"Eligible Class" means those persons whose chief source of livelihood is work at Covered Employment, and who, at any given time, are working in Covered Employment; are ready, willing, and able to work at Covered Employment; or, are seeking work in Covered Employment. 

Covered Employment is any type of work in the carpentry or related trade – within our geographic area – for which an Employer is required to make contributions (including contributions under a reciprocal agreement from another geographic area) for your work to the EASC Health Fund. Covered Employment also includes work as an employee of an employer which is required to contribute to the Plan under a participation agreement or work for the Fund Office.

Credited Hours are used to determine your eligibility to receive benefits under the Plan. Credited Hours are a combination of:

• Payment Hours, also called "Contribution Hours" (hours you worked for which employer contributions are made to the Health Fund for your work).
• Delinquent Hours are hours you worked for which employer contributions are due but which have not been paid (through no fault of yours) to the Health Fund for your work by the delinquent employer. You must provide evidence of your work such as a pay stub or similar record to the Fund Office to receive credited hours.
• Weekly Disability or Workers' Compensation Hours. (Currently, you may receive credit for up to 30 hours per week to a maximum of 104 weeks),
• School hours for Apprenticeship training.
• Qualifying Family and Medical Leave of Absence.
• Qualified Military Service. Military service up to 5 years for the United States is credited if you leave work with a contributing Plan employer for military service and return within the periods provided by law. You must present yourself for work in Covered Employment:
  (a) within 90 days after your discharge from military service over 180 days, (b) within 14 days for military service between 30 and 180 days and (c) immediately for service under a month. For military service before 1994, you had to return to Covered Employment within 90 days of discharge regardless of the length of your military service. Military service for the United States is also credited if you leave work with a contributing Plan employer for military service and you either pass away or become disabled after December 31, 2006 while performing military service. Service is credited as though you had returned to work on the date of your passing or on the date of the onset of your disability. Hours credited for Qualified Military Service are treated the same as "Payment Hours."

Covered Employment is any type of work in the carpentry or related trade - within our geographic area - for which an Employer is required to make contributions (including contributions under a reciprocal agreement from another geographic area) for your work to the Eastern Atlantic States Carpenters Health Fund. Covered Employment also includes work as an employee of an employer which is required to contribute to the Plan under a participation agreement.

Once you accumulate the required number of Credited Hours in a six-month Work Period (as defined above), you have a Qualifying Work Period, and you are covered under the Plan for a six-month Benefit Period, as long as you continue to be in the Eligible Class.  Your Benefit Period is determined by your Qualifying Work Period as shown on the following chart.

Note:  For continuing eligibility, there is a three-month lag period after the end of the Work Period before benefits begin.  This lag period allows the Fund Office the time needed to collect and process the Employer contributions that are used to determine your eligibility for coverage.

If you are an Active Covered Participant eligible for benefits under the Plan, your eligible family members are also covered for the same benefits as you, with limitations.  Eligible family members include:

• The spouse to whom you are legally married, subject to the Working Spouse rule;
• Your children (your natural child, stepchild, legally adopted child, or child placed with you for adoption) who are not yet age 26;
• Your children (your natural child, stepchild or legally adopted child) who are at least age 26 and who are incapable of self-sustaining employment because of a physical or mental handicap; and
• A child covered by a Qualified Medical Child Support Order.

In order for the Plan to enroll your Eligible Family Member in coverage, he or she must have a social security number or taxpayer identification number. Please refer to the Special Enrollment Section of this SPD for instructions on what to do if you have a new Eligible Family Member (e.g. you get married or have a child). If you pass away while you have a level of coverage in this Plan, your eligible family members are entitled to continue coverage until the end of the month that is 12 months from the date of your death.  Thereafter, your eligible family members will be offered COBRA continuation coverage.

Your spouse is required to enroll in any group health plan offering medical benefits made available to him or her by their employment. This requirement shall not apply to any spouse who does not work, is self-employed, or who is required by his or her employer to pay more than the Affordable Care Act’s Affordability Threshold for the cost of coverage. Any spouse who is eligible for employer-sponsored medical coverage but fails to enroll during an applicable open-enrollment period must enroll at the next available opportunity. Any spouse who fails to enroll in available coverage as of the next available opportunity whether that opportunity is special enrollment or open enrollment, will receive  secondary coverage after the date of that opportunity.  All spouses will be required to complete a verification each year that confirms he or she meets one of the conditions above for exemption unless copies of the other insurance carrier ID cards are already on file.

Benefit coverage for children will generally stop as of the first of the month following the date on which they turn age 26, except that if your child is permanently disabled and the disability occurred prior to your child attaining age 26, he/she may continue to be covered under the Plan as long as he/she remains totally and permanently disabled.  The Plan must be provided with supporting documentation of the disability from the Social Security Administration prior to the date on which your child would otherwise lose eligibility.  You must also complete a disabled child questionnaire provided by the Fund Office and any other documentation deemed necessary by the Board of Trustees.

Participants must complete an Annual Enrollment/COB Form for all eligible family members once per Benefit Year. If a Form or Working Spouse Form is not received, your Vacation Benefit will be suspended until the Form is completed.

COINSURANCE is your share of the costs of eligible medical expenses covered by the Plan. For example, with the Plan’s 90/10 coinsurance plan, the Plan pays 90% of covered eligible medical expense charges and you pay 10%.

A Copay is a fixed amount you pay for a covered health care service after you’ve satisfied any applicable deductible.

A DEDUCTIBLE is the amount you are required to pay before the Plan begins to pay for eligible medical expenses covered by the Plan.

OUT-OF-POCKET MAXIMUM is the maximum amount you are required to pay out-of-pocket in a Benefit Year for eligible medical expenses covered by the Plan. Once you hit your out-of-pocket maximum, the Plan will pay 100% of the eligible medical expenses covered by the Plan for the remainder of the Benefit Year. In other words, your coinsurance is 0% for eligible medical expenses covered by the Plan once you satisfy the Plan’s out-of-pocket maximum.

This Plan maintains an out-of-pocket maximum separately for medical benefits through IA and MHC (i.e. Blue Card PPO coverage), prescription drug benefits through ESI, and the Ambulance Benefit through the Fund. The combined out-of pocket maximum will not exceed the maximum limit required by federal law.

If you have no Credited Hours for a six month period, your coverage will be suspended. You will receive a letter notifying you of the impending suspension of your coverage. If contributions are received or paystubs are provided showing proof of work in Covered Employment in the six-month timeframe, your coverage will not be suspended. If your coverage is suspended and you later return to work in Covered Employment and have otherwise met the eligibility conditions set forth in this SPD, your coverage will be reinstated back to the first (1st) of the month in which you returned to Covered Employment.

If you choose to use a provider that is not a network provider, you may have additional costs, depending on your level of coverage.

For Gold Coverage, the out-of-network coinsurance for Medical/Behavioral Health and substance use disorder is 50/50, which generally means that the Plan pays 50% of the In-Network Allowable Rate for covered eligible medical expenses, and you pay 50%. Gold Coverage has a $10,000 out-of network deductible and a $25,000 out-of-pocket maximum.

For Silver Coverage, the out-of-network coinsurance for
Medical/Behavioral Health and substance use disorder
is 50/50 of the In-Network Allowable Rate. Silver
Coverage has a $20,000 out-of-network deductible and
a $30,000 out-of-pocket maximum.