A Guide to Your Chicago Regional Council of Carpenters Welfare Fund Retiree Plan of Benefits

Transcription

1 Getting Ready to Retire? A Guide to Your Chicago Regional Council of Carpenters Welfare Fund Retiree Plan of Benefits The Chicago Regional Council of Carpenters Welfare Fund is pleased to be able to offer health care coverage to keep you and your family in good health when you retire. The Fund provides coverage options for retired participants depending on whether or not you are Medicare eligible. If you are not eligible for Medicare: Prescription Drug Benefit and/or Comprehensive Medical Coverage (including preventive care, doctor office visits, hospital care and hearing aids). If you are eligible for Medicare: Prescription Drug Benefit (unless you enroll in prescription drug coverage through Medicare Part D) and/or Comprehensive Medicare Supplement Coverage that pays secondary to Medicare, up to Medicare s allowed amount. If you have any questions about the information and benefits described in this brochure, please contact the Fund Office Retirement Benefits Department at , Menu Option 4. Representatives are available by phone Monday through Friday, 8 a.m. 4:30 p.m. (Central Time). We also encourage you to visit the Fund s website at Here s to your very good health and wellness, now and in the future. The Board of Trustees

2 Eligibility for Retiree Health Care Coverage You may be eligible for Retiree health care benefits if you retire with pension benefits from one of these Pension Funds: Chicago Regional Council of Carpenters Pension Fund Chicago Regional Council of Carpenters Millmen Pension Fund Carpenters Pension Fund of Illinois (as a member of Local Union Numbers 363, 916, or 2087) Carpenters Local 496 Pension Fund Eligibility for these benefits is based on having at least 10 years of vesting credit under the applicable Pension Fund. However, if at some time during your career as a carpenter you did not earn vesting credit for a period of three or more consecutive calendar years, you must have at least 15 years of vesting credit. You can only earn one year of vesting credit per calendar year. Your lawful spouse and your children up to age 26 are eligible for coverage, as described in the Chicago Regional Council of Carpenters Welfare Fund Retiree Summary Plan Description (SPD). Your unmarried stepchild under age 26 may be eligible for coverage, provided he or she meets certain Plan qualifications. The SPD provides detailed information on eligibility for benefits, benefit coverage as well as some restrictions and exclusions. To view the SPD on our website, on the home page under Health Plan, click on Benefit Info-Retiree. You will then see a link to the SPD displayed under the Eligibility & Enrollment tab. Visit the Fund s website at How to Apply for Retiree Health Care Benefits When you request an application for a pension benefit, a Retirement Benefits Department Representative will let you know if you meet the eligibility requirements, will discuss health care coverage options with you and give you enrollment forms if you qualify. Keep in mind that your spouse and dependents are only eligible to receive coverage under the benefits in which you enroll. For example, if you do not elect prescription drug coverage, your dependents may not enroll in prescription drug coverage. You will be required to complete and return the enrollment forms to the Retirement Benefits Department along with any requested supporting documentation (marriage document, children s birth certificates, etc.). You will be asked to submit original documents to verify marriage and dependent statuses. Once your enrollment is processed, the documents will be returned to you via Delivery Confirmation through the US Postal Service.

3 When Retiree Medical and/or Prescription Benefits Begin Your Retiree health care benefits will begin on the first day of the month that your first pension check is issued, except as noted below. Please note: Coverage under the Retiree Plan cannot take effect retroactively, even if your pension has a retroactive start date. Because your group number will change, you will receive your new Retiree medical ID card and/or prescription drug ID card (depending on what options you elect) within the first month coverage takes effect. Cards will be mailed directly from each provider. You will also receive a copy of the SPD within that same time frame from the Fund Office. Special Circumstances for When Benefits Begin In certain situations, Retiree health care benefits will not begin when your initial pension check is issued. Instead, benefits and premium deductions will begin on the first day of the month after your other health care coverage ends when: You are still eligible for coverage under the Active Plan of Benefits, You elect to enroll in continuation coverage under COBRA for the Active Plan of Benefits, You elect to enroll in the Low Cost Medical Plan of Benefits, or As long as you are eligible for Retiree health care coverage at the time of your retirement, you may decide to postpone coverage under this Plan if you have coverage under another health plan, such as coverage through your spouse. However, the other plan does not need to be an employer plan. Paying for Coverage Monthly premiums for the Retiree Plan are deducted from your pension check. If the amount of your pension check is not enough to cover your premiums, the Retirement Benefits Department will make special arrangements for you to pay the difference between the premium and your pension check. 3

4 Changing Enrollment In the Plan 4

5 If you need to enroll a new spouse or dependent child, you must complete and return the required enrollment forms and the required documentation to the Retirement Benefits Department within 90 days of the date of marriage or the date you acquired a new dependent child. Required documents for adding a new dependent are listed in the Retiree SPD. You may postpone coverage for a new spouse or dependent only if he or she is covered under another health plan. If you, your spouse or a dependent child becomes eligible for Medicare, you must send a copy of the covered individual s Medicare card to the Retirement Benefits Department as soon as possible so coverage can be changed and your premiums reduced. If you enroll in the Plan at the time of your retirement, you may cancel it anytime. To cancel coverage, you must complete a cancellation form and return it to the Retirement Benefits Department by the 15th day of the month prior to the month for which you want to cancel coverage. If you want to enroll in the Plan after a cancellation or postponement, you should be aware that coverage must begin immediately following the termination of the other health care plan. You must request an enrollment form, complete the form and return it with all required supporting documents to the Retirement Benefits Department no later than 90 days after coverage with the other plan ends. You will be required to provide proof of continuous creditable coverage from the other plan. If you get divorced or legally separated, you must immediately notify the Retirement Benefits Department. To do so, submit the divorce decree or separation papers in order to terminate your former spouse s coverage, and have your premium amount adjusted. It s important to remove an ineligible dependent from your coverage as soon as possible because you are liable for any benefit expenses the Plan pays on behalf of an ineligible dependent. If your spouse or a covered dependent dies, you should immediately notify the Retirement Benefits Department so that coverage for your spouse can be cancelled and your premium amount can be adjusted. If you return to work in a type of employment that is considered prohibited under your pension plan and results in the suspension of pension benefits, coverage under this Plan ends the first day of the month in which you return to work. Contact the Retirement Benefits Department if you have questions about what type of work you can perform while still receiving your pension. If you die, coverage for your spouse and dependent children ends at the end of the month in which you die. Your spouse and any eligible dependent children can continue coverage under COBRA for a period up to 36 months. Questions? Call the Retirement Benefits Department at , Menu Option 4. Retirement Benefit Representatives are available Monday through Friday, 8 a.m. to 4:30 p.m. (CT). 5

6 Prescription Drug Benefit For Both Non-Medicare Eligible and Medicare-Eligible Retirees and dependents How the Prescription Drug Benefit Works Prescription Drug coverage is available to all Retirees and their dependents except those who are Medicare-eligible and enrolled in Medicare Part D coverage. Important Note: If you are eligible for Medicare and want coverage under the Plan s Prescription Drug Benefit, you should not enroll in Medicare Part D (prescription drug) coverage. If you enroll in Medicare Part D, your coverage under the Plan s Prescription Drug Benefit will be discontinued for both you and your covered dependents. To reduce your prescription costs, use an ESI network pharmacy or the ESI Home Delivery program, and use generic medications whenever possible. Here are some key features of the Plan: The Prescription Drug Benefit is managed by Express Scripts Inc. or ESI. If you use an ESI Participating Retail Pharmacy, you pay only a portion of the cost of the medication. If you use a non-participating retail pharmacy, you pay the full cost of the covered medication and submit a claim for reimbursement to ESI. Reimbursement is partial and based on the amount ESI would pay a participating network pharmacy for the same medication. Prescriptions for long-term medications must be filled through the ESI Home Delivery program. For example, if you take medication for high blood pressure, chances are you ve been taking it for a while. This would be considered a long-term medication. You may only fill that specific long-term medication three times at a retail pharmacy. After that, the long-term medication will only be covered if you use the Home Delivery program. Preferred Drug Step Therapy Program: The Plan also provides for a Preferred Drug Step Therapy program that identifies generic or brandname medications in certain drug classes and recommends FDA-approved lower cost generic options to the brand-name medication. If your doctor prescribes a non-preferred brand-name, you will need to switch to a generic or preferred brand-name for the Plan to cover the medication. In certain cases, if your doctor believes you cannot switch medications, he can request a coverage review by Express Scripts. 6

7 The Plan encourages you to use generic medications. If no generic is available for the medication you are prescribed, it is considered a single source. Once an individual s co-payments for single-source medications total $1,500 in a calendar year, that individual s prescription costs for all single-source medications will be covered by the Plan at 100% for the rest of that calendar year. (There is a separate outof-pocket maximum for specialty medication co-payments.) You will pay more if you elect to receive a brand-name medication when there is a generic available. Also, the out-of-pocket maximum does not apply on multisource brand name medications. A medication is considered to be multisource when it is available in both brand-name and generic formulas. Specialty medications used to treat complex, chronic or rare medical conditions are administered by Diplomat Specialty Pharmacy. There is a partial fill program for specialty medications. For certain high-cost specialty medications, the very first fill of a prescription may be for a 15-day supply to see if you are able to tolerate it. This helps protect you and the Fund from spending more than necessary if you are unable to continue using it. If your medication is subject to the partial fill program, you will pay half of the regular 30-day co-payment amount for a 15-day supply. The chart below highlights how the Prescription Drug Benefit works. Refer to your Retiree SPD for details on how the Plan covers specific medications, and any limitations on covered services. ESI Network Retail Pharmacy (Lesser of 100 pills or a 30-day supply) ESI by Mail (Up to a 90-day supply through Home Delivery) Diplomat Specialty Pharmacy (For specialty medications) Generic Co-payment $5 $12.50 n/a Single-source Brand Co-payment (A generic is not available) 20% $10 minimum Co-pay per medication with a $100 maximum 20% $25 minimum Co-pay per medication with a $250 maximum $1,500 per Individual Annual Out-of-Pocket Maximum* n/a n/a Multi-source Brand Co-payment (A generic is available, but you elect brand-name for any reason) 35% $20 minimum 35% $50 minimum n/a Specialty Medication Co-payment (Used to treat complex conditions such as cancer, hemophilia, immune deficiency, rheumatoid arthritis, etc.) n/a 20% $20 minimum Co-pay per medication with a $100 maximum $1,500 per Individual Annual Out-of-Pocket Maximum* * Out-of-Pocket Maximums for Single-source Brand co-payments and Specialty Medication co-payments are separate and cannot be combined. 7

8 Health Care Benefits If You or your dependents Are Not Yet Eligible for Medicare The Plan offers Comprehensive Major Medical coverage through BlueCross BlueShield of Illinois (BCBSIL) for Retirees and their dependents who are under age 65 and not eligible for Medicare. Coverage for Retirees is very similar to coverage provided for active participants and includes benefits for preventive care as well as illness or accidental injury, including hospital care. You are eligible for this Plan if you are under age 65 and not eligible for Medicare. How the Comprehensive Medical Benefit Plan Works Here are some key features of the Plan. For details, please refer to the Retiree SPD. The Plan contracts with BCBSIL to offer a Preferred Provider Organization (PPO). The PPO is the same one that is offered to active participants, so you can keep your same network doctors and other providers as a Retiree. You must pre-certify all scheduled hospital admissions by calling BlueCross Medical Services Advisory at For an emergency admission, you or a family member must call within 2 business days of the emergency admission. An annual comprehensive physical exam and health evaluation is offered through Health Dynamics at no charge for you and your enrolled spouse. To locate a Health Dynamics provider, go online at (username: hdhelpsu and password: hdhelpsu), or call Monday through Friday from 8 a.m. to 5 p.m. (CT). The Plan covers hearing aids, or their repair, up to a maximum of $1,500 once every five consecutive years and coverage for the device is not subject to the deductible. Discounts are offered through EPIC Hearing Services. Contact EPIC by calling Important The annual deductible and out-of-pocket maximum for the Active Plan do not carry over to the Retiree Plan. Any portion of the deductible met under the Retiree Plan in the last three months of 8 a calendar year will be applied to your deductible for the following calendar year.

9 The chart below summarizes Plan benefits for in-network and out-of-network care. Refer to the Retiree SPD for details on how the Plan covers specific services, and any limitations on covered services. In-Network PPO Provider Out-of-Network Non-PPO Provider Deductible per calendar year $300 per Individual $600 per Individual Coinsurance Plan pays 80% Participant pays 20% Plan pays 60%* Participant pays 40% Out-of-Pocket Maximum** per calendar year $2,000 per Individual $6,000 per Individual Emergency Room (ER) Co-payment Penalty for failure to Pre-certify an inpatient hospital admission $250, waived if admitted to the hospital within 72 hours for treatment of same condition (Co-payment does not apply to Out-of-Pocket Maximum) $500 per admission * Out-of-network expenses are subject to Reasonable and Customary Allowances (R&C). ** PPO and Non-PPO Deductibles and Out-of-Pocket Maximums are separate and cannot be combined. PPO vs. Non-PPO: Knowing the Difference Saves You Money PPO providers are health care providers such as doctors (or hospitals) who are under contract to provide services at a discounted rate. When you or a covered family member need medical care, be sure to use an in-network PPO provider. Doing so saves you money in two ways: 1. The overall cost of the services is lower, as a result of negotiated discounts, and 2. The Plan typically pays a higher percentage of the covered expenses. If your PPO network physician refers you to a specialist, hospital, facility or surgical center, be sure to find out in advance if they are also in-network by using the BlueCross PPO Hospital & Physician finder at or by calling You should then call the provider s office to confirm they are in-network. Also, if you will encounter more than one provider during a procedure (for example, a surgeon and an anesthesiologist) find out in advance if all the providers participate in the BCBS PPO network to avoid any surprise out-of-network charges. By using providers in the PPO network, you can maximize your medical benefits and save money for yourself and the Fund. 9

10 Health Care Benefits if You or your dependents Are Eligible for Medicare What Happens When You Become Eligible for Medicare About three months before turning age 65, you should contact Medicare about enrolling. It s important to enroll in Medicare when you (or your spouse) first become eligible at age 65 because the Plan will automatically move you to the Medicare Supplement Benefit coverage at that time. If you, your spouse or dependent child becomes eligible for Medicare due to disability, you must send a copy of your Medicare ID card to the Retirement Benefits Department as soon as you receive it. This change in coverage is not automatic, but will be retroactive to the date Medicare became effective. Once you send a copy of your Medicare ID card, the Fund will change your coverage to the Medicare Supplement plan. If you become eligible for Medicare, but your enrolled spouse and dependents are not (or vice versa), they may continue to participate in the non-medicare plan as long as they are not Medicare eligible and they continue to meet all other eligibility requirements. If you are eligible for Medicare when you retire (you are age 65 or disabled and have received Social Security disability benefits for at least 24 months), you may be eligible for Comprehensive Medicare Supplement Benefits. When you turn age 65, Medicare becomes your primary insurer and the Retiree Plan will become secondary. This means that medical claims must be submitted to Medicare first. The Retiree Plan is designed to supplement Medicare, however, it does not pay for services or equipment that Medicare does not cover. Features of this Plan You must enroll in Medicare Parts A and B when you become eligible. This Plan will pay benefits secondary to Medicare so you must be enrolled in Medicare to get maximum coverage. The Plan does not pay benefits for services that are NOT covered by Medicare. The Plan covers hearing aids, or their repair, up to a maximum of $1,500 once every five consecutive years. Discounts are offered through EPIC Hearing Services. Have Questions about Medicare? Visit for information on Medicare eligibility, benefits and how to enroll. You can also download the most recent copy of the Medicare & You handbook for more details. 10

11 How the Plan Works with Medicare The chart below summarizes coverage for covered individuals who are Medicare-Eligible. BENEFITS FOR COVERED INDIVIDUALS THAT ARE MEDICARE-ELIGIBLE AND ARE ENROLLED IN COMPREHENSIVE MEDICARE SUPPLEMENT BENEFITS Contracted Network Provider: BlueCross BlueShield of Illinois (BCBSIL) Medicare Part A Supplement (Hospital Benefit) First 60 days 61st through 90th days 91st day and after While Using 60 Lifetime Reserve Days Additional 365 Days Medicare Part B Supplement Medicare Part B Deductible Medical Expenses Blood First Three Pints Skilled Nursing Facility Care Plan Pays Medicare Part A Deductible Plan Pays Medicare Part A Co-Payment Plan Pays Medicare Part A Co-Payment Plan Pays 100% of Medicare-Eligible Expenses Not Covered by Plan Plan pays 20% of Medicare-Eligible Expenses at the Medicare Approved Amount, after the Medicare Part B Deductible Plan Pays for Three Pints Covered Individual must meet Medicare s requirements, including having been in a Hospital for at least 3 days and enter a Medicare approved facility within 30 days of leaving the hospital First 20 days 21st through 100th day At-Home Recovery Services Medicare Pays All Approved Amounts Plan Pays Medicare Part A Co-payment Home care certified by a Covered Individual s doctor, for care during recovery from an injury or sickness for which Medicare-approved a home treatment plan. Benefit for Each Visit Foreign Travel Calendar Year Deductible Plan pays up to $40 per visit. $250 per Individual Plan Pays 80%. The Plan does not pay for expenses in excess of the Reasonable and Customary Allowance for non-ppo out-ofnetwork providers. Amounts over the Reasonable and Customary allowance are the Covered Individual s responsibility Lifetime Maximum Benefit $50,000 11

12 Contact Information If You Have a Question or Need Information About Eligibility, premiums, or adding or dropping dependents Claims status (hospital, medical, mental health and substance use disorder claims) Finding Physician, hospital or Surgi-Center in the BCBS PPO network Pre-certifying all hospital admissions (elective, Emergency, maternity, etc.) other than for mental health or substance use disorder issues Mental health and substance use disorder Prescription drugs and mail order program Specialty pharmacy Comprehensive Health Evaluation and Physical Exam Hearing Aid Instruments COBRA options and eligibility COBRA premium payments Medicare For the Retiree Plan of Benefits Call Fund Office Retirement Benefits Department BlueCross BlueShield of Illinois BlueCross PPO Hospital & Physician Finder BlueCross Medical Services Advisory (MSA) BlueCross BlueShield of Illinois Express Scripts Inc. (ESI) Diplomat Specialty Pharmacy Health Dynamics EPIC Hearing Service Plan Fund Office Retirement Benefits Department Health Care Service Corporation Medicare Phone Number/Website Menu Option The MSA is available 7:30 a.m. to 5:30 p.m. (CT) Monday Friday Representatives are available 8:00 a.m. to 6:00 p.m. (CT) Monday Friday username and password: hdhelpsu Menu Option MEDICARE ( ) This brochure was produced in 2014 and highlights key features of the Plan Document. This brochure provides only highlights of certain features of the Chicago Regional Council of Carpenters Welfare Fund Retiree Plan of Benefits. Full details are contained in the documents that establish the Plan provisions. If there is a discrepancy between the wording here and the documents that establish the Plan, the Plan Document language will govern. The Trustees reserve the right to amend, modify, or terminate the Plans at any time. Chicago Regional Council of Carpenters Welfare Fund 12 East Erie Street Chicago, Illinois