|
|
|
ACTIVE
ELIGIBILITY
|
|
Active Eligibility is based
upon hours reported by employers with an agreement with Local #12 requiring
contributions to the Health & Welfare Fund. For most people, eligibility is
on a quarterly basis. If you are reported
for 200 hours or more during a qualifying work quarter, you are eligible for the
following eligibility quarter. The qualifying work quarters and eligibility
quarters are:
|
|
QUALIFYING WORK QUARTER |
LAG MONTH |
ELIGIBILITY QUARTER |
|
JAN,
FEB, MAR |
April
|
MAY,
JUN, JUL
|
|
APR,
MAY, JUN
|
July
|
AUG.
SEP, OCT
|
| JUL,
AUG, SEP |
October |
NOV,
DEC, JAN |
| OCT,
NOV. DEC |
January |
FEB,
MAR, APR
|
|
|
Note
that there is a gap between the work quarter and the eligibility quarter. This
is the lag month when the final reports are processed.
|
|
The
other method of eligibility is monthly eligibility. Some employers have special
agreements which call for monthly eligibility. If you are covered in this way,
you earn one month’s coverage for each month worked, as follows: |
| Work
Month |
Lag
Month |
Eligibility
Month |
| January |
February |
March |
| February |
March |
April |
| March |
April |
May |
|
Note
that, as with quarterly eligibility, there is a gap or lag month.
 |
|
ELIGIBILITY CARD
|
|
Every
eligible participant, Active and Retired, except those enrolled in an HMO,
receives an eligibility card. |
|
Active
Participants |
The
card is issued quarterly at the beginning of the eligibility quarter. The
card will indicate the expiration date of the eligibility including any Reserve
Hour Bank.
If
you do not receive an eligibility care and you have been employed by a signatory
employer, you must advise the Fund Office immediately. |
|
Retired
Participants
|
The card
is issued when coverage under the Retiree program begins and at the beginning of
each calendar year. There is no expiration date on the card because eligibility
is determined on a monthly basis.
|
|
|
RESERVE
ACCOUNT |
|
The
Reserve Account can provide extended eligibility to supplement your hours if you
have not been reported for enough hours to make you eligible.
For the quarterly eligibility system, all hours reported over 400 in a work
quarter go into the reserve. The maximum reserve is 500 hours which can provide
for 6 months or more of eligibility.
For participants on the monthly system, each month of reporting provides a
reserve of 15 hours, with a maximum reserve of 500 hours. 83 hours are withdrawn
from the account for one month’s eligibility so the maximum extension for 500
hours is six months.
|
|
TERMINATION
OF ELIGIBILITY
|
|
1. |
ACTIVE
eligibility will terminate on the last day of an Eligibility Quarter if the
hours worked for Contributing Employers during the most recent complete Work
Quarter, plus the hours in your Reserve Account, do not equal 200 hours.
|
| 2. |
If
you are eligible on a month-to-month basis, your eligibility will end on the
last day of the second month after the month in which you were last reported.
If you have a Reserve Hour Bank, your eligibility will be maintained
until that expires.
For
example, a member whose last month of work is July would be reported to the Fund
during the month of August and eligibility
would be established for September.
|
| 3. |
If you enter full-time active duty with the Armed Forces of the United States,
your eligibility will terminate upon entrance to active duty
if you do not follow the provisions described below:
If
you are called to Active Military Duty, you must notify the Fund Office in
writing within 60 days from the date of the call to duty. The written notice
must include your name, Social Security number and the date you are reporting
for duty. The notice should be sent to the Fund Office.
If
these procedures are followed, you will remain eligible in the Plan as if you
were still working and being reported for 30 hours per week. If you have hours
in your Reserve Hour Bank, those hours will be frozen and will remain frozen for
up to five (5) years, or until you are discharged. Eligibility for your spouse
and eligible dependents will also continue on the Plan until 90 days after the
participant is discharged from duty, up to a maximum of five (5) years.
Upon discharge from duty,
you must contact the Fund Office and submit a copy of the discharge papers. You
will then have 90 days to return to work and regain eligibility. If eligibility
is not regained, your eligibility will terminate until sufficient hours are
worked again.
|
| 4. |
Eligibility
will be terminated and Reserve Hours forfeited for any Active eligible who is in
collusion with his employer to deliberately under-report the hours actually
worked, or required to be reported to the Fund, or who works for a
non-contributing employer in a covered classification. Upon discovery of either of these incidents, the Reserve Hour
Bank will be suspended.
Unless the Active
member works 200 hours or more for which contributions are made or are required
to be made to the Fund within a work quarter in the next four consecutive work
quarters, the Reserve Hours will be forfeited permanently. However, any canceled hours may be reinstated if the Board of Trustees
receives satisfactory proof that the Active Employee was continuously on the
out-of-work list of the Union in each work quarter during which no contributions
were made on his behalf.
|
|
|
DISABILITY
EXTENSIONS |
|
If the eligible Active
member becomes disabled and because of that disability is prevented from
maintaining his eligibility, he may be entitled to disability credit. Based on the information received from the treating
physician, disability credit can extend his full benefits for himself and his
family for 3 to 6 months. His
reserve account is not affected. |
|
EXAMPLES: |
|
1. |
Mr.
Smith has eligibility from February 1 through April 30.
He becomes disabled on March 5. Since he was eligible at the time the
disability occurred, he qualifies for a disability extension.
Since this disability occurred during the Qualifying Work Quarter of January
through March, he would be granted a disability extension for the corresponding
eligibility quarter of May, June and July.
|
|
2. |
Mr.
Brown has eligibility from May 1 through July 3 1. He also became disabled on
March 5. Since he was not eligible at the time his disability occurred, he would
not qualify for the disability extension.
The application forms and complete rules may be obtained from the Fund Office.
GO TO FORMS
|
|
3. |
Mr.
Jones' employer makes contributions on a fixed-rate basis.
Mr. Jones worked in February and March and has eligibility during April
and May. He became disabled on
April 5. Since he was eligible at the time the disability occurred, he qualifies
for a disability extension. He
would be granted a disability extension for June.
|
|
4. |
After
all other disability extensions are exhausted, any eligible person, member or
dependent, who loses eligibility and is totally disabled (unable to perform
normal duties), will remain eligible for benefits based on that disability for
up to but no more than one year. This extension is only for treatment of
the disabling illness. Any expenses for unrelated illness or injury or for
other family members will not be covered. Work-incurred injuries or
illnesses do not qualify for this extension.
|
|
|
DEFINITION
OF TOTAL DISABILITY
|
|
Total
disability in the Health & Welfare Plan means that the eligible individual
is unable, due to disease, injury or pregnancy, to perform the substantial and
material duties of the occupation he or she was engaged in when the disability
occurred and that the disabled individual is not engaged in any gainful
occupation.
|
|
FAMILY
MEDICAL LEAVE ACT (FMLA) |
|
The
Family Medical Leave Act enacted by Congress in 1993 provides that in certain
situations employers are required to grant leave to employees and that in such
situations the employer is required to continue medical coverage for the
employees. The federal legislation specifically provides that more liberal
provisions of state law are permitted and also provides that more liberal
provisions contained within collective bargaining agreements are permitted.
It is not the role of the Trustees or Trust Fund to determine whether or not an
individual employee is entitled to leave with continuing medical care under the
federal statute, and state statute or the provisions of the collective
bargaining agreement. Disputes as to the entitlement to leave with
continuing medical benefits must be resolved by the employer, employee and where
applicable, the local union.
To the extent that participants are entitled to leave with continuing medical
coverage pursuant to the federal act, state legislation or provisions contained
within a collective bargaining agreement, the Trust Fund will provide continuing
medical coverage so long as required monthly contributions are received from the
contributing employer. Rights under this section in no fashion affect
rights under COBRA or rights to continuing medical care pursuant to the
disability extension features contained within the Plan.
|
|
HEALTH INSURANCE
PORTABILITY ACT (HIPAA)
|
Effective
June 1, 1997, when your coverage terminates, you will receive a
"Certificate of Coverage". The Certificate provides information
regarding the period of coverage under this Plan. This information may be
used to reduce or eliminate a pre-existing condition limitation period under a
new group health plan, under which you become covered. You may also
request a copy of the Certificate at any time within 24 months after your
coverage terminates.
If your dependent loses eligibility separately and the Fund Office is notified
that the dependent is no longer an eligible Dependent, a separate Certificate
will be provided for the Dependent; this Certificate may also be requested
within 24 months after the Dependent's coverage has been terminated.
|
|
