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.

  • You must work at least 300 hours for a contributing employer during a qualifying period to participate in the Plan and receive Level I benefits.
  • You must continue to work at least 300 hours per qualifying period in order to maintain eligibility for Level I benefits.
  • If you do not work the required 300 hours, you may maintain your health care coverage if you've worked at least 250 hours by:
    • applying the hours you've accumulated in your hours bank;
    • "dropping down" to a Level II coverage;
    • using your overtime hours;
    • buying the additional hours you need to maintain your coverage; or
    • combining hours in your bank, overtime hours or buy-in hours
  • Certain part-time employees, or employees who drop down to Level II coverage must work at least 200 contributory hours in a qualifying period to be eligible for Level II benefits for themselves and their dependents.

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

Level II

Participants

All employees with at least 300 contributory hours in a qualifying period

  • Certain part-time employees with at least 200 contributory hours in a qualifying period; or
  • Level I employees who have "dropped down" to Level II because they have worked at least 200 (but not 300) hours in a qualifying period

Benefits

  • Medical
  • Prescription Drugs
  • Vision
  • Hearing
  • Dental
  • Weekly Accident and Sickness
  • Life Insurance
  • Accidental Death and Dismemberment
  • Legal Services
  • Members' Assistance Program
  • Medical
  • Prescrition Drugs
  • Dental
  • Legal Services
  • Members' Assistance Program

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.

Qualifying Periods

Eligibility Periods

If you work at least 300 hours in…

You'll be eligible for coverage during…

January, February, March

June, July August

April, May, June

September, October, November

July, August, September

December, January, February

October, November, December

March, April, May


What is Covered Employment?

Covered employment is a category of work under which your employer makes contributions to the Fund on your behalf, according to the rules of a collective bargaining agreement.

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:

  • Use hours from your hours bank;
  • Use overtime hours;
  • Pay for the hours you need (buy-in); or
  • Combine any of the above three options.
    (See below for details.)

If your coverage for benefits terminates, you may also be eligible for a monthly Level I reinstatement.

Hours Bank

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.

Overtime Hours

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've been eligible for Level I benefits during the past year (at least one of the four most recent eligibility periods); and
  • you've earned enough overtime hours so that, when applied, you'd meet the 300 hour requirement;

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.

Buy-In Rule

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:

  • You may use this rule to earn eligibility for benefits for a maximum of five consecutive months;
  • You can only be reinstated to the level that you terminated from, regardless of the number of hours you work; and
  • The Reinstatement Rule does not apply unless you have already lost your eligibility.

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

Certain 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:

  • You may use this rule to earn eligibility for benefits for a maximum of five consecutive months;
  • You can only be reinstated to the level that you terminated from, regardless of the number of hours you work; and
  • The Reinstatement Rule does not apply unless you have already lost your eligibility.

Coverage For Your Dependents

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
  • your dependent children (including stepchildren living in your household, foster children and legally adopted children). You must present the required paperwork for dependent children. Refer to the Life Events section.

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:

  • Is under age 19*;
  • Is under age 26 and does not have access to health insurance coverage from his or her employer or his or her spouse’s employer;  OR
  • Was physically and/or mentally handicapped before he or she reached age 19, as defined below.

* 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
For purposes of this Section and Section 3, the term “access to health insurance coverage” denotes that the dependent child is eligible to enroll in any employer-sponsored health plan (other than a group health plan of a parent), regardless of the cost of that coverage or the benefits it provides.  Even if your dependent child does not have access to vision, dental or hearing benefits, the dependent child will not be eligible for coverage under this Plan if he or she has access to health insurance coverage.

Coverage for your eligible dependent child will end at the later of:

  • the end of the month in which your child becomes eligible to enroll in any employer-sponsored health plan (other than a group health plan of a parent), or

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.

  • If your child was physically and/or mentally handicapped before he or she reached age 19, your child will remain eligible as long as you are eligible under this Plan provided the child is chiefly dependent on you for support and care. You should notify the Fund Office six months prior to your child reaching age 19. The Fund Office will mail a form for you to fill out. Return this form, along with a doctor's statement certifying that your child is incapable of self-support, to the Fund Office. The Fund Office will send all required paperwork to UnitedHealthcare, Delta Dental, and Caremark for approval.

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:

  • Coverage for your dependents will end when they no longer meet the Plan's definition of an eligible dependent. If you die, your dependents' coverage will continue until the last day of the eligibility period.
  • If your employer is no longer required to make contributions to the Fund on your behalf, your and your dependents’ eligibility for coverage will cease at the end of the month in which the employer is last required to contribute to the Teamsters Local 251 Health Services and Insurance Plan.

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.

Continuing Your Coverage
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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).

Fast Facts:

  • You must apply for COBRA coverage within 60 days of a qualifying event (shown in the chart below) or, if later 60 days from the date you lose coverage.
  • COBRA applies to medical, prescriptions, hearing, vision, map and
    dental benefits, but not to Life Insurance, Weekly Accident and Sickness Benefit, Accidental Death and Dismemberment Insurance and Legal Services.
  • You must make monthly self-payments to the Fund Office on time in order to keep your coverage under COBRA.

What You Need To Do:

  • If you experience a "Qualifying Event" contact the Fund Office to obtain information on continuing your coverage through COBRA.

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.

Qualifying Event

Who May Purchase Continuation Coverage

For How Long

Employee’s termination of employment or reduction in hours or employment

Employee, spouse and/or dependent children

18 months

Termination or reduction in hours while you or your dependent is disabled

Employee, spouse and/or dependent children

29 months (18 months plus an additional 11)

Employee becomes entitled to Medicare

Spouse and/or dependent children

36 months

Employee Dies

Spouse and/or dependent children

36 months

Employee is divorced or legally separated from spouse

Spouse

36 months

Child is no longer considered a dependent child by this Plan's definition

Dependent Child

36 months

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):

  1. you divorce or legally separate;
  2. you die;or
  3. your child ceases to meet the Plan’s definition of an eligible dependent (in this case, only the child may extend coverage).

Notification Responsibilities

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

The 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 coverage.

When the qualifying event is the termination of employment or reduction in hours of employment or the death of an employee, the Fund will determine when a qualifying event has occurred. However, you are encouraged to inform the Fund Office of any
qualifying event to assure prompt handling of your COBRA rights. The Fund Office will notify you of your right to choose continuation coverage within 60 days of receiving notification of a qualifying event.

COBRA NOTICE OF QUALIFYING EVENT FOR COVERED EMPLOYEES AND OTHER QUALIFIED BENEFICIARES
CLICK HERE TO DOWNLOAD A COPY

How to Provide Notice to the Fund Office

To 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 (401)467-3323.

Where to Send the Notice

Notice should be sent by U.S. mail to the following address:

Dawn O’Connor, Administrative Assistant
Teamsters Local 251 Health Services and Insurance Plan
1201 Elmwood Avenue
Providence, RI 02907-3799
Tel.: (401)467-3323

Please keep a copy, for your records, of any notices you send to the Fund Office.

Deadline for Sending the Notice

Your timeframes for providing notice to the Fund Office are as follows:

If 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.

If you are providing notice of a Social Security Administration determination of disability, notice must be sent no later than 60 days after the latest of (1) the date of disability determination by the Social Security Administration, (2) the date of the qualifying event, or (3) the date on which the qualified beneficiary would lose coverage under the Plan due to the qualifying event, and before the end of the first 18 months of continuation coverage.

If you are providing notice of a Social Security Administration determination that you or your dependent is no longer disabled, notice must be sent no later than 30 days after the date of the determination by the Social Security Administration that you or your dependent is no longer disabled.

Who Can Provide Notice

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.

Notice from one individual will satisfy the notice requirement for all related qualified beneficiaries affected by the same qualifying event.

If you or your dependents send a notice to the Fund Office as described above and the Fund Office determines that you are not entitled to COBRA continuation coverage, the Fund Office will send you a written notice stating the reason why you are not eligible for COBRA continuation coverage. This will be provided within 14 days after the Fund Office receives your notice.

Electing Coverage

Once 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
have 60 days to make your COBRA election from the later of:

  • the date you would have lost coverage because of the qualifying event; or
  • the date you received the election form and COBRA information from the Fund Office.

Paying for COBRA

You and your dependents are required to pay the entire cost of continued group health coverage at group rates. Generally, the cost will not be more than 102% of the cost of these benefits to the Fund. However, the Fund does charge 150% of the cost of the benefits during the additional 11 months for loss of coverage due to disability.

You must send your first payment within 45 days following submission of the COBRA election form. Your first payment for COBRA continuation coverage must include payments for any months retroactive to the day you and/or dependents’ coverage under the Plan terminated. In other words, you cannot have a month without coverage—you must pay for each month from the date you lost coverage under the Teamsters Local
251 Health Services and Insurance Plan.

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:

  • You do not pay your premium to the Fund Office on time;
  • You become covered under any other group health plan as an employee, unless the plan contains an exclusion or limitation on any preexisting condition that you have;
  • You become entitled to Medicare (under Part A, Part B, or both);
  • You are reinstated to active benefits; or
  • The Fund no longer provides group health coverage


How to Elect COBRA

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.

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