Frequently Asked Questions

Specifically, the name of your insurance provider is the Lake County Indiana, NECA – I.B.E.W. Health and Benefit Plan.

Regardless of any medical network affiliation, the Lake County Indiana, NECA – I.B.E.W. Health and Benefit Plan directly provides you and any eligible dependent the benefits contained within the Plan’s Summary Plan Description book. It is the Lake County Indiana, NECA – I.B.E.W, Health and Benefit Plan that assumes the responsibility for paying claims in accordance with the terms, conditions and provisions set forth within that document.

First, read the enrollment provisions within the Summary Plan Description Book. Gather all the required information as explained within that section and then request the enrollment form from the Fund Office. You can do so by calling 219-940-6181.

Generally, for new employees who have a letter of credible coverage on file at the Plan office, coverage will begin on the first day of the month following the month in which 160 hours of employer contributions are received on your behalf within a six-month period.

If a new employee does not have a letter of credible coverage, then coverage will begin on the first day of the month following the month in which 420 hours of employer contributions are received on your behalf within a six-month period.

Refer to the section of the Health and Benefit Plan Summary Plan Description Book or contact the Health and Benefit Office for exact details.

Journeypersons or employees are required to have 420 hours contributed on their behalf during a calendar quarter or make a self-payment equivalent to the monthly cost of the hourly employer contribution requirement.

Apprentices and Indiana Plan participants need 324 hours contributed on their behalf during a calendar quarter or make a self-payment equivalent to the monthly cost of the hourly employer contribution requirement.

If you’re a journey person and your coverage has terminated, it will again be reinstated on the first day of the first month following the month in which 420 hours of employer contributions are received on your behalf within a six-consecutive month period.

Reinstatement coverage will be for the remainder of the calendar quarter in which you became eligible and the successive calendar quarter.

The same parameters will apply for Apprentices and Indiana Plan participant’s, non-bargaining employees and Owners and Owners in Fact, except the number of required hours needed to be contributed by a signatory employer is 324, 324, 160 and 500 respectively.

Congratulations! Yes, you can add your spouse to this Plan.

Recently married participants will need to reread both the Dependent and Enrollment provisions of the Plan’s Summary Plan Description Book, complete a new enrollment form and return it to the Benefit Fund Office along with a copy of your marriage certificate and your spouse’s birth certificate and Social Security Card. Provided the enrollment of your spouse occurs within thirty (30) days from the date of your marriage, your spouse will be automatically eligible for coverage effective as of the date of your marriage.

If you fail to timely submit a properly completed enrollment form and the proper supporting documentation as determined by the Plan, your spouse will be enrolled in the Plan on the first day after the Health and Benefit Plan receives and deems complete the enrollment form and all proper supporting documentation. Any bills incurred prior to the Plans enrollment of your spouse prior to that date will remain the sole responsibility of the participant.

It is recommended that when a participant enrolls a spouse, they also take a moment to review their beneficiary elections on file with the various Benefit Plans as well as the Local 697 Union office and if needed, update accordingly.

Yes, however, you will need to reread the Children and Enrollment provisions within the Plan Summary Plan Description Book, complete a new enrollment form and return it to the Benefit Office along with a copy of the child’s birth certificate and Social Security card within ninety (90) days of your child’s birth. If you fail to properly enroll your newborn within that time period, any claims incurred prior to and after that time will remain the responsibility of the participant.

Similar to when you get married, it is recommended that with each new addition to your family, you take a moment to review their beneficiary elections on file with the various Benefit Plans and Local 697 Union office and if needed, update accordingly.

Children are covered until the last day of the month in which they turn age 26. Children do not have to be students, unmarried, financially dependent or living with their parents in order to be covered.

Coverage will either terminate on the last day of the month of the calendar quarter in which you have earned coverage or on the last day of the month of the month in which you have made a monthly self-payment. After your coverage terminates, the Plan will send you a COBRA election package.

Generally, the cause of the shortage is either one or two things.

1. The employer does not adhere to the common practice of closing out the calendar quarter on the last Sunday of the month. Instead, work performed for part of the last week of the calendar quarter and the first part of the first week of the subsequent quarter, are contributed by the employer at the end of the new quarter. Or,
2. You worked outside the jurisdiction of the I.B.E.W. Local 697. If you did, then the employer’s contributions for the hours you worked were sent to the Local in the jurisdiction you worked and pursuant to your ERTS instructions, they have yet to be forwarded back to the Lake County Indiana NECA – I.B.E.W. Health and Benefit Plan.

Unfortunately, and for the reasons that the Plan neither has any control over the Fringe Benefit payment practices of an employer, nor any control over the reciprocity practices of another Local’s Benefit Fund Office, there is nothing the Health and Benefit Plan Office can do.

Simply put, the Fund Office cannot credit monies it has not received nor back date contributions because the employer does not adhere to the common methodology of closing the calendar quarter on the last Sunday of the month.

Additionally, Local 697 is signatory to the National Reciprocity Agreement. It is this document that dictates when a I.B.E.W. Local’s Benefit Office is required to remit hours back to the Local pursuant to that participant’s ERTS election. While the Local 697 Benefit Office exceeds those reciprocity remittance requirements, other Locals are more “relaxed” in their adherence to those regulations. Similar to employer contributions, the Fund Office cannot credit monies nor back date contributions if they have yet to be reciprocated and/or never received.

Further, unless you inform the Fund Office that you are working in another Local’s jurisdiction, the Fund Office does not know if it is to expect reciprocated contributions.

In both cases you will need to check in with the employer to see when they made their Fringe Benefit contributions. If you worked in another I.B.E.W Local’s jurisdiction you will also have to call that Local’s Benefit Fund Office and instruct them to forward those contributions to the Local 697 Benefit Office.

If you do not make the required self or COBRA payment, or make that payment by the mandated due date, coverage for you and any eligible dependent will terminate. If terminated, the following will occur:

1. Eligibility for dental, health, HRA, life-insurance, pharmaceutical and vision benefits cease for you and any eligible dependents.
2. Your HRA (Create) debit card is frozen, and you will have sixty days to manually submit claims for reimbursement that were incurred within the twelve months prior to the termination from the Plan.
3. Regardless of subsequent reinstatement, after sixty-days any balance within your HRA account will be forfeited.

Included Health is a tremendous resource. It is the Funds sole telehealth benefit service provider for:

• Tela-health urgent care needs.
• Second opinion needs. And/or,
• Needs as they relate to the desire to find high quality physicians and surgeons.

It is important to note that Included Health provides medical guidance. They direct you to a higher level of care, provide second opinions, research and/or supply you with additional information to help you make the right health decision for you and your family.

• Want to find the highest qualified provider and as such, the “best of the best” within any specialty within the Plans network, or available to you under the terms of this Plan? Of course, you do. Contact Included Health.
• Do you have concerns about the proposed procedure and want to make sure that the suggested course of action is correct or even necessary? Call Included Health.
• Are you confused about your treatment options? Call Included Health to discuss diagnoses, symptoms, and treatment plan options.

Included Health is available to only the active and non-Medicare participants of the Plan.

Included Health is available to only the active and non-Medicare participants of the Plan.

There are three ways in which you can sign up or register with Grand Rounds (Included Health), they are:

Mobile

• Search “Included Health” in the Apple App Store or Google Play Store.
• Download the Included health app.
• Enter your e-mail and password, then input your personal information to create your account.

Desktop

• Log on at includedhealth.com/ibew697
• Enter your e-mail and password, then input your personal information to create your account.

Phone

• Call Included Health at 1-800-929-0926 to speak with a care coordinator and set up your account.

Participants who misplaced their medical identification card, can order another one at www.mycreate.com or can either call the Fund Office (219-940-6181) or MagnaCare (855-295-1160) directly and they will order one for you.

The following is a brief overview of some services or procedures that require concurrent review or prior authorization. For the complete listing please reference the Plan’s Summary Plan Description Book:

• Outpatient
  1. Alcohol Dependency – All outpatient treatments after the seventeenth (17th) visit or treatment.
  2. Cardiac rehabilitation – All outpatient therapy treatments after the seventeenth (17th) visit or treatment.
  3. Chemical Dependency – All outpatient therapy treatments after the seventeenth (17th) visit or treatment.
  4. Dietician/Nutritionist counseling after the seventeenth (17th) visit or session.
  5. Mental Health – All outpatient treatments after the seventeenth (17th) visit or session.
  6. Occupational therapy treatments after the seventeenth (17th) visit or session.
  7. Physical therapy - – All outpatient treatments after the seventeenth (17th) visit or session.
  8. Rehabilitation therapy – All outpatient treatments after the seventeenth (17th) visit or session.
  9. Respiration therapy – All outpatient treatments after the seventeenth (17th) visit or session.
  10. Speech therapy - All outpatient treatments after the seventeenth (17th) visit or session.
  11. Substance abuse treatments - All outpatient treatments after the seventeenth (17th) visit or session.

Services, such as, but not limited to, the services found below require pre-certification or prior authorization.

• Alcohol Dependency – All Inpatient treatments
• Ambulatory Surgery
• Bariatric / Gastric Bypass Surgery
• Birthing Centers
• Brachytherapy
• Cardiac rehabilitation for all partial and inpatient stays
• Cardiac nuclear scans
• Cataract Surgery
• Chemical Dependency – All Inpatient
• Chemotherapy
• Corrective and/or cosmetic surgery
• Dental work performed in a hospital setting.
• Detoxification
• Diabetic Management
• Diagnostic Imaging/Testing
• Dialysis
• Durable medical equipment in amounts greater than $1,000.00.
• Epidural injections/nerve blockers
• Gastric Bypass
• Genetic testing
• Home health care
• Hospice of greater than 180 days
• Hospital admissions of any length of stay or of any type
• Hysteroscopy’s
• Injectable treatments of $1000 or greater, that are administered in Office.
• Infant formula that is specialized for children with an inborn error of metabolism.
• Infusion therapy if not able to be obtained through this Plans pharmaceutical/drug program.
• Inpatient care
• Inpatient mental health
• Inpatient rehabilitation
• Inpatient substance abuse rehabilitation
• Inpatient surgery
• Mastectomies
• Mental Health (Inpatient)
• Nasal Surgery
• Orthotics greater than $1,000.00.
• Orthotripsy
• Outpatient surgery
• Pharmacogenetics
• Physical therapy treatments greater than 17
• Podiatric surgeries
• Private duty nursing
• Prosthetics
• Pulmonary rehabilitation
• Physical therapy inpatient
• Radiation therapy
• Reconstructive and corrective surgery
• Rehabilitation therapy (Inpatient)
• Respiration therapy (Inpatient)
• Sclerotherapy
• Skilled nursing benefits
• Specialty drugs must be pre-certified with the Plans PBM and/or Specialty Drug PBM
• Sterilization Procedures
• Substance Abuse – All Inpatient
• Surgeries of any type
• Synagis injections
• Transplants
• Trigger point injections
• Vein therapy

The Plan will not make payment toward services that require pre-certification but did not receive authorization or for those that do not receive approval through the concurrent review process prior to the 18th or for any subsequent session, treatment or visit.

On time and as explained directly below.

Eligible journeypersons, apprentices, employees and Indiana Plan employees can receive a gross weekly income of up to fifty percent (50%) of their weekly salary (excluding any overtime) up to a maximum of $700.00 per week.

This Summary Plan Description (SPD) is a summary of the Covered Health Care Benefits available to eligible active, early retirees and Medicare eligible participants of the Lake County Indiana, NECA-IBEW Health and Benefit Plan. The SPD is a legal document and under our Plan it also serves as the Plan Document.

The Board of Trustees may, from time to time, change the Plan’s SPD by attaching legal documents called SMMs and/or Amendments that may change certain provisions of that documents. When this happens, the Plan will mail to you either the SMM’s or Amendments, post those within the Funds website and then post an updated SPD on the Funds website.

You read and learn it. All of it. In its entirety AND any and all attached Amendments, Addendums or SMMs.

Why? For many reasons, such as but not limited to:

1. Because that is what good participants of the Plan do
2. Because you may not have all of the information you need by reading just one section.
3. Because the Plan does not pay for all health care services. (Remember, benefits are limited to those that are stated within the Summary Plan Description Book)
4. Because you need to know how the Plan works so as to:
   1. Maintain eligibility,
   2. Reduce out-of-pocket expenses,
   3. Speak intelligently with your medical, dental and vision providers about any Plan limitations or level of benefits available to you.
   4. Assist other members and participants by guiding them to the exact provision of the Plan that they may be interested in, curious of, or complaining about.
   5. Stop giving out erroneous advice or guidance to other members or Plan participants. We both know you have not put in the time to learn the Plan as well as you should by this point in your career. Every time you “chime in” on a subject you know you’re not 100% certain about, you do a disservice to the individual asking the question, yourself and this organization. Instead, simply state that you are unsure and that it best to reference the source which, of course, is the SPD.
   6. Know when someone is talking nonsense about some circumstance, Plan provision, rule or interaction in order to either gain your sympathy, play the victim or worst to mislead you and others through deception. If nothing else, your time is valuable and as such should not be spent listening to foolishness or unacceptable behavior.

By the way, if there is a conflict between the SPD and any summaries provided to you, or advice given from a “purported” expert participant of the Plan, the SPD controls.

It is your responsibility to select the health care professionals who will deliver your care. If you do not know what type of physician to see or who is a very good physician, contact Included Health. They can assist you in both regards.

By the way, the Plan has arranged for a network of physicians and other health care professionals and facilities that participants can elect to utilize. However, and while the chosen network confirms public information about the professionals' and facilities' licenses and other credentials, it cannot assure the quality of their services. As such, all participants are informed that these professionals and facilities are independent practitioners and entities that are solely responsible for the care they deliver.

Come on! You’re not really asking that, are you?

Really?

Simply put, care decisions are between you and your Physician.

What?

Why would you think that?

Your Physician is not responsible for knowing or communicating your Benefits to you. That is on you. Your physician’s job is to know medicine.

If you ever needed another reasons to read the SPD and to learn your benefits, there it is.

Despite what you may have been erroneously informed or mistakenly think, and unless you are making a self-payment, or C.O.B.R.A. payments, the cost for coverage is funded by the employers in accordance to the terms and conditions of the Collective Bargaining Agreement.

Still do not believe us. Take a look at your paystubs. Do you see any deductions for HealthCare being made from your weekly gross or net pay amount? No? That’s because there are none.