Health and Welfare Plan...Plan will coordinate (supplement) those beneﬁ ts. 2. Prescription Drug...

2 0 1 0 E D I T I O N2 0 1 0 E D I T I O N

Health and Welfare Plan

Summary Plan Description for

Plan A Retirees

M I D W E S T

O P E R A T I N G

E N G I N E E R S

L O C A L 1 5 0

Union Trustees

James M. Sweeney, Chairman

Steven M. Cisco

Marshall Douglas

David Fagan

James McNally

Employer Trustees

John E. Kenny, Jr., Secretary-Treasurer

Mike Piraino

David Snelten

Britt Lienau

Steve Michaels

Administrative Manager

David S. Bodley

Consultant

R.N. Blomquist & Co.

Legal Counsel

Baum Sigman Auerbach & Neuman, Ltd.

Ford & Harrison

For more information regarding the

Health and Welfare Fund and

your benefi ts, visit the Midwest Fringe

Benefi ts website at moefunds.com.

M I D W E S T

O P E R A T I N G

E N G I N E E R S

6150 Joliet Road

Countryside, Illinois 60525

(708) 482-7300

Health and Welfare Fund

Important Contact Information As of January 1, 2010 Service providers are subject to change.

Call For Phone Number Web Site

Fund Offi ce General information (708) 482-7300

(800) 323-3060

www.moefunds.com

Midwest Benefi t Pharmacy

General questions

Physician fax line

24/7 automated refi ll line

(708) 579-6610

Fax: (708) 354-2642

(866) 850-9310

Claims Department

Medical claims

Dental claims

General Welfare Fund benefi ts

Active eligibility

(708) 579-6600

COBRA

Eligibility

Applications

Payment information

(708) 579-6600

Pension

Applications

Retiree eligibility

(708) 579-6640

Member Assistance Advocate (708)-579-6672

Precertifi cation and Case

Management Program*

Call for pre-certifi cation and case man-

agement of hospitalization, outpatient

surgery, physical/occupational/speech

therapy, chiropractic, medical equip-

ment, home health care, and hospice

Administered by

Med-Care

Management

(800) 367-1934

Members Assistance Program (MAP)

Mental Health Case Manager

and Network*

Mental health

Chemical/substance abuse treatment

Personal issues

Administered by

ComPsych

(888) 327-4315

www.compsych.com

Blue Cross Blue Shield of IL* To fi nd a PPO hospital or doctor (800) 571-1043 www.bcbsil.com

Outside Illinois

(Blue Card through BCBSIL)*

To fi nd a PPO hospital or doctor (800) 810-BLUE

(2583)

www.bcbsil.com

MRI or CAT Scan Providers and

Appointments*

To schedule an MRI or scan Through DiaTri

(800) 331-5720

Transplants and Case Management* Call for pre-certifi cation Med-Care Manage-

ment

(800) 367-1934

Guardian DentalGuard

Preferred Select Network

For a list of network dental providers (888) 600-9200 www.geoaccess.com/

guardian/po56/begin.asp

* These networks and programs are for retirees under age 65. Medicare-eligible participants should use Medicare-approved facilities and providers.

Affordable health care coverage today is a major concern for all of us. As a retired participant in

the Midwest Operating Engineers Health and Welfare Plan, you and your family receive substantial

medical benefi ts. Other benefi ts, such as Dental Benefi ts and the Family Supplemental Benefi t, are

also available to retired members.

You are able to enjoy such a high level of benefi ts because of the cooperative efforts of the Trustees

of the Midwest Operating Engineers Welfare Fund. The Trustees include members of both union

and employer groups who participate in the Midwest Operating Engineers Health and Welfare Plan.

The Trustees work toward providing you with the highest quality of welfare coverage and are pleased

to give you this description of your benefi ts.

This booklet is a Summary Plan Description (SPD) of the Health and Welfare Plan as of

January 1, 2010 for retired Plan A participants.

As you receive benefi t announcements and updates, note the change in your book and put the

announcement in the back pocket of this SPD. Please keep all of your benefi t materials together in a

safe place for future reference.

Although this booklet provides accurate and essential information about the Plan, you should

understand that this is not a complete description. If there is ever a confl ict between this booklet

|and the Plan’s legal documents, the Plan’s legal documents will control. If you have questions

about the Midwest Operating Engineers Health and Welfare Plan, please contact the Fund Offi ce.

Fund Offi ce staff will be happy to help you.

Sincerely,

Board of Trustees

To All Participants

Front Row: James M. Sweeney, Chairman,

John E. Kenny, Jr., Secretary-Treasurer,

Steven M. Cisco, David Snelten, Steve Michaels

Back Row: Mike Piraino, James McNally,

Britt Lienau, Marshall Douglas, David Fagan

The benefi ts described in this booklet generally apply to expenses incurred by eligible persons on or after January 1, 2010.

The Trustees reserve the right to change, mod-ify or discontinue all or part of this Plan at any time. The Trustees reserve the right to change the eligibility criteria for retiree benefi ts under the Plan. You will be notifi ed of any changes and all changes would be subject to the Plan’s provisions and applicable laws..

Our thanks to Mr. Ken Derry, a member of the International Union of Operating Engineers Local 150, for the wonderful crane photos.

Benefi t Highlights 1

Participation 3

Eligibility for Coverage 5

Eligibility Requirements . . . . . . . . . . . . . . . . .6

Applying for Retiree Health and Welfare Benefi ts . 7

Paying for Retiree Health and Welfare Benefi ts . . .8

If You Return to Work . . . . . . . . . . . . . . . . . .8

Dependent Eligibility 9

Full-Time Student Status . . . . . . . . . . . . . . . 10

Declining Coverage and Late Enrollment

for a Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Termination of Eligibility for Retiree

Health and Welfare Benefi ts 12

Survivor Benefi ts . . . . . . . . . . . . . . . . . . . . 13

Certifi cate of Coverage . . . . . . . . . . . . . . . . 14

Qualifi ed Medical Child Support Orders . . . . . . 14

Continuation Coverage Under COBRA 15

Retiree Health and Welfare Benefi ts

Are in Lieu of COBRA. . . . . . . . . . . . . . . . . . . . . 16

COBRA Coverage for Dependents. . . . . . . . . . 16

Notifi cation Responsibilities . . . . . . . . . . . . . 16

Electing COBRA Coverage . . . . . . . . . . . . . . 17

COBRA Self-Payment Due Dates . . . . . . . . . . 17

Life Events 18

Getting Married . . . . . . . . . . . . . . . . . . . . 19

Adding a Child . . . . . . . . . . . . . . . . . . . . . 19

Getting Legally Separated or Divorced . . . . . . . 20

Child Losing Eligibility . . . . . . . . . . . . . . . . . 20

Death of a Spouse or Child . . . . . . . . . . . . . . 21

In the Event of Your Death . . . . . . . . . . . . . . 21

Schedule of Benefi ts for Plan A Retirees 22

Table of Contents

The Health and Welfare Plan provides

different Summary Plan Description

booklets for the following participant

classes:

Plan A Quarterly Employees

Bargaining unit employees and City of

Chicago employees

Plan A Monthly Employees

Non-bargaining unit employees,

staff employees, owner-relatives and

municipalities

Plan B Monthly Employees

Plantsmen

Plan E Monthly Employees

Illinois Landscape Contractors

Bargaining Association

Medical Benefi ts

(Comprehensive Medical Benefi t) 29

How the Plan Works . . . . . . . . . . . . . . . . . . 30

Using PPO Networks . . . . . . . . . . . . . . . . . 34

Pre-Certifi cation by the Case Manager . . . . . . . 35

Eligible Medical Expenses . . . . . . . . . . . . . . 37

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . 43

Prescription Drug Program 45

The Midwest Benefi t Pharmacy Program . . . . . 45

If You Need an Emergency Medication . . . . . . . 48

If There is Other Prescription Drug Coverage . . . 48

Prescriptions Provided by Convalescent

and Nursing Homes . . . . . . . . . . . . . . . . . . 49

General Information About the Program

and the Midwest Benefi t Pharmacy . . . . . . . . . 49

Eligible Expenses . . . . . . . . . . . . . . . . . . . . 51

Expenses Not Covered . . . . . . . . . . . . . . . . 51

Expenses Covered With Limitations . . . . . . . . 52

Dental Benefi ts 53

How Benefi ts Are Paid. . . . . . . . . . . . . . . . . 54

Maximum Allowable Fee Table . . . . . . . . . . . 54

The Dental PPO Network . . . . . . . . . . . . . . . 55

Orthodontia Treatment . . . . . . . . . . . . . . . . 55

Limitations . . . . . . . . . . . . . . . . . . . . . . . 56

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . 56

If You Have Questions . . . . . . . . . . . . . . . . . 58

Maximum Allowable Fee Table

as of January 1, 2010. . . . . . . . . . . . . . . . . . 58

Family Supplemental Benefi t 60

FSB Expenses . . . . . . . . . . . . . . . . . . . . . . 61

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . 61

Examples of Eligible and Excluded Expenses

Under the Family Supplemental Benefi t . . . . . . 62

How to File Family Supplemental Benefi t Claims . 62

Retiree Medical Savings Plan 63

RMSP Benefi ts . . . . . . . . . . . . . . . . . . . . . 63

How to Use Your RMSP Account . . . . . . . . . . 64

General Exclusions 65

Other Provisions That Can Limit Benefi ts 67

Coordination of Benefi ts . . . . . . . . . . . . . . . 68

Third Party Recovery Reimbursement

(Subrogation) . . . . . . . . . . . . . . . . . . . . . . 70

Claim and Appeal Procedures 71

Defi nitions. . . . . . . . . . . . . . . . . . . . . . . . 72

Filing a Claim . . . . . . . . . . . . . . . . . . . . . . 73

Claim Processing . . . . . . . . . . . . . . . . . . . . 75

Claim Appeal Procedures . . . . . . . . . . . . . . . 76

General Plan Provisions 79

Privacy of an Individual’s Health Information . . . 80

Trustee Interpretation and Authority;

Decisions Regarding Benefi ts . . . . . . . . . . . . 80

Plan Discontinuation or Termination . . . . . . . . 81

Right to Recover Overpayments . . . . . . . . . . . 81

Your ERISA Statement of Rights . . . . . . . . . . . 81

Defi nitions 84

Administrative Information 87

Board of Trustees 91

11

Benefit Highlights

1

BENEF IT H IG HL IG HTS 2

1. Comprehensive Medical Coverage

Retired Participants Without Medicare

Covers most medical expenses up to $50,000 per

calendar year with supplemental lifetime coverage of

up to $750,000. Some of the benefi ts are not subject

to a deductible or copayment, which means they are

paid at 100% with no cost to you. Others have

a $300 per person, per calendar year deductible

(limited to a $700 per family deductible maximum).

Most Plan benefi ts are payable as follows:

■ In-network (PPO provider): 90%

■ Out-of-network (non-PPO provider): 80%

Certain types of expenses are payable at 50%.

You receive higher benefi t coverage when you go to

a medical provider associated with the medical PPO

network. This network consists of doctors and hos-

pitals that offer discounts on quality services for our

members. For more information about PPO providers

go to page 34.

Inpatient hospitalizations and outpatient surgery

require pre-certifi cation. See page 35 for more

information about the review program.

See Eligible Medical Expenses starting on page 37 for a

description of the type of medical expenses covered

by the Plan.

Retired Participants With Medicare

If and when you become eligible for Medicare,

Medicare will become your primary plan for all

medical expenses except prescription drugs. This

Plan will coordinate (supplement) those benefi ts.

2. Prescription Drug Coverage

Prescription drug benefi ts are described on pages

45 to 52.

3. Dental Benefi ts

Dental benefi ts are described beginning on page 53.

4. Family Supplemental Benefi t

You can receive up to $1,500 per year for your

family’s medically necessary non-covered health

care expenses as described on page 60.

5. Retiree Medical Savings Plan (RMSP)

The Retiree Medical Savings Plan (RMSP) is designed

to make retirees’ health care spending more manage-

able and fl exible. The funds accumulated under this

program can be utilized in a variety of ways to cover

health care expenses after retirement. See pages

63-64 for more information.

Although this booklet provides accurate and essential

information about the Welfare Plan, it is not a complete

description. If there is ever a confl ict between this booklet

and the Plan’s legal document, the Plan Document will

control.

The coverage provided by the Plan for you and your eligible dependents is one of your most

valuable assets, especially in view of today’s rising health care costs.

Your booklet includes these major features. For more details, see the complete description in

each section.

33

Participation

PART IC IPAT ION 4

You may participate in this Plan if you are a retired eligible Plan A participant who

worked under the jurisdiction of Operating Engineers Local 150 for an employer

who was required to make contributions on your behalf to the Midwest Operating

Engineers Welfare Trust Fund. You are eligible for Plan benefi ts when you satisfy

the retiree eligibility requirements.

If you fall into one of the participant classes listed below, you should read the Summary Plan

Description for that group:

Plan A Quarterly Employees Bargaining unit employees and City of Chicago employees

Plan A Monthly Employees Non-bargaining unit employees, staff employees,

owner-relatives and municipalities

Plan B Monthly Employees Plantsmen

Plan E Monthly Employees Illinois Landscape Contractors Bargaining Association

5

Eligibility for Coverage

5

EL IG IB IL ITY FOR COVER AG E 6

Retiree Health and Welfare Benefi ts are provided for the following categories of retirees:

■ Plan A bargaining unit employees;

■ Plan A City of Chicago employees;

■ Plan A staff employees;

■ Plan A owner/relatives; and

■ Plan A municipality employees.

If you are a retiree in one of the categories listed above, you will be eligible for Retiree Health and

Welfare Benefi ts if you meet ALL of the following requirements:

■ You have reached age 55 and are retiring from active covered employment; AND

■ At the time you retire, you have ten (10) years of eligibility under the Midwest Operating

Engineers Local 150 Health and Welfare Plan*; AND

■ You have ten (10) years of Credited Service under the Midwest Operating Engineers Pension

Plan**; AND

■ You are receiving normal, early, or disability retirement benefi ts under the Midwest Operating

Engineers Pension Fund***; AND

■ You have not, as of the date of your retirement, lost eligibility under this Plan for a period in excess

of twelve (12) consecutive months.

¬ This requirement will not apply if the Trustees determine that you are eligible under this Plan due to

a total disability that is continuous to the date of your retirement.

¬ A 12-month eligibility break can be repaired if, prior to retirement, you regain eligibility and remain

eligible for a continuous period of time that equals the length of your break, or 36 months, which-

ever is less.

¬ If you are awaiting the outcome of a Worker’s Compensation disability decision, the 12-month

period will be extended to 36 months.

* For municipality employees: If you are a member of the bargaining unit represented by Local 150 on the effective date of the initial collective bargaining agreement between Local 150 and the municipality, and if the municipality on the effective date of the initial collective bargaining agreement provided retiree health benefi ts which were paid in whole or in part by that employer. Your requirement for 10 years of Health and Welfare Plan eligibility may be a combination of your eligibility with the municipality and this Fund.

** With respect to a municipality employee, 10 years under the Illinois Municipality Retirement Fund.

*** With respect to a municipality employee, under the Illinois Municipality Retirement Fund.

Eligibility Requirements

7

Railroad Employees

If you worked under the Landscape Contractors Labor Agreement, you may be eligible for Retiree

Health and Welfare Benefi ts from this Plan if you meet ALL the following requirements:

■ You have reached age 55 and are retiring from active covered employment; AND

■ You were covered as an active employee under this Plan or the Railroad Maintenance and Indus-

trial Health and Welfare Fund for at least ten (10) years; AND

■ You have accumulated at least ten (10) years of credited service under the Midwest Operating

Engineers Pension Plan; AND

■ You are receiving a normal retirement pension, early retirement pension, or total and permanent

disability pension under the Midwest Operating Engineers Pension Plan; AND

■ You were eligible under the Railroad Maintenance and Industrial Health and Welfare Fund during

the 12 consecutive months immediately prior to retirement.

¬ This requirement will not apply if the Trustees determine that you are eligible under this Plan due to

a total disability that is continuous to the date of your retirement.

¬ A 12-month eligibility break can be repaired if, prior to retirement, you regain eligibility and remain

eligible for a continuous period of time that equals the length of your break, or 36 months, which-

ever is less.

¬ If you are awaiting the outcome of a Worker’s Compensation disability decision, the 12-month

period will be extended to 36 months.

It is very important that you apply for and choose Retiree Health and Welfare Benefi ts coverage

before you retire.

You may elect to cover only yourself, or you may elect to cover yourself and your eligible dependents.

If you initially elected single only coverage, you can only add a newly acquired eligible dependent by

making the proper application and self-payment to the Fund. You will have six (6) months from the

date the person becomes your dependent to add that person to your coverage. Coverage for your

new dependent will become effective on the fi rst day of the month after your application is received,

provided you have made a self-payment for your new dependent’s coverage.

Also see “Declining Coverage and Late Enrollment for a Spouse” on page 11.

Applying for Retiree Health

and Welfare Benefi ts

EL IG IB IL ITY FOR COVER AG E 8

You must make self-payments for Retiree Health and Welfare Benefi ts. The amount of the

self-payment is determined by the Trustees in their sole discretion and may be changed at any time.

Payments are due to the Fund by the 15th day of the prior month, however, the Plan provides a

30-day grace period.

Running Out Your Active Hours

Before your retiree self-payments start, you can run out your accumulated hours as an active partici-

pant. The self-payment amount for the last period during which you still have active hours will be the

lesser of the active self-payment rate or the retiree self-payment rate.

Retiree Medical Savings Plan (RMSP)

When you retire, if you are eligible for the Midwest Operating Engineers retiree health care coverage,

you can use the funds in your Retiree Medical Savings Plan (RMSP) account to cover your retiree

self-payment premiums. In addition, your RMSP account can be used to pay for tax-qualifi ed long

term care insurance premiums or tax-qualifi ed nursing care expenses. See pages 63–64 for more

information about the RMSP program.

Once you retire, if you return to permissible active employment, you are still required to make self-

payments to maintain your Retiree Health and Welfare Benefi ts. Failure to make your self-payments

will result in termination of eligibility.

After you become eligible as a retiree you are allowed to return to work as an active employee one

time without affecting your eligibility for Retiree Health and Welfare Benefi ts.

A “return to work” is defi ned as:

■ For a retiree between the ages of 55 and 59, working one or more hours; or

■ For a retiree between the ages of 60 and 70.5, working over 40 hours in any month.

If you return to work a second time, under either or both defi nitions, you will no longer be eligible for

Retiree Health and Welfare Benefi ts. There is one exception to this rule: Eligibility for Retiree Health

and Welfare Benefi ts will not terminate if the Trustees determine that there is a need for the employ-

ment of retirees where there are no active employees available to perform such work.

Paying for Retiree Health

and Welfare Benefi ts

If You Return to Work

9

Dependent Eligibility

9

DEPENDENT EL IG IB IL ITY 1 0

During any benefi t month that you are eligible for coverage, your eligible

dependents are also covered. Eligible dependents include your:

■ legal spouse other than a spouse separated by a decree of a court of competent jurisdiction; and

■ unmarried children (including natural children, legally adopted children,* step-children** and

children for whom the Plan is required by a Qualifi ed Medical Child Support Order (see page 20)

to consider eligible dependents, provided they live with you for at least one-half the calendar

year (unless you are divorced or separated) and are dependent on you for at least one-half their

support, and are:

¬ under age 19;

¬ a full-time student between the ages of 19 and 23 provided the child was eligible on his or her

19th birthday and has been continually eligible under the Plan; or

¬ physically or mentally incapacitated and unable to support themselves, provided the child was

eligible on his or her 19th birthday and has been continually eligible under the Plan.

* A child is considered legally adopted on the earlier of the date of placement or the date legal adoption proceedings have been started.

** A stepchild must be a natural or adopted child of an eligible spouse.

The Fund Offi ce requires proof every term of full-time student status for children age 19 and older.

Documentation must come from the registrar’s offi ce, and must include the school seal.

The full-time student is covered until the end of the calendar month that includes the last day of

the term for which the student provided documentation of full-time student status. At the end of

the normal school year, full-time students are covered through June 30th. If the child continues as

a full-time student the following fall, then the child is covered during the summer months. Other-

wise, coverage ends June 30th.

Plan coverage may be extended for up to one year if a child who is a full-time student age 19 or over

has to take a medical leave from school. The child must be a covered full-time student immediately

before the leave causes him or her to lose full-time student status, and the child’s physician must

certify in writing to the Plan that the leave is medically necessary because of a serious illness or

injury. A leave cannot extend a child’s coverage beyond the Plan’s limiting age or beyond the date

your eligibility terminates.

In order to maintain coverage for

your disabled child, you must submit

proof of your child’s physical

handicap or mental incapacity to

the Fund Offi ce within 31 days

of your child’s 19th birthday.

Full-Time Student Status

1 1

Children age 19 or over must maintain continuous coverage under the Plan, and, except as follows,

coverage may not be reinstated if there is a lapse in coverage:

If your child is not continuously a full-time student but maintains coverage under the Plan by

electing continuation of coverage under COBRA, then when he or she fi rst becomes or returns

to full-time student status, he or she will be considered an eligible dependent. This change from

non-dependent to dependent status is permitted only once.

A spouse of a retiree who would otherwise be eligible for Retiree Health and Welfare Benefi ts may

initially decline coverage and enroll in the Plan at a later date. Coverage may only be declined and

late enrollment is only allowable if the spouse is covered under another group health plan, health

insurance, or state Medicaid or SCHIP program, subject to the following rules:

■ The dependent must complete and sign a waiver form, and provide proof of the other coverage

that is satisfactory to the Administrative Manager within 60 days of declining Plan eligibility.

■ A dependent who has declined Retiree Health and Welfare Benefi ts because of other coverage

may enroll in the Plan after the other coverage terminates for reasons other than fraud or failure

to make the required payments, including COBRA. To do so, the affected individual must request

enrollment within 60 days after the other coverage ends.

Declining Coverage and

Late Enrollment for a Spouse

Termination of Eligibility for Retiree Health and

Welfare Benefits

1 2

1 3

You lose coverage if:

■ you do not make the required self-payment on time,

■ this Plan or the Plan’s retiree coverage terminates, or

■ you die.

Retiree Benefi ts will also terminate if you return to work more than one time (see If You Return to

Work starting on page 8.

Generally, your dependents lose coverage when you do. In addition, dependent coverage will end if:

■ you get divorced or become legally separated,

■ a child no longer meets the defi nition of a dependent child, or

■ a dependent dies.

If your coverage ends because you do not meet the eligibility requirements, or you do not make a self-

payment on time, coverage for your eligible dependents will end. A dependent’s coverage will also end if

he or she no longer meets the Plan’s defi nition of “dependent.”

If you die, your surviving dependent spouse may elect to continue coverage by making self-

payments. The amount of the required self-payment is determined by the Trustees and may be

changed at any time.

Your surviving spouse may continue coverage for herself and all dependent children who were

covered under the Plan on the day before your death.

Your dependents’ Survivor Benefi ts eligibility will end on the earliest of the following:

■ the date the required self payment is not made,

■ the date your spouse remarries,

■ the date a child no longer meets the defi nition of a dependent,

■ your spouse’s death,

■ when your spouse or child becomes entitled to coverage under another group policy or plan,

including Medicare, or

■ when your spouse establishes permanent residence outside the continental limits of the

United States.

Survivor Benefi ts

1 3

TER MINAT ION OF EL IG IB IL ITY 1 4

COBRA coverage is also available to qualifi ed dependents in the event of your death, and it can be

elected in lieu of the coverage described above. In addition, if a surviving spouse elects to make

Survivor Benefi t self-payments and loses eligibility for one of the reasons explained above, any

covered dependents may elect COBRA for the balance of the 36-month period from the beginning

with the date of your death.

When your coverage ends, you will be provided with a certifi cate of coverage shortly after you

notify the Fund Offi ce that you or your dependents’ coverage ended. The certifi cate will specify the

length of time you were covered under the Plan and additional information required by law. This may

help reduce or eliminate any pre-existing condition limitation under a new group medical plan. In

addition, a certifi cate will be provided within 45 days after receipt of a request for such certifi cate

that is made within two years after coverage under the Plan ends. To request a certifi cate, contact

the Eligibility Department at (708) 579-6600, or send a written request to: Eligibility Department,

Midwest Operating Engineers Welfare Fund, 6150 Joliet Road, Countryside, IL 60525. The Eligibility

Department will also assist you in obtaining a certifi cate from your prior plan that could reduce your

pre-existing condition limitation period under this Plan.

A Qualifi ed Medical Child Support Order (QMCSO) is a court order that requires an employee

or retiree to provide medical coverage for his or her children (called alternate recipients) in situa-

tions involving divorce, legal separation, or a paternity dispute. The Fund Offi ce will notify you and

the alternate recipient if a QMCSO is received. You can receive a copy of the Plan’s procedures for

handling QMCSOs at no cost, by calling the Fund Offi ce.

Certifi cate of Coverage

Qualifi ed Medical Child

Support Orders

1 515

Continuation Coverage Under COBRA

1 5

CONT I NUAT ION COVER AG E UNDER COBR A 1 6

When an employee’s eligibility as an active participant terminates, he or she is offered a choice

between COBRA coverage and Retiree Health and Welfare Benefi ts. If the employee elects Retiree

Health and Welfare Benefi ts, he or she waives the right to COBRA coverage at any future date.

The only circumstances under which COBRA coverage will be offered to an individual who has been

eligible for Retiree Health and Welfare Benefi ts are as follows:

■ you become divorced or legally separated,

■ you die, or

■ a dependent child no longer meets the defi nition of a dependent child.

The COBRA coverage period for a person who loses Retiree Health and Welfare Benefi ts eligibility

due to one of the qualifying events listed above is 36 months.

It is your (or your eligible dependent’s) responsibility to provide written notifi cation to the

Fund Offi ce within 60 days after:

■ you and your spouse are divorced, or

■ one of your children loses eligibility as a dependent under the Plan.

If the Fund Offi ce is not notifi ed within 60 days after the qualifying event occurs the dependent will

lose the right to COBRA coverage.

In order to protect your family’s rights, you should keep the Fund Offi ce informed of any changes in

the addresses of family members. You should also keep a copy, for your records, of any notices you

send to the Fund Offi ce or that the Fund Offi ce sends to you.

Retiree Health and Welfare

Benefi ts Are in Lieu of COBRA

COBRA Coverage for

Dependents

Notifi cation Responsibilities

Under a federal law called COBRA (Consolidated Omnibus Budget Reconciliation

Act of 1986), qualifying individuals can extend coverage temporarily at group rates

after coverage would normally end, without providing evidence of good health.

This extension of coverage is called continuation coverage or COBRA coverage.

1 7

If your dependent elects COBRA coverage, he or she will be provided with the same coverage avail-

able to eligible retirees. Your dependent will have to pay for the full amount of this coverage. Your

dependent will be sent an election notice that includes the cost of the coverage, as well as the due

dates and other pertinent information.

The person electing COBRA coverage has 60 days after being sent the election notice or 60 days

after coverage would otherwise terminate, whichever is later, to return the completed election form.

An election of COBRA coverage is considered to be made on the date the election form is per sonally

delivered or mailed back to the Fund Offi ce (the postmark date will govern the date of mailing).

If the election form is not returned to the Fund Offi ce within the allow able period, you and/or your

dependents will be considered to have waived your right to COBRA coverage.

A person electing COBRA coverage has 45 days after the signed election form is returned to the

Fund Offi ce to make the initial (fi rst) self-pay ment for coverage provided between the date coverage

would have ter minated and the date of the payment. (If you wait 45 days to make the initial

payment, the next monthly payment may also fall due within that period and must also be paid at

that time.)

The due date for each following monthly self-payment is the fi rst day of the month for which pay-

ment is made. A monthly self-payment will be accepted if it is received by the Fund Offi ce within a

30-day grace period after the due date.

If a self-payment is not made within the time allowed, COBRA coverage for all affected family

members will terminate. You may not make up the payment or reinstate coverage by making future

payments.

COBRA coverage will end earlier than the expiration of the 36-month COBRA coverage period if:

■ your dependent becomes covered under another group health care plan with similar coverage,

■ your dependent becomes eligible for Medicare,

■ the Plan is no longer provided by the Midwest Operating Engineers Welfare Fund, or

■ your dependent fails to make the required contribution within 30 days after it is due.

Electing COBRA Coverage

COBRA Self-Payment

Due Dates

L IF E EVENTS 1 8

Life Events

1 8

19

This section describes how your coverage is affected when different events occur.

Life events can affect your benefi ts coverage. Life events may include:

■ Marriage

■ Birth of a child

■ Adoption of a child

■ Divorce

■ Maximum age of a child

■ Death of a dependent

■ Death

When you marry, your spouse is automatically eligible for coverage under the Plan on the date of

your marriage. However, before claims can be processed for this person, you are required to submit

documentation to the Fund Offi ce to prove that he or she is your legal spouse. To do this, call the

Fund Offi ce and request the appropriate form. Then complete the necessary information and return

it to the Fund Offi ce, along with a copy of your marriage certifi cate. Once you have submitted the

proper proof of marriage, claims incurred by your new spouse on and after the date of your marriage

can be processed.

Your natural children will be eligible for coverage on their date of birth, but you must submit

documentation to the Fund Offi ce to prove that each child meets the Plan’s defi nition of a dependent

child. To do this, call the Fund Offi ce and request the appropriate form. Then complete the necessary

information and return it to the Fund Offi ce, along with a copy of each child’s birth certifi cate or

adoption papers. Once you have submitted the proper proof, claims incurred on and after the date

the child became your dependent can be processed. If a child is placed with you for adoption, he or

she will be eligible for coverage on the date of placement as long as you are responsible for health

care coverage and the situation meets the Plan requirements. Stepchildren who live in your home are

eligible for coverage on the date of your marriage. See the Dependent Eligibility section on page 10 for

the requirements for adopted children and stepchildren.

Getting Married

Adding a Child

If you have or adopt a child:

Notify the Fund Offi ce.

Your child will be eligible for cover-

age on the date of birth or on the

date of placement for adoption.

L IF E EVENTS 20

You must submit a copy of your divorce decree or legal separation to the Fund Offi ce. Your spouse’s

coverage will end at the end of the month in which the divorce or legal separation is decreed.

Your spouse may elect to continue coverage under COBRA for up to 36 months (see Continuation

Coverage Under COBRA starting on page 15). You or your spouse must notify the Fund Offi ce within

60 days after the divorce date in order for your spouse to obtain COBRA coverage.

Qualifi ed Medical Child Support Order (QMCSO)

This Plan recognizes Qualifi ed Medical Child Support Orders (QMCSOs) which are court orders

directing individuals to provide support for a dependent child in the event of a divorce or other

family law action. Coverage will be provided to a child even if that child does not reside with the retiree

if that child is identifi ed as an alternate recipient under a QMCSO. Orders must be submitted to the

Administrative Manager who will determine whether the order is a QMCSO as required under

federal law. You can receive a copy of the Plan’s procedures for handling QMCSOs, at no cost, by

calling the Fund Offi ce.

Once the Administrative Manager receives a QMCSO, the Administrative Manager will promptly

notify you and each alternate recipient of the receipt of the order and provide you with the Plan’s

procedures for determining whether the order is a QMCSO.

In general, your child is no longer eligible for coverage when he or she reaches the limiting age,

or is no longer dependent upon you for support (see page 9). Your child’s coverage will also end if

the child enters active military service on a full-time basis.

If your child is age 19 to 23 and a full-time student, the child’s school needs to send a letter to the

Fund Offi ce each term indicating the child is a full-time student. Otherwise, the Fund Offi ce will

assume the child is not a full-time student.

If your child loses eligibility, he or she may elect to continue coverage under COBRA for up to 36

months (see pages 15–17). You or your child must notify the Fund Offi ce within 60 days after your

child no longer meets the Plan’s defi nition of an eligible dependent to obtain COBRA coverage.

If your child is not capable of self-supporting employment because of a physical handicap or mental

retardation, you may continue coverage for that child for as long as your own coverage continues

and the child depends on you for the major portion of his or her support. To qualify, your child’s

disability must begin before his or her coverage would otherwise end.

Getting Legally Separated

or Divorced

Child Losing Eligibility

If your child loses eligibility:

Contact the Fund Offi ce immediately.

Your child may elect to continue

coverage under COBRA (see page 18).

Limiting Age

Under the Plan, the limiting age for

your unmarried dependent child is:

age 19; or

age 23, if your child is a full-time

student at an accredited school and

mainly dependent on you for support

and maintenance.

2 1

Notify the Fund Offi ce as soon as possible after the death of a dependent to change your dependent

information.

Your spouse and children may be able to continue their health care coverage under Survivor Benefi ts

or COBRA coverage. See page 13 for Survivor Benefi ts information and pages 15–17 for information

about COBRA.

If you are a retired member of former Local 537 who retired between April 1, 1987 and March 31,

1993, and are eligible under the Retiree Health and Welfare Plan, your benefi ciary will receive a

$10,000 Death Benefi t upon your death.

You may designate a benefi ciary to receive your death benefi t. If you don’t, payment will be made in

the following order:

■ to your legal spouse; or, if not living,

■ equally to your children; or, if not living,

■ to your parents in equal shares; or, if not living,

■ to your estate.

If any benefi ciary has assigned expenses in connection with the participant’s burial, the Trustees, at

their discretion, may reimburse the provider of funeral services, up to the applicable maximum bene-

fi t. In that event, the benefi ciary will be entitled to receive only the remainder, if any, of the proceeds.

You should be aware that death benefi ts may be taxable.

Death of a Spouse or Child

In the Event of Your Death

22

Schedule of Benefits for Plan A Retirees

23

All benefi ts are subject to eligibility, maximum plan benefi t, reasonable and

customary determination (or negotiated fee amounts for PPO provider services,

or Medicare-allowable fee limits for Medicare-eligible patients), pre-existing condi-

tion limitations and any special limits noted in the Plan. Charges that exceed the

reasonable and customary amount or other Plan limitations will not be considered

eligible in determining plan benefi ts. Eligible expenses must be medically neces-

sary and are subject to the calendar year deductible unless otherwise noted. Age

limitations, as specifi ed in the Schedule of Benefi ts, are applied as of the last day

of the month in which the eligible dependent’s birthday occurs.

If you are eligible for Medicare, Medicare will be your primary health plan and the benefi ts below will be

coordinated (reduced) to supplement Medicare’s benefi ts.

Reasonable and customary:

Actual charge for the service

or supply is comparable to

what is usually charged for

the same service or supply

in the provider’s geographic

area.

SC HEDU LE OF B E NEF ITS FOR PLAN A R ET IR EES 24

Comprehensive Medical Expense Benefi ts

Annual Maximum – per calendar year $50,000

Lifetime Maximum $750,000

Individual Deductible – (per person, per calendar year. All benefi ts are subject to

the deductible unless otherwise noted.) Three month carryover.

$300

Family Deductible – (per calendar year) Three month carryover does not apply. $700

Out of Pocket Expense Limitation – the amount of money an individual pays

toward covered hospital and medical expenses during any one calendar year,

including the deductible.

$2,500 per individual

$6,000 per family

PPO Network – for retirees and dependents who are not eligible for Medicare.

Medicare-eligible individuals should use providers approved by Medicare.

BlueCross BlueShield – Hospital

and Physicians

DiaTri – MRI and CT Scans

ComPsych – MAP, Mental and

Nervous and Substance Abuse

Inpatient Hospital Services – room allowances based on the hospital’s most

common semi-private room rate. Pre-admission testing, 14 days prior to admission.

90% – In Network

80% – Out of Network

Pre-certifi cation required*

Skilled Nursing Facility – recommended by a physician and confi nement begins

within 30 days of a hospital confi nement. Requires approval by Case Management.*

90% – In Network


maximum per disability – 45 days

Home Health Care – ordered by a physician. Approval by Case Management

required.*

90% – In Network


Outpatient Hospital Services – including licensed surgery centers. 90% – In Network


Pre-certifi cation required for surgery*

Diagnostic X-rays/Lab – X-rays and/or tests to diagnose a condition or to

determine the progress of an illness or injury.

90% – In Network


MRI and CT Scans – for retirees and dependents who are not eligible for Medicare.

Medicare-eligible individuals should use providers approved by Medicare.

100% – DiaTri

90% – In Network


Outpatient Physical and Occupational Therapy – requires approval by Case

Management.* Must be performed by a licensed therapist or licensed physical

therapist assistant.

90% – In Network


Outpatient Restorative Speech Therapy – (children and adults) – requires

approval by Case Management.* Must be performed by a licensed speech therapist.

90% – In Network


* Pre-certifi cation and case management are not required for Medicare-eligible participants. Medicare eligibles should follow Medicare’s procedures and use Medicare-approved facilities and providers.

25


Outpatient Speech Therapy for Developmental Condition including Congenital

Neurological Diseases for Dependent Children – dependent children age 2

through age 5. Requires approval by Case Management.*

90% – In Network


calendar year maximum $2,000

Outpatient Speech Therapy for Developmental Condition including Congenital

Neurological Diseases for Dependent Children – dependent children age 6

through age 18. Requires approval by Case Management.*

90% – In Network


calendar year maximum $500

Outpatient Physical and Occupational Therapy for Congenital Neurological

Diseases for Dependent Children – dependent children through age 18 only.

Requires approval by Case Management. *

90% – In Network


calendar year maximum $5,000

Orthoptic Training – for dependent children up to age 10 only. Training needs to be

prescribed by a covered provider.

50%

lifetime maximum 40 visits

Physician’s Medical/Surgical Care – offi ce visits, hospital visits, surgery, assistant

surgeon, etc.

90% – In Network


Preventative Care – routine physical exams. Benefi t for member and spouse only. 100%

calendar year maximum of $350

Colonoscopies – cancer screening colonoscopies recommended by a physician. 90% – In Network


Well Baby Care – includes routine hospital visits, outpatient visits and immuniza-

tions, age limitation of 0 to 24 months.

100%

lifetime maximum of $2,000

Chiropractic Services – eligible for members and dependents over age 5. Medically

necessary x-rays are covered.

maximum of 24 spinal

manipulations per calendar year

up to $60 per visit

90% – In Network


Durable Medical Equipment – rental paid up to purchase price of the equipment. No deductible

80%, if pre-approved by a

Case Manager*,

50%, not pre-approved

Electric wheelchair limited to

$15,000

Foot Orthotics – custom fi tted foot orthotics prescribed by a physician. 80%

annual maximum $300

lifetime maximum $1,500

SC HEDU LE OF B ENEF ITS FOR PLAN A R ET IR EES 26


Prosthetic Devices – artifi cial devices to restore a normal body function. Case

Management approval is required*. An electronic or microprocessor-controlled

artifi cial limb is limited to the cost of a conventional mechanical artifi cial limb that

would meet the patient’s basic needs.

80%

Transplants – Case Management approval is required.* Available to all

non-Medicare members. Medicare-eligible individuals must use Medicare approved

providers. Benefi t begins 5 days (30 days for bone marrow) before the transplant

date and ends 18 months after transplant procedure.

90% – In Network

lifetime maximum $300,000,

including organ procurement

maximum $25,000 per transplant

transportation and lodging

maximum $10,000

private duty nursing maximum

$10,000

Temporomandibular Joint Disease (TMJ) – Case Management approval is

required.*

No deductible

50%

lifetime maximum $2,500

Cochlear Implants – for dependent children age 1 through 18. Requires approval by

Case Management.*

90% – In Network only

Cochlear Implants – age 19 and older. Requires approval by Case Management. 70%

lifetime limit $30,000

Cancer Drugs – drugs used to treat cancer are subject to the annual deductible, and

annual and lifetime maximums.

80% of the prescription charge

Medical Transportation – includes ground and air transport from the site of the

injury, medical emergency or acute illness to the nearest facility.

90% – In Network


Inter-health-care-facility transfer

maximum $5,000

Acupuncture – services performed by a licensed acupuncturist (physician referral

required) or physician.

90% – In Network


maximum of 12 treatments per

calendar year

up to $125 allowable per visit

Sleep Apnea Appliances – when ordered by a physician and provided by a medical

equipment supplier or dentist.

90% - In Network

80% - Out of Network

maximum every fi ve years $3,000

all appliances

replacement of existing appliance

covered every fi ve years

* Case management is not required for Medicare-eligible participants. Medicare eligibles should follow Medicare’s procedures and use Medicare-approved facilities and providers.

27

Mental Illness and Substance Abuse

Prior authorization is required.

Inpatient Care 90%

lifetime maximum 30 days

Outpatient Care 90%

lifetime maximum 60 visits

Prescription Drug Program


All maintenance drugs must be purchased at the Midwest

Benefi t Pharmacy.

No coordination of benefi ts applies.

Brand $10 co-pay – 30 days

Generic $5 co-pay – 30 days

annual maximum $20,000 per individual

Hepatitis C maximum ends 12 months from the initial

treatment – $40,000

Pharmacy Benefi t Manager (local pharmacy) – In Network

Pharmacy Only

80% for emergency medication only from an in-network

pharmacy. A maximum of 15 days supply will be dispensed.

Nursing Home 50% – prescription drugs

When available, generic drugs will be substituted for all brand name drugs or medications. If a participant requests a brand name drug, or if the prescribing physician indicates “no substitutions,” when a generic equivalent is available, the participant will be required to pay the brand name drug co-pay plus the difference in cost between the brand name drug and its generic equivalent.

Dental Benefi ts

Deductible $0

Calendar Year Maximum $1,000

PPO Network DentalGuard Preferred Select Network

Preventative 100%

Basic and restorative 70%

Orthodontia (dependent children through age 18 only) 50%

lifetime maximum – $2,000 (treatment started 1/1/09);

$1,500 (treatment started before 1/1/09)

SC HEDU LE OF B E NEF ITS FOR PLAN A R ET IR EES 28

Death Benefi t

Death Benefi t $10,000 – Local 537 retirees who retired between

April 1, 1987 and March 31, 1993 ONLY

Family Supplemental Benefi t

Family Supplemental Benefi t – This benefi t can be used for

non-covered expenses. Items such as hearing aids, glasses,

etc. Non-covered drugs except for prescriptions which could

have been purchased under the Prescription Drug Program.

Reimbursement for plan maximums and items considered at

50% except for durable medical equipment is eligible. This

benefi t cannot be used to reimburse the deductible, co-pay

or amount over the reasonable and customary amount.

maximum per family, per calendar year – $1,500

29

Medical Benefits (Comprehensive Medical Benefit)

29

M ED I C AL B ENEF I TS (COM P R EHENS IVE MEDICAL BENEF IT ) 30

The Plan covers a large portion of medical expenses for both you and your

eligible dependents. In general, the Plan will provide benefi ts for eligible expenses

incurred only while you or your eligible dependents are covered under the Plan.

All of the following conditions apply when determining benefi ts.

Benefi ts are payable:

■ up to the stated benefi t maximums,

■ up to the reasonable and customary limit (for non-PPO provider services), or up to the negotiated

fee amount (for PPO provider services), or up to the Medicare-allowable amount (for Medicare-

eligible retirees and dependents),

■ for services rendered by an eligible provider,

■ for treatment that is medically necessary and prescribed by a legally qualifi ed physician and

is not experimental or investigative, and

■ subject to the pre-existing condition limitation.

When you (or any of your eligible dependents) receive medical services, the provider will usually

fi le the claim for you with the Fund Offi ce. Claims must be submitted within one year (twelve

months) after they are incurred. Even though the provider is submitting your claim, it is ultimately

your responsibility to see that it is fi led within the time limit.

After the Fund Offi ce has processed your claim, a written Explanation of Benefi ts (EOB) will be

mailed to you at your last known address. The EOB will show how much was applied to your

deductible, how much the Plan paid, and the amount of the claim that is your responsibility to pay.

The Fund Offi ce processes claims in the order received, not in the order in which they were incurred.

The Deductible

Each year before the Plan pays anything for most eligible expenses, you pay the fi rst dollars of

eligible medical expenses. The amount you pay before benefi ts begin is called the “calendar year

deductible.” The calendar year deductible is $300 per person; payments toward individual

deductibles are limited to a maximum of $700 per family.

How the Plan Works

3 1

The following example helps demonstrate how the individual and family deductibles work:

Example

Let’s suppose you, your spouse, and your dependent child are covered by the Plan. Your family

medical bills for the year look like this:

Date of Medical Service Eligible Charges for:

You Your Spouse Your Child

January

March

April

$300

$500

$400

We’ll also assume that all of these charges are for in-network services and are covered by the Plan

at 90% after the deductible is satisfi ed. Here’s how benefi ts would be determined:

■ In January the Fund will process your expenses and issue an EOB showing the eligible charges

and your responsibility to pay $300 out of your own pocket. This amount is credited toward your

individual deductible.

■ In March the Fund will process your spouse’s expenses and issue an EOB showing the eligible

charges and your responsibility to pay $300 for the deductible out of your own pocket. The

EOB will show a payment of $180 and your total responsibility will be $320 ($300 for the deduct-

ible plus 10% of the remainder).

■ In April the Fund will process your child’s expenses and issue an EOB showing the eligible charges

and your responsibility to pay $100 for the deductible out of your own pocket.

This is because your family’s payments toward individual deductibles will have reached the

$700 family deductible maximum. The EOB will show a payment of $270 and your total responsi-

bility will be $130.

Carryover

Any amount of eligible medical expenses incurred during the last three months of a year that are

applied to a person’s individual deductible will also be applied toward satisfaction of that person’s

deductible for the next year. For example, if you did not incur medical claims until November

and then met your individual $300 deductible, you wouldn’t need to satisfy your deductible for

the following year. The carryover provision is based on the date of service, not the date the claim

was processed.

Copayment Percentages

After satisfying the deductible, you and the Plan share responsibility for additional eligible medical

expenses. Generally, the Plan pays 90% for in-network expenses and 80% for reasonable and

customary out-of-network expenses. You pay the remaining cost. Your copayment can be different,

depending on the specifi c Plan benefi t, as shown in the Schedule of Benefi ts.

M ED I C AL B ENEF I TS (COM PR EHENS IVE MEDICAL BENEF IT ) 32

Annual Out-of-Pocket Maximum

Once your payments toward the annual deductible and copayments for covered medical charges

reach the annual out-of-pocket maximum of $2,500 per person ($6,000 per family), the Plan will

usually pay 100% of most eligible expenses for the rest of the calendar year. Expenses that are not

covered under the Plan do not apply toward the out-of-pocket limit. Also, Plan benefi ts payable at

50%, expenses in excess of specifi c benefi t maximums, and expenses covered under the Family

Supplemental Benefi t are not considered in determining the out-of-pocket limit. Expenses that have

a stated payment percentage of 50% or 80% continue to be paid at 50% or 80% (not 100%) even

after the calendar year out-of-pocket maximum is reached.

$50,000 Maximum Yearly Benefi t/ $750,000 Supplemental Lifetime Fund

The maximum amount of Comprehensive Medical Benefi ts payable for an eligible person under

the Plan is $50,000 in a calendar year. In addition to this Maximum Yearly Benefi t, each eligible

individual also has a nonrenewable Supplemental Lifetime Fund. This is a lifetime amount of

$750,000 for each eligible person that is available to supplement the Maximum Yearly Benefi t.

Most paid medical benefi ts apply toward the Maximum Yearly Benefi t and the Supplemental

Lifetime Fund. Here is an example of how this works:

During calendar year 2009, the Plan pays $150,000 in medical benefi ts for you. The fi rst $50,000 is your

Maximum Yearly Benefi t. The remaining $100,000 is deducted from your Supplemental Lifetime Fund.

At the beginning of calendar year 2010 your Supplemental Lifetime Fund is now $650,000 and your

Maximum Yearly Benefi t is $50,000. If your Supplemental Lifetime Fund becomes depleted, the Plan will

continue to provide the $50,000 Maximum Yearly Benefi t on your behalf each calendar year.

PPO Providers (for Retirees and Dependents Who Are Not Eligible for Medicare)

Retired participants and their dependents who are not eligible for Medicare have access to Preferred

Provider Organization (PPO) providers. PPO providers offer discounts on services to you and

your eligible dependents. When you use a PPO provider (also called a “network provider” or an

“in-network provider”), the Fund is charged a discounted rate for your care. The Fund shares these

savings with you by reducing your out-of-pocket costs. When you use a non-network provider (also

called an “out-of-network provider”), your out-of-pocket costs may be higher because your care

costs more. See page 34 for more information on PPO networks.

The Fund has contracts with the following types of PPO networks:

■ Medical (hospitals and physicians)

■ Diagnostic imaging (CTs and MRIs)

■ Mental health

■ Dental

Annual means from January 1

through December 31 of any year.

33

Reasonable and Customary (R&C) Limits

Charges by non-network providers are subject to the Plan’s reasonable and customary (R&C) limits.

An expense is considered R&C if the actual charge for the service or supply is comparable to what

is usually charged for the same service or supply in the provider’s geographic area. If you go to a

non-network provider and you are charged an amount higher than the reasonable and customary

fee, you are responsible for paying the difference between what this Plan pays and the actual

expense.

If you go to a PPO provider and are charged more than the negotiated fee amount for any given

service, you will not be responsible for amounts above the negotiated fee amount. R&C limits do

not apply to network provider services.

IF YOU RECEIVE SERVICES, EITHER KNOWINGLY OR OTHERWISE FROM A NON-NETWORK

PROVIDER, YOU WILL BE RESPONSIBLE FOR THE AMOUNT IN EXCESS OF R&C FEE, PLUS YOU

WILL NOT BE ABLE TO TAKE ADVANTAGE OF THE IN-NETWORK DISCOUNTS.

For example, consider the following two claims for the same surgical procedure, one performed at a

PPO surgical facility and one at a non-PPO surgical facility:

In-Network Out-of-Network

Billed Charges $12,750 $12,750

Network Discount $8,150 $0

Allowable Amount $4,600 (billed – discount) $6,500 (R&C)

Fund Benefi t 90% 80%

Fund Paid Amount $4,140 $5,200

Patient’s Responsibility $460 (10% co-pay) $7,550 (20% co-pay + amt. over R&C)

As you can see, you can save a lot of money if you use PPO providers.

Medicare-Approved Providers (for Medicare-Eligible Retirees and Dependents)

Retirees and their dependents who are eligible for Medicare should use Medicare-approved hospi-

tals, physicians and suppliers. The Plan will allow the amount approved by Medicare for an eligible

expense, and will coordinate benefi ts based on Medicare’s payment.

Pre-Existing Condition Limitation

A pre-existing condition means a condition for which medical advice, diagnosis, care or treatment

was provided within 6 months before the person’s enrollment date under this Plan. The benefi ts

payable by the Plan for an eligible person with a pre-existing condition will be subject to the

following limitation:


Benefi ts for that condition or any related condition will be limited to $15,000 for each covered person

(including eligible dependents) for a period of 12 months immediately following the person’s enrollment date.

The 12-month period shall be reduced by the number of days of prior creditable coverage the

affected individual has as of his enrollment date.

“Creditable coverage” generally means health care coverage provided by a group, individual or public

health plan. The affected individual is required to demonstrate his prior creditable coverage by pre–

senting a written certifi cate of creditable coverage provided by the prior plan. If the individual did not

receive a certifi cate, creditable coverage can be demonstrated by the presentation of documentation

or other means. Days of creditable coverage that occur before a break in coverage lasting 63 days or

more will not be used to reduce the length of an individual’s pre-existing condition limitation period.

Pregnancy is not considered a pre-existing condition. In addition, a pre-existing condition limitation

period shall not be applied to a newborn, an adopted child under age 18 or a child placed for adoption

under age 18, provided that any such child becomes covered under the Plan within 30 days of birth,

adoption or placement for adoption.

Genetic information by itself is not considered a condition. (Note that genetic testing is not covered

under the regular benefi t plan, but it may be covered under the Family Supplemental Benefi t if the

testing is medically necessary.)

Contact the Fund Offi ce at (708) 579-6600 if you have any questions as to whether this limitation

applies to your benefi ts. If you acquire a new dependent, be sure to obtain a certifi cate of creditable

coverage from your dependent’s prior plan to possibly waive or reduce the pre-existing condition limita-

tion period. You have the right to request a certifi cate from your prior plan. The Fund Offi ce will assist

you in obtaining a certifi cate if necessary.

Retirees and dependents who are not eligible for Medicare should use the Plan’s PPO networks.

Medicare-eligible retirees and dependents should use providers approved by Medicare.

Your Hospital and Physician PPO Network

As an eligible participant of the Midwest Operating Engineers Health and Welfare Fund, you can

go to any eligible medical provider for your health care needs. However, you’ll receive a higher level

of benefi ts (typically 90%) and save money on your covered health care expenses when you go

to a doctor or hospital that participates in the local PPO network. (As explained below, diagnostic

imaging services are provided through the Plan’s diagnostic imaging network, and services for

substance abuse and mental illness must be provided through the Plan’s mental health network.

In addition, as explained in the Dental Benefi ts section, there is a separate PPO network for dental

services.)

Using PPO Networks

35

If you live outside Illinois, you can use providers in the national PPO network which is a network of

hospitals and physicians throughout the United States that participate in their local PPO networks.

PPO providers work in partnership with the Fund to provide cost-effective, quality health care to you

and your covered family members. At the time you receive treatment, please verify that the provider

is still in the network.

If your primary care physician recommends surgery, make sure the surgeon and facility are in the

PPO network. Also, your children who are away at school should ask about PPO participation

whenever they seek medical care.

Your Identifi cation (I.D.) Card

The Welfare Fund I.D. card indicates that eligible members have access to the Plan’s local and

national PPO networks. Whenever you visit a PPO provider, show your I.D. card. Your health care

provider will fi le your claim for you, and your claims will be processed as quickly as possible.

Mental Health Network and Mental Health Case Worker

All treatment for substance abuse and mental illnesses must be pre-certifi ed by the Plan’s Mental

Health Case Worker, and provided through the mental health provider network.

Diagnostic Imaging Network

The Fund contracts with a network of diagnostic imaging facilities. Facilities in this network provide

MRIs and CT scans at reduced fees with ease of access to all eligible participants. If your doctor

orders an MRI or CT scan for you or one of your covered dependents, you should call the diagnostic

imaging network administrator and schedule the scan with the provider they recommend. The Plan

pays 100% (after the annual deductible) for covered scans provided through the network.

This program is for retirees and dependents who are not eligible for Medicare. Medicare-eligible

retirees and dependents should follow Medicare’s procedures.

For the name and phone number of the current Pre-certifi cation and Case Management Program

organization, see Important Contact Information in the front of this booklet.

The Pre-certifi cation Program reviews inpatient hospitalizations and outpatient surgical procedures

proposed by your physician, and works with your physician to ensure that you receive the care you

need in the most appropriate setting. Most physicians are familiar with this pre-certifi cation process

and will contact the program. Therefore, all you need to do is inform your physician about the pro-

gram and provide them with the toll free number on your I.D. card.

Pre-Certifi cation by the

Case Manager


For non-emergency situations your physician must call the pre-certifi cation organization no less than

5 days before the scheduled admission or surgical procedure. This requirement applies to all inpa-

tient hospitalizations and any surgical procedure performed in a surgical suite (in a hospital, surgical

center or medical center), or doctor’s offi ce if the procedure requires sedation or anesthesia.

In emergency situations, your physician should contact the pre-certifi cation organization no later

than the next business day following your emergency admission.

For maternity cases, ask your doctor to contact the pre-certifi cation organization as soon as possible

so that they can coordinate any services you might require during pregnancy.

It is your responsibility to see that your physician makes the call to the pre-certifi cation organization

in a timely manner.

Other Services Requiring Pre-Certifi cation

In addition to inpatient hospitalizations and outpatient surgeries, there are other types of services

that require pre-approval by the pre-certifi cation organization. The list below summarizes all the

services requiring pre-certifi cation and approval.

■ inpatient hospitalizations ■ physical therapy

■ outpatient surgery ■ occupational therapy

■ cochlear and auditory brainstem implants ■ skilled nursing facility care

■ home health care ■ speech therapy

■ medical equipment costing $250 or more ■ transplants

■ medical orthodontia (TMJ, jaw disorders) ■ substance abuse and mental illness

■ chiropractic care

Pre-approval by the pre-certifi cation organization does not guarantee payment. Following the

review procedures and having your medical care reviewed is important because the pre-certifi cation

organization will advise the Fund that your treatment is medically necessary and appropriate.

However, pre-certifi cation is not an absolute guarantee that your claim will be covered by the Plan.

Whether or not a claim is paid also depends on other factors such as a person’s eligibility for ben-

efi ts, Plan maximums, Plan limits on certain services, etc.

37

Summary—Network and Pre-Certifi cation Requirements

(For Retirees and Dependents Who Are Not Eligible for Medicare)

For this SituationYou Must ContactThis Provider

You Must USE Providers in this Network

TelephoneNumber

Transplant Med-Care

Management

(Med-Care Management

will provide you with

network information)

(800) 367-1934

Inpatient hospitalization or

outpatient surgery

Med-Care

Management

Blue Cross PPO Network

(for the highest benefi ts)

(800) 367-1934

Physical/speech/occupational

therapy, chiropractic care, home

health care, skilled nursing facility

care, medical equipment, etc.)

Med-Care

Management

(Med-Care Management

will provide you with

network information)

(800) 367-1934

Mental health or substance

abuse treatment

ComPsych ComPsych Provider

Network

(888) 327-4315

MRI or CT scan* DiaTri (DiaTri will provide you

with this information)

(800) 331-5720

* Calling the diagnostic imaging network is not a requirement, but the Plan will pay 100% (after the deductible) for covered scans performed by providers in the network.

This section describes the types of medical expenses covered by the Plan. Even if an expense is listed

in this section it will be covered only up to the reasonable and customary limit and only if the service or

supply is medically necessary.

An expense is reasonable and customary if:

■ for PPO network providers, the charge is agreed upon between the PPO and the Plan; or

■ for non-network providers, the charge is the lowest of:

¬ the reasonable and customary charge for the same or similar service or supply in the same or

similar geographic area; or

¬ the health care provider’s actual charge.

■ for Medicare-eligible participants, the charge is the amount approved by Medicare.

Medically necessary means services and supplies that:

■ have been established as safe and effective by the American Medical Association or appropriate

governing body;

■ are furnished in accordance with generally accepted professional medical standards for treatment

of Illness and Injury;

■ are consistent with the signs, symptoms or diagnosis and treatment of an illness or injury;

Eligible Medical Expenses


■ are not primarily for the convenience of the eligible person or his doctor;

■ are the most appropriate supply or level of service which can be safely provided;

■ are necessary and appropriate treatment of the illness or injury;

■ are not experimental or investigative in nature; and

■ are not cosmetic in nature; that is, the treatment restores or repairs function.

See the Schedule of Benefi ts starting on page 22 for coverage levels and limitations for the services

described in this section.

1. Wellness Benefi ts

a. Routine Physical Examination Benefi t, including:

– physician’s charges for a routine annual physical examination,

– mammogram,

– hearing examination provided by a physician or licensed audiologist,

– employment physical,

– immunizations, and

– infl uenza shots.

Only retirees and their dependent spouses are eligible for this benefi t.

b. Well Baby Care Benefi t – Expenses for physician’s fees for a well newborn child during

hospital confi nement while the mother is also confi ned for the birth of the child. This benefi t

also covers pediatric visits, immunizations, vaccinations and laboratory services during

the fi rst 24 months following birth. Plan coverage is not available to a newborn child of an

individual covered as a participant’s dependent child.

2. Hospital services and supplies

a. Room and board at the most common semi-private rate (or the room and board charge for the

intensive care unit or private room if the disease is contagious), if required for treatment due

to an injury or illness.

b. Miscellaneous services and supplies during hospital confi nement. These include medically

necessary hospital supplies and services, x-rays, charges for ambulance service, emergency

room, anesthetist, radiologist, pathologist, and charges made for unreplaced blood.

The Plan does not cover any expenses incurred if you are admitted to the hospital more than

one day before non-emergency surgery or on the weekend, unless it is medically necessary.

c. Pre-admission diagnostic tests, including those performed on an outpatient basis. These tests

must be related to the condition for which you will be hospitalized, and accepted and not

duplicated by the admitting hospital. The hospital admission must be within 14 days after the

tests are performed.

d. Emergency room and outpatient hospital services.

e. Implants, provided that the invoice from the supplier is submitted.

39

3. Outpatient ambulatory surgical center services and supplies. The surgical center must be

licensed by the state in which it operates.

4. Physicians’ professional medical and surgical services as follows:

a. Hospital, offi ce and home visits.

b. Emergency room services.

c. Surgeon’s and assistant surgeon’s services.

Expenses for outpatient surgical supplies are included in the physician’s fee.

The Plan covers orthognathic (jaw) surgery performed by a physician or dentist when deemed

medically necessary by the Case Manager.

The maximum allowable amount for an assistant surgeon is 25% of the allowable amount for

the primary surgeon. If the assistant is not a medical doctor, but is a Physician’s Assistant,

Surgical Assistant or Registered Nurse, the maximum allowable amount is 17% of the allow-

able amount for the primary surgeon.

d. Second and third surgical opinions.

Second and third surgical opinions are covered, including any diagnostic tests, when the

consultations are provided by Board Certifi ed Surgeons.

e. Reconstructive breast surgery.

The Plan covers reconstructive breast surgery following a mastectomy, including reconstruc-

tion of the breast on which the mastectomy was performed, reconstructive surgery on the

other breast to produce a symmetrical appearance, prosthesis, and physical complications of

any stage of mastectomy, including lymphedemas.

f. Anesthesia administration.

g. Blood replacement administration.

5. Diagnostic x-rays and laboratory tests.

6. Pregnancy and maternity care as follows:

a. The Plan will provide maternity benefi ts for the mother and her newborn infant for at least

48 hours of inpatient hospital care following a normal delivery and at least 96 hours of

inpatient hospital care following a Caesarean section. The Plan shall not require pre-

certifi cation for a length of stay not in excess of these periods. (The attending provider may,

however, after consultation with the mother, discharge the mother and newborn earlier

than 48 hours following a vaginal delivery or 96 hours following a Caesarean section.)

Maternity care will be paid the same as any other covered illness.

b. Home delivery by an M.D.

c. Abortions, limited to once in a twelve-month period. Evidence of medical necessity must be

provided for termination of a pregnancy in the second or third trimester.

7. MRIs and CT scans. These scans are payable at 100% (after your deductible) if you use a

facility in the diagnostic imaging network.


8. Physical therapy performed on an outpatient basis due to an injury or illness when approved by

the Case Manager.*

9. Occupational therapy performed on an outpatient basis due to an injury or illness, including but

not limited to stroke, brain tumor, brain trauma or heart attack. The therapy must be pre-certifi ed

by the Case Manager.*

10. Physical and occupational therapy for congenital neurological diseases for dependent children

through age 18 only. The therapy must be pre-certifi ed by the Case Manager.* Congenital neuro-

logical diseases include cerebral palsy, muscular dystrophy, Down’s Syndrome and Edward’s

Syndrome. The age limit will not apply to a child age 19 or over who satisfi es the Plan’s defi nition

of an eligible dependent because he is incapable of self-sustaining employment by reason of

mental retardation or physical handicap.

11. Speech therapy as follows:

a. Restorative speech therapy for adults and children performed on an outpatient basis, when

medically necessary to restore speech that was lost or impaired as a result of an illness

or injury.

b. Developmental speech therapy for children, including therapy for congenital neurological

disorders and pervasive developmental disorders.

12. Chiropractic care but only for spinal manipulations and medically necessary x-rays subject to

the limitations specifi ed in the Schedule of Benefi ts. Chiropractic services for a child under the

age of 5 are not covered.

13. Hemodialysis or peritoneal dialysis and supplies administered on an outpatient basis under

the direction of a physician including x-ray, laboratory examinations, and technician charges,

unless the charges would have been covered under Medicare. (If you are on dialysis for more than

30 months, Medicare becomes primary.)

14. Radiation therapy administered on an outpatient basis, including the rental or use of radioactive

substances, and the outpatient doctor or technician charges.

15. Chemotherapy administered on an outpatient basis, including the outpatient doctor or

technician charges, and chemotherapy drugs.

16. Allergy injections and their administration.

17. Orthoptic training in lieu of surgery for dependent children under age 10.

18. Medical supplies and devices, as follows:

a. Prostheses and support devices, including colostomy bags and necessary supplies required for

attaching. We recommend that you request verifi cation from the Fund Offi ce that the device

is an eligible expense under the Plan. Case Management approval is required for a prosthetic

device.* An electronic or microprocessor-controlled artifi cial limb is limited to the cost of a

conventional mechanical artifi cial limb that would meet the patient’s basic needs.


41

b. Foot orthotics prescribed by a medical doctor or podiatrist and custom-fi tted. Shoes are not

considered orthotics and are not covered.

c. Dressings, casts, splints, trusses, braces, and crutches.

d. Anesthetics.

e. Blood and blood plasma.

f. Oxygen and the rental of equipment for the administration of oxygen, subject to approval by

the Case Manager.*

19. Durable medical equipment which meets all of the following qualifi cations:

■ It is for repeated use and is not a consumable or disposable item;

■ It is used primarily for a medical purpose; and

■ It is appropriate for use in the home.

Examples of durable medical equipment include hospital beds, wheelchairs, hemodialysis

equipment, intermittent positive pressure breathing machines, walkers, crutches, canes,

oxygen walker units, and percussors. For purposes of determining the total allowable expense,

the cumulative cost of equipment rental or lease is limited to the actual cost of equipment

purchase. Note that equipment used for comfort only and rental costs greater than the actual

purchase price of the equipment are not covered.

The Case Manager must pre-certify the rental or purchase of equipment costing more than

$250.* Failure to pre-certify will result in a copayment of 50%. In addition, no benefi ts will be

paid if the equipment is not determined by the Case Manager or Administrative Manager to be

medically necessary.

The maximum benefi t payable for an electronic or mechanized wheelchair is $15,000.

20. Mental health treatment (treatment of a mental illness or substance abuse) when pre-certifi ed

by the Mental Health Case Manager* and provided by a provider in the mental health network.

If you fail to obtain pre-certifi cation or to utilize a network provider, no benefi ts will be payable.

The Plan also provides a Member Assistance Program (MAP) that can provide you and your

eligible dependents with confi dential assessment and referral services for your personal issues.

21. Repair to oral/facial structures due to accidental injuries including, but not limited to jaw and

facial bone fractures and sound natural teeth, provided the service is rendered within 12 months of

the accident.

22. Orthodontic treatment of TMJ and other non-dental jaw disorders when pre-certifi ed by

the Case Manager. Covered disorders include infl ammatory, infectious or parasitic disease that

destroys the structure of the jaw bones; tuberculosis of jaw bones and joints; malignant neoplasm

of mouth or jaw; cleft palate; macrognathism; micrognathism; prognathism; retrognathism;

fracture(s) of the bones of the face; crushing injury of head or face; burns of the face, head

and neck.

If you fail to obtain pre-certifi cation

from the Mental Health Case Manag-

er or to utilize a network provider, no

benefi ts will be payable. This applies

to all mental health services, includ-

ing psychological valuations.


23. Organ transplants – The following human-to-human transplant procedures are covered when

pre-certifi ed by the Case Manager* and performed at a network facility:

■ bone marrow (self– and other-donated)

■ heart

■ heart/lung

■ liver

■ lung

■ kidney

■ cornea

A patient eligible for Medicare must use a Medicare-approved provider.

The Plan does not cover:

■ transplants paid for by governmental foundation or charitable grants, or

■ “sold organs” – the amount charged to purchase an organ.

The lifetime aggregate maximum benefi t payable for these procedures is $300,000 for each

eligible person. Note that an important feature of the transplant benefi t allows you to use

the $300,000 maximum benefi t also to cover the medically necessary services incurred by

the transplant donor if the donor does not have medical coverage for the eligible transplant

expenses. The following limits also apply:

■ $25,000 for organ or tissue procurement,

■ $10,000 for transportation and lodging, and;

■ $10,000 for private nursing care.

These benefi ts do not apply to the regular yearly and lifetime maximum benefi ts.

24. Cochlear implants and auditory brainstem implants that have been pre-certifi ed by the

Case Manager.

25. Medical transportation services, as follows:

a. Initial transport – Ground or air ambulance transportation by a professional ambulance service

from the site where the injury, medical emergency or acute illness occurs to the nearest

appropriate facility; and

b. Inter-facility transfer – Transfer from one health care facility to another when the second facility

is the nearest appropriate facility for the treatment of the medical emergency. The maximum

allowable expense for an inter-facility transport will be $5,000. The $5,000 limit will not

apply if the Case Manager determines that the additional charges are medically necessary

and that no less-costly form of transport would have been appropriate due to the patient’s

health status.


43

26. Nursing services provided by a registered nurse, advanced practice nurse or nurse practitioner.

27. Home health care services provided by a licensed home health care agency, provided that

the plan of care is pre-certifi ed as medically necessary by the Case Manager,* prescribed by

a physician (M.D. or D.O.), and reviewed and approved by the physician during the entire period.

28. Licensed skilled nursing facility confi nement recommended and supervised by a physician that

begins within 30 days of a hospital confi nement for the same cause. Coverage is limited to 45 days

per period of confi nement. Successive confi nements will be considered one period of confi ne-

ment unless the patient returns to work for one full day before the second confi nement, or the

confi nements are separated by 30 days with no treatment. Skilled nursing facility care must be

pre-certifi ed by the Case Manager.*

29. Intrauterine devices (IUDs), Norplant and Depo-Provera injections.

30. Cancer screening colonoscopies recommended by a physician.

31. Acupuncture performed by a physician, or licensed acupuncturist when referred by a physician,

subject to the limitations specifi ed on the Schedule of Benefi ts.

No Comprehensive Medical Benefi ts shall be payable for:

1. care and treatment that is not medically necessary;

2. charges which exceed the maximum benefi ts allowed under the Plan;

3. illness or injury that is related to any occupation or employment for wages or profi t;

4. genetic testing;

5. cosmetic surgery or treatment, except for treatment of an accidental injury or for a congenital

anomaly in dependent children. Surgery or treatment for complications arising for non-covered

cosmetic surgery or treatment is also excluded;

6. reconstructive surgery, except for the following:

a. when performed to improve the function of a body part when the malfunction is the direct

result of congenital defect, developmental abnormality, infection, tumor, disease or trauma;

b. when performed to remove scar tissue on the neck, face or head; and

c. breast surgery following a mastectomy, including surgery and reconstruction of the other

breast to produce a symmetrical appearance;

7. reversal of sterilization, hormone therapy, artifi cial insemination, invitro fertilization, GIFT, ZIFT,

or any other direct attempt to induce or facilitate fertility or conception, with the exception of

services and supplies for the diagnosis of infertility;

8. vocational therapy;

9. services rendered by athletic trainers, kinesiologists, massage therapists, recreational therapists,

therapy aides/assistants or any other non-therapist professionals, even if an eligible provider is

supervising the therapy or billing for the treatment;

Exclusions


10. routine foot care such as removal of corns or calluses, the cutting and trimming of toenails, foot

care for fl at feet, fallen arches and chronic foot strain;

11. immunizations, routine physical examinations, or physical examinations or medical certifi cates

required for employment, except as specifi cally stated otherwise;

12. surgical or laser correction of myopia and/or other refractive errors (such as Lasik);

13. diagnosis and treatment of refractive lenses, including eye examinations, purchase, fi tting and

repair of eyeglasses or lenses and associated supplies;

14. hearing aid devices, including but not limited to hearing aids;

15. personal convenience or comfort items including, but not limited to, such items as televisions,

telephones, fi rst aid kits, exercise equipment, air conditioners, humidifi ers, saunas and hot tubs;

16. examinations or treatment ordered by a court in connection with legal proceedings unless such

examinations or treatment would otherwise qualify as an eligible expense and the provider of

the service meets the defi nition of a physician, hospital or eligible provider;

17. any operation or treatment for teeth and gums, except for tumors, or cysts (if removal requires

a surgical facility, and if pre-authorized by the Administrative Manager), or repair of injury to

sound natural teeth which occurs within 12 months of the accident;

18. telephone consultations;

19. weight loss programs such as Jenny Craig, Nutri-Systems, etc., including nutritional counseling;

20. more than one surgical procedure for obesity per lifetime;

21. wigs or toupees, hair transplants, hair weaving or any drug in connection with baldness;

22. medical, surgical, psychiatric or prescription drug treatment related to transsexual (sex change)

procedures, or the preparation for such procedures, or any complications resulting from such

procedures;

23. any expenses that are not listed as eligible medical expenses on pages 37-43;

24. treatment for substance abuse or mental illness other than as specifi cally stated on page 41;

25. transplants which are not listed on page 42;

26. psychological testing;

27. diabetic test strips and lancets are covered by the Plan’s prescription drug benefi ts;

28. treatment or medication which is experimental or investigational; or

29. expenses specifi ed as not payable in the General Exclusions section that starts on page 65.


Prescription Drug Program

The Prescription Drug Program provides benefi ts

for covered prescription drug expenses when

you fi ll your prescriptions at the Midwest Benefi t

Pharmacy or fi ll an emergency medication at a

pharmacy in the prescription benefi t manager’s

(PBM’s) network.

Medicare-eligible retirees and their dependents who are

enrolled in a Medicare prescription drug (Part D) plan are

not eligible to use this Plan’s Prescription Drug Program.

Prescription drug benefi ts are provided to eligible retirees

and their dependents through the Midwest Benefi t

Pharmacy Program. Benefi ts under this Program are avail-

able when you fi ll your prescription at the Midwest Benefi t

Pharmacy only, except for limited emergency prescriptions

as described on page 48.

There is no deductible to satisfy before benefi ts for

covered prescription drugs begin. You pay a $5 co-pay for

a 30-day supply of a generic drug, and a $10 co-pay for

each 30-day supply of a brand name drug. The Plan covers

the rest of the cost.

Prescription drug benefi ts are limited to $20,000 per

person each calendar year (Midwest Benefi t Pharmacy

and any PBM prescriptions combined).

Note: Prescription drugs used for the treatment of cancer,

chemotherapy drugs and supplies, and anti-rejection drugs

for covered transplants are not subject to this maximum

and are covered under the Comprehensive Medical

Benefi t.

Filling a New Prescription

You can fi ll your prescription in person or by mail, or your

doctor can fax it to the Midwest Benefi t Pharmacy (a

fax will only be accepted if it comes from a doctor). The

written prescription should specify the member’s name

The Midwest Benefi t

Pharmacy Program

45

P R ES CR IPT ION DR UG PR OG R AM 46

and medical I.D., the patient’s name, the name of the drug, the quantity prescribed, the number

of refi lls, and the directions for use. A completed pharmacy claim form must accompany the

prescription.

To fi ll your prescription by mail, submit your original written prescription to:


6150 Joliet Road


Be sure to include your credit card or Credit Union number to make the required copayment for your

prescription.

When available, generic medications will be substituted for brand name medications. If you request

a brand name medication when a generic is available, you will be required to pay the brand name

co-pay plus the difference in cost between the brand name and generic medication. This applies

even if your physician indicates “no substitutions.”

Your prescriptions will be mailed to you by USPS fi rst class mail. Schedule II medications are

treated differently (see page 49). If you need your prescriptions faster, we offer express mail for an

additional charge.

If you prefer to pick up your prescription in person, you may do so. The Pharmacy is open six days a

week for your convenience:


6150 Joliet Road


Monday through Friday: 8:00 a.m. – 6:00 p.m. (Thursdays until 7:30 p.m.)

Saturday: 8:00 a.m. – 12:00 p.m.

Automated refi ll line: (866) 850-9310

Prescription Refi lls

There are several ways you can refi ll your prescriptions through the Midwest Benefi t Pharmacy.

■ Call the Toll Free Automated Refi ll Line 1-866-850-9310 which is available 24 hours a day, 7 days

a week. All you will need is the date of birth for the patient and the prescription number which

can be found on the bottle. Just follow the prompts to complete your order. You can pay for your

prescription with a valid Visa or MasterCard or you can use your Credit Union savings account.

You can also designate your order for pick-up at the Pharmacy window in Countryside.

(To use your Credit Union savings account, you must complete a Credit Union Authorization Card.

This form can be obtained at the Credit Union, the Fund Offi ce, or downloaded from the Fund’s

website: moefunds.com).

47

In most cases, refi lls placed using the Toll Free Automated Refi ll Line are ready for mailing within

24 hours and are sent to you by USPS fi rst class mail. If you need your prescription faster, you can

select express mail, for an additional charge, at the time you place your order.

■ You can order your refi ll(s) by mail by sending the refi ll ticket(s) you received with your prior order

along with a completed Pharmacy Mail Order Refi ll Form to:


P.O. Box 729

La Grange, Illinois 60525-0729

You should receive a Mail Order Refi ll Form with each order. If you do not have a form, you can call

the Pharmacy and request one or you can download this form from the Fund’s website: moefunds.

com. When ordering by mail, you can make your co-pay using a valid Visa or MasterCard or if

authorized, you can use your Credit Union Savings Account. Refi ll orders received by the Fund

Offi ce via mail are generally ready to be mailed within 48 hours. Your order will be mailed to you

by USPS fi rst class mail. If you need your prescription faster, you can select express mail on the

order form and an additional charge will apply.

■ You can phone in your refi ll order by calling the Pharmacy Customer Service phone line

(708) 579-6610 Monday through Friday between the hours of 8:00 a.m. and 6:00 p.m. and

Saturday between 8:00 a.m. and noon central time. When you call in your refi ll you can request

it to be sent to you via mail, express mail, or you can designate it for pick-up at the Pharmacy

window in Countryside.

■ Finally, you can drop off your refi ll order at the Pharmacy in Countryside, Monday through

Wednesday and Friday between the hours of 8:00 a.m. and 6:00 p.m., Thursday 8:00 a.m. and

7:30 p.m. and Saturday 8:00 a.m. till noon central time. If you arrive just before the Pharmacy is

closing for the day, you may have to come back the next day to pick up your order or you can request

that it be sent to you through the mail.

Dispensing Limitations

You can receive up to a 90-day supply of a prescription provided:

■ the prescription had been previously fi lled at the Midwest Benefi t Pharmacy or a PBM network

pharmacy, and

■ your physician indicates on the written prescription that the Pharmacy can dispense up to a

90-day supply of the drug at one time.

Otherwise, the Pharmacy can only dispense up to a 30-day supply per prescription.

In addition, dispensing limits may apply to certain medications based on the manufacturer’s

recommended dosage and duration of therapy, common usage, FDA and state recommendations

and/or clinical studies, or as determined by the Trustees.

PR ES CR IPT ION DR UG PR OG R AM 48

Hepatitis C Treatment Benefi ts

The Plan pays up to $40,000 for the initial course of treatment for Hepatitis C during a 12-month

period. This includes the following medications relating to the treatment of Hepatitis C:

■ Peg-Intron,

■ Rebetron, and

■ Rebetol.

Glucose Testing Supplies

The Midwest Benefi t Pharmacy has a partnership with a specialty pharmacy to provide diabetic

testing supplies (glucose meters, test strips and lancets) to retired members who are eligible for

Medicare Part B. Under this program, the specialty pharmacy will provide these supplies at no cost

to you or the Fund. You are not required to make a co-payment to receive these supplies since the

specialty pharmacy will be reimbursed directly by Medicare. Your supplies will be mailed to your

home by the U.S. Postal Service.

This program is mandatory for all retirees and their dependents who are eligible for Medicare Part B.

For more information about this program, contact the Midwest Benefi ts Pharmacy.

While most of the time you will have your emergency medication fi lled at the Midwest Benefi t

Pharmacy, there are times when you need to have an emergency medication fi lled right away. The

Plan will pay 80% of the cost of your emergency medication if you use a PBM network pharmacy.

If you fi ll your prescription at a PBM network pharmacy rather than at the Midwest Benefi t

Pharmacy, your co-pay to the pharmacy will be 20% of the contracted cost. You will not be

reimbursed for the 20%. A maintenance prescription can only be fi lled once per lifetime on an

emergency basis.

When available, generic medications will be substituted for brand name medications.

If you have submitted a claim for your prescription to any other insurance plan, no benefi ts will

be paid under this Plan.

If You Need an Emergency

Medication

An Emergency Medication is a

medication that is medically neces-

sary and is not known to be needed

in advance, such as an antibiotic.

Be sure to show the pharmacist

your eligibility card with the PBM

Plan Code and Group Code on the

back.

If There is Other

Prescription Drug Coverage

49

Prescriptions provided by convalescent and nursing homes will be reimbursed at 50% of the

actual expense. You must submit a claim. If you have submitted a claim for your prescription to

any other insurance plan, no benefi ts will be paid from this Plan. These benefi ts apply toward the

$20,000 calendar year maximum.

Please note the following information regarding your prescription drug benefi ts. If you have

questions, please call the Pharmacy at (708) 579-6610.

If Your Prescription Expires

Most prescriptions expire 12 months (one year) after the date they are fi rst written by a physician.

Prescriptions for certain Schedule II Medications expire sooner—see the Prescription for Schedule II

Medications section below. These expiration periods apply to any refi lls indicated on the prescription

as well. If your prescription expires, you will need to submit a new prescription to the Pharmacy

before it can be fi lled.

Fax-In Prescriptions

The Midwest Benefi ts Pharmacy provides for fax-in prescriptions from your doctor. By state law, it

must be faxed from a doctor’s offi ce on the doctor’s letterhead. Your order will be mailed to your

home address unless you contact the Pharmacy ahead of time to arrange pick up at the Pharmacy.

Your co-pays must be made by one of the following payment methods:

1. direct payment from your MOE Credit Union account, or

2. charged to your credit card (VISA or MasterCard only).

Remember, if you have not provided the Fund Offi ce with your consent to direct pay from your

MOE Credit Union account or your credit card, your prescription may be delayed in processing.

Prescription for Schedule II Medications

State law requires that you follow certain procedures when fi lling a prescription for a Schedule II

medication. If your physician prescribes a Schedule II medication, you must submit your written

prescription to the Pharmacy within 7 days (including the date the prescription is written).

To ensure the Pharmacy receives the prescription within 7 days, submit the prescription in person

or use priority mail or overnight delivery. The Pharmacy will fi ll your prescription and send it to you

via UPS delivery (at no additional charge to you). If the prescription is not received in time, your

physician will need to write a new prescription.

Prescriptions Provided by

Convalescent

and Nursing Homes

General Information About

the Program and the


P RES CR IPT ION DR UG PR OG R AM 50

Ways to Pay for Your Co-Pay

How you may pay your co-pay depends on how the prescription is delivered as the following

chart indicates:

If you… You may pay with…

Pick up your prescription in person Cash, personal check, or credit card (MasterCard or VISA)

Mail in your prescription Credit card or Credit Union transfer

Call in your prescription to be mailed Credit card or Credit Union transfer

Prescription co-pay amounts do not apply to your or your family’s out-of-pocket maximum, and

prescription drug benefi ts paid by the Plan do not apply to your $50,000 Calendar Year Maximum

Benefi t under the Comprehensive Medical Benefi t.

Prescription Payments

The Local 150 Credit Union can transfer funds to the Pharmacy from your account. This process can

help expedite your drug orders. For more information about this payment option, please contact the

Credit Union at (708) 482-9606.

Helpful Hints

Here are some suggestions that you might fi nd useful when fi lling your prescriptions through the

Midwest Benefi t Pharmacy Program.

■ Every Time You Place an Order – Whenever you place a prescription drug order with the Midwest

Benefi t Pharmacy, always include the member’s Social Security number.

■ New Prescriptions

¬ If your doctor is writing a new prescription for a long-term medication, ask him or her to write the

prescription for a 90-day supply. This allows the Pharmacy to dispense up to three orders at one

time.

¬ Make sure your doctor writes the patient’s full name (including Jr., Sr., etc.) and writes specifi c

directions for taking the medication. If the doctor simply writes, “as directed,” the Pharmacy will

have to call for more information and this could delay the processing of your prescription.

¬ If you are mailing in a new written prescription, it’s not necessary for your doctor to phone in the

prescription as well.

5 1

¬ A prescription can only be transferred from another pharmacy to the Midwest Benefi t Pharmacy

after it has been fi lled at least once at the other pharmacy.

¬ The Midwest Benefi t Pharmacy staff can call your doctor for you to request information about a

new prescription. However, you’ll need to contact your doctor’s offi ce beforehand so that they are

aware of which prescriptions you need when the Pharmacy calls.

■ Special Address Request – If you’re taking a trip or live at different locations during the year, you can

request that your prescription be sent to a special address. All you have to do is include a note

with each prescription order that specifi es where the prescription should be sent.

The following medications, when prescribed by a physician for a covered condition, will be

considered eligible expenses under the Prescription Drug Program:

1. Legend drugs, which are those that must be obtained by doctor’s prescription, as opposed to

those prescribed by a doctor but available over the counter,

2. drugs for the intent of administration by a physician or R.N.,

3. injectable insulin,

4. needles and syringes,

5. diabetic test strips and lancets, up to a maximum of a 100-unit supply every 30 days, and

6. prescription oral, transdermal and injectable contraceptives.

As new drugs become available, they are normally covered. However, the Board of Trustees reserves

the right to review industry practices and consult with medical advisors before determining how the

new drugs will be covered through the Plan. Experimental or investigational drugs are not covered

through the Plan.

Expenses for the following drugs are not covered:

1. research or experimental drugs or drugs that are not prescribed or used in a manner consistent

with the manufacturer’s and the FDA’s intended and approved usage;

2. over-the-counter items;

3. drugs taken or administered in a hospital, or drugs dispensed at a physician’s offi ce, hospital

outpatient or other facility;

4. contraceptive devices, including I.U.D.’s and diaphragms;

5. drugs that promote fertility;

Eligible Expenses

Expenses Not Covered

P R ES CR IPT ION DR UG PR OG R AM 52

6. drugs that promote hair growth, including Propecia;

7. Viagra and similar drugs;

8. non-drug items, regardless of intended use, including but not limited to vitamins, nutritional

supplement, and support garments;

9. non-emergency medical prescriptions fi lled at any retail pharmacy, emergency medical

prescriptions fi lled at an out-of-network pharmacy, more than a 15-day supply of an emergency

medical prescription fi lled at a PBM network pharmacy, or more than a 90-day supply of a

drug fi lled at the Midwest Benefi ts Pharmacy;

10. any drug charges that exceed the calendar year maximum prescription drug benefi t, except for

drugs used in outpatient chemotherapy treatment;

11. drugs prescribed for use in connection with sex transformation treatments and procedures;

12. drugs prescribed for a cosmetic purpose;

13. drugs prescribed in connection with a procedure that is not covered under this Plan, including

but not limited to any complication that arises as a result of a non-covered procedure;

14. drugs that do not require a prescription to purchase; or

15. any prescription drug purchased under another group health plan.

The following drugs are covered with the limitations listed:

■ Retin A – Must have diagnosis for a medical condition/not cosmetic.

■ Renova – Must have a diagnosis of acne.

■ Progesterone – Must have diagnosis for a medical condition other than infertility.

■ Crinone Gel – Must have diagnosis for a medical condition other than infertility.

■ Muse – Maximum box of 6 dispensed.

■ Caverject – Maximum box of 6 dispensed.

■ Toradol – Limit of 6-day supply.

■ Lancets and test strips – Boxes of 100 dispensed.

■ Epipen and Epipen, Jr. – Maximum of 2 dispensed at any time.

Expenses Covered

With Limitations

53

Dental Benefits

53

DENTAL BENEF ITS 54

Dental care benefi ts are available to you and your family through the Midwest

Operating Engineers Dental Plan.

To fi le a claim for covered dental services, submit a completed dental claim form to the Fund Offi ce

within one year (twelve months) after they are incurred. Even though the provider may be submitting

your claim, it is ultimately your responsibility to see that it is fi led within the time limit.

There is no deductible to satisfy before benefi ts begin. Benefi ts payable (other than for preventive

services) are based on a Maximum Allowable Fee Table (see pages 58–59) on the type of service

received:

Preventive Services

(exams, cleanings, and bitewing x-rays)

100% (not subject to Maximum Allowable Fee)

Basic and Restorative Services

(fi llings, crowns, root canal therapy,

oral surgery, dentures, bridgework,

and other covered dental services)

70% of Maximum Allowable Fee

Orthodontics (children under age 19) 50% of Maximum Allowable Fee up to a life-

time maximum benefi t amount of $2,000 per

covered child ($1,500 maximum for treatment

started prior to January 1, 2009)

The Midwest Operating Engineers Dental Plan pays up to $1,000 per person in benefi ts each

calendar year for covered dental services. You can go to any dentist you choose and be eligible for

benefi ts. However, a Dental PPO network is available to help you maximize your dental care benefi ts.

The Midwest Operating Engineers Dental Plan provides benefi ts for non-preventive services based

on a Maximum Allowable Fee Table (see pages 58-59 for a listing of the most common dental

procedures). When you go to a PPO dentist, you pay only the applicable copayment for the services

you receive; you will not be responsible for any charges above the Maximum Allowable Fees. If you

go to a non-PPO dentist that charges more than the Maximum Allowable Fee for a covered service,

the Plan will pay benefi ts based on the Maximum Allowable Fee.

How Benefi ts Are Paid

Maximum Allowable

Fee Table

55

You can reduce your out-of-pocket costs when you receive services from a dentist who belongs

to Guardian’s DentalGuard Preferred Select PPO Network. To belong to the Dental PPO network, a

dentist must meet strict quality assessment criteria required by Guardian. In return for our member-

ship’s business, the dentists in this network have agreed to accept the Fund’s Maximum Allowable

Fees as payment in full. When you go to a PPO dentist, you pay only the applicable copayment

for the services you receive; you will not be responsible for any charges above the Maximum

Allowable Fees.

You can go to a non-PPO dentist and still be eligible for benefi ts. However, you will be responsible

for any amount in excess of the Maximum Allowable Fee for any covered service in addition to any

copayment due. Preventive services are not subject to Maximum Allowable Fees.

If you would like assistance in selecting a Dental PPO network dentist, call Guardian at

(888) 600-9200 and identify yourself as a member of the Midwest Operating Engineers Welfare

Fund. You can also use the online provider search function at www.geoaccess.com/guardian/po56/

begin.asp (or use the link on the Welfare Fund’s website). Search for and use dentists in Guardian’s

DentalGuard Preferred Select network.

If your current dentist is interested in participating in the Guardian Dental PPO network, please ask

the dentist to call Guardian at (888) 600-9200.

Dentists can go into and out of the network. Each time you make an appointment, ask your dentist

if he or she is in the network.

Orthodontia benefi ts are available to dependent children under age 19. Orthodontic treatment

basically consists of three phases: diagnosis, banding and treatment. When your child fi rst visits an

orthodontist for the purpose of braces or an orthodontic appliance, the orthodontist should submit

a treatment plan to the Fund Offi ce. The treatment plan should contain the following information:

■ estimated number of months of treatment,

■ total fee,

■ cost for initial placement of appliance (banding), and

■ monthly treatment fee.

Once the orthodontist has completed the placement of the appliance, the orthodontist should

submit a claim for payment for that procedure. Claims for additional monthly fees should be

submitted to the Fund Offi ce on a quarterly basis. The Plan pays 50% of the cost for the

placement of the appliance and then 50% of the quarterly bills until the orthodontia lifetime

maximum is reached.

If a child’s eligibility under the Plan ends or if the child reaches age 19 during the course of treatment,

payment of orthodontic benefi ts will stop.

The Dental PPO Network

Orthodontia Treatment

55

DENTAL BENEF ITS 56

If one of your children is having orthodontic work done when he or she fi rst becomes eligible for

benefi ts, the Plan will pay benefi ts for treatment received while the child is covered by the Plan

(provided he or she is eligible for orthodontic benefi ts).

Benefi ts for eligible expenses are limited as follows:

1. The maximum benefi t payable is $1,000 per calendar year for each covered person.

2. Oral examinations, prophylaxis (routine or periodontal maintenance), and fl uoride and sealant

applications for eligible children under age 19. All these services are limited to twice per

calendar year.

3. Full mouth or panoramic x-rays are limited to one every 36 months unless medically necessary.

4. Bitewing x-rays are limited to twice every calendar year.

5. Orthodontic services are covered for dependent children up to the age of 19. Benefi ts are subject

to the lifetime maximum payment shown on the Schedule of Benefi ts.

6. Covered fi lling materials are limited to silver amalgam, silicate, acrylic, synthetic porcelain, and

composite.

7. Crowns will be provided only if there is insuffi cient tooth structure to retain an amalgam,

silicate, or plastic restoration.

8. Crowns and bridgework will be provided in the presence of suffi cient breakdown or decay and

adequate bone support.

9. Benefi ts for general anesthesia are payable only when required due to medical necessity and if

administered with a covered dental procedure by a person who is licensed to administer general

anesthesia.

10. Benefi ts will be adjusted, limited or excluded for any services, treatment or supplies payable

under any group medical or dental benefi t plan which covers the eligible dependent as the

insured (see Coordination of Benefi ts on page 68).

Expenses for the following services are not covered under the Dental Benefi t:

1. charges for prescribed drugs and medicines, analgesia or local anesthesia. Please note that

prescription drugs related to dental treatment may be available through the Prescription

Drug Program;

2. cosmetic dentistry;

Limitations

Exclusions

57

3. replacement of a bridge, crown or denture within fi ve years of the date it was originally installed,

unless:

■ the full denture is made necessary by extraction of natural teeth; or

■ the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result

of an injury received while a person is insured for these benefi ts;

4. any replacement of a bridge, crown or denture repairable by common dental standards;

5. instructions for plaque control, oral hygiene and diet;

6. services that are covered under the medical plan;

7. treatment rendered by someone other than a licensed dentist, or licensed dental hygienist

working under the supervision of a dentist;

8. charges for any procedure not completed, or any prosthetic appliance unless the appliance is

actually inserted or delivered;

9. temporary bridges, dentures, or crowns;

10. infection control costs;

11. procedures, appliances, or restorations, other than fi llings, that are necessary to alter, restore or

maintain occlusion with the exception of any services listed as an eligible expense.

Excluded services shall include, but are not limited to:

■ increasing vertical dimension,

■ periodontal splinting,

■ realignment of teeth,

■ orthognathic recordings, or

■ replacing or stabilizing tooth structure loss by attrition;

12. any treatment or procedure (except orthodontia) that was incurred before the date the covered

person’s dental coverage started or after the person’s coverage terminated. Also excluded is any

treatment or procedure (except orthodontia) that started within six months before the person’s

enrollment date (subject to the creditable coverage rules and the 12-month limitation period of

the Plan’s Pre-Existing Condition Limitation, as described starting on page 33).

13. subgingival curettage and/or root planing (ADA codes 4220, 4331, and 4345) unless the

presence of periodontal disease is confi rmed by x-rays and periodontal charting of pocket

depths for each tooth involved; or

14. any experimental or investigational procedures or procedures that are not generally recognized

by the dental profession as being appropriate for the condition being treated.

DENTAL BENEF ITS 58

If you have any questions about your Dental Benefi ts, call the Fund’s Claims Department at

(800) 323-3060 or (708) 579-6600.

The table below lists the most frequently used procedures. If a procedure is not listed, call

Guardian Life’s dental customer service department at (888) 600-9200 (please have the ADA code

available) to have the maximum allowable fee for that procedure quoted to you or your dentist.

Maximum Allowable Fee Table as of January 1, 2010

ADA Code DescriptionMaximum Allowable Charge

0110 Initial oral exam $30.00

0120 Periodic oral exam $19.00

0130 Emergency oral exam $30.00

0210 Intraoral-complete series (including bitewings) $58.00

0220 Periapical-fi rst fi lm $10.00

0230 Periapical-each additional $8.00

0270 Bitewings-single fi lm $11.00

0272 Bitewings-two fi lms $17.00

0274 Bitewings-four fi lms $27.00

0330 Panoramic fi lm $50.00

1110 Prophylaxis-adult (twice in a calendar year) $41.00

1120 Prophylaxis-child (twice in a calendar year) $29.00

1203 Topical fl w/o prophy-child (under age 19) $16.00

1351 Sealant-per tooth (under age 19) $23.00

2140 Amalgam-1 surf permanent $55.00



2161 Amalgam-4 or 4+ surf permanent $100.00

If You Have Questions

Maximum Allowable Fee

Table as of January 1, 2010

59

Maximum Allowable Fee Table as of January 1, 2010

ADA Code DescriptionMaximum Allowable Charge

2330 Resin-1 surf anterior $74.00



2335 Resin-4+ or incisal, anterior $110.00

2385 Resin-1 surface, posterior permanent $78.00

2750 Crown-porcelain fused to high noble metal $602.00

2751 Crown-porcelain to predominantly base metal $532.00

2752 Crown-porcelain fused to noble metal $568.00

3310 Anterior root canal (excl fi nal rest) $378.00

3320 Bicuspid root canal (excl fi nal rest) $445.00

3330 Molar root canal (excl fi nal rest) $580.00

4341 Periodontal scaling/root planing-per quad $115.00

4910 Periodontal maintenance procedure $64.00

5110 Complete upper or lower denture $734.00

5211 Upper partial-resin base $545.00

5212 Lower partial-resin base $545.00

5213 Upper partial-cast metal base w/resin saddles $803.00

5214 Lower partial-cast metal base w/resin saddles $803.00

Family Supplemental

Benefit

60

61

You and/or your eligible dependents may receive reimbursement for non-covered, medically

necessary, and unreimbursed medical, dental or pharmacy expenses (that are considered deductible

medical expenses by the IRS) under the Family Supplemental Benefi t (FSB). There are two excep-

tions to this rule that are also covered under the FSB:

■ Expenses that are over a Plan maximum, and

■ TMJ, orthodontia, and orthoptic training charges that are payable at 50%.

These expenses will be reimbursed up to the maximum benefi t per family per calendar year as

shown on the Schedule of Benefi ts (see page 28). Under the Family Supplemental Benefi t there is no

deductible and eligible expenses are allowed at 100% subject to the Family Supplemental

Benefi t maximum.

FSB expenses include, but are not limited to the following:

1. eye exams and prescription eyeglasses or contact lenses,

2. hearing tests and hearing aids,

3. orthodontic expenses in excess of the lifetime orthodontia maximum,

4. routine physicals for children over the age of 2,

5. dental benefi ts in excess of the calendar year maximum benefi t, and

6. medically necessary genetic testing.

Requests for reimbursement must be received by the Fund Offi ce within one year (twelve months)

after the expense was incurred.

No benefi ts are payable for these expenses:

1. expenses which are not medically necessary;

2. deductibles;

3. copayments;

4. medicines and drugs that do not require a prescription to purchase;

5. weight loss programs;

6. smoking cessation programs;

7. exercise programs, health club dues or membership fees;

8. hot tubs or jacuzzis;

FSB Expenses

Exclusions

61

FAMILY S UPPLEMENTAL BENEF IT 62

9. cosmetic treatments such as teeth bleaching kits or treatments, cosmetic surgery, facials, etc.;

10. charges that are in excess of reasonable and customary charges;

11. dental charges in excess of the Maximum Allowable Fees;

12. group insurance premiums for your spouse’s employer’s health plan;

13. school expenses, including costs related to special educational programs for problem children; or

14. expenses which are not deductible for federal income tax purposes.

Eligible Expenses Excluded Expenses

Prescription eyeglasses or contacts

Hearing tests and aids

Routine physicals for children over the age of 2

Non-covered prescription drugs

Your 50% copayment percentage and

orthodontic expenses over the Plan maximum

per dependent child

Your 50% copayment percentage and TMJ

expenses over the Plan maximum

Dental benefi ts over the Dental Plan maximum

Any weight loss program

Any smoking cessation programs

Any exercise program, health club dues or

membership fees

Hot tub or jacuzzi

Cosmetic treatments such as teeth bleaching

kits or treatments, cosmetic surgery, facials, etc.

Pharmacy co-pays

Group insurance premiums from your spouse’s

employer

To fi le a Family Supplemental Benefi t claim, you must submit a Family Supplemental Benefi t Claim

Form along with your itemized bill or your Explanation of Benefi ts (EOB) from the Fund Offi ce that

relates to the claim and your paid receipt. Your Family Supplemental Benefi t claim must be received

by the Fund Offi ce within one year (12 months) of the date the expense is incurred.

Be sure to use a Family Supplemental Benefi ts Claim Form so that the Fund Offi ce will recognize

your claim as being submitted for the Family Supplemental Benefi t.

Examples of Eligible

and Excluded Expenses

Under the Family

Supplemental Benefi t

How to File Family

Supplemental Benefi t

Claims

Retiree Medical Savings Plan

If you have a Retiree Medical Savings Plan (RMSP)

account when you retire, you may use the funds

accumulated in your account in a variety of ways

to cover health care expenses after retirement.

Retiree Self-Pay Benefi ts

If you retire and are eligible for the this Fund’s Retiree

Health and Welfare Benefi ts, you can use the funds in

your RMSP account to cover your retiree self-payment

premiums.

Retiree Self-Pay Benefi ts are paid in the form of transfers

from your RMSP account to the Midwest Operating

Engineers Health and Welfare Plan in the amounts you are

required to pay for Retiree Health and Welfare Benefi ts.

If and when your account has been exhausted, you can

continue to make retiree self-pays to the Fund for Retiree

Health and Welfare Benefi ts.

If you elect the Retiree Self-Pay option, your RMSP

account can also be used to pay for tax-qualifi ed long term

care insurance premiums or tax-qualifi ed nursing care

expenses.

Supplemental Medical Benefi ts

If you are not eligible for this Fund’s Retiree Health and

Welfare Benefi ts, or do not elect that coverage, you can

use your RMSP funds to pay for:

■ premiums for another group health care plan,

■ your deductibles and co-pays under another group

health care plan,

■ premiums for Medicare Part B, a Medicare Advantage

Plan, a Medicare Part D (prescription drug) plan or a

Medicare supplement (“Medigap”),

■ premiums for a tax-qualifi ed long-term care insurance

policy, or

■ tax-qualifi ed nursing home expenses, and tax-qualifi ed

home health care and hospice care expenses.

RMSP Benefi ts

63

RET IR EE MEDICAL SAVING S PLAN 64

Non-Reimbursable Expenses

Your RMSP account may only be used to make self-payments or for the types of expenses listed

above. Your account may not be used to pay for:

■ life insurance policies,

■ loss-of-earnings policies,

■ accidental death and loss of limb, sight, etc. policies,

■ daily indemnity policies that pay you a specifi ed amount while your are hospitalized,

■ med pay coverage under your vehicle insurance, or

■ any taxes imposed by any governmental body.

Benefi ts for Your Benefi ciary

In the event of your death, the balance in your account may be used to pay premiums for continued

health care coverage under the Fund for your eligible dependents. Any such coverage will be

provided in accordance with the Plan’s surviving dependent or COBRA self-payment rules. When the

last of your survivors ceases to qualify for Plan coverage, any balance remaining in your account will

be paid in a lump sum to your designated benefi ciary(ies).

To be in force, you must have a completed RMSP Benefi ciary Statement on fi le at the Fund Offi ce

before your death. The persons you can name as benefi ciaries are limited to your eligible depen-

dents. For purposes of the RMSP, “eligible dependents” include your spouse, a qualifying child or a

qualifying relative as defi ned by the Internal Revenue Code. If more than one bene fi ciary is named,

but their respective interests are not stated, they will share equally. If you have not named a benefi -

ciary, or if your last-named benefi ciary has died, RMSP benefi ts will be paid to or for your surviving

eligible dependents equally. If there are no eligible dependents, your account balance will revert to

the general trust fund.

Initial Application

You must elect either the Retiree Self-Pay option or the Supplemental Medical Benefi ts option when

you retire. Your selection should be on an RMSP application form that must be received by the

Administrative Manager before the end of the month immediately prior to your retirement. The

application can be fi led by you, or in the event of your death, by your surviving benefi ciary.

RMSP Claims

Claims for payment of Supplemental Medical Benefi ts must be fi led in accordance with the Fund’s

normal claim procedures and time limits.

How to Use Your

RMSP Account

65

General Exclusions

The following are some general Plan exclusions

that apply to all Plan benefi ts. Other exclusions

are listed in the specifi c benefi t sections of this

booklet. For example, the exclusions that apply

to medical benefi ts start on page 43.

1. Charges that are above the reasonable and

customary limits (for non-PPO medical provider

services), and/or negotiated fees (for PPO

medical and dental provider services), and/or the

Medicare-approved amounts (for Medicare-eligible

participants);

2. Services or supplies that are not considered medically

necessary;

3. Experimental or investigational services or supplies;

4. Services or supplies that are not prescribed by a

licensed physician or eligible provider licensed to

prescribe that service or supply;

5. Services or supplies that are not performed by an

eligible provider under the Plan;

6. An illness or injury that is covered under Workers’

Compensation, or that is recoverable from a respon-

sible third party;

7. An illness or injury resulting from war or any act of

war, or from the commission of a felony, except as

the result of an act of domestic violence or a medical

condition (including both physical and mental health

conditions);

65

G ENER AL EXCLUS IONS 66

8. Illness or injury for anyone who is serving in the

armed forces of the United States or any other

government;

9. Custodial or maintenance care;

10. Cosmetic surgery or treatment;

11. Complications from non-covered procedures;

12. Food supplements;

13. The cost of an electronic or microprocessor-

controlled artifi cial limb in excess of the cost of a

conventional mechanical prosthetic that would meet

the patient’s basic needs;

14. Medical, surgical, psychiatric or prescription drug

treatment related to transsexual (sex change)

procedures, or the preparation for such procedures, or

any complications resulting from such procedures;

15. Hormone therapy, artifi cial insemination, in vitro

fertilization or other treatments for infertility in a male

or female;

16. Braces, trusses, and foot orthotics that can be

purchased over the counter; or supplies such as

bandages, gauze, tape, syringes and needles (unless

provided and used while in the hospital);

17. Any routine or preventive services or supply where

no illness or accident is present, or when required for

employment, unless specifi cally specifi ed as covered;

18. Smoking cessation products or programs;

19. Speech or occupational therapy except as specifi cally

provided under the Plan;

20. Vocational therapy or any other therapy, except as

specifi cally provided in the Plan;

21. Vision or hearing exams, except for treatment of

accidental injuries;

22. Procedures, such as Lasik, for correction of myopia or

other refractive errors;

23. Orthodontic services and supplies except as specifi -

cally provided for under the Plan;

24. Personal convenience items such as telephone,

television, cot rental, guest meals, travel, copying of

medical records or fees to complete a claim form;

25. Charges by a provider who is the parent, spouse,

child, or sibling of, or resides with the covered person;

26. Expenses incurred outside of the U.S. except for

an accident or an unforeseen and acute medical

emergency; or while on work assignment, vacation

or as a full-time student participating in a school-

sponsored program;

27. Chelation therapy, except in cases of heavy metal

poisoning; or

28. Any services or supplies for which:

a. no charge is made,

b. the individual is not legally required to pay, or

c. the Fund is not legally required to pay.

If you have a specifi c question that is not addressed above,

contact the Fund Offi ce.

67

Other Provisions That Can Limit Benefits

67

OTHER P ROVI S I ONS THAT CAN L IM IT BENEF ITS 68

Your Plan contains a coordination of benefi ts provision. This provision provides

that if you are covered under more than one group plan, benefi ts may be payable

under both plans, and establishes the priority for payment.

Coordination of benefi ts applies to all benefi ts payable by this Plan except for Prescription Drug

Program benefi ts, and death benefi ts.

If you have a claim that is covered by two or more group plans, one plan, called the primary plan,

pays its benefi ts fi rst. The other plan, called the secondary plan, adjusts its benefi ts so that the total

benefi ts paid on your behalf are not greater than the allowable expense. In no event will the total

benefi ts paid from both plans exceed 100% of the allowable expenses. An allowable expense is

any medically necessary, reasonable and customary expense for care or treatment performed by a

licensed provider that is covered under at least one of the plans. When benefi ts are reduced by the

primary plan because the participant did not comply with the plan’s provisions, such as the provi-

sions related to case management or use of certain providers under a PPO or HMO plan, the amount

of those reductions will not be considered an allowable expense by this Plan when it pays secondary.

Allowable expense includes both assigned and non-assigned expenses. If either plan has a contract

with the provider, including under a PPO or HMO agreement, the combined payments of both plans

will not be more than the contracted plan’s contract calls for. If both this Plan and the other plan have

a contract with the same provider, the allowable expense will be the lesser of the two contracted or

negotiated fees.

If you have an individual medical policy, the coordination of benefi ts rules do not apply.

A plan without a coordination of benefi ts provision is always considered the primary plan. If all plans

have a coordination of benefi ts provision, the fi rst to apply of the following rules will be used to

determine which plan is primary and which is secondary:

■ Medicare is primary over the plan that covers you as a retiree.

■ The plan that covers you as an employee is primary over a plan that covers you as a retiree.

■ The plan that covers you as an employee is primary over a plan that covers you as a dependent.

■ When both parents, member and spouse, have medical coverage for their children, the plan of the

parent whose birthday comes earlier in the calendar year is the primary plan. If both parents have

the same birthday, the plan covering the parent for the longer period of time is primary. (However,

if one plan uses a male/female rule and the other plan coordinates using the birthday rule, the

plan using the male/female rule shall pay its benefi ts fi rst.)

Coordination of Benefi ts

If you are eligible for Medicare,

these coordination of benefi ts rules

are applied as if you are eligible for

both Part A and Part B coverages

under Medicare, even if you do

not elect to take Part B coverage.

Therefore, it is important for you

to maintain both Part A and Part B

coverage under Medicare.

69

■ In the event a father and mother are separated or divorced, whether or not they were ever married,

the plan that covers the child as a dependent of the parent with fi nancial responsibility for the

child’s medical expenses by virtue of a court decree shall pay fi rst. If there is no such court decree

establishing this fi nancial responsibility, then the payment order is:

¬ the plan that covers the parent with custody pays before the plan that covers the parent without

custody; and

¬ if the parent has remarried, the plan that covers the stepparent with custody pays before the plan

that covers the parent without custody.

On coordinated claims, the Fund Offi ce must be provided with a fully completed claim form,

itemized bills, and the matching payment explanation or denial showing the other plan’s decision.

Coordination with Health Maintenance Organizations or Dental Maintenance Organizations

In order for any expense to be considered under this Plan, you must have complied with all the

requirements of the HMO or DMO for coverage of the expense under the HMO’s or DMO’s

rules. For example, if your wife is covered by an HMO and receives treatment from a non-HMO

physician (to which she was not referred by the primary HMO doctor), the HMO will deny benefi ts.

No benefi ts would be payable for the treatment under this Plan, since she did not follow the HMO

rules. It is very important for your eligible dependents to comply with the HMO’s or DMO’s rules.

Coordination with Medicare

At age 65 you normally become eligible for Medicare. However, Medicare eligibility also extends

to disabled individuals and those with certain conditions. For example, Medicare covers certain

expenses for kidney dialysis.

If you are covered by both Medicare and this Plan, then:

■ If you are an active member, this Plan is primary.

■ If you are a non-active member, Medicare is primary.

When Medicare is primary, you must submit fully itemized bills and the matching Medicare

Explanation of Benefi ts. The Plan’s benefi ts will be reduced so that the combination of benefi ts

paid by Medicare and the Plan do not exceed the amount that the Plan would have paid without

Medicare.

If the patient’s primary plan is a

Health Maintenance Organization

(HMO) or Dental Maintenance

Organization (DMO), he or she is

required to utilize the approved HMO

or DMO providers and follow all other

applicable HMO rules.

You are an active member if you are

actively employed by an employer

which pays all or part of the required

contributions for eligibility.

OTHER P ROVI S I O NS THAT CAN L IM IT BENEF ITS 70

Remember, if you are eligible for Medicare, these coordination of benefi ts rules are applied as if you

are eligible for both Part A and Part B coverages under Medicare, even if you do not elect to take Part

B coverage. Therefore, it is important for you to maintain both Part A and Part B coverage under

Medicare.

If you elect coverage under a Medicare Part D (prescription drug) plan, no prescription drug benefi ts

will be payable by this Plan.

If you enroll in a Medicare supplemental insurance (Medigap) plan or in a managed care plan (such

as an HMO), this Plan shall coordinate its benefi ts so that the sum of this Plan’s benefi ts and the

other Plan’s benefi ts, or the reasonable cash value of the managed care plan’s benefi ts, shall not

exceed the allowable expenses for the services.

If you or an eligible dependent becomes ill or is injured and a third party is responsible, and you

recover expenses from a responsible third party, Workers’ Compensation, the insurer, or a group

plan, the Trustees have the right to require you to repay any applicable benefi ts you or your depen-

dent received from this medical Plan. The Trustees may, at their own discretion, pursue a claim

against any third party, including the fi ling of a claim in court. The Trustees will require you to sign

a Subrogation Acknowledgement to attest to your understanding of the subrogation provisions and

to secure the Fund’s right to recover expenses from a responsible third party.

If you accept a settlement or receive an award, future medical expenses for any injury or illness

caused by the responsible third party are not eligible expenses under this Plan for the two-year

period following the settlement for an injury-related claim. It is your duty to notify the Fund Offi ce

of any potential third party liability and any settlement of a claim.

The Trustees have the right to require you to repay any excess payments you may have received, including

payments from a group plan with which this Plan has coordinated benefi ts. The Trustees also have the right

to deduct such excess payments from future benefi ts.

Third Party Recovery

Reimbursement

(Subrogation)

7 1

Claim and Appeal Procedures

7 1

C LA IM AND APPEAL PR OCEDUR ES 72

■ A claim is a request for Plan benefi ts, normally because the claimant has incurred a health care

expense.

■ The claimant is the person who has incurred the claim, except that if the claim is incurred by

a dependent child, then the adult who fi les the claim on behalf of the child is the claimant.

■ A claim is post-service if the treatment or supply for which payment is now being requested

has already been received.

■ A pre-service claim is a request for preauthorization of a type of treatment or supply that requires

approval in advance of obtaining the care. A request for confi rmation of Plan coverage is not a

claim if the expense has not yet been incurred, unless the Plan conditions payment on the receipt

of prior approval. A general inquiry about eligibility or coverage when no expense has been

incurred is not a claim, nor is presenting a prescription to a pharmacy.

■ An urgent care claim is a pre-service claim where the application of the time periods for making

non-urgent care determinations could seriously jeopardize the claimant’s life, health, or ability

to regain maximum function, or that could subject the claimant to severe pain that cannot be

adequately managed without the proposed treatment.

■ A concurrent care claim is a pre-service claim where a request is made to extend a course of

treatment beyond the period of time or number of treatments previously approved.

■ An authorized representative is someone who has been designated to represent a claimant for

the purpose of fi ling and/or appealing a claim. Except in the case of an urgent care claim, the

claimant’s designation of an authorized representative must be in writing on a form provided

by the Plan. An assignment of benefi ts is not such a designation. If the claimant is unable to

complete the Plan’s written statement, the Plan requires written proof such as a legal power of

attorney for health care purposes, or a court order of guardianship or conservatorship showing

that the representative has been authorized to act on the claimant’s behalf. The claimant may

revoke a designated authorized representative at any time by submitting a written statement.

The Trustees, or their designated representative, have the sole discretion to determine whether

the claimant has properly designated an authorized representative. If another person claims

to be representing the claimant in his appeal, the Review Panel has the right to require that the

claimant give the Plan a signed statement, advising the Review Panel that he has authorized

that person to act on his behalf regarding his appeal. Any representation by another person will

be at the claimant’s expense. The Plan reserves the right to withhold information from a person

who claims to be the authorized representative if there is suspicion about the qualifi cations of

the individual claiming to be the authorized representative.

Defi nitions

73

In order for the Plan to pay benefi ts, a claim must be fi led with the Administrative Manager (or

the offi ce designated for handling the claim) in accordance with the procedures described below.

A claim can be fi led by the retiree, a dependent, or by someone authorized to act on behalf of the

retiree or dependent.

Medical Claims

To help ensure that your medical claims are paid as quickly as possible, show your Plan identifi cation

(I.D.) card to your health care provider whenever you receive covered services.

Claims for in-network (PPO provider) medical services will be submitted for you by your PPO

provider. In the event that you need to fi le, a fully completed claim form for you and your eligible

dependents should be sent to the Fund Offi ce. All claims must include:

■ your full name,

■ your Social Security number and/or medical I.D. number,

■ your current home address,

■ the illness or injury being treated and the date of care,

■ the patient’s name,

■ the provider’s name, address, telephone number, professional degree or license, and federal tax

identifi cation number,

■ itemized charges,

■ when another plan or Medicare is primary, a copy of the other plan’s explanation of benefi ts

(EOB), and

■ for a pre-service claim:

¬ medical history and physical,

¬ progress notes,

¬ medical records,

¬ laboratory results and pathology reports,

¬ x-rays and radiologists’ reports, and

¬ operative reports and anesthesia reports.

To request a medical claim form, please contact the Fund Offi ce at (708) 579-6600, download one

from the website www.moefunds.com, or pick one up at your Distict Offi ce.

Normally, the provider will require you to sign a form assigning benefi ts. In that case the benefi ts

are paid directly to the provider. If you paid for the service yourself, you should attach proof of

payment (for example, a cancelled check or receipt) if you want payment made directly to you.

Claims must be fi led within

one year (twelve months) after

the expense was incurred.

Filing a Claim

Submit medical claims within

12 months after they are incurred.


Medical Claims Incurred by Medicare-Eligible Participants

Claims incurred by retirees and dependents who are eligible for Medicare should fi rst be fi led with

Medicare. After Medicare pays its portion of the claim, the itemized bill and the matching Medicare

Explanation of Benefi ts should be submitted to the Fund Offi ce.

Dental Claims

To fi le a claim for covered dental services, submit a completed dental claim form to:

Midwest Operating Engineers

6150 Joliet Road

Countryside, IL 60525

To request a dental claim form, please contact the Fund Offi ce at (708) 579-6600 or your

district offi ce.

Make sure that you sign the claim form before it is submitted to the Fund Offi ce. Benefi ts will be

paid directly to your dentist unless the claim form/bill is marked “paid in full.”

Family Supplemental Benefi t Claims

To fi le a Family Supplemental Benefi t claim, you must submit a Family Supplemental Benefi t Claim

Form along with your itemized bill or your Explanation of Benefi ts (EOB) from the Fund Offi ce that

relates to the claim and your paid receipt. Your Family Supplemental Benefi t claim must be received

by the Fund Offi ce within one year (12 months) of the date the expense is incurred.

Remember, if you do not use a Family Supplemental Benefi t Claim Form, the Fund Offi ce may not

recognize your claim as being submitted for the Family Supplemental Benefi t. This may result in your

claim payment being delayed or denied.

Filing a Death Benefi t Claim (Local 537 Members Only)

To claim a Death Benefi t, proof of death must be sent to the Fund Offi ce, and an application for

benefi ts should be made within 30 days of the date of death. Please call the Fund Offi ce for the

proper forms.

All Claims

Except as explained above, claims must be fi led within one year (twelve months) after the expense

was incurred. The Trustees have a right to deny claims received more than one year (twelve months)

after the expense was incurred. A claim is considered to have been fi led on the date it is received at

the correct claims offi ce, even if the claim is incomplete. It is your responsibility to see that claims

and medical bills are submitted promptly and no later than the time period permitted under the Plan.

Submit dental claims within 12

months after they are incurred.

Submit Family Supplement Benefi t

claims within 12 months after the

date of service.

75

The claimant may designate an authorized representative for the purposes of fi ling a claim, in which

case all notices regarding the claim will be sent to the authorized representative and not to the

claimant.

Processing Time

If all the information needed to process the claim is provided to the claims offi ce, the claim will be

processed as soon as possible. However, the processing time needed will not exceed the time frames

allowed by law, which are as follows:

■ 30 days for post-service claims,

■ 15 days for pre-service claims,

■ 72 hours for urgent care claims, and

■ 24 hours for concurrent care claims if the concurrent care is urgent and if the request for the

extension is made within 24 hours prior to the end of the already authorized treatment. If the

concurrent care is not urgent, then the pre-service time limits apply.

When Additional Information Is Needed

If additional information is needed from the claimant or the claimant’s doctor or provider, the neces-

sary information or material will be requested in writing. The request for additional information will

be sent within the normal time limits shown above, except that the additional information needed to

decide an urgent care claim will be requested within 24 hours.

It is the claimant’s responsibility to see that the missing information is provided to the claims offi ce.

The normal processing period will be extended by the time it takes the claimant to provide the

information, and the processing time period will start to run once the claims offi ce has received a

response to its request. If the claimant does not provide the missing information within 45 days

(48 hours for an urgent care claim), the claims offi ce will make a decision on the claim without it,

and the claim could be denied as a result.

Claim Processing


Plan Extension

The time periods above may be extended if the claims offi ce determines that an extension is

necessary due to matters beyond its control (but not including situations where it needs to request

additional information from the claimant or the provider). The claimant will be notifi ed prior to the

expiration of the normal approval/denial time period if an extension is needed. If an extension is

needed, it will not last more than 15 days.

Claim Denials

If all or a part of a claim is denied after the claims offi ce has received all other necessary information

from the claimant, the claimant will be sent a written notice stating the reasons for the denial. The

notice will include reference to the Plan provisions on which the denial was based and an explanation

of the claim appeal procedure. If applicable, it will give a description of any additional material or

information necessary for the claimant to perfect the claim, and the reason such information is neces-

sary. The notice will provide a description of the appeal procedures and the applicable time limits for

following the procedures. It will also include a statement concerning the claimant’s right to bring a civil

action under Section 502(a) of ERISA. In cases where the Plan relied upon an internal rule, guideline,

protocol or similar criterion to make its decision, the notice will state that the specifi c internal rule,

guideline, protocol or criterion will be provided to the claimant free of charge upon request. If the

decision was based on medical necessity or if the treatment was deemed experimental or investigative,

the notifi cation will include either an explanation of the scientifi c or clinical judgment for the determina-

tion or a statement that such explanation will be provided free of charge upon request. For urgent

claims, a description of the Plan’s expedited review process will be provided.

If a claim has been denied in whole or in part, the claimant may request a full and fair review (also

called an “appeal”) in accordance with these procedures.

For medical claims, a notice of appeal must be submitted within 180 days after the claimant receives

the written notice of denial of the claim. The appeal is considered to have been fi led on the date the

written notice of appeal is received by the offi ce designated by the Trustees

for receiving appeals.

The Review Panel will be the Board of Trustees or a committee of the Board of Trustees. The Review

Panel will not include the person, or a subordinate of the person, who made the original claim denial.

Claim Appeal Procedures

77

The Plan has a two-level process for pre-service and post-service health care claims appeals

submitted to the Review Panel.

■ The initial written appeal must be submitted to the Fund Offi ce, except in the case of an urgent

care or pre-service claim appeal which may be presented verbally.

■ If the initial appeal is denied, the claimant may submit a second-level appeal of a pre-service or

post-service health care claim to the Review Panel at the address of the Administrative Manager.

Second-level appeals are subject to the same time limits described above.

Appeals may only be initiated by the claimant (retiree or spouse) or the claimant’s authorized

representative. Appeals will not be accepted from other persons or entities, including providers who

are not duly designated authorized representatives.

If your initial appeal is denied, you have the right to request a rehearing in which you may request

to appear in person before the Review Panel. If the Trustees grant your request, your appearance

must be at your expense. Any hearing before the Review Panel to which a claimant is invited shall be

conducted in an informal manner, and no Review Panel proceeding shall be recorded, electronically

or stenographically.

The claimant may review pertinent documents and may submit comments and relevant information

in writing. Upon written request, the Administrative Manager will provide reasonable access to,

and copies of, all documents, records or other information relevant to the claim at no charge. If the

claims offi ce obtained an opinion from a medical or vocational expert in connection with the claim,

the Administrative Manager will, on written request, provide the claimant with a copy of the opinion.

In deciding the appeal, the Review Panel will consider all comments and documents that are

submitted, regardless of whether that information was available at the time of the original claim

denial. The review will not defer to the initial denial, and will take into account all comments,

documents, records and other information submitted, without regard to whether such information

was previously submitted or relied upon in the initial determination.

If an appeal involves a medical judgment, such as whether treatment is medically necessary, the

Review Panel will consult with a medical professional who is qualifi ed to offer an opinion on the

issue. If a medical professional was consulted in connection with the original claim denial, the

Review Panel will not consult with the same medical professional (or a subordinate of that person)

for purposes of the appeal.


If the appeal is for an urgent care claim, the claimant will be notifi ed of the decision about the appeal

as soon as possible, taking into account the circumstances, but not later than 72 hours after receipt

of the request for review. In the case of non-urgent pre-service claims, the claimant will be notifi ed

no later than 30 days after receipt of the request for review.

A review and determination for post-service claims will be made no later than the date of the

meeting of the Trustees that immediately follows the Plan’s receipt of a request for review, unless

special circumstances exist requiring an extension of time, in which event the decision shall be

rendered no later than 120 days from the date of receipt of the written request for Review by the

Administrative Manager. The claimant will be informed of the Trustees’ decision, normally within

fi ve calendar days of the review.

Claim appeal decisions will be in writing unless the appeal was for an urgent care claim and the

claimant was advised by telephone or fax. When the claimant receives the written decision, it will

contain the reasons for the decision and specifi c references to the particular Plan provisions upon

which the decision was based. It will also contain a statement explaining that the claimant is entitled

to receive, upon request and free of charge, reasonable access to, and copies of, all documents,

records, and other information relevant to the claim, and a statement of the claimant’s right to bring

an action under Section 502(a) of ERISA. If applicable, the claimant will also be informed of his right

to receive free of charge upon request the specifi c internal rule, guideline, protocol or similar

criterion relied on to make the decision. If the decision was based on a medical judgment, the

claimant will receive an explanation of that determination or a statement that such explanation

will be provided free of charge upon request.

While the Plan may not automatically extend the time period for an appeal determination, the time

may be extended if the claimant agrees in advance to an extension.

If the Fund fails to make timely decisions or otherwise fails to comply with the applicable federal

regulations, the claimant may go to court to enforce his rights. The claimant may not fi le suit against

the Fund until he has exhausted all of the procedures described in these provisions.

General Plan Provisions

79

G ENER AL PLAN PR OVIS IONS 8 0

The Midwest Operating Engineers Welfare Fund will use and disclose protected health information

(individually identifi able health information, regardless of the form in which it is kept) only to the

extent of and in accordance with the uses and disclosures permitted or required by the Health

Insurance Portability and Accountability Act of 1996 (HIPAA) and Department of Health and Human

Service Regulations Regarding Privacy of Individually Identifi able Health Information. The Fund will

not disclose protected health information to the Plan Sponsor, the Board of Trustees, or permit a

health insurance issuer or HMO to disclose protected health information, unless this disclosure

complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and

Department of Health and Human Service Regulations Regarding Privacy of Individually Identifi able

Health Information. The Fund further complies with HIPAA by providing to individuals covered by the

Plan, in accordance with HIPAA and its Regulations, a Notice of Privacy Practices detailing the Fund’s

practices regarding protected health information.

The Trustees or persons acting for them, such as a claims review panel, have sole authority to make

fi nal determinations regarding any application for benefi ts and the interpretation of the Plan of

Benefi ts, the Trust Agreement and any other regulations, procedures or administrative rules adopted

by the Trustees. Decisions of the Trustees (or, where appropriate, decisions of those acting for the

Trustees) in such matters are fi nal and binding on all persons dealing with the Plan or claiming a

benefi t from the Plan. If a decision of the Trustees or those acting for the Trustees is challenged

in court, it is the intention of the parties to the Trust that such decision is to be upheld unless it is

determined to be arbitrary or capricious.

All benefi ts under the Plan are subject to the Trustees’ authority to change them. The Trustees

have the authority to increase, decrease, change, amend, or terminate benefi ts, eligibility rules, or

other provisions of the Plan of Benefi ts as they may determine to be in the best interests of the Plan

participants and benefi ciaries.

Benefi ts under this Plan will be paid only when the Board of Trustees or persons delegated by them

decide, in their sole discretion, that the participant or benefi ciary is entitled to benefi ts.

The Plan is maintained for the exclusive benefi t of the Plan’s participants and their dependents. All

rights and benefi ts granted to a participant under the Plan are legally enforceable.

The right to change or eliminate any and all aspects of benefi ts provided for retired participants

is a right specifi cally reserved to the Trustees, since coverage for retired participants is not an

“accrued” or “vested” benefi t.

Privacy of an Individual’s

Health Information

Trustee Interpretation

and Authority; Decisions

Regarding Benefi ts

Right to Modify the Plan

The Trustees reserve the right to

change, modify or discontinue all

or part of this Plan at any time. The

Trustees may change the method and

amount of self-payments and the

eligibility criteria or self-payments

under the Plan. You will be notifi ed of

any changes, and all changes would

be subject to the Plan’s provisions and

applicable laws.

8 1

This Plan may be discontinued or terminated under certain circumstances, for example if future

collective bargaining agreements and participation agreements don’t require employer contributions

to the Fund. In such event, benefi ts for covered charges incurred before the termination date will

be paid on behalf of eligible family members as long as the Plan’s assets are more than the Plan’s

liabilities. Full benefi ts may not be paid if the Plan’s liabilities are more than its assets, and benefi t

payments will be limited to the funds available in the trust fund for such purposes. The Trustees will

not be liable for the adequacy or inadequacy of such funds.

The Fund has the right to recover any overpayments made under the Plan, regardless of why the

overpayment was made. Recovery can be made from any persons (including family members),

insurance companies or any other organizations.

As a participant in the Health and Welfare Plan of the Midwest Operating Engineers Health and

Welfare Fund, you are entitled to certain rights and protections under the Employee Retirement

Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be enti tled to:

Receive Information About Your Plan and Benefi ts

■ Examine, without charge, at the Plan Administrator’s offi ce (the Fund Offi ce) or the offi ce of

the Board of Trustees and at other specifi ed locations, all documents under which this Plan is

maintained, including insurance contracts, your collective bargaining agreement and copies of

all documents fi led by the Plan with the U.S. Department of Labor and available at the Public

Disclosure Room of the Employee Benefi ts Security Administration.

■ Upon written request to the Plan Administrator, obtain copies of all documents under which this

Plan is maintained, including information as to whether a partic ular employer is a contributing

employer and, if so, the employer’s address. A reasonable charge may be made for the copies.

■ Receive a summary of the Plan’s annual fi nancial report. The Plan Administrator is required by law

to furnish each participant with a copy of this summary annual report.

■ Reduction or elimination of exclusionary periods of coverage for pre-existing condi tions under

your group health Plan, if you have creditable coverage from another Plan.

Plan Discontinuation or

Termination

Right to Recover

Overpayments

Your ERISA Statement

of Rights

G ENER AL PLAN PR OVIS IONS 8 2

Continue Group Health Plan Coverage

■ In certain cases you can continue health care coverage for yourself, spouse or depen dents if

there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents

may have to pay for such coverage. Review this Summary Plan Description and the documents

governing the Plan on the rules governing your COBRA coverage rights.

■ You will be provided a certifi cate of creditable coverage, free of charge, when you lose coverage

under the Plan, when you become entitled to elect COBRA coverage, when your COBRA coverage

ceases, if you request it before losing coverage, or if you request it up to 24 months after losing

coverage. Without evidence of creditable cov erage, you may be subject to a pre-existing condition

exclusion for 12 months (18 months for late enrollees) after your enrollment date in your new

coverage.

■ You are entitled to a reduction or elimination of exclusionary periods of coverage for pre-existing

conditions under this Plan if you have creditable coverage from another plan. You should be

provided a certifi cate of creditable coverage, free of charge, from your prior group health plan or

health insurance issuer when you lose coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are

responsible for the operation of the employee benefi t plan. The peo ple who operate your Plan, called

“fi duciaries” of the Plan, have a duty to do so pru dently and in the interest of you and other Plan

participants and benefi ciaries. No one, including your employer, your Union, or any other person,

may fi re you or other wise discriminate against you in any way to prevent you from obtaining a

welfare ben efi t or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefi t is denied in whole or in part, you must receive a written explana-

tion of the reason for the denial. You have the right to have the Plan review and reconsider your

claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you

request materials from the Plan and do not receive them within 30 days, you may fi le suit in a federal

court. In such a case, the court may require the Plan Administrator to provide the materials and pay

you up to $110 a day until you receive the materials, unless the materials were not sent because of

reasons beyond the control of the Plan Administrator. If you have a claim for benefi ts that is denied

or ignored, in whole or in part, you may fi le suit in a state or federal court. If you believe that Plan

fi duciaries have misused the Plan’s money, or if you believe you have been discriminated against for

asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may fi le

suit in a federal court. The court will decide who should pay court costs and legal fees.

83

Assistance With Your Questions

If you have any questions about your Plan, you should contact the Administrative Manager. If you

have any questions about this statement or about your rights under ERISA, you should contact the

nearest offi ce of the Employee Benefi ts Security Administration, U.S. Department of Labor, listed in

your telephone directory or the Division of Techni cal Assistance and Inquiries, Employee Benefi ts

Security Administration, U.S. Depart ment of Labor, 200 Constitution Avenue N.W., Washington,

D.C. 20210. You may also obtain certain publications about your rights and responsibilities under

ERISA by calling the publications hotline of the Employee Benefi ts Security Administration. You may

also fi nd answers to your questions and list of EBSA fi eld offi ces at the website of the EBSA at

www.dol.gov/ebsa.

How to Read or Get Plan Material

You can read the material listed in the above section by making an appointment at the Administrative

Manager’s offi ce during normal business hours. Also, copies of the material will be mailed to you

if you send a written request to the Administrative Manager. There may be a small charge for

copying some of the material, so call the Fund Offi ce to fi nd out the cost before requesting material.

If a charge is made, your check must be attached to your written request for the material. The

Administrative Manager’s address and phone number are:

Mr. David S. Bodley

Midwest Operating Engineers

6150 Joliet Road


(708) 482-7300

Definitions

8 4

85

The following are defi nitions of specifi c

terms and words used in this booklet.

Eligible Provider. Eligible provider means any of the

practitioners on the right who are licensed and/or legally

authorized to practice under the laws of the state where

the services are rendered:

Experimental or Investigative. A drug, device, treatment

or procedure is considered an experimental or investigative

service if it is still being tested, or if additional tests are neces-

sary to determine it’s maximum tolerated dose, its toxicity, its

safety, its effi cacy or its effi cacy as compared with a standard

means of treatment or diagnosis. This includes products and

services that have been approved for a particular treatment

regimen but that are not being used in that manner. A more

complete defi nition is provided in the Plan Document.

Medically Necessary. A service or supply is “medically

necessary” if a physician, exercising prudent clinical

judgement, would provide it to the patient for the purpose

of evaluating, diagnosing or treating an Illness or Injury

or its symptoms, and:

1. it has been established as safe and effective by the

American Medical Association or

appropriate governing body;

2. it is furnished in accordance with generally accepted

professional medical standards for

treatment of Illness or Injury;

3. it is consistent with the signs, symptoms or diagnosis

and treatment of an illness or injury;

* The maximum allowable charge will be 85% of the allowable expense for a physician performing the same service

Eligible Providers

Physicians

Doctor of Medicine (M.D.)

Doctor of Osteopathy (D.O.)

Other Covered Practitioners

Advanced Practice Nurse*

Certifi ed Mental Health Counselor

Certifi ed Registered Nurse Anesthetist

Clinical Professional Counselor

Clinical Psychologist

Clinical Social Worker

Doctor of Chiropody (D.P.M., D.S.C.)

Doctor of Chiropractic (D.C.)

Doctor of Dental Surgery (D.D.S.)

Doctor of Medical Dentistry (D.M.D.)

Doctor of Podiatry (D.P.M.)

Licensed Acupuncturist

Occupational Therapist (O.T.)

Occupational Therapy Assistant -

when supervised by an O.T.

Optometrist – accidental injury to eye only

Orthoptic Technician – for orthoptics only

Physical Therapist (P.T.)

Physical Therapy Assistant – when supervised by a P.T.

Physician’s Assistant

Surgical Assistant (when services would be covered if

performed by an M.D.)

Registered Nurse

Speech Therapist

Facilities

Ambulance Service

Home Health Care Agency

Hospice

Hospital

Laboratory

Licensed Ambulatory Care Facility

MRI Centers

Skilled Nursing Facility

DEF IN IT IONS 8 6

4. it is not primarily for the convenience of the eligible

person or his doctor;

5. it is the most appropriate supply or level of service

which can be safely provided;

6. it is necessary and appropriate treatment of the illness

or injury;

7. it is not experimental or investigative in nature; and

8. it is not cosmetic in nature; that is, the treatment

restores or repairs function.

The fact that a physician or other health care provider

deems a service or supply to be medically necessary is not

binding on the Trustees.

Municipality Employee. An employee of a municipality

who is permitted to participate in this Plan under the terms

of a collective bargaining agreement or participation agree-

ment. “Municipality” means a city, village, town, county,

township, school district, park district, sanitary district, or

any other similar government district, or government divi-

sion or subdivision, or cooperative government body or any

“Public Employer” as defi ned in the Illinois Public Relations

Act or an “Educational Employer” as defi ned in the Illinois

Educational Labor Relations Act.

Owner/Relative. A corporate shareholder, offi cer and/or

director, or a relative (as defi ned in the collective bargain-

ing agreement) of a shareholder, offi cer and/or director for

whom contributions are required to be made to this Fund.

Reasonable and Customary Charges. With respect to a

PPO provider, the reasonable and customary charge means

the charges set forth in the agreement between the PPO

provider and the PPO or the Plan. With respect to non-PPO

providers, the reasonable and customary charge will be

determined by the Administrative Manager or its designee

to be the lowest of:

■ the usual charge by the provider for the same or similar

service or supply;

■ no more than the prevailing charge of 90% of the provid-

ers in the same or similar geographic area for the same

or similar health care service or supply; or

■ the provider’s actual charge.

The “prevailing charge” of most other providers in the

same or similar geographic area for the same or similar

health care service or supply shall be determined by the

Administrative Manager who shall use proprietary data

that is updated no less frequently than annually, and pro-

vided by a reputable company or entity.

For Medicare-eligible participants, the reasonable and

customary charge is the amount approved by Medicare.

Staff Employee. A person employed by and under the

direction and control of any of the following: the Union, an

employer association, the Trustees of the Midwest Operat-

ing Engineers Pension Fund, the Trustees of the Midwest

Operating Engineers Welfare Fund, the Trustees of the

Operating Engineers Local 150 Apprenticeship Fund, the

Trustees of Local 150, I.U.O.E., Vacation Savings Plan, the

Trustees of the Midwest Operating Engineers Construc-

tion Industry Research Service Trust Fund, or the Midwest

Operating Engineers Information Technology Services

Corporation, on whose behalf the employer is obligated to

make contributions to the Fund.

Administrative Information

87

ADMIN ISTR AT IVE INFOR MATION 8 8

This section provides you with information about how the

Midwest Operating Engineers Health and Welfare Plan is administered.

Name of Plan

Health and Welfare Plan of the Midwest Operating Engineers Welfare Fund

Plan Sponsor and Plan Administrator

Board of Trustees

Midwest Operating Engineers Health and Welfare Fund

6150 Joliet Road


(708) 482-7300

The Board of Trustees consists of an equal number of employer and union representatives, selected

by the employers and Local 150 I.U.O.E. which have entered into collective bargaining agreements

which relate to this Plan.

The Board of Trustees is responsible for the operation of the Plan. The Board is made up of an equal

number of employee representatives selected by Local 150 and employer representatives selected

by employer associations whose members have entered into collective bargaining agreements with

Local 150.


Mr. David S. Bodley

The Administrative Manager is an employee of the Fund who assists the Trustees in the

administration of the Plan.

Employer Identifi cation Number

EIN – 36-6109395

Plan Number

501

89

Funding of the Plan

This is a self-insured welfare plan governed by federal laws and not state laws. This Plan is funded

primarily through employer contributions. Self-pay contributions are also used for funding. The

amount of employer contributions and the individuals on whose behalf contributions are required

to be made are determined by the provisions of the collective bargaining agreements between

employers and employer associations, and Local 150. The collective bargaining agreements require

contributions to the Fund and stipulate the method for determining the amount to be contributed

and the date such contributions are due. The Fund Offi ce will provide you, upon written request,

information as to whether a particular employer is contributing to the Plan on behalf of participants

pursuant to a collective bargaining agreement. The Fund Offi ce will also provide you, at cost and

upon written request, copies of the collective bargaining agreements. Administrative employees

of the Fund are also entitled to participate in the Plan. The Fund may also receive rebates from its

pharmacy benefi ts manager.

The Fund provides medical, surgical, hospital, dental/orthodontia and death benefi ts on a self-

insured basis. When benefi ts are self-insured, the benefi ts are paid directly from the Fund to the

claimant or benefi ciary. The self-insured benefi ts payable by the Fund are limited to the Fund assets

available for such purposes. As described earlier in this Summary Plan Description, Blue Cross

re-prices PPO claims involving medical, surgical and hospital benefi ts, and Guardian Life re-prices

dental PPO claims. However these services are limited to the amount the Fund must pay providers,

and all benefi ts paid remain self-insured. This Plan is not an insurance policy and no benefi ts are

provided through an insurance company.

A DMIN ISTR AT IVE INFOR MATION 90

Welfare Fund Assets and Reserves

The title to all assets is held by the Trustees in their representative capacity for the purpose of

providing benefi ts to eligible employees and their eligible dependents and defraying reasonable

administrative expenses.

Plan Year

The Plan Year begins on January 1 and ends the following December 31.

Agent for Service of Legal Process

Bernard M. Baum, Esq.

Baum Sigman Auerbach & Neuman, Ltd.

200 West Adams Street, Suite 2200

Chicago, Illinois 60606-5231

or

Michael W. Duffee, Esq.

Ford & Harrison

55 East Monroe Street, Suite 2900

Chicago, Illinois 60603-5209

Legal process also may be served on the Plan Trustees.

If you have any questions about your benefi ts or if you need to provide updated address, dependent

or benefi ciary information, please contact the Fund Offi ce. Also, you have the right to get answers

from the Trustees. You are also guaranteed specifi c rights under ERISA, as outlined in the next

section.

Getting Accurate Information

As you know, benefi ts are paid in accordance with Plan provisions out of a trust fund used for that

purpose. Remember that although this booklet provides accurate and essential information about

the Welfare Plan, it is not a complete description. If there is ever a confl ict between this booklet and

the Plan’s legal document, the Plan Document will control.

91

Union Trustees Employer Trustees

Mr. James M. Sweeney, Fund Chairman

President and Business Manager

Local 150 I.U.O.E.

6200 Joliet Road


Mr. Steven M. Cisco

Recording-Corresponding Secretary

Local 150 I.U.O.E.

6200 Joliet Road


Mr. Marshall Douglas

Treasurer

Local 150 I.U.O.E.

3511 78th Avenue West

Rock Island, IL 61201

Mr. David Fagan

Financial Secretary

Local 150 I.U.O.E.

2193 West 84th Place

Merrillville, IN 46410

Mr. James McNally

Vice President

Local 150 I.U.O.E.

6200 Joliet Road


Mr. John E. Kenny, Jr., Fund Secretary-Treasurer

President

Kenny Construction Company

2215 Sanders Road, Suite 400

Northbrook, IL 60062

Mr. Mike Piraino

President

PirTano Construction Company

1766 Armitage Court

Addison, IL 60101

Mr. David Snelten

Excavators, Inc.

8603 Pyott Road

Lake in the Hills, IL 60102

Mr. Britt Lienau

Elmhurst-Chicago Stone Company

400 West First Street

Elmhurst, IL 60126

Mr. Steve Michaels

Superior Construction Company, Inc.

2045 East Dunes Highway

Gary, IN 46401


David S. Bodley

Board of Trustees

Health and Welfare Plan...Plan will coordinate (supplement) those beneﬁ ts. 2. Prescription Drug...

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