Eligibility

Before you and your dependents can start using the benefits the OLDC-OCA Insurance Fund offers, you must first become eligible, here is how :

Initial Eligibility
Once you have worked at least 450 hours in a six consecutive month period, you will be eligible for Insurance Benefits on the first day of the following month.

Please keep in mind, there is typically a one-month lag in the hours being reported to OLFBP. This reporting lag results in your eligibility being established retroactively. If you or any of your eligible dependents have any insurance claims after your eligibility date, but before you are notified of your eligibility, you can have the claims resubmitted for processing and payment.

Continuing Eligibility
In general, the more hours you work, the longer you will be eligible. Once you meet the Initial Eligibility requirements, your continued eligibility is determined using three different calculations. Each and every month is looked at individually when determining future eligibility. If you meet the minimum hours criteria for any of the three calculations for a given month, you will be eligible for that month. Your eligibility will continue if you work at least:

  • 250 hours or more in the first 3 months of the 4 months immediately preceding the month of coverage; or
  • 500 hours or more in the first 6 months of the 7 months immediately preceding the month of coverage; or
  • 1,000 hours or more in the first 12 months of the 13 months immediately preceding the month of coverage.

Eligibility Chart
Please click HERE to view the chart.

Medical Benefits

Claims Administrator
Anthem Blue Cross Blue Shield (855) 878-0128

Annual Deductible
Before the Fund pays for most covered expenses, you pay the Annual Deductible of $400 per person or $800 per family (doubled for out-of-network). All claims are subject to the Annual Deductible, unless otherwise noted.

Maximum Out-of-Pocket (MOOP) Limit
Your out-of-pocket expenses for essential health benefits are limited to $3,275 per person or $6,550 per family (doubled for out-of-network). MOOP Limit includes deductible, copayments, and coinsurance.

Coinsurance
Once you meet your Annual Deductible, the Fund Pays 80%, then 100% after MOOP Limit is reached (60% for out-of-network). All claims are subject to the Coinsurance, unless otherwise noted.

Copayments
Copayments vary depending on where you seek treatment:

LiveHealth Online $0 – FREE Service
Primary Care Office Visit $20
Specialist Office Visit $30
Urgent Care $50
Emergency Room $75 ($150 effective 1/1/17)
Emergency Room (non-emergency) $250 ($150 effective 1/1/17)


Chiropractic Services, Physical Therapy, and Outpatient Occupational Therapy
The Fund covers a combined 50 visit maximum per calendar year for Chiropractic Services, Physical Therapy, and Outpatient Occupational Therapy. There are NO copays for these visits; however, relevant deductibles and coinsurance still apply.

Hearing Aid Benefit
HearUSA administers the Hearing Aid Benefit, not Anthem. Contact HearUSA directly at (800) 442-8231 to make an appointment in your area. Benefit includes free annual hearing screening and covers hearing aids up to $1,200 per ear every 36 months.

Prescription Benefits

Claims Administrators
EnvisionRx (800) 361-4542

Mail Order: EnvisionPharmacies (866) 909-5170

Specialty Medications: EnvisionSpecialty (877) 437-9012

Copayments
Copayments will vary depending on whether you fill your prescription at a retail pharmacy or through mail order. Costs also depends on how the drug is classified on EnvisionRx Options’ drug formulary.

Retail Pharmacy (30-day supply) Mail Order (90-day supply)
Generic $10 $25
Brand Name Preferred $30 $75
Brand Name Non-Preferred $50 $125



Key Provisions
Mandatory Mail Order: You must use the mail order pharmacy to fill prescriptions for maintenance medications (certain exceptions may apply). You are permitted to use a retail pharmacy three times for a maintenance medication. Mail order refills require a 90-day prescription.

Mandatory Generic Drugs: If a generic is available, the Fund will only pay the cost of the generic drug. If you or your physician request a brand name drug instead of a generic, you will be responsible for paying the cost difference between the generic and brand name drug in addition to the higher copayment. There is an available cost difference cap of $50 per 30 day supply and $100 per 90 day supply. To be eligible for the cap, a “Brand-Name Drug Override” form will be required from your prescribing doctor. Please contact EnvisionRx to request the form be sent to your doctor.

Prior Authorization: Certain medications with a high potential for inappropriate use require authorization from your physician before your prescription can be filled.

Step Therapy: Certain medications may qualify for a step therapy program. Step therapy requires you to first attempt lower cost drugs to treat an ongoing condition. Step therapy helps you and the Fund control the rising costs of drugs. Drugs will be added to or removed from the step therapy program when deemed appropriate by the Fund. Certain exceptions may apply in cases of allergy or certain medical conditions. Your doctor would need to call the Envision Prior Authorization Department to request an exception be made.

Free Diabetic Supplies
You can get the following diabetic supplies at no cost through EnvisionRx:

  • Insulin needles and syringes
  • Lancets and devices (spring or powered)
  • Blood glucose testing strips for home glucose monitors
  • Normal, low, and high calibrator solution/chips
  • Alcohol wipes

To receive the above noted supplies at no cost, you must get a prescription from your doctor. The supplies will be subject to mandatory mail order; therefore, we recommend you ask your doctor for a 90-day prescription. You can also get certain glucometers at no cost through EnvisionRx without a prescription; contact EnvisionRx for details.

Death & Disability

Death Benefits from the Insurance Fund
If a member dies while eligible for insurance benefits from the OLDC-OCA Insurance Fund, the member’s named beneficiary will be eligible for a death benefit. It’s important to keep your beneficiaries up-to-date. Please complete a new Enrollment/Beneficiary Card and submit it to the OLFBP Fund Office if your family changes.

Class 1 (Active Members): $14,000 (additional $10,000 for accidental deaths)

Class 2 (ESRD Members): $2,500

Class 3 & 4 (Retired Members): $2,500

Short Term Disability Benefits
If you are temporarily or permanently unable to work as a Laborer, you may be eligible for a monetary benefit from the Insurance Fund. There is a one week waiting period if your disability is from a sickness. There is not a waiting period for disabilities caused by an accident.

Weekly Benefit: $280 (net after standard FICA and Medicare withholdings)

Maximum Benefit Period: 20 Weeks

In addition to the weekly monetary benefit, you may also be entitled to Disability Credit Hours from both the Insurance and Pension Funds. Disability Credit Hours could help extend your insurance eligibility and give you a higher pension benefit.

If your disability is work related, you will not be eligible for a monetary benefit, but may still be eligible for Disability Credit Hours. To be eligible for Pension Disability Credit Hours for work related disabilities, you will need to submit BWC paperwork showing the date of the injury, the company the claim was filed against, the type of BWC payments received, and the time period the BWC payments covered.

This benefit is only payable to members eligible for Class 1 insurance benefits. To apply for this benefit, please complete a Short Term Disability Form and submit it to the OLFBP Fund Office.

Dismemberment Benefits
If an eligible member suffers one of the following, the member will be eligible for the corresponding one-time payment:

Quadriplegia: $10,0000

Paraplegia: $7,500

Hemiplegia: $7,500

Loss of Hand: $5,000

Loss of Foot: $5,000

Loss of Sight in One Eye: $5,000

Loss of Speech: $5,000

Loss of Hearing: $5,000

Loss of Thumb and Index Finger on Same Hand: $2,500

This benefit is only payable to members eligible for Class 1 insurance benefits. To apply for this benefit, please complete a Short Term Disability Form and submit it to the OLFBP Fund Office.

Wellness

Wellness is an important part of the Insurance Plan. Healthier members and covered dependents = less money spent by the Insurance Fund = lower contribution rates. Following are some of the wellness provisions of the Plan.

FREE Smoking Cessation Drugs with Prescription : As you are probably already aware, smoking causes or worsens many medical issues, conditions, and diseases. If you or your eligible dependent(s) want to stop smoking, you can get Smoking Cessation Drugs for FREE. Simply get a prescription from your doctor and get it filled for FREE.

Free Annual Routine Physical Exam (Office Visit and Routine Tests) : Why get a physical? Routine physicals can alert you to potential problems before you may even know there is a problem. Early diagnosis may save your life. Plus, it’s FREE.

Free Well Child Care (preventative services covered under the affordable care act) : Even more important than with adults, children need routine preventative care and exams. You want to make sure your child is developing appropriately and getting the required immunizations.

Free Routine Mammogram (women age 40 and older) : Why Are Mammograms Important? Annual mammograms can detect cancer early — when it is most treatable. In fact, mammograms show changes in the breast up to two years before a patient or physician can feel them. Mammograms can also prevent the need for extensive treatment for advanced cancers and improve chances of breast conservation. Current guidelines from the American College of Radiology, the American Cancer Society, and the Society for Breast Imaging recommend that women receive annual mammograms starting at age 40 — even if they have no symptoms or family history of breast cancer. (Source: mammographysaveslives.org)

Free Influenza (Flu) Vaccine : CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.

Free Diabetic Supplies (not all supplies covered) : See the Prescription Benefits page for additional details.

Free Routine PAP Smear Test


NurseLine (888) 249-3820 : Health concerns can happen when you least expect them. Call the 24/7 NurseLine to talk with a registered nurse about your health concern. Whether it’s a question about allergies, fever, preventive care or any other health topic, nurses are always there to provide support and peace of mind. The nurses are there to help you choose the right place for care if your doctor isn't available and you aren’t sure what to do. Do you need to go straight to the emergency room? Is urgent care best? Or do you need to see your doctor? Making the right call can save you time and money. You also have access to prerecorded messages from Anthem’s AudioHealth Library.

Grand Rounds: Grand Rounds is a free benefit to help you take control of the healthcare process. Grand Rounds has reviewed 96% of doctors in the country and will only connect you with the top ones. In addition, over 50% of people that Grand Rounds have helped were taking the wrong medications for their conditions. Grand Rounds also provides solutions for when:

  • You need a checkup - Grand Rounds will find the best physician in your area.
  • You need an expert - Grand Rounds will get you a second opinion or personalized care plan from a world-leading expert.
  • You need support - Grand Rounds will help you make tough decisions or help you decide if surgery is right for you.
  • You need answers - Grand Rounds will tell you everything you need to know about a new diagnosis or existing condition.
  • You need a hand - Grand Rounds will book doctor's appointments, gather medical records, and handle all the details.

Retiree Insurance

Eligibility
If you are eligible for Insurance benefits with the OLDC-OCA Insurance Fund when you retire from the LDC&C Pension Fund of Ohio (or certain other affiliated pension funds), you are eligible for subsidized Retiree Insurance once you have exhausted or waived your COBRA benefits.

Determining Your Monthly Amount Due
Your monthly amount due for Retiree Insurance is calculated using the following factors: the number of pension credits you accumulated, individual or family coverage, your age, and the age of your dependents.

First, your monthly unsubsidized Self-Pay Rate is determined:

Member Only (not on Medicare) $578
Member Only (on Medicare) $379
Family Coverage (all primary) $1203
Family Coverage (one secondary/Medicare) $994
Family Coverage (all secondary/Medicare) $785

(*These rates are subject to change by Board approval.)

Once your monthly unsubsidized Self-Pay Rate is determined, your subsidy percentage (discount amount) is calculated based on the number of Pension Credits you have earned with the LDC&C Pension Fund of Ohio (or certain other eligible pension funds). Your monthly Self-Pay rate is reduced 2% for each Pension Credit you have earned. If your total number of credits is not a whole number, your credits will be rounded to the nearest whole year (.5 and over is rounded up and under .5 is rounded down).

Example 1:

Sam has 27 pension credits, and he and his wife are both under age 65 and not on Medicare. Without the subsidy, Sam would have to pay $1,203 a month for coverage for himself and his wife. However, Sam gets a subsidy of 54% for his credits (27 credits x 2%). Therefore, Sam only pays $553.38 ($1,203 x 54% = 649.62) ($1,203 - 649.62 = $553.38).

Example 2:

Jim retired with 28 pension credits at age 65. Jim is on Medicare, but his wife is 63 and not yet on Medicare. Without the subsidy, Jim would have to pay $994 a month for coverage for himself and his wife. With the subsidy, Jim only pays $437.36. (28 credits x 2% = 56%) ($994 x 56% = $556.64) ($994 - 556.64 = $437.36)

Returning to Work
If your monthly pension benefit is suspended due to Disqualifying Employment (employment that causes your monthly pension benefit to be suspended), you could lose the Retiree Insurance Subsidy for the rest of your life. Please give this much consideration if you return to work after you retire. If you have any questions about what work constitutes Disqualifying Employment, please click HERE or consult the Pension Fund's Summary Plan Description or contact the Pension Department at OLFBP.

If you return to work, you will re-establish eligibility under Class 1 Program (active members) once you work at least 1,000 hours in a 12-consecutive month period. Your hours must be reported and paid by a signatory contractor. Class 1 coverage begins the first day of the month following the month in which you meet the 1,000-hour requirement. Until Class 1 coverage begins, you will continue to be covered under the Retiree Insurance Program as long as you continue to make timely payments to the OLFBP Fund Office.

Work that does NOT affect your Pension & Retiree Insurance Benefits:

Employment outside the Construction Industry. Employment in a construction trade other than Laboring. Employment outside of Ohio (even Laboring), except in Boone, Campbell, or Kenton counties in Kentucky or Brooke or Hancock counties in West Virginia (However, if you work outside of Ohio and have hours and fringes transferred to this Fund through reciprocity or from pipeline work, this is considered disqualifying and would affect your pension and retiree insurance benefits). Any type of employment after age 70 years and 6 months (even Laboring).