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Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

AMENDMENT NO. 3
TO THE SUMMARY PLAN DESCRIPTION OF THE SOUTHERN CALIFORNIA IBEW-NECA HEALTH TRUST FUND ACTIVE HEALTH PLAN
(RESTATED AS OF JULY 1, 2022)

This Amendment to the Southern California IBEW-NECA Health Trust Fund, Active Health Plan Summary Plan Description (“SPD”) is made by the Board of Trustees of the Southern California IBEW-NECA Health Trust Fund (“Board of Trustees”) with reference to the following facts and circumstances:

  1. The Board of Trustees wishes to amend the SPD to reflect the changes in the hours requirement for initial and reinstatement of eligibility from 115 to 120 effective with the January 1, 2024 work month, as well as to increase the Hours Bank Reserve maximum from 690 to 720.
  2. The Board of Trustees also wishes to amend the SPD to reflect the termination of the COBRA subsidy benefit effective with the January 1, 2024 eligibility month.
  3. The Board of Trustees wishes to amend the SPD to reflect the termination of Anthem Blue Cross PPO Plan and implementation of the Blue Shield PPO plan with status quo benefits effective January 1, 2024.
  4. The Board of Trustees wishes to amend the SPD to reflect changes to the Kaiser and UnitedHealthcare HMO Plans effective January 1, 2024 outlined below.

    UnitedHealthcare
    1. Office Visit Copayments — Increase the copayments from $5 per visit to $20 per visit for most primary care visits including urgent care.
    2. Prescription Drug Copayments — Increase the prescription drug copayments from $20 brand-name retail prescription up to a 31-day supply to $30 per brand-name retail prescription up to a 31-day supply. Additionally, change the brand-name mail order service copayment from $40 up to a 90-day supply to $60 brand name through mail order service up to 90-day supply.


    Kaiser Permanente
    1. Hospital Admission and Outpatient Surgery Copayment — Increase from $0 per admission to $250 per admission for hospital admission and from $5 per procedure to $250 per procedure for outpatient surgery.
    2. Ambulance Services — Change from $0 per trip to $100 per trip.
    3. Emergency Room Services — Change from $5 per visit to $100 per visit.
    4. Office Visit Copayments — Increase from $5 per visit to $20 per visit for most primary care visits, including urgent care, and $25 per visit for most physician specialist visits, including infertility visit.
    5. Prescription Drug Copayments — Increase the prescription drug copayments from $0 per generic retail prescription up to a 100-day supply and $10 brand-name prescription up to a 100-day supply to $10 per generic retail prescription up to 30-day supply and $30 per brand-name prescription up to a 30-day supply. Additionally, change the generic mail order service copayment from $0 up to a 100-day supply and $10 for brand-name mail-order service prescription up to a 100-day supply to $20 generic per mail order service up to 100-day supply and $60 brand name through mail order service up to 100-day supply.
    6. Mental Health Services Inpatient — Increase the inpatient psychiatric care copayment from $0 per admission to $250 per admission.
    7. Mental Health Outpatient — Increase the outpatient individual therapy visit from $5 per visit to $20 per visit and the outpatient group visit from $2 per visit to $10 per visit.
    8. Chemical Dependency Services Inpatient — Increase the inpatient chemical dependency services copayment from $0 per admission to $250 per admission. Additionally, increase the Transitional Residential Recovery Services Copayment from $0 per admission to $100 per admission.
    9. Chempical Dependency Services Outpatient — Increase the outpatient services copayment from $5 per visit to $20 per visit for individual visits and from $2 per visit for group visits to $5 per group visit.
  5. The Board of Trustees has reserved to themselves the ability to amend the SPD from time to time.

NOW THEREFORE, effective January 1, 2024, the SPD is amended as follows:

  1. All references in the SPD appearing at Article 3, General Plan Definitions, Article 4, Eligibility and General Plan Provisions, Article 17, Disclosure Information, and elsewhere in the SPD are amended to replace the eligibility requirement of "115 hours" to "120 hours", and the Hours Bank Reserve not to exceed from "690 hours" to "720 hours"
  2. Article 4, subsection 4.2, Example 2 is amended by providing clarification to the example provided as follows:
    Example 2: You work 30 hours in January, February, March and April and the employer(s) reported and paid the contributions in February, March, April and May. By the end of May, you have worked 120 hours and the contributions have been received on your behalf, and you will be eligible for coverage August 1st.
  3. All references to the "Anthem Blue Cross PPO" plan will be deleted and replaced by "Blue Shield PPO Plan" throughout the SPD.
  4. Article 16, Nine Federal Laws You Should Know About, Section 16.1.B, Subsidized COBRA, is deleted in its entirety effective January 1, 2024 eligibility month.
  5. All references to the Subsidized COBRA will be deleted throughout the SPD.
  6. Article 6, Comparison of Blue Shield PPO, Kaiser Permanente HMO and UnitedHealthcare HMO Medical/Prescription Plans, Section 6.1, Medical and Prescription Benefits Comparison: Blue Shield PPO, Kaiser Permanente and UnitedHealthcare is amended as follows:

    Medical and Prescription Benefits Comparison: Blue Shield PPO, Kaiser Permanente and UnitedHealthcare
    Comparison of Medical/Prescription Plan Offerings
    This is only a summary of the benefits available to you under the Blue Shield PPO Plan and the Kaiser and UnitedHealthcare HMO Plans. For a complete description of the respective PPO or HMO's benefits, please refer to the carrier's EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT. The EVIDENCE OF COVERAGE AND DISCLOSURE DOCUMENT is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures. Additionally, the Summary of Benefits and Coverage (SBC) are available, routinely distributed and appear on the Trust Funds' website at www.scibew-neca.org.
    Vendor Blue Shield PPO Kaiser Permanente HMO UnitedHealthcare HMO
      In Network Out-of-Network In Network Only In Network Only
    Member Customer Service Number (855) 599-2650 (800) 464-4000 (800) 624-8822
    Website www.blueshieldca.com/pponetwork www.members.kp.org www.myuhc.com
    General Features
    Calendar Year Deductible $1,000 per individual, $3,000 per Family None None
    Maximum Benefits Unlimited Unlimited Unlimited
    Annual Co-payment Maximum $2,500 per individual, $5,000 per family $1,500 per Individual, $3,000 per family $2,500 per Individual. $5,000 per family
    Hospital Benefits 10% co-payment. Hospital Pre-Certification Required. 30% co-payment additional $200 deductible for non-Blue Shield PPO Hospital or Residential Treatment Center. Hospital Pre-certification Required.2 $250 co-payment per admission $250 co-payment per admission
    Emergency Services
    Co-payment waived if admitted
    10% co-payment 1 10% co-payment. 2 $100 co-payment $250 co-payment
    Urgently Needed Services
    Medically Necessary services required outside geographic area service by Primary Medical Group
    10% co-payment 1 30% co-payment. 2 $20 co-payment $20 co-payment
    Preexisting Conditions All Medically Necessary conditions are covered, provided they are a covered benefit.
    Benefits Available While Hospitalized as an Inpatient
    Alcohol, Drug or Other Substance Abuse Detoxification 10% co-payment 1 30% co-payment 2 $250 co-payment per admission $250 co-payment per admission
    Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). 10% co-payment 1 30% co-payment 2 $250 co-payment per admission $250 co-payment per admission
    Newborn Care 10% co-payment 1 30% co-payment 2 No Charge No Charge
    Reconstructive Surgery 10% co-payment 1 30% co-payment 2 $250 co-payment per admission $250 co-payment
    Rehabilitative Care (including physical, occupational and speech therapy) 10% co-payment. Must obtain prior approval. 1 30% co-payment (Up to $35 max benefit per visit.)2 $250 co-payment per hospital admission $250 co-payment per admission
    Skilled Nursing
    Up to 100 Consecutive Days from the first treatment per disability
    10% co-payment. 1 30% co-payment. 2 No Charge $250 co-payment per admission
    Voluntary Termination of Pregnancy (Medical, Medication and surgical) No Charge No Charge No Charge No Charge
    Benefits Available on an Outpatient Basis
    Ambulance 10% co-payment 1 10% co-payment 2 $100 per trip No Charge
    Alcohol, Drug, or Other Substance Abuse Services 10% co-payment 1 30% co-payment 2 $20 co-payment per individual visit; $5 co-payment per group visit $20 per visit
    Durable Medical Equipment 10% co-payment. 1 30% co-payment. 2 No Charge No Charge
    Durable Medical Equipment for the Treatment of Pediatric Asthma (includes nebulizer, peak flow meters, face masks and tubing for Medically Necessary Treatment of Pediatric Asthma of dependent children under the age of 19) 10% co-payment. 1 30% co-payment. 2 No Charge No Charge
    Immunizations (For Children Under two (2) years of age, refer to well-baby care) No Charge 30% co-payment 2 No Charge No Charge
    Laboratory Services (When available through or authorized by PCP) 10% co-payment. 1 30% co-payment. 2 No Charge No Charge
    Maternity Care, Tests Procedures 10% co-payment. 1 30% co-payment. 2 No Charge No Charge
    Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and children and the treatment of Serious Emotional Disturbance (SED). 10% co-payment 1 30% co-payment 2 $20 per visit $25 per visit
    Physician Office Visits and Specialty Office Visits 10% co-payment 1 30% co-payment 2 Office Visit $20 co-payment; Specialty Visit $25 co-payment Office Visit $20 co-payment; Specialty Visit $25 co-payment
    Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility 10% co-payment 1 30% co-payment 2 $20 co-payment $20 co-payment
    Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility 10% co-payment. 1 30% co-payment. 2 $250 co-payment No Charge
    Preventive Care
    Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children).
    No Charge 1 30% co-payment 2 No Charge No Charge
    Well-Baby Care (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AA), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Care Task Force and authorized through PCP for children). No Charge 1 30% co-payment 2 No Charge No Charge
    Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force). No Charge 1 30% co-payment 2 No Charge No Charge
    1. Subject to the annual deductible.
    2. Subject to the annual deductible and balance billing.
    Prescription Drugs Available on an Outpatient Basis:
    You must use a generic drug substitute whenever it is available. If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, are detailed below:
    Retail Pharmacy; Tier 1 (except Kaiser, Tier 1 represents mostly generic drugs and some brand name drugs) $10 up to a 30-day supply $10* up to a 30-day supply 1 $10 up to a 30-day supply for generic drugs $10 up to a 31-day supply
    Retail Pharmacy; Tier 2 (except Kaiser, Tier 2 represents mostly brand drugs and some generic name drugs) $20 up to a 30-day supply $20* up to a 30-day supply 1 $30 up to a 30-day supply for brand name drugs $30 up to a 31-day supply
    Mail Order; Tier 1 (except Kaiser, mostly generic drugs and some brand name drugs) $20 up to a 90-day supply N/A $20 up to a 100-day supply for generic drugs $20 up to a 90-day supply
    Mail Order; Tier 2 (except Kaiser, mostly brand drugs and some generic name drugs) $40 up to a 90-day supply N/A $60 up to a 100-day supply for brand name drugs $60 up to a 90-day supply
    1. Blue Shield PPO non-network pharmacy claims -You must file a claim to be reimbursed for your drugs within 15 months of the purchase. This option is intended for emergencies or when travelling only. Reimbursement is limited based on the price you paid for the prescription.

All other terms and conditions of the Summary Plan Description and Plan, shall remain in full force and effect.

Executed this 19th day of October 2023 at Pasadena, California.

BY: Signature on File
Chairman — Joël Barton

BY: Signature on File
Secretary — Jim Willson