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IBEW Local 11-LA NECA Retiree Health Plan
Summary Plan Description (SPD)

Introduction

The Claims & Appeal Rules described in this section do not apply to the following plans:

  1. Kaiser Permanente HMO Medical Plan (includes the Kaiser Permanente vision benefit)
  2. PacifiCare HMO Medical Plan
  3. CIGNA Dental Plan
  4. DeltaCare USA
  5. United Concordia Dental Plan
  6. Safeguard Dental Plan
  7. PacifiCare Behavioral Health Integrated Member Assistance & Managed Mental Health & Chemical Dependency Program
Benefits provided by the above Health Maintenance Organizations (HMO’s) or Dental Maintenance Organizations (DMO’s) are subject to the claims and appeal rules established by each of the above providers.  You should contact the provider directly for its claims review or grievance procedure.  The Administrative Office can provide you with information on where to write.

Federal regulations apply to the processing of claims and appeals.  The only claims and appeals processed by the Trustees are those related to eligibility and those involving the three programs set forth below:
  1. Mandatory Generic Prescription Drug Plan
  2. Self-Funded Dental Plan
  3. Self-Funded Vision Service Plan (except Kaiser Permanente participants-Kaiser Permanente maintains its own plan)
It is the intent and desire of the Trustees that these rules be consistent and complies with applicable regulations, including but not limited to 29 CFR 2560. et. seq.  These rules shall be construed in accord with that intent.  Those regulations are incorporated here as though set forth in full.  The regulations shall be construed in accord with Department of Labor guidance issued subsequent to issuance of the regulations.
 

 

 

 

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