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                              HEALTH AND WELFARE FUND

 Frequently Asked Questions 

1.  I am an apprentice and will be a new participant in the Northern Illinois Benefit Fund.  When will I be eligible?
2. What is my Deductible?
3. Does my medical treatment require Pre-Certification?
4. What is Pre-Certification and who is Med-Care Management?
5. Do I need a second opinion before I have any procedure performed?
6. What is the Chiropractic Care Benefit?
7. What do I do when I get married, get divorced, have a baby or adopt a child?
8. When I visit a Blue Cross Blue Shield of Illinois PPO provider,  do I pay my co-pay to the provider at the time of my visit?
9. Do I pay a Blue Cross Blue Shield of Illinois PPO provider for the service when I receive them?
10. Do I send my co-pay and yearly deductible to the Fund office? 
11. Can I make my COBRA payments late and can I make up a payment that I have missed?
12. How do I know when I have to make a self-payment due to lack of credited hours?
13. When are self-payments due in the Fund Office?  What happens if my self-payment for coverage is late?
14. I am a retiree making self-payments. When are my payments due in the Fund Office?  Can my payments be late?
15. My child is over 19 and is attending college. What do I need to provide the Fund Office to continue his/her coverage? When do I submit this information to the Fund Office?
16. How do I get routine vision care benefits?
17. How do I get Dental and Orthodontia Benefits?
18. How do I get Prescription Benefits?
19. When I am out of work, am I entitled to any Loss of Time Benefits?
20. If I get sick or get hurt, not related to work, can I go to any doctor or hospital?
21. Can I add my spouse to my Health Plan at a later date?
22. Since the State of Illinois requires my children to have routine school physicals and immunizations, why doesn't my Health & Welfare coverage pay all of the charges?
23. Are immunizations administered by the County Health Department covered for benefits under the Routine Physical Examination Benefit?
24. Should I keep a photocopy of information that I submit to the Fund Office?
25. What should I do if I am required to have an MRI, CT Scan or Mammogram?
26. Where can I get copies of my marriage license or birth certificates?

1.)    I am an apprentice and will be a new participant in the Northern Illinois Benefit Fund.  When will I be eligible?

If you are a first-year apprentice, or a 501 member reinstating lost eligibility for benefits, you will be eligible the first day of the second calendar month after you have 300 credited hours.  Beginning with credited hours earned on or after January 1, 2004, the new rule will accelerate the initial eligibility process for many employees.  For example, if Fred has 150 hours in March and 150 hours in April, he will become eligible June 1.  Coverage would have started July 1 under the old rule.

Once a person earns initial eligibility, he will remain eligible through the end of the benefit quarter in which his initial eligibility date falls.  (Benefit quarters end on March 31, June 30, September 30, and December 31.)  In the above example, since Fred became eligible on June 1, he will remain eligible through June 30, the end of that benefit quarter.  If Fred had become initially eligible on May 1 instead, he would still have remained eligible through June 30.  In either case, he will continue to be eligible in July-August-September if he has 500 credited hours in March-April-May.

The 300 hours needed for initial eligibility must be worked within 3 consecutive months. 

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2.)    What is my Deductible?

        Calendar Year Deductibles:

a.)     PPO deductibles ( amounts of covered medical expenses applied to   PPO deductibles also apply to  the non-PPO deductibles and vice versa):

               Individual Deductible........................ $200.00

               Family Deductible ............................ $600.00

                (satisfied by 3 or more family members)

       b.)    Non PPO deductibles

                Individual Deductible  .................... $300.00

              Family Deductible ..........................  $900.00

              (satisfied by 3 or more family members)

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3.)    Does my medical treatment require Pre-Certification?

Yes, the Plan does require pre-certification.

4.)    What is Pre-Certification and who is Med-Care Management?

Pre-certification means that any hospital confinement, surgical procedure, mental/nervous or chemical dependency treatment must be reviewed, so that both you and the Fund can be sure that you are receiving the most appropriate treatment for your condition.  Med-Care Management is the provider that the Fund uses for pre-certification.  They can also assist you if you need special services such as nursing care, or rental or purchase of durable medical equipment.  Their number is 1-800-367-1934.  If you are on Medicare, you do not need pre-authorization through Med-Care Management.

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5.)    Do I need a second opinion before I have any procedure performed?

The Plan does not require a second opinion, however, you must call Med-Care Management for pre-certification on all in-patient and out-patient hospitalizations, all surgical procedures, mental/nervous services or chemical dependency services.

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6.)    What is the Chiropractic Care Benefit?

The Plan pays 100% (no deductible applies) of covered expenses you or an eligible dependent incur for chiropractic treatment up to a maximum benefit of $35.00 per visit, subject to a calendar year maximum  benefit of $750.00. The Plan also pays 100% of the covered expenses incurred for diagnostic x-rays up to a maximum benefit of $100.00 per calendar year, which applies to the $750.00 overall maximum benefit for chiropractic  treatment.  (Benefits paid for chiropractic care during a year will also apply to a person's Comprehensive Benefit lifetime maximum benefit.) 

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7.)    What do I do when I get married, get divorced, have a baby or adopt a child?

Please contact the Fund office as soon as possible if any of the above events take place. Your membership file needs to be updated to add or remove your dependent.  If you are adding a dependent, you will be supplied with a new Participant Data Form that needs to be fully completed and returned to the Fund office along with a copy of the marriage certificate, the divorce decree or adoption papers (whichever one applies to your situation).  If you are newly married, have a baby or adopt a child, we also require a certified state copy of their birth certificate and a copy of their social security cards. 

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8.)   When I visit a Blue Cross Blue Shield of Illinois PPO provider,  do I pay my co-insurance to the provider at the time of my visit?

No, do not pay your co-pay to the provider's office at the time of your visit.  You are entitled to Blue Cross Blue Shield of Illinois discounts on the services provided.  The provider is unable to determine the discounted amount until the claim has been processed for payment; therefore, your provider is unable to determine the actual co-insurance that is owed.  Your 20% co-insurance is based on  the discounted amount not on the actual charge.  If you pay 20% co-insurance on the fees charged at the time services are provided, once Blue Cross Blue Shield of Illinois has discounted the charge, your co-insurance would be less than the amount you paid at the time of treatment and your account with the physician's office will be overpaid.

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9.)    Do I pay a Blue Cross Blue Shield of Illinois PPO provider for the service when I receive them?

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10.)    Do I send my co-pay and yearly deductible to the Fund office?       

        No, please do not send your checks for the co-insurance or your yearly cash deductible to NORTHERN ILLINOIS BENEFIT FUND.  The co-insurance and deductible amounts should be paid directly to the provider of service. This amount is indicated on the explanation of benefits (EOB) that you receive from the Fund office.  The EOB also includes the name of the provider and the date of service so that it will be easier for you to identify the individual  to whom you should send your deductible amount and the co-insurance. 

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11.)   Can I make my COBRA payments late and can I make up a payment that I have missed?

As of October 1, 2000, the Fund Office will no longer be able to accept late COBRA continuation coverage Payments.

Your Summary Plan Description states:

• A person electing COBRA continuation coverage has 45 days after the signed  
  election form is returned to the Fund Office to make the initial payment.
  However, if a person waits 45 days to make the initial payment, one or more monthly payments may also fall due within that period and must be paid at that time for continuation of coverage.
• All subsequent monthly COBRA self-payments are due on the first day of the month for which payment is being made.  A payment will be considered on time if it is received within 30 days of the date due.

• If a COBRA self-payment is not made within the time allowed, COBRA coverage for all affected family members will terminate.  You may not make up the payment or reinstate coverage by making future payments.

The Fund Office recommends in order to continuously keep your COBRA Coverage in effect without a lapse in benefits that you mail your COBRA self-payments along with the coupon that has been provided by the Fund Office, to the Fund Office no later than the 15th of the month prior to the month for which payment is being made.  For example: mail your August 2004 COBRA self-payment and coupon to the Fund Office on July 15, 2004.  This will ensure that the payment is received and credited prior to the first of the month, therefore, eliminating a lapse in coverage.

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12.)   How do I know when I have to make a self-payment due to lack of credited hours?

If you lack credited hours during the eligibility quarter, the Fund Office will send a self-payment notice to you at your last known address, telling you how much your regular self-payment will be and when it is due.

While the Fund Office will attempt to notify you when a regular self-payment is due, it is your responsibility to keep track of the credited hours and make any required Regular Self-payments on time whether or not you receive a notice from the Fund Office.

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13.)   When are self-payments due in the Fund Office?  What happens if my self-payment for coverage is late?

The properly completed self-payment form, whether due to total disability or due to lack of hours, along with your Regular self-payment must be received by the Fund Office on or before the first day of the month of the first month of the benefit quarter for which you are paying.  Effective July 1, 2001 you can take the form and the Regular Self-payment to the Fund Office or you can mail them to the Lock Box.  However, failure of the U. S. Postal Service to deliver your payment to the Fund Office on time will not extend the due date; so if you mail your payment, be sure to give it sufficient time in which to be delivered. As of October 1, 2000, the Fund Office will no longer be able to accept late self-payments. If payments are not received by the Fund Office as indicated above, your coverage and your family's coverage will terminate.

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14.)   I am a retiree making self-payments. When are my payments due in the Fund Office?  Can my payments be late?

You must make your first self-payment on or before the due date on which a self-payment to maintain continuous coverage is due.  There must be no lapse in coverage between active employee coverage and the Retiree Benefits coverage.

Effective July 1, 2001, we will be using a lock box for Retiree Self-Payments.  You can make your self-payments in person at the Fund Office or you can mail your self-payments to the Lock Box.  Each payment must be personally delivered or post-marked no later than the first of the month for which you are paying in order to be accepted by the Fund Office.  For example, to be covered for benefits during October, your self- payment must be delivered or post- marked no later than October 1.

If you fail to make a self-payment on or before the date it is due, your eligibility for Retiree Benefits will terminate at the end of the last month for which you have already paid.  You will not be allowed to make any future self-payments.

As of October 1, 2000, the Fund Office will no longer be able to accept late payments for your retiree coverage.

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15.)  My child is over 19 and is attending college. What do I need to provide the Fund Office to continue his/her coverage? When do I submit this information to the Fund Office?

Your Plan through Northern Illinois Benefit Fund provides coverage for a dependent who is age 19 or less than age 24, provided he/she is a registered student in an accredited secondary school, college or university or vocational, technical or trade school, enrolled for a minimum of the credit hours required to meet the school's criteria for "full-time" status, and  is dependent on you for more than 50% of his/her support and maintenance (proof of dependency and/or full -time student status for each school term may be required before such child will be considered a covered dependent.)

Change in Definition of Dependent-Effective for coverage on and after September 1, 2007 the Plan will cover unmarried children who are full-time students age 19 or older ONLY when the child:

1.      Is age 19 but less than age 24 at the end of the current calendar year; and

2.      Is a registered, full-time student in an accredited secondary school, college or university, or at a vocational, technical, vocational/technical, or trade school or institute; and

3.      Is dependent upon you (the participant) for the major portion of his support and maintenance; and

4.      otherwise meets the Plan’s definition of dependent.

A child who meets all the requirements above except that he will be age 24 or age 25 at the end of the current calendar year can make self-payments for continued coverage under the new Self-Pay Program for Older Students (described below), OR the child can elect and make self-payments for COBRA coverage.

If the child elects COBRA coverage, he is waiving his right to make student self-pays.  Likewise, a child who makes student self-pays is waiving his right to COBRA coverage.

Self-Pay Program for Older Students - An unmarried child who loses eligible dependent status because of exceeding the age limit (24 at the end of the calendar year) may continue his coverage under the Self-Pay Program for Older Students provided he meets the applicable requirements specified below:

1.   He must satisfy all of the requirements for being an eligible dependent other than the maximum age requirement; and

2.   At the beginning of any month for which coverage is provided, he must not be older than age 25.

The amount of the monthly self-payment is currently $50.  This amount is determined by the Trustees and may be changed at any time.

The benefits provided under this program are the same benefits provided to eligible dependents under age 24 at the end of the calendar year. 

Coverage will terminate: 1) at the end of the month during which the child reaches age 25 or otherwise fails to satisfy the requirements for continued eligibility, or 2) at the end of the month for which the last correct and timely self-payment was made. 

The Fund does require proof that the dependent child is enrolled in and attending classes.  The best way to provide this proof to the Fund Office is to submit a copy of your child's class schedule at the beginning of each semester.  Once this is received, your child's file will be updated to reflect that he/she is attending school as a full-time student. At the end of the semester, please forward a copy of your child's grades to the Fund Office.  This is verification that your child maintained his/her status as a full-time student.  If your child is a continuing student, submit a copy of the pre-registration for the next semester at the same time as the current grade report and all files will be updated accordingly.

Please remember that if your child  "drops" classes in the middle of the semester and the remaining total of classes do not meet the "full-time" student criteria, coverage will terminate on the date that the classes are dropped.  If this happens, please notify the Fund Office immediately in order that a COBRA election notice may be sent to you.

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16.)  How do I get routine vision care benefits?

Please refer to page 75 of your Benefit Fund Summary Plan Description for an overview of the Vision Service Plan. Consult the VSP pamphlet that is contained in the inside cover of your Summary Plan Description for a listing of VSP providers in your area.

When you use one of the participating VSP optometrists, you must tell them you have benefits with the Vision Service Plan. They will obtain all authorization for you without any forms to complete.

If you see a non-VSP provider such as Lenscrafters or Sears, then you will need to pay the provider of service in full and obtain a paid receipt and an itemized bill.  Please send the receipt and the itemized bill along with the member's social security number to: Vision Service Plan, P. O. Box 997100, Sacramento, CA 95899-0001

If you need any additional information, please phone 1-800-877-7195 or you can also check www.vsp.com on the Web.  VSP will reimburse you for applicable out-of-network benefits. You must file these claims with VSP within 6 months of the service date or VSP will not consider the claim.  Refer to Page 8 of your Summary Plan Description.  The Fund Office cannot process any routine vision claims.

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17.)  How do I get Dental and Orthodontia Benefits?

Please refer to Pages 59-64 of your Benefit Fund Summary Plan Description for an explanation of your Dental and Orthodontia Expense Benefit.  An organization called Delta USA administers your Dental and Orthodontia Expense Benefit and pays all dental and orthodontia benefits on behalf of the Fund.  Delta administers three types of dental programs.  The benefits and your out-of- pocket costs will vary depending on whether your dentist is a member of one or two dental provider networks or if he is not a member of either network.

You do not have to sign up with any of the three dental programs; simply make an appointment with whatever dentist you choose. You can use one program for some of your dental care and a different program for the rest of your dental care.  You may switch from one program to another at any time.  Some family members can use one program and others use a different program. The three programs are:

1.    Delta Preferred Dentist--If you use a Delta Preferred dentist, benefits will be payable according to the Delta Preferred Network Schedule on the schedule of Dental Benefits. Please refer to Page 17 of your Summary Plan Description for an outline of these Benefits.  Delta Preferred dentists' fees are discounted so the amount you pay as your co-pay percentage share of the covered dental expenses will be lower.

2.    Delta Premier Dentist:  If you use a Delta Premier dentist, benefits will be payable according to the Delta Premier Network Schedule as outlined on the Schedule of Dental Benefits on Page 17 of your Summary Plan Description.  Delta Premier dentists have agreed to base their fees on Delta Dental's usual and customary fees.  You are not responsible for charges exceeding Delta's usual and customary fee schedule.

To find out if a dentist is in the Delta Preferred or Delta Premier network:

• Call Delta's customer service department (1-800-452-1987)
• Visit Delta's web site at  www.deltadentalil.com
• Simply ask the dentist if he/she is a member of the Delta Preferred or Delta Premier Networks.

To alert your dentist to send his bill to Delta, and to identify yourself as a participant in this program, be sure to present your Delta I. D. cards when you receive dental services.

As a reminder, it is no longer necessary for your Dental claims to be submitted to the Fund Office. Please have all dental claims submitted to: Delta Dental Plan of Illinois P. O. Box  5402 Lisle, IL  60532

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18.)  How do I get Prescription Benefits?

Your prescription drug plan is offered through the Prescription Service Division of Caremark, Inc.

There are two components to your prescription drug program:

• Retail Pharmacy Prescription Drug Card for short-term medications

• Mail Service Pharmacy for long-term medications

For short-term medications, such as antibiotics, it is important that you use your Caremark Prescription Drug Card at a Caremark Participating Pharmacy in order to get the best price and the greatest savings.  The Caremark Retail Program includes over 50,000 participating pharmacies nationwide, including more than 20,000 independent community pharmacies.  To locate a Caremark Participating Pharmacy in your area, simply access the Caremark Pharmacy Locator on the Caremark website (www.caremark.com ) or call Caremark's Customer Service toll-free at (800) 841-5550.

Your co-payment at the Caremark Participating Pharmacy for up to a 30-day supply will be:

• 10% for a generic drug

• 10% for a brand name drug

The Caremark Mail Service Program must be used to obtain your long-term medications and is a cost-effective choice for your long-term needs.  Simply mail your original prescriptions, along with the Patient Profile/Order Form and your medication will be sent directly to your home.  If you are currently receiving any long-term medications, contact your doctor for a new prescription and send it to Caremark.  Ask your doctor to write your prescription for up to a 90-day supply, plus refills, when appropriate.

Your co-payment to Caremark under the Mail Service Pharmacy Program for up to a 90-day supply will be:

• $15.00 for a generic drug

• $30.00 for a brand name drug

The following services are available at  www.rxrequest.com for your convenience:

• Prescription Refills

• Forms

• Order Status

• Frequently Asked Questions

• Pharmacy Locations

• Other Helpful Information

You may contact Caremark at (800) 841-5550 if you have any questions.

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19.)  When I am out of work, am I entitled to any Loss of Time Benefits?

Loss of Time Benefits are provided for active eligible bargaining unit employees and active eligible Class A non-bargaining unit employees. (Loss of Time Benefits are not provided for Class B non-bargaining unit employees or for ANY employee whose Plan coverage is being continued under COBRA Coverage.)

To be eligible to receive weekly benefits, you must be eligible for Loss of Time benefits on the date your disability begins and you must be totally disabled and be completely prevented from engaging in any occupation or employment for compensation, wages or profit as a result of a non-occupational accidental bodily injury or sickness.

The amount of your weekly benefit is currently $350.00 per week.  The weekly benefit will be paid on the basis of a 7-day week.  If benefits are due you for a partial week, you will receive one-seventh of the weekly benefit for each day of the partial week, payable at the end of the disability.

In accordance with Federal Law, the Plan will withhold your share of FICA (Social Security) tax from each weekly payment and will send it to the government.  Also, you must include the weekly benefits you received in your gross income and pay Federal Income Tax on them.

Period of Payment/When Benefits Start--Weekly benefits are payable for up to 26 weeks while you are totally disabled, but not for more than 26 weeks for any one continuous period of disability.

Weekly benefits will begin:

• On the first day of disability due to a non-occupational accidental injury

For disabilities due to sickness:

• On the first day of disability due to patient surgery, or

• On the first day of a hospital stay if hospitalized before the eighth day of sickness; or

• On the eighth day of a disability if not hospitalized.

If a female employee is disabled due to maternity or pregnancy-related condition, the disability will be treated as a disability due to sickness.

For a full explanation of the Loss of Time Benefit, please refer to page 49 of the Benefit Fund Summary Plan Description.

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20.)  If I get sick or get hurt, not related to work, can I go to any doctor or hospital?

Yes, you may seek medical treatment from any physician or medical facility that you wish; however, you and your family should use the Blue Cross/Blue Shield of Illinois PPO providers whenever you need medical or hospital care.  If you do, you will save on your out-of-pocket share of your family's non-emergency doctor and hospital expenses because the calendar year deductibles and out-of-pocket limits are lower when you use the Blue Cross/Blue Shield or Illinois providers.

Remember to show your Northern Illinois Benefit Fund medical card to the provider of service.  If an admission into the hospital is necessary, the card is intended to alert you or your physician to contact Med-Care Management to obtain pre-admission authorization.

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21.)  Can I add my spouse to my Health Plan at a later date?

If you are married when you become eligible for benefits, your spouse and family are eligible for benefits on the same day that you become eligible for benefits.  When completing your Participant Data Form, please include all information that pertains to you and your family. In addition to the Participant Data Form, the Fund office requires a copy of your marriage license,  a copy of your spouse's and children's birth certificates and social security cards.  You must also select beneficiaries for the Life Insurance, Pension Fund and Retirement Fund.

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22.)   Since the State of Illinois requires my children to have routine school physicals and immunizations, why doesn't my Health & Welfare coverage pay all of the charges?

Prior to July 1, 1999 the Health & Welfare Plan for Northern Illinois Benefit Fund paid 100% of covered services for a routine physical examination up to a maximum of $300.00 per person per calendar year. Routine physical examination benefits were payable for employees, retirees, spouses and dependent children under age 5.

Effective January 1, 2006 the Board of Trustees increased benefits for routine physical examinations to help with the cost of the school physicals and immunizations that are mandated by the State of Illinois.   

For Employees, Retirees and Spouses--the covered expenses incurred in excess of $300.00  during a calendar year will be covered under the regular provisions of the Comprehensive Benefit.  The Comprehensive Benefit deductibles, co-pay percentages, maximum benefit limitations and exclusions will apply.

Well-Child Care for Dependent Children--Effective January 1, 2008, the Plan will pay 100% (no deductible) up to the following maximums:

• $1,000 first year of life - child's birth through day before child's 1st birthday.
• $300 second year of life - child's 1st birthday through day before child's 2nd birthday.
• $300 third year of life - child's 2nd birthday through day before child's 3rd birthday.
• $300 fourth year of life - child's 3rd birthday through day before child's 4th birthday.
• $300 fifth year of life - child's 4th birthday through day before child's 5th birthday.
• $600 for the period from the child's fifth birthday through day before child's 13th birthday.
• $600 for the period from the child's 13th birthday through day before child's 19th birthday.

These maximum benefits will apply to all covered well-child care expenses - exams, immunizations and inoculations. 

EXCESS CHARGES WILL CARRY-OVER TO MAJOR MEDICAL - Covered expenses incurred on and after January 1, 2008 that are in excess of the maximums listed above WILL carry over to the major medical benefit (the “Comprehensive Benefit”) and be paid subject to the deductible and co-payment provisions.  As with other covered expenses, the Plan pays higher benefits when you use physicians in the BlueCross PPO network.

 Only charges incurred on and after January 1, 2008 are eligible for the increased benefits.  No additional benefits are payable for claims incurred prior to that date.

There is not a Routine Physical Examinations Benefit for Dependent Children over the age of 19.

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23.)    Are immunizations administered by the County Health Department covered for benefits under the Routine Physical Examination Benefit?

Yes, immunizations administered by the County Health Department are reimbursable under the Routine Physical Examination Benefit.  Since the County Health Department usually administers routine immunizations at a lower fee than your physician, obtaining your immunizations from the Health Department will help to stretch the $1,000.00 or $300.00/$600.00  benefit.

If you obtain your immunizations from the Health Department, please obtain a receipt that indicates the date of the immunization, the type of immunization received and the cost of the immunization.  Please forward this receipt with the member's name, social security number and name of the individual who received the immunization to the Fund Office for consideration of benefits.

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24.)    Should I keep a photocopy of information that I submit to the Fund Office?

Yes, it is advisable to keep a personal record of all claims and correspondence that is sent to the Health & Welfare Office.  Therefore, if we show no record of receiving the material submitted for consideration you will have a copy that can be resubmitted to our office.

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25.)    What should I do if I am required to have an MRI, CT Scan or Mammogram? 

To access this benefit you must schedule your test through MedLink.  To schedule a test through MedLink, call them at 1-888-558-0680 when you receive the prescription for the testing from your physician.  The representatives at MedLink will help you determine which of their contracted facilities is the most convenient for you and schedule your appointment with the facility for you.  On the day of your test, advise the staff at the facility that your appointment was scheduled through MedLink and give them MedLink’s toll free number, 1-888-558-0680.  MedLink will handle the rest of the billing procedure for you with the facility.  You will make no payment and receive no bills for the tests that you schedule through MedLink.  

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