Should Amendments be made, they will be posted on this web page until a new ITPEU Health & Welfare Plan book is printed. Portions of the Health & Welfare Plan or Summary Plan Description which have been Amended will be highlighted per this example in yellow.
AMENDMENT 2015-1 TO THE ITPEU HEALTH & WELFARE PLAN SUMMARY PLAN DESCRIPTION
Effective January 1, 2015, the Second Paragraph under the heading “How Is Eligibility Acquired?” shall be amended to read as follows:
“If you are hired after the date the Fund became effective at your place of work, and before January 1, 2015, your eligibility date for coverage is the 91st day after your date of hire, provided your enrollment card has been received by the Fund.
If you are hired after the date the Fund became effective at your place of work, and on or after January 1, 2015, your eligibility date for coverage is the 31st day after your date of hire, provided your enrollment card has been received by the Fund.
AMENDMENT 2015-1 TO THE ITPEU HEALTH & WELFARE PLAN DOCUMENT
Effective January 1, 2015, the ITPEU Health & Welfare Plan Document shall be amended as follows:
1. Section 2.03 shall be amended by the addition of the underscored language as set forth below:
“2.03 Date of Participation – Future Employees.
(a) Each Employee, who has filed an enrollment card as specified in Section
2.01, and who enters into the service of an Employer after the date on which such
Employer agrees to be bound by the terms of the provisions of the Agreement and
Declaration of Trust, before January 1, 2015, shall become a Participant in the Plan
on the 91st day after the first day of such employment.
(b) Each Employee, who has filed an enrollment card as specified in Section
2.01, and who enters into the service of an Employer after the date on which such
Employer agrees to be bound by the terms of the provisions of the Agreement and
Declaration of Trust, on or after January 1, 2015, shall become a Participant in the Plan
on the 31st day after the first day of such employment.
Amendments to Summary Plan Description
AMENDMENT 2014-1 TO THE SUMMARY PLAN DESCRIPTION FOR THE ITPEU HEALTH & WELFARE FUND
Effective July 1, 2014, the third paragraph under the heading “How Do You Lose Your Eligibility For Benefits” shall be amended to read as follows:
In the event your Employer is one month delinquent in remitting contributions on your behalf to the Fund, you and your Covered Family Members’ eligibility for benefits incurred after a period of 40 days from the commencement of such delinquency shall be suspended until such time as the employer is no longer delinquent for one or more months. During such a period of suspension, the Fund shall hold such claims in abeyance pending payment of the contributions. Once your employer is no longer delinquent for one or more months, such claims will be promptly processed by the Fund.
No later than 10 days after the contributions were due, the Fund shall send written Notice to the Employees of the delinquent Employer, informing them that payment of their benefits, and the benefits of their Covered Family Members, will be suspended in 30 days due to lack of payment by their Employer unless the Employer pays off the delinquency within the 30 day period. Such Notice shall state the actual date of such suspension. Copies of such Notice shall be sent to the Employer, and the applicable Contracting Officer and DOL Wage & Hour Area Director. In addition, a separate letter, with copies to the Employer and affected Employees, will be sent by the Fund to the applicable Contracting Officer and Wage & Hour Area Director, advising of the delinquency and resulting suspensions of benefits.
AMENDMENT 2013-3 ITPEU HEALTH & WELFARE SUMMARY PLAN DESCRIPTION
Effective January 1, 2013, the Summary Plan Description for the ITPEU Health & Welfare Plan shall be amended as follows:
1. By adding the following language immediately before the heading entitled "MATERNITY":
"PRE-CERTIFICATION
What is Pre-Certification?
Pre-Certification is the process used to obtain authorization for a specific medical procedure before it is done, or to obtain authorization for admission to the hospital for a medical treatment before such admission takes place.
When does the ITPEU Health & Welfare Plan Require Pre-Certification?
You are required to obtain Pre-Certification for any in-patient admission to a Hospital. In addition, Pre-Certification is required for certain out-patient medical services. A description of the out-patient services which require pre-certification under the Plan is set forth in the Appendix to this Summary Plan Description entitled "Out-Patient Services Requiring Pre-Certification". Please refer to this Appendix in order to determine whether any out-patient medicla services which you or a Covered Family Member is scheduled to undergo requires Pre-Certification. After reviewing the Appendix, if you still have a question as to whether an out-patient medical service requires Pre-Certification, please call the Claims Administrator at the telephone number on your Medical Plan ID Card.
Emergency Medical Treatment
If you are admitted to a hospital on an emergency basis, either your Physician, your authorized representative, or you must notify the Claims Administrator within two business days after the admission, or as soon as possible within a reasonable period of time, by calling the telephone number on your Medical Plan ID Card.
Procedure for Obtaining Pre-Certification
1. If your Healthcare Provider is a Network Healthcare Provider in the States of California,
Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire,
Nevada, Ohio, Virginia and Wisconsin.
Your Healthcare Provider is responsible for obtaining Pre-Certification.
2. If Services are Provided by a Network Provider in any Other State or by an Out-of-Network Healthcare
Provider.
Your, or your authorized representative, are responsible to confirm that Pre-Certification has been obtained. In most instances, your physician, acting on his or her own, or upon your request, will take the steps necessary to obtian Pre-Certification. However, it remains your responsibility to confirm that Pre-Certification has been obtained prior to he hospital admission (unless emergency) or out-patient medical service in question.
Standard to be Applied by Claims Administrator in Determining Whether to Provide Pre-Certification.
The Claims Administrator will not provide Pre-Certification for any medical service that is either not a medical service covered by the Plan or is not deemed to be medically necessary.
Consequence of Not Obtaining Pre-Certification Before Medical Services are Provided.
If Pre-Certification is not obtained before the hospital admission (unless emergency) or the out-patient medical service is provided, you will be financially responsible for the cost of the hospitalization or medical service in question.
Time Frames for Determination of Pre-Certification
A request for Pre-Certification is considered "Urgent" when, in the opinion of your treatment Healthcare Provider the failure to receive the requested care or treatment would seriously jeopardize the life or health of you or your Covered Family Member, or the ability of you or your Covered Family Member to regain maximum function, or subject you or your Covered Family Member to severe pain that cannot be adequately managed without such care or treatment.
When the request for Pre-Certification is termed as "Urgent" the Claims Administrator shall respond within 72 hours from the receipt of the request. When the request for Pre-Certification is termed as non-urgent, the Claims Administrator will respond within 15 calendar days from the receipt of the request.
Appeal from Denial of Pre-Certification
In the event that Claims Administrator denies Pre-Certification for any hospitalization or out-patient service, you have the right to appeal such a denial pursuant to the appeal procedures set forth in this Summary Plan Description and the Plan Document.
2. By adding the following language to the Table describing the Preventive Health Care Benefits provided by the Plan:
"WOMEN'S HEALTHCARE
1. Women's contraceptives, sterilization procedures, and counseling;
2. Breastfeeding support, supplies and counseling. Benefits for breast pumps are
limited to one pump per calendar year;
3. Gestational Diabetes screening."
AMENDMENT 2013-2 - ITPEU HEALTH & WELFARE SUMMARY PLAN DESCRIPTION
Effective January 1, 2013, the Maximum Annual Benefit for all Schedules of Benefits shall be increased to $2,000,000.00 and the Schedules of Benefits contained in the Summary Plan Description for the ITPEU Health & Welfare Plan shall be revised to read as follows: (To Be Supplied)
AMENDMENT 2013-1 - ITPEU HEALTH & WELFARE SUMMARY PLAN DESCRIPTION
Effective January 1, 2013, that portion of the ITPEU Health & Welfare Plan Summary Plan Description entitled "Special Rule for Participants with Contribution Rates of $3.24/hr. or Higher" and the paragraph immediately following shall be amended to read as follows:
"Special Rule for Class III and IV Participants With Contribution Rates of $3.75/Hour or Higher, and Class I and II Participants With Contribution Rates of $4.00/Hour or Higher.
For eligible Class III and IV Participants whose contribution rates are $3.75/hour or higher, and for eligible Class I and II Participants whose contribution rates are $4.00/hour or higher, a system of co-pays shall be in effect for In-Network physician visits and In-Office testing."
AMENDMENT 2012-2 - ITPEU HEALTH & WELFARE SUMMARY PLAN DESCRIPTION
Effective July 1, 2012, the Summary Plan Description for the ITPEU Health & Welfare Plan shall be amended as follows:
1. The section entitled "Notice of Grandfathered Status" shall be deleted and the following language shall be substituted:
"Effective July 1, 2012, the Trustees of the ITPEU Health & Welfare Plan believe that this Plan is no longer a "Grandfathered Health Plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). Accordingly, effective July 1, 2012, the Plan will provide the preventive health services mandated by the Affordable Care Act without any cost sharing by Participants. In addition, effective July 1, 2012, the Plan shall afford Participants an "External Appeal" process as a voluntary final step in connection with the review of denials of medical claims.
A description of the preventive health services provided by the Plan without any cost sharing as of July 1, 2012 is set forth elsewhere in this Summary Plan Description, and at Section 9.03(c) of the ITPEU Health & Welfare Plan.
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 by calling 1-800-327-5926 or 1-912-352-7169, or writing to Board of Trustees, ITPEU Health & Welfare Fund, Attention Plan Administrator, P.O. Box 13817, Savannah, GA 31416. You may also contact the Employee Benefit Security Administration at U.S. Department of Labor at 1-866-444-3272 or www.dol.gov\ebsa\healthreform . This website has a table summarizing which protections do and do not apply to Grandfathered Health Plans.
2. The section entitled "Mental Health Services" under the heading "Covered Medical Expenses" shall be deleted.
3. A paragraph numbered 63 shall be added to the section entitled "General Exclusions and Limitations" which shall read as follows:
"63. Treatment of a Mental Health Disorder"
4. The language under the heading "Preventive Care Guidelines" shall be amended to read as follows:
"Preventive Health Services
Effective July 1, 2012, the Plan will pay 100% of the cost of all “Preventive Health Services” required by the Affordable Care Act when such services are provided by Network Healthcare Providers. Such services include well-care baby visits, preventive care physical examinations for adults, screening tests for children and adults, and immunizations for children and adults. Set forth below is an overview of the types of preventive services which are covered. If you have questions as to whether a particular service is a “Preventive Health Service” required to be provided by the Plan without cost to you under the Affordable Care Act, please call the Claims Administrator at 1-877-331-4329.
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CHILD PREVENTIVE CARE (Birth to 18 years)
Preventive physical exams including well baby care
Age-appropriate screening tests including:
- Newborn screenings
- Vision screening
- Hearing screening
- Developmental and behavioral assessments
- Oral health assessment
- Screening for lead exposure
- Hemoglobin or hematocrit (blood count)
- Blood pressure
- Height, weight and body mass index (BMI)\
- Cholesterol and lipid level screening
- Screening for depression
- Screening and counseling for obesity
- Behavioral counseling to promote a healthy diet
- Screening for sexually transmitted infections
- Pelvic exam and Pap test, including screening for
cervical cancer
-urinalysis
-tuberculin tests
-blood tests including hematocrit, hemoglobin and screening for sickle hemoglobinopathy
Immunizations:
- Hepatitis A
- Hepatitis B
- Diphtheria, Tetanus, Pertussis
- Varicella (chicken pox)
- Influenza (flu)
- Pneumococcal (pneumonia)
- Human Papillomavirus (HPV)
- Haemophilus Influenza type b (Hib)
- Polio
- Measles, Mumps, Rubella (MMR)
- Meningococcal (meningitis)
- Rotavirus
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ADULT PREVENTIVE CARE (19 years and older)
Preventive physical exams
Age-appropriate screening tests including:
- Eye chart vision screening
- Hearing screening
- Cholesterol and lipid level screening
- Blood pressure
- Height, weight and BMI
- Screening for depression
- Diabetes screening
- Prostate cancer screening including digital rectal exam and PSAtest
- Breast cancer screening, including exam and mammography
- Pelvic exam and Pap test, including screening for cervical cancer
- Screening for sexually transmitted infections
- HIV screening
- Bone density test to screen for osteoporosis
- Colorectal cancer screening including fecal occult blood test, barium enema, flexible sigmoidoscopy, screening colonoscopy and CT colonography (as appropriate)
- Aortic aneurysm screening (men)
- Screenings during pregnancy (including but not limited to, hepatitis, asymptomatic bacteriuria, Rh incompatibility, syphilis, iron deficiency anemia, gonorrhea, chlamydia and HIV)
- Intervention services (includes counseling and
education):
° Screening and counseling for obesity
° Genetic counseling for women with a family history
of breast or ovarian cancer
° Behavioral counseling to promote a healthy diet
° Primary care intervention to promote breastfeeding
° Counseling related to aspirin use for the prevention
of cardiovascular disease (does not include coverage
for aspirin)
° Screening and behavioral counseling related to
tobacco use
° Screening and behavioral counseling related to
alcohol misuse
Immunizations:
- Hepatitis A
- Hepatitis B
- Diphtheria, Tetanus, Pertussis
- Varicella (chicken pox)
- Influenza (flu)
- Pneumococcal (pneumonia)
- Human Papillomavirus (HPV)
- Measles, Mumps, Rubella (MMR)
- Meningococcal (meningitis)
- Zoster (shingles)
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5. The paragraphs dealing with "Covered Child Screening and Care" and "Mammogram and PAP Tests" under the heading "Covered Medical Expenses" shall be deleted since they are now covered under the heading "Preventive Health Services".
6. The Section entitled "CLAIM REVIEW PROCEDURES" shall be amended to read as follows:
The Following Procedures Will Be Followed For Claims
For Medical Benefits Only:
Effective July 1, 2012 all claims for medical benefits and appeals from denials of such claims shall be handled exclusively by the Claims Administrator (Anthem). It shall be the responsibility of the Participant to give proper notice of any other medical coverage he or she may have when filing a claim with the Claims Administrator (Anthem) for medical benefits. All of the time limitations set forth below begin running from the time of receipt of the claim by the Claim Administrator (Anthem).
For purposes of the these Claims Review Procedures, the term "claim for benefits" means a request for medical benefits under the Plan. The term includes both pre-service and post-service claims.
If your claim is denied:
The procedure of the Claims Administrator will follow will satisfy the requirements for a full and fair review under applicable federal regulations.
Notice of Adverse Benefit Determination
If your claim is denied, the Claims Administrator's notice of the adverse benefit determination (denial) will include:
-
Information about any internal rule, guideline, protocol, or other similar criterion relied upon in making the claim determination about your right to request a copy of it free of charge, along with a discussion of the claims denial decision;
-
Information about the scientific or clinical judgment for any determination based on medical necessity or experimental treatment, or about your right to request this explanation free of charge, along with a discussion of the claims denial decision; and
Urgent Care
Claims involving "urgent care" shall be handled differently from all other categories of claims. A claim shall be considered to involve "urgent care" if it is a claim for medical care with respect to which the application of the time period for making non-urgent care determinations could: (a) seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or (b) in the opinion of a physician with knowledge of the claimant's medical condition, subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
For claims involving urgent/concurrent care:
Appeals
You have the right to appeal an adverse benefit determination (claim denial or rescission of coverage). You or your authorized representative must file your appeal within 180 calendar days after you are notified of the denial or rescission. You will have the opportunity to submit written comments, documents, records, and other information supporting your claim. The Claims Administrator's review of your claim will take into account all information you submit, regardless of whether it was submitted or considered in the initial benefit determination.
For pre-service claims involving urgent/concurrent care, you may obtain an expedited appeal. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator's decision, can be sent between the Claims Administrator and you by telephone, facsimile or other similar method. To file an appeal for a claim involving urgent/concurrent care, you or your authorized representative must contact the Claims Administrator at the telephone number shown on your identification card and provide at least the following information:
-
The identity of the claimant;
-
The date(s) of the medical service;
-
The specific medical condition or symptom;
-
The provider's name;
-
The service or supply for which approval of benefits was sought; and
-
Any reasons why the appeal should be processed on a more expedited basis.
All other requests for appeals should be submitted in writing by the Participant or the Participant's authorized representative. You or your authorized representative must submit a request for review to:
Anthem Blue Cross and Blue Shield, ATTN: Appeals
P.O. Box 105568, Atlanta, GA 30348-5568
If the denial was based in whole or in part on a medical judgment, including whether the treatment is experimental, investigational, or not medically necessary, the reviewer will consult with a health care professional who has the appropriate training and experience in the medical field involved in making the judgment. This health care professional will not be one who was consulted in making an earlier determination or who works for one who was consulted in making an earlier determination.
Notification of the Outcome of the Appeal
If you appeal a claim involving urgent/concurrent care, the Claims Administrator will notify you of the outcome of the appeal as soon as possible, but not later than 72 hours after receipt of your request for appeal.
If you appeal any other pre-service claim, the Claims Administrator will notify you of the outcome of the appeal within 30 days after receipt of your request for appeal.
If you appeal a post-service claim, the Claims Administrator will notify you of the outcome of the appeal within 60 days after receipt of your request for appeal.
Appeal Denial
External Review
If the outcome of the mandatory first level appeal is adverse to you, you are eligible for an independent External Review pursuant to federal law. The term "External Review" refers to your right to have the decision received by independent healthcare professionals who have no association with the Claims Administrator. By voluntarily requesting an External Review you agree to have your Protected Health Information reviewed by the independent healthcare professionals conducting such review.
You must submit your request for External Review to the Claims Administrator within four (4) months of the notice of your final internal adverse determination.
A request for an External Review must be in writing unless the Claims Administrator determines that it is not reasonable to require a written statement. You do not have to resend the information that you submitted for the internal appeal. However, you are encouraged to submit any additional information that you think is important for review.
For pre-service claims involving urgent care, you may proceed with an Expedited External Review without filing an internal appeal or while simultaneously pursuing an expedited appeal through our internal appeal process. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator's decision, can be sent between the Claims Administrator and you by telephone, facsimile or other similar method. To proceed with an Expedited External Review, you or your authorized representative must contact the Claims Administrator at [the number shown on your identification care] and provide at least the following information:
-
The identity of the claimant;
-
The date(s) of the medical service;
-
The specific medical condition or symptom;
-
The provider's name
-
The service or supply for which approval of benefits was sought; and
-
Any reason why the appeal should be processed on a more expedited basis.
All other requests for External Review should be submitted in writing unless the Claims Administrator determines that it is not reasonable to require a written statement. Such requests should be submitted by you or your authorized representative to:
Anthem Blue Cross and Blue Shield, ATTN: Appeals
P.O. Box 105568, Atlanta, GA 30348-5568
A Request for External Review is Purely Voluntary on Your Part
It is not an additional step that you must take in order to fulfill your appeal procedure obligations described above. Your decision to seek External Review will not affect your rights to any other benefits under this health care plan. There is no charge for you to initiate an independent External Review. The External Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA.
Requirement to File an Appeal Before Filing a Lawsuit
You must exhaust the Plan's Claims Review Procedure, not including any voluntary External Review, before filing a lawsuit or taking other legal action of any kind against the Plan. If your appeal results in an adverse benefit determination, you have a right to bring a civil action under Section 502(a) of ERISA. No lawsuit or legal action of any kind related to a benefit decision may be filed by you in a court of law or in any other forum, unless it is commenced within the time provided by the applicable Statute of Limitations. If the Plan decides an appeal is untimely, the Plan's latest decision on the merits of the underlying claim or benefit request is the final decision date."
The Following Procedures will be Followed for Review of Claims for all Benefits
Provided by the Plan Other than Medical Benefits
TIMETABLE FOR DETERMINING CLAIMS
All of the time limitations set forth below begin running from the time of receipt of the claim by the Plan Office.
As used below, the word "process" refers to the time within which the Plan Office shall determine whether a particular claim is payable.
Claims
To process a complete claim .....................................................................................72 hours
To request additional information for an incomplete claim.........................................24 hours
Claimant's response time if additional information requested....................................48 hours
To process a claim if complete information received.................................................48 hours
Denial of Claims
If your claim is denied, the Plan Office will provide you with the following information:
1. The specific reason for the determination;
2. Reference to the specific claims provisions on which the determination is based;
3. A description of any additional material or information necessary for you to provide
to the Plan and an explanation of why the information is necessary (if applicable);
4. A description of the Plan's Claim Review Procedures and Time Limits to appeal a
denial, including a statement of your right to bring a civil action under Section 502(a)
of ERISA following an adverse benefit determination on review; and
5. A statement of any specific internal rule, guideline, protocol or other matter that was
relied upon in making the benefit denial.
Request For Review of Denial of Claims
If your request for review is denied, the notice of the Committee's determination must set forth:
1. The specific reason or reasons for the adverse determination;
2. Reference to the specific claims provision on which the determination is based;
3. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies
of all documents, records and other information relevant to the claimant's claim for benefits;
4. A statement of any specific internal rule, guideline, protocol or other similar criteria that was relied upon in making
the adverse determination;
5. A statement of the claimant's right to bring a civil action under Section 502(a) of ERISA;
6. The following statement:
"You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your State Insurance Regulatory Agency."
AMENDMENT 2012-1 - SUMMARY PLAN DESCRIPTION OF THE ITPEU HEALTH & WELFARE PLAN
Effective June 1, 2011, the Summary Plan Description for ITPEU Health & Welfare Plan shall be amended as follows:
1. The first sentence of the first paragraph under the Heading "HOW TO APPLY FOR MEDICAL BENEFITS" shall be amended to read:
"All claims for medical benefits provided by the Plan must be submitted within one (1) year from the date the claim is 'incurred'."
2. A new section entitled "TIME LIMIT FOR FILING CLAIMS" shall be inserted between the Section entitled "How Do Your Lose Your Eligibility For Benefits?" and the section entitled "YOUR BENEFICIARY" which shall read as follows:
"TIME LIMIT FOR FILING CLAIMS
All claims for Death Benefits, Covered Family Member's Death Benefits, Survivor Monthly Death Benefits and Non-Occupational Accidental Death and Dismemberment Benefits must be submitted to the Plan Office within three (3) years from the date of the death or dismemberment in question. Any claim received by the Plan Office for such benefits more than three (3) years after the date of such death or dismemberment will not be honored and will not be paid.
All other claims for benefits including, but no limited to, medical, dental, vision, prescription drug and sickness and accident benefits, must be submitted to the Plan Office or Claims Administrator within one (1) year from the date the claim is 'incurred'. A claim shall be considered 'incurred' under the following circumstances:
- A claim for hospital benefits is incurred on the date the Employee or Covered Family Member enters a hospital;
- A claim for weekly accident and sickness benefits is incurred on the first date of disability if it is caused by an accident or on the fourth day of disability if it is brought about by illness;
- Any other claim for benefits is incurred on the date the service in question is rendered.
Any claim for benefits other than Death Benefits, Covered Family Member's Death Benefits, Survivor Monthly Death Benefits or Accidental Death or Dismemberment Benefits which is received by the Plan Office or Claims Administrator more than one (1) year after such claim is incurred will not be honored and will not be paid.
Amendments to Plan Document
AMENDMENT 2014 – 1 TO THE ITPEU HEALTH AND WELFARE PLAN DOCUMENT
Effective July 1, 2014, Section 2.05(a) of the ITPEU Health & Welfare Plan Document shall be amended to read as follows:
2.05 Loss of Eligibility.
(a) An Employee and his or her Covered Family Members’ eligibility for benefits shall terminate on the date such Employee leaves the employment of an Employer or the Board of Trustees terminates the Fund, whichever happens first. If an Employer’s contributions for an Employee are delinquent for a one month period, the eligibility of such Employee and his or her Covered Family Members for benefits for any claim incurred after a period of 40 or more days from the commencement of such delinquency shall be suspended until such time as the Employer is no longer delinquent for one or more months. During the period of suspension, all claims incurred by such Employee and his or her Covered Family Members shall be held in abeyance until such time as the delinquent contributions are paid. All such claims shall be promptly processed by the Fund as soon as the Employer is no longer delinquent for one or more months. No later than 10 days after the contributions were due, the Fund shall send written Notice to the Employees of the delinquent Employer, informing them that payment of their benefits, and the benefits of their covered family members, will be suspended in 30 days due to lack of payment by their Employer unless the Employer pays off the delinquency within that 30 day period. Such Notice shall state the actual date of such suspension. Copies of such Notice shall be sent to the Employer, and the applicable Contracting Officer and DOL Wage& Hour Area Director. In addition, a separate letter, with copies to the Employer and affected Employees, will be sent by the Fund to the applicable Contracting Officer and Wage & Hour Area Director, advising of the delinquency and resulting suspensions of benefits.
AMENDMENT 2013 - 2 TO THE ITPEU HEALTH & WELFARE PLAN
Effective January 1, 2013, the ITPEU Health & Welfare Plan shall be amended as follows:
1. A new section 9.05 shall be added which shall read as follows:
(a) Definition of Pre-Certification. Pre-Certification is the process used to obtain
authorization for a specific medical procedure before it is done, or to obtain authorization for admission to a hospital for medical treatment before such admission takes place.
(b) When Pre-Certification is Required. Pre-Certification is required for any in-patient
admission to a Hospital. In addition, Pre-Certification is required for certain out-patient medical services. A description of the out-patient services which require pre-certification under the Plan is set forth in the Appendix to the Summary Plan Description entitled "Out-Patient Services Requiring Pre-Certification". (To Be Supplied).
(c) Emergency Medical Treatment. If a Participant is admitted to a hospital on an
emergency basis, either the Participant or his or her authorized representative or physician must notify the Claims Administrator within two business days after the admission, or as soon as possible within a reasonable period of time, by calling the telephone number on his or her Medical Plan ID Card.
(d) Procedure for Obtaining Pre-Certification.
1. If the Healthcare Provider is a Network Healthcare Provider in the States of
California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, Ohio, Virginia and Wisconsin.
The Healthcare Provider is responsible for obtaining Pre-Certification.
2. If Services are Providede by a Network Provider in any Other State or by an
Out-of-Network Provider.
The Participant, or his or her authorized representative, are responsible to confirm that Pre-Certification has been obtained.
(e) Standard to be Applied. The Claims Administrator will not provide Pre-Certification for any
medical service that is either not a medical service covered by the Plan or is not deemed to be medically necessary.
(f) Consequence. If Pre-Certification is not obtained before the hospital admission (unless
emergency) or the out-patient medical service is provided, the Participant will be financially responsible for the cost of the hospitalization or medical service in question.
(g) Time Frames for Determination of Pre-Certification. A request for Pre-Certification
is considered "Urgent" when, in the opinion of the treating Healthcare Provider the failure to receive the requested care or treatment would seriously jeopardize the life or health of the Participant or his or her Covered Family Member, or the ability of the Participant or his or her Covered Family Member to regain maximum function, or subject the Participant or his or her Covered Family Member to severe pain that cannot be adequately managed without such care or treatment.
When the request for Pre-Certification is termed as "Urgent" the Claims Administrator shall respond within 72 hours from the receipt of the request. When the request for Pre-Certification is termed as non-urgent, the Claims Administrator will respond within 15 calendar days from the receipt of the request.
(h) Appeal from Denial of Pre-Certification. In the event the Claims Administrator denies
Pre-Certification for any hospitalization or out-patient service, the Participant shall have the right to appeal such a denial pursuant to the appeal procedures set forth at Section 18 of this Plan Document.
2. Section 9.03(c) shall be amended to add the following items under the Heading WOMEN'S HEALTH
CARE:
1. Women's Contraceptives, sterilization procedures, and counseling.
2. Breastfeeding support, supplies and counseling. Benefits for breast pumps are limited to one
pump per calendar year.
3. Gestational Diabetes Screening.
AMENDMENT 2013 - 1 TO THE ITPEU HEALTH & WELFARE PLAN
Effective January 1, 2013, Section 9.02(g) of the ITPEU Health & Welfare Plan shall be amended to read as follows:
"(g) Special Rule for Participants in Class III and IV Whose Contribution Rates are $3.75/Hour or Higher, and Participants in Class I and II Whose contribution Rates are $4.00/Hour or Higher. Notwithstanding any other provision of this Plan to the contrary, for eligible Participants in Class III and IV whose contribution rates are $3.75/hour or higher, and eligible Participants in Class I and II whose contribution rates are $4.00/hour or higher, a system of co-pays shall be in effect for In-Network physician visits and In-Office testing. For all In-Network office visits with Primary Care Physicians and all tests/diagnostic procedures performed in such physicians' offices, the Participant shall pay the amount of the co-pay specified in his or her Schedule of Benefits and the Plan shall pay 100% of the balance. The term "Primary Care Physician" means a general practitioner, internist, family practice physician or pediatrician. For all In-Network physician visits to specialists, and all tests/diagnostic procedures performed in such specialists' offices, the Participant shall pay the amount of the co-pay specified in his or her Schedule of Benefits and the Plan shall pay 100% of the balance. No deductible shall be applicable to such physicians' visits or In-Office testing."
AMENDMENT 2012 – 2 TO THE ITPEU HEALTH & WELFARE PLAN
Effective July 1, 2012, the ITPEU Health & Welfare Plan shall be amended as follows:
1. Section 9.03(b)(12) shall be deleted and the remaining numbered portions of Section 9.03(b) shall be renumbered accordingly.
2. Section 23.01 shall be amended by adding a new number 63 which shall read as follows:
“63. Treatment of a Mental Health Disorder”.
3. Section 9.03(c) shall be amended to read as follows:
“(c) Preventive Health Services
Effective July 1, 2012, the Plan will pay 100% of the cost of all “Preventive Health Services” required by the Affordable Care Act when such services are provided by Network Healthcare Providers. Such services include well-care baby visits, preventive care physical examinations for adults, screening tests for children and adults, and immunizations for children and adults. Set forth below is an overview of the types of preventive services which are covered. If you have questions as to whether a particular service is a “Preventive Health Service” required to be provided by the Plan without cost to you under the Affordable Care Act, please call the Claims Administrator at 1-877-331-4329.
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CHILD PREVENTIVE CARE (Birth to 18 years)
Preventive physical exams including well baby care
Age-appropriate screening tests including:
- Newborn screenings
- Vision screening
- Hearing screening
- Developmental and behavioral assessments
- Oral health assessment
- Screening for lead exposure
- Hemoglobin or hematocrit (blood count)
- Blood pressure
- Height, weight and body mass index (BMI)\
- Cholesterol and lipid level screening
- Screening for depression
- Screening and counseling for obesity
- Behavioral counseling to promote a healthy diet
- Screening for sexually transmitted infections
- Pelvic exam and Pap test, including screening for
cervical cancer
-urinalysis
-tuberculin tests
-blood tests including hematocrit, hemoglobin and screening for sickle hemoglobinopathy
Immunizations:
- Hepatitis A
- Hepatitis B
- Diphtheria, Tetanus, Pertussis
- Varicella (chicken pox)
- Influenza (flu)
- Pneumococcal (pneumonia)
- Human Papillomavirus (HPV)
- Haemophilus Influenza type b (Hib)
- Polio
- Measles, Mumps, Rubella (MMR)
- Meningococcal (meningitis)
- Rotavirus
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ADULT PREVENTIVE CARE (19 years and older)
Preventive physical exams
Age-appropriate screening tests including:
- Eye chart vision screening
- Hearing screening
- Cholesterol and lipid level screening
- Blood pressure
- Height, weight and BMI
- Screening for depression
- Diabetes screening
- Prostate cancer screening including digital rectal exam and PSA
test
- Breast cancer screening, including exam and mammography
- Pelvic exam and Pap test, including screening for cervical cancer
- Screening for sexually transmitted infections
- HIV screening
- Bone density test to screen for osteoporosis
- Colorectal cancer screening including fecal occult blood test, barium enema, flexible sigmoidoscopy, screening colonoscopy and CT colonography (as appropriate)
- Aortic aneurysm screening (men)
- Screenings during pregnancy (including but not limited to, hepatitis, asymptomatic bacteriuria, Rh incompatibility, syphilis, iron deficiency anemia, gonorrhea, chlamydia and HIV)
- Intervention services (includes counseling and
education):
° Screening and counseling for obesity
° Genetic counseling for women with a family history
of breast or ovarian cancer
° Behavioral counseling to promote a healthy diet
° Primary care intervention to promote breastfeeding
° Counseling related to aspirin use for the prevention
of cardiovascular disease (does not include coverage
for aspirin)
° Screening and behavioral counseling related to
tobacco use
° Screening and behavioral counseling related to
alcohol misuse
Immunizations:
- Hepatitis A
- Hepatitis B
- Diphtheria, Tetanus, Pertussis
- Varicella (chicken pox)
- Influenza (flu)
- Pneumococcal (pneumonia)
- Human Papillomavirus (HPV)
- Measles, Mumps, Rubella (MMR)
- Meningococcal (meningitis)
- Zoster (shingles)
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4. Section 9.03(b)(10) & (11) shall be deleted, since they are covered by the new Section 9.03(c).
5. Section 18, dealing with Claims Review and Appeal Procedures shall be amended in its entirety to read as follows:
“SECTION 18. CLAIMS REVIEW AND APPEAL PROCEDURES – CLAIMS FOR MEDICAL BENEFITS
18.01. Claims Administrator. Effective July 1, 2012 all claims for medical benefits and appeals from denials of such claims shall be handled exclusively by the Claims Administrator (Anthem). It shall be the responsibility of the Participant to give proper notice of any other medical coverage he or she may have when filing a claim with the Claims Administrator (Anthem) for medical benefits. All of the time limitations set forth below begin running from the time of receipt of the claim by the Claim Administrator (Anthem).
18.02. Claims Review Procedures. For purposes of these Claims Review Procedures, the term “claim for benefits” means a request for medical benefits under the Plan. The term includes both pre-service and post-service claims.
- Pre-service claim is a claim for benefits under the Plan for which you have not received the benefit or for which you may need to obtain approval in advance.
- A post-service claim is any other claim for benefits under the Plan for which you have received the service.
If your claim is denied:
- you will be provided with a written notice of the denial; and
- you are entitled to a full and fair review of the denial.
18.03. Notice of Adverse Benefit Determination. If your claim is denied, the Claims Administrator’s notice of the adverse benefit determination (denial) will include:
- information sufficient to identify the claim involved;
- the specific reason(s) for the denial;
- reference to the specific plan provision(s) on which the Claims administrator’sdetermination is based;
- a description of any additional material or information needed to perfect your claim;
- an explanation of why the additional material or information is needed;
- a description of the plan’s review procedures and the time limits that apply to them,
including a statement of your right to bring a civil action under ERISA if you appeal
and the claim denial is upheld;
- information about any internal rule, guideline, protocol, or other similar criterion relied upon in making the claim determination and about your right to request a copy of it free of charge, along with a discussion of the claims denial decision;
- information about the scientific or clinical judgment for any determination based on
medical necessity or experimental treatment, or about your right to request this
explanation free of charge, along with a discussion of the claims denial decision; and
- the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman who may assist you.
18.04. Urgent Care. A claim shall be considered to involve “urgent care” if it is a claim for medical care with respect to which the application of the time period for making non-urgent care determinations could:
(a) Seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant’s
medical condition, subject the claimant to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the claim.
For claims involving urgent care:
- the Claims Administrator’s notice will also include a description of the applicable urgent/concurrent review process; and
- the Claims Administrator may notify you or your authorized representative within 24 hours orally and then furnish a written notification.
18.05. Appeals.
(a) General Information Regarding Appeals. You have the right to appeal an adverse benefit determination (claim denial or rescission of coverage). You or your authorized representative must file your appeal within 180 calendar days after you are notified of the denial or rescission. You will have the opportunity to submit written comments, documents, records, and other information supporting your claim. The Claims Administrator's review of your claim will take into account all information you submit, regardless of whether it was submitted or considered in the initial benefit determination.
(b) Appeal of Urgent Care Claims. For pre-service claims involving urgent care, you may obtain an expedited appeal. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s decision, can be sent between the Claims Administrator and you by telephone, facsimile or other similar method. To file an appeal for a claim involving urgent/concurrent care, you or your authorized representative must contact the Claims Administrator at the telephone number shown on your identification card and provide at least the following information:
- the identity of the claimant;
- the date (s) of the medical service;
- the specific medical condition or symptom;
- the provider’s name;
- the service or supply for which approval of benefits was sought; and
- any reasons why the appeal should be processed on a more expedited basis.
(c) Appeals of Non-Urgent Care Claims. All other requests for appeals should be submitted in writing by the Participant or the Participant’s authorized representative. You or your authorized representative must submit a request for review to:
Anthem Blue Cross and Blue Shield, ATTN: Appeals, P.O. Box 105568, Atlanta, GA30348-5568
Upon request, the Claims Administrator will provide, without charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim. "Relevant " means that the document, record, or other information:
- was relied on in making the benefit determination; or
- was submitted, considered, or produced in the course of making the benefit determination; or
- demonstrates compliance with processes and safeguards to ensure that claim determinations are made in accordance with the terms of the plan, applied consistently for similarly-situated claimants; or
- was relied on in making the benefit determination; or
- was submitted, considered, or produced in the courese of making the benefit determination; or
- demonstrates compliance with processes and safeguards to ensure that claim determinations are made in accordance with the terms of the plan, applied consistently for similarly-situated claimants; or
-is a statement of the Plan's policy or guidance about the treatment or benefit relative to your diagnosis.
The Claims Administrator will also provide you, free of charge, with any new or additional evidence considered, relied upon, or generated in connection with your claim. In addition, before you receive an adverse benefit determination on review based on a new or additional rationale, the Claims Administrator will provide you, free of charge, with the rationale.
(d) How Your Appeal Will Be Decided. When the Claims Administrator considers your appeal, the Claims Administrator will not rely upon the initial benefit determination. The review will be conducted by an appropriate reviewer who did not make the initial determination and who does not work for the person who made the initial determination.
If the denial was based in whole or in part on a medical judgment, including whether the treatment is experimental, investigational, or not medically necessary, the reviewer will consult with a health care professional who has the appropriate training and experience in the medical field involved in making the judgment. This health care professional will not be one who was consulted in making an earlier determination or who works for one who was consulted in making an earlier determination.
(e) Notification of the Outcome of the Appeal.
i. If you appeal a claim involving urgent care, the Claims Administrator will notify you of the outcome of the appeal as soon as possible, but not later than 72 hours after receipt of your request for appeal.
ii. If you appeal any other pre-service claim, the Claims Administrator will notify you of the outcome of the appeal within 30 days after
receipt of your request for appeal.
iii. If you appeal a post-service claim, the Claims Administrator will notify you of the outcome of the appeal within 60 days after receipt of your request for appeal.
(f) Appeal Denial. If your appeal is denied, that denial will be considered an adverse benefit determination. The notification from the Claims Administrator (Anthem) will include all of the information set forth in the above section entitled “Notice of Adverse Benefit Determination.”
(g) External Review.
i. If the outcome of the mandatory first level appeal is adverse to you, you are eligible for an independent External Review pursuant to federal law. The term “external review” refers to your right to have the decision reviewed by independent health care professionals who have no association with the Claims Administrator. By voluntarily requesting an External Review you are agreeing to have your Protected Health Information reviewed by the independent health care professionals conducting such review.
ii. A request for External Review must be submitted by you or your
representative to the Claims Administrator (Anthem) within four (4) months of the notice of your final internal adverse determination. A request for an External Review must be in writing unless the Claims Administrator (Anthem) determines that it is not reasonable to require a written statement. You do not have to re-send the information that you submitted for the internal appeal. However, you are encouraged to submit any additional information that you think is important for review.
iii. For urgent care claims, you may proceed with an Expedited External Review without filing an internal appeal or while simultaneously pursuing an expedited appeal through our internal appeal process. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s (Anthem’s) decision, can be sent between the Claims Administrator (Anthem) and you by telephone, facsimile or other similar method. To proceed with an Expedited External Review, you or your authorized representative must contact the Claims Administrator at [the number shown on your identification card] and provide at least the following information:
· the identity of the claimant;
· The date (s) of the medical service;
· the specific medical condition or symptom;
· the provider’s name
· the service or supply for which approval of benefits was sought; and
· any reasons why the appeal should be processed on a more expedited basis.
iv. For non-urgent care claims, all other requests for External Review
should be submitted in writing unless the Claims Administrator (Anthem) determines that it is not reasonable to require a written statement. Such requests should be submitted by you or your authorized representative to:
Anthem Blue Cross and Blue Shield, ATTN: Appeals, P.O. Box 105668 Atlanta, GA 30348-5568
v. Request for External Review is Voluntary. In order to fulfill your appeal procedure obligations it is not necessary that you request External Review. Such a request is purely voluntary on your part. Your decision to seek External Review will not affect your rights to any other benefits under the Plan. There is no charge for you to initiate an independent External Review. The External Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA.
(h) Requirement to file an Appeal before filing a lawsuit. You must exhaust the Plan's Claims Review Procedure, not including any voluntary External Review, before filing a lawsuit or taking other legal action of any kind against the Plan. If your appeal results in an adverse benefit determination, you have a right to bring a civil action under Section 502(a) of ERISA. No lawsuit or legal action of any kind related to a benefit decision may be filed by you in a court of law or in any other forum, unless it is commenced within the time provided by the applicable Statute of Limitations. If the Claims Administrator decides an appeal is untimely, the Claims Administrator’s latest decision on the merits of the underlying claim or benefit request is the final decision date.”
7. A new Section 19 shall be inserted which shall read as set forth below, with all remaining sections of the Plan Document being renumbered accordingly:
“19. CLAIMS REVIEW AND APPEAL PROCEDURES – CLAIMS FOR ALL BENEFITS PROVIDED BY THE PLAN OTHER THAN MEDICAL BENEFITS
19.01. Time Table for Determining Claims. All of the time limitations set forth below begin running from the time of receipt of the claim by the Plan Office.
As used below, the word “process” refers to the time within which the Plan office shall determine whether a particular claim is payable.
19.02. Claims
To process a complete claim ……………………………………. 72 hours
To request additional information for an incomplete claim ….. 24 hours
Claimant’s response time if additional information
requested ………………………………………………………… 48 hours
To process a claim if complete information received …………. 48 hours
19.03. Denial of Claims. If the claim is denied, the Plan Office will provide the affected Employee, Covered Family Member or their representative with the following
information:
1. The specific reason for the determination;
2. Reference to the specific claims provisions on which the determination is based;
3. A description of any additional material or information necessary for you to provide to the Plan and an explanation of why the information is necessary (if applicable);
4. A description of the Plan’s Claim Review Procedures and Time Limits to appeal a denial, including a statement of your right to bring a civil action under Section 502 (a) of ERISA following an adverse benefit determination on review; and
5. A statement of any specific internal rule, guideline, protocol or other matter that was relied upon in making the benefit denial.
19.04. Request For Review of Denial of Claims. Within one hundred and
eighty (180) days after you receive written notice that your claim has been denied, you or your representative may make a written request for a review. Your request for review must be received by the Plan within one hundred and eighty (180) days after you receive notice that your claim has been denied. Your written request for review should contain your Social Security Number and a statement of the reasons why you believe the denial of your claim was in error.
19.05. Procedure To Be Followed In Reviewing Denial of Claims. Requests
for review of denied claims will be considered and decided by a Committee designated by the Board of Trustees. Such Committee shall not include any person who participated in the initial determination to deny the claim or who is a subordinate of any individual who participated in the initial determination.
19.06. Time Table For Decision On Review Of A Denied Claim. Written or
electronic notice of the Committee’s determination on review of a claim must be transmitted to the claimant within sixty (60) days after receipt of the written request for
review.
19.07. Contents Of Determination On Appeal. If a request for review is denied, the notice of the Committee’s determination must set forth:
1. The specific reason or reasons for the adverse determination;
2. Reference to the specific claims provision on which the determination is based;
3. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the claimant’s claim for benefits;
4. A statement of any specific internal rule, guideline, protocol or other similar criteria that was relied upon in making the adverse determination;
5. A statement of the claimant’s right to bring a civil action under Section 502 (a) of ERISA;
6. The following statement:
“You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your State Insurance Regulatory Agency.”
AMENDMENT 2012 – 1 TO THE ITPEU HEALTH & WELFARE PLAN
Effective June 1, 2011, Section 17 of the ITPEU Health & Welfare Plan shall be amended to read as follows:
"SECTION 17. TIME LIMIT FOR FILING CLAIMS
17.01 – Except as set forth in Section 17.02 hereof, all claims for benefits provided by this Plan must be submitted within 1 year from the day the claim is “incurred”. Any claim received by the Plan Office or Claims Administrator more than one (1) year after the claim is incurred will not be honored and will not be paid.
17.02 – All claims for Death Benefits, Non-Occupational Accidental Death and Dismemberment, or Survivor Death Benefits under Sections 5, 6 and 7 hereof, must be submitted within three (3) years from the date of the death or dismemberment in question. Any such claim received by the Plan Office more than three (3) years after the date of death or dismemberment will not be honored and will not be paid."
AMENDMENT 2011-1 TO THE ITPEU HEALTH & WELFARE PLAN
Effective January 1, 2012, the ITPEU Health and Welfare Plan shall be amended as follows:
1. The amount of the Copay for Specialist Physicians in all Schedules of Benefits for contribution rates of $3.24/hr. and higher shall be increased from $35.00 to $40.00;
2. The amount of the Calendar Year Deductible in all Schedules of Benefits shall be increased as follows:
a. From $200.00 to $240.00 for contribution rates of $3.24/hr. and higher;
b. From $250.00 to $300.00 for contribution rates from $3.01/hr. to $3.23/hr.; and
c. From $300.00 to $360.00 for contribution rates from $2.16/hr. to $3.00/hr.
3. The amount of the Fund Maximum Payment Per Calendar Year for all Schedules of Benefits shall be increased from $750,000.00 to $1,250,000.00.
Upon request, the Claims Administrator will provide, without charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim. "Relevant" means that the document, record or other information:
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Was relied on in making the benefit determination; or
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Was submitted, considered, or produced in the course of making the benefit determination; or
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Demonstrates compliance with processes and safeguards to ensure that claim determinations are made in accordance with the terms of the plan, applied consistently for similarly-situated claimants; or
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Is a statement of the Plan's policy or guidance about the treatment or benefit relative to your diagnosis.
The Claims Administrator will also provide you, free of charge, with any new or additional evidence considered, relied upon, or generated in connection with your claim. In addition, before you receive an adverse benefit determination on review based on a new or additional rationale, the Claims Administrator will provide you, free of charge, with the rationale.
How Your Appeal will be Decided
When the Claims Administrator considers your appeal, the Claims Administrator will not rely upon the initial benefit determination. The review will be conducted by an appropriate reviewer who did not make the initial determination and who does not work for the person who made the initial determination.