The deductible is the dollar amount (shown in the Schedule of Benefits) that you and your eligible Dependents are responsible to pay before the Medical Expense Benefit is payable. Only Covered Charges may be used to satisfy the deductible. The deductible applies only once in a calendar year.

If Covered Charges used to satisfy the deductible, in part or in full, are incurred during the last three months of a calendar year, then those charges will be used to satisfy the deductible for the following year as well.

After eligible family members have collectively satisfied the family deductible (shown in the Schedule of Benefits) within a calendar year, no further deductible will be required for any family member for the remainder of that calendar year

When you reach your deductible, you must pay a percentage of the remaining costs –this is the coinsurance amount. On in-network claims, the typical co-insurance is 80%/20%. What this means is that, on allowable expenses, the Plan will pay 80% of the claim’s eligible amount and you will be responsible for the remaining 20% after your annual deductible has been met.

EXAMPLE: You incur a $1,000 hospital bill. Your Annual Deductible is $200 and your co-insurance is 20% of the allowable dollars. You pay the $200.00 deductible plus 20% coinsurance. If there were no in- network discounts on the hospital expense, the Fund will pay $640.00, while you pay the $200 deductible plus $160.00 in coinsurance.

The Out-of-Pocket Maximum applies to in-network claims only. The amount applied will be represented on both an individual and family level. Please refer to the Schedule of Benefits for specific amounts.

After you have reached your Out-Of-Pocket maximum for the Plan year, Central Laborers’ will begin to pay 100% of the allowed amount on applicable medical expenses.

Your Out-Of-Pocket maximum does not include your premiums, co-payments or charges for health care services that Central Laborers’ does not cover. It also does not include out-of-pocket expenses incurred on Out-of-Network claims.

Benefits that are based on a calendar year are calculated from January 1st through December 31st of any given year. If you use all of the benefits available for a particular type of service during the Plan year, which is also a calendar year, then the Fund will not pay anything toward that type of service for the remainder of that calendar year (Plan year).

Some examples of benefits that are based on calendar years are as follows:

• Dental benefits – $2,500 per person each calendar year.
• Rehabilitation Services (Outpatient) – 60 visits each calendar year.
• Home Health Care – 40 visits each calendar year.

Note: Consult your Summary Plan Description for other benefits that are based on a calendar year and what restrictions may apply to each.

Central Laborers’ must wait until the end of the month to send self-payment notifications so as to allow time for all employers to submit contributions for the hours of work you performed. By waiting, it allows for all hours to be added to your contributions history, possibly eliminating the need for you to self-pay for coverage or, if you must self-pay, possibly reducing the amount you will need to pay in order to maintain coverage. So long as a self-payment is sent to the Fund Office with a post-mark date on or before the designated deadline, eligibility will be reinstated retroactive to the first day of the quarter and any claims incurred will be considered.

The Retiree Plan has medical benefits provided through the BCBS PPO and the HealthLink networks. In addition, Retirees have the following benefits through Central Laborers’ Welfare Fund:

• Vision benefits – $300 per year for the routine exam, routine tests, frames, lenses and/or contact lenses.
• Hearing benefits – $100 for hearing examination services every 12 months and $750 to apply toward hearing aids every 60 months.
• Prescription benefits through CVS/Caremark and specialty medications that are purchased through CVS/Caremark Specialty mail-in service.
• Dental benefits – $2,500 per eligible participant/dependent per calendar year.
• Physical benefits

The Fund provides benefits for immunizations recommended as age appropriate immunizations by the Center for Disease Control and Prevention (CDC). A list of those immunizations can be found and downloaded here.

If you are a participant under the HealthLink Medical Plan:

Submit all medical and network vision & hearing claims to:
HealthLink
PO Box 419104
St. Louis, MO 63141

Submit all dental, non-network vision and hearing claims to:
Central Laborers’ Welfare Fund
P.O. Box 1267
Jacksonville, IL 62650

If you are a participant under the Blue Cross / Blue Shield PPO Medical Plan:

Submit all medical and network vision & hearing claims to:
BlueCross/BlueShield of Illinois
P.O. Box 805107
Chicago, IL 60690

Submit all dental, non-network vision & hearing claims to:
Central Laborers’ Welfare Fund
P.O. Box 1267
Jacksonville, IL 62650

Any questions regarding claim payments can be directed to the Fund Office Customer Service area at 800-252-6571.

All providers should be directed to call one of the numbers listed below if they have questions regarding network discounts that were applied on a specific claim.

• BlueCross/BlueShield – 800-810-2583
• HealthLink – 800-624-2680

BlueCross/BlueShield of Illinois – 800-810-2583 or http://www.bcbsil.com

HealthLink – 800-624-2680 or http://www.healthlink.com

If your spouse works full time and his/her employer offers comparable coverage to this Plan or comprehensive insurance, your spouse must enroll in that coverage before this Plan will coordinate benefits. The following further defines excluded coverage types: “In the event that a participant’s spouse has health care coverage available through his or her employment and said health care coverage contains a provision commonly known as a “wrap around” provision, or some other similar provision whose purpose is to provide primary coverage only for a small amount of comprehensive services while purporting to defer or transfer the much larger secondary coverage to the other spouse’s ERISA Welfare Fund, then in such event, this fund expressly limits said secondary coverage to the same amount or same percentage as contained in the primary coverage set forth in the “wrap around” or similar provision.

If you or your spouse have any questions regarding what is considered a comparable coverage, please contact the Fund Office at 800-252-6571 for assistance.