You are eligible for coverage if you are an active employee of an employer that is participating in the Plan, you are working in a position for which coverage is provided under the terms of the applicable collective bargaining agreement and/or participation agreement, and your employer is making the required monthly contributions to the Plan on your behalf.
Limitations on Eligibility
Eligibility under the Plan also is subject to any further requirements and limitations in the applicable collective bargaining agreement or other participation agreement. Whenever the coverage language in the applicable collective bargaining agreement or other participation agreement is inconsistent with the language in this document, the language in the applicable collective bargaining agreement or participation agreement will prevail, provided that language has been accepted by the Fund.
Eligibility While on Leave of Absence
Employees who are on an approved leave of absence, where an extension of coverage is being provided under the terms of the applicable collective bargaining agreement and/or participation agreement, are also considered to be active employees by the Plan on the condition that the extension of coverage language was approved in advance by the Plan, and the employer continues to make the required monthly contributions to the Plan on the employee’s behalf.
Eligibility During Family Medical Leave (FMLA)
Your eligibility for coverage while on FMLA will be determined by your contributing employer. However, you are eligible for leave under the FMLA if you:
Have worked for a covered employer for at least 12 months;
Have worked at least 1,250 hours over the previous 12 months; and
Work at a location where at least 50 employees are employed by the employer within 75-mile radius.
The Fund Office will maintain your prior eligibility until the end of the leave, provided your contributing employer properly grants the leave under federal law, notifies the Fund, and continues to make monthly contributions on your behalf while you are on an approved leave.
If you and your employer have a dispute over your eligibility under FMLA, your benefits will be suspended pending resolution of the dispute, in the absence of the required contribution. The Board of Trustees will have no direct role in resolving the dispute. Coverage under this Plan will continue during the FMLA leave on the same basis as other similarly situated employees.
Call your employer to determine if you are eligible for the FMLA leave. Then, contact the Fund Office if you are planning to take the FMLA leave so that the Fund is aware of your employer’s responsibility to make contributions during your absence. The Board of Trustees cannot enforce collection of contribution from your employer while you are out on leave; however, federal authorities may assist you regarding your continued coverage.
If you enter qualified military service (such as active or inactive duty training or active duty in the United States armed forces or National Guard), and you have sufficient hours in previous work periods to continue eligibility for one or more months following the month you enter the Uniformed Services, you have the option of continuing your eligibility in the Plan under the Plan’s Continuation of Eligibility rules or freezing your eligibility as of the end of the month in which you enter the Uniformed Services, or as of the date you enter the Uniformed Services if you enter on the first of the month. In addition, you may elect coverage for yourself and eligible dependent(s) under COBRA continuation coverage. However, in accordance with the Uniformed Services Employment and Reemployment Rights Act (USERRA), you must return to work or seek reemployment with an employer following a discharge, under not less than honorable conditions, within the minimum time period allowed.
If you do not return to work in covered employment or seek reemployment in covered employment within the minimum time period allowed, you will forfeit your continued eligibility rights under the Plan. In order to ensure protection of your rights under the USERRA, you must notify the Fund Office as soon as you are called up for qualified military service.
If you are covered under the Plan at the time your qualified military service leave begins, your health coverage will be continued by the Fund for your first 30 days of military service providing monthly contributions are made by your contributing employer. If you are on uniformed services for more than 30 days, you will be permitted to continue health coverage for yourself and your eligible dependents under the options set forth herein:
Coverage options for your eligible dependent(s): Coverage for your eligible dependents may be elected under COBRA continuation coverage. You will be required to self-pay for this coverage. In the alternative, coverage may be provided through the military.
Coverage options for yourself: you may elect coverage under the Plan’s continuation of coverage benefitand continue coverage for yourself for up to 24 months. However, the right to elect this continuation coverage is available only to you, not your dependents.
If you freeze your eligibility at the beginning of your qualified military leave (effective after your automatic 30-day coverage) you may reclaim this eligibility when you return to work for an employer under the criteria set forth in USERRA. You must notify the Fund Office of your selection, i.e., whether you will freeze your eligibility; elect continuation of coverage for yourself; or elect COBRA coverage for yourself, and/or your spouse and eligible dependent children. If you do not notify the Fund Office, your eligibility will be automatically extended until it is exhausted.
If you are honorably discharged from the Uniformed Services, Plan coverage for you, your spouse and your eligible dependent child will be reinstated on the day you begin work with an employer participating in the Plan, provided that you comply with the notice on return to work requirements of USERRA. These requirements and additional information on USERRA can be found at the DOL’s website at: http://www.dol.gov/vets/programs/userra/userra_fs.htm.
Your right to maintain and reinstate coverage by reason of qualified military service will be administered and interpreted by the Plan in accordance with the requirements of USERRA, employer contributions, if any, credited to you will be kept on the Plan’s records during the qualified military service leave of absence, and your coverage, as well as coverage for your spouse, and your eligible dependent child will be reinstated, provided you return to work in covered employment or seek reemployment with an employer within the time period protected under USERRA.
Benefits Upon Your Death - Eligibility of Your Surviving Spouse
Surviving spouse coverage is available for existing contributing employers only if the collective bargaining agreement and/or participation agreement provide for surviving spouse coverage, and the employee or retiree meets any required age and/or years of service rules specified in such agreements at the time of death.
To be eligible for surviving spouse coverage where provided, the death of an employee or retiree must occur while eligible for benefits under the applicable Plan, and the contributing employer must continue to make the required monthly contributions to the Plan.
There is otherwise no coverage for surviving spouses under this Plan. However, your covered surviving spouse and surviving dependent children may have rights under this Plan to make payments for continuation of coverage under COBRA as described later in this SPD.
Please check your applicable collective bargaining agreement, participation agreement, and all information provided to you by your employer for more details on whether a surviving spouse benefit is available under the terms of the applicable Plan.
Eligibility for Your Spouse and Eligible Dependent Children
Your eligible dependents include:
Your spouse to whom you are legally married pursuant to federal law and with whom you can file an income tax return, until the last day of month in which a divorce, dissolution of marriage, annulment or legal separation is obtained.
Your biological children, foster children, children placed for adoption, adopted children, stepchildren, and/or children for whom you or your covered spouse are; (a) legal guardian, or (b) required to provide medical coverage under a Qualified Medical Child Support Order (QMCSO), until the last day of the month in which the child reaches age 26.
Unmarried children of any age provided they are incapable of self-sustaining employment because of a physical or mental disability that occurred when they were covered by this Plan and turned age 26 with such disability present.
A dependent must qualify as a dependent as set forth either in the Affordable Care Act (ACA) or the Internal Revenue Code (Code), and the contributing employer must make contributions to the Plan for such coverage, where required. All eligible dependents must complete the enrollment process to ensure coverage.
Employees are required to submit a completed eligible dependent certification (EDC) form for any child whose last name differs from the employee’s last name, for stepchildren, or for other covered children. Adoption and/or placement papers are required for coverage of legally adopted children and children placed for adoption. Coverage of stepchildren requires submission of the child’s birth certificate and proof of the employee’s marriage to the child’s biological or adoptive parent. Coverage of other dependents requires submission of guardianship papers or other papers confirming the legal relationship between the employee and child. employees must provide a marriage certificate to enroll a spouse. The Fund Office also may ask you for other related information it needs to evaluate the terms of your relationship with a dependent and may periodically request verification of the covered dependent’s status on an ongoing basis.
If a dependent child, age 26 or older, is incapable of self-sustaining employment because of mental or physical disability, and the child relies on you for more than one-half of his or her financial support and maintenance, and maintains a permanent residence with you during more than one-half of the calendar year, the child’s coverage may be continued under this Plan if his or her disability began when the child was covered by this Plan, and he or she turned age 26 with the disability.
You must submit proof of your dependent child’s disability to the Fund Office no later than 30 days after the later of; (a) the date of the child’s disability diagnosis, or (b) the date of initial eligibility for coverage under the Plan. You will be asked to provide proof on the continued existence of the disability to the Fund Office periodically (proof may be required more often during the first two (2) years).
Important Rules for Dependent’s Eligibility
The Fund will not provide coverage for other relatives living in your household (e.g., mother, father, siblings, etc.) regardless of whether they are dependent upon you financially, or for non-biological children living in your household for whom you are not legally responsible. Also note:
If your eligible dependent child is employed and becomes covered under a group health plan connected to his or her employment, the plan under which he or she is an employee will be considered the primary plan for coverage. This Plan will be secondary.
For adopted children, children placed with you for adoption, or foster children to be considered eligible dependents, you must provide the Fund Office with appropriate legal documentation, satisfactory to the Plan in its sole discretion, such as adoption papers or a court order appointing you as the legal guardian for the child.
For a stepchild to be considered an eligible dependent, the Fund requires that the employee provide a copy of the child’s birth certificate and proof of the employee’s marriage to the child’s biological or adoptive parent. The Fund may also require any and all documentation, including paternity papers, court order, state order and/or divorce decree setting forth the relationship with the child.
If a dependent spouse is eligible for benefits under this Plan as an active employee, benefits will be payable for the spouse first as an employee, then as a dependent. In no event will benefits exceed 100% of covered Charges incurred.
If a dependent child loses eligibility status, the child may regain eligibility only by satisfying all of the requirements included in the Plan’s definition of an eligible dependent, and these dependent eligibility requirements.
The Fund Office will require all participants to provide documentation substantiating an individual’s right to status as an eligible dependent. Documentation required by the Fund Office may include:
A marriage certificate (in the English language);
Birth certificate of biological child showing both parents’ names;
Court (legal) documents showing legal guardianship or adoption;
Acknowledgement of paternity;
Receipt of a Qualified Medical Child Support Order pursuant to terms of the Fund; or
The date a person becomes a dependent means:
With respect to a newborn child, the date of birth;
With respect to a stepchild, the date of your marriage to your stepchild’s parent;
With respect to a foster child, the date the child is placed with you for foster care;
With respect to a child named in a QMCSO, the later of the date specified in the court order or the date it is qualified;
With respect to an adopted child, the date of adoption or placement for adoption; or
With respect to a spouse, the date of the marriage;
With respect to a child for whom you are legal guardian, the date the guardianship papers are signed by the Court.
Your coverage will become effective on the first day of the month in which you become an eligible employee, you enroll in the Plan, and your employer contributes to the Fund on your behalf.
Effective Date of Coverage for Eligible Dependents
On the day you become eligible for coverage under the Plan, your eligible dependents also become eligible, provided they are enrolled in the Plan within 30 days of your eligibility effective date, and meet all the requirements for coverage.
If you marry after the date you initially become covered under the Plan, your spouse becomes covered on the day of marriage provided you give the Fund Office timely notice of the marriage, and complete the required paperwork within the permissible time period as set forth under the subsection “Special Enrollment During Mid-Coverage Period.”
If, after the date you initially become covered under the Plan, you have a newborn biological child, an adopted child, a stepchild, a child placed with you for adoption, or a foster child, such child will become covered on the date of their birth (for a newborn biological child) or on the date the child is adopted or placed in your home (for step, adopted, or foster children).
To ensure a new dependent receives coverage, you must notify the Fund Office within 30 calendar days of the date you acquire a new dependent through marriage, birth, foster placement, or adoption. You must also submit all required paperwork, and your employer must make the required contribution for dependent coverage (e.g., employee plus spouse, employee plus children, family).
Determination of Eligibility for Coverage
Your eligibility for coverage under this Plan is determined each month, based on the contributions received from your employer. After the initial determination of your eligibility, your eligibility and coverage will terminate on the last day of any month in which you no longer qualify as an employee, and your employer does not remit the required contribution for your coverage.
If your coverage terminates because of your death, your dependents will continue coverage as if you had remained a participant until the end of the month of your death. After that, your dependents are eligible to elect COBRA continuation coverage.
Eligibility for Retiree Coverage
To be eligible for retiree coverage where provided, you must retire from active employment with a participating employer while you are eligible for benefits under this Plan, and your employer must continue to make the required monthly contributions to the Plan. Retiree coverage is only available where the collective bargaining agreement and/or participation agreement provide for retiree dental care coverage, and the covered employee meets the eligibility rules for retiree coverage under the terms of such agreements.
The Plan is required to recognize Qualified Medical Child Support Orders (QMCSOs). QMCSOs require health plans to recognize state court orders that the Plan finds to be Qualified Medical Child Support Orders, as defined in the Social Security Act, directing a participant to provide health care coverage for dependent children, even if the participant does not have custody of the children. The Plan will honor any medical child support order, which it finds to be a Qualified Medical Child Support Order (QMCSO) under the procedures set forth under the Plan, and as set forth in ERISA.
Under federal law, a QMCSO is a child support order of a court or state administrative agency that has been received by the Fund Office, and that:
Designates one parent to pay for a child’s health plan coverage;
Indicates the name and last known address of the parent required to pay for the coverage and the name and mailing address of each child covered by QMCSO;
Contains a reasonable description of the type of coverage to be provided under the designated parent’s health care plan or the manner in which such type of coverage is determined; and
States the period for which the QMCSO applies.
An order is not a QMCSO if it requires the Plan to provide any type or form of benefit or any option that the Plan does not otherwise provide. For a state administrative agency order to be a QMCSO state law must provide that such an order will have the force and effect of law, and the order must be issued through an administrative process established by state law.
If a court or state administrative agency has issued an order with respect to health care coverage for any of your dependent children, the Plan Administrator will determine if that order is a QMCSO as defined by ERISA, and under the terms of the Plan. The Plan Administrator’s determination will be binding on you, the other parent, the child and any other party acting on behalf on the child. If an order is determined to be a QMCSO, the Plan Administrator will notify the parents of each child, and advise them of the Fund’s procedures that must be followed to provide coverage to the dependent children.
Coverage of the dependent children will be subject to all terms and provisions of the Plan, including any limits on the selection of providers, and requirement for authorization of services, insofar as is permitted by applicable law.
No coverage will be provided for any dependent child under a QMCSO unless all of the Plan’s requirements for coverage of that dependent child have been satisfied. Coverage of a dependent child under a QMCSO will terminate when your coverage terminates for any reason, subject to the dependent child’s right to elect COBRA continuation coverage (if that right applies).
You may obtain a copy of the Plan’s procedures governing QMCSOs without charge from the Fund Office. If you have any questions about QMCSOs contact the Fund Office.