Health Benefits Extension using PTO Election Form

IMPORTANT DEADLINE OF JANUARY 20, 2021. FAILURE TO COMPLETE THIS FORM BY THE DEADLINE WILL AUTOMATICALLY BE CONSIDERED AN ELECTION INTO TIER I.

During this time only, you may elect to use your Personal Time Off (PTO) for health benefits coverage as follows:

TIER I OPTION

If you elect to use thirty-five (35) hours of PTO for health benefits coverage, the Employer contributions on such PTO will grant you one (1) week (i.e., seven (7) days) of Tier I health benefits coverage, as described below. For these purposes, the “Tier I” option means you will have full health plan coverage same as that which has been provided through the Industry-wide extension.

If you are a regularly scheduled part-time employee who works at least fourteen (14) hours per week, and you elect to use the number of vacation, sick, or personal hours equal to the number of hours you are normally (i.e., regularly) scheduled to work in a week, the Employer contributions on such PTO will grant you one (1) week (i.e., seven (7) days) of health benefits coverage under Tier I.

TIER II OPTION

If you elect to use fifty-six (56) hours of PTO for health benefits coverage, the Employer contributions on such PTO will grant you one (1) month (i.e., thirty (30) days) of Tier II health benefits coverage, as described below. For these purposes, the “Tier II” option means you will have access to services at your applicable Health Center, the Members’ Health Assistance Program (MHAP) and prescription drug coverage. Note, coverage for hospital, outside physician referrals, out-of-area medical (EPO) and dental benefits are NOT covered under Tier II.

Please note, once you select either the Tier I or Tier II option, you will not be able to select a different option. Please contact the Fund Office with any questions you may have regarding using PTO for health benefits coverage.

Please check the applicable next to either Tier I or Tier II to make your election.