Answers for frequently asked questions about Eligibility, Claims, Dental, and Vision are answered below separately. You may also call the Fund Office at (800)-258-6534 if you have any questions.
Eligibility Department FAQs
Your family needs to be added to the Plan before they have coverage. You were provided a Benefit Enrollment Form (Green colored form) in the packet containing your Summary Plan Description and other documents. You need to complete that form and return it with the appropriate marriage certificate, birth certificates for your children and other materials relating to divorce or adding stepchildren. See the back of the form for more information as to documents needed to enroll dependents. Be sure to designate a beneficiary for your Death Benefit (See Page 20 in the Summary Plan Description)
You will need to complete a Benefit Enrollment Form (Green colored form) listing your spouse as a dependent. Mail the Benefit Enrollment form and a copy of your marriage certificate to the Fund office.
Complete a Benefit Enrollment Form listing the child(ren) as a dependent. If you are married and/or have other children, please list your spouse and other children as well. Keep in mind that the form you are completing is replacing the form the Fund may have on file already in the Fund office so make sure you include everyone you are enrolling as dependents. Mail the Benefit Enrollment form with a copy of the child(ren)’s birth certificate or adoption papers. In the case of a newborn child, please call the Fund office as soon as you get the Social Security number if you do not already have it.
If you are unmarried, please also send a letter with information about the other parent. The Fund needs to know if the child(ren) live with you or the other parent, if the other parent is employed and/or has insurance on the child(ren), and if there are any court documents/divorce decree that specifies which parent is to carry the insurance for the child(ren).
Complete a Benefit Enrollment Form listing the child(ren) as a dependent. Please list your spouse and any other children already on the Plan as well as the new form replaces the form the Fund may have on file. Mail the Benefit Enrollment Form with a copy of the child(ren)’s birth certificate.
Please also send a letter with information about the other parent. The Fund needs to know if the child(ren) lives with you and your spouse or with the other parent, if the other parent is employed and/or has insurance on the child(ren), and if there are any court document/divorce decree that specifies which parent is to carry the insurance for the child(ren).
No, you can only add a grandchild if you have adopted him/her. The Adoption Papers will need to be provided to the Fund Office.
Complete a Benefit Enrollment Form leaving your spouse off the list of dependents; select a new beneficiary if you so choose. Mail the Benefit enrollment form with a copy of your divorce decree to the Fund office.
If there are children on the Plan, please make sure that you send the pages of the divorce decree that specify which parent has been made responsible for providing health insurance for the children.
Children can remain on the Plan until the last day of the month in which they attain age 26. (See page 17 in the Summary Plan Description)
ID cards are mailed directly from United Healthcare. They should arrive in 10-14 days from the date they are ordered. Keep in mind that your ID card will be used for both your hospital/doctor visits as well as your prescription drug purchases.
Call the Fund office. We can order cards for you. A copy can also be faxed or emailed in necessary.
Railroad Maintenance and Industrial Health and Welfare Fund is a self-funded Plan, which means we spend our own dollars on our claims. The Fund “rents” or “leases” access to the United Healthcare Choice Plus network, and in their terms, we are a “shared services” plan. Your eligibility is held here, in the Fund Office, and we updated United Healthcare with that information. The provider will need to access a different website and/or call a different phone number for your eligibility and benefits, than they do for most of their other patients who have United Healthcare. The website is www.uhss.umr.com, and the phone number is 844-836-1774.
It will depend upon your classification. Different types of employees qualify in different ways. Please refer to the Rules of Eligibility in the Summary Plan Description starting on page 10. If you have more questions, please call the Fund office.
Please refer to the Continuation Coverage Rights under COBRA in the Summary Plan Description starting on page 48. If you have more questions, please call the Fund office.
No, we need original signatures so the forms must be mailed to the Fund office.
Before this can happen, you will need to complete a privacy form and mail it to the Fund office before we can speak to anyone about your benefits or claims. This form is available on this website.
Claims Department FAQs
The Fund requires every person covered to complete the Medical Claim statement every calendar year. This form serves several purposes. We check it to make sure we have the correct address on file, in case you have moved and forgot to notify the Fund Office. We also use it to make sure that we have either added your spouse and any dependents to your benefit, or remove your spouse if you have divorced, and you didn’t notify us of those changes. This form also serves as an annual coordination of benefits check. If you, your spouse, or any dependents have other insurance, the Fund needs to investigate to determine who is the primary payor. (See Page 61 in the Summary Plan Description)
When the Fund receives a claim for you or one of your dependents that indicates an accident or injury, the Fund is required to obtain information regarding where the injury or accident took place, how it happened, and if there is any other party that might be liable for those charges. This form isn’t just an “accident” form; it doesn’t necessarily mean that your injury was an accident. If you are injured, we need that information as well. There are injuries that occur where an actual accident was not involved. You also have a Basic Accident Benefit that pays for treatment of an accidental injury at 100% up to $200 per accident for care provided within 72 hours of the accident/incident. (See page 2 in the Summary Plan Description)
If you are going to be seeing a new doctor, or going to an urgent care or prompt care, you will need to make sure that they are in-network, as the Fund has very limited out of network benefits. You may access the United Healthcare website at https://welcometouhc.com/uhss, or you may call (844)-849-5748. If you have trouble accessing the website, or have trouble maneuvering the site, you may call the Fund Office at 800-258-6534 and our staff will be glad to walk you through the website to locate a physician or facility. (See Pages 21-22 in the Summary Plan Description)
A deductible is an amount that you must meet or pay before the Plan begins to make payments on your claims. The Fund has a deductible of $400.00 per person, $800.00 per family. This means that if you are the only one covered, you will meet a $400.00 deductible before the Fund will begin to make payment on your claims. That being said, there are some services that do not require you meet a deductible before we begin paying; office visits, routine physicals, well child visits, mammograms are examples of services that are not subject to deductible. (See Covered Preventative Services, beginning on Page 28 in the Summary Plan Description)
Coinsurance is the part that you are responsible for after the Fund makes payment on your claim. For example, say that you don’t feel well, and you go to the doctor. The doctor files a claim for $100.00. When the Fund receives the claim, we will process the office visit. Since the office visit is not subject to deductible, the claim will process and make a payment of 85% of the allowed amount. Let’s say the entire billed amount of $100.00 is allowed. The Fund will pay the doctor $85.00, and the part you are responsible for is $15.00 coinsurance. What the Fund pays, and your coinsurance adds up to the $100.00 that the doctor billed.
Depending on your situation and how often you use your benefits, will determine who you ‘pay’ your deductible to. Whenever the Fund processes a claim for you and/or for one of your dependents, we send you an Explanation of Benefits. This explanation will tell you who filed the claim (provider of the service), how much they billed, what was allowed, and what we paid, applied to deductible, etc., and what your responsibility is. If any part of the claim was disallowed or denied, there will also be an explanation as to why. A good idea would be to match the Explanation of Benefits we send to you with the bill or statement you receive from the provider to make sure you are paying the correct amount. Depending on the services you have received, your deductible may be taken by one claim, or it may be met over several claims. You can always call the Fund Office at (800)-258-6534 if you have any questions. We are happy to help you.
Dental Benefits FAQs
The Dental benefit does not have a network for regular dental care. There are certain times that dental care may be considered through your medical benefit. Have your dentist call the Fund office for information about your benefits and how to submit dental claims.
If your benefits have not terminated, the provider is probably not using the correct information to locate your benefits. They MUST call the Fund office rather than United Healthcare for your eligibility.
Dental benefits are listed on pages 40-42 in the Summary Plan Description. If you have more questions, please call the Fund office.
The amounts of coverage cannot be increased. In certain instances, the Family Supplemental Benefit can be used for part of your dental claim that exceeds the annual Dental Benefit maximum. Please refer to pages 36-37 in the Summary Plan Description or call the Fund office for more information.
Vision Benefits FAQs (Plan E Only)
The Vision Benefit is for those with eligibility in Plan E only. The benefit is limited for adults covered under the Plan but is extended for children until the end of the month in which they attain age 19. See pages 38-39 in the Plan E Summary Plan Description.
If your eligibility is in Plan D, please refer to pages 36-37 regarding the Family Supplemental Benefit to see if it can be used for your vision claim. If you have more questions, please call the Fund office.
If your Plan has a Vision Benefit, the amounts of coverage cannot be increased. Please refer to pages 36-37 regarding the Family Supplemental Benefit to see if it can be used for your vision claim.