WISCONSIN PIPE TRADES HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY

Transcription

1 WISCONSIN PIPE TRADES HEALTH FUND BENEFIT HIGHLIGHTS SUMMARY Prepared by: Lee Jost and Associates April, 2007

2 WISCONSIN PIPE TRADES HEALTH FUND Eligibility Requirements 1 Employee Class Initial Eligibility Continued Eligibility Class A (active employees) & Class JD (full-time preapprentices, first and second year apprentices, maintenance tradesmen, and warehousemen) First day of the Coverage Month following the corresponding Work Month during which contributions are credited on the employee's behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. Eligibility is maintained by being credited with employer contributions for at least 140 hours per month to continue coverage under Plan A and 120 hours per month to continue coverage under Plan B. 2 The corresponding Work Months and Coverage Months are as follows: Hours Worked During the Month of January February March April May June July August September Provide Coverage for the Month of April May June July August September October November December 1 If employer contributions have not been made on your behalf and you believe you have worked enough hours to become initially eligible, please contact the Fund Office for verification. 2 If you become sick, disabled, retire or die, self-payments may be made to maintain eligibility. If you worked for another fund that has a reciprocity agreement with this Fund, it may reduce or cancel a selfpayment you otherwise would be required to make. i

3 WISCONSIN PIPE TRADES HEALTH FUND Benefit Highlights 3 Benefit Description Class A Class JD Death Benefit (Employee only) $5,000 $2,000 Accidental Death and Dismemberment Benefit (Employee only) $5,000 $2,000 Loss-of-Time Weekly Benefit (Employee only)-- Maximum 26 weeks per period of disability $ 300 $ 140 Comprehensive Major Medical Benefits for hospital services, physicians services, certain prescription drugs, x-ray and lab services, and other covered items and services when medically necessary, subject to the following: Classes A and JD Comprehensive Plan (Plan A) Lifetime maximum per person $1,000,000 Basic Plan (Plan B) Calendar year deductible 4,5 Per person $ 500 $3,000 Per family $1,500 $6,000 Out-of-pocket maximum Per calendar year for covered expenses, NOT including deductible amount or specific dollar amount copayments for emergency room visits and Physicians office visits (including outpatient Physician visits at a hospital and home visits by a Physician) Per person $2,500 $4,000 Per family $4,000 $8,000 3 All benefits and eligibility rules outlined in this summary are subject to review and changes by the Board of Trustees. 4 If an employee and/or dependent spouse participate in the Preferred Provider Preventive Care Program, the individual deductible of the person(s) who participates will be reduced by $125 each for the following calendar year. 5 If both a husband and wife are eligible under the Plan as employees, the Comprehensive Major Medical Benefits deductible amount will be waived for the entire family. ii

4 Benefit Description Classes A and JD Comprehensive Plan (Plan A) Basic Plan (Plan B) Plan s copayment of covered inpatient expenses (except treatment of nervous and mental disorders, substance abuse, and alcoholism) In-network and precertified by the utilization review 90% 80% (UR) manager In-network and not precertified by the UR manager 85% 75% Out-of-network and precertified by the UR manager 85% 70% Out-of-network and not precertified by the UR 80% 60% manager Plan s copayment of covered outpatient expenses (except treatment of nervous and mental disorders, substance abuse, and alcoholism) In-network 85% 65% Out-of-network 80% 60% Routine physical exam for employee and spouse only (subject to Comprehensive Major Medical Benefits deductible and copayment) Pre-admission testing, second surgical opinions, routine immunizations, well child care (80% at non- PPO; birth to age two-no maximum/age 2 to 12-$60 per child per calendar year at both PPO and non-ppo), hospice care, home health care (up to 10 visits per period of disability), and skilled nursing home care (up to 30 days of confinement per period of disability) Hospital emergency room Separate dollar copayment per visit after deductible and before applicable copayment percentage (waived if admitted) Physician office visits (including outpatient Physician visits at a hospital and home visits by a Physician) Eligible person s copayment per visit (deductible and other copayments do not apply) $400 maximum per person per calendar year - or - 100% of actual fee through Health Dynamics 6 100% of reasonable expenses; not subject to deductible $100 $25 6 If Health Dynamics exam is obtained, a credit toward next year s deductible is given (see footnote 2 on page 2). iii

5 Benefit Description Classes A and JD Treatment of nervous and mental disorders Hospital confinement: Plan s copayment For eligible persons using the FSP 90% For eligible persons not using the FSP Maximum per eligible person per calendar year For eligible persons using the FSP only, potential additional days per eligible person per calendar year at FSP recommendation 80% of the FSP allowable rate 31 days 15 days Partial hospitalization (including residential treatment and intensive outpatient treatment): For eligible persons using the FSP only, maximum per eligible person per calendar year, payable at 90% 15 days Outpatient treatment: For eligible persons using the FSP (not subject to deductible), Plan s copayment 100% Combined maximum per eligible person per calendar year 20 visits Potential additional benefit per eligible person per calendar year at FSP recommendation 10 visits OR For eligible persons not using the FSP (subject to deductible), Plan s copayment of the FSP-authorized rate 50% 7 Combined maximum per eligible person per calendar year 20 visits 7 50% copayment for outpatient treatment of nervous and mental disorders, substance abuse, or alcoholism when not using the FSP will not apply to the out-of-pocket maximum. iv

6 Benefit Description Treatment of substance abuse and alcoholism Classes A and JD Hospital confinement: Plan s copayment For eligible persons using the FSP 90% For eligible persons not using the FSP Maximum per eligible person per lifetime For eligible persons using the FSP only, potential additional days per eligible person per lifetime at FSP recommendation 80% of the FSP allowable rate 30 days 15 days Partial hospitalization (including residential treatment and intensive outpatient treatment): For eligible persons using the FSP only, maximum per eligible person per lifetime, payable at 90% $5,000 Potential additional benefit per eligible person per lifetime at FSP recommendation, payable at 90% $2,500 Outpatient treatment: Plan s copayment For eligible persons using the FSP (not subject to deductible) 100% For eligible persons not using the FSP 50% 8 to $35 maximum per visit Combined maximum per eligible person per lifetime $3, % copayment for outpatient treatment of nervous and mental disorders, substance abuse, or alcoholism when not using the FSP will not apply to the out-of-pocket maximum. v

7 Benefit Description Classes A and JD Preferred Provider Pharmacy Prescription Drug Benefits Deductible per eligible person per calendar year $100 Eligible person s copayment 9 Retail network pharmacy per prescription for up to a 30-day supply Generic: $10 Brand Name: 20% of the cost of the prescription, with a minimum copayment of $20 and a maximum of $40 Mail-order per prescription for up to a 90-day supply, or maximum 34-day supply of a controlled substance Generic: $10 Brand Name: $25 Delta Dental Plan Dental Benefits PPO Non-PPO Care-Plus Exams and cleanings (maximum 2 per calendar year), basic dental benefits, and full denture replacement benefits (every 5 years) Deductible None None None Plan s copayment 90% 80% 100% (including lab fees) Maximum benefit per calendar year $1,000 $1, Orthodontic Deductible None None $750 Plan s copayment 100% 100% 100% Maximum lifetime benefit $1,500 Unlimited Class A Only Vision Care Benefits, per person Exam (maximum 1 per calendar year) $40 Lenses, including contact lenses, and frames (maximum each 2 calendar years) $300 Safety glasses (maximum 1 set per Class A employee per calendar year) $60 9 Use of generics is a mandatory requirement. 10 This maximum applies to your first year of coverage; your second and subsequent years of coverage are up to $2,000 per calendar year. vi

8 Wisconsin Pipe Trades Health Fund To All Active Employees and Retirees: We are happy to provide you with this new Summary Plan Description (SPD or Summary) incorporating all Plan changes adopted through June 1, In easy-to-understand language, it tells you how to become and remain eligible for benefits, explains the benefits available, and gives you instructions on how to apply for benefits. If there should be any inconsistencies between this simplified Summary and the more technical legal Plan Document and Trust Agreement, the legal documents will govern. The Trustees have the right to change, add, or to delete benefits, self-payment rates, eligibility rules, or any other provisions relating to the operation of the Plan in an effort to best serve all Plan participants. The benefits described in this Summary Plan Description are self-funded with the exceptions of one alternative dental program and organ transplant insurance. Self-funded benefits payable are limited to Fund assets available for such purposes. The Eligibility Rules and benefits are maintained at levels in line with Trust Fund income and assets and they are reviewed regularly to provide the best protection possible within the Fund's financial means. The Eligibility Rules and other Plan provisions have been updated as necessary to comply with legal requirements, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its Privacy Rules and Security Regulations and Claims Procedure Regulations. This updated SPD incorporates Plan changes, most of which you were informed of previously in Participant Notices, including: newly revised Eligibility Rules; new two-tier benefit options; new aggregate maximum payable for vision benefits; ChoiceCare as the new Preferred Provider Network; APS Healthcare as the new utilization review manager; elimination of the First Commonwealth dental option; revised COBRA provisions; and updated claims filing and review procedures. x

9 We suggest you familiarize yourself with the information in this Summary and keep it handy for reference. If you have any questions at any time regarding the Plan, please contact the Fund Office. Yours sincerely, The Board of Trustees Ken Bastian James Colwell Jim Cox David Karlsen Kevin LaMere Todd Morris E. Larry Vance Ed Tonn, Jr. Joel Zielke The addresses of the Trustees are found on page 74. Fund Office Wisconsin Pipe Trades Health Fund One Park Plaza West Park Place, Suite 950 Milwaukee, WI Telephone: (414) locally, or call toll-free at: Office Hours: Monday-Friday 8:00 a.m. to 4:30 p.m. xi

10 TABLE OF CONTENTS Page SCHEDULE OF BENEFITS... i ELIGIBILITY RULES How an Employee Becomes Eligible for Benefits How Eligibility Is Continued How Eligibility Is Continued With Self-Payments... 2 (a) Self-Payment Option (1) If Employed Less Than the Minimum Hourly Requirements... 2 (2) If Sick or Injured... 3 (3) If Permanently and Totally Disabled... 3 (4) If a Surviving Dependent... 4 (5) If a Participant in the Senior Program (For Retirees)... 4 (b) Self-Payment Option 2 (COBRA) Reinstatement of Eligibility Employer Contributions for Work Performed Outside the Jurisdiction Coverage for Employees and Their Dependents When Employee Enters Military Service Coverage While on Family and Medical Leave Reciprocity of Welfare Contributions With Other Funds Termination of Individual Coverage Certificate of Creditable Coverage Time for Filing Claims Compliance With Claim Rules Change of Eligibility Rules Conformity With Law DEATH BENEFITS ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS LOSS OF TIME BENEFITS FICA TAX BENEFITS JURY DUTY BENEFITS COMPREHENSIVE MAJOR MEDICAL BENEFITS Deductible Copayment Lifetime Maximum Covered Expenses Hospital Services Physicians' Services Diagnostic X-Ray and Laboratory Services Prescription Drugs and Medicines Routine Physical Examinations Preferred Provider Preventive Care Program Option Routine Colonoscopies Other Covered Charges Organ Transplant Surgery xii

11 TABLE OF CONTENTS (continued) Page Alternative Ways of Obtaining Care Second Surgical Opinions Pre-Admission Testing Well Child Care Routine Immunizations Skilled Nursing Home Care Hospice Care Home Health Care Comprehensive Major Medical Benefits Exceptions and Limitations OTHER PREFERRED PROVIDERS Preferred Provider Hospital and Physician Network Preferred Provider Pharmacy FAMILY SERVICES PROGRAM UTILIZATION REVIEW VISION CARE BENEFITS DENTAL CARE BENEFITS Dental Plan 1 Care Plus Dental Plans, Inc Dental Plan 2 Delta Dental Plan of Wisconsin TRICARE STANDARD-SUPPLEMENT BENEFITS SUPPLEMENTAL DOLLAR BANK REIMBURSEMENT PROGRAM GENERAL PROVISIONS Coordination of Benefits Medicare Provisions Subrogation Right of Recoupment Physical Examinations General Exclusions Termination of Plan Interpretation by Trustees Prohibition Against Assignment to Providers Privacy Policy HIPAA Security Regulations GENERAL DEFINITIONS HOW TO APPLY FOR BENEFITS YOUR RESPONSIBILITIES AS A PARTICIPANT UNDER THE PLAN YOUR RIGHTS UNDER THE FAMILY AND MEDICAL LEAVE ACT OF INFORMATION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) Benefit Appeals Procedure Statement of Participants' Rights Under ERISA Other ERISA Information...74 xiii

12 ELIGIBILITY RULES The following Rules set forth the terms and conditions which govern how you as an employee and your dependents become and remain eligible for most benefits. The Trustees, in their discretion, are empowered to change or amend the Eligibility Rules at any time. You will be notified of any change. There are additional terms and conditions governing eligibility for specific benefits and they are described within the applicable benefit section of this booklet. Your (or your dependent's) action or inaction regarding the release or exchange of information between this Plan and any insurance company, other organization or person, when such information is necessary to determine eligibility and pay benefits may cause your eligibility to be suspended and benefits will not be paid when it results in withholding consent for such release or exchange of information. 1. How an Employee Becomes Eligible for Benefits If you work for an employer obligated by a collective bargaining agreement or participation agreement to pay contributions to this Health Fund, you and your dependents will become and remain eligible for benefits, subject to the following Rules, and any amendments to the Rules which the Trustees may adopt from time to time. (a) Initial Eligibility For bargaining unit employees, you and your dependents become initially eligible for benefits under Class A on the first day of the Coverage Month following the corresponding Work Month during which contributions are credited on your behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. The corresponding Work Months and Coverage Months are as follows: Hours Worked During the Month of January February March April May June July August September Provide Coverage for the Month of April May June July August September October November December October November December January February March For example, if you work 140 hours under Plan A or 120 hours under Plan B during January, you will become initially eligible April 1 st. For alumni, you and your dependents become initially eligible for benefits under Class A on the first day of the month following receipt of two months of contributions. You and your dependents become eligible for benefits under Class JD on the first day of the Coverage Month following the Work Month during which the Fund has received contributions on your behalf for 140 hours of work for a contributing employer for coverage under Plan A and 120 hours for Plan B. (b) Excess Contributions Employer contributions for hours worked in excess of the minimum requirement (140 or 120 hours) will be credited to your Supplemental Dollar Bank, minus a designated portion of the hourly contribution rate which is allocated by the Trustees from time to time to go to Fund assets to build Fund reserves. All deposits are tax-exempt. You may accumulate funds year-to-year and use this money according to the provisions stated on page 48. 1

13 (c) Dependent Special Enrollment Period When you acquire a new dependent through marriage, birth, or adoption, you may request a special enrollment period. Upon such a request, the Fund Office will mail you an enrollment card which must be completed with information pertaining to the newly acquired dependent. If the special enrollment period is requested and the new enrollment card is completed and submitted to the Fund Office, the new dependent s coverage will be effective as of the date of the marriage, birth, or adoption. 2. How Eligibility Is Continued (a) Bargaining Unit Employees To remain eligible, you must be credited with employer contributions for at least 140 hours per month to continue coverage under Plan A and 120 hours per month to continue coverage under Plan B. If you voluntarily leave the Fund's jurisdiction and are not immediately available for work in the industry, you will not be allowed to maintain eligibility under the Plan through self-payments. In addition, if you leave the trade, your Supplemental Dollar Bank balance at the time will be frozen for three years. At the end of the three-year period if your account balance is under $2,000 and you have not returned to the trade, the amount in your account will be forfeited. At the end of the three-year period, if your account balance is over $2,000, the balance will remain frozen until you reach age 55 and if you have not returned to the trade, the amount will be forfeited. (b) Alumni To continue your coverage on a monthly basis, your employer must contribute on all hours paid, with a minimum of 40 hours each week on your behalf. 3. How Eligibility Is Continued With Self- Payments If employer contributions have not been received for you for the required number of hours of work to maintain eligibility, you may make selfpayments to maintain your and your dependents' eligibility with either Self-Payment Option 1 or Self-Payment Option 2. (a) Self-Payment Option 1 You may use Self-Payment Option 1 to continue eligibility under the following circumstances. (1) If Employed Less Than the Minimum Hourly Requirements If your work hours are insufficient and your Supplemental Dollar Bank has sufficient funds, any shortfall automatically will be withdrawn from your Supplemental Dollar Bank. If your Supplemental Dollar Bank does not have sufficient funds, you will receive a selfpayment notice for the balance. This amount must be paid within 10 days after receiving the notice from the Fund Office or you will lose eligibility for the applicable Coverage Month. During the time when you are ineligible for coverage, you will not have access to your Supplemental Dollar Bank. Subsequent self-payments are equal to the difference between the applicable minimum hour requirement and the contribution hours with which you were credited for that month (by employer contributions), multiplied by the employer contribution rate specified in the applicable collective bargaining agreement. If you are immediately available for work in the jurisdiction of this Fund, selfpayments may be made for as long as 18 consecutive months while you are unemployed, or while you are employed outside the work jurisdiction of the Union and outside the geographical jurisdiction of the Fund. However, self-payments will 2

14 be accepted only from individuals residing in the jurisdiction of the Fund. The first self-payment is due within 10 days after you receive written notice from the Fund Office. If you remain unemployed in subsequent months, selfpayments must be made monthly, to be received by the 10th of each month. Failure to make self-payments in the amount and by the due date required will cause you to lose eligibility. (2) If Sick or Injured If contributions from employers are not sufficient to continue your eligibility because you are sick or sustained an injury, your eligibility is continued up to 12 months (unless extended further by a Board of Trustee action, for up to a maximum of 24 months) without selfpayments as long as all of the following conditions are satisfied: (i) The sickness or injury prevents your employment. However, the following provisions apply when you receive a physician's release to perform light-duty work: (A) If light-duty work is available and you elect not to perform such work, you will be required to make the necessary self-payments to continue your coverage under the Plan. (B) If you are available for light-duty work, but light-duty work is not available or there is not sufficient light-duty work for sufficient hours to maintain eligibility, your selfpayment will be waived as specified in this subsection (2). (ii) You are continuously under the care of a physician for the sickness or injury. (iii) You are not covered under any other group health care plan or group insurance program as a result of other employment or as a spouse. (iv) The sickness or injury has not caused you permanent and total disability. (v) You do not elect to retire. While you are receiving Worker's Compensation, your eligibility under the Plan may be continued without selfpayments indefinitely. However, extensions of eligibility for more than 24 months will require Trustee approval. You can receive credits toward eligibility of 35 hours weekly if you notify the Fund, in writing, that you are receiving benefits under Worker's Compensation or Occupational Disease Laws, or if you are receiving Loss of Time Benefits from this Fund. These credits no longer will be given when benefits are terminated, or when your account is credited with 420 hours, whichever occurs first. The Trustees may require a statement from your physician as evidence that you are temporarily unable to work due to the sickness or injury. When you are no longer eligible under this provision, eligibility may be continued by making self-payments as provided under paragraphs (1) and (3). (3) If Permanently and Totally Disabled Permanent and total disability is defined as any sickness or injury which permanently prevents you from performing any employment for remuneration or profit. In the event a sickness or injury causes you to become permanently and totally disabled, you no longer will be eligible under paragraph (2), but you may continue your eligibility under Class B according to this paragraph (3) by: (i) notifying the Trustees that you are eligible for permanent and total disability benefits from Social Security or the Building Trades United Pension 3

15 Trust Fund within 15 days of receiving notice from the Social Security Administration or the Pension Fund; (ii) making the first self-payment, if applicable, no later than the first day of the month following receipt of notice that you are eligible for permanent and total disability benefits; and (iii) making subsequent self-payments, if applicable, no later than the 10th calendar day of each month thereafter. Self-payments also may be paid quarterly in advance. Coverage is provided by making the appropriate self-payment to obtain benefits under Class B for Comprehensive Major Medical Benefits. No benefits are provided for Loss of Time. The benefits and amounts of selfpayments may be changed by the Trustees from time to time. Please note that permanently and totally disabled employees participating in Social Security are covered under Medicare when disabled for 24 or more consecutive months. Once eligible for Medicare, coverage is provided under Class C. (4) If a Surviving Dependent In the event of your death while an eligible employee, your surviving dependents' coverage is continued to the last day of the calendar month for which you would have been eligible as a result of employer contributions. Eligibility may be maintained indefinitely after that date, provided self-payments are made on time and in an amount determined by the Trustees. Failure to make self-payments in the amount and by the due date required will cause loss of eligibility. The right to make self-payments under this paragraph (4) ceases in the event: (ii) other group health coverage is effective as a result of employment. This paragraph (4) does not authorize coverage for children who no longer meet the definition of dependent. (5) If a Participant in the Senior Program (For Retirees) Except when otherwise prevented by law, retiree coverage is subject to change or discontinuation based on Trustee review. The Trustees retain the right in their sole discretion to modify or discontinue, in part or in whole, retiree eligibility rules, types and amount of benefits, terms and conditions under which benefits are payable, and self-payment rates. These provisions are subject to modification as may be required by law. If you retire on or after January 1, 2005: Whether you retire at age 55 or 65, the level of retiree subsidy is based on your years of service in the industry as follows: Years of Percent Subsidy Service 30 50% 25 45% 20 40% 15 35% 10 25% Under 10 0% If you retire before age 55, you won t receive a subsidy until the month after your 55 th birthday. If you make nonsubsidized self-payments from retirement to age 55, that period will qualify as years of service in the industry, and will be credited toward your level of subsidy after age 55. If you were eligible in another health fund prior to such fund merging into this Fund, you will be given credit for those prior years of service when determining your subsidy level. (i) your surviving spouse remarries; or 4

16 AT AGE 55 As a retiree, you may continue coverage for yourself and your dependents. All dependents eligible at the time of your retirement may be covered at the appropriate subsidized self-payment amount. All dependents acquired after the date of your retirement may be covered at the appropriate nonsubsidized self-payment amount. As a retiree, you may continue your coverage under Class B with subsidized self-payments under the following conditions. You must: (i) be at least 55 years of age and less than 65 years of age; (ii) be retired from any active employment; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding retirement and be eligible under this Fund at the time of your retirement; or (iv) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding normal retirement age (as defined by the Building Trades United Pension Trust Fund), have had coverage elsewhere after reaching normal retirement age, and then applied for coverage under the Senior Program within 10 years of the date of reaching normal retirement age; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make your monthly self-payment in an amount and by the due date required by the Trustees. unless you are eligible according to the prior paragraph (iv). You may make the appropriate selfpayments to provide coverage under Class B for Comprehensive Major Medical Benefits (Plan A), Vision Care, Dental Care, and a Death Benefit of $5,000. No benefits are provided for Loss of Time. AT AGE 65 As a retiree, you may continue coverage for yourself and your dependents. All dependents eligible at the time of your retirement may be covered at the appropriate subsidized self-payment amount. All dependents acquired after the date of your retirement may be covered at the appropriate nonsubsidized self-payment amount. As a retiree, you may continue your coverage under Class C with subsidized selfpayments under the following conditions. You must: (i) be at least 65 years of age; (ii) be retired from any active employment; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the 10 consecutive years immediately preceding retirement; (iv) be eligible under this Fund at the time of your retirement; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make your monthly self-payment in an amount and by the due date required by the Trustees, if applicable. Your eligibility as an active employee and then as a retiree must be continuous, 5

17 For retirees age 65 and over, coverage is provided by making the appropriate self-payments to obtain benefits under Class C for Comprehensive Major Medical Benefits (Plan A), Vision Care, Dental Care, and a Death Benefit of $5,000. No benefits are provided for Loss of Time. ELIGIBILITY FOR SENIOR PROGRAM NONSUBSIDIZED SELF-PAYMENTS Retirees who satisfy all other requirements for participation as a retiree but who do not maintain Union membership will be eligible to make nonsubsidized self-payments under the Senior Program at a rate to be determined by the Trustees from time to time. NONSUBSIDIZED RETIREE PARTICIPATION REQUIREMENTS A retiree who does not satisfy the normal retiree participation requirements will be eligible to make nonsubsidized selfpayments to continue coverage for himself and his dependents under the Senior Program, provided the following conditions are satisfied. You must: (i) be at least 55 years of age; (ii) be retired from active employment in the trade; (iii) have been eligible and had contributions or self-payments made in your behalf during each of the three consecutive years immediately preceding retirement; (iv) be eligible under this Fund at the time of retirement; (v) notify the Fund Office of your retirement plans, in writing, at least 30 days in advance of your retirement date; and (vi) make the monthly nonsubsidized selfpayment in an amount and by the due date required by the Trustees. Once you have a combination of 10 years of employer contributions and nonsubsidized self-payments, you will be eligible to make subsidized self-payments. SPECIAL PROVISIONS FOR ELIGIBLE EMPLOYEES WORKING FOR EMPLOYERS UNDER CONTRACT WITH THE UNION The Plan will waive the 10-year eligibility requirement, provided the following conditions are satisfied. You must: (i) be at least 55 years of age and less than 65 years of age; (ii) be retired from any active employment; (iii) have worked for one of the Local Unions as defined in the Trust Agreement and lost retiree coverage through such employer; (iv) make a formal written request to participate in this Fund's Senior Program at least 30 days before your requested effective date of coverage and have such request reviewed and approved by the Trustees; and (v) make the monthly, nonsubsidized selfpayment in an amount and by the due date required by the Trustees. Failure to make a required payment when due cancels your coverage and you may not become reinstated in the Senior Program. AUTOMATIC WITHDRAWAL OF MONTHLY RETIREE SELF-PAYMENTS Effective July 1, 2005, your monthly selfpayments may be deducted automatically from your personal checking or savings account on the 10 th of each month for that month of coverage. For example, your July self-payment will be deducted on July 10 th. If the 10 th falls on a weekend or holiday, your self-payment will be deducted on the next business day. 6

18 This is a voluntary arrangement which you can start or stop at any time by written authorization to the Fund Office. Your request must be received by the 15 th of any month to be effective for the payment due on the 10 th of the following month. There is no fee for this service. OPT-OUT PROVISION Once you have satisfied the requirements for participation in the Senior Program, you may elect not to participate as a retiree in the Wisconsin Pipe Trades Health Fund, provided: (i) You attest that you, or you and your spouse, have primary coverage elsewhere and you show proof of creditable coverage upon reinstatement. (ii) You, or both you and your spouse, sign an Election Form. (iii) In signing the Election Form, you, or both you and your spouse, understand you will be given a onetime option to be reinstated into the Plan at any time prior to your death. After your death, your spouse only (no other dependents) may be reinstated upon showing proof of creditable coverage. (iv) You, or you and your spouse, will be reinstated into the Plan on the first day of the month following receipt of the appropriate monthly self-payment and you show proof of creditable coverage upon reinstatement. (v) You maintain Union membership. (vi) Reinstatement will follow the Health Insurance Portability and Accountability Act (HIPAA) rules governing pre-existing condition limitations. If you wish to take advantage of this option to opt out of the Senior Program, please request an Election Form from the Fund Office. TERMINATION OF YOUR ELIGIBILITY UNDER THE SENIOR PROGRAM Your coverage under the Senior Program remains in force as long as you continue to make the necessary self-payments by the 10th day of each month. Failure to make a required selfpayment cancels your coverage and you may not become reinstated in the Senior Program. IF YOU RETURN TO WORK FOR AN EMPLOYER AFTER BECOMING ELIGIBLE UNDER A SENIOR PROGRAM You may not become eligible again for active employee benefits once you retire. Employer contributions received by the Fund on your behalf will NOT serve to reduce the amount of the selfpayment otherwise payable by you. FOR YOUR SURVIVING SPOUSE If you die while you are participating in the Senior Program, your spouse may continue dependents' coverage until: (i) the end of the period for which the last self-payment was made; (ii) coverage is provided to your spouse under another group health care plan as an employee or dependent; (iii) the date your surviving spouse remarries; or (iv) the date your surviving spouse establishes residence outside the United States. If your surviving spouse fails to make a required self-payment, the coverage terminates on the last day of the sixth calendar month following the month for which the self-payment was made. Coverage may not be reinstated in the Senior Program. Monthly contributions under this Self- Payment Option 1 will not be accepted 7

19 on behalf of surviving dependent children when both parents are deceased. (b) Self-Payment Option 2 (COBRA) The intent of these Rules is to comply with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended in all respects, including those changes required by subsequent legislation including, but not limited to, the Omnibus Budget Reconciliation Acts of 1989, 1990, and 1993, and the Health Insurance Portability and Accountability Act of Any future IRS guidance will be incorporated even if it conflicts with existing Plan provisions. Employees and dependents who do not qualify for, or do not use, Self-Payment Option 1 may, while they are Qualified Beneficiaries, continue eligibility under Self- Payment Option 2 for: health care benefits only; or health care, vision care, and dental care benefits, subject to the following conditions. (1) Qualifying Events Certain events which cause you or your dependent to lose eligibility under the Plan are Qualifying Events. Such Qualifying Events occur for you as an employee eligible because of employer contributions upon: (i) a reduction in hours of covered employment for any reason, including disability, sickness, or retirement; or (ii) voluntary or involuntary termination of covered employment for any reason, including disability, sickness, or retirement, unless for gross misconduct on your part. Such Qualifying Events occur for spouses and dependent children upon any of the following events occurring while you are an employee eligible because of employer contributions: (i) termination or reduction of your employment for any reason including disability, sickness, or retirement, unless for gross misconduct on your part; (ii) your death; (iii) divorce or legal separation from you; (iv) your entitlement to Medicare (under Part A, Part B, or both); or (v) a dependent ceasing to meet the definition of dependent under the Plan. You or your dependent becomes a Qualified Beneficiary for a specific period of time when a Qualifying Event occurs. A dependent child who is born to or placed for adoption with an employee during the employee's period of COBRA continuation coverage will be treated as a Qualified Beneficiary. As a Qualified Beneficiary, eligibility may be continued for certain benefits through self-payments under the following provisions. (2) Notifications and Due Dates (i) Qualified Beneficiary s Responsibility to Notify the Trustees When the Qualifying Event relates to your death, divorce or legal separation, or a dependent ceasing to meet the definition of dependent under the Plan, the Qualified Beneficiary must notify the Fund Office directly within 60 days of the Qualifying Event so the Fund Office may provide proper notices and explanations to Qualified Beneficiaries about continued eligibility. This notice can be provided to the Fund Office by telephone, facsimile, or in writing by mail. The Fund Office will advise the Qualified Beneficiary if additional supporting documentation is required. If the 8

20 Fund Office is not notified in writing within 60 days of the Qualifying Event, the person is no longer a Qualified Beneficiary and loses the opportunity to continue coverage. (ii) The Trustees Responsibility to Notify a Qualified Beneficiary When the Qualifying Event is Loss of Coverage Due to the Employee s Death, Divorce, Legal Separation, or to a Dependent Child Ceasing to Meet the Plan s Definition of Dependent The Fund Office, not later than 30 days after receipt of notice, will advise the Qualified Beneficiary of the coverages, options, costs, self-payment due dates, and duration of the self-payment privileges. (iii) The Trustees Responsibility to Notify a Qualified Beneficiary When Other Qualifying Events Occur Based on monthly employer reports, Trustees are aware of some Qualifying Events, such as loss of eligibility for coverage based on contributions received from contributing employers because of a reduction in your hours and your ceasing active work. The Fund Office, not later than 30 days after receipt of notice of an employee's loss of coverage from the employer or by examining monthly contribution reports, will advise the Qualified Beneficiary of the coverages, options, costs, self-payment due dates, and duration of the selfpayment privileges. (iv) Due Date for Qualified Beneficiary s Response A Qualified Beneficiary has 60 days from the date of coverage termination or receipt of the COBRA Notice, whichever is later, to elect whether to continue coverage. The election should be communicated to the Fund Office in writing on an Election Form. Each employee, spouse, and dependent child has the right to make an individual election. However, covered employees may elect to continue coverage on behalf of their spouses, and parents may elect to continue coverage on behalf of their children. Failure to state the election to the Fund Office within 60 days terminates rights to continued coverage under this provision. (v) Due Date for Initial Self-Payment The required initial self-payment must be made to the Fund Office not later than 45 days following the election to continue coverage (which is the post-mark date, if mailed). Failure to do so will cause eligibility and coverage to terminate retroactively to the date of the Qualifying Event and will cause loss of all continuation coverage rights under the Plan. The amount of the first selfpayment is for the time period beginning with the date of the Qualifying Event and extending through the month in which payment is made. (vi) Due Date for Subsequent Self- Payments Subsequent monthly selfpayments must be made to the Fund Office by the first day of the month for that month of coverage. The Plan allows a 30-day grace period for making self-payments. Continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if a periodic payment is made later than the 9

21 first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. Any claim submitted for benefits while coverage is suspended may be denied and may have to be resubmitted once coverage is reinstated. Failure to make subsequent selfpayments before the end of the grace period will cause coverage and eligibility to terminate at the end of the month for which a timely self-payment was last made and will cause loss of all rights to continuation coverage under the Plan. (3) Coverages and Options If a Qualified Beneficiary elects to continue coverage, the following benefits are available: (i) health care benefits only; or (ii) health care benefits plus vision care and dental care benefits. The coverage selected may not be changed, except to add coverage for a new spouse or to add a new dependent child as a Qualified Beneficiary upon the child's birth or placement for adoption with the employee during the employee's period of COBRA continuation coverage. The Plan is required to offer continued coverage which, as of the day before coverage terminated, is identical to similarly situated employees or family members who have not experienced a Qualifying Event. If coverage under the Plan is modified for similarly situated employees, the Qualified Beneficiary's coverage also will be modified. A Qualified Beneficiary does not have to show insurability to choose continuation coverage. (4) Cost of Continuation Coverage The self-payment amount depends on whether you choose to continue health care benefits only or health care plus vision care and dental care benefits. The costs are determined annually by the Trustees. There is a separate cost for continued coverage from the 19th through the 29th month for those individuals eligible for such disability extension. The Fund Office initially will notify the Qualified Beneficiary of the self-payment amount and due dates. (5) Duration of Continuation Coverage (Maximum Continuation Coverage Period) When eligibility is lost due to termination of employment or reduction in hours, a Qualified Beneficiary may continue eligibility for up to 18 consecutive months from the date employment terminated or hours were reduced, less the number of months eligibility was continued without employer contributions or selfpayments. This 18-month period may be extended to 36 months for the spouse and dependent children if a second Qualifying Event [e.g. employee s death, divorce or legal separation from the employee, employee s coverage by Medicare (under Part A, Part B, or both), or a dependent child ceasing to meet the definition of dependent under the Plan] occurs during the 18-month period. These Events can be a second Qualifying Event only if they would have caused the Qualified Beneficiary to lose coverage under the Plan if the first Qualifying Event 10

22 had not occurred. A Qualified Beneficiary must notify the Fund Office within 60 days after a second Qualifying Event occurs if he wants to extend his continuation coverage and must provide any supporting documentation the Fund may request. This provision does not apply in the case of a reduction in work hours followed by a termination of employment. This 18-month period may be extended up to a total of 29 months for all Qualified Beneficiaries during the disability of the employee, spouse, or dependent child, provided: (i) the Social Security Administration (SSA) determines that any of the Qualified Beneficiaries are disabled under the Social Security Act either: at the time employment terminated or hours were reduced; or at any time within 60 days of such Qualifying Event, and the disability lasts at least until the end of the 18-month period of continuation coverage; and (ii) the Qualified Beneficiary notifies the Fund Office in writing within 60 days of the SSA determination and before the end of the first 18 months of continuation coverage and provides a copy of the SSA determination to the Fund Office. Each Qualified Beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the Qualified Beneficiary is determined by SSA to no longer be disabled, the Qualified Beneficiary must notify the Fund Office within 30 days after the SSA determination. Failure to provide notice of a disability or second Qualifying Event may affect the right to extend the period of continuation coverage. When eligibility is lost due to the employee s death, divorce or legal separation from the employee, employee s coverage by Medicare (under Part A, Part B, or both), or a dependent child ceasing to meet the definition of dependent under the Plan, the spouse and eligible dependents may continue coverage for up to 36 months from the date of the Qualifying Event less the number of months eligibility was continued without employer contributions or selfpayments. When the Qualifying Event is the end of employment or reduction of the employee s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the Qualifying Event, COBRA continuation coverage for Qualified Beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. (6) Multiple Qualifying Events Your spouse or dependent child, as a Qualified Beneficiary, may experience more than one Qualifying Event. However, the combined continuation coverage period for all such events may not exceed 36 consecutive months from the date of the original Qualifying Event. The second or later events, provided they occur within the continuation period provided as a result of the original Qualifying Event, entitle a Qualified Beneficiary to continue coverage for an additional period, but not longer than 36 months from the date of the original Qualifying Event. For example, where a widow, as a Qualified Beneficiary, continued coverage for herself and children for 20 months and a child loses dependent status, that child may continue coverage for the remainder of the time the mother is entitled to continue coverage by making his own separate self-payments. This Rule does not apply in the case of a reduction in work hours followed by a termination of employment. 11

23 (7) Termination of Self-Payment Provisions for Qualified Beneficiaries Self-payments no longer are accepted and continued eligibility under this provision terminates on behalf of all Qualified Beneficiaries (unless specifically stated otherwise) when: (i) the Plan no longer provides group health care coverage to any eligible employee; (ii) the required notice of a Qualifying Event is not provided by the Qualified Beneficiary within 60 days of its occurrence; (iii) the election for continuation is not made within 60 days following the date of coverage termination or receipt of the COBRA Notice, whichever is later; (iv) the initial self-payment is not paid by the due date explained in subparagraph (v) of paragraph (2); (v) the subsequent self-payments are not paid as explained in subparagraph (vi) of paragraph (2); (vi) a Qualified Beneficiary becomes covered, after electing continuation coverage, under another group health care plan that does not impose any pre-existing condition exclusion for pre-existing conditions of the Qualified Beneficiary; (vii) the maximum continuation coverage period is reached; (viii) for a Qualified Beneficiary who was entitled to the additional 11 months continuation coverage based on a disability extension -- eligibility for continuing the disability extension will terminate when there has been a final determination that the disability no longer exists; or (ix) the Qualified Beneficiary becomes entitled to Medicare (under Part A, Part B, or both) after such person's COBRA election date (although other family members not entitled to Medicare will continue to be eligible for COBRA continuation). However, if a Qualified Beneficiary becomes entitled to Medicare due to End Stage Renal Disease (ESRD), his coverage under Self-Payment Option 2 will not terminate automatically because of eligibility for Medicare. In the case of ESRD, the Fund is the primary source of coverage for up to 30 months from the date of ESRDbased Medicare entitlement, provided the person is an active eligible employee or dependent or is covered under the Fund with COBRA continuation coverage. In the event the Fund's liability as the primary source of coverage for ESRD ends before the COBRA continuation period ends, the Fund becomes secondary to Medicare for the balance of the continuation coverage for such person. Continuation coverage also may be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation (such as fraud). When you become ineligible for benefits under Self-Payment Option 2, you can be reinstated as provided in Eligibility Rule Reinstatement of Eligibility If you lose eligibility for coverage because you did not work the required number of hours or make the required self-payment, your coverage can be reinstated when you work the required number of hours for the Plan you previously were covered under (i.e., 140 hours in a Work Month for the Comprehensive Plan or 120 hours for the Basic Plan). Eligibility cannot be reinstated 12