How the EWTF Plan Works

Understanding the EWTF Plan

The Electrical Welfare Trust Fund Plan is a comprehensive package of health and welfare benefits sponsored by the Board of Trustees. Your EWTF Plan is provided under a Collective Bargaining Agreement (or other agreement) between your employer and the IBEW Local 26 in coordination with the D.C. Chapter of the National Electrical Contractors Association (NECA). The Electrical Welfare Trust Fund is NOT an insurance company.

Note: Information about H Plan benefits and eligibility appears here.

Plan Basics

The EWTF Plan provides eligible participants and their eligible family members with a wide range of health and welfare benefits including:

  • doctor’s office visits
  • routine physical exams
  • child wellness visits
  • hospitalization and surgery
  • home health care, nursing home care and hospice care
  • maternity and gynecological care
  • prescription drug benefits
  • dental
  • vision
  • hearing
  • employee assistance program
  • mental health and substance abuse
  • death benefits
  • disability benefits (for active members only)

This Plan was created to help you pay expenses for treatment of illness and injury not related to on the job accidents. However, it is important for you to realize that not all charges are covered in full or in part under this Plan. Generally, surgery, dental or medical treatments that are optional or elective on your part are not covered under this Plan. Certain expenses are specifically excluded from coverage under the Plan. (See here.)


FAST FACTS

  • For most medical expenses, the EWTF Plan pays a percentage of the cost.
  • Generally, treatment that meets clinical guidelines for medical appropriateness for a diagnosed illness or injury is covered under this Plan if the treatment is prescribed by a licensed provider.

Payment for Coverage

There is no cost to you to participate in the Plan while you are working. Participating employers contribute to a trust fund from which your benefits are paid. However, you are responsible for deductibles and the Patient’s Portion when you receive services.

What is the “patient’s portion?”

Patient’s Portion is the portion of covered medical expenses that you must pay in addition to the annual deductible. Typically, the Plan’s share is 80% of the allowance and your Patient’s Portion is 20% of the allowance. However, for some expenses, the Plan pays more or less of the allowance. The Summary of Benefits lists the Plan portion in detail.

What is the “allowance?”

The allowance is a predetermined cost for a particular service. If you visit a provider in the UHC Choice Plus Network, the allowance is accepted with the Patient’s Portion as payment in full for a particular service.

The Annual Deductible

The annual deductible is the amount you or your family must pay each calendar year before the Plan will pay benefits. The annual deductible for each individual is $150. The annual deductible for each family is $300. The Plan’s annual deductible does not apply to Medicare-eligible retirees.

The Plan covers some expenses differently than others, but in general:

  • The Plan will pay a percentage of the allowed charges for covered medical expenses.
  • You are responsible for any Patient’s Portion and your annual deductible as well as the difference, if any, between the allowance and the actual charge. If you use a UHC provider, you cannot be billed for the difference (if any) between the allowance and the actual charge.

Coverage for Participants Covered Twice

If a person is covered twice under this Plan—either as an eligible employee married to another eligible employee or as the dependent of two eligible employees—the Plan will pay up to a maximum of 100% of the Plan’s allowance or the actual charges, whichever is less, after the annual deductible has been met. This applies to medical (includes mental health and substance abuse) and dental coverage ONLY.

Out-of-Pocket Maximum

The annual out-of-pocket maximum per family for expenses is $10,000 per calendar year. You are required to provide proof of payment of the annual out-of-pocket maximum to receive increased benefits for the balance of the calendar year.

What the Out-of-Pocket Maximum Does Not Include

  • your annual deductible
  • services that are not covered under the Plan (e.g., cosmetic surgery, TMJ treatment, fertility/infertility treatments, etc.)
  • dental and vision
  • charges above the Plan’s allowance

Lifetime Benefits

The Plan has increased the lifetime benefit it provides. In the past, once the Plan provided $1 million in total covered medical expenses during an individual’s lifetime, it would not cover any additional benefits for that individual. Mental health and alcohol/substance abuse benefits were included in the $1 million lifetime maximum. Prescription drugs were not included unless immunosuppressant drugs were prescribed in connection with an organ transplant.

Effective January 1, 2011, the Plan increased its coverage to provide that once the Plan has provided $1 million in medical benefits on behalf of an individual, it will pay for additional medical expenses that are considered “essential health benefits” at a rate of 50%.

The definition of the term “essential health benefits” is found in section 1302 of the PPACA and implementing regulations issued by the federal government. Until the federal government issues regulations further defining the term “essential health benefits,” the term includes items and services covered within the following categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Annual Limits

Overall annual limits exist during 2011, 2012, and 2013 with respect to “essential health benefits” as defined above. The annual maximums over these three years are as follows:

Plan Year

Annual Maximum

2011

$1,000,000

2012

$1,250,000

2013

$2,000,000

There are different annual limitation rules for H Plan participants. These rules are described here.

Plan Features

The Health Care Cost Containment Corporation

The Electrical Welfare Trust Fund, along with many other construction and union plans, participates in the Health Care Cost Containment Corporation of the Mid-Atlantic Region, Inc. (HCCCC). It is designed to reduce health care costs for union funds and their participants.

Sharing Durable Medical Equipment

The IBEW Local 26 Retired Members Club maintains a limited supply of crutches, canes, wheelchairs and other home health aids that you can use without cost if available. If you own this type of equipment but no longer need or use it, please consider donating it. Call the Fund Office at (301) 731-1050 (out-of-area at 1-800-929-3983) or the Local 26 office at (301) 459-2900 for information. For more information about coverage for Durable Medical Equipment can be found here.

UnitedHealth Premium® Physician Designation Program

The UnitedHealth Premium® Physician Designation Program uses clinical practice information to assist consumers in making more informed and personally appropriate choices for their medical care. The program uses national industry, evidence-based and medical society standards with a transparent methodology and robust data sources to evaluate physicians across 20 specialties to advance safe, timely, effective, efficient, equitable and patient-centered care. The program supports practice improvement and provides physicians with access to information on how their clinical practice compares with national and specialty-specific standards for quality and local cost efficiency benchmarks.

If You Have Questions

Once you have read this Summary Plan Description, if you have any questions about your coverage, call the Fund Office. By calling the Fund Office in advance, you may avoid incurring expenses for which you may not be reimbursed. Representatives of the Fund Office cannot change the terms of this plan, but may be able to help you with any questions. Help us to help you!