Eligibility

This is only a summary.  The eligibility requirements and benefits provided to Non-Bargaining Employees are governed by the Subscriber Agreement between this Trust Fund and your signatory employer.

Initial Eligibility

If you are a full-time Employee (working a minimum of 30 hours per week) of a signatory Employer currently participating in this Trust Fund, who has also signed a Subscriber Agreement with this Trust Fund, you will become eligible for benefits on the first day of the month following a waiting period of sixty days, so long as your Employer has made the required contribution on your behalf.

If you are a full-time Employee and eligible for your Employer’s benefits before your Employer begins participation in this Trust Fund, you will be eligible for benefits from this Trust Fund on the effective date of your Employer’s participation in this Trust Fund, if your Employer has also signed a Subscriber Agreement and has made the required contribution on your behalf.

Benefit and Limitations Applicable to Non-Bargaining Employees

Monthly Non-Bargaining Employees are not eligible for death benefits. Your other benefits are the same as those for hourly Employees.

Monthly Non-Bargaining Employees do not accrue a cash bank reserve as described for hourly Employees.  Their coverage terminates the first of the month following the month in which their employer fails to make the required contribution to this Trust Fund.

Termination of Coverage

Your Employee eligibility for benefits from the Trust Fund will terminate on the earlier of the following occurrences:

• The date your employer ceases to participate in the Trust Fund;
• The date your employer fails to employ any bargaining unit Employees for nine months in a calendar year except with respect to working Employers identified as such in the Subscription Agreement;
• The end of the month in which your employer makes the last contribution for your benefit coverage under the Trust Fund; or
• The date the Plan is discontinued; or
• The date of your death; or
• The date you perform any Non-Covered Employment. “Non-Covered Employment” is defined as work that is performed:
  • * In the jurisdiction of any local union of the District Council 16 of the International Union of Painters and Allied Trades;
  • * On or after the date you became eligible for benefits from the Trust Fund, and
  • * For a company that:
    • › Is doing work of the type covered by the terms of any Collective Bargaining Agreement between a local union of the District Council 16 of the International Union of Painters and Allied Trades and any Employer participating in the Trust Fund, and
    • › Is not signatory to a Collective Bargaining Agreement with a local union of the District Council 16 of the International Union of Painters and Allied Trades without the written authorization of the District Council 16 local union with jurisdiction over the company.

New Retiree Eligibility – Bargaining Employees

October 2022 SMM – Change to New Retiree Eligibility for Bargaining Employees

If you retire from active hourly employment as a Participant in District Council 16 Northern California Health and Welfare Trust Fund, you will be eligible for benefits as a Retiree if you meet all of the following requirements:

• You are receiving pension payments from the Northern California Glaziers Pension Plan or, if you are a Production Worker, from the International Brotherhood of Painters and Allied Trades Pension Plan, the Bay Area Painters and Tapers Pension Trust Fund, or the Resilient Floor Covering Pension Plan.
• You were covered under this Health and Welfare Trust Fund’s benefits program or the Health and Welfare Plan of one of the merged Trust Funds as an active bargaining Employee in the month immediately preceding your retirement date. You may use COBRA Continuation Coverage to meet this requirement.

If you were employed by the International Union of Painters and Allied Trades, this requirement will be fulfilled if you were covered under the Health and Welfare Plan provided by the International Union of Painters and Allied Trades in the month immediately preceding your retirement date.

• In each of the 3 years immediately preceding your retirement date, you earned at least 500 hours of service, as defined in the Northern California Glaziers Pension Plan or the International Brotherhood of Painters and Allied Trades Pension Plan or the Bay Area Painters and Tapers Pension Trust Fund, or the Resilient Floor Covering Pension Plan.

Any year you were an Employee of the International Union of Painters and Allied Trades will be considered a grace period and will not be counted for purposes of determining whether you have met this requirement.

If you were disabled or you were on the Union’s out-of-work list and were available for work in the 3-year period immediately preceding your date of retirement, you may receive credit hours for your period of disability or unemployment. For purposes of this provision, “disability” means a total and continuous disability from accidental bodily injury or illness that prevented you from performing any and every duty pertaining to your occupation and from receiving any remuneration for any other work or service.

• You pay the required monthly “self-payment” premium. The amount is determined by the Board of Trustees in their sole discretion.
• You are a member in good standing with any local union affiliated with the District Council 16 of the International Union of Painters and Allied Trades (including being current with your dues).

Your Retiree benefits will become effective on the later of the first day of the month following:

• the date of your retirement; or
• the last month your Active benefits are covered under the Active Plan eligibility lag; or
• the last month your Active benefits are covered by use of your one-month extended coverage under your Cash Bank; or
• the last month you receive COBRA coverage under the Active Plan.

If you are waiving Retiree Benefits at the time of your retirement, you must submit this request in writing to the Trust Fund Office at:

Health Services & Benefit Administrators
4160 Dublin Boulevard
Suite 400 Dublin, CA 94568-7756

Requirement for Continuous Coverage

Please note: Your coverage must remain in effect continuously.  If you choose to waive your Retired Employee’s benefit Plan at the time of retirement, you must submit this request in writing to the Trust Fund Office at the address below:

Health Services & Benefit Administrators
4160 Dublin Boulevard
Suite 400 Dublin, CA 94568-7756

If you do not elect dental coverage when you first become eligible for benefits as a Retiree, you may NOT add or drop the dental plan at a later date.

Cash Bank Accumulation When You Retire

You will be allowed one month of extended coverage under your Cash Bank after your Active benefits expire under the Active Plan eligibility lag. After that time, you will need to begin self-payments in order for coverage to continue. All cash accumulation in excess of the allowed one-month extension will be permanently cancelled at retirement.

There may be some Retirees who are not eligible for Retiree health coverage.  In that case, you will also be allowed to continue your Active Plan coverage by using your Cash Bank Accumulation when you retire. To continue coverage after the Cash Bank is exhausted, you would need to elect continuation coverage under COBRA Continuation. Please refer to the COBRA Continuation Coverage section for information on your self-payments.

Please Note:  Your Cash Bank may only be used to pay for your continued coverage through the Fund, and cannot be used to reimburse premiums for medical insurance in the individual market, federal Marketplace, or State Exchange.

You are permitted to permanently opt out of and waive future reimbursements from your Cash Bank at least annually, in a time and manner determined by the Plan Administrator. Upon retirement, you may (in a time and manner determined by the Plan Administrator) opt out of and waive any balance remaining in the Cash Bank.

New Retiree Eligibility – Monthly Non-Bargaining Employees

If you are covered for benefits from the Trust Fund as a Non-Bargaining Employee, you will be eligible to continue your coverage as a Retiree only under the following conditions:

• You must have been covered under the Trust Fund (or one of the three merged Trust Funds) for at least 24 consecutive months immediately prior to your date of retirement.
• You must have been a full-time active Employee of a participating employer for at least five years.
• You must be at least 62 years of age.
• You must pay the full cost of your benefits, as determined by the Board of Trustees, each month without any lapse in coverage.
• You are a member in good standing with any local union affiliated with the District Council 16 of the International Union of Painters and Allied Trades (including being current with your dues).

You Must Enroll in Medicare Part A and Part B

Retirees are eligible for the Blue Cross Network (PPO) which includes Prescription Drugs, Mental Health/Substance Abuse and Vision Benefits.  You also have the option to pay for Dental Benefits. Once you or your Spouse or Domestic Partner become eligible for Medicare due to age, disability or renal disease, you MUST enroll in both Parts A and B of Medicare.  If you are in the Kaiser (HMO), you must assign those benefits to Kaiser.  If you are in the Blue Cross Network (PPO), medical benefits for you or your Spouse (or Domestic Partner) will be paid as if you are enrolled in Medicare (whether you are or not) and Medicare has paid benefits first. 

You will have substantial out of pocket costs if Medicare has not paid full primary benefits before you submit your claims for secondary payment by this Trust Fund.  Therefore, you and your Spouse (or Domestic Partner) should enroll in Medicare as soon as you are eligible to do so.

Retirees Who Work While Receiving a Pension

A Retiree who works 39 hours or less per month while receiving Retiree pension benefits through the Trust Fund are required to pay an additional 25% of their monthly retiree premium rate for the month in which active hours were reported.

Termination of Retiree Eligibility

Your coverage as a Retiree will terminate for any of the reasons listed below:

You perform any work for an employer in the industry which does not have a collective bargaining agreement with any of the local unions participating in this Trust Fund or a trust fund that is signatory to a reciprocal agreement with this Trust Fund. Contact your Union Office or the Trust Fund Office for complete rules determining your rights to perform covered employment after your retirement date.

• You fail to pay the required monthly self-payment on time.
• Your pension benefits are terminated or suspended for any reason except for your return to full time covered employment.
• You cease to be a member in good standing with any local union affiliated with the District Council 16 of the International Union of Painters and Allied Trades.
• If the Board of Trustees decides to discontinue the Retiree Plan.

Once terminated, you will not again be eligible for Retiree benefits.

Retirees who work in covered employment after retirement will receive no credit towards eligibility for any employer cash contributions and will lose the benefit of the Active Participant funded 25% Retiree health care subsidy.

Surviving Spouse Coverage

If a Retired Employee who has elected a Joint and Survivor Pension dies, his or her surviving Spouse may continue to be covered under this Trust Fund upon payment of the required self-payment.  This coverage will terminate upon the re-marriage of the surviving Spouse.

If on the date of death an active Employee would have been eligible for a pension if he had applied, the surviving Spouse may continue to be covered under this Trust Fund upon payment of the required self-pay amount.  No break in coverage is allowed.  This coverage will terminate upon the re-marriage of the surviving Spouse.

If the surviving Spouse of a Retired or Active Employee is NOT entitled to receive pension payments from a related Pension Trust Fund, he/she may only continue receiving benefits from this Trust Fund under the COBRA continuation of coverage rules

Eligibility Rules for Dependents

Coverage for your eligible Dependents you have at the time you become eligible for coverage as either an active Employee or a Retiree will begin on the date you become eligible and enroll for coverage. Coverage for Dependents acquired after your initial eligibility will begin on the date you acquire the Dependents.  You must request to enroll newly acquired Dependents, including newborns, by contacting the Trust Fund Office within 31 days if due to marriage or registration of a Domestic Partnership, or within 60 days if due to birth, adoption or placement for adoption.

The term “Dependent” means:

• The lawful Spouse or Domestic Partner of an eligible Active or Retired Employee; and
• Children of an eligible Active or Retired Employee who are under the age of 26 (whether married or unmarried), including the following:
  • Natural, adopted children, stepchildren or foster children. Adopted children shall be considered eligible under this Trust Fund when they are placed for adoption. Placed for adoption means the assumption and retention by an Employee of the legal duty for total or partial support of a child to be adopted.
  • A child named as an “alternate recipient” under a Qualified Medical Child Support Order (QMCSO) until the earlier of 1) age 26; or 2) the date the QMCSO terminates. In accordance with ERISA Section 609(a), this Trust Fund will provide coverage for a Dependent Child of an Active Employee if required by a Qualified Medical Child Support Order (QMCSO). A QMCSO is a court order that complies with requirements of federal law requiring an Employee to provide health care coverage for a Dependent Child. The procedures regarding medical child support orders are available free of charge upon request from the Trust Fund Office.

The Trustees may request evidence of the relationship and age, such as a marriage certificate in the case of marriage, a birth record in the case of a newborn, divorce and remarriage documents in the case of stepchildren, and any such other evidence as the Trustees may deem necessary.

• Additional Dependent Children. In addition to the Dependent Children defined above, the following individuals are eligible for coverage under the Plan:
  • Disabled Adult Child: An unmarried Dependent Child (as defined above) age 26 or older who is permanently and totally disabled with a disability that existed prior to the attainment of the Plan’s age limit who will be claimed as a Dependent on the eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. This Plan may require initial and periodic proof of disability.
  • An unmarried individual under age 19 with respect to whom the eligible Active or Retired Employee has legal guardianship under a court order (proof of guardianship and age may be required) and who will be claimed as a Dependent on the Eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. Coverage may continue if the child has reached his or her 19th birthday but has not reached his or her 24th birthday and is enrolled as a full-time student in high school or in an accredited and state licensed technical school or institution of higher education. The Plan may require initial and periodic proof of student status.If the Plan receives a written certification from a child’s treating physician that (1) the child is suffering from a serious illness or injury, and (2) a leave of absence (or other change in enrollment) from a postsecondary institution is Medically Necessary, and if the loss of student status would result in a loss of health coverage under the Plan, the Plan will extend the child’s coverage for up to one year. This maximum one-year coverage begins on the first day of the Medically Necessary leave of absence (or other change in enrollment) and ends on the date that is the earlier of (i) one year later, or (ii) the date on which coverage would otherwise terminate under the terms of the Plan (for example, when the child reaches the Plan’s limiting age).

The following individuals are not eligible under the Plan: a spouse of a Dependent Child (i.e. Employee/Retiree’s son-in-law or daughter-in-law) or a child of a Dependent Child (i.e. Employee/Retiree’s grandchild) unless the Participant has been appointed legal guardian of the child.

• Children of a Domestic Partner
  If a Domestic Partner is enrolled in the Plan, the Employee may also apply for coverage for the Domestic Partner’s children who meet the requirements set out below. For the purposes of this Plan, a Domestic Partner’s Child (unless the Child is legally adopted by the eligible Active or Retired Employee) is any of the Domestic Partner’s unmarried children who have the same principal place of abode as the Employee and Domestic Partner (proof of same principal place of abode may be requested by the Plan) provided:
  • The Domestic Partner’s Child depends on the Domestic Partner and/or the Employee for more than one-half of their support; and
  • The child has not reached his or her 19th birthday; OR
  • The child has reached his or her 19th birthday but has not reached his or her 24th birthday and is enrolled as a full-time student in high school or in an accredited and state licensed technical school or institution of higher education; OR
  • An unmarried Dependent Child age 26 or older who is permanently and totally disabled with a disability that existed prior to the attainment of the Plan’s age limit who will be claimed as a Dependent on the eligible Active or Retired Employee’s tax return for each Plan Year for which coverage is provided. This Plan may require initial and periodic proof of disability.

If the Plan receives a written certification from the child’s treating physician that (1) the child is suffering from a serious illness or injury, and (2) a leave of absence (or other change in enrollment) from a postsecondary institution is Medically Necessary, and if the loss of student status would result in a loss of health coverage under the Plan, the Plan will extend the child’s coverage for up to one year. This maximum one-year coverage begins on the first day of the Medically Necessary leave of absence (or other change in enrollment) and ends on the date that is the earlier of (i) one year later, or (ii) the date on which coverage would otherwise terminate under the terms of the Plan (for example, when the child reaches the Plan’s limiting age).

It is the Domestic Partner’s obligation to inform the Plan promptly if any of the requirements set out in this definition of a child of a Domestic Partner are NOT met with respect to any child for whom coverage is sought or is being provided.

Proof of Dependent Status

Specific documentation to substantiate Dependent status will be required by the Plan and may include proof of the Dependent’s relationship to the eligible Active or Retired Employee, including any of the following:

• Marriage: the certified marriage certificate.
• Birth: the certified birth certificate showing biological child of Employee/Retiree/Domestic Partner.
• Stepchild: the birth certificate plus marriage certificate.
• Adoption or placement for adoption: court order paper signed by the judge showing that Employee/ Retiree/Domestic Partner has adopted or intends to adopt the child.
• Foster Child: court documents signed by a judge verifying legal custody of the foster child (e.g. placement papers from a qualified state placement agency), or proof of judgment decree or court order of a court of competent jurisdiction, and any proof of any state provided health coverage.
• Legal Guardianship: the court-appointed legal guardianship documents and certified birth certificate.
• Disabled Dependent Child: Current written statement from the child’s physician indicating the child’s diagnoses that are the basis for the physician’s assessment that the child is currently mentally or physically disabled (as that term disabled is defined in this document) and that disability existed before the attainment of the Plan’s age limit and is incapable of self-sustaining employment as a result of that disability; and dependent chiefly on you and/or your Spouse for support and maintenance. The Plan may require that you show proof of initial and ongoing disability and that the child meets the Plan’s definition of Dependent Child.
• Qualified Medical Child Support Order (QMCSO): Valid QMCSO document signed by judge or National Medical Support Notice.
• Domestic Partner: Signed affidavit by the Employee/Retiree and Domestic Partner that they meet the requirements of this Plan’s Domestic Partner eligibility using the Plan’s state recognized Domestic Partner registration form.

Failure to Provide Proof of Dependent Status: Claims for newly added Dependents (e.g. Spouse, Domestic Partner, children) will not be considered for payment by this Plan until the Trust Fund Office receives verification/proof of Dependent status.

Newborn Dependent Children (Special Rule for Coverage)

• Your newborn Dependent Child(ren) will be covered from the date of birth if you request enrollment of your newborn child within 60 days of birth. You must provide the Trust Fund Office with an updated Plan Enrollment Form and a copy of your child’s birth certificate as soon as practicable. If you are in the HMO, you must update your enrollment within 60 days of the child’s birth for coverage to continue.

Remember that you may not enroll a newborn Dependent Child for coverage unless you, the Employee or Retiree, are also enrolled for coverage.  Submitting a claim to the Plan for maternity care/delivery for care of a newborn child is not considered proper enrollment of that child for coverage under this Plan.

Adopted Dependent Children (Special Rule for Coverage)

Your adopted Dependent Child will be covered from the date that child is adopted or “Placed for Adoption” with you, whichever is earlier, provided you enroll the child in the Plan.  A child is “Placed for Adoption” with you on the date you first become legally obligated to provide full or partial support of the child whom you plan to adopt.

• A Newborn Child who is Placed for Adoption with you within 60 days after the child was born will be covered from the date the child was placed for adoption if you comply with the Plan’s requirements for obtaining coverage for a Newborn Dependent Child, described above in this chapter.
• A Dependent Child adopted more than 60 days after the child’s date of birth will be covered from the date that child is adopted or “Placed for Adoption” with you, whichever is earlier, if you request enrollment within 60 days of the child’s adoption or placement for adoption. You must provide the Trust Fund Office with an updated Plan Enrollment Form and provide of proof of Dependent status (if requested) as soon as practicable.

If a child is “Placed for Adoption” with you, and if the adoption does not become final, coverage of that child will terminate as of the date you no longer have a legal obligation to support that child.  Remember that you may not enroll an adopted child or a child Placed for Adoption for coverage unless you, the Employee/Retiree, are also enrolled for coverage.

Qualified Medical Child Support Orders (QMCSO) (Special Rule for Enrollment)

Under the Omnibus Budget Reconciliation Act of 1993, this Trust Fund must recognize any Qualified Medical Child Support Order (QMCSO) and enroll as directed by the Order any child of a Trust Fund Participant specified by the Order. A Qualified Medical Child Support Order is any judgment, decree, or order (including approval of a domestic relations settlement agreement or National Medical Support Notice) issued by a court that:

• provides the child of a Trust Fund Participant with child support or directs the Participant to provide the child with coverage under a health benefits plan; or
• enforces a state law relating to medical child support pursuant to Section 1908 of the Social Security Act, which provides in part that if the Employee parent does not enroll the child, then the non-Employee parent or State agency may enroll the child.

To be Qualified, a Medical Child Support Order must clearly specify:

• the name and last known mailing address of the Participant and the name and mailing address of each child covered by the order,
• the type of coverage to be provided by the Trust Fund to each such child (a reasonable description of such coverage),
• the period of coverage to which the order applies, and
• the name of each Plan to which the order applies.

A Medical Child Support Order will not qualify if it would require the Trust Fund to provide any type or form of benefit or any option not otherwise provided under this Trust Fund, except to the extent necessary to comply with section 1908 of the Social Security Act.

No eligible active Employee’s or Retired Employee’s child covered by a Qualified Medical Child Support Order will be denied enrollment on the grounds that the child is not claimed as a dependent on the parent’s Federal income tax return or does not reside with the parent.

Additional Information: For additional information (free of charge) regarding the procedures for administration of QMCSOs, contact the Trust Fund Office.

Termination of Dependent (or Domestic Partner) Coverage

Dependent or Domestic Partner coverage ends on the earliest of the date in which:

• the Employee’s/Retiree’s coverage ends; or
• your covered Spouse, Domestic Partner or Dependent Child(ren) no longer meet the definition of Spouse, Domestic Partner or Dependent Child(ren) as provided in the Definitions chapter of this document; or
• for Dependents under a QMCSO, the expiration of the period of coverage stated in the QMCSO; or
• the date the Spouse, or Domestic Partner enters the Armed Forces on full-time active duty; or
• the date of the Spouse, Domestic Partner or Dependent Child’s death.

Upon the death of an Employee, surviving dependents are eligible to continue their coverage based upon that Employee’s accrued cash bank, as described under Health & Welfare Cash Bank System in the chapter entitled “Eligibility Rules for Bargained Employees.”

Notice to the Plan

You, your Spouse, your Domestic Partner or any of your Dependent Children must notify the Plan preferably within 31 days but no later than 60 days after the date a:

• Spouse ceases to meet the Plan’s definition of Spouse (such as in a divorce or legal separation);
• Dependent Child ceases to meet the Plan’s definition of Dependent (such as the Dependent Child reaches the Plan’s limiting age or the Dependent Child ceases to have any physical or mental disability). If Dependent Child ceases to meet the Plan’s definition of Dependent due to reaching the plan’s limiting age, coverage will terminate on the last day of the month in which this occurs.;
• Domestic Partner ceases to meet the Plan’s definition of Domestic Partner.

Failure to give this Plan a timely notice (as noted above) will cause your Spouse or Domestic Partner and/or Dependent Child(ren) to lose their right to obtain COBRA Continuation Coverage or will cause the coverage of a Dependent Child to end when it otherwise might continue because of a physical or mental disability.