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Active Members

Health

How do I determine my eligibility?

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.

How do I add my spouse to the Health Plan?

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. 

Which insurance is primary when my spouse has insurance too?

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. 

How do I add my newborn child?

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. 

How long do you cover dependent children?

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. 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. 

How do I request medical and dental cards?

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 I am unemployed for a long period, how will I know if my health benefits are running out?

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. 

What if I think my employer has been delinquent in submitting my hours?

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. 

How do I find out if my claim has been paid?

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.

Do I need a referral from my primary care doctor for medical services?

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

Do I need a prior authorization for 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.

Can I get a second opinion on a diagnosis I am concerned about?

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

How do I find out if my doctor is in the Anthem Blue Cross and Blue Shield network?

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

Am I eligible for vision benefits?

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. 

What happens if I use a non-participating provider?

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.

How do I obtain prior authorization for behavioral health or substance abuse visits/hospitalization?

Contact Telligen at 1-833-374-9833.

How much is my prescription co-pay?

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). 

How do I obtain a formulary list?

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. 

How do I submit a prescription claim for a refund?

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. 

How do I obtain a prescription claim form?

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

What are my disability benefits?

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. 

Are my disability benefit payments taxed?

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. 

How do I file for disability benefits?

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

How often will I receive a disability payment?

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

Is my spouse eligible for disability benefits?

Disability benefits are for Active Members only.  

Who is my death benefit beneficiary?

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. 

What is my death benefit?

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. 

Can I designate more than one beneficiary?

You can designate as many beneficiaries as you want. 

What if I go to work for a non-union employer doing work covered by our Collective Bargaining Agreement?

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.

What if I am called to or discharged from Active Military duty?

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. 

What if I am an Active Member who is required to begin receiving Pension and Annuity benefits under the law that requires me to do so starting on the April 1 of the year following the calendar year in which I turned age 70½.

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 70½, but such individuals are not eligible for SUB. 

What happens if I incur an accidental injury, whether or not it is incurred in connection with employment?

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.

What if I am injured or ill to the extent that I cannot work for an extended period of time?

Contact the 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. 

What if I am declared disabled by the Social Security Administration?

Contact the Fund Office immediately. You may qualify for a disability Pension and Retiree Health Benefits.

Retiree Members

Health

What if I go to work for a non-union employer doing work covered by our Collective Bargaining Agreement?

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.

Under what circumstances may a Retired Member work in Covered Employment without jeopardizing his/her pension?

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.

What if I am declared disabled by the Social Security Administration?

Contact the Fund Office immediately. You may qualify for a disability Pension and Retiree Health Benefits.

How do I find out if my claim has been paid?

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.

Do I need a referral from my primary care doctor for medical services?

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

Can I get a second opinion on a diagnosis I am concerned about?

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

How do I find out if my doctor is in the Anthem Blue Cross and Blue Shield network?

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

What is my death benefit?

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. 

Who is my death benefit beneficiary?

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. 

Can I designate more than one beneficiary?

You can designate as many beneficiaries as you want. 

How do I add my spouse to the Health Plan?

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. 

Which insurance is primary when my spouse has insurance too?

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. 

How do I add my newborn child?

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. 

How long do you cover dependent children?

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. 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. 

How do I request medical and dental cards?

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. 

Do I need a prior authorization for 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.

Am I eligible for vision benefits?

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. 

What happens if I use a non-participating provider?

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.

How do I obtain prior authorization for behavioral health or substance abuse visits/hospitalization?

Contact Telligen at 1-833-374-9833.

How much is my prescription co-pay?

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). 

How do I obtain a formulary list?

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. 

How do I submit a prescription claim for a refund?

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.