Find the answers to some common questions.
If you have a question that is not answered below, please call the Fund Office at 413-733-0177 or 800-634-2700.
The Health & Welfare Fund has four Benefit Plans named Plan A, Plan B, Plan C and Plan D. To identify the plan for which you are eligible to participate, refer to the Collective Bargaining Agreement between your employer and the UFCW Union Local 1459 or contact the Fund Office.
Do I have to enroll in a health plan?
The Health & Welfare Fund is made up of employees from many different employer groups. Some employers automatically enroll you in the appropriate plan whereas others require you to elect a plan during an open enrollment period. You should contact the Human Resource Department at your place of work to find out what your options are for electing health coverage.
If I work full-time for The Stop & Shop Supermarket Company, do I have to enroll through a Web site?
Newly hired full-time employees will be mailed a paper enrollment form. Each subsequent year, you will enroll through a Web site during an open enrollment period which is usually during November and December of each year with elections effective the following January 1st. The Fund developed a new Web site for the 2012 open enrollment where all full-time employees of Stop & Shop were required to log in and make a health coverage election and authorized a weekly pre-tax payroll deduction. Subsequent years may be “passive” enrollments whereby members only need to log in to the site if they have changes to their election. The Web site is located at www.zenith-american.com.
How may I find out if a particular service is covered under my plan?
A summary of your benefits begins on page 19 of your Summary Plan Description (SPD) booklet. If you can’t find the service listed in the SPD, contact the Fund Office.
Should I have an ID card for my benefit plan?
You should have two cards – one for the health plan and a separate card for the drug plan. Contact the Fund Office if you need to order a new health plan ID card. You may order a new Medco drug card by visiting the Medco Web site or by contacting the Fund Office.
May I go to any health care provider that I want?
For medical providers, the Fund has a preferred provider arrangement with CIGNA HealthCare PPO. If you utilize CIGNA preferred providers, you will receive a higher level of benefits. If you go to a medical provider that does not participate with CIGNA, your benefits are paid at a lower rate and your out of pocket costs will be higher. Your plan does not have a preferred arrangement for dental or routine vision services.
Do I need to send in a claim form with all my claims?
You only need to complete a claim form if you are sending in a non-standardized dental or vision claim. Vision claims must provide a breakdown between appliance categories (i.e.: type of lens, frames, anti-reflective coating, etc.). You also need to complete a claim form to receive disability (weekly accident & sickness) benefits.
What is the name of my plan – ‘CIGNA’ or ‘UFCW Local 1459 and Contributing Employers Health & Welfare Fund’?
You are insured through the UFCW Local 1459 and Contributing Employers Health & Welfare Fund, which has a preferred provider arrangement with CIGNA HealthCare. The Fund pays your benefit claims but services from preferred providers are discounted by CIGNA HealthCare. Be sure to present your health plan ID card to all providers at the time of service so they may make a copy of it for their records.
What portion of my medical expenses will I be expected to pay?
Generally, covered services with a CIGNA HealthCare preferred provider are paid by the Fund at 80% after you have met your calendar year deductible of $150; then, once your 20% liability has reached you plan’s maximum individual out of pocket amount for covered services, the Fund will pay 100% of covered services for the rest of the calendar year. In addition, some office visits require a $15 or $20 copayment at the time of service.
Services with a non-CIGNA provider are generally paid by the Fund at 60% after you have met your calendar year deductible of $500; then, once your 40% liability has reached $5,000 of covered services, the Fund will pay 100% of covered services for the rest of the calendar year. Refer to pages 24 and 25 of the Summary Plan Description for more information.
Do I have to call to pre-certify any services?
You must call CareAllies at 1-800-768-4695 to pre-certify any hospital admission. The number for CareAllies is on the back of your health plan ID card with a description of hospital admissions that need to be pre-certified.
I have other insurance. Which one do I use?
The rules for coordinating benefits between multiple plans are complicated. You should contact the Fund Office if you have questions regarding this topic. The most important thing to remember is to present all your health plan ID Cards to your health care provider so they may make copies for their records. Also, be sure to complete a Medicare and Other Coverage Information form if the status of your other insurance changes. The rules for Coordinating Benefits are outlined on pages 59-64 of the Summary Plan Description booklet.
Why is my health care provider telling me that I am not eligible for benefits through CIGNA?
Providers are able to check eligibility through a Web site for some individuals who are covered under certain CIGNA plans. Eligibility for UFCW Local 1459 and Contributing Employers Health & Welfare Fund members can only be verified by the Fund Office because CIGNA is not the claims payer for your plan. If the provider checks your eligibility on the CIGNA site, you will not be listed. Please tell your provider to follow the instructions on your health plan ID Card and contact the Fund Office for eligibility, benefit, and claim payment questions.
What do I do with the Explanation of Benefits statements I receive from the Fund Office?
Every time the Fund processes a claim on your behalf, you will receive an Explanation of Benefits (EOB) statement. You should retain these statements for at least a year. You should make sure that your health care providers do not bill you for more than the amount reflected in the ‘Patient Liability’ box on the EOB. You may also need these statements to appeal a claim, prepare your taxes, or submit a claim to a health reimbursement account.