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Health General Information

 

Appeals of HMO and Insured Benefits

The following procedures apply to claims and appeals on matters within the discretion of the Board of Trustees. Please note that the Board of Trustees does not hear appeals regarding adverse actions taken by an HMO or insurance carrier. If an HMO or insurance carrier denies a claim for benefits, other than eligibility under the Plan, the claimant must appeal directly to the HMO or carrier.

 Appealing a Denied Health Care Claim

In most cases, disagreements about benefit eligibility or amounts can be handled informally by calling the Administrative Office. If a disagreement is not resolved, there is a formal procedure you can follow to have your claim reconsidered.

If your claim is denied or you disagree with the amount of the benefit, you have the right to have the initial decision reviewed. You must follow and exhaust the Plan’s appeals procedure before you file a lawsuit under ERISA, the federal law governing employee benefits, or initiate proceedings before any administrative agency. In the event you submit a claim for review and the claim again is denied, any appeal must begin within 180 days of the date the Plan provides an adverse appeal determination.

In general, you should send your written request for an appeal to the Board of Trustees at the Administrative Office as soon as possible. For urgent care claims, your appeal may be made orally. If your claim is denied or if you are otherwise dissatisfied with a determination under the Plan, you must file your written appeal within 180 days from the date of a decision.

When appealing a claim, you may authorize a representative to act on your behalf. However, you must provide notification to the Administrative Office authorizing this representative and comply with the Plan’s procedures. A health care provider that has knowledge of your medical condition may act as your authorized representative for urgent care claims.

Your written appeal must explain the reasons you disagree with the decision on your claim. Your written request for appeal must include:

  •  The Patient’s name and address;
  • The Participant’s name and address, if different;
  • A statement that this is an appeal of a denied claim;
  • The date of the denial; and
  • The basis of the appeal (i.e., the reason(s) why the claim should not be denied).
  • When filing an appeal, you may:
  • Submit additional materials, including comments, statements or documents;
  • Request to review all relevant information (free of charge);
  • Request a copy of any internal rule, guideline, protocol, or other similar criteria on which the denial was based; and
  • Request a copy of any explanation of the scientific or clinical judgment on which the denial was based if the denial was based on Medical Necessity, Experimental treatment or similar exclusion or limit.

 Appeal Decisions

If you file your appeal on time and follow the required procedures, a new, full, and independent review of your claim will be made, and the decision will not defer to the initial decision. An appropriate fiduciary of the Plan, which is the Board of Trustees, will conduct the review and the decision will be based on all information used in the initial determination as well as any additional information submitted.

 For complete appeals information and procedures, refer to the Health & Welfare Summary Plan Description.

When you submit a claim for benefits, the Plan will determine if you are eligible for benefits and calculate the amount of benefits payable, if any. All claims are processed promptly when complete claim information is received. The Plan will make an initial determination within certain timeframes, as described in the Health & Welfare Summary Plan Description.

Medical Claims

Generally, all claims must be submitted within 90 days after you receive a bill. However, if it is not possible to file a claim within 90 days, the claim must be filed within 12 months of the date of service for benefits to be payable under the Plan. Be sure to show your ID card so your provider knows where to submit your claim.

Completed forms and any attachments (such as bills or statements) should be submitted as soon as you receive them. Itemized bills, showing the date of service, charge, and description for each service will be accepted. Mail to the Administrative Office at:

Stationary Engineers Local 39 Health & Welfare Trust Fund

4160 Dublin Boulevard, Suite 400

Dublin, CA 94568


Dental Claims

If you go to a non-Delta Dental Dentist, Delta Dental cannot assure you what percentage of the charged fee may be covered. Claims for services from non-Delta Dental Dentists may be submitted to:

Delta Dental

P.O. Box 997330

Sacramento, CA 95899-7330


Prescription Drug Claims (for Use of a Non-Network Retail Pharmacy)

No claim forms are required for prescription drugs if you use a network pharmacy or the mail order program. Non-network pharmacy claims may be sent to Optum Rx with a claim form and the original prescription receipts. Visit https://www2.optumrx.com or phone 888-245-5005.

If you fill a prescription at an Out-of-Network pharmacy, you will need to pay for the drug at the time of purchase. You can then send your drug receipt to Optum Rx using the Prescription Reimbursement process.


Vision Claims (if You Use a Non-EyeMed Provider)

If you obtain services through an out-of-network provider, you must pay the provider in full and submit an itemized receipt to EyeMed. EyeMed will reimburse you up to the amounts allowed under your plan’s out-of-network benefits schedule. The reimbursement schedule does not guarantee full payment nor can EyeMed guarantee patient satisfaction when services are received from an out-of-network provider.

All claims for reimbursement must be filed within six months of the date services were completed. Reimbursement benefits are made to you and are not assignable to the provider.

If you become disabled, you may be eligible for extended coverage if this has been provided for under the terms of your Collective Bargaining Agreement.  Otherwise, you may continue your coverage under the terms of the federal COBRA Continuation of Coverage regulations.

Employees are eligible for coverage if they work for an employer who has signed a Collective Bargaining Agreement with Stationary Engineers Local 39 agreeing to contribute to the Trust Fund on behalf of eligible employees who work a minimum of 80 hours each month. Depending on the terms of the Collective Bargaining Agreement, you can become eligible for coverage in one of two ways:

  •  On the first day of the second calendar month following the month in which you worked 80 hours or more for your employer; or
  • On the first day of the calendar month immediately following the month in which you worked 80 hours or more for your employer.

You continue to be eligible for benefits provided you work the required 80 hours during a calendar month.

 Eligibility for your Spouse & Children

Your Dependents become eligible on the effective date of your eligibility once you complete the Plan’s enrollment form. However, if you are enrolled in an HMO, coverage for new Dependents may be delayed until the first day of the next month after you complete an enrollment form.

If you have a baby, your child is automatically covered by the Plan from the date of birth, provided you submit an updated enrollment form to the Administrative Office and the child’s birth certificate and Social Security number when they become available.

If you adopt a child (or have a child placed with you for adoption), you have 90 days from the date of the adoption (or placement for adoption) to enroll your child. If you are unable to get the paperwork to the Administrative Office within the 90-day period due to circumstances beyond your control, notify the Administrative Office immediately in writing to request an extension.

If you become the legal guardian of a child not otherwise eligible for benefits as a Dependent under this Plan, you may be able to add him or her as a Dependent provided you meet the requirements as the child’s guardian. You must be able to demonstrate that you have been designated as the legal guardian for the child.

 Eligibility for Domestic Partners

Your same-sex or opposite-sex domestic partner and his or her eligible children may be covered through the Plan if they meet Plan eligibility requirements, shown on page 12 of the Summary Plan Description. In addition, you must submit documentation—a notarized “Affidavit of Domestic Partnership”—in order for your domestic partner and his or her Dependent children to be eligible for coverage. You must also submit birth certificates for your domestic partner and his or her Dependent children in order to enroll them. Contact the Administrative Office for the “Affidavit of Domestic Partnership” form.

Note that enrolling a domestic partner (and his or her eligible children) might increase your taxes because the value of the coverage must be reported as taxable income to the IRS. Refer to page 12 of the Summary Plan Description for more information about eligibility for a domestic partner (and his or her eligible children). Note also that domestic partners and their Dependents are not eligible for Dependent Life insurance coverage under the Plan.

If Your Employment is Terminated

If your coverage ends due to termination of your employment or insufficient hours, you may be eligible to purchase COBRA Continuation Coverage for you and your family. Your employer will notify the Administrative Office of your termination, but you are encouraged to inform the Administrative Office to avoid confusion in the event of a delay. For complete information on COBRA, refer to the section beginning on page 23 of the Health & Welfare Summary Plan Description.

When Your Dependent’s Coverage Ends

Your Dependent’s eligibility will terminate on the date your eligibility terminates or the end of the month following the date he or she no longer qualifies as a Dependent under the Plan, whichever is earliest. You are responsible for notifying the Administrative Office in writing within 60 days of the date any of your Dependents cease to qualify as a “Dependent” under the Plan’s definition. If you fail to notify the Administrative Office, you may jeopardize the right to elect COBRA coverage and the Fund has the right to offset against future claims any amounts paid on behalf of ineligible dependents.

Eligibility for the Retiree Program

  •  You must be at least age 55 to participate in the Plan. You must also be receiving a retirement benefit from the Stationary Engineers Local 39 Pension Plan. The Plan covers eligible retirees until they are eligible for Medicare.
  •  To qualify, you must have been eligible and participating as an Active Employee in the Stationary Engineers Local 39 Health and Welfare Trust Fund for a minimum of five total years and at least 12 of the 24 months immediately preceding your retirement.
  •  You may cover Dependents under the self-pay retiree program who qualified as eligible Dependents under the Plan at the time you retire and are enrolled as Dependents under your active coverage. You may not add a dependent after your initial enrollment in the retiree plan.

When you first become eligible for coverage, you should enroll yourself and your eligible Dependents in the medical and dental coverage option that you would like. When you are first eligible for benefits, the Administrative Office will advise you what HMO options are available to you based on where you live.

If you are trying to decide between the Comprehensive Self-Funded Medical Benefits Plan and an HMO, review a copy of the Summary of Benefits and Coverage (SBC) for both plan options to obtain the differences between the two plans.

Enrollment Form

 Changing Your Coverage

If you would like to change your coverage, you may not enroll in a different benefit option unless you have been covered under your current Plan for at least 12 months. For example, if you are first hired and enroll in benefits effective October 1, 2022, your next opportunity to enroll in different benefit options is after September 30, 2023.

If you experience a Special Enrollment Event, such as a marriage or birth of a child, you may also be eligible to make certain additional changes to your benefits sooner than the 12-month period.

 Special Notice to HMO Enrollees (Kaiser, Anthem HMO, or MetLife Dental)

Enrollment materials provide you with a summary of the benefits under your plan and may not completely describe your benefits. For specific details on your HMO coverage, refer to the HMO’s Evidence of Coverage—the binding document between the insured HMO Plan and its members (or enrollees). All services and supplies must be provided, prescribed, authorized or directed by a provider in the HMO network. If there are any discrepancies between the HMO benefits represented through the dissemination of information by the Trust Fund and the HMO’s Evidence of Coverage, the Evidence of Coverage will prevail.

 Enrollment Forms

Every employee working for a contributing employer should complete an enrollment form.  After you have filed an enrollment form with the Administrative Office and upon establishing eligibility you will receive an identification card, either a Self-Funded Medical Plan Identification Card or an Identification Card from an HMO, whichever is appropriate.

You must notify the Administrative Office promptly in writing when ANY change occurs in the information provided on the enrollment form, for example marriage, birth of a child, death, divorce or any other change in dependent status or if you change your home address. You must also complete a new enrollment form to change your life insurance beneficiary.

If your enrollment form is not received within 60 days from the date you obtained initial eligibility, you will be enrolled in the Self-Funded Medical and Dental Plans. You may change this selection by completing an enrollment form and submitting it to the Administrative Office. Your change will be effective the first of the month following the month in which the enrollment form is received.

Enrolling in the Retiree Plan

Call the Administrative Office at least 30 days prior to your retirement date if you are interested in the retiree health insurance program. You will be required to complete a retiree health and welfare benefit program application before your initial eligibility becomes effective. Call the Administrative Office if you have any questions.

Once enrolled in the retiree program, you may later decide not to participate by disenrolling. Once you disenroll, you or your Dependents will not be allowed to re-enroll.

After your initial retirement, you may decide to return to work under a related Collective Bargaining Agreement. You will still be eligible for the retiree program as long as your hours of covered employment do not exceed 80 in a month. If you work enough hours to trigger an employer contribution, you will return to active status. When you do not work the necessary hours to generate an employer contribution on your behalf, you will return to retiree status and any self-pay contribution will be deducted from your pension check once again.