- The Plan defines “work” as a job you perform in covered employment for an employer who is required to make contributions to the Fund on your behalf. Your employer must report and contribute for the hours you work in order for you to be eligible for coverage.
- Hours you work that are not needed or used to provide healthcare coverage are credited to your “Hours Bank.” These include all hours worked when the 135 hours threshold is not met to earn coverage and all hours worked in excess of the required 135-hour minimum each month. You may apply those hours to maintain your coverage if you work fewer than 135 hours in a later month.
If you or a covered dependent enrolls in a separate Medicare Part D prescription program, you or your dependent will permanently lose your prescription benefits with EWTF.
You must enroll in Medicare Part A and Part B three months before your 65th birthday. To enroll:
visit the Medicare website at www.medicare.gov
visit an office of the Social Security Administration
This Plan does not cover expenses that Medicare does not cover.
Surviving spouse coverage:
- When Surviving Dependent Coverage ends, your dependents will be eligible to obtain coverage through COBRA for up to 36 months.
Eligibility for Active Electrical Workers
You are an Active Electrical Worker if you work in covered employment for an employer who is required by a collective bargaining agreement with the Union to contribute to the Fund on your behalf.
Initial Eligibility Requirements
Once your employer has reported and paid contributions for at least 135 hours of covered employment in one payroll month, you will be eligible for coverage under this Plan. The payroll month in which the work was performed and contributed for is called the Qualifying Month.
Your actual coverage starts on the first day of the third calendar month after the Qualifying Month. The calendar month in which you are entitled to receive benefits is called the Benefit Month. Eligibility is determined on a monthly basis.
The delay between the time you work and the time you are eligible for benefits is due to the delay in reporting and contributing for the time you worked. This also delays the date your benefits end when you are no longer working for a contributing employer.
Remaining a Plan Participant
After you become a Plan “participant,” you remain a participant by working at least 135 hours (for which your employer has contributed and reported) in your Employer’s payroll month. For each Qualifying Month during which you work at least 135 hours, you have Plan coverage for the month that begins three months later, as shown in the chart below:
|If You Complete At Least 135 Hours of Work in Covered Employment During the Qualifying Month of:||You Have Plan Coverage During the Benefit Month Of:|
There may be times that you work more than 135 hours a month and other times that you work less than 135 hours.
If you work more than the required 135 hours in a month, all hours in excess of 135 are credited to your hours bank the following month. If you work less than 135 hours in a month, all hours worked for that month are credited to your hours bank the following month. You may draw on the hours in your bank to prevent a lapse in coverage in subsequent months in which you lack the minimum required hours; however, you may not apply the hours from your bank to a month that happened in the past. The maximum number of hours you can bank is 810. (Active Electrical Worker Employees who become Retired Employees are eligible to use a maximum bank of 405 hours.)
If you die while you are an active participant, any of your dependents that are eligible under this Plan at the time of your death may use any remaining hours in your hours bank.
The following example illustrates typical eligibility bank account activity:
|Month||Hours Worked ||Excess Over 135||Bank of Hours|
If you leave covered employment, and cease to be covered, your remaining banked hours are held for a maximum of 24 months.
Hours Bank Donation Program
Effective July 1, 2020, the Board of Trustees of the Fund has established an Hours Bank Donation Program (“Program”) pursuant to which Fund participants may donate hours currently held in their own individual Hours Banks under the Fund’s Plan of benefits to the Fund’s newly created Hours Bank Donation Pool Account (“Pool Account”). The Pool Account will be used to provide donated Hours to participant applicants who would otherwise lose eligibility for coverage under the Fund due to reasons specifically designated by the Trustees from time to time as being subject to the Program.
Participants will be able to donate Hours, and apply to receive donated Hours, only during the time periods specifically designated by the Trustees. For example, Hours may be donated, and applications for donated Hours may submitted, through December 31, 2020 for the specific purpose of extending the eligibility of participants who otherwise would lose such eligibility because:
- The participant has been advised by a physician to self-quarantine due to COVID-19, including if a physician advises that the participant has a pre-existing condition that presents undue risk if s/he were not subject to self-quarantine; or
- The participant is providing necessary care for an individual who has been advised by a physician to self-quarantine due to COVID-19, including if a physician advises that the individual under the participant’s care has a pre-existing condition that presents undue risk if the individual were not subject to self-quarantine.
Donating Hours: In order to donate hours to the Pool Account from your personal Hours Bank, you must meet the following criteria, which are designed to help your fellow participants while protecting the long-term financial health of the Fund:
- You must currently have a full personal Hours Bank (810 Hours);
- You may donate up to a maximum of 270 Hours (two months of coverage) from your personal Hours Bank;
- You may donate Hours in one month (135 Hours) or two month (270 Hours) increments; and
- Once you have made a donation of Hours, you may not make another donation until your personal Hours Bank is full again.
Any participant who would like to donate Hours from his/her personal Hours Bank under the Fund to the Pool Account should contact the Fund office at email@example.com.
Applying to Receive Donated Hours: Any participant who would like to apply for continued eligibility through use of Hours held in the Pool Account must contact the Fund office at firstname.lastname@example.org In order to be eligible to receive Hours from the Pool Account, a participant applicant must:
- Have been eligible for coverage in the month before the extended eligibility period would begin (for example, a participant applying for extended eligibility effective July 1, 2020 must have been eligible for coverage under the Plan as of June 30, 2020);
- Complete the necessary application form; and
- Provide any documentation required by the Fund in support of the participant’s application for donated Hours.
If a participant is determined to be eligible, the participant and his eligible dependents, if any, will receive a one-time eligibility extension of up to two months of Plan coverage, subject to the availability of Hours in the Pool Account. Applications for continued eligibility through use of the Pool Account will be processed on a first come first serve basis in the event that the Pool Account does not contain sufficient Hours to cover all eligible participant applications.
All applications must email to email@example.com for inclusion in the Program. Submission of an application under the Program is not a guarantee that extended cover age will be provided. Further, in the event that extended coverage is provided and the Fund later determines that the participant did not meet the requirements for coverage, the participant will be obligated to refund the amount of any claims paid by the Fund on his behalf or on behalf of his dependent(s) during the extended coverage period.
Once you have received two months of extended eligibility through use of the Pool Account, you may not receive any further extension of eligibility through this Program. The Program is intended as a temporary measure to assist participants for a limited time period while they locate a more permanent source of health coverage.
Making Payments to Maintain Your Eligibility
If you were eligible for Plan coverage as an Active Electrical Worker and you no longer have 135 hours in your bank of hours, you may be able to self-pay to continue your coverage under the Plan for a limited time if your coverage otherwise would lapse. You may make self-payments to continue your coverage if you have at least one hour in your hours bank or you worked at least one hour of covered employment in the preceding month.
Self-payment rates are set by the Board of Trustees and may be changed from time to time based on Plan benefit levels and costs. Contact the Fund Office for the current self-payment rates. Self-payment amounts are due in the Fund Office at dates specified by the Board of Trustees.
Delinquent Contributions from Employers
If your employer does not make the required contributions on your behalf, you and your family will lose your right to benefits once any accumulated banked hours drop below 135, unless you choose to self-pay for coverage in accordance with the rules described above. Only hours that are paid for at the proper rate are credited to your eligibility. If your employer is delinquent (that is, not paying contributions), and the Plan is aware that you were working for that employer based on their last paid report, you will be notified that your employer is delinquent.
If you continue to work for a delinquent employer, benefits for you and your family will be in jeopardy. While the Plan will take action—including legal action—to collect the contributions, if the contributions are not paid, you will not be eligible for coverage during the related time periods unless you use the hours in your hours bank or self-pay for coverage. If your employer later pays the contributions owed on your behalf, your hours bank will be restored and/or the amounts you self-paid will be refunded to you. If you did not use your hours bank or self-pay during the relevant period, your eligibility will be retroactively reinstated but your family’s benefit claims and prescriptions may be delayed, and the Fund Office may be unable to verify your coverage with UnitedHealthcare and the dental PPO providers.
When Your Coverage Ends
As an Active Electrical Worker, your coverage will terminate upon the occurrence of any one or more of the following events, unless you are able to use the hours in your hours bank, or self-pay, to temporarily continue coverage:
- Your employer does not make the required contributions to the Fund on your behalf;
- You do not work the required number of hours to maintain your eligibility;
- You stop working as an Active Electrical Worker for a participating employer for any reason; or
- The Plan is terminated by the Board of Trustees.
Once you have lost eligibility as an Active Electrical Worker for any reason and have not selected one of the options to continue your coverage (through Self-Payments or through COBRA) the only way to regain eligibility is by returning to work in covered employment and meeting the initial eligibility requirements.
Eligibility for Active Non-Bargaining Unit Employees
You are considered an Active Non-Bargaining Unit Employee and eligible for benefits under this Plan if you work both:
- In a job category that is not subject to a collective bargaining agreement; and
- For: (a) an employer who has a collective bargaining agreement with IBEW Local 26, as well as a special written participation agreement with the Fund for Active Non-Bargaining Unit Employees that covers your participation; (b) Local No. 26 International Brotherhood of Electrical Workers (“Union”), within the scope of its participation agreement with the Fund; (c) IBEW 26 Federal Credit Union (“Credit Union”), within the scope of its participation agreement with the Fund; or (d) the National Electrical Contractors Association, Washington D.C. Chapter (“NECA”), within the scope of its participation agreement with the Fund.
Notwithstanding the foregoing, you are not considered an Active Non-Bargaining Unit Employee and are not eligible to participate if:
- You are a part-time or temporary employee who has never worked more than 80 hours in a payroll month;
- You are hired and work only during the months of May through September of any year regardless of the number of hours worked;
- You are not actively employed for wages; or
- Your employer does not employ at least as many Active Electrical Workers as it does Active Non-Bargaining Unit Employees, unless your employer is the Union, the Credit Union or NECA.
When Your Coverage Starts
If you are an Active Non-Bargaining Unit Employee, your employer must make contributions to the Plan on your behalf for two months before your coverage will begin. The Plan and the participation agreement with your employer require that contributions on your behalf begin for the payroll month following the first month in which you work 80 or more hours (or 100 hours in a five pay period month).
Your coverage starts on the first day of the second month following the month in which your employer first makes contributions on your behalf. For example, if you first work 80 or more hours (100 hours in a five pay period month) in January and your employer begins to contribute in February, then you become covered beginning April 1st.
Maintaining Your Coverage
Your coverage will continue as long as you are employed, and your employer makes timely payments to the Plan on your behalf. For each month that your employer makes payments, you will maintain coverage for the month that begins two months later.
When Your Coverage Ends
Your coverage as an Active Non-Bargaining Unit Employee terminates at the end of the second month following the earliest of any of the following events:
- Your employer ceases to contribute to the Fund on your behalf;
- Your employer no longer has employees in a category subject to a collective bargaining agreement with the union (unless your employer is the Union, the Credit Union or NECA);
- Your employer is no longer a party to a collective bargaining agreement with the Union (unless your employer is the Union, the Credit Union or NECA);
- Your employer terminates its participation agreement with the Board of Trustees;
- You terminate employment with your employer;
- Your employer employs fewer Active Electrical Workers than Active Non-Bargaining Unit Employees (unless your employer is the Union, the Credit Union or NECA); or
- The Board of Trustees terminates coverage for Active Non-Bargaining Unit Employees.
Continuing Your Coverage
If you leave employment while you have coverage as an Active Non-Bargaining Unit Employee, you may continue limited coverage in this Plan through COBRA Continuation Coverage, or if you are an eligible retiree, you may make self-payments through the Retiree Plan.
Eligibility for Retired Employees
If you are a retiree and you meet the requirements for participation, you may pay for coverage to participate in this Plan. If you are receiving benefits through Medicare, your benefits in this Plan will supplement your Medicare benefits provided you pay the required amount to the Plan that is established by the Trustees, which may be changed from time to time.
You are considered eligible for retiree coverage if:
- You have been covered under this Plan as an Active Electrical Worker or Active Non-Bargaining Unit Employee for 10 consecutive years immediately prior to your retirement (coverage under the H Plan does not satisfy this requirement); and
- You are eligible Medicare; or
- You are receiving a pension under the Electrical Workers Local No. 26 Pension Plan (the “Pension Plan”); or
- You are receiving Social Security retirement benefits (if you are not eligible to receive benefits under the Pension Plan); or
- You are receiving a pension under the National Electrical Benefit Fund’s Plan.
If you fail to meet the 10-consecutive year requirement, you still may be eligible to qualify by self-paying under one of the following alternatives:
- If you were covered under the Plan for 20 or more (not necessarily consecutive) years, you may self-pay “back” to fulfill the 10-consecutive year requirement;
- If you were covered under the Plan for 10 or more (not necessarily consecutive) years and you are age 62 or older, you may self-pay “ahead” to fulfill the 10-consecutive year requirement; or
- If you are retired on a Disability Pension or Social Security, you have the choice of self-paying “ahead” or “back,” whichever is most favorable to you, to fulfill the 10-consecutive year requirement, regardless of your age or the number of years you were covered.
If you meet one of the above conditions, please contact the Fund Office for specific details.
Note: If you are a former member of Local 637, and were eligible under the District 4 Plan, your eligibility with the District 4 Plan will be considered in applying the 10-consecutive year requirement.
Relief For Retirees Unemployed Between October 1, 2008 and December 31, 2013
If you meet all of the other eligibility requirements for retiree coverage set forth above, except for failure to fulfill the 10-year requirement based upon unemployment between October 1, 2008 and December 31, 2013, this period of unemployment may be disregarded for purposes of meeting the 10-consecutive year requirement, provided you meet all of the following:
- The last employment in which you engaged prior to or during your period of unemployment was for a contributing employer;
- You were available to work for a contributing employer throughout the period of unemployment;
- You were actively seeking work for a contributing employer throughout the period of unemployment;
- You complete and submit to the Fund Office the “Application to Avoid or Postpone a Break-in-Coverage”; and
- If applicable, you provide all supporting documentation to the Fund Office.
Retired Employee Monthly Payment Rates
The Trustees establish the monthly payment rates for Retired Employees, and the monthly payment may be changed by the Trustees at any time. If the rates are changed, you will be notified before the new rates go into effect. The current Retiree rates are as follows:
|Pre-Medicare Retirees (Age at Retirement) ||Current Monthly Rates|
|Ages Under 60||$200.29|
|Age 65 and Older||$73.50|
Note: If you are the survivor of a deceased Retiree and are receiving EWTF benefits, your premium rate at any age under age 65 is $200.29. The premium cap per family per month is $400.58. These premiums are subject to re-examination by the Trustees at any time.
If you are a retiree and are not yet eligible for Medicare, you may pay a premium for retiree health care coverage under the Plan. However, your coverage will not include accidental dismemberment and loss of sight, weekly accident and sickness or supplemental occupational accident benefits.
Retirees Eligible for Medicare
To be eligible for retiree coverage under the Plan, you, and your dependents, must enroll in Medicare — the federally-sponsored health care program consisting of hospital insurance (Part A) and supplementary medical insurance (Part B)— once you, and/or your dependents, become eligible to do so (e.g. due to age or disability). At that time, you and/or your dependents, as applicable, will no longer be eligible for most of this Plan’s regular benefits unless you are still working and covered as an Active Employee. Instead, you, and/or your dependents, will be eligible for this Plan’s Medicare Supplemental Benefits program. Note that you, and/or your dependents will continue your entitlement to dental and vision benefits as before, since these benefits are not covered by Medicare.
If you are Medicare-eligible and your spouse and/or dependent child(ren) are not eligible for Medicare, your dependents will remain eligible for pre-Medicare retiree dependent coverage under this Plan.
If you are retired and are eligible for Medicare due to age or disability, the Plan assumes you are enrolled for Medicare Parts A and B and will consider your claims as if you are covered under Medicare even if you are not enrolled. That is why it is essential that you apply for Medicare as soon as possible (e.g. at least three months before you reach age 65) to assure continued coverage. This Plan does not pay the Medicare Part B premium for participants.
Medicare Part D
The EWTF Plan provides prescription benefits to Retirees. The Plan’s actuary has determined that the benefits provided under the Plan exceed the Medicare Part D prescription coverage for Medicare eligible participants. The Plan therefore receives a subsidy from the Centers for Medicare and Medicaid Services for providing these benefits. If you or a covered dependent enrolls in a separate Medicare Part D program, you or your dependent will permanently lose your prescription benefits with EWTF.
When Retiree Coverage Ends
Your Retiree coverage will end when the first of the following events occurs:
- You return to covered employment;
- You fail to make any required payment in a timely manner;
- The Board of Trustees terminates retiree coverage; or
- You die.
Eligibility for Dependents (including Spouses)
If you are eligible to participate in this Plan, your dependents may also be covered for most of the benefits that are available to participants in your work category. Exceptions are noted in each section.
Your “dependents” are:
- Your legally married spouse who resides with you; and
- Your children under age 26.
“Children” includes biological 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.
If your child is totally disabled (that is, completely unable to perform the normal activities of a person of the same age), the age 26 limit for eligibility for coverage under the medical plan does not apply. You are required to provide proof of the disability before your child reaches age 26 and show that he or she is unmarried and dependent on you for support. From time to time, the Board of Trustees may require proof that your child remains disabled and financially dependent upon you.
When Dependent Coverage Starts
Generally, coverage for your dependent begins on the date you become eligible for coverage under the Plan (either as an Active Electrical Worker, Active Non-Bargaining Unit or Retired Employee), or if later, the date on which the individual becomes your dependent for purpose of coverage under this Plan. Your new spouse will be eligible as of the date of marriage. Your newborn child will be eligible from birth. Coverage for your adopted children will begin when the child is officially placed with you for adoption, not when the adoption becomes final.
When Coverage Ends for a Dependent Child
Generally, your dependent child continues to be covered while you are covered. However, if a dependent child reaches the age limit, his or her coverage will end on the last day of the Benefit Month in which he or she reaches age 26. In addition, coverage will end on the last day of the Benefit Month in which one of the following events occurs:
- The individual no longer qualifies as a dependent;
- Your coverage terminates or you cease to be eligible for coverage;
- The dependent enters the military; or
- The Board of Trustees terminates dependent child coverage under the Plan.
When Coverage Ends for a Dependent Spouse
Generally, your dependent spouse continues to be covered while you are covered. However, the coverage of a dependent spouse will end on the last day of the Benefit Month in which one of the following events occurs:
- You and your spouse are separated and living apart;
- You and your spouse are legally separated or divorced;
- Your spouse enters the military;
- Your coverage terminates or you cease to be eligible for coverage; or
- The Board of Trustees terminates dependent spouse coverage under the Plan.
Special Enrollment Events
Generally, eligible members may enroll their dependents in the Plan at any time. In the event you initially decline enrollment for your dependents (including your spouse), for example because of other health insurance or group health plan coverage, you may be able to enroll your dependents in this Plan if your dependents lose eligibility for that other coverage or if the employer stops contributing toward your or your dependents’ other coverage. However, you must request enrollment in the Plan within 30 days after your dependents’ other coverage ends or after the employer stops contributing toward the other coverage.
In addition, if you acquire a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may enroll yourself and your dependents within 30 days after the marriage, birth, adoption, or placement for adoption.
You and your dependents may enroll in this Plan if you (or your dependents) have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and lose eligibility for that coverage. However, you must request enrollment within sixty (60) days after the Medicaid or CHIP coverage ends.
You and your dependents also may enroll in this Plan if you (or your dependents) become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment within sixty (60) days after being determined to be eligible for such assistance.
For Special Enrollment events involving birth or adoption, Plan coverage will be effective as of the date of birth or placement for adoption. For Special Enrollment events involving marriage or the loss of other coverage, Plan coverage will be effective on the first of the month after you request enrollment.
To request special enrollment or obtain more information, contact the Fund Office.
Qualified Medical Child Support Orders (QMCSOs)
The Fund will provide dependent coverage to a child if it is required to do so under the terms of a Qualified Medical Child Support Order (“QMCSO”). The Fund will provide coverage to a child under a QMCSO even if the participant does not have legal custody of the child, the child is not dependent upon the participant for support, and regardless of enrollment season restrictions which otherwise may exist for dependent coverage. If the Fund receives a QMCSO and the participant does not enroll the affected child, the Fund will allow the custodial parent or state agency to complete the necessary enrollment forms on behalf of the child. You can request a copy of the Fund’s procedures for determining whether an order is a QMCSO by calling or writing to the Fund Office.
A QMCSO may require that weekly accident and sickness benefits payable by the Fund be paid to satisfy child support obligations with respect to a child of a participant. If the Fund receives such an order/notice, the order/notice meets the requirements of a QMCSO, and benefits are currently payable or become payable in the future while the order/notice is in effect, the Fund will make payments either to the Child Support Agency or to the recipient listed in the order/notice.
Coverage for Surviving Spouse and Other Dependents of Deceased Active Employees
Health benefits will be extended to your eligible dependents for a limited period of time at no cost if you die while you are an active participant. Your dependents can use all of the hours in your hours bank to maintain coverage. Beginning the first of the month after those hours are exhausted, coverage is extended for twelve months at no cost. At the end of the extension period, your dependents may apply, and pay, for COBRA continuation coverage.
Coverage for Surviving Spouse and Other Dependents of a Deceased Retired Employee
If you die while you’re retired, your eligible dependents are covered under this Plan until the last day of the third month following the date of your death. After the three-month extension, your surviving spouse may self-pay for continuation coverage for the remainder of his/her life, provided your spouse is not eligible for coverage under any other group health plan other than Medicare. Your dependent children may self-pay as long as they qualify as dependent children. Coverage is subject to the special rules for coverage of a surviving spouse of a deceased participant, as explained below.
Termination of Surviving Spouse and Other Dependent Coverage
Surviving spouse and other dependent coverage under this provision terminates on the last day of the month in which the earliest of the following events occurs:
- The surviving dependent becomes covered as an employee or dependent under this or another group health plan that is not a “limited term plan,” as defined below (provided, however, that surviving spouse coverage will resume if the spouse loses coverage under this Plan due to a termination of covered employment);
- The surviving dependent dies;
- The Board of Trustees terminates surviving dependent coverage under the Plan;
- For a dependent child, the date dependent coverage terminates; or
- The dependent fails to make any required payment for continued coverage.
When Surviving Dependent Coverage ends, your dependents are eligible to obtain coverage through COBRA for up to 36 months.
Continuing Surviving Spouse Coverage
Your surviving spouse may apply for continuing Surviving Spouse Coverage if he or she becomes covered under another group health plan that the Board of Trustees considers a limited term plan. A “limited term plan” is a group health plan that the Board of Trustees determines:
- Is temporary;
- Does not provide adequate and similar coverage to that which is available under this Plan; and
- Does not have continuation rights that are substantially similar to the rights under this Plan
If the Trustees approve the application, your surviving spouse must continue to self-pay under the terms of this Plan at the rates that are in effect at that time.
In accordance with the requirements of the Patient Protection and Affordable Care Act, the Fund will not retroactively cancel coverage except when contributions are not timely paid, or in cases of fraud or intentional misrepresentation of material fact.
Annual Enrollment Verification Process
The Fund will contact all Participants on an annual basis to confirm that the information the Fund relies on to process benefits for each Participant and his/her Dependents is accurate and up-to-date. For example, you will be required to confirm your contact information so that the Fund can provide you with Explanations of Benefit relating to your claims and other important information regarding your coverage. You also will be required to confirm other information relevant to your Fund coverage, such as whether you also have health coverage through another source. Failure to respond to the Fund’s annual enrollment verification request could result in the suspension of your and your dependents’ coverage under the Plan, so please respond promptly to any information requests you receive from the Fund.