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to the Sheet Metal Workers’ Health and Pension Plans of Southern CA, AZ & NV. Welcome. The Administrative Office. Office Hours : 7am to 5 pm Monday - Friday Mailing Address : P.O. Box 10067 Manhattan Beach, CA 90266 Phone : 800-94-SHEET or 310-798-6572

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To the sheet metal workers health and pension plans of southern ca az nv l.jpg

to the

Sheet Metal Workers’

Health and Pension Plans

of Southern CA, AZ & NV

Welcome


The administrative office l.jpg
The Administrative Office

Office Hours: 7am to 5 pm Monday - Friday

Mailing Address: P.O. Box 10067 Manhattan Beach, CA 90266

Phone: 800-94-SHEET or 310-798-6572

Fax: 310-798-0766


The administrative staff l.jpg
The Administrative Staff

Administrator - Richard Wondra

Asst. Administrator - Peggy Schack

Accounting Department

Claims Department

Eligibility Department

Pension Department

Support Staff


The accounting department duane la pointe controller craig wiseman cpa supervisor l.jpg
The Accounting DepartmentDuane La Pointe, Controller Craig Wiseman, CPA, Supervisor

Kathy Sowell Tasi Hernandez

Kelly Sieverson Delia Munoz Jide Awelewa

Joyce Liggins Donna Miller Tom Shinn

  • Receives and processes Employer Remittances(your hours worked)on a monthly basis


Your hours worked l.jpg
Your Hours Worked

  • Are due from your Employer by the 20th of the month following the actual work month

  • If your Employer reports your hours without the appropriate monies due, a completed “Declaration of Hours Worked” formis required from you before those hours will be credited to your Hour Bank


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Keep your paycheck stubs!

If there is a discrepancy in the hours that have been reported on your behalf - you may need to submit copies of your stubs to the Administrative Office for review.


The pension department jack rupert manager valeria hughes supervisor louis guerrero jaime medina l.jpg
The Pension Department Jack Rupert, ManagerValeria Hughes, SupervisorLouis Guerrero Jaime Medina

  • Processes Pension applications and Benefit checks based on contributions received from Employers for appropriate hours worked, as determined in the Collective Bargaining Agreement

    • Annual Pension Statements are mailed in May of each year, and indicate total hours reported


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The Claims DepartmentPeggy Schack, ManagerShirley Jones, SupervisorIrene Medina,* Quality Assurance Auditor

Vernell Anderson Kim Henderson

B, G E, K, N, P, W

Edna McQuirter Maria Martinez *

C, H, L, O, T, U A, F, I ,M, S

Maria Petracca *

D, J, Q , R, V, X, Y, Z

* Bilingual - Spanish


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The Claims DepartmentPeggy Schack, ManagerShirley Jones, SupervisorIrene Medina,* Quality Assurance Auditor

  • Process all claims on the Fee-for-Service Medical and Dental plans

  • Acts as liaisons on behalf of participants with outside provider benefit issues.


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The Support Staff

John Mazariegos, Supervisor

Leesa Noriega Rosie Mazariegos Eloise Corral Maynor Munoz Robert Bado Priscilla Velez Eddie Martinez

  • Mail room, files, supplies, etc

  • Assists other departments as needed

    “Behind the scenes” overall assistance


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Computer Systems

Andrea Amalfitano

Computer Systems Administrator

www. SheetMetalSam.org


The eligibility department patti a frank manager al medina pat campbell frank lopez l.jpg
The Eligibility DepartmentPatti A. Frank, ManagerAl Medina Pat Campbell Frank Lopez

  • Eligibility / Hour Bank status

  • Medical & Dental Plan Enrollments

  • Disability Extensions, Self-pay & COBRA

  • Communications / Member Service

  • Participant Data Maintenance


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Your Eligibility for Benefits

  • Establishing

  • Maintaining

  • Continuing

Determined by the Number of Hours You Work


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Your Hours Worked

  • Are due from your Employer by the 20th of the month following the actual work month, and are used to determine eligibility for the following month

  • For example: Hours worked in January are due in our office by February 20th and determine March eligibility


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Establishing EligibilityPlan B

  • Minimum of 100 hours each month for 2 consecutive months

  • One full calendar month wait

  • Eligibility begins on the 1st day of the next month.


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Examples of Establishing EligibilityPlan B

Work Month Hours or Hours

January 100 90

February 120 160

March 100 120

Your Eligibility Begins: April 1 May 1


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Maintaining Eligibility under Plan B

  • 100 hours worked = 1 month of eligibility

  • One full month in between actual hours worked and eligible month

    Example:Hours worked in January determine March eligibility


Continuing eligibility your plan b hour bank l.jpg
Continuing EligibilityYour Plan B Hour Bank

  • All hours worked go into your Hour Bank

  • Hour Bank can hold a maximum of : 200 hours (plus the current month) for Plan B

  • 100 hours are deducted from your bank on the first day of each month, for that month’s coverage


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Transferring From Plan Bto Plan A

  • You must exhaust all of the hours in your Plan B hour bank before Plan A benefits will begin, and…

  • You must obtain at least 110 hours under Plan A two (2) months prior to your Plan A effective date.


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Transferring From Plan Bto Plan A

  • As an Apprentice, your contributions from your Employer will be increased to Plan A.

  • Assuming a July, 2009 effective date of becoming an Apprentice, and you have a full Plan B Hour Bank of 200 Hours, your benefits under Plan A will become effective November 1, 2009.


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Maintaining Eligibility under Plan A

  • 110 hours worked = 1 month of eligibility

  • One full month in between actual hours worked and eligible month

    Example:Hours worked in September determine November eligibility.


Continuing eligibility your plan a hour bank l.jpg
Continuing EligibilityYour Plan A Hour Bank

  • All hours worked go into your Hour Bank

  • Hour Bank can hold a maximum of : 880 hours (plus the current month) for Plan A

  • 110 hours are deducted from your bank on the first day of each month, for that month’s coverage


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Unemployed or Disabled ?

  • 110 hour (100 for Plan B) per month deduction continues whether or not you are working

  • Extension may be available for those who are unable to work due to an injury or illness

You are responsible for knowing the status of your hour bank, and when your coverage will terminate


Unable to work due to a disability l.jpg
Unable to Work due to a Disability?

  • Extension of benefits may be availableif you are unable to work for at least 7 consecutive days.

  • 27.5 (25 for Plan B) hours per week may be added to your Hour Bank, for a period of time you are disabled, to a maximum of 357.5 hours (325 for Plan B),or 13 weeks total.

    Completed Evidence of Coverage must be submitted to the Administrative Office within 30 days of the date of your disability.


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Continuing Coverage while Unemployed or Disabled

You may continue coverage on a self-pay basis by enrolling in either the :

  • Unemployed / Disabled Self-pay Plan(Plan A participants only), or

  • COBRA Continuation Coverage

    Once you have elected one of the above programs, you may not choose to enroll in the other.


Unemployed and disabled self pay plans l.jpg
Unemployed and Disabled Self-Pay Plans

Reduced Benefits - Plan B

  • You must qualify & submit an application

  • Extension available for:

    • 12 consecutive months if unemployed,

    • 29 consecutive months if disabled

  • $250 month - Payment must be received in Administrative Office no later than the 20th of the monthprior to the month of coverage


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COBRA Continuation Coverage

  • You will receive a COBRA Continuation Coverage Notification and Election Form within 10 days of your (or your dependent’s) loss of coverage.

  • Extension available:

    • 18 consecutive months for reduction of hours

    • 36 consecutive months for loss of dependent status


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COBRA Continuation Coverage

Plan A Benefits

Current Monthly Rates as of 8/1/09

Medical, Dental & Vision Coverage

Single Person $364.00

2-Party $728.00

Family $1,103.00


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COBRA Continuation Coverage

Plan B Benefits

Current Monthly Rates as of 8/1/09

Medical, Dental & Vision Coverage

Single Person $306.00

2-Party $612.00

Family $984.00


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Reinstating Eligibilityunder Plan A

  • You must obtain at least 110 hours within 6 months of losing coverage

  • If more than 6 calendar months elapse, you must establish eligibility with 600 hours.

Remember - there is one full month between work month and coverage month.


Establishing eligibility plan a l.jpg
Establishing EligibilityPlan A

  • 600 hours for a Contributing Employer, in a period not to exceed 6 consecutive months.

  • One full calendar month wait

  • Eligibility begins on the 1st day of the next calendar month.


Examples of establishing eligibility plan a l.jpg
Examples of Establishing EligibilityPlan A

Work Month Hours orHours

January 110 155

February 120 155

March 80 170

April None 160

May 150

June 140

Your Eligibility Begins: August 1 June 1


Standard notifications l.jpg
Standard Notifications

  • New Eligible Benefit Packet

  • Reinstatement of Eligibility

  • Confirmation of receipt of Plan Enrollments & required dependent documentation

  • 440 & 220 hour “Threshold” letters - Plan A

  • Certificate of Coverage

  • COBRA


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Your Eligible Dependents

  • Legal spouse

  • Children under 19 years of age

  • Students age 19 through 23 *

  • Handicapped children *

Documentation which verifies relationship to the participant must be submitted to the Administrative Office.

*Verification required


Documentation required l.jpg
Documentation Required

Copies of the following documents are required to add or delete dependents:

  • Spouse - Marriage Certificate

  • Children - Birth Certificate or Court Orders

  • Children between ages of 19 & 23 -

    • Full-time Student Verification (at least 12 units)

  • Ex-spouse -Divorce Decree


You must immediately notify the administrative office of any change in dependent status l.jpg
You must immediately notify the Administrative Office of any change in dependent status!

If you do not notify us, and claims and/or premiums are paid on behalf of ineligible dependents, you will be held responsible for reimbursing the Plan for any and all monies paid in error, plus interest and attorney’s fees & costs.


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Your Benefit Package

  • Major Medical(including prescription drugs)

  • Dental

  • Vision

  • Employee Assistance

  • Death Benefit


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Your Medical Plan Options in NV

  • Fee-for-ServicePlan-Self-funded PlanYou may use any licensed physician, but it is to your advantage to use the PPO (Blue Cross) Network

  • Health Plan of Nevada-HMO Plan You must choose a Primary Care Physician (PCP) and use network providers

  • PacifiCare of Nevada- HMO Plan in Southern Nevada. You must choose a Primary Care Physician (PCP) and use network providers


The fee for service plan self funded ppo plan l.jpg

Offers the flexibility of “choice”. You may see any licensed physician and use any facility you choose.

Utilizing the PPO network (Preferred Provider Organization) greatly reduces your out-of-pocket expenses

Claims for services incurred are processed and paid by the Administrative Office.

The Fee-for-Service Plan Self-funded PPO Plan


The hmo plans health maintenance organization l.jpg

Managed Care Environment licensed physician and use any facility you choose.

No deductibles, lifetime maximums or claim forms

Specified co-payments due at the time of service

You (and your eligible dependents)must reside in your selected HMO’s defined service area, and have all services provided within their network

You must select a Primary Care Physician (PCP), and see him/her for all services. If it is necessary to see a Specialist, your PCP will provide the referral

The HMO Plans “Health Maintenance Organization”


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Your Prescription Benefits licensed physician and use any facility you choose.

Are determined by your Medical Plan

  • If you are enrolled on the Fee-for-Service Plan-

    • you must use the ExpressScripts program

  • If you are enrolled on an HMO-

    • you must use a participating HMO pharmacy


Your dental plan options under plan b l.jpg
Your Dental Plan Options licensed physician and use any facility you choose.under Plan B

  • Fee-for-Service Self-funded Indemnity Plan - You may use any licensed dentist. Benefits are paid based on scheduled allowable charges, as outlined in your Summary Plan Description.

  • United Concordia - You must select a United Concordia participating dentist, and have all dental services performed by that dentist


Your dental plan options under plan a l.jpg
Your Dental Plan Options licensed physician and use any facility you choose.under Plan A

  • Delta Dental Preferred Option - You may use any licensed dentist, but it is to your advantage to use a DPO network dentist, as his/her fees have been accepted in advance by Delta

  • United Concordia- You must select a United Concordia participating dentist, and have all dental services performed by that dentist.


Your dental plan options under plan a47 l.jpg
Your Dental Plan Options licensed physician and use any facility you choose.under Plan A

  • Delta Dental Preferred Option - If you are currently enrolled on the Fee-for-Service dental Plan under Plan B, you will automatically be enrolled on Delta Dental under Plan A.

  • United Concordia– If you are currently enrolled on United Concordia under Plan B, you will remain on United Concordia under Plan A.


Your vision benefits l.jpg
Your Vision Benefits licensed physician and use any facility you choose.

  • Vision Service Plan

    No up front paperwork or forms required-

    Simply contact your participating VSP optometrist to make an appointment. If you need help locating a participating doctor, call VSP at:

    (800) VSP 7195(800-877-7195)

    or visit their website at vsp.com


Employee assistance l.jpg
Employee Assistance licensed physician and use any facility you choose.

The Beat It! Program

  • If you are enrolled on the Fee-for-Service Medical Plan, you must use the Beat It! Program.

  • If you are enrolled on an HMO, you may choose between, or combine benefits available with your selected HMO.

  • For more information, call Beat It! at:

    1-800-828-3939

100% Confidential !


Selecting your medical and dental plans l.jpg
Selecting Your Medical and Dental Plans licensed physician and use any facility you choose.

You may select your plans -

  • within 60 days from your initial Eligibility date, or

  • during the Annual Open Enrollment Period

If you do not select a Plan within the specified time-frame, you will automatically remain on the Fee-for-Service Medical or Dental Plans.


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Annual Open Enrollment licensed physician and use any facility you choose.

  • Materials are mailed in April.

  • If you do NOT want to change plans- no need to reply. Keep the updated Summaries for your reference

  • If you want to change plans - or simply review materials from other Plans…...

    • Return the “Packet Request Form” to our office no later than May 1st


Annual open enrollment52 l.jpg
Annual Open Enrollment licensed physician and use any facility you choose.

Returning the Packet Request Form does not enroll you in a Plan or change your current medical or dental plan

You must submit a completed Enrollment Form for the Plan of your choice to the Administrative Office


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Annual Open Enrollment licensed physician and use any facility you choose.Effective Dates

Enrollment form rec’dEff Date

Before May 15th June 1st

After 5/15, before June 15th July 1st

All Enrollment forms must be received

no later than June 15th


Choose carefully l.jpg
Choose Carefully! licensed physician and use any facility you choose.

Once you have selected a medical or dental plan, you may change your selection only during the next Annual Open Enrollment Period.

Exceptions are made only if you move outside of your selected plan’s area.


Before you select a medical or dental plan do you l.jpg
Before licensed physician and use any facility you choose. you select a medical or dental plan , do you . . .

  • reside in your selected plan’s service area?

  • work outside of your selected plan’s service area?

  • have eligible dependents residing outside of your selected plan’s service area?


Member service numbers to remember l.jpg
Member Service licensed physician and use any facility you choose. Numbers to Remember

  • PacifiCare of Nevada HMO Medical Plan 800-347-8600

  • Health Plan of Nevada HMO Medical Plan 702-242-7300

  • Delta Dental 888-335-8227

  • United Concordia Dental 800-332-0366

  • ExpressScripts Fee-for-Service Prescription 800-357-9572

  • Beat It! Substance Abuse 800-828-3939

  • Blue Cross Pre-authorization on Fee-for-Service 800-782-7484

  • Vision Service Plan 800-877-7195

Sheet Metal Workers’ Trust Funds 800-947-4338


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PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

Soc. Sec. Nbr 123-45-6789

Name Joe Smith Birth Date: 1/01/63

12345 Elm Street Local Number: 105

Current Status: E 7/01/94

Garden Grove CA 92840

BENEFIT BENEFIT MED. DENT STAT PRIOR CURRENT CURRENT EMPL

MONTH STATUS PLAN S/F PLAN CODE BANK HOURS BANK CODE

------- -------------- ----- --- ------- ----- ------- ------- ------- -----

8/2009 ELIGIBLE B I 200.00 178.00 200.00 8605

9/2009 ELIGIBLE B I 200.00 0.00 100.00 77778

10/2009 ELIGIBLE B I 100.00 0.00 0.00 77778

11/2009 ELIGIBLE A-88 D 0.00 401.50 291.50 2955

12/2009 ELIGIBLE A-88 D 291.50 174.50 356.00 2955

---------- DEPENDENT TABLE ----------

Susie Smith -W 02/02/65 (33) Y N

Debbie Smith - D 7/22/90 ( 8) Y N

Michael Smith - S 7/27/88 (10) Y N


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PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

Soc. Sec. Nbr 123-45-6789

Name Joe Smith Birth Date: 1/01/63

12345 Elm Street Local Number: 105

Current Status: E 7/01/94

Any Town CA 90000

  • Your personal data.

  • Please verify that your address and date of birth is correct.


Slide59 l.jpg

PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

---------- DEPENDENT TABLE ----------

Susie Smith -W 02/02/65 (33) Y N

Debbie Smith - D 7/22/90 ( 8) Y N

Michael Smith - S 7/27/88 (10) Y N

  • Your eligible dependents.


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PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

BENEFIT BENEFIT MED. DENT STAT PRIOR CURRENT CURRENT EMPL

MONTH STATUS PLAN S/F PLAN CODE BANK HOURS BANK CODE

------- -------------- ----- --- ------- ----- ------- ------- ------- -----

8/2009 ELIGIBLE B I 200.00 178.00 200.00 8605

9/2009 ELIGIBLE B I 200.00 0.00 100.00 77778

10/2009 ELIGIBLE B I 100.00 0.00 0.00 77778

11/2009 ELIGIBLE A-88 D 0.00 401.50 291.50 2955

12/2009 ELIGIBLE A-88 D 291.50 174.50 356.00 2955

  • Benefit Month - month of coverage.

  • Benefit Status - “ELIGIBLE” or “IN-ELG”

  • Medical Plan- Code determines current medical plan.

  • A-88 Fee-for-Service A-N PacifiCare

  • A-H Health Plan of Nevada


Slide61 l.jpg

PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

BENEFIT BENEFIT MED. DENT STAT PRIOR CURRENT CURRENT EMPL

MONTH STATUS PLAN S/F PLAN CODE BANK HOURS BANK CODE

------- -------------- ----- --- ------- ----- ------- ------- ------- -----

8/2009 ELIGIBLE B I 200.00 178.00 200.00 8605

9/2009 ELIGIBLE B I 200.00 0.00 100.00 77778

10/2009 ELIGIBLE B I 100.00 0.00 0.00 77778

11/2009 ELIGIBLE A-88 D 0.00 401.50 291.50 2955

12/2009 ELIGIBLE A-88 D 291.50 174.50 356.00 2955

  • Benefit Month - month of coverage.

  • Benefit Status - “ELIGIBLE” or “IN-ELG”

  • Dental Plan- Code determines current dental plan.

  • I Fee-for-Service N United Concordia

    • D Delta Dental


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PARTICIPANT ELIGIBILITY STATUS INQUIRY licensed physician and use any facility you choose.

BENEFIT BENEFIT MED. DENT STAT PRIOR CURRENT CURRENT EMPL

MONTH STATUS PLAN S/F PLAN CODE BANK HOURS BANK CODE

------- -------------- ----- --- ------- ----- ------- ------- ------- -----

8/2009 ELIGIBLE B I 200.00 178.00 200.00 8605

9/2009 ELIGIBLE B I 200.00 0.00 100.00 77778

10/2009 ELIGIBLE B I 100.00 0.00 0.00 77778

11/2009 ELIGIBLE A-88 D 0.00 401.50 291.50 2955

12/2009 ELIGIBLE A-88 D 291.50 174.50 356.00 2955

  • Prior Bank - balance of Hour Bank brought forward.

  • Current Hours- hours worked 2 months prior. For example, 8/09 Benefit Month reflects 6/09 hours worked. (Note for the benefit month of 11/09- your Plan A hours may be accumulated through 9/09, and are all reflected in the “current hours” )

  • Current Bank- balance of hours left after the 100 (Plan B) or 110 (Plan A) hours deduction for the current Benefit Month.


Questions l.jpg
Questions? licensed physician and use any facility you choose.

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Call Us! licensed physician and use any facility you choose.

800-947-4338

800-94-SHEET

or

310-798-6572

We’re here for you!


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