Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

9.2 Health Insurance Portability and Accountability Act

A federal law called the Health Insurance Portability and Accountability Act (HIPAA) requires this Health Plan to furnish you with certain information.

One purpose of HIPAA is to help families minimize the impact of pre-existing condition exclusions as they move from job to job. A pre-existing condition exclusion allows a Health Plan to not cover certain illnesses (for example, a heart condition) until the individual is covered under the Health Plan for a designated period, typically six (6) to 12 months.

The Medical Plans offered as part of the Retiree Health Plan (Kaiser Permanente or UnitedHealthcare) do not contain pre-existing condition exclusions. You become eligible for benefits under the Retiree Health Plan as explained in Article 3: Eligibility and Enrollment Requirements on page 13 without regard to any pre-existing medical conditions. All covered benefits become effective on the date you become eligible for benefits under this Plan.

However, each Medical Plan does have benefit exclusions and limitations for designated illnesses and conditions. For example, each of the Medical Plans contains an exclusion for experimental surgery. A detailed list of the exclusions for each of the Plans is contained in the respective Plan's Evidence of Coverage document. Further information can be obtained by contacting the Administrative Office or the HMO benefit provider.

9.2.1 Certificate of Group Health Plan Coverage

When you lose eligibility under this Health Plan, you will be furnished with what is called Certificate of Group Health Plan Coverage. This certificate provides you with evidence of your prior health coverage with this Health Plan. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions for which you were treated before you enroll in the new plan. You may need to provide this certificate if medical advice, diagnosis, care, or treatment was recommended to you or received by you for the condition within the six (6) months prior to your enrollment in the new plan.

If you become covered under another group health plan, check with the Administrative Office to see if you need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you apply for that individual insurance policy.

9.2.2 HIPAA Privacy Rules

HIPAA also gives you certain rights with respect to your health information, and requires that Health Plans, like the Southern California IBEW-NECA Retiree Health Plan, protect the privacy of your Personal Health Information (PHI). A complete description of your rights under HIPAA can be found in the Plan's Notice of Privacy Practices, which was initially distributed to all Participants as of April 14, 2003, (or when you enroll in the Plan, if you enrolled after April 14, 2003) and which is posted on www.scibew-neca.org. You may also obtain a copy by calling the Administrative Office.

9.2.3 Information You Should Know as Required By HIPAA

Limitations on Benefit Changes in Existing Coverage and Appeals Rights

HIPAA requires that Health Plan Participants be notified of material reductions in Health Plan coverage within 60 days of the change in benefits. Article 10: Plan Amendment Procedures on page 50 explains the notice you will receive if there is a material reduction in benefits. This Health Plan will provide notice of such changes to Health Plan Participants no less than 60 days prior to the effective date of such changes.

Certain benefit plans under the Southern California IBEW-NECA Health Trust Fund have benefits guaranteed under contract between the Board of Trustees and the benefit provider. The following providers have guaranteed benefits by contract with the Board of Trustees:

Medical Plans

  • Kaiser Permanente (HMO)
  • UnitedHealthcare (HMO)
  • Kaiser Permanente - Senior Advantage (HMO)
  • UnitedHealthcare® Group Medicare Advantage (HMO)

Vision Insurance

  • Vision Service Plan

Dental Plans

  • CIGNA (DHMO)
  • DeltaCare (DHMO)
  • United Concordia (DHMO and PPO)

Health Reimbursement Arrangement

  • Coast Benefits

Questions/Assistance

  • MedExpert Program

Each of the above benefit providers maintains an appeals procedure. This appeals procedure is explained in the Evidence of Coverage document provided by each benefit provider. An example of an appeal under an HMO may be where you received emergency care outside the HMO network and the claim was denied by the HMO because they did not deem it an emergency. You can contact the benefit provider directly for information on their appeals procedure. In addition, the representative at the MedExpert Program will also assist you if you have questions or need information. You can contact MedExpert by calling (800) 999-1999.

You can contact the United States Department of Labor to seek assistance regarding your rights as provided by HIPAA. The office to contact is:

United States Department of Labor
Employee Benefits Security Administration
1055 East Colorado Boulevard, Suite 200
Pasadena, CA 91106
(626) 229-1000