The Steamfitters Industry Fund

Fund:

Information:

Eligibility Rules

Who is eligible to participate in the plan?

All employees covered by a Collective Bargaining Agreement between their Employer and the Metal Trades Branch of Local 638 will be eligible to participate in the Plan. Also, certain employees of this Trust Fund, who are not covered under any other collective bargaining agreement, who are accepted for such benefits by the Trustees are eligible to participate in the plan.

Will the Dependents of an eligible participant also be covered for benefits?

An eligible participant’s dependents will be covered for health insurance benefits. Dependents include the participant’s spouse and each unmarried dependent child to the end of the year in which they reach their 19th birthday (or date of marriage, whichever comes first), except that an unmarried dependent child will continue to be covered while enrolled on a full time basis in an accredited institution of higher education up until his or her twenty-third birthday.

An accredited institution of higher education is defined as a nationally accredited college or university providing curricula leading to degree in the arts or sciences. Full-time students who wish to attend a regionally accredited and licensed trade or training school with curricula resulting in a certificate or Associate’s Degree as a mechanic or tradesman in a particular field of work must first obtain the prior written approval from the Board of Trustees before enrollment. Schools and/or programs which are specifically excluded include but are to limited to those designed primarily to improve the student’s health or athletic skills or social graces such as schools providing training and public speaking, a foreign language, dancing, physical education, gymnastics, or the martial arts.

Dependent child shall also include an unmarried child, regardless of age, who is unable to do any work to support himself because of mental illness, developmental disability, mental retardation (as such is defined in the mental hygiene law) or physical handicap provided such child was incapacitated before reaching age 19. To continue coverage beyond age 19, the eligible participant must file a written application, together with supporting medical evidence attesting to the disabled status of such dependent child. The application must be filed with the Trustees prior to the date such child attains age 19 in order to qualify for continuance of coverage.

The term "child" as used above shall include all natural children, stepchildren and legally adopted children, (including a proposed adopted child during any mandatory waiting period prior to the finalization of the child’s adoption) provided such child is dependent upon the participant for support and maintenance.

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 Plan.

When does a participant become covered for benefits?

New participants will become eligible on the first day of the second month following the first month his employer makes the required contribution on his behalf. Generally, this means that a new participant will become eligible on the first day of the second month following thirty (30) days of employment.

How does a participant maintain his insurance benefits?

Participants will continue to be insured so long as they remain in the Collective Bargaining Unit and continue to work for an employer who makes the required contributions to the plan on their behalf.

When will an employee’s insurance benefits be terminated?

Generally, a participant’s insurance benefits will be terminated on the last day of the second month after the last month you are reported for. A participant who quits, but who wishes to continue his Health Insurance coverage with the Fund may do so by making application to the Fund Office and submitting the required COBRA payments directly to the Fund (see Section 2 of this booklet), or such participant may apply for an Individual Insurance Policy with respective Insurance Company or Hospital/Medical Plan.

Please note that only Health Insurance Benefits may be continued under the COBRA Self Payment provisions. Group Life Insurance and the Weekly Supplemental Disability cannot be continued under the Plan’s COBRA provisions. However, a participant may convert his Group Life Insurance to an Individual Contract, paying the premium directly to the Insurance Company (please refer to Section 4 of this booklet for more details).

What happens if a participant quits to enter the military service?

A participant’s insurance will immediately terminate upon entry into active military service. However, upon discharge from active duty, a participant’s insurance will be immediately reinstated providing he returns to work with a contributing employer within 90 days following the date of discharge. An eligible dependent’s insurance will terminate on the same date the participant’s insurance terminates, unless the participant wants to continue his dependent health insurance benefit by paying the required COBRA payments (See COBRA Regulations on page 8).

What happens if a participant transfers from one participating employer to another?

A participant’s insurance will continue, providing he commences work with another contributing employer prior to the 10th day of the month immediately following his last day of employment with his former employer. However, a participant who changes jobs should immediately notify the Fund Office of such change in order to assure a continuation of his health benefits (see below).

What happens if a participant is laid off?

A participant’s benefits will be terminated on the last day of the second month following the month he or she is last reported to the Fund Office, unless he elects to make a voluntary self payment to temporarily maintain his health coverage under the plan’s COBRA provisions (see Section 2). Participants must immediately notify the Fund Office (following termination of employment) if they wish to exercise this option.

Is there any way a participant can continue his benefits once he has exhausted the maximum COBRA Self Payment provisions?

Yes. In most instances he can convert his Hospital and Medical Benefits only to a Direct Payment Plan. Participants interested in converting to an individual self payment plan should contact the Fund Office for directions prior to termination of their coverage or expiration of their self payment period.

What happens if an active participant becomes temporarily disabled and unable to work?

If an active participant becomes temporarily disabled and unable to work, he and his eligible dependents will continue to be covered during the period in which he is disabled up to a maximum of six months in any twelve month period providing he furnishes timely notice and medical proof of such disability. If he is still disabled after six months, he may continue health benefits for himself and his dependents by making the required COBRA payment for a maximum period of up to thirty-six months.

Disabled employees 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 be terminated for Employee Health Benefits, but will be permitted to continue to make COBRA payments for their dependents for the remainder of the self payment period.

What happens when a disabled participant attains Age 62 while making self payments?

A disabled participant who attains Age 62 while making the COBRA self payment may be eligible for the Prepaid Retiree Health Benefits described below. All Health Benefits for disabled and retired participants and their dependents cease upon attainment of Age 65.

What is Prepaid Retiree Health Coverage?

Prepaid Retiree Health Benefits (for the period from Age 62 to Age 65) are limited to those participants whose employer is paying the required contribution for this benefit. You must check with the Fund Office to determine whether you are eligible for this benefit.

Eligible participants who retire prior to Age 65 may apply for continued Health Coverage for themselves and their dependent spouses under the Prepaid Retiree Health Continuance provisions of the plan. To be eligible, they must satisfy the following regulations:

Participants that Terminate Employment Prior to Age 62:

Participants that terminate active employment prior to Age 62, and are eligible for a Disability or Early Retirement Benefit under the MTB 638 Pension Plan, must continue their health insurance coverage by making the required self payments under the plan’s COBRA provisions until they attain Age 62. Participants who fail to maintain their coverage (through self payments) from the date of termination of employment, until they attain age 62, shall forfeit their right to continued coverage under the plan’s Prepaid Retiree Health Provisions. Further, participants whose health insurance benefits are terminated after making their 36 self payments and who had not attained Age 62 as of such date, will not be eligible for the plan’s Prepaid Retiree Health Benefit.

Eligible Participants, upon attainment of Age 62, must make written application for the Prepaid Retiree Health Benefit. Prepaid Dependent Health Coverage will be extended to only those participants whose employer has made the required contributions on their behalf, and such employee has made the required self payments for themselves and their dependents under the Plan’s COBRA provisions during the period immediately preceding the attainment of age 62.

Participants that Terminate Employment after Age 62 but Prior to Age 65:

Eligible participants must have attained age 62 and be eligible for and receiving a Pension Benefit (from The Metal Trades Branch, Local 638 Pension Fund) at the time of application, and further, the participant must have retired from the industry (i.e., from the employment with any Employer in the heating, air conditioning, oil burner and related service industries). Such participants, upon receipt and approval of a properly completed application, shall be covered for all Welfare Fund benefits except Weekly Disability Benefits. The dependents of such retiree will also be covered until the participant or dependent attains Age 65.

Upon attainment of Age 65, all coverage will cease for both the retired participant and his eligible dependents. However, an eligible retiree who attains Age 65 may elect to continue health coverage for his eligible dependents under Age 65 by making the required COBRA payments (see COBRA provision on page 6).

Is there Continued Coverage After Attainment of Age 65 for Active Participants?

Under TEFRA (the Tax Equity and Fiscal Responsibility Act of 1982), DEFRA (the Deficit Reduction Act of 1984) and COBRA (the Consolidated Omnibus Budget Reconciliation Act), full benefits are provided by this plan if you, after attaining Age 65, remain an active participant. Your dependent spouse upon attaining Age 65 may also choose this Plan as primary while you remain actively employed. However, no benefits under this plan will be provided if Medicare is chosen as primary while you remain in active employment, but a hospital and medical supplemental policy for Medicare subscribers is available on a direct-payment basis from Empire Blue Cross Blue Shield for only those participants who legally reside in New York State.

Is there Continued Coverage for Dependents of Active Participants Who Become Totally Disabled?

Under OBRA (the Omnibus Budget Reconciliation Act of 1986), the Plan’s coverage may be chosen as primary by your covered dependents should they become eligible for Medicare because of total disability. If your covered dependent chooses Medicare as primary that dependent will no longer be covered under this plan, but a hospital and medical policy for Medicare subscribers is available on a direct-payment basis from Empire Blue Cross Blue Shield.

What if a Participant or Dependent are eligible for Medicare under the End Stage Renal Disease ("ESRD") Program?

Benefits shall be payable under the Plan without regards to a regards to a participant’s or dependent’s entitlement to Medicare if the participant or dependent is entitled to Medicare as an "End Stage Renal Disease" beneficiary, and not more than 18 months has elapsed since the earliest of the

the month in which the participant or dependent began a regular course of renal dialysis;
the month in which the participant or dependent received a kidney transplant;
the month in which the participant or dependent was admitted to the Hospital in anticipation of kidney transplant that was performed within the next two months; or
the second month before the month in which the kidney transplant was performed, if performed more than two months after admission.

What is the Family and Medical Leave Act?

If you qualify for a family or medical leave of absence in accordance with the Family and Medical Leave Act of 1993 (FMLA) your eligibility will be continued under the plan provided your employer makes the required contribution on your behalf. Eligibility may be continued for up to 12 weeks during the 12 month period, for any of the following reasons:

to care for your child after the birth or placement of a child with you for adoption or foster care so long as such leave is completed within 12 months after the birth or placement of the child;
to care for your spouse, child, foster child, adopted child, stepchild, or parent who has a serious health condition; or
for your own serious health condition.

In the event you or your spouse are both covered as eligible employees, the continued coverage under (a) may not exceed a combined total of 12 weeks. In addition, if the leave is taken to care for a parent with a serious health condition, the continued coverage may not exceed a combined total of 12 weeks.

Eligibility Requirements Under The Family and Medical Leave Act

You are eligible for continuance of your Health Insurance coverage under FMLA if:

you have worked for your employer for at least one year;
you have worked at least 1,250 hours over the previous 12 months for such employer;
your employer employs at least 50 employees within 75 miles from your worksite; and
your employer continues to contribute benefit payments on your behalf.

If, on the day your eligibility is to begin, you are already on an FMLA leave of absence, you will be considered actively at work. Benefits for you and any eligible dependents (if applicable) will be in accordance with the terms of the plan as herein set forth.

You and your dependents (if applicable) are subject to conditions and limitations of the plan during your leave, except that anything in conflict with the provisions of the FMLA will be construed in accordance with the FMLA.

The FMLA continuation ends on the earliest of