Twin City Ironworkers Fringe Funds


Form 1095-B Information



HEALTH & WELFARE

PLAN DOCUMENTS AND NOTICES

Summary Plan Description (SPD)

The SPD summarizes the key provisions of the Plan and includes important information about your benefits from the Plan.

Summary of Material Modifications (SMM)

The SPD is updated from time-to-time and includes additional information and changes to the Plan in the form of an SMM.

Summary Annual Report

The Summary Annual Report provides insurance and basic financial information regarding the Plan and informs you of your rights to additional information.

Notice of Privacy Practices

This document provides you with a quick reference to covered expenses, deductibles and out-of-pocket costs. This is not a full explanation of the benefits covered by the Plan. For more information about the benefits covered by the Plan, see the enclosed Summary Plan Description and Benefit Alerts.

WHCRA and Privacy Notice

This notice includes important information about protections for individuals who elect breast reconstruction in connection with a mastectomy as well. In addition, this notice informs you how you can request a copy of the Fund’s Privacy Notice. You will also receive this notice, annually, via US Mail.

Summary of Benefits and Coverage

This document provides you with a quick reference to covered expenses, deductibles and out-of-pocket costs. This is not a full explanation of the benefits covered by the Plan. For more information about the benefits covered by the Plan, see the Summary Plan Description and Benefit Alerts.

Medicare Part D Creditable Coverage

This notice contains information about your current prescription drug benefits and Medicare prescription drug coverage.

Nondiscrimination Notice

This notice states that the Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

FORMS

Family Update Form

If you have a life-changing event and need to update dependent information, this form must be completed and sent to the Fund Office, with the appropriate documentation (birth certificate, marriage certificate, divorce decree, etc.).

Change of Address Form

Complete this form to change or correct your mailing address and return it to the Fund Office.

Change of Name Form

Complete this form to change or correct your name and return it to the Fund Office.

Beneficiary Designation Form

To designate a beneficiary for your death benefit, you must fill out this form and return it to the Fund Office.

Dependent Affidavit Form

If you are not married to your natural child’s mother/father or if you are enrolling a step-child then you need to complete this form, have it notarized, and submit it to the Fund Office with any supporting documents.

Initial Report of Claims Form

If your provider does not automatically submit your bill to the Fund Office, Wilson-McShane Corporation, please complete this form and return it to the Fund Office with the appropriate itemized bills.

Subrogation Agreement

Complete this form to acknowledge the Fund’s subrogation and reimbursement interests. For more information, please contact the Fund Office.

Initial Disability Form

If you become disabled and are unable to work, you and your physician must complete this form and submit it to the Fund Office, in order to receive the weekly disability benefits.

Initial Disability During Pregnancy Form

If you become disabled while pregnant and are unable to work, you and your physician must complete this form and submit it to the Fund Office, in order to receive the weekly disability benefits.

Supplementary Disability Form

Once approved for the weekly disability benefit, to continue to receive the weekly disability benefit, you will be responsible to complete the Supplementary Disability Form.

Authorization for Release of PHI Form

If you want the Plan to disclose your protected health information to another individual(s), persons, class of persons, or organization of your choice (for example, your spouse), you must fill out this form and return it to the Fund Office. If your spouse and/or Dependent child(ren) over the age of 17 (i.e. Dependent child(ren) who are at least 18 years old) want the Plan to disclose their protected health information to you, they also must fill out this form and return it to the Fund Office.

FREQUENTLY ASKED QUESTIONS

Contact the Fund Office and ask to speak with an Eligibility Specialist. They will verify eligibility and request a new health & welfare ID card. Your new ID card will arrive within 7-12 business days from the date you notify the Fund Office that you need a new card. If you would like a temporary ID card emailed to you, please indicate such to the Eligibility Specialist.
Visit the desired health & welfare service provider's website, HealthPartners, Delta Dental of Minnesota, and ProAct, Inc.. Once you have selected the desired provider site, you may login to your account and search for in-network providers.
If you would like to access your EOBs, please visit the HealthPartners website. Once you are on the HealthPartners website, you will need to login to your account to access your EOBs.
How to Read Your EOB thoroughly explains the layout of your EOB and how to easily read the information provided.
If you receive services from a non-participating provider you may have to submit the claim to the Plan. If you need to submit a claim, you will need to request an itemized bill from the provider then complete an Initial Report of Claim Form. Forward the bill and completed form to the address as it appears on the claim form.
Complete a Beneficiary Designation Form and mail to the Fund Office.
To enroll your dependent child under the health plan, submit a completed Family Update Form. You must submit the completed enrollment form with the appropriate documentation to the Fund Office within 30 days of the event. If you do not enroll your dependent in 30 days, claims will be denied until you submit the required information.

Your natural child is eligible for coverage on the date of his or her birth. If you adopt a child, have a child placed with you for adoption, or acquire a stepchild through marriage, he or she will be eligible for coverage on the date of placement or marriage, as long as you are responsible for healthcare coverage and your child meets the Plan’s definition of a dependent child.
In order to change your mailing address, you must complete a Change of Address Form. You may print and complete the form, or you may contact the Fund Office and a form will be mailed to you.
To enroll your spouse for coverage under the Plan, submit a completed Family Update Form along with a copy of the marriage certificate to the Fund Office.

To enroll your dependent child for coverage under the Plan, submit a completed Family Update Form along with a copy of the birth certificate or adoption papers to the Fund Office.
If you are unable to work as a result of a non-work related injury or illness and you are under the care of a physician, you may be entitled to the weekly disability income benefit. To apply, submit a completed Disability Claim Form to the Fund Office. Once approved for the weekly disability benefit, you will be responsible to complete the Weekly Disability Supplementary Form.
Submit a completed Initial Report of Claims Form to the Fund Office.
The Summary Plan Description is the document that details the benefits of the health plan. The SPD will provide information about the health plan such as the applicable co-pay amounts, deductible amounts, and out of pocket maximums.
You will receive your medical card 7-10 business days from the end of the month, following receipt of the required contributions to be eligible for benefits.
You can review the Summary Plan Description electronically or you can call the Fund Office to request a hardcopy of the SPD Booklet.
When you marry, your spouse is eligible for healthcare coverage as of the date of your marriage. However, the Fund will not pay benefits on behalf of your spouse until you enroll your spouse for coverage. To enroll your spouse, send a copy of your marriage certificate to Fund Office, as soon as it is available and complete a Family Update Form. Once your spouse is enrolled, benefits will be paid retroactively to the date of your marriage.
If you and your spouse get a divorce or legal separation, your spouse will no longer be eligible for coverage. Your spouse may elect to continue coverage under COBRA for up to 36 months upon divorce or legal separation. You or your spouse must notify the Fund Office, within 60 days of the divorce or separation date for your spouse to obtain COBRA continuation coverage. You must also submit a copy of the divorce decree to the Fund Office.
You or your spouse must notify the Plan and mail a fully executed copy of your divorce decree to the Fund Office. Once the Plan receives the divorce decree, your former spouse’s coverage will be terminated on the last day of the month in which the divorce is finalized.
If you meet certain criteria defined in the health & welfare Summary Plan Description you and your family may be eligible to elect Retiree Coverage or be eligible for the Medicare Supplemental Reimbursement Benefit. Please contact the Fund Office for your retiree options for continuing health coverage.
If you meet certain criteria defined in the health & welfare Summary Plan Description you and your family may be eligible to elect Retiree Coverage or be eligible for the Medicare Supplemental Reimbursement Benefit. Please contact the Fund Office for your retiree options for continuing health coverage.
If coverage is lost due to lack of sufficient employer contributions and hours in your individual record system, then you will have the option to elect to continue coverage under COBRA for up to 18 months. Please contact the Fund Office with questions relating to your eligibility.
You may designate anyone as a beneficiary for death benefits payable for the loss of your life by submitting a Beneficiary Designation Form to the Fund Office. In the event of your death, your dependents may continue coverage for up to 36 months by electing COBRA continuation coverage or by electing the retiree plan for surviving spouses and dependents. Your survivors will need to make the required self-contributions for this coverage, however if you are a bargaining unit employee at the time of death, your qualified beneficiary(s) will continuation coverage will be continued at no cost for a period of one year from the end of the month in which death occurred.

SERVICE PROVIDERS

BlueCross BlueShield of Minnesota Logo.

Blue Cross Blue Shield of MN

Visit Blue Cross/Blue Shield of MN to:

  • Find a network provider
  • Access Member Center to view your claims and EOBs (Explanation of Benefits)
  • Find health and wellness information
Delta Dental of Minnesota Logo.

Delta Dental of MN

Visit Delta Dental of MN to:

  • Find a network provider
  • Access Member Portal to view dental benefits and claims history
Sav-Rx Logo.

Sav-Rx

Sav-Rx provides access to a retail pharmacy network, mail order prescriptions, and a specialty pharmacy for the treatment of complex conditions. Visit Sav-Rx to:

  • Find a network provider
  • Access Member Center to view your claims and EOBs (Explanation of Benefits)
  • Find health and wellness information
TEAM Logo.

TEAM (Employee Assistance Program)

Our partners at TEAM are dedicated to providing real life solutions to help you and your family achieve your goals in the workplace and at home.

LIFE EVENTS

(952) 854-0795     (800) 535-6373

3001 Metro Drive, Suite 500    Bloomington, MN 55425

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