Rights & Protections
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Plans 5, 6, 6A, 11A, 11B
COBRA Continuation of Health Coverage
COBRA (Consolidated Omnibus Budget Reconciliation Act) is a federal law that requires the Fund to provide you and your eligible dependents with the opportunity to continue your health coverage at your expense when your employer-paid health coverage ends as the result of a “Qualifying Event.” COBRA applies to medical, dental and vision coverage but not to life insurance, AD&D insurance, and loss of time or disability coverage; however, you may convert your life insurance coverage to an individual policy as described under “Conversion Privilege For Group Life & Survivor Income Insurance Coverage”.
Under the circumstances, explained below, you must inform the Fund Administrator when you or your dependent experiences a COBRA “qualifying event” that entitles you to COBRA coverage (excepting a loss of employment or reduction hours, which your employer must report). If you are enrolled in the Kaiser HMO option, you may also be eligible for “Cal-COBRA,” a California law allowing for continuation coverage, explained below.
More on COBRA Continuation of Health Coverage
Total Disability
In the event that you cease active work because you become Totally Disabled, the Fund will extend health coverage for you and your dependents for a period not to exceed six months, provided that you remain continuously and Totally Disabled and are not gainfully employed. If your total disability ends or you become employed prior to the end of that six-month period, your extended coverage will end before expiration of the full six-month period. The six-month period will commence with the first day of the month following the last month in which your coverage would have terminated but for this extension.
Once the six-month period ends, you may extend coverage of certain Plan benefits by electing and paying for COBRA Continuation Coverage.
Medical Extension For Disability
If you or your dependent is totally disabled at the time your active coverage ends, or at the time of your COBRA qualifying event, and you do not elect COBRA continuation coverage, the Plan will extend coverage for up to twelve months, but coverage will only extend to services required for the treatment of the illness or injury causing the disability. The twelve-month period begins on the first day of the month. Coverage will continue without employer payment for up to twelve months, but will terminate the earliest of:
- When the total disability ceases, or
- When you or your disabled dependent begins to receive coverage under another health plan (and your health costs are not excluded by the preexisting condition rules of the other health plan), or
- One year after the extension starts (e., the last day of the twelve-month period following the date of extension).
FMLA
The federal Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA) provide that in certain situations employers of 50 employees or more are required to grant leave of up to three months to employees to take care of family needs such as the birth and/or care of a newborn, a newly adopted child, care of an ill child or spouse, or for the care of your own serious health condition. The employer is required to continue the employee’s health coverage during FMLA/CFRA leave.
It is not the role of the Trustees or the Fund Administrator to determine whether you are entitled to leave with continuing medical care under the FMLA or CFRA. Any disputes regarding continuation of benefits during a leave must be resolved by the employer and the local union.
To the extent that you are entitled to leave with continuing medical coverage, the Plan will provide continuing medical coverage so long as required monthly contributions are received from your employer. Rights under this section are independent of your rights under COBRA, or the Plan’s extension of coverage for disabilities. However, a COBRA Qualifying Event may occur if you do not return to work at the end of your FMLA/CFRA leave, or if you give your employer definite notice that you do not intend to return to work.
HIPAA
This federal law may affect your health coverage if you are enrolled or become eligible to enroll in a health plan that excludes coverage for preexisting medical conditions. The Fund does not exclude coverage for preexisting medical conditions. However, the information contained in this section is important if your coverage ends and you become eligible for coverage in another plan.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before you enroll. Under the law, a preexisting condition exclusion generally may not be imposed for more than 12 months (18 months for a late enrollee). The 12-month (or 18-month) exclusion period is reduced by your prior health coverage. Check with your new plan administrator to see if your new plan excludes coverage for preexisting conditions and if you need to provide a certificate or other documentation of your previous coverage. If you buy health insurance other than through an employer group health plan, a certificate of prior coverage may help you obtain coverage without a preexisting condition exclusion.
Please note that your prior health coverage may not be used to reduce any preexisting condition limitation if there has been a break in coverage of 63 days or more between your loss of coverage under this Plan and the beginning of coverage under your new plan.
CERTIFICATE OF COVERAGE
When you or your dependent lose medical, dental and/or vision coverage under the Plan, the Trust Fund will send to your last known address a “Certificate of Coverage” that states how long you were continuously covered under the Plan. You will receive this Certificate even if you elect to continue your coverage through COBRA.
You may need this Certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that existed prior to your enrollment in the new group plan.
If you have any questions or need a Certificate of Coverage, contact the Fund Administrator.
HIPP
If you are eligible for Medi-Cal, you may qualify for the Health Insurance Premium Payment Program (HIPP). Under this program the California Department of Health Services will pay your COBRA premium for you. To be eligible for this program you must:
Have a Medi-Cal share-of-cost of no more than allowed under HIPP provisions, and
Have a high-cost medical condition for which the average monthly cost is twice the amount of the monthly COBRA premium.
In addition, persons unable to work because of disability due to HIV/AIDS may qualify if they have a total monthly income less than a percentage allowed under HIPP provisions of the poverty level established by the federal government.
To Enroll in HIPP or to find out more information and requirements, call 800-952-5294.
Military Service
The Uniformed Services Employment and Re-Employment Rights Act (USERRA) provides that your employer-paid coverage under the Plan continues if you leave your job for active duty or training in the U.S. Armed Forces for a period of 31 days or less.
If the leave extends beyond 31 days, you are entitled to self-pay for coverage for up to 24 months from the date your leave started, or the date your leave ends if you do not reapply for employment with your employer, whichever occurs first. If you elect to continue coverage under USERRA, the amount charged will be determined by the Board of Trustees from time to time and shall not be more than one hundred two percent (102%) of the full premium under the Plan, determined in the same manner as the applicable premium under COBRA.
The procedure for electing USERRA self-pay coverage is the same as the procedure for electing COBRA, described on page 11 of the SPD.
No Surprises Billing Act
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Surprise Billing Notice (English)
Surprise Billing Notice (Spanish)
WHCRA
You or your dependents may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for:
- All stages of reconstruction of the breast on which the mastectomy was performed.
- Surgery and reconstruction of the other breast to produce a symmetrical appearance.
- Prostheses; and
- Treatment of physical complications of the mastectomy, including lymphedema.
Plan 7
CHIP
Medicaid or a State Children’s Health Insurance Program (CHIP):
You and your Dependents may also enroll in this Plan if you (or your eligible Dependents: have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your Dependents) lose eligibility for that coverage. However, you must request enrollment in this Plan within 60 days after the Medicaid or CHIP coverage ends; or become eligible for a premium assistance program through Medicaid or CHIP.
However, you must request enrollment in this Plan within 60 days after you (or your Dependents) are determined to be eligible for such premium assistance.
COBRA Continuation of Health Coverage
In compliance with a federal law, the Consolidated Omnibus Reconciliation Act of 1985 (commonly called COBRA), eligible Employees, and their covered Dependents (called “Qualified Beneficiaries”) will have the opportunity to elect a temporary continuation of their group health coverage (“COBRA Continuation Coverage”) under the Plan when that coverage would otherwise end because of certain events (called “Qualifying Events” by the law). COBRA-like continuation coverage is available to Domestic Partners and their children to the same degree and in the same manner as continuation coverage is available to Spouses and stepchildren.
Other Health Coverage Alternatives to COBRA
More on COBRA Continuation of Health Coverage
Disability
If you or your Dependent is Totally Disabled at the time your active coverage ends, or at the time of your COBRA qualifying event, and you do not elect COBRA continuation coverage, the Plan will extend coverage for up to twelve months, but coverage will only extend to services required for the treatment of the Illness or injury causing the disability. The twelve-month period begins on the first day of the month. Coverage will continue without Employer payment for up to twelve months, but will terminate the earliest of:
- When the Total Disability ceases, or
- When you or your disabled Dependent begins to receive coverage under another health plan, or
- One year after the extension of benefits starts (i.e., the last day of the twelve-month period following the date of extension).
Continuation of Coverage
See COBRA above and in the SPD for information on temporarily continuing your health care coverage
FMLA
The federal Family Medical Leave Act (FMLA) and the state of California’s California Family Rights Act (CFRA) provide that if you work for an Employer covered by the FMLA or CFRA you are entitled to unpaid leave for specified family or medical purposes, such as the birth or adoption of a child, to provide care for a Spouse, child or parent who is seriously ill, or for your own Illness for up to 12 weeks a year (in some cases, up to 26 weeks). In general, the Employers covered by FMLA and CFRA are those who employ 50 or more Employees for each working day during each of twenty or more calendar weeks in the current or preceding Calendar Year. If you are taking FMLA or CFRA leave that has been approved by your Employer, your Employer is responsible for making Contributions to the Fund on your behalf, as if you are working, in order to maintain your eligibility.
To find out more about Family or Medical Leave under the FMLA and CFRA, the interaction between the two laws and the terms on which you may be entitled to leave, contact your union or Employer.
No Surprises Billing Act
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Surprise Billing Notice (English)
Surprise Billing Notice (Spanish)
USERRA
A Participant who enters military service will be provided continuation and reinstatement rights in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended from time to time. The plan contains important information about your rights to continuation coverage and reinstatement of coverage under USERRA.