Welfare Fund
Summary of Medical Coverage Rules:
For initial eligibility a participant must work a minimum of 70 hours per month for six consecutive months. The participant will become eligible on the first day of the seventh month after working six consecutive months of at least 70 hours per month.
To maintain continuous coverage:
After initial eligibility has been achieved a participant can maintain continuous coverage in several different scenarios:
The 420 Hours Worked Rule:
A participant’s coverage will be extended by six months by working 420 hours in a six month period. Please note that coverage by the 420 hour rule is measured in six month blocks, one right after the other. A participant will have continuous coverage as long as he/she works 420 hours in a six month period.
The 70 Hours Worked Rule:
If a participant has failed to reach 420 hours in a six month period after initial eligibility has been obtained he/she will be credited for an additional month of coverage for every month of 70 hours worked in that six month period. Please note that because the participant failed to work the minimum 420 hours to extend coverage he/she must work 70 hours per month for six consecutive months or 420 hours in the extended coverage period to maintain eligibility.
WELFARE FUND DEPENDENT ELIGIBILITY FOR AGES 19 TO 26
Coverage for Dependent Children up to Age 26
Effective January 1, 2011, the Fund will extend coverage to participant’s eligible children up to the day on which the child attains age 26. Eligible children include natural children, legally adopted children, children placed for adoption, and children for whom the participant is the legal guardian. You must provide the Fund Office with satisfactory proof that such children are your dependents. Such proof may include adoption papers, birth certificates, marriage certificates and other additional information as required.
Coverage is available whether the child is married or unmarried, regardless of student status, employment status, financial dependency on the participant, or any other factor other than the relationship between the child and the participant. However, through December 31, 2013, in order to receive such coverage, children who are at least 19 (but below age 26) cannot have access(1) to health insurance coverage through an employer (besides that of another parent’s employer). Please note that if the child is married, coverage, however, will not be extended to the child’s spouse or children.
If you remain eligible under the Fund, coverage for the eligible dependent child will generally be provided until the child attains age 26 (i.e., the child’s 26th birthday).
For children for whom the participant is the legal guardian (excluding natural children, legally adopted children and children placed for adoption), in order to be considered a dependent, the child must be a dependent under federal tax law for the purposes of health benefits (as a qualifying child or qualifying relative under Section 152 of the Internal Revenue Code, as modified by Code Section 105) such that the value of the benefit would not be included in your gross income. In order to continue coverage for any such child under this provision, you will be required to submit proof of dependency under federal tax law.
Currently, the Fund provides coverage to unmarried children who are physically or mentally disabled as defined by New York Mental Hygiene Law, provided the condition started before the age when coverage would have normally ended. Effective January 1, 2011, the Fund will no longer provide such coverage beyond age 26. If your dependent child qualified for this coverage prior to January 1, 2011, he/she will remain under coverage until such time that they are no longer eligible under the prior rules (i.e., the child is no longer physically or mentally disabled as defined by New York Mental Hygiene Law or the participant is no longer eligible for family coverage under the Plan). Once coverage is lost, such dependent age 26 and older will not be re-enrolled in the Plan.
As a result of this change, the Affordable Care Act provides a special enrollment opportunity for certain children under age 26. Specifically, if you have a child who is under age 26 (whether married or unmarried), including a child currently receiving continuation of coverage under COBRA, that child may be eligible to enroll in the Plan as of January 1, 2011. This special enrollment opportunity applies to:
· Children between the ages of 18 and 23 who are currently enrolled in the Plan,
· Children who were not previously eligible to enroll in the Plan,
· Children who were previously denied coverage under the Plan, and
Children whose coverage under the Plan already ended.
(1)Access – denotes that the dependent child is eligible to enroll in, or purchase health coverage through an employer (regardless of the costs of that coverage or the benefits it provides). In addition, eligibility for coverage under a group health plan of the child’s spouse’s employer constitutes access to “health insurance coverage through an employer.”
You must request special enrollment on behalf of your child (and yourself) and return completed enrollment form no later than December 31, 2010. If you request special enrollment by that date, coverage will be effective on January 1, 2011.
Please note: If you have a child who is age 19 or above and you want that child enrolled on January 1, 2011, you must complete a new enrollment form on or before December 31, 2010 even if your child is already enrolled. If enrollment materials are not received by December 31, 2010, you may still enroll your dependent child. However, coverage will be effective the first day of the month following the date the Fund Office receives your completed enrollment materials.
As of January 1, 2011 dependents who are full time students no longer have to submit a letter from an accredited school to maintain medical coverage. All dependents between the ages of 19 to 26 must submit a completed enrollment form in order to be covered under the Welfare Fund Medical Benefits. If your dependent is between 19 to 23 and is currently covered under the Welfare Fund Medical Benefits you must submit a completed enrollment form by December 31, 2010 to maintain coverage.
As of January 1, 2011 any dependent between the ages of 19-26 who has not submitted a completed enrollment form, will not be eligible for Welfare Fund Medical Benefits. Benefits will be terminated for all dependents age 19 and over who are currently covered under the Welfare Fund Medical Benefits who fail to submit a completed enrollment form by December 31, 2010. Benefits will not be reinstated until a completed enrollment form is sent the Benefit Funds Office.
ALL MEMBERS HAVE PREVIOUSLY BEEN MAILED THE ENROLLMENT FORM IN A MAILING DATED DECEMBER 1, 2010 AND IN A MAILING DATED DECEMBER 14, 2010.
If you wish to request special enrollment form for your dependent child, please contact the Fund Office at (718) 784-8883.
WELFARE FUND BENEFIT MODIFICATIONS;
Optical Benefits
The $120 annual dollar maximum for expenses incurred in connection with obtaining optical services has been eliminated effective January 1, 2011 for covered eligible dependent children up to the age of 26. Eligible dependent children are now eligible for reimbursement for one optical exam per year without limit plus expenses incurred in connection with obtaining one pair of eyeglasses or contact lenses every year to a maximum of $120. Please note that there remains a $120 annual maximum for covered optical benefits per eligible covered employee, spouse, and dependent above age 26.
Discontinuation of Blood Benefit
Effective January 1, 2010, the Fund will no longer be offering the standalone Blood Benefit that allowed for reimbursement for up to four pints of blood for a transfusion in any one year at an allowance not to exceed $35 per pint. Blood benefits covered under Hospital and Medical benefits will remain unchanged.
Elimination of Lifetime Maximum on Benefits
The $1,000,000 lifetime dollar maximum for out-of-network hospital and medical benefits has been eliminated effective January 1, 2011.
Any eligible individuals whose benefits ended by reason of reaching the $1,000,000 lifetime limit under the Plan are able to have coverage restored with an unlimited lifetime maximum for hospital and medical benefits. Individuals have 30 days from the date of this notice to request enrollment.
As always, if you have any questions regarding these benefit modifications, please contact the Fund Office at (718) 784-8883.
