Medical

The plans described below are for California Active members only. The plans for active participants in the Hawaii, Nevada and Utah OE3 Health and Welfare Trust Funds are not covered on this website. Please visit the Contact Us link for information on contacting the Fringe Benefits Service Center or the Trust Fund office for your state.

Once you establish initial eligibility, your options for health plan coverage are the Comprehensive Health Plan (self-funded by the Plan), or the Kaiser Foundation Health Plan. If you do not select Kaiser, you will automatically be enrolled in the Comprehensive Health Plan.

Please consider your Plan selection carefully. The selection you make will remain in effect for you and your eligible family members for twelve months, unless you have a Special Enrollment Event. Once each year you have the opportunity to change your Medical coverage, however you must remain in the plan you selected for a minimum of 12 months unless you choose an HMO and later move out of the HMO plan's service area or otherwise have a Special Enrollment event. Any change in plans will be effective on the first day of the second month following the date the enrollment form is received by the Trust Fund Office.

If you select the Comprehensive Plan, using Providers in the Anthem Blue Cross Network of participating providers in California, or Blue Card providers in other states will maximize Plan benefits. This list changes from time to time so please contact, the trust Fund Office Claims Department at (800) 251-5013 to verify that the providers are still in the network.

For more information regarding the Kaiser Foundation Health Plan, please visit the Related Sites tab.

Comprehensive Plan Summary

Deductible $500 
$1500 Family Deductible Limit
Choice of Physician You may use any licensed providers
Your Copayment: Calendar out-of-pocket limit for covered expenses is $5,000/participant or $11,000/family when contract providers are used. 
Non-Contract Providers: $10,000 per person with a $30,000 limit.

* Your out of pocket expenses will be higher if you use non-contract providers

Physician Visits, Specialist Consultations (Outpatient)

Contract Provider For most visits, 10% of contract rates.
Non- Contract Provider For most visits, 20% of covered charges, or 10% of covered charges if out-of-area or emergency *

Coverage includes visits to a physician's office (including specialist consultations) and visits by a physician to your home.

* See "Covered Charges" below

Surgeon, Anesthetist, X-ray and Laboratory, Physician Inpatient Visits

Contract Provider <10% of contract rates.
Non-Contract Provider 20% of covered charges*

* See "Covered Charges" below

Hospital / Ambulatory Surgery Facility

10% of covered charges*

* See "Covered Charges" below

Hospital Emergency Room

Emergency $100 copay per visit plus 10% of remaining covered charges in excess of the $100 copay*

"Covered Charges" for the Comprehensive Health Plan:

For contract providers, "Covered Charges" are the negotiated contract rates.

For non-contract providers within the contract provider service area, covered charges are limited to a schedule of allowances that will be less than the billed amount in most cases.

For non-contract providers out-of-area or in an emergency, covered charges are the allowed charge.

Preventive Care

 The Plan's preventive care guidelines have been modified and expanded to reflect requirements of the Affordable Care Act (also known as "health care reform"). Preventive care services that are required under health reform are payable at 100%, with no deductible when received from a Contract Provider.

Please see the following Government website for a complete description of covered preventive care or call the Fund Office with any questions you have. http://www.healthcare.gov/law/about/provisions/services/lists.html

Physical Therapy

 Limited to a maximum of 20 visits per year; maximum increased to 40 visits if 24 months before/after related surgery or stroke in benefits.

Mental Health Services

Paid on the same basis as other medical conditions 

Maternity

 Visits and delivery covered the same as any other physician visit and surgery

Coverage includes:

  • Hospital and physician services for pregnancy and childbirth (available only to female employees or spouses, not to dependent children except as otherwise required under health reform)
  • Services of a stand-by pediatric physician at a cesarean section delivery or other at-risk delivery, but only when the stand-by physician is actually present in the delivery room. (available only to female employees or spouses, not to dependent children)

Infertility consultation (initial consultation only), including laboratory tests and screening laparoscopy for the purpose of determining the cause of infertility.

Infertility Services

 Not Covered

Hearing Aid

 $1,350 per device, payable once every 4 years. Paid at 100%

Organ Transplants (Pre-Authorization Required)

 10% of covered charges for contract providers.

20% of covered charges of the amount in the Schedule of Allowances (in area) or 10% of the usual, customary, and reasonable charges (out of area if you live out of area) for non-contract providers.

Coverage includes organ procurement and transportation, surgery, follow-up care, and immunosuppressant drugs.

Substance Abuse Treatment

Covered on the same basis as medical conditions.

Kaiser Plan Summary

An Eligible Individual who elects to be covered by Kaiser will be entitled to the following benefits provided directly by the Fund as described in the Plan:

  • Chemical Dependency Treatment Benefits See the chemical dependency benefits under the Comprehensive Plan Summary for details.
  • Vision Coverage 
    Review the pages within the Vision section under Fund Benefits for more information.
  • Dental Benefits
    Review the pages within the Dental section under Fund Benefits for more information.

The benefits described in the Plan are provided for covered expenses incurred for Medically Necessary treatment of a non-occupational Illness or Injury. An expense is incurred on the date the Eligible Individual receives the service or supply for which the charge is made. The benefits available under this Plan are subject to all other Plan provisions and exclusions.

 Deductible Amount

  • $500
  • $1000 Family Deductible Limit

Annual Out of Pocket

  • $3,000 Per Person
  • $6,000 Family

Payment

Except as otherwise stated in the Plan, payment for Covered Expenses is provided as follows:

Coinsurance/Co-payment

The following summary is intended only as a general description of Plan benefits. For a complete description of benefits and Plan exclusions and limitations, please refer to the Plan's "Disclosure of Coverage" or your Summary Plan Description.

Choice of Physicians

You must use Kaiser doctors and facilities. No benefits will be paid for services received outside of Kaiser except for emergency services.

Plan Maximum

Unlimited

Deductible

  • $500 Individual
  • $1,000/Family

 

Your Copayment

See below for each service.

Physician Visits, Specialist Consultations (Outpatient)

$20 copay

Surgeon, Anesthetist, X-ray and Laboratory, Physician Inpatient Visits

20% coinsurance

Hospital / Ambulatory Surgery Facility

20% coinsurance

Preventive Care as required under Health Reform

No charge

Physical Therapy

$20 copay

Chiropractic

$5 per visit, up to 20 visits per year. $50 allowance per year for chiropractic appliances

Home Health Care

No charge, up to 2 hours maximum per visit, 3 visit maximum per day, 100 visits per calendar year.

* In Kaiser plan, conditions of severe mental illness are covered the same as any other medical condition. The following conditions are considered severe mental illnesses: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa, serious emotional disturbances of children. 

Maternity

No charge for prenatal and postnatal care; delivery covered as any other surgery

Infertility Services

$25 per visit for outpatient services

No charge for inpatient services, lab tests and special procedures

Prescription Drugs

Retail Pharmacy

Generic Drug $10 for up to a 100-day supply, deductible does not apply
Brand Name Drug $30 for up to a 100-day supply, after $100 prescription deductible per calendar year
Mail Order Available for refills only. Same copays as shown above for retail pharmacy

 

Hearing Aid

Covered under Comprehensive Health Plan

Substance Abuse Treatment

Covered under Comprehensive Health Plan

Maximum Benefit

  • Unlimited
  • Kaiser members must use Kaiser or ARP providers for substance abuse benefits; there are no benefits for non-plan providers as of April 1, 2013.