Medical Plan Forms

This page provides a description of and links to National IAM Benefit Trust Fund forms related to Fund medical plans. Click the form titles in the table below to review or download copies.

FormDescription

Authorization Form (PDF)

Participants in a Benefit Trust Fund medical plan can authorize the Fund to disclose the participant's Protected Health Information to designated individuals. Complete and submit this form to provide such authorization.

Cancellation of Authorization Form (PDF)

If a participant in a Benefit Trust Fund medical plan has authorized the Fund to disclose the participant's PHI but no longer wishes the Fund to do so, the participant must complete and submit this form.

Disabled Dependent Certification Form (PDF)

Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the enrollment form.

Eligible Dependent Certification Form (PDF)

Eligible employees who designate eligible dependents who are not the employees' biological children, or who have a different last name from the employee, must certify the dependent's eligibility for coverage by completing and submitting this form in addition to the enrollment form.

Enrollment Form (PDF)

Eligible employees may enroll in a National IAM Benefit Trust Fund medical plan by completing and submitting this form. This form is also used to enroll eligible dependents.

Medical Claim Form (PDF)

In some cases, medical providers may require participants to submit a medical claim on their own. To submit a medical claim, download and fill out the Medical Claim Form and send it to CIGNA. Detailed instructions are on the Form.

Physician Certification of Disability Form (PDF)

Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the enrollment form. The Physician Certification of Disability Form must be completed by both the employee and the dependent's attending physician.

Waiver Form (PDF)

Eligible employees wishing to waive coverage must complete and submit this form.

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The Enrollment Form is also used to enroll eligible dependents.

Frequently Asked Question (FAQ)

How many different plans does the Fund offer?

The Fund offers multiple Medical, Dental, and Vision plans. Short-Term Disability and Life and Accidental Death & Dismemberment benefits are also available.

How do I notify the Fund of my address change?

If you move, please notify the Fund of your new address. To change your address,
fill out a new Enrollment Form and mail or fax it to the Fund using the mailing address or fax number found on the form. Always complete a new Enrollment Form when you have a change in personal information.

Do Medical Plans include Prescription Drug Coverage?

Yes. Our Plans include excellent prescription drug benefits.

What is a PPO?

A Preferred Provider Organization is a type of medical plan that covers the cost of eligible medical care and services received from network and non-network providers. Network providers (primary care doctors, specialists, hospitals, and other medical facilities) agree to a discounted fee schedule for services provided. When a participant or covered family member sees a network provider for care, the participant pays less out of pocket because of the discounted fees. The Fund contracts with CIGNA Healthcare for the use of their nationwide network of participating providers. There are currently more than 750,000 participating providers in the CIGNA "Open Access Plus" Network—the network used by the Fund’s medical plans.

Are participants required to receive services only from a PPO provider?

No. Participants have the choice of selecting a non-PPO physician. However, receiving services from a physician who participates in the CIGNA network may result in significant savings for participants.

Must participants have a referral from their primary care physician in order to see a specialist?

No. Referrals are not required.

Who processes health care plan claims?

Medical claims are processed by CIGNA Healthcare. Dental claims are processed by Delta Dental Insurance Company, and Vision claims are processed by Fund Office staff.

Do the Fund plans have a waiting period for "pre-existing conditions" under the medical plans?

No. The waiting periods for pre-existing conditions were waived for all plans by the Board of Trustees.

What are the age limits for dependent children?

Children can be covered dependents until they reach age 26 providing they continue to meet provisions for dependent coverage.

Does the Fund offer COBRA coverage for health care?

Yes. The Fund administers COBRA for its Contributing Employers. Upon notification from the Employer that a participant is losing coverage due to a "qualifying event," the Fund will send notification to the participant advising him or her of COBRA rights to continue health care coverage by making payments to the Fund Office.

Does the Fund offer Retiree Health Care Plans?

Yes. Employers that have negotiated a Benefit Trust Plan for their Active employees may also establish a Retiree plan.

How Do I Find a Contributing Employer?

To find a Contributing Employer click on this link to view a map and listings by territory.

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