Summary of Hospital & Medical Benefits

Only non-occupational accident or illness is considered a covered expense under the Indemnity Plan.

For your convenience, this Summary Plan Description provides a brief outline of your benefits under the Indemnity Plan. Complete terms of the Plan are governed by the Southern California IBEW-NECA Active Health Plan Document.  If you require additional information concerning the benefits or exclusions of the Plan, please call or write Anthem Blue Cross.

All benefits of the Indemnity Plan are subject to coordination of benefits under certain other plans. Refer to the table of contents titled "Self Funded Indemnity Plan with Anthem Blue Cross Prudent Buyer Plan (PPO)" subtitle "Coordination of Benefits" section for details.

The benefits of the Indemnity Plan are subject to reimbursement for acts of third parties. Third party means that injuries sustained by you were the result of the fault (negligence or carelessness) of a third party or parties. Under these circumstances, what is called a "Subrogation Agreement & Assignment of Benefits" will need to be signed before Plan benefits are payable. Refer to the section titled "Indemnity Plan General Plan Exclusions" subtitle "Reimbursement for Acts of Third Parties" for details.

Deductible

You and each eligible dependent must satisfy a $200 calendar year deductible before benefits are payable. Plan benefits are payable after you or an eligible dependent have satisfied the first $200 of covered expenses in a calendar year. Please refer to the Family Limit section below.

If you use a non-participating hospital, there is a separate deductible of $200 per hospital confinement. Refer to section titled "Self Funded Indemnity Plan with Anthem Blue Cross Prudent Buyer Plan (PPO)" subtitle "Introduction" which explains the meaning of the term "non-participating." The hospital deductible will apply when the hospital makes a room and board charge. When you use a Anthem Blue Cross Prudent Buyer hospital, this deductible is waived if hospital confined.

Family Limit on Annual Deductibles

There is a maximum of three accumulative deductibles per family ($600) during any calendar year. When three or more eligible family members satisfy the family cash deductible of $600 maximum in the same year, each additional eligible family member is considered as having satisfied their deductible that year.

For example, let us assume there is a family of six covered under the Plan. Mom and Dad and two of the children each have covered expenses of $150. In this example, the family deductible for the calendar year has now been satisfied for all family members because the $600 accumulative ($150 x 4 = $600) deductible has been met.

In another example, let us assume there is a family of three covered under the Plan. Mom and Dad each have covered expenses of $250. The maximum allowable deductible per person toward the family deductible is $200. Therefore, in this example, Mom and Dad each have met their $200 deductible and are eligible to receive benefits ($400 accumulative), however, the third family member will also have to meet his/her $200 deductible for the calendar year before benefits would be payable for that dependent only.

Additionally, if two or more eligible family members are injured in the same accident, only one deductible will be applied to that calendar year against expenses related to the accident.

A new deductible will apply each calendar year. However, if all or any portion of the deductible amount for a participant has been satisfied during the last three months of a calendar year (October through December), you may apply eligible expenses for the last three months to the next year's deductible.

For example, if you are credited with $75 toward your individual deductible during the month of October and an additional $25 in December, $100 will apply toward your deductible for the following year.

Lifetime Maximum - $1,000,000

Increased from $400,000, by Amendment 14

The maximum benefit that will be payable under the Indemnity Plan for any participant, Employee or eligible dependent, during his or her lifetime is $1,000,000.

Copayment

Participating Prudent Buyer Providers
After you have satisfied any applicable deductible, the Plan will pay 90% of the Prudent Buyer contract rate up to $12,500  per calendar year, and 100% of the contract rate over $12,500 per family per calendar year.

Your copayment will be 10% of the Prudent Buyer contract rate up to $12,500 per calendar year. Participating Prudent Buyer physicians, hospitals, and other health care providers have agreed to accept a reduced, pre-negotiated rate for medical expenses covered by the IBEW-NECA Indemnity Plan. Therefore, your copayment will not exceed 10% of the contract rate for covered medical expenses.

Non-Participating Providers
For a definition of non-participating providers, refer to section titled "Self Funded Indemnity Plan with Anthem Blue Cross Prudent Buyer Plan (PPO)" subtitled "Introduction". After you have satisfied any applicable deductible, the Plan will pay 80% of the first $12,500 of family covered charges, based on a fixed schedule of benefits. The Plan will pay 100% of covered charges over $12,500 per family every calendar year, based on a fixed schedule of benefits.

Required Hospital Pre-Certification Program - Penalty For Non-Compliance

All non-emergency hospitalizations must be approved (prior authorization) before you are admitted to the hospital.

For an emergency admission, Anthem Blue Cross must be notified within "one working day" of the admission, unless extraordinary circumstances prevent such notification within that time period.  In determining "extraordinary circumstances", Anthem Blue Cross may take into account whether or not the patient’s condition was severe enough to prevent him/her from notifying Anthem Blue Cross, or whether or not a family member was available to notify Anthem Blue Cross.  The enrolled member may have to prove that such "extraordinary circumstances" were present at the time of the emergency.

When you use a Prudent Buyer doctor and hospital, the pre-certification and approval process will take place automatically with no action required on your part. If you go to a hospital, which is not on the Prudent Buyer list, your non-emergency hospitalization will need to be approved in advance. This can be accomplished by phoning the utilization review number shown on your Anthem Blue Cross Identification Card. If you have any questions, phone the Administrative Office and ask for the Membership Services Department.

If your non-emergency hospitalization at a non-PPO hospital is not authorized in advance, benefits otherwise payable may be reduced up to $500. No Plan benefits will be payable for days in the hospital which are not determined to be medically necessary.