Southern California IBEW-NECA Retiree Health Plan

Amendment # 12
To the HMO Plans Available to Retirees
As Set Forth in the
Retiree Health Plan Summary Plan Description

Dated October 1, 2006  

Effective for services received on or after July 1, 2008 the office visit copayments for the Kaiser Permanente HMO Medical Plan for Early Retirees, for the PacifiCare HMO Medical Plan for Early Retirees, for the Kaiser-Permanente – Senior Advantage plan, and for the PacifiCare Secure Horizons Group Medicare Advantage Plan are reduced from $15 per office visit to $5 per office visit. Accordingly pages 54-57, 67-69, 86-88 and 96-97 of the Southern California IBEW-NECA Retiree Health Plan Summary Plan Description dated October 1, 2006 are deleted in their entirety and replaced with the respective pages bearing the same page numbers following this page.

APPROVED AND ADOPTED at the Board of Trustees’ meeting held on June 17, 2008.

BY: Signature on File
Chairman

BY: Signature on File
Secretary

Kaiser Permanente HMO Medical Plan for Early Retirees

• This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to Kaiser Permanente Foundation Health Plan, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
• A Health Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Health Plan physician. You must receive the services and supplies at a Health Plan facility or skilled nursing facility inside our Service area, except where specifically noted to the contrary in the Evidence of Coverage.
• For details on the benefit and claims review and adjudication procedures, please refer to Kaiser Permanente Health Plan’s Evidence of Coverage or contact Kaiser Permanente Membership Services at 1(800) 464-4000.

Kaiser Permanente Summary of Benefits for Early Retirees

Chiropractic
Chiropractic benefits are offered through American Specialty Health Plans of California. The co-payment for each visit is $5 for up to 30 visits per year. Please call the Member Services department for a Chiropractic Provider Directory to find a Chiropractor near you at (800) 464-4000. If you have questions about your chiropractic benefits, call ASH Plans Member Services at (800) 678-9133.

PacifiCare HMO Medical Plan for Early Retirees

NOTE: Refer to the section entitled “Mandatory Prescription Drug Plan” for an explanation of your prescription drug coverage unless you are a spouse of a participant enrolled in Secure Horizons. Spouses of Secure Horizons participants are covered under the Secure Horizons Prescription Drug Plan. Refer to the Secure Horizons Plan.

PacifiCare early retiree participants are covered for mental health benefits under a separate “carve out” plan. Refer to the separate Summary Plan Description listed in the Table of Contents under the heading “Mental Health and Chemical Dependency Plan – PacifiCare Early Retirees Only”.

• This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to PacifiCare Health Systems, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
• For details on the benefit and claims review and adjudication procedures, please refer to PacifiCare Health Plan’s Evidence of Coverage or contact PacifiCare Customer Service Department at 1(800) 624-8822.  

PacifiCare Summary of Benefits for Early Retirees

• Service requires pre-authorization from PacifiCare.
• This Co-payment applies regardless of whether this service is performed as an inpatient or on an outpatient basis. If this service is performed on an inpatient basis, you will also be required to pay the applicable inpatient Co-payment for your benefit plan, if any.
• Percentage Co-payment amounts are based upon PacifiCare’s contracted rate.

KAISER PERMANENTE – SENIOR ADVANTAGE  

An HMO with a Medicare Contract Including Prescription Drug Coverage
Kaiser Permanente Senior Advantage is a division of Kaiser Permanente who owns its hospitals and clinics and contracts with Southern California Permanente Medical Group to provide staff at these hospitals and clinics. If you live within the Enrollment Area at the time of enrollment and meet eligibility requirements, you and your spouse may enroll in Kaiser Permanente Senior Advantage.

When you join Kaiser Permanente Senior Advantage, to receive covered benefits, you must select a Kaiser Permanente physician and facility to provide care for you and your spouse. You are not restricted to the use of just one Kaiser Permanente physician or facility, but you are encouraged to select and use the one facility that will be convenient to you.

Kaiser Permanente Senior Advantage Plan benefits apply only when the services are medically necessary, prescribed, or directed by a Kaiser Permanente physician except where specifically stated in “Emergency Services.”

With each office of emergency visit, you will need to present your Kaiser Permanente ID card to the receptionist.

Principal Benefits for Kaiser Permanente Senior Advantage
The Services described below are covered only if all the following conditions are satisfied:

• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Service Area, except where specifically noted to the contrary for authorized referrals, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services described in the Evidence of Coverage

This is a brief summary of the most frequently asked about benefits and their Co-payments and Coinsurance. This chart does not describe benefits and it does not list all benefits, Co-payments, and Coinsurance. Please refer to the Evidence of Coverage to learn about coverage (including exclusions and limitations) and other benefits, Co-payments, and Coinsurance that are not included in this summary. Note: We cover benefits in accord with applicable law (for example, diabetes supplies).

Medicare Eligibility Requirements  

• You must be entitled to benefits under Medicare Part B
• You may enroll in Senior Advantage regardless of health status, except that you may not enroll if you have end-stage renal disease. This restriction does not apply to you if you are currently a Health Plan Member in the Northern California or Southern California region and you developed end-stage renal disease while a Member.
  
  You may not be enrolled in two Medicare-contracting HMOs at the same time. If you enroll in Senior Advantage, CMS will automatically disenroll you from any other Medicare-contracting plan.

Exclusions, Limitations, and Reductions

Exclusions
The Services listed below are excluded from coverage. These exclusions apply to all Services that would otherwise be covered under this EOC. Additional exclusions that apply only to a particular Service are listed in the description of that Service in the "Benefits" section.

PacifiCare Secure Horizons Group Medicare Advantage Plan Summary of Benefits

* Inpatient Hospital copayments are charged on a per admission basis. Original Medicare hospital benefit periods do not apply. For inpatient hospital, you are covered for an unlimited number of days as long as the hospital stay is medically necessary and authorized by PacifiCare or contracting providers. When you are admitted to an inpatient hospital and then subsequently transferred to another inpatient hospital, you pay the copayment charged for the first hospital admission. You do not pay a copayment for the second hospital admission, the copayment is waived.

** A benefit period begins the day you go to a hospital. The benefit period ends when you haven't received hospital or skilled care (in a SNF) for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the skilled nursing facility care copayment, if applicable, for each benefit period. There is no limit to the number of benefit periods you can have.

This is a highlight of benefits only and is not all inclusive of the Plans benefits, services, limitations or exclusions. Please refer to the enclosed Retiree Benefits Summary and your Evidence of Coverage and Disclosure Information for additional details.

Secure Horizons Group Retiree Medicare+Choice Plans are offered by PacifiCare® / PacifiCare® of Colorado, Inc. that contracts with the federal government. Anyone with Medicare Parts A and B may apply. Members must continue to pay the Medicare Part B premium and use contracting pharmacies and providers for routine care. Limitations, copayments and coinsurance will apply. Group Retiree prospects of the Secure Horizons