Answers

Q. I’m divorced. Under the terms of my divorce agreement, I have to provide my exwife with medical coverage until she remarries. I’m about to get remarried myself. Can I cover my current wife?

A. Your current wife may be covered as your dependent. Your ex-wife is eligible for coverage under COBRA for up to 36 months only if she notified the Health Fund within 60 days after the divorce that she wants to continue her coverage.

Q. I’m working outside of my normal area. My employer is supposed to make contributions to the Health Fund for my benefits but I don’t think they’re getting to the Health Fund Office in time for me to keep my eligibility. What can I do?

A. If your employer’s fund has a reciprocal agreement with the Health Fund call the Health Fund Office to be sure that you have a reciprocity authorization on file and that appropriate contributions have been received by it. Those contributions must be sent to the Health Fund Office. You may use your pay stubs to prove you have the hours needed to stay eligible. You can only use 611 hours of Pay Stub Credit per year to maintain your eligibility and 400 hours to become eligible. Your proof has to be in the Health Fund Office by February fifteenth for annual eligibility and by the fifteenth of the month after Employer Contributions were due for initial eligibility.

Q. I’m a carpenter in the Active Plan. In 1999 I had Employer Contributions for over 1,600 hours. Last year I had about 1,225. What if I’m not working enough hours next year to get enough contributions? Do I have to make Buy-In Contributions?

A. Maybe not — the Hours Bank may help you out. Carpenters who are employed or working under a bargaining agreement can accumulate up to 800 hours if they have at least 1,500 hours of Employer Contributions in any calendar year after 1998, and can use the Hours Bank if they had at least 400 hours of Employer Contributions in the prior calendar year. One hundred of your 1999 hours were deposited in your Hours Bank, which you can use to establish your eligibility as of March 1st of 2002 as long as you had contributions made for or worked at least 400 hours in 2001.

Q. I’ve never been covered by the Health Fund. It’s August. I’ve worked for three months, and my employer has contributed 400 hours on my behalf. I need coverage now, even though I’ll have to pay for it. But how do I figure out what I owe?

A. The Health Fund Office will do that for you. Your Buy-In Contribution is based on the number of months you’re buying for. You can pay in monthly installments if you owe more than $50. For example, if you reach 400 hours in May and your employer’s contribution on that 400th hour is due in May, your coverage is effective June first and runs for nine months, from June through February.

Q. I may have to make Buy-In Contributions to stay eligible. What happens if my employer makes contributions for some of the same months I’m paying for?

A. If your employer makes contributions for you for the period you’re buying in for, your Buy-In Contributions will be returned to you or your monthly payments will be adjusted.

Q. I turned down the Buy-In option because I was covered by my husband’s health insurance. Now, he’s lost that coverage. Is it too late for me to make Buy-In Contributions?

A. If you declined the Buy-In option or declined to cover your dependents when you went on total and permanent disability and then find a need for coverage, you may be eligible to do so as long as:

You told the Health Fund Office that you declined because you had other coverage, and later lost that coverage
You married
You had a baby or adopted a child

You must contact the Health Fund Office within 30 days after any change that may affect your eligibility or coverage.

Q. I was disabled and collecting income for 13 weeks and four days. For the first 13 weeks, I received $150 per week. But for the last week I got only $57. Shouldn’t I get $100 for that week?

A. No. You get 1/7 of the weekly amount for each day you were disabled and you get $100 weekly after the first 13 weeks of disability. In your case, that’s 4/7 times $100, or $57.

Q. I was a covered dependent and elected COBRA continuation coverage when I turned 24. I have a new job that will give me medical coverage through its health plan. But I have a pre-existing condition that’s not covered. What should I do?

A. Under the law, you may only be excluded from coverage for your pre-existing condition for no longer than 12 months, or 18 months if you enrolled late. However, if you had continuous coverage under the Health Fund — meaning there was no break in coverage of 63 or more days — for 12 months, or 18 months if you’re a late enrollee, you can’t be barred from coverage for your preexisting condition. Ask for a Certificate of Creditable Coverage from the Health Fund and give it to the administrator of your new plan. For the duration of the time that your new coverage doesn’t cover your pre-existing condition, you can continue your COBRA coverage for your pre-existing condition only. Your health benefits from your new job will be your primary coverage for all other claims.

Q. I’ve just become eligible for medical coverage under the Health Fund. My six-year old daughter had heart trouble when she was born but it was operated on. Does she need to have a physical exam, or do I need to send proof that her problem has been cured? And if she has heart trouble again, will that be covered?

A. The Health Fund doesn’t require anyone to submit medical proof in order to be covered under the Health Fund. And as long as she hasn’t received care for it in the previous six months before she became covered, her heart trouble will be considered to be like any other medical condition if it returns. If she has received treatment in the past six months, but has 12 months of creditable coverage and meets the Health

Fund’s eligibility requirements, she will be covered under the Health Fund with no exclusion for the pre-existing condition.

Q. My wife was in a car accident. Her emergency medical expenses were paid for by our auto insurance. She may need physical therapy. Will the Health Fund pay for her care?

A. The Health Fund will pay for any services not paid for by your auto insurance. You or your insurer may decide to file a lawsuit against a third party responsible for the accident. Auto and health insurance benefits are coordinated so that no one will receive more money than the actual cost of care. Because the Health Fund must be reimbursed for all claims paid out in a third party settlement, you will have to sign and return a Reimbursement Agreement before the Health Fund pays any claims.

Q. I think I was paid too much money from the Health Fund. What should I do?

A. If you think an error has been made, please call the Health Fund Office’s Claims Department for an explanation of what you were paid and why. If a mistake was made and you were paid too much, you have to return the amount you were overpaid. If you don’t, the Health Fund can deduct it from any future benefits due to or for you or your family.

Q. My son is covered under my wife’s health plan at her job and under my medical coverage from the Health Fund. If he needs care, where do we send claims?

A. Your son’s primary coverage is based on the month and day of your and your wife’s birthdays. Say your wife’s birthday is May 5, and yours is July 3. Because her birthday falls earlier in the year than yours does, her coverage is primary for your son. Submit claims to her insurance first, then send claims for the remaining amounts to the Health Fund Office. Enclose the Explanation of Benefits of your claim from the other insurer.

Q. A year and a half ago my 15-year-old daughter broke her nose while playing hockey. She’s covered under my wife’s medical plan and mine. My wife’s coverage is primary, but her plan won’t pay because they say the damage is purely cosmetic. She’s not doing this so she can look like a movie star — she wants to look like herself again.

A. The Health Fund does not pay for cosmetic procedures either. But it will pay to repair damage caused by an accident that happened within the past two years if a review by a medical consultant shows that the surgery is required.