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Self-Payment Contributions

If you are:

• Not eligible for Medicare or have an Eligible Dependent who is not eligible for Medicare, the self-payment required for your Retiree Program coverage is 60% of the self-payment required for normal continuation of eligibility for Active Employees.
• Eligible for Medicare and have an Eligible Dependent who is also eligible for Medicare, the self-payment required for your Retiree Program coverage is 40% of the self-payment required for normal continuation of eligibility for Active Employees.
• Eligible for Medicare and do not have an Eligible Dependent, the self-payment required for your Retiree Program coverage is 40% of the self-payment required for normal continuation of eligibility for Active Employees.

Self-payments must be received at the Fund Office within 10 days of the date you receive the self-payment notice. All notices are sent by mail to the last known address on file at the Fund Office, so it is important that any address changes be reported immediately.

Self-payments are required on a quarterly basis in accordance with the Benefit Quarters defined by the Plan’s Eligibility Rules. A change in coverage circumstances (such as eligibility for Medicare) will re-determine the Eligible Person’s benefits effective the first day of the calendar month coincident with or next following the date the change in circumstances occurs. This benefit is described in detail in the Health and Welfare Summary Plan Description (SPD) booklet.