Read this section carefully and make an informed selection. If you pick a level that you cannot support because you do not work enough hours, you may lose coverage. Know the Plan’s eligibility rules – your coverage may depend on it.
To review the Plan’s Rules, click on the section of your choice:
In order to obtain coverage you must fill out the enrollment form provided by the Administrative Office. To be eligible for coverage, your dependents must be listed on the enrollment form. Proof of dependent status must be provided to the Trust Fund Office.
Non-bargaining Unit Employee – An employee working for a contributing employer in a non-bargaining unit job classification. A non-bargaining unit employee who works at least 20 hours per week shall become eligible for coverage on the first day of the month following the month in which they complete 30 days of continuous employment for the Contributing Employer.
Non-bargaining unit employees are not eligible for Reserve Contribution Credits nor are they eligible for a Death Benefit through this Plan.
When you work in covered employment for an employer signatory to a labor agreement with Southern California Painters & Allied Trades District Council 36, contributions may be made into this Plan on your behalf. These contributions are used to determine eligibility for you and your eligible dependents.
Some employers contribute into the Plan on a per hour basis and some employers contribute into the Plan a fixed amount per month if you work the required hours or days in a month.
If you are a new Employee, or if you previously lost eligibility, you become eligible for Employee coverage on the first day of the fifth month of a period that begins with three continuous months during which you accumulate the minimum hours for the level that you have selected, so long as you are credited with at least 25 hours in the first month.
The following examples reflect how eligibility for coverage is determined
* Effective work month of October 2016 and eligibility month of January 1, 2017 (H&W rate of $8.05)
* If you work under other rates or a combination of rates, the total dollars contributed per month will determine your eligibility.
|Level A||Level B||Level C|
|Benefit Credits/Hours Needed||140||120||100|
|*Hours Needed x Hourly Contribution (Primary) Rate of $8.05||1,127||966||805|
|Maximum Hour Bank You Could Earn||4,508||3,864||3,220|
* Effective work month of October 2016 and eligibility month of January 1, 2017 (H&W rate of $8.05)
The contribution rate for non-bargaining employees is established by the Board of Trustees and is subject to the change from time to time.
When a member establishes eligibility, he/she will be enrolled in the default Medical Plan, which is the Indemnity Plan Level C. If the eligible member does not want to remain in the Indemnity Plan Level C; an enrollment form must be submitted within 90 days after establishing eligibility, wherein the member selects the desired Medical Plan and Plan Level for the next 12 months. The member has the option of lowering the Plan Level during the year as many times as needed. However, the member can only select a higher Plan Level after he or she has been enrolled in their initial or current Plan Level for 12 consecutive months. An Enrollment Form must be submitted selecting the new Plan Level prior to the eligibility month. The Plan Level change will not be done automatically. If the member does not have sufficient credits to remain eligible at the Plan Level selected. In such event he/she will lose coverage. The Plan Level Change will not be granted if requested after coverage is terminated. (If there is a difference between the hours you have worked and the contribution your employer has made towards your benefits, you may have to submit check stubs to the Trust Fund Office.)
If a member loses coverage and has bank hours and/or elects COBRA, then returns to work with no lapse or lapse in coverage, the initial eligibility requirements don’t apply if the member re-instates coverage within six (6) months.
In addition, if a member, through COBRA, maintains the full package of benefits in which he participated immediately before the COBRA “Qualifying Event”, any Reserve Benefit Credits in the Bank will be carried forward for a maximum of six months. Any hours the member works during that six month period will be added to the hour bank helping the member regain eligibility under the bank rules. In the event the member does not accumilate the hours requires to regain eligibility within the six month period, the member will loose the remaining Reserve Benefit Credits in the hour bank balance. However, your COBRA rights will continue.
The member will have the opportunity to change Medical Plans and to upgrade Plan Levels if he/she has been enrolled in their initial Medical / Dental Plan or current Plan Level for 12 consecutive months.
Having three Plan levels enables you to select an affordable level of coverage for the year ahead based on the hours you expect to work. The three Plan levels have the same Major Medical benefit options, e.g., an Indemnity PPO Plan or one of two HMOs. In addition to the amount payable by the Indemnity PPO Plan for covered services, or the HMO’s member co-pay amounts if you choose an HMO, the main differences in the three Plan levels are the availability and amount of Dental coverage provided, and the availability of Vision, Chiropractic, and Substance Abuse Detoxification benefits. (For further details, a Plan Comparison Chart is available from the Trust Fund Office.)
Coverage will become effective once:
- you have submitted a completed enrollment form; and
- you have worked enough hours to become eligible.
Increases or decreases in your level of coverage are effective on the first of the month following the month in which your request to change is approved by the Trust Fund Office.
Your coverage will automatically end on the earliest of the following dates:
- the date this Plan ends;
- the date you become ineligiblebecause of amount of hours worked;
- the date you begin active duty in the armed forces unless the period of military leave is less than thirty-one (31) days.
- the date you fail to make a required contribution; or
- 31 days after you have established residence outside the U.S. or Canada
Banking of Hours and Reserve Contribution Credits
- If your employer contributes to the Plan on a per hour basis, all hours contributed for you are used to calculate your Contribution Credits, then are used to provide for your monthly coverage. Credits earned above the amount needed to provide for your selected level of coverage on a monthly basis are banked as Reserve Contribution Credits.
- If you work more hours than are necessary to earn the Contribution Credits required for the Plan level of coverage you have selected, you will accumulate Reserve Contribution Credits in the Credit Bank. These Credits will be used if you don’t otherwise have enough work hours to maintain eligibility until there are insufficient Credits remaining in your Bank to use for a month’s eligibility. At that time you will become ineligible for coverage. (See “Continuation of Coverage” Section for possible options).
- Eligibility for coverage can be maintained by a combination of hours earned and credits available in your Contribution Credit Bank. Unused credits can be maintained indefinitely in the Credit Bank as long as you are an eligible participant in the Plan (and the Board of Trustees continues to offer the Credit Bank as a feature of this Plan).
A member can accumulate a maximum of four (4) months of Benefit Credits/Hours in their Benefit Credit/Hour Bank. If a member works more hours than are necessary to earn the Benefit Credits/Hours required for the level of coverage he/she selected, he/she will accumulate reserve Benefit Credits/Hours in the Benefit Credits/Hour Bank. These Benefit Credits/Hours will be used if the member does not have enough work hours to maintain eligibility, until there are insufficient credits to use for a month’s eligibility.
To become eligible for the hour-bank benefit, you must complete the enrollment/change form. This is not an automatic benefit. The Plan will not permit you to bank any excess credits if you do not select a benefit Plan Level.
- You may accumulate up to four (4) months of coverage in your Credit Bank.
- If you do not have sufficient Contribution Credits to maintain eligibility, and thus would otherwise lose Plan coverage, if you qualify, you may self-pay the full cost of coverage for that month, use the“Buy-Up” option, or use COBRA to continue your coverage for limited periods of time. These options are explained in the “Continuation of Coverage” Section below.
- In addition, if through one of the above-mentioned options, you maintain the full package of benefits in which you participated immediately before you utilized a “Buy Up” or COBRA option, any Reserve Contribution Credits in your Contribution Credit Bank will be carried forward for a maximum of six months. Any hours you work during that six month period will be added to your Credit Bank helping you to regain eligibility under the Credit Bank rules above. In the event you do not accumulate the hours required to regain eligibility within the six month period, you will lose your remaining Credit Bank balance. If you no longer qualify for a self-pay option, COBRA eligibility would still continue.
- If you are inactive, unused Contribution Credits that you have accumulated in the Contribution Credit Bank will be used to pay for coverage at your selected Plan level. When you do not have enough credits to pay for your selected Plan level you and your dependents will become ineligible. Any credit balance left once you become ineligible may be carried forward for a maximum of six (6) months.
Note: Contribution Credits and the Contribution Credit Bank may only be used in connection with the benefits provided by the Southern California Painting & Drywall Industries Health & Welfare Trust and have no other value. If your employer contributes a fixed amount per month, you will be assigned to the maximum Plan level that is appropriate for that contribution. You will not qualify for the Reserved Contribution Credits program except to the extent you have a frozen credit bank for prior work as a bargaining employee.
If you are an Active member who has hourly contributions paid on your behalf by a signatory employer, and you have met the standards for initial qualification and are eligible for coverage, the Self-Pay options may be available to you. These options allow you to maintain coverage when you do not have enough Contribution Credits either through hours worked or existing in your Credit Bank to pay for coverage for the next month. If you do not use the Self-Pay option, your coverage will be terminated unless you elect coverage available by law through COBRA (See Continuation of Coverage under COBRA for further details).
If you use the Self-Pay option for a given month, the Contribution Credits you earn from the hours you work that month will be credited to your Contribution Credit Bank.
The following coverage continuation options are available subject to their eligibility requirements:
If you become ineligible for benefits, you may continue coverage through the Full Self-Payment option for a maximum period of six (6) consecutive months. You will be responsible for paying the full cost of coverage every month for the Plan level you had when you lost eligibility. The full self-pay amount is due by the 20th day of the month prior to the month of coverage. These months of self-payment shall apply to the number of months of continued coverage allowed under COBRA. For information on current Self-Pay rates, please contact the Trust Fund Office at (800) 752-2394.
The claim reimbursement assignment provisions will continue during the full self-payment period.
For eligibility purposes, "dependent" includes only an Employee's:
- legal spouse, if not legally separated; and
- Dependent child, (includes a legally adopted child or a child placed in your care in anticipation of adoption where the adoption is being actively pursued, foster child, child for whom the Employee is a legal guardian, a step-child, a child who is the subject of a Qualified Medical Child Support Order under age 26.
- Additionally, while the employee is eligible, coverage shall continue for any child who is incapacitated beyond age 26. Proof of such incapacity and dependency must be furnished within 31 days after reaching the age limit or becoming initially eligible for Plan benefits and annually thereafter.An incapacitated child is one:
a.)who is dependent on the Employee for support and maintenance;
b.) who has a developmental disability or physical handicap; and
c.) is diagnosed by a Physician as having a permanent or long term disability condition.
Developmental disability means substantial handicap which results from mental retardation, cerebral palsy, epilepsy, or other neurological disorder.
While the employee is eligible, coverage shall continue for any child who is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical handicap and chiefly dependent upon the employee for support and maintenance. If dependent is older than 26 as of the commencement date of employee’s eligibility, the employee must submit a doctor’s note that the dependent has been disabled since before his/her 26th birthday.
A dependent does not include any person:
- who is eligible for coverage as an Employee under this Plan, other than your spouse.
- who is on active duty in the armed forces.
To determine eligibility, proof is required as follows:
- Dependent lawful spouse - a certified copy of a marriage certificate.
- Natural unmarried children - a certified copy of a birth certificate.
- Stepchildren - submission of a certified copy of certification of marriage and a copy of the Court Order showing that the spouse has legal custody of the child.
- Adopted child - submission of a certified copy of a birth certificate and adoption Decree or court documents reflecting placement for adoption.
- A child under legal guardianship of the Employee.
- A child upon submission of a Qualified Medical Child Support Order (QMCSO) that contains the following information:
a.) the name and last known mailing address of the participant and each alternate recipient covered by the Medical Child Support Order
b.) a reasonable description of the type of coverage to be by the plan
c.) the date through which the health benefits are provided
d.) the social security number of the participant and each Alternate Recipient covered by the order.
Your Dependent becomes eligible for coverage on the later of:
- the date you become eligible; or
- the date the individual meets the qualification as defined under the definition of Dependent.
You must apply in writing for Dependent coverage. Application must be made on an approved form.
Dependent coverage will become effective on the latest of the following dates
- the date you apply for Dependent coverage;
- the date your coverage becomes effective;
- the date the person becomes an eligible Dependent.
If you are then eligible, coverage is effective for your newborn child for 31 days from the moment of birth. Coverage will continue beyond 31 days only if you apply for Dependent coverage before the end of the 31-day period.
Increases and decreases in the amount of Dependent coverage are effective on the first of the month following the loss of eligibility or increase in the level of coverage under this Plan.
Dependent coverage will end on the earliest of the following dates:
- the date this Plan ends;
- the date you become ineligible;
- the date you fail to make a required premium contribution;
- the date your coverage ends;
- the date the person ceases to be a dependent as defined by the Plan;
- the date Dependents are no longer an eligible class under this Plan.