The Health Reimbursement Account
The Health Reimbursement Account benefit has been designed specifically to provide you and your families with the ability to pay Medical Care Expenses which are not covered by insurance, not covered by the Steamfitters’ Industry Welfare Fund or otherwise not covered under another arrangement, as well as to enable you to save for future medical expenses, on a tax-favored basis. In no event shall benefits be provided in the form of cash or any other taxable or nontaxable benefit other than reimbursement for Medical Care Expenses. This account is not subject to reciprocity.
An account is established for each participant under the Plan and is credited with contributions received in accordance with the collective bargaining agreement as well as with its allocable share of the Plan’s investment income, if such income exceeds plan expenses. Benefit disbursements will be deducted from the individual participant’s account. In addition, amounts previously contributed to the Security Benefit Fund may be transferred as contributions to your HRA account.
Contributions to your account become available to you after they have been posted to your account. Benefits paid to you from your account are deducted from your balance on the date paid. The amount of benefits available to you is limited to the balance in your account.
The maximum balance in your account cannot exceed $5,000. Any balance in excess of this amount will be transferred on a quarterly basis to your Supplemental Retirement Fund (401(a) Plan) account.
Who is Eligible for Health Reimbursement Benefits?
You, the participant of the Steamfitters’ Industry Welfare Fund, as well as your eligible dependent(s) in the Welfare Fund, are eligible for benefits from the Health Reimbursement Account at any time, provided you have a properly documented claim for benefits, that you submit the claim timely, and that you have a balance in your account upon the Fund Office’s receipt of your application. Other dependents are not eligible.
A participant who has an account balance but who is no longer eligible to receive additional contributions from any source is still eligible to receive benefit coverage under this Plan until his or her account balance is exhausted. If, or when, there are no eligible dependents in the Welfare Fund the balance in the account will be forfeited to the Plan.
After a participant’s death, substantiated Medical Care Expenses for the deceased participant may be submitted for reimbursement. Eligible dependents may continue to submit their own claims for Medical Care Expenses until the deceased participant’s account is exhausted. There is no time limit in which the account must be exhausted.
How Long is a Claim Eligible for Reimbursement?
Generally, your Health Reimbursement Account will accept properly documented claims for benefits for dates of service up to one year from the date the reimbursable expense was incurred. (Please note: a Medical Care Expense is incurred at the time the medical care or service giving rise to the expense is furnished, not when the individual incurring the expense is formally billed for, is charged for, or pays for the medical care or service.)
What is the Minimum Dollar Amount for which a Claim Will Be Processed?
In order to limit the costs of the administration of the Plan, it is requested that you accumulate a minimum of $100 in receipts in order for the Fund Office to process your reimbursement request.
If eleven months have passed from the date you have incurred a Medical Care Expense(s) then you may submit the Medical Care Expense(s) for reimbursement, even though it is less than the minimum amount allowed, so that you may qualify for reimbursement under the one-year rule.
What Happens if I Don’t Have a Sufficient Balance to Cover my Claim?
If, at any time your application is received and your claim is for an amount greater than the balance in your HRA account, the difference between the application amount and your HRA account balance can be transferred to your HRA account from your Security Benefit Fund subject to your authorization. The transfer amount cannot exceed your Security Benefit Fund account balance and is not subject to tax.
What Must I Submit with my Claim for Benefits?
You may apply for reimbursement by submitting the required application to the Fund Office. To contact the Fund Office for a form, please call (212) 465-8888 option no. 1 or you may find the form on the website at: http://www.steamfitters.com. The form will require you to know:
- The person (or persons) on whose behalf the expenses which qualify for reimbursement were incurred
- The nature of the expenses that were incurred
- The amount of the requested reimbursement; and
- A statement that the expenses have not been reimbursed and are not reimbursable through any other source.
The application for reimbursement must be accompanied by bills, invoices, medical Explanation of Benefits, dental expense statements, Medicare Part B premium proofs, or other satisfactory third party statements showing that the reimbursable expenses have been incurred and the amounts of such expenses. You must also furnish any additional information which the Plan may require.
How Long Will it Generally Take for the Processing of a Claim?
In general, within 30 days of receipt of a claim by the Fund Office, the Fund Office will reimburse the claim if the claim is approved or notify you should the claim be denied. This 30-day period may be extended for an additional 15 days for matters beyond the Fund Office’s control, including a case in which the reimbursement claim is incomplete. The Fund Office will provide written notice of any extension, including the reason for the extension. If the problem is an incomplete reimbursement claim, you will be allowed 45 days in which to complete the claim.
Which Expenses are Reimbursable?
The following expenses, not already covered by insurance, are reimbursable:
- Vision care
- Hearing aid
- Medicare Part B & D premiums
- COBRA premiums
- Qualified Long-Term Care services
- Assisted living medical costs
- Other healthcare insurance
- (Co-payment, coinsurance, deductibles)
- Over the counter medicinal products.
The definitions for these expenses are as follows:
Medical Care Expenses: The plan covers Medical Care Expenses incurred after January 1, 2005. These expenses are covered when they are incurred. A medical care expense is incurred at the time the medical care or service giving rise to the expense is furnished and not when you are billed for it. A “Medical Care Expense” as defined in Internal Revenue Code Section 213 is the “amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease for the purpose of affecting any structure or function of the body.” Medical care expenses do not include costs incurred for cosmetic surgery and similar procedures not necessary to ameliorate (improve) a deformity arising from or directly related to a con-genital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease. “Cosmetic surgery” for this purpose means a procedure directed to “improving the patient’s appearance” that does not “meaningfully promote the proper function of the body or prevent or treat illness or disease.”
“Medical care” includes treatments by persons who are not licensed to practice medicine or nursing in the conventional sense, such as chiropractors and psychologists. In order to qualify as medical care, the practitioner’s services must be addressed to a physical or mental disability, not to the participant’s general well being. For the purpose of the Plan, “Medical care” includes only transportation for ambulances and similar vehicles.
Hospital Medical Care Expenses: While in the hospital, the amount actually paid for medically necessary hospital services. Please contact the Fund Office for further details.
Dental Expenses: The amount actually paid for dental services, excluding cosmetic dentistry.
Vision Care: Eye examinations, frames, and/or lenses including contact lenses. (Non-prescription sunglasses are not eligible for reimbursement).
Hearing Aid: A small electronic apparatus that amplifies sound and is worn in or behind the ear to compensate for impaired hearing.
Medicare Part B&D Premiums: Part B - The amount paid for Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Medicare Part A.
Part D – the Medicare Part D Prescription Drug Plan is a Medicare sponsored insurance plan, sold and administered through private insurance companies, to cover prescription drug costs for people on Medicare.
COBRA Premiums: The amount paid for a health insurance plan which allows an employee who leaves a company to continue to be covered under the company's health plan, for a certain time period and under certain conditions.
Qualified Long-Term Care Insurance: Necessary diagnostic, preventive, therapeutic, curing, treating, mitigating and rehabilitative services, and maintenance or personal care services required by a “chronically ill individual” that are provided pursuant to a plan of care prescribed by a licensed health care practitioner. Medical care does not include long-term care expenses paid to certain relatives or businesses owned in whole or in part by the participant or the participant’s relatives unless the expenses are for services performed by a relative who is a licensed health care professional.
Assisted Living Medical Costs: The medical care portion of a retirement home or assisted living facility monthly life-care fee is also considered a medical expense. The percentage method is used to determine the medical care portion. For further details and an explanation as to how to determine this expense, please contact the Fund Office.
Other Healthcare Insurance:
Co-payment: The portion of a claim or medical expense that a participant must pay out of his or her own pocket to a provider or a facility for each service.
Coinsurance: A provision in a participant’s coverage that limits the amount of coverage by the plan to a certain percentage. Additional costs are paid by the participant, which is referred to as coinsurance.
Deductibles: The dollar amount a participant must pay each year before his or her medical and/or dental plan begins to pay benefits for certain covered expenses.
Over-the-Counter Products: Over the counter medicines and drugs.
Which Expenses are Not Reimbursable?
Medical care expenses, which are eligible for reimbursement through any other accident or health plan are not reimbursable. If the other plan does not fully cover your medical expenses, for example, because of co-payment or deductible limitations, this Plan can reimburse the remaining portion of the expense so long as the claim satisfies the definition of expenses covered by the Plan.
After the close of each Plan Year, if the net investment income of the Fund exceeds expenses, at the direction of the Trustees, the net amount may be proportionally allocated to each participant’s account balance.
RULES AND REGULATIONS
Assignment of Benefits
You may not assign or use as collateral any part of your account balance or any benefits you are entitled to from the Fund.
Coordination of Benefits
In no event shall the combined reimbursement payable to a Participant with respect to any Medical Care Expense, from this Plan and all other sources, exceed one hundred percent of such Medical Care Expense.
Denial of Benefits
If you do not meet the eligibility requirements as described for each benefit above, you will not be eligible for benefits from the Fund. You will be provided with a written notice of denial of your claim (whether denied in whole or in part).
This notice will state:
- The specific reason(s) for the determination,
- Reference to the specific Plan provision(s) on which the determination is based,
- A description of any additional information necessary to perfect the claim, and an explanation of why the material or information is necessary,
- A description of the appeal procedures and applicable time limits,
- A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse benefit determination on review,
- If an internal rule, guideline or protocol was relied upon in deciding your claim, you will receive either a copy of the rule or a statement that it is available upon request at no charge,
- If the determination was based on the absence of medical necessity or because the treatment was experimental, or investigational, or other similar exclusion, you will receive an explanation of the scientific or clinical judgment for the determination applying the terms of the Plan to your claim or a statement that is available upon request at no charge.
Appeal for Denial of Benefits
Your request for a review of a denied claim should be made in writing and sent to:
The Steamfitters’ Industry Welfare Fund
27-08 40th Ave, 2nd Fl
Long Island City, NY 11101-3725
Your appeal must be made in writing and sent to the Fund Office within 180 days of the notification that your claim has been denied. Your appeal will be presented at the next regularly scheduled meeting of the Board of Trustees following receipt of your request for review provided the appeal has been received at least 30 days before such meeting. However, if your request for review is not received within 30 days of the next regularly scheduled meeting, your request for review will be considered at the second regularly scheduled meeting following receipt of your request. In special circumstances a delay until the third regularly scheduled meeting following receipt of your request for review may be necessary. Once a decision on review of your claim has been reached, you will be notified of the decision no later than five (5) days after the decision has been reached.
If special circumstances require an extension of time for processing the claim, written notice of such extension, and a description of the special circumstances, must be given to you prior to the end of the review period. If such an extension is required, you will receive notice of a decision on the claim no later than five (5) days following the third regularly scheduled Board meeting following the initial submission of the claim. If notification of decision is not given within a period described herein, the claim will be considered denied.
You may review all Plan documents and records relating to your claim as well as submit comments on your claim in person or through a representative.
You must seek review of a denied claim before seeking relief in court. You may not start a lawsuit to obtain benefits until after you have requested a review and a final decision has been reached on review, or until the appropriate time frame described above has lapsed since you filed a request for review and you have not received a final decision or notice that an extension will be necessary to reach a final decision. The law also permits you to pursue your remedies under Section 502(a) of ERISA without exhausting these appeal procedures if the Plan has failed to follow them following your request for review.
If you file a claim for benefits which the Trustees determine is based upon misrepresentation or fraudulent conduct on your part, the Trustees shall deny the claim and may suspend all payments to or withdrawals by you from the Fund for a period of one year for the first offense and two years for any subsequent offense.
Indemnification of Plan Sponsor
If any Participant receives one or more payments or reimbursement under this Plan on a tax-free basis, and such payments do not qualify for such treatment under the Code, the Participant shall indemnify and reimburse the Plan Sponsor for any liability it may incur for failure to withhold federal income taxes, Social Security taxes or other taxes from such payments or reimbursements.