Welfare Fund

Summary Plan Description (SPD)

Summaries of Material Modification

Your initial and continued eligibility for benefits are determined by the collective bargaining agreement under which you are employed.

Use the charts below to determine your eligibility. And remember, there may be a delay between the period you work and the period you are eligible for benefits.

If you work under an outside construction contract, or if you work under a shop contract, which provides for quarterly eligibility, your eligibility is determined as follows:

If you work under a shop contract which provides for monthly eligibility, your eligibility is based upon work performed in the month immediately preceding the eligibility month

– OR –

work performed in the month which is two months preceding the eligibility month as follows:

Your Level of Benefit

There are four benefit levels for which you can become eligible. These levels and the monthly, quarterly and yearly costs (premiums) effective October 1, 2021, are:

Level 1 includes life insurance benefits, survivor benefits, accidental death and dismemberment, inpatient hospital, outpatient pre-admission testing, outpatient emergency room, in-network surgical centers, convalescent care, ambulance, home health care, surgical, anesthesia, doctor visits, X-ray and lab, maternity, EAP, mental health, substance abuse, Medicare, chiropractor and podiatrist.

Level 2 includes all benefits under Level 1, plus vision and accident and sickness.

Level 3 includes all benefits under Levels 1 and 2, plus dental.

Level 4 includes all benefits under Levels 1, 2 and 3 plus prescription drugs.

Enrolling a new dependent

If you wish to enroll a dependent (due to marriage, birth or adoption or placement for adoption) you must request enrollment and provide a copy of supporting documentation within 30 days of the event or else coverage will not be effective until the first of the month following our receipt of your request and documentation.

Notes:

1. If documentation is submitted within 30 days, your new dependent will become eligible for coverage as of the event date.
2. After 30 days, coverage will become effective on the first of the month following receipt of documentation.
3. The fund reserves the right to request additional documentation required to establish a dependent's eligibility.

Before You Receive Certain Care ...

The Welfare Plan requires that you or your provider call to preauthorize certain services; and when required, we recommend you or your provider call at least seven days before scheduled treatment. For emergency treatment, call within two working days or as soon as reasonably possible.

For hospital-based treatment (including participating surgicenters), call the Fund's Office at 973-671-6800 and choose the prompt for Pre-certification.

For treatment to be provided in a facility other than a hospital, such as a physician's office or a free-standing diagnostic facility, or for durable medical equipment supplies, providers should contact:

• Evicore for diagnostic imaging at 866-241-6603
• CareCentrix for durable medical equipment at 855-243-3321
• Horizon Utilization Management for other services at 800-664-2583

Questions -- including where to call -- should be directed to the Fund's Office.

If you do not preauthorize treatment, benefits will be denied unless medical necessity is later established. Following is a list of services which require preauthorization:

• • All hospital activity
  • Surgical procedures
  • Moh's surgical procedures
  • Skilled nursing facility
  • Infertility treatment
  • Home health care
  • Home IV therapy
  • Diagnostic testing over $600
  • Long-term treatment plans such as rehabilitation; speech, physical, occupational or radiation therapy
  • Drug therapy such as AZT, chemotherapy
  • Durable medical equipment over $300

At time of preauthorization you or your provider will be told if proposed treatment is covered. Please note: Preauthorization does not guarantee eligibility or payment.

Emergency Room Coverage

Medically necessary services provided within 48 hours of an accident or sudden or serious illness and billed by an emergency room provider that is a licensed MD or DO, using procedure codes denoting emergency care, are payable at 100 percent.

All other charges (for example, charges of a plastic surgeon to close a wound) are payable in accordance with the Plan's reasonable allowances, subject to the deductible, coinsurance, copayments, and charges in excess of the Plan's allowances for out-of-network providers or, if services are provided by a network provider, are payable in accordance with the Plan's contracted rates, subject to any copayment.

If coverage terminates for other than your decision to leave the industry, excess contributions are carried forward to a maximum of four quarters or 12 months. After exhausting excess contributions, you then have the option of self-purchasing coverage for an additional four quarters or 12 months.

Frequently Asked Questions

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Immunization for flu, pneumonia and shingles are covered benefits.

If your flu, pneumonia, or shingles vaccines are administered in conjunction with a physician visit, your provider should submit your claim to Horizon Blue Cross Blue Shield of New Jersey  for processing in accordance with the Plan.

If you choose to obtain your vaccine at a pharmacy or supermarket and not in conjunction with a physician's visit, we will reimburse you 100% of the cost up to $32 for the injectable flu vaccine, $40 for Flumist and up to $90 for the pneumonia vaccine.

Submit your receipt, indicating vaccine administered and charge, to the Welfare Fund, Attn: Medical Claims Department, 65 Springfield Avenue, Second Floor, Springfield, NJ 07081. Be sure to write on the receipt the patient's name and the member's name and Social Security number or the member's ID number from his or her prescription card.

Dependent coverage -- The Health Care Reform Law allows qualifying young adults to remain on their parents' insurance plan up to age 26, regardless of the availability of coverage from other sources. Dependents:

• Can be single or married
• Do not need to be a college student
• Do not need to live with their parents
• Will not be covered after turning 26

If your adult child is covered by another group health plan, the Welfare Plan will coordinate its payments with the other plan.

Motor vehicle claims -- Don't forget, medical claims resulting from a motor vehicle accident are not covered. Keep this in mind when choosing Personal Injury Protection (PIP) coverage under your auto insurance.