Health Plan FAQ's
- I just started working for a contributing Employer. When will I be eligible for coverage with the Wisconsin Carpenters Health Fund?
- How many hours do I have to work to keep my coverage?
- What are the eligibility quarters?
- What happens if I do not work enough hours?
- How can I become eligible again if I do not pay the self-contribution amount?
- I have been working but my Employer has not paid the required contributions to the Health Fund, what can I do?
- What if I work outside of the Fund's jurisdiction?
- I am close to retirement age, can I continue the Health coverage after I retire?
- What is covered under the Comprehensive Major Medical Benefits?
- What is not covered under the Comprehensive Major Medical Benefits?
- What is meant by reasonable and customary charges?
- Is there a deductible for major medical coverage?
- Is there a co-payment required on my major medical coverage?
- Is there an out-of-pocket maximum for major medical benefits?
- What is my Routine Physical Exam benefit?
- Are there dental and vision benefits under my plan?
- What hospitals and providers can I go to?
- Can I obtain medical care outside of the country?
- What if I disagree with what the Fund has paid or covered for my Health Care Claims?
- Why do I need to complete a Family Form each year even though I have had no changes?
- Why do I need to fill out an injury form?
- Do I need preauthorization for services?
Eligibility
Health Benefits
Participant Responsibilities
- I just started working for a contributing employer. When will I be eligible for coverage with the Wisconsin Carpenters Health Fund?
- How many hours do I have to work to keep my coverage?
- What are the eligibility quarters?
- What happens if I do not work enough hours?
- How can I become eligible again if I do not pay the self-contribution amount?
- I have been working but my Employer has not paid the required contributions to the Health Fund, what can I do?
- What if I work outside of the Fund's jurisdiction?
- I am close to retirement age, can I continue the Health coverage after I retire?
- Provide written proof of retirement from your pension fund
- Be receiving Social Security retirement benefits
- Be eligible as an active participant during the Coverage Quarter immediately preceding the effective date of coverage in the Retiree Program (this requirement may be waived for disabled Participants who cannot work enough hours to reinstate their eligibility. Contact the Fund Office for details)
- Have contributions made in your behalf by a contributing employer in each of the five years immediately preceding retirement; or have 20,000 or more hours of contributions from contributing employers at the time of your retirement
- Make the self-payment at a rate to be determined by the Trustee from time to time no later than the 25th of the month preceding the current coverage month.
- What is covered under the Comprehensive Major Medical Benefits?
- Hospital services for room and board and intensive care, miscellaneous services and supplies, and outpatient services for surgery or emergency room treatment.
- There is a separate co-payment for each hospital emergency room visit (see Benefits Quick Reference Card for current emergency room co-payment amounts).
- Physicians' services for: surgery, anesthesia and its administration; medical services during in-hospital, outpatient, office, and home visits; certain chiropractic services; and outpatient treatment for nervous and mental disorders, substance abuse, and alcoholism.
- Diagnostic x-ray and laboratory services
- Prescription drugs and medicines through the Preferred Provider Pharmacy Program.
- Other covered services and supplies ordered by your physician, such as ambulance service; radiation therapy; blood or plasma and its administration; specified medical supplies and specified durable medical equipment; initial artificial limbs and eyes and their medically necessary replacement; breast prostheses; and dental services for treatment of a fractured jaw or injury to natural teeth (Limitations may apply).
- What is not covered under the Comprehensive Major Medical Benefits?
- What is meant by reasonable and customary charges?
- Is there a deductible for major medical coverage?
- many routine immunizations
- routine physical examinations for you and your spouse (up to the annual maximum benefit amount)
- hospice care (requires preauthorization)
- home Health care (requires preauthorization)
- skilled nursing home care, subject to limitations (requires preauthorization)
- well child care for dependents ages newborn-19, subject to limitation
- Is there a co-payment required on my major medical coverage?
- Is there an out-of-pocket maximum for major medical benefits?
- What is my Routine Physical Exam benefit?
- Are there dental and vision benefits under my plan?
- What hospitals and providers can I go to?
- Can I obtain medical care outside of the country?
- What if I disagree with what the Fund has paid or covered for my Health Care Claims?
- Why do I need to complete a Family Form each year even though I have had no changes?
- Why do I need to fill out an injury form?
- Do I need preauthorization for services?
- Hospital confinements
- Amniocentesis
- Circumcision (if medically indicated)
- Dental procedures in a hospital setting
- Equipment for home use (including, but not limited to):
- Apnea Monitor
- C-PAP
- Hospital Beds
- Oxygen
- Wheelchairs
- Growth Hormone
- Home Health Services
- Home Intravenous Therapy
- Hospice
- Laparoscopy
- Laser Uvulectomy
- Septoplasty
- Skilled Nursing Home
- Sleep Study
Eligibility
You will be eligible for coverage on the first day of the second month after you work 500 hours of covered employment in a twelve-month period. For example, if you reach 500 hours during the month of June, you will be initially eligible on August 1.
After initial eligibility, you need 390 hours per contribution quarter or 1,560 hours per four preceding contribution quarters.
Hours that you work in the work quarter of December, January, and February will be contributed in the contribution quarter of January, February, and March and will provide eligibility for the coverage quarter of May, June, and July. There is a chart on the first page of the Eligibility Rules in your SPD that shows all the quarters for the year.
If you work less than the required 390 hours per quarter, or 1560 hours in the four preceding work quarters, you may make self payments. Payments are due by the 25th of the month preceding the month of coverage.
For example, payment for June coverage is due on May 25.
If your coverage lapses, you can become eligible again by working the required number of hours. If it has been less than 12 months since your loss of eligibility, you will be eligible on the first day of the third month following the month that you work 450 hours of covered employment.
For example, if you reach 450 hours in June, your eligibility will reinstate on September 1.
If it has been over 12 months since your loss of eligibility, the rules for initial eligibility would apply.
You can receive credit for unpaid Employer contributions for up to 3 work months in a 12-month period. Please contact the Fund Office to apply for this credit.
You may have your hours transferred to the Wisconsin Carpenters Health Fund. You should request a transfer form from the Fund Office before you begin working or no later than 60 days from the date you start working in another Fund's jurisdiction.
Yes, you may continue coverage after retirement if you satisfy the following minimum requirements:
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Health Benefits
Comprehensive Major Medical Benefits cover certain costs of medically necessary care. After a deductible has been paid, the Plan pays a specified percentage of reasonable expenses. Covered expenses include certain comprehensive major medical services related to:
There is limited coverage for some services such as chiropractic care, routine physical exams, physical therapy, TMJ, care in a Skilled Nursing Facility, inpatient and outpatient psychiatric and substance abuse treatment, hearing aids and exams, and admission kits. Please see the Benefits Quick Reference Card for limitations on these services.
Services not covered include speech pathology, treatment for infertility, cosmetic surgery, services to treat work-related illnesses or injuries, charges that exceed reasonable and customary limits, birth control devices and pills, routine circumcision, routine lab and x-ray services for dependents under 2 years of age, in-hospital convenience items, counseling for parenting issues, marriage counseling, and couple's counseling.
Reasonable expenses for X-ray and lab and surgical procedures are provided by a national company (Ingenix) that compiles a database of healthcare charges in each geographic area. Updates are provided to the Fund every six months.
There is a per person deductible per calendar year with a maximum family deductible per calendar year. See the Benefits Quick Reference Card for current deductible rates. Deductibles are waived for the following care:
A co-payment is the percentage you pay after your deductible has been met. See the Benefits Quick Reference Card for current co-payment rates. You may pay a lower co-payment by using a preferred provider. View participating providers at: www.healtheos.com/search/
There is an out-of-pocket maximum per person per calendar year with a maximum out-of-pocket per family per calendar year. Once the annual maximum has been met, the plan pays covered charges at 100% for the remainder of the calendar year. There is also a lifetime maximum per person. See the Benefits Quick Reference Card for current out-of-pocket maximums.
The Routine Physical Exam benefit includes charges for a general physical examination by a physician and routine screening labs and x-rays ordered by a physician. If you have already been diagnosed with a medical condition, the lab work, x-rays and exam are considered under the major medical benefit of your Plan and are subject to the deductible and co-insurance. If an exam and/or lab work is required to renew a prescription, those charges are payable under the major medical portion of your Plan. See the Benefits Quick Reference Card for current Physical Exam Benefits.
**Please note: Retiree Plans do not provide coverage for Routine Physical Exams for Dependent Children.**
Dental and Vision benefits are provided for all active participants and can be elected at the time of retirement for those on the Retirement plan. Please refer to the Benefits Quick Reference Card for current dental and vision benefits.
Any hospital or accredited providers within the United States, however, in order to receive the maximum benefits, you may wish to choose a Preferred Provider.
View participating facilities at: www.healtheos.com/search/
Medical services and treatment outside of the United States will be excluded unless incurred for care of an emergency condition as determined by the Plan.
If your claim has been denied in whole or in part, you may file an appeal. To file an appeal, you should submit a written appeal to the Eligibility & Appeals Committee in care of the Wisconsin Carpenters' Health Fund office within 180 days of receiving the explanation of benefits.
Provide your name, address and the reason you disagree with the decision and include any documentation, comments or information you believe supports your claim. Upon your request, we will provide you, free of charge, access to and copies of all documents, records and other information relevant to your claim, including any internal rule used in making our decision, or basis for an experimental/medical necessity exclusion.
The Eligibility & Appeals Committee will review your appeal at its next quarterly meeting, unless the appeal is received within 30 days of the preceding meeting, in which case it will be considered at the second meeting following the Plan's receipt of your request. You will be notified of the decision within five days of the meeting.
Your Plan has two levels of appeal:
The first level of appeal is decided by the Eligibility & Appeals Committee of the Trustees.
The second level is decided by the Executive Committee of the Trustees.
These rules regarding claims appeal procedures apply to each level of appeal.
The Trustees' decision is final. If your second level of appeal is denied by the Executive Committee, you have the right to bring a civil action under ERISA Section 502(a).
Participant Responsibilities
In order to keep our records updated with current information, you must complete a Family Form each year. Your previously provided family information is pre-printed on the Family Form sent to you annually. If you have had no changes, please sign and date the form and mail it to the Fund Office.
However, if there has been any change to the information we have on file, a new Family Form must be completed. These changes include adding a new spouse, adding a new child, terminating a dependent's coverage due to legal separation or divorce of a spouse, marriage of a dependent child or death of a dependent. We also require notification when other insurance coverage is effective for one or more dependents or if a previously existing coverage has terminated.
If a bill is received with an injury diagnosis, an injury form must be completed. The Plan contains subrogation language in the event an injury is the responsibility of a third party. If an injury or illness occurred at work or as a result of work, the claims must be filed with your Employer's Worker's Compensation carrier.
In order for maximum benefits to be payable, hospital confinements and other services may require preauthorization. Some services that require preauthorization are:
