Forms & Policies
Level A | Level B | Level C | Fund Policies | Employer Documents
Level A Forms
Level A Enrollment Forms - California Residents
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th).
NOTE: Submitting an enrollment application is not proof of enrollment.
Kaiser Permanente Claim Form for Emergency Medical Services
To request reimbursement for emergency services received at a non-Kaiser Permanente facility.
EyeMed Claim Form
coming soon
Life Application / Beneficiary Form
All eligible participants complete the beneficiary/enrollment form to be enrolled in Life Insurance. Please print and complete this form to designate a beneficiary, return completed form to the Trust Administrative office.
Waiver of Coverage
If you have been notified that you are eligible for benefits, but have decided not to enroll, print and complete. Upon certain conditions you may reserve your and your dependent’s right to enroll at a later date.
Submitting Forms
Claim forms should be sent to the appropriate benefit provider at the address listed on the form.
All other forms should be sent to:
Musicians Health and Welfare
c/o PacFed Benefit Administrators
200 S. Los Robles, Suite 320
Pasadena, CA 91101
Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)
Level B Forms
Level B Enrollment Forms
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th). NOTE: Submitting an enrollment application is not proof of enrollment.
Kaiser Permanente Claim Form for Emergency Medical Services
To request reimbursement for emergency services received at a non-Kaiser Permanente facility.
EyeMed Claim Form
coming soon
Life Application / Beneficiary Form
All eligible participants complete the beneficiary/enrollment form to be enrolled in Life Insurance. Please print and complete this form to designate a beneficiary, return completed form to the Trust Administrative office.
Waiver of Coverage
If you have been notified that you are eligible for benefits, but have decided not to enroll, print and complete. Upon certain conditions you may reserve your and your dependent’s right to enroll at a later date.
Submitting Forms
Claim forms should be sent to the appropriate benefit provider at the address listed on the form.
All other forms should be sent to:
Musicians Health and Welfare
c/o PacFed Benefit Administrators
200 S. Los Robles, Suite 320
Pasadena, CA 91101
Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)
Level C Forms
Level C Enrollment Form
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th). NOTE: Submitting an enrollment application is not proof of enrollment.
Kaiser Permanente Claim Form for Emergency Medical Services
To request reimbursement for emergency services received at a non-Kaiser Permanente facility.
EyeMed Claim Form
Coming soon
Life Application / Beneficiary Form
All eligible participants complete the beneficiary/enrollment form to be enrolled in Life Insurance. Please print and complete this form to designate a beneficiary, return completed form to the Trust Administrative office.
Waiver of Coverage
If you have been notified that you are eligible for benefits, but have decided not to enroll, print and complete. Upon certain conditions you may reserve your and your dependent’s right to enroll at a later date.
Submitting Forms
Claim forms should be sent to the appropriate benefit provider at the address listed on the form.
All other forms should be sent to:
Musicians Health and Welfare
c/o PacFed Benefit Administrators
200 S. Los Robles, Suite 320
Pasadena, CA 91101
Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)
Fund Policies
Reporting Engagements
It is each Employee’s responsibility to notify the Fund of engagements performed. Contributions not received timely, may not be applied to the prior qualifying period and therefore, may affect your eligibility in the Plan. Print and complete the Member Self-Reporting Form to advise the Union and Trust Fund of engagements you have performed. For more information on this subject, please refer to the Summary Plan Description (SPD).
Premium Payment Policy
Monthly member co-premium and dependent premiums are due the first of the month prior to the month of coverage.
Payments are deemed delinquent on the 20th of the month prior to the month of coverage.
A termination notice is sent if payments are not received on the 30th or 31st of the month prior to coverage.
IMPORTANT NOTE: The Fund will send you a monthly premium reminder; however, if you do not receive the reminder it is your responsibility to remit your monthly premium in a timely manner.
Late Enrollment Policy
Applications and/or member co-premium payments received during the month of January will be accepted; however the Fund shall require the remittance of an additional administrative processing fee for either:
a late enrollment (i.e., receipt of an enrollment application form) or
late payment of the required co-premium.
The administrative processing fee is the greater of $25 or 10% of the delinquent premium.
Applications received in February will not be accepted.
Late Payment Reinstatement Policy
Reinstatement requests must be made in writing within 30 days of termination.
The Administrator is authorized to grant reinstatement provided the delinquent premium is received along with the next month’s premium and the applicable administrative fee.
Administrative Fee:
First time delinquency – the greater of $25 or 10% of the delinquent premium
Second time delinquency the greater of $25 or 25% of the delinquent premium
Third time delinquency the greater of $25 or 50% of the delinquent premium
Fourth delinquency will result in loss of coverage
Dependent Re-Enrollment Policy
Termination of Dependent coverage due to non payment of premium or withdrawal from coverage for reasons other than a change in eligibility status will result in the Dependent having to wait a minimum of 12 months from the date of termination before re-enrolling in benefits. Enrollment may then occur only at the Fund’s annual open enrollment period. Dependents may only enroll if the Participant is eligible and enrolled.
Eligibility Appeal
APPEAL TO THE TRUSTEES IF YOUR ELIGIBILITY IS DENIED OR IF YOUR ELIGIBILITY IS CANCELLED OR RESCINDED OR REVOKED
A Claimant, or their duly authorized representative, has the right to appeal the denial of eligibility for participation in the Fund’s benefits and coverages (i.e. failure to attain eligibility), denial of coverage of a Dependent, or rescission of coverage (i.e. revocation of benefits, which may or may not be retroactive) to the Trustees. Claimants who wish to appeal denials or rescissions, of eligibility must submit a written appeal to the Fund Administrator’s Office. The Fund Administrator’s Office will provide the appeal documents to the Trustees. The Trustees shall make a benefit determination no later than the date of the meeting of the Trustees which immediately follows the Fund’s receipt of an appeal. Provided, however, that if the appeal is filed within 30 days preceding the date of such meeting, a final determination on the appeal may be made by no later than the date of the second Trustees’ meeting following the Fund's receipt of the appeal.
The Fund Administrator’s Office shall provide a Claimant with a written or electronic notification of the Trustee’s determination on review. The decision of the Trustees, with respect to any appeal from a denial of eligibility, revocation of enrollment and/or rescission of coverage shall be final and binding and there shall be no other or further level of appeal
Any adverse decision on an appeal shall be written in a manner which is understood by the Claimant and must (i) specify the reason(s) for the adverse determination action taken; (ii) refer to the specific plan provision on which it is based; (iii) state that the Claimant is entitled to receive, upon request, and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claimant’s claim for benefits; (iv) describe any voluntary appeals procedures offered by the Plan and the Claimant’s right to obtain the information required to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal and a statement of the Claimants’ right to bring an action, under Section 502(a) of ERISA.
Employer Documents
Employers participating in the Professional Musicians, Local 47 and Employers’ Health & Welfare Fund may find the following documents of interest. These documents provide information on eligibility, records to be retained by Employers, and guidance on agreements accepted by the Fund.
For additional information, please call the Fund Administration Office at 1-800-753-0222.
Participation Agreement
Proper Completion and Execution of Agreements
Eligibility Rules Pertaining to Participant/Owners
Recommended Records to Retain
Trust Agreement
Questions?
The Fund is administered by PacFed Benefit Administrators (PacFed). Our bilingual staff can help you with enrollment, coverage and HMO claims.
PacFed’s core goal is to ensure that members understand their plan and how to use their benefits effectively. Our Member Services department is available Monday through Friday, 8:30 a.m. to 5:00 p.m. at 1-800-753-0222 or email musicians@pacfed.com.