Schedule of Benefits

This exhibit summarizes the major provisions of the Health and Welfare Plan for Sheet Metal Workers' Union Local #265  It is not intended to be, nor should it be interpreted as, a complete statement of all plan provisions. 

Please note that the information presented is subject to change.  Contact the Fund Office for verification of current benefits.

See the updates section for enhancements tjat have been made to the Health and Welfare Benefit Plan*:

*These booklets are in pdf format. You must have Adobe® Acrobat® Reader. If you do not have this software, you can download it for free
from  Adobe's Web Site.

To go directly to a specific topic, click on it from the list below.
Alcoholism & Substance Abuse Mental Health and Nervous Disorders
Basic Hospital New Born Well Child Care
Chiropractic Organ Transplant
Dental Care Podiatry
Hearing Care Smoking Cessation
Home Health Care Speech Therapy
Infertility Vision Care
Death Benefit Vision One Comprehensive Care
Major Medical Weekly Disability Benefits

 

SCHEDULE OF BENEFITS

(the benefits shown on this schedule apply only to persons who are eligible for the applicable benefits and are subject to all limitations and exclusions)
Death Benefit
For Active Eligible Employees (Plan A)

$20,000
For Dependents (Plan A) $2,000
For Eligible Retirees Making Self-Payments (Plan B & D)

$10,000
Accidental Death And Dismemberment (AD&D) Insurance
For Active Eligible Employees  (Plan A)

$20,000
For Eligible Retired Employee Making Self-Payments (Plan B & D)

$5,000

Weekly loss of time benefit (Employee Only)
Non-Occupational Benefit

 

 Maximum Weekly Benefit

$500
(Limited to 90% of base wage x 40 hours not to exceed $500)
Maximum Number of Weeks

39
Waiting Periods Accident or Outpatient Surgery 0 days
Illness (Hospital Confined) 0 days
Illness (Non-Hospital confined) 7 days
Basic Hospital Expense, including Basic Surgical Expense and Basic In-Hospital Medical Expense Benefit 
Maximum benefit per disability

* Out-of-Network Hospital and Surgical Benefits
Basic Hospital Benefit for non-emergency out-of network claims would be paid at 100% of reasonable and customary charges up to $4,000 per disability after satisfying the $100 deductible per admission or outpatient surgery (waived if pre-certified). The remainder would be covered under the Major Medical Benefit. Any hospital inpatient or outpatient surgery claims above the $4,000 maximum that are covered by the Major Medical Benefit would not accumulate toward the out-of- pocket maximum of $2,500 per person, $5,000 per family.

$8000 *
Co-Payment Rates for Basic Benefits in excess of the first $8000. PPO Provider

90%
Non PPO Provider

80%
Daily Room and Board

Semi-Private Room Rate
Hospital Miscellaneous

100% of Reasonable and Customary Charges
Charges Related to Hospital Treatment 100% of Reasonable and Customary Charges
Outpatient Hospital Treatment 100% of Reasonable and Customary Charges
Deductible per admission

$100 (waived if admission pre-certified)
Basic Surgical Expense 100% of Reasonable and Customary Charges
Basic In-Hospital Medical Expense Benefit 100% of Reasonable and Customary Charges
Alcoholism and Substance Abuse Separate and Additional deductible of $100

MAJOR MEDICAL BENEFITS

Lifetime Maximum per person

$750,000
Deductible per person per calendar year

$100
Alcoholism and Substance Abuse Separate and Additional Deductible

$250
Co-Payment
 Outpatient and Inpatient Mental and Nervous Disorders

90%
(50% if not pre-certified)
Alcoholism and Substance Abuse

80%
All other Conditions Co-Payment PPO

90%
Non-PPO

80%
Out of Pocket Maximum Per person per calendar year

$2,500
Per Family per Calendar year

$5,000

Chiropractic Treatments
(Major Medical Out-of-Pocket Maximum not applicable)

up to $50 per visit maximum $1,500 per year
Chiropractic X-Rays and Laboratory Service
(Major Medical Out-of-Pocket Maximum not applicable)

$200 per person/ per calendar year
Mental and Nervous Disorders
(Major Medical Out-of-Pocket Maximum not applicable)
Maximum per calendar year for inpatient care

30 days per person
Maximum per person per calendar year for outpatient care

up to 52 visits
Alcoholism and Substance Abuse
(Major Medical Out-of-Pocket Maximum not applicable)
Maximum per person per calendar year for inpatient care

80%
(50% if not pre-certified)
Maximum per person per calendar year for outpatient care

50%
up to $1,000
Combined inpatient/outpatient maximum per person per lifetime

$25,000
Infertility
(Major Medical Out-of-Pocket Maximum not applicable)

80% up to $5,000 per lifetime
Organ Transplant Benefit
(Major Medical Out-of-Pocket Maximum not applicable)

80% up to $150,000 per lifetime
Routine Physical Examination Benefit
(Employee and Dependent Spouse)

100% up to $500 per person per calendar year
as of 06/01/06
Newborn and Well Child Care Benefit Through age 5

80%
Age 6 through age 18 80% up to $200  yearly maximum
Hearing Care Benefit 
For Preferred Providers call National Ear Care at 1-888-884-6327		 Deductible per person per calendar year

NONE
Co-payment

80%
Maximum per 2 year period Employee and Dependents

$1,000
Medical Speech Therapy other than Treatment needed to restore lost speech

up to $750 per year/per person
Smoking Cessation Benefit Employee and Spouse

$250 Lifetime, NO Deductible
Podiatry Office Services $750 per calendar year
Non-Office podiatry surgical expense and/or podiatry facility fee $3,500 per calendar year
Home Health Care 90%
(80% if not pre-certified)
$150 per visit w/ $10,000 maximum per calendar year
Dental Care Benefit
 (Plan A,  B & D) 		 Deductible amount per person per calendar year

None
Co-Payment Preventative and Diagnostic

100%
Restorative Procedures and Prostodontic

80%
Orthodontic Procedures
(Coverage available only for dependent children under 19 years of age)

80%
TMJ Procedures

80%
Maximums Orthodontic

$1,500/per lifetime
TMJ Therapy Procedure  $1,000/per lifetime
Surgical TMJ/Skeletal Facial Deformity

$10,000/ per lifetime
Any cutting on mouth, gums or jaw for repair or replacement of teeth $5,000/per calendar year
All other  procedures per person per calendar year

$2,000
Vision Care Benefits
(Plan A)		 Examination, Lens, and Frames Maximum

$200/per year
EyeMed
Comprehensive Care
Call 1-866-723-0514
 for a Provider		 Exam, Frames up to $110 and Lenses, including Polycarbonate with scratch resistant coating and UV coating

No Cost 

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