The Fund provides medical benefits for eligible retirees to help cover the cost of doctors’ services, hospital stays, specialists’ care, other health care services, and supplies.
Retiree medical plan options vary depending on where you live. If you live in a Southern California area served by the Fund’s HMOs, the medical plans available to you are:
- The Indemnity PPO Medical Plan (Medicare and non-Medicare benefits)
- Kaiser Plans: Kaiser Permanente HMO (non-Medicare) and Kaiser Senior Advantage (a Medicare HMO)
- UnitedHealthcare (UHC) Plans: UHC SignatureValue™ Flex HMO (non Medicare) and UnitedHealthcare Medicare Advantage (a Medicare HMO)
You must live in the HMO’s service area to enroll in that HMO. If you live outside of a Fund-sponsored HMO service area, the Indemnity PPO Medical Plan is the only option available to you.
The Indemnity PPO Medical Plan
The Indemnity PPO Medical Plan is a preferred provider organization (PPO) plan that provides up to $1,500,000 in benefits for each covered person’s lifetime (reduced by up to $500,000 in lifetime benefits paid on your behalf while you were covered as an active employee by the Indemnity PPO Medical Plan).
How the Plan Works for Eligible Non-Medicare Retirees
- You will pay less of your own money when you seek care through an in-network PPO provider.
- The plan covers some services, including doctors’ visits, with no annual deductible after you pay a copay.
- For many services, such as inpatient hospital care, you have to satisfy the plan’s annual deductible of $500 per person/$1,500 per family per calendar year before the plan pays its share of your covered expenses.
- Once you satisfy the annual deductible, you and the plan share the cost for most services through coinsurance. Your coinsurance is generally 25% of the allowed amount, and the plan typically pays 75% of the allowed amount if you use an in-network provider.
- If you receive services from an out-of-network provider, you generally will be responsible for your 50% coinsurance plus any charges above the allowed amount.
- The Plan keeps track of the amount you pay in coinsurance for services from in-network PPO providers and out-of-area providers. Once you reach the in-network annual out-of-pocket maximum, the plan pays 100% of your covered PPO charges (in-network providers) for the rest of the calendar year. The annual out-of-pocket maximum is $5,000 per person/$10,000 per family per calendar year. A lifetime maximum benefit limit also applies. The annual out-of-pocket maxiumum does not apply for out-of-network (non-PPO) expenses.
To find a PPO provider, call 855-686-5613 or go to www.anthem.com/ca. When prompted to select a network, be sure to choose “Blue Cross PPO (Prudent Buyer) – Large Group.”
IMPORTANT: The plan’s benefits are different if you receive care from non-PPO providers and you are not eligible for out-of-area benefits. Refer to your plan’s Benefits Chart for details.
You should also be aware of several important Indemnity PPO Medical Plan rules, including use of non-PPO providers for emergency services, the requirement for precertification for most hospital and inpatient facility admissions, knee and hip replacement benefits [link to kneep/hip replacement page], a benefit maximum for out-of-network surgical center visits, and other limits for certain medical services and supplies. Refer to the Health Care Benefit Highlights booklet for details.
How the Plan Works for Eligible Medicare Retirees
For retirees and their dependents who are Medicare-eligible, Medicare serves as their primary coverage, and this Fund’s coverage is secondary. For details about Medicare benefits, refer to the current Medicare and You booklet, available at www.medicare.gov.
Medicare benefits under the Indemnity PPO Medical Plan differ from non-Medicare benefits in many ways, including the following:
- For professional medical services (such as doctor office visits): Medicare determines the allowed amount for services covered by Medicare.
- For hospital services: The plan’s allowed amount for services covered by Medicare is the Medicare allowed amount. Hospital precertification is not required.
The Fund follows a “non-duplication of benefits” rule when coordinating benefits with Medicare and other insurance plans. When the Fund’s coverage is secondary to another plan’s, such as Medicare, the Fund’s benefits will be determined as follows:
- If the primary plan’s payment is the same or greater than the benefits that would be provided by the Fund if it were primary, then the Fund will not pay any additional benefits.
- If the primary plan’s payment is less than the benefits that would be provided by this Fund if it were primary, then this Fund will pay the difference between its normal benefit and the amount paid by the primary plan.
For example, if the Fund would have reimbursed 75% for a given service, but Medicare already paid 80%, the Fund will make no additional payments. However, if Medicare paid only 60% for the service, then the Fund would pay 15% (the difference between its normal payment and the amount paid by Medicare).
Refer to the Health Care Benefit Highlights booklet for details on filing claims and coordination of benefits.
HMO Plans—for Eligible Medicare and Non-Medicare Retirees
You have the option to enroll in an HMO if you live in its service area.
When you enroll in an HMO, you are restricted to using only that plan’s doctors and hospitals. If you use a doctor or hospital not affiliated with your HMO, your charges will not be reimbursed. Exceptions are made only for emergency care authorized by your medical group or HMO.
In general, HMOs cover most medical services at 100% after your copay. There are no deductibles or lifetime maximum dollar limits for medical care. Covered medical care includes routine preventive care and wellness programs.
Your covered dependents will be enrolled in the same HMO that you have. For example, if you choose Kaiser and you are on Medicare, you will be enrolled in Kaiser’s Senior Advantage HMO and your non-Medicare dependents (if any) will be enrolled in the traditional Kaiser Permanente non-Medicare HMO.
If you or an enrolled dependent are eligible for Medicare and choose HMO coverage, you must enroll in that HMO’s Medicare plan and in Medicare Part A and Part B.
Refer to the Health Care Benefit Highlights booklet for more details on how the HMOs work.
The Fund’s prescription drug program is included in all of its retiree medical plan options except the Kaiser Senior Advantage plan. (Kaiser Senior Advantage members must obtain their prescription drugs from Kaiser pharmacies.)
The Fund’s prescription drug program is described here: Prescription Drugs. Refer to your plan’s Benefits Chart for details on prescription drug coverage, and be sure to note the plan’s limitations. You should also review Notice of Creditable Coverage for Medicare-eligible Except Plan E Retirees regarding the Fund’s prescription drug coverage and Medicare Part D.
Contact the Fund Office if you have questions about prescription drug coverage for retirees.
The Fund offers retirees a choice between the Indemnity Dental Plan and the Prepaid Dental Plan.
Dental coverage is an optional benefit. You must be enrolled in one of the Fund’s retiree medical plans to enroll in dental coverage. If you elect dental coverage, you pay a monthly premium and you must enroll for a full year of dental coverage.
Both dental plan options cover dental services that qualify as a “covered procedure.” Covered procedures include preventive and diagnostic services, and basic and major restorative services. Benefits are not provided for services that do not meet the Fund’s definition for covered procedure.” See the Dental Program for Active Participants in All Plans and All Retirees booklet for a description of covered procedures.
A summary of each dental plan follows below. Also, refer to your plan’s Benefits Chart to compare the differences between coverage provided under the plans.
Indemnity Dental Plan
- If you choose the Indemnity Dental Plan, you may use any dentist.
- The plan will reimburse a portion of your dentist’s charges according to the dental plan allowances after you meet your annual deductible. You pay any difference between what the plan pays and what your dentist charges.
- There is an $1,800 annual benefit maximum per person.
- Dental services (except emergency care) rendered outside of the United States are not covered under the Plan, unless you are living abroad permanently. Services performed in Mexico may be covered, provided x-rays are submitted with each claim.
Prepaid Dental Plan
- If you enroll in the Prepaid Dental Plan, you must select a Prepaid Dental Plan Office for your dental care. A list of Prepaid Dental Plan Offices is provided with your plan enrollment materials and included in the Dental Program Description Booklet. You can also contact the Fund Office for a copy.
- The Prepaid Dental Plan provides many diagnostic, preventive and restorative services at little or no charge to you. However, if you go to a dentist who is not affiliated with your designated Prepaid Dental Plan Office, you are responsible for 100% of the costs, including charges for emergency services outside of your Prepaid Dental Plan’s service area.
The Fund provides vision care benefits to everyone enrolled in one of its medical plan options.
The plan pays up to $125 per person per calendar year for vision exams and materials (eyeglasses or contact lenses, for example). Benefits for corrective lenses and frames are payable only if no more than 12 months have elapsed between the date of the last vision examination and the date glasses or contact lenses are ordered. (This rule does not apply when a lens change is required following eye surgery or other conditions.)
You may receive vision care from any provider you wish. If you are enrolled in an HMO, you may be eligible for additional benefits for vision care provided by the HMO.
The Fund offers several additional benefits to retirees and their enrolled dependents, including:
- The Employee Member Assistance Plan (EMAP): Provides support for mental/behavioral health and substance abuse issues—provided for Indemnity PPO Medical Plan and non-Medicare UHC Participants; Medicare UHC and all Kaiser Participants receive these services through their respective HMO.
- Acupuncture and chiropractic benefits: Provided to all plan Participants; Kaiser and UHC Participants also may receive limited benefits through their respective HMO.
- Podiatry benefits: Provided to Indemnity PPO Medical Plan Participants through Podiatry Plan of California (PPOC). Kaiser and UHC Participants must receive podiatry benefits through their respective HMO.
- Hearing Aids: Provided to Indemnity PPO Medical Plan Participants. Kaiser and UHC Participants must obtain hearing aids through their respective HMO.
Refer to the Health Care Benefit Highlights booklet to learn more about these benefits.