On This Page:

• Claim Form
• Enrollment/Eligibility
• Evidence of Coverage Documents
• General
• Health Reimbursement Arrangement
• Legally Required
• Notice of Creditable Coverage
• Plan Documents (en Español)
• Plan Documents (in English)
• Summary of Benefits and Coverage (SBC)
• Video Library

Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Office. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.

Claim Form

• Orthotic Reimbursement Form (Active Only) — Complete and return this form when seeking reimbursement for covered orthotic expenses.
• Prescription Drug Program Direct Member Reimbursement — Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement.
• Health Hours Estimation Request — Use this form to request an estimate of your Health Hours for your Retiree Health Plan application.
• Accelerated Death Benefit Claim Form (Active Only) — Use this form to sign up for Anthem Blue Cross' Accelerated Death Benefit for your Group Insurance plan.
• Premium Waiver, Continued Life Insurance, and Total & Permanent Disability Form (Active Only) — Use this form to sign up for continued protection (Premium Waiver during a period of total disability), continued life insurance during total disability, or total and permanent disability.

Enrollment/Eligibility

• Medical and Dental Plan Enrollment (Active Only) — Use this form to enroll yourself and eligible dependents in a Medical and Dental Plan. Your Plan election will remain in effect until the next Open Enrollment Period.
• Health and Dental Plan Family Account Change (Active Only) — Use this form to add or remove a spouse or eligible dependents from coverage in a Health or Dental Plan.

Evidence of Coverage Documents

• Anthem Blue Cross - Prudent Buyer® — Evidence of Coverage Document
• CIGNA Dental Care Insurance - CN002 — Evidence of Coverage Document
• DeltaCare® USA - Dental Health Care Program for Eligible Employees and Dependents - CA10A — Evidence of Coverage Document
• DeltaCare® USA Addendum — Evidence of Coverage Document
• Kaiser Permanente Health Plan - Chiropractic Services Amendment — Evidence of Coverage Document
• Kaiser Permanente Health Plan - Active — Evidence of Coverage Document
• Kaiser Permanente Health Plan - 45% & 50% Sound Apprentice — Evidence of Coverage Document
• Kaiser Permanente Health Plan - Retiree — Evidence of Coverage Document
• OptumHealth - U.S. Behavioral Health Plan, California ("USBHPC") Employee Assistance Program — Evidence of Coverage Document
• SecureHorizons® MedicareComplete® Retiree Plan (HMO) — Evidence of Coverage Document
• United Concordia - Certificate of Insurance — Evidence of Coverage Document
• United Concordia Dental Plans of CA, INC. — Evidence of Coverage Document
• UnitedHealthcare Signature Value™ - Offered by UnitedHealthcare of California - Active — Evidence of Coverage Document
• UnitedHealthcare Signature Value™ - Offered by UnitedHealthcare of California - Retiree — Evidence of Coverage Document

General

• HIPAA Privacy Notice — The Southern California IBEW-NECA Health Plan may use the limited quantity of private health information available, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations.
• Life and Accidental Death & Dismemberment Insurance/Beneficiary Designation Form (Active Only) — Use this form to designate beneficiary(ies) for Life and Accidental Death and Dismemberment Insurance.
• Change of Address — Use this form to change your address. Be sure to fill it out completely and return it to the Trust Office. (English Version)
• Forma Para Solicitar Cambio De Dirección (En Español) — Use esta forma para hacer un cambio de dirección postal.  Asegúrese de completar todos los espacios en la forma, y de enviar la misma a la oficina del Trust Funds.
• Workers Compensation form (Active Only) — Complete this form for consideration of benefits.
• HIPAA Participant Authorization Form — Use this form to instruct the Fund Office to communicate with you at an alternate address regarding your eligibility, carrier changes, etc.

Health Reimbursement Arrangement

• HRA Reimbursement Claim Form — Use this form to submit claims to a Third Party Administrator.

Legally Required

• Collection Policy and Procedures — This explains the Collection Policy and Procedures. Updated October 27, 2016.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2016.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2015.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2014.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2013.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2012.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2011.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2010.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2009.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2008.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2007.
• Summary Annual Report — This describes the status of the fund at the end of Plan Year 2006.

Notice of Creditable Coverage

• 2018 Important Notice from Southern California IBEW-NECA Health Trust Fund About Your Prescription Drug Coverage and Medicare — This notice is to inform you that your current prescription drug benefit program through the Southern California IBEW-NECA Health Trust Fund provides "creditable coverage," as defined below. It also includes answers to questions you may have regarding your current prescription drug program and how it relates to Medicare Part D coverage.

Plan Documents (en Español)

• Descripción resumida del Plan — Para los participantes activos elegibles y sus dependientes elegibles.
• Suplemento a la Descripción Resumida del Plan — Para Aprendices/Participantes de Unidad de Sonido Elegibles a sueldo del 45% y del 50% y sus Dependientes Elegibles.
• Enmienda #1 — Enmienda #1 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #2 — Enmienda #2 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #3 — Enmienda #3 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #4 — Enmienda #4 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #5 — Enmienda #5 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #6 — Enmienda #6 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #7 — Enmienda #7 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #8 — Enmienda #8 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #9 — Enmienda #9 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
• Enmienda #10 — Enmienda #10 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.

Plan Documents (in English)

• Summary Plan Description — For Eligible Active Participants and Their Eligible Dependents.
• Summary Plan Description Supplement — For Eligible Sound Unit 45% & 50% Apprentices/Participants and Their Eligible Dependents.
• Amendment #1 — Amendment #1 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #2 — Amendment #2 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #3 — Amendment #3 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #4 — Amendment #4 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #5 — Amendment #5 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #6 — Amendment #6 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #7 — Amendment #7 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #8 — Amendment #8 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #9 — Amendment #9 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
• Amendment #10 — Amendment #10 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.

Summary of Benefits and Coverage (SBC)

• Anthem Blue Cross SBC — Summary of Benefits and Coverage (SBC)
• Kaiser Active SBC — Summary of Benefits and Coverage (SBC)
• Kaiser 45% & 50% Sound Apprentice SBC — Summary of Benefits and Coverage (SBC)
• Prescription Drug Program SBC — Summary of Benefits and Coverage (SBC)
• UnitedHealthCare SBC — Summary of Benefits and Coverage (SBC)

Video Library

• Review of Plan Eligibility — The Fund Office has prepared a video to understand how to gain and maintain eligibility in the SC IBEW-NECA Health Plan. Take a brief tour and review the video. The video is not a substitute for the Summary Plan Description. Prior to filing any application for benefits, you should thoroughly review the Summary Plan Description (SPD).