When and how do I become eligible for coverage?
You become eligible for coverage the first day of the third month following the month in which 210 hours have been reported and paid into your reserve account. These hours must be worked within two consecutive months. Eligibility is determined using an advanced eligibility system. For example, if you worked a total of 210 hours in February and March, and these hours were reported and paid for by your employer in April, your eligibility would begin in June.
Once I am eligible, how long will I be covered?
You will be covered so long as the hours reported and paid in by your employer each month total at least 105. As an example of how advanced eligibility operates, hours worked in May would be reported and paid in June; these hours would provide your coverage in August.
How does my reserve account work?
Hours are reported and paid in by your employer following the month in which they were worked. You need to work 105 hours in the work month to be eligible in the coverage month. Any hours in excess of 105 are placed into your reserve account. If in a month, you have fewer than 105 hours reported, you can use any hours in your reserve account to make up the difference.
Is there a limit to the number of hours that I can have in my reserve account?
Yes. The maximum number of hours that you can have in your reserve account is 420.
What are my coverage plan options?
For medical coverage, you have a choice of three plans: Kaiser, the Blue Shield HMO or the Blue Shield PPO. Dental benefits are provided on a self-funded basis through Premier Access, and vision benefits are provided through Vision Service Plan.
Which plan is better?
All plans are excellent. You should carefully study the comparisons to determine which plan would suit you and your family best. The Kaiser Plan requires all services to be obtained at Kaiser facilities with Kaiser’s practitioners. The Blue Shield HMO contracts with providers. All care must be coordinated through the HMO primary care physician that you choose. Family members may choose different primary care physicians. Participants in the Blue Shield PPO plan may visit any provider. Your benefits will be higher when you visit providers who are contracted with the Blue Shield PPO. You can enroll in the Blue Shield PPO plan only if you do not reside in one of the HMO service areas.
Does my plan have chiropractic/specialist coverage?
Yes. Please refer to your summary plan description for details.
How do I enroll in my chosen plans?
To ensure that you and your dependents are covered in the Northern California Plasterers plan, you must complete the Enrollment Form that is sent to you by Health Services & Benefit Administrators when you first become eligible for coverage. In order to enroll in one of the medical plans, you must also complete an application for that plan. Please contact Health Services & Benefit Administrators if you need assistance or have any questions about enrolling in a medical plan.
How do I add or delete dependents on my health plans?
You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to Health Services & Benefit Administrators. Please read the form carefully, as you are required to submit the appropriate documentation, i.e., birth or marriage certificate, divorce decree, etc. If you prefer, you can also contact Health Services & Benefit Administrators directly for this form. You must also complete the appropriate form for your medical plan to have the change reflected in your medical coverage.
My child has reached the limiting age, but he is completely dependent on me for support due to a physical limitation. Is there a way I can extend his coverage?
Yes. If you have a dependent child with a mental or physical limitation, you can continue his coverage provided that the following requirements are met: your child is chiefly dependent on you for support; your child is not capable of self-sustaining employment; and you give us proof of the child’s handicap: (1) not later than 31 days after the child attains the limiting age; and (2) thereafter as the Trustees may require, but not more than once every two years, by completing a Request for Continued Coverage for Incapacitated Child form.
How/when can I change plans?
The Plan conducts an annual open enrollment. During this open enrollment period, you will have the opportunity to change your medical plan, if you wish. You will be notified by Health Services & Benefit Administrators when the open enrollment period begins.
How do I file a claim for reimbursement?
Neither the Kaiser nor Blue Shield HMO require claim forms. If you are enrolled in the Blue Shield PPO and use a non-PPO provider, you can get a claim form from BlueShield.
I need to see a Doctor, but I don't know who to go to. Do you have a list of doctors near where I live or work?
If you are in one of the Blue Shield plans, you can get a list of providers close to you at the Blue Shield website. Kaiser participants can obtain information on providers at www.kaiserpermanente.org.
I need to fill my prescriptions – what pharmacy can I use?
Participants in one of the Blue Shield plans must get their prescriptions filled at a pharmacy that contracts with Blue Shield. Kaiser participants must have their prescriptions filled at Kaiser pharmacies.
I tried to pick up my prescription but the pharmacy told me that I need “prior-authorization.” What should I do?
Certain prescriptions require prior authorization from the health plan in which you are enrolled. Most pharmacies will work this through directly with Health Net and your doctor’s office. If this is not the case, your physician‘s office can contact Health Services & Benefit Administrators for assistance.
Do I need an ID card for medical and dental?
Your medical plan will issue you an ID card upon enrollment. These must be used for all medical appointments. There are no ID cards for self-funded dental benefits; simply provide your dental office with Health Services & Benefit Administrators’s phone number, (844) 663-8121, to verify your eligibility and benefits.
Does the dental plan have a PPO?
Yes, the dental plan utilizes the Premier Access PPO. You may visit any licensed dentist. The costs to the Plan are lower if you utilize a dentist who is contracted with Premier Access. You can search for Premier Access PPO providers in your area at their online provider directory.
Is there a claim form specifically for dental claims?
There are no claim forms necessary if you visit a Premier Access dentist.
I went to my doctor’s appointment today, but I was told that my coverage is terminated. I've been working steadily. Am I covered for the visit?
If there’s ever a question regarding your eligibility, contact Health Services & Benefit Administrators. We’re here to help you sort it out.
I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?
You received this notice because you had a COBRA Qualifying Event. The most common reason for this is the combination of current hours worked and the hours in your reserve account was less than 105 hours. Other COBRA Qualifying Events include divorce, death of the participant, or a dependent child’s reaching the maximum age limit. In each of these instances, you will have lost eligibility. If you wish to sign up for COBRA coverage, you must return the application to Health Services & Benefit Administrators within 60 days of the date of your Qualifying Event.
What is the self-pay benefit I’ve been hearing about? Is it the same as COBRA?
The self-pay benefit is available to active participants who are on the out-of-work list at the union local. The self-payment required is less than the COBRA payment, and there is a maximum number of months in which you can have subsidized self-pay coverage. There are additional requirements to qualify for this period of subsidized self-pay coverage. To see if you are eligible for self-pay coverage, you can contact Health Services & Benefit Administrators.
I'm on disability/worker's comp or FMLA. How do I continue my coverage?
The Trust offers disability coverage for a specified duration. You should contact Health Services & Benefit Administrators for more information. After the period of disability coverage provided by the Trust at no cost to the member, you can also elect to take COBRA coverage. FMLA coverage is through your employer only, and you must contact your employer to determine what steps you need to take.
Points Account FAQ
What is a Points Account?
Beginning with hours worked in July 2000, active employees can earn points credits for hours of covered employment, provided that the employment is in the jurisdiction of Plasterers Local Union No. 66. These credits accrue in a “Points Account,” for the active employee. Effective January 1, 2004, Points Account balances may be used to pay for certain Plan premiums or to receive reimbursement for qualified medical expenses that are not covered under a plan of benefits.
Any employee who (1) is eligible for benefits under the Plan, or (2) was eligible for benefits under the Plan within the prior 36 months, including through COBRA coverage, and who has maintained his or her enrollment continuously on the out-of-work list of the Local Union and been available for dispatch since his last period of Plan coverage, may be reimbursed from his or her Points Accounts for qualified expenses that are not otherwise covered under the Plan.
In which circumstances can I use my Points Account balance to pay for premiums?
Points Accounts may be used for premiums under the following circumstances:
- You are a retired participant who is making a retiree self-payment.
- You are a disabled participant who is paying the premium for COBRA Continuation Coverage. If you remain disabled, you may continue to purchase coverage through your Points Account until it is exhausted.
- If you die, your eligible dependents may use your Points Account to pay their COBRA premium, and may continue to purchase coverage through your Points Account until it is exhausted.
Can I use my Points Account to pay for COBRA if my loss of coverage is due to low hours?
Effective January 1, 2009, you can use your Points Account to pay for COBRA and self-pay coverage if the qualifying event is low or no hours. Please note that there is no guarantee that this provision will be permanent.
How do I use my Points Account to pay for premiums?
To use your Points Account to make a retiree self-payment or COBRA payment, you must complete and submit a Premium Payment/Reimbursement Request Form to Health Services & Benefit Administrators. Payment through your Points Account will be made on an ongoing basis until the balance is exhausted or you regain active coverage through employment, whichever is first. It is your responsibility to notify Health Services & Benefit Administrators if you return to work and wish to have the payments through your Points Account cease.
What are the qualified medical expenses that I can use my Points Account for?
Any active or retired participant can obtain reimbursement for medical expenses, which are not covered under this plan, provided that the expenses meet the definition of “qualified medical expenses,” under §213d of the Internal Revenue Code. The minimum amount of reimbursement that may be requested is $300. You must submit a Premium Payment or Reimbursement Request form, along with evidence of the expense, to Health Services & Benefit Administrators, so that your reimbursement request may be considered. Please note that, effective January 1, 2011, you must have a prescription for over-the-counter drugs and medicines to use your Points Account for these expenses. This does not apply to insulin, though, for which expenses may be reimbursed even without a prescription.
Examples of qualified medical expenses include (but are not limited to):
- dental services that are not covered under the plan;
- eye examination fees and procedures (for example, LASIK surgery);
- laboratory services and procedures that are not covered under the plan;
- chiropractor’s fees beyond plan limits;
- psychiatrist’s fees beyond plan limits.
Types of expenses that are not reimbursable include funeral expenses, cosmetic surgery, marriage counseling, and health club fees. For more information on qualified medical expenses, refer to IRS Publication 502: Medical and Dental Expenses.
How will I prove that I purchased an over-the-counter drug with a prescription?
You should keep a copy of the prescription for the over-the-counter drug, and a receipt showing the date and amount paid; or a receipt that has the name of the person for whom the drug was prescribed, the date and amount paid, and an Rx number.
Do other over-the-counter products, such as medical equipment, supplies and devices require a prescription to qualify for Points Account reimbursement?
No, the new rule that became effective January 1, 2011, due to health care reform, only applies to medicines and drugs. It does not apply to over-the-counter medical equipment, such as crutches, supplies, such as bandages, or diagnostic devices, such as blood sugar test kits. The cost of these items may still be reimbursed from your Points Account.
Is my Points Account a vested benefit?
No, your Points Account may be forfeited if you work for a non-union signatory employer in any capacity, or if you are not covered under the Welfare Plan for three consecutive calendar years.