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Questions and Answers
Displayed below is a list of frequently asked questions. Click on a question to show its answer
VSP stands for Vision Service Plan which has been contracted by the Fund to administer vision care benefits (for those participants with vision coverage). The highest benefits are paid when you use a VSP provider. To locate a list of VSP providers visit www.vsp.com or (800) 877-7197.
Based on current activity it is recommend that you file your Retirement Application with the Trust Fund office at least 60 days, but not more than 150 days, before your requested date of retirement.
You must mail or bring in your Sick-Leave claim form to the Trust Fund office or your Union Local can fax the claim form to the Trust Fund office once they have reviewed the form.
No. If the physical therapy treatments exceed 30 visits for the same injury or condition, continuing treatments are subject to medical review. But there is nothing further the patient needs to do for treatments up to 30. Prior authorization for physical therapy is not required. Blue Shield notifies the physical therapy provider that treatments beyond 30 are subject to review for medical necessity. If a PPO provider provides physical therapy treatments above 30 that are found to not meet medical necessity, the patient will not be billed. If a non-PPO provider provides physical therapy treatments above 30 that are found to not meet medical necessity, the patient may be billed for the treatments above 30 not covered by the Plan.
UEBT members - To be eligible for first day Sick-Leave Benefits, the Participant must be seen and treated by a physician during the disability period.
Drug Fund members - To be eligible for first day Sick-Leave Benefits, the Participant must be seen and treated by a physician within the seven day period following the commencement of the disability and you must also have at least 180 hours in your Sick-Leave bank on the last day of the month preceding your disability.
No, you must submit your change of address in writing by completing the Change of Contact Information Form. You can call the Trust Fund or your Union Local office for the form or you can download it off the Trust Fund website Resource Tab/Forms. Important to note: If you are collecting a pension payment from this Fund (with California state tax withheld) and are moving out of state, you will need to send/fax a Tax Withholding form to the Trust Fund indicating that you “do not want California Personal Income Tax withheld” from your monthly Pension. You can call the Trust Fund or your Union Local office for the form or you can download it off the Trust Fund website Resource Tab/Forms. The Trust Fund does not have the capability to deduct for state taxes other than California.
Coinsurance is a % of the Covered Expense that you pay. The Fund pays the balance of Covered Expenses. Coinsurance applies to services that are subject to the Deductible which must be satisfied before the Fund pays its portion of the Covered Expense. Coinsurance levels are higher for non-PPO services. Use PPO providers to lower your out-of-pocket expenses.
The IRS came out with new FIT withholding schedules, based on filing status, and the Trust Fund is required to use them. If you would like to change your withholding, click here to download a withholding election form. Please send the completed form to the Trust Fund office at 1277 Treat Blvd., Walnut Creek, CA 94597 Attn: Pension Dept. You can also fax the form to the Trust Fund office at (925 746-7552).
The cost of having tests done at a PPO hospital can be significantly higher than those performed at a free-standing PPO x-ray or lab facility. Search your PPO network website for a freestanding x-ray/lab facility near you.
Once Open Enrollment is over, you have missed the opportunity to change carriers if so eligible to do so, unless under special circumstances. If you didn’t participate in Open Enrollment, you are required to participate in Annual Verification where you provide verification of your personal and family information and update any changes. Failure to participate in Open Enrollment or Annual Verification will result in denial of claims in 2011 until you participate.
HMO stands for Health Maintenance Organization. An HMO is an organization of healthcare providers, including hospitals and diagnostic centers. A Participant must select a primary care physician who is a member of the HMO network. In most cases, the participant must obtain a referral from their primary care physician to see a specialist. HMO provides coverage only for in-network care.
PPO stands for Preferred Provider Organization. Participants covered under a PPO Plan are free to either use doctors and hospitals from within the PPO’s network or to go outside of the network for healthcare. However, there may be significantly higher out-of-pocket expenses when using an out-of network provider. Participants are not required to obtain referrals to visit a specialist healthcare provider.
Go to www.ufcwtrust.com. Resource Tab/Provider Contacts. Click Blue Shield of California:
(Instructions on finding a Blue Shield provider).
If everything is complete, seven (7) business days after the claim is received at the Trust Fund office.
Phone Center Hours: Monday thru Friday, 7:30 am to 5:30 pm Office Hours for Front Desk Walk-ins: Monday thru Friday, 8:30 am to 4:30 pm
Under the PPO Plan, you may use any provider for your medical care. However, the plan pays a higher level of benefit and your deductible is lower when you use a provider from the PPO network. You save money because the plan has negotiated rates with PPO provider. In addition, there are no claim forms to file when you use a PPO provider. You should always verify that your provider is a contracted provider in the PPO network at the time you make an appointment for services. Even if they have been a PPO provider in the past, the provider may have changed and not informed you. Also, verify that any specialist or facility referred by your PPO primary care physician is also a PPO provider, otherwise you will pay a higher level of benefit for their services.
Even if the information on record with the Trust Fund is correct and you do not want to make any changes, you are still required to participate. You may not receive important notices about your benefits because the plan may not have your correct mailing address Your beneficiary information may not be current Health care providers may not be able to verify your coverage You and your dependents’ claims will be denied until your form is returned and you may face delays when you need to use your benefits If your marital status changes and the Trust Fund Office is not notified in a timely manner, claims may be paid in error and you will be responsible for repaying the Trust Fund for any claims paid because you did not provide the information in a timely manner
Accident letters help the Trust identify those situations when another payer is responsible for the medical care expenses. Car accidents and workers comp injuries are two very common examples.
If your spouse/domestic partner is not offered other group coverage, the UFCW & Employers Benefit Trust (UEBT) Active Plan requires documentation on official letterhead from your spouse’s/domestic partner’s employer. The documentation must confirm that group health insurance is not offered or available to your spouse/domestic partner. If your spouse/domestic partner is offered coverage but is unable to enroll in his/her health plan at this time, but must instead wait until that plan’s next open enrollment, UEBT will allow a one-time grace period until that other plan’s effective date of coverage. This grace period only applies to participants who did not participate in the March 2013 Open Enrollment. You are required to provide documentation from that plan or the employer stating that immediate enrollment is not possible, the date of the next open enrollment, and the effective date of coverage. During this grace period, benefit payments through UEBT will not be reduced.
You should contact your or your spouse’s/domestic partner’s employer(s) and/or former employer(s) to ask about available coverage.
Yes, if a dependent child is eligible for coverage under UEBT, you can enroll the dependent child without enrolling your spouse/domestic partner.
You must select a different plan during Open Enrollment. Your options are the PPO Plan or Kaiser. Please note that if you choose the PPO Health Care Partnership (HCP) option or Kaiser HCP, you must complete the HCP Action Steps by the stated deadline. As a current Health Net member, you will complete the INITIAL Action Steps through MedExpert, even if you are electing Kaiser HCP for 2014. Once you are enrolled in Kaiser, you will follow the Kaiser Action Step requirements during the coming plan year.
No. If your spouse/domestic partner has access to group health coverage through their own current or former employer, only the spouse/domestic partner is required to enroll in it and is required to elect the coverage option that is most comparable to the UEBT Plan, regardless of cost. If the spouse/domestic partner does not enroll in that plan, or enrolls in a less comprehensive plan when a better plan is available to him or her, the
No. Dependent children enrolled in the UEBT Active Plan are not required to enroll in other employer provided coverage.
The premiums for Kaiser HCP and PD are the same as the PPO HCP and PD options, respectively. The dependent child premium for all plan options is calculated on a per child rate up to a maximum of 3 children, after which no additional premiums are required.
Yes. Up to 36 months of COBRA coverage is offered.
No, unless you also meet one of the following requirements: You may enroll your step-child, foster child, and adopted child or a child who has been placed with you for adoption. Legal guardianship alone is not enough to establish eligibility under UEBT.
Your spouse/domestic partner is required to take coverage available to them through their employer that is most comparable to the coverage provided by the UEBT. Therefore, in this situation your spouse would be required to enroll for medical coverage. You will be required to submit documentation, on the employer’s letterhead, stating that the other coverage is not available from that employer.
The general guidelines are to match the UEBT Active Plan levels in the following categories: Co-insurance, Out-of-Pocket maximum, and Deductible. If your spouse/domestic partner’s employer plans have a lower benefit, then they are required to take the highest level plan available that most closely resembles the UEBT plan option under which you are covered.
By January 1, 2014.
If you have had a physical after 1/1/13 and the required biometric information was collected at that time, all that is needed is for your physician to complete and return the Physician Biometric Screening Form, which is available on our website. If you have not had an annual physical, you may schedule one and take the Form with you to your doctor’s appointment. Have your Physician complete and fax the Form per the instructions on the Form. This 2013 visit may serve as your annual wellness visit provided by UEBT. Alternatively, you can contact Quest or a participating Safeway Pharmacy to schedule your biometric screening appointment. In addition, if you have already had your annual physical, but not all information was collected, the Fund will not pay for another physical at 100%. In that instance, we recommend that you obtain your biometric screening from Quest or a participating Safeway Pharmacy.
If you are currently a PPO member and would like to switch to the Kaiser HMO Health Care Partnership (HCP), you must complete all Action Steps, if not done already, through the MedExpert website by November 15, 2013. You will then complete your Healthy Lifestyles program through Kaiser based on your2014 Plan year election.
Quest Diagnostics’ phone number is 1-866-908-9440. You can call Monday-Friday, 5:00 a.m. to 6:30 p.m. PT and Saturday 5:30 a.m. to 2:00 p.m. PT. You can also schedule an appointment online by logging in to www.ufcwtrust.com, and clicking on the MedExpert button in the Open Enrollment Information page, you will then need to login to the Healthy Measures website, powered by MedExpert. After you schedule an appointment, Quest will send you a form that you must take to your appointment. You cannot schedule an appointment less than 10 days from the date you make the appointment.
Login to the Trust Fund office website at www.ufcwtrust.com. Click the MedExpert button and login to the MedExpert website. You will be able to view participating Safeway pharmacies nearest you. Click a link to schedule an appointment at your desired location. All Biometric Screening results obtained from your Safeway appointment can be viewed on the MedExpert site. You can also call (877) 258-2799.
All Kaiser Members will need to complete a Biometric Screening with Kaiser. You will need to complete your biometric health screenings (BMI, Blood Pressure, Cholesterol) per Kaiser Permanente’s clinical practice guidelines by November 15, 2013. You will be able to access the free online Total Health Assessment and Biometric Health screening instructions on October 15, 2013 by logging into www.ufcwtrust.com and clicking on the Kaiser button on the Open Enrollment Information page.
If you are currently a Kaiser member and would like to change to the Blue Shield PPO plan for 2014 you must complete your Biometric Screening through Kaiser. You will need to complete your biometric health screenings (BMI, Blood Pressure, Cholesterol) per Kaiser Permanente’s clinical practice guidelines by November 15, 2013. You will be able to access the free online Total Health Assessment and Biometric Health screening instructions on October 15, 2013 by logging into www.ufcwtrust.com and clicking on the Kaiser button on the Open Enrollment Information page.
If you are married and have enrolled your spouse/domestic partner prior to Open Enrollment or graduating to a higher plan level that offers the HCP option, both you and your spouse must complete the Action Steps by the deadline. If you get married after Open Enrollment, have enrolled in the HCP option, and completed the action steps, your new spouse will be enrolled in the HCP option also (assuming you make a timely request to enroll your spouse). Once the spouse is added, both the member and spouse are required to complete coaching calls if electing Blue Shield PPO HCP or The Kaiser Healthy Lifestyles Program if electing Kaiser HCP for the remainder of the year. At the next open enrollment, you and your spouse must complete all Action Steps by the deadline in order to remain in the HCP option. If you are enrolled in the Personal Direction option when you get married, you and your spouse will not be eligible to move to the HCP option until the next open enrollment.
It is the expectation of the Fund that you complete your required coaching calls. This does not change if you have dual coverage.
No. There are no coaching calls. Instead, Kaiser has an online only maintenance program that you must participate in. You and your covered Spouse/Domestic Partner must each earn six (6) points in the Healthy Lifestyle Program in 2014. Earning points in the Healthy Lifestyle Program consists of:
None at this time.
You AND your enrolled spouse/domestic partner (if applicable) are required to complete Coaching Calls with MedExpert. There will be several options available for you to complete these required calls:
If you are a Blue Shield PPO Member you can check your HCP Action Step status online at www.ufcwtrust.com within the HCP Action Steps portal at MedExpert or by calling 1-800-999-1999.If you are a Kaiser Member you can check the status of your HCP Action Steps by logging into www.ufcwtrust.com and clicking on the Kaiser button where you will login to your Kaiser Healthy Lifestyles program, all of your HCP information will be available to you on the Kaiser site.
In general, yes. Blue Shield of California PPO providers have agreed to accept Blue Shield’s contracted rate as payment in full for covered services.
Yes, the deductible and coinsurance apply to primary care office visits for the treatment of an illness or injury or a specialist visit. The deductible does not apply to preventive care, screenings and immunizations. The deductible does not apply to chiropractic/acupuncture visits.
No. Non-preferred drug co-payments will not be reimbursed through the HRA.
Not at this time.
Yes. Catamaran is available for calls from Members regarding the new MPD program shortly before the effective date of this program. The number for Catamaran is 1-866-635-6906 and is open 24 hours a day, 7 days a week.
If you have filled a prescription within approximately the last four months for a non-preferred medication included in the MPD program, you will receive a letter identifying the non-preferred medication, the preferred alternative medication, and the cost to you if you choose to continue to receive the non-preferred medication instead of switching to the preferred alternative medication.
To be considered for an exception, your doctor must complete and submit the exception request form to Catamaran, which will be available at www.ufcwtrust.com when this program is available.
You may appeal the denial to the Board of Trustees. All appeals received will follow the Plan’s normal appeal process.
No. In order to be eligible for PPO dual coverage, both members must be in the HCP plan option and have the same dependents covered under each plan.
Dependent children who are eligible on their own but also eligible as a dependent will receive the higher level of benefits available (generally as a dependent).
Dual covered participants meeting all the Fund’s eligibility requirements will be provided 100% network coverage and will not be subject to co-insurance, co-payments, or deductibles. This 100% benefit does not apply to non-network services or non-preferred prescription drug co-payments.
When outside of California, you should use a Blue Card provider to have the highest level of benefits for non-emergency services. Please visit our website here: www.ufcwtrust.com to find in-network providers in California, nationwide and globally or call Blue Shield at the number on the back of your Blue Shield card: (800) 810-2583. If you have an emergency while you are traveling, you should go to the nearest facility for treatment.
Unless there is a qualifying event as outlined in the Summary Plan Description (SPD), your next opportunity to enroll your eligible dependents will be at the next open enrollment.
No. If, on or after 3/1/13, a surviving spouse becomes covered under a group health plan (active or retiree), opts out to enroll in an individual/personal medical plan (HMO, PPO, indemnity, etc.), or remarries, coverage under UEBT-R will be terminated and the surviving spouse will not be able to re-enroll in UEBT-R in the future. A surviving spouse who is currently covered under UEBT-R and is also already covered by another group health plan or who was remarried prior to 3/1/13 is allowed to remain covered under UEBT-R. Coverage will also be terminated permanently for anyone else (other than a surviving spouse) who opts out of UEBT-R after 3/1/13 for any reason, except when they are covered by another group plan.
The TFO requires documentation on the employer’s letterhead confirming health insurance is not available to your spouse/domestic partner.
No, if you opt out of UEBT-R, you can only request re-enrollment if you lose your other group coverage.
During open enrollment, the Retiree will need to identify which, if any dependent(s), they are enrolling under UEBT-R. If the Retiree is married but the Retiree does not elect to enroll the spouse/domestic partner, the spouse/domestic partner will not be eligible to enroll later unless the spouse/domestic partner had other group health coverage at the time s/he declined enrollment in UEBT-R and then loses that other group coverage. You must contact the UEBT-R Plan within 60 days of losing that coverage, or at the first open enrollment following the loss of coverage, in order to re-enroll in UEBT-R. If you do not meet these timelines, your spouse/domestic partner will never be allowed to re-enroll in UEBT-R.
Yes, if a dependent child is eligible for coverage under UEBT-R, the Retiree can enroll the dependent child without enrolling their spouse. The Retiree is not required to enroll their spouse/domestic partner. For retirements on and after 3/1/13, the retiree must have at least 25 Benefit Accrual Credits (BACs) under the Pension Plan to cover dependent children under UEBT-R.
No, you must enroll yourself in the coverage, but you are not required to cover your dependent spouse/domestic partner or children.
No. Effective March 1, 2013, if you drop UEBT-R coverage for any reason other than being covered by other group health coverage, you will not be able to re-enroll in UEBT-R. Individual coverage does not preserve your right to re-enroll in UEBT-R.
No. You are not required to enroll now but you can enroll now or elect to opt out because you are covered by other group health coverage. Please see Q&A 5, above, for the rules regarding opting back in under these circumstances.
There are circumstances under which UEBT-R may provide a benefit greater than what is provided for under a primary plan (i.e. a service that is excluded under a primary plan may be a covered benefit under UEBT-R). You should carefully review the coverage options available to you, keeping in mind that if you drop UEBT-R, you can only re-enroll later if you meet all the requirements.
If the student certification documentation already received by UEBT-R confirms the dependent is currently enrolled at the institution as a full-time student no additional documentation is needed until the period of time that documentation covers has ended.
Full-time student status is based on the definition established by the accredited institution.
Yes. In addition, in the event the student does not return to school as indicated in the intent letter, coverage will be terminated back to the end date of the last student certification and any claims paid during the period of ineligibility would be the responsibility of the Retiree.
Yes, up to 36 months.
When you enroll a dependent child during open enrollment, you will be given information about the student certification requirements and documentation you must provide by the deadline before enrollment can be completed for a dependent child age 19 through age 23.
The premiums for Kaiser coverage are the same as the PPO plan and are based on years of credited service and Medicare eligibility status. Note that non-Medicare retirees will pay the same premium without regard to whether they have individual only coverage or if they cover one or more dependents whereas a Medicare retiree will pay a per enrolled person premium.
No, unless you also meet one of the following requirements: You may enroll your step-child, foster child, and adopted child or a child who has been placed with you for adoption. Legal guardianship alone is not enough to establish eligibility under UEBT-R.
Typically, yes. If a primary plan pays more than UEBT-R would have paid if it were the primary plan, the patient is responsible for the patient’s portion due under the primary plan. Contact your primary plan for more information.
This depends on your primary plan’s reason for the denial. For instance, if your primary plan denied the claim for untimely filing, there may not be any benefit paid under UEBT-R if it was also untimely filed under UEBT-R. If the primary plan denied the claim because the service is a plan exclusion, but the service is covered under UEBT-R, UEBT-R would process the claim as primary. If the primary plan denied the claim because the service was not authorized, you should appeal to the primary Plan for a retro-active authorization from the primary plan.
In general, yes. Blue Shield of California PPO providers have agreed to accept Blue Shield’s contracted rate as payment in full for covered services. However, if you are covered by Medicare and the Blue Shield allowable charge is less than the Medicare allowable charge, the provider might bill you up to the Medicare allowable charge.
No. Pregnancy benefits are not covered under UEBT-R.
Amounts you are required to pay for deductibles and co-insurance by your primary plan do not count towards the deductible and out-of-pocket maximum limits under UEBT-R. Only amounts required to be paid by you under UEBT-R apply to your UEBT-R out-of-pocket maximum.
No, office visits require a $20 copay per visit. The deductible does not apply to the office visit; however, if other services are provided as part of the office visit, such as lab or x-rays, the deductible or co-insurance applies to those services.
The Medicare Supplement applies to the Self-Pay Plan and identifies the rate charged to an individual that is eligible for/has Medicare Parts A and B. Medicare Supplement rates also apply to certain grandfathered retirees (as well as transition months until Medicare Advantage is available).
No. The non-Medicare Health Net Plan is no longer available as of 3/1/13. Health Net is only available to a Medicare retiree whose spouse/domestic partner and eligible dependent children are also Medicare-eligible.
If you have filled a prescription for a non-preferred medication you will receive a letter identifying the non-preferred medication, the preferred alternative medication, and the cost to you if you choose to continue to receive the non-preferred medication.
You may appeal the denial to the Board of Trustees. All appeals received will follow the Plan’s normal appeals process.
Yes, it is still $100 per person.
Your doctor must complete the Catamaran exception request form, which must be submitted to Catamaran, to be considered for an exception.
When both spouses (or both Domestic Partners) are covered as Employees under UEBT, or when one is covered as an Employee and one is covered as a Retiree under UEBT-R, they must both enroll and cover the same dependents to have Dual Coverage. For example, a couple (both employees) with children must each elect family coverage in Open Enrollment.
Yes. Dual Coverage applies when both participants are covered as employees by the Active Plan, when both are covered as retirees under the Retiree Plan, or when one is covered by the Retiree Plan and one is covered by the Active Plan, if these requirements are met: both must be (1) enrolled with the same carrier, (2) have authorized premiums at the same level, and (3) if an Active member(s), must elect (and participate in) the Health Care Partnership (HCP) Plan option.
Yes, but the active member and spouse must be enrolled in the Kaiser HCP plan.
There is no dual coverage under this scenario; standard non-duplication of benefit rules apply.
Dependents who are eligible for Plan C on their own but also eligible as a dependent will receive the higher level benefits as a dependent.
Yes, if you apply for re-enrollment within 60 days of losing Tri-Care coverage.
Yes, the spouse may opt back in if proof of the loss of coverage is provided to the Fund within 60 days of loss of coverage.
Yes, if dental coverage is desired and you have elected dual coverage for your medical plan, then you must also elect dual coverage for your dental plan.
A Retiree and/or spouse or domestic partner can enroll in the UEBT Retiree Health Plan due to loss of other coverage but must provide proof (evidence of other group coverage) within 60 days of loss of coverage. If proof of loss of coverage and a request to enroll is not provided within 60 days of losing coverage, the next opportunity to re-enroll will be the first Open Enrollment after losing coverage.
If you are enrolled in Kaiser Senior Advantage, all injectable drugs must be supplied by Kaiser and there is no additional coverage under UEBT-R. If you are enrolled in Health Net, injectable drugs are covered by UEBT-R, subject to the deductible and co-insurance, if they are not covered under Medicare Parts A or B; UEBT-R will coordinate benefits between Health Net and the indemnity drug benefit.
Yes, the PPO out-of-pocket maximum is $3,000 per person / $9,000 per family.
No. The UEBT-R out-of-pocket maximum only includes amounts required to be paid under UEBT-R benefits.
Yes, due to non-duplication of benefits the Indemnity Medicare plan provides limited medical reimbursement. You may wish to purchase your own INDIVIDUAL Medicare supplemental program to help offset these claims expenses. PLEASE remember the main benefit provided to Medicare Indemnity participants is the Prescription Drug coverage. It is VERY important that if you buy your own individual supplemental insurance coverage it MUST NOT have prescription drug (Part D) coverage. Members who purchase individual Part D coverage will be dropped from the UEBT prescription drug coverage.
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