Retiree Health Plan Forms

• Claim Forms

  HRA Authorization Form — Complete the authorization form to authorize the processing of a one-time COBRA or Retiree Health Plan self-payment using your HRA account funds.

  Retiree Health Plan Medicare Supplement Reimbursement (Retiree Only) — Use this form to submit your claim for reimbursement after Medicare and any other group insurance plans have adjudicated the claim.

  HIPAA Special Enrollment (Retiree Only) — Use this form to DECLINE. An eligible retiree or spouse may decline initial enrollment in the RHP in the event the retiree or spouse may decline initial enrollment in the Retiree Health Plan in the event the retiree or spouse is declining initial enrollment due to other coverage. Please review and contact the Fund Office for assistance.

  HIPAA Special Enrollment (Retiree Only) — Use this form to ENROLL during the HIPAA Special Enrollment (only if you or your spouse declined initial enrollment due to other coverage. Please review and contact the Fund Office for assistance.

  Orthotic Reimbursement Form — 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.

• Enrollment/Eligibility

  Retiree Health Plan Application (Retiree Only) — Use this application to apply for health coverage during retirement. A determination on eligibility will be made following receipt by the Fund Office of the completed application.

  Family Account Change Form (Retiree Only) — Use this form to add or remove a spouse from Medical coverage.

  Retiree Health Plan Medical Enrollment Form (For Early or Normal Retiree) — Use this form to enroll yourself and your spouse in a Medical Plan.

  Kaiser Permanente/Senior Advantage Election Form (Retiree Only) — If the retiree or eligible spouse selects one of the HMO medical Plans for health coverage and is eligible for Medicare, he or she must assign the Medicare benefits to the HMO Medicare-risk Plan that the retiree or spouse selects. Please contact the Trust Funds Office to obtain the enrollment form for Kaiser Permanente - Senior Advantage.

  UnitedHealthcare/Secure Horizons Enrollment Form (Retiree Only) — If the retiree or eligible spouse selects one of the HMO medical Plans for health coverage and is eligible for Medicare, he or she must assign the Medicare benefits to the HMO Medicare-risk Plan that the retiree or spouse selects. Please contact the Trust Funds Office to obtain the enrollment form for Secure Horizons/United Health care.

• Evidence of Coverage Documents

  Kaiser Permanente Health Plan – Evidence of Coverage – Early Retirees — Evidence of Coverage Document - EOC Documents

  Kaiser Permanente Health Plan – Evidence of Coverage – Medicare Eligible — Evidence of Coverage Document - EOC Documents

  Kaiser Permanente Health Plan – Evidence of Coverage – Chiropractic Services Amendment – Early Retirees and Medicare Eligible — Evidence of Coverage Document - EOC Documents

  Kaiser Permanente Health Plan – Delta Care Senior Advantage – Evidence of Coverage (Retirees) — Evidence of Coverage Document - EOC Documents

  OptumHealth – U.S. Behavioral Health Plan, California ("USBHPC") Employee Assistance Program – Combined EOC and Disclosure form — Evidence of Coverage Document - EOC Documents

  UnitedHealthcare Signature Value – Offered by UnitedHealthcare of California – Combined EOC and Disclosure form (HMO) - Retiree (Group #355805, #144787, #144788) — Evidence of Coverage Document - EOC Documents

  UnitedHealthcare Group Medicare Advantage Plan – Evidence of Coverage – Retiree (Group #004257) — Evidence of Coverage Document - EOC Documents

  Out of Area Plan – UnitedHealthcare Medicare Advantage Plan (Group #13601) — Evidence of Coverage Document - EOC Documents

  Out of Area Plan – UnitedHealthcare Choice Plan Group #902027 – Early Retirees — Evidence of Coverage Document - EOC Documents

  UnitedHealthcare Chiropractic Schedule of Benefits offered by ACN Group of California, Inc. - Evidence of Coverage Document (HMO Group #: 355805, 144787, 252024, 252025; PPO Group #:13601) — Schedule of Benefits

• General

  2024 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.

  2022 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.

  2021 Medicare Part D Notice of Creditable Coverage — Important Notice from Southern California IBEW-NECA Health Trust Fund About Your Prescription Drug Coverage and Medicare

  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.

  Retiree Health Plan Beneficiary Benefit Form (Retiree Only) — Use this form to designate the beneficiary(ies).

  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.

  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.

• Legally Required

  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 2018.

  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.

• Notice of Creditable Coverage

  2023 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.

  2022 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.

  2021 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.

  2020 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.

• Summary Plan Description (en Español)

  Summary Plan Description (en Español) — Descripción resumida del plan a fecha del 1 de febrero de 2018

  Enmiedna Nro. 1 — Enmiedna Nro. 1 A La Descripción Resumida Del Plan Para Empleados Jubilados Del Southern California IBEW-NECA Health Trust Fund

  Enmiedna Nro. 2 — Enmiedna Nro. 2 A La Descripción Resumida Del Plan Para Empleados Jubilados Del Southern California IBEW-NECA Health Trust Fund

  Enmiedna Nro. 3 — Enmiedna Nro. 3 A La Descripción Resumida Del Plan Para Empleados Jubilados Del Southern California IBEW-NECA Health Trust Fund

  Enmienda Nro. 4 — Enmiedna Nro. 4 A La Descripción Resumida Del Plan Para Empleados En Activo Del Southern California IBEW-NECA Health Trust

• Summary Plan Description (in English)

  Summary Plan Description — Benefits for Eligible Southern California IBEW-NECA Retirees and Their Eligible Spouses.

  Amendment 1 — Amendment No. 1 To The Summary Plan Description Of The Southern California IBEW-NECA Health Trust Fund Retiree Health Plan.

  Amendment 2 — Amendment No. 2 To The Summary Plan Description Of The Southern California IBEW-NECA Health Trust Fund Retiree Health Plan.

  Amendment 3 — Amendment No. 3 To The Summary Plan Description Of The Southern California IBEW-NECA Health Trust Fund Retiree Health Plan.

  Amendment 4 — Amendment No. 4 To The Summary Plan Description Of The Southern California IBEW-NECA Health Trust Fund Retiree Health Plan.

  Amendment 5 — Amendment No. 5 To The Summary Plan Description Of The Southern California IBEW-NECA Health Trust Fund Retiree Health Plan.

• Summary of Benefits and Coverage (SBC)

  Kaiser Early Retiree SBC (effective 3/1/19 - 12/31/19) — Summary of Benefits and Coverage (SBC)

  United Healthcare Early Retiree SBC — Summary of Benefits and Coverage (SBC)

• Video Library

  APV Process Video Walkthrough — Under a federal law known as ERISA, the Trustees have a fiduciary obligation to ensure that pension benefits are not paid to pensioners who are engaged in activities which could lead to the suspension of their monthly pension benefit under the Plan's Suspension of Benefit Rules. To discharge in part that fiduciary obligation, the Trustees require all pensioners to complete, on an annual basis, an Annual Pensioner Verification form. Completion and return of the form is "self-reporting" by an individual pensioner as to activities performed during the preceding calendar year. The Fund Office has prepared a video to introduce the APV process. 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).

  Thinking about Retirement — The Fund Office has prepared a video to introduce you to the process to apply for Retiree Pension Benefits and Retiree 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).