Important Notice – April 2011

To:    All active Health Fund participants and their eligible spouses and dependents:

Some provisions of the Patient Protection and Affordable Care Act (Affordable Care Act) apply to our Health Fund as of April 1, 2011.  We have previously written to you about one change extending eligibility beginning March 1, 2011 to adult children younger than age 26 who do not have access to their own employer-sponsored coverage (including through the adult child's spouse).  This notice describes other changes that took effect April 1, 2011.  We have tried to be as precise as possible about the details of these changes, using a good faith interpretation of existing regulations that may be changed as the government issues more guidance.  Pages 4 and 5 of this notice cover Plan changes effective April 1, 2011 made to comply with another federal law called the Mental Health Parity Act. 

1.         Lifetime and Annual Maximums.  We have eliminated the Health Plan's lifetime maximum of $1 million per person.  If your benefits ended in the past because we had paid $1 million for your treatment, then you may resume submitting claims for treatment on and after April 1, 2011 if you are still eligible for coverage. 

In place of the lifetime maximum, we have added these annual caps on benefits paid for a covered person: 

o $1 million maximum on benefits paid in and for the Plan Year beginning April 1, 2011

o $1.25 million maximum on benefits paid in and for the Plan Year beginning April 1, 2012

o $2 million maximum on benefits paid in and for the Plan Year beginning April 1, 2013

2.         Dollar Caps Removed on these Essential Health Benefits.  The Affordable Care Act requires that we eliminate dollar caps on "Essential Health Benefits" but there is very little guidance on what that term means.  Until further notice, we will treat the following as Essential Health Benefits: 

o Adult (age 18+) routine physical exams once in a calendar year, which will no longer be subject to a $500 annual maximum.

o Adult (age 18+) routine gynecological exams once in a calendar year, which will no longer be subject to a $500 annual maximum.

o Routine mammograms once in a calendar year, which will no longer be subject to a $500 annual maximum.

o Chiropractor spinal manipulations not to exceed 31 visits in a calendar year, which will no longer be subject to a $2,000 annual maximum.

o Smoking cessation products covered by a prescription (chantix, nicotine nasal spray, nicotine inhaler, and zyban tablets), which will no longer be subject to a $500 lifetime maximum.

All of the benefits listed above will continue to be subject to all other Plan rules, including the overall annual limits specified in item 1 of this notice, medical necessity, prior authorization, frequency, deductibles, copays, and coinsurance, and the requirement that services be provided by a Covered Provider (see the list on page 20 of the Health Fund's Summary Plan Description (2008 Edition) – called the 2008 SPD).   

3.         Dollar Caps Remain on these Benefits.  The Affordable Care Act permits us to retain dollar caps on Benefits that are not "Essential Health Benefits" but there is very little guidance on what that term means.  Until further notice, we will treat the following as Non-Essential Health Benefits which will continue to be subject to the stated limits and to all other Plan rules, including the overall annual limits specified in item 1, medical necessity, prior authorization, frequency, deductibles, copays, coinsurance, and use of Covered Providers.    

o Bariatric surgery once in a lifetime, which will continue to be subject to a $60,000 lifetime maximum

o Orthotics not more often than every 3 years for adults, which will continue to be subject to a $500 per pair maximum.

o Orthodontia for participants younger than age 19, which will continue to be subject to a $1,000 lifetime maximum.

o Periodontal disease treatment, including surgery not more often than once every 3 years, which will continue to be subject to a $1,000 lifetime maximum.

o Oligodontia for participants younger than age 19, which will continue to be subject to a $50,000 lifetime maximum.

o Dental treatment, which will continue to be subject to various limits as specified on pages 43-46 of the 2008 SPD, except that there will be no limits on coverage of a pediatric dental screening from an in-network provider.

o Vision care, which will continue to be subject to various limits as specified on pages 50-52 of the 2008 SPD, except that there will be no limits on coverage of a pediatric vision screening from an in-network provider.

o Durable Medical Equipment, which will continue to be subject to requirements that the participant provide a letter of medical necessity and pay 20% of the cost and a $5,000 annual maximum, except that the annual maximum will not apply to restrict coverage of DME that qualifies as an Essential Health Benefit such as crutches and basic wheelchairs.

As regulations and other guidance is issued in the upcoming months, if we are permitted to retain caps on routine exams, chiropractor treatments, or smoking cessation products, we may reinstate those limits prospectively but will not attempt to impose them on any services incurred between April 1, 2011 and the date we notify you that we are reinstating limits.  If regulations or guidance tells us that we cannot impose one or more of the limits stated in item 3 of this notice, we will eliminate those limits retroactively to April 1, 2011 and increase any claims payment to you or your providers that was affected by those limits.

4.         Pre-Existing Conditions.  If a person becomes covered by the Health Fund for the first time or has coverage reinstated after an absence of a year or more and that person received treatment for any sickness or injury in the six months before coverage started, that sickness or illness is considered a pre-existing condition and won't be covered by the Health Fund for the first six months of coverage.  That so-called Pre-Existing Condition Exclusion will not apply to limit medical or dental benefits to anyone younger than age 19.

5.         Definition of Child.  To be considered for coverage within the stated age limits, a child must be a participant's biological child; or a child lawfully adopted by, or placed for adoption with, the participant; a stepchild (meaning the biological child of a participant's spouse) or foster child of the participant; or a child for whom a court order has awarded custody to a participant.   If a Child younger than 19 is disabled, his/her health coverage may continue after the Child attains age 26, if

o the Child is disabled and incapable of self-sustaining employment, at age 19 and age 26, and

o the Child is unmarried, at age 19 and at age 26, and

o the Child is totally dependent upon the participant for support, at age 19 and at age 26, and

o the participant has provided evidence of the Child's disability and satisfaction of the other requirements to the Health Fund, which has sole discretion to determine whether the evidence is satisfactory, before the Child's 19^th birthday.

A Child's coverage will continue later than his 26^th birthday only while he or she continues to satisfy the requirements shown above.  The Health Fund has the right to require documentation that the Child continues to be disabled and meet the other requirements periodically after reaching age 26.  The Health Fund has the right to terminate such a Child's coverage if the requested documentation is not provided within 30 days after request or if the plan rules are changed.

6.         Dependent Life Insurance.  Right now, the Health Fund provides $2,500 in life insurance, payable to the participant, on the eligible spouse and children of the participant.  Despite the fact that most Health Fund benefits will now be offered to participant's adult children younger than age 26, eligibility for dependent life insurance will not be changed by the Affordable Care Act.  That means that dependent life insurance will cover a participant's eligible children who are at least 14 days old until the day before they reach age 19 or, for full-time students, until the day before they reach age 23.  The participant may be subject to taxes upon receipt of payment of the $2,500 dependent life insurance.

7.         Eligibility rules.  The Health Fund trustees decided to transition to annual eligibility the few categories of individuals entitled to month-to-month eligibility.  This affects certain office employees and millcabinet shop employees, all of whom have received a separate notice about the changes.  If you would like an outline of the eligibility transition rules, please request one by contacting the Fund Office.

Please contact the Fund Office if you have questions or comments about anything in this notice or any part of our efforts to comply with the Affordable Care Act.

Effective April 1, 2011 we have expanded the mental health and substance abuse benefits as described in this notice to comply with the Mental Health Parity and Addiction Equity Act (Mental Health Parity Act).

1.         Outpatient Mental Health treatment.   Outpatient treatment for mental health will be covered under the same rules that apply to outpatient medical treatment, meaning that office visits will be subject to a $20 copay and other outpatient services will be covered at 80% of allowable charges.  The Health Fund has eliminated the limits that previously applied to outpatient mental health services (50% coverage after deductible is satisfied, but not for more than 30 visits per year).  Also, we have eliminated the concept that two sessions of intensive outpatient treatment (called "partial hospitalization") is treated as one day of inpatient treatment.

2.         Inpatient Mental Health treatment.  Inpatient treatment for mental health will be covered under the same rules that apply to inpatient medical treatment, meaning that eligible hospital expenses will be covered, after the deductible, at 80% (or 70% if you fail to pre-certify) of the first $18,500 (individual) or $27,000 (family), then at 100% of allowable charges.   The Health Fund has eliminated the rule that it will not cover inpatient mental health treatment of more than 60 days per calendar year.

3.         Outpatient Substance Abuse treatment.   Outpatient treatment for substance abuse will be covered under the same rules that apply to outpatient medical treatment, meaning that office visits will be subject to a $20 copay and other outpatient services will be covered at 80% of allowable charges.  The Health Fund has eliminated the limits that previously applied to outpatient substance abuse services (50% coverage after deductible is satisfied, but not for more than 30 visits per year) and has eliminated the combined inpatient/outpatient lifetime limit of $20,000 (including weekly disability income) or two episodes per lifetime.  Also, we have eliminated the concept that two sessions of intensive outpatient treatment (called "partial hospitalization") is treated as one day of inpatient treatment.

4.         Inpatient Substance Abuse treatment.  Inpatient treatment for substance abuse will be covered under the same rules that apply to inpatient medical treatment, meaning that eligible hospital expenses will be covered, after the deductible, at 80% (or 70% if you fail to pre-certify) of the first $18,500 (individual) or $27,000 (family), then at 100% of allowable charges.   The Health Fund has eliminated the limits that previously applied to inpatient substance abuse services (80% coverage after deductible is satisfied, but not for more than 45 days per calendar year) and the combined inpatient/outpatient lifetime limit of $20,000 (including weekly disability income) or two episodes per lifetime.

5.         Detoxification.  The Health Fund will cover detoxification treatment that meets the Plan's requirements, even if the patient does not access rehabilitation treatment within 7 days.

6.         Maximum Out-of-Pocket.  Presently, the amount you spend out of your own pocket each calendar year towards allowable charges for covered expenses is limited to $4,000 for yourself and $6,000 for you and your family.  Your deductible and 20% coinsurance amount counts towards that limit, but a number of your costs are not counted towards the maximum out-of-pocket.  Your costs for mental health and substance abuse treatment used to be one of the excluded items but those costs incurred on and after April 1, 2011 will now be counted towards your maximum out-of-pocket.

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All of the benefits listed on pages 1-5 of this notice will continue to be subject to all other Plan rules, including specified overall annual limits, medical necessity, prior authorization, frequency, deductibles, copays, and coinsurance, and the requirement that services be provided by a Covered Provider (see the list on page 20 of the Health Fund's Summary Plan Description (2008 Edition).

Please contact the Fund Office if you have questions or comments about anything in this notice or any part of our efforts to comply with the Mental Health Parity and Addiction Equity Act. 

PLEASE remember in these difficult times that the Health Fund contracts with an independent Member Assistance Plan (MAP) that offers counselors available 24 hours a day.  The MAP can help you with family problems, anxiety and stress, drugs and alcohol, depression, gambling problems, job conflicts and marital problems.  You may be entitled to get up to 6 visits for free.  The MAP can be reached at 1-888-373-5073.  All consultations are confidential between you and the MAP. 

This Notice is intended to be a brief description of the topics described.  In any situation involving Fund benefits, the documents governing the Fund will control.  It constitutes a Summary of Material Modifications to the Fund, and we are furnishing it to you in accordance with U.S. Department of Labor regulation §2520.104b-3.  Please keep this Notice with your Summary Plan Description for future reference and contact the Benefit Office with any questions.  All benefits are subject to amendment and/or termination as the Trustees may determine to be in the best interests of the Fund's participants and beneficiaries.

For the Health Fund Board of Trustees,

Deborah L. Palmieri, Health Fund Administrator

April 2011