What is a deductable?
The deductible is the amount of out-of-pocket expenses that a member must pay before the health insurance carrier will pay benefits. For individual coverage you must pay the first $100 of charges each calendar year. There is a $200 aggregate family deductible for family coverage. This means that all family members will be added together to satisfy the $200 total family deductible per calendar year, however no one person can pay more than the individual deductible of $100 in a calendar year..
What is coinsurance?
After the deductible has been met the insurance carrier will pay 80% of the usual and customary charges for benefits covered under our group contract that are subject to coinsurance provisions. When the insurance carrier has paid out $2000 worth of coinsurance on your behalf the coinsurance provision will no longer apply and then 100% of the usual and customary charges for covered services will be covered for the remainder of the calendar year.
What is a co-payment?
A co-payment is the amount of out-of-pocket expense associated with a particular service. The PPO Plan has several levels of co-payments ranging from $10/visit for physical therapy to $250 for an inpatient hospital stay.
What is an EOB (Explanation of Benefits)?
This is a statement sent directly from the insurance carrier providing specific details about how and why benefit payments were or were not made on a claim. It summarizes the charges submitted and processed, the amount allowed, the amount applied to deductible, the amount applied to coinsurance, the amount paid, and the member's balance, if any. An EOB is generated for every claim submitted to the health insurance provider.
How do I become eligible for benefits under the Local No. 7 Welfare Plan?
Journeymen establish eligibility by working at least 840 hours in covered employment in 12 consecutive months. After working the appropriate number of hours you will satisfy the general eligibility requirements and become eligible for all benefits offered under the plan. Apprentices establish eligibility for health, prescription, and dental coverage by working at least 420 hours in covered employment in 6 consecutive months. Apprentices must work 840 hours in covered employment in 12 consecutive months to be eligible for all benefits under the plan
How is my welfare fund or personal account balance calculated?
A portion of employer contributions are credited or "deposited" in your personal account for each hour you work in covered employment. Monthly deductions or "withdrawals" will be made for your insurance coverage after the general eligibility requirements are met and you remain available for covered employment. The difference between these deposits and the withdrawals will be your personal account balance and may be used for additional reimbursements. Under no circumstances can this balance be less than $0.
When do I become eligible for reimbursements from my personal account?
To be eligible for reimbursements the balance in your account must exceed 8-months insurance premium required for family coverage, which is currently $11,286.00. Under no circumstances can you withdraw funds if your personal account balance would then be less than this minimum balance. Claims may only be submitted it they total at least $200. You may add several bills together in order to reach $200. Total reimbursements may not exceed $15,000 per plan year (July 1st - June 30th). Claims submitted for reimbursement must be made within twelve months from the date the expense was paid.
What if my reimbursable expenses do not exceed $200?
In the months of March and November covered bills may be submitted for any amount as long as the other previously mentioned requirements are met (see section "How is my welfare fund or personal account balance calculated?").
How do I withdraw money from my personal account?
All requests for reimbursements must be made on a Personal Account Reimbursement Form (PAR Form). Along with the PAR Form you must provide proof of payment, an invoice/bill from the provider and an EOB (see question #3) for expenses covered by a health insurance carrier.