Frequently Asked Questions
An Active employee, must work a minimum of 450 hours for one or more contributing Employers during a Qualifying Period to be covered for benefits in the next Eligibility Period.
The hours worked during the Qualifying Period determine the plan benefits you will be covered under during the “Eligibility Period”.
Hours needed to work during a Qualifying Period for insurance are:
An Eligibility Period is the months that you are eligible for insurance coverage.
January 1st through June 30th and July 1st through December 31st.
Hours needed to work for insurance coverage during a Qualifying Period are:
450 – 599 Coverage Plan B -Medical, (HMO) Kaiser or Health Net and Prescription Drugs
600 – 749 Coverage Plan A- Medical, HMO, Indemnity Plan, Dental, Prescription Drugs
750 + Coverage Plan A+-Medical, HMO, Indemnity Plan, Dental, Vision, Prescription Drugs
If you have worked a minimum of 450 hours during a qualifying period (see above) for a contributing employer you will be mailed an eligibility enrollment package. Packages are mailed at the end of the qualifying period in June and December.
When you receive the enrollment packages, you must remit an application for the coverage you have selected.
NO. Coverage is only available through contributions made by a contributing employer. The exception is COBRA. An Active Employee and/or eligible Dependent who loses eligibility may be eligible for continued coverage under the provisions of COBRA. To continue coverage under COBRA you are required to pay a monthly premium.
Yes. If they qualify as a legal dependent under the Plan Rules.
A “Dependent” is your lawful spouse. However, in accordance with state law, effective July 1, 2005, if you are enrolled in one of the Prepaid Medical plans, your dependent may include your domestic partner of the same sex or opposite sex (effective January 1, 2020), age 18 or older.
To qualify for domestic partner coverage, you must have registered as domestic partners with the Secretary of State and submit required proof of the relationship in accordance with the law. Your domestic partner’s children are not eligible for coverage.
Effective September 1, 2014 your dependents also include your dependent children to their 26th birthday. Legally adopted children and step-children are also considered eligible dependents.
A dependent over age 25 years of age may continue to be eligible as a dependent if he/she is incapable of self-support because of physical or mental incapacity that commenced prior to reaching the age of 26, provided a physician’s certification of disability is submitted within six months following their 25th birthday or the effective date of eligibility.
A dependent who is eligible for group benefits as an employee or as the dependent of any other employee other than one of his parents is still eligible until his or her 26th birthday. Proof as an eligible dependent is required.
PLAN B: You are required to enroll in an HMO either Kaiser or Health Net for medical benefits. You have no vision or dental benefits. Prescription drugs are reimbursed at 80% of the cost.
PLAN A and PLAN A+: have the option of enrolling in an HMO or the Roofers Indemnity Plan. You should be aware that the Roofers Indemnity Plan does have a deductible and there are some services that are not covered (see tab for Summary of Benefits and Coverage). The HMO’S have a $20.00 co-pay per office visit. Prescription Drugs are reimbursed at 80% of the cost.
PLAN A: If you elect coverage under the Roofers Indemnity Plan you MUST use the providers listed online at www.ahfonline.org for in-patient and out-patient services. Benefits are payable at 80% of the AHF contracted rate. If you do not use providers listed in their website NO benefits are payable. You have dental under Delta Care. There are no vision benefits. Prescription Drugs are reimbursed at 80% of the cost.
PLAN A+: If you elect coverage under the Roofers Indemnity Plan you MUST use the providers listed online at www.ahfonline.org for in-patient services. If you do not, NO benefits are payable. For outpatient services you may use providers not listed on their website, but benefits will be paid at 80% of the contracted AHF rate instead of 100% of the contracted rate. You have dental under Delta Care, and vision benefits. Prescription drugs are reimbursed at 80% of the cost.
For more information please click Summary of Benefits
Yes, Prescription Drugs are reimbursed at 80% of the cost. A claim form and receipt must be submitted. Go to the Forms page and click on “Prescription Drug Claim Form” and download the form. Prescription Drug Benefits are covered under the Indemnity Plan. There are no prescription drug benefits available through Kaiser or Health Net.
Carefully complete all of Part A of the claim form and attach a copy of the itemized receipt(s) for your prescription purchases. The receipt must show the drug name, the cost of the drug, the prescription number (that must match the pharmacy receipt) date of purchase, patient name, prescribing doctor and the name, address and phone number of the pharmacy where the prescription was purchased must also be shown on the receipt. The Active participant must always sign the form. If the claim is for a spouse, the spouse must sign or if the claim is for a dependent child over age 18, the dependent must sign.
Prescription Claim Form and Receipts are to be remitted to the address on the form.
Claims must be filed within 90 days of loss. If not filed within one year of the date of purchase, regardless of the reason, the claims will not be honored.
If you are unable to work due to a disability that started while you are actively eligible for benefits, you will be given credit for disability hours at the rate of 8 hours per day (excluding holidays and weekends) not to exceed 40 hours per week, for a period not to exceed the date of your recovery or 6 months (whichever occurs first). You cannot use certified disability hours to upgrade to Plan A or Plan A+.
The credited hours will be applied to the hours required during the Qualifying Period for the next Eligibility Period. These hours can only be used to qualify for Plan B benefits. Not more than 6 months of Certified Disability Credits are available for any disability.
Certified proof of disability must be furnished at the time the disability starts and once each month after that until you return to work for a contributing Employer. The proof of disability must be submitted by your Doctor (M.D., D.O. or PhD.) in writing on their letterhead (prescription forms or pre-printed forms are not acceptable). The proof must show the beginning date of total disability, the diagnosis, and the date you are expected to be able to return to work. You must be under the care of a physician to qualify for benefits
All hours actually worked by you for a contributing employer in excess of 750 in a Qualifying Period are kept in an “Hour Bank” account. Up to 50 hours per Qualifying Period may be banked for you. Your Hour Bank cannot exceed 400 hours at any time.
You may use up to 100 hours in your Hour Bank to be eligible for Plan B benefits if you do not work enough hours for other coverage. You cannot use bank hours to upgrade to Plan A or A+ coverage.
All hours in your Hour Bank will be cancelled if you do not satisfy the requirements for becoming eligible for benefits during two consecutive Qualifying Periods.
Exception: Effective May 1, 2000 if you are age 54 or older on the date eligibility is run, you may use a maximum of 200 hours from your Hour Bank to obtain Plan B coverage.
If you are an ACTIVE Union Roofer Employee, please contact the Union Roofers Health and Welfare Fund for additional information (562) 927-1434.