Eligibility / Actives
Eligible EmployeesYou may become eligible for benefits as a member of the Plan if you are covered by a collective bargaining agreement requiring contributions to the St. Louis - Kansas City Carpenters Regional Health Plan.
You are also eligible to become members of the Plan if:
- You are an employee of:
- The St. Louis - Kansas City Carpenters Regional Council;
- Benefit Plans sponsored by the Regional Council; or
- Any other employer obligated by written agreement to make contributions to the Fund on behalf of such employees and accepted by the Trustees.
- You are a retired employee for whom the Regional Council was the recognized bargaining representative when you were actively working, or were an employee of one of the employers described above.
- You are a member of an eligible Special Participation group, including:
- Non-bargained office employees of contributing employers, and
- Other groups of employees for whom contributions are made on a month-to-month basis under agreements acceptable to the Trustees.
Summary of Material Modifications, which includes all Plan changes and improvements since the last SPD was published May 1, 2015.
Initial Enrollment or Change in CircumstancesAll new members, regardless of their employment classification, must complete the Plan’s Enrollment/ Change Form before benefits will be paid.
In addition, every member must complete the Enrollment/Change Form upon your marriage, legal separation, divorce, birth or adoption of a child, or if you or a dependent becomes covered under another health plan (medical, prescription, dental, or vision). Coverage of a dependent will begin when the member's family coverage begins or when the dependent is enrolled, whichever is later. Dependents enrolled later than 30 days after a qualifying event will receive an effective Coverage date that reflects the date on which the Fund Office received a properly completed application for enrollment.
The Plan may require documentation to establish proof of eligibility of dependents, such as birth certificates or marriage licenses. The Plan may also require authentic copies of court documents, such as divorce decrees, to determine whether this Plan is the primary payer for a member or dependent.
Active Classification: Eligibility ClassesYou are a member in the active classification if your eligibility results from:
- employer contributions for your active work
- our minimum or difference self-payments; or
- your COBRA self-payments following a period of active coverage, provided that you are not eligible for Medicare. For information about benefits for members who do not meet the requirements for active classification, see Non-Active Classification and Benefits.
- Outside Eligibility: Members employed in work covered by a collective bargaining agreement or participation agreement requiring contributions to this Plan for hours (not limited to 133 hours per month)
- Inside Eligibility: members employed in work covered by a collective bargaining agreement requiring contributions to this Plan for all hours of work up to a maximum of 133 hours per month
- Special Participation Eligibility: members of a special participation group
- Outside Eligibility:An employee initially becomes eligible for benefits in the Outside Eligibility class on the first day of the month following the employee’s completion of at least 500 credit hours during the preceding six consecutive months.
- Inside Eligibility: An employee initially becomes eligible for benefits in the Inside Eligibility class on the first day of the month following the employee’s completion of at least 250 credit hours during the preceding six consecutive months.
- Special Participation Eligibility: An employee initially becomes eligible for benefits in the Special Participation Eligibility class on the first day of the month following the month in which the employer first makes a timely contribution on the employee’s behalf.
If you have established Outside or Inside Eligibility, you will continue to be eligible based on benefit quarters that follow contribution quarters. Benefit quarters begin each January 1, April 1, July 1 and October 1, as shown on the following chart:
|Your hours worked during this||Provides coverage for this|
|Contribution Quarter||Benefit Quarter|
|August, September, October||January, February, March|
|November, December, January||April, May, June|
|February, March, April||July, August, September|
|May, June, July||October, November, December|
The Plan has three separate tests to determine if you qualify for continuing eligibility, applied in this order:
- Quarterly Rule: A member who works at least 300 credit hours in a contribution quarter will have eligibility extended through the benefit quarter that next follows that contribution quarter. If you do not qualify under this rule, the next rule is applied.
- Look-Back Rule: A member who worked at least 1,200 credit hours during a period of 12 consecutive months, ending with any month in a contribution quarter, will have eligibility extended through the benefit quarter that next follows that contribution quarter. Members can maintain eligibility under this provision only if they remain eligible for covered employment. If they do not qualify under this rule, the next rule is applied.
- Plan Year Rule (Outside Eligibility only): A member in the Outside Eligibility class who worked at least 1,300 credit hours in a Plan Year will have eligibility extended until March 31 of the next Plan Year. Members in the Outside Eligibility class can maintain eligibility under this provision only if they remain eligible for covered employment. If you do not qualify under this rule, refer to Self-Payment Provisions — Active Members.
Eligibility Extension for Disability
Coverage in the Outside or Inside Eligibility class will generally end if you fail to qualify under at least one of the provisions outlined above and do not elect an available self-payment option (see page 8). However, if a member is unable to work sufficient credit hours to maintain eligibility due to an occupational or nonoccupational disability, and has worked at least 1,300 credit hours during the 12 consecutive months prior to the beginning of the disability, the member’s eligibility in the Outside or Inside Eligibility class will be automatically continued, without contributions, until the earlier of:
- The date the disability ends, or
- The last day of the benefit quarter containing the first anniversary of the date the disability began.
Termination of Active EligibilityUnless you elect an available self-payment option (see below), your coverage will end on the earliest of the following dates:
- The last day of eligibility earned by your credit hours.
- The date of your death.
- The date you falsify any information in connection with a claim for benefits or commit any action with the intent to defraud the Plan.
- The end of any month you are found to be working in non-covered employment.
- The date the Plan terminates.
Your eligibility for benefits under the Plan will also end on the date you become eligible for Medicare coverage due to age or disability. Your Medicare coverage is primary to this Plan if you are employed by a small employer as defined by Medicare, or if you have had 30 months of Medicare coverage on account of end-stage renal disease (ESRD).
If your eligibility for coverage would otherwise terminate as a result of any of the provisions described above, your eligibility will nevertheless continue to the extent required under the terms and conditions of the Family and Medical Leave Act of 1993 (FMLA) and the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). If you are absent from employment by reason of service in the uniformed services, and would otherwise lose coverage on account of such absence, you may elect to continue coverage in the Plan as provided under USERRA.
Reinstatement Provisions for Active MembersOutside and Inside Eligibility Class: If you have lost coverage in the Outside or Inside Eligibility class and are not participating as a self-pay member in the non-active classification, you may reinstate active coverage by working the same number credit hours in a contribution quarter required for continuing eligibility, as described under Continuing Eligibility: Active Members. Note that you must work these credit hours within one year of your termination date for coverage to be reinstated. The reinstated coverage becomes effective on the first day of the next benefit quarter.
If you have lost coverage in the Outside or Inside Eligibility class and do not qualify for reinstated coverage, you must again satisfy the initial eligibility requirements to regain active coverage, as described under Active Classification: Eligibility Classes and Initial Eligibility as listed above.
Special Participation Eligibility Class: If you have lost coverage in the Special Participation Eligibility class, you may reinstate the lost coverage only if your employer makes a timely contribution on your behalf. The employer’s employees must qualify as a Special Participation Group. Your coverage in the Special Participation Eligibility class will be reinstated on the first day of the month following the month in which the Plan receives the employer’s contribution.
Self-Payment Provisions - Active MembersIf you would otherwise lose coverage in the Outside or Inside Eligibility class because of insufficient credit hours, you may maintain continuous coverage for a limited time by electing either minimum/difference self-payments, as described above under Minimum/Difference Self-Payments, or COBRA continuation coverage. Note that these two options are mutually exclusive — you may select one or the other, but not both. If you elect either option, you may still regain active coverage by working credit Hours, as described under the Active Eligibility: Reinstatement Provisions for Active Members.
If you lose coverage due to working in non-covered employment, you and your dependents are excluded from enrolling in the minimum/difference payment option under the Plan. Only COBRA coverage will be offered.
If you would otherwise lose coverage in the Special Participation Eligibility class, you may maintain continuous coverage for a limited time by electing COBRA. (The minimum/difference self-payment option is not available to members in this eligibility class.)
Minimum/Difference Self-PaymentsIf you are not in the Special Participation Eligibility class and have not earned enough credit hours in a contribution quarter to maintain active eligibility, you may elect to maintain continuous active eligibility by making self-payments directly to the Fund. These are referred to as “minimum/difference payments.” If you make timely payments for a particular benefit quarter, in the required amount, your eligibility will be extended through that benefit quarter.
The required amount of your minimum/difference payment for a benefit quarter is equal to the difference between 300 and the number of credit hours you actually earned in the corresponding contribution quarter, multiplied by the current hourly employer contribution specified in the labor agreement under which most contributions are paid. If you earned no credit hours during the contribution quarter, your required payment amount is equal to the entire employer contribution for the minimum 300 credit hours.
If you choose to maintain your coverage eligibility through the use of minimum/difference payments, your coverage must be continuous — that is, it must begin with the first contribution quarter in which you earned less than 300 credit hours. You may generally maintain active coverage by minimum/difference payments for no more than six consecutive benefit quarters (18 months).
Maintaining your coverage eligibility through the use of minimum/difference payments is an alternative to making a COBRA election. COBRA continuation coverage is not available to you if you lose coverage at the end of one or more quarters of minimum/difference payments (such as if you fail to make timely payments).
If you exhaust the maximum permissible period of coverage by making minimum/difference payments, you can regain active coverage only by satisfying the continuation requirements described under Continuing Eligibility: Active Members, or the reinstatement requirements described under Reinstatement Provisions for Active Members. Alternatively, you may be able to maintain coverage in the non-active classification (see Non-Active Classification and Benefits).
If you end a period of coverage maintained by minimum/difference payments, you must have at least two consecutive quarters of active coverage earned solely with credit hours before you will be permitted to begin a new period of coverage maintained by minimum/difference payments. You have the option to pay a minimum/difference payment for a benefit quarter in one payment for the entire quarter of coverage or in monthly installments. If you choose to pay quarterly, your payment is due on the first day of the month prior to the applicable benefit quarter. It must be received by the Fund within 15 days of the due date to be accepted. The payment schedule for quarterly payments is shown in the following table:
|Benefit Quarter for Coverage||Payment Due|
|January, February, March||December 1|
|April, May, June||March 1|
|July, August, September||June 1|
|October, November, December||September 1|
If you choose to pay monthly, the amount due each month is one-third of the total payment due for the benefit quarter. Monthly payments are required to be paid automatically by direct debit or credit card on the first of the month, or the next business day, prior to the applicable month of coverage. If your payment is not received on time, your coverage will terminate at the end of the last month for which timely payment was made.
If a contractor/owner/partner/principal/officer affiliated with a contributing contractor that is in arrears and is considered delinquent, and the contractor/owner/partner/principal/officer has applied for or is currently making minimum/difference payments, the application/payment will be rejected. Delinquent contractors who participate in the Plan as active members will be allowed the option for COBRA coverage only for up to 18 months from the date of the original qualifying event that caused the loss of coverage.