Cement Masons and Plasterers Local 518 Health Care Fund Frequently Asked Questions & Answers

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1 Q. HOW DO I BECOME ELIGIBLE FOR HEALTH & WELFARE BENEFITS? A. You can become eligible and receive benefits by working a sufficient number of hours for a Contributing Employer who makes contributions to the Fund. Q. HOW MANY HOURS DO I NEED TO WORK? A. Once you have satisfied the initial eligibility requirements, you will remain eligible for benefits for the duration of that Benefit Period. Thereafter, to remain eligible you must be credited with at least 450 hours in a six month work period or 1,000 hours in a twelve month work period. See the following chart for work periods and benefit periods: ELIGIBILITY CONTRIBUTION REQUIREMENTS You must have contributions made on your behalf in one of the following amounts To be eligible for coverage during the Benefit Period 450 hours of contributions this work period: 1,000 hours of contributions this work period: April 1 September 30 August 1 January 31 February 1 January 31 October 1 March 31 February 1 July 31 August 1 July 31 Q. WHEN WILL MY COVERAGE BEGIN? A. Initial eligibility begins when the Fund receives employer contributions in your behalf for at least 450 hours in six consecutive months. You will become eligible for benefits on the first day of the third month following the month in which the 450 hours were accumulated. Q. WHAT HAPPENS IF I LOSE MY ELIGIBILITY BECAUSE OF A REDUCTION IN HOURS, TERMINATION OF EMPLOYERNT, OR CERTAIN OTHER EVENTS? A. You will be notified by the Fund Office that your Health Care Coverage has terminated and will be given the opportunity to continue coverage by electing COBRA, or purchasing coverage through the Healthcare Marketplace. Q. WHAT IS COBRA CONTINUATION COVERAGE? A. Federal law requires that sponsors of group health plans offer Covered Participants and their families a temporary extension of their health care coverage under the Plan in exchange for self-contribution payments to the Plan. (Find detailed information regarding COBRA on page 26, Section 2.11 of the Summary Plan Description and Plan Document.) Page 1 of 7

2 Q. CAN I CONTINUE MY COVERAGE AFTER I RETIRE? A. Yes, provided you are eligible at the time of retirement, meet the following requirements and pay the required self-payments. Retirees and their eligible dependents may be eligible for one of two Retiree Health Plans, Plan A or Plan B if they meet the eligibility requirements listed below: Plan A eligible retiree who meets either one of the following: A Covered Employee retires and is receiving benefits under the Kansas City Cement Masons Pension Fund or the Local 561 Retirement Plan, has earned at least 10 years of pension credit under the Kansas City Cement Masons Pension Fund, the Indiana State Council Plasterers and Cement Masons Pension Fund, the Omaha Construction Industry Pension Plan or the Local 561 Retirement Plan and has earned pension credit in each of the three Plan Years preceding the effective date of Retiree coverage under this plan. Or A Retiree has an effective date of Retiree coverage under this Plan on or prior to April 1, Plan B eligible retiree who meets the following requirement: If a Covered Employee retires and is receiving benefits under the Kansas City Cement Masons Pension Fund, the Indiana State Council Plasterers and Cements Masons Pension Fund, the Omaha Construction Industry Pension Plan or the Local 561 Retirement Plan, is at least 60 years of age and is eligible under the Cement Masons and Plasterers Local 518 Health Care Fund on the date of retirement because of eligibility earned for employment with contributing Employer(s), the Retiree will become eligible for continuing self-pay Benefit eligibility under Retiree Plan B of the Cement Masons and Plasterers Local 518 Health Care Fund. Q. WHO QUALIFIES AS A DEPENDENT ON MY COVERAGE? Eligible Dependents can include: The lawful spouse of the Covered Employee. A biological child, legally adopted child, child placed for adoption, stepchild of the Covered Employee or any other minor child (as qualified below), who: o Is under the age of 26; or o Any other unmarried minor child if the child is residing with the Covered Employee in a normal parent-child relationship and the Covered Employee has been appointed by the court as legal Page 2 of 7

3 guardian of such child as well as been required to provide medical coverage for the child. A child for whom coverage must be provided because of a Qualified Medical Child Support Order ( QMCSO ). An unmarried child over 26 years of age, if he is Totally Disabled because of a qualifying physical handicap or mental retardation. To be considered a qualified physical handicap or mental retardation as defined by the Plan. (Find detailed information in Section 2.08 of the Summary Plan Description and Plan Document) Q. HOW DO I ADD A NEW DEPENDENT? A. If you need to add a newborn child, spouse, stepchild, etc., Contact the Fund Office at (913) and request a new Enrollment Card. You must submit the appropriate legal documents to the Fund Office. For example: birth certificate, marriage certificate, divorce decree, custody agreement, decree of adoption or a Qualified Medical Child Support Order. Q. HOW DO I REMOVE MY SPOUSE FROM MY COVERAGE PLAN? A. Before a spouse could be terminated from the Plan, the Fund Office would need a copy of the divorce decree or the court document showing you are legally separated. Contact the Fund Office at (912) with this documentation and your coverage plan can be changed. Q. WHAT DO I DO IF I AM INJURED OR BECOME ILL AND AM UNABLE TO WORK? A. If you become Totally Disabled from a sickness or accidental bodily injury which prevents you from engaging in any occupation or employment for wage or profit, you will receive credit for 30 hours worked per week for a maximum of 13 weeks. These Disability Credit hours may help continue your coverage for Health Care Benefits. You must request a claim form from the Fund Office and have it completed by a Physician certifying the dates of disability. A new claim form is required for each new period of disability. Disabled Participants receiving Worker s Compensation must submit proof of compensation. Q. WHAT ARE THE HEALTH CARE BENEFITS? A. The Fund has contracted with Blue Cross Blue Shield of KC, Preferred Care Blue Network to provide participants and the Fund with discounts on medical services. By choosing an In-Network Provider for your health care needs, you will save money for Page 3 of 7

4 yourself and the Fund. The deductible is $ per individual vs. the out-of-network deductible of $ per individual. The Benefit provided by using the in-network provider is 85% vs. the out-of-network Benefit of 75%. (For further details regarding the medical Benefits available, please refer to the Summary Plan Description and Plan Document.) Description of Covered Benefit In-PPO-Network Out-of-Network Major Medical Benefit (Hospital, ER, Doctor etc.) 85% 75% Diagnostic X-ray and Lab Benefit Supplemental Accident Benefit Maternity Benefit (Employee or Dependent Spouse Only) 100% of First $100 per calendar year, major medical benefits apply after 100% of first $200 per accident, major medical benefits apply after Subject to deductible & paid at 85% 100% of First $100 per calendar year, major medical benefits apply after 100% of first $200 per accident, major medical benefits apply after Subject to deductible & paid at 75% Surgery Second Surgical Opinion 100% 100% Well Child Benefit (Eligible Dependents of Active Employees Only) 85% no deductible 85% no deductible ALL BENEFITS ARE SUBJECT TO LIMITATIONS AND EXCLUSTIONS. PLEASE REFER TO YOUR SUMMARY PLAN DOCUMENT FOR FULL PLAN INFORMATION Q. HOW DO I FIND A NETWORK PROVIDER FOR HEALTH CARE BENEFITS? A. Blue Cross and Blue Shield National Preferred Provider Organization (BCBSKC), offers a nationwide network of medical providers for all your health benefit needs. Below is information that will allow you to search for and determine if your provider(s) are participating in the Blue Cross Blue Shield PPO Nationwide Network: You can go directly to the Blue National Doctor and Hospital Finder Website at You will need the three digit account specific prefix: (KWF). This is the prefix that will be listed on the front of your identification card. You will also need the zip code of the area where you are looking for a participating provider. This will provide you with a detailed search engine where Page 4 of 7

5 you can look up a provider by name and/or specialty anywhere within the Blue Cross Blue Shield PPO Nationwide Network. To determine if a provider is in the Blue Cross Blue Shield PPO Network over the phone, you may contact Blue Cross Blue Shield of Kansas City at (800) or you can call the National Provider Finder number at (800) 810-BLUE. Q. DO I NEED AN ID CARD? A. Yes. You should carry your Health Care ID Card with you at all times, and provide it to your medical care provider at each visit. The card has information on it so your providers know where to bill for their services, and who to call for benefit and eligibility verification. Q. HOW DO I GET AN ID CARD? A. Your Health Care ID Cards will be sent to you by BCBSKC under separate cover. Once received, be sure to carry this card with you, and present to your providers when receiving medical services. This card has all the information needed for your medical providers to bill for your medical expenses. Q. HOW DO I GET A REPLACEMENT CARD IF MINE IS LOST? A. You can call The Fund Office to order a replacement card, or you can request a new card online at Q. DOES THAT COVER PRESCRIPTION DRUG COVERAGE TOO? A. Yes. Prescription medications are covered under the Welfare Fund Plan. Prescription drug charges DO NOT APPLY to the annual deductible or the out-of-pocket maximum. To use your prescription benefit, present your Prescription Drug Card (not your Welfare Health Care ID Card) and prescription to your pharmacist. Q. WHAT PRESCRIPTIONS ARE COVERED? A. The medication must have been prescribed by your physician. There are no benefits for certain prescriptions, including fertility or infertility drugs, drugs used for cosmetic purposes, investigational or experimental drugs, genetically engineered drugs, drugs used for weight control and others. Please refer to your Summary Plan Description for the full list of restrictions. Page 5 of 7

6 Q. WHERE DO I GET MY PRESCRIPTIONS? A. The Prescription Benefit Manager (PBM) for the Fund is LDI Prescription Services. You can find participating pharmacies by visiting their website at or you can call them toll-free at (866) Q. HOW MUCH WILL MY PRESCRIPTIONS COST? A. Prescriptions purchased at a retail pharmacy will cost $13.00 for generic medications (or the cost of the prescription, if less). You will pay the greater of $18 or 25% cost of the drug with a maximum of $196.00, for brand name/preferred medications and you will pay the greater of $37 or 50% cost of the drug with a maximum of $ , for brand name/non-preferred medications. (plus the difference in the ingredient cost if the prescription is filled as a brand name drug when a generic is available.) Prescriptions purchased through LDI s Mail Order Program (up to a 90-day supply), will cost $21 for generic medications (or the cost of the prescription, if less). You will pay $34 for brand name/preferred medications and you will pay $73 for brand name/non-preferred medications. ALL BENEFITS ARE SUBJECT TO LIMITATIONS AND EXCLUSIONS. PLEASE REFER TO YOUR SUMMARY PLAN DESCRIPTION AND PLAN DOCUMENT FOR FULL PLAN INFORMATION. Q. WHAT VISION BENEFITS ARE AVAILABLE? A. The Plan provides benefits for eyeglasses and vision care through Vision Service Plan (VSP). Vision Service Plan has established a network of providers who agree to provide services in exchange for contracted fees. For further details, refer to the Schedule of Benefits in the Summary Plan Description and Plan Document. ALL BENEFITS ARE SUBJECT TO LIMITATIONS AND EXCLUSIONS. PLEASE REFER TO YOUR SPD FOR FULL PLAN INFORMATION. Q. HOW DO I FIND A NETWORK PROVIDER FOR VISION BENEFITS? A. Vision Benefits are provided by the VSP Vision Care. To find providers in the VSP Vision Care Network, call Customer Service at (800) or visit Page 6 of 7

7 Q. WHAT DENTAL BENEFITS ARE AVAILABLE? A. The Plan will pay 80% of the amount charged up to $1, towards exams, cleanings, x-rays and other services and supplies provided by a dentist in a calendar year. (Please refer to the Summary Plan Description and Plan Document for more detail.) Q. WHY DO I NEED AN AIQ (ACCIDENT/INJURY QUESTIONNAIRE) A. The Fund Office requests and Accident/Injury Questionnaire to help determine How, When, Where or If the member was actually injured in an Accident. The plan has the Right of Recovery for benefits processed where there may be a Third Party Responsible, such as Automobile policy, Homeowner s or a Product Liability policy, to cover the expenses incurred for treating a member s injuries. (This form can be downloaded from Forms section of this website.) Q. WHY DO I NEED A YCOB/OI FORM (YEARLY COORDINATION OF BENEFITS/OTHER INSURANCE) A. The Fund Office requests a Yearly Coordination of Benefits Form to help determine if there is more than one group Medical/Dental policy which covers a member for benefits. This is done to determine which policy is responsible for processing primary or secondary benefits for the services provided to a member for reimbursement. (This form can be downloaded from Forms section of this website.) If you have any additional questions about your benefits or the Welfare Fund, please contact The Fund Office at (913) Page 7 of 7