Eligibility and Cost of Coverage

Unless otherwise specified, all answers apply to Plans A, B and C.

Q. How many hours are required for initial or reinstated coverage under Plan A or Plan B?
A. An Employee must receive credit for 260 hours within 12 consecutive months.

Q. When will new or reinstated coverage under Plan A or Plan B go into effect?
A. Coverage will become effective the first day of the second month following the month in which the 260th hour was worked. Example: The Employee works 100 hours each in January, February and March. Their coverage will commence May 1st because the 260th hour was worked in March. If the Employee in the above example worked 130 hours each in January and February their coverage would become effective April 1st.

Q. How will I know I have qualified for new or reinstated coverage under Plan A or Plan B?
A. The Trust Office will send a package containing information pertaining to all coverages. It is recommended that participants track their hours may contact the Trust Office to facilitate this process after working their 260th hour.

Q. Who may be covered under new or reinstated coverage?
A. Under Plan A all eligible Dependents of the Covered Employee will automatically be covered by the Plan for each month the Employee remains covered. Under Plan B the Employee cover age for their eligible Dependent(s) is optional and must be elected on a timely basis.

Q. Can I add my brother/sister/ parent/significant other to my coverage?
A. No. Eligible Dependents are an Employee’s Spouse, unmarried natural child(ren), step-child(ren) and legally adopted child(ren). See definitions for details.

Q. When does a new Dependent become covered?
A. Under Plan A, at the moment of marriage, birth or placement in the Employee’s home for the purpose of adoption. Marriage, birth certificates and new Enrollment Cards should be remitted within 30 days. Under Plan B the above would apply if dependent coverage was in effect at the time of the event, otherwise Dependent coverage may only be added as part of the next open enrollment.

Q. Why are there two months between the work month and coverage month?
A. To permit contributing employers sufficient time to prepare and remit their monthly payroll reports (due by the 15th of the following month), and for the Trust Office to process all data and then send advance notices to those did not satisfy their cost of coverage so they can make a direct payment. Example: January hours are used to determine April coverage.

Q. Where do my excess hours in Plan A or Plan B go?
A. For Bargaining Employees any hours reported in excess of their monthly cost of coverage, up to maximum of 1,000 hours, will remain in their reserve account to be available to be used to maintain future coverage when less than the Employee’s required cost of coverage may be reported for a given month.

Q. Can I lose my coverage and reserve account hours if I work non-Union?
A. Yes. Coverage will immediately cease and all reserve account hours will be frozen. If you return to covered employment and re-qualify for coverage within 12 months then all frozen reserve account hours will be reinstated and become available on a prospective basis.

Q. If I am out of work will my coverage continue?
A. Yes, so long as there are sufficient hours in the Employee’s reserve account to cover their cost of coverage and they are eligible to use those hours in accordance with the Rules of Eligibility and/or they are eligible to make a Direct Payment or COBRA payment.

Q. If I am short hours can I pay to maintain coverage?
A. Yes, so long as the Bargaining Employee is eligible to do so in accordance with the Rules of Eligibility. Direct Payments are calculated by multiplying the number of hours the Employee is short by the then current Plan A portion of the overall Health & Welfare contribution rate.

Q. When is a Direct Payment due?
A. Even though the deadline for remitting a payment is the last day of the month it is recommended that payment be received by the end of the month before coverage terminates in order to avoid any delay in having coverage verified or claims paid.

Q. How long can I make Direct Payments to maintain continuous coverage?
A. The first 12 months of COBRA Continuation Coverage runs concurrent with the maximum of 12 consecutive Direct Payments. Provided a Bargaining Employee receives credit for at least 50 hours within a continuous 12 calendar months the period for remitting Direct Payments starts over. Once 12 consecutive months have elapsed without at least 50 hours being reported there will be a maximum of 6 more payments accepted for COBRA coverage (17 if Totally Disabled) in accordance with the Rules for Continuation Coverage.

Q. What is needed to properly enroll my family for coverage under Plan A or Plan B?
A. The initial enrollment package will contain an Enrollment Card, which must be completed and returned to the Trust Office. Birth Certificates with the parents names on them are required for all Dependent Children. Marriage certificates, as well as legal papers for stepchildren, adopted Children and guardianship may also be required to properly establish dependency.

Q. When can I change my medical coverage under Plan A?
A. Each October all participants are given the opportunity to select their desired medical coverage, if applicable, for the upcoming calendar year commencing January 1st. If coverage is temporarily terminated during a calendar year, and is subsequently reinstated, the coverage previously in effect as of the date of termination will be reinstated for the balance of the calendar year.

Q. Until what age will eligible dependent children be covered?
A. Until they turn age 26.

Q. How do I designate my beneficiary for life insurance?
A. This may be done at any time by completing a new Enrollment Card.

Q. What is the monthly cost of coverage?
A. This is the minimum number of hours established by the Board of Trustees required to maintain Plan A or Plan B coverage. The cost of supplemental life insurance is reflected as additional hours derived from the current cost of such coverage and the current contribution rate. For Plan C this is the cost for medical and/or dental coverage(s) established by the Board of Trustees.

Q. Why might the Plan A HMO cost of coverage be so much more than the PPO plan?
A. The cost of coverage is determined taking into consideration actual operating and claim/premium costs associated with each Plan. If claim or premium costs for one Plan are much higher than for the other, the difference will be reflected in the monthly cost of coverage.

Plan A PPO Schedule of Benefits

Q. What is a PPO and who are PPO Providers?
A. A Preferred Provider Organization is a panel of Hospitals, Physicians and ancillary Providers who offer negotiated fee discounts to participants who use their services.

Q. How can I find out who are PPO Providers?
A. Each participant is provided a directory of all local panel Providers within the PPO or they can be located via the web site noted on the inside cover of this booklet or on the Identification Card.

Q. Are there PPO Providers outside San Diego County?
A. Yes, it is possible to access the national panel of PPO Providers via the web site noted on the inside cover of this booklet or on the Identification Card. There are now PPO Providers in certain parts of Mexico.

Q. What happens if I use a non-PPO Provider?
A. Since there are no discounts to the non-PPO Provider fees, the Plan will pay a lower percentage of the charges and the participant is obligated to pay the entire balance due.

Q. How much should I pay when using a PPO Provider?
A. Unless there is an office or drug co-payment required at the time of service nothing should be paid until you receive the Explanation of Benefits (pink copy) from the Trust Office reflecting the amount paid to the Provider and how much is owed under ‘Member Owes”. Do not pay the portion of the charges identified as ‘PPO Discount”.

Q. What is a Pre-existing Condition?
A. Any physical or mental condition for which a Covered Person sought care, medical advice, treatment or diagnosis within the 6 months immediately prior to their effective date of coverage. However, there is no Pre-existing Condition exclusion applicable to eligible Dependent Children under age 19.

Q. Are Pre-existing Conditions covered under the Plan?
A. Basically, there is no coverage for expenses relating to a Pre-existing Condition for the first 12 months of coverage. However, in accordance with HIPAA rules, the exclusion period may be shortened by each month the newly Covered Person can demonstrate they were covered by another group health plan for part or all of the 12 months immediately preceding their effective date of coverage.

Q. What is a calendar year deductible and how much is it?
A. This is the initial amount of Eligible Expense each calendar year (presently $250 per person) that the participant must pay before the Plan starts covering 80% of Eligible Expenses. However, office visit and prescription drug co-payments are not subject to a deductible.

Q. Is it possible not to have to satisfy a calendar year deductible?
A. Yes. If the full $250 deductible for a calendar year is satisfied by services rendered between October and December then that will also satisfy that Covered Person’s deductible for the next calendar year.

Q. What is an office co-payment and how much is it?
A. This is the amount noted in the Schedule of Benefits that a participant must pay toward the charge for an office visit with a PPO Provider. Any other services by the PPO physician or all charges for services rendered by a non-PPO Provider will be processed in accordance with the Schedule of Benefits.

Q. What is the maximum out of pocket cost per calendar year under the PPO Plan?
A. Presently under the PPO Plan $1,500 (excluding office and drug co-payments) is the maximum that a Covered Person is required to pay after the calendar year deductible is satisfied. This means the Plan pays 80% of the first $7,500 of Eligible Expenses and 100% thereafter. Out of pocket costs for non-PPO Providers will be much higher.

Q. Is there a maximum amount of benefits payable in a calendar year?
A. Yes, presently the Schedule of Benefits provides for an annual maximum of $2,000,000.

Q. Do I need a select or go through a primary care physician under the PPO Plan?
A. No.

Q. Can I select my own physician/hospital/facility under the PPO Plan?
A. Participants may select any Provider desired, preferably from within the PPO in order to receive the discounts and higher Plan reimbursement levels.

Q. Do I have to use a Hospital emergency room for emergency services?
A. No. Physician’s offices or free-standing Urgent care facilities should be used when there is a viable alternative and time is not of the essence. The costs for such services will be much lower. Unless the patient is admitted to the Hospital from the emergency room a much lower portion of the bills will be covered by the Plan.

Q. Should I use a Hospital for out-patient laboratory and x-ray services?
A. No. Using a physician’s office or Non-hospital laboratory/radiology facility will be much less expensive as Hospitals do not have pre-negotiated fees under their PPO Agreements.

Q. Does the Plan cover chiropractic/acupuncture services?
A. Yes. However, there are daily and calendar year limits noted in the Plan.

Q. What are usual & customary fees?
A. The fee usually and customarily charged by other than Hospitals for the service in a particular geographic area. Since all PPO Providers have agreed to a negotiated discount schedule these represent the usual and customary charge for that service to be considered under the Plan.

Q. What happens if an Employee or their Spouse is covered at the same time under more than one group health plan?
A. The Plan will ‘coordinate” between the two or more coverages so that no more than 100% of Eligible Expenses will be paid. The plan covering the Employee or Spouse as the insured will always be primary and any other coverage will be secondary.

Q. Which plan would be primary for Dependent Children?
A. The plan of the parent whose birthday falls earlier in the calendar year will be primary, regardless of which parent is older. This process can be more complicated if there are additional coverages resulting from applicable domestic relations orders.

Q. Why are there two ID cards in the enrollment package?
A. So the Employee and their Spouse or other Dependent(s) may have a card in their possession. Additional cards may be requested from the Trust Office.

Q. What information is on the Trust ID card?
A. Information outlining important features and requirements of the Plan, as well as telephone/web site access to all service Providers.

Q. How long does it take to receive the Navitus prescription ID card?
A. Navitus cards will be mailed to the participant directly from Navitus within two weeks of enrolling for medical insurance through the Trust Office.

Q. Where should I go to fill a prescription?
A. Please go to your secure Navitus member portal to find preferred network pharmacies near you. Please note: Wal-Mart Pharmacies, Walgreens, and Rite-Aid are NOT in-network.

Q. How much do I pay when filling a prescription?
A. Please go to your secure Navitus member portal to check prescription prices. To keep your out-of-pocket cost down, please use generic alternative if exists.

Q. Are generic drugs required?
A. Yes, whenever a generic alternative exists. If not, one of the preferred brand names on a list established by Navitus is recommended.

Q. Does Navitus offer a mail order option?
A. Yes! With Costco’s mail order service, you can get up to a 90-day supply of your maintenance drugs. Click here for more information.

Q. Does Navitus offer a vaccination program?
A. Yes! Sometimes it is more convenient to go your preferred network pharmacy to receive routine vaccinations.  Note: Call your pharmacy PRIOR to your visiting to ensure the pharmacists on staff are certified to give a vaccine and to find out if you are required to bring a prescription.  Remember to bring your Navitus pharmacy benefit ID card. Click here for more information.

Q. What is the Members’ Assistance Program (MAP)?
A. The MAP is a network of clinically trained mental health specialists.

Q. Are there separate Providers for mental health benefits?
A. Yes. The Plan provides for a series of free sessions for assessment and counseling through the Members’ Assistance Program (MAP), as well as out-patient/in-patient mental health and substance abuse coverage through an exclusive contractual arrangement with another Provider. For other than emergency Hospital admissions it is required that the MAP be accessed to receive a referral for all mental health/substance abuse treatment.

Health Maintenance Organization (HMO) Benefits (for Plans A, B & C)

Q. What are the advantages of an HMO?
A. Under an HMO Plan, covered benefits are provided for either no charge or for a fixed co-payment so long as HMO physicians and facilities are used.

Q. Under an HMO, can I select my primary care physician?
A. Yes, provided the physician is an HMO physician under the Plan you selected. Each family member is encouraged to select a primary care physician who must be consulted first for all non-emergency treatment.

Q. Can I change my primary care physician?
A. Yes, you are allowed to change to another primary care physician at any time.

Q. What if I go to a or facility outside of my HMO?
A. Unless the HMO you selected referred you to a specialist, there are no benefits available if you use a physician or facility outside of the HMO.

Q. Are services for medical emergencies a covered benefit under an HMO?
A. Generally yes, subject to the established rules of the HMO. The HMO has specific benefits for emergency services, within or outside the HMO service area.

Q. Must I live in an HMO service area in order to be covered by the HMO?
A. Yes, you must reside in a zip code area recognized by the HMO.

Dental and Vision Benefits

Q. Should I use only Delta Dental Providers?
A. Yes, in order to obtain maximum coverage and lowest out-of-pocket costs.

Q. Are there different benefits payable within the Delta Dental program?
A. Yes, higher benefits are payable when a PPO Provider is used as opposed to all other Delta Dental Premier Providers. PPO Providers also charge the Plan less than other Delta Dental Providers.

Q. What is the Delta Dental group number?
A. #1978.

Q. How much should I pay the dentist at the time of service?
A. Usually there is little or nothing due for routine cleaning/x-ray/filling services. For other services it is possible the Provider will ask you to pay the estimated portion not to be paid under the dental schedule of benefits. Actual out of pocket cost will depend on which Plan is being used.

Q. Must I use only Vision Service Plan Providers (Plan A and Plan B)?
A. Yes, in order to obtain maximum coverage and lowest out-of-pocket costs.

Q. How much should I pay the eye doctor at the time of service?
A. It is customary to pay the applicable deductibles for an office visit and/or pair of glasses, as well as the required portion of all scheduled allowances.

Q. How is my dental/vision coverage verified?
A. The service Provider will verify coverage through the appropriate dental/vision program.

Q. Is there a limit to dental/vision coverage each year?
A. Yes, there is a specific schedule of calendar year benefits.

Q. May I be reimbursed when using non-Delta Dental/VSP Providers?
A. Yes, it will be necessary to first pay for all such services and then remit the claim to the appropriate program. Reimbursement will be in accordance with a predetermined schedule.

Specific Service Providers

Blue Cross (a Preferred Provider Organization/PPO):

Q. How do I locate a Blue Cross panel Provider?
A. In the directory of local PPO Providers obtainable through the Trust Office, by calling (888) 685-7774 or at www.anthem.com/ca

Q. Do I need to designate a primary care physician to receive benefits?
A. No.

Q. May I choose my own physician/hospital/facilities?
A. Yes.

Q. Are there Blue Cross Providers outside San Diego County?
A. Yes. Blue Cross is a national program that can be accessed calling (888) 685-7774 or at www.anthem.com/ca.

Q. Can a Provider outside the United States be used?
A. The PPO Plan provides coverage anywhere in the world. There can be difficulties in converting billed charges into US dollars and getting complete explanations for the actual services rendered.

Q. Should I make any payment to a Blue Cross Provider at the time of my visit?
A. Only a co-payment if there is a charge for an office visit.

Pinnacle Claims Management (medical / dental / providers in Mexico):

Q. How do I locate a Pinnacle panel provider?
A. By calling (800) 649-9121 or click link Pinnacle Providers.

Q. Do I need to designate a primary care physician to receive benefits?
A. No.

Q. May I choose my own physician/hospital/facilities?
A. Yes.

Q. Should I make any payment to a Pinnacle Provider?
A. Only a co-payment if there is a charge for an office visit.

Sharp Rees-Stealy:

Q. Is Sharp Rees-Stealy a PPO Provider?
A. Yes. Any Provider and facility of Sharp Rees-Stealy will be considered a PPO Provider.

Q. How do I locate a Sharp Rees-Stealy Provider?
A. You may contact (800) 827-4277 or www.sharp.com

Q. What basic services are available through Sharp Rees-Stealy?
A. Varying Non-hospital services are available at some or all Sharp Rees-Stealy facilities.

Q. Are there emergency care facilities available?
A. Yes, subject to announced hours at some or all Sharp Rees-Stealy facilities.

Q. Can I take a NECA/IBEW drug test at Sharp Rees-Stealy?
A. Yes, but only at specific facilities. Contact the Trust Office to learn which are participating facilities. These are not Health & Welfare or PPO related services. Blue Cross of Southern California (other than PPO services):

Q. What is Hospital pre-certification?
A. If a physician recommends that a participant be Hospital confined the admission must be presented by the physician’s office to Blue Cross and pre-certified as being due to medical necessity and that sufficient treatment may not be readily obtainable on an out-patient basis. This also permits monitoring as to how long the Hospital confinement may continue and notifying case management for serious cases.

Q. What is case management?
A. When a Covered Person is seriously hurt or ill, and treatment is expected to last a long time and/or be very expensive, then a case manager will be assigned to oversee the course of treatment to not only ensure that the patient is receiving proper and appropriate care, but to also monitor the cost of same and participate with the attending physician(s) in arranging for quality treatment plans that could be less expensive whenever possible.

Q. Must I use or accept a case manager?
A. Yes, this is not optional.

Q. Are case management services rendered only while Hospital confined?
A. No. Hospital confinement is not a prerequisite as any plan of treatment expected to be long lasting and/or costly will be monitored by a case manager.

Pacific Foundation for Medical Care (provides medical necessity and utilization reviews):

Q. What is medical necessity?
A. Any service that is deemed necessary for the treatment of, or due to, a medical condition. In other words, services for which there is no diagnosis or specific medical reason would not be covered under the Plan as being routine and not medically necessary.

Q. Must all forms of therapy be prescribed by physician?
A. Yes, the same as with any prescribed medication.

Q. Must all forms of therapy, (physical, speech, etc. ) be pre-authorized to be covered? Is there a maximum number of therapy visits?
A. Yes. While all therapy requires a physician’s prescription, it is necessary for more than 6 visits to be pre-authorized in order to be covered by the Plan.

Members’ Assistance Program/MHN:

Q. What is the Members’ Assistance Program (MAP)?
A. The MAP is a network of clinically trained mental health specialists providing confidential assessment and counseling services.

Q. How do I access the MAP?
A. Call (800) 342-8111 or visit www.resourcesforliving.com/login.

Q. Who may use the MAP?
A. Any Employee and their eligible Dependent(s) who are covered by the Plan at the time of treatment.

Q. What is the cost for using the MAP?
A. There is no cost for up to 8 sessions over any 12 consecutive month period.

Q. What services does MHN provide?
A. Out-patient and in-patient treatment for mental health and substance abuse conditions.

Q. How is MHN accessed?
A. For other than an emergency Hospital admission the Employee or Dependent must first access the MAP for an initial assessment and referral to MHN.

Q. Are there maximums for in-patient and out-patient services?
A. Yes. Please refer to the schedule of benefits and descriptive content.

Q. Are there out-of-pocket costs for MHN Providers?
A. Yes. Please refer to the schedule of benefits and descriptive content.

General Sections (under Plan A):

Auto or serious Accidents:

Q. If a Covered Person is in an auto or a serious accident, how should the Plan be notified?
A. As soon as possible after the accident please contact your claims examiner.

Q. Will the Plan cover expenses related to an auto or serious accident?
A. Yes, in the same manner as any other expenses except that every effort will be made to defer portions of these expenses to any other possible source of coverage such as the third party responsible for the accident and/or auto and homeowner’s insurance policies.

Q. What is ‘Subrogation”?
A. In a situation where a loss is caused by a third party, the Plan will attempt to recover (‘subrogate”) related medical claim payments from or through that party in an effort to reduce overall claim payments and keep contribution and co-insurance costs as low as possible.

Q. Must the injured person sign a Subrogation Agreement?
A. Yes. As a condition for the Plan to make payment of all pending medical bills, while awaiting completion of often tedious and long term legal/insurance processes, the person must execute a Subrogation Agreement through which the Plan will be reimbursed for claim payments pursuant to a schedule associated with the actual amount of the person’s actual net recovery after deducting legal fees and costs.

Work Related Injuries/Illnesses:

Q. Will the Plan cover work related injury/illness expenses?
A. Technically, the Plan does not cover claims for services related to any work related injury or illness due to the presumed existence of workers’ compensation coverage. However, in the event there is a conflict over whether the claim is actually work-related it is possible for the Plan to make advance payment subject to the injured person executing a lien to be placed on their workers’ compensation claim so that the Plan may be reimbursed if an affirmative determination is made that the claim is work-related. Depending on the situation it is also possible that a Subrogation Agreement may be
required prior to the Plan making any payments.

Q. If a Covered Person sustains a work related injury or illness, how should the Plan be notified?
A. As with any accident or first time treatment, a claim form is required to be filed with the Trust Office for the purpose of providing the details of the incident. The question as to whether this is work-related should be answered ‘yes”.

Q. What is a workers’ compensation lien?
A. It is a claim placed on the workers’ compensation action to provide for the Plan to be reimbursed once a determination is made as to whether there was a work related injury/illness.

Claim Forms/Explanation of Benefits Form (“EOB”):

Q. Why are claim forms required?
A. To provide the Trust Office with current information such as address, Dependent status, existence of other group health coverage and to explain the details of any accident.

Q. How often are claim forms required?
A. For the first claim per Covered Person for each calendar year, as well as for each accident or new illness or as may be requested by the Trust Office.

Q. What is an EOB?
A. An Explanation of Benefits form is an actual copy of a payment check or claims adjudication explanation containing information regarding the billed charges and how the amount of payment was determined. There may also be an explanation as to why part or all of any billed charge was deemed ineligible. The appeals process is on the back of the EOB.