- For most medical expenses, the EWTF Plan pays a percentage of the “allowance.” The “allowance” is a pre- determined cost for a particular service. If you visit a provider in the UHC Choice Plus Network, the allowance is accepted with the Patient’s Portion as payment in full for a particular service.
- Generally, treatment that meets clinical guidelines for medical appropriateness for a diagnosed illness or injury is covered under this Plan if the treatment is prescribed by a licensed provider.
The Electrical Welfare Trust Fund Plan is a comprehensive package of health and welfare benefits sponsored by the Board of Trustees. Your EWTF Plan is a private health plan provided under a Collective Bargaining Agreement (or other agreement) between the IBEW Local 26 and the D.C. Chapter of the National Electrical Contractors Association (NECA). The Electrical Welfare Trust Fund is NOT an insurance company.
The EWTF Plan provides eligible participants and their eligible family members with a wide range of health and welfare benefits. However, it is important for you to realize that not all charges are covered in full or in part under this Plan. As one example, optional or elective treatments generally are not covered under this Plan. (See Specific Plan / Benefits Exclusions and sections titled ‘What’s Not Covered” within each benefit description.)
Payment for Coverage
There is no cost to you to participate in the Plan while you are working. Participating employers contribute to a trust fund from which your benefits are paid. However, you are responsible for deductibles and the Patient’s Responsibility when you receive services.
The Annual Deductible
The annual deductible is the amount you and/or your family must pay each calendar year before the Plan will pay benefits. The annual deductible for each individual is $150. The annual deductible for each family is $300. The Plan’s annual deductible does not apply to Medicare-eligible retirees.
Coverage for Participants Covered Twice
If a person is covered twice under this Plan—either as an eligible employee married to another eligible employee, as the dependent of two eligible employees, or as an eligible employee who is also an adult dependent of an eligible employee—the Plan will pay up to a maximum of the lesser of (a) 100% of the Plan’s allowance, or (b) the actual charges after the annual deductible has been met. This applies to medical, mental health/substance abuse, and dental coverage ONLY. No additional benefit is provided for prescription, vision, or hearing benefits.
The annual out-of-pocket maximum per family is $8,000 per calendar year. You are required to provide proof of payment of the annual out-of-pocket maximum to receive full payment of charges, up to the allowance, for covered services obtained for the balance of the calendar year.
What the Out-of-Pocket Maximum Does Not Include
- Your annual deductible;
- Services that are not covered under the Plan (e.g., cosmetic surgery, TMJ treatment, fertility/infertility treatments, etc.);
- Dental and vision expenses;
- Charges above the Plan’s allowance.
Prior authorization under the Plan is required in only a limited set of circumstances, but if you fail to obtain prior authorization in those circumstances your benefits may be denied.
Prior authorization is required in the following circumstances:
- Home Health Care; and
- Major Dental Care over $600
- Certain Prescription Drugs (see Prescription Drug Benefits Section of this SPD for more detail).
For benefits not listed above you do not need to obtain a prior authorization before you seek treatment.
The Health Care Cost Containment Corporation
The Electrical Welfare Trust Fund, along with many other union plans, participates in the Health Care Cost Containment Corporation of the Mid-Atlantic Region, Inc. (HCCCC). It is designed to reduce health care costs for union funds and their participants.
UnitedHealth Premium® Physician Designation Program
The UnitedHealth Premium® Physician Designation Program uses clinical practice information to assist consumers in making more informed and personally appropriate choices for their medical care. The program uses national industry, evidence-based and medical society standards with a transparent methodology and robust data sources to evaluate physicians across 20 specialties to advance safe, timely, effective, efficient, equitable and patient-centered care. The program supports practice improvement and provides physicians with access to information on how their clinical practice compares with national and specialty-specific standards for quality and local cost efficiency benchmarks.
The No Surprises Act requires air ambulance services to be covered with a cost-sharing requirement that is no greater than the cost-sharing requirement that would apply if the services had been furnished by an in-network provider. In general, you cannot be balance billed for these air ambulance services.
The provider directory listing those providers that are in-network because they participate in UHC’s network will be updated at least every ninety (90) days and will be available through the Fund’s website. If you receive services from a provider that you thought was in-network, based on inaccurate information in a current provider directory, then the services provided by that out-of-network provider will be covered as if the provider was in-network.
Specific Plan / Benefits Exclusions
The following is a list of links to specific plan/benefit exclusions located throughout the SPD. Also, see a list of general EWTF plan exclusions below:
General Plan Exclusions
The following is a list of general EWTF plan exclusions. Also, see a list of links to specific plan/benefit exclusions above.
Any injury or illness resulting from, or arising out of, any employment or occupation for compensation or profit;
Any injury or illness for which benefits are payable under any workers’ compensation law, occupational disease law, or similar legislation;
Any care, treatment or supplies to the extent obtained from any federal, state or local government agency or program, or from a government-owned hospital or institution unless otherwise required by law;
Any injury or illness for which medical care, treatment and supplies are available without cost or are not required to be paid;
Care provided to you or your eligible dependent(s) to the extent that the cost of the professional care or hospitalization may be recoverable by, or on behalf of, you or your eligible dependent in any action at law, any judgment, compromise or settlement of any claims against any party, or any other payment you, your dependent, or you or your dependent’s attorney may receive as a result of the accident or Injury, no matter how these amounts are characterized or who pays these amounts.
Any service, care or treatment that is experimental in nature, as defined in this SPD, or which is not considered a generally accepted medical practice;
Any injury or illness resulting from, or occurring during, an attempt to commit or in the commission of a crime; Any prosthetic device or supportive appliance, or its repair, unless specifically covered under this Plan;
Expenses for the treatment of: (a) learning deficiencies that are not attributable to, or the result of, a mental or behavioral health diagnosis; and (b) behavioral problems, (except as otherwise specifically covered under this Plan) or for special education;
Orthopedic shoes or supportive devices for the feet, such as arch supports, heel lifts, etc., except for orthotics when medically necessary and used in lieu of surgery, following surgery, or after an accidental injury to support, align, prevent or correct deformities or to improve the function of moveable parts of the body;
In-vitro fertilization, artificial insemination, or other treatment of male or female infertility, or services to reverse tubal ligation, vasectomy, or other voluntary, surgically induced infertility. The Plan will cover the diagnostic procedures for determining impotence or infertility;
Callus or corn paring; toenail trimming or excision for toenail trimming; treatment of local chronic conditions of the foot, such as weak or fallen arches, flat or pronated foot metatarsalgia, or foot strain;
Humidifiers, air conditioners, exercise equipment or whirlpools; and other non-essential durable medical equipment such as supplies or equipment for personal hygiene, comfort or convenience such as telephone, television or similar items not required for medical care;
Benefits for claims not filed within one year of service date;
Charges incurred prior to the individual becoming covered under this Plan or after termination of eligibility, except as provided under any extension or continuation of benefits provisions of this Plan;
Private-duty nursing care, medical care or treatment, or performance of surgical procedures, dental care or physical therapy when those services are rendered by a nurse, physician, dentist, or physiotherapist that ordinarily resides in the patient’s home or who is a member of the patient’s immediate family;
Travel and non-patient living expenses, whether or not recommended by a physician;
Medical, dental and vision services or supplies determined by the Board of Trustees as not medically appropriate or clinically eligible for the care or treatment of any injury or illness;
Cosmetic, plastic or reconstructive surgery, including surgery to correct developmental malformations, or as a result of earlier cosmetic, plastic or reconstructive surgery are generally excluded from coverage for all Plan participants unless the surgery is appropriate for the repair of damage caused by an accidental injury or congenital defect, or unless otherwise required to be covered under applicable law 1998 shall not be considered “cosmetic” and, thus, shall not be excluded under this provision;
Treatment by any method of jaw joint problems including temporomandibular joint (TMJ) syndrome, craniomandibular disorders, and/or other jaw joint conditions, except for surgery specifically determined in advance to meet clinical guidelines for medical appropriateness and up to specified limits set by the Trustees in consultation with the Fund’s dental and/or medical consultant;
Treatment of obesity, or weight reduction or physical fitness programs, including surgical treatment unless specifically provided elsewhere under the terms of the Plan;
Surgery, implants or other treatment or devices or drugs to enhance sexual performance;
Confinement for more than one day preceding the date of surgery, unless justified as medically appropriate by the attending physician;
Any charges in excess of actual expenses, such as may be provided under a diagnostic related group (DRG) program;
Hospital charges in connection with extraction of teeth or other dental process, unless justified as medically appropriate by the attending physician;
Charges for any individual not covered by this Plan.
These exclusions are applicable only to the extent they do not conflict with applicable law.
If You Have Questions
Once you have read this Summary Plan Description, if you have any questions about your coverage, call the Fund Office. By calling the Fund Office in advance, you may avoid incurring expenses for which you may not be reimbursed. Representatives of the Fund Office cannot change the terms of this plan but may be able to help you with your questions. Help us to help you!