Note: A “week” starts on Sunday and ends on Saturday.
(When You First Become Eligible)
Only periods of work for which contributions are made to the Fund count toward your eligibility for benefits. If your employer’s collective bargaining agreement does not require that contributions be made for a certain number of days after you start working, those days will not be counted toward the requirements explained below.
YOUR INITIAL ELIGIBILITY DATE – The date you first become eligible is called your “initial eligibility date.”
If you are a new employee, your initial eligibility date is the first day of the calendar month following two full calendar months of employer contributions.
You must remain employed (not laid off or terminated) by a contributing employer while you are working to establish your initial eligibility. If your employment terminates before the date that would otherwise have been your initial eligibility date, you will not become eligible on that date. If you are later rehired or start working for another contributing employer, you will have to resatisfy the initial eligibility requirements.
EFFECTIVE DATE OF BENEFITS (WHEN BENEFITS START) – Your benefits will start on your initial eligibility date unless your employment terminates before that date as explained above. However, after your benefits start, benefits payable for treatment of a preexisting condition will be limited for a period of time (see “Preexisting Condition Limitation”).
If you have dependents, their benefits will normally start on the date your benefits start. If you don’t have any dependents on the date your benefits start, benefits for any individuals who later become your dependents will start on the date you acquire them as dependents, provided you are eligible on that date.
After a dependent’s benefits start, benefits payable for treatment of a preexisting condition will be limited for a period of time as explained below.
PREEXISTING CONDITION LIMITATION
Your (the employee’s) “enrollment date” is the earliest date for which a contributing employer is obligated to make a contribution to the Plan on your behalf by reason of your employment. If you have dependents on your enrollment date, that same date is also your dependents’ enrollment date. If a person becomes your dependent after your enrollment date, the dependent’s enrollment date is the date the individual becomes your dependent.
A “preexisting condition” is a sickness, injury, disease or other mental or physical condition for which medical advice, diagnosis, care or treatment (including the use of prescription drugs or medicines) was recommended by a physician or received by the covered person (employee or dependent) during the 6-month period immediately prior to the employee’s enrollment date (called the “look-back period”). Genetic information is not considered a condition unless the condition related to such information was treated or diagnosed within the look-back period. If an employee acquires a dependent after his enrollment date, the look-back period for that individual will be the 6-month period immediately before the date the individual becomes a dependent of the employee.
“Creditable coverage” generally means health care coverage provided by a group, individual or public health plan. The affected person is required to demonstrate his prior creditable coverage by presenting a written certification of health coverage as provided to him by the plan providing the coverage, or if he did not receive a certificate, he has a right to demonstrate creditable coverage through the presentation of documentation or other means. Days of creditable coverage that occur before a significant break in coverage will not be used to reduce the length of a person’s preexisting condition limitation period.
A “significant break in coverage” means a period of 63 consecutive days during all of which the person did not have any creditable coverage.
HOW THE PREEXISTING CONDITION LIMITATION WORKS – Benefits payable for charges incurred by a covered person during the first 12 months after the person’s enrollment date for or in connection with treatment of each preexisting condition shall be limited to $500.
This limitation will not apply to pregnancy or to your newborn infant, adopted child under age 18 or a child under age 18 placed with you for the purpose of adoption.
A person’s 12-month limitation period will be reduced by the number of days of creditable coverage the person had as of his enrollment date.
Once you become eligible, you and your dependents will continue to be eligible for benefits as long as a contributing employer makes weekly contributions to the Fund on your behalf. (Also see “Termination of Active Plan Eligibility”.)
In the Event of Layoff or Termination
Plan coverage is provided ONLY when your employer is making contributions to the Fund on your behalf. Employers are not required to make contributions for you while you are laid off – even if the layoff is temporary and the employer still considers you “active.” If you are laid off, or if your employment terminates for any other reason, your only option for maintaining your benefits is to make a timely election and self-payment for COBRA coverage.
ELIGIBILITY DURING DISABILITY
If you become totally disabled due to a non-occupational injury or illness while you are eligible under the Plan, and if a physician chosen by the Fund certifies your total disability, coverage for you and your dependents will be continued for the duration of the disability, for up to a maximum of 52 weeks.
COVERAGE FOR DEPENDENTS OF MILITARY RESERVISTS
CALLED TO ACTIVE DUTY
If you are a member of the military reserve and are called to active duty for 31 days or more, your eligibility will be frozen. During your tour of active duty your medical care will be provided by the military.
Although not required to do so by law, this Plan will continue providing coverage for your dependents while you are on active duty for up to twelve (12) months. No self-payments are required for this coverage. However, if the family member is also enrolled in Tricare (the U.S. military’s health care program), this Plan will be secondary to any Tricare-provided services or benefits, unless the law specifies that this Plan must be primary.
In addition, if you are killed while on active duty, dependent coverage will be continued for an additional 12 months at no cost to your surviving dependents. This extension will terminate if your surviving spouse becomes covered under another group health plan or remarries. After the 12-month extension, your dependents can elect and make self-payments for 36 months of COBRA coverage.
EMPLOYEE CONTRIBUTIONS DURING LEAVE OF ABSENCE
Under some collective bargaining agreements employees may make self-payments to their employer in order to maintain Welfare Fund eligibility during a leave of absence. If you take a leave of absence, you should discuss the matter of Welfare Fund coverage with your employer. The Welfare Fund itself does not determine whether you are entitled to a leave of absence or if you can make self-payments to maintain coverage.
TERMINATION OF ACTIVE PLAN ELIGIBILITY
EMPLOYEES – You will cease to be eligible for benefit coverage under the Plan on the first to occur of the following dates unless you are entitled to COBRA coverage and on-time COBRA self-payment is made by you or on your behalf:
Note: Your employer is required to notify the Fund Office in writing when you are laid off or your employment terminates. Your employer is required to continue making contributions to the Fund on your behalf until the termination notice is issued.
DEPENDENTS – A dependent of yours will cease to be eligible for Plan coverage on the first to occur of the following dates unless the dependent is entitled to COBRA coverage and an on-time COBRA self-payment is made by or on behalf of the dependent:
REINSTATEMENT OF COVERAGE
After Termination of Coverage
AFTER SERVICE IN THE UNIFORMED SERVICES OF THE UNITED STATES – If you leave covered employment with a participating employer to enter active duty in the uniformed services of the United States, your eligibility will be frozen during your period of active duty. After your release from active duty under circumstances entitling you to re-employment under federal law, your eligibility will be reinstated on the date you return to work with a participating employer, provided your return to work is within the time prescribed by federal law. More details about the re-employment rights of persons returning to work from the uniformed services of the United States are available from the Veterans’ Employment and Training Administration of the United States Department of Labor.