Notice Of Grandfathered Health Plan
This Westchester Putnam Counties Heavy and Highway Laborers Local 60 Health & Welfare Fund (the “Plan”) believes this is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (ACA). As permitted by the ACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may include certain consumer protections of the ACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the ACA, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 914-769-2440. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at www.dol.gov/ebsa/healthreform
Medical Group Benefits Plan
RULES FOR ELIGIBILITY
Eligibility for Short Term Disability Benefits Only
As an employee working in Covered Employment, you are immediately eligible for Short Term Disability Benefits for up to 26 weeks of disability. Eligibility for these benefits is required by the New York State Disability Benefits Law.
Rules of Eligibility for All other Benefits Except Short Term DisabilityA new employee and his/her dependents become eligible for Health & Welfare Fund coverage on the first day of the first month following completion of I 000 hours worked in a twelve-month period of covered employment within the jurisdiction of Local 60.
There are two separate eligibility periods, January 1- June 30 and July 1- December 31.
The initial coverage includes eligibility to the end of the eligibility period in which coverage was obtained and for the next consecutive six (6) month period.After you become eligible for Health and Welfare Fund coverage, you will continue to remain eligible as long as you work at least 400 hours in covered employment within the jurisdiction of Local 60 during each subsequent six month eligibility period.
A new employee works 1000 hours during the time period April 1 - September 30. He/she will become eligible for Health & Welfare Fund coverage effective October 1 until June 30 of the following year. To continue eligibility, the employee must work at least 400 hours in covered employment during the eligibility period January I - June 30, and 400 hours during each eligibility period thereafter.
Termination of Your Coverage
Health and Welfare Fund coverage ends on the last day of the six-month eligibility period following your initial eligibility period, in which you work less than 400 hours in covered employment within the jurisdiction of Local60.
Reinstatement of Eligibility
If your eligibility for Health & Welfare Fund coverage has lapsed once you have not worked 400 hours in two consecutive periods of 12 months or more, you are required to work 1000 hours in covered employment in a twelve-month period before you will become eligible for Health & Welfare Fund coverage again.
Work Card Program
All active employees are required to complete and submit monthly work cards. This will enable the Fund Office to determine eligibility for coverage for you and your eligible dependents.
Eligibility for Dependents
Your Dependents become eligible for coverage on the same day you do. Dependent coverage starts when you become eligible or on the day you add the dependent (that is, if you get married or the date your child is born, legally adopted, or placed fo adoption). Eligible dependents include your legal spouse and your dependent children ( biological, adopted or placed for adoption) from birth to December 31 of the year they turn 19. If you delay enrollment for your dependents, benefits will not be payable until you properly enroll them.
Dependent Children age to 26 will continue being covered under the plan upon completion of the Coordination of Benefits Form.
Health coverage for a child chiefly dependent on you for support and maintenance, who is incapable of self-sustaining employment because of mental retardation or physical or mental handicap and whose incapacity commenced prior to age 19, shall continue so long as (a) your eligibility remains in force; (b) such incapacity continues; and (c) the child remains dependent of you for financial support. Proof of such incapacity must be submitted within 31 days of the date the dependent coverage would otherwise terminate. In addition, you must submit proof of your dependent’s financial dependence on you (such as 1040 tax forms).
How to Enroll Dependents
To enroll your eligible Dependents for Fund coverage, you need to enroll them when you are eligible. You must provide the Fund Office with a copy of each dependents Social Security card. The Fund Office will accept a copy of any of the following documents as proof of dependent status:
- Marriage: copy of the certified marriage certificate.
- Birth: copy of the certified birth certificate.
- Adoption or placement for adoption: court order paper signed by the judge.
- Disabled Dependent Children: Current written statement from the child’s physician indicating the child's diagnoses that are the basis for the physician's assessment that the child is currently mentally or physically Handicapped (as that term is defined in this document) and is incapable of self-sustaining employment as a result of that handicap; and dependent chiefly on you and/or your spouse for support and maintenance. The plan may require that you show proof of support and maintenance such as a copy of your income tax return showing you claim the child as a Dependent on IRS tax forms in compliance with the IRS Code 152 (a).
Start of Coverage Following Initial Enrollment
Your coverage begins on the first day of the month after you satisfy the eligibility requirements described earlier under the "Rules of Eligibility" section of this document. Coverage of your enrolled Spouse and/or Dependent Child(ren) begins on the date your coverage begins, provided they are properly enrolled.