Painters Trust Health Plan – Fill Out and Use This PDF

TRUST FUND

CONTACT INFORMATION

TRUST OFFICE

Zenith Administrators, Inc.

104 S. Freya Suite 220

Spokane, WA 99202

Submit all claims to:

PO Box 2523

Spokane, WA 99220

Submit all correspondence and payments to: 104 S. Freya Suite 220

Spokane, WA 99202

The Employee Painters’ Trust Health & Welfare Plan Claims Customer Service

WEBSITE

www.zenithadmin.com

This website contains:

•Helpful information about your Plan

•Notices about Plan changes

•Printable versions of claims forms, change of address forms and enrollment forms

•Links to Preferred Providers

•Summary Annual Report

•Claims History

•Eligibility

Please contact the Trust Ofice Claims Customer Service if you need a password.

YOUR GROUP INSURANCE BENEFITS

THE EMPLOYEE PAINTERS’ TRUST

HEALTH AND WELFARE PLAN

Actives

HOW TO OBTAIN PLAN BENEFITS

To obtain beneits see the Payment of Claims provision.

Forward your completed claim form to:

The Employee Painters’ Trust c/o Zenith Administrators, Inc.

P.O. Box 2523

Spokane, Washington 99220

Phone: 1-509-534-0265 or 1-800-566-4455

Fax: 1-509-534-5910

CLAIM ASSISTANCE

If you need assistance with iling your claim or an explanation of how

your claim was paid, contact:

The Employee Painters’ Trust c/o Zenith Administrators, Inc.

104 S. Freya, Suite 220

Spokane, Washington 99202

Phone: 1-509-534-0265 or 1-800-566-4455

Fax: 1-509-534-5910

A Plan Document required by law is available upon request from the Plan Administrator at the Painters’ Trust Administration Ofice. This booklet is a Summary Plan Description and is not the contract. In the event of a conlict the Plan Document will prevail.

When you utilize a Preferred Provider Hospital or Physician, the costs to the Trust are reduced. This also reduces your out-of-pocket costs. The Trust strongly urges you to utilize Preferred Provider services whenever possible. A directory of Preferred Providers may be obtained from the Union Ofice, Plan Administrator, First Choice at www.fchn.com 800-231-6935, Managed Healthcare NW at www.mhninc.com 503-413-5800 or Sierra Healthcare at 800-573-1124. Members in Anchorage have two Preferred Provider Hospitals to use. If these hospitals are not utilized, beneits are reduced. Please refer to the schedule.

Utilization Review (hospital pre-certiication) and Case Management for inpatient hospital services provide support so the patient can receive necessary, appropriate care while avoiding unnecessary expenses. To beneit from these programs, pre-certiication from CareAllies must be received before you receive medical and/or surgical services. Call CareAllies at (800) 932-7766.

To All Eligible Employees:

Please note that there is a separate booklet for Retirees. Please contact the Trust Ofice if you need a Retiree Booklet.

The Board of Trustees is pleased to present you with this new Summary Plan Description describing the medical, disability and accidental death and dismemberment beneits available to you and your family from the Painters’ Trust.

Please read this booklet carefully so you understand your beneits. Only the Trust Ofice represents the Board of Trustees in administering the Plan and providing information relating to the amount of beneits, eligibility and other Plan provisions. No participating employer, employer association, labor organization or any individual employed thereby, has any authority in this regard.

If you have any questions about your beneits, please contact the Trust Ofice for assistance.

“NOTICE - Trustees Discretion Retained. The Board of Trustees reserves the maximum legal discretionary authority to construe, interpret and apply the terms, rules and provisions of the Beneit Plan covered in this Descriptive Booklet. The Trustees retain full discretionary authority to make determinations on matters relating to eligibility for beneits, on matters relating to what services, supplies, care, drug therapy and treatments are Experimental, and on matters which pertain to Participant’s rights. The decisions of the claims adjusters, Administrator, and Board of Trustees as to the facts related to any claim for beneits and the meaning and intent of any provision of the Beneit Plan, or application of such to any claim for beneits, shall receive the maximum deference provided by law and will be inal and binding on all interested parties.”

“Amendment and Termination of Beneit Plan. The Board of Trustees expects to maintain this Beneit Plan indeinitely, however, the Trustees may, in their sole discretion, at any time, amend, suspend or terminate the Beneit Plan in whole or in part. This includes amending the beneits covered by the Beneit Plan and/or the governing Trust Agreement and Policies of Administration. If the Plan is terminated, the rights of the Participants are limited to beneits incurred before termination. All amendments to this Plan shall become effective as of a date established by the Board of Trustees.”

SCHEDULE OF BENEFITS

MEDICAL BENEFITS

All beneits described in this Schedule are subject to the exclusions and limitations described more fully under the General Exclusions and Limitations in this booklet. This includes, but is not limited to, the Plan Administrator’s determination that: care and treatment is Medically Necessary; that charges are Usual and Customary; that services, supplies and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the Deinitions section of this document.

The Plan is a plan that contains Preferred Provider Organizations.

This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers, which are called Preferred Providers. These Preferred Providers have agreed to charge reduced fees to persons covered under the Plan.

Therefore, when an Insured Person uses a Preferred Provider, that Insured Person will owe a lesser amount than when a Non-participating Provider is used. It is the Insured Person’s choice as to which Provider to use.

Additional information about this option, as well as a list of Preferred Providers will be given to covered Employees and updated as needed.

DEDUCTIBLES

Deductibles are dollar amounts that the Insured Person must pay before the Plan pays.

A deductible is an amount of money that is paid once a Calendar Year per Insured Person. Typically, there is one deductible amount per person and it must be paid before any money is paid by the Plan for any covered services. Each January 1st, a new deductible amount is required unless otherwise speciied.

Any amount applied to the deductible in the last three months of a Calendar Year will be carried over and applied to the deductible amount for the next Calendar Year.

The Plan will pay the designated percentage of covered charges until the above listed amount of out-of-pocket payments is reached, at which time the Plan will pay 100% of the remainder of covered charges for the rest of that Calendar Year unless stated otherwise.

Hospital Services

Note: The above charges for TMJ will not be counted in accumulating covered charges toward the 100% payment percentage of other charges, nor will these charges be subject to the 100% payment.

Mental Disorders