ACA Mandated Benefits
The federal health care law, the Patient Protection and Affordable Care Act, also known as the “Affordable Care Act (ACA)”. requires that all non-grandfathered health plans, such as the Cement Masons Health and Welfare Plan for Northern California provide certain benefits under the Plan.
For a complete list of ACA mandated benefits, visit: www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html
Nondiscrimination in Health Care
To the extent that an item or service is a covered benefit under this Plan, the Fund will not discriminate with respect to your choice of a health care provider so long as that health care provider is licensed by the state in which he practices and is operating within the scope of his license.
For information regarding the Health Insurance Marketplace, and Patient Protection Rights, CONTINUE READING.
The Consolidated Omnibus Budget Reconciliation Act (COBRA), a federal law enacted in 1986, requires that when eligibility under the Plan ends, certain Qualifying Events permit a Qualified Beneficiary to continue health plan coverage for a temporary period of time and is dependent on the reason eligibility was lost. The type of Qualifying Event determines the duration of COBRA Continuation Coverage available.
Qualified Beneficiary
A Qualified Beneficiary is any individual who was eligible for hospital-medical benefits (Direct Payment or Kaiser Permanente Plan) on the day before a Qualifying Event occurred.
Qualifying Events
If any of the Qualifying Events listed below occurs, a Qualified Beneficiary has the right to continue the health plan benefits that were in effect on the day before the Qualifying Event occurred. To continue coverage, the Qualified Beneficiary must apply for COBRA Continuation Coverage and make the required monthly payments to the Fund within the specified time frames.
Active Benefits: The following are Qualifying Events:
1. Work hours reported on your behalf by an Individual Employer are less than the required monthly minimum for continued eligibility;
2. Your death;
3. Your divorce or legal separation from your Dependent spouse;
4. Your child loses status as a Dependent under the Plan.
Retired Benefits: The following are Qualified Events:
1. Your death;
2. Your divorce or legal separation from your Dependent spouse;
3. Your child loses status as a Dependent under the Plan.
Duration of COBRA Continuation Coverage
If you or your Dependents qualify for COBRA Continuation Coverage, you or your Dependents can elect coverage for up to 18, 29, or 36 months, depending on the Qualifying Event:
· 18 Months—A Qualified Beneficiary, can continue coverage for up to 18 months from the date of the Qualifying Event if the Qualifying Event was because an Individual Employer ceased to make contributions to the Fund on your behalf causing loss of eligibility under the Plan.
· 29 Months—Any Qualified Beneficiary can extend the 18-month period by 11 months, for a total of 29 months, if the Qualified Beneficiary becomes disabled, as determined by the Social Security Administration, before or during the first 60 days of COBRA Continuation Coverage. See “Timely Notice to the Trust Fund Office”.
· 36 Months–Qualifying Events 2, 3 and 4 for Active Benefits and 1, 2 and 3 for Retired Benefits entitle your Dependents to up to 36 months of COBRA Continuation Coverage from the date of the Qualifying Event. (In the case of a child’s losing Dependent status, only the affected child is eligible for 36 months of coverage.)
For complete COBRA Continuation Coverage information, CONTINUE READING.
As a Participant in the Cement Masons Health and Welfare Trust Fund for Northern California, you are entitled to certain rights and protections under the Employee Retirement Income Security Act (ERISA) of 1974. ERISA provides that all Plan Participants are entitled to the following rights:
Receive Information About Your Plan and Benefits
· Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as work sites and union halls, all Plan documents governing the Plan. These documents include insurance contracts and collective bargaining agreements and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor (DOL) and available at the Public Disclosure Room of the Employee Benefits Security Administration (EBSA) (formerly the Pension and Welfare Benefits Administration). You may also locate a copy of the Form 5500 series on the DOL/EBSA website: www.dol.gov/ebsa/.
· Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan. These include insurance contracts and collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description (SPD). The administrator may make a reasonable charge for the copies. You may also locate the Plan’s SPD on the Fund’s website and the Form 5500 series can be located on the DOL/EBSA website www.dol.gov/ebsa/.
· 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.
For information regarding Continuation of Group Health Plan Coverage, Prudent Actions by Plan Fiduciaries, Enforcing Your Rights, and Assistance with Your Questions, CONTINUE READING.
Privacy of Your Health Information under HIPAA
You have certain rights under the HIPAA Privacy Rule with regard to your Health Information maintained by the Cement Masons’ “Health Plan”.
The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal Health Information and applies to Health Plans, health care clearinghouses, and those health care providers that conduct certain electronic health care transactions. This Privacy Rule requires appropriate safeguards be put in place to protect the privacy of personal Health Information and sets limits and conditions on the uses and disclosures of that information without patient authorization. The Privacy Rule also gives patients certain rights regarding their Health Information, including the right to examine and obtain a copy of health records and to request corrections.
The Health Plan’s Promise to You
Plan Administrative Team Members understand that your Health Information is private. The Board of Trustees is committed to using your health information only for the purpose of treatment, paying benefits, operating the Health Plan, and as expressly permitted or required by law.
How the Health Plan Uses and Discloses Your Health Information
Team Members can only use and disclose Protected Health Information (PHI) in ways that are expressly permitted by HIPAA. The sections entitled “Treatment,” “Payment”, and “Health Care Operations” describe how the Health Plan uses and discloses the Health Information obtained about you (your “Health Information”). Some of these uses and disclosures are routine, and are necessary to operate the Health Plan, and to provide assistance to health care providers who treat you. Others are not routine but are required by law or necessary due to special circumstances. The Health Plan has developed procedures for all of these uses and disclosures. Because the Health Plan is a member of an “Organized Health Care Arrangement” the Health Plan may share your information with other members of the “Organized Health Care Arrangement” for the purpose of “Treatment”, “Payment”, and “Health Care Operations”.
For complete HIPAA Privacy information, CONTINUE READING.
This section will explain how the Plan works with your rights under the Uniformed Services Employment and Reemployment Rights Act (USERRA), a federal law.
On the date you enter active-duty military service for more than 30 days, your eligibility and that of your Dependents will end under the Plan. The Fund, however, must provide you with Plan continuation options and reinstatement rights in accordance with USERRA.
In order for the Fund to provide you with information about USERRA Continuation Coverage, you must first notify the Board as soon as possible but no later than 60 days from the date you enter active-duty military service. When the Trust Fund Office, on behalf of the Board, receives your notice, you will be provided with information about your rights to continue your health plan coverage through self-payments under USERRA Continuation Coverage for up to 24 months or COBRA Continuation Coverage for up to 18 months.
Cost for USERRA Continuation Coverage
The cost for USERRA Continuation Coverage is determined in the same way as for COBRA Continuation Coverage. See “Cost of COBRA Continuation Coverage”.
TRICARE
When you are on active duty or retired military, you may also have access to coverage through TRICARE, the Department of Defense health care program for uniformed service members and their family. If this option is available to you, you should contact TRICARE for information about enrollment and how TRICARE works with any other Group Plan or Medicare.
Under federal law, group health plans and health insurers may not restrict benefits for any Hospital length of stay for the mother or newborn child to less than 48 hours following a normal delivery, or to less than 96 hours following a caesarean section. However, federal law does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than the 48 hours, or 96 hours stay as applicable.
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Under federal law, group health plans and health insurers may not restrict benefits for any Hospital length of stay for the mother or newborn child to less than 48 hours following a normal delivery, or to less than 96 hours following a caesarean section. However, federal law does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than the 48 hours, or 96 hours stay as applicable.
1. Reconstruction of the breast on which the mastectomy was performed,
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
3. Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
This coverage is subject to the Plan’s Copayment, Deductible and coinsurance provisions.
In addition to the information concerning Women’s Health and Cancer Rights Act (WHCRA) appearing in the SPD, the Plan is required to mail an annual notice to remind you that breast cancer patients who elect to have reconstructive surgery in connection with a mastectomy have certain protections under federal law.
WHCRA Notice (link to this document)
