Active Health Plan Forms

• Claim Forms

  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

  2019 Medicare Part D Notice of Creditable Coverage — Important Notice from Southern California IBEW-NECA Health Trust Fund About Your Prescription Drug Coverage and Medicare

  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 Privacy Notice

  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.

  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.

  VSP HIPAA Privacy Notice — Notice of Privacy Practices for VSP.

• Health Reimbursement Arrangement

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

  HRA Frequently Asked Questions — The following are frequently asked questions regarding the new Health Reimbursement Arrangement ("HRA"). Please note that an HRA account can only be used to pay for eligible expenses allowed under the terms of the Summary Plan Description ("SPD"). You should thoroughly review the SPD for full details regarding this benefit.

• Notice of Creditable Coverage

  2019 Medicare Part D Notice of Creditable Coverage — 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.

• Plan Documents (in English)

  Summary Plan Description (Restated as of 9/1/2017) — For Eligible Active Participants and Their Eligible Dependents.

  Amendment 1 — Amendment No. 1 to the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017.

  Amendment 2 — Amendment No. 2 to the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017.

  Amendment 3 — Amendment No. 3 to the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017.

• Summary Annual Report and Collection Policy

  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 2017.

  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.

• Summary of Benefits and Coverage (SBC)

  Anthem Blue Cross SBC — Summary of Benefits and Coverage (SBC)

  Health Plan Health Reimbursement Arrangement (HRA) — 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).