General Discussion - Choosing A Medical Plan That Best Suits Your Needs

As a participant in the Southern California (Local 11) IBEW-NECA Active Health Plan, you are given a choice of two Health Maintenance Organizations (HMOs, for short) and the Self-Funded Indemnity Plan. You can select from among the three Plans offered, which are Kaiser (HMO), PacifiCare (HMO), and the Self-Funded Indemnity Plan with a Anthem Blue Cross PPO option (called Prudent Buyer). As explained under the section, "Rolling Twelve-Month Open Enrollment Procedure," you are allowed to change your choice of Plans once each year.

This section is intended to help you become acquainted and familiar with the medical Plans being offered to you. Following this section and the Summary Comparison of Hospital/Medical Plans there is a separate section describing each medical Plan in greater detail.

HMO Medical Plans - Kaiser & PacifiCare

A Health Maintenance Organization consists of a network of health care providers who have contracted with Kaiser (Kaiser Plan) or PacifiCare of California (PacifiCare Plan) to provide medical services to eligible participants. Each HMO has descriptive literature, which explains the services and benefits provided, as well as the Plan limitations and exclusions.

The HMO you select (Kaiser or PacifiCare) will provide you with complete descriptive literature after you enroll, including an identification card. The medical facilities you must use are listed in the HMO packet you will receive. Importantly, you must use the doctors and hospitals associated with the HMO you select.

In order to enroll in an HMO, you must live or work within that HMO's service area. For Kaiser, your home or principal place of work zip code must be included within Kaiser's zip code listing. For PacifiCare, you must live or work within a 30-mile radius of the Medical Group selected.

Under the HMO Plans, covered services are generally provided without charge, or for a fixed copayment.

In the following sections, we have provided you with general information for each of the two HMO's under contract with the Trust. However, this information is only a summary, included herein for easy reference. For complete information on any of the HMO Plans, you should contact the HMO directly or the Administrative Office and request that they send you complete descriptive literature for the specific HMO in which you are enrolled.

Self-Funded Hospital/Medical Indemnity Plan

The Self-Funded Hospital/Medical Indemnity Plan provides you with freedom of choice in selecting a doctor. However, in order to maximize Plan benefits, it is suggested that you use doctors and hospitals, which are part of the Anthem Blue Cross Prudent Buyer PPO, called "Participating Providers." When you use health care providers that are not on the Anthem Blue Cross PPO, you may incur substantial out-of-pocket costs.

You should carefully review the benefits of the Indemnity Plan to make certain it fits your needs, and that you understand what will be your financial obligation (out-of-pocket costs) under this Plan.

Additional information is provided in the following section.