The Health & Welfare Plan
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Information
Administrative Information
Coordination
of Benefits
Subrogation
Privacy Policy
Life Events
Comprehensive Medical Benefits
Claims Filing Instructions
It is the Trustee's goal to maintain a financially stable Fund while providing adequate health care coverage to our members and their families. This is becoming more challenging as health care costs continue to rise at double-digit rates. The Fund has implemented some cost-saving methods such as medical deductibles, out-of-pocket maximums and a mail order prescription drug program to ensure that we can meet your current and future health care needs. You can do your part in helping the Fund manage health care cost by:
- Visiting PPO providers - PPO providers, including Hospital, Physicians and other health care providers, charge negotiated reduced rates. Also, the Plan pays a higher percentage when you use a PPO provider.
- Using the mail order prescription drug program - The Fund offers the mail order program for your maintenance medications because the mail order program provides medications at lower rates than retail pharmacies.
- Examining Emergency treatment alternatives - In the event of an Emergency, the most important consideration is to seek medical care, especially in a life-threatening situation. However, in some cases, you can obtain the same level of care at a Physician's office or an urgent care facility as in an Emergency room. Keep your Physician's telephone number easily accessible and locate the urgent care facility nearest to you beforehand so you'll be prepared in case of an emergency.
Locating a PPO provider
The Plan utilizes the following preferred provider network.
Comprehensive Medical Benefits, Dental, Vision, Weekly Accident and Sickness, Death and AD&D Benefits
Fund Office
Carpenters' District Council of Kansas City and Vicinity Health Plan
3100 Broadway, Suite 805
Kansas City, MO 64111
(816) 756-3313
Toll-Free (866) 756-3313
Medco
Mail Order Address
PO Box 30493
Tampa, FL 33630-3493
Customer Service Line: 1-800-939-7085
www.medco.com
When members of a family are covered under more than one plan of group benefits, there may be instances of duplication of coverage - two plans paying benefits for the same medical expenses. The Coordination of Benefits (COB) provision coordinates the benefits payable by this Plan with similar benefits payable under other plans, excluding Weekly Accident and Sickness, Death and Accidental Death and Dismemberment (AD&D) Benefits.
Under the COB provision, if you and/or your Dependent are covered by this Plan as well as by another plan, which provides group health benefits, benefits will be coordinated between the two plans. If you or any of your Dependents are covered under any other group plan, the total payment received for any one person from all programs combined may not be more than 100% of the "Covered Expenses" (excluding Weekly Accident and Sickness, Death and Accidental Death and Dismemberment (AD&D) Benefits).
The Plan can never pay more on any claim than it would if the COB provision did not exist.
"Covered Expenses" are any necessary and Reasonable and Customary Charge for medical, dental or vision services, treatment or supplies covered by one of the plans under which you are eligible.
Benefits are coordinated with other plans, which include:
- Group blanket or franchise insurance coverage;
- Group Blue Cross or group Blue Shield coverage and other group prepayment coverage;
- Coverage under labor-management trusteed plans, union welfare plans, employer organization plans or any other arrangement of individuals of a group;
- Coverage under governmental programs and any coverage required or provided by any statute.
Benefits are also coordinated with Medicare. If you or your Dependent is covered under another plan, you may contact the Fund Office to find out if the plan meets the definition of an other plan.
Who Pays First
If you or your Dependents are covered by another plan(s), the benefits under this Plan and the other plan(s) will be coordinated. This means one plan pays full benefits first, then the other plan(s) pay(s). When both you and a Dependent are covered under different group health plans as Employees, both you and your Dependent should file the claim with your own plan. Make sure you both provide all requested information on the claim forms about your Dependent's employment. The claim departments will then decide which plans have "primary" and "secondary" responsibility (see below). If you and your Dependent are both covered as Employees under this Plan, the Plan will coordinate benefits on your and your Dependent's claims. You and your Dependent must each submit a claim form.
The primary plan is the plan that must pay benefits on the claim first. The secondary plan is the plan that makes payments after benefits have been provided by the primary plan. When your claims are coordinated, you not only receive payments from the primary plan, but additional payments from the secondary plan (which may provide up to 100% payment for your claim).
If you or your Dependents are eligible under another plan(s) the following rules apply:
- If you are covered by another group plan that does not have a COB provision, the other plan will always pay first.
- When a person is covered by another group plan, the plan that covers the person as an active employee will pay first. The plan covering the person as an inactive employee or retiree will pay second.
- When another plan does have a COB provision, the plan covering the person as an Employee will pay first, and the plan covering the person as a Dependent will be second.
- If the parents of an eligible Dependent child are married (i.e., not divorced or separated), the plan of the parent whose birthday is earlier in the calendar year will pay first. If both parents' birthdays are on the same day, the plan covering the parent for the longer period of time will pay first.
- If one parent's plan uses another rule and the other parent's plan coordinates benefits as described above, the plan of the parent using the other rule pays benefits first.
- If the parents of an
eligible Dependent child are divorced or legally separated, then the
following rules apply:
- If a court decree establishes financial responsibility for medical/health care for a child, the plan covering the parent with that responsibility will pay first and the plan covering the other parent will pay second (or as otherwise specified in the court decree);
- If there is no court decree and the parent with custody has not remarried, the plan covering the parent who has custody will pay first and the plan covering the other parent will pay second; or
- If there is no court decree and the parent with custody has remarried, benefits on a claim will be payable as follows:
- The plan covering the parent who has custody will pay first;
- The plan covering the spouse of the parent who has custody (the step-parent of the child) will pay second; and
- The plan covering the parent without custody will pay third.
If none of the above rules applies, the plan that has covered the parent for the longer period of time pays first, except when one plan covers the parent as a laid-off or retiree (or a Dependent of the Employee) and the other plan includes this same rule for laid-off or retirees (or is issued in a state that requires this rule by law), then the plan that covers the parent as other than a laid-off or retiree (or as a Dependent of an Employee) will pay first.
Coordination of Benefits with Medicare
If you and/or your spouse are age 65 or older and retired or otherwise eligible for Medicare where Medicare is your primary coverage, coverage under the Plan will be coordinated with Medicare Parts A and B. The coverage will be coordinated whether or not you have applied for the coverage from the Social Security Administration. It is important that you apply for Medicare as soon as you are eligible because the benefits provided by the Plan will be reduced according to payments Medicare would make.
If you are still eligible for benefits as an active Employee and are performing work for which contributions are paid to the Fund, your benefits will also be coordinated with Medicare. However, if Medicare is not your primary coverage, the Plan will pay first, and Medicare will pay any additional amounts where Medicare coverage is applicable (if you are enrolled in Medicare).
Persons age 65 and older or disabled are eligible to enroll for benefits under Title XVIII of the Social Security Act of 1965 (Medicare). Part A of Medicare, which covers Hospital expenses, generally does not require a premium payment. Part B covers other types of medical expenses and requires you to pay a monthly premium. In order to be covered under Parts A and B, you need to apply.
When coordinating with Medicare, this Plan and Medicare together will not cover more than 100% of Covered Expenses for an accident or Illness.
Who Pays First When Coordinating With Medicare
This Plan will have primary responsibility for your or your Dependent's expenses if you meet the following qualifications:
- You are at least age 65;
- You are eligible for Medicare solely because of age; and
- With respect to the Employee only, you are actively employed by an Employer who pays all or part of the required contributions for your eligibility.
The Plan has secondary responsibility for you and your Dependent if:
- You are not actively employed by an Employer, which pays all or part of the required contributions for eligibility; and
- You are eligible for Medicare because of age.
If, while you are actively employed, you or any of your eligible Dependents become entitled to Medicare because of end-stage renal disease (ESRD), this Plan pays first and Medicare pays second for 30 months, starting the earlier of the month in which Medicare ESRD coverage begins or the first month in which the individual receives a kidney transplant. After the 31st month after the start of Medicare coverage, Medicare pays first and this Plan pays second.
Information About Medicare
Medicare is a three-part program. The first part is officially called "Hospital Insurance Benefits for the Aged and Disabled," and is commonly referred to as Part A of Medicare. The second part is officially called "Supplementary Medical Insurance Benefits for the Aged and Disabled," and is commonly referred to as Part B of Medicare. Part A of Medicare primarily covers Hospital benefits, although it also provides other benefits. Part B of Medicare primarily covers Physician's services, although it, too, covers a number of other items and services. Part C of Medicare is called Medicare+Choice and covers Medicare managed care offerings. If you are covered by a managed care plan, the Plan will presume that you have complied with the managed care program's rules necessary for your expenses to be covered by the managed care program.
If you do not enroll for Part B coverage within the three months after becoming age 65, and you stop working or lose eligibility for Plan benefits, you may enroll for Part B coverage within seven months of the first day of the first month in which you are no longer covered by the Health Plan without any penalty or waiting period. If you are such an individual and you do not enroll for Part B coverage within this seven-month period, you may enroll during the "general enrollment period." This "general enrollment period" occurs between January 1 and March 31 of each year and coverage begins the following July 1.
The monthly premium will be assessed a 10% increase for each full 12 months (after age 65) you are not enrolled in Part B coverage. However, months during which you were covered by the Health Plan are not counted.
It's your (and your Dependent's) responsibility to apply for Medicare Part A and Part B. If you or your Dependent are eligible for Medicare and want information about enrollment, contact your local Social Security Administration Office three months before your 65th birthday or when you are otherwise eligible for Medicare. Contact your local Social Security Administration Office if you have questions concerning Medicare eligibility, enrollment or coverage.
In the event the Fund provides benefits for Injury, Illness or other loss to any Covered Person, the Fund is subrogated to all rights of recovery to any funds or monies you, your spouse, Dependents, parents, heirs, guardians, conservators, next friend, executors, assignees, personal representative or other representatives may have arising out of an Injury, Illness or other loss.
The recovery is not limited by characterization of loss and includes recovery for personal Injury, lost wages, loss of service, disability and claims for wrongful death and survivor or other claims under any state or federal law. The Fund is not limited or bound by any judgment or settlement that divides up recovery among the various elements of damage. The Fund is entitled to first dollar reimbursement from any recovery, regardless of whether the Covered Person is made whole by said recovery.
The Fund's subrogation rights include, without limitation, priority to first dollar reimbursement from any settlement or judgment and all rights of recovery of a Covered Person to any payments made by, or on behalf of, a responsible person including but not limited to, a recovery:
- Against any person, insurer or other entity that is in any way responsible for providing compensation, indemnification or benefits for the Injury;
- From any fund, policy of insurance or accident benefit plan providing no fault, personal injury protection (PIP) or financial responsibility insurance or coverage;
- Under uninsured or underinsured motorist insurance;
- Under motor vehicle medical payment insurance; and
- Under specific risk accident and health coverage or insurance, including, without limitation, premises or homeowners medical payments insurance or athletic or sports "school" or "team" coverages or insurance.
The Covered Person, or if a minor, the Covered Person's parent or legal guardian, conservator or next friend will execute and deliver documents and papers (including, but not limited to, a benefits Questionnaire, Subrogation Agreement and Authorization to Release Medical Information) to the Fund as the Fund may require. The Covered Person will do whatever else is necessary to protect the rights of the Fund, including allowing the intervention by the Trustees or Fund or the joinder of the Trustees or Fund in any claim or action against the responsible party or parties. The Fund Trustees are vested with full discretionary authority to determine eligibility for benefits, to construe subrogation and other Plan provisions and to reduce the amount of the Fund's recoverable interest where, in the sole discretion of the Trustees, circumstances warrant such action. No settlement, however is binding on the Fund without the Fund's written approval and the Fund expressly reserves the right to collect the entire amount of its subrogation interest in all cases.
The amount of the Fund's subrogation interest will be deducted first from any recovery from any entity or source by, or on behalf of, the Covered Person regardless of any common fund or make-whole doctrines. The amount payable to the Fund, pursuant to the subrogation right, will not be reduced pursuant to the application of any common fund doctrine, any make-whole doctrine and/or any other common/state law doctrine purporting to reduce the amount of the Fund's recovery.
The Fund reserves the right to initiate an action in the name of the Covered Person, his or her guardian, conservator or next friend to recover its subrogation interest, and the Covered Person, his or her guardian, conservator or next friend will cooperate fully with the Fund in such instances.
The Fund may withhold payment of benefits or deduct the amount of any payments made from future claims of a Covered Person in the event of any failure or refusal by the Covered Person to:
- Execute the Subrogation Agreement or any other document requested by the Fund; or
- To take any other action requested by the Fund to protect the interest of the Fund.
The Covered Person will not do any act or engage in any negotiations that would reduce, compromise or prejudice the Fund's rights to first recovery from any third party. If the Covered Person recovers any amount by settlement or judgment from any person, corporation, insurance carrier, governmental agency, or other responsible party:
- The Fund will be repaid in an amount equal to the full amount of benefits paid by the Fund; and
- No further benefits for treatment or services related to the Injury leading to the settlement or recovery will be paid by the Fund.
If the Covered Person refuses or fails to repay such amount, or otherwise interferes with the Fund's right to subrogation, the amount of the Fund's claim will be held in constructive trust, and the Fund will be entitled to seek restitution, impose a constructive trust or seek any other legal or equitable remedies available (including recovery of the Fund's attorneys' fees and costs) by instituting legal action against the Covered person or other party. In addition, the Fund reserves the right to offset and/or deduct any amounts paid as benefits against future claims submitted by the Covered Person or his/her Dependents.
The Fund will not pay or be held responsible for any portion of the Covered Person's legal fees or expenses related to any recovery whether by settlement or judgment. The Fund reserves the right to first dollar reimbursement from any recovery to the full amount of benefits paid by Fund and claims a first lien against the proceeds of any settlement or judgment and priority over any claim or lien of legal counsel, insurers or any other third party. The Covered Person will provide all of the above referenced individuals with notice of the Fund's first right of subrogation. However, the Trustees may, in their discretion, agree to share legal fees and expenses with the Covered Person, his or her guardian, conservator or next friend, provided any an agreement is established in writing.
If the Covered Person, his or her guardian, conservator or next friend does not attempt a recovery of the benefits paid by the Fund or of which the Fund may be obligated, the Fund is entitled to institute legal action against the responsible party or parties in the name of the Fund or Trustees that the Fund may recover all amounts paid to or on behalf of the Covered Person.
In an action brought by the Fund, the reasonable cost of recovery, including Fund's attorneys' fees, will first be deducted from any recovery by judgment or settlement against the responsible party or parties. The Fund's subrogation interest, to the full extent of benefits paid or due as a result of the occurrence causing the Injury or Illness, will next be deducted with the balance paid to the Covered Person.
The Plan is required to protect the confidentiality of your protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the rules issued by the U.S. Department of Health and Human Services.
You may find a complete description of your rights under HIPAA in the Plan's Privacy Notice that describes the Plan's privacy policies and procedures and outlines your rights under the privacy rules and regulations.
Your rights under HIPAA include the right to:
- Receive confidential communications of your health information, as applicable;
- Copy your health information at a cost;
- Receive an accounting of certain disclosures of your health information;
- Amend your health information under certain circumstances; and
- File a complaint with the Plan or with the Secretary of Health and Human Services if your rights under HIPAA have been violated.
If you need a copy of the Privacy Notice, please contact the Fund Office.
Use and Disclosure of Protected Health Information (PHI)
The Plan will use protected health information to the extent and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan will use and disclose protected health information for purposes related to health care treatment, payment for health care and health care operations.
"Payment" includes activities undertaken by the Plan to obtain contributions or premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to, the following:
- Determination of eligibility, coverage and cost sharing amounts (e.g. cost of a benefit, Plan maximums and co-payments as determined for your or your Dependent's claim);
- Coordination of benefits;
- Adjudication of health benefit claims (including appeals and other payment disputes);
- Subrogation of health benefit claims;
- Establishing employee contributions;
- Risk adjusting amounts due based on enrollee health status and demographic characteristics;
- Billing, collection activities and related health care data processing;
- Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments;
- Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance);
- Medical necessity reviews, or reviews of appropriateness of care or justification of charges;
- Utilization review, including pre-certification, preauthorization, concurrent review and retrospective review;
- Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes: name and address, date of birth, Social Security Number, payment history, account number and name and address of the provider and/or health Plan); and
- Reimbursement to the Plan.
Health Care Operations
Health care operations include, but are not limited to, the following activities:
- Quality Assessment;
- Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting of health care providers and patients with information about treatment alternatives and related functions;
- Rating provider and Plan performance, including accreditation, certification, licensing, or credentialing activities;
- Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance);
- Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs;
- Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies;
- Business management and general
administrative activities of the entity, including, but not limited
to:
* Management activities relating to implementation of and compliance with the requirements of HIPAA Administrative Simplification;
* Customer service, including the provision of data analyses for policyholders, Plan sponsors or other customers;
* Resolution of internal grievances; and
* Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity or, following completion of the sale or transfer, will become a covered entity. - Compliance with and preparation of
all documents as required by the Employee Retirement Income Security
Act of 1974 (ERISA), including Form 5500's, Summary Annual Reports
(SAR's) and other documents.
The Plan will use and disclose PHI as
required by law and as permitted by authorization of the participant or
beneficiary. For purposes of this section, the Board of Trustees of the
Carpenters District Council of Kansas City and Vicinity Welfare Fund is
the Plan Sponsor. The Plan will disclose PHI to the Plan Sponsor only
upon receipt of a certification from the Plan Sponsor that the Plan
documents have been amended to incorporate the following provisions.
With respect to PHI, the Plan Sponsor agrees to :
- Not use or further disclose the information other than as permitted or required by the Plan Document or as required by law;
- Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information;
- Not use or disclose the information for employee benefit Plan of the Plan Sponsor unless authorized by the individual or pursuant to a business associate contract;
- Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware;
- Make PHI available to the individual in accordance with the access requirements of HIPAA;
- Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
- Make available the information required to provide an accounting of disclosures;
- Make internal practices, books and records relating to the use and disclosure of PHI received from the group health Plan available to the Secretary of HHS for the purposes of determining compliance by the Plan with HIPAA; and
- If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made. If return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible. Adequate separations between the Plan and the Plan Sponsor must be maintained. Therefore, in accordance with HIPAA, only the following employers or classes of employees may be given access to PHI:
- The Plan Administrator; and
- Staff designated by the Plan Administrator
The persons described above may only have access to and use and disclose PHI for Plan administration functions that the Plan Sponsor performs for the Plan. If the persons described above do not comply with this Plan document, the Plan Sponsor will provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.
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