Southwest Carpenters Health And Welfare

Eligibility for Healthcare Coverage

When you become eligible for benefits through the Southwest Carpenters Trust Health & Welfare Plan you will receive an Eligibility Packet in the mail.

You are eligible to enroll when you meet the eligibility requirements below:

Active Carpenter Eligibility

• Employees performing hourly work under a collective bargaining agreement or under the C4A program.
• At least 120 hours between your hours worked and your Hour Bank are required to maintain monthly eligibility.
• The schedule below indicates when eligibility is granted after 120 hours are deducted for monthly coverage.

Work Month (hours count towards eligibility)	Lag Month (months when hours are being reported)	Eligibility Month (month when your eligibility coverage begins)
March	April	May
April	May	June
May	June	July
June	July	August
July	August	September
August	September	October
September	October	November
October	November	December
November	December	January
December	January	February
January	February	March
February	March	April

Initial Eligibility

• "Initial" means that you have NEVER before been eligible for health coverage through the plan.
  • Establishing initial eligibility requires that you accumulate 360 work hours within a minimum of 3 months and a maximum of 6 months for eligibility in the following eligibility month.
• If Initial Eligibility is not established during the 3-6 month window, any hours accumulated in your Hour Bank will continue to roll forward. Only the recent 6 months will be used to establish coverage.
• Initial Eligibility will be granted on the first day of the second month after reaching the required 360 hour threshold but cannot be granted earlier than the 1st of the 5th month after qualifying hours are reported.
  • After initial eligibility has been established, 120 hours per month are required to maintain eligibility.

Hour Bank Balance/Reserve Bank

• Any hour remaining after deducting 120 hours for coverage (360 hours for first time participants), will be credited to your reserve bank.
• The maximum reserve bank accumulation is 720 hours.
• Eligibility is granted during any eligibility month through work hours (if any) plus hours in the reserve bank totaling 120 hours.

Loss of Coverage and Regaining Initial Eligibility

• If you lose coverage due to lack of work hours and/or not enough hours in your Hour Bank, your remaining Hour Bank Balance will carry forward and any hour worked will be added to your Hour Bank.
• If 6 months have passed and less than 120 hours have been accumulated, your hour Hour Bank balance will be forfeited, and you must follow the rules for Initial Eligibility to re-establish.

Disability

If you become disabled and are unable to work, you may be eligible to continue your health coverage with Disability Hours Credit. If you qualify, you may be credited with disability hours up to 8 hours per day for each day (excluding weekends and holidays), and up to 120 hours per month for a maximum of 6 consecutive months.

You must submit your Disability Hours Claim Form within 120 days of the date of your disability. Other rules may apply.

See https://lifeevents.carpenterssw.org/#disability for information and the claim form.

Self-Payment/Hours Buy Back

Participants who lose eligibility due to a lack of reported work hours, or reserve bank hours, have the option to make a self-payment to the Administrative Office.

The following conditions apply:

• This provision does not apply to those who are establishing Initial Eligibility.
• You are allowed to pay up to 20 hours multiplied by the current Health & Welfare contribution rate to maintain eligibility.
• This self-payment is offered 3 times per calendar year for no more than 20 hours each time to avoid a lapse in coverage.
• Payment must be received by the Administrative Office within 31 days of receipt of Hours Buy Back Letter.
• You must be eligible in the immediately preceding month.

If you qualify for the Hours Buy Back, a letter will be sent to your address on file with information regarding the amount of hours required to keep eligibility for the next month and the amount due. Payment must by made by cashiers check or money order.

Non-Bargaining Eligibility

• Eligibility is based on monthly premiums due by the 15^th of the month prior to the month of coverage.
• The employer must be voluntarily signed to the Employer Participation Agreement for Non-Bargaining Employee Coverage and continue to meet all requirements for participation.
• All non-bargained employees must be covered under the Participation Agreement unless an employee has other health coverage, lives outside the jurisdiction of the SWRCC or is a construction worker not represented by a union.
• The employer must pay a minimum of 50% of the employee's monthly premium. Dependent coverage may be subject to additional payroll deduction at the employer's discretion.
• Employees become eligible the 1^st of the month following 30 calendar days of full-time employment.
  • Examples:
    • Employees starting employment on April 15^th would become eligible on June 1^st.
    • Employees starting employment on April 1^st would become eligible on May 1^st.

COBRA Continuation

COBRA, a federal law, allows covered participants and their dependents to continue health care coverage for a limited period at their own expense under certain circumstances when health coverage would otherwise end under the terms of the Plan because of a qualifying event.

See https://lifeevents.carpenterssw.org/#cobra for additional details.

Military Service Credit

If you are absent from employment due to Military Service, you may be entitled to continue your Health Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA).

See https://lifeevents.carpenterssw.org/#military for additional details.

Plan Enrollment

When you become eligible for health coverage for the first time, you will receive a First Time Eligible Packet in the mail with plan information, required notices, authorization forms and enrollment forms.

The packet you receive in the mail will contain the following items:

If you are unable to print plan or enrollment documents as needed, you may Submit a Request for documents to be mailed to you.

Submit your completed forms via email to HWEnrollment@carpenterssw.org or by mail to:

Attn: Enrollment
Southwest Carpenters Health & Welfare
533 S. Fremont Avenue
Los Angeles, CA 90071

Enrolled Participants - Making Plan Changes

Active Plan Changes

Once enrolled, you are permitted to choose a different medical or dental plan at any time, as long as you have been enrolled on your current plan choice for a minimum of one year, by completing and returning a new enrollment form indicating your plan choice.

See Choosing your Health Plan or download Health Plan Benefits at a Glance for information regarding the medical and dental plans available in your area.

Bronze Plan Changes

If you work under a Labor Agreement in Arizona, Colorado, Utah, or New Mexico and have the option to choose the Independence Bronze Plan or the Independence Active Plan, you are now permitted to change your plan at any time as long as 12 or more months have passed since your last medical plan change.

Plan Change Effective Dates

Changes are effective on the 1^st day of the 3^rd calendar month after the enrollment form is received.

Month Form Received	Plan Change Effective Date
January	April 1st
February	May 1st
March	June 1st
April	July 1st
May	August 1st
June	September 1st
July	October 1st
August	November 1st
September	December 1st
October	January 1st
November	February 1st
December	March 1st

Enrolling Dependents

You have 90 days to enroll your dependents and provide the required documents and enrollment forms. If you wait more than 90 days, coverage will begin on the first of the month in which all the required documents are provided. The required documents are:

• Copy of Certified Marriage Certificate and your most recent tax return to enroll your spouse.
• Copy of a Domestic Partnership Registration from a Government Agency and the Domestic Partner Enrollment Affidavit to enroll a Domestic Partner.
• Copy of Certified Birth Certificate, Legal Guardianship, or Adoption Decree to enroll a dependent child.

When you become eligible for health coverage for the first time you will receive a First Time Eligible Packet in the mail with plan information, required notices, authorization forms and enrollment forms.

To add or remove an enrolled dependent, see https://lifeevents.carpenterssw.org/#dependents for more information.

Health Plan Options

See Choosing Your Health Plan or download Health Plan Benefits at a Glance for information regarding the medical and dental plans available in your area.

Active Plan Coverage

The Active Plan is offered in all jurisdictions by Labor Agreement or to Non-Bargaining plan participants.

Active Plan Coverage Includes:

• Medical
• Dental
• Vision
• Prescription
• Life Insurance & AD&D
• Coverage for Eligible Dependents is included with the Active Plan

Bronze Plan Coverage

The Bronze Plan is offered as follows:

• 1^st & 2^nd Period Apprentices in California
• 1^st, 2^nd and 3^rd Period Apprentices in Nevada
• Specific Classifications of Shop Agreements
• Drywall Agreements in Arizona, Colorado, New Mexico and Utah
  • Your base pay rate may be higher by electing the Bronze Plan according to the Labor Agreement.

Bronze Coverage includes:

• Medical
• Life Insurance and AD&D
• Dependent coverage is offered as an option with a monthly premium payment required.
  • Single - $0
  • Single +1 - $150
  • Family - $250

Choosing Your Health Plan

When you are choosing our health plan and adding dependents you should consider the following:

Your Medical Cost At A Glance

Information About the Independence PPO Plans

Type of Service	Independence Active PPO Co-Pay	Independence Bronze PPO (limited offering)
Preventative Care	$0	$0
Annual Deductible	N/A	$3,000 self / $6,000 family
Office Visit/Specialist	$15/$30 per visit	N/A
Diagnostic X-Ray or Lab	$30 per visit	N/A
Chiropractor	$15 per visit (Limit 24 visits per year)	N/A
Physician Office Visits, Urgent Care, Hospital Visits, Surgery, Lab, X-ray	N/A	20% of the negotiated cost after the deductible is met.
Hospital Admission	$500 per admission	N/A
Outpatient Surgery	$250 per surgery	N/A
Emergency Room	$250 per visit	$250 plus 10% after the deductible is met.
Urgent Care	$50 per visit	N/A
Teladoc	$5.00 per visit	$5.00 - no deductible
The examples are for in-network providers only. For coverage of out-of-network providers, see your Health Plan Benefits "At a Glance", the Summary Plan Description (SPD) or the Summary of Benefits and Coverage (SBC).

• The Independence Active Summary of Benefits and Coverage - A summary of covered benefits and costs
• The Independence Bronze Summary of Benefits and Coverage - A summary of covered benefits and costs
• The Schedule of Medical Benefits for the Independence Medical PPO Plan - A complete listing of covered benefits and costs
• Teladoc - A benefit for Independence PPO participants for virtual online medical, psychology or psychiatry visits from your smart phone or computer 24/7.
• Visit myibxtpabenefits.com to locate a provider.

Information About the Kaiser Permanente HMO Plan
(Only in California and Colorado, Bronze Plan Excluded)

Type of Service	Kaiser HMO Co-Pay
Office Visit/Specialist	$20/$30 per visit
Diagnostic X-ray/Lab	$10/$0 per encounter; 20% up to a maximum of $50 per procedure for MRI, CT, and PET scans
Chiropractor	CA: $15 per visit; CO: $20 per visit; limit 20 visits per year
Hospital Admission	20% Coinsurance after Calendar Year Deductible is met
Outpatient Surgery	20% Coinsurance after Calendar Year Deductible is met
Emergency Room	20% Coinsurance after Calendar Year Deductible is met
Urgent Care	$20 per visit, deductible does not apply

• Kaiser Summary of Benefits and Coverage - CA - A summary of covered benefits and costs
• Kaiser Summary of Benefits and Coverage - CO - A summary of covered benefits and costs
• Kaiser Evidence of Coverage - CA - A complete description of covered and limited benefits
• Kaiser Evidence of Coverage - CO - A complete description of covered and limited benefits
• Kaiser Chiropractic Services - A complete description of chiropractic services
• Visit the Kaiser Permanente Website to learn about:
  • Kaiser Hospital and Medical Facilities
  • Ways to get care
    • In office
    • E-visits
    • Telemedicine
  • Health and wellness

Virtual Office Visits

The Independence and Kaiser plan options include Virtual Office Visits. This can be a convenient choice to avoid an Urgent Care visit for common minor medical conditions. They also offer psychological counseling with licensed providers.

• Avoid the doctor's waiting room and instead wait at home.
• Prevent the spread of illness by limiting exposure to others.
• Consult with a provider by phone, iPad or Computer 24/7/365

Independence Participants

Independence Participants can access care 24/7 through Teladoc by visiting Quality care by phone, video, or app | Teladoc.

Upon initial registration through the Teladoc website, select Independence Blue Cross (IBX) as the health insurance provider.

• Pay a reduced co-pay of only $5 for all Carpenter Independence Participants (Active or Bronze) with no deductible.

Kaiser Participants

Kaiser Permanente Participants, go to the link below to sign up and get information on the Telemedicine Program:

• Southern California:  https://healthy.kaiserpermanente.org/southern-california/get-care
• Colorado:  https://healthy.kaiserpermanente.org/colorado/get-care
• Learn How It Works: How Video Visits Transform Healthcare | Kaiser Permanente (YouTube Video)

Prescriptions

Express Scripts
(Independence Active and Bronze Participants)

Type of Drug	Retail Network Pharmacy (Up to a 30-Day Supply)	Mail Order Home Delivery or Smart 90
Generic	$10; $0 for prescription contraceptives	$25; $0 for prescription contraceptives
Preferred Brand	$40	$100
Non-preferred Brand	$60	$150
Specialty	$50	$100
Preferred/Non-Preferred Brand For Which There is a Generic Equivalent Available	You will be charged the brand copayment, plus the difference in cost between the brand and the generic	You will be charged the brand copayment, plus the difference in cost between the brand and the generic

Routine maintenance medications are covered for a 30-day supply for only 2 fills. After the 2^nd fill, you will pay the retail price for the medication unless you use the mail order pharmacy or visit a CVS Pharmacy for the Smart90 program to purchase a 90-day supply.

Express Scripts can help you arrange for at home delivery or locate a pharmacy.

Kaiser
(Only in California and Colorado, Bronze Plan Excluded)

Type of Drug	Retail Network Pharmacy (Up to a 30-day Supply)	Mail Order Pharmacy (CA: 100-Day Supply; CO: 90-day Supply)
Generic	$10; $0 for prescription contraceptives	$20; $0 for prescription contraceptives
Preferred Brand	$30	$60
Specialty	20% Coinsurance (not to exceed $250 per 30-day supply)	Contact Kaiser

Dental

Information About the UnitedHealthcare Dental Plans
(Bronze Plan Excluded)

Service	DPPO All States	DC CA/NV	INO UT, AZ, CO
Deductible	$50/$150	$0	$0
Preventive	$0	$0	$0
Filling	50%	$5-$10	$5-$10
Porcelain Crown	50%	$90	$90
Root Canal	50%	$15-$60	$15-$60
Orthodontic - Child	50%	$1,500	50%
Orthodontic - Adult	50%	$1,500	50%
Calendar Year Max	$3,000	None	$5,000

For more information:

• Visit UnitedHealthcare Website
• UnitedHealthcare Dental Plan Details and Fee Schedules:
  • Benefits "At a Glance"
  • CA Dental Plan Details
  • CA Fee Schedule
  • DPPO - LA, MS, AL, TX Fee Schedule
  • DPPO - NM and all other states Fee Schedule
  • 2022 Dental Plan INO
  • INO All States except CA and NV Fee Schedule

Vision Coverage
(Bronze Plan Excluded)

• Provided by UnitedHealthcare Vision regardless of your medical plan choice.
• Go to whyuhc.com/csac for preferred providers.
• See the UHC Vision Plan Summary for more information.

Your Cost at a Glance

Service	Frequency	Price
Exam	Once Every 12 Month	$10 Copay
Lenses-Per-Pair	Once Every 12 Months, Frames-Once Every 24 Months	$20 Copay for Materials
Contact Lenses	Once Every 12 Months	Instead of Frames and Lenses, at the $20 Copay, You May Select Contact Lenses

Reach Out For Help

Your ComPsych^® Carpenters Assistance Program (CCAP)

The CCAP is a free, confidential program, available 24/7/365 to all eligible participants and family members who may be overwhelmed by life's challenges.

• Mental Health Counseling
• Drug or Alcohol Abuse
• Legal Assistance
• Financial Counseling or Planning
• Work-Life Solutions such as: Childcare, Home Repair, Pet Sitting

Call: 1-833-792-2271 (833.SWCCAP1)

Website: guidanceresources.com

Download the App: GuidanceNow^SM

When you call or sign in through the App or Website, use the WEB ID: SWCCAP

Life Insurance

All actively eligible participants, are entitled to the following Life and Accidental Death and Dismemberment Insurance, regardless of medical plan choice or enrollment. COBRA participants are excluded.

	Life Benefit	AD&D Benefit
Participant	$20,000	$5,000 - $20,000
Dependent (if enrolled)	$3,000	$0

MetLife Advantages Slipsheet

Beneficiary Form

For More Information