Eligibility Rules

Who is Eligible for Coverage?

All participants covered by a Collective Bargaining Agreement between their Employer and the Enterprise Association Metal Trades Branch Local Union 638 will be eligible to participate in the Plan.

When Does My Coverage Become Effective?

Participants will become eligible for coverage in the Welfare Fund on the first day of the second month following the first month his/her employer makes the required contractual contribution.

The contractual contributions levels required to obtain coverage are as follows:

• MCA Service Contractors/Independent Contractors
  • one hour or more per month

[Please Note: Partcipants covered through an agreement with Gilmour Pipe Supply Co., Inc. are not eligible for prescription drug benefits.]

• Parkchester North, Parkchester South, Parkchester Management and Peter Cooper Village/Tishman Speyer
      - at least 150 hours per month
• Reciprocal
      Within Local 638's jurisdiction
      - at least 100 hours per month
  
      Outside Local 638's jurisdiction
      - at least 150 hours per month
• Residential Agreement Contractors
      - at least 150 hours per month
  
  
  [Please Note: Residential Journeyman are covered for all health benefits. Residential Helper/Apprentices and 1st Year Helpers are only covered for Hospital and PPO benefits.]

How Often Is My Coverage Reviewed?

Eligibility for coverage in the Welfare Fund is reviewed on a monthly basis.

How Do I Maintain Coverage?

Participants will continue to be covered as long as their employers make the required monthly contributions on the participant's behalf (see necessary contribution levels in answer to "When Does My Coverage Become Effective?")

When Will a Participant's Coverage Terminate?

A participant's coverage in the Welfare Fund will terminate on the last day of the second month after the last month you are reported for.

What Happens If I Lose Coverage?

A federal law, commonly referred to as COBRA, requires that group health plans offer participants and their families whose coverage would otherwise end, the opportunity for a temporary extension of health coverage called "Continuation Coverage" at their own expense. The Welfare Fund will charge those electing COBRA coverage 102 percent of the Fund's cost of coverage.

If your loss of coverage is due to insufficient hours, you and your qualifying dependents may continue coverage for up to 36 months. Participants considering COBRA coverage must request the extended coverage in writing within 60 days from the date the participant is notified of the right to continue coverage.

If a spouse and dependents lose coverage due to the death of an active or retired participant (which is considered "insufficient hours"), COBRA continuation coverage is available for up to 36 months.

Divorced or legally separated spouses and dependent children who are no longer covered when they reach the age specified in the Plan may extend coverage for up to 36 months. If you become either divorced, legally separated or your children no longer qualify as dependents, you must notify the Fund Office in writing within 60 days to protect their COBRA rights.

Complete details concerning the COBRA coverage are available from the Fund Office.

How Can I Become Covered Again?

Once your coverage terminates, in order to become covered again, you must follow the procedures described in the answer to the question, "When Does My Coverage Become Effective?"

What Happens to My Coverage When I Retire?

Health coverage for a retiree is made available only for the period from Age 62 through the first of the month you become 65 (thereafter Medicare becomes available on a general basis).
Please read the following two sub-sections for details.

Participants that Retire Prior to Age 62:

If you retire prior to Age 62, you must continue your health coverage under COBRA until you attain Age 62. If you are covered under COBRA when you become Age 62, you will become eligible for health and life insurance under the Welfare Fund. If you fail to maintain your coverage under COBRA until you reach Age 62, you will forfeit any retiree coverage. Further, if you exhaust your 36 months of coverage under COBRA prior to Age 62, you will not be eligible for retiree coverage.

Participants that Retire on or after Age 62:

If you retire and receive a benefit from the Pension Fund and were covered the day before your pension effective date (by virtue of employment or COBRA) you will be eligible for health and life insurance coverage.

All coverage in the Welfare Fund for retired participants and the dependents of retired participants will terminate as of the first of the month that the dependent or retired participant becomes 65. However, an eligible dependent, who has not yet attained age 65 and who loses coverage based on the retired participant's loss of coverage may elect to continue health coverage through COBRA.

What Happens if An Active Participant Becomes Temporarily Disabled and Unable to Work?

If an active covered participant becomes temporarily disabled and unable to work, the participant and all eligible dependents will continue to be covered during the period in which the participant is disabled up to a maximum of six months in any twelve month period providing the participant furnishes timely notice and medical proof of such disability. If the participant is still disabled after six months, the participant may continue health benefits for themselves and their dependents by making the required COBRA payment for a maximum period of up to thirty-six months. (Please refer to the COBRA section of this booklet for details.)

Disabled participants who elected to continue their health benefit by making the required COBRA payment, and who subsequently qualify for Medicare during such thirty-six month period, shall lose their coverage under COBRA rules. However, they will be permitted to continue to make COBRA payments for their dependents for the remainder of the self-payment period.

What Happens if I Enter the Uniformed Services?

If you are drafted, activated from reserve status or enlist into the Uniformed Services of the United States (which includes the Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service commissioned corps, the Army National Guard and Air National Guard), your coverage as an active participant will terminate in accordance with regular eligibility rules (see "When Will a Participant's Coverage Terminate"). However, if you were a covered participant on the date of your entry, the following is applicable:

• If you are on active military duty for 30 days or less, you will continue to receive medical coverage in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).
• If you are on active duty for more than 30 days, USERRA permits you to continue medical, prescription and dental coverage for you and your dependents at your own expense for up to 24 months provided you enroll for coverage. This continuation of coverage operates in the same way as COBRA. (Please refer to the COBRA section of this booklet for details.) In addition, your dependents may be eligible for health care under the Civilian Health & Medical Program of the Uniformed Services (TRICARE). This Plan will coordinate coverage with TRICARE if your dependents are enrolled in COBRA with the Welfare Fund (see the "Coordination of Benefits" section of booklet.).
• When you return to work after receiving an honorable discharge, your full eligibility will be reinstated on the day you return to work with a participating employer, based upon time spent on military duty according to the following schedule:
  • At the beginning of the full regularly scheduled working period on the first calendar day following discharge (plus travel time and additional eight hours) if the period of service was less than 31 days.
  • 14 days from the date of discharge, if the period of military service was 31 days or more, but less than 181 days (assuming you either returned to work or applied for employment with a signed employer).
  • 90 days from the date of discharge, if the period of military service is more than 180 days (assuming you either returned to work or applied for employment with a signed employer).

If you are hospitalized or convalescing from an injury resulting from active duty, these time limits may be extended for up to two years. Please contact the Fund Office for more details.

Are All Of My Family Members Eligible For the Plan's Coverage?

Your legal spouse is eligible for coverage through the Welfare Fund. Your spouse will lose coverage on the day after the date of a divorce or legal separation is effective.

Your unmarried children will be considered qualifying dependents and eligible for coverage through the Welfare Fund in accordance wiht the following:

1. the child has not completed the end of the calendar year during which they became 19, or
2. the child has completed the end of the calendar year during which they became 19, but has not completed the end of the year during which they became 23, is primarily dependent on you for financial support and attends an accredited institution of higher education or other institution offering degree or certificate upon program completion on a full-time, day student basis as his or her principal activity. (The term "full-time student" will mean being registered for not less than 12 course credits per semester. If the institution establishes full-time status by a method other than semester credit hours, the Fund reserves the right to determine whether the student qualifies as a dependent.), or
3. children who complete the end of the calendar year during which they became 19 remain coverd if they are incapable of self-support because of mental illness, developmental disability, mental retardation (as defined in the mental hygiene law) or physical handicap provided the incapacitating condition started before dependent status would otherwise have ended. To continue coverage beyond age 19, an "Affidavit of Dependency for Mentally or Physically Handicapped Children", which includes proof of incapacitation from the dependent's physician or physicians, must be submitted. Proof of incapacitation must be submitted to the Trustees as often as requested. An independent examination must be permitted if the Trustees so request. In addition, proof of dependent status from the Internal Revenue Service income tas filings must be made available to the Trustees as often as so requested. The affidavit must be filed with the Trustees prior to date such a child attains age 19 in order to qualify for continuance of coverage.
   
   If your child is employed where other group coverage of a non-contributory nature is available, the Welfare Fund provides secondary coverage only.

The term "children" will include:

• your own or legally adopted children,
• children in your custody while awaiting final legal adoption,
• your stepchildren who are primarily dependent upon you for financial support, (an Affidavit of Dependency must be completed), and
• any other children related to you by blood or marriage who live with you in a regular parent-child relationship and are primarily dependent upon you for financial support (an Affidavit of Dependency must be completed).

Excluded: Parents, grandparents, nieces, nephews or grandchildren, even though they may reside in the participant's household and be dependent upon the participant for support and maintenance, are not covered under the Pan.

What Happens To My Family's Health Coverage If I Die?

Upon the death of a covered participant, active or retired, the coverage for the surviving spouse and any dependent(s) terminates as of the member's death date. (see answer to "What Happens If I Lose Coverage?" regarding dependent COBRA coverage for dependents of deceased participants.)