Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

Amendment No. 1
To the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017

This Amendment to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description (“SPD”) For Eligible Active Participants and the Eligible Dependents restated as of September 1, 2017, is made by the Board of Trustees of the Southern California IBEW-NECA Health Trust Fund (“Board of Trustees”) with reference to the following facts and circumstances:

  1. The Board of Trustees wishes to amend the SPD to reflect an increase in the United Concordia Preferred Provider Organization (PPO) plan individual Annual Maximum from $2,000 non-network/$2,500 network to $5,000 for all providers (network and non-network).
  2. The Board of Trustees has reserved to themselves the ability to amend the SPD from time to time.

NOW THEREFORE, effective January 1, 2018, the SPD is amended as follows:

1. The table appearing on Section 9.1 at page 51 is replaced with the following table:

Dental Provider Name United Concordia Cigna DeltaCare United Concordia
Plan Type PPO DHMO DHMO DHMO
Member Customer Service (800) 332-0366 (800) CIGNA-24 (800) 422-4234 (866) 357-3304
Website Address unitedconcordia.com cigna.com deltadentalins.com unitedconcordia.com
Claims Filing Address
Applies to PPO plan only
P.O. Box 69421, Harrisburg, PA. 17106-9421
Description MEMBER CO-PAYMENT
Network In-Network/
Out-of-Network
In-Network Only In-Network Only In-Network Only
Annual deductible        
Per individual $0/$25 N/A N/A N/A
Per family $0/$75 N/A N/A N/A
Annual Maximum
Waived for diagnostic and preventive; Annual Maximum applies to combination of in-network and non-network providers
       
Per individual $5,000 N/A N/A N/A
Per family N/A N/A N/A N/A
Diagnostic/Preventive
X-rays, exams, cleanings
0%/0%, plus balance billing $0 $0 $0
Basic
Fillings, sealants, oral surgery, root canals
5%/20% plus balance billing $0 - $430 $0 - $220 $0
(for white fillings)
Major
Crowns and casts, dentures, bridges and implants
25%/50% plus balance billing
Implants only: 25%/25% plus balance billing
$12 - $725 $0 - $195, implants not covered $0 (for metal crowns and bridges)
Orthodontics
Typical cost of completing a 24-month orthodontic treatment plan for permanent teeth for children, up to 19th birthday
50%/50% plus balance billing, up to max payment of $1,400 $50 - 2,328 $800 - $1,150 $1,500 - $2,000, startup and retention charges not noted
Emergency Services
Emergency exam
0%/0% plus balance billing $0-$68 $5 $0

2. All other terms and conditions of the Plan shall remain in full force and effect.

Executed this 19th day of October, 2017 at Commerce, California.

BOARD OF TRUSTEES
SOUTHERN CALIFORNIA IBEW-NECA
HEALTH TRUST FUND

BY: Signature on File
Chairman

BY: Signature on File
Secretary