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Health FAQ

• When and how do I become eligible for coverage?
  You become eligible for coverage the first day of the second month following the month in which 260 hours have been reported and paid into your reserve account. These hours must be worked within a consecutive six-month period. Eligibility is on a “skip month” basis. For example, if you worked a total of 260 hours by April, and these hours were reported and paid for by your employer in May, your eligibility would begin in June.  Hours in excess of 260 will be credited to your reserve account.
   
• Once I am eligible, how long will I be covered?
  You will be covered so long as the hours reported and paid in by your employer each month total at least 130. As stated above, eligibility utilizes the “skip month” method. For example, hours worked in May would be reported and paid in June; these hours would provide your coverage in July.
   
• How does my reserve account work?
  Hours are reported and paid in by your employer following the month in which they were worked. As stated above, you need to work 130 hours in the work month to be eligible in the coverage month. Any hours in excess of 130 are placed into your reserve account. If in a month, you have fewer than 130 hours reported, you can use any hours in your reserve account to make up the difference.
   
• Is there a limit to the number of hours that I can have in my reserve account?
  Yes. The maximum number of hours that you can have in your reserve account is 750. 
     
• What are my coverage plan options?
  For medical coverage, you have a choice between three plans: a self-funded PPO plan, the Aetna HMO or the Kaiser HMO.  For dental, you have a choice between the Delta Preferred DPO and Delta PMI, a dental HMO.
   
• Which medical plan is better?
  All medical plans are excellent. You should carefully study the comparisons to determine which plan would suit you and your family best. With the PPO plan, you can visit any medical provider. You will pay less out-of-pocket if you use PPO providers. The Aetna plan requires that services be coordinated by your primary care provider and provided primarily within your medical group.  The Kaiser Plan requires all services to be obtained at Kaiser facilities with Kaiser’s practitioners.
   
• Does the self-funded PPO plan have chiropractic/specialist coverage?
  Yes. Please refer to your Summary Plan Description for details.
   
• How do I enroll in my chosen plans?
  To ensure that you and your dependents are covered in the Health Plan, you must complete the enrollment form that is sent to you by Alllied Administrators when you were approaching initial eligibility. If you wish to enroll in one of the HMO's, contact Allied. We will send you an application which must also be completed in order to enroll in that HMO.   If you wish to enroll in one of the HMO plans, be sure to complete the application before your initial eligibility date or within 30 days of becoming eligible.
   
• How do I add or delete dependents on my health plans?
  You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to Allied Administrators. Please read the form carefully, as you are required to submit the appropriate documentation, i.e., birth or marriage certificate, divorce decree, etc. If you prefer, you can also contact Allied directly for this form. If you are enrolled in an HMO and wish to add or delete a dependent, you must also complete the appropriate form from that HMO.  Dependents can be added within 60 days of your becoming eligible, within 60 days of their becoming a dependent, or during the open enrollment period.
   
• My child has reached the limiting age, but he is completely dependent on me for support due to a physical limitation.  Is there a way I can extend his coverage?
  Yes.  If you have a dependent child with a mental or physical limitation, you can continue his coverage provided that the following requirements are met:  your child is chiefly dependent on you for support; your child is not capable of self-sustaining employment; and you give us proof of the child’s handicap:  (1) not later than 31 days after the child attains the limiting age; and (2)  thereafter as the Plan may require, but not more than once every two years, by completing a Request for Continued Coverage for Incapacitated Child form.
   
• How/when can I change plans?
  You can change your medical or dental plan at any time of the year provided that you have been enrolled in your current plan(s)for at least 12 months.  Contact the Administration Office to confirm that you are eligible to change plans.  Enrollment changes must be received by the Administration Ofifce by the 20th of the month to change coverage the first of the next month.
   
• How do I file a claim for reimbursement?
  You’ll need to fill out a Claim Form. Be sure to complete all sections and attach appropriate documentation. Then, submit the form to Allied Administrators for reimbursement. You can also contact Allied directly for a claims form.
   
• Is it possible for my physician to submit claims to Allied Administrators electronically?
  Yes! If your physician’s office is set up for electronic filing, simply provide Allied’s EDI number: 94177. That’s all the information they’ll need to file claims electronically.
   
• How will I know if a claim has been paid?
  Allied will send you an Explanation of Benefits (EOB) statement whenever a claim has been paid on your behalf. If you utilize PPO providers, Allied will send payment directly to the PPO provider and a copy of the EOB to you that shows all the charge and payment information regarding the claim.
   
• Can you explain how I should read the EOB?
  A sample EOB can be found here. Reading from left to right, top to bottom, the first section displays the health plan name, your masked identification number, and the number assigned to the claim.
  
  Next, you’ll see the employee’s name, the patient’s name, the claims examiner, group number and date the claim was processed.
  
  The next section covers the date(s) of treatment, the three-letter service code and the five-digit Current Procedure Terminology (CPT) code used by the billing provider of service. It also shows how the claim was adjudicated. In our sample EOB, there were two procedures (treatments) on the same day. The Charge Amount column shows what the provider has billed for these procedures. The next column shows if any charges were not covered. In this example, there were charges not covered, and the two-digit reason code is shown next. The PPO Discount is then applied, and the column after that shows the Covered Amount (Charge Amount – Not Covered – PPO Discount). The deductible and any co-pays are then applied. In this example, the calendar year deductible has already been met, and there are no co-pays. The next column in the EOB shows the percentage that the Plan pays. Because this was a PPO provider, the percentage is 90%. Finally, there is the Payment Amount, the amount that will be paid to the provider.
  
  Immediately under this section, is an area containing the patient account number from the doctor’s office (if it is available) and any adjustments or credits made in the event there is other coverage.
  
  The next item is the Patient’s Responsibility section. It is the combination of Amount not Covered, Co-Pay Amount, Deductible and Co-Insurance. This would be the amount that you would have to pay your provider.
  
  The Payment Information box shows who the plan payment was sent to, the date it was sent, check number and amount paid.
  
  The Service Code box defines the three-letter code used on the lines above.  The Reason Code box provides an explanation of the two-digit code for why charges were not covered.  Finally, the Messages box shows which PPO network was utilized, if any, and your appeal rights.
   
• Can my provider bill me for the PPO discount?
  If you visit a provider who is contracted with the PPO, the provider cannot bill you for anymore than the amount shown under Patient’s Responsibility on the EOB. Billing for any amount greater than that is known as “balance billing,” and this practice is prohibited by California state law.
   
• I need to see a Doctor, but I don't know who to go to. Do you have a list of doctors near where I live or work?
  Effective January 1, 2010, the PPO network will change to Anthem Blue Cross. You can get a listing of their physicians here.  Aetna participants can obtain information on Aetna-contracted providers at www.aetna.com.  Kaiser participants can obtain information on providers at www.kaiserpermanente.org.
   
• What happens if I’m not in California and I, or my dependents, require medical services?
  Effective January 1, 2010, if you are a California resident and you need medical care outside of California, First Health will be your PPO network. Your Anthem Blue Cross ID will have information for these providers. If you reside outside of California, First Health will be your PPO effective January 1, 2010, and you will receive an identification card specifically for First Health.
   
• I need to fill my prescriptions – what pharmacy can I use?
  If you are in the self-funded PPO, you can use any of the hundreds of pharmacies that are contracted with Express Scripts, the PPO plan’s pharmacy benefits manager. Visit their website at www.express-scripts.com for a listing of pharmacies in your area. Aetna participants must use pharmacies that have contracted with Aetna.  Kaiser participants must have their prescriptions filled at Kaiser pharmacies. 
   
• I tried to pick up my prescription but the pharmacy told me that I need “prior-authorization.” What should I do?
  Certain prescriptions require prior authorization from the health plan in which you are enrolled. If you are covered by the self-funded Plan with Express Scripts, your pharmacist will let you know if a prescription needs prior authorization. Most pharmacies will work this through directly with Express Scripts and your doctor’s office. If this is not the case your physician‘s office simply needs to get in touch with the help desk at Express Scripts (1-877-256-4679) or contact Allied Administrators.
   
• Do I need an ID card for medical and dental?
  If you are in the self-funded PPO plan and visit a provider who is in the Anthem Blue Cross Network, you do need to bring your Anthem Blue Cross PPO card to your medical appointment. HMO participants have ID’s that are issued directly by their HMO. These must be used for all medical appointments.  Delta Dental issues dental ID cards.
   
• Does the dental plan have a PPO? 
  Yes, the Delta Preferred Plan has a DPO.  Your benefits are greater of you visit a DPO office.  Delta PMI is an HMO, and you must get all your dental care from a PMI dentist.
   
• Is there a claim form specifically for dental claims?
  If you utilize Delta-contracted dentists, there are no claim forms.  For non-Delta dentists, you would need to contact Delta Dental for a claim form to obtain reimbursement.
   
• I went to my doctor’s appointment today, but I was told that my coverage is terminated. I've been working steadily. Am I covered for the visit?
  If there’s ever a question regarding your eligibility, contact Allied Administrators. We’re here to help you sort it out.
   
• I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?
  You received this notice because you had a COBRA Qualifying Event. The most common reason for this is reduced hours or the termination of employment.  If this is the case, Allied will have sent you the COBRA Notice automatically.  Other COBRA Qualifying Events include divorce, death of the employee, or a dependent child’s reaching the maximum age limit, and it is the duty of the participants to notify Allied of these qualifying events. In each of these instances, you will have lost eligibility. If you wish to sign up for COBRA coverage, you must return the application to Allied Administrators within 60 days of the date of your Qualifying Event.
   
• I'm on disability/worker's comp or FMLA. How do I continue my coverage?
  The Trust offers disability coverage for a specified duration. Please refer to your SPD for the disability provisions, and if you have further questions, contact Allied Administrators for more information. After the period of disability coverage provided by the Trust at no cost to the member, you can also elect to take COBRA coverage. FMLA coverage is through your employer only, and you must contact your employer to determine if you qualify for the FMLA benefit.
   

COBRA Subsidy FAQ - UPDATED

• I’ve been hearing about this COBRA subsidy. What is it and how do I get it?
  There was a provision in the American Recovery and Reinvestment Act of 2009, which President Obama signed into law on February 17, 2009, that provides subsidized coverage for “Assistance Eligible Individuals” for up to nine months. This period of subsidized COBRA coverage has been extended through Section 1010 of the Department of Defense Appropriations Act, 2010, which President Obama signed on December 21, 2009. This Act included a provision to extend eligibility for the subsidy to February 28, 2010, and to extend the period of subsidized coverage by six months, up to a maximum of 15 months.  The eligibility period has now been extended through March 31, 2010.  The subsidy is 65% of the COBRA premium, and for purposes of this Trust, the first period of subsidized coverage began March 1, 2009. An Assistance Eligible Individual is someone who had an involuntary termination between September 1, 2008 and March 31, 2010.  We can determine if you qualify as an “Assistance Eligible Individual” only if you submit a Request for Treatment as an Assistance Eligible Individual application. In some instances, we may have to verify with your last employer that your separation from employment was involuntary.
   
• What does “involuntary termination” mean?
  Involuntary termination is generally any action taken by an employer that causes the loss of employment and health coverage for the employee. Involuntary termination includes lay-offs and furloughs, and employer-initiated termination during a period of disability or FMLA coverage. An involuntary termination also includes an employee’s separating from employment in response to an action taken by the employer, such as any employer incentives to resign, the employer’s reducing the employee’s hours to a level that the employee cannot afford, or the employer moving the geographic location of the work. An involuntary termination does not include a reduction in hours when the employee is still working. An involuntary termination does not include any employer-initiated termination for “gross misconduct.”
   
• I received notice that my COBRA subsidy period ended November 30, 2009. I could not afford the full cost of COBRA coverage and did not make a payment for December. Now that the subsidy has been extended, can I re-gain my COBRA coverage?
  Yes. Your COBRA coverage will be reinstated effective December 1, 2009, as soon as you make your subsidized COBRA payment for December. You will be eligible for an additional six months of subsidized coverage until May 31, 2010, as long as you are still in your COBRA coverage period and make monthly payments.
   
• I paid the full cost of my COBRA coverage for December 2009. Now that the subsidy has been extended, what can I do?
  If you paid the full cost of COBRA coverage for December 2009 and had been an Assistance Eligible Individual, you may receive a refund of the subsidized portion of the premium or have the amount you overpaid credited to the cost of future COBRA coverage. Contact the Administration Office for more information.
   
• I will be losing my job in January 2010, but I will still have coverage through April 30, 2010. Will I be eligible for the subsidy in May?
  If your involuntary termination occurred during the period September 1, 2008 through the extension of March 31, 2010, you may be eligible for the subsidy even if your loss of coverage occurs after this extended eligibility period ends.
   
• Will the subsidy be payable to me?
  No. The subsidy is reflected in the fact that you’ll pay 35% of your COBRA premium if you qualify for the subsidy.
   
• My child recently had a COBRA qualifying event because she reached the limiting age. Will she be eligible for the subsidy?
  No, she does not qualify for the subsidy because she does not qualify as an Assistance Eligible Individual.
   
• What if I am denied eligibility for the subsidy, but I think I should be eligible?
  If it is determined that you do not meet the definition of an “Assistance Eligible Individual,” you can make an appeal to the U.S. Department of Labor only. Your appeal must be submitted on a U.S. Department of Labor application form, which is available on their website: www.dol.gov/COBRA. If you believe you have been inappropriately denied eligibility for the premium reduction, you may wish to speak with an Employee Benefits Security Administration Benefits Advisor at 1.866.444.3272 before filing an appeal with them.
   
• Why can’t I appeal to the Board of Trustees?
  The Board has no jurisdiction over appeals for qualification as an “Assistance Eligible Individual.” The U.S. Department of Labor is the only entity with this jurisdiction.