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No. If you are eligible and enrolled, you do not need to do anything.
Under our Plan, if you are not eligible for no more than two consecutive months, there should be no ACA penalty. While you are not eligible under this or any other Plan, you are responsible for your medical bills. (For COBRA rights under our Plan, see Summary Plan Description.)
Your eligibility terminates because you are no longer working the required hours to maintain eligibility under the Plan. This event would qualify you to continue coverage under COBRA by making a self-payment.
A qualified participant is entitled to 18 months, or up to 36 months under Cal-COBRA if enrolled in Kaiser or UnitedHealthcare, of continued coverage if the qualifying event is termination of employment or a reduction of employment hours. This may be extended 11 months if you are considered disabled under the Social Security Act. Any other qualifying event increases the available coverage term for qualified beneficiaries to 36 months (maximum). Refer to the "Qualifying Events" section in the Summary Plan Description.
Yes, provided they are eligible dependents, as defined by the Plan. Refer to section "Eligible Dependents" for a complete description of eligible dependents. Also, children born or adopted during the period of continuation coverage are considered dependents, the same as those of active eligible employees. (However, this applies only if the covered employee elects COBRA coverage during the election period and enrolls the new child upon birth or adoption.)
Yes, you can change your choice of medical Plans (from among the plans being offered) during the annual open enrollment period. Refer to section, "Rolling Twelve-Month Open Enrollment Procedures" for details on the open enrollment.
A shift from active to retiree coverage is an open enrollment right, and you have the same rights that an active employee receiving coverage through employment is entitled to. On this basis, COBRA serves as a bridge to retiree coverage.
Under the COBRA law, the Trustees are permitted to base the self-payment on a formula, which is the Plan cost plus 2% for administration. For example, if you are covered under either Kaiser or UnitedHealthcare, your monthly COBRA payment for continuation coverage is based on the applicable HMO premium cost, and prescription drug cost, plus 2% for administration. Note, for a disabled qualified participant, the premium for months 19 through 29 may be no more than 150% of the applicable non-COBRA premium.
Payments must be paid monthly.
Basic coverage includes medical (either Kaiser, UnitedHealthcare or Anthem Blue Cross). These medical plans include the prescription drug plan benefits are as described in this SPD.
The Board of Trustees have instituted a temporary pilot program, whereby the Health Fund will subsidize a portion of your COBRA payments for the first three (3) consecutive months of continuation coverage. Certain participants and beneficiaries are not eligible for the subsidized COBRA. The self-payment will be $50.00 per month for the first three consecutive months of continuation of your "Basic Coverage" of hospital/medical and prescription drug benefits. Benefits for dental and vision can be added for an additional cost. Thereafter, on the fourth month of continuation coverage, the self-payment will increase to the full amount allowed under COBRA. Life Insurance benefits are not continued by COBRA.
After you have reestablished your Hours Bank Reserve to a maximum of 600 hours. The Hours Bank Reserve is explained under the section " Hours Bank Reserve".
Not necessarily. The Trust subsidy of COBRA self-payments is not guaranteed, and may be discontinued or reduced at any time with 30 days notice to participants.
Of course, you can pay the monthly premium. However, it is also permitted for a third party to pay the premium, such as a hospital or a new employer.
No. When a person transfers from one plan to another, the benefits the person receives will be those provided under the new plan. Coverage under the new plan can be different than the coverage under the former plan.
Not necessarily. Plans may set a waiting period before individuals become eligible for benefits. HMOs may have an "affiliation period" during which an individual does not receive benefits and is not charged premiums. Affiliation periods run concurrently with any waiting period under a plan and may not last for more than 2 months (3 months for late enrollees) and are only allowed for HMOs that do not impose pre-existing condition exclusion periods.
No. The provision of health coverage by an employer is voluntary. HIPAA does not require specific benefits nor does it prohibit a plan from restricting the amount or nature of benefits for similarly situated individuals.
There is no requirement for any employer to offer health insurance coverage. If your new employer does not offer health insurance, you may be eligible to continue coverage under this Plan's COBRA continuation coverage.
HIPAA does not limit premium rates, but it does prohibit plans and issuers from charging an individual more than similarly situated individuals in the same plan because of health status. Plans may offer premium discounts or rebates for participation in wellness programs. In addition, many states limit insurance premiums and HIPAA does not preempt state laws regulating the cost of insurance.
Generally no. However, HIPAA makes two changes to the length of the COBRA continuation coverage period. Qualified beneficiaries who are determined to be disabled under the Social Security Act within the first 60 days of COBRA continuation coverage will be able to purchase an additional 11 months of coverage beyond the usual 18-month coverage period. This is a change from the previous law, which required that a qualified beneficiary be determined to be disabled at the time of the qualifying event to receive 29 months of COBRA continuation coverage. This extension of coverage is also available to non-disabled family members who are entitled to COBRA continuation coverage. COBRA rules are also modified and clarified to ensure that children who are born or adopted during the continuation coverage period are treated as "qualified beneficiaries."
The Newborns' Act affects the amount of time you and your newborn child are covered for a hospital stay following childbirth. Group health plans, insurance companies, and health maintenance organizations (HMOs) that are subject to the Newborns' Act may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section. However, the attending provider may decide, after consulting with you, to discharge you or your newborn child earlier. In any case, the attending provider cannot receive incentives or disincentives to discharge you or your child earlier than 48 hours (or 96 hours).
An attending provider is an individual licensed under state law who is directly responsible for providing maternity or pediatric care to a mother or newborn child. Therefore, a plan, hospital, insurance company, or HMO would not be an attending provider. However, a nurse midwife or a physician assistant may be an attending provider if licensed in the state to provide maternity or pediatric care in connection with childbirth.
If you deliver in the hospital, the 48-hour period (or 96-hour period) starts at the time of delivery. So, for example, if a woman goes into labor and is admitted to the hospital at 10 p.m. on June 11, but gives birth by vaginal delivery at 6 a.m. on June 12, the 48-hour period begins at 6 a.m. on June 12.
A plan, insurance company, or HMO cannot deny you or your newborn child coverage for a 48- hour stay (or 96-hour stay) because the plan claims that you, or your attending provider, have failed to show that the 48-hour stay (or 96-hour stay) is medically necessary. However, plans, insurance companies, and HMOs generally can require you to notify the plan of the pregnancy in advance of an admission if you wish to use certain providers or facilities, or to reduce your out-of-pocket costs.
Under WHCRA, group health plans, insurance companies, and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery, and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
All group health plans, and their insurance companies or HMOs, that provide coverage for medical and surgical benefits with respect to a mastectomy are subject to the requirements of WHCRA.
Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage.
If required under the terms of a Collective Bargaining Agreement or certain other agreements, an Employer may make pre-tax contributions on behalf of a Participant to this Plan for funding a Health Reimbursement Arrangement ("HRA"). Amounts contributed to an HRA Account, if any, may be used to reimburse a Participant tax-free for certain medical expenses which are not covered by this Plan or any other health plan.
The Health Reimbursement Arrangement ("HRA") account can only be used to pay for eligible expenses allowed under the terms of the Summary Plan Description. For more information you should review Article 7 of the SPD for full details regarding the benefit. For general information you may review the Frequently Asked Questions (FAQs).
Under an HMO Plan, covered benefits are provided for no charge or for a fixed copayment. Your out-of-pocket costs will generally be much lower under an HMO Plan than under the PPO Plan. There are no claim forms to complete.
Yes, provided the doctor is an HMO doctor under the Plan you selected. Each family member is encouraged to select a personal physician.
Yes, under both of the HMO Plans you are allowed to change to another doctor at any time subject to the rules of the HMO selected.
Unless the HMO you selected referred you to a specialist, there are no benefits available if you use doctors outside of the HMO.
In view of the "affordability factor," parents can seek medical attention for their children as concerns arise. Each HMO has established a limit on the total amount of copayments that you would have to pay in any one year. The exact amount of this maximum copayment liability is shown in the HMO's "Evidence of Coverage" brochure.
Yes provided you make written application to the HMO within the prescribed time period.
Generally yes, subject to the established rules of the HMO. Each HMO has specific benefits for emergency services, within or outside the HMO enrollment/service area. Refer to the "Evidence of Coverage" brochure from your HMO for specific details.
You can go to any licensed doctor of your choice and be eligible for Plan benefits, and you are not restricted to a specific service area. That is why the PPO Plan is also referred to as the "freedom of choice plan." You will have less out-of-pocket costs when using the Anthem Blue Cross Prudent Buyer PPO network, called "Participating Providers." The Administrative Office can furnish you with a Prudent Buyer directory for an area where you live or work.
Yes provided you make written application to Anthem Blue Cross within the prescribed time period and meet other requirements.
Yes, provided the following two conditions are met: 1. You are admitted to the hospital, by a licensed doctor of medicine, and 2. The hospital meets the Plan's definition of a hospital.
Yes. The Plan requires that all non-emergency hospital stays be approved in advance. Refer to section titled "Medical Benefits Comparison: Anthem Blue Cross, Kaiser and UnitedHealthcare" for more details. When you use Participating Prudent Buyer Providers, this will be accomplished with no action required on your part.
Yes. In fact, for all non-emergency surgeries, the Plan encourages you to obtain a second opinion.
Yes. The Anthem Blue Cross Plan has contracted with select doctors and hospitals, who have agreed to provide medical care at reduced rates. These doctors and hospitals are referred to as a Preferred Provider Organization (PPO) under the Anthem Blue Cross Prudent Buyer Plan. For a complete explanation, refer to table of contents titled "Anthem Blue Cross Prudent Buyer Plan (PPO)".
All Plans, both HMOs and the PPO Plan, have specific exclusions concerning experimental and investigational procedures. Contact your benefit provider directly (Kaiser, UnitedHealthcare or Anthem Blue Cross) or MedExpert if you have any questions about a specific procedure.
Contact Anthem Blue Cross of Southern California at: (800) 543-3037 or PO Box 60007, Los Angeles, CA 90060.
No. You can use any Anthem Blue Cross PPO doctor at any time. If you already have a personal physician, we suggest you determine if your physician is an Anthem Blue Cross PPO member by checking the directory or calling their office. You can also locate Anthem Blue Cross PPO doctors online. Refer to the "Online Internet Website-Anthem Blue Cross". Recognizing that there are sometimes changes in between directory printings, it is your responsibility and in your best financial interest, to verify current Anthem Blue Cross PPO Participating Provider status before your obtain services. This is simple to do. Just call the physician's office, hospital admissions office, Administrative Office, or the 800 number listed on your Identification Card.
Anthem Blue Cross PPO providers have agreed to give members health care at a special low cost. Because of these savings, the Health Plan can provide increased benefits when you choose to get your health care from an Anthem Blue Cross PPO doctor, hospital, or other provider.
When you use an Anthem Blue Cross PPO participating provider, you are responsible for only ten percent (10%) of covered charges (subject to Plan deductibles and benefit maximums) of the special PPO contract rate. When you use a non-participating provider, you will be responsible for twenty percent (20%) of covered charges (subject to Plan deductibles and benefit maximums) of the charges as determined reasonable by the Plan. In addition, all hospitalizations in other than Anthem Blue Cross PPO hospitals will be subject to a separate $200 hospital deductible per confinement.
Assume after satisfying the $200 calendar year deductible, that you have a combined doctor and hospital bill for covered charges in the amount of $10,000. By way of illustration, your out-of-pocket expense may be as follows: If you use Anthem Blue Cross PPO doctors and hospital: $10,000 of covered charges reduced to special, contract rate of $7,000. Your out-of-pocket cost would be ten percent of $7,000 or $700. If you use non-contracting doctors and hospital: $10,000 of covered charges is reduced to $9,000, which is the amount determined by the Health Trust to be reasonable and customary charges. From the $9,000 there is deducted a $200 hospital deductible, applicable to hospitals which are not part of the Anthem Blue Cross PPO network. You will be reimbursed by the Plan, eighty percent of $8,800, or $7,040. Your out-of-pocket expense will be $2,960, which is the difference between total charges of $10,000 and Plan benefits of $7,040.
No. Anthem Blue Cross PPO providers will submit your bills directly to Anthem Blue Cross of California. However, if you do not use an Anthem Blue Cross PPO provider, you are required to submit your claims to Blue Cross at: Anthem Blue Cross of California Claims Department P.O. Box 60007 Los Angeles, CA 90060-0007
Generally, you will not make a payment until you receive a statement of the claim, called an Explanation of Benefits or EOB for short, from the Anthem Blue Cross. However, in some instances, an Anthem Blue Cross PPO provider can collect a payment for services up to the amount necessary to satisfy the deductible. To receive benefits, you must meet the eligibility rules of the Health Plan and be eligible for benefits.
Yes. To receive full benefits, the Plan requires all non-emergency hospitalizations to be approved in advance. When you use an Anthem Blue Cross PPO Doctor and Hospital, the pre-certification will take place with no action required on your part. If you choose to go to a non-participating doctor or hospital, be certain that your hospital stay is approved before admission. The number for utilization review is shown on your Anthem Blue Cross PPO Identification Card.
Yes, for inpatient hospital confinement. Benefits are provided only for medically necessary and appropriate services. For example, many elective surgeries are considered cosmetic, for which no Plan benefits are payable. If you have questions as to whether a particular elective surgery is covered by the Plan, you or your doctor should contact Anthem Blue Cross.
Yes, subject to Plan benefits (deductibles and coinsurance), a second doctor's opinion for elective surgery is a covered benefit.
Cost containment provides you with valuable information, so that unexpected out-of-pocket costs can be avoided. When the hospital cost containment program is properly used, you will know in advance whether the proposed services are medically necessary and appropriate, and therefore eligible for Plan benefits.
Yes. Plan benefits otherwise payable may be reduced up to $500. In addition, Anthem Blue Cross utilization review will perform a retrospective review of your hospital stay. No Plan benefits will be provided for days in the hospital, which are not determined to be medically necessary.
Yes. A listing of Anthem Blue Cross PPO chiropractors are contained in the Anthem Blue Cross PPO Directory.
By reading the first couple of pages of the directory, you will be familiar with how to access the Anthem Blue Cross PPO network. There is a separate listing of Anthem Blue Cross PPO hospitals. There is a listing of Anthem Blue Cross PPO physicians, which is broken down by specialty. For example, internists, family practice, and pediatrician doctors. After each physician's name, there is a listing of the hospitals where the physician is affiliated.
A new drug is given two names. One is the brand name, which is what the manufacturer chooses to call the product. The other is the generic drug, which is the name of the chemical compound of the drug. Every drug has a generic name to describe its active ingredient.
When a company develops a new drug, it has a patent for about 17 years. The patent protects the drug company's right to be the only manufacturer of that drug. After the patent expires, other companies can then manufacture and sell the drug under either a different brand name or the generic name. Because of lower research costs and more competition, the new product is usually sold at a lower price than the original brand name product.
The Food and Drug Administration (FDA) reviews all name brand and generic products for safety and effectiveness. Before a generic drug is approved for use in the United States, the drug company must provide proof to the FDA that the product has the same active ingredient when compared to the brand name product. In addition, the generic product must meet FDA standards for the amount of active ingredient and speed of absorption into the body. When the generic product meets these standards, it is considered equivalent.
The role of the FDA is to ensure that all new brand and generic drugs are safe and effective. The FDA also monitors reports from doctors, pharmacists, and nurses on adverse drug reactions. As with all drugs, brand and generic, some adverse reactions are possible. To learn more about generic drugs, you can contact the FDA at 1-888-INFO-FDA, or visit the FDA Center for Drug Evaluation and Research website at http://www.fda.gov/Drugs/default.htm.
You may file the appeal yourself or you may authorize a representative (i.e., doctor, spouse, etc.) to file an appeal on your behalf. Except in pre-service claim appeals where your doctor is acting as your representative, any representative acting on your behalf must have received written authorization from you to act on your behalf and that written authorization must be filed immediately with the Administrative Office as part of your appeal. If you are physically or mentally incapacitated the Trustees will waive this written authorization requirement. It is extremely important to understand that an assignment of benefits to the provider of services does not constitute an authorization for the provider to act as your representative.
Yes. The Plan will upon request supply copies of all documents and opinions relevant to your claim in accord with federal regulations.
No. Only claims for which pre-authorization is required under the Plan are subject to the expedited decision and appeal provisions pertaining Pre-Service Claims.
No. Once medical care has been provided the only issue is what, if any, portion of the bill will be paid and the provisions of post-service claims apply to the claim for medical expenses.
You should contact the Administrative Office.