Dear Brothers and Sisters:
A packet containing important information about your Healthcare Coverage for 2016 including the following documents has been mailed out. These documents are all available on the Healthcare page of our website (www.smartlocal71.com) as well.
Nova Enrollment Kit – *Please read the information in this kit carefully*
Summary of Benefits and Coverage (SBC)
Summary of Benefits Grid (SOB)
Summary Annual Report (SAR)
ID Cards – Watch your mailbox for your new ID cards from Nova Healthcare and OptumRx. They should arrive before the end of the year. Begin using new ID Cards effective January 1, 2016.
To find an In-Network provider, please visit Nova’s website (www.novahealthcare.com) or contact Member Services (1-800-999-5703). You can find directions to search for providers online, in the Nova Enrollment Kit. Be sure to select the Independent Health Network and ‘Self-Funded Services’ as the plan.
Be sure to check with all providers at the time of service to verify that they participate in the Independent Health network. It is the member’s responsibility to ensure that their providers are In-Network.
Enrollment Forms – Be sure that you have completed and returned the enrollment form that was previously sent to you, or do so ASAP.
24 Liberty Ave.
Buffalo, NY 14215
Changes - The Trustees have made some changes to your Healthcare Coverage effective January 1, 2016. Below is a summary of the changes to the Summary Plan Description (SPD).
CHANGES EFFECTIVE JANUARY 1, 2016
In-Network - $6,850 Individual/$13,700 Family (Currently $6,350/12,700)
Out-Of-Network - $10,000 Individual/$20,000 Family (Currently $6,350/12,700)
Pre-Certification: Additional services require pre-certification. See enclosed brochure for a listing.
Pre-Certification Penalty: Reduced to $250.00 (Currently $500.00)
Routine Eye & Hearing Exam: One per calendar year (Currently one every 24 months)
Physical Therapy, Occupational Therapy and Speech Therapy: Combined limits removed, limited to a maximum of 30 visits for each type of therapy per calendar year.
Mental Illness Out-Of-Network Outpatient/Office: Coverage changed to 70% UCR after deductible (Currently 50%)
Disability Coverage: In the event you become Disabled, you will receive coverage for each month following a month in which you qualify for the Disability Income Benefit for more than 14 days, and fail to work 100 hours due to the disability. This benefit is available for a maximum of 6 months of coverage. In order to receive this coverage and maintain your eligibility, application for the Disability Benefit must be received by the Benefit Fund Office within 30 days of the date the disability began.
Disability Income Benefit: In the event you suffer a disability, you shall be entitled to receive a weekly disability benefit of One Hundred Dollars ($100.00). Your benefit will begin on the first (1st) day of disability if due to accidental bodily injury or the eighth (8th) day of disability if due to sickness. This benefit will be paid for a maximum period of fifty-two (52) weeks for each disability, or if the disability results from an occupational accident or sickness for which benefits are payable under Workers Compensation Law, the maximum period shall be twenty-six (26) weeks. However, if you are age 65 or over, the maximum period is 13 weeks for all disabilities during any 12 consecutive months.
Disability: For purposes of this section, you shall be deemed disabled if your physician certifies that you are totally disabled to perform your regular occupation and you have applied for Workers Compensation, NYS Disability or are qualified for Social Security disability. To be entitled to this benefit your disability must have occurred while you were eligible for coverage under this Plan and you must be under the care of a legally qualified physician. Disability due to self-inflicted injury or war is not covered. Application for the Disability Benefit must be received by the Benefit Fund Office within 30 days of the date the disability began. Such proof would include NYS Disability, Workers Compensation or Social Security Disability. Disability forms are available at the Fund office. Forms must be completed by a licensed physician.
Eligibility and Participation – When Coverage Begins
Eligibility: Active Employees are Eligible under the Plan as follows:
(1) A new Employee will become eligible to participate in the Plan on the first of the month next following his completion of thirty-one (31) days of employment.
(2) Continuing eligibility under the Plan will be based on completing the required hours of service (100 hrs.) in the preceding month. Any month in which more than 100 hours were recorded will have those hours in excess of 100, deposited into an hour bank which can be used to extend your coverage.
(3) The maximum allowable period for the extended coverage will be capped at six (6) months or 600 hours.
(4) Any month where the recorded hours are less than the required 100 hour minimum will result in having the number of hours needed to maintain coverage deducted from your hour bank. Once your hour bank is exhausted, your eligibility will be terminated and you would be offered to self-pay your insurance in accordance with the COBRA provision.
Continuing Eligibility: An Employee will remain Eligible during any Coverage Period following a month in which they have accumulated the required amount of Hours of Service, provided they are working in Active Service, they are available to work in Active Service or they are unable to work in Active Service due to disability. Provided, however, that benefits will continue as long as the Employee accumulates the required amount of Hours of Service by the end of each preceding month. In the event that the Employee has not accumulated the required amount of Hours of Service, the Employee may use the funds in their Individual Account to maintain Eligibility. In such case, the Employee’s Individual Account shall be reduced by the monthly premium needed to maintain Eligibility.
Employee definition: Means any person employed by an Employer or eligible to work for an Employer under a Collective Bargaining Agreement. The term Employee shall also include, with the consent of the Trustees, persons who are employed by the Sheet Metal Workers Local No. 71 Pension Fund, Sheet Metal Workers Local No. 71 Industry Welfare Fund, Sheet Metal Workers Local No. 71 Annuity Plan and the Union if their employer has become an Employer under the Plan by making required contributions to the Fund as called for by the Collective Bargaining Agreement.