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 ................................................................................... 11
Health Care......................................................................................................... 15
Participation................................................................................................... 17
Medical Benefits............................................................................................ 27
Behavioral Health and Substance Abuse Benefits ....................................... 45
Prescription Drug Benefits ............................................................................ 48
Dental Benefits.............................................................................................. 51
Vision Benefits............................................................................................... 56
Continuing Coverage .................................................................................... 59
Glossary ........................................................................................................ 63
Life Insurance and Accidental Death Benefits ............................................... 67
Participation................................................................................................... 68
Life Insurance Benefits.................................................................................. 70
Accidental Death Benefits ............................................................................. 71
Glossary ........................................................................................................ 72
Rules, Regulations and Administrative Information...................................... 73
Contact Information........................................................................................... 83
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EIT Benefits
2 September 2008 y Participatory Plan
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.
Participatory Plan 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).
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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 Die ............................................................................................................ 10
If My Dependent Dies.................................................................................... 10
Job-Related Changes........................................................................................ 11
If I’m a New Participant ................................................................................. 11
If I Terminate Employment ............................................................................ 13
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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 — 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 Accidental Death Benefits
You may wish to contact the Fund Office to update your beneficiary designation
for your Life Insurance and Accidental Death benefit coverage. Your beneficiary
designation applies to both the Basic Life Insurance and the 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.
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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 and Accidental Death Benefits
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,
or if your employer continues to make required contributions to the plan. 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 Accidental Death Benefits
You may wish to contact the Fund Office to update your beneficiary designation
for your Life Insurance and Accidental Death benefit coverage. Your beneficiary
designation applies to both the Basic Life Insurance and the 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.
Participatory Plan y September 2008 9
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 Accidental Death 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 one year 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 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.
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 or Accidental Death
benefits coverage.
10 September 2008 y Participatory Plan
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 or your
employment terminates.
If I’m a New Participant
Health Care
You are eligible for benefits beginning on the first day of the month after your
employer makes contributions to the plan on your behalf and is accepted by the
Trustees as a participating employer. You also must be employed full-time,
working at least 30 hours per week. New employees must work for the
participating employer full-time for 90 days and then will be eligible on the first
day of the following month after they complete 90 days.
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.
Participatory Plan y September 2008 11
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.
12 September 2008 y Participatory Plan
What Happens If…
Life Insurance and Accidental Death Benefits
You are eligible for benefits beginning on the first day of the month after your
employer makes contributions to the plan on your behalf and is accepted by the
Trustees as a contributing employer. You also must be employed full-time,
working at least 30 hours per week. New employees must work for the
participating employer full-time for 90 days and then will be eligible on the first
day of the following month after they complete 90 days.
Dependents are not eligible for Life Insurance and Accidental Death benefits.
Designating a Beneficiary
Designate your beneficiaries for any Life Insurance or Accidental Death benefits
by completing and returning the proper designation form. Your beneficiary
designation applies to both the Basic Life Insurance and the Accidental Death
benefit.
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.
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.
Life Insurance and Accidental Death Benefits
Life insurance and Accidental Death benefits coverage also will end the day you
terminate employment. 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.
Participatory Plan y September 2008 13
What Happens If…
14 September 2008 y Participatory Plan
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 ....................................................................................................... 17
Participant Eligibility ...................................................................................... 17
Dependent Eligibility...................................................................................... 18
Cost of Coverage .......................................................................................... 21
When Coverage Begins ................................................................................ 21
When You Have Other Coverage ................................................................. 21
Subrogation ............................................................................................ 23
Overpayment .......................................................................................... 24
If You Are on a Leave of Absence ................................................................ 24
How to Continue Coverage if You Are Disabled ........................................... 25
When Coverage Ends ................................................................................... 25
Medical Benefits ................................................................................................ 27
Using Your Medical Benefits......................................................................... 31
Paying for Your Care .............................................................................. 32
Medical Service Advisory........................................................................ 34
Covered Medical Expenses .......................................................................... 36
Additional Medical Benefits .................................................................... 37
Medical Expenses Not Covered.................................................................... 41
Filing a Claim................................................................................................. 43
Behavioral Health and Substance Abuse Benefits ........................................ 45
Using Your Behavioral Health and Substance Abuse Benefits .................... 46
Filing a Claim................................................................................................. 47
Prescription Drug Benefits ............................................................................... 48
Using Your Prescription Drug Benefits ......................................................... 48
Covered Expenses........................................................................................ 49
Expenses Not Covered ................................................................................. 50
Filing a Claim................................................................................................. 50
Dental Benefits................................................................................................... 51
Using Your Dental Benefits ........................................................................... 52
Covered Expenses........................................................................................ 53
Expenses Not Covered ................................................................................. 54
Filing a Claim................................................................................................. 55
Participatory Plan y September 2008 15
Health Care
Vision Benefits ................................................................................................... 56
Using Your Vision Benefits............................................................................ 57
Covered Expenses ........................................................................................ 57
Expenses Not Covered ................................................................................. 58
Filing a Claim................................................................................................. 58
Continuing Coverage......................................................................................... 59
Glossary.............................................................................................................. 63
16 September 2008 y Participatory Plan
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, and ends. 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
begins on the first day
of the month after you
and your employer are
accepted by the
Trustees and your
employer contributes to
the plan on your behalf.
New full-time
employees must satisfy
a 90-day waiting period
to be eligible for
coverage.
Your health care
coverage continues as
long as your employer
continues to contribute to
the plan on your behalf
and you are working at
least 30 hours per week.
Health care coverage
ends if you fail to work at
least 30 hours per week
or your employer fails to
contribute to the plan on
your behalf.
Participant Eligibility
You are eligible for health care coverage under the plan beginning on the first day
of the month after your employer makes contributions to the plan on your behalf
and is accepted by the Trustees as a participating employer. You also must be
employed full-time, working at least 30 hours per week.
New employees must work for a participating employer full-time for 90 days and
then will be eligible on the first day of the following month after they complete 90
days.
Participatory Plan y September 2008 17
Health Care
Maintaining Your Coverage
Once you become eligible, you and your eligible dependents will continue health
care coverage as long as you continue to work full-time (at least 30 hours per
week) and your participating employer makes the required contributions to the
plan on your behalf.
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 particpant 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.
18 September 2008 y Participatory Plan
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.
Participatory Plan y September 2008 19
Health Care
• 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.
• 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.
20 September 2008 y Participatory Plan
Health Care
Cost of Coverage
Generally, your employer will pay all or a portion of the premium for health care
coverage. You may pay a portion of the premium. Your employer will let you
know the amount you have to pay, if anything.
When Coverage Begins
Benefit coverage begins on the first day of the month after you complete the
eligibility requirements (see “Participant Eligibility” on page 17). 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
the date verified in the interim order. See “Dependent Eligibility” on page 18 for
more information.
Special Enrollment Periods
If you elected to waive coverage under this plan because you had other
coverage, you may be able to enroll yourself or your dependents within 30 days
of the date your coverage under the other plan ends.
In addition, if you have a new dependent as a result of marriage, birth, adoption
or placement for adoption, you may be able to enroll yourself and your new
dependents. You must request enrollment within 30 days after the marriage, birth,
adoption or placement for adoption.
If you do waive coverage, you will not be eligible to enroll until the next annual
enrollment period, unless you experience one of the above special enrollment
circumstances.
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.
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.
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.
Participatory Plan y September 2008 21
Health Care
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:
Coordinating with
COBRA
For information on how the
plan coordinates with
COBRA coverage, see
“Continuing Coverage” on
page 59.
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.
• 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.
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:
1. The amount payable by a plan covering a person as 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.
22 September 2008 y Participatory Plan
Health Care
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.
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.
Participatory Plan y September 2008 23
Health Care
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 Fund 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.
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.
If you would like to take an FMLA leave of absence, you must notify your
employer and the Fund Office. Coverage is contingent on your employer making
the required contributions to the plan. For more information about FMLA or if you
have any questions, please contact the Fund Office.
24 September 2008 y Participatory Plan
Health Care
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.
How to Continue Coverage if You Are Disabled
If you become disabled and are unable to work at least 30 hours per week, your
coverage will continue during your disability as long as your employer continues
to make the required contributions to the plan on your behalf.
When Coverage Ends
Your coverage under the plan ends when the first of the following occurs:
• You fail to work at least 30 hours per week,
• Your employer fails to make the required contributions to the plan on your
behalf,
• You retire,
• 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.
Participatory Plan y September 2008 25
Health Care
The following table summarizes situations in which coverage would normally end
and what happens to your coverage in each situation.
Health Care Coverage
Ends…
However, Health Care Coverage May Continue if…
If you fail to work at
least 30 hours per
week
You apply for COBRA continuation of coverage (see
“Continuing Coverage” on page 59).
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 59).
If you retire You apply for COBRA continuation of coverage (see
“Continuing Coverage” on page 59).
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.
26 September 2008 y Participatory Plan
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 31 for more information on
PPO providers).
Medical Benefits
In-Network Out-of-Network Out-of-Area
$300 per person.
$600 per family.
$600 per person.
$1,200 per family.
Annual calendar year deductible
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 After deductible is
satisfied, you pay
$25 office visit
copays for in-
network care, plus
10% of covered
charges for services.
Plan pays 80% of PPO
negotiated rates after
deductible; you pay
20%, plus any amount
above the negotiated
rate.
Plan pays 80% of usual
and customary (U&C)
charges after
deductible; you pay
20%, plus any amount
above U&C charges.
$3,000. $6,000. Annual calendar year out-of-
pocket maximum
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.
Participatory Plan y September 2008 27
Health Care
Medical Benefits
In-Network Out-of-Network Out-of-Area
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 90% of PPO negotiated rates in-network or 80% of U&C
charges out-of-network for one annual coronary artery scan per
person upon physician’s referral.
• 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 (or U&C charges for out-of-area), plus any
amount over the PPO negotiated rate.
$25 copay per visit. Plan pays 80% of PPO
negotiated rates. You
pay 20%, plus any
amount over the PPO
negotiated rates.
Plan pays 80% of U&C.
You pay 20%, plus any
amount over U&C
charges.
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
over the negotiated
rates.
Plan pays 80% of U&C
charges after
deductible. You pay
20%, plus any amount
over U&C charges.
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.
28 September 2008 y Participatory Plan
Health Care
Medical Benefits
In-Network Out-of-Network Out-of-Area
• Inpatient care
covered at
100%.
• Outpatient care
covered at 100%
after $25 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 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 calendar
year.
• No deductible applies.
Hearing aid benefits • Annual calendar year benefit: $475 (includes exam benefit)
• Exam: Plan pays up to $75; one visit per year per person
• Instrument: Plan pays 80% of the first $500 of U&C charges for a
hearing aid instrument each 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.
Home health care and hospice
services
• 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.
Participatory Plan y September 2008 29
Health Care
Medical Benefits
In-Network Out-of-Network Out-of-Area
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 amount 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 fees after
deductible. You pay
20% plus any amount
above the negotiated
rates.
Plan pays 80% of U&C
charges after
deductible. You pay
20% plus any amount
above U&C charges.
Ambulance service 80% of billed charges after deductible.
30 September 2008 y Participatory Plan
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 $3,000 for PPO network providers and $6,000 for out-of-
network providers. 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 $25 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 $25 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 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.
Participatory Plan y September 2008 31
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, the plan pays 80% and 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; the plan pays 80% and you pay
20%. 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 in-network deductible is $300 per person, up to a
maximum of $600 per family. The out-of-network deductible is $600 per person,
up to a maximum of $1,200 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” on page 45).
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 $25, 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 in-network out-of-pocket expense is $3,000
per family. Your annual maximum out-of-pocket expense for services you receive
outside of the PPO network is $6,000 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.
32 September 2008 y Participatory Plan
Health Care
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 63),
• 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 34
and “Precertification” under “Medical
Service Advisory” on page 34 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 45 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 58.
Participatory Plan y September 2008 33
Health Care
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.
34 September 2008 y Participatory Plan
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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.
Participatory Plan y September 2008 35
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. If you use an out-
of-area hospital or physician, the plan generally pays 80% of U&C fees after the
deductible.
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 63)
• 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
36 September 2008 y Participatory Plan
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• 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)
• 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.
Participatory Plan y September 2008 37
Health Care
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 U&C if you use
an out-of-network provider.
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 27 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” on page 45.
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 45.)
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.
38 September 2008 y Participatory Plan
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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.
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 $500 of U&C charges each
year
No deductible applies.
In addition to the types of expenses listed in “Medical Expenses Not Covered” on
page 41, 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
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
Participatory Plan y September 2008 39
Health Care
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.
40 September 2008 y Participatory Plan
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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)
Participatory Plan y September 2008 41
Health Care
• Charges for marriage counseling
• Premarital exams
• Dental services covered under a separate plan of dental benefits (see
“Covered Expenses” on page 53)
• 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 56)
• 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 48)
• 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
42 September 2008 y Participatory Plan
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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 34 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 PPO in-network 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).
Participatory Plan y September 2008 43
Health Care
• 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.
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.
44 September 2008 y Participatory Plan
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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
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 $25 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.
Participatory Plan y September 2008 45
Health Care
Behavioral Health and Substance Abuse Benefits
In-Network Out-of-Network Limits
Structured
intensive
outpatient
substance abuse
program***
Care covered at
100% after $25
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.
46 September 2008 y Participatory Plan
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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 does 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.
Participatory Plan y September 2008 47
Health Care
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.
• $20 copay for preferred drugs.
• $35 copay for brand-name and non-preferred drugs.
Mail-order
prescription drugs
(90-day supply)
• $10 copay for generic drugs.
• $40 copay for preferred drugs.
• $70 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.
48 September 2008 y Participatory Plan
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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
• $20 copay for preferred drugs
• $35 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
• $40 copay for preferred drugs
• $70 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.
Participatory Plan y September 2008 49
Health Care
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.
50 September 2008 y Participatory Plan
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.
Your Dental Benefits at a Glance
Dental Benefits In-Network Out-of-Network
Maximum annual
benefit
$1,200 per covered family
member (excluding
orthodontic).
$1,200 per covered family
member (excluding
orthodontic).
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.
Participatory Plan y September 2008 51
Health Care
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 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 PPO negotiated rates 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).
Annual maximum (excluding orthodontic): The maximum amount the plan will
pay each calendar year is $1,200 per person. When you or your covered
dependents reach this limit, you are responsible for the full cost of any additional
services received.
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.
52 September 2008 y Participatory Plan
Health Care
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
• 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
Participatory Plan y September 2008 53
Health Care
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
• 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
54 September 2008 y Participatory Plan
Health Care
• 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.
Participatory Plan y September 2008 55
Health Care
Vision Benefits
Important Note!
Before you make an
appointment, notify the
provider that you are
covered under VSP.
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.
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.
56 September 2008 y Participatory Plan
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.
Participatory Plan y September 2008 57
Health Care
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.
58 September 2008 y Participatory Plan
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 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.
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.
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.
Participatory Plan y September 2008 59
Health Care
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.
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/.
60 September 2008 y Participatory Plan
Health Care
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.
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.
Participatory Plan y September 2008 61
Health Care
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 in this “Continuing
Coverage” section, 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.
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
62 September 2008 y Participatory Plan
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.
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.
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.
Participatory Plan y September 2008 63
Health Care
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.
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 34).
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,
64 September 2008 y Participatory Plan
Health Care
• 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.
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 benefits plan
and for whom contributions are being received by EIT.
Participatory Plan y September 2008 65
Health Care
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 Participatory Plan.
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.
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 Participatory Plan.
66 September 2008 y Participatory Plan
Life Insurance and
Accidental Death
Benefits
The plan provides you with Basic Life Insurance and Accidental
Death coverage that gives you and your family protection against
some of the financial hardships that can occur if you should die.
In addition to these benefits, your spouse may also be eligible for
death benefits from Social Security.
In This Section See Page
More Information…
For definitions of terms
that are often used in
describing your benefits,
be sure to review the
“Glossary” at the end of
this section and in the
Health Care section of this
SPD.
Participation ....................................................................................................... 68
Participant Eligibility ...................................................................................... 68
When Coverage Begins ................................................................................ 68
When Coverage Ends ................................................................................... 68
Designating a Beneficiary ............................................................................. 69
Other Benefits Payable on Death.................................................................. 69
Filing a Claim................................................................................................. 69
Life Insurance Benefits ..................................................................................... 70
Conversion Privilege ..................................................................................... 70
What’s Not Covered ...................................................................................... 70
Accidental Death Benefits ................................................................................ 71
What’s Not Covered ...................................................................................... 71
Glossary.............................................................................................................. 72
Participatory Plan y September 2008 67
Life Insurance and Accidental Death Benefits
Participation
This section describes how you can participate in Life Insurance
and Accidental Death benefits, including who is eligible, when Life
Insurance and Accidental Death coverage begins, maintaining Life
Insurance and Accidental Death coverage and when Life Insurance
and Accidental Death coverage ends.
Participant Eligibility
If you are an active employee and you are eligible for health benefits, you are
eligible for Life Insurance and Accidental Death benefits.
If you stop working in active employment or become ineligible for health benefits
under the plan, your eligibility for Life Insurance and Accidental Death benefits
will end. Once your eligibility for health benefits ends, you will not be eligible for
Life Insurance and Accidental Death benefits until you resume coverage as an
active employee under the plan.
See “Participant Eligibility” in the
Health Care section for more information about
health plan eligibility requirements.
When Coverage Begins
Benefit coverage begins on the first day of the month after you complete the
eligibility requirements (see “Participant Eligibility” in the
Health Care section).
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 solely your
responsibility to know
when your coverage will
end once your
employment terminates.
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
Accidental Death
Coverage Ends…
However, Life Insurance and Accidental Death
Coverage May Continue if…
If you fail to work at
least 30 hours per
week or contributions
for coverage are not
paid
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.
68 September 2008 y Participatory Plan
Life Insurance and Accidental Death Benefits
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 Accidental
Death benefit. You may change your beneficiary designation 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
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.
To receive Accidental Death benefits, your designated beneficiary needs to
complete the following steps:
• 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.
Participatory Plan y September 2008 69
Life Insurance and Accidental Death Benefits
Life Insurance Benefits
If you die from any cause while 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 will receive $10,000.
How Long
Benefits Last
Your designated beneficiary will receive a one-time lump-
sum benefit payment.
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.
70 September 2008 y Participatory Plan
Life Insurance and Accidental Death Benefits
Accidental Death
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.
The chart below summarizes the Accidental Death benefits offered under the
plan. To fully understand how these benefits work, you should read the more
detailed information that follows the chart.
Accidental Death 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
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.
How Long Benefits
Last
Benefits are paid to your designated beneficiary in one
lump-sum payment if you die 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 90
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.
See “Designating a Beneficiary” on page 69 for details about beneficiaries for this
benefit.
What’s Not Covered
Your Accidental Death 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, or
• Commission of a felony.
Participatory Plan y September 2008 71
Life Insurance and Accidental Death Benefits
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.
72 September 2008 y Participatory Plan
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................................................................................................. 74
Your Rights Under ERISA................................................................................. 74
Your HIPAA Rights ............................................................................................ 76
Claims Review and Appeals Procedures ........................................................ 77
Health Care ................................................................................................... 77
Life Insurance/Accidental Death Benefits ..................................................... 78
Non-Assignment of Benefits ............................................................................ 80
Change or Termination of the Plan.................................................................. 80
Other Plan Details.............................................................................................. 80
Participatory Plan y September 2008 73
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
Participatory Plan, 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 Participatory Plan, 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 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.
74 September 2008 y Participatory Plan
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.
Participatory Plan y September 2008 75
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 Electrical
Insurance Trustees Health & Welfare Participatory Plan 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 creditable coverage from your
previous insurer if one is needed and you do not have one.
76 September 2008 y Participatory Plan
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 appeals process, as described below: you must submit your
first appeal to Blue Cross/Blue Shield (BCBS) within 180 days of the date 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.
Participatory Plan y September 2008 77
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.
Life Insurance/Accidental Death 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,
78 September 2008 y Participatory Plan
Rules, Regulations and Administrative Information
• Descriptions of any additional information you may have to provide and why
it’s needed,
• 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.
Participatory Plan y September 2008 79
Rules, Regulations and Administrative Information
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.
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 Participatory Plan. This SPD describes the health care benefits (medical,
prescription drug, dental, orthodontic, vision and hearing aid) and the welfare
benefits (sickness, 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 501.
80 September 2008 y Participatory Plan
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
Moton Grove, Illinois 60053-2851
1-847-291-9500
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
Participatory Plan y September 2008 81
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
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. Your employer will let you know if you have to pay a
portion. 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.
82 September 2008 y Participatory Plan
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 about 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
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
Participatory Plan y September 2008 83
Contact Information
For… Contact… At…
Life Insurance and Accidental Death Benefits
Life insurance and accidental
death 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
84 September 2008 y Participatory Plan
