THE LAKE COUNTY, INDIANA NECA - IBEW HEALTH AND BENEFIT PLAN

Transcription

1 THE LAKE COUNTY, INDIANA NECA - IBEW HEALTH AND BENEFIT PLAN Local Union No. 697, I.B.E.W. Revised January 1, 2008 IMPORTANT This 2008 Summary Plan Description (SPD) is being made available electronically for the convenience of Plan participants. The address and telephone number of Local 697 and the Fund Office, and the names and addresses of the Trustees, have been updated in this electronic document, and are current as of May No other changes have been made. Plan changes since January 2008 are described in Summaries of Material Modifications (SMMs) which are also available on this website (and which were previously distributed in paper form to all eligible participants). You may not rely on this electronic version of the SPD for benefits, eligibility or general Plan information. The paper copies of the SPD along with the SMMs that amend the SPD take precedence over the electronic documents. The actual paper copy of the SPD and the paper copies of the SMMs may be obtained by contacting the Fund Office.

2 IMPORTANT CONTACT INFORMATION FUND OFFICE/BOARD OF TRUSTEES Lake County, Indiana NECA IBEW Health and Benefit Plan 7200 Mississippi Street, Suite 300 Merrillville, IN (219) or (219) (219) (FAX) D The Fund Office handles eligibility and self-payments. D Contact the Fund Office if you or a dependent moves, if your family/dependent status changes, if anyone in your family acquires other coverage, or if you retire or enter active military service. CLAIMS ADMINISTRATOR Stewart C. Miller, Inc W. Lincoln Highway Merrillville, IN (219) (800) (219) (FAX) Office hours: M-F, 8-4:30, closed 12-12:30 D The Claims Administrator processes medical, dental, disability and MRP account claims. PPO NETWORK (PNA) (888) PRE-CERTIFICATION (HINES) PRESCRIPTION DRUG PROGRAM (SAV-RX) Sav-Rx 224 North Park Avenue Fremont, NE VISION PROGRAM (VSP) D If you use a PNA PPO preferred provider, covered services will be paid at the higher in-network benefit level. Additionally, the preferred provider will file claims for you. D If you live outside Indiana, Illinois, Iowa or Wisconsin, your PPO network is Evolutions Healthcare Systems. For provider information call (888) or go to (800) for pre-certification D Pre-certification is required for all surgery, inpatient hospitalizations, durable medical equipment costing $250 or more, MRIs, and CT or PET scans. You must also pre-certify home health care and hospice care. D Hospitals, doctors and outpatient facilities will usually make the call for you but you have the responsibility of making sure the call is made. (866) 233-IBEW (4239) (888) (FAX) D Send out-of-network drug claims to Sav-Rx. D Call the Fund Office if you need a prescription drug card or have questions about this program. Vision Service Plan P.O. Box Sacramento, CA (800) D Send all vision claims to VSP. You do not need to file claims when you use VSP doctors.

3 INTRODUCTION Lake County, Indiana NECA IBEW Health and Benefit Plan To All Plan Participants: The Trustees of your Benefit Plan are pleased to provide you with this new, updated Summary Plan Description booklet. It includes the many revisions that have been made in your Plan since the prior booklet was printed including the MAJOR CHANGES that became effective January 1, Be sure to read this booklet carefully (have your spouse read it, too) and keep it with your other important papers for future reference. Sincerely, Board of Trustees Union Trustees Patrick Bailey Raymond Kasmark Dennis Showers Employer Trustees Thomas Corsiglia Edward Shikany William Walton TRUSTEE AUTHORITY Also see Trustee Interpretation, Authority and Right on page 88. Only the full Board of Trustees is authorized to interpret the Plan described in this book. Its interpretation will be final and binding on all persons dealing with the Plan or claiming a benefit from the Plan. If a decision of the Trustees is challenged in court, it is the intention of the parties that such decision is to be upheld unless it is determined to be arbitrary or capricious. No agent, representative, officer or other person from the union or an employer has the authority to speak for the Trustees or to act contrary to the written terms of the governing Plan documents. If you have questions about eligibility or claims, only the Fund Office is authorized to answer the questions for the Trustees. Matters that are not clear, or which need interpreting, will be referred to the Trustees. PRONOUNS USED IN THIS BOOKLET Wherever the term you or your is used, it means an eligible employee or, where applicable, an eligible retiree. To avoid awkward wording, male personal pronouns are used in this book to refer to employees and retirees. Feminine pronouns are used when referring to spouses. Whenever a personal pronoun is used in the masculine gender, it shall be deemed to include the feminine also, unless the context clearly indicates the contrary. Similarly, feminine pronouns will include the masculine. Words in the singular form shall be deemed to include the plural form and vice versa. INTRODUCTION 1

4 TABLE OF CONTENTS Lake County, Indiana NECA IBEW Health and Benefit Plan This booklet also contains an alphabetical index. INTRODUCTION... 1 Trustee Authority... 1 Pronouns Used in This Booklet... 1 SPECIAL PLAN FEATURES... 4 Your Hospital and Doctor PPO Network... 4 Utilization Review... 5 Pre-Certification Requirement...5 How to Pre-Certify...6 In an Emergency... 6 SCHEDULE OF BENEFITS... 7 EXPLANATION OF CLASSES ELIGIBILITY FOR ACTIVE EMPLOYEES (CLASS 1) Definitions Applicable to Eligibility Initial Eligibility Continuing Eligibility...16 Dependent Eligibility...19 Special Circumstances Temporary Employees (Reciprocity) Family Medical Leave Act (FMLA)...20 Military Leave In the Event of Your Death Termination of Eligibility Reinstatement of Eligibility COBRA Coverage ELIGIBILITY FOR RETIREES Class 2 Retiree Benefits Class 3 Retiree Benefits Retirees and Medicare Part D Prescription Drug Coverage LIFE INSURANCE AD&D INSURANCE LOSS OF TIME BENEFIT COMPREHENSIVE MAJOR MEDICAL BENEFIT Calendar Year Deductibles $100 Utilization Review Noncompliance Deductible Plan Payment Percentages Out-of-Pocket Limits Maximum Benefits Covered Medical Expenses...42 Prescription Drug Program Individual Case Management Comprehensive Benefit Exclusions and Limitations DENTAL EXPENSE BENEFIT TABLE OF CONTENTS

5 VISION EXPENSE BENEFIT MRP ACCOUNTS How Amounts Are Credited to Your MRP Account General Rules Governing MRP Accounts MRP Covered Expenses How to File an MRP Claim...56 Non-Covered Expenses Important Notes About the MRP Program GENERAL EXCLUSIONS AND LIMITATIONS OTHER LIMITATIONS ON YOUR BENEFITS...65 Pre-Existing Condition Exclusion Health and Benefit Fund s Right to Restitution ( Subrogation ) Coordination of Benefits (C.O.B.) Excess Coverage Limitation CLAIMS How to File a Claim Additional Claim Filing Procedures Claim Processing Time Periods Claim Appeal Procedure GENERAL PLAN PROVISIONS AND INFORMATION Definitions Trustee Interpretation, Authority and Right Plan Discontinuation or Termination Circumstances Which May Result in Claim Denials or Loss of Benefits Your Rights Under ERISA Additional Plan Provisions General Information About the Plan BOARD OF TRUSTEES TABLE OF CONTENTS 3

6 SPECIAL PLAN FEATURES YOUR HOSPITAL AND DOCTOR PPO NETWORK You Save Money You and your family are encouraged to use providers (hospitals and doctors) that participate in the Plan s preferred provider organization (PPO) Preferred Network Access (PNA). PNA PPO providers will provide medical services to you and your covered dependents at reduced rates. Because PPO providers discount their fees, the Fund is able to share its savings with you in the form of a higher reimbursement level for most covered services billed by PPO providers. The Plan limits the amount it allows for non-ppo providers as follows: Outpatient Facilities - The maximum allowable for an outpatient facility visit is 130% of RBRVS, the fee schedule used by Medicare. You will be responsible for amounts in excess of this amount. SINCE SOME NON- PPO OUTPATIENT FACILITIES CHARGE EXCESSIVE AMOUNTS, this could be a substantial amount. You could be responsible for SUBSTANTIAL OUT-OF-POCKET COSTS if you don t use PPO providers. EXAMPLE - OUTPATIENT HOSPITAL BILL PPO hospital Non-PPO hospital Total amount billed $5,000 $10,000 Allowable Amount $5,000 $5,000 Deductible $200 $200 Your co-pay percentage 10% 30% YOU PAY $680 $6,640 Professional (physicians, surgeons, etc.) fees are limited to ALLOWABLE CHARGES (reasonable and customary) as determined by the Plan. Non- PPO professionals can bill you for the amounts in excess of R&C. PPO providers charge less than R&C, so you will never be responsible for non-r&c amounts. EXAMPLE - SURGEON S BILL PPO Non-PPO Total amount billed $6,000 $7,000 Allowable Amount $6,000 R&C = $6,000 Your co-pay percentage 10% 30% YOU PAY $600 $2,800 I.D. Cards You should already have received two medical I.D. cards. You should present one of your I.D. cards whenever you or a family member receive medical care (inpatient, outpatient or office). The I.D. card identifies you as a PPO participant so that the proper discounts can be applied to the bill. It also tells the providers how to submit their bills. 4 SPECIAL PLAN FEATURES - Your Hospital and Doctor PPO Network

7 How to Find PPO Providers Information about PPO hospitals and doctors is provided to participants as a separate document. If you need more current information, or need a list of PPO providers near you, you can contact PNA at (888) or go to on the internet. If You Live Outside Indiana, Illinois, Iowa or Wisconsin The PPO network for persons who do not reside in Indiana, Illinois, Iowa or Wisconsin is Evolutions Healthcare Systems. For provider information call (888) or go to UTILIZATION REVIEW The pre-certification requirements apply to Class 1 and Class 2 participants only. Pre-Certification Requirement P THE PRE-CERTIFICATION REQUIREMENTS DESCRIBED IN THIS SECTION DO NOT APPLY TO CLASS 3 PARTICIPANTS (MEDICARE RETIREES). The utilization review requirement does apply to Class 1 and Class 2 employees, retirees and dependents. It is required for services provided by PPO or non-ppo providers. You are responsible for calling the Plan s review organization for pre-certification BEFORE you or one of your dependents: Are hospitalized as an inpatient, Undergoes an outpatient surgical procedure at a hospital, surgical center or clinic, or Has a CT or PET scan, or an MRI. (Also see Other Treatments Requiring Pre-Certification on the next page.) Exceptions: Utilization review is NOT required for most minor surgical procedures performed in a doctor s office. Some examples are shown in the following box. Pre-certification is NOT required for the following surgical procedures when they are performed at the doctor s office: Minor surgery requiring no anesthesia other than a local anesthetic Venipuncture Installation or removal of IV lines & catheters Uncomplicated suturing or suture removal Cystoscopy in doctor s office In-office skin biopsies, benign lesion and wart removals Newborn circumcision Culposcopy Sigmoidoscopy SPECIAL PLAN FEATURES - Utilization Review 5

8 A $100 noncompliance deductible applies if you do not obtain pre-certification. If you fail to have one of the above services pre-certified, but the expenses are otherwise covered by the Plan, you will have to pay an additional $100 for that claim (called a noncompliance deductible ). Noncompliance deductibles apply each time you fail to pre-certify, and are in addition to the Plan s calendar year deductibles. How to Pre-Certify In an Emergency Noncompliance deductibles do not apply to Class 3 participants (Medicare retirees). Call the toll-free telephone number listed on your medical I.D. card (and the inside front cover of this booklet) when a doctor recommends that you or a dependent undergo surgery or an inpatient hospitalization, or obtain an MRI or CT or PET scan. The call should be made before the proposed service is rendered. Hospitals, doctors and outpatient facilities will usually make the call for you but you have the responsibility of making sure the call is made. The review organization will review the proposed hospitalization, surgery or scan and certify its medical necessity. As before, the Plan will not cover any service that is not medically necessary. In case of an emergency hospital admission or surgery, you should seek the necessary treatment and call within 48 hours. Other Treatments Requiring Pre-Certification Physical Therapy Pre-certification is required for physical therapy and occupational therapy visits in excess of 17 visits during a course of treatment. The 18th physical/ occupational therapy visit, plus any subsequent treatments, will not be covered unless the unless the additional therapy has been pre-certified by the review organization. Durable Medical Equipment (Rental or Purchase) Pre-certification is required for durable medical equipment that is expected to cost $250 or more. No benefits are payable for equipment that has not been reviewed and determined to be medically necessary. Home Health Care, Chemotherapy, Radiation Therapy and Other Special Services The Plan may also require that the review organization review other types of recommended treatment to assure that the treatment is medically necessary For example, pre-certification of medical necessity is required for home health care, chemotherapy and radiation therapy. 6 SPECIAL PLAN FEATURES - Utilization Review

9 SCHEDULE OF BENEFITS The following benefit schedule was adopted effective January 1, The same benefits were still in effect as of January 1, Brief Explanation of Classes Class 1 = Active employees Class 2 = Retirees under 65 Class 2S = Surviving dependents Class 3 = Retirees 65 & older See Explanation of Classes starting on page 12 for more information. INSURANCE BENEFITS (Class 1 Employees and Class 2 Retirees Only) Life insurance amount...$15,000 Accidental death & dismemberment insurance - full amount...$15,000 (Life Insurance and AD&D benefit amounts are reduced for employees age 70 and older.) LOSS OF TIME BENEFIT (Class 1 Employees Only) Weekly benefit amount...50% of weekly salary (excluding OT) up to $400 Maximum benefit period per disability...26 weeks Benefits start on the following day of disability: Accident - 1st day Sickness - 8th day Supplementary Disability Benefits Maximum benefit period...26 weeks (See page 38 for information about Supplementary Disability Benefits.) SCHEDULE OF BENEFITS 7

10 COMPREHENSIVE MAJOR MEDICAL BENEFIT ( COMPREHENSIVE BENEFIT ) (All Classes Unless Otherwise Noted) All benefits and benefit provisions are per person unless otherwise stated. Benefits apply to covered medical expenses only, and only covered expenses apply toward deductibles and out-of-pocket limits. Deductibles Utilization review noncompliance deductible...$100 (Applies to all inpatient hospitalizations, outpatient surgeries, MRIs, CT scans and PET scans when the Plan s utilization review (pre-certification) procedures are not followed.) Calendar year deductible (does not apply to Class 3): Per person... $200 Per family (2 or more family members)... $400 Maximum Benefits Payable per Person Payment Percentages Class 1, Class 2 and Class 2S, per lifetime...$1,000,000 Class 3, per calendar year...$40,000 (Also see the Special Benefits and Limitations section.) Plan payment percentages per calendar year for covered medical expenses, until the applicable out-of-pocket limit is reached (see Special Benefits and Limitations for some exceptions): The percentage not paid by the Plan is your copayment. PPO expenses...90% Emergency treatment (as defined on page 84) by non-ppo providers...90% Charges by non-ppo pathologists, anesthesiologists, radiologists and emergency room physicians for treatment at PPO facilities or offices...90% The Plan also limits the amount it allows for non- PPO providers. See You Save Money on page 4 and Special Benefits and Limitations starting on page 9 for more information. Charges by non-ppo pathologists, anesthesiologists, radiologists and emergency room physicians for treatment at non- PPO facilities or offices...70% All other non-ppo expenses...70% 8 SCHEDULE OF BENEFITS

11 Out-of-Pocket Limits (If your co-payment percentages reach the out-of-pocket limit amount, the Plan pays 100% of your remaining covered expenses that year, subject to the maximum benefit limitations and other exceptions explained on pages ) Per person: PPO expenses and prescription drugs... $2,500 ($2,700 with deductible) Non-PPO expenses... $5,000 ($5,200 with deductible) Per family (2 or more family members): PPO expenses and prescription drugs... $5,000 ($5,400 with deductibles) Non-PPO expenses... $10,000 ($10,400 with deductibles) (Expenses that apply to the PPO limit also apply to the non- PPO limit and vice versa.) Special Benefits and Limitations Annual deductible applies unless specifically stated otherwise Use PPO facilities to avoid high out-of-pocket amounts. Unless an exception is specifically stated, the maximums, deductibles, payment percentages and out-of-pocket limits shown above apply to charges subject to these special benefit limitations. Non-PPO outpatient facility charges - allowable expenses for facility fees (pre-certification required) % of RBRVS 1 Wellness benefit maximum per calendar year for covered wellness services provided by PPO providers (see page 43), no deductible applies...$500 Physical therapy and occupational therapy First 17 visits during a course of treatment... normal benefits Visits 18 and after... pre-certification required or no benefits payable Chiropractic care Plan payment percentage...90% Maximum payable per visit... $40 Maximum benefit per calendar year... $1,500 1 RBRVS = Resource Based Relative Value Scale, the fee schedule used by Medicare. You will be responsible for amounts in excess of this amount. See You Save Money starting on page 4 for more information. SCHEDULE OF BENEFITS 9

12 Manipulative therapy (by a doctor who is not a chiropractor) Maximum payable per visit... $40 Mental health (mental and nervous disorders) 1 Inpatient (pre-certification required): Maximum allowable days per calendar year...90 days Plan payment percentages (per calendar year): PPO expenses...90% of 1st $20,000; 50% thereafter The Plan excludes charges for alcohol abuse, alcoholism, drug abuse and drug addiction. Non-PPO expenses...70% of 1st $20,000; 50% thereafter Outpatient: Maximum allowable visits per calendar year...50 visits Maximum payable per visit... $40 Transplant donor benefit Maximum benefit (see Donor Benefits on page 45)... $10,000 Wheelchair Maximum benefit payable for rental an/or purchase of wheelchair or scooter (pre-certification required)... $500 Prescription Drug Program (Through Sav-Rx) Retail (30-day supply): Your Co-Pay Generic... 20%, $10 minimum Formulary brand... 20%, $20 minimum Non-formulary brand... 20%, $35 minimum Mail-Order (90-day supply): Generic... 20%, $10 minimum Formulary brand... 20%, $20 minimum Non-formulary brand... 20%, $35 minimum Out-of-network pharmacy expenses...20% of negotiated price subject to the minimums shown above Submit out-of-network pharmacy claims to Sav-Rx. The allowable amount for these claims will be limited to the negotiated price an in-network pharmacy could charge. 1 Participant co-payment percentages do not apply to the out-of-pocket limits and will not be paid at 100%. 10 SCHEDULE OF BENEFITS

13 DENTAL EXPENSE BENEFIT (Class 1 Only) Maximum benefit per calendar year PER FAMILY...$2,000 All dental benefits will be made payable to the eligible employee. Benefit assignments to the dentist will not be honored. Annual deductible...none Plan payment percentage... 75% Orthodontia maximum per lifetime...$2,000 (Benefits paid for orthodontia apply to the family s $2,000 annual Dental Expense Benefit maximum, as well as to the person s $2,000 lifetime orthodontia maximum.) VISION EXPENSE BENEFIT (Class 1 Only) Vision Care Benefits are provided through VSP (Vision Service Plan). The VSP Doctor column shows that you can receive an exam and eyewear at no cost to you when you use a VSP doctor. However, if you select eyewear that costs more than the amount allowed by VSP, you will pay an additional (discounted) charge directly to the VSP doctor. The Out-of-Network Allowance column shows the maximum amount that you can be reimbursed by VSP if you use an out-of-network provider. VSP Doctor Out-of-Network Allowance Exam, every 12 months provided in full after $5 co-pay $35 Frame, every 24 months provided in full after $10 materials co-pay* $45 Lenses (per pair, every 12 months): Single vision provided in full after $10 materials co-pay* $25 Lined bifocal provided in full after $10 materials co-pay* $40 Lined trifocal provided in full after $10 materials co-pay* $55 Lenticular provided in full after $10 materials co-pay* $80 Contacts: Elective (in lieu of eyeglasses) Covered up to $105 allowance after $10 materials co-pay $105 Visually necessary Covered up to $210 allowance after $10 materials co-pay $210 Safety glasses (employee only) Provided in full every 12 months when received in combination with an eye exam and eyeglasses or contacts no benefit * One $10 materials co-pay applies to frame and lenses combined. SCHEDULE OF BENEFITS 11

14 EXPLANATION OF CLASSES Under the terms of the Agreement and Declaration of Trust established between the Northern Indiana Chapter, National Electrical Contractors Association, hereinafter called the Association, and Local No. 697, International Brotherhood of Electrical Workers, hereinafter called the Union, the following classes of persons are eligible for coverage under this Plan subject to any specific requirements which may be imposed upon such coverage or the continuation of coverage. CLASS 1 CLASS 2 Class 1 employees are the following: 1. All employees of a contributing employer (as defined on page 84) who are covered by a collective bargaining agreement between the Union and such employer; 2. Employees of the Association; 3. Employees of the Union; 4. Employees of the instant Benefit Plan and Benefit Trust; 5. An individual who is employed by a labor organization, or an organization beneficial to labor or the industry with which the Union is affiliated; 6. Employees of the Local Union No. 697, IBEW Credit Union; 7. Employees of any other trust or fund created by agreement between the Association and the Union; 8. Employees of the Electrical Administrative Fund; 9. Persons accepted and registered as apprentices during training conducted by the Electrical Training Center sponsored by the Lake County Electricians Joint Apprenticeship and Training Committee; 10. Persons who qualify as temporary employees as that term is defined on page 15; and 11. Employees of any contributing employer not the subject of a collective bargaining agreement while such employees are working within the territorial jurisdiction of the Union, but only at the option of such employer and the Trustees. A person is eligible for Class 2 if he is under age 65, and has been covered under this Plan for at least 40 calendar quarters within the 180 months immediately prior to: 1. Receiving Disability Pension monthly payments under the Local Union No. 697, I.B.E.W. and Electrical Industry Pension Fund; 2. Receiving Early Retirement Pension monthly payments under the Local Union No. 697, I.B.E.W. and Electrical Industry Pension Fund; 12 EXPLANATION OF CLASSES - Class 2

15 3. Receiving Regular Retirement Pension monthly payments under the Local Union No. 697, I.B.E.W. and Electrical Industry Pension Fund; or 4. With respect to office personnel without a pension from the Local Union No. 697, I.B.E.W. and Electrical Industry Pension Fund, receiving Social Security retirement benefits and are age 62 or older. Such persons may elect this Plan s Class 2 coverage by paying to the Trust Fund due contributions at the rate as determined by the Trustees from time to time. Class 2 coverage shall terminate when such person attains age 65, at which time such person shall then be eligible to elect the coverage provided under Class 3. CLASS 3 Class 2S Class 2S is for qualifying surviving dependents of Class 1, Class 2 and Class 3 participants who die while covered under the Plan. Self-payments are required for Class 2S coverage. Only dependents who are under age 65 can be covered under Class 2S. (For more information, see page 21.) A person is eligible for Class 3 if he has been covered under this Plan for at least 40 calendar quarters within the 180 months immediately prior to: 1. Receiving upon, or after, attainment of age 65 Retirement Pension monthly payments under the Local Union No. 697, I.B.E.W. and Electrical Industry Pension Fund; or 2. Receiving upon, or after, attainment of age 65 Social Security retirement benefits. Such persons may elect this Plan s Class 3 coverage by paying to the Trust Fund due contributions at the rate as determined by the Trustees from time to time. A person covered under Class 2 may also elect Class 3 coverage upon attainment of age 65. So may a surviving dependent spouse who was previously covered under Class 2S, or who is age 65 or older when the eligible participant or retired participant dies. Class 3 is a supplement to Medicare plan. To be covered under Class 3, the person must be enrolled in Medicare Parts A and B. EXPLANATION OF CLASSES - Class 3 13

16 ELIGIBILITY FOR ACTIVE EMPLOYEES (CLASS 1) DEFINITIONS APPLICABLE TO ELIGIBILITY Apprentice An apprentice is a person who is accepted, registered and actively participating in a course of training in the Union s Electrical Training Center. Bargaining Unit Employee A bargaining unit employee is a person other than an apprentice who is employed by a contributing employer and whose employment is subject to a collective bargaining agreement with the Union. Hour A worked hour for which a contributing employer is required to make and does make a contribution to this Plan in the amount specified by the employer s agreement with the Union or Plan Trustees. (Also see Working Outside this Fund s Jurisdiction on page 19.) Non-Bargaining Unit Employee A non-bargaining unit employee is any of the following: 1. A person who is employed by one of the following entities: a. The Northern Chapter of the Association, b. Local Union No. 697, IBEW, c. This Benefit Plan and Benefit Trust Fund, d. The Local Union No. 697, IBEW, Credit Union, e. The Electrical Administrative Fund, f. The Local 697, IBEW & Electrical Industry Pension Fund, or g. Any other benefit fund provided by Local 697; 2. An individual not covered by a collective bargaining agreement who is working for an employer within the geographical jurisdiction of the Union, and whose employer has entered into a participation agreement with the Trustees under which the employer makes contributions to this Plan for such individual and all of its non-bargained-for employees; or 3. An individual who is employed by a labor organization or an organization beneficial to labor or the industry with which Local 697 is affiliated. The Plan requires that the entities described above specify their intent to provide coverage for their non-bargaining unit employees within 30 days from the date employment starts and make their first contributions no later than the end of that 30-day period. 14 ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Definitions Applicable to Eligibility

17 Temporary Employees ( Travelers ) Work Quarter INITIAL ELIGIBILITY An employee who is either: 1. A member of another IBEW local that is signatory to the Electrical Industry Health and Welfare Reciprocal Agreement who is temporarily working for an employer with a collective bargaining agreement with Local 697, and for whom that employer is making contributions to this Fund; or 2. A Local 697 member who is working temporarily for an employer with a collective bargaining agreement with another IBEW local that is signatory to the Electrical Industry Health and Welfare Reciprocal Agreement, and for whom that employer is making contributions to that local s health and welfare fund. The Plan determines continuing eligibility for bargaining unit employees and apprentices on a quarterly basis. The work quarters during which you must have the required number of hours in order to remain eligible for benefits, are the same as calendar quarters and are as follows: January-February-March April-May-June July-August-September October-November-December Bargaining Unit Employees and Apprentices Accelerated Eligibility A bargaining unit employee or apprentice will become initially eligible for Plan benefits on the first day of the calendar month that immediately follows the month in which he completes 420 hours of work for a contributing employer. Those 420 hours must be within a period of 26 weeks or less. Example: 420 hours in April, May, June & July = initial eligibility August 1. A bargaining unit employee or apprentice who is acquiring eligibility in this Plan for the first time may become initially eligible on the first day of the calendar month that immediately follows the month in which the Plan receives contributions for 160 hours of work from a contributing employer. This rule will only apply to employees who submit a HIPAA certificate of coverage showing that they were previously covered under another health plan, and there is no gap of 63 days or more between their prior coverage and this Plan s coverage. ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Initial Eligibility 15

18 Non-Bargaining Unit Employees A non-bargaining unit employee will become initially eligible on the first day of the calendar month that immediately follows the first 30-day period for which the employer makes contributions to the Plan on the employee s behalf for 160 hours of work. Pre-Existing Condition Exclusion CONTINUING ELIGIBILITY This Plan excludes payment for treatment of pre-existing conditions for a period of time after an employee or dependent becomes initially eligible. See page 65 for additional information. Bargaining Unit Employees 420 Hours per Quarter Once you establish initial eligibility you will remain eligible for Plan benefits through the end of each successive work quarter if you have worked 420 hours or more for a contributing employer during that quarter. Eligibility Dollar Bank Contributions in excess of 450 hours per quarter will be credited to your eligibility dollar bank. If you have a work quarter with fewer than the 420 hours needed to continue your eligibility because of unemployment, underemployment, disability or retirement the amount you are short will automatically be withdrawn from your eligibility dollar bank so that you will not lose eligibility. Reciprocal hours will not be credited to your dollar bank. Excess contributions will not be credited to your MRP account unless your eligibility dollar bank contains enough to cover two full quarters of eligibility. The maximum you can have in your eligibility dollar bank is the amount needed for two full quarters of eligibility. As of January 1, 2007, that amount was $5,208, but the maximum will change proportionally to the contribution rate. When and only when your dollar bank reaches the maximum, any additional excess contributions that would otherwise have been added to your dollar bank will be credited to your individual MRP account. The intent of your eligibility dollar bank is to help you maintain your eligibility while you are an active participant in the Plan. When you retire, any balance in your eligibility dollar bank will revert to $0. Self-Payment of Short Hours If you have fewer than 420 hours during a work quarter and your eligibility dollar bank balance is insufficient to cover the shortage, you can maintain your eligibility by making a self-payment. Your self-payment amount must 16 ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Continuing Eligibility

19 be equal to the number of hours you are short of 420 times the current contribution rate. You can also use your MRP account to make the self-payment. Note that the Fund Office will NOT automatically use your MRP account to cover an hours shortage you must make a written request to the Claims Administrator to use your MRP account to cover your self-payment. See pages for more information about MRP accounts. You can make full self-payments (420 hours per quarter) for up to a maximum of four consecutive work quarters (12 months). If you return to covered employment during a 12-month self-pay period and re-establish eligibility by working 420 hours during a work quarter, you will be entitled to a new 12-month self-pay period if you have a subsequent period of underemployment. There is currently no limit on the number of consecutive partial self-payments you can make. After the Fund Office sends you a self-payment notice, your self-payment must be made by the due date listed on your statement. Late payments will not be accepted. If you fail to make an on-time and correct self-payment, your eligibility will terminate on the last day of the month for which you previously paid (or were eligible due to hours). You must maintain continuous eligibility. If your eligibility terminates, you must once again satisfy the Plan s initial eligibility requirements before you will again be covered. You should keep track of your hours so you will know when a self-payment will be needed. Employers do not always notify the Fund Office when a person s employment terminates, so the Fund Office may not always be able to contact you in a timely manner to avoid a large self-pay balance when a self-payment is due. We recommend that you keep track of your own hours so that you know when you will need to make a self-payment. When you are out of work you should register with the Fund Office in addition to registering with Local 697. Failure to let the Fund Office know that you are out of work but that you want to maintain your Health and Benefit Plan eligibility could cause your Plan eligibility to terminate. Eligibility During Disability Non-Occupational Disabilities - If you are totally disabled and receiving Loss of Time Benefits or Supplementary Disability Benefits, an amount equal to 40 hours per week will be withdrawn from your eligibility dollar bank to help you maintain your eligibility for Plan benefits. If your dollar bank is exhausted and you are still receiving Loss of Time Benefits, you will be credited with 40 disability hours per week toward your eligibility until the earlier of the date you are no longer totally disabled or the end of your Loss of Time Benefit (or Supplementary Disability Benefits) ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Continuing Eligibility 17

20 period. (You will not receive these hours if your are receiving limited Loss of Time Benefits under the Special Rule for Persons Receiving Unemployment Compensation on page 37.) If you remain totally disabled after your Loss of Time Benefit period and are entitled to Social Security disability benefits, you can continue your coverage under the Plan s Retiree Benefits, if you meet the requirements for that coverage. If you are not entitled to Social Security disability benefits when your Loss of Time Benefits end, you will offered the opportunity to elect COBRA coverage. It is your responsibility to inform the Fund Office if you are receiving workers compensation disability benefits. Occupational Disabilities - The provisions described above for non-occupational disabilities also apply if you are disabled due to a work-related injury or disease for which you are receiving disability benefits from a workers compensation plan. No eligibility extension or hours credit will be provided unless you submit copies of your workers compensation disability paystubs to the Fund Office. Apprentices The continuing eligibility rules and requirements for apprentices who have established initial eligibility are the same as those for other members of the bargaining unit, except that: If you are an apprentice, you need 324 hours per work quarter (instead of 420 hours); and You will not be eligible to participate in the Eligibility Dollar Bank or MRP programs until you become a journeyman. The provisions set forth in the Self-Payment of Hours and Eligibility During Disability sections above also apply to apprentices. Non-Bargaining Unit Employees A non-bargaining unit employee who has established initial eligibility will remain eligible for Plan benefits through the end of each successive calendar month for which his employer has made the required contributions to the Fund on his behalf. The amount of the monthly contribution is determined by multiplying the number of weeks in the month times an amount determined by the Trustees. Contributions are due before the beginning of the coverage month. If your employer does not make a timely and correct contribution on your behalf, your eligibility will terminate on the last day of the last month for which contributions were paid. The provisions set forth in the Eligibility Dollar Bank, Self-Payment of Hours and Eligibility During Disability sections above also apply to nonbargaining unit employees. 18 ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Continuing Eligibility

21 DEPENDENT ELIGIBILITY (Classes 1, 2 and 3) If you have dependents on the date your coverage starts, their coverage will start on that same date provided you have submitted satisfactory proof to the Trustees that the person meets the Plan s definition of a dependent (this definition is on page 80). If you later acquire a dependent while you are eligible, coverage will start on the date that you provide proof satisfactory to the Trustees that the person has became your dependent. Your dependents eligibility is contingent upon your eligibility. Dependents are not eligible for Life Insurance, Accidental Death and Dismemberment Insurance or Loss of Time Benefits. The Plan s definition of a dependent starts on page 80. Only persons who meet this definition are entitled to dependent benefits from the Plan. Only persons who meet the Plan s definition of a dependent are entitled to dependent benefits from the Plan. Legal documentation (such as an original registered marriage certificate, certified government-issued birth certificate or divorce decree) is required by the Fund Office before the person can be enrolled for coverage. Proof of full-time student status for children age 19 and older is required each school semester from the registrar s office. For more information see Documentation Requirements on page 83. SPECIAL CIRCUMSTANCES Temporary Employees (Reciprocity) Working Outside this Fund s Jurisdiction The following provisions apply only to bargaining unit employees (who are not apprentices). The Fund is signatory to the Electrical Industry Pension and Health & Welfare agreement. The purpose of the reciprocity agreement is to permit you to retain eligibility when contributions are made for you to another IBEW welfare or benefit fund. Excess reciprocal hours received by this Fund will not be credited to your eligibility dollar bank or MRP account. If you want this Fund to be your home fund when you travel outside of its jurisdiction, you should register with the Electronic Reciprocal Transfer System (ERTS) at any IBEW local union office. This Fund cannot be your home fund and cannot accept reciprocal hours unless you were eligible under this Fund for at least one quarter during the last five years (60 months). If this Fund is your home fund, and it receives less than 420 hours during a work quarter while you are working out of another IBEW local, you can make a self-payment for the difference. The Fund Office will issue a statement to you explaining the amount due. Your payment for the shortage must be made by the due state shown on your statement. If you are not eligible under this Plan when you begin working in the other IBEW local s jurisdiction, the contributions sent to this Fund will first be applied to satisfy any amount you owe to this Fund. If and when that debt is ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Special Circumstances 19

22 satisfied, the amount in excess of the owed amount will be counted toward the eligibility requirements of this Plan. Excess reciprocal hours received by this Fund will not be credited to your eligibility dollar bank or MRP account. Traveling from Another Local If a temporary employee who is working within the jurisdiction of this Fund has duly designated another IBEW fund as his home fund, this Fund will transfer the contributions it receives on the employee s behalf to his home fund. In such case, the employee s health benefits will be the responsibility of the home fund, subject to home fund s eligibility and benefit rules. If a temporary employee from another local is working within this Fund s jurisdiction under a suspension of reciprocity, all contributions will apply toward this Fund s eligibility requirements. When the temporary employee later leaves the jurisdiction, this Fund will not accept reciprocity transfers from another fund. Family Medical Leave Act (FMLA) The Plan does not determine whether or not you are entitled to a family medical leave, or whether or not your employer must make contributions during a FMLA leave. The Family Medical Leave Act (FMLA) requires certain employers (but not all) to grant unpaid leave of up to twelve (12) weeks during a 12-month period. FMLA leave must be granted for specific reasons, such as the birth of a child or a serious family sickness. Eligibility for this unpaid leave is determined by the employer, not by the Trustees of this Fund. If you are granted a FMLA leave, your employer must provide the necessary documentation and make contributions to the Fund on your behalf. Failure of your employer to submit contributions on a timely basis will result in loss of coverage under this Plan. Military Leave Eligibility Freeze If you leave employment with a contributing employer to enter active duty in the uniformed services of the United States for at least 30 days, any hours you have accumulated will be frozen during your period of active duty. After your release from active duty under circumstances entitling you to reemployment under federal law, your eligibility and accumulated hours will be reinstated on the date you return to work with a contributing employer, provided your return to work is within the time prescribed by federal law. Self-Payments Instead of the freeze described above, you may choose instead to make selfpayments for continued coverage for up to 24 months, regardless of any coverage provided by the military or government. You are entitled to make these self-payments if you are covered under the Plan but leave covered employment for active duty in the U.S. military for at least 30 days. The 20 ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Special Circumstances

23 payment amounts, rules and provisions for continued coverage during military leave are very similar to COBRA coverage. This Plan will pay primary benefits before the military/government pays except for service-related disabilities. When you return, you will need to continue making self-payments until you re-establish eligibility under the regular rules (assuming you haven t previously reached the 24-month limit). You cannot have a freeze and make self-payments at the same time. For Additional Information For more information about your self-payment rights during military service, contact the Fund Office. More information about the re-employment rights of persons returning to work from the uniformed services of the United States is available from the Veterans Employment and Training Administration of the United States Department of Labor. In the Event of Your Death Automatic Continuation If you die while you are an eligible employee (who is not making COBRA self-payments), and if you would have been eligible on the last day of the month in which your death occurs, Plan coverage for your surviving dependents will be continued until the last day of the third month following your death. Self-Payment Options Class 2S After that, your dependents can continue their coverage by making COBRA self-payments, or by making self-payments for Class 2S. If your spouse chooses to make COBRA self-payments, the rules governing COBRA coverage will apply. Note that if she elects COBRA, she will not be entitled to make Class 2S self-payments at any future date. Similarly, if she chooses the Class 2S self-payment option, she will lose the right to elect COBRA coverage at any future date. Class 2S provides Comprehensive Major Medical Benefits, including prescription drug coverage for surviving dependents of employees or retirees who die while eligible for active Plan benefits. To participate in Class 2S, an application to participate must be submitted to the Fund Manager within 90 days following your death. The Class 2S self-payment amount is determined by the Trustees and may be changed at any time. Coverage under Class 2S will terminate on the date your surviving spouse remarries, or if she does not make a timely and correct self-payment. Your children s coverage will also terminate on that date, or, if earlier, on the date ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Special Circumstances 21

24 Class 3 they no longer meet the Plan s definition of a dependent (for example, when they reach the limiting age). Coverage for a surviving child will terminate in the event of the surviving parent s death. If your spouse is eligible for Medicare when you die, or if she elects Class 2S and later becomes eligible for Medicare, her coverage class will change to Class 3. Self-Payment Due Date TERMINATION OF ELIGIBILITY Self-payments for Class 2S and Class 3 are due on the first day of the coverage month. If survivor coverage terminates, it cannot be reinstated. Termination of Employee Benefits You will cease to be eligible for benefit coverage under the Plan on the earliest of the following dates unless you are entitled to COBRA coverage and a correct and on-time COBRA election and self-payment is made by you or on your behalf: 1. The date the Trustees terminate the benefits provided by this Plan; 2. The date you enter the armed forces of any country on a full-time basis, unless you make correct and on-time self-payments to continue your coverage; 3. If you fail to meet the continuing eligibility requirements, at the end of the last day of the work quarter for which you did meet the requirements, unless you are entitled to make self-payments due to disability, underemployment, unemployment or retirement and you make a correct and ontime self-payment; 4. If you are an apprentice whose participation is terminated by the apprenticeship program, at the end of the calendar month in which your termination occurs; 5. If your eligibility is being continued under the Eligibility During Disability provisions, at the end of the period for which you are eligible for an extension under those rules; 6. If you are making COBRA self-payments, at the end of the last day of the applicable maximum coverage period to which you were entitled and for which correct and on-time self-payments have been made or, on the date of occurrence of any of the events stated in Termination of COBRA Coverage on page 28, whichever occurs first; or 22 ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Termination of Eligibility

25 7. The date of your death. Termination of Dependent Benefits A dependent of yours will cease to be eligible for benefits from this Plan on the earliest of the following dates unless the dependent is entitled to COBRA coverage and a correct and on-time COBRA election and self-payment is made by or on behalf of the dependent: 1. The date the Trustees terminate dependent benefits (or all benefits) under the Plan; 2. The date the dependent enters the armed forces of any country on a fulltime basis; 3. The date you cease to be eligible for benefit coverage for reasons other than your death; 4. For your spouse, the date of your divorce; 5. For a child who fails to meet this Plan s definition of a dependent child, on the date of loss of dependent status; 6. If COBRA self-payments are being made by or on behalf of the dependent, at the end of the last day of the applicable maximum coverage period to which the dependent is entitled and for which correct and ontime self-payments have been made, or on the date of occurrence of any of the events stated in Termination of COBRA Coverage on page 28, whichever occurs first; or 7. In the event of your death: a. At the end of the last day of the third calendar month following the month in which your death occurred; or b. If your surviving spouse is making Class 2S or Class 3 self-payments to continue coverage for herself and any of your surviving dependent children, on the first of the following dates: The date any of the events in No. 1 or 2 above occurs; The last day of the last month for which a correct and on-time selfpayment was made by or on behalf of your surviving spouse; With respect to a surviving spouse covered under Class 2S, the first day of the month following the month in which she attains age 65 (however, she will then be offered the opportunity to make self-payments for Class 3 benefits); For a surviving dependent child, the date the child ceases to meet this Plan s definition of a dependent child; or The date your surviving spouse remarries. ELIGIBILITY FOR ACTIVE EMPLOYEES (Class 1) - Termination of Eligibility 23