Active Health & Welfare – Plan C
You are eligible for Plan C Medical if your employer has negotiated Plan C medical benefits with your union.
Kaiser Permanente (HMO)
You must receive all your care through a Kaiser hospital or physician. You are encouraged to select a Primary Care Physician (PCP). Expenses incurred from a non-Kaiser provider will only be covered for emergency services. You must live or work within the Kaiser Permanente service area to enroll.
There is a calendar year deductible of $1,000 per person ($2,000 per family). This is the amount you must pay in a calendar year before Kaiser provides most covered services. Some services, including most preventative care, are not subject to the deductible. Then, you must pay a portion of the charges when receiving covered services. For some services, you must pay a copayment of $10-$20. For some other services, you must pay a 20% coinsurance and the Kaiser plan would pay 80%. Your coinsurance and copayment do not apply toward your deductible, but do count toward your annual out-of-pocket maximum.
The annual out-of-pocket maximum is the maximum amount you will pay for certain covered services in a calendar year. Once you have reached that maximum, you won’t have to pay any deductible, co-pays, or coinsurance for most covered services for the rest of the calendar year.
Direct Pay Medical Plan (PPO)
In the Direct Pay Plan, unlike Kaiser HMO, medically necessary care from any licensed provider that you select will be covered according to Plan rules. The Plan has arrangements with Anthem Blue Cross under which various Hospitals, laboratories, physicians and specialists agree to provide care to you at negotiated Preferred Provider Organization (PPO) rates. You will have less out-of-pocket expense when an Anthem Blue Cross PPO hospital, laboratory, physician, or specialist is used. In California, the Anthem Blue Cross network is called “Prudent Buyer.”
In all other states, the PPO is provided through the National Blue Cross /Blue Shield Association. For provider listings in California go to www.kp.org. For provider listings in all other states go to www.bluecares.com.
You must pay the first $1,000 per person ($2,000 for family) in medical expenses every year. You must then pay a portion of covered expenses. In general, the plan will pay 85% of contracted rates for a PPO provider and 65% of allowed charges for a provider not contracted with Anthem Blue Cross or the National Blue Cross/Blue Shield Association. After you or your family have incurred $2,000 for single participant or $4,000 for a family in allowed charges billed by PPO providers in a calendar year, the Plan will pay 100% of allowed charges for the remainder to that calendar year. (Note: The 100% coinsurance provision does not apply to charges billed by non-PPO providers). You also receive greater benefits when you have an elective hospital stay pre-certified by Anthem Blue Cross before you are admitted (and within 48 hours for emergency admissions). The toll-free number for California and all other states is (800) 274-7767.
Health Reimbursement Account
Available funds from your Health Reimbursement Account (HRA) can be used to pay your deductible, copayment and coinsurance amounts for eligible medical, prescription drug, dental and vision expenses.
- Your employer will provide funding for your HRA. The amount of the funding is based on the Agreement between your employer and the Union – it may be $500/$750/$1,000 per year for a single person (twice the amount for a family)
- A card will be sent to your home address allowing you to use the benefit. The card functions just like a debit card and is accepted at the vast majority of service providers’ offices and pharmacies.
- The HRA amount will be contributed to the account whether you enroll in Kaiser or the Direct Pay Plan.
- Once the HRA contribution amount is exhausted in a calendar year, expenses are paid by you or your dependent until the out-of-pocket maximum is satisfied.
- Unused HRA amounts will not roll over from year to year. Each January when your deductible and out-of-pocket maximums are reset, your HRA funding will reset as well to the amount agreed on by the employer and Union.
- You are permitted to permanently opt out of and waive future reimbursements from the HRA at least annually, in a time and manner determined by the Fund Office. Upon your termination of employment, you may opt out and waive future reimbursements from the HRA.
- The HRA only covers medical expenses, prescription drugs, dental, vision and certain IRS approved over-the-counter supplies and medications. A list of approved over-the-counter items can be found on the IRS’s website.
- If your eligibility terminates and you have remaining credits in your HRA account, those amounts will be forfeited at the end of the month of termination. The only exception to this procedure is if you elect COBRA Continuation Coverage.
Prescription Drug Coverage
Your prescription drug coverage will depend on the plan you are enrolled in.
Kaiser Permanente (HMO) Enrollees
If you are enrolled in Kaiser, you must obtain your drugs at Kaiser Permanente pharmacies. Generic drugs are available with a $10 copayment and brand name drugs with a $30 copayment for a 30-day supply.
Direct Pay Medical Plan (PPO) Enrollees
These enrollees receive prescription drugs from the Trust Fund. You must use an OptumRx pharmacy. If you fill or refill prescriptions at a retail pharmacy, you will pay 20% of the charge plus $5 for up to a 30-day supply per formulary generic prescription or 20% of the charge per formulary brand name prescription or 20% of the charge plus $15 per non-formulary brand name prescription. The copayment is capped at $100 for certain formulary/non-formulary brand name prescriptions at retail. For mail order, prescriptions are covered in full after a $40 copayment for formulary generic drugs and a $60 copayment for brand name drugs, regardless of whether the drug is on the formulary, for a 90-day supply. The out-of-pocket limit for individual is $2,000 ($4,000 per family).
If your employer has negotiated for dental benefits with your union, dental coverage is available to you and your eligible dependents. Each of your dental care choices covers preventive, basic, and major care. Benefits depend on the plan in which you enroll. New dental eligibles cannot enroll in Delta Dental or the Scheduled Direct Pay Plan for the first 12 months of coverage. Therefore, during their first 12 months of coverage, they are limited to enroll in one of the DMOs shown below. Dental Plan Options include:
- Dental Maintenance Organization (DMO) The Bright Now!/Newport Dental, MetLife, United Healthcare Dental and United Concordia Dental Plans operate like HMOs, providing services only through participating dental offices. You will be responsible for small copayments for most covered services.
- Delta Dental Plan Like the Direct Pay Medical Plan, the Delta Dental plan allows you to use any licensed dentist, but pays a higher benefit when you use Delta Preferred Option Dentists. For most participants, there is a $3,000 annual maximum benefit and you pay 20% of covered expenses when you use a Delta Preferred Option Dentist (30% of covered expenses when you do not). The maximum does not apply to pediatric dental services.
- Scheduled Direct Pay Dental Plan The Scheduled Dental Plan also allows you to use any licensed dentist of your choice. The Plan pays 100% of a scheduled amount for covered dental treatment, not to exceed a $2,500 annual maximum per eligible person. The maximum does not apply to pediatric dental services. However, the Plan offers members access to a dental PPO network, First Dental Health (FDH). FDH providers offer members treatment at discounted rates. Therefore, your annual maximum benefit goes farther by using a FDH dentist. For information on locating a FDH dentist, please contact FDH at (800) 334-7244 or www.firstdentalhealth.com.
If your employer has negotiated for self-funded orthodontic benefits with your union, Orthodontic coverage is available to you and your eligible dependents once you have been covered by the Plan for three months. If you are eligible for orthodontic coverage, orthodontic treatment will be covered in full up to a lifetime benefit of $2,500 per individual. If you enroll in a Dental Maintenance Organization, orthodontia may be available at discounted rates if you use a panel orthodontist. Regardless which dental plan option you have selected, orthodontic benefits are paid by the Fund Office once a claim is filed by your orthodontist.
If your employer has negotiated vision benefits with your union, whichever medical plan you choose, you may use Vision Service Plan’s (VSP) network of eye care professionals to receive exams, and purchase lenses and frames. Kaiser Permanente also offers eye exams.
If you are entitled to medical coverage through the Fund, you are automatically entitled to the Burial Benefit. This benefit provides payment of $2,500 to your designated beneficiary upon the death of a covered Participant. Burial benefits are available to Active Employees and his or her covered Dependents.
If you are covered for Life Insurance, the amount available upon the death of you or your eligible dependents is dependent on your employer’s collective bargaining agreement with your union.