Health and Welfare

Eligibility Requirements

• Plan A – 1,000 recorded hours within a 12-month Qualifying Period = coverage during a 6-month Eligibility Period
• Plan B – 700 recorded hours within a 12-month Qualifying Period = coverage during a 6-month Eligibility Period

Coverage and Deductibles


Plan A and Plan B provide different levels of coverage and have different requirements for copays and deductibles. Review the coverage for medical, mental health, dental, vision, and prescriptions for both plans.

Compare Plan A & Plan B

Dependent Eligiblity


Your dependents’ eligibility will start when your eligibility starts or on the date they become your qualified dependents. Your coverage can include:

• Your lawful spouse
• Biological or legally adopted children up to age 26
• Unmarried children with disabilities beyond the age of 26
• Children for whom you have legal guardianship of, provided they are also your tax dependent

Continuing Coverage


COBRA provides an option for temporarily continuing coverage if you lose eligibility. Find additional information in our Summary Plan Description for complete details on qualifying events, who is eligible, important deadlines, and the length of time continuing coverage may last.

Eligibility Requirements

• Plan A – 1,000 recorded hours within a 12-month Qualifying Period = coverage during a 6-month Eligibility Period
• Plan B – 700 recorded hours within a 12-month Qualifying Period = coverage during a 6-month Eligibility Period

Coverage and Deductibles


Plan A and Plan B provide different levels of coverage and have different requirements for copays and deductibles. Review the coverage for medical, mental health, dental, vision, and prescriptions for both plans.

Compare Plan A & Plan B

Dependent Eligiblity
Your dependents’ eligibility will start when your eligibility starts or on the date they become your qualified dependents. Your coverage can include:

• Your lawful spouse
• Biological or legally adopted children up to age 26
• Unmarried children with disabilities beyond the age of 26
• Children for whom you have legal guardianship of, provided they are also your tax dependent

Continuing Coverage


COBRA provides an option for temporarily continuing coverage if you lose eligibility. Find additional information in our Summary Plan Description for complete details on qualifying events, who is eligible, important deadlines, and the length of time continuing coverage may last.

The Laborers’ Support Network is provided by the HMC Healthworks. It can help you with family difficulties, marital stress, child and adolescent concerns, illness of a family member, financial pressure, job stress, or alcohol and drug abuse. These services must be pre-authorized or your claim will be denied. Contact LSN at 1-800-522-6763.

Plan A and Plan B include different levels of coverage along with copay and deductible requirements for medical care.

Compare Our Medical Plans

If you go to a provider in the BlueCross BlueShield Network, there is no need to file a claim. Your provider will file it on your behalf directly with BlueCross BlueShield.

Important Note: The provider must include the “UEM” prefix when submitting claims on your behalf.

If your provider has to file an inpatient and/or outpatient claim for substance/alcohol abuse, nervous/mental illness, or complementary care, you must have the service pre-authorized by HMC HealthWorks. Your provider should submit the claim to the HMC Healthworks at the following address:

HMC HealthWorks
P.O. Box 981605
El Paso, TX 79998-1605

The Delta Preferred Option USA Plus Plan (DPO Plus) is our network dental plan provided by Delta Dental of Massachusetts. Visiting a dentist that participates in our network will ensure the greatest savings for each appointment.

Find a dentist or confirm that your current dentist participates in the DPO Plus Plan:

• Phone: (800) 872-0500
• Website: DeltaDentalMA.com

Plan A and Plan B include different levels of coverage along with copay and deductible requirements for dental care.

Compare Our Dental Plans

If you use a participating dentist there is no need to file a claim. If you go to a non-participating dentist, you must return a dental form (available at DeltaDentalMA.com) within 90 days of the date of service to Delta Dental.

Davis Vision Care is our network vision plan. If you visit one of their providers, you will not have to pay anything out of pocket. There is no coverage if you use an Out-of Network Provider for routine vision care.

Find a vision provider or confirm that your current provider participates in the Davis Vision network:

• Phone: 1-800-999-5431
• Website: DavisVision.com

The amount of coverage for exams, lenses, frames, and coatings will depend on whether you are visiting a Davis Vision Care provider or using your own provider.

Compare Our Vision Care Options

If you use a participating Davis Vision provider, there is no need to file a claim. If you use a provider outside the network, you will need to pay in full and file for the reimbursable amount within 90 days.

Express Scripts administers our prescription drug plan. Contact Express Scripts, review their list of preferred brand-name drugs, or locate a participating retail pharmacy:

• Pre-Authorization Phone: 800-417-8164
• Claim Phone: 1-800-467-2006
• Website: Express-Scripts.com

Certain drugs must be pre-authorized. If you have questions about which drugs require pre-authorization, only your physician should contact Express Scripts at 800-417-8164 or send a fax to 800-357-9577.

Plan A and Plan B include identical coverage for prescription drugs.

Review Our Prescription Drug Plan

If you use a participating retail pharmacy or the mail-order service, you do not need to file a claim. If you use a non-participating pharmacy, you must file a claim within 90 days from the date of purchase. Contact Express Scripts for a claim form at Express-Scripts.com or 800-467-2006.

Benefit

Provides payments up to $57 per day or $400 per week for up to 13 weeks.

Eligibility

• any injury not arising out of or in the course of your employment;
• any disease not entitling you to benefits under any Workers’ Compensation, occupational disease law, or similar legislation; or
• any injury or disease not entitling you to automobile insurance wage continuation payments.

When Payments Start

If the disability is the result of an accident, payment starts the first day of disability

If the disability is the result of illness, payment starts the eighth day of disability

If the disability is related to pregnancy, payment starts the eighth day of disability

Length of Payments

If you meet the eligibility requirements, you will receive up to 13 weeks for any one continuous period of disability that is due to the same or related cause(s). Refer to the Summary Plan Description for complete details.

Filing a Claim
You and your doctor must FULLY complete a Provider’s Green Claim Form and return that completed form to the Fund Office within 90 days of the date your disability began. If you and your doctor do not FULLY complete the claim form, it will be rejected.

If you move from Plan A to Plan B or vice versa during a calendar year, the payments you make toward your deductible will accumulate. For example:

If you have met the individual $250 calendar-year deductible for Plan A and then switch to Plan B for the next six-month Eligibility Period, you must pay an additional $250 to meet the individual $500 calendar-year deductible for Plan B.

If you have met the individual $500 calendar-year deductible for Plan B and then switch to Plan A for the next six-month Eligibility Period, you automatically meet the $250 individual calendar-year deductible for Plan A.

To order a new dental card, contact Delta Dental at 1-800-872-0500.

To order a new prescription drug card, contact Express Scripts at 1-800-467-2006.

To order a new medical card, contact MLBF at 1-800-342-3792 or 781-272-1000.

When you no longer have enough hours in a qualifying period to gain eligibility, you will have the option to elect COBRA continuation coverage.

Visit the BlueCross BlueShield website at BCBS.com.

Under Plan A and Plan B, the Fund will pay 80% of the provider’s charge, up to a maximum benefit of $50 per visit, with a limit of 30 visits per calendar year. No benefits provided for services outside of the BlueCross BlueShield PPO Network.

Under Plan A and Plan B, the Fund will pay 80% of a participating provider’s charge, up to a maximum benefit of $50 per visit, with a limit of 12 visits per calendar year. No authorization is required. Please print and complete the claim form located in the Important Resources and Documents section.

Your co-payment is $20 for primary care & $30 for specialist visit.

You should have received an “Explanation of Benefits” in the mail that provides the breakdown of your bill — how much was covered and how much you have to pay. If you have not received an “Explanation of Benefits” for the services on the bill, your provider must resubmit the bill.

There is a $20 copay after deductible if you use an in-network provider.

Please refer to the “Eligible Medical Expenses” chart in the Summary Plan Description for Plan A and Plan B coverage.

Your provider must contact BlueCross BlueShield for a Medical admission and HMC Healthworks for a Behavioral Health/Substance Use admission.

In an effort to control costs and make the most of your healthcare dollars, the Fund thoroughly investigates all medical claims for potential third party liability (i.e. workers compensation, motor vehicle accident, malpractice).

You may receive a letter from BlueCross BlueShield, or their partner Equian, requesting additional information for health claims that may be related to an injury.

You must respond and provide the requested information by phone or online. Instructions for responding are included in the letter you receive. If a response is not received, payment for your related medical claims will be retracted and you will become responsible for the full amount.

Go to the Member Dashboard to check your claim status.

If you would like to take advantage of the 8 free sessions with no copay or deductible that are available through The Laborers’ Support Network, you must contact HMC at 1-800-522-6763. HMC can assist you with locating a participating provider that meets your needs and fits your schedule. You do not need pre-certification for outpatient counseling sessions utilizing a BlueCross BlueShield participating provider.

Payment of the Deductible goes directly to the Provider. Please refer to your explanation of benefits (EOB) or wait for the provider to bill you.

No, you must use the Express Scripts card.

If you are a newly initiated Laborer as of November 1, 2008, you would be eligible for benefits under the Plan B policy on the 1st of the month following the month in which you attain 700 recorded hours.

The Plan provides a fitness reimbursement benefit up to $150.00 per calendar year for each member and spouse who have had a routine physical within 12 months preceding the reimbursement submission, and can provide sufficient proof of at least 4 months of a paid membership at a qualified health club for the calendar year for which the reimbursement is sought. Click here to fill out the claims form for this benefit.

A full-service health club with a variety of exercise equipment, including:

• Cardiovascular equipment like treadmills and bikes
• Strength-training equipment like free weights and weight machines

You can also be reimbursed for class fees at a studio with instructor-led group classes such as:

• Martial arts or yoga centers
• Gymnastics, tennis, aerobic, spin, barre, or kickboxing

You cannot receive the fitness reimbursement for expenses towards personal training, lessons, coaching, equipment, clothing, or any of the clubs below:

• Country clubs or social clubs
• Sports teams or leagues

The Plan provides coverage for medical nutrition counseling with a 12 visit per calendar year maximum. Benefits will be paid at 80% of Blue Cross PPO allowance (after Deductible). No benefits provided for services outside of the Blue Cross BlueShield PPO Network.

The plan gives you access to the online weight loss and nutritional counseling program Real Appeal. Completely free for beneficiaries, Real Appeal offers weight loss health coaching as well as ongoing support and resources to keep you motivated. Click here to learn more about Real Appeal.