SECTION TWO: Eligibility for Coverage
As a participant in the Teamsters Local 251 Health Services and Insurance Plan, you and your family are covered with a generous package of health and welfare benefits. This section describes the eligibility requirements you must meet in order to participate in the Plan, how you may maintain your coverage, and when your coverage ends.
Level I and Level II Coverage
Teamsters Local 251 Health Services and Insurance Plan offers two benefit Plans for active employees: Level I and Level II. The chart below shows the differences in coverage and eligibility requirements.
Level I Coverage
Qualifying Periods and Eligibility Periods
You must work at least 300 hours in covered employment during a calendar quarter called a qualifying period to be eligible for Level I coverage during another calendar quarter called an eligibility period. The chart below shows the qualifying periods and eligibility periods for this Plan.
Your coverage begins on the date you become eligible, therefore any expenses you may incur before you're eligible will not be reimbursable.
The Plan expressly reserves the right to terminate a participant’s and/or beneficiary’s eligibility and coverage for cause. For cause termination include, but are not limited to, filing fraudulent claims and covering ineligible dependents (e.g. divorced spouses or over age dependent children).
Maintaining Your Coverage
There are several ways for you to keep your Level I health care coverage, even if you do not work the required 300 hours in a qualifying period. You may:
If your coverage for benefits terminates, you may also be eligible for a monthly Level I reinstatement.
If your company contributes in excess of 520 hours during a qualifying period and in the following qualifying period you do not work the required 300 hours, you may use the extra hours you earned to avoid a break in coverage. The excess hours that you accrued during the prior qualifying period may be used, if necessary, to continue your Level I coverage for one eligibility period. Contact the Fund Office if you would like to use your banked hours to maintain your coverage.
Your overtime hours from one qualifying period can count toward your hours for eligibility for the corresponding eligibility period (refer to chart above). If you have at least 250 (but less than 300) contributory hours during a qualifying period and:
You may be able to use your credit for your overtime hours, anything over 40 hours to maintain your Level I coverage, or you may be able to use your overtime hours to reduce the amount you pay to "buy in" to Level I coverage.
You must show proof of your overtime hours to the Fund Office. Pay stubs will be accepted as proof.
Another option you may elect if you do not work the required minimum of 300 hours in covered employment during a qualifying period, is to actually buy the hours you need to maintain your Level I coverage. You must work at least 250 hours to be eligible to buy-in. You may also apply your overtime hours (see above) to reduce your cost. Contact the Fund Office at (401) 467-3323 for the current hourly cost.
150 Hours in a Month Reinstatement Rule
If your eligibility for Level I coverage terminates, you may be able to regain eligibility without meeting the 300 hours requirement. If you work at least 150 hours in a calendar month within 12 months of losing your eligibility, you will be eligible for Level I coverage for one month. That month will be the third month after the one in which you worked the required hours.
For example, if you lost your eligibility on May 31 and worked at least 150 hours in the month of June, your eligibility would be reinstated for the month of September.
The following restrictions apply to the Reinstatement Rule:
Drop Down Rule
The Plan will allow you to "drop down" to Level II coverage for the corresponding eligibility period if you do not work the required 300 hours, but you do work at least 200 hours in a qualifying period. Level II coverage consists of medical, dental, MAP, and Legal Services.
For example: Tom was eligible for Level I benefits during the December, January, February eligibility period because he worked 312 hours in covered employment during the July, August and September qualifying period. However, during the October, November, December qualifying period, Tom only worked 230 hours. Tom will "drop down" to Level II benefits during the March, April, and May, eligibility period. During those three months, Tom will have coverage for medical, dental, MAP and Legal Services.
Level II Coverage
part-time employees and employees who are full time but "drop down"
because they have not worked the required 300 hours may be eligible for
Level II coverage. For Level II coverage, you must work 200 hours in a
Qualifying Period to be covered during the corresponding Eligibility Period.
80 Hours in a Month Reinstatement Rule
If your eligibility for Level II benefits terminates, you may qualify for up to five months of coverage under the 80 hours in a month Reinstatement Rule. To qualify, you must work 80 hours in covered employment in a month within one year of the date your coverage terminated.
You will be reinstated for coverage for one month, starting on the third month following the month in which you worked 80 hours. You will remain eligible for one month for each month in which you work at least 80 hours for up to five consecutive months, or until you become eligible under the regular eligibility rules.
The following restrictions apply to the Reinstatement Rule:
While you are covered under the Plan, your legally married spouse and your children may also be covered.
The Plan defines dependents as:
Your spouse and stepchildren are eligible for benefits on the first of the month following the date of your marriage. Your adopted or foster child is eligible from the date of placement. Your child by birth is eligible from the date of birth for health care coverage, and from 14 days for dependent life insurance coverage. Coverage for your eligible dependent child will end:
Your dependent child is eligible for medical, pharmacy, dental, vision, hearing, life insurance and accidental death and dismemberment benefits if he or she:
* Your child
may remain covered through the end of the year in which he or she turns
19 even if he or she is eligible for health insurance coverage from
his or her employer or his or her spouse’s employer
Coverage for your eligible dependent child will end at the later of:
December 31 of the year in which his or her 19th birthday occurs. However, in no event will your child’s coverage continue past the end of the month in which he or she turns 26.
When Coverage Ends
Generally, coverage for you and your dependents will end on the last day of the eligibility period that corresponds with the qualifying period during which you did not meet the requirements for coverage. However:
In certain circumstances when your coverage ends, you and/or your dependents may purchase health care coverage through COBRA. Please see COBRA continuation coverage below.
If you lose coverage under the Plan due to a "Qualifying Event" you and/or your eligible dependents may purchase certain health care coverage under a federal law called the "Consolidated Omnibus Budget Reconciliation Act" (COBRA).
What You Need To Do:
COBRA Continuation Coverage Qualifying Events
If one of the qualifying events described in the chart occurs, you may be eligible to apply for coverage under COBRA for the specified length of time.
If a Second COBRA Qualifying Event Occurs
If your dependents are in an 18-month COBRA continuation coverage period because of your termination of employment or reduction in hours of employment (or a 29 month period, in the case of a Social Security disability determination) and one of the following qualifying events occurs, the maximum COBRA continuation period for your dependents will extend to 36 months (provided you and/or your dependents notify the Fund Office of the second qualifying event within the timeframe discussed in “Notification Responsibilities” below):
You and/or your dependents are responsible for providing the Fund Office with timely notice of the following qualifying events:
Your divorce or legal separation from your spouse; or a child’s ceasing to be eligible for coverage under the Plan as a “dependent child.”
In addition, you and/or dependents are responsible for notifying the Fund Office, within the timeframe noted below, of the following:
A determination by the Social Security Administration that a qualified beneficiary entitled to receive COBRA coverage with a maximum of 18 months is disabled; or a determination by the Social Security Administration that such a qualified beneficiary is no longer disabled; or the occurrence of a second qualifying event, as described under “If a Second COBRA Qualifying Event Occurs” above.
Failure to notify the Fund Office of changes to you or a family member’s eligibility may result in a delay of payment of a claim at a future date or may adversely affect you or your family’s member’s COBRA rights. In the event the Fund Office is not notified of a change in eligibility and makes an overpayment, either to you or your family member or to a service provider on you or your family member’s behalf, the Fund reserves the right to collect the overpayment an/or reduce subsequent benefit payments to you or your family member(s) by the amount or such overpayment.
You must make sure that
Fund Office is notified of any of the occurrences listed above. Failure
to provide this notice within the form and timeframes described below
will prevent you and/or your dependents from obtaining or extending COBRA
How to Provide Notice to the Fund Office
provide the Fund Office with notice of any of these five situations, you
must submit a COBRA Notice of Qualifying Event to the Fund Office. You
can obtain a copy of this notice on this website or by contacting the
Fund Office. No other form of notice will be accepted by the Fund. If
you have any questions about how to fill out this form, please contact
Dawn O’Connor, Administrative Assistant at the Fund Office phone
Deadline for Sending the Notice
Your timeframes for providing notice to the Fund Office are as follows:
you are providing notice of a divorce or legal separation, a dependent
child’s losing eligibility for coverage, or a second qualifying
event, you must send the notice no later than 60 days after the
later of (1) the date of the relevant qualifying event or (2)
the date on which coverage would be lost under the Plan as a result of
the qualifying event.
Who Can Provide Notice
may be provided by the qualified beneficiary with respect to the qualifying
event (you or your dependents, as applicable) or any representative acting
on behalf of the qualified beneficiary.
notified of a qualifying event of Social Security disability determination,
the Fund will send you information about the monthly cost of your COBRA
coverage and and an election form for you to complete and return. You
and/or covered dependents
Your COBRA payments are due on the first of the month to be covered for the following month.
Your coverage may be cut short for any of the following reasons:
Once the Fund Office determines you are no longer eligible for coverage, they will mail you a notice of termination with information about the monthly cost of your COBRA coverage and election form for you to complete and return. You must make your first premium payment within 45 days of your election date.
Contact the Fund Office within 60 days of the date of your qualifying event, or the date of your loss of coverage. If you do not notify the Fund Office within that 60-day period, you will lose your right to elect COBRA.
Failure to Notify Fund of Changes in Eligibility
It is critical that you promptly and accurately communicate any change in your marital status or the eligibility status of your dependents to the Plan. If the Plan provides benefits to which your spouse or dependent is not entitled, you will be personally liable for reimbursement to the Plan of benefits and expenses, including attorneys’ fees and costs, incurred by Plan. In addition, the amount of any overpayment may be deducted from the benefits to which you would otherwise be entitled.
If you fail to notify the Plan of a change in your marital status, and we pay a claim for your former spouse for services rendered after the divorce date or remarriage date, you and your former spouse will be held personally liable for reimbursement to the Plan for benefits and expenses, including attorneys’ fees and costs incurred by the Plan as a result of your statements, actions or failure to notify the Plan. If you fail to notify the Plan of a change in your dependent’s eligibility status, and we pay a claim for an ineligible dependent, you will be held personally liable for reimbursement to the Plan for benefits and expenses, including attorneys’ fees and costs incurred by the Plan as a result of your statements, actions or failure to notify the Plan.
Reimbursement of benefits paid by the Plan for an injury or illness for which either you or your dependent has received any recovery is the liability of the Participant.
If reimbursement is requested and not received by the Plan, in addition to any other available remedies, the amount of such benefits will be deducted from all future benefit payments to or on behalf of the Participant and/or any dependent, until the overpayment is resolved.
In addition to any other remedy, the Fund may enforce the terms of the Plan described in this section through a court action to assure that the benefits paid by the Plan, and where applicable, interest, are fully reimbursed.