ARTICLE 6:	COBRA	15
6.1	Introduction	15
6.2	Nature of COBRA Continuation Coverage	15
6.3	When COBRA Coverage Is Available	17
6.4	Participant/Spouse Obligation to Give Notice to the Plan of Certain Qualifying Events	17
6.5	How COBRA Coverage Is Provided	18
	Duration of COBRA Coverage	19
6.6	The Election Period for CBRA Continuation	20
6.7	Premium Payment for COBRA Coverage	20
6.8	Scope of Coverage	21
6.9	Enrollment of Dependents During Period of COBRA Coverage/Coverage Options	21
6.10	Qualified Medical Child Support Orders	21
6.11	Termination of COBRA Coverage	21
6.12	Keep the Plan Informed of Address Change	22
ARTICLE 7:	QUALIFIED MEDICAL CHILD SUPPORT ORDER	22
ARTICLE 8:	INTERPRETATION OF PLAN DOCUMENTS	22
ARTICLE 9:	ABSENCE DUE TO MILITARY DUTY	23
ARTICLE 10:	CHANGES TO OR TERMINATION OF COVERAGE	23
ARTICLE 11:	HIPPA PRIVACY AND SECURITY PROVISIONS	24
ARTICLE 12:	RIGHT TO RECOVERE AMOUNTS PAID FOR BENEFITS DUE TO MISTAKE OR FRAUD	24
ARTICLE 13:	PLAN INFORMATION	25
	NOTICE OF PRIVACY PRACTICES	29

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARTICLE 1 - DEFINITIONS

These are some of the terms used in this booklet. Other terms are defined as they are used. PLEASE READ THEM CAREFULLY. If you understand these definitions and how they are applied in administering the Plan, you will more fully  appreciate  the  benefits  provided  and  the  manner  in  which  claims  are  handled.

 

1.1        Active  Employee  means  an  actively  working  employee  for  whom  an  Employer is  required  to  make  contributions  to  this  Fund  on  his  behalf  pursuant  to  the  terms of  a Collective  Bargaining  Agreement, or other  agreement  satisfying  the  requirements  of the  National  Labor Relations  Act.

 

1.2        Benefit  Guides means  the  documents  explaining each separate benefit provided  under  the  terms  of  this Plan. If  there  is  a  conflict  between  the  terms  of  the  Plan  and  a  Benefit  Guide,  the   terms  of  the  Plan  will  control.

 

1.3        Children or Child means a child entitled to coverage as a Dependent of the Active Employee pursuant to the terms of eligibility as set forth herein and for each benefit in the Benefit Guides, so long as such coverage is provided pursuant to the terms of  the applicable Collective Bargaining Agreements. Any such child shall include an alternate recipient  under  a  Qualified  Medical  Child  Support  Order  of  an  Active  Employee.

 

1.4        Collective Bargaining Agreement means any contract entered into between the Union and any Employer under which the Employer has  agreed to  contribute to  the  Fund.

 

1.5        Contributions mean payments to the Fund by an Employer as required under a Collective Bargaining Agreement or other written agreement satisfying the requirements  of  the  National  Labor  Relations  Act.  Contributions  become  vested  plan  assets  at  the  time  they  become  due  and  owing  to  the  Fund.

 

1.6        Covered Person means an Active Employee, Retiree, or Dependent entitled to coverage   on  whose  behalf  the Plan pays  or  provides  any  benefit.

 

 

1.7        Dependents means, for the purpose of determining the eligibility for benefits, a person who is enrolled on the Plan’s records, provided he or she  satisfies  the  requirements  of  one  of  the  following  definitions:

 

(A)        an Active Employee’s legal spouse.

 

(B)        an Active Employee’s unmarried child who has not yet reached the end of the calendar year of his/her 19th birthday. The term “child” means a natural born or legally adopted child or stepchild who is chiefly dependent on the Active Employee for at least 50% of his or her support and maintenance. The Trustees have the right to require the Active  Employee  to  furnish  proof  of  the  child’s  eligibility  at  any   time.

 

(C)         An Active Employee’s child for whom coverage must be provided in accordance with a Qualified Medical Child Support Order (QMCSO).

 

(D)        An Active Employee’s unmarried child who is between the ages of 19 and 25 and meets the definition of a dependent as set forth by the U.S. Internal Revenue Code and is attending an accredited school as a full-time student with 12 credit hours or more. The Trustees  have the right to require the Active Employee to furnish proof of full-time  student  status  for  this  dependent  on  an  annual  basis.

 

          (E)   An Active Employee’s child, over age 19 who is (and continues to be) totally and permanently disabled before age 19 by a physical or mental condition.  This child must also meet the definition of a dependent as set forth by the U.S. Internal Revenue Code during the current calendar year.  Proof of the continued existence of such disability may be requested by the Trustees periodically.

 

1.8        Employer means:

 

(a)        any Employer engaged in work coming within the jurisdiction of the Union who is obliged by a Collective Bargaining Agreement, or other written agreement satisfying the requirements of the National Labor Relations Act,  to  make   Contributions  to  the  Fund;

 

(b)         the  Union  to the extent,  and  solely  to  the extent,  that  it  acts in the capacity  of  an  Employer of  its  business  representatives   or   other  employees  on  whose   behalf   it  makes   Contributions  to  the   Fund;

 

(c)         the Fund to the extent that it acts in the capacity of an Employer of its employees on whose  behalf it  makes   Contributions   to   the   Fund;   and

 

(d)         any other Employer obligated to make Contributions pursuant to a written agreement satisfying the requirements of the National Labor Relations Act.

 

1.9        Fund   means  the   Shopmen’s   Local   508   Health   and   Welfare   Fund.

 

1.10    Participant means an Active Employee or Retiree entitled to coverage.

 

1.11    Plan  means  the  terms  set  forth  in  this  document.

 

1.12    Plan  Administrator  means  the  Board  of  Trustees  of   Shopmen’s  Local  508  Health  &  Welfare  Fund.

 

1.13    Plan Office means the office that is currently located at 2000 Town Center, Suite 1900, Southfield, Michigan  48075, telephone number 248-945-7374, or where ever the  Trustees  may  determine  it  shall  be located.

 

1.14    Retiree means a former Active Employee.

 

1.15    Spouse means the Active Employee’s legal spouse.

 

1.16    Trustees  mean  the  Trustees  of   the   Shopmen’s   Local   508   Health  and  Welfare  Fund.

 

1.17    Union means Iron Workers Regional Shop Local 851.

 

1.18    Welfare Benefits means hearing, vision, life, loss of time, accidental death and    dismemberment, and dental  benefits  currently  provided  by  the  Fund.

 

ARTICLE 2 - ELIGIBILITY RULES

2.1        Active Employees

Eligibility is determined by reference to the applicable Collective Bargaining Agreement, or Participation Agreement, the terms of the Benefit Guides for each particular benefit provided by the Fund, and this Plan document.

 

2.2        Retirees

A Retiree is entitled to continued Welfare Benefits after retirement if he has had 10 years continuous coverage under the Fund while working for the same Employer immediately preceding his/her retirement.

 

2.3       Dependents

(a)       Active Employees:

Subject to the terms of the Benefit Guides for each particular benefit provided

by the Fund, the terms of the applicable Collective Bargaining Agreement, and this Plan Document, Dependents are eligible for benefits under the Fund when the Active Employee on whom they are dependent is eligible and subject to Section 1.7.

 

(b)   Retirees:     Dependents of Retirees are not entitled to coverage.

 

2.4       Enrollment Rights

 If an Active Employee declines enrollment for himself or his dependents when first eligible due to other insurance coverage, he may in the future be able to enroll himself or his Dependents in this plan, provided a request for enrollment is received within 30 days after such other coverage ends.  In addition, if  an  Active  Employee has a new Dependent as a result of marriage, birth, adoption, or placement for adoption, he may be  able  to enroll  himself and his Dependents as set forth in Section 2.5,  Special  Enrollment  Rights.

 

Initial Enrollment: You will be provided with Plan benefit and enrollment information when you first become eligible to enroll. You must fully complete group  enrollment  forms  and return  them  to  the  Plan  Office  within  30  days  of your eligibility date to be enrolled in a timely manner. Your coverage will become effective in accordance with the Eligibility Provisions as determined by reference to both the applicable Collective Bargaining Agreement, or Participation Agreement, and the terms of the Plan Document and Benefit Guides for each particular benefit provided by the Plan. If you do not enroll yourself or your eligible dependents for coverage when you become eligible to enroll but wish to do so later, you will not be able to enroll until the next Open Enrollment  period,  unless  you  qualify  under  one  of  the  Special  Enrollment  Periods  described   below.

 

Open Enrollment: Each calendar year, the Open Enrollment period is from May 1st through June 1st. During Open Enrollment you will have the opportunity to add or delete eligible dependents to your group benefits provided by the Plan. If you wish to make changes to your group benefits, you must return your completed enrollment change form to the Plan Office by June 1st. The changes will become effective June 1st provided the completed form is received by the Plan Office by June 1st.

 

2.5         Special Enrollment Rights:  If one of the following situations applies, you

           (or  your dependents) may be eligible to enroll before the next Open Enrollment     Period:

 

·      An individual becomes your dependent through marriage, birth, adoption, or placement for adoption.

 

·      You (or your dependents) declined coverage under the Plan because you had other coverage at the time coverage under this Plan was offered, and coverage under the other Plan ended for any of the following reasons:

 

o   the  other  coverage  was  under  a  COBRA   continuation  provision  and  the  coverage  under that   provision  was  exhausted;  or

 

o   the other coverage was not under a COBRA continuation provision and either the coverage was terminated as a result of loss of eligibility (including as a result of legal separation, divorce, death, termination of employment, or reduction in hours) or employer contributions  toward  the  other  coverage  ended.

 

·         Termination of your (or your dependents) Medicaid or State’s Children’s Health Insurance Program (CHIP) coverage   as a result of loss of eligibility.

 

·      You (or your dependents) became eligible for a premium  assistance  subsidy under  Medicaid  or  CHIP  toward  coverage  under  the  Plan.

 

If your (or your dependents’) Medicaid or CHIP coverage ended as  a  result of loss of eligibility,  you  must  contact  the Plan  Office  within  60  days of termination.  If you (or your dependents) became eligible for a premium assistance subsidy under Medicaid or CHIP, you must contact the Plan Office within 60 days of the determination of subsidy eligibility. For any other Special Enrollment event, you (or your dependents) must request enrollment by completing and returning an enrollment/change  form  no later  than  30  days  after  the  Special  Enrollment  event  occurs  to  the Plan  Office.  The new coverage election will become effective as soon as administratively practicable after the Plan Office receives your enrollment materials.

 

2.6      Termination

An Active Employee’s eligibility will terminated the earliest of:

 

a.        Termination  of  service  as  an  employee  with  a  Participating  Employer;

b.        Termination of benefits under the terms of the applicable Collective Bargaining Agreement or Participation Agreement;

c.        Termination of  benefits under the terms of  the  applicable  Benefit Guides will occur after the last day of the  calendar  month  in  which  a  termination,  layoff,  leave  of  absence,  sickness  or  injury  occurs;  or

d.        Failure of  Employer  to  remit  Contributions, or,  if  applicable, failure of Active Employee  to  remit  self-payments.

 

Dependent eligibility terminates on the date he/she ceases to be a Dependent or on the date the Participant’s eligibility terminates, whichever is earliest.

 

Reinstatement  of  Eligibility: Coverage which ends due to your leave of absence or layoff will be resumed on the  date  you   return   to   work   for   a   Participating   Employer  provided   you   have   met   the   eligibility   requirements.

 

Continuation of Eligibility under the Family and Medical Leave Act (FMLA): The  Family and  Medical  Leave  Act  of  1993  (FMLA)  requires  your  employer  to  provide  you  with up  to  twelve  (12)  weeks  of unpaid  leave during a twelve (12) month period for specified family and medical reasons, if you are eligible. During your FMLA, your  employer  must  make  contributions  to  the  Fund  on  your  behalf  so  that  your  coverage will be continued.  Federal   law   requires   that   you   receive   continued   eligibility.

 

ARTICLE 3 - SCHEDULE OF BENEFITS

3.1       Welfare Benefits

If  provided  by  the  applicable  Collective  Bargaining  Agreement,  Participation  Agreement,  and  Plan Document,  the  Fund  provides  the  following  Welfare  Benefits:

 

a.            Life Insurance;

b.            Accidental  Death  and  Dismemberment  Insurance;

c.            Loss of Time;

d.            Vision;

e.            Hearing; and

f.             Dental.

 

With the exception of Retiree Vision, these Welfare Benefits are provided pursuant to fully-insured policies currently issued by Union Labor Life Insurance Company (life, AD&D and loss of time), VSP (Active Employee vision), Fidelity Security Life Insurance Company (hearing), and Delta Dental (dental).

 

Additional terms of coverage are determined by reference to the Plan Document, applicable Benefits Guide, insurance policies and any applicable Certificates and riders.

 

Vision benefits for eligible Retirees are self-insured  and  administered by the Plan Office.  An   eligible   Retiree   may  receive  a  maximum  reimbursement  of  $100  per year  for  vision  examinations,  frames,  or  lenses  limited  to  one  examination  and one pair of eyeglasses or set of lenses during any 12-month period. To receive reimbursement,  an   eligible   Retiree   must   submit   receipts  for  such  services/products  to  the  Plan   Office.

 

The following summarizes the current benefits provided under this Plan (see the detailed  Plan  Document,  Benefit  Guides,  insurance  policies,  certificates  and  riders for  additional  information):

 

LIFE INSURANCE COVERAGE

Active Employees                                                                $ 50,000.00

 

If  you  are  absent  from  work due  to  a  medical  leave,  layoff  or  strike,  you  may  continue  your  Active Employee  Life  Insurance  benefit  at  your  own  cost  and  expense  until  the  earlier  of   24 months;  or,  your seniority  time  period.

 

Premiums must be made prior to the first day of each month in which they are due. Any payment made is not refundable. Please contact the Health & Welfare Office to find out the exact cost of this premium. It is your responsibility to ensure  that  payment  is received  in  a timely manner to avoid cancellation. All Dependent Life is excluded under this provision.

 

Retired Employees:

Prior to March 1, 1984                                                             $  1,500.00

On or after March 1, 1984 but before January 1, 1             $  2,500.00

On or after January 1, 1988                                                     $  3,500.00

On or after June 1,   2000                                                        $ 5,000.00

On or after June 1,   2015                                                        $ 7,500.00

On or after January 1, 2020                                      $10,000.00

 

DEPENDENT LIFE INSURANCE COVERAGE

Spouse                                                                                          $25,000.00

Each child, 15   days to  age  19                                                $25,000.00

 

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

(Active  Employees  Only)

    Principal Sum                                                                           $50,000.00

 

LOSS OF TIME BENEFIT

(Active  Employees  Only)

Weekly Benefit Amount                                                                       $400.00

            Waiting Period                                                         

                          Accident                                                                               1 Day

Illness                                                                           7 Days

Maximum Benefit Period (Per Disability)             52 Weeks

 

HEARING CARE BENEFIT

(Applicable  to  Active  Employees  and  their  eligible  Dependents)

 

Hearing Exam Benefit - Per Insured, Spouse and Eligible Dependent Child(ren):

$70  per  24  consecutive  month  period  following  the  date  of  the  last  covered  Hearing  Exam

 

Hearing  Aid  Benefit  (per ear) - Per Insured,  Spouse  and  Eligible  Dependent  Child(ren):

$750  per  24  consecutive  month  period following  the  date  last fitted for the covered Hearing  Aid

                                            

Hearing benefits are paid on a reimbursement basis only. In order to receive your reimbursement, you must submit your paid receipts directly to the Fund Office. Reimbursement takes about two (2) weeks and the check will be mailed directly to your home address. For  additional  information  about  the  Hearing  Benefit,  please  contact the  Fund   Office  at  248-945-7374.

 

VISION BENEFIT

(Applicable  to  Active  Employees  and  their  eligible  Dependents)

 

The  benefit  for examinations, frames and lenses is limited to one examination, frame and lens during any 12 month period from date of service to date of service the following year. There shall be a Copayment of  $10.00 for the examination payable by the Insured to the Member Doctor at the time services are rendered. If materials (lenses and frames) are provided, there shall be an additional $10.00 Copayment payable at the time materials are ordered. However, the copayment for materials shall not  apply to  elective  contact  lenses.

 

Vision Exam – Covered in Full less $10.00 copay every 12 months

Prescription Glasses - Covered in Full less $10.00 copay every 12 months

           Lenses –Single vision, lined bifocal, and lined trifocal lenses

                         Polycarbonate lenses for dependent children

Frame -$150.00 frame allowance

Contact Lens Care (in lieu of glasses) $258.00 allowance for contacts and the contact lens exam (fitting and evaluation)

Diabetic Eyecare Plus Program – As needed less $20.00 Copay

Services related to diabetic eye diseases, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes.  Limitations and coordination with medical coverage may apply. 

 

Coverage with  Network  Providers

The Fund uses provider networks for Vision, Hearing and Dental benefits in an effort to keep out-of-pocket costs to a minimum. Providers agree to accept payment according to a fee schedule, and in most cases the Plan/insurance carrier may pay a higher percentage for Covered  Services  if  services  are  sought  from  a  network  provider. Covered Persons have the option of seeking services outside of the provider network; however the benefits may be paid on a lower benefit schedule resulting in greater out-of-pocket expenses.

 

Coverage  with  Non-Network  Providers

The Fund provides for Out-Of-Network coverage from a non-network vision provider on a reimbursement basis only. Reimbursement for vision services from a non-network provider is according to the fee schedule below with the same copays and limitations as services through a network provider. You must submit a claim form for reimbursement directly to VSP. Claims for reimbursement can be obtained by calling the Fund Office at (248) 945-7384 and must be filed within six (6) months of the date of service.

 

Non-Network  Provider  Fee  Schedule

Exam	Up to $  45.00
Single Vision Lenses	Up to $  30.00
Lined Bifocal Lenses	Up to $  50.00
Lined Trifocal lenses	Up to $  65.00
Frame	Up to $  70.00
Contacts	Up to $105.00

 

For information regarding vision benefits with a Network Provider or Non-Network Provider, you may contact the Fund Office at (248) 945-7374 or Vision Service Plan (VSP) directly at (800) 877-7195; you may also visit their website at  www.vsp.com

 

DENTAL  BENEFITS

 

(Applicable  to  Active  Employees  and  their  eligible  Dependents)

 

Dental Benefits and Eligibility is determined by reference to the applicable Collective Bargaining Agreement, or Participation Agreement, this Plan Document,  and  the  terms  of  the  Dental  Care  Certificate  and  Summary  of  Dental Plan Benefits issued by Delta Dental Plan of Michigan. For information regarding dental benefits, you may contact Delta Dental at P.O. Box 30416, Lansing, Michigan 48909 (1-800-524-0149).

 

RETIREE VISION BENEFIT

(Applicable  to  Retired  Employees  Only) 

Retiree  Spouse &  Retiree  dependents  are excluded

 

An eligible Retiree may receive a maximum reimbursement of $100 per year for vision examinations, frames, or lenses limited to one examination and one pair of eyeglasses or set of lenses during any 12-month period. To receive reimbursement, an eligible Retiree must submit receipts for such services/products to the Plan Office. Claims for reimbursement must be filed within  six  (6)  months  of  the  date  of  service.

RETIREE HEARING CARE BENEFIT

(Applicable  to  Retired  Employees  Only)

  Retiree  Spouse &  Retiree  dependents  are  excluded

 

Hearing  Exam  Benefit - Per Retired Employee Only:

$70  per  24  consecutive  month  period  following  the  date  of  the  last  covered  Hearing  Exam

 

Hearing  Aid  Benefit  (per ear)- Per Retired Employee Only:

$750  per  24  consecutive  month  period following  the  date  last fitted for the covered Hearing  Aid

                                            

Hearing benefits are paid on a reimbursement basis only. In order to receive your reimbursement, you must submit your paid receipts directly to the Fund Office. Reimbursement takes about two (2) weeks and the check will be mailed directly to your home address. For additional information about the Hearing Benefit, please contact the Fund  Office  at  248-945-7374.

ARTICLE 4 – THIRD  PARTY  LIABILITY

4.1       Subrogation

a.     In General:  Subrogation means the Fund has the right to recover from a Person those amounts paid by the Fund for benefits or another expenses due to an injury caused by a third party ( for example, another person or company).  To the extent benefits are paid by the Fund to a Covered Person for any welfare benefits or other expenses arising out of such an injury,  the  Plan  is  subrogated  to  any  claims  the  Covered  Person  may  have  against  the  third  party  who  caused  the  injury.

 

The Fund’s right to subrogation applies to any amounts recovered, whether or not designated as reimbursement for welfare benefit expenses or any other benefit provided by the Fund. The right of subrogation applies  regardless  of  the  method  of  recovery,  i.e.  whether  by  legal  action,  settlement  or  otherwise.

 

The Fund’s right to subrogation applies regardless of whether the injured Participant or Dependent has been fully compensated, or made whole, for his or her losses and/or expenses by the third party or insurer, as the Fund’s right to subrogation applies to any full or partial recovery. This provision is intended to make it clear that this provision shall apply in lieu of the “make whole” doctrine. The Fund disavows the “make whole” doctrine and the “common fund” doctrine. The Fund  has  first  priority to any funds recovered  by  the  injured  Covered  Person  from  the  third  party  or  insurer.

           

The Fund also has a lien on any amounts recovered by a Participant or Dependent due to an injury caused by a third party, and such lien will remain in effect until the Fund is repaid in full  for  benefits  paid  because  of  the  injury.

 

b.        Conditions to Payment of Benefits

If a Covered Person sustains an injury caused by a third party, the Fund will pay benefits related to such injury (provided such benefits are otherwise properly payable under the terms and conditions of the Plan), provided all the following conditions are met:

 

(1)         As  soon  as  reasonably  possible,  the  Covered  Person  must  notify  the  Plan  Office  that  he  or  she  has  an  injury  caused  by  a  third  party.

 

(2)         Prior to the receipt of benefits for such injury, the injured Covered Person must assign to the Fund his or her rights to any recovery arising out of or related to any act or omission that caused or contributed to the injury. If such assignment is not made before the receipt of benefits, then the receipt of benefits automatically assigns to the Fund any rights the Participant or Dependent may have to recover payments from any third party or insurer. (If the recovery so assigned exceeds the benefits paid by the Fund, such excess  shall  be  delivered  to  the  Covered  Person  or  other  person  as  required  by  law.)

 

(3)         The  Covered  Person  does  not  take  any  action  that  would  prejudice  the  Fund’s  subrogation  rights.

 

(4)         The  Covered  Person  cooperates  in  doing  what  is  necessary  to  assist  the  Fund  in  any  recovery,  which  includes  but  is  not  limited  to  executing  and  delivering  all  necessary  instruments  and  papers.

 

c.            Right   to   Pursue   Claim

The  Fund’s  subrogation  rights  allow  the  Fund  to  directly  pursue  any  claims  the  Covered Person  has  against  any  third  party,  or  insurer,  whether  or  not  the  Covered  Person  chooses  to  pursue  that  claim.

 

d.           Enforcement

If  it  becomes  necessary  for  the Plan  to  enforce  this  provision  by  initiating  any  action  against  the Covered  Person,  the  Covered  Person  agrees  to  pay  the  Plan’s  attorney’s  fees  and  costs associated  with  the  action  regardless  of  the  action’s  outcome.  At  the  Fund’s  option,  it  may enforce  this  provision  by  deducting  amounts  owed  from future  benefits.

 

4.2   Workers Compensation

The Fund does not pay any claims covered by Workers Compensation. If a Covered Person receives any benefits that are properly payable by Workers Compensation, then this Fund must be indemnified by the Covered Person for the amount paid for such benefits. The Fund shall be indemnified out of the proceeds received from the Covered Person in settlement of any Workers Compensation claim. The Covered Person must complete any forms required by the Fund to preserve its rights under this section. At the Fund’s option, it may enforce this provision by deducting amounts owed from future benefits.

 

ARTICLE 5 - CLAIM REVIEW AND APPEALS

 

5.1  Reference to Benefit Guides: The claim review and appeal procedure for each benefit, other than the Retiree Vision benefit, is set forth in the Benefit Guide applicable to that benefit. These Benefit Guides are furnished to each Participant, without charge.

 

5.2        Claim Denial and Review Procedure for Retiree Vision Benefits: If all or part of a  claim  is  denied, the Plan Office will send  a  written  notice  which  explains  the reasons for the denial. If the Covered Person does not agree with the denial, he/she may file an appeal. An appeal is a written request to the Trustees to review a benefit denial. A claimant, free of charge and upon request, shall be provided reasonable access to, and copies of, all documents, records, and  other  information  relevant  to  the  claim  for  benefits.  The  review on  appeal  shall  take  into  account  all  comments,   documents,  records,  and other  information  submitted  by  the  claimant  relating  to  the  claim,  without regard to whether such information was submitted or considered in the initial benefit determination. Appeals must be in writing and must be received by the Plan Office within 180 calendar days after receiving the benefit denial.

 

Notice  of  Decision  on  Appeal: The  notice of a decision on appeal will include the  specific  reasons  for the denial; the  specific  provision or provisions on which the decision was based; a statement that the Claimant is entitled to receive, free of charge, copies of all documents and other information relevant to the claim for benefits; a statement of the Claimant’s right to bring a civil action under ERISA; and any internal rule or similar guideline relied upon in denying the claim.

 

A decision on an appeal will be made at the first Trustees’ meeting following receipt of an appeal, unless the appeal is filed within 30 calendar days preceding the date of such meeting. In such case, the decision may be made no later than the date of the second Board Meeting following the Trustees’ receipt of the appeal. If special circumstances require a further extension, upon due notice to the Claimant, the decision shall be made no later than the third board meeting following receipt of appeal. The Plan shall notify the Covered Person of the Trustees’ decision on appeal no later than 5 business days after the decision is made.

 

5.3        Trustee Discretion: The  Trustees  have  full  discretionary  authority  to determine  eligibility  for  benefits, interpret  the  plan  documents, and determine  the  amount  of  benefits  due.

 

5.4        Failure to Timely Submit Claims and Appeals: A COVERED PERSON WHO DOES NOT TIMELY SUBMIT CLAIMS AND APPEALS WAIVES HIS/HER RIGHT TO HAVE THE BENEFIT CLAIM SUBSEQUENTLY REVIEWED BY THE PLAN OR BE REVIEWED BY A COURT.

ARTICLE 6 - COBRA

6.1        Introduction

This  Article  contains  important  information  about your right to COBRA continuation  coverage  for vision, hearing and/or dental benefits. This is a temporary extension of coverage. This generally explains COBRA continuation coverage, when  it  may  become  available  to you  and  your  family,  and  what  you may  need  to  do  to  protect  the  right  to  receive  it.

 

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation  coverage   can  become  available  to  participants and their dependents when they would otherwise lose group coverage. Because this plan provides vision, hearing and dental benefits, COBRA applies to those benefits only. For additional information about your rights and obligations under COBRA, please  see  the  full  Plan  Document  and  contact the Plan Office, 2000 Town Center, Suite 1900, Southfield, Michigan 48075, telephone number (248) 945-7374.

6.2        Nature of COBRA Continuation Coverage

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this section. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualifying beneficiary.” A participant, his spouse, and dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

 

A participant will become a qualified beneficiary if coverage for vision, hearing or dental coverage is lost under the Plan because either one of the  following  qualifying  events  happens:

 

(1)         Hours  of  employment  are  reduced  such  that  hours  are  insufficient  to  maintain  eligibility,  or

 

(2)         Employment   ends   for   any   reason   other   than   gross   misconduct.

 

The spouse of a participant will become a qualified beneficiary if coverage for vision, hearing or dental benefits is lost  under  the  Plan  because  any  of   the   following   qualifying   events   happens:

 

(1)         Death of spouse;

 

(2)         Spouse’s  hours  of  employment  are reduced  such  that  hours  are insufficient  to  maintain  eligibility;

 

(3)         Spouse’s  employment  ends  for  any  reason,  other  than  his  or  her gross  misconduct;

 

(4)         Spouse  becomes  entitled  to  Medicare  benefits  (under  Part A, Part B,  or  both); or

 

(5)         Divorce or legal separation from the participant.

 

Dependent children become qualified beneficiaries if coverage for vision, hearing or dental is lost under the Plan because any of the following qualifying events happens:

 

(1)        The parent-participant dies;

(2)         The parent-participant’s hours of employment are reduced such that hours are insufficient to maintain eligibility;

 

(3)         The parent-participant’s  employment  ends  for  any  reason  other  than his  or  her  gross  misconduct;

 

(4)         The  parent-participant  becomes  entitled  to  Medicare  benefits  (under  Part A,  Part B,  or both);

 

(5)         The  parents  become  divorced  or legally  separated;  or

 

(6)         The  child  stops being  eligible  for  coverage  under  the  plan  as  a dependent  child.

 

6.3        When COBRA Coverage Is Available

The Plan  will  offer  COBRA  continuation  coverage to qualified  beneficiaries only after  the  Plan Administrator  has been notified that a qualifying event has occurred. When the qualifying event is the death of the participant, the employer must notify the Plan Administrator of this qualifying event within 30 days of the death. The Plan Administrator will monitor whether a qualifying event has occurred due to reduction in hours, termination of employment, or Medicare eligibility.

 

6.4        Participant/Spouse Obligation to Give Notice to the Plan of Certain Qualifying Events

In the event of divorce or a dependent child loses eligibility for coverage for vision, hearing or dental as a dependent child (for example, exceeds age limitations), or if after COBRA coverage is elected a qualified beneficiary becomes covered under another group health plan, the participant and his spouse both have an obligation to notify the Plan Administrator of such event within 60 days after this qualifying event occurs. This notice must include: the name  of  the participant, the social security number of the participant, the name of the qualified beneficiaries (for example, a former spouse after divorce or a child no longer eligible for coverage as a dependent), the qualifying event (for example, the date of a divorce), and the date on which the qualifying event occurred. If  you do  not  timely provide this notice, you forfeit your right to COBRA coverage. If  you are  divorced or a dependent  child  loses  eligibility  for  coverage  as  a  dependent child (for example, exceeds age limitations), you must notify the Benefits Administrator. After COBRA coverage is elected, you must also notify the Benefits Administrator  within  30 days if a  qualified  beneficiary  becomes  covered  under another  group  health  plan.

 

Plan  Office:  Shopmen's Local Union  No.  508  Benefits  Administrator

                        2000  Town Center,  Suite 1900,  Southfield,  Michigan   48075

 

Further, failure to timely notify the Fund Office notice of a divorce or a child losing eligibility gives the Fund the right to hold the employee and his/her spouse separately and fully liable for any benefits  paid by the Fund which would not have been paid had the Fund received timely notification of such event. At its sole election, the Fund may  suspend  the  payment  of  future  benefits  until  such  amount   has  been  recovered.

 

6.5        How COBRA Coverage is Provided

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage for vision, hearing and dental will be offered to each of the qualified beneficiaries within 14 days. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered participants may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

 

The COBRA notice will contain  information  regarding  the premium that must be paid for COBRA coverage, which is not more than 102% of the cost to the Plan for such coverage. If the period of COBRA coverage is extended due to disability, discussed  below,  the  premium  is no more than  150%  of  the  cost to the  Plan.

 

Coverage under the Plan will be terminated upon the occurrence of a qualifying event and will be retroactively reinstated to the  date  of  the  qualifying  event once a qualified beneficiary elects COBRA continuation coverage and pays the applicable premium.

 

 

Duration of COBRA Coverage

COBRA  continuation  coverage   is  a   temporary  continuation   of   coverage  for vision,  hearing  and  dental,  as  follows:

 

(1)         When the qualifying event is the death of the participant, the participant’s becoming  entitled to Medicare benefits (under Part A, Part B, or both), divorce, or a  dependent  child’s losing eligibility as a dependent child, COBRA continuation  coverage   lasts  for  up  to  a  total  of  36  months.

 

(2)         When the qualifying event is the end of employment or reduction of the participant’s hours of employment, and the participant became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the participant lasts until  36  months  after  the  date  of  Medicare  entitlement.

 

For example, if a participant becomes entitled to Medicare 8 months before the date on which his eligibility terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36  months minus  8  months).

 

(3)         In all other events, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage  generally  lasts  for  only  up to a  total  of  18  months. There  are  two ways in which  this  18-month  period  of  COBRA  continuation  coverage  can  be extended.

 

(A)         Disability Extension

 

If the qualified beneficiary or anyone in his family covered under the Plan is determined by the  Social Security Administration to be disabled and notifies the Plan Administrator in a timely fashion, all covered  family  members  may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum  of  29  months.  To  obtain this extension, the disability would  have  to have started at some time before the 60th day of COBRA  continuation  coverage  and  must  last  at  least  until  the  end  of the  18-month  period  of  continuation  coverage.

 

The Plan Administrator must be notified of the Social Security Administration’s determination within 60 days of the date of the determination and before the end of the 18-month period of COBRA continuation coverage.

 

The Plan Administrator must also be notified of any subsequent determination by the Social Security Administration that the qualified beneficiary is no longer disabled. This notice must be provided   within  30  days  of  such  determination.

 

(B)         Second Qualifying Event Extension

 

If another qualifying event occurs while receiving 18 months of COBRA continuation coverage, the covered spouse and dependent children can get up to 18 additional months of COBRA continuation  coverage,  for  a  maximum of  36 months,  if  notice  of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children  receiving  continuation  coverage if the participant or former participant dies, becomes entitled to Medicare benefits (under Part A, Part B, or both),  or  gets  divorced, or  if  the  dependent child  stops  being  eligible  under  the  Plan  as  a  dependent  child, but only if such event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

 

The  Plan  Administrator must  be  notified  of  this  second  qualifying  event within  60  days  of  such  event.

 

6.6        The Election Period for COBRA Continuation

Qualified beneficiaries have 60 days after receipt of the Election Notice, which will be sent to each qualified beneficiary's last known address, to elect COBRA continuation coverage. Each qualified beneficiary has an independent right to elect COBRA continuation coverage.

 

 

6.7        Premium Payment for COBRA Coverage

Following an election, a qualified beneficiary has 45 days to pay the initial COBRA premium. If this is not timely paid, coverage will not be reinstated and the qualified beneficiary will not be given a second chance to reinstate coverage.

 

Payments are thereafter due on the first day of the month of coverage. The postmark will serve as proof of the date paid. There is a 30-day grace period to make such payment. If payments are not made within this period, coverage  will  terminate  and  the  qualified  beneficiary  will  not  be  given  an  opportunity  to  reinstate  coverage.

 

If, for whatever reason, the Plan pays benefits for a month in which the premium was not timely paid, the qualified  beneficiary  will  be  required  to  reimburse  the  Plan  for  such  benefits.

 

The  premium  equals  the  cost  to  the  Plan  of  providing  coverage  plus  a  2%  administration  fee.  In  the event  of  extended  coverage  as a  result  of  a  disability  for  the  19th - 29^th  months  of  coverage,  the  Plan  will  charge  no  more  than  150%  of  the  cost  of  providing  coverage.

 

6.8        Scope of Coverage

Coverage for vision, hearing and dental benefits under COBRA is the same as those the qualified beneficiary had the day before coverage initially terminated. Coverage may change while on COBRA coverage due to Plan amendments that affects all participants in the plan. A qualified beneficiary may also be able to elect different coverage options during the period of time he is on COBRA coverage, provided such a right is available to similarly situated active employees.

 

6.9        Enrollment of Dependents During Period of COBRA Coverage/Coverage Options

A child born to, adopted by, or placed for adoption with a Participant during a period of COBRA coverage is considered to be a qualified beneficiary, provided that the Participant has elected continuation coverage for himself/herself. If a Participant desires to add such a child to COBRA coverage, he must notify the Plan Office within  30  days  of  the  adoption,  placement  for  adoption,  or  both.

 

During  the  COBRA coverage  period,  a  Participant  may  add  an  eligible  dependent who  initially  declined  COBRA  coverage  because  of  alternative coverage and later  lost  such  coverage due to certain qualifying reasons.  If a Participant desires  to  add  such  a  child  to  COBRA  coverage,  he  must  notify  the  Plan  Office within  30  days of  the  loss  of  coverage.

 

6.10    Qualified Medical Child Support Orders

If  a  Child  is  enrolled in the Plan pursuant to a qualified medical child support order while the Participant was an active  employee  under  the  Plan,  he  is  entitled  to  the  same  rights  under  COBRA  as  any  dependent  Child.

 

6.11    Termination of COBRA Coverage

COBRA continuation coverage terminates the earliest of the last day of the maximum coverage period, the first day timely payment (including payment for the full amount due) is not made, the date upon which the Plan terminates,  the  date  after election of COBRA that a qualified beneficiary becomes  covered  under  any  other  group  health  plan,  or  the date after election  if  a  qualified  beneficiary becomes entitled to Medicare benefits and such entitlement would have caused the qualified beneficiary to lose coverage under the Plan had the first qualifying event not occurred.

 

In the case of a qualified beneficiary entitled to a disability extension, COBRA continuation  coverage  terminates  the later of: (a) 29  months  after  the  date  of the  Qualifying  Event, or the first day of the month that is more than 30 days after the date of a final determination from Social Security that the qualified beneficiary is no longer disabled, whichever is earlier; or (b) the end of the maximum coverage period that applies to the qualified beneficiary without regard to the disability extension.

 

6.12    Keep  the  Plan  Informed  of  Address  Change

A  participant or his spouse must keep the Plan Administrator informed of any changes  in the  addresses  of  family members  and  is  advised  to  keep  a  copy  of any  notices  sent  to  the  Plan  Administrator.

 

ARTICLE 7 - QUALIFIED MEDICAL CHILD SUPPORT ORDER

 

In accordance with §609 of ERISA, this Plan shall provide benefits as may be required by a Qualified Medical Child Support Order (“QMCSO”). In general, a QMSCO is a child support order which creates  or  recognizes  the right of an alternate recipient (i.e., a child  of  the  participant)  to  receive  certain  benefits  under  a  group plan. A QMSCO must meet certain requires and cannot require a Fund to provide any type of form of benefit, or any option, not otherwise provided under the Plan,  except  to the extent  necessary  to  meet  the  requirements  of  42 U.S.C. 1396g-1.  Procedures for determining the  qualify  status  of  such  support  orders  are  available,  without  charge,  from  the  Plan  Office.

 

 

ARTICLE 8 - INTERPRETATION OF PLAN DOCUMENTS

 

The  Trustees have full discretionary authority to determine eligibility for benefits, interpret plan documents, and determine the amount of benefits due. Their decision, if not in conflict with any applicable law or government regulation, shall be final and conclusive.

 

ARTICLE 9 - ABSENCE DUE TO MILITARY DUTY

 

If coverage under the Plan is terminating due to military service, a Participant may elect to continue coverage under the Plan for up to 24 months after the absence begins, or for the period of military service, if shorter. The Participant must notify the Plan Office as soon as he volunteers for or is called to active duty. The maximum premium that will be charged is no more than 102% of the full premium for the coverage. However, if the military service is for 30 or fewer days, the maximum premium will be the self-payment amount.

 

Upon termination for military duty, a Participant’s eligibility shall be frozen, with reinstatement under that same status upon his/her discharge from the military. Exclusions and waiting periods will not be imposed upon re-employment provided coverage would have been afforded had the person not been absent for military service, unless there are disabilities that the Veterans Administration determines to be service related. For these benefits to apply, however, the period of service must be less than 5 years and a Participant must return to work under the Collective Bargaining Agreement within the following time frames:

 

For uniformed service of less than 31 days, by the next work day after the end of service plus eight hours, or as soon as possible after the end of the eight-hour period if reporting earlier is impossible through no fault of the Participant.

 

For service of more than 30 days but less than 181 days, within 14 days of completing the service, or the next full calendar day if returning earlier is impossible through no fault  of  the  Participant.

 

For service of more than 180 days, within 90   days   after  completion  of  the  service.

 

ARTICLE 10 - CHANGES TO OR TERMINATION OF COVERAGE

 

The Trustees reserve the right to amend, alter, or terminate any or all coverages hereunder,  for any or all  classes of  Participants  or  Dependents,  at  any  time.

 

The Trustees also have the right to change required self-payment amounts for any benefit or class of  Participants or  Dependents,  including  the  right  to  impose  self-payment  for  coverage  that  previously  had  been  provided  without  requiring  such  self-payments.

ARTICLE 11 - HIPAA PRIVACY AND SECURITY PROVISIONS

 

Use and disclosure of Protected Health Information (“PHI”) by the Plan is regulated by a number of federal laws, regulations and rules. The Plan’s Privacy Policy and Procedures document (eff. September 23, 2013) sets forth the Plan’s implementation of and continuing compliance with HIPAA, GINA and HITECH, and their related rules and regulations, which include: the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”); the Genetic Information Nondiscrimination Act of 2008 (“GINA”); Subtitle D of the Health Information Technology for Economic and Clinical Health Act, Title XIII of Public Law 111-005 (42 U.S.C. Section 17921 et seq., subchapter III, Privacy) (“HITECH”); the Privacy Rule (45 C.F.R. Part 160 and Subparts A and E of Part 164), Security Rule (45 C.F.R. Part 160 and Subparts A and C of Part 164), Enforcement Rule (45 C.F.R. Subparts C, D and E of Part 160), and Breach Notification Rule. Protected Health Information shall only be disclosed by the Plan in accordance with these federal  laws. The Plan has detailed rules in place to protect such information. For further details, see the Plan Document, the Plan’s Notice of  Privacy Practices, and  the  Plan’s  Privacy  Policy  and  Procedures,    available at  the  Plan  Office.

 

ARTICLE 12 - RIGHT TO RECOVER AMOUNTS

PAID  FOR  BENEFITS  DUE  TO  MISTAKE  OR  FRAUD

 

The  Plan  has  the  right  to  recover  from  any  Participant  or  Dependent  any  amounts  paid in benefits which were not properly owing under the terms of the Plan, whether such amounts were paid by mistake or due to fraud by the Participant or Dependent. Fraud by the Participant includes, but is not limited to, failing to inform the Plan when a Dependent is no longer eligible (for example, due to divorce or a child no longer meeting age limitations). The  Plan  has  the right to pursue the Participant or Dependent, jointly and severally, for the full amount due and owing under this provision. At the Plan’s sole option,  it  may enforce this provision by offsetting future benefits, or suspending benefits, for the Participant or his Dependents  until  the  amount  owed  has  been  recovered.

ARTICLE 13 - PLAN INFORMATION

 

Plan  Sponsor: The  Board  of  Trustees  of  the  Shopmen’s  Local  508  Health  and  Welfare Fund  is  the  Plan  Administrator and  Plan Sponsor.  As such, the Trustees are responsible for overall  Fund  administration.  There  are  two  (2)  Trustees  appointed  by  the  Union and  two  (2)  Trustees  appointed  by  the  Employers.  The  current  Trustees  are:

 

Union Trustees	Employer Trustees
Martin Marinack Iron Workers Regional Shop Local 851 36046 W. Michigan Ave., Suite 100 Wayne, MI  48184 (724) 416-8631	Willie Mitchell Dearborn Mid-West Company 20334 Superior Road Taylor, Michigan  48180 (734) 288-4400

 Michael Bauman                                                 Joe Gluck

 Iron Workers Regional Shop Local 851                       Aristeo Construction Co.

 36046 W. Michigan Ave, Suite 100                              12822 Stark Rd

 Wayne, MI  48184                                                        Livonia, MI  48150

( 734) 788-6545                                                            (734) 427-9111

 

Day to day administration is handled by the Plan Office: 2000 Town Center ▪ Suite 1900, Southfield, MI  48075 ▪ Telephone (248) 945-7374 Email: benefits508@ameritech.net.  Fund’s website address: www.shopmens508benefits.com.

Questions concerning Fund benefits or your COBRA continuation coverage rights should be addressed to the Plan Office. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group plans, you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)

 

Type of Funding/Collective Bargaining Agreements/Welfare Assets: The Fund is maintained pursuant to collective bargaining agreements. Copies of such agreements may be obtained upon written request to the Plan Office, or are available for examination by participants and beneficiaries at the Plan Office. Alternatively, within 10 days of a written request, such agreements will be made available at the Union hall or at any employer establishment where at least 50 or more participants are customarily working. The Fund may impose a reasonable charge for such copies. A  complete  list  of the employers contributing to the Fund may be obtained upon written request to the Plan Office and may be examined at the Plan Office. The  primary  source  of  financing for the benefits provided by the Plan and Fund expenses are employer contributions.  The rates of contribution are set forth in applicable Collective Bargaining Agreements. Additionally, under certain circumstances, an employee may make self-payments to retain eligibility. The Board of Trustees holds all assets in  trust  for  the  purpose of  providing  benefits  to   eligible  participants  and  defraying   reasonable   administrative  expenses.

 

Type of Plan/Employer Identification Number/Plan Number: The Fund provides dental, vision, hearing, life  and  accidental death and dismemberment, and loss of time  benefits. Active vision, hearing, life, dental, accidental death and dismemberment, and  loss  of  time  benefits  are  provided  via  contracts of  insurance and are fully insured. Retiree vision benefits are self-insured. The employer identification number assigned by the IRS is 38-6237159. The Plan Number is 501.

 

Agent  For  Service  of  Legal  Process: Service of process should be made upon the Benefit  Administrator  of  Shopmen's  Local  Union  No.  508  Health  and  Welfare  Fund,  2000  Town  Center,  Suite  1900,  Southfield,  MI   48075.   Service of legal process may also be made upon any Trustee or Fund Legal Counsel, Lisa M. Smith, 3950 W. 11 Mile Rd, Berkley, MI  48072

The Plan Year: The Plan Year and fiscal year for accounting purposes is June 1 – May 31.

 

Plan Change Or Termination: The Trustees reserve the right to change or discontinue (a) the types and amounts of benefits under the Plan and (b) the eligibility rules for extended or accumulated eligibility, if any, even if extended eligibility has already been accumulated. The nature and amount of benefits are always subject to the actual terms of the plan documents as they exist at the time the claim occurs. The Trustees have full discretionary authority to determine eligibility for benefits. Their decision, if not in conflict with any applicable law or government regulation, shall be final and conclusive. If the Fund is terminated, remaining assets shall be used to pay eligible claims and expenses incurred prior to termination and expenses incident to the termination. The Trustees will, in their discretion, allocate any remaining assets in a manner which best effectuates the purposes of the Trust. In no event will such assets revert to or inure  to  the  benefit  of  contributing  employers.

 

Statement of ERISA Rights: As a participant in the Shopmen’s  Local  508 Health  and Welfare Fund you are entitled to certain rights and protections under the Employee Retirement  Income  Security Act of 1974 (ERISA).  ERISA provides that all plan participants  shall  be  entitled  to:

Receive Information About Your Plan and Benefits:

Ø   Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Fund with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.