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Active Health Plan Benefit Tabs™

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.


UnitedHealthcare is a network model Health Maintenance Organization (HMO). It contracts with doctors who are in private practice or are part of established Medical Groups. You choose a participating Medical Group and from that Medical Group you must select a primary care physician (PCP). Your PCP will be responsible for all of your healthcare needs, and will refer you to a specialist when necessary. Note that certain providers allow for annual enrollments only.

Lifetime Maximum

No plan maximum

Annual Copayment Maximums

$2,500/individual and $5,000 for family

Inpatient Hospital Charges

$250 per admission

Outpatient Office Visits and Most Outpatient Services

Your copayment is: $5 (for most primary care visits)
$25 (for most physician specialist visits)

Other Outpatient Services
  • Ambulance - Paid in Full
  • Cochlear Implants - Paid in Full
  • Health Education Services - Paid in Full
  • Home Health Care Visits (Up to 100 per calendar year) - Paid in Full
  • Hospice Care (Prognosis of life expectancy of one year or less) - Paid in Full
  • Laboratory and Radiology - Paid in Full
  • Maternity Care, Tests and Procedures - Paid in Full
  • Outpatient Surgery at a participating Free-Standing or Outpatient Facility - Paid in Full
  • Well-Baby Care - Paid in Full
Emergency Services and Urgently Needed Services

$250 Copayment unless admitted to hospital.


The Chiropractic benefits covers the services described in this section when performed by a Participating ACN Group, Inc. Chiropractor and authorized when necessary by ACN Group, up to the Annual maximum Benefit listed.

  • Copayments for Each Visit - $5.00
  • Annual Maximum Benefit - 30 Visits
  • Annual Maximum Benefit for Chiropractic Appliances - $50.00

BIN/PCN/Submitted Group
BIN: 610279
PCN: 9999