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_________________________________________________________________________ INDUSTRY BOARD ANNOUNCEMENTS: ____________________________________________________________________________________
8th Annual Health & Employee Benefit Fair
On Wednesday, October 17, 2007 from 3:30 to 6:30 P.M. the Plumbers Local Union No. 1 Fund Office will hold it's 8th annual Health & Employee Benefit Fair at the Plumbers Local 1 Trade Education Center in Long Island City. The Fair will provide members with valuable information on a wide range of employee benefit matters. Pension plan representatives, and 401K plan representatives will be available to provide information to members about these important benefits. Network Health Providers will be present to answer questions. Free Blood Pressure tests, Blood Sugar tests, and Body Weight Composition screening will be available as well as refreshments, giveaways, and raffles. We have added new features to the fair this year. Be sure to check it out October 17, 2007 at 3:30!
____________________________________________________________________________________ Health Care Service Providers
November 2004 To all Eligible Members: As you were recently informed, the Welfare Fund Board of Trustees amended the Welfare Plan’s network of healthcare providers that are available under the Plumbers Local Union No.1 Welfare Fund. Effective January 1, 2005 Better Health Advantage (BHA), MagnaCare, and Syntonic Systems, Inc. will no longer provide healthcare services to the Plumbers Local Union No.1 Welfare Fund. As a result of these changes, Empire Blue Cross/Blue Shield and Group Health Incorporated (GHI) will each offer Major Medical and Hospital Network Service Providers under their Preferred Provider Organization (PPO). Therefore, members that are currently enrolled under Better Health Advantage (BHA) or not enrolled in a network must elect to enroll with Empire Blue Cross/Blue Shield, or Group Health Incorporated (GHI). If you are currently enrolled with Empire or GHI you will be given the option to change your network, but you can, of course, elect to remain with Empire or GHI. However, you must still complete the enclosed Universal Welfare Enrollment Form.
Through the new Empire and GHI Preferred Provider Organization (PPO) Networks you will continue to have freedom of choice regarding where to seek medical care. Empire and GHI will each offer a network of healthcare providers that will be available to you through their PPO. This network includes doctors, hospitals, laboratories and other medical facilities that provide healthcare services. Whether you elect to enroll in Empire or GHI, when you need healthcare services, you have a choice. Depending on the healthcare services you need, you may get healthcare from providers who participate in your PPO or you can use outside providers. If you receive services from an outside provider you will need to file a claim to be reimbursed by the PPO. You are covered for medically necessary services under the terms of the Plan no matter which you choose. Choosing to receive health care services from a participating doctor, hospital or lab will limit your out of pocket expenses. However, if you chose to use a non-participating doctor, hospital or lab you will be responsible for an annual deductible and coinsurance, plus any amount above the allowed amount, and you will also need to file a claim to be reimbursed by your PPO. Some services are only available in network.
In-Network services are services provided by a doctor, hospital, or healthcare facility that has been selected by the PPO to provide care to our members. When you choose in-network care, you get these advantages: * You can choose any participating provider from the PPO in New York State or the national network of the PPO. * You do not need a referral to see a specialist, so you direct your care. * Benefits are paid after a small co-payment for the office visit and also for certain other services. * Benefits are available for a broad range of healthcare services, including visits to specialists, physical therapy, and home health care. * You usually do not have to file a claim.
Out-of-Network services are healthcare services provided by a licensed provider outside of the PPO network. For most covered services you can choose in-network or out-of-network. However some services are only available in network. When you use out of network services: * You pay an annual deductible and coinsurance, plus any amount above the allowed amount (the maximum the PPO will pay for covered service). Fund pays claim based on Usual and Customary Rates (UCR). * You will usually have to pay the provider when you receive care. * You will need to file a claim to be reimbursed by the PPO. * For doctor, hospital or healthcare facility services received from outside providers, the benefits paid are subject to an annual deductible of $200 per individual/$500 per family. * After the deductible, the Plan pays 80% of the first $5,000 per member or $12,500 per family of eligible expenses per calendar year and the Employee is responsible for the balance, thereafter 100% of eligible expenses are paid for that calendar year.
If you live or travel outside of your PPO’s local operating area, Empire and GHI each provide a network of participating doctors, hospitals or labs through the following programs.
Empire Blue Cross/Blue Shield BlueCardÒ PPO Program - Nationwide, Blue Cross and Blue Shield plans have established PPO networks of physicians, hospitals and other healthcare providers. By presenting your Empire I.D. card to a provider participating in the BlueCardÒ PPO Program, you receive the same benefits as you would receive from an Empire PPO network provider. Call 1-800-553-9603 or visit www. empireblue.com to locate participating providers in or outside of Empire’s operating area.
Group Health Incorporated (GHI) QualCare and MultiPlan Network - The QualCare network www.qualcare-usa.com offers New Jersey residents a comprehensive network of providers, including hospitals, primary care physicians, and specialists. Residents outside New York and New Jersey use MultiPlan. If you live outside NY and NJ, you have access to the MultiPlan network www.multiplan.com of providers. The MultiPlan PPO network includes acute care hospitals, ancillary facilities, and practitioners in 48 states.
As you can see, Empire and GHI will each offer Major Medical and Hospital networks on a National level. Therefore, if you elect to enroll with Empire or GHI you will continue to have freedom of choice regarding where to seek medical care. However, managing your health includes getting the information you need to make informed decisions, and making sure you get the maximum benefits the Plan will cover. To help you manage your health your PPO provides important Medical Management services. Your PPO’s Medical Management Program is a service that precertifies hospital admissions and certain treatments and procedures to ensure that you receive high quality care for the right length of time, in the right setting, with maximum coverage. In most situations, you or someone acting on your behalf need to call your PPO’s Medical Management Program to precertify hospital admissions and other services; if you fail to do so, benefits may be reduced (see benefit summary). In other cases the vendor or provider of services needs to call.
For a description of benefits available under the Empire and GHI PPO, see the enclosed Benefit Summaries. Please call your physician to determine if they participate in the network that you are choosing or visit the websites listed above for an up to date listing on participating providers and health care facilities. Once your choice is made you must complete the enclosed Universal Welfare Enrollment Form and select Empire or GHI as your Preferred Provider Organization (PPO). It is important that you include the names, dates of birth and social security numbers of all of your dependents. It is also necessary for you to provide information on any other medical insurance coverage available to you or your dependents. A self-addressed postage paid envelope has been included for your convenience. Failure to return the requested Universal Enrollment Form by November 19th, 2004 will result in a delay in your claims processing until the information is received.
As you know, open enrollment for the Welfare Fund is held in October each year during which you may change your Medical Network Election. Any changes made will be effective January 1, 2005. A summary Plan Description, new Medical/Hospital identification cards and related information will be mailed to all eligible members prior to January 1st. Therefore, at this time please return the enclosed election form no later than November 19th, 2004.
The above changes do not apply to members enrolled in the Fund’s Medicare Wrap-Around retiree continuation of coverage. The Board of Trustees appreciates your cooperation in this process. As always, if you have any questions regarding Enrollment, please contact the Fund Office. Sincerely, Plumbers Local Union No.1 Welfare Fund Board of Trustees ____________________________________________________________________________________
Plumbers Local Union No.1 Welfare Fund November 2004 - Health Care Service Providers Q&A
Q1. Do I need to complete and return a Universal Welfare Enrollment Form if I am currently enrolled with GHI or Empire and I elect to remain with GHI or Empire? Yes. A complete Universal Welfare Enrollment Form must be returned to the Fund Office in the enclosed postage paid return envelope by November 19, 2004. It is important that you include the names, dates of birth and social security numbers of all your dependents. It is also necessary for you to provide information on any other medical insurance coverage available to you or your dependants. Failure to do so will result in a delay in your claims processing until the information is received.
Q2. What if I’m currently enrolled in Better Health Advantage (BHA) or No Network? Do I have to enroll with GHI or Empire? Yes. If you are currently enrolled under BHA or not enrolled in a network you must elect to enroll with GHI or Empire (See Q1 above).
Q3. How will my Hospital claims be processed once I enroll with GHI or Empire? GHI and Empire will each offer Major Medical and Hospital networks on a national level. Therefore, in-network and out-of-network Hospital claims will be processed by the PPO you elect. As a reminder, if you receive services from a non-participating provider you will need to file a claim for reimbursement by your PPO. You will also be responsible for an annual deductible and coinsurance, plus any amount above the allowed amount.
Q4. Will I continue to have a freedom of choice regarding where to seek medical care? Yes. Depending on the healthcare services you need, you may choose to get healthcare from providers who participate in your PPO or you can use non-participating providers. Some services, however, are only available in network (See GHI & Empire’s Benefit Summary).
Q5. Do I need to file a claim if I receive services from a non-participating provider? Yes. If you receive services from a non-participating provider you will need to file a claim form to be reimbursed by your PPO. However, you will be responsible for an annual deductible and coinsurance, plus any amount above the allowed amount.
Q6. How will out of network claims be reimbursed? For doctor, hospital or healthcare facility services received from outside providers, the benefits paid are subject to an annual deductible of $200 per individual/$500 per family. After the deductible, the Plan pays 80% of the first $5,000 per member or $12,500 per family of eligible expenses per calendar year based on Usual and Customary Rates (UCR) and the Employee is responsible for any amount above the allowed amount (the maximum the PPO will pay for covered services).
Q7. What if I received services from a non-participating provider prior to January 1, 2005? Claims incurred but not filed prior to January 1, 2005 will require processing. Therefore, claims incurred for services provided by non-participating providers prior to January 1, 2005 should be submitted to Syntonic Systems, Inc (Medical claims) and Castrovinci Associates, Inc. (Hospital claims). Both Syntonic and Castrovinci will continue to process such claims until further notice.
Q8. Are in-network services available if I live or travel outside of my PPO’s operating area? Yes. GHI and Empire will each offer Major Medical and Hospital networks on a national level. (See letter for related information on the GHI and Empire National Network).
Q9. Do I need to precertify certain medical services? Yes. To help you manage your health your PPO provides important Medical Management services. Your PPO’s Medical Management Program is a service that precertifies hospital admissions and certain treatments and procedures such as MRI’s and MRA’s. To ensure that you receive high quality care for the right length of time, in the right setting, with maximum coverage. In most situations, you or someone acting on your behalf need to call your PPO’s Medical Management Program to precertify hospital admissions and other services (see enclosed benefit summary); if you fail to do so, benefits may be reduced by 50% up to $2,500 for each admission, treatment or procedure.
Q10. In reviewing the GHI and Empire Benefit Summary it appears that the description of benefits are equal. How do I go about choosing between GHI and Empire? Make a list of doctors and facilities that you currently use to see which PPO they belong to. Choose the one that is best for you. Fill out and send your enrollment form to the Fund Office in the enclosed postage paid return envelope by November 19, 2004.
Remember, check with your doctor or service provider to see if they participate in the network that you are electing. You can also contact GHI or Empire directly for information on participating providers.
· Empire Blue Cross/Blue Shield Blue Card PPO
1-800-662-5193 (press option No.2), In NYC www.empireblue.com Outside NYC www.bluecrossblueshield.com
· GHI (Qualcare/ Multipan) PPO
In NYC go to www.ghi.com In NJ go to www.qualcare-usa.com Outside NY & NJ go to www.multiplan.com
Q11. Will this change apply to members enrolled in the Fund’s Medicare Wrap-Around retiree continuation of coverage? No. Changes to the Medicare Wrap-Around continuation of coverage will be provided under a separate notice.
Q12. Will I receive a new Identification Card? Yes. New Medical/Hospital identification cards and related information will be mailed to all eligible members prior to January 1, 2005.
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