Summary of Eligibility Rules

Active Eligibility

Active Eligibility is based upon hours reported by employers with an agreement with Local #12 requiring contributions to the Health & Welfare Fund. For most people, eligibility is on a quarterly basis. If you are reported for 200 hours or more during a qualifying work quarter, you are eligible for the following eligibility quarter. The qualifying work quarters and eligibility quarters are:

Qualifying Work Quarter  Lag Month Eligibility Quarter
Jan, Feb, Mar April May, Jun, Jul
Apr, May, Jun July Aug, Sep, Oct
Jul, Aug, Sep October Nov, Dec, Jan
Oct, Nov, Dec January Feb, Mar, Apr

Note that there is a gap between the work quarter and the eligibility quarter. This is the lag month when the final reports are processed.

The other method of eligibility is monthly eligibility. Some employers have special agreements which call for monthly eligibility. If you are covered in this way, you earn one month’s coverage for each month worked, as follows:

Work Month Lag Month Eligibility Month
January February March
February March April
March April May

Note that, as with quarterly eligibility, there is a gap or lag month.

Eligibility I.D. Cards

Every eligible participant, Active and Retired receives an eligibility card.

Active Participants 

The card is issued either by Anthem Blue Cross or the HMO you have enrolled in and will come to you at the beginning of your eligibility or upon enrollment in one of the Fund’s HMO plans.  If you do not receive an eligibility card and you have been employed by a signatory employer, you must advise the Fund Office immediately.

Retired Participants (Without Medicare as Primary Coverage)

The card is issued by Anthem Blue Cross or the HMO you have enrolled in when coverage under the Retiree program begins.

Retired Participants (With Medicare as Primary Coverage)

The card is issued by the Fund Office or the HMO you have enrolled in once Medicare becomes your primary coverage.  You will also receive a replacement card in January of each year.

Reserve Account

The Reserve Account can provide extended eligibility to supplement your hours if you have not been reported for enough hours to make you eligible.

For the quarterly eligibility system, all hours reported over 400 in a work quarter go into the reserve. The maximum reserve is 500 hours which can provide for six months.

For participants on the monthly system, each month of reporting provides a reserve of 15 hours, with a maximum reserve of 500 hours. 83 hours are withdrawn from the account for one month’s eligibility so the maximum extension for 500 hours is six months.

Termination of Active Eligibility

  1. ACTIVE eligibility will terminate on the last day of an Eligibility Quarter if the hours worked for Contributing Employers during the most recent complete Work Quarter, plus the hours in your Reserve Account, do not equal 200 hours or more.
  2. If you are eligible on a month-to-month basis, your eligibility will end on the last day of the second month after the month in which you were last reported. If you have a Reserve Hour Bank, your eligibility will be maintained until that expires. For example, a member whose last month of work is July would be reported to the Fund during the month of August and eligibility would be established for September.
  3. If you enter full-time active duty with the Armed Forces of the United States, your eligibility will terminate upon entrance to active duty if you do not follow the provisions described below:

    If you are called to Active Military Duty, you must notify the Fund Office in writing within 60 days from the date of the call to duty. The written notice must include your name, Social Security number and the date you are reporting for duty. The notice should be sent to the Fund Office.

    If these procedures are followed, you will remain eligible in the Plan as if you were still working and being reported for 30 hours per week. If you have hours in your Reserve Hour Bank, those hours will be frozen and will remain frozen for up to five (5) years, or until you are discharged. Eligibility for your spouse and eligible dependents will also continue on the Plan until 90 days after you are discharged from duty, up to a maximum of five (5) years.

    Upon discharge from duty, you must contact the Fund Office and submit a copy of the discharge papers. You will then have 90 days to return to work and regain eligibility. If eligibility is not regained, your eligibility will terminate until sufficient hours are worked again.

  4. Eligibility will be terminated and Reserve Hours forfeited for any Active eligible who is in collusion with his employer to deliberately under-report the hours actually worked, or required to be reported to the Fund, or who works for a non-contributing employer in a covered classification. Upon discovery of either of these incidents, the Reserve Hour Bank will be suspended. Unless the Active member works 200 hours or more for which contributions are made or are required to be made to the Fund within a work quarter in the next four consecutive work quarters, the Reserve Hours will be forfeited permanently. However, any canceled hours may be reinstated if the Board of Trustees receives satisfactory proof that the Active Employee was continuously on the out-of-work list of the Union in each work quarter during which no contributions were made on his behalf.

Active Disability Extensions

If the eligible Active member becomes disabled and because of that disability is prevented from maintaining his eligibility, he may be entitled to disability credit. Based on the information received from the treating physician, disability credit can extend his full benefits for himself and his family for 3 to 6 months. His reserve account is not affected.

Examples
  1. Mr. Smith has eligibility from February 1 through April 30. He becomes disabled on March 5. Since he was eligible at the time the disability occurred, he qualifies for a disability extension. Since this disability occurred during the Qualifying Work Quarter of January through March, he would be granted a disability extension for the corresponding eligibility quarter of May, June and July.
  2. Mr. Brown has eligibility from May 1 through July 31. He also became disabled on March 5. Since he was not eligible at the time his disability occurred, he would not qualify for the disability extension. The application forms and complete rules may be obtained from the Fund Office. GO TO FORMS
  3. Mr. Jones’ employer makes contributions on a fixed-rate basis. Mr. Jones worked in February and March and has eligibility during April and May. He became disabled on April 5. Since he was eligible at the time the disability occurred, he qualifies for a disability extension. He would be granted a disability extension for June.

After all other disability extensions are exhausted, any eligible person, member or dependent, who loses eligibility and is totally disabled (unable to perform normal duties), will remain eligible for benefits based on that disability for up to but no more than one year. This extension is only for treatment of the disabling illness. Any expenses for unrelated illness or injury or for other family members will not be covered. Work-incurred injuries or illnesses do not qualify for this extension.

Definition of Total Disability

Total disability in the Health & Welfare Plan means that the eligible individual is unable, due to disease, injury or pregnancy, to perform the substantial and material duties of the occupation he or she was engaged in when the disability occurred and that the disabled individual is not engaged in any gainful occupation.

Family Medical Leave Act (FMLA)

The Family Medical Leave Act enacted by Congress in 1993 provides that in certain situations employers are required to grant leave to employees and that in such situations the employer is required to continue medical coverage for the employees. The federal legislation specifically provides that more liberal provisions of state law are permitted and also provides that more liberal provisions contained within collective bargaining agreements are permitted.

It is not the role of the Trustees or Trust Fund to determine whether or not an individual employee is entitled to leave with continuing medical care under the federal statute, state statute or the provisions of the collective bargaining agreement. Disputes as to the entitlement to leave with continuing medical benefits must be resolved by the employer, employee and where applicable, the local union.

To the extent that participants are entitled to leave with continuing medical coverage pursuant to the federal act, state legislation or provisions contained within a collective bargaining agreement, the Trust Fund will provide continuing medical coverage so long as required monthly contributions are received from the contributing employer. Rights under this section in no fashion affect rights under COBRA or rights to continuing medical care pursuant to the disability extension features contained within the Plan.

Health Insurance Portability Act (HIPAA)

When your coverage terminates, you will receive a “Certificate of Coverage”. The Certificate provides information regarding the period of coverage under this Plan. This information may be used to reduce or eliminate a pre-existing condition limitation period under a new group health plan, under which you become covered. You may also request a copy of the Certificate at any time within 24 months after your coverage terminates.

If your dependent loses eligibility separately and the Fund Office is notified that the dependent is no longer an eligible Dependent, a separate Certificate will be provided for the Dependent; this Certificate may also be requested within 24 months after the Dependent’s coverage has been terminated.

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