Article 5: Choosing Between the HMO Plans and the PPO Plan >>

5.1 Choosing a Medical Plan That Best Suits Your Needs

There are two ways to find out if you live or work within either the UnitedHealthcare or Kaiser Permanente service area. For UnitedHealthcare you can either call Member Services at (800) 624-8822, or you can log on to the UnitedHealthcare website at www.uhcwest.com. For Kaiser Permanente, you can either call Member Services at (800) 464-4000, or you can log on to the Kaiser Permanente website at www.kaiserpermanente.org.

As a Participant in the Southern California IBEW-NECA Health Trust Fund, you may choose to enroll in either of the two Health Maintenance Organizations (HMOs) or in the Blue Shield PPO Plan. The HMO plans are Kaiser Permanente and UnitedHealthcare. As explained in Article 5.3 Rolling 12-Month Open Enrollment Procedure, you are allowed to change your choice of Plans after 12 months of continuous coverage.

This section is intended to help you become acquainted and familiar with the medical Plans available to you. A summary comparison of the two HMO plans and the Blue Shield PPO Plan appears at the end of this section, which provides greater detail regarding your benefits. For detailed and specific information about the benefits, exclusions and limitations of either of the HMO plans (Kaiser Permanente and UnitedHealthcare) or Blue Shield PPO Plan, please refer to the specific Evidence of Coverage document provided by either of the respective HMO plans or the Blue Shield PPO Plan. Copies of Blue Shield's, Kaiser Permanente's and UnitedHealthcare's Evidence of Coverage documents are available from the Administrative Office at no charge, or on the Trust Fund website at www.scibew-neca.org.

A. HMO Medical Plans – Kaiser Permanente and UnitedHealthcare

A Health Maintenance Organization consists of a network of health care providers and facilities. In the case of Kaiser Permanente, the physicians are employees of Kaiser Permanente and Kaiser Permanente typically owns the facilities. In the case of UnitedHealthcare, the physicians are independent practitioners who contract with UnitedHealthcare to provide medical services to eligible participants. UnitedHealthcare also contracts with hospitals and other facilities to provide services to eligible participants. Each HMO provides an Evidence of Coverage document, which explains in detail the services and benefits provided, as well as the limitations and exclusions of their respective plans.

The HMO you select (Kaiser Permanente or UnitedHealthcare) will provide you with an Evidence of Coverage document and other descriptive literature after you enroll, including an identification card. The medical facilities you must use are listed in the HMO packet you will receive. Importantly, you must use the physicians, hospitals and other medical providers associated with the HMO you select.

In order to enroll in an HMO, you must live or work within that HMO's service area. For Kaiser Permanente, the ZIP code of your home or principal place of work must be within Kaiser Permanente's service area which is defined by Kaiser Permanente's ZIP code listing. For UnitedHealthcare, you must live or work within a 30-mile radius of the Medical Group to which your selected primary care physician belongs.

Under the HMO Plans, covered services are generally provided without charge, or for a fixed co-payment.

The following sections provide you with general information for each of the two HMO's under contract with the Trust Fund. However, this information is only a summary, included here for easy reference. For complete information on either of the HMO plans, you should contact the HMO directly or the Administrative Office and request that they send you the HMO's Evidence of Coverage document and other descriptive literature for the HMO in which you are interested or enrolled. Copies of these documents are also available on www.scibew-neca.org.

B. Alternate Kaiser Permanente Plan–Sound Unit 45% and 50% Apprentices Only

The Board of Trustees recognizes that certain Sound Unit Apprentices (45% and 50%) receive contributions to the Plan at a substantially reduced contribution rate than that provided for other classifications of participants in the Plan, resulting in a significant pro-ration of those contributions which effectively prohibited the apprentice from every gaining eligibility.

A separate set of benefits are provided exclusively through Kaiser Permanente for the Sound Unit 45% and 50% apprentices only. Refer to Article 6.5 45% and 50% Sound Apprentice – Kaiser Permanente for more information. None of the other benefits described in this Active SPD are available to eligible Sound Unit 45% and 50% Apprentices and their dependents. However, the non-benefit provisions of this Plan, such as definitions, COBRA rights and appeal rights do apply to the 45% and 50% Sound Unit Apprentices.

Upon graduation to a 55% Sound Unit Apprentice level or higher, the hours remaining in the Hours Bank Reserve for the Alternate Kaiser Permanente Plan benefit will be transferred to the Active Hours Bank Reserve. The Participant will be transferred to the Active Kaiser Permanente HMO Plan of benefits and will remain enrolled in that plan for a minimum of 12 months and the participant will receive documentation from the Administrative Office regarding the additional benefits available at the time of transfer to the Active Kaiser Permanente HMO Plan.

Eligibility for coverage for Active Employees is based on your working a certain minimum number of hours as explained below with one or more Employers who actually make Contributions to the Fund on your hours of employment.

Even if an Employee's Hours Bank Reserve contains sufficient hours for initial eligibility, the only benefit an employee will have until he or she completes an enrollment form for the Alternate Kaiser Permanente HMO Plan will be life insurance. Even if the employee fails to return the enrollment forms to the Administrative Office in a timely fashion, the employee's Hours Bank Reserve will be charged as if the employee has completed all the steps required for enrollment in the benefits offered by the Plan. However, the employee will have no actual coverage (except for life insurance) until the employee has completed all the steps required for enrollment in benefits offered by the Plan. The employee's failure to take appropriate action in enrolling for benefits will cause a reduction in the employee's Hours Bank Reserve without providing the employee with benefits or coverage, which would exist if the employee enrolled in the benefit available to him or her on a timely basis.

C. Blue Shield PPO Plan

The Blue Shield PPO Plan provides you with freedom of choice in selecting a physician, hospital or other medical provider. However, in order to maximize benefits under the PPO plan, you should use doctors and hospitals which are part of the Blue Shield PPO network, called "Participating Providers." When you use health care providers that are not in the Blue Shield PPO Plan network, you may incur substantial out-of-pocket costs which are your financial responsibility.

This section provides you with general information for the Blue Shield PPO Plan under contract with the Trust Fund. However, this information is only a summary, included here for easy reference. For complete information on the Blue Shield PPO Plan, you should contact Blue Shield directly or the Administrative Office and request that they send you the Blue Shield PPO Plan's Evidence of Coverage document and other descriptive literature for the PPO in which you are interested or enrolled.

Blue Shield will provide you with an Evidence of Coverage document. You should carefully review the benefits of the Blue Shield PPO Plan to make certain it fits your needs and that you understand what your financial obligation (out-of-pocket costs) under this Trust Fund will be. By learning and applying a few basics, you may be able to reduce your out-of-pocket costs substantially.

When you use Blue Shield Participating physicians and hospitals, you receive greater benefits than if you were to go to a physician or hospital who is not an Blue Shield Participating provider. The difference in benefits between using a Participating Blue Shield provider and non-participating provider can be substantial, which affects your out-of-pocket costs.

The PPO providers under contract with the Blue Shield Plan agree to provide services at a reduced fee, and the savings are passed along to you in the form of a higher coinsurance, or less out-of-pocket cost to you. When you use a participating physician (In-Network), the coinsurance factor is 90% of a reduced pre-negotiated rate. If you use a non-participating provider (Out-of-Network), the coinsurance factor is reduced to 80% of the amount Blue Shield determines to be the reasonable and customary fee for the services provided. In this situation, you will be financially responsible for the 20% of the allowed amount that Blue Shield does not reimburse as well as the difference between what the physician charges and what Blue Shield allows as an eligible medical expense.

IMPORTANT: Blue Shield's reimbursement for out-of-network providers is based on 80% of covered charges and not 80% of the physician's bill for the services you receive. For example, if Blue Shield determines that a non-PPO physician charges a greater amount than what Blue Shield determines are the covered charges for the care provided (e.g. charges which are usual and customary and for medically necessary services), Blue Shield will reimburse 80% of the covered charges, which may be equivalent to only 60% or 70% of the provider's bill, instead of 80%.

Under the Blue Shield PPO Plan, you are responsible for the difference between what Blue Shield pays and what the provider charges.

A Plan directory is available for each of seven areas within the state of California. For example, there are separate directories for each of the following areas: Los Angeles County, Orange County and Inland Empire, Tri-Counties (San Luis Obispo/Santa Barbara/Ventura), and Bay Area Counties. You can find participating providers throughout the state of California.

Recognizing that there are sometimes changes between printings of the Summary Plan Description and other Plan documents, it is your responsibility to verify current status before you obtain services. Remember to ask your doctor if he is a Blue Shield Participating Provider. You can also phone the Administrative Office for assistance in identifying or locating a doctor, hospital, or other health care provider.

Blue Shield will supply you with an identification card, which identifies you as being eligible to use the Plan network of Participating Providers. Of course, to be eligible for Plan benefits you must work the required hours and be eligible for benefits as explained in Article 4: Eligibility and General Plan Provisions.