C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d P
l a n
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An
accident is
an unplanned, unforeseen and unexpected event that wasn’t due to any
misconduct on your part that causes injury or death. An
Active Member is a person working in the
carpentry industry under the terms of a collective bargaining agreement, or
an eligible employee of the Pension Fund, any of the local unions, the
Apprentice and Training Fund or the Carpenters Labor Management Program, or
an agent or organizer employed by the NERCC. The
Health Fund pays allowable charges for
services. Allowable charges are based on reasonable and customary (R&C)
charges or charges at the PPO contracted rate for services. The
American Academy of Pediatrics schedule of
immunizations for children up to age 18 is:
An
approved rehabilitation facility is a
free-standing licensed rehabilitation facility, or licensed rehabilitation
unit in an acute care hospital or Skilled Nursing Facility. Payments
from the Health Fund can be assigned, that is,
paid directly to the provider of your care and services, if you sign an
“assignment of benefits” at the provider’s office that directs the Health
Fund to do so. If a claim is $5,000 or more, or if a provider tells the
Health Fund Office that an assignment is on file, benefits are paid directly
to the provider. |
The
beneficiary is
the person named to receive death benefits under the life and AD&D
insurance benefits. The beneficiary must be designated on the form provided by
the Health Fund. The form must be on file and approved by the Health Fund
Office before the covered person’s death.
If
your baby is delivered in a birthing center, in order for you to be covered under the
Health Fund the birthing center has to:
·
maintain
a medical staff of physicians, nurses and licensed anesthesiologists,
·
maintain
at least two delivery rooms and one recovery room,
·
maintain
diagnostic laboratory and X-ray facilities,
·
maintain
equipment for emergency care,
·
maintain
a blood supply,
·
maintain
medical records,
·
have
agreements with hospitals for immediate acceptance of patients who need to be
confined in the hospital as inpatients, and,
·
be
legally licensed by appropriate legally authorized agencies.
The
Board of Trustees is established under rules in the
Trust Agreement and consists of equal representation of union and management.
Buy-In Contributions are contributions that you
make to meet the annual or initial eligibility requirement.
The
calendar year is
the period beginning January 1 and ending December 31
Your
child or children
are:
·
biological,
·
lawfully
adopted, or
·
stepchildren or foster children who live
with you and depend on you for support and maintenance.
If
you’re granted custody of a child, or ordered to provide health care for your
biological child, that child is considered yours under the Health Fund between
the date the Health Fund Office receives the court order and the date your
custody or health coverage responsibility ends.
COBRA is the Consolidated Omnibus
Budget Reconciliation Act of 1985, which requires that coverage be offered to
formerly eligible employees and their eligible dependents at group rates.
Coinsurance is the percentage of the
cost of services which you’re responsible to pay.
A contributing employer (or employer)
is any person, firm, corporation or other business entity who employs members
of a Local Union or other employees and must, under a collective bargaining
agreement, make contributions to the Health Fund on behalf of members or
employees.
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The
copay is a set
dollar amount you must pay out of your pocket. Cost containment is
a way to be sure that the most appropriate level of medical care is given,
and assuring that it’s medically necessary and the best value. The
coverage year begins on March 1 and ends
on February 28 or 29 of the following year. Covered employment is employment with a
Contributing Employer in a category of work covered by a collective
bargaining agreement or participation agreement. A
covered provider is a Doctor of
Medicine, Doctor of Osteopathy, Psychologist, Psychiatrist, Podiatrist,
Certified Nurse Practitioner, Clinical Nurse Specialist, Chiropractor,
Registered Nurse Anesthetist, Dentist, Nurse Midwife, Occupational Therapist,
Physical Therapist, Optometrist, Ophthalmologist, Orthoptist, Medical or
Psychiatric Social Worker, or a Physician’s Assistant who is licensed and
certified by the state in which services are being rendered and acting within
the scope of his or her license, unless stated otherwise, and Speech
Therapists. Custodial care
provides a person with services and supplies to help him or her with the
activities of daily living. The
deductible is
the amount you must pay out of your own pocket before you receive benefits
from the Health Fund. Detoxification treatment for incapacitation by, or
physiological or psychological dependence on, drugs or alcohol includes: ·
diagnostic evaluation, ·
medical, psychiatric and psychological care, and ·
counseling and rehabilitation when prescribed and supervised by a
physician. Note
that rehabilitation treatment is required within seven days of receiving
detoxification. Detoxification alone is not covered. An episode of treatment for substance abuse occurs within 60 days following the completion of formal treatment, which can include detoxification, residential care, and intensive outpatient care followed by outpatient and/or aftercare treatment. |
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An Explanation of Benefits (EOB) describes the payment
made by an insurer or payer — such as the Health Fund Plan — to you or the
provider.
A
full time student is one who attends an accredited school or college on a full
time basis (with a course load of at least 12 credits per semester).
The
Full Plan provides medical benefits to
people who are eligible for Full Spectrum, Full Health, Medical/Drug Only,
Disabled Member and Retiree Full coverage.
A generic drug is:
·
manufactured
and marketed under the chemical name or a shortened version of the chemical
name,
·
approved
by the U.S. Food and Drug Administration for safety and effectiveness,
·
manufactured
by a company which is the same or different than the company that originally
patented the drug after the original patent expires, and
·
less
expensive than the product manufactured by the company that originally patented
the drug.
HIPAA is the Health Insurance
Portability and Accountability Act of 1996, which guarantees renewability and
availability of health coverage to certain individuals and limits the exclusion
period for pre-existing conditions.
A home health care agency is one which:
·
is
primarily engaged in, federally certified as, and licensed by any appropriate
licensing authority, to provide nursing and therapeutic services,
·
has
policies that are established and governed by a professional group associated
with it, including at least one physician and at least one registered nurse,
·
provides
for full-time supervision of services by a physician or registered nurse, and
it maintains a complete medical record on each patient, and
·
has
an administrator.
A home health care plan is a program for
continued care and treatment, established and approved in writing by the
patient’s attending physician.
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A
hospice gives
counseling and incidental medical services to a terminally ill person on an
inpatient or outpatient basis. It must: ·
be approved and operating under any required state or governmental
license or permit, ·
provide service 24 hours a day, seven days a week, ·
operate under the direct supervision of a physician, ·
have a nurse coordinator who is a registered nurse with four years of
full-time clinical experience, with two out of three years involved in caring
for terminally ill patients, ·
have a social-service coordinator who is licensed in the area in
which the hospice is located, ·
have a full-time administrator, and ·
maintain written records of services provided to patients. Hours and
hours of work mean: ·
each hour worked by a member for which contributions are paid to the
Health Fund by an employer under a collective bargaining agreement, or ·
any hours worked for which contributions were made and accepted by
the Trustees according to policies established by the Trustees. The
Hours Bank is a reserve of hours worked. If a
carpenter works more than 1,500 hours in a calendar year after 1997, the
excess hours — up to 800 — are held in reserve for future eligibility, if
needed. A
legend drug is required by federal law
to bear the following statement, “Caution: Federal law prohibits dispensing
without a prescription.” Under
the AD&D benefit, loss
of limb means that your
hand has been permanently severed at or above the wrist, or your foot has
been permanently severed at or above the ankle joint. Loss of sight means you’ve totally and permanently lost the
ability to see out of one or both eyes.
The
maximum annual out-of-pocket is a limit on
the amount you have to spend before the Health Fund begins to pay 100% for
covered procedures. |
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The
Newborns’ and Mothers’ Health Protection Act of 1996 provides that mothers and their
newborn babies are covered for a hospital stay of no less than 48 hours
following vaginal delivery or 96 hours following delivery by caesarean section.
Your doctor may decide, after consulting with you, to discharge you or your
newborn child earlier.
Non-covered employment means employment as a
carpenter for a non-union employer or acting as an officer, director,
supervisor or owner of such a business.
A QMCSO is a Qualified Medical Child Support Order that
recognizes the right of a child of an active or retired member to receive
benefits from the Health Fund. It has to clearly state:
Reasonable and customary (R&C) charges are those that are medically necessary and
don’t exceed the level of charges made by other providers in the area where the
service was performed.
Your
spouse is the
person to whom you’re lawfully married. If you’re legally separated, under
Connecticut law you’re not married.
Your
stepchild is
the biological child of your spouse, provided that you have legal
responsibility for the child. (See child.)
The
Supplemental Plan provides medical
benefits to people who are eligible for Medicare and Retiree Reduced coverage.
Termination for Cause means that any person who is eligible for benefits under the Health
Fund may lose eligibility and COBRA rights if he or she:
·
is
convicted of a crime against the Health Fund, another employee benefit fund, a
local union, the Union, the NERCC or any contributing employer, or any of their
respective officers, directors, trustees, employees or agents,
·
makes,
gives or causes to be made or given, directly or indirectly, any false or
misleading statement which the Trustees determine was made or given knowingly
to induce the Health Fund to make a person eligible for a benefit that the
person would not otherwise have been eligible to receive, or
·
engages
in any non-covered employment on or after January 1, 1998.
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The
Trustees are
the Board of Trustees,
established by the Trust Agreement, with equal representation of union and
management.
ULLICO is the Union Labor Life
Insurance Company, which provides coverage to you and your eligible dependents
under the Life Insurance, Dependent Life Insurance and Accidental Death &
Dismemberment plans. The address is:
ULLICO, Inc.
111 Massachusetts Avenue
Washington DC 20001
The
Union is the
United Brotherhood of Carpenters and Joiners of America.
The
Union Locals refers to Local No. 24, Local No.
43 and Local No. 210 of the United Brotherhood of Carpenters and Joiners of
America.