Your Initial Eligibility

Your eligibility for Plan coverage will be determined on a quarterly basis. You become eligible for benefits under the Plan in an Eligibility Quarter based on the hours of contributions actually made (except as provided below) for work you performed in Covered Employment in the corresponding Contribution Quarter, as described in the chart below. To be eligible for coverage in an Eligibility Quarter, you must have at least 250 hours in the corresponding Contribution Quarter or 1,000 hours in the previous four Contribution Quarters as follows:

Jan/Feb/March
To be eligible for benefits in Jan/Feb/March you must have 250 hours during Aug/Sept/Oct OR you must have 1,000 hours November through October.

Apr/May/June
To be eligible for benefits in Apr/May/June you must have 250 hours during Nov/Dec/Jan OR you must have 1,000 hours February through January.

July/Aug/Sept
To be eligible for benefits in July/Aug/Sept you must have 250 hours during Feb/Mar/Apr OR you must have 1,000 hours May through April.

Oct/Nov/Dec
To be eligible for benefits in Oct/Nov/Dec you must have 250 hours during May/June/July OR you must have 1,000 hours August through July.

Covered Employment is defined as work for which a contributing Employer is required to make contributions on your behalf to this Welfare Fund under the terms of a collective bargaining agreement with Sheet Metal Workers’ Local 73. Notwithstanding any language to the contrary in this SPD, you will be credited with the number of hours actually reported by a contributing Employer for up to three consecutive months even if the contributing Employer fails to make the required contributions on your behalf for those months.

Example 1

Tom worked 267 hours during the May, June, and July Contribution Quarter. As a result, he would be eligible for coverage during the October, November, and December Eligibility Quarter.

Example 2

Sam worked only 200 hours during November, December, and January. However, Sam worked 1,015 hours during the preceding February through January (four Contribution Quarters). Even though Sam did not work 250 hours during the November, December, and January Contribution Quarter, he is still eligible for coverage during the April, May, and June Eligibility Quarter because he worked 1,000 hours during the previous four Contribution Quarters of February through January.

If you are an Apprentice and you attend the 101/2-week pre-apprentice program, you are eligible to participate in the Fund immediately after you successfully complete the program.

Your Initial Eligibility

Your Eligible Dependents become Participants in the Fund on the later of:

• The day you begin participation; or
• The date you enroll them with the Fund Office.

Your newborn Child, adopted Child, or Child placed with you for adoption will generally become covered as a Dependent under the Fund on the date the Child is born, adopted, or placed for adoption.

Example: Your Dependent’s Eligibility

In example 1 above, Tom becomes eligible for coverage on June 1, 2022. Tom enrolls his spouse and his Dependent Children and they become eligible on the same date.

Eligible Dependents are defined as follows:

• Your legal spouse;
• Your Dependent Children up to age 26; and
• Your Dependent Children of any age if mentally or physically disabled, as long as the mental or physical handicap began before the Child reached the end of the month that he or she turned age 26.

Dependent Children include married or unmarried dependents, regardless of student status, who are the member’s natural children, adopted children, or children placed for adoption with the member, stepchildren, foster children placed with the member by an authorized agency or by court order, judgment or decree and any other children for whom the member may have legal guardianship by court order, judgment or decree.

To enroll your newborn or newly acquired Child, you must provide the Fund Office with a copy of the birth certificate or adoption papers. Dependent status may continue until the end of the month of each Child’s 26th birthday.

You must contact the Fund Office within 31 days before Plan benefits might otherwise terminate (on the 1st of the month following the end of the month that he or she turns age 26) to apply for continued coverage for your disabled or handicapped Dependent Child. If your Dependent Child is mentally or physically disabled or handicapped and is chiefly dependent on you, Plan benefits will continue as long as your Dependent is disabled or handicapped. To be eligible, your Child must be unable to engage in the normal activities of a person of like gender and age in good health due to disability or handicap. You must contact the Fund Office within 31 days before Plan benefits might otherwise terminate on the 1st of the month following the end of the month that he or she turns age 26) to apply for continued coverage for your disabled or handicapped Dependent Child, and provide proof that your Dependent Child’s disability will continue past the end of the month of his or her 26th birthday. For this purpose, you should submit the following documents for review: (1) Proof of approval by the Social Security Administration; (2) Copy of Child’s Medicare card (if applicable); and (3) Letter from at least two (2) physicians which includes the disabled or handicapped Dependent Child’s complete diagnosis and a description of mental and physical limitations. If you do not provide proof of your Dependent Child’s continuing disability, his or her welfare coverage under the Plan will terminate as of the 1st of the month following the end of the month of his/her 26th birthday.

An unmarried disabled Child who has reached the end of the month that he or she turns age 26, but does not reside with you, will be a Dependent Child under the Plan if:

• The Child’s parents are divorced or legally separated under a decree of divorce or separate maintenance, are separated under a written separation agreement, or live apart at all times during the last six months of the calendar year;
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• The Child’s parents provide over one-half of the Child’s support during the calendar year; and
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• The Child is in the custody of one or both of his or her parents for more than one-half of the calendar year and is not the qualifying child of any other person during the calendar year.

The Plan will provide benefits for your Dependent Child who is named as an alternate recipient in a Qualified

Your Eligible Dependents become Participants in the Fund on the later of:

• The day you begin participation; or
• The date you enroll them with the Fund Office.

Your newborn Child will automatically become covered as a Dependent under the Fund on the date the Child is born.

Example: Your Dependents' Eligibility

In example 1 above, Tom becomes eligible for coverage on October 1, 2014. Tom’s spouse and his unmarried Dependent Children become eligible on the same date.

Eligible Dependents are defined as follows:

• Your legal spouse;
• Your Dependent Children up to age 26; and
• Your Dependent Children of any age if mentally or physically disabled, as long as the mental or physical handicap began before the Child reached age 26.

Dependent Children include married or unmarried dependents, regardless of student status, who are the member’s natural children, adopted children, or children placed for adoption with the member, stepchildren, and foster children placed with the member by an authorized agency or by court order, judgment or decree.

To enroll your newborn or newly acquired Child, you must provide the Fund Office with a copy of the birth certificate or adoption papers. Dependent status may continue until each Child’s 26th birthday.

If your Dependent Child is mentally or physically disabled or handicapped and is chiefly dependent on you,   Plan benefits will continue as long as your Dependent is disabled or handicapped. To be eligible, your Child must be unable to engage in the normal activities of a person of like gender and age in good health due to disability or handicap. You must contact the Fund Office within 31 days before Plan benefits might otherwise terminate (at age 26) to apply for continued coverage for your disabled or handicapped Dependent Child, and provide proof that your Dependent Child’s disability will continue past his or her 26th birthday. If you do not provide proof of your Dependent Child’s continuing disability, his or her welfare coverage under the Plan will terminate as of his/her 26th birthday. If you provide such proof after your Dependent Child’s coverage has already been terminated, coverage will be reinstated.

An unmarried disabled child who has reached age 26, but does not reside with you, will be a Dependent Child under the Plan if:

• The Child’s parents are divorced or legally separated under a decree of divorce or separate maintenance, are separated under a written separation agreement, or live apart at all times during the last six months of the calendar year;
• The Child’s parents provide over one-half of the Child’s support during the calendar year; and
• The Child is in the custody of one or both of his or her parents for more than one-half of the calendar year and is not the qualifying child of any other person during the calendar year.

The Plan will provide benefits for your Dependent Child who is named as an alternate recipient in a Qualified Medical Child Support Order (QMCSO).

Your Dependents’ benefits are subject to the rules outlined in the Coordination of Benefits.

A QMCSO is a court order that requires you to provide medical coverage for your Children (called alternate recipients) in situations involving a divorce, legal separation or a paternity determination.

This Plan provides benefits according to the requirements of the QMCSO. The Fund Administrator will notify you and any alternate recipient when a QMCSO is received. If the QMCSO is a valid order, the Plan will cover the named Dependent as an alternative recipient even though the Dependent might not otherwise be eligible for coverage.

A copy of the Fund’s QMCSO procedures is available upon request from the Fund Administrator.

In general, your coverage continues on the basis of your hours worked. Refer to the Eligibility Chart to determine continuing eligibility requirements.

The requirements for continuing coverage are the same as the requirements for initial eligibility, as described in Your Initial Eligibility.

In general, your coverage continues on the basis of your hours worked. Refer to the Eligibility Chart to determine continuing eligibility requirements.

Eligibility for your Dependents continues while you are eligible for benefits, as long as they continue to meet the definition of Dependent under the Plan.

Your eligibility for Plan benefits is affected when you do not meet the minimum hours worked requirements described above. Eligibility for all Plan benefits stop as indicated in the Eligibility Chart.

If You are Disabled

For all Plan benefits, any month in which you have a Certified Disability for 18 or more days will be counted as a month in which you have worked in Covered Employment. However, you may not receive credit for a Certified Disability for more than six months in a period of twelve consecutive months.

A Certified Disability is one for which you would otherwise receive Weekly Accident and Sickness Disability Benefits from the Plan, were you eligible, or benefits under any Workers’ Compensation Law, Occupational Disease Law or similar legislation. However, if you are not eligible for this extension, you may continue health coverage under Continuation of Health Benefits (COBRA) as explained on page 20.

If You Retire

If you retire and are eligible for retiree medical benefits under the Sheet Metal Workers’ Local 73 Retiree Welfare Fund, you may continue your coverage under the Plan for Active Employees until the end of the calendar year in which you retire if you have not yet reached age 65. Beginning January 1 of the following calendar year, coverage under the Active Plan ends, and you may continue coverage under Retiree Plan. However, you must begin making self-payments for retiree coverage on your retirement date (the date you begin receiving pension payments from the Sheet Metal Workers’ Local 73 Pension Fund).

If you retire after you have reached age 65, you may not maintain coverage under the Active Plan. You must enroll in Medicare and you will have certain benefits other than major medical coverage under the Retiree Plan, if you are eligible for such coverage.

There are two exceptions to this rule: The Fund’s Death Benefit and the Accidental Death and Dismemberment Benefit will stop six months after your retirement date.

Your Dependent’s eligibility ends at the same time your eligibility under the Plan ends, on the last day of the month in which a Dependent child attains age 26, the date your Dependent child no longer meets the criteria set forth above in the Your Dependent’s Eligibility section, or the date your Dependent spouse no longer meets the definition of Dependent, whichever comes first.

If you die, eligibility for your Dependents will continue without self-payment for as long as you would have been eligible, based on your accumulated eligibility. If your Dependents elect COBRA Continuation Coverage, coverage that is provided on the basis of your accumulated eligibility will be run out before the COBRA Continuation Coverage period begins. If the Dependents elect the Special Health Coverage Continuation, payments at the applicable retiree rate will begin after the period in which Dependents have exhausted the coverage provided on the basis of the Employee’s accumulated eligibility. If your surviving spouse is eligible for, and begins receiving a pension benefit from the Sheet Metal Workers’ 73 Pension Fund, he or she and any eligible Dependent Children will begin retiree coverage immediately under the Special Health Coverage Continuation coverage, will begin paying the retiree rate for coverage, and will not be entitled to exhaust your accumulated eligibility under this Plan.

Eligibility for your Dependents ends when your eligibility ends or when they no longer meet the Plan’s definition of Dependent.

If you lose your eligibility for Plan benefits, your coverage will be reinstated when you meet the initial eligibility requirements again.

Example: Reinstatement of Eligibility

Tom became eligible for coverage on October 1, 2022. He did not work at least 250 hours during the months of August, September and October of 2022 and he did not work 1,000 hours between November 2021 through October 2022, so he loses his eligibility for coverage as of January 1, 2023, and remains ineligible for coverage during that Eligibility Quarter of January, February, and March 2023. If Tom works 250 hours during the Contribution Quarter of November 2022, December 2022, and January 2023, he will be eligible to reinstate coverage beginning with the next Eligibility Quarter (April, May, June of 2023).

To enroll in the Plan, complete the Benefit Enrollment Form and provide the required documentation as soon as it is available.

Enrollment procedures are as follows:

• New member:Complete the Fund’s Benefit Enrollment Form, available through the Fund Office and submit a copy of your driver’s license.
• New spouse:Submit a copy of your marriage certificate and your spouse’s birth certificate to the Fund Office when you get married, along with your spouse’s social security number.
• Newborn Child: Submit a copy of the Child’s birth certificate to the Fund Office, along with your Child’s social security number.
• Newly adopted Child:Submit a copy of the initial placement papers to the Fund Office along with a copy of the birth certificate and adoption papers (when available), along with your Child’s social security number.
• New stepchild:Submit a copy of the stepchild’s birth certificate and court decree (Qualified Medical Child Support Order) (if available) to the Fund Office, along with your Child’s social security number.
• New foster Child placed by an authorized agency or by court order, judgment or decree or any other Child for whom you may have legal guardianship by court order, judgment or decree: Submit a copy of the court order documents signed by a judge verifying legal custody of the child (e.g., placement papers from a qualified state placement agency), or proof of judgment, decree, or court order from a court of competent jurisdiction, along with the Child’s social security number.

This Plan complies with the Federal law regarding special enrollment procedures because all eligible Employees and their Eligible Dependents are automatically enrolled in this Plan as soon as they meet the Plan’s eligibility requirements. There is no option to decline coverage.

Special enrollment is allowed for newly acquired Dependents, including a new spouse, newborn child, newly adopted child, and child newly placed for adoption with the Employee. A Dependent eligible for special enrollment, including a spouse, birth child, child placed for adoption or adopted child, will become an eligible Participant on the date you acquire the Dependent. You must request special enrollment within 30 days of the date you acquire the Dependent to receive coverage as of the date you acquire the Dependent.

Special enrollment rights also may exist in the following circumstances:

• If you or your Dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or
• If you or your Dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact Patrick Ludvigsen, Fund Administrator at 708-449-7373.

A rescission of coverage is a cancellation or discontinuance of coverage that has retroactive effect, meaning that it will be effective back to the time that you should not have been covered by the Plan. The Plan may rescind your coverage for fraud or intentional misrepresentation of a material fact after the Plan provides you with 30 days advance written notice of that rescission of coverage. However, the following situations will not be considered rescissions of coverage and do not require the Plan to give you 30 days advance written notice:

• When the Plan terminates your coverage retroactive to the date you lose eligibility for coverage, if there is a delay in administrative recordkeeping between the date you lose eligibility and the date the Plan is notified of your loss of eligibility;
• When the Plan retroactively terminates your coverage because you fail to make timely self-payments for your coverage; or
• When any unintentional mistakes or errors result in you and your Dependents being covered by the Plan when you should not have been covered, the Plan will cancel your coverage prospectively – for the future – once the mistake is identified.

When you marry, your spouse is eligible for healthcare coverage as of the date of your marriage. However, the Fund will not pay any benefits on behalf of your spouse until you enroll your spouse for coverage. You must request enrollment within 30 days after the marriage. You must send a copy of your marriage certificate, your spouse’s birth certificate, and your spouse’s Social Security Number to the Fund Office as soon as it is available. Once your spouse is enrolled, benefits will be paid retroactively back to the date of your marriage.

Your natural Child will be eligible for coverage on the date of birth. If you adopt a Child, have a Child placed with you for adoption, or acquire a stepchild through marriage, he or she will be eligible for coverage on the date of placement or date of marriage, as long as you are responsible for healthcare coverage and your Child meets the Plan’s definition of a Dependent.

You must enroll your Child for coverage before the Fund pays any benefits for that Child. To enroll your Child for coverage, provide the required documentation to the Fund Office as soon as it is available. See the Enrollment Procedures section on page 12 for more details.

Keep in mind that when you experience a life event that adds or eliminates a Dependent from coverage, you need to notify the Fund Office, and provide the required documentation about your Dependents.

If you and your spouse get a divorce or legal separation, your spouse will no longer be eligible for coverage. Your spouse may elect to continue coverage under COBRA for up to 36 months upon divorce or legal separation. You or your spouse must notify the Fund Office within 60 days of the divorce or legal separation date for your spouse to obtain COBRA continuation coverage. If you or your spouse do not timely notify the Fund Office of your divorce, both you and your former spouse are required to reimburse the Fund for any claims paid for your former spouse or ineligible dependents after the date of your divorce. Any and all benefit payments for you, your former spouse and any Dependents may be withheld until the Fund is made whole.

A Qualified Medical Child Support Order (QMCSO) that is issued in the course of a divorce, legal separation or domestic relations proceeding could have an effect on your benefit coverage or elections. Please notify the Fund Office if your situation involves a QMCSO. You or your Dependent may request a copy, free of charge, of the Fund’s procedures for handling these orders.

In general, your Dependent Child is no longer eligible for coverage when he or she reaches the end of the month in which he or she turns age 26. However, if your child is determined to be mentally or physically disabled before reaching the end of the month in which he or she turns age 26 and continues to be mentally or physically disabled and dependent on you for at least half of his or her support, your child will continue to be covered as your Dependent. To qualify, your Child’s disability must begin before his or her coverage would otherwise end. You must contact the Fund office within 31 days before Plan benefits might otherwise terminate and provide proof of your Child’s continuing disability in order to apply for continued coverage for your disabled or handicapped Child. You should notify the Fund Office immediately when your Dependent Child is no longer eligible for coverage.

If eligible, your Dependent Child may elect to continue coverage under COBRA for up to 36 months after your Dependent Child loses eligibility. You or your Dependent Child must notify the Fund Office within 60 days of the date your Child no longer meets the definition of a Dependent Child in order to obtain COBRA continuation coverage. If you or your Dependent Child fails to do so, the child will not be eligible to elect COBRA continuation coverage.

If your Employer is required to grant you leave under the Family and Medical Leave Act (FMLA), and you qualify for such leave, the FMLA allows you to take up to 12 weeks, or 26 weeks if applicable, of unpaid leave during any 12-month period due to:

• The birth or adoption of a Child or placement of a Child with you for foster care or adoption;
• The care of a seriously ill spouse, parent, or Child;
• Your serious illness; or
• You have an urgent need for leave because your spouse, son, daughter, or parent is on active duty in the armed services in support of a military operation.

In addition, under the FMLA, you may be able to take up to 26 weeks of unpaid leave during any 12-month period to care for a service member. The service member must be your spouse, son, daughter, parent, or next of kin, must be undergoing medical treatment, recuperation, or therapy, for a serious illness or Injury incurred in the line of duty while in military service, and must be an Outpatient, or on the temporary disability retired list of the armed services.

Your leave will end on the earlier of your return to work or 12 weeks, or 26 weeks if applicable. If you do not return to work within 12 weeks, or 26 weeks if applicable, you may qualify for COBRA continuation coverage.

The Fund will maintain your eligibility and medical coverage until the end of the leave, provided your Employer properly grants the leave under the federal law and makes the required notification to the Fund. Contact your Employer for more information relating to a leave under the FMLA.

An Employer is required to grant FMLA leave to eligible Employees if it employs 50 or more Employees within a 75-mile radius for at least 20 weeks of the current or preceding year. To be eligible for FMLA benefits, an Employee must:

• Work for an Employer required to grant FMLA leaves;
• Have worked for that Employer for a total of at least 12 months;
• Have worked at least 1,250 hours over the previous 12 months; and
• Work at a location in the United States or in any territory or possession of the United States where at least 50 Employees are employed by the Employer within 75 miles.

You or your Employer must notify the Fund Office if you are taking a FMLA leave.

If you and your spouse both work for the same Employer, you and your spouse are eligible for a combined total of 12 weeks (or 26 weeks, if applicable) of leave during a 12-month period.

If you enter military service (active duty or inactive duty training) for up to 31 days, your health coverage will continue for the duration of your military leave as long as contributions have been received for your coverage.

If you enter military service for more than 31 days, and you would like to continue your Plan coverage for yourself and your eligible Dependents during your service, you have a choice of either: (1) making self-payments for coverage and having your remaining eligibility frozen until your reemployment after service; or (2) using your remaining eligibility for coverage, continuing coverage through self-payments when your eligibility is exhausted, and making self-payments for coverage upon reemployment after service. You may continue your Plan coverage through either of these methods for up to 24 months, or if shorter, the end of the period during which you are eligible to apply for reemployment in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA).

Your coverage under USERRA will continue until the earliest of the following:

• The date you or your Dependents do not make the required self-payments within 30 days of the due date;
• The date you reinstate your eligibility for coverage under the Plan;
• The date you lose your rights under USERRA (for instance, for a dishonorable discharge);
• The end of the period during which you are eligible to apply for reemployment in accordance with USERRA;
• The last day of the month after 24 consecutive months; or
• The date the Fund no longer provides any group health benefits.

You need to notify the Fund Office in writing when you enter the military. For more information about Self-Payments under USERRA, contact the Fund Office. Continuation coverage under USERRA will be administered by the Fund Office in the same way that COBRA continuation coverage is administered, except that coverage may continue for up to 24 months under USERRA. The Trustees will set the amount of your premium payment for continuation coverage under USERRA. USERRA and COBRA rights run concurrently.

If you do not continue coverage under USERRA, your coverage will end immediately within 31 days of the date you enter active military service. Your Dependents will have the opportunity to elect COBRA continuation coverage.

When you are discharged or released from military service, you have up to the USERRA-specified time period to report to work for a Contributing Employer. If you return to work or make yourself available for work during this period, any remaining coverage eligibility that you and your Dependents have will be reinstated on the day you report to work or make yourself available for work. If you do not report to work in Covered Employment within the USERRA-specified period, you will be considered a new Employee and you will need to satisfy the initial eligibility requirements.

Reemployment

Following your discharge from service, you may be eligible to apply for reemployment with your former Employer in accordance with USERRA. Reemployment includes your right to elect reinstatement in any existing healthcare coverage provided by your Employer.

If you die, your spouse and Eligible Dependents may continue coverage for up to 36 months by electing COBRA continuation coverage and making the necessary Self-Payments, or, if eligible, by electing Special Health Continuation Coverage.

Coverage for you and your Dependents will end if contributions needed to maintain your eligibility are not made on your behalf. You may be eligible to continue coverage by electing COBRA continuation coverage and making the necessary self-payments for such coverage by the due date.

Contact the Fund Office about your coverage options as you get closer to your retirement date. They can provide you with a copy of the booklet that explains Retiree coverage. If you retire, you may be eligible for Retiree coverage. You should refer to the Summary Plan Description/Plan Document for the Sheet Metal Workers’ Welfare Plan for Retirees for information about Retiree eligibility. Contact the Fund Office for a copy of that booklet.

Contact the Fund Office about your coverage options as you get closer to your retirement date. They can provide you with a copy of the booklet that explains Retiree coverage.

Your Dependents have several options for continuing coverage after your death. Their options depend on whether or not you were eligible for coverage when you die.

If You Were Eligible For Coverage When You Died

If you die while you are eligible for Plan coverage as an Active Employee, eligibility for your Dependents will continue without self-payment for as long as you would have been eligible for coverage, based on your accumulated eligibility.

After your death, your surviving spouse and Dependent Children may choose to continue coverage by either:

• Exhausting your Active coverage and then electing COBRA continuation coverage, or
• Electing Special Health Continuation Coverage, which is coverage under the Retiree Plan, if eligible. In this case, coverage under the Retiree Plan would begin on the date your surviving spouse begins receiving a pension from the Sheet Metal Workers’ Local 73 Pension Fund and begins payment for Retiree coverage.

If you die without meeting the requirements for Special Health Continuation Coverage, your Dependents will be entitled to COBRA continuation coverage only.

Health Continuation Coverage

Your Dependents may continue coverage under the Retiree Plan through Special Health Continuation Coverage if:

• You die as an Active Employee,
• You had at least nine pension credits awarded by the Sheet Metal Workers’ Local 73 Pension Fund at the time of your death,
• You were eligible for a pension (including a Reciprocal Pension) from the Sheet Metal Workers’ Local 73 Pension Fund at the time of your death and your surviving spouse is receiving a survivor’s pension, and
• You worked at least fifteen full years with Employers that were signatories to collective bargaining agreements with the Sheet Metal Workers’ International Union or one of the Sheet Metal Workers’ Local Unions.

Your surviving spouse and Eligible Dependents must make the required self-payments to the Retiree Plan for this Special Health Continuation Coverage at a rate set by the Trustees. You may contact the Fund Office for information about the rates for this coverage. Self-payments must begin in the month following the month of your death. If self-payments are not being deducted from the pension check, they are due on the first of the month for which coverage is being provided. There is a 30-day grace period to make such direct self-payments.

The premium for coverage is based upon the surviving spouse’s age and the Participant’s years of service. The rate will change on March 1st following the years the surviving spouse reaches age 60, age 62 and age 65.

This special coverage is only available if your surviving spouse was married to you throughout the 12-month period immediately before your death. Coverage for your spouse under the Special Health Continuation Coverage provision will terminate on the first day of the month in which your spouse remarries following your death. However, your surviving spouse and any covered Dependent Children will be entitled to elect COBRA continuation coverage under the Active Plan for the remainder of the 36-month period that started on the date of your death by making timely self-payments at the COBRA rate. If the surviving spouse does not remarry, coverage will terminate for a Dependent Child who continues coverage under the Special Health Coverage Continuation provisions when the Dependent Child no longer meets the definition of Eligible Dependent under the Plan. The Dependent Child will have the option of electing COBRA continuation coverage under the Retiree Plan when a qualifying event occurs.

To be eligible to continue coverage under the Special Health Continuation Coverage provision, your Dependents must waive COBRA Continuation Coverage. However, if your Dependents lose this coverage because your surviving spouse remarries within 36 months of your death, they will be eligible to elect COBRA Continuation Coverage under the Active Plan for the balance of the 36-month period that began on the date of your death. The cost of coverage will be the COBRA rate.

If you were retired at the time of your death, your Dependents will be entitled to continue coverage under the provisions of the Sheet Metal Workers’ Local 73 Welfare Plan for Retired Employees.

Your surviving Dependent Child may elect COBRA continuation coverage for up to 36 months from the date the Child no longer meets the Plan’s definition of a Dependent.

Retiree benefits are described in more detail in the Summary Plan Description for Retired Employees. If your surviving spouse is receiving a pension from the Sheet Metal Workers’ Local 73 Pension Fund, there is no continuation of eligibility under the Active Plan and self-payments for Retiree Plan benefits must begin immediately.

Special Health Continuation Coverage is available to your survivors if you met certain requirements while you were covered by the Plan.

If You Were Not Eligible For Coverage When You Died

If you were not eligible for Plan coverage at the time of your death, your Dependents may make self-payments for coverage under the Special Health Continuation Coverage provision if:

• You had earned 25 pension credits under the Sheet Metal Workers’ Local 73 Pension Fund; and
• You were credited with a minimum of three pension credits in the period consisting of the Pension Plan Year in which you died and the six consecutive Pension Plan Years immediately preceding the year in which you died.

Pension credits mean only those directly awarded by the Sheet Metal Workers’ Local 73 Pension Fund, not those awarded by another pension fund. If you served as a full-time Officer or Business Agent of the Union, you will be given credit for the years of service to the Union. See the Fund Office for more details.

See taking a Family and Medical Leave of Absence for information about continuing coverage during a leave under the Family and Medical Leave Act (FMLA).

See page 15 for information about continuing coverage during a leave under the Family and Medical Leave Act (FMLA).

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides for continuation of health coverage for you, your spouse and Dependent Children, if you lose coverage under the Plan due to a qualifying event. You and your Dependents may continue health coverage for a limited period of time by making self-payments to the Plan.

If you lose eligibility due to insufficient hours or termination of your employment, your coverage will continue without self-payment, depending upon how long you worked in Covered Employment. You may generally then elect COBRA Continuation Coverage for up to a maximum of 18 months, unless you are entitled to an extension as described below in the Length of COBRA Continuation section. Your COBRA Continuation Coverage will be partially subsidized for the first six months and then you will pay the full rate for any remaining coverage thereafter. The Fund is responsible for subsidizing up to 50% of the full COBRA Continuation Coverage rate during this six month period, the Union is responsible for 50% of the remainder after the Fund’s contribution and then you will be responsible for the remainder, which amounts to 25% of the full COBRA Continuation rate. This provision applies only when you elect COBRA for yourself or you elect family coverage.

If you or your Dependent loses eligibility for any other reason, the full COBRA Continuation Coverage rate will be charged for the entire period of coverage.

You and your Dependents may choose individual coverage or family coverage. Each qualified beneficiary has an independent right to elect COBRA.

When coverage under the Plan would otherwise end due to a qualifying event, you and/or your Dependents may be able to continue coverage by electing COBRA continuation coverage.

Eligibility for COBRA Continuation Coverage

If you or your Dependents are eligible for COBRA continuation coverage, you are considered qualified beneficiaries, meaning you were covered by the Plan on the day before the qualifying event.

If you marry, have a newborn Child, or have a Child placed with you for adoption while you are enrolled in COBRA continuation coverage, you may enroll that spouse or Child for the balance of the period of your coverage. You must complete the enrollment within 30 days after the birth, marriage, or placement for adoption. Children born to, adopted, or placed for adoption with you will have the rights of a qualified beneficiary if they are properly enrolled in the Plan. However, other Dependents who are added to the coverage will not have the rights of a qualified beneficiary.

Scope of COBRA Continuation of Coverage

If you choose COBRA continuation coverage, you are entitled to the same type of coverage that you had on the day before the date of the qualifying event that triggered COBRA. Your COBRA continuation coverage includes the Death Benefit for you as the Employee; however, COBRA continuation coverage does not include the Accidental Death and Dismemberment,

Weekly Accident and Sickness Disability Benefits, or Weekly Maternity Benefit currently provided to Active Employees by the Fund. The Death Benefit is not included in COBRA continuation coverage for your Spouse or Dependent Children. If there is a change in the health coverage, including Prescription Drug coverage that is provided by the Plan to Active Participants, that same change will be made to your COBRA continuation coverage.

COBRA continuation coverage allows you to pay to continue your coverage when it would otherwise end due to a qualifying event. You and/or your Dependents may be eligible to elect COBRA continuation coverage if you experience a qualifying event.

Qualifying Events That Trigger COBRA Continuation Coverage 

If you experience a qualifying event that causes you to lose coverage, you will be considered a qualified beneficiary, and the Fund will send you a COBRA Election Notice and a form for you to elect coverage. The qualifying events under which you and/or your Dependents may lose coverage under the Plan and the period of time for which you may make self-payments to continue benefits are described below.

You become a qualified beneficiary if you lose coverage because of one of the following qualifying events:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

Your spouse becomes a qualified beneficiary if he or she loses coverage because of any of the following qualifying events:

• Your death,
• Your hours of employment are reduced,
• Your employment ends for any reason other than your gross misconduct,
• You and your spouse become divorced or legally separated, or
• You become entitled to Medicare benefits under Part A, Part B or both. Becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Your Eligible Dependent Children become qualified beneficiaries if they lose coverage because of any of the following qualifying events:

• Your death,
• Your hours of employment are reduced,
• Your employment ends for any reason other than your gross misconduct,
• The parents become divorced or legally separated,
• The Child stops being eligible for coverage under the Plan as an Eligible Dependent Child, or
• You become entitled to Medicare benefits under Part A, Part B or both. Becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Length of COBRA Continuation Coverage

If you lose eligibility for coverage because your hours are reduced or your employment is terminated, you and your Dependents may continue COBRA continuation coverage for a maximum period of 18 months from the date of loss of coverage. Once coverage is lost, the monthly contribution rate for individual or for family coverage for the first six months will be subsidized. The contribution rate for the seventh through the eighteenth month is not subsidized and, therefore, is higher.

If your Dependents lose coverage under the Plan because of divorce, legal separation, your death, or loss of Dependent status, your Dependents may maintain COBRA continuation coverage for a maximum period of 36 months from the date coverage was lost.

In no case are you entitled to COBRA continuation coverage for more than a total of 18 months, unless you qualify for an additional period of up to 11 months because of disability as described below. Other family members may be entitled to COBRA continuation coverage for a total of 36 months.

Second Qualifying Event During Initial COBRA Continuation Coverage Period

If, during an 18- month period of COBRA continuation coverage following your termination of employment or reduction in hours, you die, divorce, legally separate, become entitled to Medicare, or your Child loses Dependent status under the Plan, the maximum period is extended to 36 months from the date you initially lost eligibility. This extension only applies to:

• Qualified beneficiaries who are members of your family and were covered by the Plan before the loss of your eligibility, and
• Your Dependent Children who were born, adopted, or placed for adoption with you while you were covered under COBRA continuation coverage.

Extended Coverage in Certain Cases of Disability

If, during or before the first 60 days of an 18-month period of COBRA continuation coverage, you or one of your Dependents are determined by the Social Security Administration (SSA) to be totally and permanently disabled so as to be entitled to Social Security Disability benefits, the 18-month maximum period can be extended for up to 11 more months (for a total of 29 months) for all qualified beneficiaries who have elected COBRA continuation coverage. This extension is available only if:

• The disability starts at some time before the 60th day of COBRA continuation coverage, and
• The qualified beneficiary or another family member notifies the Fund Office of the Social Security Administration’s determination within 60 days after the determination is received by the qualified beneficiary, and
• That notice is received by the Fund Office before the end of the 18-month COBRA continuation coverage period.

additional 11 months of coverage under the disability extension will be higher than the monthly self- payment rate paid for the first 18 months, as explained in the next section.

In addition to the above, if your Employer is obligated to provide COBRA coverage to you because you are a Qualified Beneficiary under the Employer’s private health care plan at the time that the Employer initially becomes eligible to participate in this Plan, you will be offered COBRA under this Plan. You will receive this coverage only to the extent of the remaining COBRA period from your Employer’s prior private health care plan.

For example if you were enrolled in COBRA under your Employer’s private health care plan for 6 months because of termination of employment, and then your Employer began participating in this Plan, you would be offered 12 months of COBRA coverage under this Plan, because that would be the remainder of your 18-month COBRA period under your Employer’s prior private health plan.

Cost of and Payment for COBRA Continuation Coverage

Any qualified beneficiary who elects COBRA continuation coverage will pay the full cost of the coverage. The Fund can charge the full cost of coverage for similarly situated Employees and their families (including both the Fund’s share and Employee’s share, if any) plus an additional 2%.

If the 18-month period of COBRA continuation coverage is extended because of disability, the Fund can charge the cost plus an additional 50%.

The monthly cost depends on how many people are covered. Rates are provided for one person or for family coverage. If a qualified beneficiary adds Dependents that are acquired during the COBRA continuation coverage period and the qualified beneficiary was previously paying for individual coverage, the qualified beneficiary will be required to pay the higher rate.

The Trustees will establish the COBRA continuation coverage rates in accordance with ERISA and the Internal Revenue Code. Generally, the Trustees will set new rates each Plan Year beginning July 1.

When you elect COBRA continuation coverage, you are required to make the first payment no later than 45 days after the date of your election, which is the date your COBRA Election Notice is post-marked, if mailed. If you do not make the first payment for continuation coverage in full within the 45-day deadline after your election, you will lose all rights to COBRA continuation coverage. You are responsible for contacting the Fund Office to make sure that the amount of your first payment is correct.

Your subsequent payments for COBRA continuation coverage are due on the first day of the month for which coverage is being provided. However, you have a 30-day grace period to make the payment. If the payment is not made within the grace period, you will lose all continuation coverage rights under the Plan. COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the month for which it applies, but before the end of the grace period (the end of the month) for the coverage, coverage under the Plan will be suspended as of the first day of the month and then retroactively reinstated, going back to the first day of the month when your payment is received.

If you lose eligibility due to insufficient hours and you elect COBRA Continuation Coverage, you will be required to pay at the subsidized rate for the first six months and at the full rate thereafter. This provision applies both to you and to any of your Eligible Dependents covered by the COBRA Continuation Coverage. You and your Dependents may separately choose individual coverage or jointly choose family coverage. If your Dependent loses eligibility for any other reason, he or she will be required to pay the full rate for the entire period of coverage.

COBRA Continuation Coverage Notice and Election

You or your covered family member must inform the Fund Office of a divorce, legal separation, or of a Child losing Dependent status. You or your Dependent must provide written notice within 60 days of the event or the person affected forfeits the right to COBRA continuation coverage.

Your Employer has the responsibility to notify the Fund Office of your death, termination of employment or reduction in hours within 30 days of the date that you would lose coverage due to the event. However, you or your covered Dependents are encouraged to notify the Fund Office of any event that may qualify you or your Dependents for continuation of coverage.

When the Fund Office is notified that one of these events has occurred, it will in turn notify you or your Dependents of the right to choose continuation coverage and the time frame within which you must make the election. If you are not entitled to COBRA continuation coverage, the Fund will notify you of your ineligibility in writing.

You or your Dependents have an election period of at least 60 days from the date the notice is provided to inform the Fund Office of your election of COBRA continuation coverage.

You may elect individual coverage or family coverage. Once you make your election for COBRA continuation coverage, you cannot change it unless it is within the 60-day election period. This means that after the 60-day election period ends, if you elect individual coverage, you cannot change to family coverage, and if you elect family coverage, you cannot change to individual coverage. However, if you elect family coverage for only two family members and one of the family members dies so that individual coverage would be less expensive, the surviving individual may change to individual coverage. The Plan will charge for the individual premium starting on the first day of the month following the day the covered family member dies.

If your Dependent’s coverage ends due to divorce, legal separation, or loss of Dependent status, you or your Dependent must notify the Fund Office within 60 days of the event to qualify for COBRA continuation coverage.

COBRA Benefit Coverage

Under COBRA continuation coverage, you are entitled to the same type of coverage that you had before the event that triggered coverage. If you or your Dependents choose COBRA continuation coverage and make the required self-payments, the Welfare Fund will provide coverage for all medical, dental, prescription drug, wellness, Substance Abuse, employee assistance plan, hearing and vision benefits under the Plan. Death, Accidental Death and Dismemberment, Weekly Accident and Sickness Disability Benefits and Weekly Maternity Benefits are excluded from COBRA continuation coverage.

In addition, if there is a change in the healthcare coverage that is provided by the Plan to Active Participants, that same change will be made to the COBRA continuation coverage of qualified beneficiaries.

Keep in mind that COBRA continuation coverage does not include Weekly Accident and Sickness Disability Benefits, so that if you become disabled while you are on COBRA continuation coverage, you will not receive those benefits.

However, you may receive a disability extension of COBRA continuation coverage if you meet the requirements in the Extended Coverage in Certain Cases of Disability.

Termination of COBRA Continuation Coverage

If you or your Dependent elects COBRA continuation coverage, coverage will terminate as of the date the first of any of the following events occur:

• You or your Dependents do not pay the self-payment for COBRA continuation coverage within 30 days of the due date (i.e., within the grace period).
• You or your Dependents become covered under another group health plan. Contact the Fund Office for details.
• You or your Dependents become eligible for Medicare. Contact the Fund Office for details.
• The Welfare Fund no longer provides any healthcare benefits.
• The Social Security Administration determines that you are no longer disabled during the COBRA disability extension period. You or your Dependent must give the Fund Office notice that you are no longer disabled within 30 days of the date that the Social Security Administration has determined that you are no longer disabled.

Availability of Other Coverage Besides COBRA Continuation Coverage

There may be other coverage options for you and your family besides COBRA continuation coverage. For example, you may be eligible to buy an individual plan, through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of- pocket costs will be before you make a decision to enroll. Additionally, you may have coverage options under Medicare, Medicaid, Children’s Health Insurance Program (CHIP) or you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.

Once you lose COBRA continuation coverage, you must meet the Plan’s initial eligibility requirements to once again be eligible for coverage under the Plan.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or
• The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

If You Have Questions

If you have questions about your COBRA continuation coverage, you should contact Patrick Ludvigsen, Fund Administrator at 708-449-7373, or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa/.

Keep the Fund Informed of Address Changes

In order to protect your family’s rights, you should keep the Fund informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Fund.

The Fund provides comprehensive medical coverage through Blue Cross Blue Shield of Illinois, a Preferred Provider Organization (PPO) that has agreed to provide medical services to you and your Dependents at pre-negotiated rates.

You are encouraged to use PPO Hospitals and Physicians whenever possible. You will receive the maximum benefits available under the Fund when you use PPO Providers because the Fund will be paying a greater percentage of your covered expenses. Your share will also be less because those covered expenses are generally billed at a discount by the PPO.

To select a PPO Provider in your area or to find out whether your Provider is in the PPO network, you may contact Blue Cross Blue Shield of Illinois, free of charge, at 1-800-810-BLUE (2583), visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com, or call the Fund Office at 1-708-449-7373. Have your medical ID card handy so that you can provide any information required about your Fund. 

Each calendar year, before the Plan begins to pay benefits, you must pay the individual deductible listed in your Schedule of Benefits. Your family meets the deductible when three family members have paid their individual deductibles during the calendar year. After that, no other covered family members will have to meet the individual deductible.

The deductible applies only once in a calendar year even though you may have several different Sicknesses or Injuries during that period. So that your medical claims will not be subject to a deductible late in one calendar year and soon again in the following year, any expenses applied against the deductible in the last three months of a calendar year may also be applied against the deductible for the next calendar year.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, you are not required to pay the deductible for these expenses. You also do not need to satisfy the deductible before being eligible for Hospice benefits.

If two or more eligible family members are injured in the same accident, only one deductible will apply in the current and next succeeding calendar year for all their covered expenses directly resulting from the accident.

You and the Fund share your healthcare expenses. Coinsurance is:

• The amount that the Plan pays of your eligible expenses after you have paid your deductible, and
• Listed in the Schedule of Benefits as a percentage of your eligible expenses, after the deductible.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, the Plan’s coinsurance provisions do not apply to your transplant expenses. The coinsurance provisions also do not apply to Hospice benefits.

Each calendar year after you reach the out-of-pocket maximum per person listed in the Schedule of Benefits, the Plan generally pays 100% of your remaining covered expenses during that calendar year, except for the following expenses:

• Treatment for infertility,
• Treatment received at a non-PPO Hospital or non-PPO Ambulatory Surgical Facility, or treatment received from a non-PPO Physician, and

The following expenses are not counted toward the out-of-pocket maximum:

• Deductibles,
• Treatment received at a non-PPO Hospital or non-PPO Ambulatory Surgical Facility, and
• Services performed by non-PPO Physicians.

When your Physician recommends elective or non-emergency hospitalization or Inpatient surgery, you must call the Blue Cross Blue Shield Medical Service Advisory (MSA) for prior approval of the admission at least one business day before you go into the Hospital. Contact the Blue Cross Blue Shield MSA at 1-800-255-5192.

If you have an emergency admission, you, your Physician, the Hospital or a family member must call the Blue Cross Blue Shield MSA within two business days of the date of your admission. This provision does not apply to maternity admissions.

Pre-admission authorization is not a guarantee that all services and charges will be paid for by the Fund. Your benefits are still subject to the terms and conditions of the Plan.

If you do not notify the Blue Cross Blue Shield MSA within the required periods of time, you will have to pay an additional $250 copayment before the Fund will pay any benefits.

Services received at the following facilities will be subject to an additional $250 copayment unless approved by Blue Cross Blue Shield MSA:

• Hospital,
• Dialysis facility, or
• Skilled nursing facility.

1. The fact that your Health Care Provider recommends Surgery, Hospitalization, confinement in a Health Care Facility, or that your Health Care Provider proposes or provides any other medical services or supplies doesn’t mean that the recommended services or supplies will be an Covered Expense or be considered Medically Necessary for determining coverage under the Plan.
2. The Utilization Management Program is not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefits. The UM Company’s certification that a service is Medically Necessary doesn’t mean that a benefit payment is guaranteed. Eligibility for and actual payment of benefits are subject to the terms and conditions of the Plan.
3. All treatment decisions rest with you and your Provider. You should follow whatever course of treatment you and your Health Care Provider believes to be the most appropriate, even if the UM Company does not certify a proposed surgery/treatment/service or admission as Medically Necessary. However, the benefits payable by the Plan may be affected by the determination of the UM Company.

You should contact the Fund Office if you have any questions regarding the precertification process or if you are unsure if a service or treatment must be pre-certified. The following services require pre-certification and medical review:

• Durable Medical Equipment as provided in Appendix A
• Skilled Nursing Care
• All Elective Hospital Admissions
• All Elective In-Patient Admissions (For Medical and Mental Health and Substance Used Disorder Admissions)
• All Elective Surgery and/or Surgical Procedures
• Hospice Benefits
• Private Duty Nursing/Coordinated Home Care Program
• Growth Hormones for Dependent Children
• Physical and Occupational Therapy beginning when you need 30 visits or more in a calendar year, pre-certification required after 30th visit.

If an emergency requires hospitalization, there may be no time to contact the UM Company before you are admitted. If this happens, the UM Company must be notified of the hospital admission within 48 hours. You, your Health Care Provider, the hospital, a family member or friend can make that phone call to the UM Company. This will enable the UM Company to assist you with your discharge plans, determine the need for continued medical services, and/or advise your providers of the various benefits available for you and offer recommendations, options and alternatives for your continued care.

1. When you are receiving medical services in a hospital or other inpatient facility, the UM Company will monitor your stay by contacting your Providers to assure that continuation of medical services in the facility is Medically Necessary, and to help coordinate your care with benefits available under the Plan.
2. Concurrent review may include such services as coordinating home health care or durable medical equipment, assisting with discharge plans, determining the need for continued medical services; and/or, advising your Providers of various options and alternatives for your care available under this Plan.
3. You or your eligible Dependent may be denied payment if services or treatment are found to be not medically necessary or not covered under the Plan.

At any time during the review process, you may be asked by the UM Company to obtain an additional opinion about a proposed service to help determine if the service is Medically Necessary, or if an alternative effective approach to your or your Dependent’s care management exists.

Claims for services or supplies that have not been reviewed under the Plan’s Precertification, Concurrent Review, or Second and Third Opinion Programs may be subject to retrospective review to determine if they are Medically Necessary. If the Plan receives a determination from a UM Company that services or supplies were not Medically Necessary, the Plan may deny benefits.

Case Management is a voluntary process, administered by the UM Company. Case Management services are particularly helpful when you or your eligible Dependent needs complex, costly, and/or high-technology services, and when assistance is needed to guide patients through a maze of potential Providers.

You, your eligible Dependent, or Provider can request Case Management services by calling the UM Company. However, the UM Company will actively search for those cases where you or your eligible Dependent could benefit from Case Management services, and it will initiate Case Management services automatically.

The Case Manager of the UM Company will work directly with your Provider, Hospital, and/or other facility to review proposed treatment plans and to assist in coordinating services, locating in-network providers, and providing other services as needed. From time to time, the Case Manager may confer with your Provider, and may contact you or your Dependent to assist in making plans for continued care and to assist you or your Dependent in obtaining information to facilitate those services.

You may call the Case Manager of the Utilization Management Company or the Fund Office at any time to ask questions or obtain information.

You may request an appeal of any adverse review decision made during the precertification, concurrent review, retrospective review, Case Management or second opinion review process.

The Hospice Benefit covers 100% of Reasonable and Customary Charges for the services outlined in the chart below and on the next page.

To be eligible for hospice benefits, the hospice care must be rendered as part of a Hospice Care Program by a licensed Hospice Care Agency. Before a covered individual enrolls in a Hospice Care Program, they should contact the Fund Office to verify that services will be covered under this benefit.

Schedule of Benefits for Hospice Services

Services and equipment covered at 100% include:

• Physician services,
• Physical, respiratory and occupational therapies,
• Drugs, medications and medical supplies when provided under the Hospice Care Program through Hospice Care Agency,
• Private duty nursing services by a Registered Nurse or Licensed Practical Nurse, if certified by a Physician,
• Rental of Durable Medical Equipment (DME), as described in Appendix A on page 115, and
• Oxygen and rental of related equipment.

Outpatient Hospice Care – Care that you receive in a licensed medical facility. After you receive treatment, you return to your home.

Services covered at 100% include:

• Physician services,
• Laboratory, x-ray and diagnostic testing, and
• Ambulance service or alternative types of transportation.

Inpatient Hospice Care – Care received while you are an admitted patient in a Hospital or Hospice facility.

Services covered at 100% include:

• Room and board for you which may include overnight accompaniment by family,
• Nursing services,
• All other related Hospital expenses,
• Physician services, and
• Ambulance service or alternative types of transportation.

Other Services – In addition to the services outlined above, certain other services for you and your family are also covered.

Services covered at 100% include:

• Visits by a licensed social worker to evaluate the social, psychological and family problems related to the terminal illness. In addition, this professional will help develop a plan to assist in resolving these problems;
• Emotional support services to help relieve stress, cope with the anticipated loss, complete unfinished family business and maintain the patient in the most appropriate environment;
• Special incidental services for the patient, such as special dietary requirements, transportation between home and other sites of care; and
• Bereavement counseling for the immediate family following the death of the Hospice patient. (Coverage is limited to six visits.)

If coverage terminates for any reason while benefits are being paid under the Comprehensive Major Medical Benefit, benefits may be extended if:

• The eligible person was Totally Disabled on the date coverage terminated,
• Expenses were incurred in connection with the Injury or Sickness causing such Total Disability, and
• The total maximum amount of benefits, if any, have not been paid.

Benefits will continue until the earliest of:

• The end of the calendar year following the calendar year in which coverage terminated,
• The date that the total amount of benefits have been paid, or
• The date that you are no longer Totally Disabled.

No benefits will be payable after the above date for that disability nor will any benefits be payable with respect to separate disabilities beginning after coverage terminated.

This Plan provides coverage for certain Preventive Services as required by the Patient Protection and Affordable Care Act of 2010 (ACA). Coverage is provided on an in-network basis, with no cost-sharing (for example, no deductibles, coinsurance, or copayments), and on an out-of-network basis, subject to cost-sharing, for the following services:

1. Services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations,
2. Services described in the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC), and
3. Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures guidelines.

In-network preventive services that are identified by the Plan as part of the ACA guidelines will be covered with no cost-sharing by the Participant or Dependent. This means that the service will be covered at 100% of the Plan’s Reasonable and Customary Charge, with no coinsurance, copay, or deductible. Out-of-network preventive services that are identified by the Plan as part of the ACA guidelines will be covered at 70% of the Reasonable and Customary Charge.

In some cases, federal guidelines are unclear about which preventive benefits must be covered under the ACA. In that case, the Trustees will determine whether a particular benefit is covered under this Preventive Services benefit.

1. Physical Examination Benefit: The Plan will cover the expense related to a routine physical examination (including routine OB/GYN exams) by a Physician. Routine physical examinations include baseline examinations, periodic examinations and those examinations performed due to a relevant family history.
2. Testing for asbestos/spirometry on Participants and Dependents will only be covered under the annual physical examination benefit charges for respiratory clearance or as required by federal law. The asbestos/spirometry tests must be performed in conjunction with an annual physical.
3. Physical examinations that are for purposes of meeting employment requirements will be covered by the Plan, but only if they are performed as part of the in-network annual physical examination. Such examinations will be subject to the benefit limitations listed on the Schedule of Benefits for wellness expenses and will be subject to the provisions governing the Plan’s use and disclosure of your protected health information. These examinations must be performed in conjunction with an in-network annual physical examination.
4. Your Eligible Dependents through the age of 21 are entitled to coverage for well-child care benefits when provided by a network provider. Well-child care benefits include: a) Physical examinations; and b) Well-Child Required Immunizations, as recommended by the American Academy of Pediatrics.
5. The Plan also covers the immunization of girls and young women, ages 13 to 33, and boys ages 11 and 12, to prevent the human papillomavirus (HPV), a virus that can cause cervical cancer and other diseases.
6. Please note that Well-Child Required Immunization charges will be reimbursed when the service is rendered by a local Public Health Department but only after proof of payment is submitted to the Fund Office.
7. Non-preventive Services are not covered without Cost-Sharing: The plan will impose cost-sharing for treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
8. Preventive Services for Dependents: All covered participants and Dependents are eligible to obtain, all required in-network (without cost sharing) and out-of-network (with cost-sharing) preventive services applicable to them (e.g., for their age group). This includes ACA-required pregnancy-related preventive services and well woman visits, which must be provided to Dependent Children (up to the end of the month that they turn age 26) where an attending provider determines that the services are age and developmentally appropriate.

The Plan covers certain Preventive Services required by ACA. Coverage of these services is provided by PPO providers, with no cost-sharing (e.g., no deductibles, coinsurance, or copayments) and by non-PPO providers, with cost-sharing, for the following services:

1. Services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations;
2. Services described in the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC);
3. Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures guidelines; and
4. With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in certain recommendations of the USPSTF.

Preventive services that are identified by the Plan as part of the ACA guidelines will be covered in network (with no cost-sharing) and out-of-network (with cost-sharing). This means that the service will be covered in-network at 100% of the Plan’s Reasonable and Customary Charge, with no coinsurance, copay, or deductible, and out-of-network at 70% of the Plan’s Reasonable and Customary Charge.

In some cases, federal guidelines are unclear about which preventive benefits must be covered under the ACA. In that case, the Trustees will determine whether a particular benefit is covered under this Preventive Services benefit.

1. Abdominal aortic aneurysm one-time screening for men ages 65-75 who have ever smoked.
2. Unhealthy alcohol use screening and counseling: screening and behavioral counseling interventions to reduce unhealthy alcohol use by adults ages 18 and older, including pregnant women, in primary care settings.
3. Low-dose aspirin to prevent cardiovascular disease and colorectal cancer when prescribed by a health care provider, in adults ages 50 to 59 years who have a 10% or greater 10-year cardiovascular disease (CVD) risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. A prescription must be submitted in accordance with plan rules.
4. Blood pressure screening for all adults age 18 and older. Blood pressure screening is not payable as a separate claim, as it is included in the payment for a Physician visit. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
5. Cholesterol screening (Lipid Disorders Screening) for adults aged 40-75.
6. Colorectal cancer screening using stool-based methods (such as fecal occult blood testing), sigmoidoscopy, or colonoscopy, in adults beginning at age 50 and continuing until age 75. The test methodology must be medically appropriate for the patient. The Plan will not impose cost sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. The plan will not impose cost sharing with respect to the following services when these services are provided in connection with a screening colonoscopy and the attending provider determines the service is medically appropriate: bowel preparation medications, anesthesia services, a pre-procedure specialist consultation, or a pathology exam on a polyp biopsy. The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49.
7. Depression screening for adults.
8. Type 2 Diabetes in adults aged 40 to 70 who are overweight or obese, as part of cardiovascular risk assessment, with intensive behavioral counseling for those with abnormal blood glucose to promote a healthful diet and physical activity.
9. Healthy diet and physical activity behavioral counseling for adults with cardiovascular disease risk factors.
10. Screening for hepatitis B virus infection in adults at high risk for infection.
11. Screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.
12. HIV screening for all adolescents and adults ages 15 to 65 and for younger and older individuals at increased risk.
13. Annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 20 pack/year smoking history and currently smoke or have quit within the past 15 years.
14. Obesity screening and intensive counseling and behavioral interventions to promote sustained weight loss for adults with a body mass index of 30 kg/m2 or higher.
15. Sexually Transmitted Infection (STI) behavioral counseling for adults at higher risk.
16. Syphilis screening for all adults at increased risk of infection.
17. Tobacco Use screening for all adults and cessation interventions for tobacco users.
18. Counseling for young adults to age 24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.
19. Exercise or physical therapy to prevent falls in community-dwelling adults age 65 years or older who are at increased risk for falls.
20. Low to moderate dose statin for the prevention of cardiovascular disease (CVD) events and mortality in adults ages 40 to 75 years with one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking), and a calculated 10-year risk of a cardiovascular event of 10% or greater, when identified as meeting these factors by their treating physician.
21. Screening for latent tuberculosis infection in populations at increased risk.
22. Preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

1. Well woman office visits for women beginning in adolescence and continuing across the lifespan, for the delivery of required preventive services.
2. Bacteriuria urinary tract or other infection screening for pregnant women. Screening for asymptomatic bacteriuria with urine culture for pregnant women is payable at 12 to 16 weeks’ gestation or at the first prenatal visit, if later.
3. BRCA counseling about genetic testing for women at higher risk. Women whose family history is associated with an increased risk for deleterious mutations in BRCA 1 or BRCA 2 genes will receive referral for counseling. The Plan will cover BRCA 1 or 2 genetic tests without cost sharing, if appropriate as determined by the woman’s health care provider, including for a woman who has previously been diagnosed with cancer, as long as she is not currently symptomatic or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer.
4. Breast cancer screening mammography for women with or without clinical breast examination and with or without diagnosis, every 1 to 2 years for women aged 40 and older.
5. Breast Cancer Chemoprevention counseling for women at higher risk. The Plan will pay for counseling by Physicians with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention, to discuss the risks and benefits of chemoprevention. The Plan will also pay for risk-reducing medications (such as tamoxifen or raloxifene) for women at increased risk for breast cancer and at low risk for adverse medication effects.
6. Comprehensive lactation support and counseling by a trained provider during pregnancy and for the duration of breastfeeding, and costs for renting breastfeeding equipment. The Plan may pay for purchase of lactation equipment instead of rental, if deemed appropriate by the Fund Administrator.
7. Cervical Cancer screening for women ages 21 to 29 with Pap smear every three years; for women ages 30-65, screening with Pap smear alone every three years, or screening with Pap smear and human papillomavirus testing every five years.
8. Chlamydia Infection screening for all sexually active non-pregnant young women aged 24 and younger, and for older non-pregnant women who are at increased risk, as part of a well woman visit. For all pregnant women aged 24 and younger, and for older pregnant women at increased risk, Chlamydia infection screening is covered as part of the prenatal visit.
9. FDA-approved contraceptives methods, sterilization procedures, and patient education and counseling for women of reproductive capacity. FDA-approved contraceptive methods include barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. The Plan may cover a generic drug without cost sharing and charge cost sharing for an equivalent branded drug. The Plan will accommodate any individual for whom the generic would be medically inappropriate, as determined by the individual’s health care provider. Services related to follow-up and management of side effects, counseling for continued adherence, and device removal are also covered without cost sharing.
10. Folic Acid supplements for women who are planning or capable of pregnancy, containing 0.4 to 0.8 mg of folic acid. Over-the-counter supplements are covered only if the woman obtains a prescription.
11. Gonorrhea screening for all sexually active women age 24 and younger and in older women who are at increased risk for infection, provided as part of a well woman visit. The Plan will pay for the most cost-effective test methodology only.
12. Counseling for sexually transmitted infections, once per year as part of a well woman visit.
13. Counseling and screening for HIV, once per year as part of a well woman visit, and for pregnant women, including those who present in labor who are untested and whose HIV status is not known.
14. Hepatitis B screening for pregnant women at their first prenatal visit.
15. Osteoporosis screening for women. Women aged 65 and older will be eligible for routine screening for osteoporosis. Younger women will be eligible for screening if their risk of fracture is equal to or greater than that of a 65-year old woman. The Plan will pay for the most cost-effective test methodology only.
16. Rh Incompatibility screening for all pregnant women during their first visit for pregnancy related care, and follow-up testing for all unsensitized Rh (D) negative women at 24-28 weeks’ gestation, unless the biological father is known to be Rh (D) negative.
17. Screening for diabetes after pregnancy in women with history of gestational diabetes who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes.
18. Screening for gestational diabetes in asymptomatic pregnant women between 24 and 28 weeks’ gestation and at the first prenatal visit for pregnant women identified to be at risk for diabetes.
19. Tobacco Use screening and interventions for all women, as part of a well woman visit, and expanded counseling for pregnant tobacco users.
20. Syphilis screening for all pregnant women or other women at increased risk, as part of a well woman visit.
21. Screening and counseling for interpersonal and domestic violence, as part of a well woman visit.
22. Low-dose aspirin after 12 weeks of gestation for women who are at high risk for preeclampsia. A prescription must be submitted in accordance with Plan rules.
23. Screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. Blood pressure screening is not payable as a separate claim, as it is included in the payment for a physician visit.
24. Depression screening for pregnant and postpartum women.
25. Screening for urinary incontinence annually.
26. Screening for anxiety.
27. Behavioral counseling interventions aimed to promote healthy weight gain and prevent excess gestational weight gain during pregnancy.

1. Well baby and well child visits from age newborn through 21 years as recommended for pediatric preventive health care by “Bright Futures/American Academy of Pediatrics.” Visits will include the following age-appropriate screenings and assessments:
   1. Alcohol and Drug Use assessments for adolescents.
   2. Autism screening for children at 18 and 24 months.
   3. Behavioral assessments for children of all ages.
   4. Blood pressure screening.
   5. Cervical Dysplasia screening at age 21.
   6. Depression screening for adolescents ages 12 and older.
   7. Developmental screening for children under age 3, and surveillance throughout childhood.
   8. Dyslipidemia screening for children at higher risk of lipid disorders.
   9. Hearing screening.
   10. Height, Weight and Body Mass Index measurements for children.
   11. Hematocrit or hemoglobin screening for children.
   12. Critical congenital heart defect screening in newborns.
   13. Lead screening for children at risk of exposure.
   14. Medical history.
   15. Oral Health risk assessment for young children from 6 months to 6 years.
   16. Sexually Transmitted Infection (STI) prevention counseling and screening for sexually active adolescents.
   17. Tuberculin testing for children at higher risk of tuberculosis.
   18. Vision screening at least once in all children 3 to 5 years to detect amblyopia or its risk factors.
   19. Counseling for children, adolescents, and young adults ages 6 months to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce their risk for skin cancer.
   20. Interventions, including education or brief counseling, to prevent initiation of tobacco use (including e-cigarettes) in in school-aged children and adolescents.
   21. Screening for hepatitis B virus infection in adolescents at high risk for infection.
   22. Application of fluoride varnish to the primary teeth of all infants and children through to age five starting at the age of primary tooth eruption, in primary care practices.
   23. Syphilis screening for adolescents who are at increased risk for infection.
   24. For adolescents, screening and counseling for interpersonal and domestic violence.
   25. For adolescent women, screening for anxiety.

• Newborn screening tests recommended by the Advisory Committee on Heritable Disorders in Newborns and Children (such as hypothyroidism screening for newborns and sickle cell screening for newborns).
• Prophylactic ocular topical medication for all newborns for the prevention of gonorrhea.
• Oral fluoride supplementation at recommended doses (based on local water supplies) to preschool children older than 6 months of age whose primary water source is deficient in fluoride. Over-the-counter supplements are covered only with a prescription.
• Obesity screening for children aged 6 years and older, and counseling or referral to comprehensive, intensive behavioral interventions to promote improvement in weight status.
• HIV screening for adolescents ages 15 and older and for younger adolescents at increased risk of infection.
• Preexposure prophylaxis (PrEP) with effective antiretroviral therapy to adolescents who are at high risk of HIV acquisition.

Routine adult immunizations are covered for Participants and Dependents who meet the age and gender requirements and who meet the Centers for Disease Control and Prevention (CDC) medical criteria for recommendation.

1. Immunization vaccines for adults – doses, recommended ages, and recommended populations must be satisfied:
   1. Diphtheria/tetanus/pertussis (DTaP)
   2. Measles/mumps/rubella (MMR)
   3. Influenza
   4. Human papillomavirus (HPV)
   5. Pneumococcal (polysaccharide)
   6. Zoster (Shingles)
   7. Hepatitis A
   8. Hepatitis B
   9. Meningococcal
   10. Varicella
   11. COVID-19
2. Immunization vaccines for children from birth to age 18—doses, recommended ages, and recommended populations must be satisfied:
   1. Hepatitis B
   2. Rotavirus
   3. Diphtheria, Tetanus, Pertussis (DTaP)
   4. Haemophilus influenza type b
   5. Pneumococcal
   6. Inactivated Poliovirusv
   7. Influenza
   8. Measles, Mumps, Rubella (MMR)
   9. Varicella
   10. Hepatitis A
   11. Meningococcal
   12. Human Papillomavirus (HPV)
   13. COVID-19

You can go to any licensed Dentist, but you could increase your benefits and lower your out-of-pocket costs by going to a Dentist who participates with Delta Dental. There are two levels of savings within this program. The highest level of cost savings occurs if you go to a Delta Preferred Option (DPO) Dentist. Your savings would be the result of lower out-of-pocket costs under your co-pays.

If you do not go to a DPO Dentist, savings are still possible if the Dentist participates in another Delta Dental program called Delta Premier. This second level of coverage may reduce your costs in comparison to a Dentist that does not participate with Delta Dental, but you might have to pay more than if you chose a DPO Dentist.

Dentists who participate in the DPO USA (Point-of-Service) program at either level have agreed to accept payment based on a predetermined schedule. If the Dentist’s fee is higher than the amount in the Delta Dental fee schedule, he or she cannot charge you the difference. This means you will pay only your copayment and deductible, if any, for covered services when you go to a Delta Dental of Illinois participating Dentist. Participating Dentists will also complete and file claims for you.

There are more than 108,000 Delta Premier Dentists. To find the names of participating Dentists near you, call the Fund Office or visit www.deltadentalil.com. Please note that you remain free to visit any Dentist you choose regardless of DPO or Delta Premier membership.

Important. If you go to a Delta Dental participating Dentist, the Dentist will submit the claim form and you will only be responsible for any deductibles and copayments. If you go to a non-participating Dentist, you may be required to pay the Dentist his or her fees at the time of service, and then file a claim with Delta Dental for reimbursement under the Dental Plan.

In order to help you avoid any large, unexpected dental bills, if your Dentist expects that the course of treatment recommended will exceed $300, you should ask your Dentist to submit to Delta Dental of Illinois the treatment plan that describes each procedure necessary to fully complete treatment before starting any dental work. Delta Dental of Illinois will review the information to determine how much the Fund will pay.

This Predetermination of Benefits is a convenience to let you know in advance what portion of the cost of your dental treatment will be your responsibility. Delta Dental of Illinois will respond directly to your Dentist with its decision as to whether or not the dental treatment will be covered and how much will be paid. The Predetermination of Benefits is also available if your Dentist is not participating in the Delta Dental Plan.

This Predetermination of Dental Benefits is not a guarantee of coverage. It is intended to let you know in advance what portion of the cost of your dental treatment will be your responsibility.

Be prepared: By requesting a Predetermination of Benefits, you can find out from Delta Dental how much the Plan will cover for your dental procedure and how much you will be required to pay.

Class I Benefits – Preventive Services

1. Diagnostic and Preventive Services: Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include examinations, prophylaxes, fluoride treatments and sealants.
2. Emergency Palliative Treatment: Emergency treatment to temporarily relieve pain.
3. Radiographs: X-rays as required for routine care or as necessary for the diagnosis of a specific condition.
4. Recement Crowns.

Class II Benefits – Basic Services

1. Endodontic Services: The treatment of teeth with diseased or damaged nerves (for example, root canals). Excludes apicoectomy.
2. Minor Restorative Services: Minor services to rebuild and repair natural tooth structure when damaged by disease or Injury. Minor restorative services include amalgam (silver) and resin (white) fillings.
3. Emergency and Specialty Exams.

Class III Benefits – Major Services

1. Oral Surgery Services: Extractions and dental surgery, including preoperative and postoperative care.
2. Periodontic Services: The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (periodontal prophylaxes). Actisite is a covered benefit.
3. Relines and Repairs: Relines and repairs to crowns, bridges, partial dentures, and complete dentures.
4. Major Restorative Services: Services to rebuild and repair natural tooth structure when damaged by disease or Injury, such as crowns, used when teeth cannot be restored with another filling material.
5. Prosthodontic Services: Services and appliances that replace missing natural teeth (such as bridges, partial dentures, and complete dentures).
6. Veneers – Labial Veneers – (cosmetic bonding).
7. Apicoectomy – Periradicular Surgery.
8. Implant.
9. Dental Anesthesia: Dental anesthesia is payable at 50%, subject to the deductible and calendar year maximum. General anesthesia/IV sedation is a covered charge only if there is demonstrated medical need, including the following:
• Toxicity to local anesthetic,
• Severe disability, spastic or severe behavioral problems,
• Prolonged or severe surgical procedure (includes removal of impacted tooth-soft tissue, removal of impacted tooth – partial bony, removal impacted tooth – completely bony impacted, surgical removal of residual tooth roots (cutting procedure) and surgical exposure impacted/unerupted teeth for orthodontia purposes,
• Extractions in two or more quadrants,
• Acute infection around the injection site,
• Failure of local anesthesia to control pain, or
• Subject is under four years of age.

Class IV Benefits – Orthodontic Services

• Orthodontic Services (to age 19): Services, treatment, and procedures to correct malposed teeth. If your Eligible Dependent begins receiving Orthodontic services under an Orthodontic treatment plan before reaching age 19, benefits for Orthodontic services under that treatment plan will continue after your Eligible Dependent reaches age 19 until he or she no longer meets the definition of Eligible Dependent, subject to the limitations in the Schedule of Benefits on page 6.

Covered dental services are limited in certain cases. All charges for the following dental services will be your responsibility. All time limitations are measured from the last date of service in any Delta Dental plan record or, at the request of your group, any dental plan record:

• 1. Four bitewing X-rays are payable once in any calendar year. Full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. A panographic X-ray (including bitewings) is considered a full mouth X-ray. Bitewing X-rays, full mouth X-rays and Periapical X-rays are covered without limitation for Dependent Children up to age 26.
• 2. Prophylaxes and oral exams are payable twice in any calendar year. Two additional periodontal prophylaxes are payable per calendar year for individuals with a documented history of periodontal disease. Preventive fluoride treatments are covered without limitation for Dependent Children up to age 26. Oral exams, excluding specialty and emergency exams, are covered without limitation for Dependent Children up to age 26. Sealants are covered once per lifetime.
• 3. A space maintainer is a covered benefit for patients up to the age of 26.
• 4. Cast restorations (including jackets, crowns, inlays and onlays) and associated procedures (such as core build-ups and post substructures) on the same tooth are payable once in any five-year period.
• 5. A crown, inlay, or onlay is a covered benefit only for extensive loss of tooth structure due to caries and/or fracture.
• 6. An individual crown over an implant is payable at the prosthodontic benefit level.
• 7. Porcelain, porcelain substrate, and cast restorations are not payable for Children younger than 12 years of age.
• 8. A stayplate is a covered benefit only for the replacement of permanent anterior teeth during the healing period or for missing anterior permanent teeth for Dependent Children 16 years or younger.
• 9. Prosthodontic (Class III) benefit limitations:
  1. One complete upper and one complete lower denture are benefits once in any five-year period for any individual.
  2. A removable partial denture or fixed bridge for any individual can be covered once in any five-year period, unless the loss of additional teeth requires the construction of a new appliance. Fixed bridges are covered only for Participants 16 years or older.
  3. A reline or the complete replacement of denture base material is limited to once in any three-year period per appliance.
  4. A soft reline is limited to once in any three-year period.
  5. Root planing benefits are payable once per year.

• 10.Orthodontic (Class IV) benefit limitations:
1. Orthodontic benefits are payable until your Eligible Dependent’s 19th birthday.
2. If the treatment plan is terminated before completion of the case for any reason, the Fund’s obligation will cease with payment to the date of termination.
3. The Dentist may terminate treatment, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. In those cases, the Fund’s obligation for payment of benefits ends on the last day of the month in which the patient was last treated.
4. An observation and adjustment is a benefit twice in a 12-month period.
5. Delta Dental will pay 50% of your initial down payment and then provide 50% coverage for your ongoing treatment in quarterly installments until the rest of the Fund’s orthodontic maximum benefit is reached.
6. The calendar year deductible does not apply to orthodontic benefits.

• 11. The Plan’s obligation for payment of benefits ends on the last day of the month in which coverage is terminated. However, the Plan will make payment for covered services provided on or before the last day of the month in which coverage is terminated, unless otherwise specified.
• 12. When services in progress are interrupted and completed later by another Dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each Dentist.
• 13. Care terminated due to the death of a Participant will be paid to the limit of the Fund maximum for the services completed or in progress.
• 14. Optional treatment: If the Participant chooses a more expensive service than is customarily provided or for which the Plan or Delta Dental does not determine a valid dental need is shown, the Plan or Delta Dental can make an allowance based on the fee for the customarily provided service. For example, if the Participant chooses an overdenture, the Fund will pay only the applicable amount that it would have paid for a conventional denture.
• 15. Maximum Payment:
  1. The maximum benefit payable in any one calendar year will be limited to the amount specified in the Schedule of Benefits on page 6.
  2. The payment for orthodontic (Class IV) benefits will be limited to the lifetime maximum in the Schedule of Benefits on page 6.
• 16. The Plan and Delta Dental will not be obligated to pay for any services to which the deductible applies until the Plan deductible amount is met.
• 17. Processing policies, such as periodic limitations on certain services, may limit treatment.

No payment will be made by the Plan for the following services. A participating Dentist cannot charge you or your eligible Dependent for these services. All charges from non-participating Dentists for the following services will be your responsibility:

1. Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.
2. Cores and other substructures are covered benefits only when needed to retain a crown on a tooth with excessive breakdown due to caries and fractures.
3. Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date or within 12 months of payment for a recementation.
4. Retention pins are benefits once in a 24-month period. Only one substructure per tooth is a covered benefit.
5. Benefits for periodontal surgery, including subgingival curettage, is payable once in any three-year period.
6. A complete occlusal adjustment is a covered benefit once in a five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not a covered benefit more than three times in a five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.
7. Tissue conditioning is not a covered benefit more than twice per arch in 36 months.
8. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.
9. More than one root planing per year.

In addition to the General Exclusions and Limitations listed beginning on page 72, the Fund does not cover any loss under the Dental Benefits caused by, incurred for or resulting from the following excluded charges. All charges for the following services will be your responsibility, although your payment obligation may be satisfied by insurance or some other arrangement for which you are eligible:

1. Services, as determined by the Fund, for correction of congenital or developmental malformations, cosmetic surgery, or dentistry for cosmetic aesthetic reasons including repair to facings posterior to the second bicuspid position.
2. Prescription drugs (except intramuscular injectable antibiotics), premedications, medicaments/solutions, and relative analgesia. Medicines or drugs that can be obtained without a Dentist’s prescription.
3. General anesthesia and/or intravenous sedation for restorative dentistry (or for surgical procedures) except as provided under Class III Benefits, item (h).
4. Acupuncture, acupressure or hypnosis.
5. Charges for hospitalization, laboratory tests and histopathological examinations.
6. Treatment performed by anyone other than a Dentist, except for services performed by a licensed Dental Hygienist under the scope of his or her license.
7. Services that are covered under the Major Medical or Prescription Drug Benefits.
8. Fluoride rinses, self-applied fluorides or desensitizing medicaments.
9. Preventive control programs (including oral hygiene instructions, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, nutritional guidance, etc.).
10. A space maintainer for maintaining space due to the premature loss of the anterior primary teeth.
11. Lost, missing, or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.
12. A prefabricated crown used as a final restoration on a permanent tooth.
13. Appliances, surgical procedures, and restorations for: increasing vertical dimension; altering, restoring, or maintaining occlusion; replacing tooth structure loss resulting from attrition, abrasion, or erosion; or implantology techniques or periodontal splinting, except orthodontic care for Dependent Children under age 19.
14. A substructure to a single/abutment crown over an implant.
15. A paste-type root canal filling on a permanent tooth.
16. Occlusal guards.
17. Chemical curettage.
18. Services associated with overdentures.
19. Acusil, flexiplast or similar partial denture.
20. A metal base on a removable prosthesis.
21. The replacement of teeth beyond the normal complement of teeth.
22. Personalization/characterization of any service or appliance.
23. Temporary appliances.
24. Precision attachments.
25. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint dysfunction (TMJ or TMD).
26. Diagnostic photographs and cephalometric films, unless done for orthodontics.
27. Myofunctional therapy.
28. Mounted case analysis.
29. The replacement or alteration of full or partial dentures or fixed bridgework, unless the charge is required due to one of the following events and if the replacement or alteration is completed within 12 months after the event:
    1. An Injury requiring surgery; or
    2. Oral surgery treatment involving the repositioning of muscle attachments or the removal of a tumor, cyst, torus or redundant tissue; or
    3. Replacement of a full denture, unless required as the result of structural change within the mouth and unless made more than five years after the installation of the denture.
30. Orthodontic treatment for you and your spouse.
31. Charges for failure to keep a scheduled visit with the Dentist.
32. Services, as determined by Delta Dental, for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental or investigational in nature as determined by the standards of generally accepted dental practice.
33. Those benefits excluded by the policies and procedures of Delta Dental including the processing policies.
34. Services or supplies for which no charge is made, for which you are not legally obligated to pay or for which no charge would be made in the absence of Delta Dental coverage.
35. Services or supplies received as a result of dental disease, defect or Injury due to an act of war, declared or undeclared.
36. Services that are not within the classes of benefits that have been selected and that are not in the contract.
37. Replacement, repair, relines or adjustments of occlusal guards.

No payment will be made by the Plan or Delta Dental for the following services. A participating Dentist cannot charge you or your Eligible Dependent for these services. All charges from non-participating Dentists for the following services will be your responsibility:

1. The fee for a consultation that is part of the fee for the examination and/or diagnostic procedure(s).
2. Acid etching, cement bases, cavity liners, and a base or temporary filling.
3. Infection control.
4. Gingivectomy as an aid to the placement of a restoration.
5. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.
6. Diagnostic casts not done in conjunction with orthodontics. They are considered to be a part of the fee for restorative or prosthodontic procedures.
7. Palliative treatment, when any other service is provided on the same date, except X-rays and tests necessary to diagnose the emergency condition.
8. Postoperative radiographs, when done following any completed service or procedure.
9. Periodontal charting, when done on the same day as an oral examination. An examination, when done on the same day as a periodontal prophylaxis.
10. Pins and/or a preformed post, when done with a core for a crown, onlay, or inlay.
11. A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with the opening and drainage of a tooth or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done on the same day a root canal is initiated.
12. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.
13. Retreatment of a root canal within 12 months of the original root canal treatment.
14. A prophylaxis, when done on the same day as root planing. Root planing, when done on the same day as subgingival curettage.
15. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.
16. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.
17. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.
18. The completion of claim forms.
19. Temporary crowns.
20. Local Anesthesia, except as provided under Class III Benefits, item (h).

Dental and orthodontic benefits may be payable for unfinished dental work performed within 60 days after termination of coverage as if the expenses were incurred while covered if coverage terminates:

• For any reason other than termination of the Fund, and
• Before the completion of a course of dental or orthodontic treatment which began before such termination.

In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. Any balance of the total fee not paid by Delta Dental is your responsibility.

If you wish, you may elect to cease coverage for Dental Benefits under the Plan for yourself or your Eligible Dependents at any time during the Plan year by providing written notice to the Fund Office of your intention to cease Dental coverage. Cessation of Dental coverage will be effective as of the first day of the following month after the Fund Office receives such notice from you.

If you previously elected to cease coverage for Dental Benefits under the Plan, you may reinstate coverage by providing written notice to the Fund Office. Reinstatement of Dental coverage will be effective as of the first day of the Plan Year following the date the Fund Office receives such written notice from you.

If you wish, you may elect to cease coverage for Optical Benefits under the Plan for yourself or your Eligible Dependents at any time during the Plan Year by providing written notice to the Fund Office of your intention to cease coverage of Optical Benefits. Cessation of Optical Benefit coverage will be effective as of the first day of the following month after the Fund Office receives such notice from you.

If you previously elected to cease coverage for Optical Benefits under the Plan, you may reinstate coverage by providing written notice to the Fund Office. Reinstatement of Optical Benefit coverage will be effective as of the first day of the Plan Year following the date the Fund Office receives such written notice from you.

The retail pharmacy network is offered through Express Scripts, Inc. (“ESI”) national network of pharmacies. To find out whether a particular pharmacy is a participating network pharmacy, call an ESI customer service representative at 1-866-544-2916 or visit the ESI website at www.express-scripts.com. Members are able to obtain both 30 day acute medication as well as maintenance medications for 90 days through retail pharmacies. For long-term medications, it is encouraged to utilize the mail order facility.

Acute medications are usually prescribed to treat acute conditions of a short-term or temporary nature such as an infection or the flu. They are limited to a 30-day supply.

To fill this type of prescription simply:

1. Take the prescription to a participating ESI network pharmacy,
2. Identify yourself as an eligible Local 73 Welfare Fund Participant (for instance, by showing your prescription drug plan card), and
3. Pay the required copayment and any deductible as shown in the Schedule of Benefits on page 4 and you will receive the prescription drug with no additional paperwork or charge.

Use a network retail pharmacy for an emergency or one-time prescription and the mail order service for a long-term prescription.

If you use a non-participating network pharmacy, you must pay for the entire cost of the medication when the prescription is filled. You must then complete an ESI Claim Form and submit it along with the original prescription receipt to the ESI Claims Department. You will be reimbursed at the negotiated pharmacy rate less the appropriate copayment.

You may obtain an ESI Claim Form by calling ESI at 1-866-544-2916 visiting their website at www.express-scripts.com, or contacting the Fund Office.

If your Physician has prescribed a maintenance medication (long-term treatment), you should have your prescription filled by the mail order program. The mail order prescription drug service is administered by ESI.

To fill a maintenance prescription through ESI, simply:

1. Obtain a new written prescription for each covered medication. ESI can only dispense the amount of medication your Physician has prescribed up to a 90-day supply. Show your Physician the material attached to the Prescription Drug Benefits brochure to help him or her write a prescription for this program.
2. Complete the Mail Service Order Form/Patient Profile.
3. Mail the written prescription, the profile, the order form and your copayment to ESI at the address on ESI’s order form. The copayment for each prescription order is shown in the Schedule of Benefits on page 4. If you need assistance determining the copayment amount, call ESI at 1-866-544-2916or visit their website at www.express-scripts.com.

You will receive refill labels (if refills remain) and a new order form in your prescription package. To obtain a refill order, simply affix the refill label to the back of the order form and send it to ESI. If you have no refills remaining or if your prescription has expired, contact your Physician for a new written prescription to send to ESI.

If you have a question about your prescription, call ESI at 1-866-544-2916 to speak with a Customer Service Representative.

All forms of contraceptives including medicines and devices (IUD-patches) are reviewed and covered.

Benefits are not payable under Prescription Drug Benefits for:

• 1. Medicines or drugs obtainable without a Physician’s prescription, except insulin,
• 2. Medications used for cosmetic purposes, including Vitamin A derivatives (retinoids) for dermatological use (i.e., Retin A, Renova),
• 3. Vitamins and nutritional supplements (except as provided under the Preventive Services Benefit),
• 4. Smoking deterrents (except as provided under the Preventive Services Benefit),
• 5. Fertility drugs (except as provided under the Infertility Benefit),
• 6. Viagra and other erectile dysfunction drugs are reviewed and covered by ESI. Prescription Drugs prescribed by the treating Physician to treat erectile dysfunction will be covered if:
  1. You have or had one of the following: Prostate and testicular cancer, disorders of the prostate (including prostatic enlargement and hyperplasia), low testosterone level, Diabetes, Crohn’s disease, Peripheral neuropathy, Hypertension and other vascular conditions, or erectile dysfunction as a side effect from another prescription medication or combination of medications that can be verified as a side effect, which is listed in the Physician’s Desk Reference; and
  2. You provide the following information: A letter of Medical Necessity from your attending Physician, complete diagnosis, and name and dosage of medication prescribed.
  3. Re-verification from the Physician is required every twelve-month period.
• 7. Anabolic steroids,
• 8. Weight control or drugs or anorexiants, except those used for treatment of Children with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) or individuals with narcolepsy,
• 9. Serum allergy antigen solutions, and
• 10. Existing and new drugs that are not uniformly and professionally endorsed by the general medical community for prescription in the course of standard medical care, including existing and new drugs that are experimental in nature.
• 11. Gene therapy prescription drugs regardless of where such drugs are administered.

If you or your Eligible Dependents are eligible for and enroll in Medicare Part D, the Plan will not provide you with the Prescription Drug Benefits and will not coordinate benefits with Medicare Part D benefits.

If you or your Eligible Dependent are eligible for but do not enroll in Medicare Part D, the Plan will continue to provide your Prescription Drug Benefits.

Claims Administrator(s)

The Plan Administrator has delegated responsibility for initial claims decisions to the following companies/organizations:

Medical Post-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162, 1-708-449-7373 | www.sm73funds.org

Urgent Care, Concurrent and Pre-Service Medical Claims

Blue Cross Blue Shield Medical Services Advisory for Hospital admissions/inpatient medical services | P.O. Box 805107,Chicago, IL 60680-4112 | 1-800-255-5192, www.bcbsil.com;

Blue Cross Blue Shield Behavioral Health Services | P.O. Box 805107, Chicago, IL 60680-4112 | 1-800-851-7498 | www.bcbsil.com

Dental Benefit Claims

Delta Dental of Illinois | 1-800-523-1743 | https://www.deltadentalil.com/

All required pre-admission authorization

Valenz Care Medical Services Advisory | 1-800-367-1934 | Fax: 1-312-236-8547 | 23048 N. 15th Ave. Phoenix, AZ 85027 | www.medicalcost.com

Urgent Care Concurrent and Pre-Service Claims may require pre-admission authorization. Refer to the Utilization Management section at page 29 for additional information.

Valenz Care Medical Services Advisory | 1-800-367-1934 | Fax: 1-312-236-8547 | 23048 N. 15th Ave. Phoenix, AZ 85027 | www.medicalcost.com

Pre-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Post-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Pre-Service Claims for prescription drugs

Express Scripts (ESI) | 1-866-544-2916 | www.express-scripts.com

Pre-Service Claims for vision benefits

EyeMed | PO Box 8504, Cincinnati, OH 45040-7111 | 1-866-723-0514 | www.eyemedvisioncare.com

Post-Service hearing benefit claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Weekly Disability Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Weekly Maternity Benefit Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Death Benefit Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Accidental Death and Dismemberment Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

For the purpose of the initial claims and appeal processes, “days” refers to calendar days, not business days.

In carrying out their respective responsibilities under the Plan, the Plan Administrator, other Plan fiduciaries, Claims Administrators, and other individuals to whom responsibility for the administration of the Plan has been delegated, have discretionary authority to interpret the terms of the Plan and to interpret any facts relevant to the determination, and to determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made under that discretionary authority will be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

An adverse benefit determination, for the purpose of the internal claims and appeal process, means:

• A denial, reduction, or termination of, or a failure to provide or make payment in whole or in part for a benefit, including a determination of an individual’s eligibility to participate in the Plan or a determination that a benefit is not a covered benefit;
• A reduction of a benefit resulting from the application of any utilization review decision, source-of-injury exclusion, network exclusion, or other limitation on an otherwise covered benefit or failure to cover an item or service for which benefits are otherwise provided because it is determined to be not Medically Necessary or appropriate, or Experimental or Investigational; or
• A rescission of coverage, whether or not there is an adverse effect on any particular health or weekly disability benefit. An adverse benefit determination does not include rescissions of coverage with respect to accidental death and dismemberment insurance/death benefits.

A health care professional, for the purposes of the claims and appeals provisions, means a Physician or other health care professional licensed, accredited or certified to perform specified health services consistent with state law.

All notices sent to claimants relating to internal claims and appeal review for health, weekly disability benefits, and weekly maternity benefits will contain a notice about the availability of Spanish language services. Assistance with filing a claim for internal review in Spanish is available by calling 1-708-449-2123. Notices relating to internal review will be provided in Spanish upon request.

SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-449-2123.

A claim is a request for a Plan benefit made by you or your covered Dependent (also referred to as “claimant”) or your authorized representative in accordance with the Plan’s reasonable claims procedures.

Health Benefit Claims

Health benefit claims can be filed for medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits.

There are four categories of health claims as described below:

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) - A Pre-Service Claim is a claim for a benefit that requires approval of the benefit (in whole or in part) before health care is obtained. Under this Plan, prior approval is required for medical, mental health, substance abuse, EAP, and prescription drug benefits.
• Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) – An Urgent Care Claim is any Pre-Service Claim for health care treatment that (i) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or (ii) in the opinion of the claimant’s attending health care provider with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. However, the Plan will not deny benefits for these procedures or services if it is not possible for the claimant to obtain the pre-approval, or the pre-approval process would jeopardize the claimant’s life or health.
• Concurrent Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) - A Concurrent Claim is a claim that is reconsidered after an initial approval has been made and results in a reduced or terminated benefit. Also, a Concurrent Claim can pertain to a request for an extension of a previously approved treatment or service.
• Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits) - A Post-Service Claim is a request for benefits under the Plan that is not a Pre-Service Claim. Post-Service Claims are requests that involve only the payment or reimbursement of the cost of the care that has already been provided. A standard paper claim or electronic bill submitted for payment after services have been provided are examples of a Post-Service Claim. A claim regarding the rescission of coverage will be considered to be a Post-Service Claim.

Weekly Disability Benefit Claims

A Weekly Disability Claim is a request for benefits during a period of disability. Weekly Disability Claims are filed after a participant suffers a disability and benefits are paid if the Claims Administrator determines that the participant has suffered a disability as defined by the terms of the Plan.

Weekly Maternity Benefit Claims

A Weekly Maternity Benefit Claim is a request for benefits from an active female member following a live birth. Weekly Maternity Benefit Claims are filed after an active female member gives birth and benefits are paid if the Claims Administrator determines that the member is eligible for such benefits under the terms of the Plan.

Accidental Death and Dismemberment Insurance/Death Benefit Claims

An Accidental Death and Dismemberment Insurance/Death Benefit Claim is a request by a designated beneficiary for benefit payment following the death of the participant or the death of a covered Dependent. A claim for Accidental Death and Dismemberment Benefits may also be filed by a participant after he or she has provided the Plan with proof of a bodily loss.

An initial claim must include the following elements to trigger the Plan’s internal claims process:

• Be written or electronically submitted (oral communication is acceptable only for Urgent Care Claims);
• Be received by the Plan Administrator or Claims Administrator (as applicable);
• Name a specific individual participant and his/her Social Security Number;
• Name a specific claimant and his/her date of birth;
• Name a specific medical condition or symptom;
• Provide a description and date of a specific treatment, service or product for which approval or payment is requested (must include an itemized detail of charges);
• Identify the provider’s name, address, phone number, professional degree or license, and federal tax identification number (TIN); and
• When another plan is primary payer, include a copy of the other Plan’s Explanation of Benefits (EOB) statement along with the submitted claim.

A request is not a claim if it is:

• Not made in accordance with the Plan’s benefit claims filing procedures described in this section;
• Made by someone other than you, your covered Dependent, or your (or your covered Dependent’s) authorized representative;
• Made by a person who will not identify himself or herself (anonymous);
• A casual inquiry about benefits such as verification of whether a service/item is a covered benefit or the estimated allowed cost for a service;
• A request for prior approval where prior approval is not required by the Plan;
• An eligibility inquiry that does not request benefits. However, if a benefit claim is denied on the grounds of lack of eligibility, it is treated as an adverse benefit determination and the individual will be notified of the decision and allowed to file an appeal;
• The presentation of a prescription to a retail pharmacy or mail order pharmacy that the pharmacy denies at the point of sale. After the denial by the pharmacy, you may file a claim with the Plan;
• A request for an eye exam, lenses, frames or contact lenses that is denied at the point of sale from the Plan’s contracted in-network vision provider(s). After the denial by the vision service provider, you may file a claim with the Plan.

If you submit a claim that is not complete or lacks required supporting documents, the Plan Administrator or Claims Administrator, as applicable, will notify you about what information is necessary to complete the claim. This does not apply to simple inquiries about the Plan’s provisions that are unrelated to any specific benefit claim or which relate to proposed or anticipated treatment or services that do not require prior approval.

Claim Filing Deadline

There is a two-year period beginning with the date you incur charges for medical services (including wellness, hearing, optical services and accident and sickness) during which you must file a claim for reimbursement of the charges.

There is a one-year period beginning with the date you incur charges for prescription drug claims during which you must file a claim for reimbursement of the charges.

If you file a claim after this two-year period, or one-year period in the case of prescription drug benefits, no reimbursement will be made.

The time period for making a decision on an initial claim request starts as soon as the claim is received by the appropriate Claims Administrator, provided it is filed in accordance with the Plan’s reasonable filing procedures, regardless of whether the Plan has all of the information necessary to decide the claim. A claim may be filed by you, your covered Dependent, an authorized representative, or by a network provider. In the event a claim is filed by a provider, the provider will not automatically be considered to be your authorized representative.

Health Care Claims – Decision Timeframes

The Plan will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection with the claim. Such evidence will be provided as soon as possible (and sufficiently in advance of the date on which notice of an adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date. Additionally, before the Plan issues an adverse benefit determination on review based on a new or additional rationale, you will be provided, free of charge, with the rationale. The rationale will be provided as soon as possible (and sufficiently in advance of the date on which notice of adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date.

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits)
  
  Claims for Pre-Service (that are not for Urgent Care) will be decided no later than fifteen (15) days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the initial fifteen (15) day period whether the claim was approved or denied (in whole or in part).
  
  The time for deciding the claim may be extended by up to fifteen (15) days due to circumstances beyond the Claims Administrator’s control (e.g., inability of a medical reviewer to meet a deadline); provided you are given written (or electronic, if a applicable) notification before the expiration of the initial fifteen (15) day determination period.
  
  If you improperly file a Pre-Service Claim, the Claims Administrator will notify you in writing (or electronically, as applicable) as soon as possible, but in no event later than five (5) days after receiving the claim. The notice will describe the proper procedures for filing a Pre-Service Claim. Thereafter, you must re-file a claim to begin the Pre-Service Claim determination process.
  
  If a claim cannot be processed due to insufficient information, the Claims Administrator will notify you in writing (or electronically, as applicable) about what specific information is needed before the expiration of the initial fifteen (15) day determination period. Thereafter, you will have 45 days following your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision is suspended. The claim decision deadline is suspended until the earlier of 45 days or the date the Claims Administrator receives your response to the request for information. The Claims Administrator then has fifteen (15) days to make a decision and notify you in writing (or electronically, as applicable).
• Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits)
  
  In the case of an Urgent Care Claim, if a health care professional with knowledge of your medical condition determines that a claim constitutes an Urgent Care Claim, the health care professional will be considered by the Plan to be your authorized representative bypassing the need for completion of the Plan’s written authorized representative form.
  
  The appropriate Claims Administrator will decide claims for Urgent Care as soon as possible, but in no event later than 72 hours after receipt of the claim. The Claims Administrator will orally communicate its decision telephonically to you. The determination will also be confirmed in writing (or electronically, as applicable) no later than three (3) days after the oral notification.
  
  If you improperly file an Urgent Care Claim, the Claims Administrator will notify you, as soon as possible, but in no event later than 24 hours after receiving the claim. The written (or electronic, as applicable) notice will describe the proper procedures for filing an Urgent Care Claim. Thereafter, you must re-file a claim to begin the Urgent Care Claim determination process.
  
  If a claim cannot be processed due to insufficient information, the Claims Administrator will provide you with a written (or electronic, as applicable) notification about what specific information is needed as soon as possible and no later than 24 hours after receipt of the claim. Thereafter, you will have not less than 48 hours following receipt of the notice to supply the additional information. If you do not provide the information during the period, the claim will be denied (i.e., an adverse benefit determination). Written (or electronic, as applicable) notice of the decision will be provided to you no later than 48 hours after the Claims Administrator receives the specific information or the end or the period given for you to provide this information, whichever is earlier.
• Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug claims)
  
  Claims for Post-Service treatments or services will be decided no later than 30 days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the 30-day initial determination period if the claim is denied (in whole or in part).
  
  The time for deciding the claim may be extended by fifteen (15) days due to circumstances beyond the Claim Administrator’s control (e.g., inability of a medical reviewer to meet a deadline); provided you are given written (or electronic, as applicable) notification before the expiration of the initial 30-day determination period.
  
  If a claim cannot be processed due to insufficient information, the Claim Administrator will notify you in writing (or electronically, as applicable) about what information is needed before the expiration of the initial 30-day determination period. Thereafter, you will have 45 days after your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision on the claim is suspended. The claim decision deadline is suspended until the earlier of 45 days or until the date the Claims Administrator receives your written response to the request for information. The Claims Administrator then has fifteen (15) days to make a decision and notify you in writing (or electronically, as applicable).

Weekly Disability Claims and Weekly Maternity Benefit Claims – Decision TimeframesM/i>

Claims for Weekly Disability benefits and Weekly Maternity Benefit Claims will be decided no later than 45 days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the 45-day initial determination period if the claim is denied (in whole or in part).

The time for deciding the claim may be extended by 30 days due to circumstances beyond the Claim Administrator’s control; provided you are given written (or electronic, as applicable) notification before the expiration of the initial 45-day determination period. A decision will be made within 30 days of the date the Claims Administrator notifies you of the delay. The period for making a decision may be delayed an additional 30 days if due to matters beyond the control of the Claims Administrator, provided you are notified of the additional delay, before the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision.

If a claim cannot be processed due to insufficient information, the Claims Administrator will notify you in writing (or electronically, as applicable) about what information is needed before the expiration of the initial 45-day determination period. Thereafter, you will have 45 days after your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision on the claim is suspended. The claim decision deadline is suspended until the earlier of 45 days or until the date the Claims Administrator receives your written response to the request for information. The Claims Administrator then has 30 days to make a decision and notify you in writing (or electronically, as applicable).

Accidental Death and Dismemberment Insurance or Death Benefit – Decision Timeframe

Generally, you will receive written (or electronic, as applicable) notice of a decision on your initial claim within 90 days of receipt of your claim by the Claims Administrator. If additional time or information is required to make a determination on your claim (for reasons beyond the control of the Claims Administrator, you will be notified in writing (or electronically, as applicable) within the initial 90-day determination period. The 90-day period may be extended up to an additional 90 days.

Notice of Adverse Benefit Determination

If the Claims Administrator denies your initial claim, in whole or in part, you will be given a notice about the denial (known as a “notice of adverse benefit determination”). The notice of adverse benefit determination will be given to you in writing (or electronically, as applicable) within the timeframe required to make a decision on a particular type of claim. The notice of adverse determination must:

• Identify the claim involved (and for health benefit claims – include the date of service, health care provider, claim amount if applicable, denial code and its corresponding meaning);
• Give the specific reason(s) for the denial (and for health benefit claims - include a statement that the claimant has the right to request the applicable diagnosis and treatment code and their corresponding meanings; however such a request is not considered to be a request for an internal appeal or external review for health benefit claims);
• If the denial is based on a Plan standard that was used in denying the claim, a description of such standard.
• Reference the specific Plan provision(s) on which the denial is based;
• Describe any additional material or information needed to perfect the claim and an explanation of why such added information is necessary;
• With respect to health, weekly disability benefit,and weekly maternity benefit claims, the opportunity, upon request and without charge, reasonable access to and copies of all documents, records and other information relevant to an initial claim for benefits;
• Provide an explanation of the Plan’s internal appeal and external review for health benefit claims processes along with time limits and information about how to initiate an appeal and an external review for health benefit claims;
• Contain a statement that you have the right to bring civil action under ERISA section 502(a) following an appeal;
• With respect to health, weekly disability benefit,and weekly maternity benefit claims, if the denial was based on an internal rule, guideline, protocol, standard, or similar criteria, a statement will be provided that a copy of such rule, guideline, protocol or similar criteria that was relied upon will provided to you free-of-charge upon request;
• If the denial of a health , weekly disability, or weekly maternity benefit claim was based on Medical Necessity, Experimental treatment, or similar exclusion or limit, a statement will be provided that an explanation regarding the scientific or clinical judgment for the denial will be provided to you free-of-charge upon request;
• With respect to a weekly disability claim, a discussion of the Plan’s initial claim discussion, including the basis for disagreeing with: (i) any disability determination by the Social Security Administration (SSA); (ii) the views of a treating health care professional or vocational expert evaluating the claimant, to the extent the Plan does not follow such views as presented by the claimant; or (iii) the views of medical professionals or vocational experts whose advice was obtained on behalf of the Plan, regardless of whether or not the advice was relied upon by the Plan in making an adverse benefit determination; and
• For Urgent Care health benefit claims, the notice will describe the expedited internal appeal and external review processes applicable to Urgent Care Claims. In addition, the required determination may be provided orally and followed with written (or electronic, as applicable) notification; and
• With respect to health benefit claims, provide information about the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist you with the Plan’s internal claims and appeal processes as well as with the external review process.

If a Pre-Service claim is approved, you will receive written (or electronic, as applicable) notice within fifteen (15) days of the appropriate Claims Administrator’s receipt of the claim. Notice of Approval of an Urgent Care Claim will be provided in writing (or electronically, as applicable) to you within the applicable timeframe after the Claims Administrator’s receipt of the claim.

• Health Care Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits) If an initial health care claim is denied (in whole or in part) and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an internal appeal. You have 180 calendar days following receipt of a notice of adverse benefit determination to submit a written request for an internal appeal. The Plan will not accept appeals filed after this 180-day period. Under limited circumstances, explained below in the section on External Review, you may bypass the Plan’s internal claims and/or appeal processes and file a request for an external review.
• Weekly Disability Claims and Weekly Maternity Benefit Claims) If an initial Weekly Disability Claim or Weekly Maternity Benefit Claim is denied and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an internal appeal. You have 180 calendar days following your receipt of an initial notice of adverse benefit determination to submit a written request for an internal appeal. The Plan will not accept appeals filed after this 180-day period.
• Accidental Death and Dismemberment Insurance/Death Benefits) If an initial accidental death and dismemberment/death benefit claim is denied and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an appeal. You have 60 calendar days following your receipt of an initial notice of adverse benefit determination to submit a written request for an appeal. The Plan will not accept appeal requests filed after this 60-day period.

Appeal Procedures

To file an internal appeal, you must submit a written statement to the Plan at the following address:

Board of Trustees c/o Benefits Appeal Committee
Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members
4530 Roosevelt Road
Hillside, IL 60162
1-708-449-7373
www.sm73funds.org

Appeal requests involving Urgent Care Claims may be made orally by calling the Board of Trustees at the telephone number listed above.

Your request for an internal appeal must include the specific reason(s) why you believe the initial claim denial was improper. You may submit any document that you feel is appropriate to the internal appeal determination, as well as submitting any written issues and comments.

As a part of its internal appeals process, the Plan will provide you with:

• The opportunity, upon request and without charge, reasonable access to and copies of all documents, records and other information relevant to your initial claim for benefits;
• The opportunity to submit to the Plan written comments, documents, records and other information relating to your initial claim for benefits;
• With respect to health, weekly disability benefit and weekly maternity benefit appeals, the Plan will automatically provide you with a reasonable opportunity to respond to new information by presenting written evidence and testimony;
• A full and fair review by the Plan that takes into account all comments, documents, records and other information submitted by you, without regard to whether such information was submitted or considered in the initial claim determination;
• With respect to health, weekly disability benefit and weekly maternity benefit claims, the Plan will automatically provide you free-of-charge, with any new or additional evidence or rationale considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection with the denied initial claim. The Plan will automatically provide you with any new or additional evidence or rationale as soon as possible once it becomes available to the Plan and sufficiently in advance of the date on which notice of an adverse determination on appeal is scheduled to be provided to you. New or additional evidence or rationale will be provided to you so that you have a reasonable opportunity, sufficiently in advance of the date on which a notice of an adverse benefit determination upon appeal is required to be provided, to respond to the Plan regarding such evidence. If the new or additional evidence or rationale is received by the Plan so late that it would be impossible to provide it to you in time for you to have a reasonable opportunity to respond, then the period for providing a notice of a final adverse benefit determination will be delayed (tolled) until you have had a reasonable opportunity to respond. After you respond (or do not respond after having a reasonable opportunity to do so), the Plan (acting in a reasonable and prompt manner) will notify you of its benefit determination upon appeal as soon as it can provide a notice of determination, taking into account any medical exigencies;
• A review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate fiduciary or fiduciaries of the Plan who is neither the individual who made the initial adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual;
• With respect to health, weekly disability benefit and weekly maternity benefit claims appeals, continued coverage during the pendency of the appeal process; and
• In deciding an appeal of any adverse benefit determination regarding a health benefit claim that is based in whole or in part on a medical judgment, including whether a particular treatment, drug or other item is Experimental, Investigational, not Medically Necessary or appropriate, the fiduciary or fiduciaries will:
  • Consult with a health care professional who has appropriate experience in the field of medicine involved in the medical judgment; and
  • Is neither an individual who was consulted in connection with the initial adverse benefit determination that is the subject of the appeal nor the subordinate of any such individual; and
  • The Plan will provide, upon request, the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with an adverse benefit determination without regard to whether the advice was relied upon in making the benefit determination.

Health Care Claims

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits).A determination will be made and a written (or electronic, as applicable) notice regarding the appeal will be sent to you within 30 days from the date your written request for an appeal is received by the Plan. A plan administrator may extend the 30-day period due to special circumstances (e.g., the need to hold a hearing) if the claimant is notified of such extension within the initial 30-day period. The extension cannot extend beyond 60 days from the end of the initial 30-day determination period.
  • Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits). This is an expedited internal appeals process under which a written notice regarding a decision on the approval or denial of the expedited internal appeal will be sent to you no later than within 72 hours of the Plan’s receipt of your (oral or written) request for appeal. If your situation involves an urgent medical condition, which the timeframe for completing an expedited internal appeal would seriously jeopardize your ability to regain maximum function, and the claim involves a medical judgment or a rescission of coverage, you may seek an expedited external review at the same time that you request an expedited internal appeal (you must seek both).
  • Concurrent Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits). You may request an internal appeal of a Concurrent Claim by submitting the request orally (for an Urgent Care Claim) or in writing to the Board of Trustees. A determination will be made on the internal appeal and you will be notified as soon as possible before the benefit is reduced or treatment is terminated.
  • Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits). A written (or electronic, as applicable) notice regarding the Plan’s determination on the internal appeal will be sent to you within 60 days from the date your written request for an appeal is received by the Plan. A plan administrator may extend the 60-day period due to special circumstances (e.g., the need to hold a hearing) if the claimant is notified of such extension within the initial 60-day period. The extension cannot extend beyond 60 days from the end of the initial 60-day determination period.
  • The Plan will make an appeal determination no later than the date of the Board of Trustees’ meeting immediately following the Plan’s receipt of your written request for an internal appeal, unless the request for an internal appeal review is filed within 30 calendar days preceding the date of such meeting. In such case, an appeal determination will be made no later than the date of the second meeting following the Plan’s receipt of your written request for an appeal. If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, an appeal determination will be rendered not later than the third meeting following the Plan’s receipt of your written request for review. If such an extension is necessary, the Plan will provide you with a written (or electronic, as applicable) notice of extension describing the special circumstances and date the appeal determination will be made. The Board of Trustees will notify you in writing (or electronically, as applicable) of the benefit determination no later than five (5) calendar days after the benefit determination is made.
• Weekly Disability Benefit Claims and Weekly Maternity Benefit Claims
  A written (or electronic, as applicable) notice regarding a decision on your appeal will be sent to you within 45 days from the date your written request for an appeal is received by the Plan. The Plan will make an appeal determination no later than the date of the meeting immediately following the Plan’s receipt of your written request for an appeal, unless the request for an appeal review is filed within 30 calendar days preceding the date of such meeting. In such case, an appeal determination will be made no later than the date of the second meeting following the Plan’s receipt of your written request for review. If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, a benefit determination shall be rendered not later than the third meeting following the Plan’s receipt of your written request for review. If such an extension is necessary the Plan must provide you with a written (or electronic, as applicable) notice of extension describing the special circumstances and date the appeal determination will be made. The Board of Trustees will notify you of the benefit determination no later than five (5) calendar days after the benefit determination is made.
• Accidental Death and Dismemberment Insurance/Death Benefit Claims
  A written (or electronic, as applicable) notice regarding a determination of your appeal will be sent to you within 60 days from the date your written request for an appeal is received by the Plan.

A written (or electronic, as applicable) notice of the appeal determination must be provided to you that includes:

• The specific reason(s) for the adverse benefit determination upon appeal, including (i) the denial code (if any) applicable to a health benefit claim and its corresponding meaning, (ii) a description of the Plan’s standard (if any) that was used in denying the claim, and (iii) a discussion of the decision;
• Reference the specific Plan provision(s) on which the denial is based;
• A statement that you are entitled to receive upon request, free access to and copies of documents relevant to the claim;
• A statement that you have the right to bring civil action under ERISA Section 502(a) following the appeal;
• An explanation of the external review process, along with any time limits and information about how to initiate a request for an external review regarding the denied internal appeal of a health benefit claim;
• If the denial of a health benefit claim, a weekly disability benefit claim or a weekly maternity benefit claim was based on an internal rule, guideline, protocol, standard, or similar criterion a statement must be provided that such rule, guideline, protocol or criteria will be provided free of charge, upon request;
• If the denial of a health benefit claim, a weekly disability claim or a weekly maternity benefit claim was based on a medical judgement (Medical Necessity, Experimental or Investigational), a statement must be provided that an explanation regarding the scientific or clinical judgement for the denial will be provided free of charge, upon request;
• With respect to weekly disability claims, a discussion of the Plan’s initial claim discussion, including the basis for disagreeing with(i) any disability determination by the Social Security Administration (SSA); (ii) the views of a treating health care professional or vocational expert evaluating the claimant, to the extent the Plan does not follow such views as presented by the claimant; or (iii) the views of medical professionals or vocational experts whose advice was obtained on behalf of the Plan, regardless of whether or not the advice was relied upon by the Plan in making an adverse benefit determination; and
• With respect to a health benefit claim, disclosure of the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist you with internal claims and appeals and external review processes.

This concludes the appeal process under this Plan.

If your initial claim for health care benefits has been denied (i.e., an adverse benefit determination) in whole or in part, and you are dissatisfied with the outcome of the Plan’s internal claims and appeals process described earlier, you may (under certain circumstances) be able to seek external review of your claim by an Independent Review Organization (“IRO”). This process provides an independent and unbiased review of eligible claims in compliance with the Affordable Care Act.

All notices relating to external review sent will contain a notice about the availability of Spanish language services. Assistance with filing a claim for external review in Spanish is available by calling 1-708-449-2123. Notices relating to external review will be provided in Spanish upon request.

SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-449-2123. Claims Eligible For The External Review Process

Post-Service, Pre-Service, Urgent Care, and Concurrent Care Claims, in any dollar amount, are eligible for external review by an IRO if:

• The adverse benefit determination of the claim involves a medical judgment, including but not limited to, those based on the Plan’s requirements for Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, denial related to coverage of routine costs in a clinical trial, or a determination that a treatment is Experimental or Investigational. The IRO will determine whether a denial involves a medical judgment.
• The denial is due to a rescission of coverage (i.e., the retroactive elimination of coverage), regardless of whether the rescission has any effect on any particular benefit at that time.

The following types of claims are not eligible for the external review process:

• Claims that involve only contractual or legal interpretation without any use of medical judgment.
• A determination that you or your Dependent are not eligible for coverage under the terms of the Plan.
• Claims that are untimely, meaning you did not request review within the four (4) month deadline for requesting external review.
• Claims as to which the Plan’s internal claims and appeals procedure has not been exhausted (unless a limited exception applies).
• Claims that relate to benefits other than health care benefits (such as dental or vision benefits that are considered excepted benefits).
• Claims that relate to benefits that the Plan provides through insurance. Claims that relate to benefits provided through insurance are subject to the insurance company’s external review process, not this process.

In general, you may only seek external review after you receive a “final” adverse benefit determination under the Plan’s internal appeals process. A “final” adverse benefit determination means the Plan has continued to deny your initial claim in whole or part and you have exhausted the Plan’s internal claims and appeals process.

Under limited circumstances, you may be able to seek external review before the internal claims and appeals process has been completed:

If the Plan waives the requirement that you complete its internal claims and appeals process first.

• In an urgent care situation (see “Expedited External Review of an Urgent Care Claim”). Generally, an urgent care situation is one in which your health may be in serious jeopardy or, in the opinion of your health care professional, you may experience pain that cannot be adequately controlled while you wait for a decision on your internal appeal.
• If the Plan has not followed its own internal claims and appeals process and the failure was more than a minor error. In this situation, the internal claims and appeal is “deemed exhausted,” and you may proceed to external review. If you think that this situation exists, and the Plan disagrees, you may request that the Plan explain in writing why you are not entitled to seek external review at this time.

Your request for external review of a standard (not Urgent Care) claim must be made in writing within four (4) months after you receive notice of an adverse benefit determination.

Because the Plan’s internal claims and appeals process generally must be exhausted before external review is available, external review of standard claims will ordinarily only be available after you receive a “final” adverse benefit determination following the exhaustion of the Plan’s internal claims and appeals process.

To begin the standard external review process, contact the following:

Plan Administrator
Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members
4530 Roosevelt Road
Hillside, IL 60162
1-708-449-7373
www.sm73funds.org

Within five (5) business days of the Plan’s receipt of your request for external review of a standard claim, the Plan will complete a preliminary review of the request to determine whether:

• You are/were covered under the Plan at the time the health care item or service is/was requested; or, in the case of a retrospective review, you were covered at the time the health care item or service was provided.
• The adverse benefit determination satisfies the above-stated requirements for a claim eligible for external review and does not, for example, relate to your failure to meet the requirements for eligibility under the terms of the Plan; or to a denial that is based on a contractual or legal determination, or a failure to pay premiums causing a retroactive cancellation of coverage.
• You have exhausted the Plan’s internal claims and appeals process (or a limited exception allows you to proceed to external review before that process is completed).
• Your request is complete, meaning that you have provided all of the information or materials required to process an external review.

Within one (1) business day of completing its preliminary review, the Plan will notify you in writing whether:

• Your request is complete and eligible for external review.
• Your request is complete but not eligible for external review. (In this situation, the notice will explain why external review is not available, and provide contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272).)
• Your request is incomplete. (In this situation, the notice will describe the information or materials needed to make the request complete. You must provide the necessary information or materials within the four (4) month filing period, or, if later, within 48 hours after you receive notification that your request is not complete.)

If your request is complete and eligible for external review, the Plan will assign it to an accredited IRO. The Plan has arranged for at least three (3) accredited IROs to provide external review of claims, and it rotates assignments among these IROs. In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of claims.

Once the claim has been assigned to an IRO, the following procedures apply:

•  The IRO will timely notify you in writing that your request is accepted for external review.
•  The IRO will explain how you may submit additional information regarding your claim if you wish. In general, you must provide additional information within ten (10) business days. The IRO is not required to, but may, accept and consider additional information you submit after the ten (10) business day deadline.
•  Within five (5) business days after the claim has been assigned to the IRO, the Plan will provide the IRO with the documents and information it considered in making its adverse benefit determination.
• If you submit additional information to the IRO related to your claim, the IRO must forward that information to the Plan within one (1) business day. Upon receipt of any such information (or at any other time), the Plan may reconsider its adverse benefit determination regarding the claim that is the subject of the external review. Any reconsideration by the Plan will not delay the external review. If Plan reverses its determination after it has been assigned to an IRO, the Plan will provide written notice of its decision to you and the IRO within one (1) business day. Upon receipt of such notice, the IRO will terminate its external review.
• The IRO will review all of the information and documents timely received. In reaching a decision, the IRO will review the claim de novo, meaning that the IRO is not bound by the Plan’s previous internal claims and appeal decisions. However, the IRO must review the Plan’s terms to ensure that its decision is not contrary to the terms of the Plan, unless those terms are inconsistent with applicable law. For example, the IRO must observe all of the Plan’s standards, including standards for clinical review, Medical Necessity, appropriateness, health care setting, level of care, and effectiveness of a covered benefit.
•  To the extent additional information or materials are available and appropriate, the assigned IRO may consider the additional information including information from your medical records, any recommendations or other information from your treating health care providers, any other information from you or the Plan, reports from appropriate health care professionals, appropriate practice guidelines, the Plan’s applicable clinical review criteria and/or the opinion of the IRO’s clinical reviewer(s).
•  In a standard case, the IRO will provide written notice of its final decision to you and the Plan within 45 days after the IRO receives the request for the external review.

The IRO’s decision notice will contain:

• A general description of the reason(s) for the request for external review, including information sufficient to identify the claim, including the date or dates of service, the health care provider, the claim amount (if applicable), and the reason for the previous denial.
• The date that the IRO received the assignment to conduct the external review and the date of the IRO decision.
•  References to the evidence or documents, including the specific coverage provisions and evidence-based standards, considered in reaching its decision.
• A discussion of the principal reason(s) for the decision, including the rationale for the decision and any evidence-based standards relied upon.
• A statement that the IRO’s decision is binding on you and the Plan, except to the extent that other remedies may be available to you or the Plan under applicable state or federal law.
• A statement that judicial review may be available to you.
• A statement regarding assistance that may be available to you from an applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act.

U.S. Department of Labor 
Employee Benefits Security Administration 
200 Constitution Ave., NW 
Washington, DC 20210 
(866) 4-USA-DOL ((866) 487-2365) 
http://www.dol.gov/ebsa/consumer_info_health.html

You may request an expedited external review in the following situations if:

• You receive an adverse benefit determination regarding your initial claim that involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an expedited internal appeal.
• You receive a “final” adverse benefit determination after exhausting the Plan’s internal appeals procedure that (i) involves a medical condition for which the timeframe for completion of an standard external review would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function; or (ii) concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, and you have not yet been discharged from a facility.

To begin a request for expedited external review, contact the following:

Plan Administrator

Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members

4530 Roosevelt Road
Hillside, IL 60162

1-708-449-7373

www.sm73funds.org

Immediately upon receipt of a request for expedited external review, the Plan will complete a preliminary review of the request to determine whether the requirements for preliminary review are met (as described above for the standard claim external review process). The Plan will defer to your attending health care professional’s determination that a claim constitutes “urgent care.” The Plan will immediately notify you (e.g., telephonically, via fax) whether your request for review meets the requirements for expedited review, and if not, it will provide or seek the information described above for the standard claim external review process.

Upon a determination that a request is complete and eligible for an expedited external review following the preliminary review, the Plan will assign an accredited IRO. The Plan has arranged for at least three (3) accredited IROs to provide external review of claims, and rotates assignments among those IROs. In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of claims.

The Plan will expeditiously provide or transmit to the IRO all necessary documents and information that it considered in making its internal adverse benefit determination.

The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described in the procedures for standard review. In reaching a decision, the IRO must review the claim de novo meaning that it is not bound by any previous decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO decision must not be contrary to the terms of the plan, unless the terms are inconsistent with applicable law. For example, the IRO must observe all of the Plan’s standards, including standards for clinical review, Medical Necessity, appropriateness, health care setting, level of care, and effectiveness of a covered benefit.

The IRO will provide notice of the final external review decision, in accordance with the requirements set forth above for the standard claim external review process, as expeditiously as your medical condition or circumstances require, but not more than seventy-two (72) hours after the IRO receives the request for an expedited external review. If notice of the IRO decision is not provided to you in writing, the IRO must provide written confirmation of the decision to you and the Plan within forty-eight (48) hours after it is made.

If the IRO’s final external review decision reverses the Plan’s internal adverse benefit determination, upon the Plan’s receipt of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim. However, even after providing coverage or payment for the claim, the Plan may, in its sole discretion, seek judicial remedy to reverse or modify the IRO’s decision.

If the final external review upholds the Plan’s internal adverse benefit determination, the Plan will continue not to provide coverage or payment for the reviewed claim.

If you are dissatisfied with the external review determination, you may seek judicial review to the extent permitted under ERISA section 502.

The Plan recognizes an authorized representative as any person at least 18 years old whom you have designated in writing as the person who can act on your behalf to file an initial claim and appeal an adverse benefit determination under the Plan. An authorized representative under the Plan also includes a health care professional. You do not need to designate in writing that the health care professional is your authorized representative if that health care professional is part of the claim appeal. A health care provider with knowledge of your medical condition may act as your authorized representative in connection with an Urgent Care Claim without filing a written statement with the Plan.

The Plan requires you to provide a written statement declaring your designation of an authorized representative along with the representative’s name, address, phone number, and email address. To designate an authorized representative, you must submit a completed authorized representative form (available from the Plan Administrator).

If you are unable to provide a written statement, the Plan will require written proof that the proposed authorized representative has the power of attorney for health care purposes (e.g., notarized power of attorney for health care purposes, court order of guardianship/conservatorship or is your legal spouse, parent, grandparent, or child over the age of 18).

Once the Plan receives an authorized representative form all future claims and appeals-related correspondence will be routed to the authorized representative rather than to you. The Plan will honor the designated authorized representative for one (1) year before requiring a new authorization/until the designation is revoked, or as mandated by a court order. You may revoke a designated authorized representative status by submitting a completed change of authorized representative form available from and to be returned to the Plan Administrator.

The Plan reserves the right to withhold information from a person who claims to be your authorized representative if there is suspicion about the qualifications of that individual.

You or any other claimant may not start a lawsuit or other legal action to obtain Plan benefits, including proceedings before administrative agencies, until after all administrative procedures have been exhausted (including this Plan’s internal claims and appeal procedures described in this section) for every issue deemed relevant by the claimant, or until 90 days have elapsed since you filed a request for appeal review if you have not received a final decision or notice that an additional 60 days will be necessary to reach a final decision. With respect to health claims, weekly disability benefit claims, and weekly maternity benefit claims, the law also permits you to pursue your remedies under section 502(a) of the Employee Retirement Income Security Act without exhausting these appeal procedures if the Plan has failed to follow them properly. For post-service claims, please be advised that your appeal will be decided at the second quarterly Board meeting, or if the Plan received the appeal within 30 days of a Board meeting, the third meeting from receipt.

In addition, with respect to health care claims, you are not required to exhaust external review before seeking judicial remedy.

The Plan has a 2-year statute of limitations. Notwithstanding any other state or federal law, any and all legal actions against the Plan or its Trustees must be filed within two (2) years of the action or inaction complained of. This includes but is not limited to actions to recover benefits that must be filed within two (2) years of the final decision on your claim. The situs of the Plan is in Cook County, Illinois. Legal actions must be brought in the appropriate state or federal court located in Cook County, Illinois.

You and your Eligible Dependents’ right to receive benefit payments, appeal a claim, or bring a cause of action against the Plan is personal to you or your Eligible Dependents. Any claim or rights under the Plan, which includes but is not limited to any right to appeal a claim under the procedure set forth in the Plan document, any right to bring a cause of action against the Plan in any forum, or any right to receive benefits or benefit payments from the Plan, is not assignable or transferrable in whole or in part to any other person, Provider, or other entity at any time. Any assignment or transfer of a claim or other rights to receive benefit payments is void unless you or your Eligible Dependents receive written consent from the Board of Trustees. Nothing in this clause will prevent the Plan from paying a Provider or similar entity directly and any such payment shall not constitute a waiver of this anti-assignment clause. In addition, the Trustees’ consent or lack thereof to the assignment or transfer of benefits does not affect your or your Eligible Dependents’ eligibility for benefits under the Plan.

With respect to health claims, weekly disability benefit claims, and weekly maternity benefit claims, to ensure that the persons involved with adjudicating claims and appeals (such as claim adjudicators, medical professionals and vocational experts) act independently and impartially, decisions related to those persons’ employment status (such as decisions related to hiring, compensation, promotion, termination or retention), will not be made on the basis of whether that person is likely to support a denial of benefits.

If the Board of Trustees or its designee determines that you cannot submit a claim or prove that you or your covered Dependent paid any or all of the charges for health care services that are covered by the Plan because you are incompetent, incapacitated or in a coma, the Plan may, at its discretion, pay Plan benefits directly to the health care professional(s) who provided the health care services or supplies, or to any other individual who is providing for your care and support. Any such payment of Plan benefits will completely discharge the Plan’s obligations to the extent of that payment. Neither the Plan, Board of Trustees, appropriate Claims Administrator nor any other designee of the Plan will be required to see to the application of the money so paid.

If you or your Dependents are covered by another plan or plans, the benefits under this Fund and the other plan(s) will be coordinated. This means one plan pays its full benefits first, then the other plan or plans pay.

1. The primary plan (which is the plan that pays benefits first) pays the benefits that would be payable under its terms in the absence of this provision.
2. The secondary plan (which is the plan that pays benefits after the primary plan) will limit the benefits it pays so that the sum of its benefits and all other benefits paid by the primary plan will not exceed the greater of:
   a) 100% of total covered expenses, or
   b)  The amount of benefits it would have paid had it been the primary plan.

If you or your Dependents are eligible under another plan, there are a few simple rules that determine the order in which benefits are paid.

1. When another plan does not have a Coordination of Benefits provision (COB provision), that plan must determine benefits first.
2. When another plan does have a COB provision, the first of the following rules that applies governs:
   a)   If a plan covers the claimant as an active Employee, then that plan will pay its benefits first.
   b) For an Eligible Dependent child whose parents are not divorced or separated, the plan of the parent whose birthday (month and day) is earlier in the calendar year will pay first. If both parents’ birthdays are the same day, the last rule will apply.
   c) For an Eligible Dependent child whose parents are divorced or separated, the following rules apply:
   i) A plan that covers a child as a Dependent of a parent who by court decree must provide health coverage will pay first.
   ii) When there is no court decree that requires a parent to provide health coverage for a Dependent child, the following rules will apply:

•  When the parent who has custody of the child has not married, that parent’s plan will pay first and the non-custodial parent’s plan will pay second.
• When the parent who has custody of the child has remarried, benefits will be determined by that parent’s plan first, by the stepparent’s plan second, and by the non-custodial parent’s plan third.
  
  d) If none of the above rules apply, the plan that has covered the claimant for the longest period of time will pay its benefits first, except:
  i) When one plan covers the claimant as a laid-off or retired Employee (or a Dependent of such Employee), and the other plan includes a COB rule for laid-off or retired Employees, the plan that covers the claimant as other than a laid-off or retired Employee (or a Dependent of such an Employee) will pay first,
  ii)If both plans cover the claimant as a laid-off or a retired Employee (or a Dependent of such Employee) the plan that covered the Employee for the longest period of time will pay first.

If part of a plan coordinates benefits and a part does not, each part will be treated like a separate plan. The Plan will always pay primary to Medicaid.

Notwithstanding any provision to the contrary, if an Eligible Dependent is covered by another group health plan that reduces or eliminates its benefits when a Dependent is covered by another group health plan, or if the other group health plan has COB provisions that differ from those of this Plan, this Plan will only pay the amount of benefits that would be payable if the other group health plan had the same coordination of benefit provisions as this Plan.

The birthday rule provides that the plan of the parent with the birthday that occurs earlier in the year pays first. The birthday comparison is by month and day only and not by year. For example, the plan of a parent who is older but who has a December birthday will be secondary to the parent who may be younger but who has a birthday earlier in the year.

For the purposes of Coordination of Benefits, the Fund Office:

1. May release to or obtain from any other plan or other organization or person any claim information, and any person claiming benefits under the Fund must furnish any information that the Fund may require to coordinate benefits, in accordance with the federal law governing privacy and security of your medical records,
2. Has the right, if an overpayment is made, to recover such overpayment from any other person or any other plan or organization, and
3.  Has the right to pay to any other plan or organization an amount it will determine to be warranted, if payments that should have been made by the Fund have been made by such organization.

Medicare is a four-part program. The first part is officially called “Hospital Insurance Benefits for the Aged and Disabled” and this part is commonly referred to as Part A of Medicare. The second part is officially called “Supplementary Medical Insurance Benefits for the Aged and Disabled” and this part is commonly referred to as Part B of Medicare. The third part is Medicare Advantage or Medicare Part C and generally involves coverage under one of the Medicare HMO (Health Maintenance Organization) offerings for Participants who live in a geographic area served by a Medicare HMO and who choose to be covered by a Medicare HMO. Medicare Part D provides Prescription Drug coverage. Part A of Medicare primarily covers Hospital benefits, although other benefits are also provided. Part B of Medicare primarily covers Physician’s services, although it, too, covers a number of other items and services. Part C covers both Hospital and Physician services. Part D covers Prescription Drug expenses.

Typically, a person becomes eligible for Medicare upon reaching age 65. Under certain circumstances, a person may become eligible for Medicare before age 65 if the person is a disabled worker, disabled widow, or Dependent widower or has chronic renal disease.

When you reach age 65, you are eligible to apply for all parts of Medicare coverage, even if you have not yet retired or are not yet receiving Social Security benefits. Part A of Medicare is ordinarily free, and premiums are required for the other Parts of Medicare. If you are not yet receiving Social Security benefits, you must pay any required premium to the Social Security Administration. If you are receiving Social Security Benefits, you will have the premium deducted from your monthly Social Security benefit check.

The Plan coordinates benefits with Medicare.

This Plan is the primary plan responsible for payment of your benefits and your Dependents’ benefits if you are an eligible Active Employee. This means that if you are an Active Employee and you are also covered by Medicare, when you or your Dependents incur covered medical expenses, the Plan will pay benefits first and then Medicare will determine what benefits it will pay of the remaining expense not covered by the Fund.

Keep in mind that when you retire, your coverage under the Sheet Metal Workers’ Local 73 Welfare Fund Plan A for Active Members ends and you will be able to continue coverage only through COBRA, if you are eligible. If you are eligible for Medicare when you retire, you should enroll in Medicare, which will then cover your eligible medical expenses. You may contact the Fund Office if you have any questions regarding your coverage under the Plan.

The Plan’s Reimbursement provisions apply to the following benefits paid by the Plan: medical, dental, vision, prescription drug, hearing aid, and accident and sickness disability benefits. The Plan’s Reimbursement provisions do not apply to Death Benefits or Accidental Death and Dismemberment Benefits provided by the Plan.

The Plan has the right of reimbursement for benefits that it pays as a result of an Injury, accident or Sickness for which any third party may be liable. This can include auto accidents, workers’ compensation injuries, personal injuries, medical malpractice injuries, injuries from fights or beatings, poisonings or toxic injuries, or a case of slip and fall.

The Board of Trustees has established reimbursement procedures for the Welfare Fund which they may change from time to time. The Fund Office will follow the reimbursement procedures. The Board of Trustees of the Welfare Fund has delegated full discretionary authority to the Benefits Appeals Committee of the Board of Trustees to collect and settle Reimbursement claims.

If you sign a Reimbursement Agreement, the Fund may reduce its share of the recovery for its proportionate share of attorneys’ fees and its share of your out-of-pocket expenses. The Trustees or Appeals Committee have the discretion to settle reimbursement claims or liens. Other guidelines apply to the recovery available by the Fund. Contact the Fund Office for more details.

The Fund Office may suspend benefit payments for your claims related to third-party Injury or illness until you return a signed Reimbursement Agreement to the Fund Office. The Fund Office may also suspend benefits or withhold future benefit payments if you refuse to provide information to the Fund Office or otherwise refuse to cooperate with the Fund Office.

The Fund Office may suspend all Welfare Benefit payments or withhold future benefit payments, regardless of the nature or source, from you and/or your Dependents if you receive a recovery and you either fail to report that recovery to the Fund Office, refuse to reimburse the Fund Office, or reject a settlement in accordance with the Plan’s Reimbursement guidelines. Benefits should recommence after the total amount of payments withheld equals the amount of recovery due the Fund under the Fund’s Reimbursement policies and procedures.

You have the right to:

• Examine, without charge, at the Fund Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan. These include insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration (EBSA).
• Obtain, upon written request to the Fund Administrator, copies of documents governing the operation of the Plan. These include insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Fund Administrator may make a reasonable charge for the copies.
• Receive a summary of the Plan’s annual financial report. The Fund Administrator is required by law to furnish each Participant with a copy of this summary annual report.

You also have the right to:

• Continue healthcare coverage for yourself, spouse, or Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan for the rules governing your COBRA continuation coverage rights.

In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the Employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including your Employer, your Union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Fund Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Fund Administrator.

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

If you have any questions about your Plan, you should contact the Fund Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Fund Administrator, you should contact the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or:

The Division of Technical Assistance and Inquiries
Employee Benefits Security Administration
U.S. Department of Labor
200 Constitution Avenue N.W.
Washington, D.C. 20210

You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration (EBSA). For single copies of publications, contact the EBSA Brochure Request Line at 866-444-3272 or contact the EBSA field office nearest you.

You may also find answers to your Plan questions at the website of the EBSA at http://www.dol.gov/ebsa/. A list of EBSA Field Offices is located at http://www.dol.gov/ ebsa/aboutebsa.

Your Plan coverage begins on the first day of the second calendar month after you have worked 200 hours in Covered Employment in a two-consecutive-month period during which your Employer contributed to the Fund on your behalf (except as provided below).

Covered Employment is defined as work for which a contributing Employer is required to make contributions on your behalf to this Welfare Fund under the terms of a collective bargaining agreement with Sheet Metal Workers’ Local 73.

For the first two months only, you will be credited with the number of hours actually reported by a contributing Employer for up to two consecutive calendar months even if the contributing Employer fails to make the required contributions on your behalf for those months.

Example:  Your Plan Eligibility

John begins working on March 1, 2020 and works steadily through April 2020, accumulating more than 200 hours by the end of April 2020. John is eligible for coverage under the Plan on June 1, 2020.

Your Eligible Dependents become Participants in the Fund on the later of:

• The day you begin participation; or
   
• The date you enroll them with the Fund Office.

Your newborn Child, adopted Child, or Child placed with you for adoption will automatically become covered as a Dependent under the Fund on the date the Child is born, adopted, or placed for adoption.

Eligible Dependents are defined as follows:

• Your legal spouse;

• Your Dependent Children up to age 26; and
   
• Your Dependent Children of any age if mentally or physically disabled, as long as the mental or physical handicap began before the Child reached age 26.

Dependent Children include married or unmarried dependents, regardless of student status, who are the member’s natural children, adopted children, or children placed for adoption with the member, stepchildren and foster children placed with the member by an authorized agency or by court order, judgment or decree.

To enroll your newborn or newly acquired Child, you must provide the Fund Office with a copy of the birth certificate or adoption papers. Dependent status may continue until each Child’s 26th birthday.

An unmarried disabled Child who has reached age 26, but does not reside with you, will be a Dependent Child under the Plan if:

• The Child’s parents are divorced or legally separated under a decree of divorce or separate maintenance, are separated under a written separation agreement, or live apart at all times during the last six months of the calendar year;
   
• The Child’s parents provide over one-half of the Child’s support during the calendar year; and
   
• The Child is in the custody of one or both of his or her parents for more than one-half of the calendar year and is not the qualifying child of any other person during the calendar year.

The Plan will provide benefits for your Dependent Child who is named as an alternate recipient in a Qualified Medical Child Support Order (QMCSO).

Your Dependents’ benefits are subject to the rules outlined in the Coordination of Benefits.

A Qualified Medical Child Support Order (QMCSO) is a court order that requires you to provide medical coverage for your Children (called alternate recipients) in situations involving a divorce, legal separation or a paternity determination.

This Plan provides benefits according to the requirements of the QMCSO. The Fund Administrator will notify you and any alternate recipient when a QMCSO is received. If the QMCSO is a valid order, the Plan will cover the named Dependent as an alternative recipient even though the Dependent might not otherwise be eligible for coverage. 

A copy of the Fund’s QMCSO procedures is available upon request from the Fund Administrator.

The requirements for continuing coverage for you and your Dependents are outlined in the following chart.

Eligibility for your Dependents continues while you are eligible for benefits, as long as they continue to meet the definition of Dependent under the Plan.

Example: How Coverage Continues

Continuing from the previous eligibility example, John first became eligible for coverage on June 1, 2020. In order to continue eligibility in July 2020, John must have either 1,700 hours from June 1, 2019 through May 31, 2020 or have at least 100 hours during the month of May 2020.

Your eligibility for Plan benefits stops in accordance with the Chart above when you stop working in Covered Employment.

Example: Termination of Eligibility

Continuing with the previous eligibility examples, John started participating in the Plan on June 1, 2020 and continues to participate through April 30, 2021. On May 1, 2021, John does not have 1,700 hours in the 12 months from April 1, 2020 through March 31, 2021 or 100 hours in the month of March 2021. John’s eligibility terminates on April 30, 2021.

If You Are Disabled 

For all Plan benefits except the Weekly Accident and Sickness Disability Benefit, any month in which you have a Certified Disability for 18 or more days will be counted as a month in which you have worked in Covered Employment. However, you may not receive credit for a Certified Disability for more than six months in a period of twelve consecutive months.

A Certified Disability is one for which you would otherwise receive Weekly Accident and Sickness Disability Benefits from the Plan, were you eligible, or benefits under any Workers’ Compensation Law, Occupational Disease Law or similar legislation. However, if you are not eligible for this extension, you may continue health coverage under Continuation of Health Benefits (COBRA) as explained on page 16.

If You Retire

If you retire, you and your Dependents may continue coverage under COBRA, as provided in the Section entitled COBRA Continuation Coverage.

Your Dependent’s eligibility ends at the same time your eligibility under the Plan ends, on the last day of the month in which a Dependent child attains age 26, the date your Dependent child no longer meets the criteria set forth above in the Your Dependent’s Eligibility section, or the date your Dependent spouse no longer meets the definition of Dependent, whichever comes first. If you die, eligibility for your Dependents will continue for as long as you would have been eligible. You should notify the Fund Office immediately when your Dependent Child is no longer eligible for coverage.

However, your Dependents may be able to continue coverage under COBRA, as explained on page 16.

If you lose your eligibility for Plan benefits, your coverage will be reinstated when you meet the initial eligibility requirements again. These are explained in the Your Initial Eligibility section on page 7.

Enrollment procedures are as follows:

New member: Complete the Fund’s Benefit Enrollment Form, available through the Fund Office and submit a copy of your driver’s license.

New spouse: Submit a copy of your marriage certificate and your spouse’s birth certificate to the Fund Office when you get married, along with your spouse’s social security number.

Newborn Child: Submit a copy of the Child’s birth certificate to the Fund Office, along with your Child’s social security number.

Newly adopted Child: Submit a copy of the initial placement papers to the Fund Office along with a copy of the birth certificate and adoption papers (when available), along with your Child’s social security number.

New stepchild: Submit a copy of the stepchild’s birth certificate and court decree (Qualified Medical Child Support Order) (if available) to the Fund Office, along with your Child’s social security number.

New foster Child placed by an authorized agency or by court order, judgment or decree or any other Child for whom you may have legal guardianship by court order, judgment or decree: Submit a copy of the court order documents signed by a judge verifying legal custody of the child (e.g., placement papers from a qualified state placement agency), or proof of judgment, decree, or court order from a court of competent jurisdiction, along with the Child’s social security number.

If you are declining enrollment for yourself or your Dependents (i.e., your spouse and Children) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your Dependents in this plan if you or your Dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your Dependents’ other coverage). However, you must request enrollment within 60 days after your or your Dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your Dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Special enrollment rights also may exist in the following circumstances:

• If you or your Dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or
• If you or your Dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact Patrick Ludvigsen, Fund Administrator at 708-449-7373.

A rescission of coverage is a cancellation or discontinuance of coverage that has retroactive effect, meaning that it will be effective back to the time that you should not have been covered by the Plan. The Plan may rescind your coverage for fraud or intentional misrepresentation of a material fact after the Plan provides you with 30 days advance written notice of that rescission of coverage. However, the following situations will not be considered rescissions of coverage and do not require the Plan to give you 30 days advance written notice:

• When the Plan terminates your coverage retroactive to the date you lose eligibility for coverage, if there is a delay in administrative recordkeeping between the date you lose eligibility and the date the Plan is notified of your loss of eligibility;
• When the Plan retroactively terminates your coverage because you fail to make timely self-payments for your coverage; or
• When any unintentional mistakes or errors result in you and your Dependents being covered by the Plan when you should not have been covered, the Plan will cancel your coverage prospectively – for the future – once the mistake is identified.

When you marry, your spouse is eligible for healthcare coverage as of the date of your marriage. However, the Fund will not pay any benefits on behalf of your spouse until you enroll your spouse for coverage. You must send a copy of your marriage certificate, your spouse’s birth certificate, and your spouse’s Social Security Number to the Fund Office as soon as it is available. Once your spouse is enrolled, benefits will be paid retroactively back to the date of your marriage.

Your natural Child will be eligible for coverage on the date of birth. If you adopt a Child, have a Child placed with you for adoption, or acquire a stepchild through marriage, he or she will be eligible for coverage on the date of placement or date of marriage, as long as you are responsible for healthcare coverage and your Child meets the Plan’s definition of a Dependent Child.

You must enroll your Child for coverage before the Fund pays any benefits for that Child. To enroll your Child for coverage, provide the required documentation to the Fund Office as soon as it is available. See the Enrollment Procedures section for more details.

If you and your spouse get a divorce or legal separation, your spouse will no longer be eligible for coverage. Your spouse may elect to continue coverage under COBRA for up to 36 months upon divorce or legal separation. You or your spouse must notify the Fund Office within 60 days of the divorce or legal separation date for your spouse to obtain COBRA Continuation Coverage. If you or your spouse do not timely notify the Fund Office of your divorce, both you and your former spouse are required to reimburse the Fund for any claims paid for your former spouse or ineligible dependents after the date of your divorce. Any and all benefit payments for you, your former spouse and any Dependents may be withheld until the Fund is made whole.

A Qualified Medical Child Support Order (QMCSO) that is issued in the course of a divorce, legal separation or domestic relations proceeding could have an effect on your benefit coverage or elections. Please notify the Fund Office if your situation involves a QMCSO. You or your Dependent may request a copy, free of charge, of the Fund’s procedures for handling these orders.

In general, your Dependent Child is no longer eligible for coverage when he or she reaches age 26. However, if your child is determined to be mentally or physically disabled before reaching age 26 and continues to be mentally or physically disabled and dependent on you for at least half of his or her support, your child will continue to be covered as your Dependent. To qualify, your Child’s disability must begin before his or her coverage would otherwise end. You must contact the Fund office within 31 days before Plan benefits might otherwise terminate and provide proof of your Child’s continuing disability in order to apply for continued coverage for your disabled or handicapped Child. You should notify the Fund Office immediately when your Dependent Child is no longer eligible for coverage.

If eligible, your Dependent Child may elect to continue coverage under COBRA for up to 36 months after your Dependent Child loses eligibility. You or your Dependent Child must notify the Fund Office within 60 days of the date your Child no longer meets the definition of a Dependent Child in order to obtain COBRA Continuation Coverage. If you or your Dependent Child fails to do so, the child will not be eligible to elect COBRA Continuation Coverage.

If your Employer is required to grant you leave under the Family and Medical Leave Act (FMLA), and you qualify for such leave, the FMLA allows you to take up to 12 weeks, or 26 weeks if applicable, of unpaid leave during any 12-month period due to:

• The birth or adoption of a Child or placement of a Child with you for foster care or adoption;
• The care of a seriously ill spouse, parent, or Child;
• Your serious illness; or
• You have an urgent need for leave because your spouse, son, daughter, or parent is on active duty in the armed services in support of a military operation.

In addition, under the FMLA, you may be able to take up to 26 weeks of unpaid leave during any 12-month period to care for a service member. The service member must be your spouse, son, daughter, parent, or next of kin, must be undergoing medical treatment, recuperation, or therapy, for a serious illness or injury incurred in the line of duty while in military service, and must be an Outpatient, or on the temporary disability retired list of the armed services.

Your leave will end on the earlier of your return to work or 12 weeks, or 26 weeks if applicable. If you do not return to work within 12 weeks, or 26 weeks if applicable, you may qualify for COBRA Continuation Coverage.

The Fund will maintain your eligibility and medical coverage until the end of the leave, provided your Employer properly grants the leave under the federal law and makes the required notification to the Fund. Contact your Employer for more information relating to a leave under the FMLA.

An Employer is required to grant FMLA leave to eligible Employees if it employs 50 or more Employees within a 75-mile radius for at least 20 weeks of the current or preceding year. To be eligible for FMLA benefits, an Employee must:

• Work for an Employer required to grant FMLA leaves;
• Have worked for that Employer for a total of at least 12 months;
• Have worked at least 1,250 hours over the previous 12 months; and
• Work at a location in the United States or in any territory or possession of the United States where at least 50 Employees are employed by the Employer within 75 miles.

You or your Employer must notify the Fund Office if you are taking a FMLA leave.

If you enter military service (active duty or inactive duty training) for up to 31 days, your health coverage will continue for the duration of your military service as long as contributions have been received for your coverage.

If you enter military service for more than 31 days, and you would like to continue your Plan coverage during your service, you have a choice of either: (1) making self-payments for coverage and having your remaining eligibility frozen until your reemployment after service; or (2) using your remaining eligibility for coverage, continuing coverage through self-payments when your eligibility is exhausted, and making self-payments for coverage upon reemployment after service. You may continue your Plan coverage through either of these methods for up to 24 months, or if shorter, the end of the period during which you are eligible to apply for reemployment in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA).

Your coverage under USERRA will continue until the earliest of the following:

• The date you or your Dependents do not make the required self-payments within 30 days of the due date;
• The date you reinstate your eligibility for coverage under the Plan;
• The date you lose your rights under USERRA (for instance, for a dishonorable discharge);
• The end of the period during which you are eligible to apply for reemployment in accordance with USERRA;
• The last day of the month after 24 consecutive months; or
• The date the Fund no longer provides any group health benefits.

You need to notify the Fund Office in writing when you enter the military. For more information about Self-Payments under USERRA, contact the Fund Office. Continuation coverage under USERRA will be administered by the Fund Office in the same way that COBRA continuation coverage is administered, except that coverage may continue for up to 24 months under USERRA. The Trustees will set the amount of your premium payment for continuation coverage under USERRA.

If you do not continue coverage under USERRA, your coverage will end immediately within 31 days of the date you enter active military service. Your Dependents will have the opportunity to elect COBRA Continuation Coverage.

When you are discharged or released from military service, you have up to the USERRA-specified time period to report to work for a Contributing Employer. If you return to work or make yourself available for work during this period, any remaining coverage eligibility that you and your Dependents have will be reinstated on the day you report to work or make yourself available for work. If you do not report to work in Covered Employment within the USERRA-specified period, you will be considered a new Employee and you will need to satisfy the initial eligibility requirements.

If you die, your spouse and Eligible Dependents may continue coverage for up to 36 months by electing COBRA Continuation Coverage and making the necessary Self-Payments.

Coverage for you and your Dependents will end if contributions needed to maintain your eligibility are not made on your behalf. You may be eligible to continue coverage by electing COBRA Continuation Coverage and making the necessary self-payments for such coverage by the due date.

If you retire, you may be eligible for Retiree coverage. You should refer to the Summary Plan Description/Plan Document for the Sheet Metal Workers’ Welfare Plan for Retirees for information about Retiree eligibility. Contact the Fund office for a copy of that booklet.

See page 13 for information about continuing coverage during a leave under the Family and Medical Leave Act (FMLA).

See page 14 for information about continuing coverage while you serve in the Uniformed Services of the United States under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides for continuation of health coverage for you, your spouse and Dependent Children, if you lose coverage under the Plan due to a qualifying event. You and your Dependents may continue health coverage for a limited period of time by making self-payments to the Plan.

You and your Dependents may choose individual coverage or family coverage. Each qualified beneficiary has an independent right to elect COBRA.

Eligibility for COBRA Continuation Coverage

If you or your Dependents are eligible for COBRA Continuation Coverage, you are considered qualified beneficiaries, meaning you were covered by the Plan on the day before the qualifying event.

If  you marry, have a newborn Child, or have a Child placed with you for adoption  while you are enrolled in COBRA Continuation Coverage, you may enroll that spouse or Child for the balance of the period of your coverage. You must complete the enrollment within 30 days after the birth, marriage, or placement for adoption. Children born to, adopted, or placed for adoption with you will have the rights of a qualified beneficiary if they are properly enrolled in the Plan. However, other Dependents who are added to the coverage will not have the rights of a qualified beneficiary.

Scope of COBRA Continuation of Coverage

If you choose COBRA Continuation Coverage, you are entitled to the same type of coverage that you had before the event that triggered COBRA. Your COBRA Continuation Coverage includes the Death Benefit for you as the Employee; however, COBRA Continuation Coverage does not include the Accidental Death and Dismemberment or Weekly Accident and Sickness Disability Benefits currently provided to Active Employees by the Fund. The Death Benefit is not included in COBRA Continuation Coverage for your Spouse of Dependent Children. If there is a change in the health coverage, including Prescription Drug coverage that is provided by the Plan to Active Participants, that same change will be made to your COBRA Continuation Coverage.

Qualifying Events That Trigger COBRA Continuation Coverage

If you experience a qualifying event that causes you to lose coverage, you will be considered a qualified beneficiary, and the Fund will send you a COBRA Election Notice and a form for you to elect coverage. The qualifying events under which you and/or your Dependents may lose coverage under the Plan and the period of time for which you may make self-payments to continue benefits are described below.

You become a qualified beneficiary if you lose coverage because one of the following qualifying events:

• Your hours of employment are reduced, or
   
• Your employment ends for any reason other than your gross misconduct.

Your spouse becomes a qualified beneficiary if he or she loses coverage because any of the following qualifying events:

• Your death,
   
• Your hours of employment are reduced,
   
• Your employment ends for any reason other than your gross misconduct,
   
• You and your spouse become divorced or legally separated, or
   
• You become entitled to Medicare benefits under Part A, Part B or both. Becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Your Eligible Dependent Children become qualified beneficiaries if they lose coverage because any of the following qualifying events:

• Your death,
   
• Your hours of employment are reduced,
   
• Your employment ends for any reason other than your gross misconduct,
   
• The parents become divorced or legally separated,
   
• The Child stops being eligible for coverage under the Plan as an Eligible Dependent Child, or
   
• You become entitled to Medicare benefits under Part A, Part B or both. Your becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Length of COBRA Continuation Coverage

If you lose eligibility for coverage because your hours are reduced or your employment is terminated, you and your Dependents may continue COBRA Continuation Coverage for a maximum period of 18 months from the date of loss of coverage. Once coverage is lost, the monthly contribution rate for individual or for family coverage for the first six months will be subsidized. The contribution rate for the seventh through the eighteenth month is not subsidized and, therefore, is higher.

If your Dependents lose coverage under the Plan because of divorce, legal separation, your death, or loss of Dependent status, your Dependents may maintain COBRA Continuation Coverage for a maximum period of 36 months from the date coverage was lost.

Medicare Entitlement and COBRA Continuation Coverage. When the qualifying event is the end of employment or reduction of your hours of employment, and you became qualified for and enrolled in Medicare benefits less than 18 months before the qualifying event, COBRA Continuation Coverage for qualified beneficiaries other than you lasts until 36 months after the date of Medicare entitlement. However, your maximum period of COBRA Continuation Coverage will be 18 months.

In no case are you entitled to COBRA Continuation Coverage for more than a total of 18 months, unless you qualify for an additional period of up to 11 months because of disability as described below. Other family members may be entitled to COBRA Continuation Coverage for a total of 36 months.

Second Qualifying Event During Initial COBRA Continuation Coverage Period. If, during an 18-month period of COBRA Continuation Coverage following your termination of employment or reduction in hours, you die, divorce, legally separate, or your Child loses Dependent status under the Plan, the maximum period is extended to 36 months from the date you initially lost eligibility. This extension only applies to:

•  Qualified beneficiaries who are members of your family and were covered by the Plan before the loss of your eligibility, and
   
• Your Dependent Children who were born, adopted, or placed for adoption with you while you were covered under COBRA Continuation Coverage.

Extended Coverage in Certain Cases of Disability. If, during or before the first 60 days of an 18-month period of COBRA Continuation Coverage, you or one of your Dependents are determined by the Social Security Administration (SSA) to be totally and permanently disabled so as to be entitled to Social Security Disability benefits, the 18-month maximum period can be extended for up to 11 more months (for a total of 29 months) for all qualified beneficiaries who have elected COBRA Continuation Coverage. This extension is available only if:

• The disability starts at some time before the 60th day of COBRA Continuation Coverage, and
   
• The qualified beneficiary or another family member notifies the Fund Office of the Social Security Administration’s determination within 60 days after the determination is received by the qualified beneficiary, and
   
• That notice is received by the Fund Office before the end of the 18-month COBRA Continuation Coverage period.

If a disability extension is granted, the monthly self-payment rate for COBRA Continuation Coverage for the additional 11 months of coverage under the disability extension will be higher than the monthly self-payment rate paid for the first 18 months, as explained in the next section.

Cost of and Payment for COBRA Continuation Coverage

Any qualified beneficiary who elects COBRA Continuation Coverage will pay the full cost of the coverage. The Fund can charge the full cost of coverage for similarly situated Employees and their families (including both the Fund’s share and Employee’s share, if any) plus an additional 2%.

If the 18-month period of COBRA Continuation Coverage is extended because of disability, the Fund can charge the cost plus an additional 50%.

The monthly cost depends on how many people are covered. Rates are provided for one person or for family coverage. If a qualified beneficiary adds Dependents that are acquired during the COBRA Continuation Coverage period and the qualified beneficiary was previously paying for individual coverage, the qualified beneficiary will be required to pay the higher rate.

The Trustees will establish the COBRA Continuation Coverage rates in accordance with ERISA and the Internal Revenue Code, the laws that governs the Plan. Generally, the Trustees will set new rates each Plan Year beginning July 1.

When you elect COBRA Continuation Coverage, you are required to make the first payment no later than 45 days after the date of your election, which is the date your COBRA Election Notice is post-marked, if mailed. If you do not make the first payment for continuation coverage in full within the 45-day deadline after your election, you will lose all rights to COBRA Continuation Coverage. You are responsible for contacting the Fund Office to make sure that the amount of your first payment is correct.

Your subsequent payments for COBRA Continuation Coverage are due on the first day of the month for which coverage is being provided. However, you have a 30-day grace period to make the payment. If the payment is not made when due, you will lose all continuation coverage rights under the Plan. COBRA Continuation Coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the month for which it applies, but before the end of the grace period (the end of the month) for the coverage, coverage under the Plan will be suspended as of the first day of the month and then retroactively reinstated, going back to the first day of the month when your payment is received.

If you lose eligibility due to insufficient hours and you elect COBRA Continuation Coverage, you will be required to pay at the subsidized rate for the first six months and at the full rate thereafter. This provision applies both to you  and to any of your Eligible Dependents covered by the COBRA Continuation Coverage. You and your Dependents may separately choose individual coverage or jointly choose family coverage. If your Dependent loses eligibility for any other reason, he or she will be required to pay the full rate for the entire period of coverage.

COBRA Continuation Coverage Notice and Election

You or your covered family member must  inform the Fund Office of a divorce, legal separation, or of a Child losing Dependent status. You or your Dependent must provide written notice within 60 days of the event or the person affected forfeits the right to COBRA Continuation Coverage.

Your Employer has the responsibility to notify the Fund Office of your death, termination of employment or reduction in hours within 30 days of the date that you would lose coverage due to the event. However, you or your covered Dependents are encouraged to notify the Fund Office of any event that may qualify you or your Dependents for continuation of coverage.

When the Fund Office is notified that one of these events has occurred, it will in turn notify you or your Dependents of the right to choose continuation coverage and the time frame within which you must make the election. If you are not entitled to COBRA Continuation Coverage, the Fund will notify you of your ineligibility in writing.

You or your Dependents have an election period of at least 60 days from the date the notice is provided to inform the Fund Office of your election of COBRA Continuation Coverage.

You may elect individual coverage or family coverage. Once you make your election for COBRA Continuation Coverage, you cannot change it unless it is within the 60-day election period. This means that after the 60-day election period ends, if you elect individual coverage, you cannot change to family coverage and if you elect family coverage, you cannot change to individual coverage. However, if you elect family coverage for only two family members and one of the family members dies so that individual coverage would be less expensive,  the surviving individual may change to individual coverage. The Plan will charge for the individual premium starting on the first day of the month following the day the covered family member dies.

COBRA Benefit Coverage

Under COBRA Continuation Coverage, you are entitled to the same type of coverage that you had before the event that triggered coverage. If you or your Dependents choose COBRA Continuation Coverage and make the required self-payments, the Welfare Fund will provide coverage for all medical, dental, prescription drug, wellness, Substance Abuse, employee assistance plan, hearing, and vision benefits under the Plan. Death, Accidental Death and Dismemberment, and Weekly Accident and Sickness Disability Benefits are excluded from COBRA Continuation Coverage.

In addition, if there is a change in the healthcare coverage that is provided by the Plan to Active Participants, that same change will be made to the COBRA Continuation Coverage of qualified beneficiaries.

Termination of COBRA Continuation Coverage

If you or your Dependent elects COBRA Continuation Coverage, coverage will terminate as of the date the first of any of the following events occur:

• You or your Dependents do not pay the self-payment for COBRA continuation coverage within 30 days of its due date.
   
• You or your Dependents become covered under another group health plan. Special rules exist concerning pre-existing conditions. Contact the Fund Office for details.
   
• You or your Dependents become eligible for Medicare. Contact the Fund Office for details.
   
• The Welfare Fund no longer provides any healthcare benefits.
   
• The Social Security Administration determines that you are no longer disabled during the COBRA disability extension period. You or your Dependent must give the Fund Office notice that you are no longer disabled within 30 days of the date that the Social Security Administration has determined that you are no longer disabled.

Availability of Other Coverage

There may be other coverage options for you and your family. With the implementation of the Affordable Care Act you are able to buy coverage through the Health Insurance Marketplace.  In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll.  Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.

If You Have Questions

If you have questions about your COBRA Continuation Coverage, you should contact the Fund Office, or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA).  Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa/.

Keep the Fund Informed of Address Changes

In order to protect your family’s rights, you should keep the Fund informed of any changes in the addresses of family members.  You should also keep a copy, for your records, of any notices you send to the Fund.

You are encouraged to use PPO Hospitals and Physicians whenever possible. You will receive the maximum benefits available under the Fund when you use PPO Providers because the Fund will be paying a greater percentage of your covered expenses. Your share will also be less because those covered expenses are generally billed at a discount by the PPO.

To select a PPO Provider in your area or to find out whether your Provider is in the PPO network, you may contact Blue Cross Blue Shield of Illinois, free of charge, at 1-800-810-BLUE (2583), visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com, or call the Fund Office at 1-708-449-7373. Have your medical ID card handy so that you can provide any information required about your Fund. 

Each calendar year, before the Plan begins to pay benefits, you must pay the individual deductible listed in your Schedule of Benefits. Your family meets the deductible when three family members have paid their individual deductibles during the calendar year. After that, no other covered family members will have to meet the individual deductible.

The deductible applies only once in a calendar year even though you may have several different Sicknesses or Injuries during that period. So that your medical claims will not be subject to a deductible late in one calendar year and soon again in the following year, any expenses applied against the deductible in the last three months of a calendar year may also be applied against the deductible for the next calendar year.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, you are not required to pay the deductible for these expenses. You also do not need to satisfy the deductible before being eligible for Hospice benefits.

If two or more eligible family members are injured in the same accident, only one deductible will apply in the current and next succeeding calendar year for all their covered expenses directly resulting from the accident.

You and the Fund share your healthcare expenses. Coinsurance is:

• The amount that the Plan pays of your eligible expenses after you have paid your deductible, and
• Listed in the Schedule of Benefits as a percentage of your eligible expenses, after the deductible.

When you use a Blue Cross Blue Shield Center of Excellence facility to receive transplant benefits, the Plan’s coinsurance provisions do not apply to your transplant expenses. The coinsurance provisions also do not apply to Hospice benefits.

Each calendar year after you reach the out-of-pocket maximum per person listed in the Schedule of Benefits, the Plan generally pays 100% of your remaining covered expenses during that calendar year, except for the following expenses:

• Treatment for infertility,
• Treatment received at a non-PPO Hospital, a non-PPO Ambulatory Surgical Facility, or treatment received from a non-PPO Physician, and

The following expenses are not counted toward the out-of-pocket maximum:

• Deductibles,
• Treatment received at a non-PPO Hospital, a non-PPO Ambulatory Surgical Facility, or treatment performed by a non-PPO Physician, and
• Treatment received for infertility.

When your Physician recommends elective or non-emergency hospitalization or Inpatient surgery, you should call MED-CARE MANAGEMENT, INC. for prior approval of the admission at least one business day before you go into the Hospital. Contact MED-CARE MANAGEMENT, INC. at 1-800-367-1934.

If you have an emergency admission, you, your Physician, the Hospital or a family member should call MED-CARE MANAGEMENT, INC. within two business days of the date of your admission. This provision does not apply to maternity admissions.

Pre-admission authorization is not a guarantee that all services and charges will be paid for by the Fund. Your benefits are still subject to the terms and conditions of the Plan.

The fact that your Health Care Provider recommends Surgery, Hospitalization, confinement in a Health Care Facility, or that your Health Care Provider proposes or provides any other medical services or supplies doesn’t mean that the recommended services or supplies will be an Covered Expense or be considered Medically Necessary for determining coverage under the Plan.

The Utilization Management Program is not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefits. The UM Company’s certification that a service is Medically Necessary doesn’t mean that a benefit payment is guaranteed. Eligibility for and actual payment of benefits are subject to the terms and conditions of the Plan.

All treatment decisions rest with you and your Provider. You should follow whatever course of treatment you and your Health Care Provider believes to be the most appropriate, even if the UM Company does not certify a proposed surgery/treatment/service or admission as Medically Necessary. However, the benefits payable by the Plan may be affected by the determination of the UM Company.

You should contact the Fund Office if you have any questions regarding the precertification process or if you are unsure if a service or treatment must be pre-certified.

The following services require pre-certification and medical review:

• Durable Medical Equipment as provided in Appendix A
• Skilled Nursing Care
• All Elective Hospital Admissions
• All Elective In-Patient Admissions (For Medical and Mental Health and Substance Used Disorder Admissions)
• All Elective Surgery and/or Surgical Procedures
• Hospice Benefits
• Private Duty Nursing/Coordinated Home Care Program
• Growth Hormones for Dependent Children
• Physical and Occupational Therapy beginning when you need 30 visits or more in a calendar year, pre-certification required after 30th visit.

If an emergency requires hospitalization, there may be no time to contact the UM Company before you are admitted. If this happens, the UM Company must be notified of the hospital admission within 48 hours. You, your Health Care Provider, the hospital, a family member or friend can make that phone call to the UM Company. This will enable the UM Company to assist you with your discharge plans, determine the need for continued medical services, and/or advise your providers of the various benefits available for you and offer recommendations, options and alternatives for your continued care.

When you are receiving medical services in a hospital or other inpatient facility, the UM Company will monitor your stay by contacting your Providers to assure that continuation of medical services in the facility is Medically Necessary, and to help coordinate your care with benefits available under the Plan.

Concurrent review may include such services as coordinating home health care or durable medical equipment, assisting with discharge plans, determining the need for continued medical services; and/or, advising your Providers of various options and alternatives for your care available under this Plan.

You or your eligible Dependent may be denied payment if services or treatment are found to be not medically necessary or not covered under the Plan.

At any time during the review process, you may be asked by the UM Company to obtain a an additional opinion about a proposed service to help determine if the service is Medically Necessary, or if an alternative effective approach to your or your Dependent’s care management exists.

Claims for services or supplies that have not been reviewed under the Plan’s Precertification, Concurrent Review, or Second and Third Opinion Programs may be subject to retrospective review to determine if they are Medically Necessary. If the Plan receives a determination from a UM Company that services or supplies were not Medically Necessary, the Plan may deny benefits.

Case Management is a voluntary process, administered by the UM Company. Case Management services are particularly helpful when you or your eligible Dependent needs complex, costly, and/or high-technology services, and when assistance is needed to guide patients through a maze of potential Providers.

You, your eligible Dependent, or Provider can request Case Management services by calling the UM Company. However, the UM Company will actively searching for those cases where you or your eligible Dependent could benefit from Case Management services, and it will initiate Case Management services automatically.

The Case Manager of the UM Company will work directly with your Provider, Hospital, and/or other facility to review proposed treatment plans and to assist in coordinating services, locating in-network providers, and providing other services as needed. From time to time, the Case Manager may confer with your Provider, and may contact you or your Dependent to assist in making plans for continued care and to assist you or your Dependent in obtaining information to facilitate those services.

You may call the Case Manager of the Utilization Management Company or the Fund Office at any time to ask questions or obtain information.

You may request an appeal of any adverse review decision made during the precertification, concurrent review, retrospective review, Case Management or second opinion review process.

The Hospice Benefit covers 100% of Reasonable and Customary charges for the services outlined in the following chart up to a lifetime maximum shown in the Schedule of Benefits.

To be eligible for hospice benefits, the hospice care must be rendered as part of a Hospice Care Program by a licensed Hospice Care Agency. Before a covered individual enrolls in a Hospice Care Program, they should contact the Fund Office to verify that services will be covered under this benefit.

SCHEDULE OF BENEFITS FOR HOSPICE SERVICES

Home Hospice Care - Allows patient to receive care in his or her own home.

Services and equipment covered at 100% include:

• Physician services,
• Physical, respiratory and occupational therapies,
• Drugs, medications and medical supplies when provided under the Hospice Care Program through Hospice Care Agency,
• Private duty nursing services by a Registered Nurse or Licensed Practical Nurse, if certified by a Physician,
• Rental of Durable Medical Equipment (DME), as described in Appendix A, and
• Oxygen and rental of related equipment.

Outpatient Hospice Care – Care that you receive in a licensed medical facility. After you receive treatment, you return to your home.

Services covered at 100% include:

• Physician services,
• Laboratory, x-ray and diagnostic testing, and
• Ambulance service or alternative types of transportation.

Inpatient Hospice Care – Care received while you are an admitted patient in a Hospital or Hospice facility.

Services covered at 100% include:

• Room and board which may include overnight visits by family,
• Nursing services,
• All other related Hospital expenses,
• Physician services, and
• Ambulance service or alternative types of transportation.

Other Services – In addition to the services outlined above, certain other services for you and your family are also covered.

Services covered at 100% include:

• Visits by a licensed social worker to evaluate the social, psychological and family problems related to the terminal illness. In addition, this professional will help develop a plan to assist in resolving these problems;
• Emotional support services to help relieve stress, cope with the anticipated loss, complete unfinished family business and maintain the patient in the most appropriate environment;
• Special incidental services for the patient, such as special dietary requirements, transportation between home and other sites of care; and
• Bereavement counseling for the immediate family following the death of the Hospice patient. (Coverage is limited to six visits)

If coverage terminates for any reason while benefits are being paid under the Comprehensive Major Medical Benefit, benefits may be extended if:

• The eligible person was Totally Disabled on the date coverage terminated,
• Expenses were incurred in connection with the Injury or Sickness causing such Total Disability, and
• The total maximum amount of benefits, if any, have not been paid.

Benefits will continue until the earliest of:

• The end of the calendar year following the calendar year in which coverage terminated,
• The date that the total amount of benefits have been paid, or
• The date that you are no longer Totally Disabled.

No benefits will be payable after the above date for that disability nor will any benefits be payable with respect to separate disabilities beginning after coverage terminated.

This Plan provides coverage for certain Preventive Services as required by the Patient Protection and Affordable Care Act of 2010 (ACA). Coverage is provided on an in-network basis, with no cost-sharing (for example, no deductibles, coinsurance, or copayments), and on an out-of-network basis, subject to cost-sharing, for the following services:

1. Services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations,
2. Services described in the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC), and
3. Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures guidelines.

In-network preventive services that are identified by the Plan as part of the ACA guidelines will be covered with no cost-sharing by the Participant or Dependent. This means that the service will be covered at 100% of the Plan’s Reasonable and Customary Charge, with no coinsurance, copay, or deductible. Out-of-network preventive services that are identified by the Plan as part of the ACA guidelines will be covered at 70% of the Reasonable and Customary Charge.

In some cases, federal guidelines are unclear about which preventive benefits must be covered under the ACA. In that case, the Trustees will determine whether a particular benefit is covered under this Preventive Services benefit.

1. Physical Examination Benefit: The Plan will cover the expense related to a routine physical examination (including routine OB/GYN exams) by a Physician. Routine physical examinations include baseline examinations, periodic examinations and those examinations performed due to a relevant family history.
2. Testing for asbestos/spirometry on Participants and Dependents will only be covered under the annual physical examination benefit charges for respiratory clearance or as required by federal law. The asbestos/spirometry tests must be performed in conjunction with an annual physical.
3. Physical examinations that are for purposes of meeting employment requirements will be covered by the Plan, but only if they are performed as part of the in-network annual physical examination. Such examinations will be subject to the benefit limitations listed on the Schedule of Benefits for wellness expenses and will be subject to the provisions governing the Plan’s use and disclosure of your protected health information. These examinations must be performed in conjunction with an in-network annual physical examination.
4. Your Eligible Dependents through the age of 21 are entitled to coverage for well-child care benefits when provided by a network provider. Well-child care benefits include: a) Physical examinations; and b) Well-Child Required Immunizations, as recommended by the American Academy of Pediatrics.
5. The Plan also covers the immunization of girls and young women, ages 13 to 33, and boys ages 11 and 12, to prevent the human papillomavirus (HPV), a virus that can cause cervical cancer and other diseases.
6. Please note that Well-Child Required Immunization charges will be reimbursed when the service is rendered by a local Public Health Department but only after proof of payment is submitted to the Fund Office.
7. Non-preventive Services are not covered without Cost-Sharing: The plan will impose cost-sharing for treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
8. Preventive Services for Dependents: All covered participants and Dependents are eligible to obtain, all required in-network (without cost sharing) and out-of-network (with cost-sharing) preventive services applicable to them (e.g., for their age group). This includes ACA-required pregnancy-related preventive services and well woman visits, which must be provided to Dependent Children (up to the end of the month that they turn age 26) where an attending provider determines that the services are age and developmentally appropriate.

The Plan covers certain Preventive Services required by ACA. Coverage of these services is provided by PPO providers, with no cost-sharing (e.g., no deductibles, coinsurance, or copayments) and by non-PPO providers, with cost-sharing, for the following services:

1. Services described in the United States Preventive Services Task Force (USPSTF) A and B recommendations;
2. Services described in the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC);
3. Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures guidelines; and
4. With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in certain recommendations of the USPSTF.

In-network preventive services that are identified by the Plan as part of the ACA guidelines will be covered with no cost-sharing by you or your Dependent. This means that the service will be covered at 100% of the Plan’s Reasonable and Customary Charge, with no coinsurance, copay, or deductible. If you receive preventive services from a non-PPO provider, you will not be eligible for coverage under this Preventive Services benefit.

In some cases, federal guidelines are unclear about which preventive benefits must be covered under the ACA. In that case, the Trustees will determine whether a particular benefit is covered under this Preventive Services benefit.

1. Abdominal aortic aneurysm one-time screening for men ages 65-75 who have ever smoked.
2. Unhealthy alcohol use screening and counseling: screening and behavioral counseling interventions to reduce unhealthy alcohol use by adults ages 18 and older, including pregnant women, in primary care settings.
3. Low-dose aspirin to prevent cardiovascular disease and colorectal cancer when prescribed by a health care provider, in adults ages 50 to 59 years who have a 10% or greater 10-year cardiovascular disease (CVD) risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. A prescription must be submitted in accordance with plan rules.
4. Blood pressure screening for all adults age 18 and older. Blood pressure screening is not payable as a separate claim, as it is included in the payment for a Physician visit. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
5. Cholesterol screening (Lipid Disorders Screening) for adults aged 40-75.
6. Colorectal cancer screening using stool-based methods (such as fecal occult blood testing), sigmoidoscopy, or colonoscopy, in adults beginning at age 50 and continuing until age 75. The test methodology must be medically appropriate for the patient. The Plan will not impose cost sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. The plan will not impose cost sharing with respect to the following services when these services are provided in connection with a screening colonoscopy and the attending provider determines the service is medically appropriate: bowel preparation medications, anesthesia services, a pre-procedure specialist consultation, or a pathology exam on a polyp biopsy. The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49.
7. Depression screening for adults.
8. Type 2 Diabetes in adults aged 40 to 70 who are overweight or obese, as part of cardiovascular risk assessment, with intensive behavioral counseling for those with abnormal blood glucose to promote a healthful diet and physical activity.
9. Healthy diet and physical activity behavioral counseling for adults with cardiovascular disease risk factors.
10. Screening for hepatitis B virus infection in adults at high risk for infection.
11. Screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.
12. HIV screening for all adolescents and adults ages 15 to 65 and for younger and older individuals at increased risk.
13. Annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 20 pack/year smoking history and currently smoke or have quit within the past 15 years.
14. Obesity screening and intensive counseling and behavioral interventions to promote sustained weight loss for adults with a body mass index of 30 kg/m2 or higher.
15. Sexually Transmitted Infection (STI) behavioral counseling for adults at higher risk.
16. Syphilis screening for all adults at increased risk of infection.
17. Tobacco Use screening for all adults and cessation interventions for tobacco users.
18. Counseling for young adults to age 24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.
19. Exercise or physical therapy to prevent falls in community-dwelling adults age 65 years or older who are at increased risk for falls.
20. Low to moderate dose statin for the prevention of cardiovascular disease (CVD) events and mortality in adults ages 40 to 75 years with one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking), and a calculated 10-year risk of a cardiovascular event of 10% or greater, when identified as meeting these factors by their treating physician.
21. Screening for latent tuberculosis infection in populations at increased risk.
22. Preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

If you wish, you may elect to cease coverage for Optical Benefits under the Plan for yourself of your Eligible Dependents at any time during the Plan Year by providing written notice to the Fund Office of your intention to cease coverage of Optical Benefits. Cessation of Optical Benefit coverage will be effective as of the first day of the following month after the Fund Office receives such notice from you.

If you previously elected to cease coverage for Optical Benefits under the Plan, you may reinstate coverage by providing written notice to the Fund Office. Reinstatement of Optical Benefit coverage will be effective as of the first day of the Plan Year following the date the Fund Office receives such written notice from you.

The retail pharmacy network is offered through Express Scripts, Inc. (“ESI”) national network of pharmacies. To find out whether a particular pharmacy is a participating network pharmacy, call an ESI customer service representative at 1-866-544-2916 or visit the ESI website at www.express-scripts.com. Members are able to obtain both 30 day acute medication as well as maintenance medications for 90 days through retail pharmacies. For long-term medications, it is encouraged to utilize the mail order facility.

Acute medications are usually prescribed to treat acute conditions of a short-term or temporary nature such as an infection or the flu. They are limited to a 30-day supply.

To fill this type of prescription simply:

1. Take the prescription to a participating ESI network pharmacy,
2. Identify yourself as an eligible Local 73 Welfare Fund Participant (for instance, by showing your prescription drug plan card), and
3. Pay the required copayment and any deductible as shown in the Schedule of Benefits on page 4 and you will receive the prescription drug with no additional paperwork or charge.

If you use a non-participating network pharmacy, you must pay for the entire cost of the medication when the prescription is filled. You must then complete an ESI Claim Form and submit it along with the original prescription receipt to the ESI Claims Department. You will be reimbursed at the negotiated pharmacy rate less the appropriate copayment.

You may obtain an ESI Claim Form by calling ESI at 1-866-544-2916 visiting their website at www.express-scripts.com, or contacting the Fund Office.

If your Physician has prescribed a maintenance medication (long-term treatment), you should have your prescription filled by the mail order program. 

To fill a maintenance prescription, simply:

1. Obtain a new written prescription for each covered medication. OptumRx can only dispense the amount of medication your Physician has prescribed up to a 90-day supply. Show your Physician the material attached to the Prescription Drug Benefits brochure to help him or her write a prescription for this program.

2. Complete the Mail Service Order Form/Patient Profile.

3. Mail the written prescription, the profile, the order form and your copayment to ESI at the address on ESI’s order form. The copayment for each prescription order is shown in the Schedule of Benefits on page 4. If you need assistance determining the copayment amount, call ESI at 1-866-544-2916 or visit their website at www.express-scripts.com.

You will receive refill labels (if refills remain) and a new order form in your prescription package. To obtain a refill order, simply affix the refill label to the back of the order form and send it to ESI. If you have no refills remaining or if your prescription has expired, contact your Physician for a new written prescription to send to ESI.

If you have a question about your prescription, call ESI at 1-866-544-2916 to speak with a Customer Service Representative.

Benefits are not payable under Prescription Drug Benefits for:

1. Medicines or drugs obtainable without a Physician’s prescription, except insulin,
     
2. Medications used for cosmetic purposes, including Vitamin A derivatives (retinoids) for dermatological use (i.e. Retin A, Renova),
    
3. Vitamins and nutritional supplements,
    
4. Smoking deterrents (except as provided under the Wellness Benefit),
    
5. Fertility drugs (except as provided under the Infertility Benefit),
    
6. Viagra and other erectile dysfunction drugs. However, Prescription Drugs prescribed by the treating Physician to treat erectile dysfunction will be covered if:
    
   • You have or had one of the following:  Prostate and testicular cancer, disorders of the prostate (including prostatic enlargemetn and hyperplasia), low testosterone level, Diabetes, Crohn’s disease, Peripheral neuropathy, Hypertension and other vascular conditions, or erectile dysfunction as a side effect from another prescription medication or combination of medications that can be verified as a side effect, which is listed in the Physician’s Desk Reference; and
      
   • You provide the following information: A letter of Medical Necessity from your attending Physician, complete diagnosis, and name and dosage of medication prescribed.
     
     Re-verification from the Physician is required every twelve-month period.
7. Anabolic steroids,
     
8. Weight control or drugs or anorexiants, except those used for treatment of Children with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) or individuals with narcolepsy,
    
9. Serum allergy antigen solutions, and
    
10. Existing and new drugs that are not uniformly and professionally endorsed by the general medical community for prescription in the course of standard medical care, including existing and new drugs that are experimental in nature.
    
    
11. Gene therapy prescription drugs regardless of where such drugs are administered.

If you or your Eligible Dependents are eligible for and enroll in Medicare Part D, the Plan will continue to provide you with the Prescription Drug Benefits and will not coordinate benefits with Medicare Part D benefits.

If you or your Eligible Dependent are eligible for but do not enroll in Medicare Part D, the Plan will continue to provide your Prescription Drug Benefits.

Your eligibility for the Weekly Accident and Sickness Disability Benefit ends when your eligibility for all other Plan benefits ends, as indicated in the Eligibility Chart.

If you lose your eligibility for the Weekly Accident and Sickness Disability Benefit, your eligibility will be reinstated when you meet the initial eligibility requirements as set forth in Your Initial Eligibility.

This section describes the procedures followed by the Sheet Metal Workers’ Local 73 Welfare Fund Plan C (Bargained) for Active Members in making internal claim decisions and reviewing appeals of denied claims. These procedures apply to claims for medical, mental health, substance abuse, employee assistance program (EAP), vision, hearing, wellness, prescription drug, disability, death, and accidental death and dismemberment benefits.

The Plan’s internal claims and appeal procedures are designed to provide you with full, fair, and fast claim review and so that Plan provisions are applied consistently with respect to you and other similarly situated participants and Dependents. With respect to health benefit claims, the Plan must consult with a health care professional with appropriate training and experience when reviewing an adverse benefit determination that is based in whole or in part on a medical judgment (such as a determination that a service is not Medically Necessary or appropriate, or is Experimental or Investigational).

The internal claims process pertains to determinations made by the appropriate Claims Administrator about whether a request for benefits (known as an initial “claim”) is payable. If the appropriate Claims Administrator denies your initial claim for benefits (known as an “adverse benefit determination”), you have the right to appeal the denied claim under the Plan’s internal appeals process.

For health benefits, you may be able to seek an external review with an Independent Review Organization (IRO) that conducts reviews of adverse benefit determinations either (i) after the Plan’s internal appeals process has been exhausted, or (ii) under limited circumstances before the Plan’s internal claims and appeals process have been exhausted.

Claims Administrator(s)

The Plan Administrator has delegated responsibility for initial claims decisions to the following companies/organizations:

Medical Post-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162, 1-708-449-7373 | www.sm73funds.org

Urgent Care, Concurrent and Pre-Service Medical Claims

Blue Cross Blue Shield Medical Services Advisory for Hospital admissions/inpatient medical services | P.O. Box 805107,Chicago, IL 60680-4112 | 1-800-255-5192, www.bcbsil.com;

Blue Cross Blue Shield Behavioral Health Services | P.O. Box 805107, Chicago, IL 60680-4112 | 1-800-851-7498 | www.bcbsil.com

Dental Benefit Claims

Delta Dental of Illinois | 1-800-523-1743 | https://www.deltadentalil.com/

All required pre-admission authorization

Valenz Care Medical Services Advisory | 1-800-367-1934 | Fax: 1-312-236-8547 | 23048 N. 15th Ave. Phoenix, AZ 85027 | www.medicalcost.com

Urgent Care Concurrent and Pre-Service Claims may require pre-admission authorization. Refer to the Utilization Management section at page 29 for additional information.

Valenz Care Medical Services Advisory | 1-800-367-1934 | Fax: 1-312-236-8547 | 23048 N. 15th Ave. Phoenix, AZ 85027 | www.medicalcost.com

Pre-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Post-Service Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Pre-Service Claims for prescription drugs

Express Scripts (ESI) | 1-866-544-2916 | www.express-scripts.com

Pre-Service Claims for vision benefits

EyeMed | PO Box 8504, Cincinnati, OH 45040-7111 | 1-866-723-0514 | www.eyemedvisioncare.com

Post-Service hearing benefit claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Weekly Disability Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Weekly Maternity Benefit Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Death Benefit Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

Accidental Death and Dismemberment Claims

Plan Administrator | 4530 Roosevelt Road, Hillside, IL 60162 | 1-708-449-7373 | www.sm73funds.org

A claim is a request for a Plan benefit made by you or your covered Dependent (also referred to as “claimant”) or your authorized representative in accordance with the Plan’s reasonable claims procedures.

Health Benefit Claims

Health benefit claims can be filed for medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits.

There are four categories of health claims as described below:

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) - A Pre-Service Claim is a claim for a benefit that requires approval of the benefit (in whole or in part) before health care is obtained. Under this Plan, prior approval is required for medical, mental health, substance abuse, EAP, and prescription drug benefits.
• Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) – An Urgent Care Claim is any Pre-Service Claim for health care treatment that (i) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or (ii) in the opinion of the claimant’s attending health care provider with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. However, the Plan will not deny benefits for these procedures or services if it is not possible for the claimant to obtain the pre-approval, or the pre-approval process would jeopardize the claimant’s life or health.
• Concurrent Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits) - A Concurrent Claim is a claim that is reconsidered after an initial approval has been made and results in a reduced or terminated benefit. Also, a Concurrent Claim can pertain to a request for an extension of a previously approved treatment or service.
• Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits) - A Post-Service Claim is a request for benefits under the Plan that is not a Pre-Service Claim. Post-Service Claims are requests that involve only the payment or reimbursement of the cost of the care that has already been provided. A standard paper claim or electronic bill submitted for payment after services have been provided are examples of a Post-Service Claim. A claim regarding the rescission of coverage will be considered to be a Post-Service Claim.

Weekly Disability Benefit Claims

A Weekly Disability Claim is a request for benefits during a period of disability. Weekly Disability Claims are filed after a participant suffers a disability and benefits are paid if the Claims Administrator determines that the participant has suffered a disability as defined by the terms of the Plan.

Weekly Maternity Benefit Claims

A Weekly Maternity Benefit Claim is a request for benefits from an active female member following a live birth. Weekly Maternity Benefit Claims are filed after an active female member gives birth and benefits are paid if the Claims Administrator determines that the member is eligible for such benefits under the terms of the Plan.

Accidental Death and Dismemberment Insurance/Death Benefit Claims

An Accidental Death and Dismemberment Insurance/Death Benefit Claim is a request by a designated beneficiary for benefit payment following the death of the participant or the death of a covered Dependent. A claim for Accidental Death and Dismemberment Benefits may also be filed by a participant after he or she has provided the Plan with proof of a bodily loss.

An initial claim must include the following elements to trigger the Plan’s internal claims process:

• Be written or electronically submitted (oral communication is acceptable only for Urgent Care Claims);
• Be received by the Plan Administrator or Claims Administrator (as applicable);
• Name a specific individual participant and his/her Social Security Number;
• Name a specific claimant and his/her date of birth;
• Name a specific medical condition or symptom;
• Provide a description and date of a specific treatment, service or product for which approval or payment is requested (must include an itemized detail of charges);
• Identify the provider’s name, address, phone number, professional degree or license, and federal tax identification number (TIN); and
• When another plan is primary payer, include a copy of the other Plan’s Explanation of Benefits (EOB) statement along with the submitted claim.

A request is not a claim if it is:

• Not made in accordance with the Plan’s benefit claims filing procedures described in this section;
• Made by someone other than you, your covered Dependent, or your (or your covered Dependent’s) authorized representative;
• Made by a person who will not identify himself or herself (anonymous);
• A casual inquiry about benefits such as verification of whether a service/item is a covered benefit or the estimated allowed cost for a service;
• A request for prior approval where prior approval is not required by the Plan;
• An eligibility inquiry that does not request benefits. However, if a benefit claim is denied on the grounds of lack of eligibility, it is treated as an adverse benefit determination and the individual will be notified of the decision and allowed to file an appeal;
• The presentation of a prescription to a retail pharmacy or mail order pharmacy that the pharmacy denies at the point of sale. After the denial by the pharmacy, you may file a claim with the Plan;
• A request for an eye exam, lenses, frames or contact lenses that is denied at the point of sale from the Plan’s contracted in-network vision provider(s). After the denial by the vision service provider, you may file a claim with the Plan.

If you submit a claim that is not complete or lacks required supporting documents, the Plan Administrator or Claims Administrator, as applicable, will notify you about what information is necessary to complete the claim. This does not apply to simple inquiries about the Plan’s provisions that are unrelated to any specific benefit claim or which relate to proposed or anticipated treatment or services that do not require prior approval.

Claim Filing Deadline

There is a two-year period beginning with the date you incur charges for medical services (including wellness, hearing, optical services and accident and sickness) during which you must file a claim for reimbursement of the charges.

There is a one-year period beginning with the date you incur charges for prescription drug claims during which you must file a claim for reimbursement of the charges.

If you file a claim after this two-year period, or one-year period in the case of prescription drug benefits, no reimbursement will be made.

The time period for making a decision on an initial claim request starts as soon as the claim is received by the appropriate Claims Administrator, provided it is filed in accordance with the Plan’s reasonable filing procedures, regardless of whether the Plan has all of the information necessary to decide the claim. A claim may be filed by you, your covered Dependent, an authorized representative, or by a network provider. In the event a claim is filed by a provider, the provider will not automatically be considered to be your authorized representative.

Health Care Claims – Decision Timeframes

The Plan will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection with the claim. Such evidence will be provided as soon as possible (and sufficiently in advance of the date on which notice of an adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date. Additionally, before the Plan issues an adverse benefit determination on review based on a new or additional rationale, you will be provided, free of charge, with the rationale. The rationale will be provided as soon as possible (and sufficiently in advance of the date on which notice of adverse benefit determination on review is required to be provided) to give you a reasonable opportunity to respond prior to that date.

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits)
  
  Claims for Pre-Service (that are not for Urgent Care) will be decided no later than fifteen (15) days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the initial fifteen (15) day period whether the claim was approved or denied (in whole or in part).
  
  The time for deciding the claim may be extended by up to fifteen (15) days due to circumstances beyond the Claims Administrator’s control (e.g., inability of a medical reviewer to meet a deadline); provided you are given written (or electronic, if a applicable) notification before the expiration of the initial fifteen (15) day determination period.
  
  If you improperly file a Pre-Service Claim, the Claims Administrator will notify you in writing (or electronically, as applicable) as soon as possible, but in no event later than five (5) days after receiving the claim. The notice will describe the proper procedures for filing a Pre-Service Claim. Thereafter, you must re-file a claim to begin the Pre-Service Claim determination process.
  
  If a claim cannot be processed due to insufficient information, the Claims Administrator will notify you in writing (or electronically, as applicable) about what specific information is needed before the expiration of the initial fifteen (15) day determination period. Thereafter, you will have 45 days following your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision is suspended. The claim decision deadline is suspended until the earlier of 45 days or the date the Claims Administrator receives your response to the request for information. The Claims Administrator then has fifteen (15) days to make a decision and notify you in writing (or electronically, as applicable).
• Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits)
  
  In the case of an Urgent Care Claim, if a health care professional with knowledge of your medical condition determines that a claim constitutes an Urgent Care Claim, the health care professional will be considered by the Plan to be your authorized representative bypassing the need for completion of the Plan’s written authorized representative form.
  
  The appropriate Claims Administrator will decide claims for Urgent Care as soon as possible, but in no event later than 72 hours after receipt of the claim. The Claims Administrator will orally communicate its decision telephonically to you. The determination will also be confirmed in writing (or electronically, as applicable) no later than three (3) days after the oral notification.
  
  If you improperly file an Urgent Care Claim, the Claims Administrator will notify you, as soon as possible, but in no event later than 24 hours after receiving the claim. The written (or electronic, as applicable) notice will describe the proper procedures for filing an Urgent Care Claim. Thereafter, you must re-file a claim to begin the Urgent Care Claim determination process.
  
  If a claim cannot be processed due to insufficient information, the Claims Administrator will provide you with a written (or electronic, as applicable) notification about what specific information is needed as soon as possible and no later than 24 hours after receipt of the claim. Thereafter, you will have not less than 48 hours following receipt of the notice to supply the additional information. If you do not provide the information during the period, the claim will be denied (i.e., an adverse benefit determination). Written (or electronic, as applicable) notice of the decision will be provided to you no later than 48 hours after the Claims Administrator receives the specific information or the end or the period given for you to provide this information, whichever is earlier.
• Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug claims)
  
  Claims for Post-Service treatments or services will be decided no later than 30 days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the 30-day initial determination period if the claim is denied (in whole or in part).
  
  The time for deciding the claim may be extended by fifteen (15) days due to circumstances beyond the Claim Administrator’s control (e.g., inability of a medical reviewer to meet a deadline); provided you are given written (or electronic, as applicable) notification before the expiration of the initial 30-day determination period.
  
  If a claim cannot be processed due to insufficient information, the Claim Administrator will notify you in writing (or electronically, as applicable) about what information is needed before the expiration of the initial 30-day determination period. Thereafter, you will have 45 days after your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision on the claim is suspended. The claim decision deadline is suspended until the earlier of 45 days or until the date the Claims Administrator receives your written response to the request for information. The Claims Administrator then has fifteen (15) days to make a decision and notify you in writing (or electronically, as applicable).

Weekly Disability Claims and Weekly Maternity Benefit Claims – Decision TimeframesM/i>

Claims for Weekly Disability benefits and Weekly Maternity Benefit Claims will be decided no later than 45 days after receipt by the appropriate Claims Administrator. You will be notified in writing (or electronically, as applicable) within the 45-day initial determination period if the claim is denied (in whole or in part).

The time for deciding the claim may be extended by 30 days due to circumstances beyond the Claim Administrator’s control; provided you are given written (or electronic, as applicable) notification before the expiration of the initial 45-day determination period. A decision will be made within 30 days of the date the Claims Administrator notifies you of the delay. The period for making a decision may be delayed an additional 30 days if due to matters beyond the control of the Claims Administrator, provided you are notified of the additional delay, before the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision.

If a claim cannot be processed due to insufficient information, the Claims Administrator will notify you in writing (or electronically, as applicable) about what information is needed before the expiration of the initial 45-day determination period. Thereafter, you will have 45 days after your receipt of the notice to supply the additional information. If you do not provide the information during the 45-day period, the claim will be denied (i.e., an adverse benefit determination). During the period in which you are permitted to supply additional information, the normal period for making a decision on the claim is suspended. The claim decision deadline is suspended until the earlier of 45 days or until the date the Claims Administrator receives your written response to the request for information. The Claims Administrator then has 30 days to make a decision and notify you in writing (or electronically, as applicable).

Accidental Death and Dismemberment Insurance or Death Benefit – Decision Timeframe

Generally, you will receive written (or electronic, as applicable) notice of a decision on your initial claim within 90 days of receipt of your claim by the Claims Administrator. If additional time or information is required to make a determination on your claim (for reasons beyond the control of the Claims Administrator, you will be notified in writing (or electronically, as applicable) within the initial 90-day determination period. The 90-day period may be extended up to an additional 90 days.

Notice of Adverse Benefit Determination

If the Claims Administrator denies your initial claim, in whole or in part, you will be given a notice about the denial (known as a “notice of adverse benefit determination”). The notice of adverse benefit determination will be given to you in writing (or electronically, as applicable) within the timeframe required to make a decision on a particular type of claim. The notice of adverse determination must:

• Identify the claim involved (and for health benefit claims – include the date of service, health care provider, claim amount if applicable, denial code and its corresponding meaning);
• Give the specific reason(s) for the denial (and for health benefit claims - include a statement that the claimant has the right to request the applicable diagnosis and treatment code and their corresponding meanings; however such a request is not considered to be a request for an internal appeal or external review for health benefit claims);
• If the denial is based on a Plan standard that was used in denying the claim, a description of such standard.
• Reference the specific Plan provision(s) on which the denial is based;
• Describe any additional material or information needed to perfect the claim and an explanation of why such added information is necessary;
• With respect to health, weekly disability benefit,and weekly maternity benefit claims, the opportunity, upon request and without charge, reasonable access to and copies of all documents, records and other information relevant to an initial claim for benefits;
• Provide an explanation of the Plan’s internal appeal and external review for health benefit claims processes along with time limits and information about how to initiate an appeal and an external review for health benefit claims;
• Contain a statement that you have the right to bring civil action under ERISA section 502(a) following an appeal;
• With respect to health, weekly disability benefit,and weekly maternity benefit claims, if the denial was based on an internal rule, guideline, protocol, standard, or similar criteria, a statement will be provided that a copy of such rule, guideline, protocol or similar criteria that was relied upon will provided to you free-of-charge upon request;
• If the denial of a health , weekly disability, or weekly maternity benefit claim was based on Medical Necessity, Experimental treatment, or similar exclusion or limit, a statement will be provided that an explanation regarding the scientific or clinical judgment for the denial will be provided to you free-of-charge upon request;
• With respect to a weekly disability claim, a discussion of the Plan’s initial claim discussion, including the basis for disagreeing with: (i) any disability determination by the Social Security Administration (SSA); (ii) the views of a treating health care professional or vocational expert evaluating the claimant, to the extent the Plan does not follow such views as presented by the claimant; or (iii) the views of medical professionals or vocational experts whose advice was obtained on behalf of the Plan, regardless of whether or not the advice was relied upon by the Plan in making an adverse benefit determination; and
• For Urgent Care health benefit claims, the notice will describe the expedited internal appeal and external review processes applicable to Urgent Care Claims. In addition, the required determination may be provided orally and followed with written (or electronic, as applicable) notification; and
• With respect to health benefit claims, provide information about the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist you with the Plan’s internal claims and appeal processes as well as with the external review process.

Notice of Approval of Pre-Service and Urgent Care Claims

If a Pre-Service claim is approved, you will receive written (or electronic, as applicable) notice within fifteen (15) days of the appropriate Claims Administrator’s receipt of the claim. Notice of Approval of an Urgent Care Claim will be provided in writing (or electronically, as applicable) to you within the applicable timeframe after the Claims Administrator’s receipt of the claim.

Internal Appeal Request Deadline

• Health Care Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits) If an initial health care claim is denied (in whole or in part) and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an internal appeal. You have 180 calendar days following receipt of a notice of adverse benefit determination to submit a written request for an internal appeal. The Plan will not accept appeals filed after this 180-day period. Under limited circumstances, explained below in the section on External Review, you may bypass the Plan’s internal claims and/or appeal processes and file a request for an external review.
• Weekly Disability Claims and Weekly Maternity Benefit Claims) If an initial Weekly Disability Claim or Weekly Maternity Benefit Claim is denied and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an internal appeal. You have 180 calendar days following your receipt of an initial notice of adverse benefit determination to submit a written request for an internal appeal. The Plan will not accept appeals filed after this 180-day period.
• Accidental Death and Dismemberment Insurance/Death Benefits) If an initial accidental death and dismemberment/death benefit claim is denied and you disagree with the Claims Administrator’s decision, you or your authorized representative may request an appeal. You have 60 calendar days following your receipt of an initial notice of adverse benefit determination to submit a written request for an appeal. The Plan will not accept appeal requests filed after this 60-day period.

Appeal Procedures

To file an internal appeal, you must submit a written statement to the Plan at the following address:

Board of Trustees c/o Benefits Appeal Committee
Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members
4530 Roosevelt Road
Hillside, IL 60162
1-708-449-7373
www.sm73funds.org

Appeal requests involving Urgent Care Claims may be made orally by calling the Board of Trustees at the telephone number listed above.

Your request for an internal appeal must include the specific reason(s) why you believe the initial claim denial was improper. You may submit any document that you feel is appropriate to the internal appeal determination, as well as submitting any written issues and comments.

As a part of its internal appeals process, the Plan will provide you with:

• The opportunity, upon request and without charge, reasonable access to and copies of all documents, records and other information relevant to your initial claim for benefits;
• The opportunity to submit to the Plan written comments, documents, records and other information relating to your initial claim for benefits;
• With respect to health, weekly disability benefit and weekly maternity benefit appeals, the Plan will automatically provide you with a reasonable opportunity to respond to new information by presenting written evidence and testimony;
• A full and fair review by the Plan that takes into account all comments, documents, records and other information submitted by you, without regard to whether such information was submitted or considered in the initial claim determination;
• With respect to health, weekly disability benefit and weekly maternity benefit claims, the Plan will automatically provide you free-of-charge, with any new or additional evidence or rationale considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection with the denied initial claim. The Plan will automatically provide you with any new or additional evidence or rationale as soon as possible once it becomes available to the Plan and sufficiently in advance of the date on which notice of an adverse determination on appeal is scheduled to be provided to you. New or additional evidence or rationale will be provided to you so that you have a reasonable opportunity, sufficiently in advance of the date on which a notice of an adverse benefit determination upon appeal is required to be provided, to respond to the Plan regarding such evidence. If the new or additional evidence or rationale is received by the Plan so late that it would be impossible to provide it to you in time for you to have a reasonable opportunity to respond, then the period for providing a notice of a final adverse benefit determination will be delayed (tolled) until you have had a reasonable opportunity to respond. After you respond (or do not respond after having a reasonable opportunity to do so), the Plan (acting in a reasonable and prompt manner) will notify you of its benefit determination upon appeal as soon as it can provide a notice of determination, taking into account any medical exigencies;
• A review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate fiduciary or fiduciaries of the Plan who is neither the individual who made the initial adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual;
• With respect to health, weekly disability benefit and weekly maternity benefit claims appeals, continued coverage during the pendency of the appeal process; and
• In deciding an appeal of any adverse benefit determination regarding a health benefit claim that is based in whole or in part on a medical judgment, including whether a particular treatment, drug or other item is Experimental, Investigational, not Medically Necessary or appropriate, the fiduciary or fiduciaries will:
  • Consult with a health care professional who has appropriate experience in the field of medicine involved in the medical judgment; and
  • Is neither an individual who was consulted in connection with the initial adverse benefit determination that is the subject of the appeal nor the subordinate of any such individual; and
  • The Plan will provide, upon request, the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with an adverse benefit determination without regard to whether the advice was relied upon in making the benefit determination.

Appeal Determination Timeframes

Health Care Claims

• Pre-Service Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits).A determination will be made and a written (or electronic, as applicable) notice regarding the appeal will be sent to you within 30 days from the date your written request for an appeal is received by the Plan. A plan administrator may extend the 30-day period due to special circumstances (e.g., the need to hold a hearing) if the claimant is notified of such extension within the initial 30-day period. The extension cannot extend beyond 60 days from the end of the initial 30-day determination period.
  • Urgent Care Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits). This is an expedited internal appeals process under which a written notice regarding a decision on the approval or denial of the expedited internal appeal will be sent to you no later than within 72 hours of the Plan’s receipt of your (oral or written) request for appeal. If your situation involves an urgent medical condition, which the timeframe for completing an expedited internal appeal would seriously jeopardize your ability to regain maximum function, and the claim involves a medical judgment or a rescission of coverage, you may seek an expedited external review at the same time that you request an expedited internal appeal (you must seek both).
  • Concurrent Claims (applicable to medical, mental health, substance abuse, EAP, and prescription drug benefits). You may request an internal appeal of a Concurrent Claim by submitting the request orally (for an Urgent Care Claim) or in writing to the Board of Trustees. A determination will be made on the internal appeal and you will be notified as soon as possible before the benefit is reduced or treatment is terminated.
  • Post-Service Claims (applicable to medical, mental health, substance abuse, EAP, dental, vision, hearing, wellness, and prescription drug benefits). A written (or electronic, as applicable) notice regarding the Plan’s determination on the internal appeal will be sent to you within 60 days from the date your written request for an appeal is received by the Plan. A plan administrator may extend the 60-day period due to special circumstances (e.g., the need to hold a hearing) if the claimant is notified of such extension within the initial 60-day period. The extension cannot extend beyond 60 days from the end of the initial 60-day determination period.
  • The Plan will make an appeal determination no later than the date of the Board of Trustees’ meeting immediately following the Plan’s receipt of your written request for an internal appeal, unless the request for an internal appeal review is filed within 30 calendar days preceding the date of such meeting. In such case, an appeal determination will be made no later than the date of the second meeting following the Plan’s receipt of your written request for an appeal. If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, an appeal determination will be rendered not later than the third meeting following the Plan’s receipt of your written request for review. If such an extension is necessary, the Plan will provide you with a written (or electronic, as applicable) notice of extension describing the special circumstances and date the appeal determination will be made. The Board of Trustees will notify you in writing (or electronically, as applicable) of the benefit determination no later than five (5) calendar days after the benefit determination is made.
• Weekly Disability Benefit Claims and Weekly Maternity Benefit Claims
  A written (or electronic, as applicable) notice regarding a decision on your appeal will be sent to you within 45 days from the date your written request for an appeal is received by the Plan. The Plan will make an appeal determination no later than the date of the meeting immediately following the Plan’s receipt of your written request for an appeal, unless the request for an appeal review is filed within 30 calendar days preceding the date of such meeting. In such case, an appeal determination will be made no later than the date of the second meeting following the Plan’s receipt of your written request for review. If special circumstances (such as the need to hold a hearing) require a further extension of time for processing, a benefit determination shall be rendered not later than the third meeting following the Plan’s receipt of your written request for review. If such an extension is necessary the Plan must provide you with a written (or electronic, as applicable) notice of extension describing the special circumstances and date the appeal determination will be made. The Board of Trustees will notify you of the benefit determination no later than five (5) calendar days after the benefit determination is made.
• Accidental Death and Dismemberment Insurance/Death Benefit Claims
  A written (or electronic, as applicable) notice regarding a determination of your appeal will be sent to you within 60 days from the date your written request for an appeal is received by the Plan.

A written (or electronic, as applicable) notice of the appeal determination must be provided to you that includes:

• The specific reason(s) for the adverse benefit determination upon appeal, including (i) the denial code (if any) applicable to a health benefit claim and its corresponding meaning, (ii) a description of the Plan’s standard (if any) that was used in denying the claim, and (iii) a discussion of the decision;
• Reference the specific Plan provision(s) on which the denial is based;
• A statement that you are entitled to receive upon request, free access to and copies of documents relevant to the claim;
• A statement that you have the right to bring civil action under ERISA Section 502(a) following the appeal;
• An explanation of the external review process, along with any time limits and information about how to initiate a request for an external review regarding the denied internal appeal of a health benefit claim;
• If the denial of a health benefit claim, a weekly disability benefit claim or a weekly maternity benefit claim was based on an internal rule, guideline, protocol, standard, or similar criterion a statement must be provided that such rule, guideline, protocol or criteria will be provided free of charge, upon request;
• If the denial of a health benefit claim, a weekly disability claim or a weekly maternity benefit claim was based on a medical judgement (Medical Necessity, Experimental or Investigational), a statement must be provided that an explanation regarding the scientific or clinical judgement for the denial will be provided free of charge, upon request;
• With respect to weekly disability claims, a discussion of the Plan’s initial claim discussion, including the basis for disagreeing with(i) any disability determination by the Social Security Administration (SSA); (ii) the views of a treating health care professional or vocational expert evaluating the claimant, to the extent the Plan does not follow such views as presented by the claimant; or (iii) the views of medical professionals or vocational experts whose advice was obtained on behalf of the Plan, regardless of whether or not the advice was relied upon by the Plan in making an adverse benefit determination; and
• With respect to a health benefit claim, disclosure of the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist you with internal claims and appeals and external review processes.

This concludes the appeal process under this Plan.

If your initial claim for health care benefits has been denied (i.e., an adverse benefit determination) in whole or in part, and you are dissatisfied with the outcome of the Plan’s internal claims and appeals process described earlier, you may (under certain circumstances) be able to seek external review of your claim by an Independent Review Organization (“IRO”). This process provides an independent and unbiased review of eligible claims in compliance with the Affordable Care Act.

All notices relating to external review sent will contain a notice about the availability of Spanish language services. Assistance with filing a claim for external review in Spanish is available by calling 1-708-449-2123. Notices relating to external review will be provided in Spanish upon request.

SPANISH (Español): Para obtener asistencia en Español, llame al 1-708-449-2123. Claims Eligible For The External Review Process

Post-Service, Pre-Service, Urgent Care, and Concurrent Care Claims, in any dollar amount, are eligible for external review by an IRO if:

• The adverse benefit determination of the claim involves a medical judgment, including but not limited to, those based on the Plan’s requirements for Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, denial related to coverage of routine costs in a clinical trial, or a determination that a treatment is Experimental or Investigational. The IRO will determine whether a denial involves a medical judgment.
• The denial is due to a rescission of coverage (i.e., the retroactive elimination of coverage), regardless of whether the rescission has any effect on any particular benefit at that time.

The following types of claims are not eligible for the external review process:

• Claims that involve only contractual or legal interpretation without any use of medical judgment.
• A determination that you or your Dependent are not eligible for coverage under the terms of the Plan.
• Claims that are untimely, meaning you did not request review within the four (4) month deadline for requesting external review.
• Claims as to which the Plan’s internal claims and appeals procedure has not been exhausted (unless a limited exception applies).
• Claims that relate to benefits other than health care benefits (such as dental or vision benefits that are considered excepted benefits).
• Claims that relate to benefits that the Plan provides through insurance. Claims that relate to benefits provided through insurance are subject to the insurance company’s external review process, not this process.

In general, you may only seek external review after you receive a “final” adverse benefit determination under the Plan’s internal appeals process. A “final” adverse benefit determination means the Plan has continued to deny your initial claim in whole or part and you have exhausted the Plan’s internal claims and appeals process.

Under limited circumstances, you may be able to seek external review before the internal claims and appeals process has been completed:

If the Plan waives the requirement that you complete its internal claims and appeals process first.

• In an urgent care situation (see “Expedited External Review of an Urgent Care Claim”). Generally, an urgent care situation is one in which your health may be in serious jeopardy or, in the opinion of your health care professional, you may experience pain that cannot be adequately controlled while you wait for a decision on your internal appeal.
• If the Plan has not followed its own internal claims and appeals process and the failure was more than a minor error. In this situation, the internal claims and appeal is “deemed exhausted,” and you may proceed to external review. If you think that this situation exists, and the Plan disagrees, you may request that the Plan explain in writing why you are not entitled to seek external review at this time.

Your request for external review of a standard (not Urgent Care) claim must be made in writing within four (4) months after you receive notice of an adverse benefit determination.

Because the Plan’s internal claims and appeals process generally must be exhausted before external review is available, external review of standard claims will ordinarily only be available after you receive a “final” adverse benefit determination following the exhaustion of the Plan’s internal claims and appeals process.

To begin the standard external review process, contact the following:

Plan Administrator
Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members
4530 Roosevelt Road
Hillside, IL 60162
1-708-449-7373
www.sm73funds.org

You may request an expedited external review in the following situations if:

• You receive an adverse benefit determination regarding your initial claim that involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an expedited internal appeal.
• You receive a “final” adverse benefit determination after exhausting the Plan’s internal appeals procedure that (i) involves a medical condition for which the timeframe for completion of an standard external review would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function; or (ii) concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, and you have not yet been discharged from a facility.

To begin a request for expedited external review, contact the following:

Plan Administrator

Sheet Metal Workers’ Local 73 Welfare Fund
Plan A for Active Members

4530 Roosevelt Road
Hillside, IL 60162

1-708-449-7373

www.sm73funds.org

Preliminary Review of an Urgent Care Claim by the Plan

Immediately upon receipt of a request for expedited external review, the Plan will complete a preliminary review of the request to determine whether the requirements for preliminary review are met (as described above for the standard claim external review process). The Plan will defer to your attending health care professional’s determination that a claim constitutes “urgent care.” The Plan will immediately notify you (e.g., telephonically, via fax) whether your request for review meets the requirements for expedited review, and if not, it will provide or seek the information described above for the standard claim external review process.

Review of an Urgent Care Claim by the IRO

Upon a determination that a request is complete and eligible for an expedited external review following the preliminary review, the Plan will assign an accredited IRO. The Plan has arranged for at least three (3) accredited IROs to provide external review of claims, and rotates assignments among those IROs. In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of claims.

The Plan will expeditiously provide or transmit to the IRO all necessary documents and information that it considered in making its internal adverse benefit determination.

The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described in the procedures for standard review. In reaching a decision, the IRO must review the claim de novo meaning that it is not bound by any previous decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO decision must not be contrary to the terms of the plan, unless the terms are inconsistent with applicable law. For example, the IRO must observe all of the Plan’s standards, including standards for clinical review, Medical Necessity, appropriateness, health care setting, level of care, and effectiveness of a covered benefit.

The IRO will provide notice of the final external review decision, in accordance with the requirements set forth above for the standard claim external review process, as expeditiously as your medical condition or circumstances require, but not more than seventy-two (72) hours after the IRO receives the request for an expedited external review. If notice of the IRO decision is not provided to you in writing, the IRO must provide written confirmation of the decision to you and the Plan within forty-eight (48) hours after it is made.

What Happens after the IRO Decision is made?

If the IRO’s final external review decision reverses the Plan’s internal adverse benefit determination, upon the Plan’s receipt of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim. However, even after providing coverage or payment for the claim, the Plan may, in its sole discretion, seek judicial remedy to reverse or modify the IRO’s decision.

If the final external review upholds the Plan’s internal adverse benefit determination, the Plan will continue not to provide coverage or payment for the reviewed claim.

If you are dissatisfied with the external review determination, you may seek judicial review to the extent permitted under ERISA section 502.

The Plan recognizes an authorized representative as any person at least 18 years old whom you have designated in writing as the person who can act on your behalf to file an initial claim and appeal an adverse benefit determination under the Plan. An authorized representative under the Plan also includes a health care professional. You do not need to designate in writing that the health care professional is your authorized representative if that health care professional is part of the claim appeal. A health care provider with knowledge of your medical condition may act as your authorized representative in connection with an Urgent Care Claim without filing a written statement with the Plan.

The Plan requires you to provide a written statement declaring your designation of an authorized representative along with the representative’s name, address, phone number, and email address. To designate an authorized representative, you must submit a completed authorized representative form (available from the Plan Administrator).

If you are unable to provide a written statement, the Plan will require written proof that the proposed authorized representative has the power of attorney for health care purposes (e.g., notarized power of attorney for health care purposes, court order of guardianship/conservatorship or is the your legal spouse, parent, grandparent, or child over the age of 18).

Once the Plan receives an authorized representative form all future claims and appeals-related correspondence will be routed to the authorized representative rather than to you. The Plan will honor the designated authorized representative for one (1) year before requiring a new authorization/until the designation is revoked, or as mandated by a court order. You may revoke a designated authorized representative status by submitting a completed change of authorized representative form available from and to be returned to the Plan Administrator.

The Plan reserves the right to withhold information from a person who claims to be your authorized representative if there is suspicion about the qualifications of that individual.

You or any other claimant may not start a lawsuit or other legal action to obtain Plan benefits, including proceedings before administrative agencies, until after all administrative procedures have been exhausted (including this Plan’s internal claims and appeal procedures described in this section) for every issue deemed relevant by the claimant, or until 90 days have elapsed since you filed a request for appeal review if you have not received a final decision or notice that an additional 60 days will be necessary to reach a final decision. With respect to health and weekly disability benefits, the law also permits you to pursue your remedies under section 502(a) of the Employee Retirement Income Security Act without exhausting these appeal procedures if the Plan has failed to follow them properly. For post-service claims, please be advised that your appeal will be decided at the second quarterly Board meeting, or if the Plan received the appeal within 30 days of a Board meeting, the third meeting from receipt.

In addition, with respect to health care claims, you are not required to exhaust external review before seeking judicial remedy.

The Plan has a 2-year statute of limitations. Notwithstanding any other state or federal law, any and all legal actions against the Plan or its Trustees must be filed within two (2) years of the action or inaction complained of. This includes but is not limited to actions to recover benefits that must be filed within two (2) years of the final decision on your claim. The situs of the Plan is in Cook County, Illinois. Legal actions must be brought in the appropriate state or federal court located in Cook County, Illinois.

You and your Eligible Dependents’ right to receive benefit payments, appeal a claim, or bring a cause of action against the Plan is personal to you or your Eligible Dependents. Any claim or rights under the Plan, which includes but is not limited to any right to appeal a claim under the procedure set forth in the Plan document, any right to bring a cause of action against the Plan in any forum, or any right to receive benefits or benefit payments from the Plan, is not assignable or transferrable in whole or in part to any other person, Provider, or other entity at any time. Any assignment or transfer of a claim or other rights to receive benefit payments is void unless you or your Eligible Dependents receive written consent from the Board of Trustees. Nothing in this clause will prevent the Plan from paying a Provider or similar entity directly and any such payment shall not constitute a waiver of this anti-assignment clause. In addition, the Trustees’ consent or lack thereof to the assignment or transfer of benefits does not affect your or your Eligible Dependents’ eligibility for benefits under the Plan.

With respect to health and weekly disability benefits, to ensure that the persons involved with adjudicating claims and appeals (such as claim adjudicators, medical professionals and vocational experts) act independently and impartially, decisions related to those persons’ employment status (such as decisions related to hiring, compensation, promotion, termination or retention), will not be made on the basis of whether that person is likely to support a denial of benefits.

If the Board of Trustees or its designee determines that you cannot submit a claim or prove that you or your covered Dependent paid any or all of the charges for health care services that are covered by the Plan because you are incompetent, incapacitated or in a coma, the Plan may, at its discretion, pay Plan benefits directly to the health care professional(s) who provided the health care services or supplies, or to any other individual who is providing for your care and support. Any such payment of Plan benefits will completely discharge the Plan’s obligations to the extent of that payment. Neither the Plan, Board of Trustees, appropriate Claims Administrator nor any other designee of the Plan will be required to see to the application of the money so paid.

The Welfare Fund does not cover any claims for work-related Injuries or Sicknesses. However, if the Industrial Commission initially determines that your Injury or Illness did not arise in the course of your employment, and you comply with the reimbursement agreement provisions of the Plan, which are outlined in the section beginning on page 71, the Plan may cover such claims, provided you do the following:

• You must promptly notify the Fund Office in the manner designated by the Fund Office that you have filed a workers’ compensation claim.
• The Fund Office must verify that the benefit claims have been denied or disputed and are not being paid by the workers’ compensation carrier pending resolution of the workers’ compensation proceeding, and that such benefits are provided under the Fund. You must promptly inform the Plan Administrator or its designee in writing of all material developments with respect to your workers’ compensation proceeding, and you must submit all benefit claims within six months of the decision in your workers’ compensation case.
• The Fund will conditionally pay the covered benefit claims/expenses not paid by workers’ compensation. The Plan will not pay Weekly Accident and Sickness Disability benefits for any period in which you are receiving workers’ compensation benefits.
• The Fund’s reimbursement provisions will control how the Plan provides coverage of any Plan benefits, rather than the terms of any workers’ compensation settlement. You may contact the Fund Office or review the Reimbursement provisions on page 88.

You must comply with all applicable reimbursement provisions outlined in the next section, including completion of the Fund’s Reimbursement Agreement.

If you or your Dependents are covered by another plan or plans, the benefits under this Fund and the other plan(s) will be coordinated. This means one plan pays its full benefits first, then the other plan or plans pay.

• The primary plan (which is the plan that pays benefits first) pays the benefits that would be payable under its terms in the absence of this provision.
   
• The secondary plan (which is the plan that pays benefits after the primary plan) will limit the benefits it pays so that the sum of its benefits and all other benefits paid by the primary plan will not exceed the greater of:
   
  • 100% of total covered expenses, or
     
  • The amount of benefits it would have paid had it been the primary plan.

If you or your Dependents are eligible under another plan, there are a few simple rules that determine the order in which benefits are paid.

• When another plan does not have a Coordination of Benefits provision (COB provision), that plan must determine benefits first.
   
• When another plan does have a COB provision, the first of the following rules that applies governs:
   
  • If a plan covers the claimant as an active Employee, then that plan will pay its benefits first.
     
  • For an Eligible Dependent child whose parents are not divorced or separated, the plan of the parent whose birthday (month and day) is earlier in the calendar year will pay first. If both parents’ birthdays are the same day, the last rule will apply.
     
  • For an Eligible Dependent child whose parents are divorced or separated, the following rules apply:
• A plan that covers a child as a Dependent of a parent who by court decree must provide health coverage will pay first.
   
• When there is no court decree that requires a parent to provide health coverage for a Dependent child, the following rules will apply:
   
  • When the parent who has custody of the child has not married, that parent’s plan will pay first and the non-custodial parent’s plan will pay second.
     
  • When the parent who has custody of the child has remarried, benefits will be determined by that parent’s plan first, by the stepparent’s plan second, and by the non-custodial parent’s plan third.
• If none of the above rules apply, the plan that has covered the claimant for the longest period of time will pay its benefits first, except:
   
• When one plan covers the claimant as a laid-off or retired Employee (or a Dependent of such an Employee), and the other plan includes a COB rule for laid-off or retired Employees, the plan that covers the claimant as other than a laid-off or retired Employee (or a Dependent of such an Employee) will pay first,
   
• If both plans cover the claimant as a laid-off or a retired Employee (or a Dependent of such Employee) the plan that covered the Employee for the longest period of time will pay first.

If part of a plan coordinates benefits and a part does not, each part will be treated like a separate plan. The Plan will always pay primary to Medicaid.

Notwithstanding any provision to the contrary, if an Eligible Dependent is covered by another group health plan that reduces or eliminates its benefits when a Dependent is covered by another group health plan, or if the other group health plan has COB provisions that differ from those of this Plan, this Plan will only pay the amount of benefits that would be payable if the other group health plan had the same coordination of benefit provisions as this Plan.

For the purposes of Coordination of Benefits, the Fund Office:

1. May release to or obtain from any other plan or other organization or person any claim information, and any person claiming benefits under the Fund must furnish any information that the Fund may require to coordinate benefits, in accordance with the federal law governing privacy and security of your medical records,
    
2. Has the right, if an overpayment is made, to recover such overpayment from any other person or any other plan or organization, and
    
3. Has the right to pay to any other plan or organization an amount it will determine to be warranted, if payments that should have been made by the Fund have been made by such organization.

Medicare is a four-part program. The first part is officially called “Hospital Insurance Benefits for the Aged and Disabled” and this part is commonly referred to as Part A of Medicare. The second part is officially called “Supplementary Medical Insurance Benefits for the Aged and Disabled” and this part is commonly referred to as Part B of Medicare. The third part is Medicare Advantage or Medicare Part C and generally involves coverage under one of the Medicare HMO (Health Maintenance Organization) offerings for Participants who live in a geographic area served by a Medicare HMO and who choose to be covered by a Medicare HMO. Medicare Part D provides Prescription Drug coverage. Part A of Medicare primarily covers Hospital benefits, although other benefits are also provided. Part B of Medicare primarily covers Physician’s services, although it, too, covers a number of other items and services. Part C covers both Hospital and Physician services. Part D covers Prescription Drug expenses.  

Typically a person becomes eligible for Medicare upon reaching age 65. Under certain circumstances a person may become eligible for Medicare before age 65 if the person is a disabled worker, disabled widow, or Dependent widower or has chronic renal disease.

When you reach age 65, you are eligible to apply for all parts of Medicare coverage, even if you have not yet retired or are not yet receiving Social Security benefits. Part A of Medicare is ordinarily free, and premiums are required for the other Parts of Medicare. If you are not yet receiving Social Security benefits, you must pay any required premium to the Social Security Administration. If you are receiving Social Security Benefits, you will have the premium deducted from your monthly Social Security benefit check. 

The Plan coordinates benefits with Medicare.

This Plan is the primary plan responsible for payment of your benefits and your Dependents’ benefits if you are an eligible Active Employee. This means that if you are an Active Employee and you are also covered by Medicare, when you or your Dependents incur covered medical expenses, the Plan will pay benefits first and then Medicare will determine what benefits it will pay of the remaining expense not covered by the Fund.

Keep in mind that when you retire, your coverage under the Sheet Metal Workers’ Local 73 Welfare Fund Plan C for Active Members ends and you will be able to continue coverage only through COBRA, if you are eligible. If you are eligible for Medicare when you retire, you should enroll in Medicare, which will then cover your eligible medical expenses. You may contact the Fund Office if you have any questions regarding your coverage under the Plan.

The Plan’s Reimbursement provisions apply to the following benefits paid by the Plan: medical, dental, vision, prescription drug, hearing aid, and accident and sickness disability benefits. The Plan’s Reimbursement provisions do not apply to Death Benefits or Accidental Death and Dismemberment Benefits provided by the Plan.

The Plan has the right of reimbursement for benefits that it pays as a result of an Injury, accident or Sickness for which any third party may be liable. This can include auto accidents, workers’ compensation injuries, personal injuries, medical malpractice injuries, injuries from fights or beatings, poisonings or toxic injuries, or a case of slip and fall.

The Board of Trustees has established reimbursement procedures for the Welfare Fund which they may change from time to time. The Fund Office will follow the reimbursement procedures. The Board of Trustees of the Welfare Fund has delegated full discretionary authority to the Benefits Appeals Committee of the Board of Trustees to collect and settle Reimbursement claims.

If you sign a Reimbursement Agreement, the Fund may reduce its share of the recovery for its proportionate share of attorneys’ fees and its share of your out-of-pocket expenses. The Trustees or Appeals Committee have the discretion to settle reimbursement claims or liens. Other guidelines apply to the recovery available by the Fund. Contact the Fund Office for more details.

The Fund Office may suspend benefit payments for your claims related to third-party Injury or illness until you return a signed Reimbursement Agreement to the Fund Office. The Fund Office may also suspend benefits or withhold future benefit payments if you refuse to provide information to the Fund Office or otherwise refuse to cooperate with the Fund Office.

The Fund Office may suspend all Welfare Benefit payments or withhold future benefit payments, regardless of the nature or source, if you receive a recovery and you either fail to report that recovery to the Fund Office, refuse to reimburse the Fund Office, or reject a settlement in accordance with the Plan’s Reimbursement guidelines. Benefits should recommence after the total amount of payments withheld equals the amount of recovery due the Fund under the Fund’s Reimbursement policies and procedures.

If you have not yet reached age 65 and are not yet eligible to enroll in Medicare, you may be eligible for benefits from this Plan. To be eligible, you must be receiving a pension from the Sheet Metal Workers’ Local No. 73 Pension Fund (referred to as the Pension Fund or Pension Plan), and:

• You must be receiving a pension from the Pension Fund that is based on a minimum of ten (10) pension credits, but if the pension you are receiving from the Pension Fund is based on less than twenty-five (25) pension credits, you must have been credited with a minimum of three (3) pension credits within the period consisting of the Pension Plan year in which you retired and the six consecutive Pension Plan years immediately preceding the Plan Year during which you retired.
  
  
• If you have retired from a municipal or other governmental employer following a period of service that was covered under a collective bargaining agreement between such employer and the Union and are receiving a pension from the Pension Fund based on a minimum of twenty (20) but less than twenty-five (25) pension credits, you are eligible for coverage under this Plan if you are not eligible for coverage under a retiree health plan that your former municipal or governmental employer sponsors, contributes to or previously contributed to.  For purposes of this paragraph, retiree health coverage means either self-insured or fully-insured health plan coverage, including an arrangement under which the retiree has the opportunity to select one or more self-insured or fully-insured health plan coverage options that are partially or fully subsidized by the retiree health plan that the municipal or governmental employer sponsors, contributes to, or previously contributed to.  For the avoidance of doubt, retiree health coverage does not include a health reimbursement arrangement or health savings account arrangement that is not linked to either: (a) a self-insured or fully-insured health plan or (b) an arrangement under which the retiree has the opportunity to select one or more self-insured or fully-insured health coverage options; retiree health coverage shall, however, include a health reimbursement arrangement or health savings account arrangement that is linked to either: (a) a self or fully-insured health plan or (b) an arrangement under which the retiree has the opportunity to select one or more self-insured or fully-insured health coverage options that are subsidized in part or in full by the health reimbursement arrangement or health savings account.  For the avoidance of doubt, if you have retired with twenty-five (25) or more pension credits from the Pension Fund, your eligibility for coverage under this Plan is not determined based on this bullet point paragraph but is determined under the other bullet point paragraphs of this section.
  
  
• If you served as a full-time officer or business agent of the Union, you will receive credit for the years of service to the Union as if you were receiving Pension Credits for the sole purpose of determining eligibility for coverage under this Plan at the time of retirement.  Service as a full-time officer or business agent of the Union will not affect eligibility for welfare coverage upon retirement since contributions are made to the Welfare Fund by the Union for such service.
  
  
• For purposes of determining eligibility for benefits from this Plan, pension credits mean only those pension credits directly awarded by the Pension Fund and do not include pension credits awarded by another pension fund that are taken into consideration in regard to a Reciprocal Pension.

When you retire, you have the choice of electing coverage in the Retiree Plan or electing COBRA continuation coverage. If you choose COBRA continuation coverage, you waive coverage under this Retiree Plan. If you choose coverage under this Retiree Plan, you waive COBRA continuation coverage. This means that if you elect either COBRA continuation coverage or coverage under the Retiree Plan, you may not at a later date choose the other type of coverage.

As a Retiree, you are not eligible for Weekly Accident and Sickness Benefits. Those benefits end on the last day of your coverage under the Sheet Metal Workers’ Local 73 Welfare Plan A for Active Members. For the administrative convenience of the Plan, if you elect Retiree coverage and pay the required selfpayment, you will continue to receive the benefits provided by the Sheet Metal Workers’ Local 73 Welfare Plan A for Active Members until the end of the calendar year in which you retire. On and after the January 1 that follows your retirement date, you will receive the benefits provided by this Plan.

Once you are eligible for Retiree Benefits, you must contribute toward the cost of this Plan for yourself and your eligible Dependents in order to continue your coverage.

Your contribution for Retiree Plan coverage may be deducted from your Pension each month.

If you are a Non-Medicare Eligible Retiree, your Dependents become eligible for Benefits on the same date you become eligible, or, if later, on the date you acquire an eligible Dependent. Eligible Dependents are defined on pages 12 and 13.

These benefits are subject to Coordination of Benefits rules explained on page 97.

 At the time you retire, and provided your spouse produces evidence that your spouse is covered by another health benefit plan, you may elect that no self-contributions be paid for coverage of your spouse under this Plan, thereby excluding your spouse from coverage. There will be no coordination of benefits for such excluded spouse.

This election to defer your spouse’s coverage is limited to your spouse at the time of your retirement only, or your surviving spouse, and will not cover any other future spouse. The election will not cover any spouse who marries you after your retirement. If your spouse loses other medical coverage during your retirement, you may elect to have your spouse added to coverage under this Plan within ninety (90) days of your spouse’s loss of coverage. You may exercise this election only one time.

If your spouse or surviving spouse is, or becomes, eligible for this Plan and has health coverage under another plan through employment, your spouse or surviving spouse will be given a one-time opportunity to defer coverage under this Plan until your spouse or surviving spouse is no longer covered by your spouse’s or surviving spouse’s employer health plan.

To defer Plan coverage, you, your eligible spouse or surviving eligible spouse must meet the following requirements:

• Your eligible spouse or surviving eligible spouse must be eligible for coverage under this Plan,
  
  
• Your eligible spouse or surviving eligible spouse who becomes eligible for coverage under this Plan after September 1, 1995, must file a written election with the Fund Office,
  
  
• Your eligible spouse or surviving eligible spouse must provide proof of other insurance with the election, and
  
  
• If your eligible spouse or surviving eligible spouse does not file an election, your spouse will not be permitted to defer coverage.

To resume coverage, your eligible spouse or surviving eligible spouse must meet the following requirements:

• Your eligible spouse or surviving eligible spouse must have made a valid election to defer coverage as stated on page 10,
  
  
• Your eligible spouse or surviving eligible spouse must have been continuously covered by the health plan of his or her employer since the date that your spouse opted out of this Plan, and provide proof of that coverage,
  
  
• Your eligible spouse or surviving eligible spouse must apply to resume coverage with the Fund Office in writing, on or before the ninetieth (90th) day after termination of coverage under the health plan of your spouse’s employer. If your spouse does not enroll within this period, your spouse will not be allowed to enroll at a future date, and
  
  
• Your eligible spouse or your surviving eligible spouse must make the contributions and payment required by the Sheet Metal Workers’ Local 73 Welfare Fund Plan for Retired Members to maintain coverage.

If you or your eligible Dependent fails to pay the required self-payments, coverage for you and your Dependents will terminate at the beginning of the month for which the required contribution was not paid.

When you or your Dependents become eligible to enroll in Medicare for any reason, coverage for you and your eligible Dependents will end under this Plan (regardless of whether you and your Dependents actually enroll in Medicare) unless you and your Medicare eligible Dependents enroll in the SMW+ Plan described on page 15.

Your surviving eligible spouse or eligible Dependents will remain covered by this Plan as long as they continue to meet the eligibility requirements.

If you become eligible for Medicare and you fail to enroll in the SMW+ Plan, your coverage and coverage for your eligible spouse will end under this Plan and will not be reinstated.

Your Eligible Dependents become Participants in the Plan on the later of:

• The day you begin participation; or
   
• The date you enroll them with the Fund Office.

Your newborn Child, adopted Child, or Child placed with you for adoption, will automatically become covered as a Dependent under the Plan on the date the Child is born, adopted, or placed with you for adoption.

Eligible Dependents are defined as follows:

• Your legal spouse;

• Your Dependent Children up to age 26; and
   
• Your Dependent Children of any age if mentally or physically disabled, as long as the mental or physical handicap began before the Child reached age 26.

Dependent Children include married or unmarried dependents, regardless of student status, who are the member’s natural children, adopted children, or children placed for adoption with the member, stepchildren and foster children placed with the member by an authorized agency or by court order, judgment or decree.

To enroll your newborn or newly acquired Child, you must provide the Fund Office with a copy of the birth certificate or adoption papers. Dependent status may continue until each Child’s 26th birthday.

If your Dependent Child is mentally or physically disabled or handicapped and is chiefly dependent on you, Plan benefits will continue as long as your Dependent is disabled or handicapped. To be eligible, your Child must be unable to engage in the normal activities of a person of like gender and age in good health due to disability or handicap. You must contact the Fund Office within thirty-one (31) days before Plan benefits might otherwise terminate (on the 1st of the month following the end of the month that he or she turns age 26) to apply for continued coverage for your disabled or handicapped Dependent Child, and provide proof that your Dependent Child’s disability will continue past the end of the month of his or her 26th birthday. For this purpose, you should submit the following documents for review: (1) Proof of approval by the Social Security Administration; (2) Copy of Child’s Medicare card (if applicable); and (3) Letter from at least two (2) physicians which includes the disabled or handicapped Dependent Child’s complete diagnosis and a description of mental and physical limitations. If you do not provide proof of your Dependent Child’s continuing disability, his or her welfare coverage under the Plan will terminate as of the 1st of the month following the end of the month of his/her 26th birthday.

An unmarried disabled Child who has reached age 26, but does not reside with you, will be a Dependent Child under the Plan if:

• The Child’s parents are divorced or legally separated under a decree of divorce or separate maintenance, are separated under a written separation agreement, or live apart at all times during the last six months of the calendar year;
   
• The Child’s parents provide over one-half of the Child’s support during the calendar year; and
   
• The Child is in the custody of one or both of his or her parents for more than one-half of the calendar year and is not the qualifying child of any other person during the calendar year.

The Plan will provide benefits for your Dependent Child who is named as an alternate recipient in a Qualified Medical Child Support Order (QMCSO).

Your Dependents’ benefits are subject to the rules outlined in the Coordination of Benefits Section.

A QMCSO is a court order that requires you to provide medical coverage for your Children (called alternate recipients) in situations involving a divorce, legal separation or a paternity determination.

This Plan provides benefits according to the requirements of the QMCSO. The Fund Administrator will notify you and any alternate recipient when a QMCSO is received. If the QMCSO is a valid order, the Plan will cover the named Dependent as an alternative recipient even though the Dependent might not otherwise be eligible for coverage.

This Plan complies with the federal law regarding special enrollment procedures, as follows. With the exception for a spouse’s deferral of coverage explained on page 10, if you are a Non-Medicare Eligible Retiree who is participating in the Plan, and you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may enroll the new Dependent in the Plan. However, you must request enrollment of the Dependent within thirty (30) days after the date you acquire the Dependent.

If you are a Retiree that previously participated in the Sheet Metal Workers’ Local 73 Welfare Fund Plan C for Staff (“Plan C for Staff”) who retired on or after January 1, 2022 who is eligible to enroll in Medicare, you and your spouse may be eligible for the benefits listed in the Schedule of Benefits on page 7. You are not eligible for Weekly Accident and Sickness Benefits or the Death Benefit, which end on the last day of your coverage under the Plan C for Staff.

To be eligible for the benefits listed in the Schedule of Benefits, you must enroll in the current Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund, must make the required selfpayment, and must satisfy at least one the following additional eligibility requirements: 

• You must have at least three (3) years of service with the applicable employer through which you participated in Plan C for Staff within the consecutive six (6) year period prior to your attainment of age sixty-five (65) and have ten (10) total years of service with the applicable employer through which you participated in Plan C for Staff at the time of your retirement from employment with the applicable employer through which you participated in Plan C for Staff; or
  
  
• You must be at least age sixty-five (65) at the time of your retirement from employment with the applicable employer through which you participated in Plan C for Staff and started employment with the applicable employer through which you participated in Plan C for Staff prior to January 1, 2022.

If you are at least age sixty-five (65) at the time of your retirement and meet the eligibility requirements set forth above, you will be able to enroll in the current Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund and participate in this Retiree Plan right away.  If you are not at least age sixty-five (65) at the time of your retirement, you will have to wait until you attain age sixty-five (65) to enroll in the current Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund and participate in this Retiree Plan.  

To enroll in the Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund, you must complete an enrollment form and forward it to the Fund Office. The Fund Office will mail the enrollment form to the Sheet Metal Workers’ National Welfare Fund, along with a copy of your Medicare card. The Plan will pay the Medicare Advantage Plan premium to the Sheet Metal Workers’ National Health Fund for the Medicare Advantage Plan coverage for you and you will be responsible for sending in the required self-payment monthly to the Fund Office at a rate set by the Trustees. The Trustees reserve the right to make changes to the required self-payment at any time and for any reason in their sole discretion.

If you are at least age sixty-five (65) when you retire, you have the choice of electing coverage in the Retiree Plan or electing COBRA continuation coverage with respect to your Active Employee benefits under Plan C for Staff. If you choose COBRA continuation coverage with respect to your Active Employee benefits, you waive coverage under this Retiree Plan. If you choose coverage under this Retiree Plan, you waive COBRA continuation coverage. This means that if you elect either COBRA continuation coverage or coverage under the Retiree Plan, you may not at a later date choose the other type of coverage.

If you are not at least age sixty-five (65) at the time of your retirement, you have the choice of electing COBRA continuation coverage with respect to your Active Employee benefits under Plan C for Staff.  Such COBRA continuation coverage does not count towards any years of service requirements for eligibility purposes.  When you attain age sixty-five (65), you will be able to enroll in the current Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund and participate in the Retiree Plan if you meet the eligibility requirements set forth above.  

If you meet the eligibility requirements for Retiree coverage, your coverage will continue if you contribute toward the cost of the Plan for yourself. As indicated above, you must make the required self-payment to the Fund Office on a monthly basis. 

If your spouse is eligible for Medicare when you first become eligible as a Plan C Staff Retiree, he or she will be eligible for the same benefits as you.  You must contribute toward the cost of the Plan for your eligible spouse and make the required self-payment to the Fund Office on a monthly basis. 

If your spouse is not yet eligible for Medicare when you first become eligible as a Plan C Staff Retiree, he or she will become eligible for the same benefits as you upon becoming Medicare eligible.  Therefore, when your spouse becomes eligible for Medicare, he or she must enroll in the Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund in order to gain coverage under the portion of this Plan for Medicare Eligible Plan C Staff Retirees.

Dependents of Medicare Eligible Plan C Staff Retirees (other than spouses who are eligible for Medicare) are not eligible for benefits.

If you fail to pay the required self-payment, your coverage and coverage for your eligible spouse will terminate at the beginning of the month for which the required self-payment was not paid.

If you fail to enroll in the Medicare Advantage Plan offered by the Sheet Metal Workers’ National Welfare Fund, your coverage and coverage for your eligible spouse will end under this Plan and will not be reinstated.

Your spouse will remain covered by this Plan as long as he or she remains your spouse under the terms of the Plan, and you meet the continuing eligibility requirements.

If you wish, you may elect to cease medical and/or prescription drug coverage, as applicable, under the Plan for only yourself at any time during the Plan Year and allow your eligible Dependents, if applicable, to remain covered under the Plan.  Such election shall be made by providing written notice to the Fund Office of your intention to cease coverage. Cessation of medical and/or prescription drug coverage will be effective as of the first day of the following month after the Fund Office receives such notice from you. 

If you previously elected to cease your coverage for medical and/or prescription drug benefits under the Plan, you may reinstate your coverage by providing written notice to the Fund Office. Reinstatement of your medical and/or prescription drug coverage will be effective as of the first day of the Plan Year following the date the Fund Office receives such written notice from you. 

This opportunity to cease coverage and be reinstated at a later time is only available to you one time. 

A rescission of coverage is a cancellation or discontinuance of coverage that has retroactive effect, meaning that it will be effective back to the time that you should not have been covered by the Plan. The Plan may rescind your coverage for fraud or intentional misrepresentation of a material fact after the Plan provides you with thirty (30) days advance written notice of that rescission of coverage. However, the following situations will not be considered rescissions of coverage and do not require the Plan to give you thirty (30) days advance written notice:

• When the Plan terminates your coverage retroactive to the date you lose eligibility for coverage, if there is a delay in administrative recordkeeping between the date you lose eligibility and the date the Plan is notified of your loss of eligibility; 
  
  
• When the Plan retroactively terminates your coverage because you fail to make timely selfpayments for your coverage; or
  
  
• When any unintentional mistakes or errors result in you and your Dependents being covered by the Plan when you should not have been covered, the Plan will cancel your coverage prospectively – for the future – once the mistake is identified.

Your Dependents may continue coverage after your death, in accordance with the following rules.

If you die while you are eligible for Plan coverage as an active Employee under the Sheet Metal Workers’ Local 73 Welfare Plan A for Active Members, eligibility for your Dependents will continue under Plan A for Active Members without self-contribution for as long as you would have been eligible for coverage under Plan A for Active Members, based on your accumulated eligibility.

Your Dependents may then continue coverage under this Plan, the Sheet Metal Workers’ Local 73 Welfare Fund Plan for Retired Members, through this special health coverage continuation rule if:

• You died as an active Employee,
  
  
• Your accumulated eligibility under Plan A for Active Members has been exhausted,
  
  
• You had at least ten (10) pension credits awarded by the Sheet Metal Workers’ Local 73 Pension Fund at the time of your death,
  
  
• You were eligible for a pension (including a Reciprocal Pension) from the Sheet Metal Workers’ Local 73 Pension Fund at the time of your death, and your surviving spouse is receiving a survivor’s pension as the result of your death, and
  
  
• You worked at least fifteen (15) full years with Employers that were signatories to collective bargaining agreements with the Sheet Metal Workers’ International Union or one of the Sheet Metal Workers’ Unions.

To be eligible to continue coverage under this Special Health Coverage Continuation provision, your surviving spouse must waive COBRA continuation coverage.

Your surviving eligible spouse and Eligible Dependent Children must make the required self-payments to the Plan for this coverage at a rate set by the Trustees. If you die prior to commencing your pension, your surviving spouse may be entitled to subsidized coverage for the first twenty-four (24) months after his or her survivor pension commences and will only be responsible for a self-payment of 5% of his or her gross monthly survivor pension amount during that initial twenty-four (24) month period.  Self-payments must begin in the month following the month of your death. This special coverage is only available if your spouse was married to you throughout the twelve (12) month period immediately before your death.  The Trustees reserve the right to make changes to the required self-payment at any time and for any reason in their sole discretion.  

Your spouse’s coverage under this provision will terminate if your surviving eligible spouse remarries following your death. If your surviving eligible spouse remarries, your spouse may elect to continue coverage for an additional thirty-six (36) month period after remarriage. This coverage will be the same coverage the surviving spouse received under the Special Health Coverage. Continuation provisions, will be offered at the COBRA rate of coverage, but will not constitute COBRA coverage.

Coverage will terminate for your surviving Dependent Child who continues coverage under the Special Health Coverage Continuation provisions when the Dependent Child no longer meets the definition of Eligible Dependent under the Plan. The Dependent Child may elect COBRA continuation coverage for up to thirty-six (36) months from the date the Child no longer meets the definition of an Eligible Dependent.

If you die as an active Employee without meeting the requirements of this provision, your surviving eligible spouse and Eligible Dependent Children will be entitled to COBRA continuation coverage only.

If your surviving eligible spouse is receiving a pension from the Sheet Metal Workers’ Local 73 Pension Fund, there is no continuation of eligibility under the Sheet Metal Workers’ Local 73 Welfare Fund Plan A for Active Members and self-payments for Retiree Plan benefits must begin immediately.

Except in limited circumstances for surviving spouses entitled to subsidized coverage for the first twentyfour (24) months after commencement of a survivor pension, the premium for coverage is based upon the surviving eligible spouse’s age. The rate will generally be decreased when the surviving spouse reaches age 60, again when the surviving spouse reaches age 62, and again when the surviving spouse reaches age 65. If the surviving spouse remarries, the Eligible Dependent Children’s coverage will continue under the Special Health Coverage Continuation provisions until each Child reaches the limiting age.

If you die while you are eligible for Retiree coverage, eligibility for your Dependents will continue to the end of the month in which you die, and then your surviving Dependents may elect to continue coverage under the Retiree Plan.

To be eligible to continue coverage under this provision, your surviving spouse must waive COBRA continuation coverage, except that if your surviving spouse remarries within thirty-six (36) months of your death, Special Continuation Coverage will end, but your surviving spouse may elect COBRA continuation coverage under the Retiree Plan for the surviving spouse and Dependent Children for the balance of the thirty-six (36) month period that begins on the date of your death.

Your surviving spouse and Eligible Dependent Children must make the required self-payments to the Plan for this continuation coverage at a rate set by the Trustees. Self-payments must begin in the month following the month of your death. This coverage is only available if your surviving spouse was married to you throughout the twelve (12) month period immediately before your death.

Coverage provided to your surviving spouse and Dependent Children under this provision will terminate if your surviving spouse remarries following your death. Coverage for your surviving spouse who remarries and any covered Dependent Children will terminate at the end of the month in which your surviving spouse remarries. However, your surviving spouse and any covered Dependent Children will be entitled to elect COBRA continuation coverage under the Retiree Plan for the remainder of the thirty-six (36) month period that started on the date of your death by making timely self-payments at the COBRA rate of coverage. If your surviving spouse does not remarry, coverage will terminate for a Dependent Child who continues coverage under these provisions when the Dependent Child no longer meets the definition of Eligible Dependent under the Plan. The Dependent Child may elect COBRA continuation coverage under this Retiree Plan for up to thirty-six (36) months from the date the Child no longer meets the definition of an Eligible Dependent.

The premium for coverage is based upon your surviving spouse’s age. The rate will generally be decreased when your surviving spouse reaches age 60, again when your surviving spouse reaches age 62, and again when your surviving spouse reaches age 65. If your surviving spouse remarries, your Eligible Dependent Children’s coverage will continue under these provisions until each Child reaches the limiting age.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides for continuation of health coverage for your spouse and Dependent Children if you lose coverage under the Plan due to a qualifying event. Your Dependents may continue health coverage for a limited period by making selfpayments to the Plan.

If your Dependents lose eligibility because of the qualifying event of your death, your entitlement to Medicare, divorce or legal separation, or loss of Dependent status, they may elect COBRA continuation coverage.

You and your Dependents may choose individual coverage or family coverage.

Eligibility for COBRA Continuation Coverage

If your Dependents are eligible for COBRA continuation coverage, they are considered qualified beneficiaries, meaning they were covered by the Plan on the day before the qualifying event.

If your Dependents marry, have a newborn Child, or have a Child placed with them for adoption while they are enrolled in COBRA continuation coverage, they may enroll that spouse or Child for the balance of the period of their coverage. They must complete the enrollment within thirty (30) days after the birth, marriage, or placement for adoption. These Dependents who are added to your Dependent’s COBRA coverage will have COBRA coverage but will not have all of the rights of a qualified beneficiary (such as adding additional beneficiaries).

Scope of COBRA Continuation of Coverage

If your Dependents choose COBRA continuation coverage, they are entitled to the same type of coverage that they had on the day before the date of the event that triggered COBRA. If there is a change in the health coverage, including Prescription Drug coverage that is provided by the Plan to similarly situated Participants, that same change will be made to COBRA continuation coverage.

Qualifying Events That Trigger COBRA Continuation Coverage

If your Dependents experience a qualifying event that causes them to lose coverage, they will be considered qualified beneficiaries, and the Fund will send them a COBRA Election Notice and a form for them to elect coverage. The qualifying events under which your Dependents may lose coverage under the Plan and the period for which they may make self-payments to continue benefits are described below.

Your spouse becomes a qualified beneficiary if he or she loses coverage because any of the following qualifying events:

• Your death,
  
  
• You and your spouse become divorced or legally separated, or
  
  
• You become entitled to Medicare benefits under Part A, Part B or both. Becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Your Eligible Dependent Children become qualified beneficiaries if they lose coverage because any of the following qualifying events:

• Your death,
   
• The Child’s parents become divorced or legally separated,
  
  
• The Child stops being eligible for coverage under the Plan as an Eligible Dependent Child, or
  
  
• You become entitled to Medicare benefits under Part A, Part B or both. Becoming entitled to Medicare means that you: 1) were eligible for Medicare benefits, and 2) enrolled in Medicare (under Part A, Part B, or both). The entitlement date is the date of enrollment in Medicare.

Length of COBRA Continuation Coverage

If your Dependents lose coverage under the Plan because of divorce, legal separation, your death, or loss of Dependent status, your Dependents may maintain COBRA continuation coverage for a maximum period of thirty-six (36) months from the date coverage was lost.

Cost of and Payment for COBRA Continuation Coverage

Any qualified beneficiary who elects COBRA continuation coverage will pay the full cost of the coverage. The Fund can charge the full cost of coverage for similarly situated Retirees and their families (including both the Fund’s share and Retiree’s share, if any) plus an additional 2%.

The monthly cost depends on how many people are covered. Rates are provided for one person or for family coverage. If a qualified beneficiary adds Dependents that are acquired during the COBRA continuation coverage period and the qualified beneficiary was previously paying for individual coverage, the qualified beneficiary will be required to pay the higher rate.

The Trustees will establish the COBRA continuation coverage rates in accordance with ERISA and the Internal Revenue Code, the laws that govern the Plan. Generally, the Trustees will set new rates each Plan Year beginning July 1.

When you elect COBRA continuation coverage, you are required to make the first payment no later than forty-five (45) days after the date of your election, which is the date your COBRA Election Notice is postmarked, if mailed. If you do not make the first payment for continuation coverage in full within the fortyfive (45) day deadline after your election, you will lose all rights to COBRA continuation coverage. You are responsible for contacting the Fund Office to make sure that the amount of your first payment is correct.

Your subsequent payments for COBRA continuation coverage are due on the first day of the month for which coverage is being provided. However, you have a thirty (30) day grace period to make the payment. If the payment is not made when due, you will lose all continuation coverage rights under the Plan. COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the month for which it applies, but before the end of the grace period (the end of the month) for the coverage, coverage under the Plan will be suspended as of the first day of the month and then retroactively reinstated, going back to the first day of the month when your payment is received.

COBRA Continuation Coverage Notice and Election

You or your covered family member must inform the Fund Office of a divorce, legal separation, or a Child losing Dependent status. You or your Dependent must provide written notice within sixty (60) days of the event or the person affected forfeits the right to COBRA continuation coverage.

Your surviving Dependent spouse or Child should notify the Fund Office of your death within thirty (30) days of the date that your surviving Dependents would otherwise lose coverage due to your death.

When the Fund Office is notified that one of these events has occurred, it will in turn notify your Dependents of the right to choose continuation coverage and the time frame within which they must make the election. If your Dependents are not entitled to COBRA continuation coverage, the Fund will notify them of their ineligibility in writing.

Your Dependents have an election period of at least sixty (60) days from the date the notice is provided to inform the Fund Office of their election of COBRA continuation coverage.

Your Dependents may elect individual coverage or family coverage. Once they make an election for COBRA continuation coverage, they cannot change it unless it is within the sixty (60) day election period. This means that after the sixty (60) day election period ends, if they elect individual coverage, they cannot change to family coverage (except as explained in the next sentence), and if they elect family coverage, they cannot change to individual coverage. However, if they elect family coverage for only two family members and one of the family members dies, and individual coverage would be less expensive, the surviving individual may change to individual coverage. The Plan will charge for the individual premium starting on the first day of the month following the day the covered family member dies.

COBRA Benefit Coverage

Under COBRA continuation coverage, your Dependents are entitled to the same type of coverage that they had on the day before the date of the event that triggered coverage. If your Dependents choose COBRA continuation coverage and make the required self-payments, the Welfare Fund will provide coverage for all medical, dental, prescription drug, wellness, Substance Abuse, hearing, and vision benefits under the Plan.

In addition, if there is a change in the healthcare coverage that is provided by the Plan to Retired Participants, that same change will be made to the COBRA continuation coverage of qualified beneficiaries.

Termination of COBRA Continuation Coverage

If your Dependent elects COBRA continuation coverage, coverage will terminate as of the date the first of any of the following events occur:

• Your Dependents do not pay the self-payment for COBRA continuation coverage within thirty (30) days of its due date.
  
  
• Your Dependents become covered under another group health plan. Contact the Fund Office for details.
  
  
• Your Dependents become eligible for Medicare. Contact the Fund Office for details.
  
• The Welfare Fund no longer provides any healthcare benefits.

Availability of Other Coverage

There may be other coverage options for you and your family besides COBRA continuation coverage. For example, you may be eligible to buy an individual plan, through the Health Insurance Marketplace. . By enrolling in coverage through the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. Additionally, you may have coverage options under Medicare, Medicaid, Children’s Health Insurance Program (CHIP) or you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within thirty (30) days.

If You Have Questions

If you have questions about your COBRA continuation coverage, you should contact Patrick Ludvigsen, Fund Administrator, at 708-449-7373, or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa/. 

Keep the Fund Informed of Address Changes

In order to protect your family’s rights, you should keep the Fund informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Fund.

1. The fact that your Health Care Provider recommends Surgery, Hospitalization, confinement in a Health Care Facility, or that your Health Care Provider proposes or provides any other medical services or supplies doesn’t mean that the recommended services or supplies will be an Covered Expense or be considered Medically Necessary for determining coverage under the Plan.
   
   
2. The Utilization Management Program is not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefits. The UM Company’s certification that a service is Medically Necessary doesn’t mean that a benefit payment is guaranteed. Eligibility for and actual payment of benefits are subject to the terms and conditions of the Plan.
   
   
3. All treatment decisions rest with you and your Provider. You should follow whatever course of treatment you and your Health Care Provider believes to be the most appropriate, even if the UM Company does not certify a proposed surgery/treatment/service or admission as Medically Necessary. However, the benefits payable by the Plan may be affected by the determination of the UM Company.

You should contact the Fund Office if you have any questions regarding the precertification process or if you are unsure if a service or treatment must be pre-certified.

The following services require pre-certification and medical review:

• Durable Medical Equipment as provided in Appendix A
  
  
• Skilled Nursing Care 
  
  
• All Elective Hospital Admissions
  
  
• All Elective In-Patient Admissions (For Medical and Mental Health and Substance Used Disorder Admissions)
  
  
• All Elective Surgery and/or Surgical Procedures
  
  
• Hospice Benefits
  
  
• Private Duty Nursing/Coordinated Home Care Program
  
  
• Growth Hormones for Dependent Children
  
  
• Physical and Occupational Therapy beginning when you need 30 visits or more in a calendar year, pre-certification required after 30th visit.