Question 1

How do I become eligible and continue to be eligible?

Accepted Answer

Initial Eligibility
The way you establish initial eligibility is on a monthly basis. You must have 100 hours of credited hours in a month to be eligible for coverage as shown on the following chart:

The gap between the Calendar Month in which hours are worked and the Benefit Month in which eligibility is received allows time for payment and recording purposes.

Continuation Of Eligibility 
After establishing initial eligibility, you must have 100 credited hours in a Calendar Month to continue eligibility for a Benefit Month. The same Calendar Month/Benefit Month char above used for initial eligibility applies for calculating continuing eligibility.

Reserve Credit
After establishing initial eligibility, if you have more than 100 credited hours in a Calendar Month, the hours in excess of 100 are considered Reserve Credit and should be used to continue eligibility during periods of unemployment or under-employment. The maximum amount of reserve Credit that shall be credited to any individual's account shall be equal to six months.

Self-Contribution Payments
If you are in danger of losing eligibility due to a period of unemployment or under-employment, and you are available for employment in the jurisdiction of the Union, you are allowed to make self-payments to the Fund. The contribution shall be in an amount equal to the difference between the credited hours multiplied by the current contribution rate for the Calendar Month and the required 100 hours multiplied by the current contribution rate.

If you have some credited hours in the applicable Calendar Month, there is no limit to the number of self-payments you may make. However, you may only make 24 consecutive monthly self-contribution payments in the full amount of the required 100 hours multiplied by the current contribution rate.

The self-contribution payment must be made monthly and received by the Fund Office on or before the 10th day of the benefit month.

Question 2

If I lose my eligibility, how can I reinstate my eligibility?

Accepted Answer

Reinstatement Of Eligibility 
If you lose your eligibility, you shall become eligible again by being credited with 100 hours of contributions at the current contribution rate. If an Employee receives credit for less than the 100 hours at the current contribution rate, the Employee may not pay the difference in order to reinstate eligibility.

Question 3

When do I notify the Plan to become eligible for retiree or disabled benefits?

Accepted Answer

Section 3.15 - Eligibility For Retired Or Disabled Individuals 
A Retired or Disabled individual who has been employed under the jurisdiction of the Plan may become eligible for benefits for himself and his Eligible Dependents under the Retired and Disabled Employee Program if he meets all of the following terms and conditions:

A.  Eligibility 
(1) The individual provides proof that he is receiving pension or disability benefit payments from a pension plan to which a local Union affiliated with the United Association of Plumbers and Pipefitters is a sponsor and has been eligible under the Plan under the active contribution rate for twelve (12) consecutive months immediately preceding the date of receiving the retiree contribution rate. In the event the individual is not eligible for one (1) of the aforementioned Pensions, the individual must have been continuously eligible under the Plan for five (5) years immediately preceding the date of application to the Retiree and Disabled Employee Program.

(2)  If retired, the individual is at least age fifty-five (55).

(3)  If Disabled, the individual is receiving disability benefits from the Social Security Administration.

(4)  If qualified, the initial eligibility date of coverage shall be the first day of the Benefit Quarter following the date the application is approved or proof of pension or disability payments is received and proper payment is received. Dependents must meet the definition of Eligible Dependent as set forth in Section 1.15.

B.  Forfeit of Eligibility
Retired or Disabled Employees who fail to enroll within the time limits set forth herein shall forfeit all future rights to participate in the Retired and Disabled Employee Program for themselves and their Eligible Dependents

Question 4

If I am eligible for Medicare, do I need to enroll in Medicare?

Accepted Answer

All coverage (except Death, Accidental Death and Dismemberment, Prescription Drug Benefits and Medicare Supplemental Benefits) shall cease as of the date an Eligible Employee or Dependent becomes eligible for hospital and medical insurance under Social Security Medicare whether or not the individual is enrolled in the program. This provision applies only to expenses incurred on or after the date the person becomes eligible for Medicare.

For purposes of making it clear what this means, if the individual qualifies for Medicare coverage for either hospital or physician services, and the individual does not enroll in Medicare, the claims under this Plan shall be calculated as if the individual had enrolled in both Part A and B of Medicare and benefit limits shall be restricted by the regular rules of the Plan and shall be reduced by any payments which would have been made by Medicare regardless of the fact that the individual is not enrolled in the program.

Question 5

If I die, can my spouse continue to be eligible?

Accepted Answer

Section 3.16 - Eligibility For Widows/Widowers Of Active Employees Or Retired Or Disabled Employees
The widow or widower of a deceased, active Employee or eligible retired or Disabled individual and his Eligible Dependents that were eligible under this Plan at the time of death may elect to maintain eligibility for benefits from the Plan by making self-payments in a timely manner as set by the Trustees provided the widow or widower meets all of the following terms and conditions:

A.   Eligibility 
In order to be eligible for this program, the widow or widower:

(1) will become eligible upon the death of the active, eligible Employee or retired or Disabled individual and upon approval of the Plan.

(2) will become eligible no later than ninety (90) days after the expiration or cancellation of any other health care plan, program or policy in effect on the active, eligible Employee or retired or Disabled individual's date of death, which provided coverage to such widow or widower, including COBRA coverage and upon approval of the Plan.

B.   Effective Date of Coverage
The window or widower's coverage under this program shall commence with the first day of the month following the receipt of the required self-payment and approval by the Trustees.

C.   Contribution Payments
Contribution payments must be made on a monthly or quarterly basis and must be made by the tenth day of the eligibility month or the tenth day of the first month of the Benefit Quarter.

Failure to make timely and continuous payments as described above shall terminate the individual's right to make further payments and be covered under the Plan. NO LATE PAYMENTS SHALL BE ACCEPETED.

D.   Benefits
Benefits payable under the Widow/Widower Program shall be the same as provided to the dependent spouse of active, eligible employees or retired or disabled individuals. In addition, all benefits shall be coordinated with Medicare or Medicaid programs. No Death, Accidental Death and Dismemberment or Weekly Disability Benefits shall be payable.

E. Termination of Coverage
Coverage un the Widow/Widower Program shall terminate on:

(1) the first day of any month for which no contribution is paid; or

(2) the first day of the Benefit Quarter following the Benefit Quarter in which the widow or widower remarries; or

(3) the first day of the Benefit Quarter in which the widow or widower is covered for benefits under another group health care or group insurance plan.

(4) the effective date of the withdrawal of the Employee's Union from the Plan.

The Trustees reserve the right to terminate benefits or to change the requirements for participation of widows or widowers.

Question 6

How do I add dependents, and how long are my children eligible as dependents?

Accepted Answer

To add dependents, please complete the dependent form found in your initial eligibility packet or download it from this website under Members - Forms page and submit it along with the applicable documents requested on the BACK OF THE FORM.

Section 1.15 Eligible Dependent
"Eligible Dependent" means:

A.   the legal spouse of the eligible Employee;

B.  a child, adopted child, stepchild or legal ward of the eligible Employee from birth until the end of the month the child turns age twenty-six (26);

As used herein "adopted child" shall also include a child placed for adoption and means an individual who has not reached age twenty-six (26) as of the date of the assumption and retention by an eligible Employee of a legal obligation for total or partial support of such child in anticipation of such child. The child's placement with the eligible Employee terminates upon the termination of the legal obligation set forth above;
or

C.   an unmarried child, adopted child, stepchild or legal ward of the eligible Employee over age twenty-six (26) who is incapable of self-sustaining employment due to mental or physical handicap, who is dependent upon the eligible Employee for primary support and maintenance, and whose mental or physical handicap commenced prior to his attaining age twenty-one (21). In order for said individual to remain eligible, notification of such handicap must be given to the Plan Office prior to said child's attaining age twenty-one (21) and a determination made by the Board of Trustees of continuing eligibility;

D.  a child for whom an eligible Employee is ordered by a United States court of competent jurisdiction to provide medical coverage in accordance with the provisions of a Qualified Medical Child Support Order.

"Eligible Dependent" shall NOT include an individual who is in military service. Please notify the Plan immediately of any status changes for your dependents.

Question 7

What are my loss of time benefits?

Accepted Answer

Section 4.04 - Weekly Disability Benefit 
When Sickness, Accident,  or Injury suffered on or off the job shall disable and prevent a Covered Employee in the labor market area from engaging in any gainful employment, the Plan shall pay the benefit set forth in the Schedule of Benefits. Benefits shall be paid for full weeks of Disability only and no benefits shall be paid for partial weeks of Disability. In the case of a Disability which extends over two (2) calendar years, the maximum period of benefits will NOT extend beyond the maximum period of fifteen (15) weeks. In order to qualify for additional benefits after a calendar year period, the Employee must return to active employment for one (1) full week consisting of forty (40) hours.

Accrued Weekly Disability Benefits shall, subject to receipt of proper proof of loss, be paid provided the period for which payment is sought has elapsed. In the case of an Accident or Injury, payment will be made beginning with the first day of the Accident or Injury. In the case of a Sickness, payment with begin on the eighth day of the Sickness. However, if the Sickness is due to a maternity leave after the birth of a child for a child-bearing Covered Employee working under a Collective Bargaining Agreement, payment will begin on the first day of the Sickness.

Payment will NOT be made if: 
(A)   the Employee engages in any work or gainful employment during any period for which he is claiming benefits; or

(B)   the Employee is NOT under the regular care and treatment of a Physician or surgeon; or

(C)   the Employee is receiving a salary or would be receiving pay while in either a retired status or while Sick or Injured.

In accordance with federal law, the appropriate amount of Social Security taxes (FICA) shall be withheld from each payment and forwarded to the appropriate governmental agency.

No Weekly Disability Benefits shall be paid on behalf of an Eligible Dependent, a retired or Disabled individual or a widow or widower.

Question 8

What requires pre-certification?

Accepted Answer

Section 5.02 – Prior Authorization
Prior authorization is the process the Plan uses to evaluate the Medical Necessity of certain services, treatments, and facility stays, the number of days required to treat your condition, and any applicable benefit limitations and criteria.

In most cases, your Covered Provider or Covered Facility will take care of requesting prior authorization. As you are still responsible for ensuring that prior authorization is completed, you should always ask your physician, hospital, inpatient residential treatment center, whether or not they have contacted the Plan’s medical management vendor and provided all necessary information.

The following medical services require prior authorization: Please see the Prescription Drug benefit for information on drugs and services covered by the Prescription Drug benefit that may require prior authorization.

Outpatient ServicesArteriograms/Angiograms/AortagraphyMRI/MRACardiac RehabOrthotics & ProstheticsChemotherapyOccupational TherapyCochlear Implants/Other Auditory ImplantsPain Management Epidural Steroid InjectionsCT/CTAPain Management Trigger Point or Facet InjectionDental General AnesthesiaPhotodynamic TherapyDurable Medical Equipment (C-Pap doesn’t require prior authorization)Physical TherapyGenetic TestingPulmonary RehabHome Health CareRadiofrequency Ablation/RhizotomyHome Infusion TherapyShock wave lithotripsy/radiation for Plantar FasciitisSleep StudiesSpinal ProceduresMedical SuppliesSpeech TherapyMedication by Infusion & by InjectionSurgery in an outpatient FacilityMental Health IOPVein Ablation/Varicose Vein TreatmentMental Health PHPVision Therapy

Inpatient Services

Outpatient Services

This list may change over time and should not be considered an exhaustive list of services requiring prior authorization. For more information, contact the Fund Office.

Special Note Regarding Medicare: If you are enrolled in Medicare on a primary basis (Medicare pays before the Plan), the prior authorization requirements for services covered by Medicare do not apply to you. Since Medicare is the primary payer, in the Plan will process payments as secondary payer.

Question 9

What are the Plan's wellness benefits?

Accepted Answer

Section 5.06 – Wellness Benefits
Benefits will be paid for the specific routine preventive services listed in this section, as set forth in the Schedule of Benefits. If you do not meet the requirements and limitations for the wellness services described in this Section 5.06, these services and supplies will be subject to coverage under the Plan’s Major Medical Benefit, as described in Section 5.03 and the Schedule of Benefits.

A.  Routine Adult Physical Exam
One (1) office visit for a routine adult physical exam per Calendar Year is available for Eligible Individuals age two (2) and over. All other services and supplies provided in connection with a Routine Adult Physical Exam may be paid under the Plan’s Major Medical Benefit, as described in Section 5.03 and the Schedule of Benefits.

B.  Routine Pap Smear for Cervical Cancer Screening
One (1) routine pap smear per year is available.

C.  Routine Prostate Specific Antigen (PSA) Test for Prostate Cancer Screening
One (1) routine PSA test per year is available.

D.  Routine Mammogram for Breast Cancer Screening
One (1) routine mammogram per year is available to a Covered Individual aged forty (40) and over.

E.  Routine Sigmoidoscopy for Colorectal Cancer Screening
One (1) routine sigmoidoscopy every five (5) years is available to a Covered Individual aged forty-five (45) and over.

F.   Routine Colonoscopy for Colorectal Cancer Screening
One (1) routine colonoscopy every five (5) years is available to a Covered Individual aged forty-five (45) and over.

G.  Well-Child Exam and Routine Immunizations
Routine well child exams and all routine immunizations recommended by the Center for Disease Control are available for Covered Individuals from birth through age twenty-four (24) months.

H.  Routine Adult and Childhood Immunization
Routine adult and childhood immunizations recommended by the Center for Disease Control are available for Covered Individuals age two (2) and over if the immunization is recommended by a Physician, excluding the purposes of occupation and/or vacation travel.

Question 10

Who can I designate as my beneficiary?

Accepted Answer

Section 4.01 - Death Benefit
Upon the death of an eligible individual and receipt of proper proof of death, the Plan shall pay the Death Benefit as set forth in the Schedule of Benefits to the designated Beneficiary. In the event that the deceased Employee dies without designating a Beneficiary or in the event that the designated Beneficiary has predeceased the Employee, the amount of the Death Benefit shall be paid to the first applicable of the following surviving individuals in equal shares, in descending order:

The deceased Employee's surviving Spouse; child or children; parents; siblings; or failing these, to the deceased Employee's estate.

Benefits payable to minor children may be paid to the minor’s legal guardian.

Notwithstanding the foregoing, an Employee’s designation of his spouse as Beneficiary shall become null and void automatically upon divorce. Should the Employee wish to maintain the Beneficiary designation of an ex-spouse, he must fill out a new beneficiary card after the divorce.

An eligible individual may designate a new Beneficiary at any time by filing a written request for a change on forms provided by the Plan. A change of Beneficiary shall NOT be effective until received by the Plan provided that said change is received prior to the eligible individual's death.

No Death Benefits shall be paid on behalf of a deceased Eligible Dependent, widow or widower.

Question 11

Are breast pumps a covered benefit for dependent spouses?

Accepted Answer

Breast Pump Benefit 
Effective September 1, 2024, the Plan will implement a new breast pump benefit that will include expenses incurred for a breast pump that is ordered by a Physician for an Employee or a Dependent Spouse during the 3rd trimester of pregnancy through six months after delivery.

The Plan will reimburse the Employee or Dependent Spouse for a breast pump subject to the following limitations:
100% of the cost of one of the following breast pumps; not subject to the Plan’s annual deductible:
-  Abana™ Hands-Free Wearable Breast Pump
-  Ameda® Mya Joy Double Electric Pump
-  Cimilre® E1 Portable Breast Pump
-  Lansinoh® SignaturePro® Double Electric Pump
-  Lansinoh® DiscreetDuo™ Breast Pump
-  Medela Pump In Style with MaxFlow Double Electric Breast Pump
-  Motif Twist Breast Pump
-  Zomee Z2 Double Electric Breast Pump
and only 1 breast pump per birth.

To receive reimbursement under this benefit, the Employee or Dependent Spouse must provide a copy of:
the Physician’s prescription written for the Employee or Dependent Spouse for the breast pump,
the itemized bill/invoice of the breast pump, and
the paid in full receipt from the vendor/provider providing the breast pump.

Breast pump supplies or replacement costs will not be covered by the Plan.

As a reminder, the Plan does not provide maternity benefits, including this new breast pump benefit, for Dependent Children who may become pregnant.

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