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Healthcare FAQ

 
Q: How do I determine my eligibility? Back to top
A:

Your eligibility is determined based on whether you pass any one of three tests with respect to the hours paid on your behalf: a 200/hour/3 month test, a 400 hour/6 month test and an 800 hour/12 month test. For more information on eligibility, or to keep track of your individual hours and eligibility, visit the Member's Only section of our Web site. If you have any questions regarding the commencement of your eligibility, call the Fund Office. 

Q: How do I add my spouse to the Health Plan? Back to top
A:

Call the Fund Office to request the paperwork you must fill out to add your spouse to the Plan. You will be required to submit a copy of your marriage certificate and your spouse's Social Security number. We handle all participant information, including Social Security identification numbers, within strict guidelines with respect to privacy and security. 

Q: Which insurance is primary when my spouse has insurance too? Back to top
A:

The Fund would be the primary payer for you and the secondary payer for your spouse. If you have children, we follow the birthday rule to determine coordination of benefits between our Fund and the other carrier. The spouse whose birthday falls first within the year holds the primary insurance for the children. (If a Local 478 Member's birthday is February 15, and his spouse's birthday is August 15, the Member would hold the primary insurance for the children.) The year of birth is not considered. 

Q: How do I add my newborn child? Back to top
A:

Call the Local 478 Fund Office as soon as the child is born. You'll need to provide the baby's name and date of birth, and a copy of the long-form birth certificate. This should be done as soon as possible to avoid any delay in processing the newborn's claims. We will need the baby's Social Security number as soon as it is available in order to continue processing benefit payments. 

Q: How long do you cover dependent children? Back to top
A:

The Fund covers eligible dependents until the age of 19. If the dependent attends a school of higher learning and earns 12 credits or more in a semester, we will cover that dependent until age 23 or graduation. Dependent children who are declared disabled by the Social Security Administration may be covered indefinitely. You should notify the Fund Office if your child has a disability. Dependents who want to qualify for self-pay coverage under COBRA must contact the Fund Office within 60 days of the date that he or she ceases to be a full-time student. We need each covered dependent's Social Security number in order to process his or her claims. 

Q: How do I request medical and dental cards? Back to top
A:

Once you become eligible for Health Benefits in our system, your medical and dental cards are automatically sent to you. One set of (2) cards will be sent for the family with the Member's name and ID. If you need additional medical cards, please contact the Health Fund office, if you need Dental cards please contact Delta Dental at 1-800-452-9310. 

Q: If I am unemployed for a long period, how will I know if my health benefits are running out? Back to top
A:

If your eligibility terminates, possibly because of a long gap in employment, the Fund Office will notify you within approximately 7-10 days. You can view the hours paid in on your behalf and your health benefit eligibility on the Member's Only section of this Web site. 

Q: What if I think my employer has been delinquent in submitting my hours? Back to top
A:

If you are concerned that your employer might be delinquent, call the Local 478 Fund Office. If your employer is not paying your benefit contributions, we may already be aware of the situation and taking action to collect the amounts due on your behalf. There are some rare instances where we might not know that a member is working for a particular employer. Therefore, you should notify us of any problems. Always keep copies of your pay stubs and any other documentation in case a problem comes up. 

Q: How do I find out if my claim has been paid? Back to top
A:

You will receive an explanation of benefits statement from the Fund Office to show that a claim has either been paid or denied. You can also check your benefits information on the Member's Only side of this Web site, or by calling the Local 478 Fund Office and asking for the claims department. Remember, the Fund is required by law to have a fully executed HIPAA designation form before we can discuss claim-related issues involving participants who are 18 or older with other individuals, including parents and spouses. 

Q: Do I need a referral from my primary care doctor for medical services? Back to top
A:

No, this plan does not require you to obtain a referral to receive medical benefits. 

Q: Do I need a prior authorization for benefits? Back to top
A:

The only time you need to obtain a prior authorization is before you receive In-patient treatment under the Anthem-Healthlink behavioral health (psychiatric/substance abuse) Program. For more information, contact Anthem-Healthlink at 1-877-284-0102. You also need to obtain pre-certification for In-patient hospital or Rehabilitation stays from Hines Associates by calling them at 1-800-323-3454. This requirement applies only to Active Members and Pre-Medicare Retiree participants.

Q: Can I get a second opinion on a diagnosis I am concerned about? Back to top
A:

Yes, the Fund will cover a second opinion provided your physician submits the claim according to the Plan rules.  

Q: How do I find out if my doctor is in the Anthem Blue Cross and Blue Shield network? Back to top
A:

Call Anthem at 1-800-810-2583, or go to their Web site at www.bcbs.com.  

Q: Am I eligible for vision benefits? Back to top
A:

Adults are eligible for vision benefits once every two years, and children 12 and under are eligible once a year. If you are not sure when you last used your vision benefit, contact the Fund Office and ask for the claims department. 

Q: What happens if I use a non-participating provider? Back to top
A:

If you use a non-participating provider for dental, medical or vision visits, your claims will still be considered, but they will be paid at a different rate and may be subject to a deductible. For more information, contact the Fund Office. 

Q: What happens if I use a non-participating provider? Back to top
A:

If you are an Active Member and use a provider who is not participating with LHV, or if you do not obtain a prior authorization, your claims will be denied. Medicare Retiree Participants, however, are not required to stay within the LHV network. 

Q: How do I obtain prior authorization for behavioral health or substance abuse visits/hospitalization? Back to top
A:

Contact Anthem-Healthlink at 1-877-284-0102

Q: How much is my prescription co-pay? Back to top
A:

If you purchase your prescription at a pharmacy that participates with the CVS/Caremark network, you will pay the following co-pays or the cost of the prescription: $15 for generic, $30 formulary, or $45 non-formulary for a 30-day supply. The co-pays for CVS Caremark Mail order drugs are: $25 for generic, $55 for brand and $85 for brand (non-formulary). 

Q: How do I obtain a formulary list? Back to top
A:

Formulary lists are updated every three months. You can find the latest list at www.Caremark.com, or by calling CVS/Caremark at 1-888-790-8084.  

Q: How do I submit a prescription claim for a refund? Back to top
A:

If you purchased prescriptions on your own or have other insurance, you may submit a paper claim for a refund. You need to submit the prescription receipt with a prescription claim to CVS/Caremark at the address provided on the back of the claim form. 

Q: How do I obtain a prescription claim form? Back to top
A:

Contact CVS/Caremark at 1-888-780-8084 or the Local 478 Fund Office. 

Q: What are my disability benefits? Back to top
A:

Disability benefits are paid for time lost due to injury or illness that is not related to work. This short-term benefit is paid at $400 a week ($365 after Social Security is deducted) for a maximum of 182 days or 26 paid weeks. However, payment is based on the Medical Disability Advisor according to the diagnosis that your doctor submits, so it may cover less than 26 weeks. 

Q: Are my disability benefit payments taxed? Back to top
A:

Yes. The law requires us to deduct Social Security tax automatically. You may choose to have federal or state taxes taken out at the time of payment by completing and submitting the appropriate tax forms.  

Q: How do I file for disability benefits? Back to top
A:

You can obtain a disability claim and tax forms from the Local 478 Fund Office. 

Q: How often will I receive a disability payment? Back to top
A:

Disability benefits are paid every other week on a pay period basis ending on Saturday. 

Q: Is my spouse eligible for disability benefits? Back to top
A:

Disability benefits are for Active Members only.  

Q: Who is my death benefit beneficiary? Back to top
A:

If you are not sure who your beneficiary is, contact the Fund Office. You can change your beneficiary at any time by completing the appropriate beneficiary form. 

Q: What is my death benefit? Back to top
A:

For Active Members, the death benefit is $25,000. For accidental death, the benefit doubles to $50,000. If you are on our retiree plan, the death benefit is $5,000. This taxable benefit is paid to the beneficiary of your choice at the time of death and is fully taxable. 

Q: Can I designate more than one beneficiary? Back to top
A:

You can designate as many beneficiaries as you want.