News & Changes

Welfare Fund Patient Protection and Affordable Care Act benefit changes effective July 1, 2011

Section I - Notices
Notice of Grandfathered Health Plan

This group health plan believes this District Council Iron Workers of Northern New Jersey Welfare Fund is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 

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 at 973-376-7230.  You may also contact the Employee Benefits Security Administration, 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.


Notice About the Early Retiree Reinsurance Program

You are a plan participant, or are being offered the opportunity to enroll as a plan participant, in an employment-based health plan that is certified for participation in the Early Retiree Reinsurance Program. The Early Retiree Reinsurance Program is a Federal program that was established under the Affordable Care Act. Under the Early Retiree Reinsurance Program, the Federal government reimburses a plan sponsor of an employment-based health plan for some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family members of early retirees participating in the employment-based plan. By law, the program expires on January 1, 2014.

Under the Early Retiree Reinsurance Program, your plan sponsor may choose to use any reimbursements it receives from this program to reduce or offset increases in plan participants’ premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs. If the plan sponsor chooses to use the Early Retiree Reinsurance Program reimbursements in this way, you, as a plan participant, may experience changes that may be advantageous to you, in your health plan coverage terms and conditions, for so long as the reimbursements under this program are available and this plan sponsor chooses to use the reimbursements for this purpose. A plan sponsor may also use the Early Retiree Reinsurance Program reimbursements to reduce or offset increases in its own costs for maintaining your health benefits coverage, which may increase the likelihood that it will continue to offer health benefits coverage to its retirees and employees and their families.


NOTICES OF ENROLLMENT OPPORTUNITIES
Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26

Effective July 1, 2011, the Fund will extend coverage to participants’ eligible children up to the end of the month the child attains age 26. Coverage is available whether the child is married or unmarried, regardless of student status, employment status, financial dependency on the participant, or any other factor other than the relationship between the child and the participant. The Plan amendment pertaining to the new definition of Dependent Children is described in Section II of this announcement.  If you have a child who is under age 26 (whether married or unmarried), including a child currently receiving continuation coverage under COBRA, that child may be eligible to enroll in the Plan as of July 1, 2011. 

Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the Welfare Fund.  If you wish to request enrollment for your child, please complete the attached enrollment form and return it to the Fund Office by July 31, 2011.  You must request enrollment on behalf of your child no later than July 31, 2011. If you request enrollment by that date, coverage will be effective  retroactive to July 1, 2011.  If you wish to request enrollment for your dependent child, please complete the attached enrollment form and return it to the Fund Office by the July 31st deadline.  For more information, contact Fund Office of the District Council Ironworkers Welfare Fund of Northern New Jersey, 12 Edison Place, Springfield, New Jersey, 07081, (973) 376-7230.

Please note you must also complete the enclosed enrollment form for those children between the ages of 19 and 23 even if they are currently enrolled in the Plan. Failure to do so may result in your children’s coverage being suspended.

Lifetime Limit No Longer Applies

The overall lifetime limit of $500,000 on the Out-of-Network Benefits for participants and each covered dependent covered under the Welfare Fund no longer applies.  Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the Plan.  Individuals have 30 days from the date of this notice to request enrollment.  For more information, contact the Fund Office at the address and number above.  Please see the next section on Plan changes for information on annual limits now applicable for the Plan effective July 1, 2011.


SECTION II - PLAN CHANGES EFFECTIVE JULY 1, 2011

The section titled “When Dependent Participation Begins” in your SPD, page 11,  is replaced in its entirety with the following:

B. When Dependent Participation Begins

1. Your eligible dependents become participants in the District Council Iron Workers Welfare Fund of Northern New Jersey when your participation begins, and their participation will continue for as long as you remain a participant and they remain eligible dependents. Your eligible dependents include your lawful spouse and your children (married or unmarried) under the age of 26.

a) Child means your biological child or legally adopted minor child, as long as the child does not have his/her own employer-sponsored health care coverage. It also includes a child placed with you for adoption awaiting finalization of the adoption.  You are required to submit written proof of your child’s age and relationship to you to the Fund Office.

2. For the most part, your dependents are covered for the same benefits as you, but there are exceptions (such as Disability, Life and AD&D Insurance benefits). Refer to the chart on page 31 to find out the benefits for which your dependents are and are not covered.

3. Disabled children over age 26. Extended coverage is available for an unmarried child who is over age 26, who is (i) physically or mentally disabled; (ii) incapable of self-sustaining employment due to that physical or mental disability; (iii) solely depend on you for support; (iv) became so disabled before reaching age 19; and (v) was covered under the Plan at that time. You must submit written proof of incapacity to the Fund Office within 31 days of the date the child’s eligibility would have otherwise ceased and from time to time thereafter, as required by the Trustees.

Coverage for your children continues until  the end of the month of the child’s 26th birthday.  Coverage for a covered Child who is disabled prior to reaching age 19, while covered under the Plan, continues under the Plan until the earliest of the date the child: (1) is no longer disabled as defined by the Plan; (2) marries; (3)  no longer depends on you (the Participant) for support; or (4) the date you are no longer covered under the Plan.

For plan years beginning prior to January 1, 2014, an adult Dependent Child is not eligible for coverage under the Plan if such adult child is eligible for coverage under another employer-sponsored health plan other than a group health plan of a parent.

Section D. “When Dependent Participation Ends” in your SPD, page 12, is replaced with the following subsections:

D: Dependent Participation Ends

1. Dependent participation generally stops when yours does (as described above) or when a dependent is no longer eligible, whichever happens first. (For example, your spouse’s coverage will end if you and your spouse are divorced).

Coverage for you and/or your dependents may be terminated retroactively (rescinded) due to any of the following:

  • in cases of fraud or intentional misrepresentation (in such cases, you will be provided with a 30 day notice).
  • due to non-payment of premiums (including COBRA premiums). 

Failure to provide complete, updated and accurate information to the Fund Office on a timely basis regarding your marital status, employment status of a spouse or child, or the existence of other coverage (or, in the case of adult children, eligibility for other employer-sponsored coverage) constitutes intentional misrepresentation of material fact to the Plan.

Please go to the Welfare Fund forms section to view the "Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26" form.

Elimination of Lifetime Limit for Major Medical Expense Benefit Effective July 1, 2011

The Lifetime maximum of $500,000 under the Plan for out-of-network benefits is eliminated and replaced with an annual limit for out-of-network benefits for each covered individuals of $750,000 for the Plan Year July 1, 2011 to June 30, 2011, for Active Participants only.

Elimination of Certain Annual Limits

The following annual limitations are removed or amended as noted:

Well-child visits and immunizations: The $300 annual maximum for in-network and/or out-of-network well-child visits and immunizations will no longer apply.  Benefits will otherwise continue to be paid in accordance with the Plan’s benefit schedule subject to any applicable deductible and coinsurance, or copayment.

Out-of-Network Wellness Benefits:
• Gynecological exams: The $125 annual maximum for out-of-network care is removed. 
• Prostrate Screening: The $125 annual maximum for out-of-network care is removed. 
• Pap Smear: The $125 annual maximum for out-of-network care is removed. 
• Laboratory/Pathology, X-ray and Radiology, Non-Routine Diagnostic and Mammography: The $100 annual maximum for out-of-network care is removed. 

Benefits will otherwise continue to be paid in accordance with the Plan’s benefit schedule subject to any applicable deductible and coinsurance, or copayment.

Home Health Care Agency: The $4,500 annual maximum per benefit period will no longer apply.  Benefits will otherwise continue to be paid in accordance with the Plan’s benefit schedule subject to any applicable visit limit and any applicable deductible and coinsurance, or copayment.

Therapy Services: The $45 allowance per visit for out-of-network care is removed.  Benefits will otherwise continue to be paid in accordance with the Plan’s benefit schedule subject to the current visit limit and any applicable deductible and coinsurance, or co-payment.

Optical Benefits for Pediatric Services
Pediatric vision benefits for children under the age of 19 will be payable for examinations and lenses during a 24 month period in accordance with the Plan's benefit schedule.

This summary only highlights the key changes made to District Council Iron Workers of Northern New Jersey Welfare Fund.  Summary of material modifications (SMMs) together with the Summary Plan Description make up your official plan descriptions; please keep them together and refer to them as necessary.  If you would like to request a copy of the SPD, please contact the Fund Office.

Please click here to view the letter
 

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