Kaiser

The Board of Trustees has made arrangements for members to elect hospital, medical and surgical coverage through a health maintenance organization ("HMO"), in place of the self-funded PPO Plan. The HMO option currently offered to active Employees and pre-Medicare retirees is the Kaiser Foundation Health Plan (“Kaiser”). For Medicare-eligible retirees, the option currently offered is the Kaiser Senior Advantage Plan.  A separate booklet describing this program is available at no charge from the Trust Fund Office.

 

To elect coverage through an HMO, you must complete a Plan election card and the enrollment packet of the HMO.  You may elect HMO coverage when first eligible under the Plan, or at the open enrollment period established by the Board of Trustees.  Currently there is an annual open enrollment election period in October of each year, to be effective on January 1 of the next year.  If you do not actively enroll in an HMO, you will automatically be enrolled in the PPO Plan or, if you are retired and eligible for Medicare, the Medicare Supplemental Plan.  Electing HMO coverage will have the following effects on the benefits you and your family receive:

1. If you elect hospital, medical and surgical coverage through a Plan HMO, neither you nor your dependent is eligible for hospital, medical, or surgical benefits from the self-funded Plan.
2. To have your eligible dependents receive benefits from your HMO, you must enroll them when you enroll; or for a new dependent, you must enroll him or her within 30 days of the marriage, birth, adoption or other event which qualifies the person as an eligible dependent under the Plan.  Failure to enroll a dependent in your HMO in a timely fashion may result in loss of coverage for that dependent until the next open enrollment date, unless late enrollment is accepted by the HMO.
3. All Participants who elect coverage through an HMO remain eligible for dental benefits, life insurance, and accidental death and dismemberment insurance.  All active Employees remain eligible for weekly disability benefits. Vision Coverage is no longer covered under Kaiser effective 2-1-2008, but is now covered under Vision Service Plan.

 

The following summary of the available HMO options are presented for your convenience only.  Please refer to the Evidence of Coverage booklet of each HMO for a detailed statement of the benefits it provides.

 

Plan Summary

Kaiser Benefits
GENERAL CHARGES
Office Visit Copayment:	$10 copayment
Deductible:	Not Applicable
Annual out-of-pocket limit:	Not Applicable
Lifetime Maximum:	Not Applicable
SPECIFIC CHARGES
INPATIENT BENEFITS:
Alcohol and Substance Abuse	No charge (detox only)
Anesthesia	No charge
Blood	No charge
Inpatient Hospital Benefits	No charge
Inpatient Rehabilitation Care	No charge
Maternity Care (incl. delivery & C-section)	No charge
Mental and Nervous Conditions	No charge up to 45 days per year; unlimited for AB88 conditions
Newborn Care	No charge
Physician Visit	No charge
Surgeon/Assistant Surgeon	No charge
Skilled Nursing Facility	No charge; limited to 100 days per year
OUTPATIENT BENEFITS:
Allergy Testing	$3 copayment
Ambulance	No charge
Durable Medical Equipment	No charge
Emergency Room/Urgent Care: PPO Facility (see booklet for other rules)	$10 copayment; waived if admitted
Immunizations	No charge
Infertility Treatment	$10 per visit
Laboratory and Radiology	No charge
Maternity Care, Tests and Procedures	$10 copayment
Mental Health Services	$10 copayment per visit; 20 visits per year - non-AB88 conditions; 40 visits per year - AB88 conditions
Outpatient Surgery	$10 copayment
Physician Care	$10 copayment
Prenatal/Postnatal Office Visits	$10 copayment
Routine Physical Exam	$10 copayment
Therapy (physical, speech, rehabilitative)	$10 copayment
Well Baby Care	$10 copayment
Rx        Retail-Brand	$10 for a 100 day suppky
Retail-Generic	$10 for a 100 day suppky
Mail Order-Brand	Option at some facilities
Mail Order-Generic	Option at some facilities

 

 

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