To: All Participants in the NASI Welfare Fund
From: The Board of Trustees
The economic downturn continues to put financial pressure on participants of the NASI Welfare Fund and on the NASI Welfare Fund itself. Most of the money the NASI Welfare Fund uses to pay health benefits comes from employer contributions based on hours worked in the industry. Recent hours worked in the sprinkler industry are among the lowest numbers seen in decades. Broad economic recovery appears to be something that will begin sometime in the future.
Effective January 1, 2011, significant changes were made to the plan of benefits provided by the NASI Welfare Fund in an effort to conserve the Fund’s financial reserves. More remains to be done. Nevertheless, the Trustees have decided that there will be no change to the deductibles, co-insurance levels or out-of-pocket maximums for 2012.
New Dental Preferred Provider Network – Delta Dental
Effective January 1, 2012, the NASI Welfare Fund will provide dental benefits through the Delta Dental PPO plus Premier network of dentists. A review of dentists used by the participants and their dependents covered by the NASI Welfare Fund indicates that more than 4 out of 5 dentists already participate in the Delta Dental Premier network.
To see if your dentist participates with Delta Dental, you can ask your dentist, contact Delta Dental at 800-932-0783, or you can use the search tool using the link on the NASI Welfare Fund’s website; www.nasifund.org.
Easy to Use
No ID card is required to receive dental services; just let your dentist know that starting January 1, 2012, they can file the claim directly with Delta Dental. Your dentist’s office will need your name, date of birth and your ID number from your BCBS (or NASI Welfare Fund) ID card.
Even though ID cards are not required, you will receive two ID cards from Delta Dental in the coming weeks and your BCBS ID card will be reissued with updated information regarding this change for your easy reference.
If your non-participating dentist will not file the claim on your behalf, you may mail your dental claim to:
P. O. Box 2105
Mechanicsburg, PA 17055-2105
You will also be able to call Delta Dental’s customer service toll-free at 800-932-0783 once we have completed the transition of enrollment and eligibility information to Delta Dental. Of course, the Fund office remains available to you at the 800-638-2603 number to answer questions about this change, your medical benefits, your eligibility for benefits, or if you are not sure whether your question is best directed to Delta Dental.
What if you are going to a Dental Network of America Dentist?
In recent years, the NASI Welfare Fund has accessed discounts on dental services through the Dental Network of America (“DNoA”). The last date of service we will be able to obtain discounted dental services through the DNoA is December 31, 2011. Dental claims sent to the Fund office for services incurred after December 31, 2011, will be forwarded to Delta Dental for processing.
Same Benefit Structure
Delta Dental will administer the same benefit structure you have received through the NASI Welfare Fund; the deductibles and coinsurance levels remain the same. You will still be able to visit any dentist, and there is no financial penalty to you or to your dentist if your dentist is not a part of the Delta Dental Network. You will usually pay less for your portion of your dental expenses when you use a Delta Dental provider because to participate with Delta Dental, the dentist agrees to accept a lower reimbursement as payment in full. You will still be responsible for your deductible and coinsurance portion of the dentist’s charges. When Delta Dental processes your claim submitted by your dentist, you will receive a dental benefits statement from Delta Dental showing the services provided, the costs of the treatment and the portion of the cost that is your responsibility.
Orthodontic treatment in progress
Payments for orthodontic treatment and services that began before 2012 will continue to be handled by the Fund office. Orthodontic treatment that begins after this year will be administered by Delta Dental.
Prescription Drug Coverage for Proton Pump Inhibitors for Certain Diagnoses
Proton Pump Inhibitors are a group of drugs that reduce stomach acid. This class of drugs includes Nexium, Protonix and Prilosec and will be referred to below as “PPIs”. A more comprehensive list of PPIs is shown below. Effective January 1, 2011, the NASI Welfare Fund eliminated coverage for all PPIs because the Trustees were advised that there were effective over-the-counter alternatives to prescription PPIs. The Trustees have received many requests from participants and their physicians for coverage for specific PPIs; many associated with the treatment of severe medical conditions. These many requests were considered very seriously by the Board of Trustees. The result of the Trustees’ consideration is the January 1, 2012, reinstatement of PPI coverage for certain medical conditions and in situations where it can be medically established that a patient needs a PPI that is not available over-the-counter (“OTC”).
The medical conditions for which PPI coverage will be available under the NASI Welfare Plan are as follows:
• Hypersecretory conditions such as Zollinger-Ellison Syndrome, mastocytosis, and multiple endocrine adenomas
• Barrett’s Esophagus
• Esophageal peptic stricture
• Erosive esophagitis
• Esophageal cancer
The Fund office will review the recent appeals from individuals whose physician has documented one of the above conditions. Individuals identified this way will receive a letter from the Fund office in the coming weeks to confirm that as of January 1, 2012, Medco will be advised that the NASI Welfare Fund will pay for the prescribed PPI for that individual. Others will need to go through the medical review process with the Fund office before coverage will be provided. Such process will require information regarding the patient’s diagnosis as well as confirmation from the physician as to which OTC PPI had been tried for a medically reasonable period of time (e.g. once or twice a day OTC PPIs for six weeks) and that the attempted treatment failed the patient. Reimbursement will be available for PPIs purchased beginning January 1, 2012, once medical necessity has been established with the process described above, even if the review process is not complete until after the purchase has been made.
List of PPIs
Brand Name Generic Name Available OTC?
· Prilosec Omeprazole Yes
· Prevacid Lansoprazole Yes
· Protonix Pantoprazole No
· Nexium Esomeprazole No
· Dexilant Dexlansoprasole No
· Aciphex Rabeprazole No
· Zegerid Omeprazole/Sod Bicarb Yes
Some of the drugs listed above are marketed under other names by their manufacturer.
Pensioner Medical Coverage
Some years ago, it was announced that in the coming years, pensioners and beneficiaries will be asked to pay an increasing portion of the cost of their coverage eventually reaching the goal of retirees paying 50% of the cost of retiree coverage. The change below is projected to have retirees pay, as a group, 48% of the cost of providing medical coverage to retirees. The NASI Welfare Fund pays the remainder of the cost.
Pensioners and beneficiaries who do NOT have Medicare
The monthly self-payment for pensioners or beneficiaries who are not yet eligible for Medicare will increase to $790 per month beginning January 1, 2012.
Pensioners and beneficiaries whose Local Union has a Retired Employee Subsidy Account (RESA) and who are eligible for their local union’s RESA will continue to benefit from their Local Union’s subsidy of the cost of their coverage. If your Local Union plans to change the amount of the subsidy, you will be advised in a separate announcement.
Pensioners and beneficiaries WITH Medicare
In keeping with the policy as stated above, the monthly self-payment for pensioners or beneficiaries who became eligible for Medicare before 2002 will be increased from $245 per month to $260 per month effective January 1, 2012. For those pensioners or beneficiaries who become eligible for Medicare after 2001, the monthly self-payment cost for coverage will increase from $295 per month $310 per month effective January 1, 2012.
Medicare-eligible Pensioners and beneficiaries whose Local Union has a Retired Employee Subsidy Account (RESA) and who are eligible for their local union’s RESA will continue to benefit from their Local Union’s subsidy of the cost of their coverage. If your Local Union plans to change the amount of the subsidy, you will be advised in a separate announcement.
Monthly Cost for Those Participating in NASI Welfare Fund through Participation Agreements
The premium for the NASI Welfare Fund for those participating in the Fund through participation agreements (e.g. owner members) will increase to $1,347.20 per month.
Quit For Life®
The Quit For Life® Program has resources to help you quit the use of tobacco products. The NASI Welfare Fund will pick up the entire cost of your participation (except for your prescription coinsurance should you choose to use certain prescription drugs, like Chantix or Zyban – prescriptions not otherwise covered except within this new program). With their counseling, your chances of quitting for life are 8 times greater than trying to quit on your own. Hundreds of NASI participants and family members have already benefited from using the Quit For Life Program. It works.
Call today for FREE coaching at 1.866.QUIT.4.LIFE (866.784.8454) or visit www.quitnow.net.
If you choose to participate, the fact of your participation will not be shared with anyone except for Fund staff and professionals (and, if necessary, Medco) as necessary to follow up on long-term cost benefits of the program, in keeping with federal privacy law.
Retiree Benefits and Medicare
Medicare is the primary coverage for retirees, dependents of retirees and beneficiaries. The NASI Welfare Plan requires that individuals who are eligible for Medicare Part B benefits sign up for those benefits. Additionally, if an individual is not entitled to cost-free Medicare Part A, that individual must also purchase Part A coverage from Medicare when they become eligible to do so at age 65.
Annual Reminder regarding Women’s Health and Cancer Rights Act of 1998
Do you know that the NASI Welfare Plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?