United Food and Commercial Workers
Tri-State Health and Welfare Fund

Enrollment

If you have any questions regarding eligibility for coverage or if you have enrollment questions,
please call the Fund office at 1-800-228-7484, prompt 2.

SUMMARY PLAN DESCRIPTION

A SUMMARY PLAN DESCRIPTION (SPD) booklet is issued to all eligible participants and contains important benefit plan information. Since there are many variations of benefit plans, according to employment status (full-time or part-time), length of service and other factors, it is important to contact the Fund office for a SPD that provides a description of your specific benefits.

When there is a change in a benefit plan, the Fund office mails a SUMMARY OF MATERIAL MODIFICATIONS (SMM) to the affected participants. The SMM should be kept with your SPD since it contains information regarding changes and/or updates regarding coverage, eligibility and other items that occurred after the printing and mailing of the SPD. These changes typically occur after contract negotiations and/or as a result of changes in health care laws.

It is important to note that the language in the SMMs supersedes the language included in the SPD.

ENROLLMENT FORM

An Enrollment Form must be fully completed and submitted to the Fund office in order to ensure that benefits are made available as promptly as possible. When returning an Enrollment Form, it is important to send copies of all required documents such as marriage license and birth certificates. Please note that birth certificates must show the full name of both parents. Beneficiary information must also be completed and include an address for your beneficiary.

ELIGIBILITY PROVISIONS

REFER TO APPENDIX A OF YOUR SPD TO DETERMINE YOUR ELIGIBILITY FOR DEPENDENT COVERAGE OR A SPECIFIC BENEFIT. THIS SUMMARY MAY CONTAIN A DEFINITION OR EXPLANATION THAT DOES NOT APPLY TO YOUR PLAN.

You are eligible to participate in this Plan if you are employed by a Contributing Employer who makes the necessary contributions on your behalf to provide the benefits as outlined in Appendix A of your SPD and in accordance with the Collective Bargaining Agreement between such Contributing Employer and Union.

You may be eligible for particular benefits based upon whether they are included under your Collective Bargaining Agreement or if the particular benefit is available in your geographic location. You may either contact the Fund Office or refer to your Collective Bargaining Agreement to determine which, if any, of the Benefits you may be eligible to receive.

You are covered by this Plan, without an initial medical examination, upon completion of the stated eligibility period in the Collective Bargaining Agreement. Your eligible Dependents (if applicable) are covered by this Plan, without an initial medical examination upon completion of the stated eligibility period and, if required, receipt of the appropriate payroll deduction* request during the period allotted for such request as set forth in the Collective Bargaining Agreement between your Employer and your Union. Such eligibility periods will be measured from your date of hire or date of promotion, whichever is applicable.

A Dependent means, in addition to yourself, any one of your eligible Family Members who is covered under the Plan as defined below. Benefits for each Dependent will be determined on the same basis as for you except where noted.

Notwithstanding anything in the SPD to the contrary, effective January 1, 2011, a Dependent includes your natural child, stepchild, or adopted child (or a child placed for adoption with you) who is under age 26 and who is not eligible for employer-based health insurance coverage (except coverage provided by the Fund).

Dependents Include:

a)Your spouse, provided you are not separated, legally or otherwise, for 36 months.
b)Your natural children, to the age limits described under Termination of Benefits - Dependents, if they qualify as your dependents. However, the Fund will comply with the terms of a Qualified Medical Child Support Order (QMCSO) that has been properly entered by a Family Court and filed with the Fund Office.
c)Your step children, legally adopted children, dependent children placed with a Participant for adoption irrespective of whether the adoption has become final, will be covered to the same extent as your natural children, subject to the same described in "b" above.
d)Your unmarried children who are mentally or physically incapable of earning their own living may be continued beyond the age limit described under Termination of Benefits – Dependent, if within 31 days after the date benefits would otherwise be canceled, you submit proof, satisfactory to the Trustees, of your child's incapacity directly to the Fund Office.
e)Benefits begin at birth for any properly enrolled eligible newborn child.

Payroll Deductions

If required and permitted in the Collective Bargaining Agreement, each Eligible Participant may purchase coverage for those Dependents listed above. Please refer to your Collective Bargaining Agreement or contact your Employer for details on enrollment and payroll deductions.

Delay in Eligibility

If you are absent from work on the day your eligibility would otherwise begin for all benefits other than health benefits (e.g., legal services, life insurance and weekly disability benefits), the effective date for all benefits other than health benefits will be the first of the month following the first date you are actively at work with a Contributing Employer. Likewise, if a Dependent is confined in a Hospital or similar facility on the date his benefits (other than health benefits) would otherwise begin, the effective date for that Dependent would be the earlier of 30 days after discharge from the Hospital, or the date proof of complete recovery is provided to the Fund. Such proof must be satisfactory to the Trustees. However you will not become eligible for any benefit improvements until the first of the month following the day you actually return to work with a Contributing Employer.

Termination of Benefits

(Also refer to Extension of Benefits under General Provisions and Definitions Section of your SPD)

A Dependent's eligibility shall terminate at the end of the month upon the occurrence of the following:

a)When a dependent child becomes an employee of any employer and becomes eligible for coverage under a plan sponsored by or participated in by that employer; or earns enough income to lose dependency status under the Internal Revenue Code; or
b)When the Participant's eligibility terminates; or
c)When a dependent enters full-time military service; or
d)When a dependent ceases to be a "Dependent" as defined herein; or
e)When a Participant's child(ren) attains the disqualifying age of 26; or
f)When they cease to qualify for COBRA; or
g)When you are separated or divorced, the spouse’s coverage will terminate the earliest of:
            - the effective date of the divorce, or
            - the date you have been separated 36 months.
h)For purposes of this plan “divorce” means the filing of a final judgment of divorce or the entry of a judgment for divorce from bed and board.

KEEP YOUR RECORDS UP TO DATE

It is important that you give prompt written notice to the Fund Office of any changes that may occur such as change in address, marital status, birth of a child, death of a spouse, or the addition or loss of other insurance. Failure to do so may result in delay of payment of a claim at a future date or you will be held responsible for claims paid in error. In certain situations you may be required to submit proof, acceptable to the Trustees, to support your claim of an eligible Dependent.

The forms required in order to update your records can be obtained by calling the Fund office at 1-800-228-7484.

HIPAA AUTHORIZATION FORM

To provide you with the benefits to which you are entitled, the U.F.C.W. Tri-State Health and Welfare Fund (the “Fund”) must collect, create and maintain information about you. We at the Fund are concerned about the privacy of this information which is referred to as “Protected Health Information” or “PHI” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). To protect PHI, HIPAA requires health plans such as the Fund to set up new policies and procedures regarding how they use and disclose information about participants such as you.

The Notice of Privacy Practices that has been mailed to all members of the Fund’s health plans describes how the Fund may use and disclose Protected Health Information about you, as well as the Fund’s obligations and your rights with respect to that information. If you would like another copy of the Notice of Privacy Practices, you may request one by calling the Fund Office at 1-800-228-7484.

HIPAA establishes limits on those with whom the Fund can discuss your Protected Health Information when you are not present for the conversation. These limits include information regarding your eligibility and the eligibility of your covered dependents, treatment dates and the reasons for any denial of benefits. If you want to authorize the Fund Office to discuss this type of Protected Health Information with another person, including your spouse, or a business agent, or other staff member of a Local Union or District Council, you must complete the Fund’s standard Authorization Form. Generally, you will not need an authorization to obtain Protected Health Information about your minor children, with some exceptions. However, you will need an authorization to obtain Protected Health Information about covered dependents that are adults.

You may obtain additional information regarding authorizations by writing to Privacy Officer, Frank M. Vaccaro, Jr., Esq., 27 Roland Avenue, Suite 100, Mount Laurel, NJ 08054.

Click here for a Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) Form.