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Health FAQ

• When and how do I become eligible for coverage?
  You become eligible for coverage the first day of the third month following two consecutive months in which you fulfilled the initial eligibility hours requirement.  For Shop Employees, this is 250 hours reported and paid into your reserve account.  For Installers, this is 170 hours reported and paid into your reserve account.  Eligibility is determined using an advanced eligibility system. For example, if you worked the initial eligibility hours required in March and April, and these hours were reported and paid for by your employer in April and May, your eligibility would begin in July.
   
• Once I am eligible, how long will I be covered?
  You will be covered so long as the hours reported and paid in by your employer each month total at least 125 if you are a Shop Employee and 85 if you are an Installer. As an example of how advanced eligibility system operates, hours worked in May would be reported and paid in June; these hours would provide your coverage in August.
   
• How does my reserve account work?
  Hours are reported and paid in by your employer following the month in which they were worked. As stated above, you need to work a minimum of 125 hours in the work month as a Shop Employee, and a minimum 85 hours in a work month as an Installer, to be eligible in the coverage month. The coverage month begins the first of the second month following the income month. Any hours in excess of the monthly requirement are placed into your reserve account. If, in a month, you have fewer than the minimum required hours reported, you can use any hours in your reserve account to make up the difference.
   
• Is there a limit to the number of hours that I can have in my reserve account?
  Yes. For Shop Employees, the maximum number of hours that you can have in your reserve account is 500.  For Installers, the maximum number is 340.
   
• What are my coverage plan options?
  For medical coverage, you have a choice between two plans: a self-funded PPO plan or the Kaiser HMO. The dental plan is also self-funded, and vision benefits are provided through Vision Service Plan.
   
• What is a PPO plan?
  With a PPO plan, you can select and visit any medical provider. Your out-of-pocket costs will be lower if you visit a PPO provider. These are providers who are contracted with the Anthem Blue Cross Prudent Buyer Network.
   
• Which plan is better?
  Both plans are excellent. You should carefully study the comparisons to determine which plan would suit you and your family best. The PPO plan allows you to visit providers of your choice. The Kaiser Plan requires all services to be obtained at Kaiser facilities with Kaiser’s practitioners. 
   
• Does my plan have chiropractic/specialist coverage?
  Yes. Please refer to your Summary Plan Description for details.
   
• How do I enroll in my chosen plans?
  To ensure that you and your dependents are covered in the Sign plan, you must complete the Enrollment Form that is sent to you by Allied Administrators when you first become eligible for coverage. If you wish to enroll in Kaiser, contact Allied. We will send you an application which must also be completed in order to enroll in Kaiser.
   
• How do I add or delete dependents on my health plans?
  You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to Allied Administrators. Please read the form carefully, as you are required to submit the appropriate documentation, i.e., birth or marriage certificate, divorce decree, etc. If you prefer, you can also contact Allied directly for this form. If you are enrolled in Kaiser and wish to add or delete a dependent, you must also complete the appropriate form from Kaiser. 
   
• My child has reached the limiting age, but he is completely dependent on me for support due to a physical limitation. Is there a way I can extend his coverage?
  Yes. If you have a dependent child with a mental or physical limitation, you can continue his coverage provided that the following requirements are met: your child is completely dependent on you for support; your child is not capable of self-sustaining employment; and you give us proof of the child’s handicap: (1) not later than 31 days after the child attains the limiting age; and (2) thereafter as the Trustees may require, but not more than once every two years, by completing a Request for Continued Coverage for Incapacitated Child form.
   
• How/when can I change plans?
  The Plan conducts an annual open enrollment. During this open enrollment period, you will have the opportunity to change your medical plan, if you wish. You will be notified by Allied Administrators when the open enrollment period begins.
   
• How do I file a claim for reimbursement?
  You’ll need to fill out a Claim Form. Be sure to complete all sections and attach appropriate documentation. Then, submit the form to Allied Administrators for reimbursement. You can also contact Allied directly for a claims form.
   
• Is it possible for my physician to submit claims to Allied Administrators electronically?
  Yes! If your physician’s office is set up for electronic filing, simply provide Allied’s EDI number: 94177. That’s all the information they’ll need to file claims electronically.
   
• How will I know if a claim has been paid?
  Allied will send you an Explanation of Benefits (EOB) statement whenever a claim has been paid on your behalf. If you utilize PPO providers, Allied will send payment directly to the PPO provider and a copy of the EOB to you that shows all the charge and payment information regarding the claim.
   
• Can you explain how I should read the EOB?
  A sample EOB can be found here. Reading from left to right, top to bottom, the first section displays the health plan name, your masked identification number, and the number assigned to the claim.
  
  Next, you’ll see the employee’s name, the patient’s name, the claims examiner, group number and date the claim was processed.
  
  The next section covers the date(s) of treatment, the three-letter service code and the five-digit Current Procedure Terminology (CPT) code used by the billing provider of service. It also shows how the claim was adjudicated. In our sample EOB, there were two procedures (treatments) on the same day. The Charge Amount column shows what the provider has billed for these procedures. The next column shows if any charges were not covered. In this example, there were charges not covered, and the two-digit reason code is shown next. The PPO Discount is then applied, and the column after that shows the Covered Amount (Charge Amount – Not Covered – PPO Discount). The deductible and any co-pays are then applied. In this example, the calendar year deductible has already been met, and there are no co-pays. The next column in the EOB shows the percentage that the Plan pays. Because this was a PPO provider, the percentage is 90%. Finally, there is the Payment Amount, the amount that will be paid to the provider.
  
  Immediately under this section, is an area containing the patient account number from the doctor’s office (if it is available) and any adjustments or credits made in the event there is other coverage.
  
  The next item is the Patient’s Responsibility section. It is the combination of Amount not Covered, Co-Pay Amount, Deductible and Co-Insurance. This would be the amount that you would have to pay your provider.
  
  The Payment Information box shows who the plan payment was sent to, the date it was sent, check number and amount paid.
  
  The Service Code box defines the three-letter code used on the lines above.  The Reason Code box provides an explanation of the two-digit code for why charges were not covered.  Finally, the Messages box shows which PPO network was utilized, if any, and your appeal rights.
   
• Can my provider bill me for the PPO discount?
  If you visit a provider who is contracted with the PPO, the provider cannot bill you for anymore than the amount shown under Patient’s Responsibility on the EOB. Billing for any amount greater than that is known as “balance billing,” and this practice is prohibited by California state law.
   
• I need to see a Doctor, but I don't know who to go to. Do you have a list of doctors near where I live or work?
  Absolutely.  If you are in the PPO plan, you can get a list of providers close to you at the Anthem Blue Cross Prudent Buyer website. Kaiser participants can obtain information on providers at www.kaiserpermanente.org.  
   
• I need to fill my prescriptions – what pharmacy can I use?
  If you are in the self-funded PPO, you can use any of the hundreds of pharmacies that are contracted with Express Scripts, the PPO plan’s pharmacy benefits manager. Visit their website at www.express-scripts.com for a listing of pharmacies in your area. Kaiser participants must have their prescriptions filled at Kaiser pharmacies. 
   
• I tried to pick up my prescription but the pharmacy told me that I need “prior authorization.” What should I do?
  Certain prescriptions require prior authorization from the health plan in which you are enrolled. If you are covered by the self-funded Plan with Express Scripts, your pharmacist will let you know if a prescription needs prior authorization. Most pharmacies will work directly with Express Scripts and your doctor’s office. If this is not the case, your physician‘s office should get in touch with the help desk at Express Scripts (1-877-256-4679) or contact Allied Administrators.
   
• Do I need an ID card for medical and dental?
  If you are in the self-funded PPO plan and visit a provider who is in the Anthem Blue Cross Prudent Buyer Network, you do need to bring your Anthem Blue Cross PPO card to your medical appointment. Kaiser participants have ID’s that are issued directly by Kaiser. These must be used for all medical appointments. There are no ID cards for dental benefits, simply provide your dental office with Allied’s phone number, (415) 986-6276, to verify your eligibility and benefits.
   
• Does the dental plan have a PPO? 
  No. You can visit any dentist you wish.
   
• Is there a claim form specifically for dental claims?
  There is a Dental Claim Form, which you can bring with you to your dental appointment.  Your dentist can also utilize electronic filing.  Simply give your dentist's office Allied's EDI number:  94177.
   
• I went to my doctor’s appointment today, but I was told that my coverage is terminated. I've been working steadily. Am I covered for the visit?
  If there’s ever a question regarding your eligibility, contact Allied Administrators. We’re here to help you sort it out.
   
• I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?
  You received this notice because you had a COBRA Qualifying Event. The most common reason for this is the combination of current hours worked and the hours in your reserve account was less than 125 hours if you are a Shop Employee, or less than 85 hours if you are an Installer. Other COBRA Qualifying Events include a dependent child's reaching the maximum age limit, divorce, or death of the participant. In each of these instances, you will have lost eligibility. If you wish to sign up for COBRA coverage, you must return the application to Allied Administrators within 60 days of the date of your Qualifying Event.
   
• What is the self-pay coverage option I’ve been hearing about?
  If the combination of current hours and hours in your reserve account do not satisfy the monthly eligibility requirement, you may be eligible to make a self-payment to maintain your coverage.  The self-payment amount required is a flat amount set from time to time by the Board of Trustees.  You must work a certain number of hours in order to be eligible for self-pay coverage.  If you are a Shop Employee you must work a minimum of 90 hours in a month.  For Installers, you must work a minimum of 60 hours in a month.  Self-payments must be made by the 20th of the month prior to the coverage month. For example, Allied must receive your self-payment in June to allow your coverage in July. You can check your hours on this site to determine if you would need to make a self-payment to continue coverage. So, for this example, the work month is April, and your hours would be reported in May. At the beginning of June, you’d be able to determine if you had enough hours for coverage in July. If you don’t have enough hours but did work the minimum hours in April to qualify for this benefit. you would print the Self-Payment Remittance Form and return it with your payment by June 20th.
   
• I'm on disability/worker's comp or FMLA. How do I continue my coverage?
  The Trust offers disability coverage at no cost to the member for a specified duration. You should contact Allied Administrators for more information. When your period of disability coverage has ended, you can elect to take COBRA coverage. FMLA coverage is through your employer only, and you must contact your employer to determine what steps you need to take.
   

COBRA Subsidy FAQ - UPDATED

• I’ve been hearing about this COBRA subsidy. What is it and how do I get it?
  There was a provision in the American Recovery and Reinvestment Act of 2009, which President Obama signed into law on February 17, 2009, that provides subsidized coverage for “Assistance Eligible Individuals” for up to nine months. This period of subsidized COBRA coverage has been extended through Section 1010 of the Department of Defense Appropriations Act, 2010, which President Obama signed on December 21, 2009. This Act included a provision to extend eligibility for the subsidy to February 28, 2010, and to extend the period of subsidized coverage by six months, up to a maximum of 15 months.  The eligibility period was extended to involuntary terminations before May 31, 2010.  As of June 1, 2010, the eligibility period expired, and no new legislation has been enacted to extend it.  The subsidy is 65% of the COBRA premium, and for purposes of this Trust, the first period of subsidized coverage began March 1, 2009. An Assistance Eligible Individual is someone who had an involuntary termination between September 1, 2008 and May 31, 2010.  We can determine if you qualify as an “Assistance Eligible Individual” only if you submit a Request for Treatment as an Assistance Eligible Individual application. In some instances, we may have to verify with your last employer that your separation from employment was involuntary.
   
• What does “involuntary termination” mean?
  Involuntary termination is generally any action taken by an employer that causes the loss of employment and health coverage for the employee. Involuntary termination includes lay-offs and furloughs, and employer-initiated termination during a period of disability or FMLA coverage. An involuntary termination also includes an employee’s separating from employment in response to an action taken by the employer, such as any employer incentives to resign, the employer’s reducing the employee’s hours to a level that the employee cannot afford, or the employer moving the geographic location of the work. An involuntary termination does not include a reduction in hours when the employee is still working. An involuntary termination does not include any employer-initiated termination for “gross misconduct.”
   
• I received notice that my COBRA subsidy period ended November 30, 2009. I could not afford the full cost of COBRA coverage and did not make a payment for December. Now that the subsidy has been extended, can I re-gain my COBRA coverage?
  Yes. Your COBRA coverage will be reinstated effective December 1, 2009, as soon as you make your subsidized COBRA payment for December. You will be eligible for an additional six months of subsidized coverage until May 31, 2010, as long as you are still in your COBRA coverage period and make monthly payments.
   
• I paid the full cost of my COBRA coverage for December 2009. Now that the subsidy has been extended, what can I do?
  If you paid the full cost of COBRA coverage for December 2009 and had been an Assistance Eligible Individual, you may receive a refund of the subsidized portion of the premium or have the amount you overpaid credited to the cost of future COBRA coverage. Contact the Administration Office for more information.
   
• I will be losing my job in May 2010, but I will still have coverage through June 30, 2010. Will I be eligible for the subsidy in July?
  If your involuntary termination occurred during the period September 1, 2008 through the extension of May 31, 2010, you may be eligible for the subsidy even if your loss of coverage occurs after this extended eligibility period ends.
   
• Will the subsidy be payable to me?
  No. The subsidy is reflected in the fact that you’ll pay 35% of your COBRA premium if you qualify for the subsidy.
   
• My child recently had a COBRA qualifying event because she reached the limiting age. Will she be eligible for the subsidy?
  No, she does not qualify for the subsidy because she does not qualify as an Assistance Eligible Individual.
   
• What if I am denied eligibility for the subsidy, but I think I should be eligible?
  If it is determined that you do not meet the definition of an “Assistance Eligible Individual,” you can make an appeal to the U.S. Department of Labor only. Your appeal must be submitted on a U.S. Department of Labor application form, which is available on their website: www.dol.gov/COBRA. If you believe you have been inappropriately denied eligibility for the premium reduction, you may wish to speak with an Employee Benefits Security Administration Benefits Advisor at 1.866.444.3272 before filing an appeal with them.
   
• Why can’t I appeal to the Board of Trustees?
  The Board has no jurisdiction over appeals for qualification as an “Assistance Eligible Individual.” The U.S. Department of Labor is the only entity with this jurisdiction.