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Benefits And Covarage
The table describes inpatient visits, physician visitm, annual physical exams, well child care, chiropractic, care/ services and other visits. the table describes network and out of network payments and deductions.
When reading this booklet, you may encounter some terms with which you may not be familiar or which may have a specific meaning for purposes of this booklet.
As an Active Employee of an Employer for whom Contributions are being paid into the Local 805 Welfare Fund pursuant to a Collective Bargaining Agreement or other written agreement, you and your Eligible Dependent(s) are eligible to participate in the Fund.
Eligibility and effective dates coverage>>
If you have a temporary termination of Employment and you return to Covered Employment within six (6) months and provided that you remain in Covered Employment until at least one (1) month of Contributions is received on your behalf, your coverage will be reinstated immediately.
- Medical
- Dential
- Vision
- prescription
This section contains important information about COBRA continuation coverage, which is a temporary extension of group health coverage (i.e., medical, dental, vision and prescription drug benefits) under the Plan under certain circumstances in the event that you or your family members lose your coverage.
Cobra - continue of health coverage>>
The Fund provides benefits for Injury or Illness, as defined herein. Benefits payable are based upon Reasonable and Customary charges for Covered Expenses resulting from services and supplies that qualify as Medically Necessary care and treatment. How the Fund makes these determinations is discussed below. Note that certain Major Medical benefits are subject to benefit limitations, as set forth below.
If you use a Network provider, you will not have to submit any paperwork to file your claims. You should just present your GHICard at the time of service. . You should contact the Fund Office if you have not received or cannot locate your GHI Card.
General Information Timing Of Initial Claim Determinations. Pre-Service Claims Post-Service Claims Urgent Care Claims Concurrent Care Claims (Ongoing Course of Treatment) Notice of Initial Claim Determinations Requests for Review of Claim Denials and Other Adverse Benefit Determinations
Network And non-Network Coverage Hospitalization Benefits Hospital Exclusions Major Medical Benefits Surgical Ana Anesthesia Benefits The Women’s Health And Cancer Rights Act Major Medical Exclusions
This Section describes your Hospitalization and Major Medical benefits, including the PPO networks offered by the Fund. The Fund's reimbursement levels and your out-of-pocket expenses vary depending on whether you use network or out-of-network providers, so please read this Section carefully.
Hospitalization and major medical benefits>>
In addition to any limitations or specific exclusions described in this Summary Plan Description, there are general imitations and exclusions, which apply to all benefits. No payments will be made for expenses incurred for you or your eligible dependents.
General limitations and exclusions>>
General Benefits Provided And Commencement Alternative Benefit Provision Prior Approval Managed Care Option Standard Reimbursement Option Special Limitations Applicable to Specific Dental Services Schedule Of Covered Dental Expenses
Dental Expenses not Covered
The optical plan covers you and each of your eligible dependents for the purchase of up to one pair of prescription lenses and frames every 24 months from last date of service. You may use your own optometrist, or you may go to one of the participating optical centers listed on the following page.
This Plan provides a prescription drug benefit that allows Participants and their eligible dependents to obtain prescription drugs with the co-payments listed below. This section does not provide benefits covering expenses incurred for all prescription drugs. A prescription drug may not be covered unless it is medically necessary for the prevention or treatment of al illness or condition. There are exclusions, co-payment features and, maximum benefit features. These are described further below.
The Plan provides for payments of benefits to a designated Beneficiary upon the death of a Participant who dies while covered by this Plan. The Plan also provides accidental death, dismemberment, and loss of sight benefits.
This Fund operates under rules that prevent it from paying benefits which, together with the benefits from any other group health care plan, Medicare, workers' compensation, coverage provided by a federal, state or local government or agency, coverage under any motor vehicle no- fault coverage (or any other coverage) for medical expenses or loss of earnings that is required by law, or recovery you may receive from a negligent or wrongful third party, would allow you to recover more that 100% of medical and/or dental expenses you incur.
Coverage under more than one group health plan>>
Generally, anyone age 65 or older is eligible for Medicare coverage. Anyone under age 65 who is entitled to Social Security Disability Income Benefits is also eligible for Medicare coverage after a waiting period. If you, your covered Spouse or Dependent Child becomes covered by Medicare, either because of disability or age, you may either retain or cancel your coverage through this Fund.
Medicare and government plans>>
Benefits payable by the Fund for the treatment of an illness or injury shall be limited in the following ways when the illness or injury is the result of an act or omission of another (including a legal entity) and when the Participant or Eligible Dependent pursues or has the right to pursue a recovery for such act or omission.
Repayment of medical benefits>>
If you (or your dependent or beneficiary) are overpaid for a claim, you (or your dependent or beneficiary) must return the overpayment to the Fund. The Fund has the right to recover any payments made that were based on false or fraudulent information, as well as any payments made in error. Amounts recovered may include interest and costs.
As a Participant in the Local 805 Welfare Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to:
Your rights under employee retirement income>>
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) gives you certain rights with respect to your health information, and it also imposes certain obligations on the Fund as a group health plan. The following describes the ways your health information is protected under HIPAA when that health information is disclosed to or used or disclosed by the Board of Trustees (the “Board”), in its capacity as the sponsor of the Fund.
HIPAA Privacy of protected health infomation>>
The Board of Trustees and/or Fund Office will give notice by first class mail to participants of actions taken with respect to eligibility, claims and other important matters affecting your rights and obligations under the Plan.
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or:
Assistance with your questions>>
Description and information on plans, ID , plan number, type of administration, plan administrator, agents, and collective bargaining agreements.
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