Pf597.org

We are pleased to provide you with this updated booklet describing your health benefits under the Pipe Fitters’ Welfare Fund, Local 597, effective January 1, 2014, unless otherwise indicated. This booklet describes the benefits offered under the Plan and the Plan’s eligibility rules. Although this booklet is meant to be an easy-to-understand description of your Plan benefits, it also serves as the Plan Document and contains the Plan’s official rules. The following is a list of significant changes made to your Plan of Benefits since the booklet was last printed in 2008: 1. Pursuant to the Patient Protection and Affordable Care Act of 2010 (“ACA”), the following changes were made effective January 1, 2011: a. A notice regarding the Plan’s grandfathered status was added (preamble); b. The $3,500 limit on Home Birth Services was eliminated (Section 1.01(A) and Section c. The $3,500 limit on Outpatient Physical/Speech Therapy and the $3,500 limit on Outpatient Occupational Therapy were eliminated and a 40 visit calendar year maximum was implemented (Section 1.01(A) and 1.01(B)); d. The calendar year maximum on Diagnostic and Preventive Dental services was eliminated for Dependent children of Active Employees who are under the age of 19 (Section 1.01(A)); and e. The out-of-network calendar year maximum was eliminated for vision exams for Dependent children of Active Employees who are under the age of 19 (Section 1.01(A)). 2. Pursuant to the ACA, the following changes were made to the Plan effective January 1, 2014: a. The limit for medical expenses related to the treatment of TMJ was eliminated (Section b. The annual maximum benefit paid under the Major Medical Benefit was eliminated (Section c. Spinal Manipulation and Naprapathy services are now limited to 20 visits per calendar year instead of the previous dollar limit of $1,500. However, spinal manipulation and naprapathy benefits remain excluded for Dependent children under the age of 16 (Section 1.01(A) and Section 1.01(B)); d. The lifetime limit on Orthodontia for Dependent children of Active Employees who are under the age of 19 was eliminated in limited circumstances (Section 1.01(A)); e. Language regarding coverage options under the Marketplace was added to the COBRA Continuation Coverage provisions in Section 2.04(A); f. Opt-out language was added to Section 3.03(C) to allow retirees to opt-out of the HRA g. The definition of Dependent child was amended to provide coverage for children under the age of 26, regardless of their eligibility for other employer sponsored group health coverage. 3. The Death Benefit was increased from $10,000 to $25,000 and the Accidental Death and Dismemberment Benefit was changed to an Accidental Dismemberment Benefit effective July 1, 2010 (Section 1.01(A), Section 1.01(B) and Section 5). 4. Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, the following changes a. Coinsurance for outpatient treatment of Mental and Nervous Disorders and Chemical Dependency now apply to the calendar year Out-of-Pocket Maximum (Section 1.01(A) and Section 1.01(B)); and b. The outpatient co-insurance paid under the Plan for Mental and Nervous Disorders and Chemical Dependency was increased to 85% of PPO Charges and 75% of Non-PPO Charges (Section 1.01(A) and Section 1.01(B)). 5. The Trustees added a $500 per eye lifetime LASIK benefit under the Major Medical Benefit for Active Employees who have been eligible under the Plan for at least 5 years (Section 1.01(A) and Section 7.08(A)(33)). 6. The calendar year maximum for Dental Benefits for Active Employees other than Orthodontia Care was increased to $2,500 and the Plan payment for Diagnostic and Preventive Services was increased from 80% to 100% of the Usual and Customary Fees (Section 1.01(A)). 7. The lifetime limit on Orthodontia was increased to $2,000 effective January 1, 2013 for Active Employees and their eligible dependents (Section 1.01(A)). 8. The Weight Watchers benefit was increased to 12 months of an online membership per lifetime per person for participants and eligible spouses (Section 1.01(A) and Section 1.01(B)). 9. The amounts payable by Retired Employees under the Supplemental Major Medical Expense Benefit were increased based on the changes to the amounts paid by Medicare Part A (Section 1.01(C)). 10. The provisions related to leave taken under the Family and Medical Leave Act of 1993 (FMLA) as stated in Section 2.01(J) were restated to reflect legislative changes. 11. The Retired Employee Eligibility rules stated in Section 2.02(A) were revised effective January 1, 2011 by adding defined benefit plans sponsored by the Gary Community School Corporation or the School City of Hammond to the list of defined benefit plans which entitle retirees to Retired Employee coverage under this Plan, provided 25 years of coverage was earned in one of those plans. 12. Reduced and subsidized COBRA Continuation Coverage rates were added under Section 2.04(C)(3) for Apprentices Actively Available for work effective November 1, 2009. 13. Subsidized COBRA Continuation Coverage rates were added under Section 2.04(C)(4) for Employees Unable to Work Due to Non-Work Related Accident or Sickness effective January 1, 2011. 14. Clarification language was added to the Surviving Spouse provisions regarding a delayed election of Surviving Spouse Medical Benefit coverage under Section 2.04. 15. Clarification language was added to the Health Reimbursement Arrangement (HRA) for Retirees under Section 3.03(A) regarding the requirement for the Retiree to be alive on November 1st of each year in order for his HRA to be credited. 16. The amount credited to HRAs under Section 3.03(A) was increased to $60 multiplied by the number of Pension Years a retiree has accumulated under the Pipe Fitters’ Retirement Fund, Local 597 effective October 1, 2012. However the maximum amount credited remains 200% of the monthly pension check the retiree receives from the Pipe Fitters’ Retirement Fund, Local 597. 17. The Weekly Accident and Sickness Disability Benefit language under Section 6.01 was revised to clarify that: (1) participants covered under the Active Employee Benefits through COBRA Continuation Coverage are not eligible for Weekly Accident and Sickness Disability Benefits and (2) if an Active Employee is receiving Weekly Accident and Sickness Disability Benefits while on FMLA leave, that employee will be credited with FMLA hours or Disability hours but not both. 18. Language was added under Section 7.07 regarding the Plan’s pre-authorization and utilization 19. The Plan expanded the list of covered providers to include a qualified professional acting within the scope of their license as defined by State law. (Section 7.08(A)(2)). 20. Language was added to clarify that the Plan covers MRIs, PET and CT/CAT scans effective April 21. The organ and bone marrow transplant coverage was revised to reflect general industry practice 22. Applied behavior analysis (ABA) services were added as a covered expense effective May 21, 23. Effective July 1, 2010 coverage was added under the Prescription Drug Benefit for (A) up to six pills of Viagra, Cialis or Levitra per month for the treatment of erectile dysfunction and (B) prescription federal legend vitamins and minerals (Section 9.02(J) and (K)). 24. A definition was added for Dental Usual and Customary Fees (Section 20.01(V)). Important terms used throughout this booklet are capitalized and defined in the Plan. Please keep this booklet with your other important papers and share this information with your family. If you have questions about information in this booklet, you should contact the Fund Office. This booklet replaces and supersedes any previous written explanation of the Plan. Sincerely, The Board of Trustees

Source: http://www.pf597.org/assets/1/7/SMM_-_SPD_Plan_Restatement_.pdf