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Tri-State Plan SPD >> Eligibility and Participation
When You Are Eligible
Eligibility for benefits from the Plan depends upon the particular agreement that covers your work. Unless specified otherwise in your collective bargaining agreement or participation agreement, eligibility is as follows.
Your employer will be required to begin making contributions to the Plan on your behalf when you have completed 180 consecutive days of covered employment with the same employer working full-time (as defined by your collective bargaining agreement or participation agreement) more than 2 days a week, unless specified otherwise in your collective bargaining agreement or participation agreement. For this purpose, covered employment includes certain leaves of absence. Days of illness, pregnancy or injury count toward the 180-day waiting period. When you have completed that 180-day period working for your employer, you and your eligible dependents become eligible for the benefits described in this booklet on your 181st day of covered employment.
Additional eligibility requirements apply to death benefits for pensioners.
When You Are No Longer Eligible
Your eligibility for the Plan ends:
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at the end of the 30th day after you no longer regularly work full-time in covered employment, subject to COBRA rights (see the "Continued Group Coverage" section)
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on the date when your employer terminates its participation in the Plan, or
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on the date the Plan is terminated.
In addition, the Board reserves the right in its sole discretion to terminate eligibility if your employer becomes seriously delinquent in its contributions to the Fund.
If You Come Back To Work
If your employment ends after your eligibility commenced and you return to covered employment (with the same contributing employer, or a different contributing employer):
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within 90 days, your Plan participation starts again on your first day back at work, or
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more than 90 days later, you would have to complete 180 consecutive days of covered employment with the same employer before being able to resume participation.
As long as you are eligible, your dependents are eligible, provided they meet the definition of “dependent” under the Plan (see “Dependent Eligibility” below).
Extension of Health Benefits
Health coverage may be continued by the Plan while you are not working in the following circumstances:
COBRA
Under a Federal law called the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), group health plans are required to offer temporary continuation of health coverage, on an employee-pay-all basis, in certain situations when coverage would otherwise end. “Health coverage” includes the Plan’s hospital, medical, EAP, prescription drug, dental and vision coverage ( see the section on COBRA for more information).
Disability
If provided in your collective bargaining agreement or participation agreement, you may continue to be eligible for up to 30 months of health coverage, provided you enroll for coverage, are unable to work and are receiving (or are approved to receive) one of the following disability benefits:
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statutory short-term disability
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Workers’ Compensation, or
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Building Service 32BJ Pension Fund Disability Pension.
When any of the following events occurs, your extended coverage will end:
- if you work at any job
- on the date your LTD benefit is terminated because the Fund has determined that you are no longer totally disabled
- 30 months after you stopped working due to a disability
- when you receive the maximum benefits under statutory short-term disability or Workers' Compensation and are not eligible for a disability pension under the Building Service 32BJ Pension Fund, or
- when you become eligible for Medicare as your primary insurer.
If you die while receiving extended health coverage, your dependents’ eligibility will end 30 days after the date of your death.
To receive this extended coverage, you must apply and submit proof of disability no later than 60 days after the date coverage would have been lost (90 days after you stopped working due to a disability). You can obtain an application form from the Member Service Center. The Plan reserves the right to require proof of your continued disability from time to time. This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA. See the Continued Group Coverage section for COBRA information.
Arbitration
If you are discharged and the Union takes your grievance to arbitration seeking reinstatement to your job, your health coverage will be extended for up to six months or until your arbitration is decided, whichever occurs first. This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA.
FMLA
You may be entitled to take up to a 12-week leave of absence from your job under the Family and Medical Leave Act (FMLA). You may be able to continue Plan coverage during an FMLA leave. See the section on "FMLA" for more information.
Military Leave
If you are on active military duty, you have certain rights under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) provided you enroll for coverage. See the section on "Military Leave" for more information. This extension of coverage will count toward the period in which you are entitled to continuing coverage under COBRA.
Dependent Eligibility
If your collective bargaining agreement or participation agreement provides for dependent coverage, eligible dependents under the Plan are described below:
Dependency |
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Age Limitation |
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Requirements |
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lawful spouse |
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None |
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The person of the opposite gender to whom you are legally married under the laws of the place where you live (if you are legally separated or divorced, your spouse is not covered). |
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domestic partner
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You and your domestic partner are two individuals 18 years or older of the same gender who:
• have been living together for at least 12 months; and
• are not married to anyone else, and are not related by blood in a manner that would bar marriage under the law; and
• are financially interdependent, and can show proof of such; and
• have a close and committed personal relationship and have not been registered as members of another domestic partnership within the last 12 months.
In order to establish eligibility for these benefits, you and your domestic partner will need to provide affidavits attesting to your relationship, plus:
• a marriage certificate from a state in the U.S. or a province in Canada where same-gender marriages are valid, or
• a domestic-partner registration under state or local law (if permitted where you live), and proof of financial interdependence.
Contact the Member Service Center for an application or general information.
There may be significant tax consequences for covering your domestic partner. Contact a tax advisor for tax advice.
If you lose coverage due to a qualifying event, you and your domestic partner may elect to continue coverage on a self-pay basis through COBRA. Domestic partners will not have an independent right to COBRA continuation coverage unless the qualifying event is the participant’s death. |
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Children
(except disabled
children)
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Until end of calendar year in which dependent child reaches age 19 (or age 23, if a full-time student in an accredited college, university or trade school) |
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The child:
• is not married
• has the same principal address as the participant*, or as required under the terms of a “QMCSO” -- see the "Assignment of Plan Benefits" section, and
• is dependent on the participant for over one-half of his or her annual support and is claimed as a dependent on your tax return*.
AND
is one of the following:
• your biological child
• your adopted** child or one placed with you in anticipation of adoption
• your stepchild: this includes your spouse's biological or adopted child
• your domestic partner's biological or adopted child
• a foster child is eligible only if you have adopted** the child or applied for adoption
• your grandchild is eligible ONLY if you are the legal guardian and the child is dependent on you and only you for all support and maintenance; if application for legal guardianship is pending, you must provide documentation that papers are filed and provide proof when legal process is complete. |
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Children (disabled) |
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None |
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The child:
• is totally and permanently disabled
• became disabled while an eligible dependent, and
• meets all of the requirements listed above for a dependent child except age.
You must apply for a disabled child’s dependent coverage extension and provide proof of the child’s total and permanent disability no later than 60 days after the date the child would have otherwise lost eligibility, and you must remain covered under the Plan. You will be notified by the Fund if your adult disabled child is found eligible for continuing coverage. You must enroll your adult disabled child within 60 days of receiving confirmation of your adult child’s eligibility. Failure to enroll at this time means your disabled adult child loses his or her special eligibility. If your child becomes eligible for extended coverage as a result of disability, you will be required to pay a monthly premium to cover part of the coverage cost. Contact the Member Service Center for details. |
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A child is not considered a dependent under the Plan if he or she:
*If you are legally separated or divorced, then your child may live with and/or be the tax dependent of the legally separated or divorced spouse.
**Your adopted dependent child will be covered from the date that child is adopted or "placed for adoption" with you, whichever is earlier (but not before you become eligible), if you enroll the child within 30 days after the earlier of placement or adoption (see “Your Notification Responsibility”). 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. However, if a child is placed for adoption with you, but the adoption does not become final, that child's coverage will end as of the date you no longer have a legal obligation to support that child. If you adopt a newborn child, the child is covered from birth as long as you take custody immediately after the child is released from the hospital and you file an adoption petition with the appropriate state authorities within 30 days after the infant's birth. However, adopted newborns will not be covered from birth if one of the child's biological parents covers the newborn's initial hospital stay, a notice revoking the adoption has been filed or a biological parent revokes consent to the adoption.
When Your Dependents Are No Longer Eligible
Your dependents remain eligible for as long as you remain eligible except for the following:
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Your spouse’s eligibility ends 30 days after legal separation or divorce. Your domestic partner’s eligibility ends 30 days after the requirements for domestic partnership in the "Dependent Eligibility" section are no longer satisfied.
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Your child’s eligibility ends when your child marries or no longer satisfies the rules regarding residence or financial dependency that are described in the "Dependent Eligibility" section, or
- if not in school, at the end of the calendar year in which the child reaches age 19, or
- if in school,
- 30 days after the child’s graduation from school, or, if earlier,
- 30 days after the date the child leaves school, or, if earlier,
- at the end of the calendar year in which the child reaches age 23.
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Eligibility of a spouse, a domestic partner, and dependent children ends 30 days after your death.
How to Enroll
Coverage under the Plan is not automatic. In order for your coverage to begin, you must enroll in the Plan by completing the Building Service 32BJ Health Fund Enrollment Form (Enrollment Form) and submitting it to the Fund for processing. In most cases, your coverage will begin on the date you were first eligible, not the date you completed and returned the Enrollment Form. However, a delay in completing and returning the Enrollment Form will delay any claims payment(s) to you. You may contact the Member Service Center for information or a copy of the Enrollment Form.
Enroll your dependents as soon as they become eligible. Please see the "Dependent Eligibility" section to determine when your dependents are eligible. If at the time you enroll in the Plan, your dependents are eligible for benefits, you must complete the “Dependent Information” section of the Enrollment Form. You will be required to submit documents proving dependent status including a marriage certificate (for your spouse), birth certificates and, if applicable, proof of full-time student status (for your children). In most cases, your dependent’s coverage will begin on the date he or she was first eligible. However, if you do not enroll your dependents that are eligible when you first complete the Enrollment Form, your dependent’s coverage will not begin until the date you notify the Fund. No benefits will be paid until you provide the Fund with your eligible dependent’s information and supporting documentation. After your coverage under the Plan begins, if you have a change in family status (e.g., get married, adopt a child) or wish to change existing dependent coverage for any reason, you must complete the appropriate form. Special rules apply regarding the effective date of your new dependent’s coverage. Please see the "Your Notification Responsibility" section below for further details.
Claims for eligible expenses will be paid only after the Fund has received your completed Enrollment Form, supporting documentation and proof of hiring from your contributing employer. If your forms are not completely or accurately filled out, or if the Fund is missing requested documentation, any benefits payable will be delayed. The Fund may periodically require proof of continued eligibility for you or a dependent. Failure to provide such information could result in a loss of coverage.
Your Notification Responsibility
If, after your coverage under the Plan becomes effective, there is any change in your family status (e.g., marriage, legal separation, divorce, birth or adoption of a child), it is your responsibility to notify the Fund immediately of such change and complete the appropriate form. If you notify the Fund within 30 days of marriage or birth or adoption of a child, coverage for your new spouse or child will begin as of the date of marriage or date of birth or adoption. If you do not notify the Fund within 30 days, coverage for your new spouse or child will begin as of the date you notify the Fund. No benefits will be paid until you provide the Fund with the necessary supporting documentation. Also, be sure to notify the Fund if your child is between age 19 and 23 and graduates or otherwise leaves school, or if your child marries or no longer satisfies the rules regarding residence or financial dependency that are described in the "Dependent Eligibilty" section .
Failure to notify the Fund of a change in family status could lead to a delay or denial in the payment of health benefits or the loss of a right to elect health continuation under COBRA. In addition, knowingly claiming benefits for someone who is not eligible is considered fraud and could subject you to criminal prosecution.
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