FAQ

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.

Call the Health Fund Office to request the paperwork you must fill out to add your spouse to the Plan. Retirees, on retiree copay, have 60 days to notify the Fund Office of the marriage. 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. 

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. 

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. 

The Fund covers eligible dependents until the age of 26.  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. We need each covered dependent's Social Security number in order to process his or her claims. 

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. 

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. 

If you are concerned that your employer might be delinquent, call the Health and Contributions departments of 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. 

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 I-Site portal (IUOE Local 478 Benefit Funds (issisystems.com)), 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.

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

The only time you need to obtain a prior authorization is before you receive in-patient hospital or Rehabilitation stays from Telligen by calling them at 1-833-374-9833. This requirement applies only to Active Members and Pre-Medicare Retiree participants. Members can contact the Health Fund Office for support or confirmation of authorization.

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

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

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 Health Fund Office and ask for the claims department. 

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.

Contact Telligen at 1-833-374-9833.

If you purchase your prescription at a pharmacy that participates with the OPTUMRx 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 OPTUMRx order drugs are: $25 for generic, $55 for brand and $85 for brand (non-formulary). 

Formulary lists are updated every three months. You can find the latest list at www.OPTUMRx.com, or by calling OPTUMRx at 855-295-9140. 

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 OPTUMRx at the address provided on the back of the claim form. 

Contact OPTUMRx at 855-295-9140 or the Local 478 Fund Office. 

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 $800 a week (paid bi-weekly) and has required taxes withheld 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. 

Yes. The law requires us to deduct Social Security tax and CT FMLA 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. 

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

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

Disability benefits are for Active Members only.  

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. 

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. 

You can designate as many beneficiaries as you want. 

Your Health Benefits will be terminated immediately and you will not be eligible for COBRA.  You will be prohibited from taking an Annuity Distribution. If you are receiving a pension, your Pension Benefit and any Retiree Health Benefits you may be receiving will be terminated. You will be ineligible for SUB, referral by the Local, and Training classes.

You must notify both the Referral Hall and Fund Office promptly regarding both. You may be eligible for special benefits through the Health, Pension, Annuity and SUB funds. 

Such Members are considered to be Active Members and may earn and receive Active Health benefits and SUB. Members who voluntarily retire prior to being required to begin receiving Pension and Annuity benefits may work unlimited hours upon attainment of age 73, but such individuals are not eligible for SUB. 

Contact the Fund Office immediately. The Health Fund must determine whether there is another party who is responsible for paying any claims related to the injury, via a third-party lawsuit or via a worker's compensation claim . Depending on the particular circumstances, the Health Fund may pay such claims pursuant to an agreement to reimburse the Fund for any bills it paid. If you have a work-related claim or you are deemed disabled, you may also be entitled to limited Pension credits. Also, you may be able to collect SUB benefits if you have been released for light duty.

Contact the Health Fund Office immediately. You may qualify for the Health Fund's weekly disability benefit. You should be aware that Members cannot receive disability benefits and SUB at the same time as SUB requires that you are available and physically capable of accepting work in covered employment. In addition, you may be eligible for a limited amount of Pension credit. 

Contact the Health and Contributions departments of the Local 478 Fund Office immediately. You may qualify for a disability Pension and Retiree Health Benefits.

Your Health Benefits will be terminated immediately and you will not be eligible for COBRA.  You will be prohibited from taking an Annuity Distribution. If you are receiving a pension, your Pension Benefit and any Retiree Health Benefits you may be receiving will be terminated. You will be ineligible for SUB, referral by the Local, and Training classes.

Retired Members who choose to pay dues and join the Active Retiree Organization may be referred to work in Covered Employment. Retirees between the ages of 55 and 61 may work up to 160 hours every other calendar quarter; retirees between the ages of 62 and 70½ may work up to 59½ hours per month; and retirees over age 70½ may work unlimited hours. These rules were designed to reduce the likelihood that retired Members would gain eligibility for Active Member Health Benefits to minimize the problems associated with a Member's eligibility, and flipping back and forth between the Retiree and Active Health Plans.

Contact the Health and Contributions departments of the Local 478 Fund Office immediately. You may qualify for a disability Pension and Retiree Health Benefits.

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 I-Site portal (IUOE Local 478 Benefit Funds (issisystems.com)), 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.

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

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

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

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. 

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. 

You can designate as many beneficiaries as you want. 

Call the Health Fund Office to request the paperwork you must fill out to add your spouse to the Plan. Retirees, on retiree copay, have 60 days to notify the Fund Office of the marriage. 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. 

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. 

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. 

The Fund covers eligible dependents until the age of 26.  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. We need each covered dependent's Social Security number in order to process his or her claims. 

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. 

The only time you need to obtain a prior authorization is before you receive in-patient hospital or Rehabilitation stays from Telligen by calling them at 1-833-374-9833. This requirement applies only to Active Members and Pre-Medicare Retiree participants. Members can contact the Health Fund Office for support or confirmation of authorization.

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 Health Fund Office and ask for the claims department. 

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.

Contact Telligen at 1-833-374-9833.

If you purchase your prescription at a pharmacy that participates with the OPTUMRx 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 OPTUMRx order drugs are: $25 for generic, $55 for brand and $85 for brand (non-formulary). 

Formulary lists are updated every three months. You can find the latest list at www.OPTUMRx.com, or by calling OPTUMRx at 855-295-9140. 

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 OPTUMRx at the address provided on the back of the claim form.