Health Rights & Protections
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the annual WHCRA notice, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or visit www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444 EBSA (3272).
If your coverage under the Health and Welfare Plan ends due to a “Qualifying Event” (see below), you and/or your eligible Dependents may be eligible to continue your health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
By making monthly payments, you and/or your Dependents may continue the same medical, prescription drug, vision and dental coverage that you had before your coverage ended. Your coverage can last for up to 18, 29, or 36 months, depending on the Qualifying Event that resulted in your loss of coverage.
Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for it at their own expense.
Other Health Coverage Alternatives to COBRA
You may also have other health coverage alternatives to COBRA available to you that can be purchased through the Health Insurance Marketplace (the Marketplace helps people without health coverage find and enroll in a health plan, for California residents see: www.coveredca.com. For non-California residents see your state Health Insurance Marketplace or www.healthcare.gov).
NOTE: Domestic Partners and children of Domestic Partners are offered the ability to elect “COBRA-like” temporary continuation of benefits when coverage ends (described in this chapter); however, Domestic Partners and children of Domestic Partners are not considered Qualified Beneficiaries and therefore may not have all the federally protected rights afforded to a Qualified Beneficiary. This chapter describes in general how the Domestic Partner COBRA-like benefit will work. For questions, contact the Administrative Office.
For complete information about COBRA Continuation Coverage, refer to Section 4 of the Health & Welfare Summary Plan Description.
As a Participant in the I.U.O.E. Stationary Engineers Local 39 Plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act (ERISA) of 1974. ERISA provides that all Plan Participants shall be entitled to:
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 the summary annual report.
If you are entitled to take Family Medical Leave to deal with a serious illness, birth of a child, or to care for a seriously ill parent or spouse, the Family Medical Leave Act (FMLA) allows you to continue coverage for the period of authorized leave (generally 12 weeks and in some cases, up to 26 weeks). The Trust Fund will provide continuing medical coverage so long as required monthly contributions are received from your contributing employer. Your employer should certify that you meet the requirements of FMLA and make the required contribution to the Administrative Office.
It is not the role of the Trustees or the Administrative Office to determine whether or not an individual employee is entitled to leave with continuing coverage under the federal statute, any state statute or the provisions of a Collective Bargaining Agreement. Disputes as to the entitlement to leave with continuing medical benefits must be resolved between you, your employer, and where applicable, the local union.
Reinstatement of Coverage for FMLA
If your coverage ends while you are on an approved leave of absence for family, medical or military leave, if you are benefits-eligible upon return, your coverage will be reinstated on the first day of the month following your return to active employment, if you return within 14 days after your leave of absence ends, and subject to all accumulated maximum plan benefits that were incurred prior to the leave of absence.
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 Stationary Engineers Local 39 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.
Notice of Privacy Practices
A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order (QMCSO), National Medical and Support Notice, or other court or administrative order. You may also enroll a child who is not in your custody if a QMCSO requires you to provide health coverage to that child. To be considered “qualified”, a medical child support order must include:
Your name and current address;
QMCSOs should be sent to the Administrative Office. You will be notified of the Plan’s procedures for determining if the order is qualified. If the order is qualified, you may cover your children who are not in your care under the Plan. As a beneficiary covered under the Plan, your child will be entitled to information that the Plan provides to other beneficiaries under ERISA.
The Plan Sponsor will determine if the court order is “qualified.” A Medical Child Support Order will not qualify if it would require the Plan to provide any type or form of benefit or any option not otherwise provided under this Plan, except to the extent necessary to comply with Section 1908 of the Social Security Act
You must notify the Administrative Office if you are called to military leave in order to make any required payments to continue your health care coverage in your absence.
If your coverage ends under the Plan because you are absent from employment due to your service in the United States Armed Forces for less than 31 days, your coverage will be reinstated when you return to full-time employment as required by the Uniformed Services Employment and Reemployment Rights Act (USERRA).
If your coverage ends under this Plan because you are absent form employment due to your service in the United States Armed Forces for more than 30 days, you and your Dependents will be considered “Qualified Beneficiaries” for purposes of electing USERRA Continuation Coverage, which operates similar to COBRA continuation coverage, except as provided below. (See information beginning on page 23 for a full explanation of the COBRA coverage provisions, which may allow you to continue your health care coverage at your own expense.)
In addition, your Dependents may be eligible for health care coverage under a government health insurance program known as TRICARE. This Plan will coordinate with TRICARE in accordance with the requirements of federal regulations if you elect to continue coverage and make the required self-payments.
You and your eligible Dependents will receive a right to elect USERRA coverage for up to 24 months from the date on which your absence due to active duty begins. The maximum period of coverage will be shorter if your coverage ends before 24 months or if you fail to apply for or return to a position of covered employment within the timeframes allowed under USERRA. If you elect to continue coverage under this provision, the cost of your coverage will be up to 102% of the full cost of coverage. Payment must be received in a timely manner in order for coverage to continue. If you do not elect continuation coverage under USERRA, your Dependents may elect to continue coverage under COBRA.
When you are discharged (not less than honorably) from “service in the uniformed services,” your full eligibility will be reinstated on the day you return to work, provided that you return to employment:
If you are hospitalized or convalescing from an injury caused by active duty, these time limits may be extended up to two years.
Reinstatement of Coverage for USERRA
Your Health and Welfare Plan requires group coverage to provide a minimum hospital stay for the mother and newborn child of 48 hours after a normal, vaginal delivery and 96 hours after delivery by cesarean section unless the attending physician, in consultation with the mother, determines a shorter hospital length of stay is adequate. If you are discharged earlier, your physician may decide, at his or her discretion, that you should be seen at home or in the office, within 48 hours of the discharge, by a licensed health care provider whose scope of practice includes postpartum care and newborn care.
Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hours (or 96-hours) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.
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, insurers, and HMOs that provide medical and surgical benefits in connection with a mastectomy must provide benefits for reconstructive surgery, as requested by the patient in consultation with the attending physician for:
This coverage is subject to the Plan’s deductibles, coinsurance, or co-payment provisions.
