A violent, external, unexpected and unintentional event.
A weekly dollar benefit paid to the employee if he/she is off work due to an accident or sickness.
A claim that is denied in whole or in part.
An amount the Plan has determined to be the cost for a particular service. This may be called “eligible expense”, “payment allowance” or “negotiated rate.”
A request by a Fund participant or beneficiary that the Fund and/or Board of Trustees reconsider the claim under circumstances in which the initial claim was denied in whole or in part.
A legally operated institution, other than a hospital, that provides care and treatment through medical, diagnostic or surgical facilities on the premises, under supervision of a physician and approved by the Board of Trustees. A determination by the Board of Trustees as to whether or not an institution constitutes an approved facility is definite.
When a provider bills for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill for the remaining $30. A preferred provider may not balance bill for covered services.
For the purposes of this plan a beneficiary is someone who is chosen by you to receive the Death Benefits.
Note: The Department of Labor (DOL) uses the word “beneficiary” to describe what the Fund Office defines as Spouses and Dependents.
A process to help the participant obtain or be referred to clinically appropriate treatment for mental health or substance abuse issues by a qualified and covered mental health professional.
A claim for benefits is a request by a participant or beneficiary that certain benefits, which the participant or beneficiary believes are covered under the terms of the Fund, be paid by the Fund.
Coordination of Benefits. If you are entitled to other health care coverage in addition to EWTF coverage (including Medicare), your benefits are coordinated by submitting your claim first to what is called the primary plan. If any charges remain to be paid, then they are submitted to the secondary plan. It is the participant’s responsibility to keep the Fund Office informed of any changes in any other health care coverage.
Acronym for the federal law “Consolidated Omnibus Budget Reconciliation Act of 1985”. This law allows you and your eligible dependents to continue health care coverage at your own expense under certain circumstances when health care coverage would otherwise end.
Your share of the costs of a covered health service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the Plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The Plan pays the rest of the allowed amount. (Refer to Patient’s Portion below.)
Fixed amount you pay for a covered health care service usually when you receive the service. The amount can vary by the type of covered health care service. For example, your co-pay for a prescription drug is fixed. Your co-insurance for a medical visit is not fixed because it is a percentage of the charge.
Only those expenses for medically appropriate treatments, services and supplies relating to the benefits provided by this Plan that are performed, recommended, approved or prescribed by the attending physician and are not excluded under the terms of the Plan.
This is an amount determined by the Board of Trustees that must be satisfied before EWTF pays a percentage of the allowed amount. A new deductible is effective each January 1. The current deductibles are:
For the purposes of this plan dependent children are your fully dependent unmarried children under age 26. Refer to What’s New in Health Benefits for information concerning coverage for dependents up to age 26.
“Children” includes natural children, stepchildren, adopted children, children placed with you for adoption, foster children, and those children for whom you are the legally appointed guardian, provided you can show proof of parental responsibility.
Explanation of Benefit(s).
This federal law ensures that you have certain rights and protections under the Employee Retirement Income Security Act of 1974. Refer to the Summary Plan Description or the Department of Labor (DOL) website for more information.
A list of drugs that health plans use to administer prescription benefits. Formulary drugs are also known as preferred brand drugs.
Generic drugs contain the same active ingredients in the same dosage forms and strengths as their brand alternatives but are significantly less expensive. The U.S. Food and Drug Administration approves both generic and brand drugs before they are marketed in the United States.
A health plan that was in existence on March 23, 2010, the enactment date of the PPACA, is referred to under the PPACA as a “grandfathered health plan.” As permitted by the PPACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Fund may not include certain consumer protections of the PPACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the PPACA, for example, coverage of dependents up to age 26.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Fund Manager at: Peter Klein, Electrical Welfare Trust Fund, 10003 Derekwood Ln, Ste. 130, Lanham, MD 20706-4811, (301) 731-1050. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.
The Plan provides benefits for employees whose classification is house wiring specialists. Their employers are contributing to the Plan on their behalf under the residential CROP agreement..
This is the acronym for Health Care Cost Containment Coalition. This coalition was formed to have more bargaining power when negotiating different fees with the PPO’s, PBM’s, Vision and Dental groups. Currently there are over 60 groups in the HCCCC and include most of the building trades in the Washington, DC area.
Health Insurance Portability and Accountability Act of 1996. This federal law requires that the Plan provide you with a Certificate of Creditable Coverage that indicates the period of time you and/or your dependents were covered under the Plan. This law also provides regulations on privacy, security and standards for electronic transmissions.
Nursing care or special therapy in the home usually following hospitalization.
A recognized institution which provides care for the terminally ill.
Hours you work in excess of the required 135-hour minimum each month are credited to a “bank” so that you may apply those hours to maintain your coverage if you work fewer than 135 hours in a later month.
This is a group health plan that the Board of Trustees determines is temporary and does not provide adequate and similar coverage to that which is available under the EWTF plan, nor does it have continuation rights that are substantially similar to the rights under this Plan. This definition is used in determining coverage for a Surviving Spouse.
Only expenses for treatments, services and supplies provided by a hospital, physician or other appropriately licensed provider in the diagnosis or treatment of an illness or injury may be considered “medically necessary.” In addition, the treatments, services and supplies must be:
consistent with the diagnosis and treatment of the condition; in accordance with good medical practices;required other than for the convenience of the patient or provider; and the most appropriate treatments, services or supplies that may be provided safely. Care as a hospital inpatient is considered medically necessary only if the care cannot be provided safely on an outpatient basis.
These are brand drugs that are not on the preferred list maintained by Caremark. These drugs typically cost more than their preferred brand alternatives, and are often more expensive because their manufacturer markets them heavily.
The out-of-pocket maximum is a catastrophic benefit. The plan limits the amount of eligible expenses you have to pay each year. After you pay the out of pocket maximum of $10,000 per family, EWTF will pay 100% up to the allowance of your eligible expenses for the rest of the calendar year.
A period of disability normally begins at the time you become disabled and ends when you are no longer disabled.
Permanent and total disability is the inability to perform the duties of your job for 12 months, and, beyond the first 12 months, the complete inability to engage in any occupation or employment for which you are fitted by reason of education, training or experience.
A physician is a doctor, chiropractor, podiatrist, psychologist, optometrist or surgeon licensed to practice medicine or perform surgery under the laws of the state where such services are performed, and who is acting within the scope of his license. A duly licensed practitioner, who, under the supervision of a physician, performs services that would be covered under this Plan if performed by the physician, is also treated as a “physician.”
Most claims are post-service claims where you are requesting payment to your doctor or other medical provider, or reimbursement to yourself of some or all of the charges previously incurred for medical services that have already been rendered.
Pre-certification is a requirement that certain services are pre-approved before EWTF will pay benefits.
The dental benefits under this Plan require that a pre-determination is made when the billed amount is $600 or higher.
Anytime you and/or your family members require inpatient hospitalization, you should contact UHC 48 hours prior to a scheduled hospital admission. For emergency admissions, call within two business days following the admission.
Services for physical, occupational, and speech therapy plus chiropractic care require pre-notification by UnitedHealthcare.
Preferred brand drugs are “formulary” drugs that health plans use to administer prescription benefits which give the greatest value for your dollar.
Preferred Provider Organization (PPO)
A Preferred Provider Organization is an organization that has a network of participating medical or dental providers that have agreed to negotiated rates for services rendered. OneNet PPO is EWTF’s current dental Preferred Provider Organization. These negotiated rates are passed on to the participants so that their out-of-pocket expense is less. By using a dental provider in a PPO network you are also saving the Fund money.
These are claims that are submitted before services are rendered, but do not meet the definition of “urgent care claims.” A pre-service claim may be submitted orally or in writing by a participant or authorized representative, including a participant or beneficiary’s doctor.
Protected Health Information is a provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Your legally married spouse who resides with you.
A widow or widower of an Active Employee, Retired Participant or a Non-Bargaining Unit Employee.
An urgent claim is a claim for medical care or treatment that, if normal pre-service standards are applied:
would seriously jeopardize the life or health of the claimant; or the ability of the claimant to regain maximum function; or in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
An active participant is anyone working in a job for which contributions are required to be made to the Plan. You become an active participant on the first day you work on a job for which contributions are required to be made. You cease to be an active participant on December 31 of any year in which you do not work at least 400 hours.
Benefit units are used to determine the amount of your pension. There are two types of benefit units:
Past Benefit Units for employment under a collective bargaining agreement with Local 26 or employment within its jurisdiction before July 1, 1961; and Future Benefits Units for covered employment after June 30, 1961.
The agreed upon contract that is the result of negotiations between the contributing employers and a labor union (Local Union No. 26, IBEW)
An employer who contributes to the Plan is called a Contributing Employer.
You are covered by the Pension Plan if you are an employee working under a collective bargaining agreement between a signatory employer and Local Union No. 26, IBEW, and that agreement provides for contributions to this Pension Fund. You are also covered if you are an employee of the Local Union, the Pension Fund, the Electrical Welfare Trust Fund, the Electrical Workers Local No. 26 Joint Apprenticeship and Training Trust Fund or another organization that has executed a valid agreement to participate with the Board of Trustees. Work covered by the Plan is called Covered Employment.
The Deferred Pension provides for employees who have a vested right to a pension but leave active employment prior to retirement. It is called a Deferred Pension because payments will not begin, at the earliest, until you reach age 55. If you elect to receive a Deferred Pension beginning before Normal Retirement Age (62), your monthly benefits will be reduced.
A defined benefit plan promises a specified monthly amount at retirement. Benefits are calculated using a formula that includes working the minimum number of hours (1600 per year) multiplied by the unit amount that is determined by the Board of Trustees. The Electrical Workers Local No. 26 Pension Trust Fund is a defined benefit plan.
This type of Plan does not promise you a specific amount of benefits at retirement but rather is based on contributions made to the Plan. The Electrical Workers Local Union No. 26 Individual Account Plan is a defined contributions plan.
Disability Pension is a benefit of the Plan that allows participants who
have at least 5 years of vesting service, and
have become totally and permanently disabled from an unavoidable cause while working in Covered Employment or within 6 months after you leave Covered Employment, and can furnish satisfactory proof of their total and permanent disability.
You may retire under this Plan as early as age 55 if you are an active participant, you are vested and have earned the right to a pension. If you choose Early Retirement, your monthly benefits will be reduced from the Normal Pension unless you meet the requirements of the “Rule of 85.”
This pension is payable to the surviving spouse of a deceased employee who is eligible for (but who had not yet received) a Normal, Early or Deferred Pension.
This acronym is for the federal law entitled “Employee Retirement Income Security Act of 1974.” Refer to the Department of Labor (DOL) website for more information or the current Summary Plan Description.
This bonus is a one time payment of $2500. Certain requirement must be met to qualify for this bonus. You must:
A Normal Pension under this plan is active participants who have at least 5 years of vesting service as of the date you reach age 62 or, if later, the date on which you have at least 5 years of vesting service.
Pension Benefit Guaranty Corporation (PGBC) is a U.S. government corporation that insures this pension plan.
A Permanent Break in Service is an absence from covered employment that may cause you to lose your years in vesting service resulting in cancellation of your benefit units.
Qualified Domestic Relations Order (QDRO). This Plan is required by law to honor a QDRO to settle property rights, pay child support or pay alimony in a divorce. Reciprocal Employees who decide to go to work out of another IBEW local can reciprocate their hours to their “home” Pension Plan in certain situations. To find out more about reciprocating your pension contributions, visit the ERTS website.
This rule is for active participants who retire after January 1, 1997 on an Early Retirement Pension and their age at their last birthday plus the number of years of vesting service equals or exceed 85, the benefit will not be reduced because of early retirement but will be payable in the same amount as the Normal
The Fund has been qualified by the Internal Revenue Service, which means that the Plan has met the requirements of the Internal Revenue Code and therefore may receive tax advantages.
Temporary (One-Year) Break in Service A Temporary (One-Year) Break in Service occurs if you fail to work at least 400 vesting hours of service in any Plan year.
This term is used to indicate the rules for earning the right to a Pension under this Plan. Vesting means you have worked for 5 years with a minimum of 1600 hours each year. Once you are “vested” you have earned the right to a pension that cannot be taken away.
Years of Vesting Service are used to determine your eligibility for the various pensions under the Plan. There are two types of vesting service:
Past Years of Vesting Service for employment under a collective bargaining agreement (CBA) with Local 26 or employment within its jurisdiction before July 1, 1961; and
Future Years of Vesting Service for covered employment after June 30, 1961.
The accumulated share is the resulting value of the following formula:
The value of your Individual Account as of the last valuation date PLUS Employer contributions and changes in the market value of your investment options since the last valuation date MINUS Any benefit payments made from the account and a share of operating expenses of the Fund since the last valuation date
The agreed upon contract that is the result of negotiations between the contributing employers Local Union No. 26, IBEW.
Contributions are made to the Individual Account Plan on your behalf under the terms of the collective bargaining agreement between IBEW Local 26 and signatory employers or pursuant to an authorized written agreement established between the Trustees and certain other employers. The amount of the contribution is specified in the collective bargaining agreement or other authorized written agreements applicable to you and can change from time to time.
You are eligible to participate in the Individual Account Plan when you begin working in a job covered by a collective bargaining agreement (or other written agreement) between your employer and Local Union No. 26, IBEW that requires your employer to make contributions to the Plan on your behalf.
You are not eligible for Plan coverage if you are not a member of a bargaining unit represented by Local 26. In addition, you are not eligible for coverage if you are a sole proprietor, are a partner in partnership, or own or control at least 15% of any class of the outstanding stock of an incorporated contributing employer.
Once you become covered by this Plan, it is your duty to report to the Trustees, in writing, any change in your employment status that may make you ineligible to participate under this rule.
A defined benefit plan is a plan that promises you a specific amount at retirement. The Electrical Workers Local Union No. 26 Pension Plan is a defined benefit plan.
This type of Plan does not promise you a specific amount of benefits at retirement. The benefit amount is based upon investment earning or losses and employer contributions. The Electrical Workers Local Union No. 26 Individual Account Plan is a defined contributions plan.
This acronym is for the federal law entitled “Employee Retirement Income Security Act of 1974”. ERISA sets minimum standards for participation, vesting, benefit accrual and funding. Refer to the Summary Plan Description or the Department of Labor (DOL) website for more information concerning your rights under this law.
An Individual Account is an account established for each employee covered by the Plan. The accumulation in your Individual Account is valued according to the Plan rules.
You have several choices of funds in which you may elect to invest the monies in your account. These choices are investment options picked by the Board of Trustees with advice from Fund Consultants. Refer to Summary Plan Description or the Fidelity website for information about the investment options that are available.
Your retirement benefits are intended for your personal financial security. They cannot be sold, borrowed against, garnished or attached in anyway. However, the plan is required by law to honor a Qualified Domestic Relations Order (QDRO) and a federal tax lien against your benefits.
You are covered by the Plan if you are working on a job covered by a collective bargaining agreement between your employer and Electrical Workers Local No. 26, IBEW or some other written agreement that requires your employer to make contributions to the Fund on your behalf.
This benefit is a monthly annuity for your legally married spouse’s lifetime if you should die before her/him that is the actuarial equivalent, as defined by the Plan, of not less than 50% of your accumulated share determined on your date of death.
Qualified Domestic Relations Order (QDRO). This Plan is required by law to honor a QDRO to settle property rights, pay child support or pay alimony in a divorce. Summary Plan Description (SPD) The Summary Plan Description is a description of benefits of the Electrical Workers Local No. 26 Individual Account (IA) Plan. The current SPD has a blue column on the left hand side and white cover with red and blue lettering. The introduction page is dated May 2003.
The Fund has been qualified by the Internal Revenue Service, which means that the Plan has met the requirements of the Internal Revenue Code and therefore may receive tax advantages.
You are considered totally and permanently disabled if you are unable to work in covered employment as a result of an injury or illness that is likely to continue for the rest of your life. The Trustees make the determination of your total and permanent disability. The Trustees may:
rely on a Social Security Disability Award;
require you to submit medical reports; and/or
undergo a physical exam by a physician of the Trustees’ choosing.