If you are an Employee of a newly signatory Contributing Employer on the effective date of your Employer’s initial participation in the Fund, your eligibility for benefits will begin on the first day of the calendar month following a period of time after you work at least 130 hours for your contributing employer.
You become eligible for benefits from this Trust Fund when you work for an Employer who is required to make hourly contributions to this Trust Fund on your behalf. New Employees become eligible for benefits on the first day of the second calendar month following the calendar months in which you worked at least 130 hours for one or more Contributing Employers. You will need to work a minimum of 130 hours per month in order to receive 100% employer paid coverage.
If you work more than 130 hours in a month, the administrator will credit any excess dollars to a reserve called your “Cash Bank” that can be used to pay for your continued coverage in any month following a month in which you work less than 130 hours. The maximum amount you can accumulate in your cash bank is the amount needed to cover three (3) months of health care contributions.
Please Note: Your Cash Bank may only be used to pay for your continued coverage through the Fund, and cannot be used to reimburse premiums for medical insurance in the individual market, federal Marketplace, or State Exchange.
Your monthly eligibility will be determined by hourly cash contributions made by your employer during each month you work. If you work 130 hours or more in a month, your employer hourly cash contributions will pay 100% of the cost of your monthly health care contribution. If you work less than 130 hours in a month, you will need to make up the dollar shortfall. The shortfall will first be withdrawn from your Cash Bank (if funds are available). If any shortfall remains, the balance may be made up through a participant self-payment directly from you. The amount of the shortfall you will need to make up in the months you work less than 130 hours will be the difference in the actual hours you worked and 130 hours at your Employer’s contribution rate. Your self-payment is due on or before the 20th of the month following the month you worked less than 130 hours in order to count towards the subsequent month of eligibility. Self-payments should be mailed to the Trust Fund Office at the address below.
Identify the payment as “Payment for Active Coverage”.
Example 1 In January, you work 130 hours, your employer hourly cash contributions will pay 100% of the monthly contribution for your health care coverage for March. You do not need to make a self-payment or use any of your Health & Welfare Cash Bank money to obtain coverage for March.
Example 2 In January, you work 125 hours, your employer will pay for most of the cost of your health care premium cost for March. However, your employer’s hourly cash contributions would be five hours short of covering your health care premium. You can make up the shortage by using your Health & Welfare Cash Bank (if funds are available) or by making a participant self-payment, or by a combination of Health & Welfare Cash Bank and participant self-payment. If you choose to make a participant self-payment, it would be due to the Trust Fund by February 20.
It is your responsibility to know the balance of your Cash Bank and whether or not you have enough to cover a short fall in the number of hours worked in a given month. You should carefully keep track of your hours worked in each month to make sure you are prepared to make a self-payment for the months that you work less than 130 hours and your Health & Welfare Cash Bank is insufficient to make up the difference if you wish to continue your health care coverage.
For your Dependents whose coverage is extended due to accumulated reserves in your Cash Bank, coverage under the Plan in which you were enrolled immediately prior to your death will remain in effect for the number of months the accumulated reserves will cover (remember, the maximum amount you can accumulate in your cash bank is the amount needed to cover three (3) months of health care contributions).
> Is not signatory to a Collective Bargaining Agreement with a local union of the District Council 16 of the International Union of Painters and Allied Trades without the written authorization of the District Council 16 local union with jurisdiction over the company.
If there are no Employer contributions made on the Employee’s behalf for a 12-month consecutive period, then the Health & Welfare Cash Bank will be cancelled. It will be reinstated if the Employee returns to work within 12-months of the cancellation. The cash bank is not vested. Participants do not have the right to receive payment of their cash bank balances in cash.
If your Employer fails to make contributions when due and has not submitted a report form, you may request that the Trust Fund Office continue your benefits based on acceptable proof (such as pay stubs) of hours worked. The acceptable proof (such as pay stubs) must be submitted to your Local Union Business Representative in order to be processed. Please be sure to complete, review, and sign your timecard or time records every week so that you may receive benefits correctly.
This is only a summary. The eligibility requirements and benefits provided to Non-Bargaining Employees are governed by the Subscriber Agreement between this Trust Fund and your signatory employer.
If you are a full-time Employee (working a minimum of 30 hours per week) of a signatory Employer currently participating in this Trust Fund, who has also signed a Subscriber Agreement with this Trust Fund, you will become eligible for benefits on the first day of the month following a waiting period of sixty days, so long as your Employer has made the required contribution on your behalf.
If you are a full-time Employee and eligible for your Employer’s benefits before your Employer begins participation in this Trust Fund, you will be eligible for benefits from this Trust Fund on the effective date of your Employer’s participation in this Trust Fund, if your Employer has also signed a Subscriber Agreement and has made the required contribution on your behalf.
Monthly Non-Bargaining Employees are not eligible for death benefits. Your other benefits are the same as those for hourly Employees.
Monthly Non-Bargaining Employees do not accrue a cash bank reserve as described for hourly Employees. Their coverage terminates the first of the month following the month in which their employer fails to make the required contribution to this Trust Fund.
› Is not signatory to a Collective Bargaining Agreement with a local union of the District Council 16 of the International Union of Painters and Allied Trades without the written authorization of the District Council 16 local union with jurisdiction over the company.
You are receiving pension payments from the Northern California Glaziers Pension Plan or, if you are a Production Worker, from the International Brotherhood of Painters and Allied Trades Pension Plan, the Bay Area Painters and Tapers Pension Trust Fund, or the Resilient Floor Covering Pension Plan.
You were covered under this Health and Welfare Trust Fund’s benefits program or the Health and Welfare Plan of one of the merged Trust Funds as an active bargaining Employee in the month immediately preceding your retirement date. You may use COBRA Continuation Coverage to meet this requirement.
If you were employed by the International Union of Painters and Allied Trades, this requirement will be fulfilled if you were covered under the Health and Welfare Plan provided by the International Union of Painters and Allied Trades in the month immediately preceding your retirement date.
In each of the 3 years immediately preceding your retirement date, you earned at least 500 hours of service, as defined in the Northern California Glaziers Pension Plan or the International Brotherhood of Painters and Allied Trades Pension Plan or the Bay Area Painters and Tapers Pension Trust Fund, or the Resilient Floor Covering Pension Plan.
Any year you were an Employee of the International Union of Painters and Allied Trades will be considered a grace period and will not be counted for purposes of determining whether you have met this requirement.
If you were disabled or you were on the Union’s out-of-work list and were available for work in the 3-year period immediately preceding your date of retirement, you may receive credit hours for your period of disability or unemployment. For purposes of this provision, “disability” means a total and continuous disability from accidental bodily injury or illness that prevented you from performing any and every duty pertaining to your occupation and from receiving any remuneration for any other work or service.
You pay the required monthly “self-payment” premium. The amount is determined by the Board of Trustees in their sole discretion.
You are a member in good standing with any local union affiliated with the District Council 16 of the International Union of Painters and Allied Trades (including being current with your dues).
the last month you receive COBRA coverage under the Active Plan.
If you do not elect dental coverage when you first become eligible for benefits as a Retiree, you may NOT add or drop the dental plan at a later date.
There may be some Retirees who are not eligible for Retiree health coverage. In that case, you will also be allowed to continue your Active Plan coverage by using your Cash Bank Accumulation when you retire. To continue coverage after the Cash Bank is exhausted, you would need to elect continuation coverage under COBRA Continuation. Please refer to the COBRA Continuation Coverage section for information on your self-payments.
You are permitted to permanently opt out of and waive future reimbursements from your Cash Bank at least annually, in a time and manner determined by the Plan Administrator. Upon retirement, you may (in a time and manner determined by the Plan Administrator) opt out of and waive any balance remaining in the Cash Bank.
You must have been covered under the Trust Fund (or one of the three merged Trust Funds) for at least 24 consecutive months immediately prior to your date of retirement.
You must have been a full-time active Employee of a participating employer for at least five years.
You must pay the full cost of your benefits, as determined by the Board of Trustees, each month without any lapse in coverage.
Retirees are eligible for the Blue Cross Network (PPO) which includes Prescription Drugs, Mental Health/Substance Abuse and Vision Benefits. You also have the option to pay for Dental Benefits. Once you or your Spouse or Domestic Partner become eligible for Medicare due to age, disability or renal disease, you MUST enroll in both Parts A and B of Medicare. If you are in the Kaiser (HMO), you must assign those benefits to Kaiser. If you are in the Blue Cross Network (PPO), medical benefits for you or your Spouse (or Domestic Partner) will be paid as if you are enrolled in Medicare (whether you are or not) and Medicare has paid benefits first.
You will have substantial out of pocket costs if Medicare has not paid full primary benefits before you submit your claims for secondary payment by this Trust Fund. Therefore, you and your Spouse (or Domestic Partner) should enroll in Medicare as soon as you are eligible to do so.
A Retiree who works 39 hours or less per month while receiving Retiree pension benefits through the Trust Fund are required to pay an additional 25% of their monthly retiree premium rate for the month in which active hours were reported.
You perform any work for an employer in the industry which does not have a collective bargaining agreement with any of the local unions participating in this Trust Fund or a trust fund that is signatory to a reciprocal agreement with this Trust Fund. Contact your Union Office or the Trust Fund Office for complete rules determining your rights to perform covered employment after your retirement date.
You fail to pay the required monthly self-payment on time.
Your pension benefits are terminated or suspended for any reason except for your return to full time covered employment.
You cease to be a member in good standing with any local union affiliated with the District Council 16 of the International Union of Painters and Allied Trades.
If the Board of Trustees decides to discontinue the Retiree Plan.
Once terminated, you will not again be eligible for Retiree benefits.
Retirees who work in covered employment after retirement will receive no credit towards eligibility for any employer cash contributions and will lose the benefit of the Active Participant funded 25% Retiree health care subsidy.
If a Retired Employee who has elected a Joint and Survivor Pension dies, his or her surviving Spouse may continue to be covered under this Trust Fund upon payment of the required self-payment. This coverage will terminate upon the re-marriage of the surviving Spouse.
If on the date of death an active Employee would have been eligible for a pension if he had applied, the surviving Spouse may continue to be covered under this Trust Fund upon payment of the required self-pay amount. No break in coverage is allowed. This coverage will terminate upon the re-marriage of the surviving Spouse.
Coverage for your eligible Dependents you have at the time you become eligible for coverage as either an active Employee or a Retiree will begin on the date you become eligible and enroll for coverage. Coverage for Dependents acquired after your initial eligibility will begin on the date you acquire the Dependents. You must request to enroll newly acquired Dependents, including newborns, by contacting the Trust Fund Office within 31 days if due to marriage or registration of a Domestic Partnership, or within 60 days if due to birth, adoption or placement for adoption.
Natural, adopted children, stepchildren or foster children. Adopted children shall be considered eligible under this Trust Fund when they are placed for adoption. Placed for adoption means the assumption and retention by an Employee of the legal duty for total or partial support of a child to be adopted.
A child named as an “alternate recipient” under a Qualified Medical Child Support Order (QMCSO) until the earlier of 1) age 26; or 2) the date the QMCSO terminates. In accordance with ERISA Section 609(a), this Trust Fund will provide coverage for a Dependent Child of an Active Employee if required by a Qualified Medical Child Support Order (QMCSO). A QMCSO is a court order that complies with requirements of federal law requiring an Employee to provide health care coverage for a Dependent Child. The procedures regarding medical child support orders are available free of charge upon request from the Trust Fund Office.
The Trustees may request evidence of the relationship and age, such as a marriage certificate in the case of marriage, a birth record in the case of a newborn, divorce and remarriage documents in the case of stepchildren, and any such other evidence as the Trustees may deem necessary.
Disabled Adult Child: An unmarried Dependent Child (as defined above) age 26 or older who is permanently and totally disabled with a disability that existed prior to the attainment of the Plan’s age limit who will be claimed as a Dependent on the eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. This Plan may require initial and periodic proof of disability.
An unmarried individual under age 19 with respect to whom the eligible Active or Retired Employee has legal guardianship under a court order (proof of guardianship and age may be required) and who will be claimed as a Dependent on the Eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. Coverage may continue if the child has reached his or her 19th birthday but has not reached his or her 24th birthday and is enrolled as a full-time student in high school or in an accredited and state licensed technical school or institution of higher education. The Plan may require initial and periodic proof of student status.If the Plan receives a written certification from a child’s treating physician that (1) the child is suffering from a serious illness or injury, and (2) a leave of absence (or other change in enrollment) from a postsecondary institution is Medically Necessary, and if the loss of student status would result in a loss of health coverage under the Plan, the Plan will extend the child’s coverage for up to one year. This maximum one-year coverage begins on the first day of the Medically Necessary leave of absence (or other change in enrollment) and ends on the date that is the earlier of (i) one year later, or (ii) the date on which coverage would otherwise terminate under the terms of the Plan (for example, when the child reaches the Plan’s limiting age).
The following individuals are not eligible under the Plan: a spouse of a Dependent Child (i.e. Employee/Retiree’s son-in-law or daughter-in-law) or a child of a Dependent Child (i.e. Employee/Retiree’s grandchild) unless the Participant has been appointed legal guardian of the child.
An unmarried Dependent Child age 26 or older who is permanently and totally disabled with a disability that existed prior to the attainment of the Plan’s age limit who will be claimed as a Dependent on the eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. This Plan may require initial and periodic proof of disability.
If the Plan receives a written certification from the child’s treating physician that (1) the child is suffering from a serious illness or injury, and (2) a leave of absence (or other change in enrollment) from a postsecondary institution is Medically Necessary, and if the loss of student status would result in a loss of health coverage under the Plan, the Plan will extend the child’s coverage for up to one year. This maximum one-year coverage begins on the first day of the Medically Necessary leave of absence (or other change in enrollment) and ends on the date that is the earlier of (i) one year later, or (ii) the date on which coverage would otherwise terminate under the terms of the Plan (for example, when the child reaches the Plan’s limiting age).
It is the Domestic Partner’s obligation to inform the Plan promptly if any of the requirements set out in this definition of a child of a Domestic Partner are NOT met with respect to any child for whom coverage is sought or is being provided.
The Domestic Partner and the child of a Domestic Partner may not qualify as tax Dependents and, if so, the Employee or Retiree will be taxed on the value of the benefit provided to him or her. This is called “imputed income” and the Employee or Retiree will have to pay income and payroll taxes on this amount.
Marriage: the certified marriage certificate.
Birth: the certified birth certificate showing biological child of Employee/Retiree/Domestic Partner.
Stepchild: the birth certificate plus marriage certificate.
Adoption or placement for adoption: court order paper signed by the judge showing that Employee/ Retiree/Domestic Partner has adopted or intends to adopt the child.
Foster Child: court documents signed by a judge verifying legal custody of the foster child (e.g. placement papers from a qualified state placement agency), or proof of judgment decree or court order of a court of competent jurisdiction, and any proof of any state provided health coverage.
Legal Guardianship: the court-appointed legal guardianship documents and certified birth certificate.
Disabled Dependent Child: Current written statement from the child’s physician indicating the child’s diagnoses that are the basis for the physician’s assessment that the child is currently mentally or physically disabled (as that term disabled is defined in this document) and that disability existed before the attainment of the Plan’s age limit and is incapable of self-sustaining employment as a result of that disability; and dependent chiefly on you and/or your Spouse for support and maintenance. The Plan may require that you show proof of initial and ongoing disability and that the child meets the Plan’s definition of Dependent Child.
Qualified Medical Child Support Order (QMCSO): Valid QMCSO document signed by judge or National Medical Support Notice.
Domestic Partner: Signed affidavit by the Employee/Retiree and Domestic Partner that they meet the requirements of this Plan’s Domestic Partner eligibility using the Plan’s state recognized Domestic Partner registration form.
Failure to Provide Proof of Dependent Status: Claims for newly added Dependents (e.g. Spouse, Domestic Partner, children) will not be considered for payment by this Plan until the Trust Fund Office receives verification/proof of Dependent status.
To comply with federal Medicare coordination of benefit regulations and certain IRS reporting rules, you must promptly furnish to the Plan Administrator, or its designee, the Social Security Number (SSN) of your Eligible Dependents for whom you have elected, or are electing, Plan coverage, and information on whether you or any of such dependents are currently enrolled in Medicare or have disenrolled from Medicare. This information will be requested when you first enroll for Plan coverage but may also be requested at a later date.
If a dependent does not yet have a social security number, you can go to this website to complete a form to request a SSN: http://www.socialsecurity.gov/online/ss-5.pdf. Applying for a social security number is FREE.
Failure to provide the SSN or failure to complete the CMS model form (form is available from the Claims Administrator or http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Downloads/New-Downloads/RevisedHICNSSNForm081809.pdf) means that claims for eligible individuals may not be considered a payable claim for the affected individuals.
Your newborn Dependent Child(ren) will be covered from the date of birth if you request enrollment of your newborn child within 60 days of birth. You must provide the Trust Fund Office with an updated Plan Enrollment Form and a copy of your child’s birth certificate as soon as practicable. If you are in the HMO, you must update your enrollment within 60 days of the child’s birth for coverage to continue.
Remember that you may not enroll a newborn Dependent Child for coverage unless you, the Employee or Retiree, are also enrolled for coverage. Submitting a claim to the Plan for maternity care/delivery for care of a newborn child is not considered proper enrollment of that child for coverage under this Plan.
Your adopted Dependent Child will be covered from the date that child is adopted or “Placed for Adoption” with you, whichever is earlier, provided you enroll the child in the Plan. A child is “Placed for Adoption” with you on the date you first become legally obligated to provide full or partial support of the child whom you plan to adopt.
A Newborn Child who is Placed for Adoption with you within 60 days after the child was born will be covered from the date the child was placed for adoption if you comply with the Plan’s requirements for obtaining coverage for a Newborn Dependent Child, described above in this chapter.
A Dependent Child adopted more than 60 days after the child’s date of birth will be covered from the date that child is adopted or “Placed for Adoption” with you, whichever is earlier, if you request enrollment within 60 days of the child’s adoption or placement for adoption. You must provide the Trust Fund Office with an updated Plan Enrollment Form and provide of proof of Dependent status (if requested) as soon as practicable.
If a child is “Placed for Adoption” with you, and if the adoption does not become final, coverage of that child will terminate as of the date you no longer have a legal obligation to support that child. Remember that you may not enroll an adopted child or a child Placed for Adoption for coverage unless you, the Employee/Retiree, are also enrolled for coverage.
enforces a state law relating to medical child support pursuant to Section 1908 of the Social Security Act, which provides in part that if the Employee parent does not enroll the child, then the non-Employee parent or State agency may enroll the child.
the name of each Plan to which the order applies.
A Medical Child Support Order will not qualify if it would require the Trust Fund to provide any type or form of benefit or any option not otherwise provided under this Trust Fund, except to the extent necessary to comply with section 1908 of the Social Security Act.
No eligible active Employee’s or Retired Employee’s child covered by a Qualified Medical Child Support Order will be denied enrollment on the grounds that the child is not claimed as a dependent on the parent’s Federal income tax return or does not reside with the parent.
Additional Information: For additional information (free of charge) regarding the procedures for administration of QMCSOs, contact the Trust Fund Office.
the date of the Spouse, Domestic Partner or Dependent Child’s death.
Domestic Partner ceases to meet the Plan’s definition of Domestic Partner.
Failure to give this Plan a timely notice (as noted above) will cause your Spouse or Domestic Partner and/or Dependent Child(ren) to lose their right to obtain COBRA Continuation Coverage or will cause the coverage of a Dependent Child to end when it otherwise might continue because of a physical or mental disability.