaluate the benefits for opportunities for enhancement while maintaining a financially sound Health Benefits Fund. When we design our benefit programs and make improvements, we try to do what s best for the participants. This revised Summary Plan Description is a reflection of our efforts. Note that medical benefits and weekly accident and sickness benefits are provided directly by the Fund. Life insurance and accidental death and dismemberment benefits are underwritten by Hartford Life Insurance Company. A New Approach This book has been designed to be easy to read and understand. Fast Facts appear at the beginning of each section to give you a quick overview of what is contained within that section. Also, useful information such as phone numbers and definitions appear in the margin as a quick reference. In addition, this book provides the required information about your rights and protection under the law in order to comply with the Employee Retirement Income Security Act of 1974 (ERISA). This information is on page 67. We encourage you and your family to read this Summary Plan Description carefully to make the best use of the benefits the New England Carpenters Health Benefits Fund offers. If you have any questions concerning the benefits or your eligibility, please feel free to contact the Fund Office at (800) Sincerely, Board of Trustees
6 2 BOARD OF TRUSTEES Employer Trustees William J. Sullivan Secretary/Treasurer Stephan A. Adamic Co-Secretary/Treasurer George M. Bidgood Theodore H. Brodie Donald L. Colavecchio Thomas J. Gunning Michael Shaughnessy William Shea Thomas Steeves Union Trustees Thomas J. Harrington Chairman Mark L. Erlich Co-Chairman Thomas J. Flynn Simon R. James Bruce King John Murphy Michael Nelson David Wallace Jack Winfield David A. Woodman Executive Director Harry R. Dow Director and Field Representative James W. Buckley, Jr. Legal Counsel O Reilly, Grosso & Gross Krakow & Souris, LLC. Consultants and Actuaries The Segal Company The Board of Trustees reserves the right to terminate or amend the Plan at any time. This includes the right to amend or terminate benefits or eligibility for any class of participant, including retirees, when in their sole discretion the Board determines such action is in the best interest of the Fund and its participants. Changes to your plan of benefits can happen at any time, so if you have a question about a particular service or program, contact the Fund Office for the most up-to-date information.
7 TABLE OF CONTENTS 3 Key Contact Phone Numbers and Addresses Your Health Benefits Fund Eligibility Maintaining Your Eligibility If You re Short of Hours Eligible Dependents If Your Child s Eligibility for Benefits Changes Extension of Benefits for Totally Disabled Members When Coverage Ends Retiree Health Benefits Plan Continuing Your Coverage COBRA Continuation Coverage Life Events If You Move If You Get Married If You Have a Baby If You Adopt a Child If You Divorce If You Enter Active Military Service If You Become Disabled If You Become Eligible for Medicare Upon Your Death Your Medical Plan Lifetime Maximum Plan Benefit Managed Health Care Program Preauthorization Wellness Benefits Annual Physical Exams Annual Pap Tests and Mammograms Well-Child Exams Hospitalization and Surgery Hospitalization Surgeon s Charges Mental Health and Substance Abuse Preauthorization Home Health Care Hospice Care Carpenters Assistance Program Prescription Drugs Dental Care Vision Care Life Insurance Coverage for Your Spouse If Your Coverage Ends Accidental Death and Dismemberment Seatbelt Benefit Weekly Accident and Sickness General Exclusions Coordination of Benefits Reimbursement and Subrogation Filing Your Claims When Claims Must Be Filed When A Claim Is Considered Received By The Health Benefits Fund Urgent, Pre-Service and Concurrent Claims Prescription Drug Claims Claims Communications Comprehensive Medical Benefits Claims Disability Claims (Weekly Accident and Sickness Benefit) Appeal Process Your ERISA Rights Plan Facts Schedule of Benefits for Plan I Schedule of Dental Benefits for Plan I Schedule of Benefits for Plan II Schedule of Benefits for the Retiree Plan Glossary of Terms New England Carpenters Health Benefits Fund Privacy Notice
8 4 KEY CONTACT PHONE NUMBERS AND ADDRESSES Benefit Address Phone Number Website Medical Care The Fund Office Fordham Road Wilmington, MA Dental Care Delta Dental Medford Street Boston, MA Vision Care Carpenters Vision Center Everett Street Allston, MA Davis Vision Express St. TTY: Plainview, NY Prescription Drugs Ullicare Rx/Medco Parsons Pond Drive Franklin Lakes, NJ Carpenters 350 Fordham Road Assistance Program Wilmington, MA Health Management Hines & Associates Program (Preauthorization)
9 YOUR HEALTH BENEFITS FUND 5 The New England Carpenters Health Benefits Fund offers eligible members and their families comprehensive health care coverage. Benefits include office visits, hospitalization and surgery, home health care, coverage for prescription drugs, mental health and substance abuse treatment, dental and vision care. You want the comfort of knowing that your family will be protected if something happens to you. Eligible members qualify for a life insurance benefit, accidental death and dismemberment insurance benefits and weekly accident and sickness benefits. The Fund also offers an extension of medical benefits for you and your family if you become disabled, or for your family at no charge in the event of your death. HOW THE HEALTH BENEFITS FUND WORKS The Health Benefits Fund contains three comprehensive health care plans, which offer coverage depending on your eligibility: PLAN I, for active members and their dependents; PLAN II, for active members and their dependents; and THE RETIREE PLAN, for eligible retirees and their dependents.
10 6 ELIGIBILITY FAST FACTS: You must work a specified number of hours in a six-month work period to be able to initially participate in the Plan. You must also work a specified number of hours to be eligible to receive benefits for you and /or your eligible dependents. When you don t work enough hours to qualify for benefits, you may be able to purchase Continuation Coverage under the Federal program known as COBRA. When you retire, you may be able to purchase coverage under the Retiree Plan if you meet all the requirements. What is Covered Employment? Covered employment is work you do for which contributions are made by a contributing employer under the terms of a collective bargaining agreement or signed participation agreement. What is a Collective Bargaining Agreement? A Collective Bargaining Agreement is a written agreement between a union and an employer that requires the employer to make contributions to the Fund on behalf of its employees. Your eligibility to participate in Plan I or Plan II is based on the number of hours you work in covered employment and the contribution rate your employer is required to make to the Fund on your behalf. Plan I offers coverage for members that work 600 hours or more in a six-month period. Plan II offers a lower level of coverage for members that work at least 350 hours (but fewer than 600) in a six-month period. These rates are outlined in a Collective Bargaining Agreement between your employer and the New England Carpenters Health Benefits Fund. Hours Requirements Your eligibility for benefits which is different from your eligibility to participate depends on the number of hours you work in covered employment during a six-month work period. If you work the required number of hours and your employer contributes to the Fund for those hours you and your eligible dependents will be eligible for coverage for six months. The hours requirements for a six-month work period are: Plan I 600 hours in one work period or 1,250 hours in two consecutive work periods. Plan II 350 hours in one work period Local 1996 Plan I 750 hours in one work period or 1,550 hours in two consecutive work periods. Plan II 425 hours in one work period. Work Periods and Coverage Periods There are two work periods per year. The hours you work during the work period are used to determine whether you re eligible for coverage during the six-month coverage period. Coverage periods begin on April 1 or October 1. Review Date If you work the required hours You ll be eligible for coverage during the work period... during the coverage period... April 1 August, September, October, April, May, June, July, August November, December and January and September October 1 February, March, April, May, October, November, December, June and July January, February and March
11 7 MAINTAINING YOUR ELIGIBILITY Once you gain eligibility, that will continue as long as you work at least 600 hours (Plan I) or 350 hours (Plan II) in the six-month work period prior to the coverage period. If you do not work the required number of hours, you may be able to maintain your coverage, as explained below, by: Buying-In to the Fund; or Using the banked hours you ve accumulated in your Hours Bank for hours worked before Banked hours are removed once you retire. Plan I Active Members Plan I members may continue coverage provided they work at least 1,250 hours in the previous two consecutive six-month work periods preceding the period they were covered. Local 51 and Shops in Plan I Only Shop employers contribute a set dollar amount for hours worked in the current month to be covered for the following month. Members must work one hour and the employer must make the monthly contribution to be covered. For example, a member who works one hour in May is entitled to full Plan I coverage for the month of June. IF YOU RE SHORT OF HOURS If you do not qualify for continued coverage based on your hours worked, coverage may be continued in two other ways through the use of a Buy-In or Banked Hours. Short Hours Buy-In If you do not work enough hours during a work period to maintain your eligibility, you may purchase Buy-In coverage if you were short by 30 hours or less. In order to take advantage of the buy-in provision, you must have been eligible during the preceding coverage period under that plan with worked hours only. You may buy into the plan of coverage you were eligible for in the prior coverage period at the special buy-in rate per hour. For example, if you are in Plan I and you had worked at least 570 hours, you could buy the 30 hours you were short (600 required 570 worked) for the buy-in rate times 30. To buy into Plan II coverage, you must work at least 320 hours in a work period. For the most up-to-date buy-in rate, contact the Fund Office. Payment must be made in one lump sum. You have only until the end of April or October to choose this buy-in option. Otherwise, continuation coverage would be available under COBRA at COBRA rates. (See page 11 for information on COBRA Continuation Coverage.) If late hours are received and would bring you into 30 hours short, you would have 30 days from the date of notification to choose this buy-in option. Special Rule for New Members New members may buy into Plan II after working eight hours in the current work period.
12 8 An eligibility statement with the monthly cost will be mailed to you in March or September (the end of the insured period) indicating the cost for coverage starting the following month, the next coverage period. Be sure to keep your address current with the Fund Office so you can receive this statement. Banked Hours Hours that were banked prior to August 1, 1989, may be drawn upon to maintain your coverage when you do not work the required number of hours in a work period for active members. You will be permitted to use hours from your bank to continue eligibility, provided you worked some hours in covered employment during the previous or current work period. You must be eligible to buy into COBRA to exercise this option. Proving Eligibility for Dependents You are required to furnish the following documentation for dependent coverage if you have not already done so: Marriage certificate from City Hall or Town Hall; Birth certificate document showing both parents names, court document or written statement on letterhead from appropriate governmental agency showing legal guardianship and date of birth of each child; Divorce decree if applicable; Proof of a dependent child s attendance at an accredited school or college as a full-time student upon attainment of age 19 must be submitted to the Fund Office twice each year, as directed by the Fund Office, on an original form which contains the accredited institution s seal. He or she must provide a letter from the registrar. The letter should include: Verification of his or her enrollment; The number of course hours for which he or she is enrolled; and The beginning and ending dates of the term. Banked hours are credited at $1.90, which was the actual dollar value of the contribution rate in effect at the time the hours were banked. Therefore, the total banked hours used to maintain eligibility will reduce the actual cost of the insurance coverage. To use your banked hours, you must indicate your wishes on a COBRA form (continuation coverage) or send a letter of request to the Fund Office. ELIGIBLE DEPENDENTS When you become eligible for coverage in the New England Carpenters Health Benefits Fund, your eligible dependents are also eligible for coverage. Plan s Definition of Dependent The term dependent means (1) your lawful spouse; (2) your unmarried children (including a legally adopted child) who are under 19 years of age; and your unmarried children who are at least 19 but less than 24 years of age who are enrolled as full-time students in an accredited school, college or university, not employed on a full-time basis and dependent upon you for financial support. If Your Child is Disabled If an unmarried dependent child is incapable of self-sustaining employment because of physical handicap or mental retardation and he or she is dependent upon you for support and maintenance, his/her coverage will be continued provided his/her incapability commenced prior to attaining age 19 or age 24 if a full-time student. You must submit proof of your dependent child s incapability to the Fund Office on the later of 31 days after the date he/she attains 19 years of age or age 24 if a full-time student or 31 days after you are notified of his/her eligibility. Benefits will continue to be provided for your child as long as you remain covered under the Fund. No person may be eligible for benefits both as a member and as a dependent. Proof of the continued existence of such incapability shall be furnished to the Fund Office yearly. The term child also includes a stepchild or foster child, provided the child depends upon you for support and maintenance and has been reported to the Fund Office.
13 9 When Coverage Ends Your dependents eligibility for coverage will end on: What You Need to Do If you are adopting a child, the following is needed: A copy of the birth certificate once it is available; A copy of the paperwork from the adoption agency showing the date the child was placed in the home. (Coverage for an adopted child will begin on the date the child was placed in the home.) If you are the legal guardian, the following is needed: A copy of the birth certificate; A copy of the court document stating that the member is the legal guardian of the child. (Coverage will begin on the date of the legal document.) If you have not adopted the child or do not have legal guardianship and are only the stepparent by marriage, then the following is needed: A copy of the birth certificate; A copy of the natural parent s divorce decree, the medical insurance section, along with the front page that has the name of the defendant and plaintiff s names. A copy of the tax return. See page 20 for more information. The date your child or spouse no longer meets the definition of an eligible dependent under the Fund; or The date your eligibility ends. IF YOUR CHILD S ELIGIBILITY FOR BENEFITS CHANGES If your child s eligibility status changes, you must notify the Fund Office as soon as possible. Your child may be eligible for COBRA Continuation Coverage for up to 36 months. See page 11 for more information. EXTENSION OF BENEFITS FOR TOTALLY DISABLED MEMBERS If you become totally disabled while covered for benefits under this Fund, you may be eligible for an extension of benefits for up to two consecutive coverage periods. Your coverage will be under the same Plan you had at the time of your disability, subject to proper documentation. This option is available only once per lifetime. If only one free coverage period is required, the option for a second coverage period is voided. Contact the Fund Office for an Extension of Benefits form. If you are eligible for a Social Security Disability Pension, you may be eligible for coverage under the Retiree Health Benefits Plan for up to 24 months or until you are covered by Medicare, whichever comes first. Widow(er) Extension If a member is covered by this Fund under worked hours or buying into Plan I at the time of his or her death, the surviving spouse and eligible dependents will be covered by the Fund for a maximum of three additional years under Plan I. Coverage is provided at no premium cost, provided that the spouse and dependents have no other health insurance, including Medicare. However, if the member was buying into Plan II at the time of his or her death, the surviving spouse and eligible dependents are only eligible for coverage under Plan II. WHEN COVERAGE ENDS Generally, your coverage under the New England Carpenters Health Benefits Fund will end: For Shop Employees, the first day of the following month in which you stop working in covered employment; The date you do not meet the requirements for eligibility; or The date the Plan terminates.
14 10 RETIREE HEALTH BENEFITS PLAN What You Need To Do If your child is no longer eligible for coverage under the Fund, he or she may elect to continue coverage under COBRA. You or your child must: Contact the Fund Office within 60 days of losing eligibility; and Enroll in COBRA Continuation Coverage. Failure to contact the Fund Office and provide notice of the Qualifying Event (discussed in more detail on page 11) will result in a loss of rights to COBRA. These same rules apply to a Spouse who loses coverage due to a separation or divorce. If you retire on or after April 1, 1995, with a Service, Normal, Early or Disability Pension and meet the Plan s other eligibility requirements, you and your eligible dependents are eligible for the New England Carpenters Retiree Health Benefits Plan. There are five requirements: You must be eligible for five out of the past ten coverage periods, have 3,000 hours during the five-year period immediately prior to retirement and be covered by the Plan in the period immediately preceding your application for retiree coverage. You must have no other group health insurance, including Medicare. You must share the cost of coverage with the Fund. Your monthly premiums will increase from time to time. You must obtain medical services from providers in the Carpenters Preferred Provider Network unless you do not live within a 20-mile radius of the nearest network provider. You must obtain pre-certification for all inpatient hospital stays. Continued Eligibility for Retirees Eligibility to participate ends on the earlier of: The last day of the month when you do not pay the premium when required; The date your pension benefit is suspended for any reason; The date you become eligible under another group health plan; The date you or your eligible dependent become entitled to Medicare; or The date the Plan terminates. Local 108 cannot participate in the Retiree Plan. Continuing Your Coverage Under COBRA When your coverage under this Fund ends, you may be eligible to continue some of the same coverage you had under the Health Benefits Fund for a limited time under COBRA. For information about COBRA Continuation Coverage, see page 11. Eligibility for Widow(ers) and Dependent Children If you were eligible for a Service, Normal, Early or Disability Pension from the New England Carpenters Pension Fund at the time of your death, your widow(er) and eligible dependent children may continue coverage under the Retiree Health Plan on a selfpayment basis. If a dependent child is covered under a member who is purchasing the Retiree Health Plan and the child reaches the age limit, the dependent is eligible to buy into Plan II under COBRA.
15 CONTINUING YOUR COVERAGE 11 FAST FACTS: You and your dependents may continue certain medical benefits if your coverage ends due to a Qualifying Event. Your children are eligible to continue coverage under COBRA when they no longer satisfy the Fund s definition of eligible dependent because of age, marriage or student status. To keep your coverage under COBRA, you must make monthly payments to the Fund Office on time. You are fully responsible for the payment of your benefits through COBRA. COBRA CONTINUATION COVERAGE If your coverage under the New England Carpenters Health Benefits Fund ends due to a Qualifying Event (see below), you and/or your covered dependents may be eligible to continue your health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). By making monthly payments, you and/or your dependents may continue the same medical, dental, vision and prescription drug coverage that you had before your coverage ended. Your coverage can last for up to 18, 29 or 36 months, depending on the Qualifying Event that resulted in your loss of coverage. Qualifying Events To be eligible to elect COBRA Continuation Coverage, you (as the member) and/or your dependent(s) must lose coverage due to any one of the Qualifying Events, which are listed in the first column in the table below. The last column indicates how individuals find out that they re eligible for continuation coverage, which are explained below. Qualifying Event Who May Purchase Eligibility Notification Requirements (Qualified Beneficiary) Member terminated for Member, spouse and/or 18 months Fund Office will other than gross misconduct dependent children advise eligible participants (including retirement) Member reduction in hours Member, spouse and/or 18 months Fund Office worked (making Member inel- dependent children igible for coverage or the same coverage under the Plan) Member becomes Spouse and/or 36 months Fund Office will advise entitled to Medicare dependent children eligible participants when member reaches 65. If member becomes eligible before 65, he or she must advise Fund Office Member becomes Member, spouse 11 months in Member must advise eligible for disability through and/or children addition to the Fund Office Social Security 18 months Death of Member Spouse and/or 36 months minus Family member must dependent children the number of notify Fund Office months covered since the divorce Member is divorced or legally Spouse and/or 36 months Member or Spouse must separated from spouse dependent children advise Fund Office so notification can occur Child ceases to be a Dependent child 36 months Member must advise dependent child under Fund Office so Plan definition notification can occur
16 12 Who May Elect COBRA? Under the law, only Qualified Beneficiaries are entitled to elect COBRA Continuation Coverage. A Qualified Beneficiary is any member, his or her spouse or dependent who was covered by the New England Carpenters Health Benefits Fund when a Qualifying Event occurs. A child who becomes a dependent child by birth, adoption or placement for adoption with the Member during a period of COBRA Continuation Coverage is also a qualified beneficiary. However, a dependent purchasing COBRA who acquires a spouse during COBRA Continuation Coverage is not a qualified beneficiary.!! One or more of your family members may elect COBRA even if you do not. Additionally, one member may elect COBRA for all Qualified Beneficiaries. However, in order to elect COBRA Continuation Coverage, the members of the family must have been covered by the Plan on the date of the Qualifying Event. A parent may elect or reject COBRA Continuation Coverage on behalf of dependent children living with him or her. How to Elect COBRA Continuation Coverage In order to elect COBRA Continuation Coverage, the Fund Office must be notified when you experience a Qualifying Event. You must notify the Fund Office within 60 days from the date that the Qualifying Event occurs, or the date that you would lose coverage under the Fund because of the Qualifying Event, whichever is later. See the following Notification Procedures. When the Fund Administrator receives notice of the Qualifying Event, he or she will mail you an election form, information about COBRA and the date on which your coverage will end. Under the law, you and/or your covered dependents have 60 days from the later of the date: You would have lost coverage because of the Qualifying Event; or You and/or your covered dependents received the election form and COBRA information. If you and/or any of your covered dependents do not elect COBRA within 60 days of the Qualifying Event (or, if later, within 63 days from the mailing date), you and/or your covered dependents will not have any group health coverage from this Fund after your coverage ends. COBRA Notification Procedures As a covered Member or Qualified Beneficiary you are responsible for providing the Fund Administrator with timely notice of certain qualifying events. You must provide the Fund Administrator notice of the following qualifying events: The divorce or legal separation of a covered Member from his or her spouse. A beneficiary ceasing to be covered under the Plan as a dependent child of a member. The occurrence of a second qualifying event after a Qualified Beneficiary has become entitled to COBRA with a maximum of 18 (or 29) months. This second qualifying event could include a Member s death, entitlement to Medicare, divorce or legal separation or child losing dependent status.
17 13 In addition to these qualifying events, there are two other situations when a covered Member or Qualified Beneficiary is responsible for providing the Fund Administrator with notice within the timeframe noted in this section: When a Qualified Beneficiary entitled to receive COBRA coverage with a maximum of 18 months has been determined by the Social Security Administration to be disabled. If this determination is made at any time during the first 60 days of COBRA coverage, the Qualified Beneficiary may be eligible for an 11-month extension of the 18 months maximum coverage period, for a total of 29 months of COBRA coverage. When the Social Security Administration determines that a Qualified Beneficiary is no longer disabled. You must make sure that the Fund Administrator is notified of any of these five occurrences listed above. Failure to provide this notice within the form and timeframes described below may prevent you and/or your dependents from obtaining or extending COBRA coverage. How Should a Notice Be Provided? In order to provide the Fund notice of any of these five situations you must complete and sign the Fund s COBRA Notice Form for Covered Employees and Qualified Beneficiaries. You can obtain a copy of the form by calling the Fund Office at (800) Alternatively, you may send a letter to the Fund containing the following information: your name, for which of the five events listed above you are providing notice, the date of the event, the date in which the participant and/or beneficiary will lose coverage. To Whom Should the Notice Be Sent? Notice should be sent to the Fund at the following address: Director and Field Representative The New England Carpenters Health Benefits Fund P.O Box 7075 Wilmington, MA Phone: (800) Fax: (978) When Should the Notice Be Sent? If you are providing notice due to a divorce or legal separation, a dependent losing eligibility for coverage or a second qualifying event, you must send the notice no later than 60 days after the later of (1) the date upon which coverage would be lost under the Plan as a result of the qualifying event (2) the date of the qualifying event or (3) the date on which the Qualified Beneficiary is informed through the furnishing of a summary plan description or initial COBRA notice of the responsibility to provide the notice and the procedures for providing this notice to the Fund Administrator. If you are providing notice of a Social Security Administration determination of disability, notice must be sent no later than the end of the first 18 months of continuation coverage.
18 14 Notify The Fund Office You or a family member should notify the Fund Office when any Qualifying Event occurs to avoid confusion over the status of your health care in the event that your Employer does not provide prompt or correct information. If you are providing notice of a Social Security Administration determination that you are no longer disabled, notice must be sent no later than 30 days after the later of (1) the date of the determination by the Social Security Administration that you are no longer disabled or (2) the date on which the Qualified Beneficiary is informed through the furnishing of a summary plan description or initial COBRA notice of the responsibility to provide the notice and the procedures for providing this notice to the Fund Administrator. Who Can Provide a Notice? Notice may be provided by the covered Member, Qualified Beneficiary with respect to the qualifying event, or any representative acting on behalf of the covered Member or Qualified Beneficiary. Notice from one individual will satisfy the notice requirement for all related qualified beneficiaries affected by the same qualifying event. For example, if a member and his or her spouse and child are all covered by the Plan, and the child ceases to become a dependent under the Plan, a single notice sent by the spouse would satisfy this requirement. Where you or your dependents have provided notice to the Fund Administrator of a divorce or legal separation, beneficiary ceasing to be covered under the Plan as a dependent or a second qualifying event, but are not entitled to COBRA, the Fund Administrator will send you a written notice stating the reason why you are not eligible for COBRA. Paying for COBRA Continuation Coverage You are responsible for the entire cost of COBRA Continuation Coverage. When you and/or your dependents become eligible for this coverage, the Fund Administrator will notify you of the COBRA premium amounts that you must pay. What You Need To Do: If you lose coverage due to a Qualifying Event: Inform the Fund Office of the Qualifying Event and request a COBRA election form. Complete and mail back the election form within 63 days of the date of the mailing, or 60 days of the date the Qualifying Event occurred, whichever is later. Make your first payment to the Fund Office within 45 days from the date the Fund Office receives your COBRA election form. Your COBRA premiums may be as high as 102% of the Plan s cost, except in the case of Social Security disability. (See the section below entitled COBRA Continuation Coverage for Disabled Participants. ) You must send the first COBRA payment to the Fund Office within 45 days from the date on which the Fund Office receives your COBRA election form, as determined by postage cancellation. You must make payments so that coverage is continuous there can be no lapse in coverage. If you choose COBRA within the election period but after the date on which your eligibility ended, you must pay the required COBRA premiums retroactively to cover the elapsed period. Late COBRA Payments Your monthly payments are due on the 1st day of each month. You will have 30 days in which to pay. Payments should be mailed to the Fund Office. If you do not make payment by the end of the 30 days, your coverage will be cancelled retroactively to the last day of the previous month and you will lose your right to continuation coverage.
19 15 COBRA Continuation Coverage for Disabled Participants If you are covered under COBRA for 18 months, and within the first 60 days of coverage you (or your covered dependent) become disabled, you (and your Qualified Beneficiaries who elected COBRA) may be eligible to continue your COBRA coverage for an additional 11 months for a total of 29 months. To be eligible, the Social Security Administration must make a formal determination that you (or your dependent) were disabled effective within the initial 60-day period of the start of your COBRA coverage and therefore entitled to Social Security Disability income benefits. You (or your dependent) must notify the Fund Office of the Social Security determination of disability by the end of the 18-month initial COBRA period if you wish to continue with the 11-month extension. If you are eligible for the 11-month extension, your COBRA premiums may be as high as 150% of the regular premiums for the additional 11 months of coverage. This extended period of COBRA coverage will end on the earlier of: The last day of the month that occurs 30 days after Social Security has determined that you and/or your dependent(s) are no longer disabled; The end of the 29 months COBRA Continuation Coverage; The date the disabled person becomes entitled to Medicare. If you recover from your disability before the end of the initial 18 months of COBRA Continuation Coverage, you will not have the right to purchase extended coverage. You must notify the Fund Office within 30 days of: The date that you receive a final Social Security determination that you and/or your dependent(s) are no longer disabled; or The date that the disabled person becomes entitled to Medicare. Multiple Qualifying Events While Covered Under COBRA The maximum period of coverage under COBRA is 36 months, even if you experience another Qualifying Event while you re already covered under COBRA. If you re covered under COBRA for 18 months because of your termination of employment or reduction in hours, your affected spouse or dependent may extend coverage for another 18 months in the event of your death or if: You get divorced or legally separated; You become entitled to Medicare; or Your child is no longer a dependent under the Fund s definition. For example, you stop working (the first COBRA-Qualifying Event), and you enroll yourself and your dependents for COBRA Continuation Coverage for 18 months. Three months after your COBRA Continuation Coverage begins, your child turns 19 and no longer qualifies as a dependent child under the Fund s definition. Your child then can continue COBRA coverage separately for an additional 33 months, for a total of 36 months COBRA Continuation Coverage.
20 16 You, as the member, are not entitled to COBRA Continuation Coverage for more than a total of 18 months if your employment is terminated or you have a reduction in hours (unless you are entitled to additional COBRA Continuation Coverage on account of disability). Therefore, if you experience a reduction in hours followed by a termination of employment, the termination of employment is not treated as a second Qualifying Event and you may not extend your coverage. Coverage for Your Dependents if You re Enrolled in Medicare If you are entitled to or enrolled in Medicare and you have a termination of employment or reduction in hours, your eligible dependents would be entitled to COBRA for a period of 18 months (29 months if the 11-month Social Security Disability extension applies) from the date of your termination of employment or reduction in hours or 36 months from the date you became entitled to Medicare, whichever is longer. Special COBRA Enrollment Rights If you marry, have a newborn child, adopt a child or have a child placed with you for adoption while you are enrolled in COBRA, you may enroll that spouse or child for coverage for the balance of the period of COBRA Continuation Coverage. You must enroll your new dependent within 31 days of the marriage, birth, adoption or placement for adoption, with proper documentation. In addition, if you are enrolled for COBRA Continuation Coverage and your spouse or dependent child loses coverage under another group health plan, you may enroll that spouse or child for coverage for the balance of the period of COBRA within 31 days after the termination of the other coverage. To be eligible for this special enrollment right, your spouse or dependent child must have been eligible for coverage under the terms of the Plan but declined when enrollment was previously offered because they had coverage under another group health plan or had other health insurance coverage, with proper documentation. Confirmation of Coverage to Health Care Providers Under certain circumstances, federal rules require the Fund to inform your physician and health care providers as to whether you have elected and/or paid for COBRA Continuation Coverage. This rule only applies in certain situations where the physician or provider is requesting confirmation of coverage and you are eligible for, but have not yet elected, COBRA coverage, or you have elected COBRA coverage but have not yet paid for it. Termination of COBRA Continuation Coverage COBRA Continuation Coverage will terminate on the last day of the maximum period of coverage unless it is cut short for any of the following reasons: You do not make all required payments on time; The person receiving the coverage becomes covered by another group health plan that does not contain any legally applicable exclusion or limitation with respect to pre-existing conditions that the covered person may have;
SECTION I ELIGIBILITY A. Who Is Eligible B. When Your Coverage Begins C. Enrolling in the Fund D. Coordinating Your Benefits E. When Your Benefits Stop F. Your COBRA Rights 11 ELIGIBILITY RESOURCE GUIDE
APPENDIX D CONTINUATION OF COVERAGE SAMPLE DESCRIPTIONS This Appendix contains important information about continuation coverage which may be available to Covered Individuals under federal and/or Illinois
HMSA s COBRA INSTRUCTION GUIDE To assist employers in meeting their obligations under the final federal COBRA regulations, HMSA s COBRA contains sample notices that incorporate the new requirements. As
Carpenters Health and Security Plan of Western Washington COBRA Coverage Election Notice This notice contains important information about your right to continue your health care coverage in the Carpenters
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