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IMPORTANT NOTICE TO PARTICIPANTS

April 2020

To All Participants:

The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Fund") regularly review the Summary Plan Description/Plan Document ("SPD") and make changes when necessary. Please take time to read this notice, which is called a summary of material modifications ("SMM"), carefully and thoroughly because it contains important information regarding changes to the SPD.

Please be advised that, although this notice must be mailed to all Fund Participants, the changes in this notice apply only to those on an Active Plan or those on a Retiree Plan who are not yet on Medicare. Medicare-eligible Participants on a Retiree Plan will receive information directly from UnitedHealthcare as it relates to COVID-19.

Briefly, this SMM reflects recent Trustee action to:

• Increase accident and sickness weekly benefit payments to $450 a week for any injury or sickness starting on or after March 19, 2020;

• Waive the eight-day waiting period for weekly accident and sickness benefits until the U.S. Department of Health and Human Services ("HHS") declares that the COVID-19 health emergency has ended;

• Add coverage for COVID-19 testing and diagnostic visits consistent with the Families First Coronavirus Response Act, effective March 18, 2020; and

• Add coverage for COVID-19 treatment, effective April 1 – May 31, 2020.

Please keep this Notice with your SPD booklet for future reference. If you have any questions, feel free to call the Fund Office.

Yours very truly,

THE BOARD OF TRUSTEES

43301110

Summary of Material Modifications

1. Effective for any accident or sickness starting on or after March 19, 2020, the Plan will increase the Accident and Sickness weekly benefit rate from $350 to $450. The benefit table on page xi of the SPD is amended to reflect this increase.

2. Effective for any accident or sickness starting on or after March 18, 2020, the

Plan will waive the eight-day waiting period for accident and sickness weekly benefits until the U.S. Department of Health and Human Services declares that the COVID-19 health emergency has ended. The benefit table on page xi is amended accordingly.

The benefit table on page xi of the SPD is amended to read as follows:

Classes C and O

For Active Employees Only DEATH BENEFITS

Amount of Death Benefit Principal Sum for Accidental Death and Dismemberment

$20,000 $20,000

ACCIDENT AND SICKNESS WEEKLY BENEFITS

Weekly benefit rate $450 Maximum number of weeks payable per disability 26

Accident and Sickness Weekly Benefits are limited to 10 days per Eligible Employee per Calendar Year for treatment of nervous and mental disorders while Hospital- confined and 30 days per each Eligible Employee’s Lifetime for treatment of alcoholism and substance abuse while Hospital-confined.

Benefits begin on the first day of a disability caused by an Injury and on the eighth day of a disability caused by a Sickness. Effective March 18, 2020 until the U.S. Department of Health and Human Services declares the COVID-19 health emergency has ended, there will be no waiting period for a disability caused by a Sickness.

An $800 per week pregnancy and post-delivery Accident and Sickness Weekly Benefit is available for mothers who are disabled while pregnant and/or following delivery of a child for a maximum of 26 weeks. The pregnancy and post- delivery Accident and Sickness Weekly Benefit is available during pregnancy for a pregnancy-related condition resulting in disability. Following childbirth, up to six weeks of post-

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3. Effective March 18, 2020 and ending when the HHS declares the end of the COVID-19 National Emergency, the Plan will provide 100% coverage of qualifying COVID-19 testing and 100% coverage of related office visits (including telehealth visits), urgent care visits, and emergency room visits that result in a COVID-19 test, consistent with the requirements of the Families First Coronavirus Response Act. New language is added to the Schedule of Benefits to reflect this change:

For Active and Retiree Classes C, E, G, O, P, R and

non-Medicare-eligible retirees and dependents of Classes S and U COVID-19 Testing (effective from March 18, 2020 until the end of the COVID-19 National Emergency)

Qualifying COVID-19 Testing Office visits (including telehealth), urgent care visits and emergency room visits

100% 100%

4. Effective April 1, 2020 through May 31, 2020, the Plan will provide 100% coverage of negotiated charges for treatment of COVID-19 from an in-network provider and 100% of Reasonable Expenses for treatment of COVID-19 from an out-of-network provider. New language is added to the Schedule of Benefits to reflect this change:

For Active and Retiree Classes C, E, G, O, P, R and

non-Medicare-eligible retirees and dependents of Classes S and U COVID-19 Treatment (effective April 1, 2020 – May 31, 2020)

COVID-19 Treatment 100%

delivery benefits are payable under the pregnancy and post- delivery Accident and Sickness Weekly Benefit (up to eight weeks for Cesarean delivery), subject to limitations noted on page 58.

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Additionally, a new subsection "10." is added to the Other Covered Charges section beginning on page 32 of the SPD in the Covered Expenses section under Comprehensive Major Medical Benefits to read as follows:

10. COVID-19 virus testing, if for in-vitro diagnostic testing that is authorized by the

FDA or otherwise required to be covered under Federal law, and the related costs incurred during an office visit (including a telehealth visit), urgent care visit, or emergency room visit that results in a COVID-19 test. Coverage applies without regard to whether the test is provided in-network or out-of-network and no prior authorization or medical management requirements will apply to the qualifying COVID-19 testing. Coverage will be provided consistent with the Families First Coronavirus Response Act or other applicable Federal law, and related guidance.


March 2020


The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Fund") regularly review the Summary Plan Description/Plan Document ("SPD") and make changes when necessary. Please take time to read this notice, which is called a summary of material modifications ("SMM"), carefully and thoroughly because it contains important information regarding changes to the SPD.

Briefly, this SMM reflects recent Trustee action to:

Increase credit hours for employees receiving short-term disability benefits to 26 weeks effective for disabilities occurring on and after January 1, 2020;

Add coverage for virtual office visits and expand LiveHealth Online coverage for behavioral health benefits; and

Require use of the Smart-90 pharmacy program.

This SMM also describes the changes resulting from the Fund's partnership with Express-Scripts’ program, SaveOnSP and updates the benefits provided under the Employee Assistance Program ("EAP") resulting from the change in EAP providers from ComPsych to TEAM Corporation ("TEAM"). Finally, a new Trustee listing is included.

SaveOnSP

To help combat the high cost of specialty medications, the Trustees have partnered with SaveOnSP. As described in other materials you have received, the SaveOnSP program can help you save money on certain specialty medications. If you are currently taking certain specialty medications, SaveOnSP may have already contacted you about participating in the program. By participating in this program, select specialty medications will be free of charge ($0). Your prescriptions will still be filled through Accredo, your existing specialty mail pharmacy.

If you are currently taking or will be taking a medication on the enclosed list (2020 SaveOnSP Specialty Drug List), you are eligible to participate in the SaveOnSP program. The Trustees encourage you to participate if you are eligible. If SaveOnSP has not already contacted you, you should call SaveOnSP at 1-800-683-1074 prior to April 1, 2020 to avoid delays in obtaining your prescription(s).

If you are eligible to participate in the SaveOnSP Program but choose not to participate, the copay for your drug will increase to the amount shown on the enclosed list. Keep in mind that the copay will not count towards your deductible or out-of-pocket maximums.

* * *


Yours very truly,


Summary of Material Modifications

1. Effective July 1, 2019, the Plan will cover virtual office visits subject to the same in-network and out-of-network terms as in-person office visits. To incorporate this change, the first sentence of item 3 of the Physicians' Services section on page 30 under COVERED CHARGES is amended to read:

Medical services rendered during in-Hospital, Hospital outpatient, office, home, or virtual office visits.

Additionally, the Online/Internet-Based Physician Visits section on page 40 under ALTERNATIVE WAYS OF OBTAINING CARE is amended to read:

Online/Internet-Based Physician Visits

You may take advantage of the Preferred Provider Online Physician Visit Program as described on page 55.

2. Effective January 1, 2020, for disabilities beginning on or after that date, the RULE IV. MAINTENANCE OF ELIGIBILITY OF EMPLOYEES RECEIVING DISABILITY BENEFITS (CLASS C ONLY) section on page 16 of the SPD is amended to credit employees up to 780 hours per disability.

3. Effective April 1, 2020, the Plan is implementing the following changes for the SaveOnSP Program:

Schedule Changes

The Preferred Provider Pharmacy Program Schedule of Benefits found on page x of your SPD is replaced with the following:

Classes C, E, G, O, P, R and non-Medicare-eligible retirees and dependents of Classes S and U

For Active and Retiree Classes PREFERRED PROVIDER PHARMACY PROGRAM

Retail Eligible Person's copayment per covered prescription for up to a 30-day supply:

Generic $8.00 Brand name (including multi-source brand name contraceptives)

The greater of $15.00 or 25% of the cost, to a maximum of $35.00 per prescription

ACA Preventive Care drugs, with Physician’s written prescription $0.00

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Smart-90 Retail Network Eligible Person's copayment per covered prescription for up to 90-day supply

Generic maintenance drugs $16.00 Brand name maintenance drugs The greater of $30.00 or

25% of the cost, to a maximum of $70.00 per prescription

Mail-Service Eligible Person's copayment per covered prescription for up to 90-day supply

Generic $16.00 Brand name (including multi-source brand name contraceptives)

The greater of $30.00 or 25% of the cost, to a maximum of $70.00 per prescription

ACA Preventive Care drugs, with Physician's written prescription $0.00

Specialty Medications (through Specialty Pharmacy) Eligible Person's copayment per prescription for up to a 30-day supply

Non-Select Specialty Medications 25% of the cost, to a maximum of $50.00 per prescription

Select Specialty Medications1 Amount listed in the SaveOnSP Specialty Drug List2

Out-of-Pocket PPRx Maximum per Calendar Year Per Eligible Person $5,350 Per family $9,200

1 The copayments for Select Specialty Medications do not apply toward satisfying your deductible or the out-of-pocket PPRx maximum. 2 The SaveOnSP Specialty Drug List is available at www.saveonsp.com/carpenters or by contacting the Fund Office.

The DEDUCTIBLE section on page 26 of your SPD is replaced with the following:

DEDUCTIBLE

The deductible is the amount of covered charges you must pay before benefit payments will begin. The deductible is stated in the Schedule of

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Benefits. The deductible amount will be waived for the alternative ways of obtaining care on pages 37 through 40 and preventive care on pages 36 and 37. The deductible applies only once in any Calendar Year. So that you will not have to satisfy a deductible late in one Calendar Year and soon again the following year, any expenses incurred and applied against the deductible in the last three months of a Calendar Year also may be applied toward satisfying the deductible in the next Calendar Year.

Normally, the deductible is applied separately to each Eligible Person in a family. But, if two or more eligible members of a family are injured in the same accident, only one deductible will be charged against all resulting covered charges, regardless of the number of family members injured. A combined deductible also will apply to related covered charges for such common accident incurred in subsequent Calendar Years when new deductible amounts otherwise would apply.

Copayments for Select Specialty Medications do not apply toward the deductible.

The OUT-OF-POCKET section on page 26 of your SPD is replaced with the following:

OUT-OF-POCKET

Reasonable Expenses you pay for covered charges (including amounts applied to the deductible amount; and the separate emergency room visit copayment) accumulate to the out-of-pocket maximum. When your out-of-pocket expenses reach the maximum stated in the Schedule of Benefits in any one Calendar Year, the Plan will pay 100% of the balance of covered Reasonable Expenses that exceed the out-of-pocket maximum for such Eligible Person(s) for the remainder of that Calendar Year. The chiropractic visit maximums will continue to apply once you have satisfied the out-of-pocket maximum.

The following charges are not included in the out-of-pocket maximum:

Copayment reduction of 5% up to $500 for each non-emergency Hospital confinement, including inpatient admissions, that is not precertified as required;

Copayment for out-of-network preventive care in excess of maximum;

Amounts in excess of maximum for out-of-network chiropractic visits;

Copayment for Select Specialty Medications (for the out-of-pocket PPRx maximum stated in the Preferred Provider Pharmacy Program Schedule of Benefits);

Premiums;

Balanced-billed charges; and

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Health care this Plan does not cover.

The PREFERRED PROVIDER PHARMACY PROGRAM (PPRx) section of your SPD is revised to describe the SaveOnSP Program and the specialty medications for which your costs will not apply to the out-of-pocket PPRx maximum. Specifically, a new section is added on page 50 above the General Rules section, to read:

SaveOnSP Program for Select Specialty Medications The Plan uses a specialty pharmacy copay assistance program administered by SaveOnSP (the "SaveOnSP Program"). Under the SaveOnSP Program, your copayments for Select Specialty Medications are not applied toward satisfying your deductible or your out-of-pocket PPRx maximum. Additionally, the copayments that apply for the Select Specialty Medications vary from other specialty medications covered under the Plan. The SaveOnSP Specialty Drug List (available at www.saveonsp.com/carpenters or by calling the Fund Office) lists the Select Specialty Medications subject to the SaveOnSP Program and their copayments. The specialty medications and copayment amounts listed on the SaveOnSP Specialty Drug List may be changed by SaveOnSP from time to time. You should visit www.saveonsp.com/carpenters to find the most up-to-date information on specialty medications subject to the Program and copayment amounts.

The GENERAL DEFINITIONS section of your SPD is revised to add a new definition of "Select Specialty Medication" on page 95:

Select Specialty Medication means a prescription drug which is designated as a non-essential health benefit under the Affordable Care Act by SaveOnSP and is named in the SaveOnSP Specialty Drug List that is available at www.saveonsp.com/carpenters and is incorporated by reference.

4. Effective April 1, 2020, 90 day supplies of maintenance drugs are covered

only through mail order or the Smart-90 Retail Network. To reflect this change, the Quantity Limits section under the PREFERRED PROVIDER PHARMACY PROGRAM (PPRx) on page 49 is amended to read:

Quantity Limits

For each prescription purchased at a retail PPRx, you will pay the copayment for generic drugs or for brand name drugs per prescription for up to a 30-day supply as stated in the Schedule of Benefits.

Maintenance prescriptions are available for purchase up to a 90-day supply through the Express Scripts Mail-Service Preferred Provider Pharmacy or the Express Scripts Smart-90 Retail Network, currently Walgreens. For each maintenance prescription filled through Express Scripts, you will pay the

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copayment for generic drugs or for brand name drugs per prescription as stated in the Schedule of Benefits. Call Express Scripts at: 1-855-778-1444, or visit their website at: express-scripts.com/3-month. Express Scripts will contact your Physician to get your new prescription. You should have a one-month supply on hand when you place your order.

5. Effective April 1, 2020, the Plan is implementing the following changes for the EAP:

The PREFERRED PROVIDER EMPLOYEE ASSISTANCE PROGRAM (EAP) section beginning on page 54 of your SPD is replaced with the following:

PREFERRED PROVIDER EMPLOYEE ASSISTANCE PROGRAM (EAP) Because we care about you and recognize that personal issues can affect your job performance and cause you stress, the Plan provides an EAP through TEAM . The EAP provides personal and work-life support, resources, and information to you and your Dependents. This service is provided at no cost to you and your Dependents. You or your Dependents can access the EAP by calling the TEAM toll-free number at: (800) 634-7710. Your EAP provides help with the following: Confidential Counseling provides assessment and short-term

counseling service, with ongoing case follow-up to help address issues such as stress, anxiety, and depression; marital, relationship, and family conflict; grief and loss; substance abuse; or job pressures that you or your Dependents may have.

When you call the EAP, a professional counselor will get some general information about you and talk with you about your needs. This counselor will assess your situation and recommend next steps. You and your Dependents can each receive up to six free counseling sessions per episode of care, per year. However, if it is determined that a matter would be best met through alternative services or providers, you will be referred to a specialist for longer-term treatment that may be covered under other Plan provisions.

Work-Life Support Services

Childcare TEAM work-life consultants provide assistance with childcare needs. You can receive consultation from a trained specialist and receive assistance with finding local resources for childcare, summer care and camps. You can also access resources for child and elder care electronically.

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Eldercare offers qualified geriatric care specialists and provides education and resources for caretakers, assists in locating in-home health care options and helps plan for housing transitions.

Legal Consultation provides an attorney “on call” whenever you have

questions about legal matters. You can speak with on-staff legal advisors about legal concerns and they can answer simple legal questions. If you require representation, you can be referred to an attorney for one free consultation for each separate legal matter. After the initial consultation, you may continue receiving legal services and a discount in the provider's customary legal fees will apply.

Financial Counseling provides referrals for financial services. You can receive one free consultation with a financial professional. After the initial consultation, you can continue to receive financial services at a discounted rate from the provider's standard billing rate.

Online Resource Library provides online access to webinars, timely expert articles and information related to parenting, aging, balancing, thriving, working and living. . You can also search for qualified child and elder care, attorneys, and financial planners on the website.

The definition of Preferred Provider Employee Assistance Program (EAP) in the General Definitions section on page 94 of your SPD is replaced with the following:

“Preferred Provider Employee Assistance Program (EAP)" means the EAP which is party to a contract with Trustees, currently TEAM Corporation.

5. Effective April 1, 2020, the PREFERRED PROVIDE ONLINE PHYSICIAN VISIT PROGRAM on page 55 is amended to add behavioral health visits:

PREFERRED PROVIDER ONLINE PHYSICIAN VISIT PROGRAM You and your Dependent can consult with a Physician through the Preferred Provider Online Physician Visit Program, LiveHealth Online, in lieu of an in-person Physician visit. You can use LiveHealth Online for common health conditions such as: flu colds sinus infections stress family health questions However, for emergencies, call 911.

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LiveHealth Online providers can prescribe medication, if necessary, except for controlled substances and lifestyle drugs. If you sign up for Future Moms, you will also receive a lactation video and postpartum support. Medical LiveHealth Online visits are generally available 24 hours a day without an appointment on your smartphone, tablet or computer. LiveHealth Online Psychology appointments are available 7 days a week, 7 a.m. to 11 p.m for adults and children ages 10 and older and are subject to appointment availability. Visit www.livehealthonline.com or download the free app to access this benefit. Excluded Services Excluded services include, but are not limited to, communications used for: Reporting normal lab or other test results; Office appointment requests; Billing, insurance coverage or payment questions; Requests for referrals to Physicians outside of LiveHealth Online

covered providers; Benefit precertification; and Physician to Physician consultation.

6. The BOARD OF TRUSTEES section on page ii of the SPD is amended to replace Pat Nilsen with Michael Adamavich as a Union Trustee, effective September 1, 2019. Additionally, a new Trustee Listing is enclosed that replaces the one found on page 119 of your SPD.

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This notice also updates the information in your Summary of Benefits and Coverage ("SBC"). Specifically, in the "Important Questions" chart, the "Answer" to "What is not included in the out-of-pocket limit?" now includes "certain specialty medications." In the "Common Medical Event" chart, the "Limitations, Exceptions, & Other Important Information" section for the "If you need drugs to treat your illness or condition" row now includes the following statement: "The cost of certain specialty medications is not applied toward the out-of-pocket limit for prescription drugs."

THE NAMES AND ADDRESSES OF TRUSTEES Union Trustees Employer Trustees Corey Bialcik North Central States Regional Council of Carpenters N2216 Bodde Road Kaukauna, WI 54130

Eric Ballweg Vogel Brothers Building Company P.O. Box 7696 Madison, WI 53707

Chris Hill North Central States Regional Council of Carpenters 5238 Miller Trunk Highway Hermantown, MN 55811

Bob Barker AGC of Wisconsin 4814 East Broadway Madison, WI 53716

Burt Johnson North Central States Regional Council of Carpenters 700 Olive Street St. Paul, MN 55130

Sean Cullen J.P. Cullen & Sons, Inc. 330 East Delavan Street Janesville, WI 53547

Michael Adamavich North Central States Regional Council of Carpenters 1210 North 8th Street Sheboygan, WI 53082

Brad Deprez IEI General Contractors, Inc. P.O. Box 5067 DePere, WI 54115-5067

Wayne Nordin North Central States Regional Council of Carpenters 1190 West Laurence Road Croquet, MN 55720

F. William Harvat N6506 County Road W Waupaca, WI 54981

John Raines North Central States Regional Council of Carpenters 700 Olive Street St. Paul, MN 55130

Jeff McLean J.H. Findorff & Son, Inc. 300 South Bedford Street Madison, WI 53703

Pat Rodriguez North Central States Regional Council of Carpenters 2421 Larson Street La Crosse, WI 54603

Sid Samuels The Samuels Group 311 Financial Way, #300 Wausau, WI 54401

Chuck Spoehr North Central States Regional Council of Carpenters N2216 Bodde Road Kaukauna, WI 54130

Jerry Shea Market & Johnson P.O. Box 630 Eau Claire, WI 54702

Scott Watson North Central States Regional Council of Carpenters 5202 Monument Lane Madison, WI 53704

Dave Smestad C.R. Meyer Company P.O. Box 2157 Oshkosh, WI 54903

North Central States Regional

Council of Carpenters

2020 SaveonSP Specialty Drug List

Drug NameMonthly

CopayDrug Name

Monthly

CopayDrug Name

Monthly

CopayDrug Name

Monthly

CopayAbraxane $830 Gazyva $2,080 Nivestym $830 Sprycel $1,250

Actemra $1,250 Gilenya $1,666 Northera $1,330 Stelara $1,666

Adcetris $1,666 Gilotrif $2,080 Nplate $830 Stivarga $1,330

Advate $1,000 Glatiramer $1,000 Nucala $1,250 Sutent $2,080

Afinitor $1,250 Glatopa $1,000 Nuplazid $600 Symdeko $3,333

Alecensa $2,080 Haegarda $1,000 Ocaliva $1,250 Tafinlar $1,250

AlphaNine $5,000 Harvoni $7,500 Ocrevus $1,000 Tagrisso $2,166

Alprolix $1,000 Herceptin $2,080 Odomzo $1,250 Takhzyro $3,333

Austedo $1,000 Humira $1,666 Olumiant $1,000 Taltz $1,330

Avastin $2,080 Hemlibra $1,250 Opdivo $2,080 Talzenna $2,080

Avonex $600 Ibrance $2,080 Opsumit $1,666 Tarceva $2,080

Benefix $1,000 Ilaris $2,666 Orencia $1,250 Tasigna $1,250

Benlysta $1,250 Ilumya $1,330 Orenitram $1,666 Tecentriq $2,080

Betaseron $1,200 Increlex $1,000 Orkambi $3,333 Tecfidera $600

Bosulif $2,080 Inflectra $1,666 Otezla $1,000 Tegsedi $2,000

Cabometyx $2,080 Inlyta $2,080 Palynziq $1,666 Tobi Podhaler $1,000

Cerdelga $1,250 Iressa $2,166 Perjeta $2,080 Tracleer $1,000

Cimzia $1,250 Jakafi $2,080 Piqray $1,250 Tremfya $1,666

Cinryze $1,666 Jivi $1,000 Plegridy $600 Treprostinil $600

Copaxone $1,000 Kadcyla $2,080 Polivy $2,080 Tykerb $1,250

Cosentyx $1,666 Kalbitor $2,000 Promacta $1,250 Udenyca $1,250

Cotellic $2,080 Kalydeco $3,333 Pulmozyme $830 Uptravi $830

Darzalex $1,666 Kanjinti $1,666 Ravicti $830 Valchlor $1,666

Daurismo $2,080 Kevzara $1,250 Rebif $2,000 Ventavis $830

Doptelet $600 Ledipasvir/Sofosbuvir $7,500 Remicade $2,000 Verzenio $2,080

Dupixent $1,000 Lenvima $3,333 Remodulin $600 Vitrakvi $2,000

Elaprase $1,250 Letairis $750 Renflexis $1,666 Vizimpro $2,080

Empliciti $2,080 Lonsurf $2,000 Revatio $1,000 Vosevi $6,350

Enbrel $1,250 Lorbrena $2,080 Revlimid $830 Votrient $1,250

Entyvio $1,666 Lucentis $1,666 Rituxan $830 Vyndaqel $5,000

Epclusa $6,350 Lumizyme $1,250 Rixubis $1,000 Xalkori $2,080

Erbitux $2,080 Lupaneta Pack $750 Rydapt $1,250 Xeljanz $1,250

Erivedge $2,080 Lynparza $2,166 Sabril $1,330 Xgeva $830

Erleada $1,250 Mayzent $1,330 Serostim $1,666 Xolair $1,000

Esbriet $2,080 Mekinist $1,250 Siliq $1,666 Xtandi $2,080

Evenity $600 Nerlynx $2,000 Simponi $1,666 Yervoy $2,080

Eylea $1,250 Neulasta $830 Sofosbuvir/Velpatasvir $6,350 Zarxio $830

Fasenra $1,250 Nexavar $2,080 Somatuline Depot $1,666 Zelboraf $2,080

Firazyr $1,666 Ninlaro $2,080 Spinraza $2,000 Zydelig $2,080

Forteo $750

Below are the associated copays for the medications in the SaveonSP program. Once enrolled, your responsibility will be $0.

Please call 1-800-683-1074 to enroll.

Updated 09/18/2019

Effective 01/01/2020

Copays may vary based on drug manufacturer allowed amounts

Drug list is subject to change

The inclusion of eligible drugs within the Program is subject to applicable laws or regulations


December 2019


The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Fund") regularly review the Summary Plan Description/Plan Document ("SPD") and make changes when necessary. Please take time to read this notice, which is called a summary of material modifications ("SMM"), carefully and thoroughly because it contains important information regarding changes to the SPD. Briefly, this SMM describes the following changes:

1. Effective March 1, 2018, classroom hours in any Training Center in the North Central States Regional Council of Carpenters' jurisdiction will count toward credit of hours for eligibility purposes.

2. Effective September 1, 2019, you must seek prior authorization for genetic treatments. If you do not seek prior authorization and the genetic treatment is determined to be not Medically Necessary, coverage will be denied. Additionally, the Plan will cover most genetic treatments as medical benefits but the gene therapy Zolgensma will be covered under the prescription drug benefit.

3. Effective November 1, 2019, you may submit reimbursements for Plan covered medical expenses directly to the HRA without first seeking coverage under the Plan. Additionally, HRA reimbursements will be made on a monthly basis.

4. Effective December 5, 2019, the precertification requirements are clarified to confirm that only non-emergency in-patient admissions must be precertified or are subject a reduction in copayment.

5. Effective January 1, 2020:

(a) The Fund's vision benefit will be provided by Anthem and will include a new safety eyewear benefit for active employees. The vision benefits have also been changed. Please review the rest of the SMM for specific details.

(b) The Delta Dental Benefit Maximum is increased to $2,400 every two calendar years, the dental deductible is increased to $50 every two calendar years, and annual preventive and diagnostic services will be paid at 100% and not subject to deductible or biennial maximum. There is no change to the CarePlus Dental benefit.

(c) The Fund's Medicare retiree benefit is now being provided through the UnitedHealthCare Group Medicare Advantage and Prescription Drug Plan ("MAPDP"). Medicare-eligible retirees will receive a separate mailing with information on the new MAPDP benefit.

(d) The Fund's self-funded organ transplant benefit for Medicare-eligible retirees is eliminated.

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6. Effective February 1, 2020, the Retiree Subsidy Rates will be adjusted.

7. Effective July 1, 2020, Medicare-eligible retirees must enroll in Medicare Parts A and B when they are eligible. If a Medicare-eligible retiree fails to enroll in Medicare Parts A and B, he or she will no longer be eligible for coverage under the Plan.

Because some of these changes effect the same plan provisions, the SMM describes the changes together and in the order in which they are found in the SPD for clarity. However, please refer back to the effective dates noted above for questions on any specific rule change.

Schedule Changes

The vision and dental schedules of benefits found on page ix of your SPD are replaced with the following:

Classes C, G, O, P, S, and T For Active and Optional Retiree Classes

VISION CARE BENEFITS In-Network Provider Non-Network Provider Routine Eye Exam Limited to one per calendar year

$0 Up to $42 allowance

Prescription Lenses Includes factory scratch coating and, for Eligible Persons under age 19, polycarbonate lenses and photochromic lenses when received from network providers. Limited to one set of lenses per Eligible Person every two calendar years.

Single vision lenses $0 Up to $40 allowance Bifocal lenses $0 Up to $60 allowance Trifocal lenses $0 Up to $80 allowance

Frames Limited to one set of frames per Eligible Person every two calendar years

Up to $130 allowance then 20% off any balance

Up to $45 allowance

Prescription Contact Lenses1 Available once every two calendar years

Elective conventional (non-disposable) contact lenses


Up to $105 allowance

Elective disposable contact lenses Up to $130 allowance Up to $105 allowance Medically necessary contact lenses $0 Up to $210 allowance

1 Contact lenses are in lieu of your eyeglass lens benefit. If you receive elective or non-elective contact lenses then no benefits will be available for eyeglass lenses until you satisfy the benefit frequency listed in this Schedule of Benefits.

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Classes C, G, O, P, S, and T For Active and Optional Retiree Classes

VISION CARE BENEFITS If you receive covered eyewear from a Blue View Vision provider, you may be eligible for additional discounts on vision benefits such as lens enhancements, additional glasses, contact lens fittings, LASIK surgery.

Classes C and O For Active Employees Only

SAFETY VISION CARE BENEFITS In-Network Provider Non-Network Provider Eyewear Frame Limited to one set of frames per Participant every other calendar year


Up to $45 allowance

Lenses Includes factory scratch coating and polycarbonate lenses when received from network providers. Limited to one set of lenses per Participant every two calendar years.

Single vision lenses $0 Up to $40 allowance Bifocal lenses $0 Up to $60 allowance Trifocal lenses $0 Up to $80 allowance

If you receive covered eyewear from a Blue View Vision provider, you may be eligible for additional discounts on lens enhancements.

DENTAL CARE BENEFITS

Delta Dental CarePlus Dental2 PPO

Premier and Out-of-

Network Deductible Amount per Eligible Person

$50 every two Calendar

Years

$50 every two Calendar

Years $0 Plan's Coinsurance

Diagnostic and Preventive Services 100%3 100%3 100%4 Basic and Major Services 90% 90% 80%4

2 There is no coverage for out-of-network services under the CarePlus Dental benefit. 3 Deductible and Benefit Maximum do not apply. 4 No deductible applies.

4



Premier and Out-of-

Network Benefit Maximum per Eligible Person

$2,400 every two Calendar

Years5

$2,400 every two Calendar

Years5 $2,000 each

Calendar Year6 Routine Orthodontic Services7

Deductible Amount $0 $0 $0 Plan's Coinsurance 100%8 100% 50% Orthodontia Lifetime Maximum per Eligible Person $2,000 $2,000 $3,000

Additionally, the first row of the Preferred Provider Pharmacy Program schedule on page x of your SPD is replaced with the following:

Classes C, E, G, O, P, R and non-Medicare-eligible retirees and dependents of Classes S and U

For Active and Retiree Classes

The Retired Employees schedule on page xii is replaced with the following:

For Retired Employees and Dependents and Surviving Spouses The following benefits are available for Classes P, R, S, T, U, and V:

COMPREHENSIVE MAJOR MEDICAL BENEFITS and PREFERRED PROVIDER PHARMACY PROGRAM

Classes P, R, S and U (non-Medicare-eligible retirees and dependents only)

Identical to Class C

Classes T, V, S and U (Medicare-eligible retirees and dependents only)

Medical and prescription drug benefits are available solely through the Group Medicare Advantage plan

VISION CARE BENEFITS Classes P, S, and T only1

5 Benefit Maximum does not apply to diagnostic and preventive services. For Eligible Persons under age 19, basic and major dental services are subject to the deductible and coinsurance, but are not subject to the Benefit Maximum. 6 Cleanings and exams are not subject to the Benefit Maximum. 7 Orthodontics is not covered for Eligible Persons age 19 and older under the CarePlus Dental benefit. 8 For Eligible Persons under age 19, Medically Necessary orthodontic services that are pre-approved by Delta Dental are covered at 90% coinsurance with no deductible or lifetime maximum. 1 Please Note: At the time of retirement, you have a one-time option to elect vision and dental coverage at an

additional cost. This coverage is provided under Classes P, S, and T.

5

For Retired Employees and Dependents and Surviving Spouses The following benefits are available for Classes P, R, S, T, U, and V:

DENTAL CARE BENEFITS Classes P, S, and T only1

DEATH BENEFITS (Employees Only)

Amount of Death Benefit $4,000

Principal Sum for Accidental Death and Dismemberment

$4,000

ACCIDENT AND SICKNESS WEEKLY BENEFITS No Coverage

The Preauthorization chart on page xviii is revised to include gene therapy:

Gene Therapy All gene therapy

The first paragraph of Eligibility Rule I: Initial Eligibility on page 2 of your SPD is replaced with the following:

RULE I. INITIAL ELIGIBILITY

Bargaining Unit Employees, Non-Bargaining Unit Employees, and Alumni

You and your Dependents become initially eligible on the first day of the second month following the month in which you have worked and are credited with at least 500 hours of contributions at the Prevailing Contribution Rate as shown in the following chart. Hours spent in the classroom of any Training Center in the North Central States Regional Council of Carpenters' jurisdiction are considered hours for eligibility. Hours contributed at less than the Prevailing Contribution Rate will be prorated. Such contributions must be credited within 12 consecutive months.

The Retiree Eligibility provisions within Eligibility Rule III: Self-Payment Options (pages 6-10 of your SPD) are replaced with the following:

When an Employee Retires or is Totally and Permanently Disabled Please Note: Retiree benefits are not vested and are subject to change or discontinuation as determined by Trustees. Trustees retain the right in their sole discretion to modify or discontinue retiree eligibility rules, types and amount of benefits, terms and conditions under which benefits are payable, and self-payment rates. You will be considered retired for Plan purposes when you receive a

6

retirement or disability benefit from the North Central States Regional Council of Carpenters’ Pension Fund or another construction industry pension fund. At that time, you may use your accumulated eligibility (banked hours). However, when you have used your banked hours, you no longer will be eligible to continue coverage under any of the active Employee programs. Exception: If you work and are credited with 390 or more hours during any Work Quarter, and you and/or your Spouse are Medicare-eligible, the Medicare-Eligible Person(s) will receive Class C active Employee benefits for the corresponding Coverage Quarter. If in any subsequent Work Quarter you are credited with less than 390 hours, benefits for the Medicare-Eligible Person(s) for the corresponding Coverage Quarter will revert back to the Class under which you were covered just prior to reinstatement in Class C. You will have a one-time opportunity when you retire to elect coverage under the Retiree Program. If you elect not to continue coverage in the Retiree Program at the time of your retirement, you will not be allowed to elect such coverage at a later date unless you qualify for the one-time waiver/reinstatement provision on page 10. Retiree coverage will become effective no later than the first day of the quarter for which the active self-payment (based on hours worked prior to retirement date) exceeds the Retiree Program self-payment, provided you have completed the proper application for such coverage.

1. Retiree Program Requirements

When you retire, you may continue coverage under the Plan provided you satisfy the following requirements. a. provide written proof of retirement from your pension fund, be

receiving Social Security retirement benefits, or, for Non-Bargaining Unit or Alumni Employees, provide: (i) If an owner, documentation of the change of officers filed

with the state or proof of sale of the company. (ii) If an officer, documentation of the change of officers filed

with the state and a letter from the company verifying the change.

(iii) If an office Employee who is not an owner or officer, a letter from the company verifying your retirement; and

b. be eligible as an active Employee during the Coverage Quarter immediately preceding the effective date of coverage in the Retiree Program [however, this requirement will be waived if you: became permanently partially disabled, as determined by Trustees, on or after January 1, 2001; retired on or after January 1, 2005; were credited with 35,000 or more hours of contributions from contributing Employer(s) at the time of retirement; and are unable to perform enough Covered Work due to such disability in order to

7

be eligible in the Coverage Quarter immediately preceding retirement]; and

c. have contributions made on your behalf by a contributing Employer(s) in each of the five years immediately preceding retirement [however, this requirement will be waived if you have been credited with 20,000 or more hours of contributions from contributing Employer(s) at the time of your retirement]; and

d. make the self-payment no later than the 25th day of the month preceding the current Coverage Month at a rate to be determined by Trustees from time to time. Self-payments postmarked by the 15th day of the month preceding the current coverage month will be considered timely.

If you are unable to satisfy the requirement in the prior subparagraph 1.c. because the collective bargaining unit in which you are employed has not participated in the Fund for five years. Eligibility for participation may be determined by Trustees in other ways than from Fund records, such as determining your relationship to the industry prior to the bargaining unit joining the Fund. Further, solely for the purpose of satisfying subparagraph 1.c., hours of employment with the Carpenters Industrial Council prior to its merger into the Union shall be credited for purposes of satisfying the 20,000-hour requirement. If you satisfy the above requirements, you will have the choice of the following benefits for yourself and your Dependents:

If you are not yet Medicare-eligible: Health Care Benefits only or, at your option, Health Care, Vision Care, and Dental Care Benefits. If you are Medicare-eligible: Group Medicare Advantage plan only or, at your option, Group Medicare Advantage plan, Vision Care and Dental Care Benefits provided you also enroll in Medicare Part A and Part B. If you fail to enroll in Medicare Part A and Part B, you will not be eligible for Plan coverage.

If you are Medicare-eligible and do not enroll in the Group Medicare Advantage plan, there is no other Plan coverage available to you.

2. Retiree Program Reinstatement

When you or your surviving Spouse fail to make the required self-payment when due, you lose eligibility. However, you may request reinstatement of eligibility to participate in the Retiree Program. Such request for reinstatement must be made within 90 days of the date your eligibility otherwise would terminate and include an explanation satisfactory to Trustees of why it was not reasonably possible for you to make the required self-payment when due.

8

When your or your surviving Spouse's request for reinstatement in the Retiree Program is made within 90 days of the date your coverage otherwise would terminate and such request is approved, the required self-payment will be accepted retroactive to the first day of the first month for which a self-payment was not made.

3. Eligibility for Retiree Program Subsidized Self-Payments

In order to qualify for a subsidy, you must be a member of a participating Union or pay a service fee to a carpenters’ local Union. Persons retiring at age 55 or later with a minimum of 10 years of service under this Plan, having at least 10,000 hours, will be eligible for a subsidy if available. Owners must submit proof of retirement before the subsidy will be granted. Totally and Permanently Disabled Participants will be eligible for a subsidy regardless of age to the extent they qualified prior to their disability.

Retirees age 55 or over with a minimum of 10 years of service

and:

Percentage of Subsidy

Medicare-Eligible Non-Medicare-Eligible

0-9,999 hours 0% 0% 10,000-14,999 hours 10% 10% 15,000-19,999 hours 15% 15% 20,000-24,999 hours 20% 20% 25,000-29,999 hours 25% 25% 30,000-34,999 hours 35% 35% 35,000 or more hours 45% 45%

The percentage of subsidy for persons who retired prior to November 1, 2000, will not increase or decrease by more than 5% from the percentage of subsidy in effect April 30, 2002, in recognition of prior Trustee action which provided a 35% subsidy for persons who retired prior to November 1, 1995, and further provided a five-year transition rule for persons who retired on or after November 1, 1995, but prior to November 1, 2000. Subsidy rates will not increase after retirement because of your age or return to Covered Employment.

Surviving Spouses are eligible for the Retiree Program and the scheduled subsidy to the extent you satisfied the eligibility requirements. If you die either before or after retirement, your surviving Spouse retains the rights to your subsidized rate, so long as Trustees continue the practice.

9

Trustees will reevaluate subsidies from time to time to make sure they are in line with the Fund’s best interests. Any adjustments in the percent of subsidy in the future will affect each percentage category. If you are a non-Medicare-eligible retiree who works for wage or profit for any non-signatory Employer in the construction industry or performs Covered Work for wage or profit for any non-signatory Employer, including work in an industrial trade you learned through Covered Employment, your eligibility to make subsidized self-payments will cease as of the last day of the month in which you begin such employment. If, within 60 days of the date your eligibility for a subsidy ends, you submit proof that your non-covered employment is terminated, your eligibility for a subsidy will be reinstated on a one-time basis.

If you are a retired Employee who continues to work at such non-covered employment, you will be eligible to make nonsubsidized self-payments at a rate to be determined by Trustees from time to time. If you continuously make nonsubsidized self-payments under this provision, and you otherwise are eligible for a subsidy under these Eligibility Rules, you will once again be eligible for a subsidy when you are enrolled in Part A and Part B of Medicare.

4. Eligibility for Retiree Program Nonsubsidized Self-Payments

You may make nonsubsidized self-payments under the Retiree Program at a rate to be determined by Trustees from time to time if you:

a. Satisfy the Retiree Program requirements stated in paragraph 1,

but who do not qualify for a subsidy. b. Do not maintain membership in a participating Union or do not

maintain continuous payment of a service fee to the Health Fund. Retirees who choose not to continue coverage under the Self-Payment Option 1-Retiree Program may choose to continue coverage under Self-Payment Option 2-COBRA continuation coverage.

5. Retiree Program Waiver/Reinstatement Provision

Retirees will have a one-time option to waive Health Plan coverage. If you are eligible to continue, or you are currently continuing coverage under the Retiree Program, you may elect to waive or terminate eligibility for all Health Plan benefits if you are enrolled in another employer-sponsored group health plan. You and your Spouse, if applicable, must sign a waiver form certifying your coverage under another group health care plan and submit proof of such coverage. The

10

waiver will be effective as of the first day of the month following receipt of the waiver form and proof of other coverage. However, if you have accumulated eligibility under the Active Plan, the waiver will take effect when your accumulated eligibility runs out. You can reinstate coverage in the Plan only at the time you and your Spouse, if applicable, terminate or become ineligible for the other group health coverage. To be eligible for reinstatement, you must submit an enrollment form to the Fund Office within 60 days following termination of coverage under the other group health plan along with proof that you and all your eligible Dependents were continuously covered under another employer-sponsored group health care plan after waiver of coverage under this Health Plan. Coverage will be reinstated on the first day of the month following receipt of an enrollment form, proof of other coverage, and the applicable self-payment. Your eligibility for a subsidy, if any, is frozen when the waiver takes effect. You will be eligible for the subsidy applicable to your years of service and hours credited prior to retirement based on the rules in effect on the date of reinstatement into the Retiree Program. The self-payment amount will be based on the applicable rate at that time.

The OUT-OF-POCKET section on page 26 of your SPD is replaced with the following:

OUT-OF-POCKET

Reasonable Expenses you pay for covered charges (including amounts applied to the deductible amount; and the separate emergency room visit copayment) accumulate to the out-of-pocket maximum. When your out-of-pocket expenses reach the maximum stated in the Schedule of Benefits in any one Calendar Year, the Plan will pay 100% of the balance of covered Reasonable Expenses that exceed the out-of-pocket maximum for such Eligible Person(s) for the remainder of that Calendar Year. The chiropractic visit maximums will continue to apply once you have satisfied the out-of-pocket maximum.

The following charges are not included in the out-of-pocket maximum:

Copayment reduction of 5% up to $500 for each non-emergency Hospital confinement, including inpatient admissions, that is not precertified as required;

Copayment for out-of-network preventive care in excess of maximum;

Amounts in excess of maximum for out-of-network chiropractic visits;

Premiums;

Balanced-billed charges; and

11

Health care this Plan does not cover.

The COVERED CHARGES section of your SPD is revised to include coverage for gene therapy and to clarify the precertification requirements for surgical benefits. Specifically, covered charge number 2 under Hospital Services on page 27 is revised to read:

2. Drugs, medicines, gene therapies, diagnostic x-rays and laboratory tests, and other Hospital miscellaneous services and supplies not included in the room charges, if used while confined in the Hospital as a resident patient;

Footnote 1 on page 28 is replaced with the following:

It is recommended that certain procedures specified on page xviii be preauthorized or Plan benefits will be denied if they are determined not to be Medically Necessary.

Additionally, covered charge number 4 under Drugs and Medicines on page 32 is revised to read:

4. Drugs and medicines, including gene therapies, administered by a

Physician. Preauthorization is recommended for specialty medications given in an office setting including, but not limited to Orencia, Remicade; iron infusions; and gene therapies (see page xviii).

The COVERED CHARGES section of your SPD is also revised to eliminate the self-funded organ transplants for Medicare-retirees. The Organ Transplants section on page 34 is replaced with the following:

Organ Transplants. Benefits for covered charges for cornea transplants. All other organ and tissue transplant coverage is provided under a separate insurance policy (described in Organ & Tissue Transplant Certificate attached as Appendix B). Such policy pays benefits for certain organ and tissue transplants without regard to any benefits that may be provided by the Plan. Refer to the enclosed Certificate for benefit information, preauthorization of transplant services, and transplant network provider access. Expenses billed by the transplant provider that are not covered by the Certificate are subject to the Plan's benefits and the payment terms and conditions of the transplant provider's contracted rates.

Additionally, the first sentence on page 35 is revised to eliminate the reference to Medicare-approved organ transplants.

The EXCEPTIONS AND LIMITATIONS section on page 40 of your SPD is revised to clarify that the gene therapy Zolegnsma is not covered under the Comprehensive Major Medical Benefit by adding the following:

6. Zolgensma.

12

The VISION CARE BENEFITS described in page 41 of the SPD is replaced with the following:

Vision Care Benefits are characterized under the Plan as an excepted benefit under HIPAA and the Affordable Care Act.

Benefit Maximums, Allowances and Frequency Limits

Vision benefits are subject to benefit maximums, allowances and frequency limits. Vision care services that go over your benefit maximums or allowances, or that are received more than the allowed frequency limits are not covered. Benefit maximums, allowances, and frequency limits are stated in the Schedule of Benefits.

Your Cost Share Requirements

The Plan pays up to the maximum allowable amount for covered services. You may be required to pay a part of the maximum allowable amount. See the Schedule of Benefits for your cost share amount for covered services.

Your cost share amount may vary depending on whether you receive vision care from a network or non-network provider. You may be required to pay higher cost sharing amounts when using non-network providers.

The Plan does not pay for vision care that is not covered. You are required to pay all charges for vision care that is not covered.

Covered Services

Services and supplies or treatment which are performed, prescribed, directed or authorized by a provider. To be a covered service the service, supply or treatment must be:

Within the scope of the license of the provider performing the service;

Rendered while coverage is in force;

Within the maximum allowable amount;

Not specifically excluded or limited;

Specifically included as a benefit.

A covered service is incurred on the date the service, supply or treatment was provided to you. The maximum amount allowed for covered vision services is based on the fee schedule. All covered services are subject to the exclusions listed in the Exclusions section and all other conditions and limitations of the Plan.

13

Routine Vision Benefits

Routine Eye Exam. A complete eye exam with dilation as needed is covered. An eye exam does not include a contact lens fitting fee.

Eyeglass Lenses. You have a choice in your eyeglass lenses. Eyeglass lenses include factory scratch coating at no additional cost. Your dependent children under 19 may also receive polycarbonate and photochromic eyeglass lenses at no additional cost when received from a network provider.

Covered eyeglass lenses include plastic lenses up to 55 mm in single vision, bifocal, trifocal.

Frames. You have a benefit allowance towards your choice of frames. You may apply the allowance toward the purchase of any frame. If your frame choice is more than your allowance then you are responsible for the balance. The Schedule of Benefits lists your allowance and benefit frequency.

Contact Lenses. The Plan covers elective or non-elective contact lenses. You may receive a benefit for elective contact lenses or non-elective contact lenses, but not both.

Note: Contact lenses are in lieu of your eyeglass lens benefit. If you receive elective or non-elective contact lenses then no benefits will be available for eyeglass lenses until you satisfy the benefit frequency listed in the Schedule of Benefits.

Elective Contact Lenses. Elective contact lenses are contacts that you choose for appearance or comfort. The contact lens allowance must be completely used at the time of initial service. The Schedule of Benefits lists the contact lens allowance available.

Non-Elective Contact Lenses. Non-elective contact lenses are prescribed by your provider for diagnoses listed below:

Extreme visual acuity or other functional problems that cannot be corrected by spectacle lenses; or

Keratoconus-unusual cone-shaped thinning of the cornea of the eye which usually occurs before the age of 20 years; or

High Ametropia-unusually high levels of near sightedness, far sightedness, or astigmatism are identified; or

Anisometropia-when one eye requires a much different prescription than the other eye

Important Note: Non-elective contact lenses for any Eligible Person who has undergone prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or LASIK are not covered.

14

Safety Vision Benefits – Active Employees Only

Safety Eye Exam. The Plan covers a complete eye exam with dilation as needed. An eye exam does not include a contact lens fitting fee.

Safety Eyewear Lenses. You have a benefit allowance to apply towards your choice of safety eyeglass lenses. If the eyeglass lenses you pick are more than your allowance, then you are responsible to pay for the difference.

Safety Eyewear Frames. You have a benefit allowance towards your choice of frames. You may apply the allowance toward the purchase of any frame. If your frame choice is more than your allowance then you are responsible for the balance. The Schedule of Benefits lists your allowance and benefit frequency.

Additional Options. Benefits are available for additional services in accordance with the Additional Savings Program. For additional information on available discounts please contact the Plan Office.

Limitations

In addition to General Exclusions on pages 78 through 83, Vision Care Benefits do not cover:

1. Services not listed in the Covered Services section.

2. Any amounts in excess of the maximum benefits.

3. This includes fittings for more complex applications, including toric, bifocal/multifocal, cosmetic color, post-surgical and gas permeable lenses. It also includes extended/overnight wear lenses.

4. This includes non-prescription eyewear and lenses, plano lenses or lenses that have no refractive power.

5. Any diagnostic testing or medical or surgical treatment of the eyes, including any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia) and/or astigmatism. Contact lenses or eyeglasses required as a result of this surgery are also excluded.

6. Any lost or broken lenses or frames, unless you have reached a new benefit period.

7. Any services actually given to you by a local, state, or federal government agency, or by a public school system or school district, except when payment under this plan is expressly required by federal or

15

state law. We will not cover payment for these services if you are not required to pay for them or they are given to you for free.

8. Treatment or services rendered by non-licensed providers and treatment or services for which the provider of services is not required to be licensed. This includes treatment or services from a non-licensed vision care provider under the supervision of a licensed physician or licensed vision care provider, except as specifically provided or arranged by us.

9. Inpatient or outpatient hospital vision care.

10. Orthoptics or vision training and any associated supplemental testing.

11. Your benefit allowance under this plan will not apply to services or supplies when combined with other offers, coupons or in-store advertisements. However, if your provider chooses, they may apply offers, coupons or in-store advertisements to the remaining balance.

The PREFERRED PROVIDER PHARMACY PROGRAM (PPRx) section on Covered Expenses section is revised to add coverage for the gene therapy Zolgensma. Specifically, Covered Expense number 10 on page on page 51 of the SPD is replaced with the following:

10. Infused medications, the gene therapy Zolgensma, and other specialty

medications administered by a Physician, at the Physician’s option. Preauthorization is recommended for gene therapies (see page xviii).

The PREFERRED PROVIDER OPTICAL CENTER section on pages 53-54 of your SPD is replaced with the following:

PREFERRED PROVIDER OPTICAL CENTER

Network Providers. Anthem has a network of vision care providers for you to use. These network providers have agreed to take part in the Blue View Vision network. They have agreed to provide covered services to you for a negotiated rate. Covered services you receive from the network provider are considered In-Network care.

If you opt to receive optometric services or procedures that are NOT covered services under the Plan, a network provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with optometric services or procedures that are not covered services, the provider should provide you with a treatment plan that includes each anticipated service or procedure to be given and the estimated cost of each service or procedure.

Non-Network Providers. Non-network providers are vision care providers that did not agree to participate in the Blue View Vision network. They have

16

not agreed to a negotiated rate and do not have a provider contract with Anthem. Using a non-network provider will typically increase your out of pocket costs. Covered services you receive from non-network providers are considered Out-of-Network care.

Please call Anthem at 1-800-810-2583 or visit their website at www.anthem.com for help in finding a network provider.

The HEALTH REIMBURSEMENT ACCOUNT (HRA) PROGRAM section on ORDERING RULES found on page 69 of the SPD is replaced with the following:

ORDERING RULES

If your or your Dependent's expenses are covered under the HRA Program and a health flexible spending account under a Code Section 125 cafeteria plan, or under another health reimbursement arrangement, such claims must be submitted to the health flexible spending account or other health reimbursement arrangement before they are submitted to the HRA Program.

The MEDICARE PROVISIONS on page 74 is revised to delete the second paragraph.

The definition of Classes of Eligible Persons on page 87 is replaced with the following:

Classes of Eligible Persons means all the classifications of coverage under the Plan as follows:

Class C (Active): Employees (and their Dependents) of Employers obligated by a collective bargaining agreement to pay contributions to this Fund. The term “Employees” includes Bargaining Unit Employees and, provided the Employer is party to an approved participation agreement, certain Non-Bargaining Unit or Alumni Employees. Class O (Active Employees of Industrial Employers): An Industrial Employer’s Bargaining Unit and Non-Bargaining Unit Employees (and their Dependents) who satisfy the applicable Eligibility Rule requirements. Class E and G (COBRA):

1. Class E – An Eligible Person continuing coverage for Comprehensive Major Medical Benefits through COBRA self-payments.

2. Class G – An Eligible Person continuing coverage for Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits through COBRA self-payments.

17

Class P, R, S, T, U and V (Retired): 1. Class P – Retired Employees and their Dependents who are not eligible

for Medicare and who are continuing Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits through self-payments.

2. Class R – Retired Employees and their Dependents who are not eligible for Medicare and who are continuing Comprehensive Major Medical through self-payments.

3. Class S – Retired Employees and their Dependents, one of whom is

eligible for Medicare and the other is not, who are continuing Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits through self-payments.

4. Class T – Retired Employees and their Dependents who are both

Medicare-eligible and who are continuing Comprehensive Major Medical Benefits, Vision Care Benefits, and Dental Care Benefits through self-payments.

5. Class U – Retired Employees and their Dependents, one of whom is

eligible for Medicare and the other is not, who are continuing Comprehensive Major Medical through self-payments.

6. Class V – Retired Employees and their Dependents who are both

Medicare-eligible and who are continuing Comprehensive Major Medical through self-payments.

Please Note: Early retirees/Spouses who become initially entitled to Medicare due to End Stage Renal Disease will remain in an early retiree Class (R or P) until the full 30-month coordination period specified in the Medicare Provisions on page 74 has elapsed (even if such person turns age 65 during that period). Medicare-eligible retirees and/or Spouses in Classes U, S, V, and T who cover children under age 26 will have their self-payment amount based at the level required for retired Employees and Spouses who are not Medicare-eligible (Classes R and P).

The definition of Preferred Provider Optical Center on page 94 is replaced with the following:

"Preferred Provider Optical Center" means the optical center that is party to a contract with the Trustees, currently Anthem.

The HOW TO APPLY FOR BENEFITS section beginning on page 97 of your SPD is revised to clarify the rules for PRE-SERVICE CLAIMS and to update the contact

18

information in the POST-SERVICE CLAIMS. The PRE-SERVICE CLAIMS section is replaced with the following:

PRE-SERVICE CLAIMS: It is recommended that you obtain Preauthorization for certain services and supplies as specified on page xviii or Plan benefits will be denied if determined not to be Medically Necessary. Precertification is required for any non-emergency Hospital confinement to be eligible for the maximum level of benefits. Also, you must contact the Fund Office for prior approval for all organ transplants. These claims are called, “pre-service claims,” which means any claim that requires approval of the benefit in advance of obtaining medical care. Pre-service claims may be submitted initially by telephone or in writing to CMS. There are special provisions in the Claims Procedure Regulations for “urgent care claims” (referred to under the Plan as “emergencies”), but, by definition, these provisions do not apply because the Plan does not require prior approval of emergency admissions.

The contact information included in the POST-SERVICE CLAIMS section is replaced with the following:

Send all insured organ transplant claims to:

OT Claims Department P.O. Box 3028 Costa Mesa, CA 92626

Send all dental claims to the dental program in which you are enrolled:

Delta Dental of Wisconsin P.O. Box 828 Stevens Point, WI 54481-0828

CarePlus Dental 3333 North Mayfair Road, Suite 311 Wauwatosa, WI 53222

Send all claims for vision to:

Blue View Vision P.O. Box 8504 Mason, OH 45040-7111 Phone: (866) 723-0515

After you receive vision care from a non-network provider, you will need to contact Anthem, either by phone or mail within 20 days of the date you received vision care to obtain claim forms for filing (or as soon as possible). Anthem will provide claim forms within 15 days after notification. The claim

19

form will have instructions on how to fill it out and where to submit. If you do not receive a claim form within 15 days of your claim notice, you may send an itemized bill instead. The itemized bill should include the following:

1. The date of service; 2. The patient’s name, date of birth, and identification number; 3. The type and place of service; 4. Your signature and the provider’s signature.

You must provide the claim form or an itemized bill to Anthem within 90 days after the date you received vision care. If it is not reasonably possible to provide your claim form/itemized bill within this time, your claim will not be invalidated or reduced but you must send it as soon as reasonably possible, and in no event later than a year from when it was due, unless you are legally incapacitated.

Claims will be paid immediately upon receipt of written proof of your claim, but generally no later than 60 days after receipt of a complete claim.

Send all claims for Death and Accidental Death and Dismemberment Benefits to:

Fund Office North Central States Regional Council of Carpenters’ Health Fund P.O. Box 4002 Eau Claire, WI 54702

Send all other medical claims for services obtained in Wisconsin to:

Anthem Blue Cross and Blue Shield P.O. Box 34210 Louisville, KY 40232-4210

Send all other medical claims for services obtained outside Wisconsin to your local Blue Cross and Blue Shield Plan.

Claims should be complete, including, at a minimum:

1. Fund name (North Central States Regional Council of Carpenters’ Health Fund);

2. Participant’s name and identification number;

3. full name (including “Jr.,” if applicable) and date of birth of the Eligible Person who incurred the covered expense;

4. name and address of the service provider;

5. federal tax identification number of provider;

6. diagnosis of the condition;

7. procedure or nature of the treatment;

20

8. date of and place where the procedure or treatment has been provided; amount billed and the amount of the covered expense not paid through coverage other than this Plan, as appropriate; and

9. evidence that substantiates the nature, amount, and timeliness of each covered expense that is in a reasonably understandable format and is in compliance with all applicable law.

* * *


Yours very truly,


OVER

January 2019 To All Participants: The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Fund") are pleased to offer a new dental coverage option—CarePlus Dental. In this packet, you will find a summary of material modifications to the Summary Plan Description that describes the new benefit and an enrollment form should you choose to enroll in this new benefit. The Fund will offer an open enrollment period to enroll in the CarePlus Dental option beginning February 1, 2019 through July 31, 2019. Your coverage effective date depends on when you enroll:

Deadline to submit form to the Fund Office

CarePlus Dental coverage effective date

February 28, 2019 April 1, 2019 March 31, 2019 May 1, 2019 April 30, 2019 June 1, 2019 May 31, 2019 July 1, 2019 June 30, 2019 August 1, 2019 July 31, 2019 September 1, 2019

If you are interested in enrolling in the optional CarePlus Dental benefit, please complete the enclosed optional dental election form and return it to the Fund Office no later than July 31, 2019. If you want to remain with Delta Dental, you do not need to take any action at this time—your coverage will continue. If you enroll in the CarePlus Dental benefit, you must keep this benefit until December 31, 2020. The only exception is if your coverage under the Fund terminates. If you choose not to enroll in the CarePlus Dental benefit at this time, you will have another opportunity to enroll at the next open enrollment period (generally occurring late 2020 for coverage effective January 1, 2021).

NOTE: If you are currently covered under the Delta Dental PPO option and are undergoing orthodontic treatment or major restorative work, the Plan will only pay for services and supplies received if you terminate Delta Dental coverage. Delta Dental calculates all orthodontic treatment schedules according to the following formula: 25% of the total case fee is considered the initial payment, which is payable at 100%, up to the $2,000 lifetime benefit maximum. The remaining allowable fees are divided by the total number of treatment months, and monthly payments are made by the Plan at 100%, not to exceed the $2,000 lifetime benefit maximum. Although CarePlus does not have any waiting periods for coverage, and will accept enrollees during treatment in progress, we encourage you to consult your Delta Dental dentist before changing dentists during orthodontic treatment. Similarly, if you are undergoing major restorative work, we encourage you to consult your Delta Dental dentist about completing the work in progress before changing dentists. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

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January 2019 To All Participants: The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Fund") regularly review the Plan Document and make changes when necessary. Please take time to read this Notice carefully and thoroughly because it contains important information regarding changes to the Summary Plan Description (SPD). Effective April 1, 2019, the Fund will offer a new dental coverage option—CarePlus Dental. The Dental Care Benefits schedule in the Schedule of Benefits in your SPD is revised as follows:



Premier and Out-of-

Network Calendar Year Maximum per Eligible Person $1,2003 $1,2003 $2,0004 Deductible Amount per Eligible Person per Calendar Year $25 $25 $0 Plan's Coinsurance

Diagnostic and Preventive Services 90% 90% 100%5 Basic and Major Services 90% 90% 80%5

Routine Orthodontic Services5 Eligible Persons under age 19

Plan's coinsurance 100%6 100%6 50% Orthodontia lifetime maximum $2,000 $2,000 $3,000

2 There is no coverage for out-of-network services under the CarePlus Dental benefit. 3 For Eligible Persons under age 19, diagnostic and preventive, basic and major dental services are subject to the deductible and coinsurance, but are not subject to the Calendar Year maximum. 4 Cleanings and exams are not subject to the Calendar Year maximum 5 No deductible applies. 6 Medically Necessary orthodontic services that are pre-approved by Delta Dental are covered at 90% coinsurance with no lifetime maximum.

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Premier and Out-of-

Network per Eligible Person

Eligible Persons age 19 and older Plan's coinsurance 100% 100% Not covered Orthodontia lifetime maximum per Eligible Person $2,000 $2,000 Not covered

Additionally, the Dental Care Benefits section of your SPD is revised to add a new section:

CAREPLUS DENTAL BENEFIT

This Summary describes the benefits applicable for Participants who enroll in the CarePlus Dental Benefit. The CarePlus Dental Benefit is fully insured and the Dental Care Group Policy issued to the Fund and the Certificate of Insurance is the complete document of coverage and governs all claims processing. This is only a summary of the CarePlus Dental Benefit. For additional detail, you should refer to the Certificate of Insurance. Enrollment The Fund offers an open enrollment period for the CarePlus Dental Benefit. If you elect to enroll, you must retain this benefit for a minimum of two years. However, if your coverage under the Fund terminates, your coverage under the CarePlus Dental Benefit will also terminate. Selecting a Dentist CarePlus has a network of 85 dental offices in Wisconsin, which include 14 offices operated by Dental Associates and 71 offices operated by Midwest Dental. There is no dental coverage for any services provided out-of-network. You can find a participating Dentist by visiting www.dentalassociates.com and/or www.midwest-dental.com. Description of Services Covered services are subject to applicable coinsurance and maximums stated in the Schedule of Benefits and the limitations and exclusions described below. Refer to the Certificate of Insurance for a full description of covered services.

http://www.dentalassociates.com/

http://www.midwest-dental.com/

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Exclusions and Limitations Coverage is NOT provided under the CarePlus Dental Benefit for:

(a) Dental services not specifically described in the Dental Care Group Policy and Certificate of Insurance as a benefit.

(b) Dental services with respect to congenital malformations or which are primarily for cosmetic or aesthetic purposes, except congenitally missing teeth.

(c) Any duplicate prosthetic device or any other duplicate appliance, except as otherwise provided.

(d) The replacement of lost or stolen prosthetic devices or appliances, except as otherwise provided.

(e) The replacement of an orthodontic appliance, except as otherwise provided.

(f) Treatment of temporomandibular joint (TMJ) dysfunction.

(g) Gold foil, gold or other precious metal restorations, except when used as a necessary functional material.

(h) Transplants, implants

(i) Dental service or emergency service:

(1) That would be furnished, without charge, to you by any person or entity other than CarePlus;

(2) That you would be entitled to have furnished or paid for, fully or partially, under any law, regulation or agency of any government;

(3) That you are entitled or would be entitled if you were enrolled, to have furnished or paid for under any voluntary medical or dental insurance plan established by any government if the Dental Care Group Policy were not in effect;

(4) To the extent that Medicare is your primary payor, except where Medicare

is secondary by law. Where Medicare is primary payor, no benefits are available to the extent you would have been entitled to Medicare benefits had you enrolled in Medicare or complied with Medicare requirements;

(5) For, or resulting from injuries, disease or conditions for which you receive,

or is the subject of, any award or settlement under a Worker’s Compensation Act or any Employer Liability Law;

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(6) Rendered or furnished after the date you cease to be covered under this

Contract, except for:

i. Procedures (other than prosthetic services) commenced prior to, and completed in one visit within thirty-one (31) days following termination of coverage; and

ii. Prosthetic devices that are ordered and fitted prior to, and completed within sixty (60) days following termination of coverage; or

(7) Provided at a location other than the offices of the primary provider except

for Emergency Service.

(j) Hospital or physician services of any kind whether or not related to covered dental services.

(k) Dental service and emergency service resulting from diseases contracted or injuries sustained as a result of war, declared or undeclared, enemy action or action of the Armed Forces of the United States, or its allies, or while serving in the Armed Forces of any country; or any illness or injury occurring after the effective date of the Dental Care Group Policy and caused by atomic explosion whether or not the result of the war.

(l) Reimbursement to you or any dental office for the cost of dental services provided by dentists, other than the primary provider, unless expressly authorized in writing by the primary provider or due to an emergency.

(m)Out-of-network services, unless due to an emergency and then covered only to the extent of the emergency service benefit.

(n) Dental service and emergency service received from a dental or medical department maintained on behalf of an employer, a mutual benefit association, a labor union, academic institution, trustee or similar person or group.

(o) Replacement of an existing removable partial denture, full denture, crown or fixed bridge by a new removable partial denture, full denture, crown or a fixed bridge if the existing appliance was provided in the previous five years. The five-year period will be measured from the date on which the existing appliance was last supplied, whether under the Dental Care Group Policy or under any other dental coverage.

(p) If a satisfactory result can be achieved by a conventional removable partial denture in the case of bilateral edentulous areas, but you select a more complicated treatment (precision attachments or fixed bridgework), benefits shall be limited to the appropriate procedures necessary to eliminate oral disease and restore missing teeth. The balance of the cost for the more elaborate selected procedure will be your responsibility.

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(q) Services or supplies for personalization or characterization of dentures or bridges.

(r) Crowns to restore diseased or broken teeth when the tooth can be restored by a conventional type filling.

(s) Any expense arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which:

(1) Benefits are provided or payable under any Workers’ Compensation, Employer Liability Law or Occupational Disease Act or Law; or

(2) You would have been eligible for benefits under any Workers’ Compensation, Employer Liability Law, or Occupational Disease Act or Law had such coverage been applied for.

(t) Any service related to:

(1) Altering vertical dimension;

(2) Restoration of occlusion;

(3) Splinting teeth including multiple abutments or any service to stabilize

periodontally weakened teeth;

(4) Replacing tooth structures as a result of abrasions, attrition, or erosion; or

(5) Bite registration or bite analysis.

(u) Missed appointment charges.

(v) Removal of asymptomatic third molars (wisdom teeth).

(w) Procedures done in conjunction with fixed complex implant retainer prosthetics.

* * * Please keep this Notice with your SPD booklet for future reference. This Notice also updates the information provided in your Summary of Benefits and Coverage for the coverage period of January 1, 2019 to December 31, 2019. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES


January 2019 To All Participants: The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Plan") regularly review the Plan and make changes when necessary. Please take time to read this Notice carefully and thoroughly because it contains important information regarding changes to the Summary Plan Description (SPD). The Affordable Care Act requires the Plan to adopt a benchmark plan to serve as a basis for the Plan's definition of essential health benefits. The Plan previously adopted the Utah state benchmark for this purpose. As allowed under the Utah state benchmark, the Trustees have made the following changes to the Plan, effective April 1, 2019: Chiropractic Benefit Maximums Chiropractic benefits will be amended to include an annual 26-visit limit, in addition to the $40 maximum benefit payment per outpatient visit. The chiropractic benefit maximums in the Schedule of Benefits on page v of your SPD is amended as follows: Maximum payment per outpatient chiropractic visit: $40/visit up to 26 visits per calendar year. The deductible applies to chiropractic visits. Amounts you pay up to $40/visit will count for both the deductible and out-of-pocket maximum. Once your deductible is satisfied, amounts you pay in excess of $40/visit do not count toward the out-of-pocket maximum. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. This Notice also updates the information provided in your Summaries of Benefits and Coverage for the coverage period of January 1, 2019 to December 31, 2019. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

November 2018

To All Employees and Dependents:

The purpose of this Notice is to inform you of the following:

• Women's Health and Cancer Rights Act annual notification; and • HIPAA Privacy update.

Women's Health and Cancer Rights Act Annual Notification

The Women's Health and Cancer Rights Act of 1998 requires that we notify you annually of the coverage required under this Act. This Notice fulfills that requirement.

The Act amended ERISA by requiring group health plans which provide medical and surgical benefits for a mastectomy to provide the following coverage if you elect breast reconstruction in connection with a mastectomy, in a manner determined in consultation with the attending physician and the patient:

»» all stages of reconstruction of the breast and nipple of the breast on which the

mastectomy has been performed; »» surgery and reconstruction of the other breast to produce symmetrical

appearance; »» prostheses and surgical bras; and »» treatment of physical complications in all stages of the mastectomy, including

lymphedemas.

Subject to any applicable deductible and copayment requirements, your Plan provides coverage for the preceding items on the same basis as any other medical or surgical procedure covered by the Plan.

HIPAA Privacy Update

On April 14, 2003, the HIPAA Privacy Regulations went into effect for the North Central States Regional Council of Carpenters’ Health Fund. These Regulations were further revised effective February 17, 2010, and again revised effective September 23, 2013. In October of 2013 (or when you enrolled, if later), the Plan provided you an updated Privacy Practices Notice as required by the Privacy

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Regulations. This Notice provided information regarding the Plan’s uses and disclosures of your medical information, your rights regarding your medical information, and the Plan’s duties to protect the privacy of your medical information.

This is a reminder that the Plan’s Privacy Practices Notice is available upon request. To request a copy, please contact the Fund’s Privacy Officer, Bridget Welke, (715) 835-3174 or 1-800-424-3405.

Other Enclosures

Also enclosed with this Notice are the following:

• The Summary of Benefits and Coverage (SBC), for coverage period

beginning on or after January 1, 2019, as required under the rules of the Patient Protection and Affordable Care Act (PPACA); and

• The annual CHIP Notice. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office.

Yours very truly,


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Important Notice of Prescription Drug Creditable Coverage From North Central States Regional Council of Carpenters' Health Fund

October 2018 To All Employees and Dependents: This Notice is being sent to inform you how your benefits through North Central States Regional Council of Carpenters' Health Fund are affected by Medicare Part D. It is being sent to all participants even though it applies only to those eligible for Medicare or who may become eligible for Medicare in the next 12 months. Medicare prescription drug coverage, referred to as "Medicare Part D," became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage plans that offer prescription drug coverage. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans offered by independent insurance companies might offer more coverage for a higher monthly premium. The following information is provided to help you decide whether it would benefit you to enroll in Medicare Part D for prescription drug coverage. North Central States Regional Council of Carpenters' Health Fund Trustees have determined that your current prescription drug coverage is "creditable coverage," which means that it is, on average for all Fund participants, expected to pay out as much or more than the standard Medicare prescription drug coverage. Since you have prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund, the most cost effective option for you, generally, is to not enroll in a Medicare prescription drug plan unless you are eligible for extra help from Medicare for persons with low income. Joining a Medicare prescription drug plan will not reduce the monthly self-payment required by North Central States Regional Council of Carpenters' Health Fund because your current self-payment is for both medical and prescription drug expenses. Retirees with limited income may be eligible for financial support from the government to help pay for the Medicare prescription drug plan. Information about this extra help is available from the Social Security Administration (SSA) online at: www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778). If you are eligible for special assistance, you should review your options carefully because it may be beneficial for you to enroll in a Medicare prescription drug plan.

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http://www.socialsecurity.gov/

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Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare prescription drug plan. In addition, if you lose or decide to leave employer/union-sponsored coverage, you will be eligible to join a Medicare prescription drug plan at that time using an Employer Group Special Enrollment Period. Will your current coverage through North Central States Regional Council of Carpenters' Health Fund be affected if you join a Medicare prescription drug plan? Yes. Your Medicare prescription drug plan will become the primary payer for your prescription drug benefits, unless you are covered under an Active Plan through North Central States Regional Council of Carpenters' Health Fund, in which case the Fund remains the primary payer. The Fund will consider your prescription drug expenses for payment only after the expenses have been considered by your Medicare prescription drug plan. In addition, it will be your responsibility to submit proof of what the Medicare prescription drug plan paid (Explanation of Benefits) before the Fund considers any balance. Again, joining a Medicare prescription drug plan will not reduce your monthly self-payment to North Central States Regional Council of Carpenters' Health Fund since you receive both medical coverage as well as prescription drug coverage from the Fund. Will Medicare penalize participants who do not enroll in a Medicare prescription drug plan? Because coverage through North Central States Regional Council of Carpenters' Health Fund is creditable coverage, you will not have to pay a penalty if you enroll later, provided you do not go 63 days or longer without creditable coverage. If you do go 63 days or longer without creditable coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have creditable coverage. For example, if you go 19 months without creditable coverage before enrolling in a Medicare prescription drug plan, your premium always may be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll. What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date unless you

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qualify for the one-time waiver/reinstatement provision described in the Notice to Participants dated May 20, 2013. Where can you find information about this Notice or your current prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund? Please refer to your Summary Plan Description (SPD) for information on your current prescription drug coverage or call the Fund Office at (715) 835-3174 or 1-800-424-3405. NOTE: You will receive this Notice annually and at other times in the future such as before future periods during which you can enroll in Medicare prescription drug coverage, and if our Plan's coverage changes. You also may request a copy of this Notice at any time. Where can you find information on Medicare prescription drug coverage? The following resources are available to explain your options and help you make your decision: • Medicare & You Handbook, which should be mailed to you every year in October, or you can

download an electronic version of the Handbook by visiting: www.medicare.gov/gopaperless.

• Visit www.medicare.gov for personalized help. An online Medicare Prescription Drug Plan Finder tool will be available on this website.

• Call your State Health Insurance Assistance Program (see your copy of the Medicare &

You Handbook for their telephone number). • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Keep this Notice of Prescription Drug Creditable Coverage. If you enroll in one of the Medicare prescription drug plans, you may need to give a copy of this Notice when you join to show that you are not required to pay a higher premium amount. An updated Notice will be provided to you annually. However, upon receipt of the updated Notice, DO NOT THROW AWAY PRIOR NOTICES! You may need them in a future year to prove you had creditable coverage in a specific time period. If you have any questions, please call the Fund Office at (715) 835-3174 or 1-800-424-3405. Yours very truly, THE BOARD OF TRUSTEES

http://www.medicare.gov/

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IMPORTANT NOTICE TO PARTICIPANTS September 2018 To All Participants: The Trustees of the North Central States Regional Council of Carpenters' Health Fund (the "Plan") regularly review the Plan and make changes when necessary. Please take time to read this Notice carefully and thoroughly because it contains important information regarding changes to the Summary Plan Description (SPD). Health Dynamics Preferred Provider Preventive Care Program Effective January 1, 2019, the Health Dynamics Preferred Provider Preventive Care Program will be eliminated. Accordingly, references to the Preferred Provider Preventive Care Program in the Schedule of Benefits for Classes C, E, G, O, P, R, S, T, U, and V on page ix and page 38 in the Preventive Care section of the SPD are removed. Additionally, the Preferred Provider Preventive Care Program section on page 50 and the "Preferred Provider Preventive Care Program" definition on page 82 of the SPD are deleted. Accident and Sickness Weekly Benefits (Classes C and O Employees Only) – Enhanced Coverage Effective March 1, 2018, the Trustees took action to amend the Plan to offer an increased weekly benefit rate of $800 per week under the Accident and Sickness Weekly Benefits for eligible employees who are disabled as a result of pregnancy or following delivery of a child. This increased weekly benefit rate will be payable to the mother for a maximum of twenty-six weeks. Effective May 1, 2018, the Trustees took action to amend the Plan to increase the standard weekly benefit rate for disabilities caused by an injury or sickness to $350 per week and to increase the maximum number of weeks payable per disability to 26 weeks.

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The Schedule of Benefits for Classes C and O, on page x of the SPD, has been revised, in part, as follows: ACCIDENT AND SICKNESS WEEKLY BENEFITS

Weekly benefit rate $350 Maximum number of weeks payable per disability 26 Accident and Sickness Weekly Benefits are limited to 10 days per eligible employee per calendar year for treatment of nervous and mental disorders while hospital-confined and 30 days per each eligible employee’s lifetime for treatment of alcoholism and substance abuse while hospital-confined.

(Continued) Benefits begin on the first day of a disability caused by an injury and on the eighth day of a disability caused by a sickness. An $800 per week pregnancy and post-delivery Accident and Sickness Weekly Benefit is available for mothers who are disabled while pregnant and/or following delivery of a child for a maximum of 26 weeks. The pregnancy and post-delivery Accident and Sickness Weekly Benefit is available during pregnancy for a pregnancy-related condition resulting in disability. Following childbirth, up to six weeks of post-delivery benefits are payable under the pregnancy and post-delivery Accident and Sickness Weekly Benefit (up to eight weeks for Cesarean delivery), subject to limitations noted on page 53.

Further, the section titled ACCIDENT AND SICKNESS WEEKLY BENEFITS, beginning on page 53 of the SPD, has been revised, in part, as follows:

When you are determined to be totally disabled by Trustees, based upon certification by a physician, chiropractor, or doctor of dental surgery (D.D.S.), Accident and Sickness Weekly Benefits will be paid to you at the weekly benefit rate and up to the maximum number of weeks payable during any disability as specified in the Schedule of Benefits. During partial weeks of disability, you will be paid at the daily rate of one-seventh of the Weekly Benefit for each day you are disabled. Benefits are payable for disabilities due to nervous and mental disorders, alcoholism, and substance abuse only while hospital-confined and limited as specified in the

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Schedule of Benefits. The weekly benefit rate for a pregnancy and/or post-delivery related disability is payable to a mother during pregnancy and/or following childbirth as specified in the Schedule of Benefits.

Elimination of Reduced Plan Option Effective August 1, 2018, the Trustees took action to amend the Plan to eliminate the Reduced Plan Option due to low enrollment. The section titled When Completely or Partially Unemployed in Fund’s Jurisdiction, under ELIGIBILITY RULES, RULE III. SELF-PAYMENT OPTIONS, Self-Payment Option 1, beginning on page 5 of the SPD, will be revised, as follows:

When Completely or Partially Unemployed in Fund's Jurisdiction

Class C benefits, as described in the Schedule of Benefits, are available to you when you are completely or partially unemployed in the Fund’s jurisdiction, provided you certify in writing that you are available for covered employment in the Fund’s jurisdiction, you are completely unemployed or credited with 120 hours or less of covered employment in the Work Quarter preceding the Coverage Quarter, and you are credited with 1,290 hours or less in the four Work Quarters preceding the Coverage Quarter. Self-payments for Class C benefits will be in an amount equal to the hourly contribution rate multiplied by 390 hours. Trustees may revise the self-payment rate from time to time.

When completely unemployed in the Fund's jurisdiction, your self-payments will be limited to six consecutive Coverage Quarters.

Further, the Schedule of Benefits for Reduced Plan Option For Employees and Dependents Continuing Coverage Under Self-Payment Option 1 When Completely or Partially Unemployed in the Fund’s Jurisdiction, on page xiii of the SPD, will be deleted. Eligibility for Surviving Spouses with Other Insurance Coverage Effective for surviving spouse coverage elections on and after September 1, 2018, the Plan will allow surviving spouses a one-time opportunity to waive coverage under the Plan if they have other employer-sponsored group health plan coverage. Additionally, the Trustees took action effective September 1, 2018 to allow surviving spouses to maintain Plan eligibility if they are or become

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eligible for benefit coverage from another group health care plan by reason of employment, but do not enroll in that plan. The section titled When an Employee Dies on page 6 of the SPD will be revised to read as follows:

When you die, your dependents' eligibility for benefits will terminate as follows:

1. If you were an active employee when you died: on the date your accumulated eligibility is exhausted; or

2. If you were a retired employee when you died: on the last day of the month following your death, except as otherwise provided in this section, "When an Employee Dies."

After your accumulated eligibility has been exhausted, your eligible surviving spouse will be permitted to continue coverage under the applicable retiree class of coverage for herself/himself and your eligible dependents (as defined on pages 76 and 77) by making self-payments. If your surviving spouse has access to other employer-sponsored group health plan coverage, and elects to enroll in that coverage, he or she will have a one-time opportunity to waive coverage under the Plan. To waive coverage under the Plan, your surviving spouse must sign a waiver form certifying his or her coverage under the other employer-sponsored group health plan and submit proof of such coverage. Your surviving spouse may reinstate coverage in the Plan upon loss of the other employer-sponsored group health plan coverage. To reinstate coverage, your surviving spouse must submit a completed enrollment form to the Fund Office within 60 days following the loss of other employer-sponsored group health plan coverage and proof that he or she, and any eligible dependents, if applicable, were continuously covered under employer-sponsored group health plan coverage. Your surviving spouse’s, and dependents’, coverage under the Plan will be reinstated on the first day of the month following the Fund Office’s receipt of an enrollment form, proof of continuous coverage, and the applicable self-payment., The privilege to obtain continued benefit coverage under this Plan by making self-payments will terminate on the day:

1. your surviving spouse remarries; 2. your surviving spouse and/or dependent children enroll in

benefit coverage under another group health care plan by

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reason of employment, unless your surviving spouse has submitted a waiver form, as described above; or

3. your surviving spouse and/or dependent children establish residence outside of the United States.

Coverage of Tooth Extraction and Replacement Teeth Under Comprehensive Major Medical Benefits Effective December 1, 2017, the Trustees took action to amend the Plan to provide for coverage of tooth extraction and replacement teeth (through dental implant or dental appliance, such as dentures), under the Plan’s Comprehensive Major Medical Benefits when tooth loss is caused by head and neck radiation or chemotherapy treatment. The Trustees took action to further amend the Plan effective June 1, 2018, to extend the limitations period for replacement of missing teeth to five years following the date of the injury to the jaw or natural teeth, provided the attending physician submits a treatment plan substantiating the need to extend the time period for corrective treatment. The section titled Other Covered Charges, under COVERED CHARGES, appearing on page 32 of the SPD, has been revised, in part, to provide as follows:

: Dental services rendered by a physician or dentist for treatment within 12 months of an injury to the jaw or natural teeth, or when arising from head and neck radiation or chemotherapy treatment, within 12 months of completion of such treatment, including the initial replacement of these teeth and any necessary dental x-rays. Treatment may be extended past the initial 12-month treatment period for a period of up to five years following the date of injury or radiation/chemotherapy treatment, provided a treatment plan from the treating physician or dentist is submitted to the Plan with substantiation that the corrective treatment could not be completed within the initial 12-month treatment period.

Coverage of Preventive Services Effective January 1, 2018, the Trustees took action to amend the Plan to designate colonoscopies as the exclusive colorectal cancer screening method under Preventive Care coverage. Also effective January 1, 2018, the Trustees took action to amend the Plan to approve coverage of Cologuard (for screening of colorectal cancer) under the Plan’s Comprehensive Major Medical Benefits. Prior to January 1, 2018,

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effective January 1, 2015, Cologuard was covered as an experimental medical treatment and procedure, subject to the aggregate maximum reflected in the Schedule of Benefits, as detailed in the November 2014 Notice to the SPD. The section titled Other Covered Charges under COVERED CHARGES beginning on page 32 has been revised, in part, to add the following:

10. The Cologuard colorectal cancer screening test when ordered by a physician, payable subject to these Medicare guidelines. The Cologuard test will be covered once every three years for eligible persons who meet all of the following criteria:

a. Age 50 to 85 years old;

b. Asymptomatic (no signs or symptoms of colorectal disease, including but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and

c. At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

The first paragraph in the section titled When Obtained at a Network Provider, under PREVENTIVE CARE, beginning on page 37 of the SPD, has been revised as follows:

1. Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force, including but not limited to: routine pap smears; routine hearing exams; routine physical exams for employee and dependent spouse, including office visit and routine x-rays and laboratory tests.

The Plan covers routine colonoscopy, specifically excluding CT colonography (virtual colonoscopy), as the exclusive preventive care service for colorectal cancer screening.

Effective January 1, 2018, the Trustees took action to amend the Plan to expand and clarify the manner in which the Plan will cover preventive care services without cost sharing when such services are obtained at a network provider, as required by the Affordable Care Act.

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The fourth paragraph in the section titled When Obtained at a Network Provider, under PREVENTIVE CARE, appearing on page 37 of the SPD, has been revised to provide as follows:

4. With respect to preventive services for women, as required by the Affordable Care Act, evidence-informed preventive care and screening as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration, as follows:

: Annual well-women preventive care visits unless more than

one is needed to obtain all necessary services. This includes visits to obtain recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care.

: Gestational diabetes screening for pregnant women

between 24 and 28 weeks gestation and who are identified at high risk for diabetes at first prenatal visit.

: Human papillomavirus (HPV) DNA screening for women

age 30 or older, once every three years. : Annual counseling on HIV and sexually transmitted

infections (STIs) for sexually active women. : Contraception counseling. : Initiation of contraceptive use and follow-up care. : One form of contraception in each FDA-approved

contraceptive method in accordance with the Affordable Care Act, including, but not limited to: injectable hormones, implanted devices, and sterilization for women with reproductive capacity. See page 47 for contraceptive methods covered under the PPRx.

: Lactation support and counseling for pregnant and

postpartum women, and breastfeeding equipment. Electric or manual breast pumps are limited to one every five calendar years.

: Annual screening and counseling for interpersonal and

domestic violence.

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Preferred Provider Pharmacy Program (PPRx) – Covered Charges Effective January 1, 2018, the Trustees took action to amend the following prescription drug coverages, as required by the Affordable Care Act. The section titled Covered Expenses, under PREFERRED PROVIDER PHARMACY PROGRAM (PPRx), on page 47 of the SPD, has been revised, in part, as follows:

… 12. Over-the-counter (OTC) aspirin for cardiovascular protection

and the prevention of colorectal cancer, to the extent recommended by the United States Preventive Services Task Force.

13. Smoking cessation products, including OTC nicotine

replacement therapy (gum, lozenge, patch, inhaler, and nasal spray) and federal legend drugs (sustained-release bupropion and varenicline), up to two 90-day supplies per 365-day period.

14. Federal legend fluoride for dependent children six months to

sixteen years of age whose primary water source is deficient in fluoride.

15. OTC folic acid for doses of 400-800 mcg/day for women who

are planning or capable of pregnancy. 16. Synagis when preauthorized by and purchased through the

Specialty Pharmacy. When the initial dose is administered while a newborn is hospitalized, it will be payable under Comprehensive Major Medical Benefits, if preauthorized.

17. Suboxone.

Change in Basis for Determination of Reasonable Expense Effective March 1, 2018, the Trustees took action to amend the Plan to provide that a schedule of prevailing medical charges selected by the Trustees will be used to determine the reasonable expense for a medical procedure for purposes of Plan coverage. Prior to March 1, 2018, the Plan utilized the Fair Health schedule of prevailing medical charges. Effective March 1, 2018, the Trustees selected the Anthem schedule. The definition of Reasonable Expense, appearing on page 83 of the SPD, has been revised to provide as follows:

- 9 -

Reasonable Expense means the charges incurred for services and supplies which are medically necessary for treatment and which are regular and customary as determined by the charges generally incurred for cases of comparable nature and severity in the particular geographical area concerned. Reasonable expenses for medical procedures are based on the schedule of prevailing medical charges selected by the Trustees.

Disability Claims and Appeals Procedures Effective for claims filed on or after April 1, 2018, the Department of Labor has issued new regulations for administering claims and appeals for disability benefits (the "Final Regulations"). The changes require that the Plan provide you with additional information in the written denial of a claim for disability benefits under the Plan. The section titled Claims Appeal Procedures, beginning on page 88 of the SPD, has been revised, in part, as follows, for the Final Regulations and to clarify how the Plan's claims and appeals procedures differ for different types of claims.

For disability claims, the Plan has a reasonable period of time, not in excess of 45 days, to provide written notice of an adverse benefit determination for any claim for disability benefits under the Plan. The Plan may extend the decision-making period for up to an additional 30 days for reasons beyond the Plan’s control but the Plan will notify you in writing before the expiration of the 45-day period of the reason for the delay and when the decision will be made. A second 30-day extension is allowable if the Plan still is unable to make the decision for reasons beyond its control. You will be provided, before the expiration of the first 30-day extension period, a notice that details the reasons for the delay and the date as of which the Plan expects to render a decision. If an extension is needed because the Plan needs additional information from you, the extension notice will specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and specify the additional information needed to resolve those issues, in which case you will have 45 days from receipt of the notification to provide the requested information. The Plan will issue its decision within 30 days of the date you submit your information (subject to the 30-day extension previously described). Your claim will be denied if you do not submit the requested information in a timely manner. If the Plan denies coverage for your claim, the denial is called an adverse benefit determination as defined under the U.S. Department of Labor Regulations. An adverse benefit

- 10 -

determination includes a rescission of your coverage under the Plan, except in the case of fraud or intentional misrepresentation of a material fact. The Regulations define a rescission as a cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuance is not a rescission if the cancellation or discontinuance only has a prospective effect. The following are not considered rescissions under the Regulations even though retroactive:

1. Retroactive termination to the extent attributable to failure to pay a timely premium (self-payment) towards coverage.

2. Retroactive elimination of coverage back to the date of termination of employment, due to delays in administrative recordkeeping if the employee does not pay any premiums for coverage after termination of employment.

3. The Plan’s termination of coverage retroactive to the date

of a divorce. To clarify, this means that, in general, the Plan cannot terminate your coverage retroactively. However, the Plan may do so under the circumstances described and in other instances as may be prescribed in the Regulations. The Plan is required to provide at least 30 days advance written notice to each eligible person who is affected by a rescinding of coverage before the coverage may be rescinded. If your claim for benefits is denied in whole or in part, the Administrative Manager will provide you, your dependents, beneficiaries, or authorized or legal representatives, as may be appropriate (hereafter referred to as “you” or “your”) with written or electronic notice of adverse benefit determinations within the time frames previously stated. Such notice will be provided in a culturally and linguistically appropriate manner (i.e., the Plan will provide a statement regarding translation assistance if you reside in a county identified by the Census Bureau as having 10% or more of its population literate only in the same non-English language). Notices will include the following information stated in an easily understandable manner:

- 11 -

Health Claims

1. The specific reason or reasons for the adverse benefit determination.

2. References to specific Plan provision(s) on which the adverse benefit determination is based.

3. Information sufficient to identify the claim involved,

including the date(s) of service; healthcare provider; claim amount; and diagnosis, treatment, and denial codes, including their corresponding meanings, upon request and without charge.

4. A description of any additional material or information, if

any, necessary for you to perfect your claim and an explanation of why the material or information is necessary.

5. A description of the Plan’s internal claims appeal

procedures and time limits applicable to such appeal procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review or, for health claims other than dental and vision, to request an external review with an Independent Review Organization (IRO) after the Plan’s claims procedures have been exhausted.

6. Copies of any internal rule, guideline, protocol, standard,

or similar criteria relied upon in making the adverse benefit determination, or a statement that such rule, guideline, protocol, standard, or other similar criteria is available free of charge upon request.

7. If the adverse benefit determination was based on a

medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances is available free of charge upon request.

8. The availability of, and contact information for, any

applicable ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes.

- 12 -

Disability Claims

1. The specific reason or reasons for the adverse benefit determination, including a discussion of the decision, explaining the basis for disagreeing with or not following:

a. The views presented by you to the Plan of any healthcare professionals who treated you or vocational professionals who evaluated you;

b. The views of any medical or vocational experts

whose advice was obtained by the Plan in connection with your claim; and

c. A disability determination made by the Social

Security Administration presented by you to the Plan.

2. References to specific Plan provision(s) on which the

adverse benefit determination is based.

3. A description of any additional material or information, if any, necessary for you to perfect your claim and an explanation of why the material or information is necessary.


procedures and time limits applicable to such appeal procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review.

5. Copies of any internal rule, guideline, protocol, standard,

or similar criteria relied upon in making the adverse benefit determination, or a statement that such criteria does not exist.

6. If the adverse benefit determination was based on a

medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request.

7. A statement that you are entitled to receive, upon request

and free of charge, reasonable access to, and copies of,

- 13 -

all documents, records, and other information relevant to your claim for benefits.

Death and Accidental Death and Dismemberment Benefit Claims

1. The specific reason or reasons for the adverse benefit determination

2. References to specific Plan provision(s) on which the adverse benefit determination is based.

3. A description of any additional material or information, if

any, necessary for you to perfect your claim and an explanation of why the material or information is necessary.


procedures and time limits applicable to such appeal procedures, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review.

The Plan will pay charges incurred for copies of medical records which have been requested by the Plan as necessary for processing a claim, whether it is determined that the Plan benefits are payable or denied. If you feel that the action taken on your eligibility or claim is incorrect, you immediately should ask the Fund Office to review your claim with you. In some cases, the Fund Office may request additional information from you which might enable the Fund Office to reevaluate its decision. Internal Claims Appeal Procedures If all or part of a claim is denied or if you are otherwise dissatisfied with the determination made by the Plan, or if you have not received the notice of denial of your claim within the applicable time limits after the Plan has received all necessary claim information, you have the right to appeal the decision and request an internal review of the claim. The Plan will provide for a full and fair review of a claim and adverse benefit determination, pursuant to the following:

1. The Plan has three levels of appeal for health claims other than dental and vision and two levels of appeal for

- 14 -

all other claims. The first level of appeal is decided by the Eligibility and Appeals Committee of the Trustees. The second level is decided by the Executive Committee of the Board of Trustees. The third level is the Federal External Claims Review Process and is decided by an Independent Review Organization (IRO). The rules regarding claims appeal procedures apply to the first and second levels of appeal, while the Federal External Claims Review Process has its own independent appeal procedure.

2. You will have 180 days after you receive the notice of an adverse benefit determination to file your appeal in writing to the Fund Office and it must include the specific reasons you feel denial was improper.

3. You will be allowed the opportunity to submit written

issues and comments, documents, records, and other information relating to the claim for benefits which may have been requested in the notice of denial or which you may consider desirable or necessary.

4. You or your duly authorized representative will be

provided, upon request and free of charge, reasonable access to, and copies of, all designated, pertinent documents, records, and other information relevant to your claim for benefits.

5. The review will take into account all comments,

documents, records, and other information submitted by you relating to the claim, whether or not such information was submitted or considered in the initial benefit determination.

6. For health and disability claims, the Plan will provide you,

free of charge, any new or additional evidence considered, relied on, or generated in connection with an appeal or any new or additional rationale relied upon in connection with the denial of an appeal and allow you to respond. Such information will be provided as soon as possible and sufficiently in advance of the date on which notice of the Plan’s final adverse benefit determination must be provided, in order to allow the claimant a reasonable opportunity to respond prior to that date.

- 15 -

For health claims, if the new or additional evidence is received so late that the claimant will not have a reasonable opportunity to respond within the prescribed timeframe, the time period for the Plan to issue a decision will be pended until the claimant has an opportunity to respond. The Plan will issue its decision on the appeal as soon as reasonably practical after the claimant either responds or fails to respond.

7. The Plan will assign a decision maker on appealed

claims that is an appropriate named fiduciary for the Plan and different than and not the subordinate of the person deciding the initial claim. The decision maker on appeal will not afford deference to the initial adverse benefit determination. The Plan will ensure that all claims and appeals are adjudicated with the utmost impartiality and avoid conflicts of interest. The claims or appeals adjudicator will be independent from and impartial to the Plan.

8. The Plan will consult with appropriate healthcare

professionals in deciding appealed claims that are based in whole or in part on medical judgment, including determination of experimental or investigational treatments and medical necessity. Such healthcare professional will have appropriate training and experience in the field of medicine involved in the medical judgment. The healthcare professional consulted for the appeal of an adverse benefit determination will be someone who was not consulted in the initial adverse benefit determination nor the subordinate of such individual.

9. If a medical or vocational expert's advice was obtained in

behalf of the Plan in connection with your claim, you may request the identity of the expert, regardless of whether the advice was relied on.

10. For appeals of pre-service claims, the Plan will notify you

of the decision within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days of receiving the first appeal request and 15 days of receiving the second appeal request, if applicable.

- 16 -

11. For appeals of post-service claims, the Plan will notify you of the decision within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days of receiving the first appeal request and 30 days of receiving the second appeal request, if applicable.

12. For appeals of disability claims, the Plan will notify you of

the decision within a reasonable period of time, but not later than 45 days after receiving the first appeal request and 45 days of receiving the second appeal request, if applicable.

13. The Plan will provide you with written or electronic notice

of an adverse benefit determination within the time frames provided in this Section. Such notice will be provided in a culturally and linguistically appropriate manner and will include the following information stated in an easily understandable manner:

Health Claims

a. Information sufficient to identify the claim involved, including the date(s) of service; healthcare provider; claim amount; and diagnosis, treatment, and denial codes, including their corresponding meanings, upon request and without charge.

b. The specific reason or reasons for the adverse benefit determination, including a discussion of the decision.

c. References to specific Plan provision(s) on which

the adverse benefit determination is based.

d. A statement that you will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.

e. A statement describing any further appeal

procedures offered by the Plan including your right to obtain the information about such procedures.

f. A statement of your right to bring a civil action

under Section 502(a) of ERISA after you have

- 17 -

exhausted the Plan’s claims appeal procedures or, for health claims other than dental and vision, to request an external review with an Independent Review Organization (IRO) after the Plan’s claims procedures have been exhausted.

g. Copies of any internal rule, guideline, protocol,

standard, or similar criteria relied upon in making the adverse benefit determination or a statement that such rule, guideline, protocol, standard, or other similar criteria will be provided free of charge upon request.

h. If the adverse benefit determination was based on

a medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge upon request.

i. Disclosure of the availability of, and contact

information for, any applicable ombudsman established under the Affordable Care Act to assist individuals with the external claims and appeals on external review procedures.

Disability Claims

a. The specific reason or reasons for the adverse

benefit determination, including a discussion of the decision, explaining the basis for disagreeing with or not following:

i. The views presented by you to the Plan of any healthcare professionals who treated you or vocational professionals who evaluated you;

ii. The views of any medical or vocational experts whose advice was obtained by the Plan in connection with your claim; and

- 18 -

iii. A disability determination made by the Social Security Administration presented by you to the Plan.

b. References to specific Plan provision(s) on which

the adverse benefit determination is based.

c. A statement that you will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits.

d. A statement of your right to bring a civil action

under Section 502(a) of ERISA after you have exhausted the Plan’s claims appeal procedures and a description of the applicable contractual limitations period that applies to your right to bring a civil action under Section 502(a) of ERISA, including the calendar date on which such contractual limitations period expires.

e. Copies of any internal rule, guideline, protocol,

standard, or similar criteria relied upon in making the adverse benefit determination or a statement that such rule, guideline, protocol, standard, or criteria does not exist.

f. If the adverse benefit determination was based on

a medical necessity or experimental treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment of the Plan in applying the terms of the Plan to your medical circumstances will be provided free of charge to you upon request.

Death and Accidental Death and Dismemberment Benefit Claims

a. The specific reason or reasons for the adverse benefit determination

b. References to specific Plan provision(s) on which the adverse benefit determination is based.

c. A statement that you will be provided, upon request and free of charge, reasonable access to,

- 19 -

and copies of, all documents, records, and other information relevant to your claim for benefits.

d. A statement of your right to bring a civil action under Section 502(a) of ERISA after you have exhausted the Plan’s claims appeal procedures.

Federal External Claims Review Process If the Plan has denied your health claim and issued you an adverse benefit determination under the internal claims appeal procedures, you have the right to appeal your decision externally. Only health claims that involve medical judgment or a rescission of coverage are eligible for external review. Dental, vision, disability, death, and accidental death and dismemberment benefit claims are not eligible for external review.

. . . The Trustees will make every effort to interpret Plan provisions in a consistent and equitable manner. You will be given maximum opportunity to present your viewpoint on any denied claim. You may not begin any legal action, including proceedings before administrative agencies, until you have followed the procedures and exhausted the internal and, for certain health claims and rescissions of coverage, external appeal opportunities described here. However, if the Plan fails to adhere strictly to the requirements of the Regulations, you will be deemed to have exhausted the internal claims appeal procedures with respect to a claim and can seek external review or file a claim in court (unless the violation was de minimis, non-prejudicial, due to good cause or matters beyond the Plan’s control, or in the context of an ongoing, good-faith exchange of information with you, and not reflective of a pattern or practice of non-compliance). In the event that you request a written explanation of the violation, the Plan will provide an explanation within 10 days, including a specific description of its bases, if any, for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted. For health claims, if the external reviewer or court rejects your request for immediate review, the Plan will provide you notice of the opportunity to resubmit and pursue the internal appeal of the claim. This notice must be sent within a reasonable time after the external reviewer or court rejects the claim for

- 20 -

immediate review, but not later than 10 days. For disability claims, the claim will be considered refiled on appeal upon the Plan's receipt of the decision of the court rejecting your request for immediate review. The Plan will provide you with notice of the resubmission within a reasonable time after receipt of the decision of the court. You may, at your own expense, have legal representation at any stage of these review procedures. No legal action for any benefits under the Plan may begin later than two years after the time the claim was required to be received by the Fund Office as specified on page 85. Benefits under this Plan will be paid only if the Board of Trustees (or its Administrative Manager) decides in its discretion that you are entitled to them. The Plan will be interpreted and applied in the sole discretion of the Board of Trustees (or its delegate, including but not limited to, its Administrative Manager). Such decision will be final and binding on all persons covered by the Plan who are claiming any benefits under the Plan.

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES


Emergency Room Copayment Increase Effective January 1, 2018

October 2017

This Notice is to inform you of an increase to the emergency room copay starting in 2018. The Plan will revise the in-network and out-of-network medical emergency room copay effective January 1, 2018, from $50 per visit to $150 per visit. The copay will be waived if you are admitted to the hospital. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES ncsrcc\not\2017\Oct2017

♦♦ IMPORTANT NOTICE TO PARTICIPANTS ♦♦

September 2017 To All Employees and Dependents: The purpose of this Notice is to inform you that the Plan has been amended, retroactively effective to January 1, 2017, with respect to coverage for Sexual Transformation. Your Summary Plan Description (SPD) currently states the exclusion as, “Sexual reassignment surgery, services, counseling, or supplies.” Effective January 1, 2017, the SPD will read, “to provide that plastic or reconstructive surgery for the treatment of gender dysphoria will be considered medically necessary under the Plan if such surgery is considered medically necessary under clinical utilization management guidelines or medical policies approved by the Trustees for the treatment of gender dysphoria.”

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES ncsrcc\not\September 2017

- over -

September 2017


This Notice is being sent to inform you how your benefits through North Central States Regional Council of Carpenters' Health Fund are affected by Medicare Part D. It is being sent to all participants even though it applies only to those eligible for Medicare or who may become eligible for Medicare in the next 12 months. Medicare prescription drug coverage, referred to as "Medicare Part D," became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage plans that offer prescription drug coverage. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans offered by independent insurance companies might offer more coverage for a higher monthly premium.

North Central States Regional Council of Carpenters' Health Fund Trustees have determined that your current prescription drug coverage is "creditable coverage," which means that it is, on average for all Fund participants, expected to pay out as much or more than the standard Medicare prescription drug coverage. Since you have prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund, the most cost effective option for you, generally, is to not enroll in a Medicare prescription drug plan unless you are eligible for extra help from Medicare for persons with low income. Joining a Medicare prescription drug plan will not reduce the monthly self-payment required by North Central States Regional Council of Carpenters' Health Fund because your current self-payment is for both medical and prescription drug expenses.

Retirees with limited income may be eligible for financial support from the government to help pay for the Medicare prescription drug plan. Information about this extra help is available from the Social Security Administration (SSA) online at: www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778). If you are eligible for special assistance, you should review your options carefully because it may be beneficial for you to enroll in a Medicare prescription drug plan.

The following information is provided to help you decide whether it would benefit you to enroll in Medicare Part D for prescription drug coverage.



- 2 -

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare prescription drug plan. In addition, if you lose or decide to leave employer/union-sponsored coverage, you will be eligible to join a Medicare prescription drug plan at that time using an Employer Group Special Enrollment Period.

Will your current coverage through North Central States Regional Council of Carpenters' Health Fund be affected if you join a Medicare prescription drug plan? Yes. Your Medicare prescription drug plan will become the primary payer for your prescription drug benefits, unless you are covered under an Active Plan through North Central States Regional Council of Carpenters' Health Fund, in which case the Fund remains the primary payer. The Fund will consider your prescription drug expenses for payment only after the expenses have been considered by your Medicare prescription drug plan. In addition, it will be your responsibility to submit proof of what the Medicare prescription drug plan paid (Explanation of Benefits) before the Fund considers any balance. Again, joining a Medicare prescription drug plan will not reduce your monthly self-payment to North Central States Regional Council of Carpenters' Health Fund since you receive both medical coverage as well as prescription drug coverage from the Fund.

Will Medicare penalize participants who do not enroll in a Medicare prescription drug plan? Because coverage through North Central States Regional Council of Carpenters' Health Fund is creditable coverage, you will not have to pay a penalty if you enroll later, provided you do not go 63 days or longer without creditable coverage.

If you do go 63 days or longer without creditable coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have creditable coverage. For example, if you go 19 months without creditable coverage before enrolling in a Medicare prescription drug plan, your premium always may be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll.

What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date unless you

- 3 -

qualify for the one-time waiver/reinstatement provision described in the Notice to Participants dated May 20, 2013.

Where can you find information about this Notice or your current prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund? Please refer to your Summary Plan Description (SPD) for information on your current prescription drug coverage or call the Fund Office at (715) 835-3174 or 1-800-424-3405. NOTE: You will receive this Notice annually and at other times in the future such as before future periods during which you can enroll in Medicare prescription drug coverage, and if our Plan's coverage changes. You also may request a copy of this Notice at any time.

Where can you find information on Medicare prescription drug coverage? The following resources are available to explain your options and help you make your decision:

• Medicare & You Handbook, which should be mailed to you every year in October, or you can

download an electronic version of the Handbook by visiting: www.medicare.gov/gopaperless.



You Handbook for their telephone number).

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have any questions, please call the Fund Office at (715) 835-3174 or 1-800-424-3405.

Yours very truly,


NCSRCC\not\2017\Creditable Coverage Notice 2017 09

Keep this Notice of Prescription Drug Creditable Coverage. If you enroll in one of the Medicare prescription drug plans, you may need to give a copy of this Notice when you join to show that you are not required to pay a higher premium amount. An updated Notice will be provided to you annually. However, upon receipt of the updated Notice, DO NOT THROW AWAY PRIOR NOTICES! You may need them in a future year to prove you had creditable coverage in a specific time period.

http://www.medicare.gov/gopaperless



March 2017 To All Employees and Dependents:

The purpose of this Notice is to inform you that the Plan has been amended, retroactively effective to January 1, 2016, with respect to coverage for the prescription drug, Suboxone.

Suboxone is a prescription medication (narcotic) which combines buprenorphine and naloxone to combat the effects of narcotics. It is primarily used to treat opioid addictions.

The Plan has been amended to reflect this change. Please refer to page 48 of your Summary Plan Description (SPD) booklet. Item 9 under Limitations is amended to read:

9. medications to treat addictions, including but not limited to,

methadone; Under Covered Expenses on page 48 of your SPD booklet, item 18 is added to read:

18. Suboxone.

Also, we want to clarify that Suboxone is covered only when filled through the Preferred Provider Pharmacy Program (Express Scripts) and is not reimbursable under Comprehensive Major Medical Benefits.

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office.

Yours very truly,

THE BOARD OF TRUSTEES ncsrcc\not\March 2017

NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY SERVICES

The North Central States Regional Council of Carpenters’ Health Fund complies with applicable Federal civil rights laws and does not

discriminate on the basis of race, color, national origin, age, disability, or sex. The Fund does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex. The Fund provides free aids and services to people with disabilities to

communicate effectively with us, such as: qualified sign language interpreters and written information in other formats (large print, audio,

accessible electronic formats, other formats) as well as language services to people whose primary language is not English, such as:

qualified interpreters and information written in other languages. If you need these services, please contact the Fund Office.

If you believe the Fund has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age,

disability, or sex, you can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,

electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or

phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C.

20201, 1‐800‐368‐1019, 1‐800‐537‐7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

****

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Rufnummer: 1‐800‐424‐3405.

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ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1‐800‐424‐3405.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1‐800‐424‐3405.

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch

Schprooch. Ruf selli Nummer uff: Call 1‐800‐424‐3405.

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1‐800‐424‐3405.

ध्यान द: यिद आप बोलते ह तो आपके िलए मुफ्त म भाषा सहायता सेवाएं उपलब्ध ह। 1‐800‐424‐3405 पर कॉल कर।

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa

1‐800‐424‐3405.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1‐800‐424‐3405.

Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families

December 2015


The North Central States Regional Council of Carpenters’ Health Fund (the "Plan") is furnishing you this Notice as required by federal law. In most cases, the information presented in this Notice will have a limited application to employees (and dependents) eligible for Plan coverage. It may apply if you are required to pay a premium for coverage under the Plan. If you believe the information in the Notice applies to your situation, you should contact the applicable office in the state where you reside as shown in the attached listing.

If you or your dependents are eligible for Medicaid or CHIP and also are eligible for health coverage under the Plan, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for these programs and also are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit: www.HealthCare.gov.

If you or your dependents already are enrolled in Medicaid or CHIP and you live in a state listed in the attachment, you can contact your state Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for an employer- sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under this Plan’s health coverage, your employer’s health plan is required to permit you and your dependents to enroll in the Plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have any questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free: 1-866-444-EBSA (3272).

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference.

Yours very truly,


http://www.healthcare.gov/

http://www.insurekidsnow.gov/

http://www.askebsa.dol.gov/

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility –

ALABAMA – Medicaid GEORGIA – Medicaid

Website: http://www.myalhipp.com Phone: 1-855-692-5447

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ALASKA – Medicaid INDIANA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529

Website: http://www.in.gov/fssa Phone: 1-800-889-9949

COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

FLORIDA – Medicaid KANSAS – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid NEW YORK – Medicaid Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-977-6740 TTY: 1-800-977-6741

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dhs.state.mn.us/id_006254

Click on Health Care, then Medical Assistance Phone: 1-800-657-3739

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604

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http://www.myalhipp.com/

http://dch.georgia.gov/

http://health.hss.state.ak.us/dpa/programs/medicaid/

http://www.in.gov/fssa

http://www.colorado.gov/hcpf

http://www.dhs.state.ia.us/hipp/

http://www.flmedicaidtplrecovery.com/

http://www.kdheks.gov/hcf/

http://chfs.ky.gov/dms/default.htm

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf


http://dhh.louisiana.gov/index.cfm/subhome/1/n/331


http://www.state.nj.us/humanservices/

http://www.njfamilycare.org/index.html

http://www.maine.gov/dhhs/ofi/public-

http://www.nyhealth.gov/health_care/medicaid/

http://www.mass.gov/MassHealth

http://www.ncdhhs.gov/dma

http://www.dhs.state.mn.us/id_006254

http://www.nd.gov/dhs/services/medicalserv/medicaid/


MISSOURI – Medicaid SOUTH DAKOTA - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://dss.sd.gov Phone: 1-888-828-0059

MONTANA – Medicaid TEXAS – Medicaid Website: http://medicaid.mt.gov/member Phone: 1-800-694-3084

Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

NEBRASKA – Medicaid UTAH – Medicaid and CHIP Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633

Website: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-866-435-7414

NEVADA – Medicaid VERMONT– Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

OKLAHOMA – Medicaid and CHIP VIRGINIA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

OREGON – Medicaid WASHINGTON – Medicaid Website: http://www.oregonhealthykids.gov

http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx

Phone: 1-800-562-3022 ext. 15473

PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid Website: http://www.dhs.state.pa.us/hipp Phone: 1-800-692-7462

Website: http://www.dhhr.wv.gov/bms/ Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

RHODE ISLAND – Medicaid WISCONSIN – Medicaid Website: http://www.eohhs.ri.gov Phone: 401-462-5300

Website: https://www.dhs.wisconsin.gov/badgercareplus/ p-10095.htm Phone: 1-800-362-3002

SOUTH CAROLINA – Medicaid WYOMING – Medicaid

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

Website: https://wyequalitycare.acs-inc.com Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

ncscrcc/not/2015/CHIP Dec 2015

2

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm


http://dss.sd.gov/

http://medicaid.mt.gov/member

http://www.gethipptexas.com/

http://www.accessnebraska.ne.gov/

http://health.utah.gov/medicaid

http://health.utah.gov/chip

http://dwss.nv.gov/

http://www.greenmountaincare.org/

http://www.insureoklahoma.org/

http://www.coverva.org/programs_premium_assistance.cfm



http://www.oregonhealthykids.gov/

http://www.hijossaludablesoregon.gov/

http://www.hca.wa.gov/medicaid/premiumpymt/pages/

http://www.hca.wa.gov/medicaid/premiumpymt/pages/

http://www.dhs.state.pa.us/hipp

http://www.dhhr.wv.gov/bms/

http://www.eohhs.ri.gov/

http://www.dhs.wisconsin.gov/badgercareplus/

http://www.scdhhs.gov/

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/

November 2016 To All Employees and Dependents: The purpose of this Notice is to inform you of the following:

• ComPsych EAP; • Women's Health and Cancer Rights Act annual notification; and • HIPAA Privacy update.

ComPsych Employee Assistance Program (EAP) Because we care about you and recognize that personal problems can affect your job performance and cause you stress, the Plan provides an EAP through ComPsych. The EAP is a strictly confidential employee benefit which provides assessment and short-term counseling to you, your spouse, and your dependent children who may be affected by personal problems. You or your dependent can access the EAP by calling the ComPsych GuidanceResources toll-free number at: 1-844-393-4984. Call anytime about concerns such as marital, relationship, and family problems; stress, anxiety, and depression; grief and loss; job pressures; and substance abuse. When you call the EAP, an intake specialist will get some general information about you and talk with you about your needs. This specialist will provide the name of a counselor who best fits your personal needs. Then, you will set up an appointment to speak with the counselor over the phone or schedule a face-to-face visit. If the counselor determines that your issues can be resolved within five sessions, you will receive free short-term counseling through the EAP. However, if it is determined that the problem cannot be resolved in short-term counseling through the EAP, you will be referred to a specialist for longer-term treatment which may be covered under other Plan provisions. Your EAP also provides help with the following:

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• Work-Life Solutions provides qualified referrals and customized resources for child and elder care, moving, pet care, college planning, home repair, buying a car, planning an event, selling a house, and more.

• Legal Support provides an attorney "on call" whenever you have questions about legal matters. You can speak with on-staff licensed attorneys about legal concerns such as divorce, custody, adoption, real estate, debt and bankruptcy, landlord/tenant issues, civil and criminal actions, and more. If you require representation, you can be referred to a qualified attorney for a free 30-minute consultation and a 25% discount in customary legal fees.

• Financial Information gives you answers to your questions about

budgeting, debt management tax issues, and other money concerns from on-staff CPAs, Certified Financial Planners, and other financial experts.

Take advantage of these services your EAP offers for you. Women's Health and Cancer Rights Act Annual Notification The Women's Health and Cancer Rights Act of 1998 requires that we notify you annually of the coverage required under this Act. This Notice fulfills that requirement. The Act amended ERISA by requiring group health plans which provide medical and surgical benefits for a mastectomy to provide the following coverage if you elect breast reconstruction in connection with a mastectomy, in a manner determined in consultation with the attending physician and the patient: »» all stages of reconstruction of the breast and nipple of the breast on which the



lymphedemas. Subject to any applicable deductible and copayment requirements, your Plan provides coverage for the preceding items on the same basis as any other medical or surgical procedure covered by the Plan. HIPAA Privacy Update On April 14, 2003, the HIPAA Privacy Regulations went into effect for the North Central States Regional Council of Carpenters’ Health Fund. These Regulations were further revised effective February 17, 2010, and again revised effective

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September 23, 2013. In October of 2013 (or when you enrolled, if later), the Plan provided you an updated Privacy Practices Notice as required by the Privacy Regulations. This Notice provided information regarding the Plan’s uses and disclosures of your medical information, your rights regarding your medical information, and the Plan’s duties to protect the privacy of your medical information. This is a reminder that the Plan’s Privacy Practices Notice is available upon request. To request a copy, please contact the Fund’s Privacy Officer, Bridget Welke, (715) 835-3174 or 1-800-424-3405. Other Enclosures Also enclosed with this Notice are the following:

• The Summary of Benefits and Coverage (SBC), for coverage period beginning

on or after January 1, 2017, as required under the rules of the Patient Protection and Affordable Care Act (PPACA); and

• The annual CHIP Notice. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

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IMPORTANT NOTICE Summary of Material Modifications

TO: Participants and Beneficiaries of the North Central States Regional Council of Carpenters’ Health Fund FROM: The Board of Trustees of the North Central States Regional Council of Carpenters’ Health Fund DATE: October 27, 2016 The Board of Trustees of the North Central States Regional Council of Carpenters’ Health Fund has amended the Summary Plan Description and Plan Document as indicated below. Effective November 1, 2016, the Plan will cover telemedicine services provided through LiveHealth Online. LiveHealth Online lets you talk face-to-face with a doctor through your mobile device or a computer with a webcam. Using LiveHealth Online for common health concerns such as colds, flu, fevers, rashes and allergies is faster and more convenient than visiting an urgent care center and saves you money because it is provided at NO cost to you. LiveHealth Online is available to you and your dependents (adults and children) and can treat most common non-emergency medical issues. LiveHealth Online should not be used for emergency care. LiveHealth Online physicians can write prescriptions when medically necessary, but narcotics and pain medications are excluded from this program. Additional details about LiveHealth Online are outlined in the enclosed brochure. To use LiveHealth Online, go to www.livehealthonline.com or download the app (available for Apple, Android, and Kindle). Doctors are available on LiveHealth Online at your convenience, 24 hours a day, 7 days a week, 365 days a year. If you have any questions about this new program, please contact the Claims Department at 1-800-424-3405 or call LiveHealth Online at 1-855-603-7985. You may also contact LiveHealth Online via e-mail at [email protected].

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September 23, 2016








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What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date unless you

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qualify for the one-time waiver/reinstatement provision described in the Notice dated May, 2013.



• Medicare & You handbook, which should be mailed to you every year in October, or you can

get a copy electronically online at: www.medicare.gov/gopaperless.



You handbook for their telephone number).



Yours very truly,



http://www.medicare.gov/gopaperless


NORTH CENTRAL STATES REGIONAL COUNCIL OF CARPENTERS' HEALTH FUND

PRIVACY PRACTICES NOTICE

October 2016

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL

INFORMATION IS IMPORTANT TO US.

Summary of Our Privacy Practices The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and Health Information Technology for Economic and Clinical Health Act (“HITECH”) and their Privacy Rules grant certain rights to participants and beneficiaries of the North Central States Regional Council of Carpenters' Health Fund (the “Plan”) in relation to their protected health information (called “medical information”). This Privacy Practices Notice discusses those rights and obligations.

The Plan may use and disclose your medical information without your permission for treatment, payment, and health care operations activities and, when required or authorized by law, for public health activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

The Plan may disclose your medical information to your family members, friends,

and others you involve in your health care or payment for your health care, and to appropriate public and private agencies in disaster relief situations. IMPORTANT NOTE: The Plan reserves the right to provide your medical information to any person identified by you (such as a Business Agent), or whom the Plan in good faith believes was identified by you, or to a family member, other relative, or close personal friend. For example, the Plan may disclose your medical information to your spouse if the spouse contacts the Plan to help resolve a payment issue on your behalf. The Plan only will provide medical information in such a situation if it is directly relevant to such person’s involvement with your care or payment related to your health care. If you object to such disclosures, please express your written objection to the contact person listed at the end of this notice.

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The Plan may disclose to the sponsor of the Plan, the Board of Trustees of the North Central States Regional Council of Carpenters' Health Fund (the “Board of Trustees”), whether you are enrolled or disenrolled in the Plan, summary health information for certain limited purposes, and your medical information for the Board of Trustees to administer the Plan if the Board of Trustees explains the limitations on its use and disclosure of your medical information in the Plan Document.

Except for certain legally-approved uses and disclosures, the Plan otherwise will not use or disclose your medical information without your written authorization.

You have the right to examine and receive a copy of your medical information, to receive

an accounting of certain disclosures the Plan may make of your medical information, and to request that the Plan amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information. You have the right to receive notice of breaches of your unsecured medical information. Please review this entire notice for details about the uses and disclosures the Plan may make of your medical information, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

The Plan’s Legal Duties

The Plan is required by applicable federal and state law to maintain the privacy of your medical information. The Plan also is required to give you this notice about its privacy practices, its legal duties, and your rights concerning your medical information. The Plan must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 23, 2016, and will remain in effect unless the Plan replaces it.

The Plan reserves the right to change its privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. The Plan reserves the right to make any change in its privacy practices and the new terms of its notice applicable to all medical information that the Plan maintains, including medical information the Plan created or received before the Plan made the change.

Uses and Disclosures of Your Medical Information

Treatment: The Plan may disclose your medical information, without your permission, to a physician or other health care provider to treat you.

Payment: The Plan may use and disclose your medical information, without your permission, to pay claims from physicians, hospitals, and other health care providers for services delivered to you that are covered by the Plan, to determine your eligibility for benefits, to coordinate your benefits with other payers, to determine the medical necessity of care delivered to you,

to obtain premiums for your health coverage, to issue explanations of benefits to the participant of the Plan in which you participate and the like. The Plan may disclose your medical information to a health care provider or another health plan for that provider or plan to obtain payment or engage in other payment activities. Health Care Operations: The Plan may use and disclose your medical information, without your permission, for health care operations. Health care operations include:

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• health care quality assessment and improvement activities;

• reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing, and credentialing activities;

• conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention;

• rating the risk and determining the necessary funding levels for the Plan, and obtaining stop-loss and similar reinsurance for the Plan’s health coverage obligations; and

• business planning, development, management, and general administration, including customer service, grievance resolution, claims payment and health coverage improvement activities, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

The Plan may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan’s or provider’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

Your Authorization: You may give the Plan written authorization to use your medical information or to disclose it to anyone for any purpose. If you give the Plan an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give the Plan a written authorization, the Plan will not use or disclose your medical information for any

purpose other than those described in this notice. The Plan generally may use or disclose any psychotherapy notes it holds only with your authorization. Family, Friends, and Others Involved in Your Care or Payment for Care: The Plan may disclose your medical information to a family member, friend, or any other person you involve in your health care or payment for your health care. The Plan will disclose only the medical information that is relevant to the person’s involvement. The Plan may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts. The Plan will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, the Plan will use its professional judgment to determine whether disclosing medical information related to your care or payment is in your best interest under the circumstances. Your medical information remains protected by the Plan at least 50 years after you die. After you die, the Plan may disclose to a family member, or other person involved in your heatlh care prior to your death, the medical information that is relevant to that person’s involvement, unless doing so is inconsistent with your preference and you have told the Plan so. Disclosures to the Board of Trustees: The Plan may disclose to the Board of Trustees whether you are enrolled or disenrolled in the Plan. The Plan may disclose summary health information to the Board of Trustees to obtain premium bids for the health

- 3 -

insurance coverage offered under the Plan or to decide whether to modify, amend, or terminate the Plan. Summary health information is aggregated claims history, claims expenses, or types of claims experienced by the enrollees in the Plan. Although summary health information will be stripped of all direct identifiers of these enrollees, it still may be possible to identify medical information contained in the summary health information as yours. The Plan is expressly prohibited from using or disclosing any health information containing your genetic information for underwriting purposes.

The Plan may disclose your medical information and the medical information of others enrolled in the Plan to the Board of Trustees to administer the Plan. Before the Plan may do that, the Board of Trustees must amend the Plan Document to establish the limited uses and disclosures the Board of Trustees may make of your medical information. Please see the Plan Document for a full explanation of those limitations.

Health-Related Products and Services: The Plan may use your medical information to communicate with you about health- related products, benefits and services, and payment for those products, benefits, and services that the Plan provides or includes, and about treatment alternatives that may be of interest to you. These communications may include information about the health care providers in the Plan’s network, if any, about replacement of or enhancements to the Plan, and about

health-related products or services that are available only to the Plan’s enrollees that add value to, although they are not part of, the Plan. Public Health and Benefit Activities: The Plan may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and public benefit activities: • for public health, including to report

disease and vital statistics, child abuse, and adult abuse, neglect, or domestic violence;

• to avert a serious and imminent threat to health or safety;

• for health care oversight, such as activities of state insurance commis- sioners, licensing and peer review authorities, and fraud prevention agencies;

• for research; • in response to court and administrative

orders and other lawful process; • to law enforcement officials with regard to

crime victims and criminal activities; • to coroners, medical examiners, funeral

directors, and organ procurement organizations;

• to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and

• as authorized by state Worker’s Compensation laws.

Individual Rights

Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. You must make a written request to obtain access to your medical information. You should submit your request to the contact at the end of this notice.

The Plan may charge you reasonable, cost- based fees (including labor costs) for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact the Plan using the

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information at the end of this notice for information about these fees.

Your medical information may be maintained electronically. If so, you can request an electronic copy of your medical information. If you do, the Plan will provide you with your medical information in the electronic form and format you requested, if it is readily producible in such form and format. If not, the Plan will produce it in a readable electronic form and format as the Plan and you mutually agree upon.

You may request that the Plan transmit your medical information directly to another person you designate. If so, the Plan will provide the copy to the designated person. Your request must be in writing, signed by you and must clearly identify the designated person and where the Plan should send the copy of your medical information.

Disclosure Accounting: You have the right to a list of instances from the prior six years, in which the Plan disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

You should submit your request to the contact at the end of this notice. The Plan will provide you with information about each accountable disclosure that the Plan made during the period for which you request the accounting, except the Plan is not obligated to account for a disclosure that occurred more than six years before the date of your request and never for a disclosure that occurred before the Plan’s effective date (if the Plan was created less than six years ago).

Amendment: You have the right to request that the Plan amend your medical information. You should submit your request in writing to the contact at the end of this notice.

The Plan may deny your request only for certain reasons. If the Plan denies your request, the Plan will provide you a written explanation. If the Plan accepts your request, the Plan will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who the Plan knows may have relied on the unamended information to your detriment, as well as persons you want to receive the amendment. Restriction: You have the right to request that the Plan restrict its use or disclosure of your medical information for treatment, payment, or health care operations, or with family, friends, or others you identify. The Plan is not required to agree to your request, except for certain required restrictions described as follows. If the Plan does agree, the Plan will abide by the agreement, except in a medical emergency or as required or authorized by law. You should submit your request to the contact at the end of this notice. Any agreement the Plan may make to a request for restriction must be in writing signed by a person authorized to bind the Plan to such an agreement. The Plan will agree to (and not terminate) a restriction request if: • the disclosure is to a health plan for

purposes of carrying out payment or health care operations and is not otherwise required by law; and

• the medical information pertains solely to

a health care item or service for which the individual, or person other than the Plan on behalf of the individual, has paid the covered entity in full.

Confidential Communication: You have the right to request that the Plan communicate with you about your medical information in confidence by means or to locations that you specify. You must make your request in writing, and your request

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must represent that the information could endanger you if it is not communicated in confidence as you request. You should submit your request to the contact at the end of this notice.

The Plan will accommodate your request if it is reasonable, specifies the means or location for communicating with you, and continues to permit the Plan to collect contributions and pay claims. Please note that an explanation of benefits and other information that the Plan issues to the participant about health care that you received for which you did not request confidential communications, or about health care received by the participant or by others covered by the Plan, may contain sufficient information to reveal that you obtained health care for which the Plan paid, even though you requested that the Plan communicate with you about that health care in confidence.

Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Notification may be delayed or not provided if so required by a law enforcement official. You

may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if the Plan knows the identity and address of such individual(s). Electronic Notice: If you receive this notice on the Plan’s website or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact the Plan using the information at the end of this notice to obtain this notice in written form. State Law: As a condition of Plan participation, the Board of Trustees requires that the privacy rights of you, your spouse, and dependents be governed only by HIPAA and the laws of the State of Wisconsin (but only to the extent such laws are not preempted by the Employee Retirement Income Security Act of 1974, as applicable), without regard to whether HIPAA incorporates privacy rights granted under the laws of other states and without regard to Wisconsin’s choice of law provisions.

Questions and Complaints

For more information about the Plan’s privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact the Plan using the information at the end of this notice.

If you are concerned that the Plan may have violated your privacy rights, or you disagree with a decision the Plan made about access to your medical information, about amending your medical information, about restricting the Plan’s use or disclosure of your medical information, or about how the Plan communicates with you about your medical information (including a breach notice communication), you may complain

to the Plan using the contact information at the end of this notice. You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201. You may contact the Office of Civil Rights’ Hotline at 1-800-368-1019. The Plan supports your right to the privacy of your medical information. The Plan will not retaliate in any way if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.

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Contact Person: Bridget Welke

Telephone: (715) 835-3174, local 1-800-424-3405, toll-free

Address: North Central States Regional

Council of Carpenters' Health Fund P.O. Box 4002 Eau Claire, WI 54702

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Important Notice

UPDATE: A CONTRACT AGREEMENT HAS BEEN REACHED BETWEEN HSHS SACRED HEART HOSPITAL AND AFFILIATES AND ANTHEM

We are pleased to announce that a new contract agreement has been reached with HSHS Sacred Heart Hospital and Clinics and Anthem, effective 8/1/2016. Any claims incurred between May 1, 2016 and July 31, 2016 will be processed as out of network.

As always, we strongly recommend that you always call the Anthem Locater phone number (800) 810-2583, which is on the back of your Identification Card, before you use a provider. They will advise you as to whether or not a provider is in the Anthem network.

If you have any other questions, please call the Claims Department at (800) 424-3405.

Board of Trustees

North Central States Regional Council of Carpenters’ Health Fund

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IMPORTANT NOTICE

HSHS SACRED HEART HOSPITAL AND AFFILIATES TERMINATE AGREEMENT WITH ANTHEM

This is to notify you that HSHS Sacred Heart Hospital (Eau Claire, WI) and affiliated clinics (Eau Claire and other cities noted) are no longer contracted providers with Anthem, effective May 1, 2016.

If you use any of the affiliated providers on the attached sheets, all covered services and items will be applied to your out of network benefit. Your deductible and coinsurance amounts are higher when you use an out of network provider.

We strongly recommend that you always call the Anthem Locater phone number (800) 810-2583, which is located on the back of your Identification Card, before you use a provider. They will confirm whether or not a provider is in the Anthem network.

If you have any other questions, please call the Claims Department at 800-424-3405.

Board of Trustees

North Central States Regional Council of Carpenters’ Health Fund

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Provider Detail HSHS Sacred Heart Hospital and Clinics 900 W Clairemont Ave Eau Claire, WI 54701 Sacred Heart Hospital - Eau Claire Sacred Heart Hospital Urgent Care - Eau Claire Sacred Heart and Vascular Center - Eau Claire Sacred Heart Obstetrics and Gynecology - Eau Claire Sacred Heart Behavioral Health - Eau Claire Sacred Heart Clinics - Arcadia, Eau Claire, Osseo Sacred Heart Hearing and Balance Center - Baldwin, Chippewa Falls, Eau Claire, Stanley Sacred Heart Clinics d/b/a Prevea Clinic - Arcadia, Chippewa Falls, Cornell, Eau Claire, Menomonie, Osseo. Affiliate Provider list for all affected providers:

Lora L Thaxton MD Physical Medicine & Rehab 900 W Clairemont Ave Eau Claire Emil K Ibrahim MD Psychiatry 4235 Southtowne Dr Eau Claire Ricardo P Bayola MD Psychiatry 900 W Clairemont Ave Eau Claire Ricardo P Bayola MD Psychiatry 4235 Southtowne Dr Eau Claire Louis A Suarez MD Thoracic Surgery 900 W Clairemont Ave Eau Claire Louis A Suarez MD Thoracic Surgery 900 W Clairemont Ave Eau Claire Nancy L Charlier MD Psychiatry 900 W Clairemont Ave Eau Claire Nancy L Charlier MD Psychiatry 4235 Southtowne Dr Eau Claire Michael A Lace PsyD Clinical Psychology 900 W Clairemont Ave Eau Claire Michael A Lace PsyD Clinical Psychology 4235 Southtowne Dr Eau Claire Suzanne J Wolf NP Advanced Nurse Practitioner 2509 County Hwy I Chippewa Falls Jill A Hasenberg DO Family Practice 2509 County Hwy I Chippewa Falls Paul M Ippel MD Family Practice 2509 County Hwy I Chippewa Falls Jonathon A Snider PsyD Clinical Psychology 4235 Southtowne Dr Eau Claire Victoria L Vande Zande MD Internal Medicine 320 N 7th St Cornell John D Anczak PAC Physician Assistant 900 W Clairemont Ave Eau Claire Justin W Corbit PAC Physician Assistant 900 W Clairemont Ave Eau Claire Benjamin G Anderson APNP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire Benjamin G Anderson APNP Advanced Nurse Practitioner 2509 County Hwy I Chippewa Falls Jeffrey A Jackson PA Physician Assistant 4235 Southtowne Dr Eau Claire Michael F Tiffany DO Obstetrics/Gynecology 2661 County Hwy I Chippewa Falls Monica L McDonald MD Thoracic Surgery 900 W Clairemont Ave Eau Claire Melee E Thao PAC Physician Assistant 900 W Clairemont Ave Eau Claire Larry C Studt MD Family Practice 2509 County Hwy I Chippewa Falls Kristie L Gering MD Family Practice 2509 County Hwy I Chippewa Falls Donald D Weinmeister MD Family Practice 2509 County Hwy I Chippewa Falls Keith W Elkins MD Family Practice 2661 County Hwy I Chippewa Falls Wahab A Kazi MD Family Practice 13029 9th St Osseo Wahab A Kazi MD Family Practice 13029 9th St Osseo Robert S Lea MD Family Practice 2509 County Hwy I Chippewa Falls Stacy L Schmidt PAC Physician Assistant 900 W Clairemont Ave Eau Claire Jeni L Gronemus LPC Counselor 4235 Southtowne Dr Eau Claire

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Angela R Bentley NP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire Greg F Broyles PAC Physician Assistant 900 W Clairemont Ave Eau Claire Aaron D Yohann PAC Physician Assistant 900 W Clairemont Ave Eau Claire Richard A Harrison PA Physician Assistant 900 W Clairemont Ave Eau Claire Steven W Steinmetz MD Family Practice 2509 County Hwy I Chippewa Falls Kathy Ann Boe APNP Advanced Nurse Practitioner 945 Dettloff Dr Arcadia Kathy Ann Boe APNP Advanced Nurse Practitioner 945 Dettloff Dr Arcadia Cari A Eggert MD Physical Medicine & Rehab 900 W Clairemont Ave Eau Claire Thomas I Joles MD Family Practice 945 Dettloff Dr Arcadia Thomas I Joles MD Family Practice 945 Dettloff Dr Arcadia Kimberly A Arndorfer NP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire John L Waciuma MD Thoracic Surgery 900 W Clairemont Ave Eau Claire Jory J Adam PAC Physician Assistant 900 W Clairemont Ave Eau Claire Lisa K Fields NP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire Michael J Nielsen PA Physician Assistant 900 W Clairemont Ave Eau Claire Jessica M Armstrong FNP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire Kristina J Roou NP Advanced Nurse Practitioner 13029 9th St Osseo Kristina J Roou NP Advanced Nurse Practitioner 13029 9th St Osseo Cynthia L Eckes APNP FNPC Advanced Nurse Practitioner 2509 County Hwy I Chippewa Falls Kevin R Hess MD Psychiatry 900 W Clairemont Ave Eau Claire Courtney L Hovland LPC Counselor 4235 Southtowne Dr Eau Claire Ellen N Canopy PAC Physician Assistant 900 W Clairemont Ave Eau Claire Ellen N Canopy PAC Physician Assistant 2509 County Hwy I Chippewa Falls Andrea S Erickson PAC Physician Assistant 900 W Clairemont Ave Eau Claire Shae M Wheeler PAC Physician Assistant 900 W Clairemont Ave Eau Claire Erica C Barrette MD Obstetrics/Gynecology 900 W Clairemont Ave Eau Claire Erica C Barrette MD Obstetrics/Gynecology 3213 Stein Blvd Eau Claire Corina L Fisher LCSW Clinical Social Worker 4235 Southtowne Dr Eau Claire Shawna Lee AUD Audiology 2661 County Hwy I Chippewa Falls Laura J Isaacson DO Family Practice 2509 County Hwy I Chippewa Falls Madeline R Heidel PAC Physician Assistant 900 W Clairemont Ave Eau Claire James G Lopez MD Family Practice 900 W Clairemont Ave Eau Claire James G Lopez MD Family Practice 1125 Broadway St N Ste 3 Menomonie Karen S Wirtanen SLP Speech Pathology 2661 County Hwy I Chippewa Falls Connie Jo A Caldwell PAC Physician Assistant 900 W Clairemont Ave Eau Claire Cara L Helmer APNP Advanced Nurse Practitioner 900 W Clairemont Ave Eau Claire Kelly A Leaver PAC Physician Assistant 900 W Clairemont Ave Eau Claire Amanda J Kops PAC Physician Assistant 900 W Clairemont Ave Eau Claire Ashley F Dalstra PAC Physician Assistant 900 W Clairemont Ave Eau Claire Lucas G Hechimovich PAC Physician Assistant 900 W Clairemont Ave Eau Claire Laura B Bottelson PAC Physician Assistant 900 W Clairemont Ave Eau Claire Erica L Vogel PAC Physician Assistant 900 W Clairemont Ave Eau Claire Emily R Duch NP Psychiatric Nurse 900 W Clairemont Ave Eau Claire John T Lamoureux MD Physical Medicine & Rehab 900 W Clairemont Ave Eau Claire John T Lamoureux MD Physical Medicine & Rehab 900 W Clairemont Ave Eau Claire Ashley A Cooper PAC Physician Assistant 900 W Clairemont Ave Eau Claire Amy M Dupont PAC Physician Assistant 900 W Clairemont Ave Eau Claire Michele S Elkin AUD Audiology 900 W Clairemont Ave Eau Claire

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Joseph A Cochran MD Neurological Surgery 900 W Clairemont Ave Eau Claire Alison M Ramaeker PAC Physician Assistant 900 W Clairemont Ave Eau Claire Kimberly M Schmidt NP Psychiatric Nurse 900 W Clairemont Ave Eau Claire Kimberly M Schmidt NP Psychiatric Nurse 4235 Southtowne Dr Eau Claire Idriys A McField PAC Physician Assistant 900 W Clairemont Ave Eau Claire


December 2015 To All Active Employees and Non-Medicare-Eligible Retirees and Dependents: The Plan’s benefits for organ and tissue transplants are provided under an insurance policy. The coverage provisions are currently described in your Summary Plan Description (SPD) booklet, but are governed by the insurance policy. To avoid any confusion, we are amending the Plan to remove the insured transplant provisions from your SPD booklet, and instead, are furnishing you with the enclosed Certificate which details coverage provisions and governs the Plan’s benefits for all organ and tissue transplant-related expenses incurred during a transplant benefit as defined by the policy. Benefits are payable only during the time you are an eligible person. Please note that cornea transplants continue to be self-funded and benefits are as described in your SPD booklet as are organ and tissue transplant benefits for Medicare-eligible persons. Please keep this Notice and the Enclosures with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES Enclosure

December 2015


The purpose of this Notice is to inform you of the following:

• Change in self-payment provisions; • Continuation of Reduced Plan subsidy; • Coverage of newborn circumcision; • PPRx out-of-pocket maximum increase; • Hearing aid benefit increase; • ComPsych EAP; • Women's Health and Cancer Rights Act annual notification; and • HIPAA Privacy update.

Change in Self-Payment Provisions

There is a change in the self-payment provisions effective January 1, 2016. Self- payments must be post marked by the 15th of the month or be received by the 25th of the month in order to receive credit.

Continuation of Reduced Plan Subsidy

We are pleased to inform you that the subsidy for the Reduced Plan will continue for another six months through July 31, 2016.

Coverage of Newborn Circumcision

Retroactively effective to January 1, 2015, the Plan will cover circumcision of a newborn male dependent child.

PPRx Out-of-Pocket Maximum Increase

Effective January 1, 2016, the Preferred Provider Prescription Drug out-of-pocket maximum will increase to $5,350/person and $9,200/family for actives and retirees and to $1,850/person and $3,700/family for the Reduced Plan Option.

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Hearing Aid Benefit Increase The hearing aid benefit will increase to $2,000 per ear every three years effective January 1, 2016.

ComPsych Employee Assistance Program (EAP)

Because we care about you and recognize that personal problems can affect your job performance and cause you stress, the Plan will provide an EAP through ComPsych effective January 1, 2016.

The EAP is a strictly confidential employee benefit which provides assessment and short-term counseling to you, your spouse, and your dependent children who may be affected by personal problems. You or your dependent can access the EAP by calling the ComPsych GuidanceResources toll-free number at: 1-844-393-4984.

When you call the EAP, an intake specialist will get some general information about you and talk with you about your needs. This specialist will provide the name of a counselor who best fits your personal needs. Then, you will set up an appointment to speak with the counselor over the phone or schedule a face-to-face visit.

If the counselor determines that your issues can be resolved within five sessions, you will receive free short-term counseling through the EAP. However, if it is determined that the problem cannot be resolved in short-term counseling through the EAP, you will be referred to a specialist for longer-term treatment which may be covered under other Plan provisions.

Women's Health and Cancer Rights Act Annual Notification

The Women's Health and Cancer Rights Act of 1998 requires that we notify you annually of the coverage required under this Act. This Notice fulfills that requirement.

The Act amended ERISA by requiring group health plans which provide medical and surgical benefits for a mastectomy to provide the following coverage if you elect breast reconstruction in connection with a mastectomy, in a manner determined in consultation with the attending physician and the patient:

»» all stages of reconstruction of the breast and nipple of the breast on which the


appearance; »» prostheses and surgical bras; and

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»» treatment of physical complications in all stages of the mastectomy, including lymphedemas.

Subject to any applicable deductible and copayment requirements, your Plan provides coverage for the preceding items on the same basis as any other medical or surgical procedure covered by the Plan.

HIPAA Privacy Update

On April 14, 2003, the HIPAA Privacy Regulations went into effect for the North Central States Regional Council of Carpenters’ Health Fund. These Regulations were further revised effective February 17, 2010, and again revised effective September 23, 2013. In October of 2013 (or when you enrolled, if later), the Plan provided you an updated Privacy Practices Notice as required by the Privacy Regulations. This Notice provided information regarding the Plan’s uses and disclosures of your medical information, your rights regarding your medical information, and the Plan’s duties to protect the privacy of your medical information.

This is a reminder that the Plan’s Privacy Practices Notice is available upon request. To request a copy, please contact the Fund’s Privacy Officer, Bridget Welke, (715) 835-3174 or 1-800-424-3405.

Other Enclosures

Also enclosed with this Notice are the following:

• The Summary of Benefits and Coverage (SBC), for coverage period

beginning on or after January 1, 2016, as required under the rules of the Patient Protection and Affordable Care Act (PPACA); and

• The annual CHIP Notice. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office.

Yours very truly,


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November 2016 To All Employees and Dependents: The North Central States Regional Council of Carpenters’ Health Fund (the "Plan") is furnishing you this Notice as required by federal law. In most cases, the information presented in this Notice will have a limited application to employees (and dependents) eligible for Plan coverage. It may apply if you are required to pay a premium for coverage under the Plan. If you believe the information in the Notice applies to your situation, you should contact the applicable office in the state where you reside as shown in the attached listing. If you or your dependents are eligible for Medicaid or CHIP and also are eligible for health coverage under the Plan, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for these programs and also are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit: www.HealthCare.gov. If you or your dependents already are enrolled in Medicaid or CHIP and you live in a state listed in the attachment, you can contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under this Plan’s health coverage, your employer’s health plan is required to permit you and your dependents to enroll in the Plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have any questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free: 1-866-444-EBSA (3272). Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. Yours very truly, THE BOARD OF TRUSTEES

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http://www.healthcare.gov/

http://www.insurekidsnow.gov/



ALABAMA – Medicaid FLORIDA – Medicaid Website: http://www.myalhipp.com Phone: 1-855-692-5447

Website: https://www.flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://www.myakhipp.com Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP)

Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://www.myarhipp.com Phone: 1-855-MyARHIPP (855-692-5447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864

COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-422-6003 TTY: Maine relay 711

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

2

http://www.myalhipp.com/

http://www.flmedicaidtplrecovery.com/hipp/

http://www.myakhipp.com/

mailto:[email protected]

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://dch.georgia.gov/medicaid

http://www.myarhipp.com/

http://www.hip.in.gov/

http://www.indianamedicaid.com/

http://www.colorado.gov/hcpf

http://www.dhs.state.ia.us/hipp/

http://www.kdheks.gov/hcf/


http://chfs.ky.gov/dms/default.htm

http://www.state.nj.us/humanservices/

http://www.njfamilycare.org/index.html


http://www.nyhealth.gov/health_care/medicaid/

http://www.maine.gov/dhhs/ofi/public-

http://www.ncdhhs.gov/dma

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://www.mn.gov/dhs/ma/ Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebras ka/Pages/accessnebraska_index.aspx Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.govfree-or-low-cost-healthcare/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://www.gethipptexas.com/ Phone: 1-800-440-0493

Website: http://www.dhhr.wv.gov/bms/ Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/ p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

3

http://www.mass.gov/MassHealth


http://www.mn.gov/dhs/ma/

http://www.insureoklahoma.org/


http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.dhs.pa.gov/hipp

http://dhhs.ne.gov/Children_Family_Services/AccessNebras

http://www.eohhs.ri.gov/

http://dwss.nv.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/

http://www.hca.wa.govfree-or-low-cost-health-/

http://www.gethipptexas.com/

http://www.dhhr.wv.gov/bms/

http://health.utah.gov/medicaid

http://health.utah.gov/chip

http://www.dhs.wisconsin.gov/publications/p1/

http://www.greenmountaincare.org/



To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

4



** IMPORTANT NOTICE **

Affordable Care Act Reporting Obligations for

Employers Contributing to North Central States Regional Council of Carpenters’ Health Fund (the “Fund”)

September 2015

As you may know, the Affordable Care Act (“ACA” or “Health Care Reform”) requires applicable large employers to report to the Internal Revenue Service ("IRS") certain information regarding the coverage offered to full-time employees. This reporting obligation is effective beginning with the coverage offered during the 2015 calendar year and the filing is generally due to the IRS no later than February 29, 2016 (March 31, 2016 if filing electronically). Applicable large employers must also separately provide a copy of the report to their full-time employees by February 1, 2016. This is an ongoing, annual obligation for applicable large employers. More information on these requirements is available on the IRS website: http://www.irs.gov/Affordable-Care-Act/Employers/Questions-and-Answers-on-Reporting-of-Offers-of-Health-Insurance-Coverage-by-Employers-Section-6056 and http://www.irs.gov/Affordable-Care-Act/Employers/Questions-and-Answers-about-Information-Reporting-by-Employers-on-Form-1094-C-and-Form-1095-C.

As an initial matter, you will need to determine whether you are an “applicable large employer.” An “applicable large employer,” for this purpose, generally means an employer that, for the prior calendar year, employed an average of 50 or more full-time employees (those employees who worked an average of 30 hours per week) and full-time employee equivalents (generally, a representative number of the employer’s part-time employees). You may wish to discuss this requirement further with your benefits consultant or broker or your legal counsel.

Additionally, you may be aware that the IRS has provided interim relief from certain ACA requirements for employers that contribute to multiemployer plans. As described in the instructions for Forms 1094-C and 1095-C (the forms applicable large employers will use to satisfy their reporting requirement):

An employer is treated as offering health coverage to an employee if the employer is required by a collective bargaining agreement or related participation agreement to make contributions for that employee to a multiemployer plan that offers, to individuals who satisfy the plan’s eligibility conditions, health coverage that is affordable and provides minimum value, and that also offers health coverage to those individuals’ dependents or is eligible for the section 4980H transition relief regarding offers of coverage to dependents.

You may wish to consult your legal counsel to determine whether you qualify for this relief. If you determine that you qualify for this multiemployer transition relief, you may be eligible for simplified reporting, as described on page 9 of the draft instructions for Forms 1094-C and Form 1095-C:

For reporting offers of coverage for 2015, an employer relying on the multiemployer arrangement interim guidance should enter code 1H on line 14 for any month for which the employer enters code 2E on line 16 (indicating that the employer was required to contribute to a multiemployer plan on behalf of the employee for that month and therefore is eligible for multiemployer interim rule relief). For reporting for 2015, Code 1H may be entered without regard to whether the employee was eligible to enroll in coverage under the multiemployer plan. For 2016 and future years, reporting for offers of coverage made through a multiemployer plan may be reported in a different manner. (emphasis added)

While this reporting obligation is the responsibility of the employer, the following Fund-specific information should assist in determining whether you qualify for the multiemployer transition relief and completing the report:

• The Fund offers minimum value coverage to employees who meet the Fund’s eligibility requirements. The Fund also offers minimum value coverage to dependent children and spouses.

• The Fund’s waiting period complies with the ACA rules.

• The Fund does not require any employee contributions for active coverage.

You should contact the undersigned if you determine that you will require the Fund to provide you with coverage information to allow you to satisfy your ACA reporting obligation. Note that the Federal agencies have not yet created a HIPAA exception that would permit the Fund to provide employers with eligibility information required to complete the ACA reports.

Finally, you will likely conclude that this relief applies only to your employees who participate in the Fund (or other multiemployer plans where the transition relief applies). How you report your employees who do not participate in a multiemployer plan will depend upon the coverage offered to them. You will need separate information to report those employees’ coverage. You may wish to seek assistance from your benefits consultant or broker or legal counsel on the specific information you will need.

Please contact the Fund Office if you have any questions regarding the above. Sincerely, Board of Trustees NCSRCC Health Fund

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September 30, 2015 To All Employees and Dependents: This Notice is being sent to inform you how your benefits through North Central States Regional Council of Carpenters' Health Fund are affected by Medicare Part D. It is being sent to all participants even though it applies only to those eligible for Medicare or who may become eligible for Medicare in the next 12 months. Medicare prescription drug coverage, referred to as "Medicare Part D," became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage plans that offer prescription drug coverage. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans offered by independent insurance companies might offer more coverage for a higher monthly premium. The following information is provided to help you decide whether it would benefit you to enroll in Medicare Part D for prescription drug coverage. North Central States Regional Council of Carpenters' Health Fund Trustees have determined that your current prescription drug coverage is "creditable coverage," which means that it is, on average for all Fund participants, expected to pay out as much or more than the standard Medicare prescription drug coverage. Since you have prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund, the most cost effective option for you, generally, is to not enroll in a Medicare prescription drug plan unless you are eligible for extra help from Medicare for persons with low income. Joining a Medicare prescription drug plan will not reduce the monthly self-payment required by North Central States Regional Council of Carpenters' Health Fund because your current self-payment is for both medical and prescription drug expenses. Retirees with limited income may be eligible for financial support from the government to help pay for the Medicare prescription drug plan. Information about this extra help is available from the Social Security Administration (SSA) online at: www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778). If you are eligible for special assistance, you should review your options carefully because it may be beneficial for you to enroll in a Medicare prescription drug plan.

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Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th to December 71". However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare prescription drug plan. In addition, if you lose or decide to leave employer/union-sponsored coverage, you will be eligible to join a Medicare prescription drug plan at that time using an Employer Group Special Enrollment Period. Will your current coverage through North Central States Regional Council of Carpenters' Health Fund be affected if you join a Medicare prescription drug plan? Yes. Your Medicare prescription drug plan will become the primary payer for your prescription drug benefits, unless you are covered under an Active Plan through North Central States Regional Council of Carpenters' Health Fund, in which case the Fund remains the primary payer. The Fund will consider your prescription drug expenses for payment only after the expenses have been considered by your Medicare prescription drug plan. In addition, it will be your responsibility to submit proof of what the Medicare prescription drug plan paid (Explanation of Benefits) before the Fund considers any balance. Again, joining a Medicare prescription drug plan will not reduce your monthly self-payment to North Central States Regional Council of Carpenters' Health Fund since you receive both medical coverage as well as prescription drug coverage from the Fund. Will Medicare penalize participants who do not enroll in a Medicare prescription drug plan? Because coverage through North Central States Regional Council of Carpenters' Health Fund is creditable coverage, you will not have to pay a penalty if you enroll later, provided you do not go 63 days or longer without creditable coverage. If you do go 63 days or longer without creditable coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have creditable coverage. For example, if you go 19 months without creditable coverage before enrolling in a Medicare prescription drug plan, your premium always may be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll. What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date unless you

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qualify for the one-time waiver/reinstatement provision described in the Notice dated May, 2013. Where can you find information about this Notice or your current prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund? Please refer to your Summary Plan Description (SPD) for information on your current prescription drug coverage or call the Fund Office at (715) 835-3174 or 1-800-424-3405. NOTE: You will receive this Notice annually and at other times in the future such as before future periods during which you can enroll in Medicare prescription drug coverage, and if our Plan's coverage changes. You also may request a copy of this Notice at any time. Where can you find information on Medicare prescription drug coverage? The following resources are available to explain your options and help you make your decision: • Medicare & You handbook, which should be mailed to you every year in October.

• Visit www.medicare.gov for personalized help. An online Medicare Prescription

Drug Plan Finder tool will be available on this website.

• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number).



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August 2015 To All Employees and Dependents: The purpose of this Notice is to inform you that the Plan has been amended effective September 1, 2015, with respect to preauthorization recommendations and to inform you of the Fund’s coverage for experimental and investigational medical treatment or procedures. Preauthorization Amendment Preauthorization is a valuable tool to allow early case management for certain procedures and treatments and to determine the medical necessity of new, sometimes overused technology. There is a list of these procedures and treatments for which the Trustees highly recommend you obtain preauthorization by Case Management Specialists (CMS) on page xviii of your Summary Plan Description (SPD) booklet. The Trustees have added prophylactic mastectomies, breast MRIs, and biofeedback after the 8th visit to this preauthorization recommendation list. If you do not obtain preauthorization for these services and it is determined that they are not medically necessary, Plan benefits will be denied. You can contact CMS for preauthorization at: 1-800-861-8744. Experimental or Investigational Medical Treatment Coverage “Experimental or investigational” means any kind of treatment, device, or medication which is recommended by a physician but is not considered by the medical community as accepted medical practice or is either not safe or not effective for the condition for which it is being used. This can include any treatment, procedure, equipment, drug, device, or supply which requires federal or other governmental agency approval.

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The Fund provides a $5,000 benefit for experimental or investigational treatment per disability; however, the treatment must be medically necessary. Though your physician may advise you that the treatment or procedure is experimental or investigational in nature, it may not be covered by the Fund as medically necessary under the $5,000 benefit. It is strongly recommended that you contact Case Management Specialists (CMS) at 1-800-861-8744 for prior authorization of these types of services before the treatment/procedure is scheduled. This allows for a neutral third-party to review the facts and determine, in advance, if the Fund should cover the treatment/procedure. This protects you against additional out-of-pocket expenses. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

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July 2015 To All Employees and Dependents: The purpose of this Notice is to inform you that the Plan has been amended, and retroactively effective to September 15, 2014, with respect to coverage for compound medications. Pharmacy compounding is a practice in which a licensed pharmacist combines, mixes, or alters pharmaceutical ingredients to create a medication tailored to the individual medical needs of certain patients. These medications are produced in many different forms: capsules, creams, lotions, and liquids to be swallowed or injected. Please note that compound medications are not FDA-approved. This means that the Food and Drug Administration (FDA) has not verified the quality, safety, and effectiveness of these medications. While compounding medications can serve the health needs of certain people, the compound pharmacy industry is now under scrutiny by the FDA because there have been numerous instances in which these compounded medications have endangered the health and lives of patients. In addition, some compound pharmacies make large amounts of drugs that are copies of FDA-approved and commercially-available drugs, without clinical evidence that patients need to receive a compound version of the drug. As an additional layer of protection for you, the Trustees have elected to participate in a program offered by the Plan’s prescription benefit manager, Express Scripts (ESI), that specifically manages compound medications. ESI has identified an initial list of 25 pharmaceutical ingredients that are excluded from coverage. If you received a prescription from ingredients that will be excluded from coverage, you were previously notified by ESI. The Plan has been amended to reflect this change. Please refer to page 47 of your Summary Plan Description (SPD) booklet. Item 2 under Covered Expenses is amended to read:

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Compound medications of which at least one ingredient is a prescription legend drug and which are deemed medically necessary, clinically appropriate, and reasonably priced by Express Scripts.

Although the benefit change is effective September 2014, the Fund will not retroactively deny claims that have previously been paid. Also, we want to clarify that compound medications are covered only when filled through the Preferred Provider Pharmacy Program (Express Scripts) and are not reimbursable under Comprehensive Major Medical Benefits. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

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February 16, 2015 Dear Participant: Re: Anthem Cyber-Attack

As you may know, Anthem has reported that it was the victim of a recent, very sophisticated external cyber-attack. Anthem stated that the attacks may have gathered participant and beneficiary data, including names, birthdays, Social Security numbers, telephone numbers, e-mail addresses and addresses. Anthem does not believe that medical information or credit card information has been accessed. Anthem is working with the FBI and other authorities to assess the full impact of the attack.

The Fund contracts with Anthem to access the Anthem PPO network. The Fund does not exchange information with Anthem on Medicare-eligible retirees, but this notice is being sent to all Participants including Medicare-eligible retirees in the event you retired recently and you previously were covered under the Anthem PPO. The Trustees are deeply concerned and pursuing Anthem for more information, but at this time Anthem has not confirmed whether the Fund's participant data has been affected. The Fund's computer systems and Fund-maintained data have not been attacked.

The Trustees will continue to work with Anthem and keep participants informed. In the meantime, participants should be aware that scam e-mail campaigns are targeting current and former participants. These scams are designed to capture personal information (known as "phishing") and appear as if they are coming from Anthem and may include a "click here" link for credit monitoring. These e-mails are not from Anthem or the Fund. If you receive an e-mail related to the cyber-attack:

• DO NOT click on any links in the e-mail.

• DO NOT reply to such an e-mail or reach out to the senders in any way.

• DO NOT supply any information on any website that may open if you click on a link in such an e-mail.

• DO NOT open any attachments that arrive with the e-mail.

February 16, 2015 Page 2

Anthem may be sending informational e-mails to participants, but these e-mails will not request information from you or direct you to a link to another webpage. In addition, Anthem is not calling participants and beneficiaries regarding the data breach, and is not asking for credit card information or Social Security numbers over the phone. If you receive such a phone call requesting this information, do not provide the information.

Anthem will provide identity repair services and credit monitoring to any affected individuals. Anthem has said that it will send information related to these services via U.S. mail.

As a precautionary step, you may wish to put a fraud alert on your credit file. A fraud alert tells creditors to contact you before they open any new accounts or change existing accounts. Members can call any one of the three major credit bureaus listed below. As soon as one credit bureau confirms a fraud alert, the others are notified to place fraud alerts. All three credit reports will be sent to the member, free of charge, for review.

Equifax 800-525-6285

Experian 888-397-3742

TransUnion Corp 800-680-7289

The Trustees will continue to communicate with Anthem and provide you with information. Please contact the Fund office with any questions. You can also visit Anthem's dedicated website regarding the cyber-attack (www.AnthemFacts.com) or call Anthem's dedicated toll-free number, 1-877-263-7995.

Sincerely,

Board of Trustees North Central States Regional Council of Carpenters’ Health Fund

http://www.anthemfacts.com/

November 2014 To All Employees and Dependents: The purpose of this Notice is to inform you of the following:

• Changes to in-network out-of-pocket maximums; • Coverage for new Cologuard colorectal cancer screening test; • New maximum for smoking cessation products; • Women’s Health and Cancer Rights Act annual notification; and • HIPAA Privacy update.

Changes to In-Network Out-of-Pocket Maximums Effective January 1, 2015 For Active and Retiree Classes, there will be no change to the Comprehensive Major Medical Benefits in-network or out-of-network out-of-pocket maximums. However, the Express Scripts Preferred Provider Pharmacy Program will have a new calendar year out-of-pocket maximum of $5,100 per person/$8,700 per family. For the Reduced Plan Option, the Comprehensive Major Medical Benefits in-network out-of-pocket maximum per calendar year will remain at $5,000 per person, but will change from $12,700 to $10,000 per family. The Express Scripts Preferred Provider Pharmacy Program will have a new calendar year out-of-pocket maximum of $1,600 per person/$3,200 per family. In addition to the deductible and copayment amounts, covered services/supplies that now will be applied to the in-network out-of-pocket maximum include the following:

• For those under age 19, the 10% copayment you must pay for one exam every two calendar years for pediatric vision and also your copayment for vision hardware (10% up to $400 aggregate and then 90%).

• For in-network chiropractic services, the eligible amount that exceeds the

$40/visit maximum.

• The separate $50 copayment for each hospital emergency room visit.

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Coverage for New Cologuard Colorectal Cancer Screening Test Effective January 1, 2015 The Plan will provide coverage for the new Cologuard colorectal cancer screening test under the experimental medical treatment and procedures benefit when ordered by a physician. Cologuard is a multitarget stool DNA test that is used as a colorectal cancer screening test. Benefits will be payable subject to these Medicare guidelines. The Cologuard test will be covered once every three years for eligible persons who meet all of the following criteria:

• age 50 to 85 years old; • asymptomatic (no signs or symptoms of colorectal disease, including but

not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and

• at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

New Maximum for Smoking Cessation Products Effective January 1, 2015 Currently, smoking cessation products, including OTC nicotine replacement therapy and federal legend drugs, are limited to one 90-day supply per 365-day period. This will increase to two 90-day supplies per 365-day period. Women's Health and Cancer Rights Act Annual Notification The Women's Health and Cancer Rights Act of 1998 requires that we notify you annually of the coverage required under this Act. This Notice fulfills that requirement. The Act amended ERISA by requiring group health plans which provide medical and surgical benefits for a mastectomy to provide the following coverage if you elect breast reconstruction in connection with a mastectomy, in a manner determined in consultation with the attending physician and the patient: »» all stages of reconstruction of the breast and nipple of the breast on which the



lymphedemas.

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Subject to any applicable deductible and copayment requirements, your Plan provides coverage for the preceding items on the same basis as any other medical or surgical procedure covered by the Plan. HIPAA Privacy Update On April 14, 2003, the HIPAA Privacy Regulations went into effect for the North Central States Regional Council of Carpenters’ Health Fund. These Regulations were further revised effective February 17, 2010, and again revised effective September 23, 2013. In October of 2013 (or when you enrolled, if later), the Plan provided you an updated Privacy Practices Notice as required by the Privacy Regulations. This Notice provided information regarding the Plan’s uses and disclosures of your Protected Health Information (PHI), your rights regarding your PHI, and the Plan’s duties to protect the privacy of your PHI. This is a reminder that the Plan’s Privacy Practices Notice is available upon request. To request a copy, please contact the Fund’s Privacy Officer, Bridget Welke, (715) 835-3174 or 1-800-424-3405. Other Enclosures Also enclosed with this Notice are the following:

• The Summary of Benefits and Coverage (SBC), for coverage period beginning on or after January 1, 2015, as required under the rules of the Patient Protection and Affordable Care Act (PPACA); and

• The annual CHIP Notice. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

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November 2014 To All Employees and Dependents: The North Central States Regional Council of Carpenters’ Health Fund (the "Plan") is furnishing you this Notice as required by federal law. In most cases, the information presented in this Notice will have a limited application to employees (and dependents) eligible for Plan coverage. It may apply if you are required to pay a premium for coverage under the Plan. If you believe the information in the Notice applies to your situation, you should contact the applicable office in the state where you reside as shown in the attached listing. If you or your dependents are eligible for Medicaid or CHIP and also are eligible for health coverage under the Plan, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for these programs and also are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit: www.HealthCare.gov. If you or your dependents already are enrolled in Medicaid or CHIP and you live in a state listed in the attachment, you can contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under this Plan’s health coverage, your employer’s health plan is required to permit you and your dependents to enroll in the Plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have any questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free: 1-866-444-EBSA (3272). Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. Yours very truly, THE BOARD OF TRUSTEES



ALABAMA – Medicaid COLORADO – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-855-692-5447

Medicaid Website: http://www.colorado.gov/

Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943

ALASKA – Medicaid FLORIDA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

ARIZONA – CHIP GEORGIA – Medicaid

Website: http://www.azahcccs.gov/applicants

Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150

IDAHO – Medicaid MONTANA – Medicaid

Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/ PremiumAssistance/tabid/1510/Default.aspx

Medicaid Phone: 1-800-926-2588

Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml

Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa

Phone: 1-800-889-9949

Website: www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633

IOWA – Medicaid NEVADA – Medicaid

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

Medicaid Website: http://dwss.nv.gov/


KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-800-792-4884

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://www.lahipp.dhh.louisiana.gov

Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

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http://dhhs.ne.gov/medicaid/Pages/med_kidsconx.aspx

http://dwss.nv.gov/

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

MINNESOTA – Medicaid TEXAS – Medicaid

Website: http://www.dhs.state.mn.us/

Click on Health Care, then Medical Assistance

Phone: 1-800-657-3629

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

MISSOURI – Medicaid UTAH – Medicaid and CHIP

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://health.utah.gov/upp

Phone: 1-866-435-7414

OKLAHOMA – Medicaid and CHIP VERMONT– Medicaid

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

OREGON – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm


CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1-855-242-8282 PENNSYLVANIA – Medicaid WASHINGTON – Medicaid

Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx Phone: 1-800-562-3022 ext. 15473

RHODE ISLAND – Medicaid WEST VIRGINIA – Medicaid

Website: www.ohhs.ri.gov

Phone: 401-462-5300

Website: www.dhhr.wv.gov/bms/

Phone: 1-877-598-5820, HMS Third Party Liability

SOUTH CAROLINA – Medicaid WISCONSIN – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

Website: http://www.badgercareplus.org/pubs/p-10095.htm

Phone: 1-800-362-3002

SOUTH DAKOTA - Medicaid WYOMING – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://health.wyo.gov/healthcarefin/equalitycare

Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 NCSRCC/Not/2014/CHIP November 2014

2



Important Notice of Prescription Drug Creditable Coverage

From North Central States Regional Council of Carpenters' Health Fund October 1, 2014 To All Employees and Dependents: This Notice is being sent to inform you how your benefits through North Central States Regional Council of Carpenters' Health Fund are affected by Medicare Part D. It is being sent to all participants even though it applies only to those eligible for Medicare or who may become eligible for Medicare in the next 12 months. Medicare prescription drug coverage, referred to as "Medicare Part D," became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage plans that offer prescription drug coverage. All Medicare prescription drug plans will provide at least a standard level of coverage set by Medicare. Some plans offered by independent insurance companies might offer more coverage for a higher monthly premium. The following information is provided to help you decide whether it would benefit you to enroll in Medicare Part D for prescription drug coverage. North Central States Regional Council of Carpenters' Health Fund Trustees have determined that your current prescription drug coverage is "creditable coverage," which means that it is, on average for all Fund participants, expected to pay out as much or more than the standard Medicare prescription drug coverage. Since you have prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund, the most cost effective option for you, generally, is to not enroll in a Medicare prescription drug plan unless you are eligible for extra help from Medicare for persons with low income. Joining a Medicare prescription drug plan will not reduce the monthly self-payment required by North Central States Regional Council of Carpenters' Health Fund because your current self-payment is for both medical and prescription drug expenses. Retirees with limited income may be eligible for financial support from the government to help pay for the Medicare prescription drug plan. Information about this extra help is available from the Social Security Administration (SSA) online at: www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778). If you are eligible for special assistance, you should review your options carefully because it may be beneficial for you to enroll in a Medicare prescription drug plan.

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Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th to December 71". However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare prescription drug plan. In addition, if you lose or decide to leave employer/union-sponsored coverage, you will be eligible to join a Medicare prescription drug plan at that time using an Employer Group Special Enrollment Period. Will your current coverage through North Central States Regional Council of Carpenters' Health Fund be affected if you join a Medicare prescription drug plan? Yes. Your Medicare prescription drug plan will become the primary payer for your prescription drug benefits, unless you are covered under an Active Plan through North Central States Regional Council of Carpenters' Health Fund, in which case the Fund remains the primary payer. The Fund will consider your prescription drug expenses for payment only after the expenses have been considered by your Medicare prescription drug plan. In addition, it will be your responsibility to submit proof of what the Medicare prescription drug plan paid (Explanation of Benefits) before the Fund considers any balance. Again, joining a Medicare prescription drug plan will not reduce your monthly self-payment to North Central States Regional Council of Carpenters' Health Fund since you receive both medical coverage as well as prescription drug coverage from the Fund. Will Medicare penalize participants who do not enroll in a Medicare prescription drug plan? Because coverage through North Central States Regional Council of Carpenters' Health Fund is creditable coverage, you will not have to pay a penalty if you enroll later, provided you do not go 63 days or longer without creditable coverage. If you do go 63 days or longer without creditable coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have creditable coverage. For example, if you go 19 months without creditable coverage before enrolling in a Medicare prescription drug plan, your premium always may be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll. What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date.

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Where can you find information about this Notice or your current prescription drug coverage through North Central States Regional Council of Carpenters' Health Fund? Please refer to your Summary Plan Description (SPD) for information on your current prescription drug coverage or call the Fund Office at (715) 835-3174 or 1-800-424-3405. NOTE: You will receive this Notice annually and at other times in the future such as before future periods during which you can enroll in Medicare prescription drug coverage, and if our Plan's coverage changes. You also may request a copy of this Notice at any time. Where can you find information on Medicare prescription drug coverage? The following resources are available to explain your options and help you make your decision: • Medicare & You handbook, which should be mailed to you every year in October.



• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number).



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♦♦ IMPORTANT NOTICE TO PARTICIPANTS ♦♦ May 2014


The purpose of this Notice is to inform you of the following recent Plan changes.

Dental Care Benefits Administered by Delta Dental

Clarification of Coverage for Composite Resin Fillings

Since January 1, 2014, the Plan has covered composite resin (tooth colored) fillings on molars only up to the amount allowed for amalgam (silver) fillings. We are pleased to inform you that retroactive to January 1, 2014, the Plan no longer will reduce the allowance for composite resin fillings on molars when the composite resin filling is a new filling or is to replace a defective filling.

Delta Dental will reprocess claims incurred from January 1, 2014, to date for composite resin fillings that are eligible for the higher allowance. If you are seeing a Delta Dental network dentist, the additional benefit payment will be sent to the dentist and you will receive an Explanation of Benefits showing the additional benefit payment. If you are not seeing a Delta Dental network dentist, then the additional benefit payment will be sent to you.

If you have questions, please contact Delta Dental at 800-236-3712.

Predetermination of Benefits

If you are anticipating major dental care like a crown or a bridge, we strongly urge you to ask your dentist to send the treatment plan to Delta Dental for a predetermination of benefits. The treatment plan will be reviewed by Delta Dental and you and your dentist will receive a Predetermination of Benefits Form detailing the benefits available for your services. This is an excellent way to plan ahead for any out-of-pocket costs and also to avoid any surprises when you receive the bill from your dentist.

Prescription Drugs and Changes to the Formulary

The Plan includes a list of preferred drugs that are either more effective at treating a particular condition than other drugs in the same class of drugs, or as

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effective as and less costly than similar medications. This list of drugs makes up the Plan’s Formulary. The Plan’s Formulary is updated periodically and is subject to change, so to get the most up-to-date list, go online to www.express-scripts.com and create an online account with Express Scripts if you currently do not have one. Beginning April 1, 2014, drugs that are excluded from the Plan’s Formulary are not covered under the Plan unless approved in advance through a Formulary exception process managed by Express Scripts.

Under the Formulary exception process, Express Scripts makes a determination of coverage on the basis that: (1) the drug requested is medically necessary and essential to the eligible person’s health and safety; and/or (2) all Formulary drugs comparable to the excluded drug have been tried by the eligible person. If approved through that process, the applicable copay would apply for the approved drug. Without such approval, eligible persons selecting drugs excluded from the Formulary will be required to pay the full cost of the drug without any reimbursement under the Plan. If the eligible person’s Physician believes that an excluded drug meets the requirements previously described, the Physician should take the necessary steps to initiate a Formulary exception review by contacting Express Scripts directly.

The Formulary will continue to change from time to time. For example:

• A drug may be moved to a higher or lower cost-sharing Formulary tier. • Additional drugs may be excluded from the Formulary. • A restriction may be added on coverage for a Formulary-covered drug

(e.g., prior authorization). • A Formulary-covered brand name drug may be replaced with a Formulary-

covered generic drug. Please be sure to check with Express Scripts before the drug is purchased to make sure it is covered on the Formulary, as you may not have received notice that a drug has been removed from the Formulary. Certain drugs, even if covered on the Formulary, will require prior authorization in advance of receiving the drug. Other Formulary-covered drugs may not be covered under the Plan unless an established protocol is followed first; this is known as Step-Therapy. As with all aspects of the Formulary, these requirements also may change from time to time.

Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office.

Yours very truly,


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http://www.express-scripts.com/

♦♦ IMPORTANT NOTICE TO PARTICIPANTS ♦♦ January 2014 To All Employees and Dependents: The purpose of this Notice is to inform you that the Plan has been amended, effective April 1, 2014, with respect to services provided by a chiropractor. Currently services of a chiropractor are limited to treatment of musculoskeletal conditions. For services incurred on or after April 1, 2014, coverage for treatment by a chiropractor is expanded to include neuromusculoskeletal conditions. All other Plan provisions related to coverage for chiropractic care will continue to apply. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES

CHANGES TO YOUR DENTAL BENEFITS EFFECTIVE JANUARY 1, 2014

DELTA DENTAL OF WISCONSIN

Named New Dental Claims Administrator www.deltadentalwi.com 800-236-3712

December 2013 To All Employees and Dependents with Dental Benefits: We are pleased to inform you that Delta Dental of Wisconsin has been selected to administer and manage your dental benefits beginning with claims incurred on or after January 1, 2014. WHY DELTA DENTAL WAS SELECTED – HOW YOU WILL BENEFIT The primary reason the Fund selected Delta Dental is increased access to network dentists. Delta Dental has two networks – Delta Dental PPO and Delta Dental Premier – with more than 247,000 dentist locations nationwide. Based on our study, approximately 87% of dental claims submitted to the Fund over a recent time period were from providers participating in the Delta Dental PPO or Delta Dental Premier network. When you use a participating network provider, you save through Delta Dental’s contracted fees (network discounts) with providers. Contracted fees not only help you save money on dental services, but also may lower the amounts applied to your annual and lifetime maximums. PLAN DESIGN INFORMATION Your benefit levels, such as deductibles and coinsurance, are the same whether your services are provided by a participating (in-network) provider or a non-participating (out-of-network) provider. However, Delta Dental PPO and Delta Dental Premier Dentists agree to contracted fees. Plus, you cannot be “balance billed” when you see an in-network provider – which means the dentist cannot charge you any more than their agreed upon fee. While you may visit a non-participating provider and your benefit levels are the same, please note that if the non-participating provider charges more than the Delta Dental Maximum Plan Allowance (MPA), you will be responsible for the amount exceeding the MPA. In addition, payment for any out-of-network services will be issued to you and it will be your responsibility to pay the provider.

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http://www.deltadentalwi.com/

Please refer to pages 4-5 for a glossary that includes more information on the MPA and descriptions of participating and non-participating providers. The current dental benefit deductible, coinsurance, annual maximum, and orthodontics lifetime maximum will not change, except for the expansion of pediatric dental benefits of which you were previously notified. We have added frequency limits for certain services to align with dental-industry standards and the limits already in place for pediatric dental services. Also, the scope of some services may be more limited, again, to align with dental-industry standards. For example, composite (tooth-colored) fillings are payable only for front teeth. Amalgam (silver) fillings are payable for molars. Please refer to the enclosed Your Dental Benefits for a summary of the dental benefit plan design effective January 1, 2014. New Dental Identification Cards Before January 1, 2014, you will receive in the mail an identification card (ID) card from Delta Dental. This is a permanent card and is in addition to your medical/pharmacy ID card. To file a claim, simply present your Delta Dental ID card to the receptionist at the dental office. Remember, any dental claims incurred on or after January 1, 2014, should NOT be submitted to the Fund Office. Please remember to present your new Delta Dental ID card at your next dental visit so your provider has the information necessary to submit your claim directly to Delta Dental of Wisconsin Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office at 800-424-3405. Yours very truly, THE BOARD OF TRUSTEES

Enclosures

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ADDITIONAL PLAN INFORMATION Orthodontic Procedures Orthodontic services include orthodontic appliances and treatment, and related services for orthodontic purposes, including examinations, x-rays, extractions, photographs, study models, etc., for eligible persons. Payment for orthodontic treatment in progress will be handled by Delta Dental after January 1, 2014. Delta Dental’s payment for orthodontic treatment in progress extends only to the unearned portion of the treatment. Delta Dental will determine the unearned amount eligible for coverage. Repair or replacement of orthodontic appliances is not covered by the Plan. If orthodontic treatment is stopped for any reason before it is completed, the Plan only will pay for services and supplies actually received. No benefits are available for charges made after treatment stops. Delta Dental calculates all orthodontic treatment schedules according to the following formula: One-fourth of the total case fee is considered the initial or down payment fee; the remainder of the allowed fee is divided by the total number of months of treatment. Monthly payments are made by Delta Dental at the coverage percent stated in Your Dental Benefits (enclosed). Predetermination of Benefits After an examination, your dentist may recommend a treatment plan. If the services involve crowns, fixed bridgework, partial or complete dentures, implants, or orthodontics, you may wish to ask your dentist to send the treatment plan with radiographs to Delta Dental. The available coverage will be calculated and printed on a Predetermination of Benefits form. Copies of the form will be sent to you and your dentist. The Predetermination of Benefits form is valid for one year from the date issued. Before you schedule dental appointments, you should discuss with your dentist the amount to be paid by the Plan and your financial obligation for the proposed treatment. Predeterminations are not required except for “medically necessary orthodontics” (see following paragraph), but you are encouraged to use this service. Should you have any questions about a predetermination, just call Delta Dental at 800-236-3712. Please note that Delta Dental must pre-approve all pediatric medically necessary orthodontic services before treatment begins. As you were previously informed, “medically necessary orthodontic services” are defined as “orthodontic treatment that is directly related to and an integral part of the medical and surgical correction of a functional

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impairment resulting from a congenital defect or anomaly”. Delta Dental will determine whether the treatment is medically necessary. This benefit is available only to eligible persons under age 19. The vast majority of orthodontic services are considered “routine” and will not fall under the medically necessary standard and will continue to be paid for all ages up to a $2,000 lifetime maximum. Grievance Procedures A grievance is any dissatisfaction with the administration or claims practices of this Plan submitted to Delta Dental. Delta Dental will acknowledge a grievance within 10 days of receiving it. All grievances will be resolved within 30 days from the date the grievance is received. Should Delta Dental be unable to resolve the grievance within that time, they will notify you when a resolution may be expected, within 30 additional days, and the reason for the delay. Delta Dental will notify you in writing of the resolution of the grievance. You have the right to appear in person before the Grievance Committee to present written and oral information and ask questions of those people responsible for the determination which resulted in the grievance. Delta Dental will provide written notice of the meeting place and time at least seven days before the meeting. In addition, the claims appeal procedures that begin on page 88 of your Summary Plan Description (SPD) apply to your dental benefits. Glossary

Maximum Plan Allowance (MPA) Maximum Plan Allowance (MPA) means the total dollar amount allowed under the contract for a specific benefit. The MPA will be reduced by any deductible and coinsurance the subscriber or covered dependent is required to pay. Delta Dental’s Maximum Plan Allowance varies by region due to contractual arrangements or, in some instances, state regulations. Delta Dental determines an MPA for each CDT code published in the most current version of Current Dental Terminology (CDT). The MPA established by Delta Dental is developed from various sources, such as contracts with dentists, input from our dental consultants, the simplicity or complexity of the procedure, and the billed charges for the same procedures by dentists in the same geographic location. Delta Dental PPO Dentists Delta Dental PPO Dentists have signed a contract with Delta Dental, agreeing to accept reduced fees for the dental procedures they provide. This reduces your out-of-pocket costs, because you will be responsible only for applicable deductible amounts,

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copayments, and coinsurance for benefits. And because these dentists agree to fees approved by Delta Dental, they receive payment directly from Delta Dental. Delta Dental Premier Dentists Delta Dental Premier Dentists have signed a contract with Delta Dental, agreeing to accept direct payment from Delta Dental. They also have agreed not to charge you any amount that exceeds the Maximum Plan Allowance (MPA). However, you will be responsible for deductibles, copayments, coinsurance, and fees for services that are not benefits under this dental plan. The MPA is the total dollar amount allowed for a specific benefit and will be reduced by any deductible, copayment, and coinsurance you are required to pay. Out-of-Network Dentists If your dentist has not signed a contract with Delta Dental, claim payments will be calculated based on the MPA, but they will be sent directly to you rather than to the dentist. You then will need to reimburse your dentist through his or her usual billing procedure. You will be responsible for any amount in excess of the MPA, as well as any deductible, copayment, coinsurance, and fees for services that are not benefits under this dental plan. Please note that if the fee charged by an out-of-network dentist is not allowed in full, Delta Dental is not implying that the dentist is overcharging. Dental fees vary and are based on each dentist’s overhead, skill, and experience. Therefore, not every dentist will have fees that fall within the MPA. For information on Delta Dental PPO or Delta Dental Premier Dentists, call 800-236-3712, or visit Delta Dental’s website at www.deltadentalwi.com.

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http://www.deltadentalwi.com/

Your Dental Benefits

Specially Prepared for the Participants of North Central States Regional Council of Carpenters’

Health Fund The summary below does not cover all plan details. Further information can be found in the summary plan description or dental benefit handbook. That document provides a thorough explanation of your dental plan, including any limitations or exclusions that might apply. If there are any discrepancies between information found here and the group contract, the group contract shall govern.

Benefit Plan Design Delta Dental

PPO Delta Dental

Premier When you see a When you see a Delta Dental Delta Dental Premier PPO dentist or any other dentist

Individual Annual Maximum $1,200 $1,200 Deductible Individual $25 $25

Dependent Eligibility: Dependents are eligible to the end of the month in which they attain age 26

The Maximum Individual Out-of-Pocket for covered services, per calendar year, for dependents under age19 is $6,350 and $12,700 per family for dependents under age 19 only. Services after the Out of Pocket Maximum is met are covered at 100%.

Diagnostic & Preventive Services 90% 90% Deductible applies Yes Yes Exams - two per calendar year Routine cleanings - two per calendar year Fluoride treatments - two per calendar year Bitewing x-ray - once each calendar year Full-mouth x-rays - once each 5 years Sealants for dependents through age18 Space maintainers

For dependent children under age 19: Diagnostic & Preventive dental services will be payable subject to the deductible and coinsurance amounts, but will not be subject to the calendar year maximum.

Basic & Major Services 90% 90% Deductible applies Yes Yes Bleaching – teeth whitening Emergency treatment to relieve pain Amalgam (silver) fillings – for molars Composite resin (tooth-colored) fillings – for front teeth Endodontics – nonsurgical Endodontics – surgical Periodontics – maintenance (see following pages for Evidence-Based Integrated Care Plan (EBICP) information) Periodontics – nonsurgical Periodontics – surgical Extractions - nonsurgical Extractions - surgical and other oral surgery Crowns, inlays, onlays - paid at seat date not prep date Bridges and dentures - paid at seat date not prep date Repairs and adjustments to bridges and dentures Implants For dependent children under age 19: Basic and Major dental services will be payable subject to the deductible and coinsurance amounts, but will not be subject to the calendar year maximum.

Routine Orthodontic Services Coverage copayment 100% 100% Individual lifetime maximum $2,000 $2,000 Dependents eligible to age 26 26 Adult ortho Yes Yes Deductible applies No No

Medically Necessary Orthodontic Services: Delta Dental Must Pre-Approve Before Treatment Begins Coverage copayment 90% 90% Individual maximum N/A N/A Dependents under age 19 19 Deductible applies No No

Specially prepared for the participants of North Central States Regional Council of Carpenters’ Health Fund A Better PPO from Delta Dental

Delta Dental is the nation’s largest and oldest dental-benefits specialist built on the guiding principle that dental benefits should be simple and hassle-free. Delta Dental of Wisconsin was founded in 1962 with the same goal. Combined, member companies of the Delta Dental Plans Association serve more than 59 million people in nearly 97,000 groups nationwide.

With some PPO plans, you don’t get much choice of providers. And if you go out of network, your provider may balance-bill you. But your Delta Dental PPO plan is different. The Delta Dental PPO network, with more than 165,000 dentist locations nationwide, is backed by the Delta Dental Premier network, with more than 247,000 dentist locations nationwide – almost 80% of the nation’s dentists. Your lowest out-of-pocket costs come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a Delta Dental Premier dentist. That means savings on out-of-pocket costs and better choice. Here’s an example:

PPO Savings, With A “Safety Net”

Delta Dental PPO Dentist

Delta Dental

Premier Dentist

Out-of-Network Dentist

Dentist’s Normal Fee $720 $720 $720 Allowed Amount $590 $680 $680 Dentist Fee Adjustment Due to Delta Dental Agreement

$130 $40 None

90% Benefit Paid by Plan $531 $612 $612 Patient Responsibility $59 $68 $108

Advantages of Delta Dental Network Dentists

Noncontracted Dentists

Delta Dental Premier Network Dentists

Delta Dental PPO Network Dentists

Agreed-to fee ceilings (no balance-billing): Dentist agrees to fee ceilings. If his/her normal charge is higher than the fee ceiling, he/she can’t pass the balance on to you.

Additional fee schedule savings: Dentist agrees to a reduced fee schedule. Saves out-of-pocket

expenses for you.

Convenient claims processing: Dentist is required to file claims on your behalf, saving you the hassle of doing so yourself. Claims payments go directly to the dentist.

Treatment guarantees: Examples -- Repair or replace dental restorations should they fail within 24 months.

Predetermination of Benefits - Confirming Your Coverage If you are not sure of the effective date of your coverage, please call Delta Dental at 800-236-3712 before you have any dental work done. Also, before scheduling appointments for extensive dental care, you may ask your dentist to send the treatment plan to Delta Dental. The plan will be reviewed by Delta Dental and you and your dentist will receive a Predetermination of Benefits form. You and your dentist may then discuss the treatment and your out-of-pocket costs. Delta Dental encourages you to be informed about your dental care. Delta Dental’s Website www.deltadentalwi.com has a lot to offer. You can use it to obtain coverage information under your plan, check the status of a claim, find a network dentist, evaluate your oral health and learn ways to improve and protect it.

Visit www.deltadentalwi.com for eligibility, claims or dentist information. Also, our Benefit Advisors are available every weekday from 7:30 a.m. to 5 p.m. (Central Time) to answer your questions. Call us at 800-236-3712. We look forward to talking with you!

A Smarter Dental Plan With EBICPD

elta Dental of W

isconsin

Enhanced dental benefits for those who need them most

A variety of medical conditions have oral-health implications. Your group dental coverage includes Delta Dental of Wisconsin’s Evidence-Based Integrated Care Plan (EBICP), which provides additional cleaning(s) and/or fluoride treatments to people with these conditions. These benefits can play an important role in the management of these medical conditions.

If you have one or more of these conditions you can enroll yourself or your dependents, or your dentist can enroll you. Once you enroll, you are immediately eligible for the EBICP benefits.

How to enroll• Go to www.deltadentalwi.com.

• Click on the “I Am A … Member” link.

• Sign in to the Member Connection usingyour member ID and password. If you don’thave a member ID and password you’llneed to establish one before you proceed.

• Click on the “Enhanced Benefits” tab at the top of the Member Connection home page. Note: If your plandoes not have EBICP, the “Enhanced Benefits” tab will not appear on your Member Connection page.

• On the Enhanced Benefits page, choose the member(s) receiving the enhanced benefits and the qualifyingcondition(s). Once this information is successfully entered, all registered members will be immediately eligiblefor the enhanced benefits.

• Another way of enrolling is to click on the “My Benefits” tab at the top of the Member Connection page, thenselect “Benefits and Claims.” Under the “Extra Benefits Levels” heading, click on the “Enroll in EBICP” button.You will then be taken to the Enhanced Benefits page, where the enrollment process will proceed as describedabove.

• You may also enroll in EBICP by calling Delta Dental’s Benefit Center at 800-236-3712.

Enhanced benefit

ConditionAdditional cleaning(s)

Topical fluoride

Cancer-related treatments 2 1

Suppressed immune systems 2 1

Periodontal disease* 2 1

High-risk cardiac conditions 2

Kidney failure or dialysis 2

Diabetes 2

Pregnancy 1

This chart provides a brief summary of additional benefits to persons enrolled in EBICP. Go to www.deltadentalwi.com/EBICP for details regarding each listed condition and additional benefits offered. Frequency limitations may apply. Refer to your handbook or call our Benefit Center at 800-236-3712.

* Periodontal cleanings may fall under basic services and may not be covered 100% by the EBICP plan. If you havequestions regarding coverage for periodontal cleanings, please contact the Benefit Center at 800-236-3712 beforeservices are performed.

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November 26, 2013 To All Employees and Dependents: This Notice is to inform you of the following:

• Changes necessary to comply with the Affordable Care Act; and • Women’s Health and Cancer Rights Act Annual Notification.

Affordable Care Act Changes The following Plan changes will take effect January 1, 2014, to comply with the Affordable Care Act:

• The $2,000,000 calendar year maximum per person for essential health benefits (including prescription drugs purchased through the PPRx) will be eliminated.

• The Plan will provide coverage for routine patient costs incurred by eligible persons with cancer and other life-threatening diseases who are determined to be a qualified individual to participate in an approved clinical trial. There are specific guidelines as to who is a "qualified individual," what is an "approved clinical trial," and what are "routine patient costs." The Plan's Medical Case Manager will review all services related to participation in a clinical trial to determine whether related services are payable by the Fund under these guidelines. If you are recommended for participation in a clinical trial, please contact the Fund Office to determine if you satisfy the parameters for this coverage.

• For Classes C, G, O, P, S, and T: Currently, Vision Care Benefits are payable at 90%, up to a $400 aggregate maximum per person each two consecutive calendar years (current two-year benefit period is 2012-2013). One vision exam every two calendar years is not subject to the aggregate maximum for dependent children under age 18. Effective January 1, 2014, the Plan will expand services for pediatric vision to include up to age 19, versus age 18. Also, Vision Care Benefits for dependents under age 19 will be payable at 10% for amounts over the $400 aggregate maximum.

• For Classes C, G, O, P, S, and T: Similarly, the Plan will expand services provided for pediatric dental to include up to age 19, versus age 18. In addition, the $1,200 annual

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maximum will not apply to any covered dental services for eligible persons under age 19. Currently, only preventive dental services are not subject to the annual maximum.

Orthodontics will continue to be paid at 100% up to the $2,000 lifetime maximum, except that medically necessary orthodontic services will be payable at 90% and are not subject to the annual or lifetime maximum. "Medically necessary orthodontic services" are defined as orthodontic treatment that is directly related to and an integral part of the medical and surgical correction of a functional impairment resulting from a congenital defect or anomaly. Medically necessary orthodontic services will require predetermination of benefits. Additional details will be provided in a future mailing.

• The Plan will remove its exclusion for services related to a dependent child's pregnancy.

• To the extent an item or service is a covered benefit under the Plan, and consistent with reasonable medical management techniques specified under the Plan with respect to the frequency, method, treatment, or setting for an item or service, the Plan will not discriminate based on a provider's license or certification, to the extent the provider is acting within the scope of the provider's license or certification under applicable state law.

• For the Reduced Plan Option, the family out-of-pocket maximum for in-network services (including the deductible and copayment amounts) will be reduced from $15,000 to $12,700.

Women's Health and Cancer Rights Act Annual Notification The Women's Health and Cancer Rights Act of 1998 requires that we notify you annually of the coverage required under this Act. This Notice fulfills that requirement. The Act amended ERISA by requiring group health plans which provide medical and surgical benefits for a mastectomy to provide the following coverage if you elect breast reconstruction in connection with a mastectomy, in a manner determined in consultation with the attending physician and the patient: »» all stages of reconstruction of the breast and nipple of the breast on which the mastectomy

has been performed; »» surgery and reconstruction of the other breast to produce symmetrical appearance; »» prostheses and surgical bras; and »» treatment of physical complications in all stages of the mastectomy, including lymphedemas. Subject to any applicable deductible and copayment requirements, your Plan provides coverage for the preceding items on the same basis as any other medical or surgical procedure covered by the Plan. Please keep this Notice with your Summary Plan Description (SPD) booklet for future reference. If you have any questions, feel free to call the Fund Office. Yours very truly, THE BOARD OF TRUSTEES


October 14, 2013






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What will happen if you drop your North Central States Regional Council of Carpenters' Health Fund coverage? In addition to prescription drug benefits, your current Fund coverage provides medical benefits, death benefits, and optional dental and vision benefits. None of these benefits are available separately, so if you decide to drop your Fund coverage, ALL Fund benefits will terminate. If you drop your coverage through the Fund, you will need to obtain coverage elsewhere for ALL your benefits, not just prescription drugs. We cannot guarantee that in all cases our prescription drug coverage is more advantageous than Medicare prescription drug coverage, although it generally will be. You must ultimately decide for yourself which program offers the better coverage at the most affordable price. You should compare your current Fund coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop your coverage with North Central States Regional Council of Carpenters' Health Fund, you cannot reinstate in the Fund's Retiree Program at a later date.

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• Medicare & You handbook, which should be mailed to you every year in October.




You handbook for their telephone number). • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.



Yours very truly,


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NORTH CENTRAL STATES REGIONAL COUNCIL OF CARPENTERS' HEALTH FUND

PRIVACY PRACTICES NOTICE

October 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL

INFORMATION IS IMPORTANT TO US.

Summary of Our Privacy Practices The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and Health Information Technology for Economic and Clinical Health Act (“HITECH”) and their Privacy Rules grant certain rights to participants and beneficiaries of the North Central States Regional Council of Carpenters' Health Fund (the “Plan”) in relation to their protected health information (called “medical information”). This Privacy Practices Notice discusses those rights and obligations.

The Plan may use and disclose your medical information without your permission for treatment, payment, and health care operations activities and, when required or authorized by law, for public health activities, law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

The Plan may disclose your medical information to your family members, friends,

and others you involve in your health care or payment for your health care, and to appropriate public and private agencies in disaster relief situations. IMPORTANT NOTE: The Plan reserves the right to provide your medical information to any person identified by you (such as a Business Agent), or whom the Plan in good faith believes was identified by you, or to a family member, other relative, or close personal friend. For example, the Plan may disclose your medical information to your spouse if the spouse contacts the Plan to help resolve a payment issue on your behalf. The Plan only will provide medical information in such a situation if it is directly relevant to such person’s involvement with your care or payment related to your health care. If you object to such disclosures, please express your written objection to the contact person listed at the end of this notice.

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The Plan may disclose to the sponsor of the Plan, the Board of Trustees of the North Central States Regional Council of Carpenters' Health Fund (the “Board of Trustees”), whether you are enrolled or disenrolled in the Plan, summary health information for certain limited purposes, and your medical information for the Board of Trustees to administer the Plan if the Board of Trustees explains the limitations on its use and disclosure of your medical information in the Plan Document.

Except for certain legally-approved uses and disclosures, the Plan otherwise will not use or disclose your medical information without your written authorization.

You have the right to examine and receive a copy of your medical information, to receive

an accounting of certain disclosures the Plan may make of your medical information, and to request that the Plan amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information. You have the right to receive notice of breaches of your unsecured medical information. Please review this entire notice for details about the uses and disclosures the Plan may make of your medical information, about your rights and how to exercise them, and about complaints regarding or additional information about our privacy practices.

The Plan’s Legal Duties

The Plan is required by applicable federal and state law to maintain the privacy of your medical information. The Plan also is required to give you this notice about its privacy practices, its legal duties, and your rights concerning your medical information. The Plan must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 23, 2013, and will remain in effect unless the Plan replaces it.

The Plan reserves the right to change its privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. The Plan reserves the right to make any change in its privacy practices and the new terms of its notice applicable to all medical information that the Plan maintains, including medical information the Plan created or received before the Plan made the change.

Uses and Disclosures of Your Medical Information

Treatment: The Plan may disclose your medical information, without your permission, to a physician or other health care provider to treat you.

Payment: The Plan may use and disclose your medical information, without your permission, to pay claims from physicians, hospitals, and other health care providers for services delivered to you that are covered by the Plan, to determine your eligibility for benefits, to coordinate your benefits with other payers, to determine the medical necessity of care delivered to you,

to obtain premiums for your health coverage, to issue explanations of benefits to the participant of the Plan in which you participate and the like. The Plan may disclose your medical information to a health care provider or another health plan for that provider or plan to obtain payment or engage in other payment activities. Health Care Operations: The Plan may use and disclose your medical information, without your permission, for health care operations. Health care operations include:

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• health care quality assessment and improvement activities;

• reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing, and credentialing activities;

• conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention;

• rating the risk and determining the necessary funding levels for the Plan, and obtaining stop-loss and similar reinsurance for the Plan’s health coverage obligations; and

• business planning, development, management, and general administration, including customer service, grievance resolution, claims payment and health coverage improvement activities, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

The Plan may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan’s or provider’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

Your Authorization: You may give the Plan written authorization to use your medical information or to disclose it to anyone for any purpose. If you give the Plan an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give the Plan a written authorization, the Plan will not use or disclose your medical information for any

purpose other than those described in this notice. The Plan generally may use or disclose any psychotherapy notes it holds only with your authorization. Family, Friends, and Others Involved in Your Care or Payment for Care: The Plan may disclose your medical information to a family member, friend, or any other person you involve in your health care or payment for your health care. The Plan will disclose only the medical information that is relevant to the person’s involvement. The Plan may use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts. The Plan will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, the Plan will use its professional judgment to determine whether disclosing medical information related to your care or payment is in your best interest under the circumstances. Your medical information remains protected by the Plan at least 50 years after you die. After you die, the Plan may disclose to a family member, or other person involved in your heatlh care prior to your death, the medical information that is relevant to that person’s involvement, unless doing so is inconsistent with your preference and you have told the Plan so. Disclosures to the Board of Trustees: The Plan may disclose to the Board of Trustees whether you are enrolled or disenrolled in the Plan. The Plan may disclose summary health information to the Board of Trustees to obtain premium bids for the health

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insurance coverage offered under the Plan or to decide whether to modify, amend, or terminate the Plan. Summary health information is aggregated claims history, claims expenses, or types of claims experienced by the enrollees in the Plan. Although summary health information will be stripped of all direct identifiers of these enrollees, it still may be possible to identify medical information contained in the summary health information as yours. The Plan is expressly prohibited from using or disclosing any health information containing your genetic information for underwriting purposes.

The Plan may disclose your medical information and the medical information of others enrolled in the Plan to the Board of Trustees to administer the Plan. Before the Plan may do that, the Board of Trustees must amend the Plan Document to establish the limited uses and disclosures the Board of Trustees may make of your medical information. Please see the Plan Document for a full explanation of those limitations.

Health-Related Products and Services: The Plan may use your medical information to communicate with you about health- related products, benefits and services, and payment for those products, benefits, and services that the Plan provides or includes, and about treatment alternatives that may be of interest to you. These communications may include information about the health care providers in the Plan’s network, if any, about replacement of or enhancements to the Plan, and about

health-related products or services that are available only to the Plan’s enrollees that add value to, although they are not part of, the Plan. Public Health and Benefit Activities: The Plan may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and public benefit activities: • for public health, including to report

disease and vital statistics, child abuse, and adult abuse, neglect, or domestic violence;

• to avert a serious and imminent threat to health or safety;

• for health care oversight, such as activities of state insurance commis- sioners, licensing and peer review authorities, and fraud prevention agencies;

• for research; • in response to court and administrative

orders and other lawful process; • to law enforcement officials with regard to

crime victims and criminal activities; • to coroners, medical examiners, funeral

directors, and organ procurement organizations;

• to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and

• as authorized by state Worker’s Compensation laws.

Individual Rights

Access: You have the right to examine and to receive a copy of your medical information, with limited exceptions. You must make a written request to obtain access to your medical information. You should submit your request to the contact at the end of this notice.

The Plan may charge you reasonable, cost- based fees (including labor costs) for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request. Contact the Plan using the

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information at the end of this notice for information about these fees.

Your medical information may be maintained electronically. If so, you can request an electronic copy of your medical information. If you do, the Plan will provide you with your medical information in the electronic form and format you requested, if it is readily producible in such form and format. If not, the Plan will produce it in a readable electronic form and format as the Plan and you mutually agree upon.

You may request that the Plan transmit your medical information directly to another person you designate. If so, the Plan will provide the copy to the designated person. Your request must be in writing, signed by you and must clearly identify the designated person and where the Plan should send the copy of your medical information.

Disclosure Accounting: You have the right to a list of instances from the prior six years, in which the Plan disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

You should submit your request to the contact at the end of this notice. The Plan will provide you with information about each accountable disclosure that the Plan made during the period for which you request the accounting, except the Plan is not obligated to account for a disclosure that occurred more than six years before the date of your request and never for a disclosure that occurred before the Plan’s effective date (if the Plan was created less than six years ago).

Amendment: You have the right to request that the Plan amend your medical information. You should submit your request in writing to the contact at the end of this notice.

The Plan may deny your request only for certain reasons. If the Plan denies your request, the Plan will provide you a written explanation. If the Plan accepts your request, the Plan will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who the Plan knows may have relied on the unamended information to your detriment, as well as persons you want to receive the amendment. Restriction: You have the right to request that the Plan restrict its use or disclosure of your medical information for treatment, payment, or health care operations, or with family, friends, or others you identify. The Plan is not required to agree to your request, except for certain required restrictions described as follows. If the Plan does agree, the Plan will abide by the agreement, except in a medical emergency or as required or authorized by law. You should submit your request to the contact at the end of this notice. Any agreement the Plan may make to a request for restriction must be in writing signed by a person authorized to bind the Plan to such an agreement. The Plan will agree to (and not terminate) a restriction request if: • the disclosure is to a health plan for

purposes of carrying out payment or health care operations and is not otherwise required by law; and

• the medical information pertains solely to

a health care item or service for which the individual, or person other than the Plan on behalf of the individual, has paid the covered entity in full.

Confidential Communication: You have the right to request that the Plan communicate with you about your medical information in confidence by means or to locations that you specify. You must make your request in writing, and your request

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must represent that the information could endanger you if it is not communicated in confidence as you request. You should submit your request to the contact at the end of this notice.

The Plan will accommodate your request if it is reasonable, specifies the means or location for communicating with you, and continues to permit the Plan to collect contributions and pay claims. Please note that an explanation of benefits and other information that the Plan issues to the participant about health care that you received for which you did not request confidential communications, or about health care received by the participant or by others covered by the Plan, may contain sufficient information to reveal that you obtained health care for which the Plan paid, even though you requested that the Plan communicate with you about that health care in confidence.

Breach Notification: You have the right to receive notice of a breach of your unsecured medical information. Notification may be delayed or not provided if so required by a law enforcement official. You

may request that notice be provided by electronic mail. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if the Plan knows the identity and address of such individual(s). Electronic Notice: If you receive this notice on the Plan’s website or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact the Plan using the information at the end of this notice to obtain this notice in written form. State Law: As a condition of Plan participation, the Board of Trustees requires that the privacy rights of you, your spouse, and dependents be governed only by HIPAA and the laws of the State of Wisconsin (but only to the extent such laws are not preempted by the Employee Retirement Income Security Act of 1974, as applicable), without regard to whether HIPAA incorporates privacy rights granted under the laws of other states and without regard to Wisconsin’s choice of law provisions.

Questions and Complaints

For more information about the Plan’s privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact the Plan using the information at the end of this notice.

If you are concerned that the Plan may have violated your privacy rights, or you disagree with a decision the Plan made about access to your medical information, about amending your medical information, about restricting the Plan’s use or disclosure of your medical information, or about how the Plan communicates with you about your medical information (including a breach notice communication), you may complain

to the Plan using the contact information at the end of this notice. You also may submit a written complaint to the Office for Civil Rights of the United States Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201. You may contact the Office of Civil Rights’ Hotline at 1-800-368-1019. The Plan supports your right to the privacy of your medical information. The Plan will not retaliate in any way if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.

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Contact Person: LaVonne Stratton

Telephone: (715) 835-3174, local 1-800-424-3405, toll-free

Address: North Central States Regional

Council of Carpenters' Health Fund P.O. Box 4002 Eau Claire, WI 54702

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September 2013

To All Active Employees and Dependents:

You recently received or will soon receive a notice from your employer describing the new health insurance marketplaces (previously referred to as "exchanges") created as part of the Patient Protection and Affordable Care Act ("ACA" or "Health Care Reform"). That notice describes how the marketplaces will work and notes that you may be eligible for premium tax credits to help pay for coverage. The Trustees feel that it is important to provide you with this notice to give you additional information on the marketplaces and how your participation in the North Central States Regional Council of Carpenters’ Health Plan (the Plan) impacts these new options.

Most importantly, the Trustees want to assure you that your eligibility for coverage under the Plan is not affected by the existence of such marketplaces. As long as you continue to meet the Plan's eligibility requirements, you will remain eligible for coverage under the Plan.

As described in the notice from your employer, the marketplaces are intended to be online exchanges where anyone can shop for, compare, and ultimately purchase health insurance coverage. The marketplace will accept applications for coverage, determine eligibility for premium tax credits and cost sharing reductions, determine Medicaid and CHIP eligibility, and enroll people for coverage.

Your eligibility for coverage under the Plan generally makes you ineligible for premium tax credits through the marketplace. The coverage provided by the Plan is considered "affordable" and provides "minimum value" under the federal government's guidelines. Because the Plan's coverage is affordable to you and provides minimum value, you will not be eligible to receive any premium tax credits. However, if you must self-pay for coverage because you did not work enough hours, the cost of coverage under the Plan may not be "affordable" to you and you may be eligible for premium tax credits if you choose to enroll in coverage through the marketplace rather than self-pay.

You do not need to purchase coverage through the marketplace. If you are currently enrolled in the Plan, you will continue to receive Plan coverage for as long as you continue to meet the Plan's eligibility requirements.

The Trustees recognize that the ACA is complex and confusing. If you have any questions or if you would like more information to understand the implications of this notice or ACA in general, please contact the Fund Office.

Yours truly,

The Board of Trustees North Central States Regional Council of Carpenters’ Health Fund

August 30, 2013 RE: North Central States Regional Council of Carpenters’ Health Fund (“Plan”)

Employer Exchange Notice (“Notice”) As you may know, the Patient Protection and Affordable Care Act ("ACA" or "Health Care Reform") will soon require employers to send all employees a Notice of exchange availability. This Notice will provide information about the public insurance exchanges effective in 2014 and information about premium tax credits (commonly referred to as "subsidies") that may be available through the exchanges. The delay of the employer shared responsibility rules (the requirement to offer healthcare coverage or pay a penalty) does not delay this Notice obligation, the exchanges, or premium tax credits. Generally, all employers must provide the Notice to every new employee at the time of hiring beginning October 1, 2013. The Notice will be considered provided "at the time of hiring" if it is provided within 14 days of the employee's start date. Additionally, employers must provide the Notice to all current employees no later than October 1, 2013. Employers must provide this Notice to every employee, regardless of Plan enrollment or part-time or full-time employment status. Employers are not required to provide a separate Notice to dependents who are not employees. Employers must provide the Notice in writing, free of charge. The Notice may be provided by first-class mail. The Department of Labor has issued a model Notice that employers may use to satisfy this notice obligation. You can find a copy of the notice here: http://www.dol.gov/ebsa/pdf/FLSAwithplans.pdf. You will note that the model Notice includes sections to describe the coverage you provide to employees. To assist you with this Notice obligation, the Plan has completed its half of "Part B" of the Notice and enclosed a version of the model notice, with the Plan's suggested revisions, that youcan use to satisfy this Notice obligation with respect to employees that participate in the North Central States Regional Council of Carpenters’ Health Fund (“Plan”). The Plan completed Part B assuming that the benefits and coverage you provide for any non-bargained employees who participate in the Plan are the same as for the bargained employees. You are not obligated to use the Plan's version of the model Notice but

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you must send some form of exchange notice by the deadlines noted above. If you choose to use this Notice, you need only fill in your contact information on page 1, complete questions 3-12 in Part B on page 2, and confirm the information provided in part 15 is accurate for any non-bargained employees covered by the Plan. Your notice obligation extends to all your employees. The model Notice provided by the Plan can be used only for Plan participants. A separate Notice is required for your employees who are not covered by the Plan.1 You may also have heard that the exchange application includes a document called the "Employer Coverage Tool." Your employees may request you to complete this tool if they apply for coverage through the exchanges (the “Health Insurance Marketplace”). Because the information provided in the exchange Notice is the same as the information requested in the Employer Coverage Tool, you may want to refer the employee to the exchange Notice or provide the employee with a copy of Part B. Employers have an obligation to provide the Notice (not the Plan). You should therefore consider reviewing your legal obligations with your legal counsel. Neither this letter nor its enclosures should be construed as advice or guidance from the Plan. Instead, the Plan is sending these materials to you as general information because the Notice requires Plan-specific information that employers may not possess. Please contact the Fund Office at 800-424-3405 if you have any questions regarding the above information.

Sincerely,

The Board of Trustees

1 If you do not currently offer coverage to employees who are not Plan participants, the Department of Labor has also provided a model Notice for employers who do not offer coverage (available here: http://www.dol.gov/ebsa/pdf/FLSAwithoutplans.pdf).

Inter-Plan Programs Financial Policies Compliance Model Simplified Member Benefit Booklet Contract Disclosure

Language (PPO/Traditional)

I. Out-of-Area Services Anthem Blue Cross Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Programs.” Whenever you obtain healthcare services outside of ’s Anthem Blue Cross Blue Shield service area, the claims for these services may be processed through one of these Inter-Plan Programs, which include the BlueCard Program and may include negotiated National Account arrangements available between Anthem Blue Cross Blue Shield and other Blue Cross and Blue Shield Licensees.

Typically, when accessing care outside Anthem Blue Cross Blue Shield’s service area, you will obtain care from healthcare providers that have a contractual agreement (i.e., are “participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, you may obtain care from non¬participating healthcare providers. The payment practices in both instances are described below.

A. BlueCard®

Under the BlueCard

Program ®

Whenever you access covered healthcare services outside Anthem Blue Cross Blue Shield ‘s service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of:

Program, when you access covered healthcare services within the geographic area served by a Host Blue, Anthem Blue Cross Blue Shield will remain responsible for fulfilling its contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers.

• The billed covered charges for your covered services; or

• The negotiated price that the Host Blue makes available to Anthem Blue Cross Blue Shield

Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price.

Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price Anthem Blue Cross Blue Shield use[s] for your claim because they will not be applied retroactively to claims already paid.

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered healthcare services according to applicable law.

B. Negotiated (non-BlueCard Program) National Account Arrangements As an alternative to the BlueCard Program, your claims for covered healthcare services may be processed through a negotiated National Account arrangement with a Host Blue.

The amount you pay for covered healthcare services under this arrangement will be calculated based on the lower of either billed covered charges or negotiated price made available to Anthem Blue Cross Blue Shield by the Host Blue.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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