New Designated Hospitals

and New Benefit Tier

To All Class 1 and Class 2 Participants in the Lake County, Indiana NECA-IBEW Health and Benefit Plan:

We are very pleased to announce that the Franciscan hospitals have become designated hospitals.  In addition, the Franciscan hospitals will comprise a new Level A Payment Tier.  The Plan will waive your deductible and coinsurance for any covered charges you incur at a Level A hospital.

Level A Designated Hospitals

(Deductible and Coinsurance Waived)
Franciscan St. Anthony Health – Crown Point, IN
Franciscan St. Anthony Health – Michigan City, IN
Franciscan St. Margaret Health – Dyer, IN
Franciscan St. Margaret Health – Hammond, IN
Franciscan Healthcare – Munster, IN
The complete street addresses of these hospitals are on www.pna-usa.com.
 
Designated hospitals will not balance-bill you for amounts in excess of the Plan’s reimbursment.
 
The new payment tier is effective with charges incurred on or after October 1, 2015.
 
Level A is a designation and benefit tier only for hospitals.  If you use a Level A Hospital, the usual deductible and coinsurance (90%/10% or 70%/30%) will continue to apply to professional (non-facility) services.  Even if you pay $0 for the hospital’s charges, you will still be responsible for paying a portion of your doctors’ charges, including charges by your surgeon and anesthesiologist, plus services billed by independent radiologists and pathologists.
 
Note:  Reference-based pricing and designated hospitals do not apply to persons for whom Medicare is primary (retirees and dependents of retirees).

Level B Designated Hospitals

(90% after Deductible)
Methodist Hospital – Gary, IN
Methodist Hospital – Merrillville, IN
Portage Hospital – Portage, IN 
Porter Regional Hospital – Valparaiso, IN
Pinnacle Hospital – Crown Point, IN
Community Hospital, Munster, IN
St. Mary Medical Center, Hobart, IN
St. Catherine’s Hospital, East Chicago, IN
University of Chicago, Chicago, IL
The complete street addresses of these hospitals are on www.pna-usa.com.
 
Remember that designated hospitals have agreed not to balance-bill you for amounts in excess of the Plan’s reference-based price.
You can see the complete list of participating providers at www.pna-usa.com.  Click on “Lake County Indiana NECA-IBEW Local No. 697 Members.”

 

Note:  Reference-based pricing and designated hospitals do not apply to persons for whom Medicare is primary (retirees and dependents of retirees).

NOTICE REGARDING GRANDFATHERED STATUS

The Trustees of the Lake County, Indiana NECA-IBEW Health and Benefit Plan have determined that the Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the “Affordable Care Act”).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement to cover preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Fund Office at 7200 Mississippi Street, Suite 300, Merrillville, IN 46410, telephone 219-845-4433.  You may also contact the Employee Benefits Security Administration, U.S. Department of Labor, at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.  This website has a table summarizing which protections do and do not apply to grandfathered health plans.

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The Plan is sponsored by a joint labor-management Board of Trustees. The Board of Trustees is the Plan Administrator. The Board is divided equally between Trustees appointed by the Union and by Trustees appointed by the employer Association. The names and addresses of the individual Trustees are shown on page 100.

The Fund receives contributions from employers under the terms of collective bargaining agreements and participation agreements and from the Union. The Fund also receives self-payments from employees, retirees and dependents for the purpose of continuing coverage under the Plan. It may also receive rebates from its prescription benefit manager.

The classes of persons who are entitled to participate in this Plan are described on pages 12-13. The Lake County, Indiana N.E.C.A. I.B.E.W. Health and Benefit Plan is classified as a health and welfare benefit plan, providing benefits of the type described in the following paragraph. Employer contributions and self-payments by employees, retirees and dependents are received and held in trust by the Trustees pending the payment of benefits, insurance premiums and administrative expenses.

The Plan provides medical, surgical, hospital, disability, dental and vision benefits on a self-insured basis. When benefits are self-insured, the benefits are paid directly from the Fund to the claimant or beneficiary. The self- insured benefits payable by the Plan are limited to the Plan assets available for such purposes. Although, as described earlier in the Summary Plan Description, PNA re-prices claims involving medical, surgical and hospital benefits, and Vision Service Plan reprices and processes vision claims, the services of these companies are in the nature of providing preferred provider networks and all benefits paid remain self-insured.
    
Please take some time to review the Plan’s Summary Plan Description. If you’re married, share the information with your spouse. The SPD is the most recent printed version, so changes have been made since then. The latest change concerned how allowable charges will be determined–for more information select the "2015 May SMM" on this page. ("SMM stands for Summary of Material Modifications, a participant notice about Plan changes.)

The Trustees will continue to keep you advised of any changes in the Plan.  Please be sure that the Benefits Office has your current address at all times.

If you have any questions, you should contact the Benefits Office
at (219) 845-4433 or (219) 940-6181

 

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Frequently Asked Questions

We are sending this question-and-answer sheet to participants in the Lake County, Indiana NECA/IBEW Health and Benefit Plan in order to help answer their questions about the Plan’s new reference-based pricing approach to benefits for hospital bills.

Note:  Reference-based pricing and designated hospitals do not apply to persons for whom Medicare is primary (retirees and dependents of retirees).

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Q. What is referenced-based pricing?

A.  Reference-based pricing is an approach that health plans use to control claim costs.  It uses a stable criteria, such as Medicare’s payment rate, to determine a fair and reasonable price for a medical service or supply.  The plan usually adds a percentage to that fixed rate so that it pays more than Medicare would pay.  The intent is to provide a fair and reasonable reimbursement to the facility, while at the same time protecting the plan from unreasonable and unfair overcharges.

Note:  Reference-based pricing and designated hospitals do not apply to retirees or dependents of retirees with Medicare. 

Q. Why is the Fund using reference-based pricing?

A.  The Fund moved to reference-based pricing in order to control the escalating, unreasonable and widely varying prices charged by area hospitals and outpatient facilities.

The reference-based price is a reasonable and customary price, and the Fund will still pay a reasonable amount for its participants’ medical care.  

Q. Which types of services does reference-based pricing apply to?

A.  Reference-based pricing applies to charges by hospitals and outpatient facilities.  It does not apply to professional fees by physicians, laboratories, pharmacies or home health care.

Q. What is a designated hospital?

A.  A designated hospital is a hospital or facility that has agreed to accept the Plan’s reference-based price and not balance-bill the patient for the difference (other than the usual deductible and coinsurance).

Q. Are there any designated hospitals?

A.  Several facilities that perform outpatient surgery or diagnostic testing and imaging are now considered “designated facilities.”  You can see the complete list of providers at www.pna-usa.com.  Click on “Lake County Indiana NECA-IBEW Local No. 697 Members.”

Q. What about inpatient facilities?

A.  The Plan is in the final stages of negotiations with several inpatient facilities.  We will send you more information in the very near future.  

Q. What should I do in the event of an emergency?

A.  You should not hesitate to seek treatment in an emergency.  PNA will work with the hospital after the fact to make sure you aren’t unfairly charged for those services.

Q. What if I need to schedule inpatient medical care at a facility?

A.  If your provider or facility calls Hines, the Plan’s medical review organization, for pre-determination of medical necessity, Hines may advise you about whether or not the facility you want to use will accept the Plan’s reference-based price.  If not, Hines may be able to help direct you to an alternate facility.  You can also call PNA at 1-888-476-2776 before scheduling your services.  They will help you find a facility that will lessen the amount you will have to pay.  

Q. A local hospital told me I have no coverage.  Is that true?

A.  No. A non-designated hospital is like an out-of-network hospital.  You have coverage, but the Plan will pay it at the out-of-network rate.  The Plan pays 70% up to 130% of the Medicare rate for out-of-network facility charges (minus your deductible if it was not previously satisfied).  You should ask the hospital what they anticipate charging for the procedure.  Then you can call PNA to find out what 130% of the Medicare rate will be.

Q. Will PNA help me after I have already used a non-designated facility and incurred a substantial out-of-pocket bill?

A.  Yes. You should call PNA at 1-888-476-2776 and ask for help.  They will negotiate the charges for you, but there is no guarantee what the final charges will be.  You must call PNA for assistance as soon as possible. 

Q.  How does a participant initially become eligible?

A.  A bargaining unit employee or apprentice will become initially eligible for Plan benefits on the first day of the calendar month that immediately follows the month in which he completes 420 hours of work for a contribution employer. Those 420 hours must be within a period of 26 weeks or less.

Ex:  420 hours in April, May, June & July = initial eligibility August 1st.

Accelerated Eligibility:  A bargaining unit employee or apprentice who is acquiring eligibility in this Plan for the first time may become initially eligible on the first day of the calendar month that immediately follows the month in which the Plan receives contributions for 160 hours worked from a contributing employer.  This rule will only apply to employees who submit a HIPAA Certificate of Coverage showing that they were previously covered under another health plan, and there is no gap of 63 days or more between their prior coverage and this Plan’s coverage.

Q.  How do I receive my Insurance & Prescription Cards?

A.  Once the Benefits Office receives your hours they will contact you either by letter or phone call.  You need to come into the office to fill out an Information Update Form, Beneficiary Forms, drop off any needed documents that they might need, then they will give you the cards & booklets.

Q.  What do I need to do to add on my spouse and children to my coverage?

A.  When you become eligible , or if you already are covered, you will need to bring in a marriage license, birth certificates, social security #’s and HIPAA Certificates in order for the benefits office to add them on.  

Q.  What do I need to do if I get divorced?

A.  The benefits office will need a copy of your divorce decree in order for them to remove the spouse from the health plan.  This needs to be done immediately as by law we must offer COBRA to the ex-spouse within 60 days of the divorce date.  You will also need to change your beneficiaries in the various funds within the office. 

Q.  How can I view and print out my Explanation of Benefits?

A.  On this website we have a link under Stewart C. Miller that will allow you to view and print your medical/dental claims history.  You can also go to their website: www.scmiller.com to register.  You will need to create a Member ID for yourself and or spouse.  If you have any questions regarding their website please call 1-800-552-6550.

Q.  Where does the Doctors/Hospital or myself mail the claims too?

A.  All claims should be directly mailed to the Claims Office @ Stewart C. Miller. 
Their address is 2111 W. Lincoln Highway, Merrillville, IN  46410.  

Q.  Do I need to precertify if I am having a procedure done?

A.  You must precertify for all In-Patient Hospitalization, Surgical Procedures, MRI, CT & Pet Scans.  If you are unsure of what Procedure you are having done always call Hines & Associates @ 1-800-670-7718 and ask them.  They will be glad to help you with your situation.  Failure to precertify will result in lower plan benefits.  

Q.  Can I go to any Doctor in my area, or in any area?

A.  You should use doctors in the Preferred Network Access PPO network. You can ask your doctor if he or she is in the PNA network. You can also call contact PNA at 1-888-476-2776 or look for network doctors at website: www.pna-usa.com.

Q.  Do I have dental insurance?

A.  All active participants have a $2,000.00 family dental benefit.  All dental benefit payments will be made directly to the participant.  Please submit your dental claim to the claims office as soon as possible for you to get reimbursed.  The Plan pays 75% of the covered expenses incurred by you and your eligible dependents.  See your Health & Benefit booklet for more details.

Q.  What is the Plan's hospital network?

A.  YThe plan uses reference-based pricing for hospital service. Hospitals that agree to accept the Plan's payment without balance billing the patient for the remainder are called "designated hospitals." Designated hospitals form the Plan's hospital network, which is managed and administered by Preferred Network Access (PNA). The Fund will mail out lists of designated facilities from time to time. But you can also call PNA at 1-888-476-2776 or go to www.pna-usa.com for the most up-to-date list.

Q.  What happens if I don’t not work enough hours?

A.  If you have fewer hours than 420 hours during a work quarter and your eligibility dollar bank is insufficient to cover the shortage, you can maintain your eligibility by making a self-payment.  You can call the Benefits Office to find out how many hours you are short and what the billing rate is at that time and make a payment in that quarter.  You will be billed sometime in the following quarter for the shortage of hours, if you do not pay for your shortage of hours , your eligibility will be terminated.  In order for us to reinstate you , you will then need to work 420 hours to get reinstated.

Q.  What is the Eligibility Bank?

A.  Once you establish your 420 hours any contributions in excess of 450 hours per quarter will be credited to your eligibility dollar bank.  The maximum you can have in your eligibility dollar bank is the amount needed for two full quarters of eligibility.  As of July 1, 2015 the amount was $7,686.00.  If you have a quarter with fewer than the 420 hours needed because of unemployment, underemployment, disability, the amount you are short will automatically be withdrawn from your eligibility dollar bank so that you will not lose eligibility.

Q.  What happens if I don’t work the 420 hours in a quarter?

A.  As an active eligible member you are required to work the 420 hours in a quarter.  If you work less than what is required you as a member are responsible for the shortage of hours.  You will be billed according to the current billing rate times the number of hours short.  Each quarter all members who are short hours will receive an invoice approximately 1-2 months after the quarter you are short.  Please make sure that you pay this invoice or your eligibility will be terminated.

Q.  Is there anything that I can do to avoid getting an invoice:

A.  You can keep track of your hours weekly and send in money owed each week or each month, so that you will not be billed for a large amount.  Call the Benefits Office to get the current billing rate and to find out how many hours you are short.  

Q.  What happens when I reach my maximum amount in my eligibility dollar bank:

A.  When you have reached your maximum amount, any additional excess contributions that would otherwise have been added to your eligibility dollar bank, will then be credited to your MRP account.

Q.  What is the MRP Account?

A.  This is an account for the participants to use for qualifying expenses on a non-taxable basis.  Currently the maximum amount in the MRP Account is $6,300.00 as of July 1, 2013. See your booklet for covered expenses.

Q.  How do I know what my MRP balance is?

A.  You need to call Stewart C. Miller (219-845-4433) to get this balance.  You also receive a quarterly statement from them as well.

Q.  Do I need to fill out this Information Update Form that I get every year in the mail?

A.  Yes, if you fail to fill this form out, the Claims Office will not pay any claims on you or your dependents until they receive this form.  You need to fill it out on a timely matter in order for your claims to be processed.

Q.  What happens to my benefits when I work in another local union’s jurisdiction?

A.  You must be registered on the Electronic Reciprocal Transfer System (ERTS) in order for your benefits to be reciprocated to your home local or fund you have designated.  Begin the process of registration at your home Local Union or a participating fund office.  Once you are registered you will receive by mail your user ID and password.  This reciprocal authorization will remain in effect until you modify your registration.  Please remember to update your information on ERTS if your address changes. Visit ERTS website

Q.  If I am sick or suffer a non-occupational injury would I be entitled to any benefits?

A.  Yes you would be entitled to a maximum of $550.00 per week from the date of your injury.  In addition, you will continue to get credit toward your Health & Benefit as well as your Pension Benefit.  Before any benefit is issued, a Statement of Loss of Time (Download Form) must be completed by your Physician and returned to the Benefits Office.

Q.  How long am I able to collect for Loss of Time?

A.  If you remain totally disabled after 26 weeks of Loss of Time Benefits have been paid, you may qualify for Supplementary Disability Benefits for the remainder of your disability period up to a maximum of 26 additional weeks.  

If the Plan pays you unreduced Supplementary Disability Benefits and you later receive disability benefits from another source to cover any retroactive period for which Supplemental Disability Benefits were paid, you must refund the Plan the amount it overpaid.  If you do not refund the overpayment, the Fund has the right to collect its overpayment from future benefits payable to you under any of the Plan’s benefit provisions.

Q.  Will State and Federal Taxes be taken out of my check?

A.  In accordance with federal law, the Fund will withhold federal taxes from each weekly payment, and you must include your Loss of Time Benefits in your gross income for federal income tax purposes.  If you have a question about this, or about exclusions I the law, you should check with a competent tax advisor or attorney.

Q.  What happens if I am awarded a Social Security Disability Award?

A.  At that point you need to make an appointment with the Benefits Office and bring in the award.

Q.  Do I have Life Insurance?

A.  The Plan provides a $15,000.00 Life Insurance benefit for eligible Class 1 active employees and Class 2 retirees under age 65. 

Q:  What happens if I join the Military?

A:  Participants that receive a Military Order to report for Duty must report in person to the Local 697 Benefits Office. 

Those discharged from Military Service must report to the Benefits Office and provide a copy of Form DD214

(Certificate of Release or Discharge from Active Duty) or other official written documentation from the Military, upon returning to work.