Your session is about to expire due to inactivity.
Health Fund
print

Grandfather Status Under The Affordable Care Act

The Trustees believe the Fund is no longer a "Grandfathered Health Plan" under the Affordable Care Act as of January 1, 2012. Accordingly, the Trustees have decided to implement the necessary changes (as reflected herein) under the Affordable Care Act that apply to non-grandfathered group health plans. These changes were effective as of January 1, 2012.

Family and Medical Leaves of Absence

Through the Family and Medical Leave Act (FMLA), you are allowed take up to 12 week's unpaid leave during any 12-month period due to:

  • The birth, adoption, or placement with you for adoption of a child;
  • To provide care for a spouse, child, or parent who is seriously ill; or
  • Your own serious illness

If you take at least one week of unpaid FMLA leave, your employer is required to continue contributions on your behalf to the Fund for the entire period of unpaid leave. However, if, when your leave begins, the employer has already paid the maximum amount required under the collective bargaining agreement or the COBRA rate, no further employer contributions are required. Whether or not your employer is required to continue contributing, your coverage through the Fund will continue (and, in the case of a dependent, coverage will continue provided you continue to pay the quarterly dependent coverage premiums in full and on time). Of course, any changes in the Fund's terms, rules or practices that go into effect while you are away on leave apply to you and your dependents, the same as to active employees and their dependents.

If you do not return to work after your FMLA leave ends, you may be required to repay the amount that your employer paid before or during your leave which applies to your coverage during your leave. However, if you do not return to work due to your or a family member's serious health condition or other circumstances beyond your control, this repayment rule may not apply.

If you do not return to work after your FMLA leave ends, you may qualify for COBRA Continuation Coverage, as described here.

Expanded FMLA Rules for Military Personnel

The 2010 National Defense Authorization Act (2010 NDAA) amends the Family and Medical Leave Act of 1993 by expanding its leave provisions relating to "Qualifying Exigency Leave" and "Military Caregiver Leave." FMLA leave is available to covered employees whose spouse, child or parent is in the U.S. Armed Forces, including the National Guard or Reserves, who is ordered to active duty and who is deployed overseas. "Qualifying Exigencies" include time preparing for short notice deployment, arranging for child care, updating financial or legal arrangements, attending counseling, time for rest and recuperation, and post-deployment activities. You may be entitled to up to 12 week's leave within a 12-month period for a "Qualified Exigency."

The 2010 NDAA also amends the FMLA to create leave protections for family members of injured veterans who provide "Military Caregiver Leave." They may be entitled to a total of 26 week's unpaid leave during a 12-month period to care for the service member. This form of leave applies only if the service member in need of care is undergoing medical treatment, recuperation or therapy (including outpatient care) for a serious illness or injury that was incurred in the line of active duty and that may render the service member medically unfit to perform the duties of his or her office, grade, rank or rating.

Note: If you take this type of leave along with a FMLA leave for any other purpose (for example, the birth of a child), the combined total leave may not exceed 26 weeks in the 12-month period.

If you believe you qualify for FMLA leave, please contact your employer and advise the Administrative Office.

Military Leave

If you enter military service, you will be provided continuation and reinstatement rights under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). USERRA protects employees who leave for and return from active duty in the uniformed services (including the Army, Navy, Air Force, Marines, Coast Guard, National Disaster Medical Service, the reserves of the armed forces and the commissioned corps of the Public Health Service). If you elect continuation coverage under USERRA, you and any eligible dependents covered under this Fund when your leave began may continue coverage for up to 24 months.

If you are on active duty for 31 days or less, you (and your eligible dependents covered under the Fund when your leave began) will continue to receive the health care coverage that you would otherwise have received under the Fund. If you are on active duty for more than 31 days, you can continue coverage for yourself (and your eligible dependents covered under the Fund when your leave began) for up to 24 months but you will need to pay the applicable COBRA rate for such coverage. Payment under USERRA and termination of coverage for nonpayment of USERRA work just like COBRA coverage (described above). In addition, you and your dependents may be eligible for health care coverage under TRICARE (the Department of Defense's health care program for uniform service members and their families). This Fund coordinates benefits with TRICARE with the Fund paying first and TRICARE paying second. Please refer to Coordination of Benefits section on pages 51-54 and visit www.tricare.mil for additional information.

If you are called to active duty, you must notify the Administrative Office in writing as soon as possible but no later than 60 days after the date on which you will lose coverage due to the call to active duty, unless it is impossible or unreasonable to give such notice. Once the Administrative Office receives notice that you have been called to active duty, you will be offered the right to elect USERRA coverage for yourself and any eligible dependents covered under the Fund on the day your leave started. Unlike COBRA coverage, if you do not elect USERRA for your dependents, they cannot elect it separately.

When you are discharged (not less than honorably) from the uniformed services, your full eligibility may be entitled to be reinstated on the day you return to work with a contributing employer, provided that you return to employment within:

  • 90 days from the date of discharge, if the period was more than 180 days; or
  • 14 days from the date of discharge, if the period of service was at least 31 days but less than 180 days; or
  • The next regularly scheduled working day following discharge (plus travel time and an additional eight (8) hours) if the period of service was less than 31 days.

No waiting period or exclusion will be imposed in connection with such reinstatement (unless the waiting period or exclusion would have been imposed if you had remained covered during your military service) except in the case of illness or injury determined by the Secretary of Veterans' Affairs to be connected with your military service. Separation from uniformed service that is dishonorable or based on bad conduct, on grounds less than honorable, absence without leave (AWOL), or ending in a conviction under court martial would disqualify you from any rights under USERRA.

Mental Health Parity And Addiction Equity Act

To comply with the Mental Health Parity And Addiction Equity ActThe Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health and chemical dependency use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. of 2008, the Fund coverage for mental health and chemical dependency benefits will be provided at the same benefit levels as the medical coverage. Effective January 1, 2012, mental health and chemical dependency benefits will have the same deductibles, copays, coinsurance and out-of-pocket maximums as medical benefits. In addition, please note the following:

Calculation of deductibles and out-of-pocket expenses will combine mental health and chemical dependency treatment costs with other medical costs; co-insurance rules will apply to all such services.

  • Coverage for mental health and chemical dependency treatments will still be subject to medical necessity considerations and reasonable and customary industry practice.
  • Blue Cross/BlueCard provider network is the current approved network for both medical and mental health care.
  • Claims processing for mental health benefits is administered by the Administrative Office.
Genetic Information Non-Discrimination Act ("GINA")

Effective June 1, 2009, GINA prohibits discrimination by group health plans, such as the Fund, against an individual based on the individual's genetic information. Group health plans and health insurance issuers generally may not request, require or purchase genetic information for underwriting purposes, and may not collect genetic information about an individual before the individual is enrolled or covered. Pursuant to the applicable requirements of GINA, the Fund is also prohibited from setting premium and contribution rates for the group on the basis of genetic information of an individual enrolled in the Fund.

Not A Contract Of Employment

This SPD is not a contract of employment (including without limitation Covered Employment) – it neither guarantees employment or continued employment with your Contributing Employer or any Contributing Employer, nor diminishes in any way the right of Contributing Employers to terminate the employment of any employee.

Severability

If any provision of this SPD is held invalid, unenforceable or inconsistent with any law, regulation or requirement, its invalidity, unenforceability or inconsistency will not affect any other provision of the SPD, and the SPD shall be construed and enforced as if such provision were not a part of the SPD.

Construction Of Terms

Words of gender shall include persons and entities of any gender, the plural shall include the singular and the singular shall include the plural. Section headings exist for reference purposes only and shall not be construed as part of the SPD.

Applicable Law

The Fund shall be construed and enforced according to the laws of the State of California to the extent not preempted by ERISA and any other applicable Federal Law.

No Vested Interest

Except for the right to receive any benefit payable under the Fund in regard to a previously incurred claim, no person shall have any right, title, or interest in or to the assets of any Contributing Employer due to their relationship with the Fund.

No Liability For Practice Of Medicine

The Fund and the Trustees, or any of their designees are not engaged in the practice of medicine, nor do any of them have any control over any diagnosis, treatment, care or lack thereof, or any healthcare services provided or delivered to you by any healthcare provider. Neither the Fund, the Trustees, or any of their designees will have any liability whatsoever for any loss or injury caused to you by any provider by reason of negligence, by failure to provide care or treatment, or otherwise.

Facility Of Payment

Every person receiving or claiming benefits through the Fund will generally be presumed to be mentally and physically competent and of age. However, if the Plan Administrator (or its designee) determines that a person entitled to receive benefits hereunder is a minor, or is physically or mentally incompetent to receive the payment or to give a valid release for benefits, the Fund may issue payments to the person's legally appointed guardian, committee or representative (upon proof of the appointment) or, if none, to another person or entity that the Trustees determine appropriate in their sole and absolute discretion. Any payment made in accordance with this provision will entirely discharge the obligation of the Fund