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Summary Plan Description (SPD)
Southern California IBEW-NECA Active Health Plan
Amendment # 34
To the Self-Funded Indemnity Plan With Blue Cross Prudent Buyer PPO Plan
As Set Forth in the
Active Health Plan Summary Plan Description
Dated June 1, 2004
The Self-Funded Indemnity Plan with Blue Cross Prudent Buyer Plan (PPO) as set forth in the Southern California IBEW-NECA Health Plan Summary Plan Description for Eligible Active Participants and their Eligible Dependents effective June 1, 2004 is amended as follows:
Effective for claims incurred on and after July 1, 2008, bariatric (weight loss) surgical procedures will be considered a covered expense when the Participant meets the medical criteria described on page 74 B as attached to this Amendment. All elective hospitalizations (including elective hospitalizations for bariatric surgery) shall continue to be subject to the mandatory non-emergency hospital pre-certification requirement set forth in the Plan.
Also effective for claims incurred on and after July 1, 2008 adult immunizations will be a considered a covered expense when the immunizations are recommended by a Physician and are in accordance with the current recommendations of the Centers for Disease Control.
Accordingly pages 60, 74 and 79 are replaced in their entirety by pages 60, 74 A and 74 B, and 79 as attached to this Amendment.
APPROVED AND ADOPTED at the Board of Trustees’ meeting held on June 17, 2008.
BY: Signature on File
Chairman
BY: Signature on File
Secretary
Self-Funded Indemnity Plan – with Blue Cross Prudent Buyer Plan |
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Physician Services
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(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. |
Emergency Care
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(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. |
Diagnostic Studies & Laboratory Procedures |
(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. |
Pregnancy & Maternity Care
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(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. $150 Doctor |
Family Planning
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Infertility Treatment to $4,000 Maximum Per Couple Covered Benefit, After Deductible |
Preventive/Maintenance Care
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Not Covered |
Mental or Nervous Disorders
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Refer to separate Summary Plan Description in the table of contents titled “Integrated Employee Assistance & Managed Mental Health & Chemical Dependency Program”. |
Alcoholism & Drug Addiction
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Durable Medical Equipment, Orthotics, Prosthetics
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(90% of PPO) (80% non PPO) of First $12,500 Covered Charges After Deductible, 100% of Covered Charges Thereafter. Per Calendar Year. |
Chiropractic Services/Physical Therapy- utpatient |
Combined Total of 50 visits, After Deductible |
► Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
► Prostheses and physical complications in all stages of the mastectomy, including lymphedemas.
In a manner determined in consultation with the attending physician and the patient.
Screening for Blood Lead Levels
► Services and supplies provided in connection with screening for blood lead levels if your eligible dependent child is at risk for lead poisoning, as determined by your physician, when the screening is prescribed by your physician.
Well Baby and Well Child Care (Dependent s through Age 6)
Services for well baby and well childcare are a covered expense for a dependent child under 7 years of age:
► A physician's services for routine medical examinations.
► Immunizations given as standard medical practice for children.
► Radiology and laboratory services in connection with routine physical examinations.
► Services and supplies provided in connection with screening for blood lead levels if your dependent child is at risk for lead poisoning, as determined by your physician, when the screening is prescribed by your physician.
Preventive Care (Dependent s Age 7 to Age 16)
Services for a dependent child from age 7 through age 16:
► A physician's services for routine physical examinations, limited to no more frequently than once every 12 months.
► Immunizations given as standard medical practice.
► Radiology and laboratory services and tests ordered by the examining physician in connection with routine physical examinations.
Annual Physical Examination Benefit (Age 16 and Older)
► A physician's services for routine physical examinations, limited to no more frequently than once every twelve months.
► A maximum annual benefit allowance not to exceed $250 for physician’s services. The Plan will pay the lesser of the physician’s charges or $250.
► Annual examinations received from a Prudent Buyer Participating Provider will not be subject to the Plan deductible or co-insurance.
► Annual examinations received from a Non-Participating Provider will be Subject to the annual deductible and co-insurance factor.
Preventive Care (Adults)
Services for adult participants age 17 and above:
► Immunizations given as standard medical practice in accordance with current recommendations of the Centers for Disease Control.
Other Medical Care That Is a Covered Expense
► Charges for registered graduate nurse (R.N.) provided the services are usual-customary prescribed by the attending physician. There is no coverage for a nurse who resides in your home or who is related to you by blood or marriage.
► Expenses for dental work or oral surgery, not to exceed $300.00 additional accident benefit, for prompt repair of natural teeth and other body tissue required as a result of a non-occupational injury which occurs while the Employee or eligible dependent is covered for benefits under this Plan within 90 days from the date of accident.
► Speech therapy when prescribed by a doctor for an illness or injury that first occurs to a person (with normal speech) while covered by this Plan.
Limited and Reduced Benefits
Bariatric Surgery (Weight Loss Surgery)
Charges for surgical procedures to effect weight loss in order to treat morbid obesity will be covered under this Plan only if the participant requesting the procedure meets the following criteria as defined by the National Institutes of Health:
► The candidate for surgery has severe obesity that has persisted for at least the last two years, defined as any of the following:
- A body mass index (BMI) greater than or equal to 40; or
- A body mass index (BMI) greater than 35 in conjunction with any of the following medical conditions that indicate severe co-morbidity:
- Coronary heart disease; or
- Type 2 diabetes mellitus; or
- Clinically significant obstructive sleep apnea; or
- Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90mmHg diastolic despite optimal medical management;
- Member has completed growth (18 years of age or documentation of completion of bone growth); and
- Member has attempted weight loss in the past without successful long-term weight reduction
Examples of covered bariatric surgical procedures include Laparoscopic Roux-En-Y Gastric Bypass (LGBP), Laparoscopic Vertical Banded Gastroplasty LVBG), Laparoscopic Adjustable Banding (LB), Laparoscopic Bileopancreatic Diversion (LBPD), Laparoscopic BPD & Duodenal Switch (LBPD/DS), Standard Roux-En-Y Gastric Bypass (GBP), Distal Roux-En-Y Gastric Bypass (DGBP), Vertical Banded Gastroplasty (VBG), Silastic Ring Gastroplasty (SRG), Gastric Banding (GB), Banded Gastric Bypass (BGB), Biliopancreatic Diversion (BPD), and Biliopancreatic Diversion & Duodenal Switch (BPD/DS – BPD). The physician/surgeon will determine the appropriateness of the bariatric surgical procedure based upon the participant’s clinical findings and in consultation with the surgical candidate. Any surgical treatment plan for morbid obesity must be approved, in advance, by Blue Cross in order to ensure that the proposed services are medically necessary and appropriate and that the Participant meets the criteria set forth above.
Infertility Treatment - Lifetime Maximum Benefit of $4,000 Per Couple for Invitrofertilization - Artificial Insemination
Treatment for infertility consistent with established medical practices by a licensed Doctor of Medicine is a covered expense subject to the benefits and limitations stated below.
► For the purpose of this benefit, infertility means either:
- The presence of a demonstrated bodily malfunction recognized by a licensed medical physician as a cause of infertility; or
- Because of a demonstrated bodily malfunction, the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.
► Initial diagnostic tests furnished in connection with infertility are a covered expense. Covered expense included doctor's services and all necessary laboratory expense.
► The following are excluded from coverage:
- For or incident to intersex surgery (transsexual operations);
- Sexual dysfunctions;
- Sexual inadequacies, including but not limited to reversal of surgical sterilization; or
- For any resulting complications of any such procedures
M) Custodial Care.
Charges for custodial care. Custodial care means care comprised of services and supplies, including room and board and other institutional services, which are provided to an individual, whether disabled or not, primarily to assist him in the activities of daily living.
Such services and supplies are custodial without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed.
N) Eye and Hearing.
Charges for eye refractions or examinations for the fitting of glasses or hearing aids, as well as expenses for eyeglasses and hearing aids.
O) Non-Essential Items.
Non-essential items while hospitalized, such as TV, telephone, guest trays and other personal items. Photocopy of records, etc.
P) Sex Change.
Sex change. All services related to sex change.
Q) Dental.
Expenses incurred in connection with services performed on or to the teeth, including orthodontics, nerves of the teeth, gingivae, or alveolar processes, except to tumors or cysts or as otherwise specifically included herein. Diagnostic services and treatments of jaw joint problems by any method. These jaw joint problems include conditions such as temporomandibular joint (TMJ) and crainiommandibular disorders.
R) Charges forsenile deterioration or mental deficiency or mental retardation and learning disabilities.
S) Charges forradial keratotomy.
T) Charges for reverse, voluntary, surgically induced infertility and sterility for purposes of fertility again. Developmental delay condition and embryo transfer.
U) Loss caused by accidental bodily injury or illness, which arises out of or occurs in the course of any occupation or employment for wage or profit.
V) Any charges for nervous and mental illness or drugs or alcohol services or supplies. Refer to separate SPD subtitled “Integrated Employee Assistance and Managed Mental Health & Chemical Dependency Benefits Program”.
W) All non-surgical medical procedures for weight loss are generally excluded services under this Plan. This includes, but is not limited to, special diets and dietary supplements, acupuncture, biofeedback, hypnosis and exercise programs. Any non-surgical, medical treatment plan for morbid obesity as a life threatening illness must be approved, in advance, by Blue Cross for any benefits to be considered as covered charges. Any surgical treatment plan for morbid obesity (i.e., bariatric surgery) must meet the criteria set forth on page 74 B under the heading “Bariatric Surgery (Weight Loss Surgery)” and must be approved, in advance, by Blue Cross for any benefits to be considered as covered charges.