Medical Plan & Weekly Disability Benefits

Medical Benefits

  Preferred Provider
Organization (PPO)
Health Maintenance Organization (HMO)
Plan Administrator

Your medical PPO network is being administered by Blue Shield of California

The Fund has HMO contracts with Kaiser Foundation Health Plan and PacifiCare for hospital and medical care.

How the Plan Works

Under the PPO plan, providers charge fees when you use their services. The Plan pays a percentage of the allowable charges (after you have met the deductible, if applicable). You pay the remaining percentage (your co-pay) and any charges that are not covered. You may use the providers of your choice, but you can receive a higher level of benefits coverage by using (PPO) providers—hospitals, doctors, and other health care professionals who have agreed to accept reduced fees for their services.

For an overview of your medical benefits go to page 33 of your Summary Plan Description.

To be eligible for either HMO, you must reside within their service area.

Most care will be provided at no charge or in exchange for a specified co-pay (a fixed dollar amount), and you will not have to worry about filling out claim forms. However, except in an emergency, you should use only the health care professionals and facilities that are part of the HMO. If you use other providers, no benefits will be paid.

For an overview of your medical benefits go to page 33 of your Summary Plan Description.

Employee Assistance Program (EAP)

The EAP provided by MHN is available to you and your eligible dependents regardless of which medical plan you elect. The EAP can help you when you are faced with personal problems. An MHN representative will also assist you in obtaining access to the appropriate care under your medical program. Contact MHN at 1-800-646-9923. MHN will not charge you for its services, so there will be no claim to file.

Mental Health and Substance Abuse Benefits

A mental health and substance abuse plan is available for you and your dependents through MHN, if you are enrolled in the medical PPO plan option. If you are enrolled in a Kaiser HMO plan, your mental health and substance abuse benefits will be provided under that plan and you should refer to the materials from Kaiser for information. Refer to your Schedule of Benefits on page 33 of your Summary Plan Description for complete details on mental health and substance abuse benefits.

Weekly Disability Benefits (for Members Only)

Allows for the provision of benefits should you become unable to work due to an accidental injury or a sickness.

Eligibility

You are entitled to receive weekly disability benefits if you become wholly and continuously disabled and are unable to work due to an accidental injury or illness. You must be under the care of a physician to receive benefits, and the Administrative Office must be provided with proof of the disability.

Benefit

Either $85 per week or 35 percent of your basic weekly salary (not including overtime payments and bonuses). Refer to your Schedule of Benefits by Employer to find the amount of weekly benefit you are entitled to.

Length of Benefit

You may receive disability benefits for up to 26 weeks. Disabilities that occur less than 2 weeks apart will be considered as one continuous period of disability.

When Payments Start

  • Benefits for a disability caused by an accidental injury can begin on the first day of your disability.
  • Benefits for a disability due to an illness can begin on the fourth day of your disability.

Frequency of Payments

Benefits will be paid twice a month during the period of disability.

Filing a Claim

To file a claim for weekly disability benefits, you must establish proof of your disability. Click here for the necessary form or call the Administrative Office at Phone: (925) 954-1439. You will need to provide:

  • Proof that your disability started during a period when you were working for a participating employer who contributes to this benefit;
  • Proof of entitlement to benefits under Workers’ Compensation or State Disability; and
  • A doctor’s certification in writing that as a result of illness or injury, you are unable to perform any and every aspect of your job.

Mail your claim with the required proof and certification to the following address:

Los Angeles Machinist Benefit Trust
3313 Vincent Rd. #216
Pleasant Hill, CA 94523
Phone: (925) 954-1439
Fax: (925) 405-0659