Milwaukee Carpenters' District Council Health Fund. Summary Plan Description

Transcription

1 Milwaukee Carpenters' District Council Health Fund Summary Plan Description Effective June 1, 2014

2 Milwaukee Carpenters District Council Health Fund To All Active Employees and Retirees: We are happy to provide you with this new Summary Plan Description (SPD), effective June 1, In easy-tounderstand 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 SPD and the more technical legal Plan Document and Trust Agreement, the legal documents will govern. The Trustees reserve the right in their sole discretion to change, interpret, withdraw, or add benefits, self-payment rates, eligibility rules, or any other provisions relating to the operation of the Plan or terminate the Plan at any time by written amendment in an effort to best serve all Plan participants. All Plan benefits described in this SPD are self-funded, except for certain organ transplant benefits which are insured. 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 you with the best protection possible within the Fund's financial means. The Eligibility Rules and other Plan provisions are updated as necessary to comply with legal requirements, including the Patient Protection and Affordable Care Act and Mental Health Parity Addiction and Equity Act. We suggest you familiarize yourself with the information in this SPD carefully to have a clear understanding of your Plan, and then keep it handy for reference. If you have questions at any time regarding the Plan, please contact the Fund Office. Yours sincerely, The Board of Trustees Peter DiRaffaele Arcadio Perez Mark Scott Tom DuFour Larry Rocole John Topp The addresses of the Trustees are found on page 80. Fund Office N25 W23055 Paul Road, Suite 2 Pewaukee, WI Telephone: (262) locally, or call toll-free in Wisconsin at: FAX: (262) Office Hours: Monday - Friday 8:00 a.m. to 4:30 p.m. i

3 DISCLOSURE LANGUAGE FOR GRANDFATHERED PLANS This group health plan believes it is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrative Manager at: Milwaukee Carpenters District Council Health Fund, N25 W23055 Paul Road, Suite 2, Pewaukee, WI ; (262) or You also may contact the Employee Benefits Security Administration, U.S. Department of Labor at: or This website has a table summarizing which protections do and do not apply to grandfathered health plans. ii

4 TABLE OF CONTENTS Page ELIGIBILITY RULES How an Employee Becomes Eligible for Benefits Class A Active Employees How Eligibility Is Continued Class A Active Employees How Eligibility Is Continued With Self-Payments All Classes... 5 (a) Self-Payment Option (b) Self-Payment Option 2 (COBRA) Reinstatement of Eligibility for Active Employees Use of Transfers Under Reciprocity Agreement Dependents Coverage for Employees and Their Dependents When Employee Enters Military Service Coverage While on Family and Medical Leave Retiree Benefits and Self-Payments are Subject to Change by the Trustees Termination of Individual Coverage Certificate of Creditable Coverage DEATH BENEFITS ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS LOSS OF TIME BENEFITS COMPREHENSIVE MAJOR MEDICAL BENEFITS Deductible Coinsurance Covered Expenses Hospital Services Skilled Nursing Home Care Services Physicians' Services Diagnostic X-Ray and Laboratory Services Prescription Drugs and Medicines Other Covered Charges Organ Transplant Surgery Genetic Testing and Counseling Alternative Ways of Obtaining Care Pre-Admission Testing Routine Physical Examinations Preferred Provider Preventive Care Program Option Hospice Care Home Care Treatment for Hemophilia Routine Mammograms Routine Immunizations Exceptions and Limitations iii

5 TABLE OF CONTENTS (continued) Page FAMILY SERVICES PROGRAM CASE MANAGEMENT OTHER PREFERRED PROVIDERS Preferred Provider Network Preferred Provider Pharmacy DENTAL CARE BENEFITS VISION CARE BENEFITS MEDICARE-PLUS BENEFITS GENERAL PROVISIONS Coordination of Benefits Medicare Provisions Subrogation/Reimbursement Right of Recoupment Physical Examinations General Exclusions Amendment and Termination of Plan Prohibition Against Assignment to Providers Genetic Information Nondiscrimination Act HIPAA Security Regulations Discretionary Authority Applicable Governing Law Release of Responsibility for Tax Consequences PRIVACY POLICY 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) Claims Review and Appeal Procedures Statement of Participants' Rights Under ERISA Other ERISA Information iv

6 ELIGIBILITY RULES The following Eligibility 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 such change. There are additional terms and conditions governing eligibility for specific benefits and they are described within the applicable benefit section of this booklet. Participants may include: The Plan generally uses a quarterly eligibility system. WORK QUARTER For work you perform during... January February March CONTRIBUTION QUARTER Employer contributions we receive during... February March April COVERAGE QUARTER With the required hours, you and your dependents are eligible for benefits during... June July August employees working for a contributing employer(s) under a collective bargaining agreement requiring contributions to this Fund; or non-bargaining unit employees and alumni (including certain owners) who are part of a classification specified in a Trustee-approved participation agreement. April May June July August September October November December May June July August September October November December January September October November December January February March April May Although sole proprietors, partners, and 100% owners may perform work covered by a labor contract or are alumni or non-bargaining unit employees, such persons will not be eligible to participate in this Plan. Participation in and eligibility under the Plan is conditional upon you or your dependent not objecting by your action or inaction to 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. Though Eligibility Rule requirements may have been satisfied, eligibility will be suspended and benefits will not be paid when you withhold consent for such release or exchange of information. You and your dependents will be eligible to receive benefits under the Plan provided the following eligibility requirements are satisfied. Eligibility for benefits from this Plan is based on an employee having the required hours from employer contributions, self-payments, or credits. Coverage quarters follow contribution quarters with one month in between for necessary bookkeeping. If insufficient employer contributions or other credits are received during a contribution quarter because you are not fully employed, or are sick or injured and unable to work, the bookkeeping month allows the Trustees time to notify you in advance that a self-payment is due to continue eligibility of you and your dependents for the next coverage quarter. In these Rules, the terms covered work and employment mean work for which an employer is obligated to pay contributions to this Fund under the terms of a collective bargaining agreement with the Chicago Regional Council of Carpenters Northern Region or under an approved participation agreement with the Trustees. Generally under these Rules, credits for eligibility are based on employer contributions being received by the Trustees. However, a bargaining unit employee also will receive credit for selfpayments and disability hours, and apprentices will receive credit for training hours as specified on 1

7 page 5. Non-bargaining unit employees and alumni will not receive credit for disability hours. Further, for up to three months out of every twelve months, Trustees may waive the requirement for bargaining unit employees that contributions be received, provided evidence acceptable to them is furnished which proves you performed covered employment for which the required contributions were not paid. Trustees will not waive the contribution requirement for non-bargaining unit employees or alumni. You will receive a quarterly notice summarizing hours for which employer contributions were received and disability hours for which you have been credited. 1. How an Employee Becomes Eligible for Benefits Class A Active Employees (a) Initial Eligibility You, as a new employee, will become initially eligible for Class A benefits on the first day of the month following the month in which you are credited with employer contributions for at least 400 hours of covered employment within two consecutive work quarters. You and your dependents will remain eligible for three consecutive months. In the event your initial eligibility date is other than the first day of the first month of a coverage quarter, your eligibility will be continued for a part of the next coverage quarter. You will remain eligible for the next coverage quarter, or remainder of the next coverage quarter, subject to Rule 2, How Eligibility Is Continued, which begins on this page. The credit apprentices receive for training hours will be used toward establishing initial eligibility requirements. (b) Dependent Special Enrollment Period When you acquire a new dependent through marriage, birth, adoption, or placement for 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 within 45 days of the marriage, birth, adoption, or placement for adoption, the new dependent s coverage will be effective as of the date of the marriage, birth, adoption, or placement for adoption. If the request is not made within 45 days, the dependent s coverage will be effective on the first day of the month following receipt by the Fund Office of the completed enrollment card. (c) Other Special Enrollment Rights You or your dependent also will be entitled to special enrollment rights if: (1) you or your dependent had other coverage under Medicaid or the State Children s Health Insurance Program ( CHIP ) and lose eligibility for that coverage; or (2) you or your dependent becomes eligible for financial assistance with respect to coverage under the Plan through Medicaid or CHIP. You also may request a special enrollment period upon a child s loss of other health coverage. The effective date of coverage for any of these qualifying events will be the first day of the month following receipt of the request for enrollment. Special enrollment must be requested within 30 days of the qualifying event except for a CHIP event as previously described which must be requested within 60 days of such event. 2. How Eligibility Is Continued Class A Active Employees Eligibility under the Plan is continued subject to the following provisions, provided you are available for full-time covered work. If you work for a non-contributing employer in the construction industry, coverage under the Plan for you and your dependents will 2

8 terminate effective the first day of the month following notice from the Fund Administrative Manager, but not earlier than 20 days after the date of such notice. You will not be allowed to make self-payments under Self-Payment Option 1 as of such termination date; you only will be allowed to make self-payments under Self-Payment Option 2 (COBRA), according to the provisions on pages 13 through 17. The termination of benefits and privileges under this provision does not apply if full-time covered work is not available. However, if you are offered covered work by a contributing employer and you refuse such offer, these termination provisions will apply as of the date of your refusal. If your eligibility for coverage was terminated according to these provisions and then you return to covered work, you will become eligible for benefits effective the day you return, provided you had sufficient accumulated banked hours remaining on the date your eligibility was terminated. If the banked hours remaining to your credit are insufficient for eligibility, you will be required to meet the requirements for initial eligibility in order for you and your dependents to once again become eligible under the Plan. (a) When Credited With Sufficient Hours (1) Bargaining Unit Employees Once you become eligible, you and your dependents will continue to be eligible for Class A benefits as long as you are credited with at least 345 hours for each work quarter. You do not have to receive credit each month of the work quarter to remain eligible, provided you earn the total number of required credits within the quarter. (2) Non-Bargaining Unit Employees and Alumni You must be credited with a minimum of 160 hours in each month of a work quarter in order to remain eligible. If you are not credited with 160 hours in each month of a work quarter, your eligibility will end on the last day of the work month for which at least 160 hours are credited. (b) When Credited With Less Than Required Hours (1) When a bargaining unit employee is credited with less than 345 hours for a work quarter, the hours credited in that quarter and the prior three quarters will be considered. You and your dependents will maintain eligibility for Class A benefits if you are credited with employer contributions or other credits for at least 1,380 hours during the four immediately preceding consecutive work quarters. (2) If an alumni is totally unemployed or totally and permanently disabled and is credited with less than 160 hours in each month of a work quarter, the hours credited in that quarter and each of the preceding three quarters will be considered. You and your dependents will maintain eligibility for Class A benefits if you are credited with employer contributions or other credits for at least 1,920 hours during the four immediately preceding consecutive work quarters. (3) When a bargaining unit employee or an alumni is credited with less than the required number of hours, eligibility for you and your dependents will end, as specified in the following table, unless you continue eligibility with selfpayments as provided in Rule 3, How Eligibility Is Continued With Self- Payments, which begins on page 5. (4) If a non-bargaining unit employee is credited with less than the required number of hours, eligibility for you and your dependents will end as of the last day of the work month for which contributions were last received unless you continue eligibility with selfpayments as provided in Rule 3(b), Self-Payment Option 2 (COBRA), which begins on page 13. 3

9 There are four possible dates on which your continued eligibility terminates, depending on when you fail to meet the credit requirements (does not apply to nonbargaining unit employees). If you do not meet any of the credit requirements by the work quarter ending in: March May 31 Your continued eligibility ends: June August 31 September November 30 December February 28/29 (c) When Receiving Worker's Compensation Benefits [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] (1) When a disability prevents you from working after becoming eligible, you will be given credit for 27 hours per week, up to 115 hours per month for up to eight work quarters in order to help maintain eligibility for Class A benefits. (2) You receive the disability hours credit provided: (i) you receive temporary total or permanent total disability weekly Worker's Compensation Benefits as a result of injury or sickness; (ii) your disability was incurred because of employment by an employer and for which employer contributions are payable to this Fund; (iii) you submit proof to the Fund Office that you are receiving temporary total or permanent total disability weekly Worker's Compensation Benefits; and (iv) you furnish medical evidence satisfactory to the Trustees, upon request. In addition, you will receive the disability hours credit if you are receiving temporary partial disability weekly Worker s Compensation Benefits as a result of injury or sickness and you have returned to light-duty work. Such credit will be based on the difference between the number of hours you work and 115 hours per month for up to 24 months. You will not receive the credit if you are receiving total partial disability Worker's Compensation Benefits. If an injury or sickness for which Worker's Compensation Benefits are paid allows you to return to work but later requires additional treatment, disability hours can be credited while receiving the additional treatment, up to a total of eight work quarters. You also receive the disability hours credit when receiving Loss of Time Benefits from this Plan as stated in the following subsection (d), When Receiving Loss of Time Benefits. (d) When Receiving Loss of Time Benefits [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] (1) When you receive Loss of Time Benefits from this Plan, you are credited with 27 hours per week, up to 115 hours per month, for such injury or sickness in order to help maintain eligibility for Class A benefits. (2) If you receive Loss of Time Benefits from this Plan as a result of light-duty work, no disability hours credit will be given for the month once your light-duty work equals 115 hours per month. 4

10 However, you will be given full credit toward eligibility for all light-duty hours worked for which employer contributions were paid. (3) You will receive the disability hours credit for up to 26 weeks. (e) When Apprentices Are Being Trained Apprentices will be credited with 40 hours each quarter while attending training school. These hours will be granted to establish or maintain eligibility. (f) When You Die or Divorce [This subsection will apply only to bargaining unit employees and will not apply to non-bargaining unit employees and alumni.] Your dependents who, at the time of your death or divorce, were eligible because of employer contributions or payments under Self-Payment Option 1, will remain eligible for health care, dental, and vision benefits to the end of the coverage quarter in which you died or the divorce judgment was granted, plus two additional coverage quarters. If you are a retiree, your dependents will remain eligible to the end of the month in which you died or the divorce judgment was granted, plus six additional months. Near the end of the additional coverage period, your dependents will receive an initial notice describing how and when to make self-payments to continue coverage. 3. How Eligibility Is Continued With Self- Payments All Classes Under certain circumstances, you and your dependents may continue eligibility by making self-payments under one of two options. If you are eligible to do so, you will receive a notice. Self-Payment Option 1 is the Fund's traditional self-payment provisions and Self-Payment Option 2 is the COBRA continuation provisions required by law. You must elect one option or the other. If you elect Option 1, you cannot subsequently elect Option 2 unless you experience a second Qualifying Event as defined on page 13. (a) Self-Payment Option 1 [Self-Payment Option 1 will apply to bargaining unit employees. It also will apply to alumni, except for the following subsection (a)(3), If a Bargaining Unit Employee Is Partially Employed. Nonbargaining unit employees will not be eligible for Self-Payment Option 1 except as a retiree in limited circumstances as described in subsection (a)(7), If a Retiree, which begins on page 9.] (1) The following may use Option 1 to continue eligibility for applicable benefits: (i) an employee or former employee who is: (A) available for full-time covered work; or who is (B) totally and permanently disabled; or (ii) a retired employee; or (iii) a surviving spouse who, at the time of your death, was eligible because of employer contributions or selfpayments under Self-Payment Option 1. You will be considered not available for work and, therefore, not eligible to make self-payments to this Fund when: (i) you work for a non-contributing employer in the construction industry (The term non-contributing employer means an employer in the construction industry who does not contribute to a multi-employer health benefit plan anywhere); or (ii) you are not registered on the out-of-work list of the Northern Region of the Chicago Regional Council of Carpenters for the 5

11 work quarter that corresponds with the coverage quarter to which the self-payment is applicable. Remember: At the time of your first self-payment notice, you are given the opportunity to elect Self-Payment Option 1 or Self-Payment Option 2 (COBRA Continuation). If at that time you elect or have already elected Self-Payment Option 1 and you subsequently become ineligible to make a self-payment under Self- Payment Option 1 because you have not registered on the out-of-work list, you will not be offered another opportunity to elect Self-Payment Option 2. (2) Types of Notices and Self-Payment Due Dates If you are an active employee, a quarterly notice will be sent to you summarizing hours reported and selfpayments received. This notice will tell you if you and your dependents are eligible for the next coverage quarter and the amount due if a self-payment is needed to continue eligibility. The selfpayment must be received at the Fund Office by the 15th day of the month prior to the month for which coverage is applicable. If the self-payment is not received by the 15th day of the month prior to the coverage month, you will lose eligibility as of the last day of the month for which a timely self-payment was made. If the amount due for the quarter exceeds one-third of the full selfpayment amount, the self-payment amount may be made in three equal monthly installments. Coverage will be extended for each applicable month once the monthly installment is received. Self-payments must be received by the 15th day of the month prior to the month for which coverage is applicable. If the self-payment is not received by the 15th day of the month prior to the coverage month, you will lose eligibility as of the last day of the month for which a timely self-payment was made and must reinstate using hours worked in the next work quarter after termination (no previous work hours can be used toward reinstatement). Those who retire or become totally and permanently disabled or those who become surviving spouses entitled to make self-payments will receive an initial notice that the first self-payment is due, provided the Trustees have been notified. This notice names the coverage month (or quarter) for which a self-payment is needed and the amount due to continue eligibility. Selfpayments must be received prior to the first day of the coverage month. Failure to make self-payments when due causes a loss of eligibility. (3) If a Bargaining Unit Employee Is Partially Employed Duration of Self-Payments: If hours credited are insufficient, you can make self-payments to keep yourself and your dependents eligible for all applicable Class A benefits, subject to the following conditions, provided you remain available for full-time covered employment. You will be allowed to make up to an aggregate maximum of six consecutive quarters of self-payments, whether you are partially employed, fully unemployed, or any combination of the two. If you are making self-payments and have not reached the six-quarter maximum, and you, as a bargaining unit employee, are credited with 345 hours in one work quarter, or as alumni are credited with 160 hours in each month of a work quarter, you become eligible to make self-payments for an additional six consecutive quarters. Once you have made six consecutive quarters of any combination of partial and full self-payments, you will not be eligible to make further self-payments. If you lose eligibility, you must satisfy the 6

12 reinstatement rules on page 17 to again have coverage in the Fund. Self-Payment Amount: The initial and subsequent self-payment amount will be shown on the notices. The self-payment required is the difference between the hours credited and the minimum hours needed per quarter to maintain eligibility, multiplied by the employer hourly contribution rate specified in the current collective bargaining agreement. (4) If Unemployed Duration of Self-Payments: As an unemployed person available for fulltime covered work, you can make full self-payments to keep yourself and your dependents eligible for applicable Class A benefits, subject to the following conditions, provided you remain available for full-time covered employment. You will be allowed to make up to an aggregate maximum of six consecutive quarters of self-payments, whether you are partially employed, fully unemployed, or any combination of the two. If you are making self-payments and have not reached the six-quarter maximum, and you, as a bargaining unit employee, are credited with 345 hours in one work quarter, or as alumni are credited with 160 hours in each month of a work quarter, you become eligible to make self-payments for an additional six consecutive quarters. Once you have made six consecutive quarters of any combination of partial and full selfpayments, you will not be eligible to make further self-payments. If you lose eligibility, you must satisfy the reinstatement rules on page 17 to again have coverage in the Fund. Self-Payment Amount: The initial and subsequent self-payment amount will be shown on the notices. The full selfpayment is based on the minimum requirement of 345 hours for a bargaining unit employee or 480 hours for an alumni, per quarter, multiplied by the employer hourly contribution rate specified in the current collective bargaining agreement. Low Cost Option - Class A Bargaining Unit Employees: To qualify for the Low Cost Option in a coverage quarter, you must be: completely unemployed in the work quarter preceding the coverage quarter; available for full-time covered employment in the Fund s jurisdiction; and registered on the out-of-work list of the Northern Region of the Chicago Regional Council of Carpenters for such work quarter. You will be given the opportunity to enroll in the Low Cost Option at the time you receive your first full self-payment notice. If you do not elect the Low Cost Option at that time, you will not be eligible to elect the Low Cost Option in a subsequent coverage quarter. To elect this option, you must complete the election form included with your quarterly self-payment notice and return it to the Fund Office by the 15th of the month prior to the month for which coverage is applicable. Eligibility may be continued under the Low Cost Option: for up to six consecutive coverage quarters; or until you satisfy the Plan s reinstatement rules by being credited with employer contributions for 400 hours of covered employment within two consecutive work quarters, whichever is earlier. Benefits under the Low Cost Option include Comprehensive Major Medical Benefits and Preferred Provider Pharmacy Prescription Drug Benefits only, at different benefit levels than Class A as stated in the Schedule of Benefits. Death Benefits, Loss of Time Benefits, Vision Care Benefits, and Dental Care Benefits are not available under the Low Cost Option. Although out-of-pocket expenses are increased under the Low Cost Option, self-payments are lower than for full Class A benefits. The quarterly selfpayment amount for the Low Cost Option is reviewed at least annually and is subject to change. You can make 7

13 monthly versus quarterly self-payments, provided the payment is received by the 15th of the month prior to the month for which coverage is applicable. Coverage will be provided for the applicable month. Once you elect the Low Cost Option, you will not be eligible for full Plan benefits again until you satisfy the Plan s initial eligibility or reinstatement of Eligibility Rules. (5) If Totally and Permanently Disabled When the Trustees determine that the requirements of total and permanent disability as defined on page 67 have been met, you will receive an initial notice describing the self-payment amount and due dates. If you are disabled and receiving benefits from the Building Trades United Pension Trust Fund, your first selfpayment is due after your bank of hours, if any, is exhausted. Duration of Self-Payments: If totally and permanently disabled, you will be able to make self-payments to keep yourself and your dependents eligible for all applicable Class RA, RAO, RAM, RB, RBO, and RBM benefits. Selfpayments under this section may continue as long as you continue to furnish medical and other information when requested and the Trustees continue to determine total and permanent disability. Self-Payment Amount: The selfpayment amount is set by the Trustees and may be changed at their discretion. Return to Work: If you are eligible under Class RA, RAO, RAM, RB, RBO, or RBM and no longer are totally and permanently disabled and you are released to return to covered work, you will become reinstated under Class A as of the first day of the month following your return to covered employment. You and your dependents will remain eligible for the remainder of the coverage quarter in which you are reinstated. You will remain eligible for subsequent coverage quarters subject to Rule 2, How Eligibility Is Continued, which begins on page 2. Such automatic reinstatement, without having to satisfy the requirements for initial eligibility, will apply only if you are totally and permanently disabled and you have not retired due to age. Evidence of retirement will be your receipt of retirement benefits from a pension trust fund covering Carpenters or Social Security. (6) If a Surviving Spouse of a Deceased Employee Your surviving spouse may continue eligibility for benefits for herself and your eligible dependents by making selfpayments with the consent of the Trustees. The Class of benefits for which eligibility may be continued is the one under which your surviving spouse was covered at the time of your death or, if covered under Class A, your surviving spouse may choose Class RA, RAO, RAM, RB, RBO, RBM, RC, or RD. Duration of Self-Payments: The right to maintain coverage by making selfpayments under this provision ends on the day: (i) your surviving spouse remarries; or (ii) your surviving spouse and/or dependent children become eligible to participate in any other group health care plan as a result of employment and elect not to participate in such plan; or (iii) your surviving spouse and/or dependent children establish residency outside the United States. Self-Payment Amount: The selfpayment amount is set by the Trustees and may be changed at their discretion. The amount and dates due will 8

14 be specified in the self-payments. initial notice of continue eligibility for yourself and your eligible dependents provided you: For Surviving Spouses Who Work for Wage or Profit: Effective January 1, 2015, surviving spouses who are employed and do not have medical coverage available through their employer will be subject to the following earnings rules. If a surviving spouse works for wage or profit, her eligibility to make subsidized self-payments will cease as of April 1 of any year following a calendar year in which her annual earnings from such employment exceed 710 hours multiplied by the hourly base rate for journeymen carpenters specified in the current collective bargaining agreement requiring contributions to the Fund, rounded to the nearest hundred dollars. Such surviving spouses who continue to work may make non-subsidized selfpayments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time to continue coverage under the Plan. Surviving spouses who continuously make nonsubsidized self-payments under this provision once again will be eligible for a subsidy when they are enrolled in Part A and Part B of Medicare. If a surviving spouse chooses not to make non-subsidized self-payments, her eligibility under the Plan will terminate and she will not be eligible for reinstatement in the Retiree Program. All non-medicare-eligible surviving spouses will be required to complete a form annually certifying the extent of their business and employment-related earnings. Surviving spouses may be asked to furnish information verifying the extent of such earnings, including copies of income tax returns and Form W-2. (7) If a Retiree If eligible for Class A or COBRA benefits at the time of retirement, you may (i) retire because you have reached at least the age of 55 or you are disabled from the kind of work for which employer contributions are payable to this Fund; and (ii) were credited with hours worked (and/or COBRA self-payments made) just prior to retirement (the year in which retirement occurs may be included if it is to your advantage) or prior to becoming a non-bargaining unit employee or alumni as follows: (A) 4,800 hours in five consecutive calendar years; or (B) 5,760 hours in six consecutive calendar years; or (C) 6,720 hours in seven consecutive calendar years; or (D) 7,680 hours in eight consecutive calendar years; or (E) 8,640 hours in nine consecutive calendar years; or (F) 9,600 hours in 10 consecutive calendar years; and (iii) remain a member in good standing of a Local Union participating in this Fund or make non-subsidized selfpayments. Retirees who satisfy the prior requirements may be eligible for a subsidized self-payment based on the work hours credited to the Health Fund over their working career. Please contact the Fund Office to determine your level of subsidy, if any, and the applicable rate. These retiree eligibility requirements may be satisfied, in whole or in part, with coverage as a non-bargaining unit 9

15 employee or alumni. Such retirees may make non-subsidized self-payments under Self-Payment Option 1 at a rate determined by the Trustees from time to time. Duration of Self-Payments: Starting with receipt of the first retirement benefit from the Building Trades United Pension Trust Fund, Milwaukee and Vicinity (BTUPTF), you may continue coverage by making self-payments. You will receive an initial notice of the amount of and due dates for self-payments. A non-bargaining unit employee or alumni not eligible for a retirement benefit from BTUPTF will receive an initial self-payment notice following: written statement from his employer of his retirement date; or proof of the sale of his company, if the employee is an owner. Your first self-payment is due after your bank of hours, if any, is exhausted. Non-bargaining unit employees do not accumulate a bank of hours and therefore may not extend eligibility beyond their date of retirement, except with non-subsidized self-payments. Classes of Benefits (see definitions on pages 60 and 61): (i) When Employee and Dependents Are Eligible for Medicare You may continue eligibility under Class RAM or RBM benefits for yourself and your eligible dependents. (On or before March 20, 2014, you also had the option of electing Class RC.) (ii) When Either the Employee or Dependent Spouse Is Eligible for Medicare and the Other Is Not Eligible for Medicare You may continue eligibility under either Class RAO or RBO. [On or before March 20, 2014, you also had the option of electing Class RD. Class RD provides coverage for you under Class RC and for your dependent child(ren) and spouse under Class RB.] (iii) When Employee and Dependents Are Not Yet Eligible for Medicare You may continue eligibility under Class RA or RB for yourself and your eligible dependents. If you are eligible for Medicare, you must enroll in Part A and Part B of Medicare. Please refer to the Medicare Provisions on pages 47 and 48. Retired employees are not eligible for Loss of Time Benefits. You will have the opportunity to choose under which Class of benefits you want coverage. You may choose a lower Class of benefits at any time, but you will not be permitted to change your election to obtain a higher Class of benefits. Retired employees or their dependents continuing coverage under Class RA, RAO, RAM, RB, RBO, or RBM who become initially entitled to Medicare due to End Stage Renal Disease will not be eligible for Class RC until the expiration of the full 30-month coordination period specified in the Medicare Provisions on pages 47 and 48. If a Medicare-eligible person continuing coverage under Class RAO, RAM, RBO, RBM, RC, or RD enrolls in Medicare Prescription Drug Benefits, he will become ineligible for the Plan s prescription drug benefits upon the effective date of his Medicare Prescription Drug Benefits. (He will have a one-time option to drop Medicare Prescription Drug Benefits and become covered under the Plan s prescription drug benefits again.) If such person does not enroll in Medicare Prescription Drug Benefits, he will continue eligibility for the Plan s prescription drug benefits, 10

16 provided he is otherwise eligible under the Plan. The Amount of Self-Payment Is Set by the Trustees: A retiree who does not maintain Union membership may make non-subsidized self-payments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time, or the retiree may continue coverage under Self-Payment Option 2. When a retired employee fails to make self-payments on the due date and thereby becomes ineligible for benefits, he can be reinstated as provided under Rule 4, Reinstatement of Eligibility for Active Employees, on page 17 or by consent of the Trustees. Retirees Returning to Work: (i) When a Retiree Returns to Covered Employment: For Retirees in Classes RA, RAO, RAM, RB, RBO, and RBM: If a retiree accepts temporary covered employment and contributions for any work month are equal to or in excess of the required monthly selfpayment, the employee will not be required to make any payment for the related coverage month. If the employer contribution for any contribution month is less than the required monthly self-payment, the employee will be required to make payment for the difference between the contributions received and the retiree self-payment rate. For All Classes of Retirees: A retiree will be reinstated to the status of an active employee and become entitled to all Class A benefits on the first day of the month following the month in which he is credited with employer contributions for at least 400 hours of covered employment within two consecutive work quarters. (ii) When a Non-Medicare-Eligible Retiree Returns to Non-Covered Employment: If a retiree works for wage or profit for a non-contributing employer in the construction industry or in an industrial trade he learned through covered employment, his eligibility to make subsidized self-payments will cease as of the last day of the month in which he begins such employment. If, within 60 days of the date his eligibility for a subsidy ends, he submits proof that his noncovered employment is terminated, his eligibility for a subsidy will be reinstated on a one-time basis. If a retiree works for wage or profit at non-covered employment other than the type specified in the prior paragraph, his eligibility to make subsidized self-payments will cease as of April 1 of any year following a calendar year in which his annual earnings from such employment exceed 710 hours multiplied by the hourly base rate for journeymen carpenters specified in the current collective bargaining agreement requiring contributions to the Fund, rounded to the nearest hundred dollars. Retirees who continue to work at non-covered employment may make non-subsidized self-payments under Self-Payment Option 1 at a rate to be determined by the Trustees from time to time to continue coverage under the Plan. Retirees who continuously make non-subsidized self-payments under this provision once again will be eligible for a subsidy when they are enrolled in Part A and Part B of Medicare. If a retiree chooses not to make non-subsidized self-payments, his eligibility under the Plan will terminate and he will not be 11

17 eligible for reinstatement in the Retiree Program unless he once again satisfies the Eligibility Rules described on page 2. All non-medicare-eligible retirees will be required to complete a form annually certifying the extent of their business and employment-related earnings. Retirees may be asked to furnish information verifying the extent of such earnings, including copies of income tax returns and Form W-2. Retiree Waiver/Reinstatement Provisions: If you are eligible to continue Plan benefits as a retiree, you may elect to waive or terminate your eligibility for all Plan benefits if you are eligible for and enrolled in another employer-sponsored group health care plan. You and your spouse, if applicable, will be required to sign a waiver form certifying that you are covered by another group health care plan and submit proof of such coverage. If you subsequently terminate or become ineligible for the other group health care coverage, you will be given a one-time option to be reinstated into the Milwaukee Carpenters District Council Health Fund. To be eligible for such reinstatement, you must submit proof that you and your eligible dependents were continuously covered under another employersponsored group health care plan within 60 days of the date your other coverage terminates. Your coverage will be reinstated on the first day of the month following termination of your other coverage assuming receipt of your proof of other coverage and receipt of your applicable self-payment. There can be no lapse in coverage. Coverage will be reinstated under the retiree Class of benefits for which you were eligible at the time you waived your eligibility or, if you are eligible for a lesser Class of benefits, you may elect a lesser Class of benefits upon your reinstatement. Your self-payment amount will be based on the then current rate for your applicable Class of coverage. Your eligibility for a subsidy, if any, is frozen at the time of your termination. Upon your reinstatement, you will be eligible for the subsidy applicable to your years of service and hours credited prior to your termination based on the rules in effect on the date of your reinstatement. Reinstatement will follow the Health Insurance Portability and Accountability Act (HIPAA) rules governing pre-existing condition limitations. (8) Information in Support of Self-Payments When an active or retired employee returns a self-payment notice or application to the Fund Office, his signature attests that all of the information furnished is correct and complete and that no facts have been omitted with respect to eligibility for making self-payments to, or receiving benefits from, the Fund. Failure to disclose relevant information or stating of misleading facts will be cause for termination and recovery of any benefits paid by this Fund to the employee or his dependents, retroactive to the date of receipt of such self-payment notice or application. Self-payments improperly made to the Fund may, in the Trustees' discretion, be declared forfeited to the Fund and will be used as an offset against any benefits improperly paid. Any improperly paid benefits must be repaid to the Fund. 12

18 (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; the Health Insurance Portability and Accountability Act of 1996; and the American Recovery and Reinvestment Act of Any future regulatory 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 (described as follows), continue eligibility under Self-Payment Option 2 for: health care benefits only; or health care, dental, and vision 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) voluntary or involuntary termination of covered employment for any reason (except gross misconduct on your part), including disability, sickness, or retirement; or (ii) reduction in the amount of covered employment. Such Qualifying Events occur for your eligible spouse and dependent children upon any of the following events occurring while you are eligible because of employer contributions: (i) termination or reduction of your covered employment for any reason (except gross misconduct on your part), including disability, sickness, or retirement; (ii) your death; (iii) divorce or legal separation from you; (iv) a dependent child ceases to meet the definition of dependent; or (v) your entitlement to Medicare (under Part A, Part B, or both). You or your dependent become 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 you during your period of COBRA continuation coverage also will be treated as a Qualified Beneficiary. As a Qualified Beneficiary, you may continue eligibility for certain benefits through self-payments under the following provisions. (2) Notification and Due Dates (i) Qualified Beneficiary's Responsibility to Notify the Trustees of a Qualifying Event When the Qualifying Event relates to your death, divorce or legal separation, or to a dependent child ceasing to meet the definition of dependent under the Plan, the Qualified Beneficiary must notify the Fund Office within 60 days of the event so the Fund Office may provide proper notices and explanations to a Qualified Beneficiary 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 Fund Office is not notified within 60 days of the Qualifying Event, the person is no longer a Qualified Beneficiary and loses the opportunity to continue coverage. 13

19 (ii) The Trustees' Responsibility to Notify a Qualified Beneficiary When the Qualifying Event is Loss of Coverage Due to the Employee's Death, Divorce or Legal Separation, or to a Dependent Child Ceasing to Meet the 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, selfpayment 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, selfpayment due dates, and duration of self-payment privileges. (iv) Due Dates 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 the Election Form provided. 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. A parent or legal guardian may elect to continue coverage on behalf of a minor child. Failure to provide the written 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 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. Claims for reimbursement will not be processed and paid until you have elected COBRA and made your first COBRA self-payment. (vi) Due Date for Subsequent Self- Payments Subsequent monthly self-payments 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 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 14

20 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 selfpayment last was made and will cause loss of all rights to continuation coverage under the Plan. (3) Coverage 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 dental and vision 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 or to enroll dependents who gain eligibility through Medicaid or CHIP. 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 evidence of 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 dental and vision benefits. The costs are determined annually by the Trustees. There is an additional cost for continued coverage from the 19th through the 29th month for those individuals eligible for such disability extension. The cost may be increased up to 150% of the applicable selfpayment. 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. 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 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. 15