UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Who is Eligible

You are eligible to participate in the Plan if you are an active employee, as provided in your collective bargaining agreement. (Refer to your collective bargaining agreement to determine your eligibility for benefits.) Your dependents are eligible under the Plan if you choose Option III. There are special rules on dependent eligibility for the Educational Benefit. There are three options you can choose from under this Plan. Here are the benefits each option provides: Option I    Mental, Nervous, Drug and Alcohol    Dental    Vision    Disability    Life Insurance    Accidental Death & Dismemberment    Child Care    Educational Benefit Program    Physical Well Being Program    Legal-provided under the UFCW Local 1776 and Participating Employers Legal Trust Fund Option II - Single Coverage    Mental, Nervous, Drug and Alcohol    Dental    Vision    Disability    Life Insurance    Accidental Death & Dismemberment    Child Care    Educational Benefit Program    Physical Well Being Program    Prescription Drug *    Prescription Incentive Program *    Keystone Point of Service *    Legal - provided under the UFCW Local 1776 and Participating Employers Legal Trust Fund * Co-payment required - $50.00 per month. Option III - Family Medical Coverage    Mental, Nervous, drug and Alcohol    Dental    Vision    Disability    Life Insurance    Accidental Death and Dismemberment    Child Care    Educational Benefit Program    Physical Well Being Program    Prescription Drug *    Prescription Incentive Program *    Keystone Point of Service *    Legal- provide under the UFCW Local 1776 and Participating Employers Legal Trust Fund * Co-payment required - $120.00 per month. You are automatically enrolled in Option I benefits. You may, however, select Option II or III benefits instead. To select Option II or III benefits, you must complete and return the enclosed Plan Selection Form within 60 days of the date you are notified that you are eligible for benefits. The option you choose depends on your personal needs. For example, Option I offers benefits at no cost to you, but does not include medical coverage. If you already have medical coverage under another benefit plan, such as your spouse's group health plan, then Option I may be the best selection for you. If you do not have any other medical coverage, you may want to be covered under Option II or III. Your decision is final - so make your selection carefully. Whether you remain in Option I or change to Option II or III, your selection will remain in effect until you are eligible for a plan upgrade in accordance with your collective bargaining agreement. Qualified Medical Child Support Orders Your child may be covered under the Plan even though he or she is not your federal income tax dependent or does not reside with you. The child must be your biological or adopted child. However, it does not matter if the child was born out of wedlock, is not a dependent for federal income tax purposes or does not live with you. The Plan will provide such coverage if it receives a "qualified medical child support order" (QMCSO). A QMCSO is a court or administrative order which provides for child support, is made under the state domestic relations law, and relates to medical benefits. Generally, these orders are obtained by the custodial parent in connection with divorce or separation. However, they may also be obtained by the government. In order for the Fund to honor a QMCSO, the order must specifically refer to the UFCW Local 1776 and Participating Employers Health and Welfare Fund and must contain the following information:    The name and last known mailing address of the participant and of each child covered by the order.    A description of the coverage to be provided, or the manner in which coverage is to be determined.    The period to which the order applies (i.e., start and stop dates). The order cannot require the Plan to provide any type or form of benefit that is not available under the Plan, except as required under the law relating to medical child support in section 1908 of the Social Security Act. When the Fund receives a medical child support order, it will send the participant and each child covered under the order (or the child's parent or legal guardian) notification of the order's receipt and a copy of the Plan's procedures for determining whether the order is "qualified". A copy of these procedures will be furnished to you without charge upon request at any time.) Each child covered under the order (or the child's parent or legal guardian) may designate a representative to receive notices on his or her behalf. If the Plan Administrator rules that an order is not a QMCSO, this determination can be appealed under the Plan's claims review procedure. If the Plan Administrator determines that an order is a QMCSO, it will review procedure. If the Plan Administrator determines that an order is a QMCSO, it will enroll the child (or children) for group health benefits. The Plan will reimburse any reimbursable payments made by the child (or the child's parent or legal guardian) directly to that person. Benefit payments will be made in accordance with any assignment of rights made by or on behalf of the child (or beneficiary of the child) as required by a state plan for medical assistance approved under Title XIX of the Social Security Act. Eligibility for Medicaid or any other state medical assistance plan is not relevant to benefit eligibility or payments. The Plan will reimburse the state for any payments made under a state plan for medical assistance if the state has been assigned the rights of the participant for payment.