EIT Benefits
Electrical Insurance Trustees (EIT Benefit Funds) is pleased to
provide you with this Summary Plan Description (SPD or handbook)
describing the health care and welfare benefits available to eligible
participants as of January 1, 2008.
The SPD provides information about the plan provisions governing
your health care benefits — including eligibility, coverage levels and
plan guidelines. Consider this SPD, which is available in print and
online at www.fundoffice.org, to be your primary reference guide for
your benefits — the first place to turn when you have a question
about your benefits or your rights as a plan participant.
Table of Contents
EIT Benefits .......................................................................................................... 1
About this Handbook .......................................................................................... 3
What Happens If… ............................................................................................... 5
Family/Life Changes ....................................................................................... 6
Job-Related Changes ................................................................................... 12
Health Care......................................................................................................... 17
Participation................................................................................................... 19
Medical Benefits............................................................................................ 30
Behavioral Health and Substance Abuse Benefits ....................................... 48
Prescription Drug Benefits ............................................................................ 51
Dental Benefits.............................................................................................. 54
Vision Benefits............................................................................................... 59
Continuing Coverage .................................................................................... 62
Glossary ........................................................................................................ 67
Disability............................................................................................................. 73
Participation................................................................................................... 74
Short-Term Disability Benefits....................................................................... 77
Long-Term Disability Benefits ....................................................................... 79
Glossary ........................................................................................................ 82
Life Insurance and AD&D.................................................................................. 83
Participation................................................................................................... 84
Life Insurance Benefits.................................................................................. 87
Accidental Death & Dismemberment (AD&D) Benefits................................. 88
Glossary ........................................................................................................ 90
Rules, Regulations and Administrative Information...................................... 91
Contact Information......................................................................................... 101
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EIT Benefits
2 September 2008 y BHSM
About this Handbook
If You Have Questions
If you have questions
about the information in
this handbook, contact the
claims administrators for
the plans in question or
call the Fund Office at
1-312-782-5442.
See the Contact
Information section of this
handbook for claims
administrator names and
other contact information.
This Summary Plan Description (SPD or handbook) explains how
you become eligible for coverage and how coverage can be lost —
and describes the health care and welfare benefits available as of
January 1, 2008 to participants in the Electrical Insurance Trustees
(EIT) Health & Welfare Plan that applies to you. To understand the
plan, you must read the whole SPD. This SPD also serves as the
official plan document, and supersedes and replaces any prior SPD
and Summaries of Material Modification previously provided by EIT
for the plans of benefits described in it. If you need more
information, you may examine copies of the applicable collective
bargaining agreement and other related documents at the Fund
Office.
The benefits and other principal provisions described in this handbook are
effective only if you are eligible for coverage, become covered and remain
covered according to the provisions of the applicable benefit plan.
Benefits are contingent upon the financial adequacy of the plan to which
employer contributions are made. Benefits under the plan will be paid only when
the Trustees, or persons delegated by them to make such decisions, decide in
their sole discretion, that the participant or beneficiary is entitled to benefits under
the terms of the plan. The Trustees have the authority and unconditionally
reserve the right, in their sole and unrestricted discretion, to change, amend or
end the plan at any time, or from time to time, for any reason.
The Trustees want to assure you that your personal information will be kept
private. The information will only be disclosed to appropriate parties as required
by the operation of the plan, such as to determine plan eligibility and benefit
eligibility, process claims, set contribution rates or to occasionally monitor the
performance of the claims administrators.
Overview of the Handbook
This handbook is designed to help you understand how your benefits work. It is
divided into sections describing each benefit plan, as shown in the table of
contents. For details about a specific plan, refer to that section. There, you’ll find
another table of contents to help you find what you’re looking for in that section.
BHSM y September 2008 3
About this Handbook
Health Care Benefits
Benefits as of January 1, 2008 include:
• Medical
• Behavioral Health/Substance Abuse
• Prescription Drug
• Dental
• Vision
Disability Benefits (not available for Participatory Plan participants)
Benefits as of January 1, 2008 include:
• Short-Term Disability
• Long-Term Disability
Insurance Benefits*
Benefits as of January 1, 2008 include:
• Basic Life Insurance (formerly called Death Benefits)
• Accidental Death & Dismemberment (AD&D)
* Insurance benefits for Participatory Plan participants include Basic Life Insurance and Accidental
Death benefits.
Each benefit is described in this handbook. The handbook also includes
important information regarding:
• What to do when certain family/life or job changes occur,
• Eligibility for benefits,
• How to file a claim under the benefit plans, and
• Certain legal rights you have as a plan participant.
If You Need Help Understanding this Handbook
This handbook contains a summary of your plan rights and benefits under the EIT
Health & Welfare Plan that applies to you. If you have difficulty understanding any
part of this handbook, contact the Fund Office. You may also call the claims
administrators for the individual plans of benefits for assistance (see the Contact
Information section of this handbook for claims administrator names and other
contact information).
4 September 2008 y BHSM
What Happens If…
EIT benefits are designed to help and support you during family/life
and job changes, expected and unexpected. This section gives you
information on your benefits and outlines the steps you should take
when certain events occur.
In This Section See Page
Family/Life Changes............................................................................................ 6
If I Marry .......................................................................................................... 6
If I Legally Separate or Divorce....................................................................... 8
If I Become a Parent ....................................................................................... 8
If My Dependent Loses Eligibility .................................................................... 9
If I Become Disabled ..................................................................................... 10
If I Die ............................................................................................................ 11
If My Dependent Dies.................................................................................... 11
Job-Related Changes........................................................................................ 12
If I’m a New Participant ................................................................................. 12
If I Do Not Meet the Contributed Hours Requirement................................... 14
If I’m Laid Off ................................................................................................. 15
If I Terminate Employment ............................................................................ 15
If I Retire........................................................................................................ 16
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What Happens If…
Family/Life Changes
This section describes what you should do if you experience family
or life changes such as getting married, becoming a parent,
becoming disabled — or in the event you or your covered
dependent loses eligibility or dies.
If I Marry
Health Care
In the case of a marriage, you may want to add dependents to your health care
coverage, such as your new spouse and any stepchildren. If your spouse is
already covered as a participant under the plan, he or she can be covered as a
dependent, too. (See “Participation” in the Health Care section for more
information about eligibility requirements for you and your dependents.)
Contact the Fund Office to make benefit changes and provide the following
documentation or information as applicable:
Eligible
Dependents
What You Must Do to Add Dependents
Lawful spouse You must provide:
• A copy of the marriage certificate, which has been
certified by the state in which you were married.
• A certified copy of your spouse’s birth certificate, his or
her Social Security number, and all insurance
information to assist in the coordination of benefits.
Unmarried
stepchildren
under the age of
19
See “Participation” in the Health Care section for details
about eligibility requirements for dependent children.
To enroll eligible new dependents, you must:
• Provide a certified copy of the child’s birth certificate and
a letter from you requesting coverage for the stepchild.
• Include information on any other health care coverage
the child has, including the policyholder’s name and
Social Security number, policy name, policy number and
mailing address. If there is no other health care
coverage, indicate this in your letter.
Important Note!
If both you and your
spouse are covered as
participants, you both may
cover your eligible
dependents under the
plan. However, your and
your dependents’ health
care coverage will be
coordinated so the plan
won’t pay more than 100%
of the covered expenses
for services and supplies.
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What Happens If…
Eligible
Dependents
What You Must Do to Add Dependents
Unmarried
children under
the age of 23 if
full-time
students
In addition to the documentation noted above, if your new
dependent is age 19 through age 22 and a full-time student,
you must provide verification of student status and full-time
enrollment every term, semester, trimester, etc. Verification
includes a letter from the school’s Registrar’s office
indicating full-time student status and dates of the term.
(Eligibility continues for 120 days after the last day of full-
time attendance.)
Note: Health care coverage under the plan ends on the
dependent’s 23
rd
birthday regardless of full-time student
status.
See “Participation” in the Health Care section for details
about eligibility requirements for dependent children.
Children ages 19
and older if
physically or
mentally
disabled
In addition to the documentation noted above, if your new
dependent is age 19 or older and disabled, you will have to
provide proof of disability (based on medical evidence) and
financial dependence. You have 31 days before your child
turns age 19 (or age 23 if covered as a full-time student) to
apply for continuation of dependent benefits. Proof of
disability and financial dependence may also be requested
on an ongoing basis.
See “Participation” in the Health Care section for more
information about dependent benefits for physically or
mentally disabled children and the definition of disabled.
If both you and your spouse are covered as participants, you both may cover your
eligible dependents under the plan. However, your and your dependents’ health
care coverage will be coordinated so the plan won’t pay more than 100% of the
covered expenses for services and supplies.
Life Insurance and AD&D Benefits
You may wish to contact the Fund Office to update your beneficiary designation
for your Life Insurance and AD&D benefit coverage. Your beneficiary designation
applies to both the Basic Life Insurance and the AD&D accidental death benefit.
You may change your beneficiary at any time by filing a new beneficiary
designation form with the Fund Office. Forms must be received by the Fund
Office during your lifetime in order to be valid.
Retirement
Pension Plan No. 4
Your new spouse may be entitled to a benefit under Pension Plan No. 4 when
you die. Contact the Fund Office to add your spouse to their benefit records.
BHSM y September 2008 7
What Happens If…
If I Legally Separate or Divorce
If you get divorced or legally separated, contact the Fund Office to make benefit
changes or update your beneficiary forms.
Health Care
The health care coverage of your ex-spouse and any stepchildren will end at the
time of your divorce or legal separation. Upon termination of coverage, your ex-
spouse and stepchildren will be notified of their COBRA rights.
You Are Responsible…
If you do not notify the
Fund Office of your
divorce or legal separation
and the plan pays benefits
for an ineligible
dependent, you must
reimburse the plan for any
such benefits paid.
A Qualified Medical Child Support Order (QMCSO) may be required to document
your responsibility for medical coverage of your eligible dependent children. If a
court order says you are responsible for medical coverage, be sure to notify the
Fund Office.
It is your responsibility, as the participant, to provide the Fund Office with a copy
of the final entered Order of Dissolution of marriage. If you do not notify the Fund
Office of your divorce or legal separation and the plan pays benefits for an
ineligible dependent (e.g., an ex-spouse or stepchild) you must reimburse the
plan for any such benefits paid. See “Overpayment” in the Health Care section.
Life Insurance & AD&D Benefits and Retirement
To ensure benefits are paid as you want if you should die, you may want to
update your beneficiary designations for these benefits. Contact the Fund Office
for new beneficiary designation forms. Forms must be received by the Fund
Office during your lifetime in order to be valid.
If I Become a Parent
Family leave benefits may be available during and after a pregnancy or adoption.
If you do not provide notice, your coverage would end when a shortage of hours
occurs. For more information, see “Family Medical Leave Act (FMLA)” in the
Health Care section.
Health Care
Contact the Fund Office to add your new dependent for health care coverage.
You will need to provide the following information as applicable:
Eligible
Dependents
What You Must Do to Add Dependents
Natural born
unmarried
children under
the age of 19
Provide a certified copy of the birth certificate or paternity
test. These documents must list the eligible participant as
one of the biological parents.
Adopted
children (or
children placed
in your home for
legal adoption)
under the age
of 19
Provide a finalized copy of the adoption papers (in English)
or an interim order through the courts.
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What Happens If…
If both you and your spouse are covered as participants, you both may cover your
eligible dependents under the plan. However, your dependents’ health care
coverage will be coordinated so the plan won’t pay more than 100% of the
covered expenses for services and supplies.
Life Insurance and AD&D Benefits
You may wish to contact the Fund Office to update your beneficiary designation
for your Life Insurance and AD&D benefit coverage. Your beneficiary designation
applies to both the Basic Life Insurance and the AD&D accidental death benefit.
You may change your beneficiary at any time by filing a new beneficiary
designation form. Forms must be received by the Fund Office during your lifetime
in order to be valid.
If My Dependent Loses Eligibility
Health Care
You should contact the Fund Office to notify them that your dependent is going to
lose eligibility for health care coverage due to:
• Reaching age 19 (or age 23 if he or she is a full-time student living with you
and financially dependent on you),
• Loss of student status after reaching age 19,
• Marriage, or
• Your divorce or legal separation.
You can also obtain information from the Fund Office on COBRA continuation of
coverage procedures and costs.
Divorce or Legal Separation
Ex-spouses and stepchildren who are no longer eligible for health care coverage
because of divorce or legal separation may be able to continue such coverage
through COBRA for up to 36 months from the date on which coverage ends.
Important Note!
If you do not notify the
Fund Office of your
divorce or legal separation
and the plan pays benefits
for an ineligible
dependent, you must
reimburse the plan for any
such benefits paid.
Notify the Fund Office of the family status change. Once health care coverage is
terminated, your ex-spouse and stepchildren will receive COBRA information,
including COBRA procedures, necessary forms and costs.
It is your responsibility, as the participant, to provide the Fund Office with a copy
of the final entered Order of Dissolution of marriage. If you do not notify the Fund
Office of your divorce or legal separation and the plan pays benefits for an
ineligible dependent (e.g., an ex-spouse or stepchild) you must reimburse the
plan for any such benefits paid. See “Overpayment” in the Health Care section.
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What Happens If…
If I Become Disabled
Health Care
If you become disabled as a result of an accident or injury while an active
employee, you may be entitled to receive a benefit from the plan. You or your
beneficiary must notify the Fund Office of your disability.
Your health care coverage will be continued as described below:
• If you become disabled, your health care coverage will continue for up to 27
weeks, provided you are receiving weekly short-term disability benefits or
Workers’ Compensation.
• After the 27-week period ends, you may continue to be eligible for up to an
additional 104 weeks of coverage if you have been a participant for at least
one year before your disability began — and you provide proof of continued
disability to the Trustees.
You may also be eligible for COBRA continuation coverage when your health
care coverage would otherwise end. In the event of a disability, COBRA coverage
may be continued for up to a total of 29 months. See “Continuing Coverage” in
the Health Care section
for more information.
Disability
To file a claim for disability benefits, contact the Fund Office for a claim form and
all disability procedures to follow.
Retirement
Pension Plan No. 4
You may be eligible for a disability pension if your employment ends because of a
disability that begins after you have at least 10 years of eligibility service. Contact
the Fund Office to apply for disability benefits and to see if you qualify for a
disability pension.
If I Have a Workers’ Compensation Claim…
If you become disabled because of an occupational injury or illness, your health
care and welfare benefits will continue during your disability for up to 27 weeks.
To continue coverage you must have filed a claim with your employer and
Workers’ Compensation. If you are still disabled after 27 weeks, you may be
eligible for up to an additional 104 weeks of coverage if:
• You have been a participant in the plan for at least one year before your
disability began, and
• You provide the Trustees with proof of continued disability. Contact the Fund
Office for the necessary application form.
Note: Claims must be filed within 365 days of the last day worked. Claims filed
after 365 days will not be accepted and no eligibility credit will be provided.
Applying for Social
Security Benefits…
Be sure to apply for Social
Security disability benefits
by contacting the Social
Security Administration at
1-800-772-1213.
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What Happens If…
If I Die
Health Care
If you die, your surviving spouse will remain eligible for health care coverage for
90 days, whether or not he or she is entitled to Medicare. Your eligible dependent
children will also remain eligible for health care coverage for 90 days. If your child
stops attending school during this time, he or she is eligible for 120 days of health
care coverage from the last day of full-time attendance (not to exceed a total of
90 days or past his or her 23
rd
birthday).
Your spouse and eligible dependent children may then apply for and continue
health care coverage under COBRA for up to 36 months by paying the applicable
premium. See “Continuing Coverage” in the Health Care section for more
information about COBRA.
Life Insurance and AD&D Benefits
Your designated beneficiary must notify the Fund Office of your death and obtain
a claim form. The claim form must be completed and filed with the Fund Office
within 365 days of the date of your death. The Trustees may require your
beneficiary to submit additional information to the Fund Office.
You or your designated beneficiary must also contact the Fund Office to obtain a
claim form in the event you need to file an accidental death or dismemberment
claim. The claim form must be completed and returned within 90 days of the date
of the accident or death. You or your designated beneficiary may also be asked
to supply other information as requested.
Retirement
Pension Plan No. 4
If you die while actively employed, your spouse may be eligible for a monthly
benefit from Pension Plan No. 4. To apply for pension benefits, your spouse
should contact the Fund Office for benefit forms. He or she may be asked to
supply evidence of age and any other additional information, such as a death
certificate.
If My Dependent Dies
If a covered dependent dies, you should consider the following:
• Cancel dependent health care coverage, if appropriate.
• Update your beneficiary designations for Life Insurance and AD&D coverage.
• Adjust your W-2 withholding rate.
Contact the Fund Office for more information.
BHSM y September 2008 11
What Happens If…
Job-Related Changes
This section describes what you should do if you experience job-
related changes such as becoming a new participant, failing to meet
contributed hours requirements, being laid off, ending employment,
or retiring.
If I’m a New Participant
Health Care
You are eligible for benefits beginning, retroactively, on the first day of the month
after receipt of contributions from your employer for 600 hours of active work. You
must have worked these hours within a period of six consecutive months.
If the collective bargaining agreement under which you are employed requires
your employer to contribute for a full 40-hour week for any week in which you
perform any work covered by the agreement, you will be credited with 40 hours
for each such week for which your employer contributes.
When you receive your insurance acknowledgement, you will be asked to submit
a certified copy of your birth certificate.
You cannot be covered as both a participant and a dependent child under
the plan.
Once you are eligible for benefits, you can also choose to cover your dependents.
Eligible dependents and the documentation or information you must provide
include:
Eligible
Dependents
What You Must Do to Add Dependents
Lawful spouse You must provide:
• A copy of the marriage certificate, which has been
certified by the state in which you were married, and
• A certified copy of the spouse’s birth certificate, his or
her Social Security number, and all insurance
information to assist in the coordination of benefits.
Natural born
unmarried
children under
the age of 19
See “Participation” in the Health Care section for details
about eligibility requirements for dependent children.
To enroll natural born children, you must provide a certified
copy of the birth certificate or paternity test. These
documents must list the eligible participant as one of the
biological parents.
Important Note!
If both you and your
spouse are covered as
participants, you both may
cover your eligible
dependents under the
plan. However, your and
your dependents’ health
care coverage will be
coordinated so the plan
won’t pay more than 100%
of the covered expenses
for services and supplies.
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What Happens If…
Eligible
Dependents
What You Must Do to Add Dependents
Unmarried
stepchildren
under the age
of 19
To enroll stepchildren, you must:
• Provide a certified copy of the child’s birth certificate and
a letter from you requesting health care coverage for the
stepchild.
• Include information on any other coverage the child has,
including the policyholder’s name and Social Security
number, policy name, policy number and mailing
address. If there is no other coverage, indicate this in
your letter.
See “Participation” in the Health Care section for details
about eligibility requirements for dependent children.
Adopted
children (or
children placed
in your home for
legal adoption)
under the age
of 19
Provide a finalized copy of the adoption papers (in English)
or an interim order through the courts.
Unmarried
children under
the age of 23 if
full-time
students
In addition to the documentation noted above, if your
dependent child is age 19 through age 22 and a full-time
student, you must provide verification of student status and
full-time enrollment every term, semester, trimester, etc.
Verification includes a letter from the school’s Registrar’s
office indicating full-time student status and dates of the
term. (Eligibility continues for 120 days after the last day of
full-time attendance.)
Note: Health care coverage stops on the dependent’s 23
rd
birthday regardless of full-time student status.
See “Participation” in the Health Care section for details
about eligibility requirements for dependent children.
Children ages 19
and older if
physically or
mentally
disabled
In addition to the documentation noted above, if your
dependent child is age 19 or older and disabled, you will
have to provide proof of disability (based on medical
evidence) and financial dependence. You have 31 days
before your child turns age 19 (or age 23 if covered as a full-
time student) to apply for continuation of dependent
benefits. Proof of disability and financial dependence may
also be requested on an ongoing basis.
See “Participation” in the Health Care section for more
information about dependent benefits for physically or
mentally disabled children and the definition of disabled.
If both you and your spouse are covered as participants, you both may cover your
eligible dependents under the plan. However, your and your dependents’ health
care coverage will be coordinated so the plan won’t pay more than 100% of the
covered expenses for services and supplies.
BHSM y September 2008 13
What Happens If…
Disability
You are eligible for benefits beginning, retroactively, on the first day of the month
after receipt of contributions from your employer for 600 hours of active work. You
must have worked these hours within a period of six consecutive months.
Dependents are not eligible for disability benefits. You are automatically the
beneficiary of any disability benefits.
Life Insurance and AD&D Benefits
You are eligible for benefits beginning, retroactively, on the first day of the month
after receipt of contributions from your employer for 600 hours of active work. You
must have worked these hours within a period of six consecutive months.
Dependents are not eligible for Life Insurance and AD&D benefits.
Designating a Beneficiary
Designate your beneficiaries for any Life Insurance or AD&D benefits by
completing and returning the proper designation form. Your beneficiary
designation applies to both the Basic Life Insurance and the AD&D accidental
death benefit. (Under the AD&D plan, benefits for accidental
injury/dismemberment are paid to you.)
Beneficiary designation forms are available by contacting the Fund Office. You
may change your beneficiary at any time by filing a new beneficiary designation
form. Forms must be received by the Fund Office during your lifetime in order to
be valid.
Retirement
Pension Plan No. 4
Contact the Fund Office or refer to the Pension Plan No. 4 Summary Plan
Description (SPD) for information on this plan.
If I Do Not Meet the Contributed Hours
Requirement
Health Care
If you fail to meet any contributed hours requirements, your health care benefit
coverage will end. You may apply for COBRA continuation of coverage in the
fourth consecutive quarter (see “Continuing Coverage” in the Health Care
section).
Note: If you are on an approved family medical leave or military leave of
absence, your coverage may also continue. Contact the Fund Office for more
information.
Disability
If you fail to meet any contributed hours requirements, your welfare benefit
coverage will end.
Life Insurance and AD&D Benefits
Your Life Insurance and AD&D benefit coverage also will end if you fail to meet
any contributed hours requirements.
14 September 2008 y BHSM
What Happens If…
Retirement
Pension Plan No. 4
Contact the Fund Office or refer to the Pension Plan No. 4 Summary Plan
Description (SPD) for information on this plan.
If I’m Laid Off
Health Care
You may apply for COBRA continuation of coverage (see “Continuing Coverage”
in the Health Care section).
Disability
Disability coverage will end the day you no longer meet eligibility requirements.
Life Insurance and AD&D Benefits
You may apply for Life Insurance conversion. See “Conversion Privilege” in the
Life Insurance and AD&D section for information.
Retirement
Pension Plan No. 4
Contact the Fund Office or refer to the Pension Plan No. 4 Summary Plan
Description (SPD) for information on this plan.
If I Terminate Employment
Health Care
If you terminate your employment with a contributing employer, your benefit
coverage will end. However, you may be able to continue your health care benefit
coverage — medical, prescription drug, dental, orthodontic, vision and hearing
aid — for yourself and your eligible dependents for a limited period of time under
COBRA. See “Continuing Coverage” in the Health Care section.
When your or your covered dependent’s health care coverage under the plan
ends, you will receive a certificate of prior health coverage. Show this to your new
employer to avoid a loss of coverage and/or pre-existing conditions limitations.
Disability
Disability coverage will end the day you no longer meet eligibility requirements.
Life Insurance and AD&D Benefits
Life Insurance and AD&D coverage will end the day you no longer meet eligibility
requirements. However, you may have the option to convert your Basic Life
Insurance benefit to an individual life insurance policy if you terminate
employment. Contact the Fund Office for more information.
Retirement
Pension Plan No. 4
Contact the Fund Office or refer to the Pension Plan No. 4 Summary Plan
Description (SPD) for information on this plan.
BHSM y September 2008 15
What Happens If…
If I Retire
Disability
Other Things to
Consider
Contact the Social
Security Administration at
1-800-772-1213 at least
three months before you
plan to retire to apply for
Social Security and
Medicare Benefits.
Your disability benefits will end upon your retirement.
Life Insurance and AD&D Benefits
Your Life Insurance and AD&D benefits will end upon your retirement. However,
you may have the right to convert your Basic Life Insurance benefit to an
individual life insurance policy when you retire. Contact the Fund Office for more
information.
Retirement
Pension Plan No. 4
Contact the Fund Office or refer to the Pension Plan No. 4 Summary Plan
Description (SPD) for information on this plan.
16 September 2008 y BHSM
Health Care
The Health & Welfare Plan provides you with comprehensive health
care coverage that gives you and your eligible family members
protection against the financial impact of covered medical, dental
and other health care expenses.
In This Section See Page
Participation ....................................................................................................... 19
Participant Eligibility ...................................................................................... 19
Dependent Eligibility...................................................................................... 21
Cost of Coverage.................................................................................... 23
When Coverage Begins ................................................................................ 24
When You Have Other Coverage ................................................................. 24
Subrogation ............................................................................................ 26
Overpayment .......................................................................................... 26
If You Are on a Leave of Absence ................................................................ 27
If Benefits Are Suspended ............................................................................ 27
How to Continue Coverage if You Are Disabled ........................................... 28
When Coverage Ends ................................................................................... 28
Medical Benefits ................................................................................................ 30
Using Your Medical Benefits ......................................................................... 33
Paying for Your Care .............................................................................. 34
Medical Service Advisory........................................................................ 36
Covered Medical Expenses .......................................................................... 38
Additional Medical Benefits .................................................................... 39
Medical Expenses Not Covered.................................................................... 44
Filing a Claim................................................................................................. 46
Behavioral Health and Substance Abuse Benefits ........................................ 48
Using Your Behavioral Health and Substance Abuse Benefits .................... 49
Filing a Claim................................................................................................. 50
Prescription Drug Benefits ............................................................................... 51
Using Your Prescription Drug Benefits ......................................................... 51
Covered Expenses........................................................................................ 52
Expenses Not Covered ................................................................................. 53
Filing a Claim................................................................................................. 53
Dental Benefits................................................................................................... 54
Using Your Dental Benefits ........................................................................... 55
Covered Expenses........................................................................................ 56
Expenses Not Covered ................................................................................. 57
Filing a Claim................................................................................................. 58
BHSM y September 2008 17
Health Care
Vision Benefits ................................................................................................... 59
Using Your Vision Benefits............................................................................ 60
Covered Expenses ........................................................................................ 60
Expenses Not Covered ................................................................................. 61
Filing a Claim................................................................................................. 61
Continuing Coverage......................................................................................... 62
Glossary.............................................................................................................. 67
18 September 2008 y BHSM
Health Care
Participation
This section describes how you and your eligible dependents can
participate in health care benefits, including who is eligible, when
health care coverage begins, maintaining health care coverage and
when health care coverage ends.
Your Health Care Coverage at-a-Glance
The following table summarizes when participant health care coverage begins,
continues, ends and resumes. See the remainder of this “Participation” section for
more details.
Health Care
Coverage
Begins…
Health Care
Coverage
Continues…
Health Care
Coverage
Ends…
Health Care
Coverage
Resumes…
As an eligible
participant, health
care coverage
begins
retroactively on
the first day of the
month after
receipt of
contributions for
600 hours of
active work within
a period of six
consecutive
months.
Your health care
coverage
continues as long
as you have 450
contributed hours
in the previous
three months or
1,800 contributed
hours in the
previous 12
months.
Health care
coverage ends at
the end of the
second month
after your
contributed hours
are fewer than:
• 450 hours in
the previous
three months;
or
• 1,800 hours
in the
previous 12
months.
If you lose health
care coverage,
your coverage
resumes if you
again have 450
contributed hours
during any three
consecutive
months within 52
weeks of your
loss of coverage.
Participant Eligibility
You are eligible for health care coverage under the plan beginning, retroactively,
on the first day of the month after receipt of contributions for 600 hours of active
work. You must have worked these hours within six consecutive months.
Contribution Periods
A contribution period is
defined by the month in
which a paycheck is
issued, and is based on
the date an employer is
required to make a
contribution.
If the collective bargaining agreement under which you are employed requires
your employer to contribute for a full 40-hour week for any week in which you
perform any work covered by the agreement, you will be credited with 40 hours
for each such week for which your employer contributes.
BHSM y September 2008 19
Health Care
Maintaining Your Coverage
Once you become eligible, you and your dependents will continue health care
coverage depending on the contributions received from your employer during
quarterly or annual contribution periods. You need contributions received for at
least:
• 450 hours in the most recent three months, or
• 1,800 hours in the most recent 12 months.
The Fund Office reviews your contributed hours each month to determine your
eligibility for benefits. Here’s how it works:
• If you worked sufficient hours for the quarter of review or the previous three
months or the previous 12 months, your benefits continue until the next
review.
• If you fail both hours requirements, your coverage ends.
• Benefits continue for the current month, while the calculations of the prior
month are being reviewed. Current hours are not a factor in your termination
of benefits.
If you are unable to work because of a sickness or injury, you may be credited
with 37-1/2 hours for each week of proven disability during any one period of
continuous disability. You must be:
• Eligible for short-term disability or long-term disability benefits from the
Welfare Fund, or
• Receiving disability benefits from Workers’ Compensation.
Credit will be given for up to 131 weeks if you were covered under the plan for at
least 12 consecutive months prior to the disability or for up to 27 weeks if you
were covered for fewer than 12 consecutive months prior to the disability.
Insufficient Contributed Hours
It is your responsibility to know when your coverage will end because of
insufficient contributed hours. The Fund Office, Welfare Fund and the Trustees
are not obligated or required to notify you of loss of coverage.
If the plan mistakenly pays benefits for an ineligible dependent or after you have
lost coverage because of insufficient hours, you must reimburse the plan for
any such benefits paid.
How to Reinstate Coverage
If you lose coverage due to the contributed hours requirements, you can reinstate
your coverage. Reinstatement begins, retroactively, on the first day of the month
after receipt of contributions for 450 hours of active work. You must have worked
these hours during any three consecutive months.
If you do not qualify for reinstatement within 52 weeks, you can become eligible
for coverage like a new participant. This means you need to complete 600
contributed hours of active work within six consecutive months.
20 September 2008 y BHSM
Health Care
Dependent Eligibility
You can also choose to cover your eligible dependents for health care benefits
under the plan. Eligible dependents and required documentation include the
following. (See the “Definition of Dependent” and “Definition of Child” below for
more information on who is considered to be an eligible dependent.)
Eligible
Dependents
Documentation Requirements
Lawful spouse Provide a copy of your marriage certificate. The certificate
must have been certified by the state in which you were
married.
Natural born
unmarried
children under the
age of 19
Provide a certified copy of the birth certificate or paternity
test. These documents must list the eligible participant as
one of the biological parents.
Unmarried
stepchildren
under the age
of 19
Provide a copy of the child’s birth certificate and a letter
with information on any other coverage the child has,
including the policyholder’s name and Social Security
number, policy name, policy number and mailing address.
If there is no other coverage, indicate this in your letter.
Adopted children
(or children
placed in your
home for legal
adoption) under
the age of 19
Provide a finalized copy of the adoption papers (in English)
or an interim order through the courts.
Unmarried
children under the
age of 23 if full-
time students
To be eligible, the child must be a full-time student as
determined by the educational institution, must rely on you
or your spouse for more than 50% of his or her financial
support, and normally reside in your home.
Once your child reaches age 19 through age 22, you must
provide verification of student status every term, semester,
trimester, etc. Verification includes a letter from the
school’s Registrar’s office indicating full-time student
status and dates of the term. Eligibility continues for 120
days after the last day of full-time attendance.
Coverage stops on the dependent’s 23
rd
birthday
regardless of full-time student status.
BHSM y September 2008 21
Health Care
Eligible
Dependents
Documentation Requirements
Children ages 19
and older if
physically or
mentally disabled
To be eligible, the child must rely on you or your spouse
for more than 50% of his or her financial support and
normally reside in your home.
The child is considered disabled if he or she is so severely
impaired, physically or mentally, that he or she cannot
perform in school or at work without assistance, and he or
she is not capable of self-support. The impairment must be
considered permanent or expected to last at least 12
months. The determination must be based on medical
evidence. The child is not considered disabled if disability
is solely due to alcoholism or drug addiction.
You have 31 days before your child turns age 19 (or
age 23 if covered as a full-time student) to apply for
continuation of dependent benefits. You may have to
provide proof of disability and financial dependence on an
ongoing basis.
Definition of Children
“Children” means any one of the following individuals:
• Your legitimate child born of a valid marriage or your natural child who is not
a legitimate child born of a valid marriage,
• A child, under age 19, who you legally adopt or who is placed in your home
pending legal adoption, or
• A stepchild, which means a child of your current spouse who, prior to your
marriage, was born to your spouse.
Definition of Dependent
“Dependent” means any one of the following individuals:
• Your lawful spouse
• Your unmarried child, provided that your child:
− Is dependent on you for at least one-half of his or her support,
− Lives with you for at least one-half of the calendar year, and
− Is less than 19 years old or, if at least 19 but less than 23 years old, is a
registered full-time student in an accredited secondary school, college,
university, vocational or technical school.
• Your unmarried child who does not live with you, provided that:
− Your child does not provide more than one-half of his or her own support,
− Your child is your legitimate child born of a valid marriage,
− Your child is in the custody of his or her other parent, from whom you are
divorced or legally separated, and
− Under a domestic relations order or a written agreement with the child’s
custodial parent, you are entitled to claim the child as a dependent for
income tax purposes.
22 September 2008 y BHSM
Health Care
• Your unmarried child who does not live with you, if the plan is required by a
Qualified Medical Child Support Order (QMCSO) to consider that child as an
eligible dependent. Any benefits paid by the plan pursuant to a QMCSO, in
reimbursement of expenses paid by the child’s custodial parent or legal
guardian, will be paid to the child’s custodial parent or legal guardian.
• Your unmarried disabled child, provided that your child:
− Is dependent on you for at least one-half of his or her support,
− Lives with you for at least one-half of the calendar year, and
− Is 19 years or older and became disabled prior to age 19. For purposes
of this paragraph, “disabled” means that the child is unable to engage in
any gainful activity without assistance by reason of a medically
determinable physical or mental impairment that is expected to result in
death or last for a continuous period of 12 months or more. The Trustees
may require you to furnish proof of the child’s continued disability from
time to time, but not more often that once in a 12-month period.
Coverage will terminate if the Trustees determine, based upon medical
evidence, that the child is no longer disabled or if the child does not
undergo an examination or furnish proof required by the Trustees.
If Both You and Your Spouse Are Covered Participants
If both you and your spouse are covered as participants, you both may cover your
eligible dependents for health care benefits under the plan. However, your and
your dependents’ coverage will be coordinated so the plan won’t pay more than
100% of the covered expenses for services and supplies.
Qualified Medical Child Support Order (QMCSO)
A Qualified Medical Child Support Order (QMCSO) is a legal judgment, decree or
order issued under a state domestic relations law by a court or an administrator.
A QMCSO creates or recognizes the rights of a child to coverage for health care
benefits.
Under a child support order, a court can require you to provide coverage to a
child under this plan.
The Fund Office will notify you if any of your children are affected by a QMCSO.
You may contact the Fund Office to request a copy of the procedures, free of
charge, the plan uses to determine whether a medical child support order is
qualified.
Cost of Coverage
In general, your employer pays the entire cost of coverage. However, if the
collective bargaining agreement states a specific dollar amount to be contributed
by your employer, you may have to pay the difference in the cost of coverage.
Your employer will let you know the amount you have to pay if anything.
BHSM y September 2008 23
Health Care
When Coverage Begins
Benefit coverage begins on the first day of the month after you complete the
eligibility requirements (see “Participant Eligibility” on page 19). Your dependents
are eligible to join the plan on the same day you are eligible for coverage.
If you marry, your new spouse and your spouse’s dependent children are eligible
for coverage on your marriage date. For newborn eligible dependents, coverage
begins on the date of birth. For adopted children, coverage begins as directed in
the final adoption papers. For children placed in your home, coverage begins on
he date verified in the interim order. See “Dependent Eligibility” on page 21 for
more information.
When You Have Other Coverage
When you or your eligible family members are covered by more than one health
care plan, benefits may be payable under both plans. When this happens, the
benefit payments are coordinated so that your total benefits from both plans do
not exceed 100% of the usual and customary (U&C) costs of the services
provided.
Prescription Drug
Benefits
Prescription drug benefits
under this plan are not
coordinated with any other
coverage. You or your
dependents must receive
prescription drug benefits
through the primary plan to
have them covered.
Coordinating with
COBRA
For information on how the
plan coordinates with
COBRA coverage, see
“Continuing Coverage”
beginning on page 62.
See “Coordinating with Other Health Plans” below for the coordination rules that
apply to this plan.
Coverage Under Another EIT Plan
If you are eligible for health care coverage as a participant under another EIT
plan, and become covered by that plan, your benefits under this plan will stop
while you are covered by the other plan. You cannot receive benefits as a
participant under two different EIT plans at the same time. You also cannot
receive benefits as a participant and a dependent child under two EIT plans.
You can, however, be covered as a dependent spouse under one EIT plan and a
participant under another EIT plan. In this case, coordination of benefits will
apply.
Coordinating with Other Health Plans
When you and any covered dependent have other health care coverage, benefits
from this plan will be coordinated with the other coverage. Your total benefits will
not be more than 100% of the U&C costs of the services provided. Benefits
payable from other plans are considered, even if:
• You do not request payment of them, or
• The other plan refuses to pay due to a failure to follow plan rules. For
example, if your dependents have primary coverage under a health
maintenance organization (HMO), your dependent must access care through
the HMO and follow all procedures of the HMO.
The plan will pay benefits as discussed in each benefit section. In any case,
where more than one plan may provide benefits, applications for benefit
payments should be made to all plans concerned. Keep in mind, however, that
prescription drug benefits under this plan are not coordinated with any other
coverage. You or your dependents must receive prescription drug benefits
through the primary plan to have them covered.
24 September 2008 y BHSM
Health Care
Using COB provisions, one group plan has “primary” responsibility and pays first.
The other group plan has “secondary” responsibility and considers any additional
benefits not covered by the primary carrier. Generally, this is how COB works:
Claims for Secondary
Coverage
If the provider will not
submit a claim for
secondary coverage, it is
your responsibility, as the
participant, to file the claim
in a timely manner.
1. The amount payable by a plan covering a person as a an active employee
will be determined first. Then, the benefits of a different plan covering the
same person as a dependent are determined.
2. If a child is covered by more than one plan or under this plan by both parents:
− Primary coverage for a dependent child will be the plan of the person
(participant or spouse) whose birth date (month and day) occurs first in
the calendar year.
− If the father and mother have the same birthday, the plan that has
covered the child the longest will be primary.
− If the other plan coordinates benefits based on the gender of the parents,
the child’s primary plan will be the male parent’s primary plan.
Primary coverage for a dependent child whose parents are separated or
divorced will be determined in the following order:
− The plan of the parent with legal custody of the child, or
− If a court decree establishes financial responsibility for a child’s health
care expenses, the primary plan is the plan of the parent with that
responsibility.
3. When none of these situations applies, the medical plan that has covered a
person the longest will pay first.
It is the participant’s responsibility to see that a claim for secondary coverage is
filed in a timely manner. COB claims can be filed within one year of the date that
the primary carrier either pays their portion or denies the claim.
Claims Administrators’ Rights
The plan has the right to receive and release necessary information to determine
whether coordination of benefits or any similar provisions apply to a claim. If the
plan makes larger payments than are necessary under the COB provision, the
appropriate claims administrator has the right to recover those excess payments.
Recovery may be made from any insurance company, any organization and/or
any persons to or for whom those payments were made. In the case of
underpayment, the plan may reimburse another plan directly instead of paying
the person requesting benefit payment.
Coordinating with Medicare
Integrating Benefits with Medicare
While you are actively employed, regardless of your age, the plan is primary to
Medicare for you and your covered dependents. Benefits under the plan are
determined before Medicare’s benefits.
Medicare Coverage for Disabled Individuals
If you or your covered dependents are totally disabled for at least 24 months and
do not have current employment status, Medicare will provide primary medical
coverage. Once you or your dependent is declared disabled by Social Security,
the disabled individual should apply for coverage under Medicare Parts A and B.
BHSM y September 2008 25
Health Care
Medicare Coverage for Individuals with End-Stage Renal Disease
In all situations involving end-stage renal disease (ESRD), regardless of age or
Medicare status, the plan is the primary payor of medical expenses for the first 30
months of entitlement to Medicare because of ESRD. After the first 30 months of
ESRD entitlement, Medicare is the primary payor, and the plan is the secondary
payor. Primary coverage ends 36 months after the month in which a patient has a
successful kidney transplant.
Subrogation
If you or your dependent incurs medical or dental charges due to injuries caused
by a third party, you may have a claim against the third party, or an insurer, for
payment of those medical or dental charges. By accepting benefits for those
charges under this plan, you automatically assign the plan any rights you or your
dependent may have to recover payments from the third party or insurer.
This subrogation right allows the plan to pursue any claim you or your dependent
has against any third party or insurer, whether or not you or your dependent
chooses to pursue that claim. The plan may make a claim directly against the
third party or against the insurer. If you or your dependent file a claim, the plan
has a right to any amount recovered by you or your dependent, whether or not it
is designated as payment for medical or dental expenses. This remains in effect
until the plan is paid in full.
When you accept benefits under this plan, you acknowledge the plan’s right to
subrogation and reimbursement. The plan’s rights to subrogation and
reimbursement give the plan priority over any funds paid by a third party to you or
your dependent relative to the injury or sickness. This includes priority over any
claim for non-medical or dental charges, attorneys’ fees or other costs and
expenses (the Illinois Common Doctrine or any other state law affecting these
rights is preempted). The plan’s rights are limited to the extent to which it has
made or will make payments for medical or dental charges, as well as any costs
and fees incurred as a result of enforcing its rights under the plan.
When a right of recovery exists, no benefits will be paid unless and until you
return a signed agreement to the Fund Office stating that you will do whatever is
necessary to secure the plan’s right of subrogation. In addition, you must not do
anything to hinder the plan’s right to subrogate.
If the entire amount paid by the plan is not refunded out of the amount you
receive from the third party or insurer, the Trustees reserve the right to deduct the
missing amount from your future claims or from your dependents’ future claims.
Overpayment
The plan has a right to a refund from you or your dependent, if either of the
following apply:
• You or your covered dependent recovers money for expenses incurred due
to an illness or injury for which a benefit has been paid under this plan. The
amount to be refunded will be the lesser of the full amount that you or your
covered dependent recovers or the amount of benefits paid by the plan.
• The plan pays benefits for an ineligible individual you had listed as a covered
dependent. The amount to be refunded is the amount of benefits paid by the
plan.
26 September 2008 y BHSM
Health Care
If You Are on a Leave of Absence
Family Medical Leave Act (FMLA)
Coverage during FMLA
or Military Leave
Health care coverage
under the plan continues
during your approved
FMLA leave or military
leave of absence.
If you are eligible, you are entitled to request up to a 12-week FMLA leave in any
12-month period for the following reasons:
• Birth and care of a newborn child
• Placement of a child with you for adoption or foster care
• Care of your spouse, child or parent with a serious health condition
• A serious health condition that prevents you from performing your job
If your request is granted, your health care coverage under the plan continues
during your approved leave.
To be eligible for FMLA, you must:
• Have worked at least 12 months for a participating employer, and
• Have at least 1,250 hours of contributions within the last 12 months from the
leave starting date.
If you would like to take an FMLA leave of absence, you must notify your
employer and the Fund Office. For more information about FMLA or if you have
any questions, please contact the Fund Office.
Military Leave of Absence (Voluntary or Involuntary)
If you are on a military leave of absence under the Uniformed Services
Employment and Reemployment Rights Act (USERRA), your and your
dependents’ coverage will continue under the plan.
You must provide the Fund Office with a copy of your orders that gives both a
report date and a discharge date. You will receive five hours of credit for each
day you are on a military leave. For additional information about a military leave
of absence, contact the Fund Office.
If Benefits Are Suspended
If your participating employer has not submitted contributions for the hours you
worked, coverage for you and your covered dependents will be suspended if you
continue working for that employer while they are delinquent.
Your coverage will be retroactively reinstated once your employer is in
compliance with the collective bargaining agreement or if you stop working for
that employer.
Suspension of benefits is not a COBRA qualifying event. That means you and
your eligible dependents are not entitled to COBRA solely because benefit
coverage is suspended. See “Continuing Coverage” on page 62 for information
about events that do qualify you and your dependents for COBRA.
BHSM y September 2008 27
Health Care
How to Continue Coverage if You Are Disabled
If you become disabled and are unable to work, your coverage will continue
during your disability for up to 27 weeks. To continue coverage, you must receive
weekly short-term disability benefits or Workers’ Compensation.
If you are still disabled after 27 weeks, you may be eligible for up to an additional
104 weeks of coverage if:
• You have been a participant in the plan for at least one year, and
• You provide the Trustees with proof of continued disability.
When Coverage Ends
Your coverage under the plan ends when the first of the following occurs:
Notice of Insufficient
Contributed Hours
It is your responsibility to
know when your coverage
will end due to insufficient
contributed hours. Notice
of loss of coverage from
the Fund Office is not an
obligation of the Welfare
Fund, its Trustees or the
Fund Office.
You must reimburse the
plan for any benefits paid
that:
• Have already been
recovered by you or a
dependent, or
• Have been paid for an
ineligible individual.
• You fail to meet either contributed hours requirement,
• Your employer fails to make the required contributions to the plan on your
behalf,
• You receive benefits under Pension Plan No. 4,
• You die,
• You become eligible under another plan administered by EIT, or
• The plan terminates, for any reason.
Your dependent coverage ends when the first of the following occurs:
• When your coverage ends (see the following table for information about
continuing coverage for your spouse and eligible dependent children in the
event of your death),
• For your spouse and any stepchildren, at the time of your legal divorce or
legal separation,
• On your dependent’s death,
• When your dependent child reaches the age limit, or
• You become eligible under another plan administered by EIT.
The following table summarizes situations in which coverage would normally end
and how you may be able to maintain or continue coverage in each situation.
28 September 2008 y BHSM
Health Care
Health Care Coverage
Ends…
However, Health Care Coverage May Continue if…
At the end of the
month following the
month you fail to meet
the hours requirement
You apply for COBRA continuation of coverage (see
“Continuing Coverage” on page 62).
If you retire and are
receiving a benefit
from Pension Plan
No. 4
You apply for COBRA continuation of coverage (see
“Continuing Coverage” on page 62).
If you die You are survived by a spouse and/or other eligible
dependents. Coverage continues for 90 days for your
surviving spouse, regardless of whether or not he or
she is entitled to Medicare.
Eligible dependent children also remain eligible for 90
days. If your child stops attending school during this
time, he or she is eligible for 120 days of coverage
from the last day of full-time school (not to exceed a
total of 90 days or past his or her 23
rd
birthday).
Coverage then ends unless your dependents apply
for and pay COBRA continuation of coverage (see
“Continuing Coverage” on page 62).
If the plan is
discontinued
No further coverage.
The Trustees will make every effort to notify you by mail if you lose coverage for
any reason. The notice will be sent to the address on file at the Fund Office. Be
sure to notify the Fund Office in writing if you or any covered dependent has a
change of address.
BHSM y September 2008 29
Health Care
Medical Benefits
The medical benefits available to you under the plan help you pay
for covered medical care and protect you from the financial impact
of catastrophic expenses.
Your Medical Benefits at-a-Glance
You can visit any licensed physician or other covered provider you select. In
general, the plan pays a percentage of the charges for medically necessary
covered services after you have met your deductible. When you use a PPO
network provider, you will receive the highest level of benefits available through
the plan (see “Using Your Medical Benefits” on page 33 for more information on
PPO providers).
Medical Benefits
In-Network Out-of-Network
Annual calendar year
deductible
$250 per person.
$500 per family.
Note: An additional $200 penalty applies if the utilization review
organization is not notified or does not certify hospital admissions and
extensions.
Coinsurance and copays Plan pays 90% of PPO
negotiated rates after deductible;
you pay 10%, plus 10% of
covered charges for services.
Generally, the plan pays 80% of PPO
negotiated rates after deductible; you
pay 20%, plus any amount above the
negotiated rate.
Annual calendar year out-of-
pocket maximum
$2,250 per person.
$4,500 per family (includes deductible, but excludes copays and
behavioral health/substance abuse expenses).
Lifetime maximum benefit $2 million per person; separate $40,000 per person for substance abuse
treatment.
Wellness benefits • Plan pays for one annual physical per person, up to $75 (charges in
excess of $75 will be applied to the calendar year deductible and paid
based on the applicable percentage, as noted in “Coinsurance and
copays” above).
• Plan pays for one annual coronary artery scan per person upon
physician’s referral. Benefits are paid based on the applicable
percentage noted in “Coinsurance and copays” above.
• Plan pays for immunizations for children up to age 19 at 100% of PPO
negotiated rates, or 90% for individuals age 19 or older.
• No deductible applies.
Note: Regardless of age, if you use an out-of-network provider, you pay
20% of PPO negotiated rates, plus any amount over the PPO negotiated
rate.
30 September 2008 y BHSM
Health Care
Medical Benefits
In-Network Out-of-Network
$15 copay per visit. Plan pays 80% of PPO negotiated
rates. You pay 20%, plus any amount
over the PPO negotiated rates.
Physician office visits
• You may use any licensed physician; copays are not applied to
calendar year deductible or out-of-pocket maximum.
• Deductible applies
Plan pays 90% of PPO
negotiated rates after deductible.
Plan pays 80% of PPO negotiated
rates after deductible. You pay 20%,
plus any amount above the
negotiated rates.
Hospital services: inpatient,
outpatient and diagnostic
tests
Note: The utilization review organization must be notified of non-
emergency hospital admissions at least three days before treatment or
within 48 hours following an emergency admission or penalties may apply.
• Inpatient care covered at
100%.
• Outpatient care covered at
100% after $15 copay.
• $100 annual deductible per
person if out-of-network services
are used (separate from other
calendar year medical
deductible); then plan pays 80%
of usual and customary (U&C)
charges.
Behavioral health/substance
abuse benefits (not included in
out-of-pocket maximum)
• There is no referral requirement; participants may access outpatient
treatment directly for up to 30 visits per calendar year.
• Treatment limited to 30 inpatient days and 30 outpatient visits per
person per year unless additional days/visits are approved as
medically necessary.
• Plan pays 90% of PPO
negotiated rates.
• Plan pays 80% of PPO
negotiated rates. You pay 20%
plus any amount above the
negotiated rates.
Chiropractic and naprapathic
services
• Plan pays up to the first $3,000 in covered expenses per person per
calendar year.
• No deductible applies.
Hearing aid benefits • Annual calendar year benefit: $4,075 (includes exam benefit)
• Exam: Plan pays up to $75; one visit per year per person
• Instrument: Plan pays 80%, up to $2,500 per ear per person once
every 36 months, not to exceed two hearing aids.
• No deductible applies.
Home health care and hospice
services
• Plan pays 90% of PPO
negotiated rates.
• Plan pays 80% of PPO
negotiated rates. You pay 20%
plus any amount above the
negotiated rates.
BHSM y September 2008 31
Health Care
Medical Benefits
In-Network Out-of-Network
• Deductible applies.
• A medical necessity review is required.
Plan pays 90% of PPO
negotiated rates.
Plan pays 80% of PPO negotiated
rates. You pay 20%, plus any amount
above the negotiated rates.
Occupational therapy
• Plan pays up to the first $3,000 in covered expenses per person per
calendar year.
• A medical necessity review is required if expenses exceed $3,000 per
person per calendar year.
• No deductible applies.
Plan pays 90% of PPO
negotiated rates.
Plan pays 80% of PPO negotiated
rates. You pay 20%, plus any amount
above the negotiated rates.
Physical therapy
• Plan pays up to the first $3,000 in covered expenses per person per
calendar year.
• A medical necessity review is required if expenses exceed $3,000 per
person per calendar year.
• No deductible applies.
Plan pays 90% of PPO
negotiated rates.
Plan pays 80% of PPO negotiated
rates. You pay 20% plus any
compound above the negotiated
rates.
Speech therapy benefits
• Plan pays up to the first $3,000 in covered expenses per person per
calendar year.
• A medical necessity review is required if expenses exceed $3,000 per
person per calendar year.
• No deductible applies.
Other covered services:
• Emergency care
• Durable medical equipment
• Prosthetic devices
• Casts and splints
Plan pays 90% of PPO
negotiated rates after deductible.
Plan pays 80% of PPO negotiated
rates. You pay 20% plus any amount
above the negotiated rates.
Ambulance services 80% of billed charges after deductible.
32 September 2008 y BHSM
Health Care
Using Your Medical Benefits
You can visit any licensed physician or other covered provider you select. In
general, you pay the least for provider services if you use one of the plan’s PPO
network providers. For hospital services, such as inpatient, outpatient and
diagnostic tests, the amount you pay differs depending on if you visit a PPO
network provider or a non-PPO network (or “out-of-network”) provider. If you visit
a PPO provider, the plan pays 90% of PPO negotiated rates for covered
expenses after you pay the deductible, then you pay 10%. If you visit a non-PPO
provider, you generally pay 20% of PPO negotiated rates after the deductible,
plus all charges above the PPO negotiated rates. Your maximum out-of-pocket
cost in any year is $2,250 per person and $4,500 per family. Charges by out-of-
network providers above negotiated rates do not count toward the deductible or
out-of-pocket maximum.
I.D. Cards
If you’ve lost or misplaced
your I.D. card, contact
Blue Cross/Blue Shield
(BCBS) at 1-800-862-3386
for a replacement I.D.
card.
In-Network Care
When you receive care from in-network providers, you pay the full cost of
services until you meet your annual deductible. After you meet the deductible,
you pay a $15 copay for office visits and 10% of covered charges for any services
received during your office visit. Once you reach the out-of-pocket maximum, you
continue to pay your $15 office visit copay and the plan pays 100% for additional
covered expenses for the remainder of the calendar year.
If your in-network provider refers you to a specialist, he or she typically refers you
to another in-network provider. However, it is your responsibility to confirm that
the specialist participates in the Blue Cross/Blue Shield (BCBS) PPO network.
For a directory of PPO providers, visit www.bcbsil.com or call BCBS at
1-800-810-2583. You may also contact your physician directly to confirm whether
he or she participates in the BCBS PPO network.
Out-of-Network Care
Since out-of-network providers have not agreed to charge PPO negotiated rates,
they may charge any amount for services or supplies — which can cost you
more. If you receive care from an out-of-network provider, you pay the full cost of
services until you meet your annual deductible. After you meet the deductible, the
plan generally pays 80% of what the negotiated rate would have been had you
used a network provider. You are responsible for paying 20% of the negotiated
rate plus all charges above the negotiated rate. Charges by out-of-network
providers above negotiated rates do not count toward the deductible or out-of-
pocket maximum. With out-of-network providers, you have to pay the provider,
file claim forms and then wait for reimbursement.
Out-of-Area Care
If you live 10 miles or more from an in-network provider, you can receive health
care coverage from the plan of up to 80% of usual and customary (U&C) charges
after you meet the deductible. You pay 20%, plus any amount above U&C
charges. If you are out-of-area, any amount you pay above U&C does not apply
to your deductible or out-of-pocket maximum.
The 10-mile radius is based on the address that the Fund Office has on file for
you at the time of treatment.
BHSM y September 2008 33
Health Care
Out-of-Network Emergency Care
In an emergency, you or your dependents should seek treatment from the closest
physician or hospital. You will receive health care coverage of up to 80% of U&C
charges after you meet the deductible.
Any follow-up treatment that you or your dependent receives after discharge is no
longer considered emergency treatment. That means you or your dependent will
receive out-of-network benefit levels if the provider you see is not an in-network
provider. It is your responsibility to verify that any provider you see for follow-up
care after emergency treatment is an in-network provider or you will pay 20% of
the PPO negotiated rate plus any amount above the negotiated rate.
Participating Provider Option (PPO)
A PPO provider is a member of a network of providers that has agreed to provide
services at lower costs to network participants. By using one of the plan’s PPO
network (or “in-network”) providers you receive a higher level of coverage with a
lower out-of-pocket cost than if you use a non-PPO (“out-of-network”) provider.
When you use a PPO provider, the plan pays 90% of covered expenses and you
pay 10%. If you live within 10 miles of a network provider but you visit a non-PPO
provider, you pay 20% plus any amount above the negotiated rate. If you live
more than 10 miles away from all PPO network providers, out-of-area benefits
are available. For a list of the plan’s PPO network providers, log onto
www.bcbsil.com.
Paying for Your Care
Annual Deductible
For most services, you must satisfy a deductible before the plan begins to pay
benefits. The calendar year deductible is $250 per person and $500 per family. A
separate $100 calendar year deductible applies to out-of-network behavioral
health and substance abuse treatments (see “Behavioral Health and Substance
Abuse Benefits” beginning on page 48).
Coinsurance and Copays
Once you satisfy the deductible the plan pays 90% of PPO negotiated rates for
most covered in-network services; you pay 10%. For most covered out-of-
network services, the plan pays 80% of PPO negotiated rates; you pay 20%, plus
any amount above the PPO negotiated rate.
Copays for in-network office visits are $15, and do not apply to your annual out-
of-pocket maximum.
Annual Out-of-Pocket Maximum
The plan limits the amount you have to pay for covered medical expenses in any
calendar year. Your annual maximum out-of-pocket expense is $2,250 per
person and $4,500 per family. After you reach the out-of-pocket maximum, the
plan pays 100% of the remaining covered expenses for the rest of the year.
34 September 2008 y BHSM
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The out-of-pocket maximum does not include:
• Amounts in excess of PPO negotiated rates or U&C charges (for the
definition of usual and customary, see the “Glossary” on page 67),
• Office visit copays,
• Behavioral health and substance abuse treatment expenses,
• Prescription drug expenses, or
• Claims paid by third parties.
New deductible and out-of-pocket requirements apply each January 1 for the
remainder of the calendar year.
Lifetime Maximum
The plan’s lifetime maximum benefit for most covered medical expenses is
$2 million per person. Substance abuse treatment has a separate $40,000
lifetime maximum.
Know Which Services Need Precertification
Before you receive medical care, make sure you’re following the correct
procedures so you will receive the highest level of benefits for those services.
See “Medical Service Advisory” on page 36 and “Precertification” under “Medical
Service Advisory” on page 36 for details.
Information You Need to Provide
When you contact the plan’s utilization review organization, be prepared to
provide the following information:
• Name, address and telephone number of the attending and/or admitting
physician,
• Name of the hospital/location where the admission has been scheduled,
• Scheduled admission date, and
• Preliminary diagnosis or reason for the admission.
Behavioral Health and Substance Abuse Care
For behavioral health and substance abuse care, all inpatient services and
treatment must be precertified, whether provided in-network or out-of-network.
Additional days or visits (above the 30-day or 30-visit limit) also must be
approved by the behavioral health and substance abuse claims administrator as
medically necessary. See “Behavioral Health and Substance Abuse Benefits” on
page 48 for specific coverage information for this type of care.
After Treatment
File a Claim if Necessary
After you’ve seen your provider, remember to file a claim if necessary. See “Filing
a Claim” on page 46.
BHSM y September 2008 35
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Medical Service Advisory
The utilization review process helps you receive the appropriate levels of care in
the proper setting and for an appropriate length of time. The BCBS Medical
Service Advisory (MSA), the plan’s utilization review organization, must certify in
advance any:
Important Note!
Failure to precertify when
needed may result in
certain penalties and/or a
reduction in benefits.
• Hospital stays,
• Certain services which follow hospital stays, and
• Alternative courses of inpatient treatment from what was initially approved.
This helps ensure that your treatment is medically necessary. It also helps to
keep your health care costs under control. Failure to precertify may result in
certain penalties and/or a reduction in benefits.
You, a family member or your physician must notify the BCBS MSA, at
1-800-635-1928 at least three days before a scheduled procedure or within 48
hours following an emergency admission or when you:
• Are admitted to a hospital,
• Need an extension to a hospital stay,
• Have outpatient therapies in excess of $3,000 per person per year,
• Need durable medical equipment,
• Need home health care,
• Need hospice care, or
• Need skilled nursing facilities.
When you contact the utilization review organization, be prepared to provide the
following information:
• Name, address and telephone number of the attending and/or admitting
physician,
• Name of the hospital/location where the admission has been scheduled,
• Scheduled admission date, and
• Preliminary diagnosis or reason for the admission.
The utilization review organization will review the medical information provided
and may follow up with your physician. Keep in mind, the utilization review
organization may determine that the services to be provided are not medically
necessary. (Services must be considered medically necessary to be covered by
the plan.)
Precertification
When you or a family member are hospitalized, you must notify the utilization
review organization for your treatment to be reviewed. Notice must be received:
• At least three days before treatment for non-emergency hospital admissions,
or
• Within 48 hours following an emergency admission.
36 September 2008 y BHSM
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If you do not precertify when required, the following penalties and benefit limits
apply:
• You pay a $200 penalty for failure to precertify a hospital admission, and
• Your room and board expenses may be covered at 50% of the PPO
negotiated rates for not precertifying an admission or for any admission
reviewed but not approved.
The penalty and additional covered expenses apply toward your out-of-pocket
maximum.
Certifying Additional Days
If your physician feels it’s necessary for you to be confined longer than already
certified, you, your physician or the hospital may request an extension. Call the
utilization review organization no later than the last day that has already been
certified. If an extension is not certified, a continued hospital stay may not be
considered medically necessary. (Services must be considered medically
necessary to be covered by the plan.)
Hospital Stays for Childbirth
By law, benefits for any hospital stay in connection with childbirth for the mother
or the newborn cannot be restricted to less than:
• 48 hours following a normal vaginal delivery, or
• 96 hours following a cesarean section.
Neither you nor your physician need to precertify any length of stay less than
these periods. However, the physician, after consulting with the mother, may
discharge the mother or newborn before the 48 or 96 hours.
Case Management
After the utilization review organization evaluates your case, you may be
assigned a case manager. If you or a covered dependent has a serious or
prolonged illness, the case manager may discuss available treatment alternatives
with you and your physician. The case manager will continue to monitor your
case for the duration of your condition.
Centers of Excellence
The plan includes coverage for medically necessary, qualified transplant
procedures through the Centers of Excellence Program — a national transplant
network. The Centers of Excellence Program is a voluntary program that
coordinates care for those needing solid organ transplants or other specialized
care for a life-threatening and complex illness. The program is based on the idea
that the more experience a facility has with treating a complex medical condition,
the better it becomes at providing the treatment. That means you and your
covered dependents receive care at medical facilities that have been identified as
excelling in the type of treatment required.
Transplant procedures must be pre-authorized by the plan’s utilization review
organization and take place at one of the plan’s national transplant network
hospitals.
BHSM y September 2008 37
Health Care
Qualified procedures include:
• Combination heart/bilateral lung,
• Heart,
• Liver,
• Pancreas,
• Pancreas/kidney, and
• Single or bilateral lung.
Medical and surgical benefits provided through the network include coverage of
inpatient professional services and related institutional services and organ
procurement services for pre-authorized transplants.
Covered Medical Expenses
Generally, the plan pays 90% of PPO negotiated rates after the deductible for
covered medically necessary services provided in-network. For non-PPO
services, the plan usually pays 80% of PPO negotiated rates. Covered services
include:
• Semiprivate hospital room and board, routine nursing services and ancillary
charges
• Intensive or cardiac care services
• Cardiac rehabilitation, including Phase 1 and Phase 2 services started within
six months of release from an inpatient confinement (excludes programs
primarily for exercise such as Phase 3 services)
• Medical services and supplies, including anesthesia and its administration
• X-rays, laboratory tests and other diagnostic services
• Physicians’ charges for medical care and treatment, including surgery
• Transportation charges from the place where a disability began to the closest
facility or hospital equipped to furnish special treatment (transportation
includes professional ambulance service or air ambulance)
• Charges for treatment by a licensed physical, occupational or speech
therapist
• Charges for treatment of morbid obesity (for the definition of morbid obesity,
see the “Glossary” on page 67)
• Artificial limbs or eyes
• Orthotic devices including casts, splints, trusses, crutches and braces.
Excludes dental braces and over-the-counter orthotics
• Oxygen and rental of equipment to administer it
• Rental, or purchase at the option of the plan, of durable medical equipment,
including glucose and apnea monitoring devices, transneuromuscular
stimulators, wheelchairs, manually operated hospital beds and oxygen
machines (excludes sports equipment, convenience items like wheelchair
lifts, extended warranties, repairs and consumable items; e.g., air cleaners,
air purifiers, vacuum systems and filters)
38 September 2008 y BHSM
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• Dental care, artificial tooth implants and x-rays needed because of an
accidental injury to sound and healthy natural teeth; restorative dental care
needed due to chemical, x-ray or surgical treatment of mouth cancer; or the
rare congenital condition amelogenesis imperfecta
• Syringes for anything other than diabetes, which are covered under
prescription drug benefits
• Tuberculosis vaccines
• Mastectomy procedures including:
− Reconstruction of the breast on which the mastectomy has been
performed
− Surgery and reconstruction of the other breast to produce a symmetrical
appearance
− Prostheses and treatment of physical complications of all stages of
mastectomy, including lymphedemas
• Midwife services at a hospital or home delivery
• Services rendered by:
− Nurse practitioners
− Clinical nurse specialists
− Physician assistants
• Vision therapy
Additional Medical Benefits
Other services, treatment and supplies covered by the plan include the following:
Wellness Benefits
Wellness benefits are designed to encourage preventive treatment and routine
exams that can detect problems early.
Routine Physical Exam
You and your covered dependents may receive a routine physical exam once per
year. The plan pays the first $75 of the physician’s fees per covered person, per
year (any charge in excess of $75 will be applied to the calendar year deductible
and paid at the applicable in-network or out-of-network rate).
Note: Services must be billed as a physical exam to be covered as a wellness
benefit.
Coronary Artery Scan
You or your covered dependents may obtain a coronary artery scan to detect
calcification once a year upon a physician’s referral. The plan will pay 90% of
PPO negotiated rates if you use an in-network provider, or 80% of PPO
negotiated rates if you use an out-of-network provider.
BHSM y September 2008 39
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Immunizations
Immunizations for children up to age 19 are covered at 100% if you use an in-
network provider. The plan also covers flu shots for participants and covered
dependents at 100% of PPO negotiated rates. Immunizations for individuals
age 19 or older are covered at the applicable in-network or out-of-network rate.
See “Your Medical Benefits at-a-Glance” under “Medical Benefits” on page 30 for
other information about the coinsurance that may apply to wellness benefits.
Members Assistance Program (MAP)
The MAP provides counseling and education for covered participants and
dependents for up to three sessions per presenting issue at no charge.
For general information about the services provided, call the MAP at the number
listed in the Contact Information section.
Behavioral Health and Substance Abuse Benefits
See “Behavioral Health and Substance Abuse Benefits” beginning on page 48.
Attention-Deficit Disorder (ADD)/Attention-Deficit Hyperactivity
Disorder (ADHD) Benefits
The plan covers the initial assessment process, treatment and maintenance
medication for Attention-Deficit Disorder (ADD) and Attention-Deficit Hyperactivity
Disorder (ADHD). You must follow the behavioral health and substance abuse
precertification requirements for any inpatient treatment and for approval of
days/visits in excess of 30 for medical necessity. (See “Behavioral Health and
Substance Abuse Benefits” on page 48.)
Chiropractic Benefits
The plan covers treatment performed by a licensed chiropractor or naprapath for
you or your covered dependents. Chiropractic care means adjustments,
manipulation or other treatment (including naprapathy) to detect and correct
imbalance or dislocation of the bone structure in the human body. Naprapathic
care is a form of chiropractic care but follows a more holistic approach and does
not use drugs in treatment.
The plan pays 90% of up to $3,000 (combined limit for chiropractic and
naprapathic care) of PPO negotiated rates per person per calendar year. No
deductible applies.
Hearing Aid Benefits
The plan covers medically necessary hearing aid-related expenses.
You must visit a Board-certified otologist or otolaryngologist when you need
hearing aid care. You will be reimbursed for part of the expense of hearing exams
and hearing aid instruments (receipts must accompany claim forms). For hearing
aid instruments, the prescription must include the name, model number, battery
power and frequency response.
40 September 2008 y BHSM
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The plan pays benefits for the following expenses:
• Charges for a hearing exam performed by a legally qualified otologist or
otolaryngologist, up to $75 per calendar year
• Charges for a hearing aid instrument prescribed by a legally qualified
otologist or otolaryngologist, up to 80% of the first $2,500 per person per ear
once every 36 months, not to exceed two hearing aids
You pay no deductible.
In addition to the types of expenses listed in “Medical Expenses Not Covered” on
page 44, the plan does not cover the following hearing aid expenses:
• Exams not performed and hearing aid instruments not prescribed by a legally
qualified otologist or otolaryngologist
• Replacement of lost or stolen hearing aid instruments
• Batteries or repair of hearing aid instruments
Hearing aid discounts are available through the EPIC Hearing Service Plan. For
more information, see the following box. You may not be covered under both
the BCBS hearing benefits and EPIC. If you choose not to utilize EPIC,
submit claims to BCBS.
EPIC Hearing Aid Benefits
The EPIC (Ear Professionals International Corporation) Hearing Service Plan is a
negotiated and managed benefit. You pay nothing to join and you enjoy reduced
rates for most fees and costs associated with your hearing health care under the
plan. EPIC identifies and screens qualified experts in hearing evaluation and
treatment — physicians and audiologists. EPIC negotiates prices for treatment
protocols and hearing aids, which may be 20%-60% less than manufacturers’
suggested retail price for hearing devices you might get from a non-EPIC
provider.
EPIC coordinates coverage with your existing health care plan hearing aid
benefits.
Summary of Benefits and Savings
• Hearing tests
• Hearing aids
• Hearing aid batteries*
• Ear protection*
• Swimmer ear plugs*
• Musician ear plugs*
• Hearing aid cleaning supplies and accessories*
• Assistive listening devices*
• TV Ears (amplifies and clarifies television sound)*
• Telephone amplification*
• Alerting and signaling devices*
* EPIC can help you obtain these supplies at a reduced cost; however, these services are not
covered under your healthcare plan.
BHSM y September 2008 41
Health Care
EPIC Hearing Aid Benefits
How to Activate and Use Your EPIC Benefits
1. Call EPIC Hearing Healthcare at 1-866-956-5400.
2. EPIC will send you a card with all the information you need to access your
benefits, including:
– Referrals to provider(s) located near you
– An Activation Form to access the provider(s)
– A booklet outlining all plan benefits in detail
– An EPIC phone contact to answer any questions about the plan
3. Follow through with appointment, examination and treatment.
4. All payments are to EPIC HSP. No other billings or payments should occur.
5. Contact EPIC at any time for assistance, advice and information.
EPIC Hearing Claims
If you use EPIC discounts and benefits, EPIC will process your hearing claim,
and bill you for your coinsurance payment (your coinsurance amount is 20% of
the charge for covered services). EPIC then reimburses your provider directly.
You may not be covered under both BCBS hearing benefits and EPIC.
Participants who do not utilize EPIC may submit hearing claims to BCBS,
with covered expenses paid as described in “Hearing Aid Benefits” under
“Additional Medical Benefits” on page 39.
Home Health Care Benefits
The plan covers part-time or intermittent basis home nursing care of a
homebound participant or covered dependent if:
• Care is provided by a licensed home health care organization,
• Continued hospitalization of the participant or covered dependent would
otherwise be required, and
• Care is reviewed and certified in advance as medically necessary by the
utilization review organization.
Covered services include professional services of appropriately licensed and
certified individuals in skilled nursing and home health aide care, as well as other
care approved by the plan.
The following home health care expenses are not covered:
• Expenses for custodial or homemaker services, food and housing
• Supportive items such as air conditioners, hand rails, ramps, telephones and
similar items
• Benefits that are the subject of other plan provisions, such as prescription
drugs, durable medical equipment, ambulance service or diagnostic services
• Items excluded from coverage by any other plan provision
42 September 2008 y BHSM
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Hospice Care Benefits
The plan covers services provided for a terminally ill participant or covered
dependent if:
• Care is provided by a hospice care organization, hospital or skilled
nursing/inpatient rehabilitation facility,
• The attending physician statement indicates the life expectancy to be six
months or less, and
• Care is reviewed and certified in advance as medically necessary by the
utilization review organization.
Covered services include professional services of appropriately licensed and
certified individuals in skilled nursing and home health aide care, as well as other
care approved by the plan.
The following hospice care benefits are not covered:
• Expenses for custodial or homemaker services, food and housing
• Supportive items such as air conditioners, hand rails, ramps, telephones and
similar items
• Benefits that are the subject of other plan provisions, such as prescription
drugs, durable medical equipment, ambulance service or diagnostic services
• Items excluded from coverage by any other plan provision
• Charges for pastoral, financial, legal, bereavement or other counseling
• Charges associated with funeral arrangements
Physical and Occupational Therapy Benefits
Physical and occupational therapy benefits cover expenses for restoring physical
capabilities lost due to an accident or illness. Benefits are available per condition
per year for each type of therapy.
Physical therapy is covered by the plan if:
• Treatment is ordered by a physician,
• Treatment is performed by a licensed physical therapist using physical
means, hydrotherapy or biomechanical and neurophysiological principles,
and
• Services are expected to allow the participant or covered dependent to regain
physical capabilities lost due to an accident or illness.
Occupational therapy is covered by the plan if:
• Treatment is ordered by a physician,
• Treatment is performed by a licensed occupational therapist using
constructive means designed and adapted to restore physical capabilities lost
due to an accident or illness, and
• Services are expected to allow the participant or covered dependent to
perform tasks required by his particular occupation or the ordinary tasks of
daily living.
BHSM y September 2008 43
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The plan pays 90% of PPO negotiated rates for the treatment if you use an in-
network provider — or 80% of PPO negotiated rates if you use an out-of-network
provider — up to $3,000 for each type of therapy per person per calendar year.
No deductible applies. If more than $3,000 in expenses is requested for physical
or occupational therapy, a medical necessity review will be required. Coverage
will be discontinued if significant progress is not made within a usual and
predictable period of time, or if progress stops or becomes minimal.
Speech Therapy Benefits
Speech therapy benefits cover expenses for restoring a speech function. Speech
therapy is covered by the plan if:
• Therapy is ordered by a physician,
• Therapy is performed by a licensed speech therapist, and
• Services are expected to restore a speech function lost due to disease, injury
or surgery.
The plan pays 90% of PPO negotiated rates if you use an in-network provider for
the treatment — or 80% of U&C if you use an out-of-network provider — up to
$3,000 per person per calendar year. No deductible applies. If more than $3,000
in expenses is requested, a medical necessity review will be required. Coverage
will be discontinued if significant progress is not made within a reasonable and
predictable period of time, or if progress stops or becomes minimal.
Medical Expenses Not Covered
Following is a list of expenses not covered by the plan:
• Deductibles and amounts in excess of PPO negotiated rates and U&C
charges
• Copays and the annual out-of-pocket maximum
• Expenses over the lifetime maximum benefit of $2 million per person
• Expenses over the substance abuse lifetime maximum benefit of $40,000 per
person
• Expenses for services that, in the judgment of the claims administrator, are
not medically necessary
• Expenses incurred after coverage has ended
• Expenses to treat a participant’s illness or injury arising from any electrical
work and any other paid work; expenses for a dependent paid or payable
under any Workers’ Compensation law (whether performed for pay or not)
and any other paid work
• Medical expenses incurred while you or a dependent is not under the care of
a licensed physician, surgeon or licensed midwife
• Charges for outpatient therapy or counseling unless provided directly and
personally by a psychiatrist, licensed psychologist, licensed clinical social
worker or substance abuse counselor authorized by the appropriate
behavioral health and substance abuse review organization
• Maternity expenses for anyone not a covered participant or lawful wife of a
participant (maternity expenses for dependent children will not be covered
by the plan)
44 September 2008 y BHSM
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• Charges for marriage counseling
• Premarital exams
• Dental services covered under a separate plan of dental benefits (see
“Covered Expenses” on page 56)
• Cosmetic, plastic or reconstructive surgery unless needed to:
− Correct the effects of an injury if the surgery is performed in the year of
the injury or the next year,
− Improve a congenital deformity, or
− Improve a deformity resulting from disease or medically necessary
surgery
For some conditions, photographs may be required for appraisal of medical
necessity.
• Eye exams to prescribe or fit glasses (covered under a separate plan of
vision benefits — see “Vision Benefits” on page 59)
• Treatment for infertility, including related prescribed drugs
• Charges for an experimental or investigational procedure or drug
• Confinement in other than an accredited hospital with 24-hour nursing care,
and organized facilities for diagnosis and major surgery
• Treatment in a hospital operated by the federal government or a federal
agency for a disability connected to military service
• Illness or injury resulting from any act of war or international armed conflict,
participating in a riot or the commission of a criminal act
• Treatment for which there would be no charge if these benefits were not
available
• Services provided by a relative or a person who ordinarily resides with you
• Services provided without charge or paid through any other plan
• Expenses that are reimbursable by Medicare
• Treatment of any intentionally self-inflicted injury (except in cases of mental
illness)
• Broken appointments
• Prescribed drugs and medicine dispensed by a physician or licensed
pharmacist and covered under a separate plan of prescription drug benefits
(see “Prescription Drug Benefits” on page 51)
• Any court-ordered services or testing
• Nursing home or assisted living facilities and services
• Over-the-counter drugs or baby formulas
• Massage therapists
• Dietitian used for weight loss (except in cases of morbid obesity) and all
weight loss programs
• Personal convenience items
BHSM y September 2008 45
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• Nutritional supplements, dietary supplements, and food products for special
dietary needs
• Acupuncture by a licensed acupuncturist
• Therapeutic devises and appliances, support garments or other non-medical
items, regardless of their intended use
• Claims filed more than 365 days after the date the expense was incurred
Filing a Claim
In-network PPO providers will submit a claim directly to the claims administrator.
However, if you need to submit the claim, call BCBS at 1-800-862-3386 for a
Request for Benefit Payment form. Specify the type needed — general medical or
hearing. For medical claims, you can complete the form and attach the bills that
explain your treatment. Submit your claim forms to the address listed on the back
of your BCBS card.
Filing Deadline
Claims must be filed within
365 days of the date they
are incurred or
reimbursement will be
denied.
Important Note!
For the highest level of
benefits, be sure to
contact the utilization
review organization at
least three days before a
non-emergency hospital
admission or within 48
hours after an emergency
admission (see “Medical
Service Advisory” on
page 36 for more
information about the
utilization review program).
When you submit your Request for Benefit Payment form, it should be completed
fully, following the instructions printed on the form. Failure to do so may delay
payment or result in denial of benefits. Attach a statement from your physician or
other health care provider together with bills or receipts for all covered expenses,
including those that count toward the deductible. Receipts for hearing aid
services provided through BCBS also must be attached to requests for payment.
To make sure you receive all the benefits you are entitled to, you should keep
copies of bills or receipts for supplies, as well as those for hospitalization and
treatment. If all charges are not detailed on the request form, attach an itemized
statement.
For treatment at a hospital, present your medical benefits identification card. If
your provider is in the PPO network, you usually won’t have to submit a claim —
the in-network PPO provider will do it for you.
If a person entitled to benefits is unable to complete a Request for Benefit
Payment form, the Trustees may pay benefits to the spouse or a blood relative, or
to any person whom the Trustees determine is rightfully entitled to the payment.
After completing all necessary forms, mail your claim to the appropriate claims
administrator. Once your claim has been documented, the administrator who
handles your claim must initially process it according to the type of claim you file.
The law requires that the following time frames apply to claims processing. If you
file:
• An urgent care claim (involving threats to the patient’s life or health): The
claim must be decided as soon as possible considering the medical
emergency, but no later than 72 hours after it is received (up to 48-hour
extension).
• A non-urgent pre-service claim (for services requiring notification of the
utilization review organization, e.g., hospitalization): The claim must be
decided within 15 days after it is received (up to 15-day extension).
• A non-urgent post-service claim (after you have received services): The
claim must be decided within 30 days after it is received (up to 15-day
extension).
46 September 2008 y BHSM
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• A concurrent care claim (decision to reduce or terminate previously-
approved benefits while you are under care): The claim must be decided
sufficiently in advance to give you an opportunity to appeal and obtain a
decision before the benefit is reduced or terminated.
• Any other claim under the plan: The claim must be decided within 90 days
after it is received (up to 90-day extension).
In some cases more time may be needed to process your claim. If this happens,
you’ll be notified that an additional processing period is required. The
circumstances requiring the extension, any information needed to make a claim
acceptable and the date by which the plan expects to make a decision (indicated
as extensions above), will be included in the notification. For urgent care claims,
you must send in any additional or missing information in a reasonable amount of
time (that is, within 48 hours). For non-urgent care claims, you’ll be given up to 45
days to provide any missing information. If your claim involves a medical
judgment, the plan must consult with a health care professional. You or your
beneficiary may always examine materials related to a claim, such as the plan’s
official documents.
Medical and Hearing Aid Claims
Generally no claim forms are required when you use a BCBS participating
provider. (See “Hearing Aid Benefits” under “Additional Medical Benefits” on
page 39 for information on claims filing and payment when you use the EPIC
program instead of BCBS.)
In most cases, participating providers agree to submit your claims for you. If the
provider does not submit the claim, you may submit your claims directly to BCBS
at the following address:
Blue Cross/Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60680
For more information about appealing claims and additional claims review
procedures, see “Claims Review and Appeals Procedures” in the Rules,
Regulations and Administrative Information section. For additional contact
information for claims administrators, see the Contact Information section.
BHSM y September 2008 47
Health Care
Behavioral Health and
Substance Abuse
Benefits
The plan also provides benefits for covered behavioral health and
substance abuse care. These types of care are administered by
CIGNA Behavioral Health (CIGNA), separately from your medical
benefits and must also be precertified by CIGNA before receiving
services.
Your Behavioral Health and Substance Abuse Benefits at-a-
Glance
Behavioral Health and Substance Abuse Benefits
In-Network Out-of-Network Limits
Deductible No deductible. $100 annual
deductible per
person.
Separate from
medical
deductible;
applies for
inpatient and
outpatient out-of-
network services.
Members
Assistance
Program (MAP)
1 to 3 sessions at
no cost to
participants.
No coverage.
Inpatient care
(hospital
expenses include
room and board,
drug, x-ray,
detoxification and
lab and physician
charges)*
Inpatient care
covered at 100%.
Inpatient care
covered at 80% of
usual and
customary (U&C)
charges.
Treatment limited
to 30 inpatient
days per person
per year*/**,
combined for both
in- and out-of-
network services.
Outpatient care*
Outpatient care
covered at 100%
after $15 copay
per visit.
Outpatient care
covered at 80% of
U&C charges.
Treatment limited
to 30 outpatient
visits per person
per year**,
combined for both
in and out-of-
network services.
48 September 2008 y BHSM
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Behavioral Health and Substance Abuse Benefits
Structured
intensive
outpatient
substance abuse
program***
Care covered at
100% after $15
copay per visit;
$150 maximum
out-of-pocket per
program.
Care covered at
80% of U&C
charges.
No limit other than
$150 out-of-
pocket maximum
for in-network
services per
program.
Lifetime limit
(combined for all
in and out-of-
network benefits)
Behavioral health: Included in $2 million medical benefit
lifetime limit.
Substance abuse: $40,000 per person.
Precertification
and review
Precertification is
required for all
inpatient services.
Precertification is
not required for
outpatient
services except
for visits in excess
of 30.
Precertification is
required for all
inpatient services.
Precertification is
not required for
outpatient
services except
for visits in excess
of 30 Failure to
call within 24
hours of an
admission will
result in a
reduction of
coverage.
Benefits will be
payable at 50% of
the out-of-network
benefit levels.
All coverage is
subject to medical
necessity.
Emergency: For
an emergency
admission,
notification must
be received within
48 hours to be
covered at the in-
network level.
* Lab and pharmacy management are covered under the behavioral health or substance abuse
plans only when ordered by a psychologist or psychiatrist.
** Two partial hospitalization days or two residential treatment days are considered one inpatient
day.
*** Days or sessions above the 30-visit limit will be reviewed and authorized based on medical
necessity.
Using Your Behavioral Health and Substance
Abuse Benefits
All in-network and out-of-network inpatient services for behavioral
health/substance abuse treatment must be precertified by calling the behavioral
health and substance abuse claims administrator at the number listed in the
Contact Information section. Outpatient care does not require precertification.
However, additional days or visits (above the 30-day or 30-visit limit) will be
covered only if the behavioral health and substance abuse claims administrator
approves the treatment based on medical necessity.
BHSM y September 2008 49
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There is an annual $100 deductible per person for out-of-network services, in
addition to the $100 calendar year deductible that applies to other medical
benefits under this plan. The deductible, copays and out-of-pocket expenses for
behavioral health and substance abuse do not count toward your medical plan
annual out-of-pocket maximum.
If you or your covered dependent is in treatment for behavioral health conditions
or substance abuse when plan coverage ends, benefits will continue until the
lesser of:
• The balance of the treatment period,
• 60 days, or
• Benefits are exhausted.
Behavioral Health Treatment
A licensed psychiatrist, psychologist, licensed clinical professional counselor,
licensed professional counselor or clinical social worker must perform the
treatment. Psychological evaluations are not covered if they relate to:
• Fitness to act as a custodial parent, or
• Diagnosis of a learning disability.
If you are covered under Medicare and Medicare is the primary payor, you are
expected to seek treatment from a Medicare-approved provider. If you do not, the
Fund will only consider 20% of your expense as eligible for reimbursement.
Substance Abuse Treatment
The maximum lifetime benefit for treatment of substance abuse is $40,000. (This
is separate from the $2 million lifetime maximum medical benefit limit.) Any prior
benefits you received from all EIT plans for these services will be included in the
maximum lifetime benefit for substance abuse.
Treatment must be performed at a licensed or certified facility for alcohol and/or
drug treatment. Expenses for enrolling in court-ordered safety counseling courses
are not covered.
One Methadone treatment is considered one outpatient visit and is applied
against the 30 visits available annually for substance abuse treatment.
Filing a Claim
All claims should be submitted to:
Filing Deadline
If you do not file a claim
within 365 days of the date
you incur an expense
reimbursement will be
denied.
CIGNA Behavioral Health
P.O. Box 46270
Eden Prairie, MN 55344-6270
For more information about appealing claims and additional claims review
procedures, see “Claims Review and Appeals Procedures” in the Rules,
Regulations and Administrative Information section. For additional contact
information for claims administrators, see the Contact Information section.
50 September 2008 y BHSM
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Prescription Drug
Benefits
You can buy prescription drugs at a low cost through any pharmacy
that participates in the CVS/Caremark network or through a
convenient mail-order program. The medical deductible and copay
provisions do not apply to the prescription drug benefits.
Your Prescription Drug Benefits at-a-Glance
Prescription Drug Benefits
Retail prescription
drugs purchased
through a network
pharmacy (34-day
supply)
• $5 copay for generic drugs.
• $18 copay for preferred drugs.
• $33 copay for brand-name and non-preferred drugs.
Mail-order
prescription drugs
(90-day supply)
• $10 copay for generic drugs.
• $36 copay for preferred drugs.
• $66 copay for brand-name and non-preferred drugs.
Prescription drugs
purchased at a
nonparticipating
pharmacy
No coverage.
Prescription Drug Benefits and the Medical Plan
The prescription drug benefit is separate from your medical benefit. So
prescription drug copays do not apply to the medical plan deductible and out-of-
pocket maximum. Nor do the medical benefit deductible and copay provisions
apply to the prescription drug benefit.
Using Your Prescription Drug Benefits
Retail Pharmacies
Important Note!
Always ask your pharmacy
if it is a member of the
CVS/Caremark network
before filling a prescription.
Prescriptions purchased at
a nonparticipating
pharmacy are not covered
under this plan.
The plan contracts with CVS/Caremark to fill prescriptions for you and your
covered dependents. Before filling a prescription, ask the pharmacy if it is a
member of the CVS/Caremark network. Prescriptions purchased at a
nonparticipating pharmacy are not covered under this plan.
You must present your prescription drug identification card to receive benefits for
drugs bought at a pharmacy. For your covered dependents’ prescriptions, you will
also need to provide a date of birth.
BHSM y September 2008 51
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When you purchase up to a 34-day supply of prescribed drugs and medications,
the plan pays 100% after you pay a:
• $5 copay for generic drugs
• $18 copay for preferred drugs
• $33 copay for brand-name and non-preferred drugs
If you do not present your prescription drug identification card, you will be
reimbursed for a drug, provided you:
• Pay the full price of the prescription at the time of purchase,
• Have your pharmacist fill out a claim form, and
• Submit the claim form to the prescription drug claims administrator for
reimbursement.
However, your reimbursement may be less than if you had presented your card at
the time of service. You will pay the copay and any amounts above the network
pharmacy discount to the pharmacy.
Mail-Order Prescriptions
If you take prescribed drugs on a long-term or continuing basis, you can obtain
them by mail. When you purchase up to a 90-day supply of mail-order prescribed
drugs and medications, the plan pays 100% after you pay a:
• $10 copay for generic drugs
• $36 copay for preferred drugs
• $66 copay for brand-name and non-preferred drugs
Your prescription will automatically be filled with a generic drug, unless your
doctor has indicated otherwise on your prescription. New prescriptions generally
take two to three days to process and fill. Refills take one to two days to process
and fill. Shipping is free of charge, and takes 10-14 days for standard delivery.
You can choose two-day or next-day shipping; however, it will still take one to
three days for your order to be processed before it is shipped. If delivery is
delayed for any reason, your order will not be reprocessed until 15 days from the
original shipping date.
For further information, order forms and pre-addressed envelopes, contact
CVS/Caremark at the number listed in the Contact Information section.
Covered Expenses
Covered drugs include:
• Prescribed drugs that are lawfully obtainable only from a licensed dispenser
of drugs under the written order of a physician or dentist licensed to prescribe
• Injectable insulin
• Prescribed syringes and hypodermic needles in quantities compatible with
the number of doses of insulin prescribed (Note: You must fill the insulin
order first for the syringes to be covered by the plan.)
Call CVS/Caremark at the number listed in the Contact Information section to
determine whether or not a new drug is covered.
52 September 2008 y BHSM
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Expenses Not Covered
The following are not covered under the plan:
• Contraceptive devices, regardless of the purpose for which they are
prescribed (Oral contraceptives are covered, but skin implant contraceptives
such as Norplant are not.)
• Fertility drugs
• Drugs or medications lawfully obtainable without a prescription, except insulin
• Therapeutic devices and appliances, support garments or other nonmedical
items, regardless of their intended use
• Drugs labeled “Caution: Limited by federal law to investigational use” or
experimental drugs, even though a charge is made to the individual
• Charges for the administration of prescription drugs or injectable insulin
• Drugs taken by or administered to an individual in whole or in part while an
inpatient in a hospital or other health care facility licensed for dispensing
pharmaceuticals
• A quantity in excess of the number specified by the prescriber for a 34-day
supply (90-day for mail-order)
• Any refill dispensed more than one year after the date of the prescription
• Prescription drugs that may be properly received without charge under local,
state or federal programs, including Workers’ Compensation
• Renova (Tretinoin)
• Lifestyle drugs such as drugs treating weight loss (except in the case of
morbid obesity) and hair loss. Drugs prescribed for erectile dysfunction (ED)
in excess of six doses per month
• Prescriptions purchased at a nonparticipating pharmacy
• Expenses for drugs obtained through another medical or prescription drug
plan (no coordination of benefits)
• Claims filed more than one year after the date the expense was incurred
Filing a Claim
If you do not have your prescription drug card when you make a retail purchase,
you must pay for the prescription when purchased and have the pharmacist fill
out a CVS/Caremark claim form. You must then submit your claim to:
Filing Deadline
If you do not file a claim
within 365 days of the date
you incur an expense,
reimbursement will be
denied.
CVS/Caremark
P.O. Box 52116
Phoenix, AZ 85072
For more information about appealing claims and additional claims review
procedures, see “Claims Review and Appeals Procedures” in the Rules,
Regulations and Administrative Information section. For additional contact
information for claims administrators, see the Contact Information section.
BHSM y September 2008 53
Health Care
Dental Benefits
The BlueCare® Freedom Dental PPO program allows you and/or
your eligible dependent(s) the freedom to choose any licensed
dentist when you need dental care. You will maximize your dental
benefits when you access a contracting general or specialty dentist
through the BlueCare Dental PPO Network. Advantages of using
the BlueCare Dental PPO Network are:
• Reduced out-of-pocket costs due to discounted fees
• No balance billing
• No referral needed for specialty dentists
• Contracting dentists will submit claims for you
Your dental benefits remain the same whether you select a dentist from within or
outside the network; services are covered at the same benefit level. However, if
you choose to receive services from a dentist outside of the network, the plan will
pay a percentage of the charges for covered services, based on usual and
customary (U&C) charges, up to a maximum annual or lifetime benefit depending
on the services received.
When your dependent needs orthodontic care, treatment must begin before
age 16.
54 September 2008 y BHSM
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Your Dental Benefits at a Glance
Dental Benefit In-Network Out-of-Network
Maximum annual
benefit
$1,000 per covered
family member
(excluding orthodontic).
Effective 1/1/09 the
annual maximum will
increase to $1,500.
$1,000 per covered
family member
(excluding orthodontic).
Effective 1/1/09 the
annual maximum will
increase to $1,500.
Annual calendar year
deductible
No deductible applies. No deductible applies.
Preventive Care (two
oral exams/year)
Plan pays 100% of PPO
negotiated rates.
Plan pays 100% of U&C
charges.
All non-orthodontic
dental care
Plan pays 80% of eligible
expenses, based on the
PPO negotiated rate, up
to the maximum annual
benefit.
Plan pays 80% of eligible
expenses, based on the
U&C amount, up to the
maximum annual benefit.
Orthodontic dental care Plan pays 80% of U&C,
up to a lifetime maximum
of $2,000, for each
eligible covered
dependent.
Plan pays 80% of U&C,
up to a lifetime maximum
of $2,000, for each
eligible covered
dependent.
Using Your Dental Benefits
Dental benefits provide comprehensive coverage for preventive and other types
of dental services, including orthodontia. When you need dental care, you must
visit a licensed dentist. The plan pays a percentage of PPO negotiated rates or
U&C charges for covered services, up to a maximum annual or lifetime benefit.
You pay no deductible for dental benefits.
In-network dental benefits are available when you choose a provider that
participates in the Blue Cross/Blue Shield (BCBS) BlueCare® Freedom Dental
PPO Program. The benefit remains the same whether you use an in-network or
out-of-network provider. However, in-network providers have agreed to accept a
negotiated rate for their services.
Benefit Amounts
Preventive care: Preventive care is covered at 100% of the PPO negotiated rate
for in-network dentists or U&C charges for out-of-network dentists. Preventive
services include two oral exams a year, including teeth cleaning, fluoride
applications (up to 19 years of age) and dental x-rays (two bitewings per year and
one full mouth x-ray every 36 months).
Other care: The plan pays 80% of the PPO negotiated rate for other covered
dental care provided by in-network dentists (80% of U&C charges for out-of-
network dentists).
BHSM y September 2008 55
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Annual maximum (excluding orthodontic): The maximum amount the plan will
pay each calendar year is $1,000 per person. When you or your covered
dependents reach this limit, you are responsible for the full cost of any additional
services received. Effective 1/1/09 the annual maximum will increase to $1,500
per person.
How the Orthodontic Benefit Works
When your covered dependent needs orthodontic care, he or she must visit a
licensed orthodontist or dentist. The plan pays a percentage of the U&C charges
for covered services, up to a maximum annual benefit. You pay no deductible.
Orthodontic treatment must begin before age 16 and may continue beyond
age 19 (when the dependent would otherwise lose eligibility), provided your
covered dependent remains:
• A full-time student,
• Unmarried,
• Financially dependent on you, and
• A resident in your household.
Benefit Amount
The plan pays 80% of the first $2,500 of expenses for each covered dependent
under age 19. That’s a lifetime maximum orthodontia benefit of $2,000 per
covered dependent.
Cost
Generally, an orthodontist establishes the total cost of his or her services,
supplies and appliances before treatment starts. This is paid by an initial down
payment with regular monthly payments thereafter. You are responsible for the
initial down payment. You will be reimbursed for the down payment (but not more
than 16% of the entire treatment — 80% of 20%), and the plan will make regular
monthly payments of the benefit for the remaining costs. The plan’s payments for
orthodontic services will end when you meet the lifetime maximum benefit or
coverage under the plan ends.
To receive your monthly reimbursements, you must:
• Continue to qualify as a plan participant, and
• Submit paid receipts from your orthodontist for your monthly payment.
You cannot receive your total reimbursements in less than 24 months unless your
dentist certifies that the orthodontic correction is completed.
Covered Expenses
Your dental benefits provide coverage at PPO negotiated rates or U&C charges
for the following types of services:
• Two oral exams, including teeth cleaning and scaling, every calendar year;
additional cleanings (up to four per year) to treat periodontal disease with a
letter of medical necessity
• Fluoride applications up to age 19
• Application of dental sealant up to age 19
56 September 2008 y BHSM
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• Dental x-rays (bitewings limited to two per year; full mouth limited to once
every 36 months)
• Extractions and oral surgery
• Fillings and inlays
• Crowns and initial installation of fixed bridgework
• Artificial tooth implants
• Treatment of diseases of the gums and tissue of the mouth
• Initial installation of removable partial or full dentures
• The addition of teeth to an existing removable partial or full denture or fixed
bridgework, or its total replacement, if made necessary by drifting of anchor
teeth
• Repair or recementing of crowns, inlays, bridgework or dentures
• Treatment for tooth damage that results from the grinding or biting of teeth
(occlusal services)
• General anesthesia for dental procedures when medically necessary
• Orthodontia
Expenses Not Covered
Dental benefits do not cover:
• Expenses to treat a participant’s illness or injury arising from any electrical
work or any other paid work; expenses for a dependent paid or payable
under any Workers’ Compensation law (whether performed for pay or not) or
any other paid work
• Treatment by someone other than a licensed dentist or physician (the plan
will cover teeth cleaning by a licensed dental hygienist who is supervised by
a dentist)
• Any work performed directly by a lab and billed to you without a prescription
from a dentist, such as manufacture or repair of dentures, liners and other
devices and appliances; services and supplies of any kind furnished directly
by a lab
• Replacement of a lost or stolen prosthetic device
• Services and supplies that are solely for cosmetic reasons, such as bonding
or whitening
• Services that are not medically necessary
• Treatment in a hospital operated by the federal government or a federal
agency for a disability connected to military service
• Illness or injury resulting from any act of war or international armed conflict,
participation in a riot or the commission of a criminal act
• Treatment for which there would be no charge if these benefits were not
available
• Services provided by a relative or a person who ordinarily resides with you
• Services provided or paid through any other plan
BHSM y September 2008 57
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• Treatment of any intentionally self-inflicted injury (except in cases of mental
illness)
• Broken appointments
• Claims filed more than one year after the date the expense was incurred
Orthodontic Expenses Not Covered
• Expenses for participants other than eligible covered dependents
• Expenses for a dependent paid or payable under any Workers’
Compensation law (whether performed for pay or not) or any other paid work
• Treatment by anyone who is not a licensed orthodontist or dentist
• Replacement of lost or stolen retainers
• Services or supplies furnished on or after the date your dependent turns
age 16, unless those procedures began before age 16
• Services and supplies that are solely for cosmetic reasons
• Treatment for which there would be no charge if these benefits were not
available
• Services provided by a relative or a person who ordinarily resides with you
• Services provided without charge or paid through any other plan
• Broken appointments
• Claims filed more than one year after the date the expense was incurred
Filing a Claim
In-network providers will file a claim for you. Out-of-network providers will usually
file a claim for you; but if you are required to file a dental claim, call BCBS at
1-800-862-3386 to obtain a dental claim form. All dental claims should be
submitted to:
Filing Deadline
If you do not file a claim
within 365 days of the date
you incur an expense,
reimbursement will be
denied.
Blue Cross/Blue Shield of Illinois
c/o DNoA
P.O. Box 23059
Belleville, IL 62223
When you submit your Request for Benefit Payment form, it should be completed
fully, following the instructions printed on the form. Failure to do so may delay
payment or result in denial of benefits. Attach a statement from your physician or
dentist together with bills or receipts for all covered expenses, including those
that count toward the deductible. To make sure you receive all the benefits you
are entitled to, you should keep copies of bills or receipts for supplies, as well as
those for hospitalization and treatment. If all charges are not detailed on the
request form, attach an itemized statement.
For more information about appealing claims and additional claims review
procedures, see “Claims Review and Appeals Procedures” in the Rules,
Regulations and Administrative Information section. For additional contact
information for claims administrators, see the Contact Information section.
58 September 2008 y BHSM
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Vision Benefits
In-network vision benefits are provided by VSP (Vision Service
Plan). However, you can visit any out-of network licensed optician,
optometrist or ophthalmologist and receive a lesser out-of-network
benefit.
Important Note!
Before you make an
appointment, notify the
provider that you are
covered under VSP.
Your Vision Benefits at a Glance
Vision Benefits
In-Network Out-of-Network
Annual calendar year
deductible
No deductible applies.
Annual calendar year
benefit maximum
Not applicable.
Exam After a $20 copay per
exam, plan pays 100%
on up to one exam per
year.
After a $20 copay per
exam, plan reimburses up
to $45 on one exam per
year.
Lenses (includes
glasses and frames)
After $20 copay per pair,
plan pays 100% (frame
costs in excess of
$31.25 are your
responsibility, but
discounted by 20%).
After a $20 copay per pair,
plan reimburses up to
specified limits depending
on the type of lens and
frame.
Contact lenses Participant: Plan pays
100% of discounted
prices up to $200 per
pair per year.
Dependent: Plan pays
100% of discounted
prices up to $200 per
year.
Participant: Plan
reimburses up to $200 per
pair per year.
Dependent: Plan
reimburses up to $200 per
year.
Participant annual
limits
Two sets of framed lenses or two sets of contact lenses
or one of each.
Dependent annual
limits
One set of framed lenses or one set of contact lenses.
BHSM y September 2008 59
Health Care
Using Your Vision Benefits
You must visit a licensed optician, optometrist or ophthalmologist. You may
choose to visit either in-network or out-of-network providers, but with in-network
providers the cost savings can be substantial. For in-network services, the plan
pays the cost of covered services after you pay a copay. For out-of-network
services, you pay a copay, then you will be reimbursed for part of the expense of
eye exams, frames and lenses. You pay no deductible.
You must submit claim forms within six months for non-VSP providers. When you
submit claim forms, you must include receipts.
VSP Network Advantages
You and your covered dependents benefit when you use providers who
participate in the VSP network (network providers) because:
• Network providers have agreed to accept pre-negotiated, discounted rates for
their services. Since network providers charge discounted rates, you (and the
Fund) save money when you use them.
• Network providers will file claims for you. When you go to a network provider,
all you have to do is pay your $20 copay(s) (and any amount that exceeds
specific maximums) and your provider will file a claim with VSP for
reimbursement. There are no copays for contact lenses.
• You receive discounted prices on all your vision care needs, including those
that are not covered by your plan, such as extra supplies and laser vision
correction services.
• When you go to a non-network provider, you must pay for the services at the
time you receive them and then file a claim with VSP. After any applicable
copays, the plan will then reimburse you up to the scheduled amount. This
amount will not be sufficient to pay for the entire cost of the eye examination
or materials and you will not receive discounted prices.
Finding VSP Network Providers
VSP’s network includes many providers; so your current provider may already be
in the VSP network. To locate a VSP network provider, you can:
• Ask your provider if he/she participates in the VSP network
• Call VSP Member Services at 1-800-877-7195, Monday-Friday, 8:00 a.m.
until 8:00 p.m.
• Visit their Web site at www.vsp.com for more information
Covered Expenses
The plan pays benefits for the following medically necessary expenses in a
calendar year:
• Complete vision analysis, including eye exam, refraction, visual therapy and
case history
• Two sets of framed lenses or two sets of contact lenses (or one set of each)
for a participant if required by a prescription. One set of framed lenses or
contact lenses for a dependent if required by a prescription.
60 September 2008 y BHSM
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Expenses Not Covered
The plan does not cover:
• Expenses to treat a participant’s illness or injury arising from any electrical
work or any other paid work. Expenses for a dependent paid or payable
under any Workers’ Compensation law (whether performed for pay or not) or
any other paid work
• Replacement of lost or stolen glasses, or broken frames
• Services in connection with vision therapy, orthoptics, vision training,
aniseikonia, or medical or surgical treatment of the eye unless performed by
a licensed medical physician or licensed therapist
• Any surgical treatment in place of corrective lenses such as LASIK,
photorefractive keratectomy (PKR) or radial keratotomy (RK)
• Treatment in a hospital operated by the federal government or a federal
agency for a disability connected with military service
• Charges for services or supplies covered in whole or in part under any other
portion of this benefit plan
• Illness or injury resulting from any act of war or international armed conflict,
participation in a riot or the commission of a criminal act
• Treatment for which there would be no charge if these benefits were not
available
• Services provided by a relative or a person who ordinarily resides with you
• Services or supplies provided without charge or paid through any other plan
• Expenses that are reimbursable by Medicare
• Treatment of any intentionally self-inflicted injury (except in cases of mental
illness)
• Broken appointments
• Claims filed more than one year after the date the expense was incurred
Filing a Claim
No claim forms are required when you use a VSP participating provider. All
claims are filed directly with VSP by the provider.
Important Note!
If you see a non-VSP
provider, you must file
your claim(s), and the filing
limit is six months from
date of service.
To submit a nonparticipating provider claim, you must contact VSP at
1-800-877-7195 to obtain a claim form. The reimbursement rate is significantly
less than it would be if you used a VSP provider.
For more information about appealing claims and additional claims review
procedures, see “Claims Review and Appeals Procedures” in the Rules,
Regulations and Administrative Information section. For additional contact
information for claims administrators, see the Contact Information section.
BHSM y September 2008 61
Health Care
Continuing Coverage
A federal law, the Consolidated Omnibus Budget Reconciliation Act
(COBRA) of 1985, requires that participants and their covered
dependents be able to continue certain health care coverage when
they would otherwise lose coverage. Coverage continues at your
own expense.
Under COBRA, you and your covered dependents (or former dependents) have
the right to continue medical, prescription drug, dental, orthodontic, vision and
hearing aid coverage. Or you may elect to continue medical and prescription drug
coverage only. You receive the same benefits as active employees for the option
you choose. COBRA does not extend to other benefits under this plan, such as
short-term disability, long-term disability, dismemberment or life insurance.
COBRA coverage for you and your covered dependents continues for up to 18
months if you become eligible for COBRA because your hours are reduced below
the number required for coverage or your employment terminates.
COBRA coverage is also available to your covered dependents for up to 36
months if their coverage ends because:
• You die,
• A covered child becomes ineligible due to age,
• You get a divorce or legal separation, or
• You become entitled to Medicare.
If you retire at age 60 and meet the qualifications for retiree health care, you are
eligible for COBRA coverage for 18 months. You can request interim coverage
which extends your coverage for up to six months; you pay the full cost of the
coverage. This interim coverage will take you to age 62, at which time you would
be eligible for retiree coverage. You must contact the Fund Office in writing to
request interim coverage.
You or a family member is responsible for notifying the Trustees of any event that
makes continuation of coverage applicable. Such events include divorce, death,
or becoming Medicare-entitled because of disability or a dependent becoming
ineligible because of age.
Who Is Eligible for COBRA Coverage
You and your eligible dependents are eligible for COBRA.
Newborns and children adopted by you while you are covered under COBRA are
eligible to elect COBRA coverage immediately. Your new child is a “qualified
beneficiary” with independent election and second qualifying event rights.
If you have any questions about your eligibility for COBRA, or you do not receive
coverage information within 14 days of notification of a qualifying event, contact
the Fund Office.
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Health Care
How to Enroll for COBRA Coverage
EIT’s COBRA coverage is administered by EIT Benefit Funds. You will receive an
election form from the Fund Office and more information about COBRA coverage
if you become eligible for it. In the case of a divorce or ineligibility of a dependent
child, the qualified beneficiary must notify the Fund Office to receive an election
form.
To continue coverage, you or your affected dependent must elect COBRA
coverage within 60 days after an event qualifies you for COBRA or after the Fund
Office mails your election form, whichever is later. Your spouse and dependent
children have separate election rights. You have an additional 45 days from the
date you return your election form to pay the premiums necessary to avoid any
gap in coverage. Any claims you file are not paid until the plan receives your
contribution.
If coverage is modified for active employees, COBRA coverage will also be
modified. If you do not elect COBRA coverage within the 60 days described
above, coverage will end and will not be reinstated.
You, your spouse and dependent children who lose coverage as a result of the
COBRA qualifying event are qualified beneficiaries entitled to elect COBRA. A
child born to, adopted by or placed for adoption with you during the period of
COBRA coverage would also be a qualified beneficiary with a right to COBRA
coverage. Each qualified beneficiary has an independent right to elect COBRA
coverage. You may elect COBRA coverage on behalf of your spouse, and
parents may elect COBRA coverage on behalf of their children.
In deciding to elect COBRA coverage, you should know that a failure to continue
your group health coverage will affect your future rights under federal law as
follows:
• You can lose the right to avoid having pre-existing condition exclusions
applied to you by other group health plans if you have more than a 63-day
gap in health coverage. Election of COBRA coverage may help you not have
such a gap.
• You will lose the guaranteed right to purchase individual health insurance
policies that do not impose such pre-existing condition exclusions if you do
not elect and maintain COBRA coverage for the maximum time available to
you.
• You should take into account that you have special enrollment rights under
federal law. You have the right to request special enrollment in another group
health plan for which you are otherwise eligible (such as a plan sponsored by
your spouse’s employer) within 30 days after your group health coverage
ends because of the qualifying event listed above. You will also have the
same special enrollment right at the end of COBRA coverage if you elect and
maintain COBRA coverage for the maximum time available to you.
BHSM y September 2008 63
Health Care
How Much COBRA Coverage Costs
You pay 102% of the regular contribution rate or the cost of coverage for
participants and dependents (100% of the premium plus a 2% administration fee).
The Trade Act of 2002 created a new tax credit for certain individuals who
become eligible for trade adjustment assistance and for certain retired individuals
who are receiving pension payments from the Pension Benefit Guaranty
Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible
individuals can either take a tax credit or get advance payment of 65% of
premiums paid for qualified health insurance, including COBRA continuation
coverage. If you have questions about these new tax provisions, you may call the
Health Coverage Tax Credit Customer Contact Center toll-free at
1-866-628-4282. TTD I TTY callers may call toll-free at 1-866-626-4282. More
information about the Trade Act is also available at www.doleta.gov/tradeact/.
How Long COBRA Coverage Lasts
COBRA coverage can continue up to 18, 29 or 36 months depending on the
qualifying event. If more than one qualifying event applies, the maximum
coverage period is 36 months total. The following chart shows when you and your
dependents may continue health care coverage under COBRA and for how long.
Maximum Period Coverage Can Continue
COBRA Qualifying
Event
You Spouse Child
You lose coverage
because:
• Your hours are
reduced
• Your employment
ends for any reason
(except gross
misconduct)
18 months 18 months 18 months
You or your qualified
dependent are disabled
(as defined by Social
Security) when you lose
coverage
29 months 29 months 29 months
You die N/A 36 months 36 months
You and your spouse
divorce or become legally
separated
N/A 36 months 36 months
You become entitled to
Medicare*
N/A 36 months 36 months
Your child no longer
qualifies as an eligible
dependent
N/A N/A 36 months
* If you become entitled to Medicare before your coverage ends, your spouse and any dependent
children are entitled to elect COBRA coverage for up to the greater of 36 months from the date of
Medicare entitlement, or 18 months from the date your coverage ends.
64 September 2008 y BHSM
Health Care
Additional Qualifying Events
The 18-month COBRA period may be extended to 36 months for your spouse
and dependent children who are qualified beneficiaries if a second qualifying
event (death, divorce, legal separation or a dependent child ceasing to be a
dependent under the terms of the plan) occurs during the 18-month COBRA
continuation period. However, this extension will only be allowed if the second
event would have caused the spouse or dependent child to lose coverage under
the plan had the first qualifying event not occurred. To be granted an extension,
the qualified beneficiary must notify the Fund Office within 60 days of the second
qualifying event.
Please note: Your Medicare entitlement (Part A, Part B or both) is considered a
second qualifying event for your spouse and dependent children under the EIT
plan.
Disability Extension
The 18-month COBRA continuation period may be extended by up to 11 months
for a total of 29 months if a qualified beneficiary is determined by Social Security
to be disabled at any time within 60 days of the start of the COBRA continuation
period. This 11-month extension is available to all individuals who were qualified
beneficiaries at the time of the initial termination or reduction in hours of
employment. To be granted this extension, you must notify the Fund Office at
1-312-782-5442 within 60 days of the determination and within the 18-month
COBRA continuation period. You must also provide a copy of the determination
of disability notification from the Social Security Administration.
The disabled individual must also notify the Fund Office within 30 days of any
final determination that such individual is no longer disabled.
When COBRA Coverage Ends
COBRA health care coverage will end before the maximum period described in
the “Maximum Period Coverage Can Continue” chart on page 64, if:
• Required premiums are not paid by the due date.
• You, your spouse or dependent becomes covered under another group
health plan, including a Medicare plan, after you have made your COBRA
election (this does not apply if the new plan has pre-existing condition limits
affecting the covered person).
• You, your spouse or dependent become eligible for Medicare (this only
affects the person with Medicare coverage).
• You, your spouse or dependent recover from disability during the 11-month
extension period.
• EIT no longer provides health care coverage to any of its active employees.
COBRA coverage may also be terminated for any reason the plan would
terminate coverage of a participant or beneficiary not receiving COBRA coverage
(such as fraud).
If your COBRA coverage terminates for any reason, it cannot be reinstated.
BHSM y September 2008 65
Health Care
Notice and Election Procedures
To protect your family’s rights, you should keep the appropriate parties informed
of any changes in address, as follows:
• Participant address: If your address changes, you should notify the Fund
Office.
• Dependent address: Also notify the Fund Office if your spouse or
dependent(s) changes address (to an address other than your address).
If you have any questions or need to provide notice or make an election related to
your COBRA rights, contact the Fund Office at 1-312-782-5442 Monday through
Friday between 8:30 a.m. and 4:30 p.m. Central Time or write to:
EIT Benefit Funds
221 North La Salle Street, Suite 200
Chicago, Illinois 60601-1214
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Health Care
Glossary
The definitions included in this glossary will help you understand your plan
benefits.
Active Employee
A person who meets the definition of employee, who is actively at work or
available for work for a contributing employer, and who is not a retiree.
Chiropractic and Naprapathic Care
Skeletal adjustments, manipulation or other treatment (including naprapathy) in
connection with the detection and correction by manual or mechanical means of
structural imbalance or subluxation in the human body. Treatment is performed to
remove nerve interference resulting from, or related to, distortion, misalignment or
subluxation of, or in, the vertebral column.
Coinsurance
The percentage of covered expenses you must pay after you have met your
annual deductible. For example, if you use an in-network provider, you pay 10%
of the PPO negotiated rate for most medical procedures and the plan covers the
remaining 90%.
Copay
A fee charged by the plan for certain health care services or care. For example,
copays are charged at the time of a medical office visit or when you have
prescriptions filled. This fee is usually a flat amount.
Cosmetic Surgery
Plastic or reconstructive surgery or other services and supplies which improve,
alter or enhance appearance, whether or not performed or used for emotional or
psychological reasons.
Credited Service
Credited service is used to determine the amount of your pension benefit under
Pension Plan No. 4.
Generally, you receive one full year of credited service for each calendar year in
which you have 1,800 hours of covered employment. Before 1970, you received
one-fourth of a year of credited service for each 600 hours of covered
employment in a calendar year and one-fourth of a year of credited service for
each additional 400 hours of covered employment you worked — up to the
maximum full year of credited service. Between 1970 and 1975, you received
one-fourth of a year of credited service for each 450 hours you worked during
each year — up to the maximum full year of credited service. After 1975, you
receive one full year of credited service for each year in which you work 1,800
hours. For each year in which you have at least 400, but fewer than 1,800 hours,
you receive credited service in proportion to your number of hours — up to the
maximum full year of credited service.
Refer to the Electrical Contractors’ Association (ECA) and Local 134 International
Brotherhood of Electrical Workers (I.B.E.W.) Joint Pension Trust Pension Plan
No. 4 for more information on credited service.
BHSM y September 2008 67
Health Care
Deductible
The amount you pay for covered services each year before the plan begins to
pay benefits.
Durable Medical Equipment (DME)
Medical equipment that can withstand repeated use without significant
deterioration. DME is primarily and customarily used to serve a medical purpose,
and generally is not useful to a person in the absence of an illness or injury. DME
is covered when it is designed and medically necessary to assist an injury or
illness of the covered person and is appropriate for use in the home.
Eligibility Service
Eligibility service is used to determine when you qualify for a pension under
Pension Plan No. 4.
You receive one year of eligibility service for each calendar year in which you
have at least 400 hours of covered employment. Generally, covered employment
includes any period of work for which your employer is obligated to make
contributions to the plan. You also receive one year of eligibility service for each
calendar year in which you have at least 1,000 hours of non-covered employment
with a participating employer. The 1,000-hour period must immediately precede
or follow covered employment with the same employer. Refer to the ECA and
Local 134 I.B.E.W. Joint Pension Trust Pension Plan No. 2 for more information
on eligibility service.
Home Health Care (HHC)
Physician-ordered services for part-time or intermittent home nursing care by a
licensed HHC organization when continued hospitalization would otherwise have
been required if home care was not provided.
Hospice Care
Services provided for a terminally ill person. To be considered “terminally ill,” the
covered individual must provide a statement from the attending physician
indicating life expectancy to be six months or less. Hospice care programs
provide either home care or inpatient care through an affiliated hospital or nursing
facility.
Industry Employment
The term “industry employment” means any period of employment in which a
participant is engaged in any capacity, whether as an employee, sole proprietor,
owner-operator, independent contractor, self-employed person or otherwise,
within the trade and geographic jurisdiction of the Union.
In-Network (PPO Provider)
A health care service or supply furnished by a PPO network provider. In general,
in-network services are covered at a higher benefit level than out-of-network
services.
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Health Care
Investigational/Experimental
Procedures, drugs, devices, services and/or supplies which are:
• Provided or performed in special settings for research purposes or under a
controlled environment and which are being studied for safety, efficiency and
effectiveness; and/or
• Awaiting endorsement by the appropriate National Medical Specialty College
or federal government agency for general use by the community at the time
they are rendered to a covered person; and
• Specifically with respect to drugs, combination of drugs and/or devices, are
not finally approved by the Federal Drug Administration at the time used or
administered to the covered person.
Lifetime Maximum
The total amount of benefits you can receive under the plan in your lifetime.
Medical Services Advisory (MSA)
Blue Cross/Blue Shield (BCBS) Medical Service Advisory is the organization
responsible for precertifying or authorizing medical services received from a
hospital or other inpatient facility (see “Medical Service Advisory” on page 36).
Medically Necessary (Medical Necessity)
Health care services and supplies that are:
• Determined by the claims administrator to be medically appropriate,
• Necessary to meet the basic health needs of the patient,
• Rendered in the most cost-efficient manner and setting appropriate for the
delivery of the service or supply,
• Consistent in type, frequency and duration of treatment with scientifically
based guidelines of national medical, research or health care coverage
organizations, or governmental agencies that are accepted by the claims
administrator,
• Consistent with the diagnosis of the condition,
• Required for reasons other than the convenience of the patient or physician,
and
• Demonstrated through prevailing peer-reviewed medical literature to be
either:
− Safe and effective for treating or diagnosing the sickness or condition for
which their use is proposed, or
− Safe with promising efficacy for treating a life-threatening sickness or
condition in a clinically controlled research setting using a specific
research protocol that meets standards equal to those defined by the
National Institutes of Health.
BHSM y September 2008 69
Health Care
Morbid Obesity
A condition that exists when weight is at least twice the ideal weight for frame,
age, height and gender, according to the Federal Guidelines on Obesity.
Occupational Therapy
Physician-ordered treatment by a licensed occupational therapist. The physically
disabled person is treated by means of constructive activities designed and
adapted to promote the functional restoration of the person’s abilities lost or
impaired by disease or accidental injury to satisfactorily accomplish the ordinary
tasks of daily living and those required by the person’s particular occupational
role.
Out-of-Area
A medical care service or supply that is provided outside the PPO network area
(if you live more than 10 miles away from all in-network providers).
Out-of-Network (Non-PPO Provider)
A medical care service or supply furnished by a provider that does not participate
in the PPO network. In general, out-of-network services are covered at a lower
benefit level than services from a PPO network provider.
Orthotic Devices
Appliances such as braces and splints which are required for support for an
injured or deformed part of the body as a result of a disabling congenital condition
or an injury or sickness.
Out-of-Pocket Maximum
The most you pay out-of-pocket in a calendar year for eligible medical expenses.
If your deductible plus coinsurance toward eligible expenses reaches the out-of-
pocket maximum, the plan pays 100% for most additional covered expenses for
the rest of the calendar year. (In-network office visit copays and amounts charged
by out-of-network providers above negotiated rates or U&C charges do not count
toward the out-of-pocket maximum.)
Participant
A person who is employed by an employer participating in the EIT benefit plan
and for whom contributions are being received by EIT.
Participating Provider Option (PPO)
A medical organization that allows you to choose from a list of participating
providers. The providers agree to provide appropriate medical care for negotiated
rates to plan participants. You pay less for services when you use participating
PPO providers because their charges are based on the PPO negotiated rates.
Physical Therapy
Physician-ordered treatment by a licensed physical therapist using physical
means, hydrotherapy or biomechanical and neurophysiological principals.
Plan Administrator
The plan administrator controls and manages the operation and administration of
the benefits and programs of a plan. The Trustees serve as the plan administrator
for the Electrical Insurance Trustees (EIT) Health & Welfare Plan for Building,
Hotel, Sign and Maintenance Employees.
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Health Care
Preventive Care
Health care services intended to prevent or provide early diagnosis of illness or
injury, such as routine physical exams, gynecological exams, well-child care and
immunizations.
Referral Hall
The Referral Hall refers to the Union office where members must register their
availability for work and from where employment is assigned.
Skilled Nursing Facility (SNF)
A licensed facility that provides 24-hour professional nursing services on an
inpatient basis to persons convalescing from injury or sickness. SNFs maintain a
complete medical record on each service recipient and are supervised on a full-
time basis by a physician.
Speech Therapy
Speech therapy as directed by a physician and performed by a licensed speech
therapist. Treatment is covered by the plan if the services are expected to restore
a speech function lost due to disease, injury or surgery.
Timely Filing
The length of time in which a claim must be filed in order to receive benefits.
Usual and Customary (U&C) Charges
The charges considered appropriate in your geographic area for medically
necessary services, treatments, supplies or drugs. You pay any charges over the
U&C amount.
Welfare Fund
Refers to the assets held in trust for the EIT Health & Welfare Plan for Building,
Hotel, Sign and Maintenance Employees.
BHSM y September 2008 71
Health Care
72 September 2008 y BHSM
Disability
Your plan provides you with disability coverage that gives you and
your family protection against some of the financial hardships that
can occur if you become disabled or injured. The benefits include:
More Information
For definitions of terms
that are often used in
describing your benefits,
be sure to review the
“Glossary” on page 82 and
in the Health Care section
of this SPD.
• Short-Term Disability benefits
• Long-Term Disability benefits
In addition to these benefits, you may also be eligible for benefits
from Pension Plan No. 4 and Social Security. See the What
Happens If… section for more information.
In This Section See Page
Participation ....................................................................................................... 74
Participant Eligibility ...................................................................................... 74
When Coverage Begins ................................................................................ 74
When Coverage Ends ................................................................................... 75
Filing a Claim................................................................................................. 75
What’s Not Covered ...................................................................................... 76
Short-Term Disability Benefits ......................................................................... 77
When Benefits Begin and End ...................................................................... 78
Receiving Benefits......................................................................................... 78
Recurring Disabilities .................................................................................... 78
Long-Term Disability Benefits.......................................................................... 79
When Benefits Begin and End ...................................................................... 79
Qualifying for a Benefit.................................................................................. 80
Receiving Benefits......................................................................................... 80
Recurring Disabilities .................................................................................... 80
Pension Plan Disability Benefits.................................................................... 81
Social Security Disability Benefits................................................................. 81
Disability Advancement................................................................................. 81
Rehabilitative Employment............................................................................ 82
Glossary.............................................................................................................. 82
BHSM y September 2008 73
Disability
Participation
This section describes how you can participate in disability benefits,
including who is eligible, when disability coverage begins,
maintaining disability coverage and when disability coverage ends.
Participant Eligibility
If you are an active employee and you are eligible for health benefits, you are
eligible for disability benefits.
If you stop working in active employment or become ineligible for health benefits
under the plan, your eligibility for disability benefits will end. Once your eligibility
ends, you will not be eligible for disability benefits until you resume coverage as
an active employee under the health plan.
See “Participant Eligibility” in the Health Care section for more information about
health plan eligibility requirements.
Credited Hours During Periods of Disability
If you are unable to work because of a certified disability, you are credited with up
to 37.5 hours for each week of proven disability while eligible for short-term
disability or long-term disability benefits during any one period of continuous
disability.
To receive credited hours, you must be:
• Receiving disability benefits from Workers’ Compensation or from the
Welfare Fund, or
• Eligible for but not receiving benefits from the Welfare Fund because Social
Security disability benefits are greater.
Insurance eligibility credit will be given for up to 131 weeks if you were covered
under the plan for at least 12 consecutive months prior to the disability or for up to
27 weeks if you were covered for fewer than 12 consecutive months prior to the
disability.
When Coverage Begins
Short-term disability coverage begins on the first day of the month after you
complete the plan’s eligibility requirements. (See “Participant Eligibility” in the
Health Care section.)
Eligibility for long-term disability coverage begins on the first day of the month
after you have been enrolled in the Health & Welfare Plan for 12 consecutive
calendar months.
74 September 2008 y BHSM
Disability
When Coverage Ends
Coverage ends when you fail to meet eligibility requirements or if the plan is
discontinued. The following table summarizes situations in which coverage would
normally end and what happens to your coverage in each situation.
It is your responsibility to
know when your coverage
will end because of
insufficient contributed
hours. The Fund Office,
Welfare Fund and the
Trustees are not obligated
or required to notify you of
loss of coverage.
Important Note
You can receive benefits
for a maximum of 2 years
and 26 weeks.
Disability Coverage
Ends…
However, Disability Coverage May Continue
if…
At the end of the month
following the month you
fail to meet the contributed
hours requirement
No further coverage is available.
If you are disabled, after
the maximum disability
period ends
No further coverage is available.
If the plan is discontinued No further coverage is available.
The Trustees will make every effort to notify you by mail if you lose coverage for
any reason. The notice will be sent to the address on file at the Fund Office. Be
sure to notify the Fund Office if you have a change of address.
Note: You must reimburse the plan for any benefits that may have been paid
after you have lost coverage because of insufficient hours.
Filing a Claim
To collect short-term disability or long-term disability benefits, you must contact
the Fund Office and obtain a claim form. The Fund Office will send a claim form
to you. It must be completed by you, your employer and your physician and
returned to the Fund Office. The completed claim form must be filed with the
Fund Office within 365 days from the date of your disability. You also must supply
the Fund Office with information the Trustees require (i.e., proof of your claim).
The Fund Office will forward your completed claim form to a third-party case
management service for medical review before any benefits are paid. All benefits
are subject to certification by the case management service.
Benefits will not be available for any claim that began more than 365 days before
receipt of the completed claim form by the Fund Office. In addition, if the Fund
Office determines that you received short-term disability or long-term disability
benefits to which you were not entitled, you will be required to reimburse the
Fund for any benefit payments made to you.
BHSM y September 2008 75
Disability
Proof of Claim
Your proof of claim must show:
• That you are under the regular care of a licensed physician or behavioral
health provider,
• The date your disability began,
• The cause of your disability,
• The extent of your disability — including restrictions and limitations
preventing you from performing your regular job, and
• The name and address of any hospital or facility where you received
treatment, as well as all attending physicians.
EIT Benefit Funds reserves the right to request an independent exam by a
selected physician to review your eligibility for disability benefits.
Refer to “Claims Approval and Denial” in the Rules, Regulations and
Administrative Information section for more claims information.
What’s Not Covered
You will not receive benefits for any period of disability:
Important Note!
See the “What’s Not
Covered” list for
exclusions that apply to
both short-term disability
and long-term disability
benefits.
• During which you are not under the regular care of a licensed physician or
behavioral health provider,
• During which your disability is not certified by the case management service,
• During which you are treated by a relative or a person who ordinarily resides
with you,
• That results from injury or sickness caused directly or indirectly by war or an
act of war,
• Caused by participation in a riot,
• That results from intentionally self-inflicted injury,
• For which you are paid by an employer,
• That results from an accident while intoxicated or under the influence of
narcotics not administered by a physician,
• That results from an injury or sickness arising from any electrical work or any
other paid work or is payable under any Workers’ Compensation or
occupational disease law,
• That results from travel in a private aircraft, or
• That occurs after the date you retire.
These exclusions apply to both your short-term disability and your long-term
disability benefits.
76 September 2008 y BHSM
Disability
Short-Term Disability
Benefits
You receive short-term disability benefits if you are disabled by an
illness or accidental injury while an active employee. The disability
must prevent you from returning to work with a participating
employer and make you totally unable to perform your job. You also
must be under the care of a licensed physician or behavioral health
provider during your disability.
The chart below summarizes the short-term disability benefits
offered under the plan. To fully understand how these benefits
work, you should read the more detailed information that follows the
chart.
Short-Term Disability Benefits
When Coverage
Begins
On the first day of the month after you become eligible for
health and welfare benefits under this plan
When Benefits
Are Payable
After you are unable to work and have been under the care
of a licensed physician or behavioral health provider for
seven consecutive days
What You
Receive
$550 a week for up to 26 consecutive weeks
How Long
Benefits Last
If you remain totally disabled and your disability continues to
be certified by a case management service, payments
continue for up to 26 weeks.
Other Benefits You remain eligible for health and welfare benefits.
BHSM y September 2008 77
Disability
When Benefits Begin and End
Your benefits will begin after you are unable to work for seven consecutive days,
and you are under the care of a licensed physician or behavioral health provider.
What’s the Definition of
Disability?
You are considered
disabled if you suffer from
an illness or accidental
injury that prevents you
from being continuously
able to perform your job,
and you are under the
care of a licensed
physician or behavioral
health provider.
If you remain totally disabled, payments continue for up to 26 weeks, but not
beyond the date your physician allows you to return to work.
See “What’s Not Covered” on page 76 for exclusions and limits that apply to
disability benefits under the plan.
Receiving Benefits
You will receive the benefit shown in the “Short-Term Disability Benefits” chart on
page 77 at the end of each pay period during which you have provided proof of
your continuing disability. Because of federal law, Social Security and Medicare
taxes will be withheld from your weekly short-term disability benefit. If you want
federal income and state taxes withheld from your check, you must notify the
Fund Office.
Recurring Disabilities
If you recover from a short-term disability, return to work and are later disabled
again from the same cause, the two periods will count as one 26-week disability
period, unless your physician released you for full-time unrestricted work and:
• You returned to full-time unrestricted work for at least four consecutive weeks
doing the same or similar work as you did before the disability.
If you recover from one short-term disability and then become disabled from a
different cause, you will receive benefits for up to 26 weeks for each period of
disability if:
• Your physician allowed you to return to full-time unrestricted work between
the two periods of disability, and
• You returned to full-time unrestricted work for at least four consecutive weeks
doing the same or similar work as you did before the disability.
78 September 2008 y BHSM
Disability
Long-Term Disability
Benefits
You may receive long-term disability benefits for up to 24 months
while you continue to be disabled and under a physician’s care.
Applying for Social
Security Disability
Benefits
If your disability is
expected to last six
months or longer, you are
expected to apply for
Social Security disability
benefits.
The chart below summarizes the long-term disability benefits
offered under the plan. To fully understand how these benefits
work, you should read the more detailed information that follows the
chart.
Long-Term Disability Benefits
When Coverage
Begins
On the first day of the month after you have been enrolled in
the Health & Welfare Plan for 12 consecutive months
When Benefits
Are Payable
After 27 weeks of disability (26 weeks of short-term disability
plus the seven day short-term disability waiting period)
What You
Receive
60% of your average monthly pay (up to a maximum
monthly benefit of $2,000). The benefit will be reduced by
any disability benefit paid or payable by Social Security.
How Long
Benefits Last
Your benefits will continue for up to 24 months after they
begin as long as you remain disabled or until you retire,
whichever comes first.
Other Benefits
while You Are
Disabled
• You remain eligible for health and welfare benefits
• You may qualify for a benefit from Pension Plan No. 4
• You may qualify for a Social Security disability benefit
Note: After your long-term disability benefits end, you may qualify to continue
medical, prescription drug, dental, orthodontia, vision and hearing aid benefits for
up to 29 months by paying premiums as available through COBRA. (See
“Continuing Coverage” in the Health Care section for more information about
COBRA continuation of coverage.) COBRA does not include disability benefits.
When Benefits Begin and End
Your long-term disability benefits begin after 27 weeks of disability. (During this
27-week period, you may be eligible for short-term disability benefits — see
“Short-Term Disability Benefits” on page 77.)
Your benefits end at the first instance of any of the following circumstances:
• The disability ends
• 24 months after benefits begin
• When you receive a disability award from Social Security and elect to receive
a pension from EIT
BHSM y September 2008 79
Disability
Qualifying for a Benefit
To qualify for long-term disability benefits, you must:
• Be covered by the Health & Welfare Plan for at least 12 consecutive calendar
months before the disability began,
• Be prevented from performing any gainful work due to a physical or mental
impairment,
• Not have engaged in any gainful employment for 27 consecutive weeks,
• Be under the continuous care and attendance of a licensed physician or
behavioral health provider or surgeon for treatment of your disability, and
• Have applied for Social Security disability benefits and your application is still
pending, or be eligible to receive Social Security benefits.
The Fund Office determines disability and the right of any participant to receive
disability benefits from the plan.
See “What’s Not Covered” on page 76 for exclusions and limits that apply to
disability benefits under the plan.
Receiving Benefits
Your long-term disability benefit is paid monthly for up to 24 months after benefits
begin. The benefit amount is based on the formula shown below:
Average Monthly Pay
Average monthly pay
means the wages or salary
paid to you by participating
employers in the 12
calendar months before
your disability began,
divided by 12.
60% of your average monthly pay
(up to a maximum monthly benefit of $2,000)
MINUS
Disability benefits paid or payable by Social Security or any other group
disability plan
An Example: If your monthly pay is more than $3,333, you will receive 60% of
your average monthly pay up to a maximum benefit of $2,000 per month. If your
average monthly pay is $3,333 or less, your benefit is 60% of your average
monthly pay.
Any disability benefits paid or payable by Social Security or any other group
disability plan will reduce the benefits payable by this plan.
Vacation and holiday pay, bonuses and commissions are not included in figuring
your long-term disability benefit.
Recurring Disabilities
If you recover and are then disabled again within six months from the same or a
related cause, you are considered to have a continuation of the first disability. If
more than six months have passed since your recovery, and you have worked
doing the same or similar work for six consecutive months as you did before your
first disability, you are considered to have a new disability for which you may
receive up to 24 months of benefits, subject to a 27-week waiting period.
80 September 2008 y BHSM
Disability
Pension Plan Disability Benefits
You may be eligible to receive a disability pension from Pension Plan No. 4 if you
have been granted a disability benefit from Social Security and you have 10 or
more years of eligibility service.
Note: If you start your disability pension, payments from this plan will stop.
What’s the Definition of Total and Permanent Disability?
You are considered totally and permanently disabled if:
• A physical or mental impairment prevents you from doing any gainful work,
• The impairment is expected to continue for at least 24 months or result in an
earlier death, and
• You are eligible to receive a Social Security disability benefit.
Social Security Disability Benefits
Social Security may also provide disability benefits to you and your eligible family
members. You must apply for a Social Security disability benefit within five
months of disability to remain eligible for long-term disability benefits through this
plan. If your initial application for Social Security disability benefits is denied, you
must pursue your right to appeal the denial. That means you must complete each
of the following steps on a timely basis until your claim is allowed:
• A reconsideration
• A hearing before an administrative law judge
• A review by an Appeals Council
• An action in a federal district court
In each step, you must apply in writing within 60 days of notification that your
appeal was not granted at the earlier step.
After you have been eligible for Social Security disability benefits for 24 months,
you become eligible for Medicare — regardless of your age. This is another
important reason to pursue your claim for Social Security benefits throughout the
entire appeals process.
Disability Advancement
The Trustees may grant you a short-term emergency advance from the plan while
you wait for the determination of your right to receive Social Security disability
benefits. Contact the Fund Office for an application.
The advancement is secured by your benefit under this plan or any benefits that
you may receive from the Trustees. On approval by the Trustees, you will receive
up to one month of your long-term disability benefit. You can apply for an
advance once each month until Social Security has made a final determination on
your right to disability benefits. The advancement must be paid back to the
Trustees within 30 days after you receive a Social Security disability benefit.
If your application for Social Security disability benefits is not approved after you
have completed the entire appeals process, as stated in “Social Security
Disability Benefits” on page 81, the advancement reverts to the basic long-term
disability benefit and would not have to be repaid.
BHSM y September 2008 81
Disability
Rehabilitative Employment
Your long-term disability benefit will continue if you participate in rehabilitative
employment, but it will be reduced by 80% of your income from such
employment. The reduction may apply for the whole 24-month benefit period.
Glossary
The definitions included in this glossary will help you understand your plan
benefits.
Active Employee
A person who meets the definition of employee, who is actively at work or
available for work for a contributing employer, and who is not a retiree.
82 September 2008 y BHSM
Life Insurance and
AD&D
More Information…
For definitions of terms
that are often used in
describing your benefits,
be sure to review the
“Glossary” on page 90 at
the end of this section and
in the Health Care section
of this SPD.
The plan provides you with life and accident coverage that gives
you and your family protection against some of the financial
hardships that can occur if you become injured or die. These
benefits include:
• Basic Life Insurance
• Accidental Death & Dismemberment (AD&D)
In addition to these benefits, you or your spouse or beneficiary may
also be eligible for benefits from Pension Plan No. 4 and Social
Security. See the What Happens If… section for more information.
In This Section See Page
Participation ....................................................................................................... 84
Participant Eligibility ...................................................................................... 84
When Coverage Begins ................................................................................ 84
When Coverage Ends ................................................................................... 84
Designating a Beneficiary ............................................................................. 85
Other Benefits Payable on Death.................................................................. 85
Filing a Claim................................................................................................. 85
Life Insurance Benefits ..................................................................................... 87
Conversion Privilege ..................................................................................... 87
What’s Not Covered ...................................................................................... 87
Accidental Death & Dismemberment (AD&D) Benefits ................................. 88
Receiving Benefits......................................................................................... 88
What’s Not Covered ...................................................................................... 89
Glossary.............................................................................................................. 90
BHSM y September 2008 83
Life Insurance and AD&D
Participation
This section describes how you can participate in Life Insurance
and AD&D (accidental death and dismemberment) benefits,
including who is eligible, when Life Insurance and AD&D coverage
begins, maintaining Life Insurance and AD&D coverage and when
Life Insurance and AD&D coverage ends.
Participant Eligibility
If you are an active employee and you are eligible for health benefits, you are
eligible for Life Insurance and AD&D benefits.
If you stop working in active employment or become ineligible for health benefits
under the plan, your eligibility for Life Insurance and AD&D benefits will end.
Once your eligibility for health benefits ends, you will not be eligible for Life
Insurance and AD&D benefits until you resume coverage as an active employee
under the health plan.
See “Participant Eligibility” in the Health Care section for more information about
health plan eligibility requirements.
When Coverage Begins
Coverage begins on the first day of the month after you complete the plan’s
eligibility requirements. See “Participant Eligibility” in the Health Care section for
details.
When Coverage Ends
Coverage ends when you fail to meet eligibility requirements or if the plan is
discontinued. The following table summarizes situations in which coverage would
normally and what happens to your coverage in each situation.
It is solely your
responsibility to know
when your coverage will
end because of insufficient
contributed hours. Notice
of loss of coverage from
the Fund Office is not an
obligation of the Welfare
Fund, its Trustees or the
Fund Office.
Life Insurance and
AD&D Coverage
Ends…
However, Life Insurance and AD&D Coverage May
Continue if…
At the end of the
month following the
month you fail to meet
the contributed hours
requirement
No further coverage is available.
If you are disabled,
after the maximum
disability period ends
No further coverage is available.
If the plan is
discontinued
No further coverage is available.
84 September 2008 y BHSM
Life Insurance and AD&D
The Trustees will make every effort to notify you by mail if you lose coverage for
any reason. The notice will be sent to the address on file at the Fund Office. Be
sure to notify the Fund Office if you have a change of address.
Designating a Beneficiary
You may designate anyone you want as your beneficiary by completing and
returning the beneficiary designation form available from the Fund Office. Your
beneficiary designation applies to both Basic Life Insurance and the AD&D
accidental death benefit. You may change your designated beneficiary at any
time by filing a new beneficiary designation form with the Fund Office. Completed
beneficiary designation forms must be received by the Fund Office during your
lifetime.
If there is no designated beneficiary still surviving at the time of your death, your
death benefit is divided equally among the then living members of the first
surviving class listed below:
• Your spouse
• Your children
• Your parents
• Your estate
Other Benefits Payable on Death
Your spouse or dependent children may be eligible for a survivor benefit from
Pension Plan No. 4.
To apply for your pension plan benefits, your surviving spouse or dependent
children may call or write to the Fund Office for benefit forms. Then, he or she
must file the application with the Fund Office, which will submit it to the Trustees.
Your spouse or dependent children may be asked to supply evidence of age and
any other additional information (such as a death certificate) the Trustees
consider necessary.
Depending on your age and other circumstances, your spouse may also be
eligible to receive death benefits from Social Security.
Filing a Claim
To collect the Life Insurance benefit, your designated beneficiary must advise the
Fund Office of your death and obtain a claim form. The completed claim form
must be filed with the Fund Office within 365 days of the date of your death. Your
designated beneficiary must supply the Fund Office with information the Trustees
require.
BHSM y September 2008 85
Life Insurance and AD&D
To receive AD&D benefits, you or your designated beneficiary need to complete
the following steps:
• For a dismemberment benefit, you must contact the Fund Office to obtain a
claim form. You must complete and return the claim form within 90 days of
the date of the accident and provide other information, such as proof of loss,
as requested.
• To receive the accidental death benefit under this coverage, your designated
beneficiary must complete and return the claim form within 365 days of the
date of your death. He or she must also provide other information as
requested by the Trustees.
Refer to “Claims Approval and Denial” in the Rules, Regulations and
Administrative Information section for more claims information.
86 September 2008 y BHSM
Life Insurance and AD&D
Life Insurance Benefits
If you die from any cause while you are an active employee and you are eligible
for health benefits, the plan provides a Basic Life Insurance benefit.
The chart below summarizes the Life Insurance benefits offered under the plan.
To fully understand how these benefits work, you should read the more detailed
information that follows the chart.
Life Insurance Benefits
When Coverage
Begins
On the first day of the month after you become eligible for
health benefits under this plan
When Benefits Are
Payable
If you die while you are an active employee eligible for
health benefits under this plan
What You Receive Your designated beneficiary may receive $10,000.
How Long
Benefits Last
Your designated beneficiary will receive a one-time lump-
sum benefit payment.
Other Benefits Your spouse or dependent children may be eligible for
survivor benefits from Pension Plan No. 4.
Receiving Benefits
Your Basic Life Insurance benefit is paid to your designated beneficiary as a
single lump-sum payment.
Conversion Privilege
If your Life Insurance coverage ends for any reason other than termination of the
plan, you may purchase an individual life insurance policy from an insurance
carrier designated by the Trustees, currently Fort Dearborn Life Insurance
Company, without giving any evidence of insurability. Contact the Fund Office in
advance for an application form and premium and coverage information.
To use this conversion privilege, a written application and payment of the first
premium must be made to and received by Fort Dearborn Life Insurance
Company within 31 days after termination of coverage. The individual policy
issued will be of the form used by the insurance company for conversion of group
life insurance at the time conversion is made. The effective date will be the date
following the date coverage ends under the plan.
What’s Not Covered
No exclusions apply under Basic Life Insurance coverage.
BHSM y September 2008 87
Life Insurance and AD&D
Accidental Death &
Dismemberment (AD&D)
Benefits
If you die because of an accident while an active employee, the plan pays your
designated beneficiary an accidental death benefit in addition to the Basic Life
Insurance benefit. If you are injured in an accident and become dismembered,
the plan pays a dismemberment benefit to you.
The chart below summarizes the AD&D benefits offered under the plan. To fully
understand how these benefits work, you should read the more detailed
information that follows the chart.
AD&D Benefits
When Coverage
Begins
On the first day of the month after you become eligible
for health benefits under this plan
When Benefits Are
Payable
If, while you are eligible for this benefit, you die due to an
accident, or you are injured in an accident and become
dismembered
What You Receive Your designated beneficiary will receive $5,000 in one
lump-sum payment (in addition to your Basic Life
Insurance benefit) if you die because of an accident.
You will receive up to $5,000 in one lump-sum payment if
you become dismembered in an accident.
How Long Benefits
Last
Benefits are paid to you or your designated beneficiary in
one lump-sum payment if you die or are dismembered as
a result of an accident.
Other Benefits Not applicable
Receiving Benefits
An accidental death benefit will be paid to your designated beneficiary if you die
as a direct result of an accident and independent of all other causes within 365
days of the date of the accident. This accidental death benefit is in addition to any
other life insurance (or death benefit) coverage you may have under a Local 134
benefit plan. However, the benefit is reduced by the amount of any accidental
dismemberment benefits paid as a result of the same accident.
88 September 2008 y BHSM
Life Insurance and AD&D
If, within 90 days of the date of the accident, you become dismembered due to an
accident while you are an active employee, you may receive one of the following
benefits:
If a Covered Accident Results in… The Benefit Amount
Payable Is…
Covered Loss
Loss of both hands, both feet, the sight in both eyes,
one hand and one foot, one hand or foot and sight of
one eye, or hearing in both ears and speech
$5,000
Loss of one hand, one foot, the sight of one eye, loss of
speech or hearing in both ears
$2,500
Loss of a thumb and index finger on the same hand $1,250
Paralysis
Quadriplegia (paralysis of both upper and both lower
limbs)
$5,000
Paraplegia (paralysis of both upper or both lower limbs)
or hemiplegia (paralysis of the upper and lower limbs on
the same side of the body)
$2,500
Triplegia (hemiplegia with paralysis of a limb on the
other side)
$3,750
Uniplegia (the entire and irrecoverable paralysis of one
limb)
$1,250
Seat Belt and Air Bag Benefit
The plan will pay to your designated beneficiary an additional $5,000 if you die in
a private passenger car accident, and your seat belt was in use at the time of the
accident. The plan will pay $500 air bag benefit, in addition to the full benefit
amount, if the air bag deployed. Based on the police report, if it cannot be
determined whether the seat belt was in use at the time of the accident, then the
benefit will be reduced to $1,000, and the plan will pay an additional $250 if the
air bag deployed.
What’s Not Covered
Your AD&D benefit is not paid if death or dismemberment results from:
• Bacterial infections (except pyogenic infections that occur with or through an
accidental cut or wound),
• Ptomaines,
• Bodily or mental infirmity or any other kind of disease,
• Suicide or attempted suicide,
• An act of war,
• Participation in a riot,
• Commission of a felony, or
• An act of terrorism.
BHSM y September 2008 89
Life Insurance and AD&D
Glossary
The definitions included in this glossary will help you understand your plan
benefits.
Active Employee
A person who meets the definition of employee, who is actively at work or
available for work for a contributing employer, and who is not a retiree.
Retiree
A person who meets the applicable eligibility requirements as stated in the
Electrical Insurance Trustees Pension Plan No. 4 SPD.
90 September 2008 y BHSM
Rules, Regulations and
Administrative
Information
This section contains important administrative information about the
benefit provided to you by the Electrical Insurance Trustees and
described in this handbook. The information in this section applies
to all of your benefits and includes details about your rights as
provided under the Employee Retirement Income Security Act of
1974, as amended (ERISA). Although you may not need this
information on a day-to-day basis, it is important for you to
understand your rights and the procedures you need to follow
should certain situations arise.
Your benefits are sponsored and administered by a joint labor-
management Board of Trustees. The Fund Administrator assists the
Board of Trustees in the administration of the Fund. The Fund
Administrator and other personnel of the administration office are
employees of the Fund Office.
In This Section See Page
Plan Documents................................................................................................. 92
Your Rights Under ERISA................................................................................. 92
Your HIPAA Rights ............................................................................................ 94
Claims Review and Appeals Procedures ........................................................ 95
Health Care ................................................................................................... 95
Disability and Life Insurance/AD&D Benefits ................................................ 96
Non-Assignment of Benefits ............................................................................ 98
Change or Termination of the Plan.................................................................. 98
Other Plan Details.............................................................................................. 98
BHSM y September 2008 91
Rules, Regulations and Administrative Information
Plan Documents
This Summary Plan Description (SPD, or handbook) serves as the official plan
document for the Electrical Insurance Trustees (EIT) Health & Welfare Plan for
Building, Hotel, Sign and Maintenance Employees, and supersedes and replaces
any prior SPD and Summaries of Material Modification previously provided by EIT
for the plans of benefits described in it. If you need more information, you may
examine copies of the applicable collective bargaining agreement and other
related documents at the Fund Office.
Your Rights Under ERISA
As a participant in the EIT Health & Welfare Plan for Building, Hotel, Sign and
Maintenance Employees, you are entitled to certain rights and protections under
the Employee Retirement Income Security Act of 1974, as amended (ERISA).
Although ERISA does not require an employer to provide benefits, it does set
standards on how a plan is run. It also requires that you be kept fully informed of
your rights and benefits — the details of which are included in this booklet.
ERISA provides that all plan participants shall be entitled to the following rights:
Receive Information about Your Plan and Benefits
• You may examine, free of charge, all documents governing the plan including
insurance contracts, collective bargaining agreements and the latest annual
report (Form 5500 Series). These documents are available at the plan
administrator’s office and at other specified locations. The annual report also
is filed with the U.S. Department of Labor and is available at the Public
Disclosure Room of the Employee Benefits Security Administration.
• You may obtain copies of all documents governing the operation of the plan,
including updated Summary Plan Descriptions by writing to the plan
administrator. The plan administrator may make a reasonable charge for the
copies.
• You may also receive a summary of the plan’s annual financial report. The
plan administrator is required by law to furnish each participant with a copy of
this summary annual report.
Continue Group Health Plan Coverage
• Under COBRA, you may continue health care coverage for yourself, your
spouse or your dependents if there is a loss of coverage under the plan as a
result of a qualifying event. However, 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.
Prudent Actions by Plan Fiduciaries
• In addition to creating rights for plan participants, ERISA imposes duties upon
the people who are responsible for operating the plan. These people are
called “fiduciaries” of the plan. They have a duty to act prudently and in the
interest of you and other plan participants and beneficiaries.
92 September 2008 y BHSM
Rules, Regulations and Administrative Information
• No one, including your employer or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining
a benefit to which you are otherwise entitled or from exercising your rights
under ERISA.
Enforcement of Your Rights
• If your claim for a benefit is denied, in whole or in part, the plan administrator
must give you a written explanation of the reason for the denial, and you can
obtain copies of documents relating to the decision, without charge. You also
have the right to have the plan administrator review and reconsider your
claim, all within certain defined time schedules.
• Under ERISA, there are steps you can take to ensure the above rights. For
instance, if you request materials from the plan administrator 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 plan 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 plan
administrator.
• If your claim for benefits is denied or ignored, in whole or in part, you may file
suit in a state or federal court. You may also file suit in a federal court if you
disagree with a decision, or the lack of a decision, concerning the qualified
status of a medical child support order. If 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 (for example, if the court finds your claim is frivolous), it
may order you to pay these costs and fees.
Assistance with Your Questions
• If you have any questions about your plan, you should contact the plan
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 plan administrator, you should contact the nearest office of the Employee
Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory or contact 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 publication hotline of the
Employee Benefits Security Administration.
BHSM y September 2008 93
Rules, Regulations and Administrative Information
Your HIPAA Rights
According to the Health Insurance Portability and Accountability Act of 1996
(HIPAA), if you lose coverage under the plan, you are entitled to a certificate that
shows evidence of your prior medical coverage.
The claims administrator promptly provides this certificate:
• If you or your covered dependents lose coverage under the plan,
• If you or your dependents lose coverage under COBRA, or
• Whenever you submit a written request within 24 months after either of the
above events.
The certificate identifies:
• Who was covered under the plan,
• The period of coverage, and
• Any waiting periods.
This certificate is used to determine pre-existing condition exclusion periods in
the future because, according to HIPAA, your period of coverage under this plan
will offset the exclusion period of a new medical plan.
If you leave this plan and enroll in coverage under another medical plan, check
with your new plan’s administrator to find out whether:
• The plan has a pre-existing condition exclusion, and
• You need to provide a certificate or other documentation of your medical
coverage through this plan.
Under HIPAA, if you have creditable coverage from another plan, you will receive
a certificate of coverage that helps to reduce or eliminate exclusionary periods of
coverage for pre-existing conditions under your new group health plan. You will
be provided a certificate of creditable coverage, free of charge, from the EIT
Health & Welfare Plan for Building, Hotel, Sign and Maintenance Employees or
your health insurance insurer when:
• You lose coverage under the plan,
• You become entitled to elect COBRA continuation coverage, or
• Your COBRA continuation coverage ends.
You may also request a certificate of coverage before your coverage ends, or for
up to 24 months after losing coverage.
Without evidence of creditable coverage, you may be subject to a pre-existing
condition exclusion for 12 months (18 months for late enrollees) after you enroll in
your new coverage.
EIT will assist you in obtaining a certificate of coverage from your previous insurer
if one is needed and you do not have one.
94 September 2008 y BHSM
Rules, Regulations and Administrative Information
Claims Review and Appeals Procedures
In all circumstances relating to any claim or appeal for benefits under any plan,
the plan administrator or claims administrator responsible for making a
determination on the claim or appeal will have discretionary authority in making
the determination, including but not limited to, interpreting and applying the terms
and conditions of the plan, making any necessary factual determinations and
determining eligibility under the plan. Benefits under the plan will be paid only
when the Trustees, or persons delegated by them to make such decisions,
decide in their sole discretion, that the participant or beneficiary is entitled to
benefits under the terms of the plan.
Health Care
The plan has a specific amount of time, by law, to evaluate and respond to claims
for benefits covered by the Employee Retirement Income Security Act of 1974, as
amended (ERISA). The period of time the plan has to evaluate and respond to a
claim begins on the date the claim is first filed with the applicable claims
administrators.
Filing Claims
You may file claims for plan benefits, and appeal adverse claim decisions, either
yourself or through an authorized representative. If your claim is denied in whole
or in part, you will receive a written notice of the denial from BCBS. The notice
will explain the reason for the denial and the review procedures.
An “authorized representative” means a person you authorize, in writing, to act on
your behalf. The plan will also recognize a court order giving a person authority to
submit claims on your behalf, except that in the case of a claim involving urgent
care, a health care professional with knowledge of your condition may always act
as your authorized representative.
If you have any questions regarding how to file or appeal a claim, contact the
claims administrator. For more information on filing claims and claims
administrator’s addresses, please see “Filing a Claim” in each applicable benefit
plan section and the Contact Information section.
Appealing Denied Claims
If your claim is denied, in whole or in part, you may appeal the denial. You will
receive a written notice explaining why and on which specific plan provisions the
claim has been denied. The notice also will explain how to file an appeal. There
are two levels to the appeal process, as described below: you must submit your
first appeal to Blue Cross/Blue Shield (BCBS) within 180 days of the initial BCBS
non-favorable decision. If the BCBS appeal is not favorable, you may then
request a second level of appeal with the Trustees within 180 days of the date of
the BCBS non-favorable decision. You may choose to name an authorized
representative to handle your appeal.
A first level appeal is decided by a BCBS review unit that did not conduct the
initial review of your claim. The timelines for deciding appeals will differ based
upon the type of claim you file.
BHSM y September 2008 95
Rules, Regulations and Administrative Information
A second level appeal is decided by the Board of Trustees after a full and fair
review and is based upon the information submitted in the appeal and the terms
of the plan. The timelines for deciding appeals will differ based upon the type of
claim you file.
If your appeal is:
Note
An appeal of a concurrent
care decision to reduce or
terminate previously-
approved benefits may be
an urgent care, pre-service
or post-service claim,
depending on the facts.
• An urgent care claim: BCBS or CIGNA Behavioral Health will review your
claim as applicable. The appeal will be decided as soon as possible, but no
later than 72 hours after it is received (no extensions).
• A non-urgent pre-service claim: BCBS or CIGNA Behavioral Health will
review your claim. The appeal will be decided within 30 days after it is
received, or 15 days for each level of appeal, if two mandatory appeals are
allowed (no extensions).
• A non-urgent post-service claim: The appeal must be decided within 60
days after it is received, or 30 days for each level appeal, if two mandatory
appeals are allowed (no extensions).
• Any other claim under the plan: The claim must be decided within 60 days
after it is received (up to 60-day extension).
The Trustees’ decision on a second level appeal is final. If either you or your
authorized representative still believes a claim for benefits has been improperly
denied, you or your authorized representative may contact the plan administrator.
You have the right to receive without charge, upon written request, reasonable
access to any documents relied on in making this determination. Furthermore, if
you believe the Trustees have erred in determining your rights under the Plan’s
provisions, you have the right to bring a civil action under Section 502(a) of the
Employee Retirement Income Security Act of 1974, as amended (ERISA).
Besides having the right to appeal, you or your authorized representative can
examine any documents, records and other information relevant to your denied
claim. You can also submit, in writing, reasons why you think the claim should not
be denied.
If your claim for benefits is denied, you can file suit in a state or federal court.
However, you may not initiate any action at law or in equity to recover under the
plan until you have exhausted the appeal rights described above and the plan
benefits requested in that appeal have been denied in whole or in part.
Disability and Life Insurance/AD&D Benefits
Filing a Claim
If your claim is approved, you will receive all applicable benefits as soon as the
Fund Office receives and approves all necessary documentation.
If your claim is denied, you will receive a written explanation from the Fund Office
within 90 days from the time the application was received by the Trustees (or
within 180 days if the Trustees notify you that additional time is needed for
processing the application). This written notice includes:
• Specific reasons for the denial,
• References to the plan provisions on which the denial is based,
• Descriptions of any additional information you may have to provide and why
it’s needed,
96 September 2008 y BHSM
Rules, Regulations and Administrative Information
• Explanations of the plan’s claim review procedure including the steps to take
if you or your beneficiary wish to appeal the decision, and
• A statement of your right to bring a civil action lawsuit under ERISA section
502(a) following a denial of your claim or review.
Appealing a Claim
You or an authorized representative may appeal any claim denial by filing a
written request for a full and fair review by the Trustees. A request for a review
must be filed within 180 days after you receive written notice of the denial. You
may also review documents pertinent to the administration of the plan and submit
written comments and issues outlining the basis of the appeal. You may have
legal representation throughout the review procedure.
The review on appeal will take into account any information you submit, even if it
was not submitted or considered as part of the initial determination. Upon request
and free of charge, you will also be provided reasonable access to and copies of
all documents, records, and information relevant to your claim.
The person filing the appeal may request a written answer, including specific
reasons and references to pertinent plan provisions, within 60 days after the
appeal is made (or within 120 days if special circumstances require additional
time and the Trustees notify you that additional time is needed before the end of
60 days).
The Trustees will provide you written notification of the decision on an appeal,
usually within 45 days of when it is received (within 90 days in special cases).
If your appeal is denied, the notification will:
• Include specific reasons for the denial,
• Refer to the specific plan provisions on which the determination is based,
• State that you are entitled to receive, upon request and free of charge,
reasonable access to or copies of all documents, records, or other
information relevant to the claim,
• Describe any voluntary appeal procedures offered by the plan and state your
right to bring civil action under federal law,
• Disclose any internal rule, guideline, protocol, or similar criterion relied on in
making the adverse determination (or state that information will be provided
free of charge upon request), and
• If the denial on appeal is based on a medical necessity, experimental
treatment or similar exclusion, explain the scientific or clinical judgment for
the adverse determination (or state that an explanation will be provided free
of charge upon request).
The Trustees’ decision on an appeal is final. If you or your authorized
representative still believe a claim for benefits has been improperly denied, you or
your authorized representative may contact the plan administrator.
Besides having the right to appeal, you or your authorized representative can
examine any plan documents related to your claim. You can also submit, in
writing, reasons why you think the claim should not be denied. If your claim for
benefits is denied or ignored, you can file a suit in state or federal court, once you
have exhausted all appeals and administrative remedies available under the plan.
BHSM y September 2008 97
Rules, Regulations and Administrative Information
Non-Assignment of Benefits
Generally, benefits from the plan belong to you. You may not sell, assign, transfer
or garnish these benefits.
Change or Termination of the Plan
Although the Electrical Insurance Trustees intend to continue the plan indefinitely,
the Trustees have the authority and unconditionally reserve the right, in their sole
and unrestricted discretion, to change, amend or end the plan at any time, or from
time to time, for any reason.
Changes may be made retroactively, if necessary, to qualify or maintain the
benefits under the Internal Revenue Code or the Employee Retirement Income
Security Act of 1974, as amended (ERISA). If the plan is amended or ends, you
may not receive benefits as described in this handbook. However, you may be
entitled to receive different benefits, or benefits under different conditions or no
additional benefits.
Other Plan Details
This section contains other important information about the administration and
funding of the benefit plans described in this handbook.
Plan Name
The official name of the plan is the Electrical Insurance Trustees Health &
Welfare Plan for Building, Hotel, Sign and Maintenance Employees. This SPD
describes the health care benefits (medical, prescription drug, dental, orthodontic,
vision and hearing) and the welfare benefits (sickness, disability, life, and
accidental death and dismemberment insurance) provided under the plan.
Plan Administrator and Sponsor
The plan administrator controls and manages the operation and administration of
the plan. The administrator and sponsor of the plan is:
Electrical Insurance Trustees
221 North LaSalle Street, Suite 200
Chicago, IL 60601-1214
1-312-782-5442
Employer Identification Number
The employer identification number is 36-1033970.
Plan Number
The plan number is 502.
98 September 2008 y BHSM
Rules, Regulations and Administrative Information
Agent for Legal Process
The agent for service of legal process concerning the plan is:
Sean P. Madix
Fund Administrator
221 North LaSalle Street, Suite 200
Chicago, Illinois 60601-1214
Service may also be made on the Board of Trustees or an individual Trustee at
the addresses listed under “Trustees.”
Trustees
The Trustees who authorize the plan benefits have authority to:
• Resolve questions concerning the plan,
• Make rules to implement the plan,
• Construe the plan terms, and
• Determine when plan benefits will be paid.
As of January 1, 2008, the Trustees are as follows:
Employer Trustees
William T. Divane, Jr.
Divane Bros. Electric Company
2424 North 25
th
Avenue
Franklin Park, Illinois 60131-3323
1-847-455-7143
Kevin M. O’Shea
Shamrock Electric Company Inc.
1281 East Brummel Avenue
Elk Grove Village, Illinois 60007
1-847-593-6070
I. Steven Diamond
Malko Electric
6200 Lincoln Avenue
Morton Grove, Illinois 60053-2851
1-847-967-9500
Kenneth Bauwens
Jamerson & Bauwens Electrical Contractors, Inc.
3055 MacArthur Blvd
Northbrook, Illinois 60002
1-847-291-2008
Michael R. Walsdorf
Advent Systems, Inc.
435 West Fullerton Avenue
Elmhurst, Illinois 60126-1404
1-630-279-7171
BHSM y September 2008 99
Rules, Regulations and Administrative Information
Union Trustees
Timothy Foley
Michael J. Caddigan
Lawrence J. Crawley
Samuel Evans
James T. North
600 West Washington Boulevard
Chicago, Illinois 60661-2490
1-312-454-1340
Discretion of Trustees and Fund Administrator
The Trustees and the Fund Administrator have full discretion in determining any
and all questions related to the plan, the fund or the operation of the plan. This
discretion also applies to:
• Any claim for benefits,
• The construction of the language or meaning of the rules and regulations
adopted by the Trustees,
• This SPD and any amendments thereto, and
• Any writing concerned with or provided in connection with the operation of the
plan.
Benefits under the plan will be paid only when the Trustees, or persons delegated
by them to make such decisions, decide in their sole discretion, that the
participant or beneficiary is entitled to benefits under the terms of the plan. The
good faith decision of the Trustees or the Fund Administrator is binding upon
anyone dealing with the plan or claiming any benefit under the plan.
Plan Funding
In general, coverage for you and your dependents under the plan is paid for by
contributions from the participating employers. The amount of the contribution is
established annually by an actuary. If the collective bargaining agreement states
a specific dollars amount to be contributed by your employer, you may have to
pay the difference in the cost of coverage. Your employer will let you know the
amount you have to pay if anything. Assets are held in trust by the Trustees and
disbursed by them.
Plan Year
The plan year begins on July 1 and ends on the following June 30.
For More Information
All questions and requests for information should be sent to the Trustees at the
following address:
Attention: Fund Administrator
221 North LaSalle Street, Suite 200
Chicago, Illinois 60601-1214
You may also call 1-312-782-5442 for more information.
100 September 2008 y BHSM
Contact Information
This section shows you where to go for questions about your
benefits. For claims filing information and addresses, see “Filing a
Claim” in the applicable benefit plan sections.
Claims Administrators
For… Contact… At…
Medical, Hearing Aid and Vision
Medical benefit PPO network
provider information, benefit
information (including
information hearing aid
benefits), forms and claim
information
Blue Cross/Blue
Shield of Illinois
(BCBS)
1-800-862-3386
www.bcbsil.com
The Medical Services Advisory
(MSA) Program (the plan’s
utilization review organization)
Blue Cross/Blue
Shield of Illinois
(BCBS)
1-800-635-1928*
www.bcbsil.com
Hearing aid discounts EPIC 1-866-956-5400
Vision services Vision Service
Plan (VSP)
1-800-877-7195
www.vsp.com
Behavioral Health and Substance Abuse
Information on mental health
and substance abuse benefits
CIGNA Behavioral
Health
1-888-218-7210
www.cignabehavioral.com
The Members Assistance
Program (MAP) counseling and
education information
MAP (CIGNA
Behavioral
Health)
1-888-218-7210
Prescription Drug Information
Prescription drug information,
order forms and preaddressed
envelopes for mail service
CVS/Caremark 1-800-566-5693
www.caremark.com
P.O. Box 94467
Palatine, Illinois 60094
Dental and Orthodontia
Dental and orthodontia benefit
information, forms and claim
information
Blue Cross/Blue
Shield of Illinois
(BCBS)
1-800-862-3386
www.bcbsil.com
BlueCare® Freedom
Dental PPO
P.O. Box 23059
Belleville, Illinois 62223
BHSM y September 2008 101
Contact Information
For… Contact… At…
Disability Benefits
Short-term and long-term
disability benefit information,
forms and claim information
EIT Fund Office 1-312-782-5442
Life Insurance and AD&D Benefits
Life insurance and AD&D
benefit information, forms and
claim information
EIT Fund Office 1-312-782-5442
* Monday through Friday, 7:00 a.m. through 7:00 p.m. Central Time. Weekend and after-hours
emergency calls are answered by an answering service.
Fund Office
Electrical Insurance Trustees (EIT)
221 North La Salle Street, Suite 200
Chicago, Illinois 60601-1214
1-312-782-5442
102 September 2008 y BHSM
