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Article / How to Get Covered & Stay Covered Under the Health Plan

How to Get Covered & Stay Covered Under the Health Plan.

First, new or returning members must earn initial eligibility under the health plan to begin health coverage. After initial coverage is earned, members and their families will remain covered by hours for as long as they continue to work in covered employment or by paying for coverage for a limited amount of time. 

Initial Eligibility
Members obtain initial eligibility the first day of the month after working at least 500 Capped and Uncapped Credit Hours OR 250 Capped Credit Hours for a contributing employer within six consecutive months. 

As described in the Health Plan document:
Capped Credit Hours refer to hours received by the health plan for a member working in covered employment that requires contributions to the Fund for hours worked up to a maximum each month.
Uncapped Credit Hours mean hours received by the health plan for a member employed in work covered by a collective bargaining agreement or participation agreement requiring contributions to this Fund for all hours of work (unlimited, no cap).  

For example in the following example, initial eligibility is obtained the first of the month after the initial 500 Capped and Uncapped hours are worked.

Continuing Eligibility

There are four eligibility rules, or “tests,” to check to see if eligibility can be extended after the member earns initial eligibility. These “tests” for continuing eligibility are the Quarterly Rule, the Look-Back Rule, the Plan Year Rule and the Extension of Hours-Based Eligibility for Disability. Members must meet at least one of these rules to maintain eligibility in the Plan through hours worked. Each eligibility rule is used to determine if coverage can be extended further into the future. If the first rule does not extend coverage, the Plan moves on to the second. The Plan Year Rule is evaluated only once per year. 

  • Quarterly Rule
  • First, the Plan checks hours worked to see if the member fulfills the Quarterly Rule. If a member works at least 300 Capped and/or Uncapped hours in a Contribution Quarter, the Quarterly Rule will allow coverage to be extended into the next Benefit Quarter (see example). There is a two (2) month waiting period between the end of a Contribution Quarter when the hours are worked until the beginning of the Benefit Quarter in which the coverage will take effect.

    To understand the Quarterly Rule, refer to the example below:

  • Look-Back Rule
  • If the Quarterly Rule does not extend coverage, the Plan uses the Look-Back Rule as the second “test” to determine if coverage can be extended. In this test, members who have worked at least 1,200 Capped and/or Uncapped hours within 12 consecutive months, with the period ending with any month in a Contribution Quarter will continue coverage for the corresponding Eligibility Benefit Quarter.

    For example – in the chart below, this member is looking for coverage for the Benefit Quarter April/May/June. To continue eligibility, the Plan looks back 12-months from each month that falls within the corresponding Contribution Quarter (work months) to check for 1,200 Capped and/or Uncapped hours. In this example, November, December and January are used as the months to look back 12 months. November, December and January in the same Contribution Quarter may all be used to look back 12-months and continue coverage in April, May and June.

    In the above example, 1,190 hours were worked during the 12-month Look-Back period from November, which is not enough to extend coverage. However, looking back 12 months from December, the member worked 1,220 hours. This would be enough to extend coverage into April, May and June. The January Look-Back also would also extend coverage for April, May and June.

  • Plan Year Rule
  • The Plan Year Rule considers Uncapped hours only. Members who work at least 1,300 Uncapped hours during a Plan Year (May 1 – April 30) will earn coverage for the following three (3) Benefit Quarters (July 1 – March 31). If a member works at least 1,300 hours May through April, coverage is extended from July 1 through March 31 of the following year. Once coverage based on the Plan Year Rule ends on March 31, the Plan will look to both the Quarterly Rule and the Look-Back Rule to extend coverage for the next Benefit Quarter (April/May/June).

  • Extension of Hours-Based Eligibility for Disability
  • If a member is unable to work sufficient hours to continue eligibility due to occupational or non-occupational Total Disability, and has worked a total of at least 1,300 Capped and/or Uncapped hours during the 12-consecutive months ending with the month they became Totally Disabled, the member’s eligibility will be automatically continued, without contributions, until the earlier of:

    1. The date the member's Total Disability ends;
    2. The date the member returns to work; or
    3. The last day of the Benefit Quarter containing the first anniversary of the date the member's Total Disability began.

Minimum or Difference Payments (MDP)

In the event that members do not have enough hours to continue coverage by any of the eligibility rules listed above, members may continue coverage by making a Minimum or Difference Payment (MDP). A Minimum Payment may be made when a member has no hours worked and chooses to continue eligibility by “paying the minimum” of 300 hours. A current Minimum Payment is calculated by taking 300 multiplied by the current contribution rate ($7.95). A Difference Payment would “pay the difference” between actual credit hours worked and the minimum 300 credit hours required. To calculate, $7.95 would be multiplied by the total hours needed to equal 300 (the hours that member is “short” of reaching 300 hours). It is important to note that this coverage is an alternative to COBRA Coverage. You may make a combination of MDP for no longer than six consecutive benefit quarters (18 months). 

COBRA Continuation Coverage
Another option to extend coverage when hours are not sufficient is COBRA. The Plan provides continued health and welfare coverage on a self-pay basis as required by the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA. COBRA is available to members and their families as an opportunity for a temporary extension of health coverage when there is a “qualifying event.” A “qualifying event” may be any one of the following situations: (1) members do not meet the hour requirements to continue active coverage; (2) a spouse and member divorce; or (3) when a dependent child reaches age 26. Depending on the type of qualifying event, “qualified beneficiaries” would include members, the member’s spouse and the member’s dependent children. “Qualified beneficiaries” would continue the same coverage as active members.
Note: When continuing coverage under COBRA Continuation Coverage, members are not eligible for Short Term Disability or Life insurance.

Member’s coverage and benefits will end on the date a Member is found to have engaged in employment in the construction industry by an Employer who is not obligated to contribute to the Plan.

Please note: If there are any discrepancies from the
Plan document in this article, the Plan document will prevail.