HEALTH PLAN

The North Central States Regional Council of Carpenters' Health Plan is an employer-paid health plan providing coverage to eligible employees and their dependents. Coverage may include major medical, dental, vision and prescription. Avoid unnecessary serious financial loss due to health care expenses with our Health Plan.

The majority of Fund assets are accrued through hours worked under a labor contract or approved participation agreement which require Employer payments to this Fund. In addition to Employer contributions, Fund assets also include interest earnings and employee self-payments.

Fund assets are used solely to provide a health care Plan to eligible employees, dependents, and beneficiaries and to pay for administrative expenses. The Plan covers certain expenses for medical, vision, and dental care and provides a weekly benefit if an eligible employee is determined to be temporarily disabled due to injury or sickness.

FORMS / PLAN DOCUMENTS & NOTICES

FORMS

Authorization to Release PHI Form

Beneficiary Form

Beneficiary Form (Spanish)

Health Family Form

Health Family Form (Spanish)

Reciprocity Forms

Statement of Illness of Injury Form

Statement of Illness of Injury Form (Spanish)

Deduct Premium Directly from Pension Check Form

Change of Address Form

Temporary Change of Address Form

Anthem Claim Form-Medical

Anthem Claim Form-Vision

Adult Child Coverage Cancellation Form

Accident and Sickness Benefit Form

PLAN DOCUMENTS & NOTICES

Health Summary Plan Description

Changes in Benefits 2024

Changes in Benefits 2022

Vision Benefits Summary

Organ Transplant Certificate 2023-2024

Health Plan Change Letter

Summary of Benefits and Coverage - Active Employee Plan 2025

Summary of Benefits and Coverage - Retired Employee Plan 2025

Important Health Coverage Tax Documents

Retiree Health Rates

COBRA Rates

CHIP Notice

COVID-19 OTC Test Reimbursement

Balance Billing

Notice of Nondiscrimination and Accessibility Services

Dental Election Notice

Dental Associates and Midwest Dental Locations

CarePlus Dental Program

Creditable Coverage

Amplifon Notice

Privacy Practices

Summary Annual Report (SAR)

Independence Administrators (IA) Announcement Letter

Teladoc General Member Independence Administrators (IA) Flyer

Independence Administrators (IA) Baby Beginnings Maternity Flyer

WEX Announcement

RetireeFirst Announcement

RetireeFirst FAQs

FREQUENTLY ASKED QUESTIONS

ELIGIBILITY

I just started working for a contributing employer. When will I be eligible for coverage with the North Central States Carpenters Health Plan?
You will be eligible for coverage on the first day of the second month after you work 390 hours of covered employment in a twelve-month period. For example, if you reach 390 hours during the month of June, you will be initially eligible on August 1.
How many hours do I have to work to keep my coverage?
After initial eligibility, you need 390 hours per work quarter or 1,560 hours per four preceding work quarters.
What are the quarters for eligibility?
Hours that you work in the work quarter of December, January, and February will determine eligibility for the coverage quarter of May, June, and July. There is a chart on the first page of the Eligibility Rules in your SPD that shows all the quarters for the year.
What happens if I do not work enough hours?
If employer contributions are not received to continue your eligibility, you will be notified thirty days prior to the end of your coverage and will be given the option to make self-payments. Payments are due by the 25th of the month preceding the month of coverage. For example, payment for June coverage is due on May 25.
How are the self-payments calculated?
The amount of your self-payment is based on the number of hours that you are short of the required number of hours, multiplied by the current Health Fund rate. Self-payments can be made for up to 18 months with no work hours reported.
Can I apply for single coverage?
No. The plan offers family coverage only.
How can I become eligible again if I do not pay the self-contribution amount?
If your coverage lapses, you can become eligible again by working the required number of hours. If it has been less than 12 months since your loss of eligibility, you will be eligible on the first day of the third month following the month that you work 450 hours of covered employment. For example, if you reach 450 hours in June, your eligibility will reinstate on September 1.

If it has been over 12 months since your loss of eligibility, the rules for initial eligibility would apply.
I have been working but my employer has not paid the required contributions to the health fund, what can I do?
Contact the Fund Office and let them know. You will be asked to send copies of your check stubs and to provide jobsite information. If you lose your eligibility because your employer failed to make the required contributions, you will receive self-payment information. If you do not make the self-payment, you will not have coverage until the employer makes the contributions. If you do make the self-payment and the contributions come in from the employer, you will be refunded up to the amount that you self-paid.
What if I work outside of the fund's jurisdiction?
You may have your hours transferred to the North Central States Carpenters' Health Fund. You should request a transfer form from the Fund Office before you begin working. The Fund will accept health contributions as long as it is within the previous twelve months. It can take up to 45 days for contributions to be reported to the Fund Office. Click the link to print a copy of the Health Reciprocity Form.
I am close to retirement age, can I continue the health coverage after I retire?
Yes, you may continue coverage for either Medical Benefits only or Medical, Dental and Vision Benefits. The retiree rates are available under Notices in the Health section. You may continue coverage after retirement if you satisfy the following minimum requirements:

  • Provide written proof of retirement from your pension fund; OR
  • By receiving Social Security retirement benefits; AND
  • Be eligible as an active participant during the Coverage Quarter immediately preceding the date of coverage in the Retiree Program; AND
  • Have contributions made in your behalf by a contributing employer in each of the five years immediately preceding retirement; or have 20,000 or more hours of contributions from contributing employers at the time of your retirement; AND
  • Make the self-payment no later than the 25th of the month preceding the current coverage month at a rate to be determined by the Trustees from time to time.
Where are my EOB's online?
EOB's are not available online. To request an EOB, please call the Fund Office.

HEALTH BENEFITS

What is covered under the comprehensive major medical benefits?
Comprehensive Major Medical Benefits cover certain costs of medically necessary care. After a deductible has been paid, the Plan pays a specified percentage of reasonable expenses. Covered expenses include certain comprehensive major medical services related to:

  1. Hospital services for room and board and intensive care, miscellaneous services and supplies, and outpatient services for surgery or emergency room treatment. Inpatient services for nervous or mental disorders and AODA treatment.
  2. There is a separate co-payment for each hospital emergency room visit of $150.
  3. Physicians' services for: surgery, anesthesia and its administration; medical services during in-hospital, outpatient, office, and home visits; certain chiropractic services; and outpatient treatment for nervous and mental disorders, substance abuse, and alcoholism.
  4. Diagnostic x-ray and laboratory services
  5. Prescription drugs and medicines through the Preferred Provider Pharmacy Program. Express Scripts/Accredo
  6. Other covered services and supplies ordered by your physician, such as ambulance service; radiation therapy; blood or plasma and its administration; specified medical supplies and specified durable medical equipment; initial artificial limbs and eyes and their medically necessary replacement; breast prostheses; and dental services for treatment of a fractured jaw or injury to natural teeth (Limitations may apply).
What is not covered under the comprehensive major medical benefits?
There is limited coverage for some services such as chiropractic care, routine physical exams, TMJ, care in a Skilled Nursing Facility, hearing aids and exams, and admission kits.

Services not covered include speech pathology, treatment for infertility, cosmetic surgery, services to treat work-related illnesses or injuries, charges that exceed reasonable and customary limits, in-hospital convenience items, counseling for parenting issues, marriage counseling, and couple's counseling.
What is meant by reasonable and customary charges?
Reasonable expenses for X-ray and lab and surgical procedures are provided by a national company that compiles a database of healthcare charges in each geographic area. Updates are provided to the Fund every six months.
Is there a deductible for major medical coverage?
There is a per person deductible per calendar year with a maximum family deductible per calendar year. Please refer to In-Network/Out-of-Network for more information. Deductibles are waived for the following care:

  • many routine immunizations
  • routine physical examinations for you and your spouse (up to the annual maximum benefit amount)
  • hospice care (requires preauthorization)
  • skilled nursing home care, subject to limitations (requires preauthorization)
  • well child care for dependents ages newborn-26, subject to limitation
Is there a co-insurance required on my major medical coverage?
A co-insurance is the percentage you pay after your deductible has been met. Please refer to In-Network/Out-of-Network for more information. You may pay less out of pocket by using a preferred provider. View participating providers at: www.anthem.com.
Is there an out-of-pocket maximum for major medical benefits?
There is an out-of-pocket maximum per person per calendar year with a maximum out-of-pocket per family per calendar year. Once the annual maximum has been met, the plan pays covered charges at 100% for the remainder of the calendar year. Please refer to In-Network/Out-of-Network for more information.
What is my routine physical exam benefit?
The Routine Physical Exam benefit includes charges for a general physical examination by a physician and routine screening labs and x-rays ordered by a physician. If you have already been diagnosed with a medical condition, the lab work, x-rays, and exam are considered under the major medical benefit of your Plan and are subject to the deductible and co-insurance. If an exam and/or lab work is required to renew a prescription, those charges are payable under the major medical portion of your Plan.
Are there dental and vision benefits under my plan?
Dental and Vision benefits are provided for all active participants and can be elected at the time of retirement for those on the Retirement plan.
What hospitals and providers can I go to?
Any hospital or accredited provider within the United States; however, in order to receive the maximum benefits, you may wish to choose a Preferred Provider.

View participating facilities at: www.anthem.com
Can I obtain medical care outside of the country?
Medical services and treatment outside of the United States will be excluded unless incurred for care of an emergency condition as determined by the Plan.

PARTICIPANT RESPONSIBILITIES

Why do I need to complete a family form each year even though I have had no changes?
In order to keep our records updated with current information, you must complete a Family Form each year. Your previously provided family information is pre-printed on the Family Form sent to you annually. If you have had no changes, please sign and date the form and mail it to the Fund Office.

However, if there has been any change to the information we have on file, a new Family Form must be completed. These changes include adding a new spouse, adding a new child, terminating a dependent's coverage due to legal separation or divorce of a spouse, or death of a dependent. We also require notification when other insurance coverage is effective for one or more dependents or if a previously existing coverage has terminated.
Why do I need to fill out an injury form?
If a bill is received with an injury diagnosis, an injury form must be completed. The Plan contains subrogation language in the event an injury is the responsibility of a third party. If an injury or illness occurred at work or as a result of work, the claims must be filed with your Employer's Worker's Compensation carrier.
Do I need preauthorization for services?
In order for maximum benefits to be payable, hospital confinements and other services may require preauthorization/precertification. Some services that require preauthorization/precertification are:

  1. Hospital confinements
  2. Amniocentesis
  3. Non-Routine Circumcision
  4. Dental procedures in a hospital setting older than age 6
  5. Equipment for home use (including, but not limited to):
    • a. Sleep Apnea Supplies
    • b. Hospital Beds
    • c. Oxygen
    • d. Wheelchairs
  6. Growth Hormone
  7. Home Health Services
  8. Home Intravenous Therapy
  9. Hospice
  10. Diagnostic Laparoscopy (Women)
  11. Laser Uvulectomy
  12. Septoplasty
  13. Skilled Nursing Home
  14. Sleep Study performed in facility and/or for patients under the age of 35

SERVICE PROVIDERS

Livongo Logo.
TEAM Logo.
Express Scripts Logo.
Express Scripts
ESI Formulary Exclusions
COVID-19 OTC Test Reimbursement Online
FDA Logo.
Teladoc Health Logo.
Delta Dental Logo.
Independence Administrators Logo.

(715) 835-3174     (800) 424-3405

Street Address:
1704 Devney Drive    Altoona, WI 54720


Mailing Address:
PO Box 4002    Eau Claire, WI 54702

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