Health and Welfare Plan / Benefits
Levels of BenefitsThere are two schedules of medical benefits within the Plan, the Platinum Schedule and the Gold Schedule.
The schedule applicable to you and your dependents depends on the rate at which your employer is contractually obligated to contribute to the Plan.
Platinum Schedule of Benefits (Platinum Plan)
The Platinum Plan is the highest level of medical benefits, providing generally 90% medical coinsurance (coinsurance is the percentage of the allowable amount you must pay after any deductible and before the Plan starts paying benefits). If you and your dependents are in the active classification and covered under the Platinum Plan, you will continue to be covered under the Platinum Plan after entering the non-active classification, until you are eligible for Medicare.
Gold Schedule of Benefits (Gold Plan)
The Gold Plan is a high level of medical benefits, providing generally 80% medical coinsurance. If an active member’s employer is contractually obligated to contribute at the Gold Plan rate, the member and dependents are covered under the Gold Plan. If you and your dependents are in the active classification and covered under the Gold Plan, you will continue to be covered under the Gold Plan after entering the non-active classification, until your are eligible for Medicare.
Click here for the Medical Schedule of Benefits
Network ProvidersThe Plan enters into contracts with medical network sponsors that allow covered persons to have access to networks of hospitals, physicians, and other health care providers. In general, the Plan’s benefits will be higher for an in-network provider than for an out-of network provider. Covered persons are generally free to obtain most medical services and supplies from either an in-network provider or an out-of-network provider. However, certain services are covered under the Platinum and Gold Plans only if obtained from an in-network provider.
If you choose an in-network provider, the Plan’s benefits covered under either the Platinum Plan or the Gold Plan are higher than if you choose an out-of-network provider. In addition, in-network providers may not charge more than the amount contractually agreed with the network sponsor, and may not require covered persons to pay more than the copayment, or the deductible and coinsurance share, based on that amount.
If you choose an out-of-network provider, the Plan’s benefits covered under either the Platinum Plan or the Gold Plan are lower than for an in-network provider, and are subject to the Plan’s reasonable and customary limitation. An out-of-network provider is not limited in the amount it can charge a covered person after receiving the Plan’s benefits.
General Medical NetworksThe Plan’s general medical networks, offered through Coventry Health Care, are Coventry PPO/ASO and Coventry National Networks. In-network benefits apply to all providers in these networks, except for organ transplants and treatment covered as mental health and substance abuse, including the Member Assistance Program.
Prescription Drug Benefit NetworkThe Plan’s Prescription Drug Benefit is provided automatically, without additional contributions or premium, to members in the active classification and members who are not eligible for Medicare in the non-active classification and their dependents.
The Prescription Drug Benefit covers medically necessary prescription drugs, as well as certain preventive medications. There are two Prescription Benefit Schedules (just as there are two Medical Benefit schedules): the Platinum Schedule and the Gold Schedule, as set forth in the chart below.
Express Scripts is the prescription drug network for the Carpenters' Health and Welfare Trust Fund of St. Louis.
Dental Benefit NetworkThe Plan’s Dental Benefit provides coverage for a comprehensive range of dental services and encourages preventive care. The Dental Benefit is provided automatically to members in the active classification and their dependents, without additional contributions or premiums.
The Dental Benefit is also available as optional coverage, at an additional premium, to members and dependents in the non-active classification, including members enrolled in the UHC Medicare Advantage Program and their dependents. The Dental Benefit may be elected at the time of initial enrollment in the non-active classification, or during an Open Enrollment period held October 1 through December 15 each year. If the Dental Benefit is dropped after having been elected, it may not be reinstated.
The Dental Benefit is self-funded by the Plan. The Plan has contracted with Delta Dental of Missouri to serve as network sponsor, to process dental claims, and to provide access to its dental networks. All necessary claims for dental benefits (whether from in-network or out-of-network providers) must be submitted directly to Delta Dental.
Preferred Orthopedic ProviderWithin the Coventry networks identified above, Signature Health Services is designated as a preferred provider of orthopedic services. Members will receive in-network benefits when they use Signature Health Systems providers, and in addition, the Plan will rebate $150 to a covered person who completes the entire course of treatment recommended by Signature (education, surgery and post-operative rehabilitation) for any of the following procedures: total knee replacement, hip replacement, rotator cuff repair or carpal tunnel surgery.
Click here for the most up-to-date St. Louis area Signature orthopedic physician listings.
Vision Benefit NetworkThe vision benefit is designed to provide assistance for members and eligible dependents who need eyeglasses or contact lenses to improve their vision. This benefit is provided automatically, without additional contributions or premiums, to eligible members and dependents not enrolled in the UHC Medicare Advantage Program.
The Plan has access to the VSP comprehensive network of vision providers. VSP provides discounted rates on vision services and equipment when you use its network. All claims for vision services (whether from in-network or out-of-network providers) must be submitted directly to VSP.
Mental Health and Substance Abuse NetworkMercy Managed Behavioral Health Network is the Plan’s mental health and substance abuse network. Members will receive in-network benefits for treatment of mental health and substance abuse only when they see providers in the Mercy Managed Behavioral Health network. The Mercy Member Assistance Program is the Plan’s network for counseling services. Like the mental health and substance abuse network, MAP services are in-network services and payable only when you see providers in the Mercy MAP.
Transplant NetworkThe Plan’s transplant network is a designated group of providers within the Coventry Networks. Services and supplies for organ transplants must be obtained from a provider in Coventry’s transplant network to be covered.
Weekly Disability BenefitIf you are a member in the active classification and unable to work due to a period of disability, the Plan provides a short-term benefit to protect a portion of your income.
If you are in the active classification and become temporarily disabled because of a non-occupational accident or sickness while you are eligible for medical benefits under the Plan, you are eligible for the Weekly Accident and Sickness Benefit.
For purposes of this benefit, “disabled” means that you are prevented from engaging in gainful employment, due solely to sickness or injury. In addition:
- You must be under the direct care of a physician, other than a chiropractor, who certifies your disability and states your expected return to work date.
- The treating physician must notify the Plan of any changes to the expected return-to-work date. The physician may also be required to document any determinations of continued disability.
- If your disability is caused by an accident, you must provide the Plan with complete details of time, place and circumstances of the accident.
The Weekly Accident and Sickness Benefit pays $300 per week, for up to 26 weeks, and begin as follows:
|In case of||Benefits begin|
|Disability due to accident, hospital confinement or outpatient surgery||First day of disability|
|Disability due to sickness, not involving hospital confinement or outpatient surgery||Eighth day after onset of disability|
No benefits are payable under the Plan for:
- Any day of disability on which a member is eligible for, or receiving, compensation from the member’s employer, or workers’ compensation benefits, even if occupational and nonoccupational disabilities are unrelated.
- Disabilities resulting from any injury or sickness due to the act or omission of a third party, unless the member has fully complied with the reimbursement and subrogation provisions of this Plan.
- Periods that exceed accepted standards of disability, unless properly documented by the treating physician.
- Any day prior to or after the period when a member was under treatment, and was certified as disabled by an attending physician, even if the sickness or illness may have been present.
- Any day on which the Trustees determine that a member is not disabled, though certified as such by a physician.
- Disability resulting from any injury or sickness for which no medical benefits are payable.
- Any member covered under COBRA.
Life InsuranceLife Insurance
The Plan provides Life and Accidental Death and Dismemberment (AD&D) benefits under policies insured by the Metropolitan Life Insurance Company (MetLife), a commercial insurance company. The terms and conditions of the benefits are as stated in the policies. The description provided here is intended to be a summary of your benefits and may not include all policy provisions. If there is a discrepancy between this document and the policies issued by MetLife, the terms of the policies will prevail. You may examine the policy documents at the Plan Office. All claim forms needed to file for benefits under the life insurance and AD&D policies can be obtained from the Plan Office.
Eligibility for Life and AD&D Benefits
You are eligible for Life Insurance and AD&D benefits if you are member and are eligible for medical benefits in the Plan or are enrolled in the UHC Medicare Advantage Program. (The exception is that members in the non-active classification who are covered under the reinstatement provisions of this Plan are not eligible for Life Insurance and AD&D benefits.)
A dependent who dies while eligible for medical benefits or while enrolled in the UHC Medicare Advantage Program is eligible for Life Insurance, but not AD&D benefits. Exceptions to this rule are the following dependents, who are not eligible for either Life Insurance or AD&D benefits:
- An individual who lived outside the United States or Canada at the time of death;
- A stillborn or unborn child;
- An individual in whom the insurance company determines that the related member had no insurable interest; or
- A dependent in the non-active classification who is covered under the reinstatement provisions of this Plan.
Level of Death Benefits
Life Insurance and AD&D death benefits are payable in the amounts shown in the following table:
|Insurance on life of member||$8,000|
|Insurance on life of eligible dependent||$2,000|
|AD&D death benefit (members only)||$8,000|
The Life Insurance benefit is payable on account of death from any cause. The death benefit under the AD&D policy is payable only for accidental death. The AD&D death benefit, when payable under the terms of the AD&D policy, is payable in addition to the Life Insurance benefit. Benefits payable will not exceed the applicable amount shown in the chart above, except for interest that may become payable after death under the terms of the policy.
Refer to the Plan's Summary Plan Description for additional information on Life Insurance Benefits and the AD&D Policy.