UNION ROOFERS HEALTH AND WELFARE FUND SUMMARY OF MATERIAL MODIFICATION IMPORTANT NOTICE
Date: April 20, 2023
To: Participants and COBRA Beneficiaries in the Union Roofers Health and Welfare Fund
Re: Pre-Certification Requirements, Improved Vision Benefits, and Clarification of Dental Options
This notice advises you of certain material modifications (plan changes) that have been made to the Union Roofers Health and Welfare Fund (the Plan). This information is very important for you and your eligible dependents. Please take the time to read this notice carefully. Also, please keep it along with your Summary Plan Description (SPD) dated January 1, 2020 and other Summaries of Material Modifications (SMMs).
Aviso a los participantes de habla hispana: Si tienen alguna pregunta relacionada con este aviso o necesitan información adicional sobre su cobertura de salud, por favor comuníquense con la oficina administrativa al (562-927-1434), donde habrá varios representantes bilingües que estarán dispuestos a ayudarles.
1. Effective July 1, 2023, the Union Roofers Health and Welfare Fund (Fund) has revised its pre-certification
requirements under its “Claims and Appeals Procedures,” as follows:
b. Pre-Service Claims
Pre-Service Claims are claims that require pre-certification before treatment is rendered. You must obtain
pre-certification in the following situations:
1. Elective procedures must be pre-certified by calling the Trust Fund Office at (562) 927-1434.
2. Dental expenses that are estimated to exceed $500.00 must be submitted for prior approval. The Dentist or orthodontist must submit the proposed treatment plan and x-rays to the Fund Office.
This section above replaces the “Pre-Service Claims” section set out on page 121 of the SPD, located under “Article XII, section A.2.b” of the Plan. (The SPD includes the complete text of the Plan, beginning on page 72). Further, these Pre-Service rules are subject to change and may be modified again in the future.
2. Improved Vision Benefits
Effective January 1, 2023 the vision care benefits have been enhanced, The allowance for glass frames is increased to $185, with an additional $20 provided for featured frame brands. The combined allowance for contacts and the contact lens exam, instead of glasses, is $150. (Before this improvement, the allowance for contact lenses was $75). Please see the attached benefits summary for more information.
This section above should be read alongside pages 70 and 71 of the SPD.
3. Clarification of “Dental Benefits Available to Non-Contract Employees”
The Fund permits Non-Contract Employees to be covered under the Fund, provided certain requirements are met. After having been in the prepaid DHMO Dental plan for one year, Non-Contract Employees may change to the PPO Dental plan during the Open Enrollment Period (or remain in the prepaid DHMO Dental Plan), but they may not enroll in the Indemnity Dental Plan. The Indemnity Dental Plan has not and is not available to Non-Contract employees, who are not currently enrolled in that plan.
The section above replaces the second to last sentence under “Benefits Available to Non-Contract Employees” on page 1 1 of the SPD and replaces the last sentence under Article Il, section 2(c) on page 80 of the Plan.
Please direct any questions to the Fund office at (562) 927-1434.
Board of Trustees
In accordance with ERISA reporting requirements, this document serves as your Summary of Material Modifications (SMM) to the Plan and we are advising you of these Plan changes within 60 days of the adoption of the Plan changes. Receipt of this notice does not constitute a determination of your eligibility. If you wish to verify eligibility, or if you have any questions regarding these Plan changes, contact the Administrative Office.
NOTICE OF GRANDFATHERED STATUS
This group health plan believes that this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). As permitted by the PPACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the PPACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the PPACA, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Union Roofers Health and Welfare Fund. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered plans.