This page contains answers to common questions handled by our support staff, along with some other information that we have found useful, and is presented here as questions and answers.

Please contact us with your questions at the numbers above or e-mail us at Ochw@aol.com. A list of our staff and their primary responsibilities is provided for
your use.

1. Q&A's for Everyone
2. Q&A's for Active Members and Dependents
3. Q&A's for Retirees and Those Eligible for Medicare

Q. What information do I need to include with my monthly premium payment?

A. When making monthly premium payments, please include the following:

1. Write the member's social security number on the check. (This is the account number.)

2. Make sure the last name of the member is on the check.

3. Mark the envelope as to what type of payment is enclosed - active or retiree.

 

Q. How do I determine the eligibility of my dependents?

A. Your eligible dependents are any of the following individuals who are not employees:

1. Your legal spouse; and

2. Each of your children who is under nineteen (19) years of age and unmarried, as well as an adopted child, also a dependent child placed within the participant's home prior to and in anticipation of adoption, provided proper documentation satisfactory to the Trustees of a pending adoption is submitted or a stepchild who resides in your household and is dependent on you for principal support.

3. Each of your children who is unmarried and over nineteen (19) years of age and under TWENTY-FIVE (25) YEARS OF AGE IF ENROLLED AS A FULL-TIME STUDENT IN AN ACCREDITED SCHOOL, COLLEGE, OR UNIVERSITY; WITH THE INTENT OF OBTAINING A DEGREE and is dependent on you for principal support (the Board of Trustees will have the right and opportunity to require proof of a child's status as a student and the right to verify any information submitted as evidence) and;

4. Each of your unmarried children who is incapable of self-sustaining employment because of mental or physical handicap, and who became so incapable before age nineteen (19), and while eligible for benefits under this Plan.

Proof of such Dependent child's incapability must be furnished to the Fund Off ice not later than thirty-one (31) days after attainment of age nineteen (19).

The Trustees, upon receipt of proof of such incapability, have the right to have a physician they designate examine such Dependent when and so often they may reasonably require, but not more than once every year after such incapability has continued uninterruptedly for at least two (2) years beyond the date the initial written proof is received by the Fund Office.

Dependent coverage is contingent upon your maintaining eligibility. Upon death of an Employee, Dependents will remain eligible until the end of the period for which coverage has been earned or paid as of the date of death.

At the expiration of earned coverage, Dependents of deceased Employees may, upon application, arrange with the Fund Office to make payments to provide continuing coverages. The benefits are as shown in the Schedule of Benefits for Dependents and the amount of payment required is determined by the Board of Trustees, based on the costs of the benefits.

The payments and coverage may be continued until the surviving Dependents no longer meet the eligibility requirements or other coverages are obtained.

If your Dependent (other than a newborn) is confined in a hospital on the date coverage would otherwise become effective, that Dependent will become eligible for all benefits, except Major Medical, on the day following discharge. Major Medical Benefits will become effective on the 30th day following discharge.

 

Q. How does it work if I need medical equipment?

A. Durable Medical Equipment for active and retired employees and dependents not enrolled in Medicare Supplement.

Reimbursement will be made at the usual, customary and reasonable cost under your schedule of benefits on the purchase of durable medical equipment, which meets all of the following criteria:

It can stand repeated use;

It is used to serve a medical purpose rather than being primarily for comfort or convenience; It is not useful to a person in the absence of illness or injury;

It is appropriate for home use;

It is certified in writing by a physician as being medically necessary; It is related to the patient's physical disorder;

The anticipated length of time the equipment will be required for therapeutic use must be certified in writing; and

It is for the exclusive use of the covered person for who the physician has certified that is medically necessary.

In addition, any durable medical equipment, at a cost that exceeds $1,500, needs to be pre-approved by the Board of Trustees prior to payment being made.

Q. What is included in "Well Baby Care?"

A. Well Baby Care for active and retired employees and dependents not enrolled in medicare supplement.

Birth to 1 Year:
Coverage for a History and Physical examination, development assessment, anticipatory guidance and laboratory services and immunizations at birth, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months/1 year, subject to a maximum dollar benefit of $500 per year for each covered dependent under your current schedule of benefits. Intervals are based on the current Recommendations for Preventative Pediatric Health Care
of the American Academy of Pediatrics.

Immunizations will be covered based on physician recommendation as the AAP schedule for immunizations varies based on the latest medical findings or research.

1 Year to Age 9:
Benefits will be provided for a History and Physical examination, development assessment, anticipatory guidance and laboratory services and immunizations at 15 months, 18 months, 24 months, 3 years, 4 years, 5 years, 6 years, and 8 years subject to a maximum dollar benefit of $150 per year for each covered dependent under your current schedule of benefits. Intervals are based on the current Recommendations for Preventative Pediatric Health Care of the American Academy of Pediatrics.

Immunizations will be covered based on physician recommendation as the AAP schedule for immunizations varies based on the latest medical findings or research.

Not Covered:
Services which are covered to any extent under any other benefit section of the Plan.

Services which are for diagnosis or treatment of a suspected or identified injury or disease. Services not performed by a physician under his/her direct supervision during a single visit. Medicine, drugs, appliances, equipment or supplies.

Dental exams.

 

Q. What is the deal about HMOs?

A. From time to time, you may be contacted by insurance companies about Medicare HMO policies they are selling to retirees covered under Parts A and B of Medicare.

You may already be familiar with some of these plans. If you are considering joining a Medicare HMO, we want you to understand how they work and how they affect your current Ohio Carpenters Health and Welfare Fund benefits. Medicare HMO plans offer many advantages; however, they may contain provisions that could be harmful to you and your family member (s) if you don't have all the facts:

Here are some points you should be aware of before you join a Medicare HMO:

• Medicare HMO's "replace" traditional Medicare coverage. If you join a Medicare HMO, you must receive all non-emergency medical care through the HMO's hospital and physician network. If you receive non-emergency services outside the HMO network benefits will not be paid by Medicare, the HMO or the Ohio Carpenters Health and Welfare Fund, and you will be required to pay for the services.
  
• If you join a Medicare HMO and end your participation in the Ohio Carpenters Health and Welfare Fund Medicare Supplement, your life insurance coverage provided by the Ohio Carpenters will be continued at no cost to you.
  
• If you end your participation in the Ohio Carpenters Health and Welfare Fund because you joined a Medicare HMO, you will be able to re-enroll under the Ohio Carpenters Fund only once per year during the month of January. When you re-enroll during January, your Ohio Carpenters coverage will be reinstated effective March 1st.
  
• If your dependent spouse is not eligible to join a Medicare HMO, your spouse may continue to be covered by the Ohio Carpenters Fund even if you join a Medicare HMO. Your monthly self-payment to the Ohio Carpenters Fund will be reduced to reflect spouse only coverage through the Ohio Carpenters Fund.
  

We have enclosed a few questions and answers which may help you to better understand how Medicare HMO's work. As Trustees, we cannot recommend which policy is best for you, since everyone has different health care requirements. We hope the attached questions and answers will help you collect the information you need to make the decision, which is right for you.

 

QUESTIONS AND ANSWERS ABOUT MEDICARE HMO'S

HMO Q1. What are HMO's?

HMO A1. Health Maintenance Organizations (HMO's) are managed care plans, which provide a full range of medical care to their members through selected networks of doctors and hospitals. HMO's sign contracts with doctors, hospitals, pharmacies and other health care providers to furnish quality, cost effective health care. HMO's emphasize preventative health and early screening and treatment, to maintain good health and to avoid extensive treatment later.

 

HMO Q2. What are Medicare HMO's?

HMO A2. Medicare HMO's are HMO's that contract with the Federal government to provide health care services to Medicare beneficiaries. These HMO's are an alternative to the standard Medicare program. They offer comprehensive benefits that include, and generally exceed, the benefits available under standard Medicare. For example, Medicare HMO's provide routine physical exams and other preventative health care services that are not covered by standard Medicare. In addition, some Medicare HMO's offer outpatient prescription drugs, which are not covered by standard Medicare.

Medicare HMO's are regulated by the Health Care Financing Administration (HCFA), which is the Federal agency that oversees Medicare. HCFA maintains rigorous standards that HMO's must meet to earn a Medicare HMO contract. HCFA then monitors Medicare HMO's to ensure that beneficiaries receive quality health care in compliance with these standards.

 

HMO Q3. Do Medicare HMO's provide benefits and services not covered by standard Medicare?

HMO A3. Yes. Medicare HMO's provide routine physicals and other preventative health care services which are not covered by standard Medicare. In addition, some Medicare HMO's offer prescription drug coverage and other benefits such as dental and eye care. The additional benefits provided by Medicare HMO's differ from one HMO to another, so you are encouraged to review each HMO's benefit programs carefully.

 

HMO Q4. How much does a Medicare HMO cost?

HMO A4. The Federal government pays the Medicare HMO directly for the majority of the health care provided. You will still have to pay the monthly Medicare Part B premium, just as you do now. Some Medicare HMO's charge additional premiums to provide extra benefits, such as prescription drugs or dental care.

 

HMO Q5. Do I have to enroll in Medicare to be eligible to join a Medicare HMO?

HMO A5. Yes, and you must continue to pay your current Medicare Part B premium each month to keep your Medicare HMO enrollment.

 

HMO Q6. Why should I join a Medicare HMO?

HMO A6. There a several reasons. First Medicare HMO's offer you expanded benefits such as routine physicals and preventative health care, and some Medicare HMO's cover prescription drugs, dental care and eye examinations. Second, Medicare HMO's use the primary physician as the coordinator of your health care to ensure the continuity and the quality of your health care. Third, by joining a Medicare HMO, you avoid having to pay for Ohio Carpenters supplemental coverage, and the Medicare deductibles and coinsurance. Fourth, there are no claim forms for the Medicare HMO.

 

HMO Q7. This all sounds good, but what are the disadvantages of a Medicare HMO?

HMO A7. Medicare HMO's may not be the right health plan for everyone. To be eligible for a Medicare HMO, you must reside in the HMO's service area for at least nine months each year. HMO's cover health care services that are ordered and managed by your primary care physician. If you go to a non-HMO doctor, you may not get coverage unless it is an emergency or urgent situation. If you travel frequently for extend periods of time the HMO coverage may not be right for you. Our goal is to help you make sure you have the right health plan for you and your spouse and dependents. Therefore, we encourage you to carefully evaluate the information you receive from Medicare HMO's so you can make the best choice of health plans.

 

HMO Q8. Do I have to join a Medicare HMO?

HMO A8. No. Medicare HMO coverage is an alternative to the standard Medicare program and Ohio Carpenters Health and Welfare Fund coverage. You do not have to join a Medicare HMO. You can choose to remain with your current coverage.

 

HMO Q9. If I join a Medicare HMO and don't like it, what do I do?

HMO A9. If you join a Medicare HMO and you are not satisfied, you can switch to another Medicare HMO in your area or you can return to the standard Medicare program and the Ohio Carpenters Fund coverage.

To disenroll from a Medicare HMO, you must provide notice in writing to either the Medicare HMO or to a Social Security Administration office. By law, you can disenroll from a Medicare HMO at the end of any month. However, you will not be eligible to re-enroll in the Ohio Carpenters Fund coverage until the next Open Enrollment Period. The Ohio Carpenters Open Enrollment Period will be in January of each year. Your coverage will be reinstated on March 1st if you re-enroll during the Open Enrollment Period.

 

HMO Q10. Can I join a Medicare HMO if I am over 65 and my spouse is not?

HMO A10. Yes, if you decide to join a Medicare HMO, your spouse and/or dependents may continue to be enrolled in the Ohio Carpenters Fund coverage.

Q. What does the plan cover for Gastric Surgery?

A. Gastric Surgery for clinically severe obesity must meet the criteria used by Claim Management as approved by the Board of Trustees. In addition, the patient must be in a multidisciplinary non-surgical program including a low or very low calorie diet, supervised exercise, behavior modification and support for at least six (6) months prior to the surgery and under the direction of the physician who refers the patient for surgery. Failure of the program will be considered if the patient has not lost significant weight despite compliance with the non-surgical program.

Additional criteria include: the patient must be 100 pounds over ideal weight or has a body mass index over 40 kilograms M2, or has body mass index over 35 kilograms M2 and a serious condition. The patient has no specifically correctable cause for obesity and has reached full growth. The patient must be treated in a surgical program with experience in obesity surgery and include multidisciplinary preoperative and postoperative approach. Gastric Surgery must be pre-approved by Claim Management at 1-800-888-8956.

 

Q. What are the plan Hearing Aid Benefits?

A. The Fund will reimburse participants and their eligible dependents for one medically required hearing aid per person once every two consecutive calendar years, up to a per person maximum of $1,000.

In order to obtain the reimbursement of this benefit, you must submit the claim to the Fund Office directly for payment.

 

Q. Are Flu shots covered?

A. No, because a flu shot is considered preventative medicine. However, in some instances a flu shot is covered because, of medical necessity. A doctor's prescription is required.

 

Q. I recently read that some drugs are used for "off-label" purposes. What does that mean?

A. "Off-label" use means that a drug is being used for a purpose not listed on the products' label.

This is common and acceptable practice by physicians, allowed by the Food and Drug Administration (FDA) for drugs the agency has already approved. The practice is also known as "new uses."

For example, the drug amitriptyline (am-i-TRIP-tuh-leen) is approved by the FDA as an antidepressant, but the drug is also sometimes prescribed "off-label" to treat migraine headaches or chronic pain.

Off-label use is permitted because FDA approval of any drug is very comprehensive. Rigorous and thorough testing is required is required to help determine if a drug is safe and if it actually works for a designated disease or condition.

Once that's established and a drug is FDA-approved for a certain use, it's not uncommon for research into the drug to continue. Along the way, scientists may discover that the drug can do something else useful beyond that for which it was approved -- hence, an off-label or new use. Often, these uses are eventually listed on product labels.

Source: Mayo Clinic Health Letter 10/98

 

Q. How can I help in getting my claims processed more efficiently?

A. We need your policy number on all claims submitted. Your policy number is your security number. Your policy number is the way we identify you and your dependents.

 

Q. What information is need in completing an beneficiary card?

A. When completing a beneficiary card, please complete both the front and the back of the card. You must sign and date the card and have it witnessed by someone other than the beneficiary.

 

Q. What is a contingent beneficiary?

A. A contingent beneficiary is person to whom you wish your death benefit be payable to if the original beneficiary is deceased.

 

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Active Members and Dependents

Q. When does my coverage end?
A. Individual Employee Terminations

The eligibility of a person will terminate on the earliest of the following dates:

1. The date of termination of this Plan.

2. The date the person enters the Armed Forces.

3. The first day of the Eligibility Month for which the Employee has failed to accumulate the required hours of contributions, unless the Employee has chosen to make self-payments.

 

Q. Can I lose my eligibility to participate in the Plan? (Updated 1/21/2000)

A. Yes, an employee or former employee will cease to be an eligible participant in this Plan if the employee is employed in any capacity, including but not limited to supervision, by an employer who is not signatory to a collective bargaining agreement requiring contributions to this Plan, either directly or through reciprocity on that employee's behalf. As used in this Notice, "employer" and / or "employed" shall relate only to a contractor that is engaged in the building and construction trade industry. An employee who engages in such employment will have his coverage and that of his dependents terminated on the last day of the calendar month during which employment of this type occurs. In addition, the employee whose coverage terminates under this provision will forfeit any reserve hours.

An employee shall not be allowed to make self-payments to continue eligibility if the employee is employed in any capacity by an employer who is not signatory to a Collective Bargaining Agreement requiring contributions to this Plan, either directly or through reciprocity on that employee's behalf. Such employee will be afforded COBRA continuation rights in accordance with applicable federal law.

 

Q. What are my dental benefits?

A. Effective January 1, 2001 the Board of Trustees has revised your Dental Benefits as follow. $600.00 maximum per person per calendar year with a $1200.00 family maximum per calendar year.

Under this Plan, orthodontia services are not covered. Benefits for Temporal Mandibular Joint Syndrome will be paid at 50% of the Usual, Customary and Reasonable charge up to a lifetime maximum benefit of $500.

 

Exclusion and Limitations

Benefits shall not be payable for the following:

1. Charges due to an occupational accident where benefits are payable under the Workers Compensation law or other similar law, or due to injury arising out of or in the course of any employment for wage or profit.

2. Treatment or service paid for or provided by any government agency.

3. Payment for examination of the oral cavity and full series of X-Rays will be provided initially and at intervals of not less than two years thereafter.

4. Payment for examination of the oral cavity and four bitewing X-Rays will be provided only if the interval since the last preceding examination covered under this Plan is not less than six months.

 

Q. What are my Vision Benefits?

A. Vision care benefits for employees, spouses and children

The reimbursement for contact lenses will not exceed the allowance in the Schedule of Vision Care Benefits for single vision lenses and frames. However, expenses for contact lenses will be covered up to $90.00 if required after cataract surgery or when visual acuity of a patient is not correctable to 20/70 in the better eye by use of conventional type lenses, but can be improved to 20/70 or better by use of contact lenses.

Q. What do I do if my employer is delinquent?

A. Please call or write to the Fund Office and request a discrepancy report. The discrepancy report should be completed by you and returned to our office along with your pay receipts. We will then contact the employer about the delinquency. In the meantime the required self payment should be submitted to assure coverage will be continued. If hours are received at a later date, you will be entitled to a refund.

Self payments can only be made to the Fund by those who are available for work. This provision is not meant to bar anyone who is working as a Carpenter or available for such work, but merely to restrict eligibility to those who should not be in the Fund under the rules established by the Board of Trustees. All self payments received will be verified with the individual local involved as to the eligibility of the person making the payment.

 

Q. What are the Chiropractic Benefits?

A. The Plan will pay 80% of all reasonable and customary covered charges up to a maximum of $1,000 per person per calendar year. Any remaining balance, which is more that the amount allowed by the Plan will not be paid.

 

Q. Can I cover my child who is in college?

A. Yes. Each of your children who is unmarried and over 19 and under 25 years of age if enrolled as full-time student in an accredited school, college or university, with the intent of obtaining a college degree. You must provide the Fund Office with proof of the child's status as a student (a copy of their schedule outlining the number of hours or a letter from the school indicating their status).

 

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Retirees and Those Eligible for Medicare

Q. What is an EOMB?

A. The information Medicare sends to patient when they pay a claim is called an Explanation of Medicare Benefits (EOMB). The EOMB from Medicare should be filed with the Fund Office along with an original bill in original to have the Fund Office process your claim properly.

 

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All rights reserved. Q&A's for Retirees and Those Eligible for Medicare