AGVA Welfare Trust Fund
Contact Information
New York office:
363 Seventh Avenue 17th Floor
New York, NY 10001
office (212) 627-4820
fax (646) 692-4213
AGVAWTF@agvawelfaretrustfund.org
Hours 12 PM - 6 PM EST
AGVA Welfare Trust Fund Staff
IMPORTANT MESSAGE FROM THE AGVA WELFARE TRUST FUND
Plan Sponsor: Board of Trustees of AGVA Welfare Trust Fund
Sponsor’s EIN:13-1687014
Plan Number: 501
This announcement will serve as a Summary of Material Modifications to the AGVA Welfare Trust Fund. Its purpose is to inform you of important changes to the AGVA Welfare Trust Fund. Please keep this letter and other similar communications with your Summary Plan Description (SPD) for future reference since these documents together provide you with an accurate description of your current AGVA Welfare Trust Fund.
The Board of Trustees or its duly authorized designee, reserves the right, in its sole and absolute discretion, to amend, modify or terminate the Plan, or any benefits provided under the Plan, in whole or in part, at any time and for any reason, in accordance with the applicable amendment procedures established under the Plan and the Agreement and Declaration of Trust establishing the Plan (the "Trust Agreement"). No individual other than the Board of Trustees (or its duly authorized designee) has any authority to interpret the plan documents, make any promises to you about benefits under the Plan, or to change any provision of the Plan. Only the Board of Trustees (or its duly authorized designee) has the exclusive right and power, in its sole and absolute discretion, to interpret the terms of the Plan and decide all matters arising under the Plan.
he AGVA Welfare Trust Fund is a self-funded Major Medical insurance plan, governed by a Board of Trustees, for the purpose of providing medical, optical and dental insurance coverage to eligible AGVA performers.
To All Individuals and COBRA Beneficiaries:
As per the Board of Trustees of the AGVA Welfare Trust Fund, the following changes are in effect for dates of service as of April 1, 2024:
The annual maximum coverage for Dental benefits is raised from $2,000 per year to $3,000 per year, as paid via the AGVA Welfare Trust Fund Schedule of Benefits
*The AGVA Welfare Trust Fund Schedule of Benefits will be updated as per similar fund schedules dated 2023
*The annual maximum coverage for Optical benefits is raised from $200 to $300 per year
*Benefits previously paid at 80% up to a maximum of $50 per visit per year will now be paid at 80% up to a maximum of $75 per visit per year, and this applies to:
· 10 ANNUAL VISITS OF ACUPUNCTURE (BY M.D., O.M.D. OR LICENSED ACUPUNCTURIST)
· 20 ANNUAL VISITS OF CHIROPRACTIC CARE (BY D.C.)
· 20 ANNUAL VISITS OF VISION THERAPY (BY M.D.)
· 40 ANNUAL VISITS OF P.T. (IN ANY COMBINATION OF PHYSICAL, SPEECH & OCCUPATIONAL THERAPY (BY P.T., S.T. OR O.T.)
The Board is pleased to make this announcement, increasing these benefits by 50%.
Plan Sponsor: Board of Trustees of AGVA Welfare Trust Fund
Sponsor’s EIN:13-1687014
Plan Number: 501
GENERAL ELIGIBILTY AND ENROLLMENT
What are the eligibility requirements for coverage?
All Performers/Stage Managers employed under an AGVA Collective Bargaining Agreement or Casual/Club date Contract (referred to herein as "participants" or "member") may accrue medical coverage provided by the AGVA Welfare Trust Fund.
The Fund administers one Major Medical Healthcare plan, Plan A. Plan B is supplemental only, (commencing after three (3) days of employment) and is in place only during the waiting period between days 3 and 15, after which a Member is eligible for Plan A. Plan M is supplemental only, to Medicare coverage, for eligible Members.
ENROLLMENT
Coverage is automatically effective for you after you have accrued the necessary number of days or weeks of employment under an AGVA Collective Bargaining Agreement. However, no claims will be payable until you complete a Coordination of Benefits/Enrollment Form and return it to the Fund Office.
Under Plans A and B, your eligible dependent child(ren) (as defined below) are also eligible for the same Plan A or Plan B coverage as you are on the later of the day you become eligible for your own coverage or the day you acquire the eligible dependent child as described below. In order to enroll your eligible dependent child(ren), you must complete the Enrollment/Coordinate of Benefits Form and return it to the Fund Office within 30 days of the date the dependent child(ren) is eligible for coverage. You must also provide proof of dependent child status and pay the required contribution for coverage of the dependent child(ren). Weekly premium rates are available from the Fund Office. If you do not enroll your dependent child(ren) within 30 days of when they are first eligible and/or pay the applicable premium amounts on a timely basis, you will not have an opportunity to enroll them late except in accordance with a Special Enrollment event as listed below or in connection with a subsequent period of employment that re-establishes your eligibility for coverage.
You should complete and submit the Coordination of Benefits/Enrollment Form for yourself and (as to Plans A or B) the eligible child(ren) that you wish to enroll as soon as they become eligible. You will need to submit copies of marriage certificates and birth certificates to enroll our dependent child(ren) in Plans A or B.
Please note that spouses are not eligible for coverage by any of the Fund's Plans, and dependent children are only eligible for coverage under Plans A or B.
Qualified Medical Child Support Orders (QMCSOs)
According to Federal law, you might be required to enroll your children in Plan A or B due to a Qualified Medical Child Support Order (QMCSO) including a National Medical Support Order (NMSO). A QMCSO or a NMSO is a support order of a court or state administrative agency that usually results from a divorce or legal separation. Participants and dependents may obtain a copy of these procedures without charge by contacting the Fund Office.
SPECIAL ENROLLMENT
If you are declining enrollment for your dependent child(ren) because of other health insurance or group health plan coverage, you may be able to enroll your dependent child(ren) in Plan A or B if your dependent child(ren) lose eligibility for that other coverage (or if the employer stops contributing towards your dependent child(ren)'s other coverage). However, you must request enrollment within 30 days after your dependent child(ren)'s other coverage ends (or after the employer stops contributing towards the other coverage). You must state whether you are declining coverage for your dependent child(ren) due to other coverage in writing on the Coordination of Benefits/Enrollment Form. If you fail to so state, your dependent children will not be entitled to special enrollment in Plan A or B if they lose other coverage.
In addition, if you have a new dependent child as a result of birth, adoption, or placement for adoption, you may be able to enroll your dependent children. However, you must request enrollment within 30 days after the birth, adoption, or placement for adoption. If you enroll your dependent child within 30 days, coverage will be effective as of the date of loss of other coverage or the birth, adoption or placement for adoption. Newborns who are adopted or placed for adoption within 30 days of birth will be covered as of the date of birth.
Finally, if your dependent children were not enrolled when first eligible because your dependent children had coverage through Medicaid or a State Children's Health Insurance Program (CHIP), you may enroll your eligible dependent child(ren) if they lose eligibility for Medicaid or CHIP coverage, or if they become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment in the Plan within 60 days of the date when they lose coverage under Medicaid or CHIP or become eligible for the premium assistance program.
To request special enrollment or obtain more information, contact the Fund Office.
PLAN A RULES AND BENEFITS
ELIGIBILITY
Performers/Stage Managers engaged under an AGVA Collective Bargaining Agreement, accruing fifteen (15) days or three (3) consecutive weeks of employment within the past six (6) month period, meet Plan A eligibility, provided that their employer has contributed to the AGVA Welfare Trust Fund on their behalf. The length of coverage is determined as follows:
For ongoing engagements of twelve (12) consecutive weeks or longer, with continued contributions for every week of work, Plan A coverage is in effect after the first 15 days (necessary for eligibility), and benefits extend an additional five months beyond the last day of employment, unless otherwise modified by your particular Collective Bargaining Agreement (please refer to your CBA to access otherwise negotiated provisions of the term of coverage).
For engagements of less than twelve consecutive weeks, Plan A coverage is in effect after the first 15 days (necessary for eligibility), and extends an equivalent of the length of the engagement, unless modified by your particular Collective Bargaining Agreement (please refer to your CBA to access otherwise negotiated provisions of the term of coverage).
For example: if the engagement is for twenty (20) days, Plan A coverage is in effect after the first 15 days (necessary for eligibility), and benefits would then extend for another twenty (20) days following the last day of employment; if the engagement is for four (4) weeks, Plan A coverage is in effect after the first 15 days (necessary for eligibility), and benefits would then extend for another four (4) weeks following the last day of employment.
Self-employed, casual and club date AGVA members who have registered fifteen (15) shows of employment under an AGVA contract within the six-month periods of January to June or July to December, are eligible for the self-pay plan. The self-pay plan payment schedule may be obtained, upon request, from the AGVA Welfare Trust Fund.
A participant's child is eligible for Plan A coverage if the child falls into any of the categories listed below, if the child is under the age of 26 (whether married or unmarried), and if the child's Social Security Number (SSN) and proof of dependent status (as listed below) have been provided to the Fund:
- Biological child (son or daughter). You are required to provide a copy of the certified birth certificate showing biological child of employee.
- Legally adopted child or child placed for adoption with the employee/member. You are required to provide a copy of the court order paper signed by the judge showing that employee had adopted or intends to adopt a child and a copy of the certified birth certificate. Placed for adoption means the assumption and retention by the employee/member of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child's placement for adoption terminates upon the termination of such legal obligation.
- Qualified Medical Child Support Order (QMCSO): If you are enrolling your child(ren) pursuant to a QMCSO, you must provide a valid QMCSO document signed by a judge or a National Medical Support Notice.
- Coverage ends for a dependent child the last day of the month in which the child turns age 26.
Dependent coverage is not paid for b y employer contributions to the Fund, and thus if you wish to secure coverage for your dependent children, you must purchase such coverage within thirty (30) days of when you become eligible for coverage. You must identify the dependents you wish to cover at that time.
DEDUCTIBLE
A $100.00 DEDUCTIBLE (OF THE COVERED AMOUNT) PER CALENDAR YEAR (1/1 TO 12/31) APPLIES
OTHER COVERAGE AND CO-ORDINATION OF BENEFITS
IF YOU OR YOUR DEPENDENT CHILD HAVE EXISTING HEALTH COVERAGE, YOU MUST DECLARE IT, AND A COORDINATION OF BENEFITS/ENROLLMENT FORM MUST BE ON FILE FOR BENEFITS TO BE PROCESSED AND COORDINATED.
AN EXPLANATION OF BENEFITS FORM (FROM YOUR PRIMARY INSURANCE CARRIER) MUST BE PROVIDED WITH ALL BILLS SUBMITTED TO THE AGVA WELFARE TRUST FUND FOR PROCESSING.
ADDITIONALLY, IF YOU WISH TO DECLINE COVERAGE UNDER PLAN A FOR YOUR DEPENDENT CHILD(REN) DUE TO OTHER COVERAGE, YOU MUST SO STATE IN WRITING TO THE FUND OFFICE ON THE COORDINATION OF BENEFITS/ENROLLMENT FORM. IF YOU FAIL TO SO STATE, YOUR DEPENDENT CHILDREN WILL NOT BE ENTITLED TO SPECIAL ENROLLMENT IN PLAN A IF THEY LOSE THE OTHER COVERAGE. Please see above for details on special enrollment.
BENEFITS SUMMARY:
Major Medical:
- 80% of reasonable & customary covered expenses
- Includes: doctor visits (M.D.), Out-Patient Psychiatric Care only by: M.D., Ph.D. or C.S.W., Prescription drugs, X-rays (must be ordered by an M.D.), labs, etc.
-Although not mandatory, choosing Providers who participate in Multiplan/PHCS offers overall enhanced savings on discounted rates, which are reflected in your 20% co-pay
- Letters of Medical Necessity may be required
- Please submit only original bills and original prescription receipts
In-Hospital Room Expenses:
- Semi-private room and board payable at 100%
In-Hospital Doctor Charges:
- Payable at 100%
Other In-Hospital Expenses:
-Payable at 100%
Outpatient Hospital Services:
- Payable at 80% for surgery, MRI, and other medical testing
- Facility fee, other medical care & treatment payable at 100% for hospital only
Surgical Care Centers: (located outside of Hospitals)
- 80 % of reasonable & customary charges
- Pre-Certification from AGVA Welfare Trust Fund is required for
Surgery and Medical Procedures including an MRI, PET scan, or CAT scan
- Letters of Medical Necessity may be required
Acupuncture by - M.D., O.M.D or Licensed Acupuncturist
- 10 visits per calendar year
- Payable at 80% up to a maximum of $75.00 per visit
Chiropractic Care by - D.C.
- 20 visits per calendar year
- Payable at 80% up to a maximum of $75.00 per visit
Vision Therapy by - M.D.
- You can opt out of vision coverage for yourself and/or any of your dependent children
who you enroll for Plan benefits. If you do not opt out, the coverage is as set forth below.
- 20 visits per calendar year
- Payable at 80% up to a maximum of $75.00 per visit
Physical, Speech & Occupational Therapy by - P.T., S.T. and O.T.
- 40 visits per calendar year
- Payable at 80% up to a maximum of $75.00 per visit
Special Mammogram Program:
- For women on Plan A over the age of 35: AGVA Welfare Trust Fund will provide a free
mammogram every other year (payable up to $150.00, for which the yearly deductible is
not applied), after which a 20% coinsurance applies.
Maternity Benefits:
- CAREALLIES should be informed at the beginning of your pregnancy 1-800-331-0890
- Members requiring Hospitalization at any time during and through the pregnancy
should contact CAREALLIES at 1-800-331-0890
- Prenatal visits paid at 80% of reasonable and customary charges
- Laboratory tests, Sonograms, Ultra-sound all paid at 80%
- Hospitalization - Semi-Private rate paid at 100%
- Vaginal delivery and C-Section are paid at 80%
- Delivered Dependents are covered effective at birth, if they are enrolled in the Fund within 30 days of birth
Optical Coverage:
- You can opt out of optical coverage for yourself and/or any of your eligible dependent children
who you enroll for Plan benefits. If you do not opt out, the coverage is as set forth below.
- OPTHALMOLOGIST: covered at 80% of all customary and reasonable charges
- OPTOMETRIST: Exam, Glasses and or Contact Lenses are paid at up to $300.00
per calendar year. No deductible applies
Dental Coverage:
- You can opt out of dental coverage for yourself and/or any of your eligible dependent children
who you enroll for Plan benefits. If you do not opt out, the coverage is as set forth below.
- $3000.00 maximum benefit paid per calendar year
- Benefits are paid according to a fee schedule. The amount covered per procedure can be obtained from the Fund Office.
- $200.00 deductible is based on the Fund fee schedule payment for each procedure,
per calendar year
- A pre-treatment review of dentist’s proposed charges is available and recommended
- No coverage for: orthodontics, night guards or TMJ
Death Benefit:
- $5000.00 paid to designated Beneficiary or Member’s Estate
- Please ensure that a Death Beneficiary card is on file
ADDITIONAL INFORMATION ON SCOPE OF BENEFITS
Benefits are provided for both in-patient and out-patient services as long as they are required as a result of an illness, pregnancy, childbirth (or related medical condition), accident or injury unrelated to employment (see complete Exclusions and Limitations). Benefits for preventive care consist only of the benefits for contraceptives requiring a prescription, the mammogram benefit, benefits for any prophylactic dental or vision care within the scope of the Dental and Vision benefits, and diagnostic tests ordered in the course of a covered hospital or doctor's office visit, all as described elsewhere in this booklet. Please note that over-the-counter and prophylactic/preventive drugs (except contraceptives requiring a prescription) are not covered.
Hospital Expense Benefits
When you are confined in the hospital, the Plan will pay 100% of the following up to 365 days for each hospital admission, except as indicated:
-Hospital Services for room and board in a semi-private room. (if you are in a private room, you will have to pay the difference between the private and semi-private room.)
-Miscellaneous Hospital fees which include charges for the operating room, laboratory and X-rays, drugs and medicines, blood and oxygen.
-Anesthesia and it administration is paid at 100% if provided by in-house staff and billed as part
of the hospital confinement charges, and is otherwise paid at 80%.
-Emergency Room Visits
-Emergency Transportation Service by professional ambulance to and from the hospital or other
medical facility is paid at 80%.
-Pre-admission testing if you require diagnostic tests before entering the hospital for surgery;
the surgery must take place within seven days of the testing and is paid at 80%
Medical Expense Benefits
Medical Expense Benefits are payable to you at the rate of 80% of reasonable and customary
charges (unless otherwise noted) and include the following:
-Physicians and Surgeons Services for surgical procedures and other medical care and treatment
received in the hospital, office or home. (NOTE: An Assistant Surgeon in a teaching Hospital is
not covered.)
-Psychiatric Care by a Psychiatrist, M.D., licensed psychologist, or social worker (C.S.W. or M.S.W.)
-Chiropractic Care - 20 visits with a D.C. per calendar year payable at 80% up to a maximum of $50.00 per visit.
-Vision Therapy - As noted above, you can opt out of vision coverage for yourself and/or any of
your eligible dependent children who you enroll for Plan benefits. If you do not opt out, the Plan will cover 20 visits per calendar year payable at 80% up to a maximum of $50.00 per visit.
-Acupuncture - 10 visits with an M.D., O.M.D. or Licensed Acupuncturist per calendar year payable at 80% up to a maximum of $50.00 per visit.
-Physical, Occupational and Speech Therapies - Benefits provided when medically necessary as a result of a serious illness or injury unrelated to employment (see complete Exclusions and Limitations). A maximum of 40 visits are allowed in one calendar year, not including visits rendered as Post-Hospital Care in a facility as set forth below.
-Nursing Care by a Registered Nurse, Nurse Practitioner or PA provided your doctor certifies that you medically need the nursing care.
-Prescription Drugs - Charges incurred for medications prescribed by a medical doctor including contraceptives (Note: Drugs are not covered if purchased in Doctors Office). Over-the-counter and prophylactic/preventive drugs (except contraceptives requiring a prescription) are not covered.
-Durable Equipment - Devices prescribed by a Medical Doctor deemed necessary for one's general health, including sleep apnea devices, oxygen and the rental of respiratory paralysis equipment.
- Professional Ambulance charges to and from the hospital or other medical facility
- X-ray and Laboratory Examinations made for diagnostic or treatment purposes and requested by an M.D. (This is separate from pre-admission testing.)
- Radiation Therapy by x-ray, radon, radium, or radioactive isotopes
- Anesthesia charges and its administration not covered under the Hospital Expense Benefits
- Medical Supplies which include prescription drugs and medicines while you are hospitalized; and surgical supplies such as bandages, crutches, dressings, and appliances to replace physical organs or parts or to aid in their function, but limited to the initial charge for the first such appliance.
- Post-Hospital Care, which includes care in a convalescent care facility (which includes a residential treatment facility for mental health or substance abuse disorders) or received from a home health care agency, provided you've been hospitalized at least 3 days for the same or related condition. Your doctor must certify in writing that the post-hospital care is necessary and the care must begin within 14 days of your discharge from the hospital. If care is received in a convalescent care facility, your benefit is the lesser of the facility's regular semi-private room and board rate or 50% of the facility's daily semi-private room rate. No benefits are paid after the first 120 days of confinement.
If care is provided by Home Health Care Agency, benefits are provided for:
- part-time professional nursing by a Skilled Nurse
- physical, occupational or speech therapy when medically necessary as a result of a serious illness or injury unrelated to employment
- A maximum of 40 visits is allowed in one calendar year
- Special Mammogram Program - for women age 35 and over, benefits are provided for a mammogram every other year, payable up to $150.00 (for which the yearly deductible is not applied), after which 80% is payable.
Death Benefit
This Plan provides hat $5,000 of life insurance will be paid to your beneficiary named on the most current beneficiary designation card filed with the Fund Office in the event of your death while you are covered under the Plan. If no beneficiary is named, the death benefit will be paid to your estate.
EXCLUSIONS AND LIMITATIONS
Under this Plan, no benefits are payable for the following:
- Hearing aids, except when required because of accidental injury
- Charges resulting from war or international armed conflict
- Charges in connection with any injury resulting from an accident or illness pertaining to any occupation or employment for remuneration or profit
- Charges resulting from an illness, injury or disease for which Workers' Compensation is payable
- Charges in connection with any injury resulting from a motor vehicle accident in which auto insurance compensation is responsible for payment of such coverage
- Orthodontia
- Charges incurred while you are confined in a hospital operated by the United States of America or any of its agencies
- Charges that would not have been made if you did not have insurance
- Charges for education, training, and bed and board while you are confined in an institution which is primarily a school or other institution for training, a place of rest, a place for the ages or a nursing home
- Charges for custodial care
- Pharmacy charges without prescription numbers and receipts
- Charges resulting from commission of a criminal act unless the injuries arise as a result of an act of domestic violence
- Charges of a Cosmetic Nature, including Prescription Drugs pertaining to Medical, Dental and Optical
- Charges resulting from the use of a Midwife in child birth
THE BENEFITS DESCRIBED IN THIS SUMMARY ARE SUBJECT TO THE PLAN OF BENEFITS ADOPTED BY THE BOARD OF TRUSTEES, AS AMENDED FROM TIME TO TIME. WHERE A DISPUTE ARISES REGARDING THIS SUMMARY AND THE PLAN OF BENEFITS, THE DECISION OF THE BOARD OF TRUSTEES SHALL BE FINAL AND BINDING ON ALL PARTIES.
PLAN B RULES AND BENEFITS
PLAN B
PLAN B IS OFFERED SOLELY AS A SUPPLEMENTAL BENEFIT UNTIL PLAN A BECOMES EFFECTIVE (BETWEEN DAYS 3-15 OF EMPLOYMENT)
ELIGIBILITY
Performers/Stage Managers engaged under an AGVA Collective Bargaining Agreement, accruing three (3) days employment within a six (6) month period, but less than three (3) consecutive weeks or fifteen (15) days of employment, qualify for Plan B benefits, provided that their employer has contributed to the AGVA Welfare Trust Fund on their behalf. Your dependent child(ren) (as defined above for purposes of Plan A) ae also eligible for Plan B benefits if you both identify the dependent child(ren) you wish to enroll and purchase coverage for them within thirty (30) days of when you become eligible for coverage.
Plan B benefits are in effect after the first 3 days of employment (necessary for eligibility). Plan B benefits extend an equivalent of the length of the engagement, up to 3 weeks (when Plan A becomes effective with continued Contributions).
For example: if the engagement is for three (3) days, Plan B coverage is in effect after the first 3 days (necessary for eligibility), and benefits would then extend for an additional three (3) days following the last day of the employment; if the engagement is for two (2) consecutive weeks, Plan B coverage is in effect after the first 3 days (necessary for eligibility), and benefits would then extend for an additional two (2) weeks following the last day of employment. For ongoing engagements of more than three (3) weeks, with continued employer contributions, Plan A begins on the 16th day.
DEDUCTIBLE
- Plan B is subject to a $300.00 deductible per calendar year
- All claims must be submitted within ninety (90) days of treatment
PLAN B – BENEFITS SUMMARY
Hospital Expenses:
- Up to $100.00 a day
Other In-Hospital Miscellaneous Expenses:
- Up to $1000.00 payout per hospitalization
Out-Patient Hospital Treatment:
- Up to $1500.00 payout per treatment
Surgical:
- Up to $600.00 payout per surgery
Doctor’s Visits (in Physician’s Office)
- $30 per visit - beginning with the 4th visit
X-ray & Laboratory:
- Up to $150.00 payout for all such testing ordered in relation to the same hospital or doctor's office visit, or other medical consultation or examination
Prescription Drugs:
- 20% coinsurance applies until $300.00 in benefits is paid out per calendar year, after which 10% is payable
Optical Coverage:
-You can opt out of optical coverage. If you do not opt out, the benefit is up to $55.00 per calendar year, subject to the deductible (unlike under Plan A, where the deductible does not apply to the $200 optical benefit).
Death Benefit:
- $1000 paid to designated Beneficiary or Member’s Estate if the Member was covered by the Plan at the time of his or her death
-Ensure that a Death Beneficiary card is on file
EXCLUSIONS - The following are not covered:
- Chiropractic care
- Acupuncture
- Physical, Speech & Occupational Therapy
- Skilled Nursing Care
- Dental Coverage
- Spouses
THE BENEFITS DESCRIBED IN THIS SUMMARY ARE SUBJECT TO THE PLAN OF BENEFITS ADOPTED BY THE BOARD OF TRUSTEES, AS AMENDED FROM TIME TO TIME. WHERE A DISPUTE ARISES REGARDING THIS SUMMARY AND THE PLAN OF BENEFITS, THE DECISION OF THE BOARD OF TRUSTEES SHALL BE FINAL AND BINDING ON ALL PARTIES.
Plan M (MEDICARE SUPPLEMENT) BASIC COVERAGE: Part A/Part B
ELIGIBILITY
Participants are covered by Plan M if they are eligible for Plan A and are also eligible for Medicare
Part A or B.
SPECIAL CLAIM PROCEDURES
- Provider must first submit claim to Medicare
- You will receive an Explanation of Benefits from Medicare
- Mail your Original Claim along with Medicare’s Explanation of Benefits to AGVA Welfare Trust Fund
BENEFITS
- 20% of the allowed Medicare amount will be paid
- Hospital Deductible (Part A only) will be paid
- All of the benefits and restrictions of Plan A apply, including the $100.00 deductible per calendar
year
THE BENEFITS DESCRIBED IN THIS SUMMARY ARE SUBJECT TO THE PLAN OF BENEFITS ADOPTED BY THE BOARD OF TRUSTEES, AS AMENDED FROM TIME TO TIME. WHERE A DISPUTE ARISES REGARDING THIS SUMMARY AND THE PLAN OF BENEFITS, THE DECISION OF THE BOARD OF TRUSTEES SHALL BE FINAL AND BINDING ON ALL PARTIES.
COBRA Benefits
MULTIPLAN AND PHCS INFORMATION
The AGVA Welfare Trust Fund participates in Multiplan for hospital coverage and PHCS for medical providers. You will find these insignias on your insurance card.
Although the AGVA Welfare Trust Fund is not a PPO, and members may choose any provider, if one is chosen within the PHCS network, the costs to the Fund and co-payment to the member are reduced. Some providers do not require a co-payment.
If you would like to utilize a PHCS provider, please go to Multiplan.com and under “Search for a Doctor or Facility” indicate PHCS Network. On the next screen click “doctor” and finally, enter your search criteria to find the kind of provider you are seeking in your area.
If you have any questions regarding this option, please contact the AGVA Welfare Trust Fund directly.
Please check with your provider to find out if he or she is a Multiplan/PHCS provider.
COBRA Benefits
UPON EXPIRATION OF COVERAGE, IF A MEMBER QUALIFIES FOR COBRA AND WISHES TO CONTINUE WHEN COVERAGE TERMINATES, THE AGVA WELFARE TRUST FUND MUST BE NOTIFIED TO DETERMINE ELIGIBILITY AND COORDINATE PREMIUMS. THE RIGHT TO COBRA CONTINUOUS COVERAGE WAS CREATED BY A FEDERAL LAW, THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA).