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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.

NCSRCC HF Happenings Newsletter - Q1, 2025

NCSRCC HF Happenings Newsletter - Q2, 2025

NCSRCC HF Happenings Newsletter - Q3, 2025

NCSRCC HF Happenings Newsletter - Q3, 2025 (SPANISH VERSION)

NCSRCC HF Happenings Newsletter - Q4, 2025

NCSRCC HF Happenings Newsletter - Q4, 2025 (SPANISH VERSION)

FORMS / PLAN DOCUMENTS & NOTICES

FORMS

Dependent Eligibility Verification Audit (DEVA) Form

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

Vision Safety Benefits Summary

Organ Transplant Certificate 2025-2026

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

Dollar Bank 2025

Dollar Bank 2025 (Spanish)

FREQUENTLY ASKED QUESTIONS

ELIGIBILITY

What is the Dollar Bank?
  • The Dollar Bank is a notional account that is established for you as a Plan Participant.
  • When you work for an Employer, the hourly contributions submitted on your behalf are credited to your Dollar Bank to establish and maintain eligibility for coverage under the Plan.
  • The hourly contribution amount is set forth in the applicable collective bargaining agreement.
  • The Dollar Bank is merely a record keeping system with the purpose of tracking contributions; it does not hold actual dollars.
  • A Dollar Bank is a non-vested benefit and can be forfeited.
  • If you have sufficient contributions in your Dollar Bank to cover the Plan’s required contribution (the “monthly premium”), the monthly premium will automatically be deducted from your Dollar Bank to pay for your monthly coverage.
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 become eligible on the first day of the calendar month following the calendar month in which the amount of total contributions in your Dollar Bank exceeds the Monthly Premium for Plan coverage.
How do I maintain my coverage with a Dollar Bank?
Once you meet the initial eligibility rules, you will remain covered for any succeeding month provided (1) the dollar amount of contributions made on your behalf by the 25th of the prior month is equal to or exceeds the Monthly Premium , (2) your Dollar Bank has sufficient contribution credits from prior monthly contributions to pay the Monthly Premium, or (3) you continue coverage pursuant to the self-payment procedures.
What happens if I do not have enough contributions in my Dollar Bank?
If the amount of contributions credited to your Dollar Bank are insufficient to pay the monthly premium, you will receive a self-pay notice from the Fund Office which will offer you the choice of continuing coverage by either:
  • Self-Paying the difference between (a) the amount of contributions made on your behalf plus any available amount in your Dollar Bank and (b) the required Monthly Premium; or
  • Electing COBRA continuation coverage
If I lose eligibility, how do I regain my eligibility under the Plan?
If you become ineligible for coverage because of insufficient contributions in your Dollar Bank and you fail to make the required self-payment to maintain eligibility, you will have to satisfy the Plan's initial eligibility rules in order to restore your eligibility for coverage without self-payments. You cannot make self-payments to acquire eligibility once it is lost. If you lose eligibility through active employment, but then maintain coverage through COBRA continuation coverage, you will need to satisfy the Plan's initial eligibility rules to restore your eligibility for coverage without self-contributions for COBRA continuation coverage.
Is there a maximum amount I can have in my Dollar Bank?
Yes. The maximum amount that you can have in your Dollar Bank is six (6) months of eligibility. All amounts in excess of the six-month threshold will fund your HRA account.
Can my Dollar Bank forfeited?
Yes. Your Dollar Bank will be forfeited in the following scenarios:
  • While you are in the process of obtaining initial eligibility and once monthly premiums are made to the Plan, you will have a rolling six (6) month period to establish initial eligibility for coverage under the Plan. If you are unable to establish initial eligibility during the first six (6) months, the contributions made on your behalf in the first month of the initial six (6) month period that were credited to your Dollar Bank will be forfeited. The rolling six (6) month initial eligibility period will continue until the dollar amount of total contributions during a consecutive six (6) month period exceeds the required contribution.
  • The same rolling six (6) month period will apply for continuing eligibility such that any Dollar Bank amount that is not sufficient to cover a Monthly Premium will forfeit after six months if not used to offset your self-pay.
  • If you begin working Covered Employment within the jurisdiction of the UBC International Union for a nonparticipating Employer who is not subject to a written agreement requiring contributions to the Plan or you continue working for a former Participating Employer after the Employer withdraws from the Plan, your Dollar Bank and HRA are forfeited.
What happens to my coverage if I am unable to work as a result of an accidental Injury or Sickness?
If you are eligible to or are receiving Accident and Sickness Weekly Disability benefits under this Plan, or if you provide evidence of entitlement to benefits under any workers’ compensation or occupational disease law, you will receive the equivalent of 1/4 of the monthly premium each week into your Dollar Bank for each week that you are entitled to or are drawing such benefits up to 26 weeks per disability. In no case will the monthly contributions under this section exceed the amount required to pay the Monthly Premium. No credit will be provided for periods in which your Employer contributes to the Plan for your time on leave.
Can I apply for single coverage?
No. The plan offers family coverage only.
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?
Medical claim EOBs are available online at www.ibxtpa.com or you can contact Independence Administrators at 833-242-3330.

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.ibxtpa.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.ibxtpa.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

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TEAM Logo.
Express Scripts Logo.
Express Scripts
ESI Formulary Exclusions
COVID-19 OTC Test Reimbursement Online
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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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