Milwaukee Painters Local 781/1204 Health Fund

 

Email the Health Fund Office


 

Login: painters781      Password: 781PAINT
Phone: 414-577-3716   Fax: 414-577-3710


 

 

Important Contact Information


If you have questions or need information about:

 

Contact. . .

 

Phone Number

 

Eligibility and Benefits

 

Fund Office

 

262-662-2564

 


Loss of Time Checks

 


Fund Office


262-662-2564


Medical Network Providers, Claims and Notification (formerly called Pre-certification)

 

United Healthcare

(UHC)

(Group #710828)

 

800-741-8786-Members

 

(*Providers call 877-842-3210)


Mental Health and Substance Abuse Providers and Notification (formerly called Pre-certification)

 

United Behavioral Health (UBC)

(Group #710828)

 

866-873-3903

 

 

Health Promotion and Cancer Screening Program

 

Health Dynamics

 

414-443-0200

 

Prescription Drug

Benefits

 

 

Catalyst

(Group: MIL781)

 

866-795-6816

 

Dental Benefits

 

for ALL questions concerning your eligibility status, or the status of any dental claims:

 

 

MetLife

 

(Group #106190)

 

800-942-0854

(Have the member social security number available when you call Select  “3” for dentist list or “6” to speak to a Customer Service Consultant)

 

Hearing Care

Benefits

 

Hear USA/National Ear Care Plan

 

888-884-6327

 

Class C Retiree Benefits


AARP Medicare Supplement

AARP Medicare Prescription Drug Plan

UHC Medicare Complete


800-392-7537

 

877-710-5083

 

888-867-5548

United Healthcare (UHC) On Line

http://www.myuhc.com/

Please use this site to locate our Network medical providers, hospitals, and misc. facilities.  United Healthcare is the Fund’s only PPO network.  Through UHC ChoicePlus PPO network, you have access to network hospitals, physicians, and other healthcare providers.  Network access means that you will be able to take advantage of discounts available from these providers, receive the Fund’s highest coinsurance for network providers, and not be subject to balance billing for charges above usual and customary amounts.  To take advantage of the cost savings of a PPO, you must use network providers and you must show your ID card when you receive services.

 

The Plan gives you flexibility in how you receive your medical are.  Each time you seek care, you have a choice of using a network or non-network provider; HOWEVER, the Plan pays a higher percentage for most covered services when you use a network provider.

 

UNITED HEALTH CARE MEDICAL CLAIMS

MAILING ADDRESS:

P O BOX 30555

SALT LAKE CITY, UT  84130-0555

 

Important Information about Your
Health and Welfare Benefits

July 2011

Dear Participant:

 

As Trustees of the Milwaukee Painters Local Union 781 Health Fund (the “Plan”), we value your service and are proud to offer coverage to help meet the health care needs of you and your family. We are committed to keeping you informed and want to make you aware of enhancements to your benefits effective April 1, 2011. (The Plan provided information to you on some of these changes in February.) These changes are a result of the Patient Protection and Affordable Care Act (the “Affordable Care Act”) and are highlighted in this announcement.

 

Statement of Grandfathered Status

The Board of Trustees believes that the Plan is a “grandfathered health plan” under the Affordable Care Act, which means that our Plan existed when the health care reform law was signed on March 23, 2010, and that we can preserve certain basic health coverage that was already in effect when the law was passed. However, as with all grandfathered health plans, we must still comply with certain consumer protections in the Affordable Care Act (for example, the elimination of the Plan’s lifetime maximum). Consequently, because this Plan is “grandfathered” and not required to adopt other changes required by the Affordable Care Act, this Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans (for example, the provision of preventive health services without any cost sharing).

Contact the Fund Office if you have questions about what it means for a health plan to have grandfathered status and what might cause a plan to lose its grandfathered status. You may also contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. The website includes a chart summarizing the protections that do and do not apply to grandfathered health plans.

 

Elimination of Plan Maximums

Under the Affordable Care Act, all group health plans must eliminate the overall lifetime dollar limit. In addition, group health plans must eliminate any annual dollar limits on essential benefits.

Elimination of Annual and Per Treatment Maximums

We are eliminating several annual and per treatment maximums effective April 1, 2011:

         Transplant Benefits: The $10,000 per transplant period limits on Donor Services and Private Duty Nursing for cornea transplants are eliminated.

         Prescription Drug Benefits: The $1,500 Calendar Year limit for Class B Participants is eliminated.

         Smoking Cessation: The $600 lifetime limit on smoking cessation physician office visits and related medications is eliminated. The Plan will now pay 75% of one PRESCRIPTION smoking cessation treatment cycle per Calendar Year.

         Hearing Benefits: The coverage of exam expenses will not be included under the $500 per ear maximum every five years. The Plan will now pay for one exam per Calendar Year with no maximum. Devices will continue to be subject to the dollar maximum.

         Shoe Orthotics: The two-year maximum of $500 is eliminated. The Plan will now pay for one device or pair of devices per Calendar Year.

         Vision Benefits: The Calendar Year maximum of $50 for a Non-Network vision exam no longer applies. The Plan will now pay 100% for a Network or Non-Network vision exam. The vision maximums will continue to apply to lenses, frames and contacts.

Elimination of Lifetime Maximums

Effective April 1, 2011, the Plan eliminated the $1,000,000 lifetime maximum to comply with the Affordable Care Act. Beginning April 1, 2011, it was replaced with a $1,000,000 annual limit. In addition, the $1,000 Lifetime limit on TMJ Treatment was modified and will now apply only to non-surgical treatment. The Plan will also cover one surgical TMJ treatment per Lifetime with no dollar maximum. The Schedule of Benefits enclosed with this announcement reflects these changes.

Special Enrollment Opportunity Due to Elimination of Lifetime Maximum

In February, the Plan distributed information on the $1,000,000 lifetime maximum change and provided a special enrollment opportunity. If coverage for you, your spouse, and/or your Dependent child(ren) ended under the Plan because you reached the current lifetime maximum, you were able to re-enroll yourself and/or your Dependents in the Plan as of April 1, 2011. To receive Plan coverage, you must have requested special enrollment to cover you, your spouse, and/or Dependent children no later than March 31, 2011. If you requested special enrollment by that date, coverage was effective as of April 1, 2011. Your coverage began April 1, 2011 and was not retroactive to when you originally lost coverage.

 

Extension of Dependent Coverage to Age 26

A significant change required by the Affordable Care Act is the extension of Dependent coverage to children up to age 26, regardless of whether they are students, reside with you, and/or are married as of April 1, 2011. You previously received information and an enrollment form with a deadline of March 30, 2011 from the Fund Office describing this change.

 

Revised Definition of Dependent Children

As a result of this extension, the Plan’s definition of a Dependent child changed. Effective April 1, 2011, an eligible Dependent child (whether a student, married or unmarried) includes your:

         Children under age 26 who are your natural children, adopted children, children placed with you for adoption, and stepchildren;

         Children for whom you or your covered spouse are required to provide medical coverage under a Qualified Medical Child Support Order (QMCSO);

         Unmarried child age 26 or older who:

°         Is Permanently and Totally Disabled, which means that the child is unable to engage in any gainful activity by reason of a medically determinable physical or mental impairment that is expected to result in death or last for a continuous period of 12 months or more;

°         Is incapable of sustaining employment by reason of the disability;

°         Experienced the onset of the disability before reaching age 26;

°         Is financially dependent on you for more than one-half of his or her support during the Calendar Year; and

°         Maintains a principal place of residence with you for more than one-half of the Calendar Year.

 

The Fund will continue health care coverage for this child as long as your coverage remains in force and the incapacity continues. Proof of incapacity must be submitted to the Trustees within 31 days of the date the Dependent child’s coverage would otherwise end due to reaching age 26, or, if you are a new Employee, within 31 days after you initially become eligible under the Plan.

An unmarried disabled child who has reached age 26, but does not reside with you will be a Dependent child under the Plan if:

§         The child’s parents are divorced or legally separated under a decree of divorce or separate maintenance, are separated under a written separation agreement, or live apart at all times during the last six months of the Calendar Year;

§         The child’s parents provide over one-half of the child’s support during the Calendar Year;

§         The child is in the custody of one or both of his or her parents for more than one-half of the Calendar Year; and

§         The child is not the qualifying child or qualifying relative of any other person.

Children’s coverage will terminate at the end of the month in which they reach age 26 unless they qualify for extended coverage as Permanently and Totally Disabled.

 

Special Enrollment Opportunity for Children

If you have a child who is under age 26 regardless of whether the child is a student, resides with you, is married/unmarried, or currently receiving continuation coverage under COBRA, that child has a right to coverage under the Plan as of April 1, 2011. This ONE TIME special enrollment opportunity applies to:

         Children whose coverage under the Plan has already ended;

         Children who were previously denied coverage under the Plan; and

         Children who were not previously eligible to enroll in the Plan because eligibility for Dependent coverage under the prior Plan provisions ended before the child reached age 26.

 

You must furnish the Trustees with any requested documentation relating to your Dependents. Required documentation proving Dependent relationship may include one or more of the following:

         Original Birth Certificate—for your children, it must list you and/or your spouse as a parent; and

         Social Security Number.

 

Note: If your Dependent was previously covered under the Plan, you are not required to provide documentation. If you submitted the enrollment form by March 31, 2011, your child’s coverage began April 1, 2011 and is not retroactive to when he/she originally lost coverage.

 

Other Benefit Changes

Coverage under the Plan’s Mental Health and Substance Abuse Benefits is changing so that such benefits will be treated in the same manner as other medical benefits. After you satisfy the individual or family medical deductible, the Plan will now cover 70% of Non-Network provider services with no additional annual inpatient deductible. The Substance Abuse combined inpatient and outpatient limit of three courses of treatment per lifetime is also eliminated.

 

Rescission of Your Coverage

The Plan may rescind your coverage for fraud or intentional misrepresentation of a material fact after the Plan provides you with 30 days notice, as required by law. A rescission of coverage is a cancellation or discontinuance of coverage that has retroactive effect, meaning that it will be effective back to the time that you should not have been covered by the Plan.

However, this does not include situations involving termination of coverage back to the date of loss of eligibility when there is a delay in administrative recordkeeping between your loss of eligibility and notice to the Plan of that loss, when you fail to make timely required self-payments for coverage, or when you and your spouse divorce. For any other unintentional mistakes or errors under which you were covered by the Plan when you should not have been covered, the Plan will cancel your coverage prospectively once the mistake is identified.

 

A Final Note

Please take some time to review this announcement. If you are married, share this information with your spouse. Contact the Fund Office at 262-662-2564 if you have any questions about the benefits described in this notice.

For more information about the Affordable Care Act, you may also contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.

Sincerely,

Your Board of Trustees

This announcement, which serves as a Summary of Material Modifications, contains only highlights of recent changes to the Milwaukee Painters Local Union 781Health Fund. 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 document language will govern. The Trustees reserve the right to amend, modify, or terminate the Plan at any time.

 

Milwaukee Painters Local Union 781 Health Fund
Schedule of Benefits
2011

The following chart highlights key features of the Benefit Plan and indicates in bold the changes effective
April 1, 2011. Certain expenses that you pay toward medical costs may be reimbursable through the Plan’s Health Reimbursement Arrangement (HRA). The HRA credit awarded for participating in the Health Dynamics wellness program increases the amount available to offset your out-of-pocket medical expenses. These benefits are described in detail in the SPD booklet

.

Medical Benefits1

Coverage

Annual Maximum

$1,000,000 per Eligible Person

Annual Deductible

$300 per Eligible Person; $600 family maximum

Out-of-Pocket Maximum

$5,000 per family (does not include deductible)

Pre-Certification Failure Penalty2

$100 per occurrence

Coinsurance
Network Provider
Non-Network Provider

Unless specified otherwise, the Plan pays:
90% of eligible expenses after the deductible
3
70% of eligible expenses after the deductible

Durable Medical Equipment
Network Provider
Non-Network Provider

After deductible, Plan pays:
90%
80%

Ambulance Service
Network Provider
Non-Network Provider

After deductible, Plan pays
90%
80%

Home Health Care
Network Provider
Non-Network Provider
Calendar Year Maximum

After deductible, Plan pays:
90%
80%
60 visits

Emergency Health Services

Plan pays 90% after deductible (network and non-network)

Mental Health and Substance Abuse
Network Provider

Non-Network Provider

Plan pays:
90% after deductible (the first five outpatient visits are covered at 100% before the deductible)
70% after deductible

Dental Services due to Accident 2

Plan pays 90% after the deductible (network and non-network)

Specific Benefit Maximums
Skilled Nursing Facility/Inpatient Rehabilitation
Chiropractic Treatment
Infertility Treatment
Shoe Orthotics
TMJ Treatment

Wigs (due to certain hair loss)



30 days per inpatient stay
24 visits per Calendar Year; $750 per Eligible Person per year
$4,000 per Eligible Person per Lifetime
One device or pair of devices per Eligible Person per Calendar Year
Non-Surgical Treatment: $1,000 per Eligible Person per Lifetime
Surgical Treatment: One treatment per Eligible Person per Lifetime
$500 per Eligible Person per Lifetime

Health Promotion and Cancer Screening Program

Health Dynamics Coverage
(paid at 90% for Class B Participants)

Covered Services

Annual physical exams, mammograms, pap smears, PSA tests, blood tests, pulmonary evaluations, urine analysis

Coinsurance

Plan pays 100% when you receive routine physical exam services through this program in lieu of those available under the Plan’s medical benefits

 

Medical Benefits1

Coverage

Annual Maximum

$1,000,000 per Eligible Person

Annual Deductible

$300 per Eligible Person; $600 family maximum

Out-of-Pocket Maximum

$5,000 per family (does not include deductible)

Pre-Certification Failure Penalty2

$100 per occurrence

Coinsurance
Network Provider
Non-Network Provider

Unless specified otherwise, the Plan pays:
90% of eligible expenses after the deductible
3
70% of eligible expenses after the deductible

Durable Medical Equipment
Network Provider
Non-Network Provider

After deductible, Plan pays:
90%
80%

Ambulance Service
Network Provider
Non-Network Provider

After deductible, Plan pays
90%
80%

Home Health Care
Network Provider
Non-Network Provider
Calendar Year Maximum

After deductible, Plan pays:
90%
80%
60 visits

Emergency Health Services

Plan pays 90% after deductible (network and non-network)

Mental Health and Substance Abuse
Network Provider

Non-Network Provider

Plan pays:
90% after deductible (the first five outpatient visits are covered at 100% before the deductible)
70% after deductible

Dental Services due to Accident 2

Plan pays 90% after the deductible (network and non-network)

Specific Benefit Maximums
Skilled Nursing Facility/Inpatient Rehabilitation
Chiropractic Treatment
Infertility Treatment
Shoe Orthotics
TMJ Treatment

Wigs (due to certain hair loss)



30 days per inpatient stay
24 visits per Calendar Year; $750 per Eligible Person per year
$4,000 per Eligible Person per Lifetime
One device or pair of devices per Eligible Person per Calendar Year
Non-Surgical Treatment: $1,000 per Eligible Person per Lifetime
Surgical Treatment: One treatment per Eligible Person per Lifetime
$500 per Eligible Person per Lifetime

Health Promotion and Cancer Screening Program

Health Dynamics Coverage
(paid at 90% for Class B Participants)

Covered Services

Annual physical exams, mammograms, pap smears, PSA tests, blood tests, pulmonary evaluations, urine analysis

Coinsurance

Plan pays 100% when you receive routine physical exam services through this program in lieu of those available under the Plan’s medical benefits

Transplant Benefits4

Medical Benefits

Insured Policy

Maximum

Subject to Plan’s medical annual maximum

$2,000,000 per Eligible Person per Lifetime

Covered Transplants

Cornea (payable the same as other medical benefits covered under the Plan)

Bone marrow, heart, heart/lung, lung, pancreas, liver, kidney, kidney/pancreas, pancreas, digestive

Donor Services

No maximum

Plan pays up to $25,000 per transplant period for procurement only

Lodging and Meals

Plan pays up to $100 per day for one companion or $200 per day for two companions; up to $2,500 per transplant benefit period

Plan pays up to $150 per day; up to $10,000 per transplant benefit period

Private Nursing Care

No maximum

Plan pays up to $2,000,000 per Eligible Person per Lifetime

Prescription Drug Benefits5

Class A and Class B

Annual Maximum

No maximum

Retail Pharmacy Program
Generic Medication
Preferred Brand Name Medication
Non-Preferred Brand Name Medication

For up to a 34-day supply, you pay:

10%, up to a maximum of $25 per prescription
20%, up to a maximum of $25 per prescription
30%, up to a maximum of $25 per prescription

If you go to a non-network pharmacy, you must pay the full-cost of the medication when you have your prescription filled and submit a receipt to Caremark for reimbursement.

Mail Order Program
Generic Medication
Preferred Brand Name Medication
Non-Preferred Brand Name Medication

For up to a 90-day supply, you pay;
$10 per prescription
$25 per prescription
$30 per prescription

Generic Substitution

If your prescription is filled with a brand name medication when a generic is available, you pay the difference in cost between the generic medication and the brand name medication, plus your preferred or non-preferred brand name medication copayment.

Smoking Cessation Medications
(Prescription and OTC with Rx)

You pay 25%; Plan pays 75% of one treatment cycle per Eligible Person per Calendar Year.

Hearing Benefits6

National Ear Care Plan Coverage

Annual Exam

Plan pays 100% for one annual exam; no maximum

Hearing Aids

Plan pays 100% up to $500 per ear once every five years

Vision Benefits
(Class A and Non-Bargained Class)

Network Provider

Non-Network Provider

Exam

Plan pays 100% once each year

Plan pays 100% once each year

Lenses (single vision7)

Plan pays 100% once each year

Plan pays up to $75 each year

Frames

Plan pays 100% once each year, up to $130

Plan pays up to $75 each year

Contact Lenses (in lieu of lenses and frames)

Plan pays 100% once each year

Plan pays up to $150 each year

Dental Benefits (through MetLife)

Available to Class B Participants on a self-payment basis only

Annual Maximum Benefit

$1,500 per Eligible Person

Type A Services

Plan pays 100%

Type B Services
Network Provider
Non-Network Provider

Plan pays:
90%
80%

Type C Services
Network Provider
Non-Network Provider

Plan pays:
80%
70%

Type D Services
Network Provider
Non-Network Provider

Plan pays:
80%
50%

Orthodontia Lifetime Maximum
Network Provider
Non-Network Provider


$2,500 per Eligible Person
$1,500 per Eligible Person

Death and Disability Benefits
(Class A Employees Only)

Benefits (Not available to Class B or Non-Bargained Class)

Loss of Time Benefits

$325 per week for up to 26 weeks per period of disability

Death Benefits

$15,000 per Employee

AD&D Benefits

$15,000 per Employee (principal sum)

UnitedHeathcare (UHC), working with United Behavioral Health (UBC), will be responsible for pre-authorizing all of your health care benefits.  UBC, UHC’s utilization review provider for mental health and substance abuse, replaces our previous network provider and claims administration for mental health and substance abuse benefits.  THIS MEANS A NEW PHONE NUMBER FOR NOTIFICATION, A NEW NETWORK OF PROVIDERS, AND A NEW ADDRESS FOR SUBMITTING CLAIMS.  (See address above)

 

The Plan requires notification for certain medical benefits.  Generally, when you use network providers, most will notify UHC for you; HOWEVER, when a provider does NOT, IT IS THEN YOUR RESPONSIBILITY TO DO SO.  Notification is required for:

 

Ø       Hospital Admissions

Ø       Durable Medical Equipment that costs more than $1,000 (purchase price or cumulative rental)

Ø       Home Health Care Services

Ø       Elective Skilled Nursing Facility and/or Inpatient Rehabilitation Facility Admissions

Ø       Dental Services Resulting from an Accident

Ø       Reconstructive Procedures

Ø       Transplant Benefits

Ø       Hospice Care

Catalyst Prescription Drug Benefits on Line

http://www.catalystrx.com/

Order replacement ID cards; get information, refills, etc.  The Rx Group is: “MIL781”.

 

MAIL ORDER PRESCRIPTIONS:

Why use Mail Order?  It can save you money!  If you are taking medication to treat any on-going health condition, such as high blood pressure, asthma or diabetes, this is a good alternative.  Let your doctor know that you have a mail order service program that permits up to a 90-days supply of medication, plus refills, for up to one year.  All you have to do is mail in all of the information or ask you doctor to call 1-800-327-9791 for instructions on how to fax the prescription.  Orders are usually processed and mailed within 48 hours of receipt.  IF YOU HAVE ANY QUESTIONS, CALL CUSTOMER SERVICE @ 1-800-818-0093.

MetLife Dental On Line

http://www.metlife.com/dental

At this site, you can locate network dentists and your benefit schedule. You may also register to view YOUR claims online – see “My Benefits” on this website.  Call the phone number listed above for ALL questions concerning your eligibility status, or the status of any dental claims:

 

METLIFE DENTAL CLAIMS

MAILING ADDRESS:

P. O. Box 981282

El Paso, TX 79998-1282

 

Our Dental Program is MetLife Preferred Dentist Program (PDP).  Here is a brief description of the coverage that is NOW in effect IF YOU USE IN-NETWORK SERVICES:

 

Ÿ100% Preventative Dental Care

Ÿ90% Basic Restorative

Ÿ80% Major Restorative

Ÿ80% Orthodontia

ŸANNUAL MAXIMUM BENEFIT $1500 PERSON

ŸNo Deductible

 

Dental benefits will be paid at a lower rate with reasonable and customary charges based on your dentist if you do not use A DENTIST-WHO IS A PARTICIPATING PROVIDER IN METLIFE’S PREFERRED DENTIST PROGRAM (PDP).  (Please note: There are dentists that accept MetLife, but are NOT in the network.  To get the higher coverage, the dentist must be a participating provider in MetLife’s Preferred Dentist Program (PDP).

 

Vision Benefits: 

Effective (retroactively) April 1, 2007, your Health and Welfare Fund is changing Vision Care Benefits.  Your new Vision Care Program is administered by Spectera (a UnitedHealth Group Company).  Spectera has excellent network coverage throughout the state.  Participating in the program is easy.  To find a Spectera Vision provider call 1-800-839-3242 or go to their website at www.spectera.com

 

Loss of Time Benefits:

As an active eligible participant, you may receive loss of time benefits if you are unable to work because of an injury or illness, provided you are under the care of a legally qualified physician.  You may be eligible for the loss of time benefit of up to $300 (pre-tax) per week.  Loss of time benefits are payable for up to 26 weeks for any one period of disability.  If you are being treated for alcoholism or substance abuse (both of which require pre-certification), loss of time benefits are limited to up to 13 weeks.  IF YOU ARE RECEIVING LOSS OF TIME BENEFITS, YOU ARE NOT ENTITLED TO COLLECT UNEMPLOYMENT BENEFITS AT THE SAME TIME!

 

Benefits begin on the first day of absence from work due to a non-occupational injury or illness.  Successive periods of disability due to the same or related causes are considered one period unless they are separated by return to active, full-time employment.

 

You must provide the Health Fund with a medical certification from a legally, qualified physician on a continuing basis.  Payment is withheld until your injury or illness is medically documented.

 

Health Dynamics Program:

This is the Plan’s Health Promotion and Cancer Screening Program.  This is a comprehensive physical that includes blood tests, EGK, etc. which is done at a discounted rate  versus the full cost of over $750.00.  For an active, eligible participants, the Fund pays 100%of the cost for the member and spouse only (other dependents not included) to take the Health Dynamics physical once per calendar year. (For Class B retirees only, the Plan will pay 90% after your deductible is satisfied.  This benefit is NOT available to other retirees.)

 

FUND OFFICE:

S68 W22665 National Avenue

P. O. Box 189

Big Bend, WI 53103-0189

Telephone: (262) 662-2564

Facsimile: (262) 662-2860

 

Office Hours: 8:00 a.m. to 4:30 p.m. (weekdays)

 

IUPAT, 781 Health Fund Trustees

Labor:

Management:

Joe Jazdzewski Secretary/Treasurer

Michael Chmielewski

Chairman

Joel Allen

John Topp

Adam Holmes

Will Stevens

 

Support Staff:

Joyce Gutilla

Administrator

Patty VanWilligen

Administrative Assistant

 

PLEASE NOTE

The information provided here is intended to give you a brief glance at the benefits available through the Milwaukee Painters Local 781 Health Fund.  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 document language will govern.  The Trustees reserve the right to amend, modify or change the Plan at anytime.

 

 

Appeals:

If you feel a claim has not been paid properly, you have the right to appeal the payment.  The appeal must be submitted in writing to:

 

Attention: Board of Trustees

Milwaukee Painters Local 781 Health Fund

P. O. Box 189

Big Bend, WI 53103-0189

 

Please include a copy of the Explanation of Benefits (EOB) form as well as any pertinent information and documentation related to your appeal.  The trustees meet once per month (if this is an emergency situation, please call the Health Fund @ 262-662-2564), you will receive a written notice of the Board’s decision within five (5) days of the meeting date.

 

Eligibility Requirements:

You will be able to participate in the Health Plan on the first of the month after you are credited with at least 650 hours of employer contributions for work performed in a period of at least six (6) consecutive months, but no more than twelve (12) consecutive months.

 

To maintain eligibility, you must be credited with 1300 hours of employer contributions in the preceding four (4) work quarters.  If you are “newly eligible” or have not been eligible for 12 months, you must be credited with 325 hours in the preceding quarter.

 

Coverage quarters are as follows:

 

1st

Jan/Feb/Mar

2nd

Apr/May/June

3rd

July/Aug/Sept

4th

Oct/Nov/Dec

 

Your eligibility will end if you do not have enough credited employer contribution to meet the continued eligibility requirements and do not pay your SELF PAYMENT bill.  Eligibility may be reinstated on the first day of the next Coverage Quarter after you are credited with at least 325 hours of employer contributions in a 3-month consecutive period.  If you remain ineligible for a period of 12 consecutive months or longer, you must meet the initial eligibility requirements to participate in the Health Plan again.

 

Self-Payment Bills:

Self-payment bills are issued when eligibility requirements are not met.  This bill is sent to participants at the beginning of each quarter when the 1300 hours are not attained in a 12-month period.  It will clearly indicate the hours credited on your behalf and by which employer(s).

 

Here is an example:

Joe Smith worked 1250 hours:


1300 hours
(minimum eligibility requirement)


Minus:

1250 hours credited

on his behalf


Equals:

50 hours (short of eligibility requirement)


50 Hours


X $8.20

health contrib. rate


= $410.00


$410.00 divided by 3 months = $136.67 per month

 

Your self-payment is $136.67for each month in that quarter.  Payment is due by the 15th day of each month.  If your payment is not made, your insurance coverage will be terminated.  If you worked hours that were not recorded, you may bring in your pay-stubs and you will be credited for the hours.  As a reminder, keep all of your pay-stubs for your protection in credited work hours.

 

PLAN ON RETIRING – PRE-FUNDING CREDIT:

If you an active, eligible participant and plan on retiring, you need to contact the Health Fund Office 2 months in advance.  At retirement, we total all the straight time hours that were credited from employers and self-payment bills.  Credits are awarded for all the hours worked in covered employment under this Health Fund with a minimum of 5 years and a maximum of 30 years of service with certain limitations.

 

The current service credit of $14.13 per month is payable to a participant who retires after the age of 63 with at least 5 years of service.  If you retire prior to age 63, the service credit is reduced by 2% per year for each year that a retiree’s retirement age is less than 63.  The program is the Pre-Funding Credit.

 

Here is an example of the pre-funding calculation  (2007 Rates used in illustration):

 

 

 

Group

 

Gross 

Premium


 (
30 years service)

Credit


Premium

After

Credit


Pre

Medicare

 

$935.85

 

$423.90

 

$511.95


Post

Medicare

 

$10.00

 

$142.20

 

-($132.20)

 

 

$423.90 ($14.13 x 30 = $423.90) until he reaches Medicare eligibility age of 65.  After he is eligible for Medicare, his self-pay credit will be $4.74 x 30 equals $142.40.  The $4.74 is the 2002 rate.  Credit rates change.

 

If you are under the age of 65 and retire from active employment, you may be eligible to make self-payments to continue health coverage for yourself and your non-Medicare eligible dependents as Class B participants.  The Class B Plan Coverage includes major medical, prescription drug and hearing aid benefits for you and your eligible dependents.