Medical Expense Benefits

Medical Care Expenses

You may use some or all of the money in your HRA Account to pay for services such as hospitalization, doctors and dentists, prescription drugs and amounts you pay for deductibles, copays or coinsurance.  However, not all medical care expenses will be considered “Covered Expenses” that qualify for reimbursement under the Fund.  Generally, only expenses within the meaning of Section 213 of the Internal Revenue Code are eligible.

Common medical care expenses include: acupuncture, contraceptives, chiropractic services, contact lenses/eyeglasses, crutches, dental treatment but not teeth whitening, diabetic supplies, eye examination by an optometrist, device to measure blood pressure, fertility treatment, surgical dressing supplies, elastic bandages like an Ace wrap, hearing aids, immunizations and flu shots, laboratory tests, LASIK eye surgery, tobacco cessation drugs, orthodontia treatment/dental braces and walker/wheelchair and weight loss programs/weight loss drugs only if recommended by a Physician to treat a specific medical condition (e.g. diabetes, obesity, heart disease).

However, not all medical care expenses will be considered “Eligible Medical Care Expenses” that qualify for reimbursement under the Fund.  Generally, only medical care expenses within the meaning of Section 213 of the Internal Revenue Code are eligible.   If you have any questions as to whether an expense is reimbursable, call the Fund Office.

Excludable Expenses

The following expenses are examples of the kinds of expenses that are not reimbursable from your HRA account, as they do not meet the definition of “medical care” under Code Section 213.  This is not intended to be a complete list of all services that are not payable under the plan, but an example of more commonly submitted services that are not reimbursed from the plan. The plan does not pay for/reimburse any item that does not constitute “medical care” as defined under Internal Revenue Code Section 213.  Please note that if the HRA is used to reimburse expenses of a Domestic Partner or a child of a Domestic Partner that is not a tax dependent (that is, does not satisfy the requirements of a Dependent under IRS Code Section 152 (d) (1) and (d) (2) (H) without regard to the gross income limit), those payments will be considered imputed income to the Employee or Retiree.

  1. Health insurance premiums for individual policies or for any other group health plan including health insurance premiums for coverage that has been reimbursed under a Spouse’s plan. Premiums for individual health insurance whether purchased in the individual insurance marketplace, private exchange (except a retiree Medicare exchange), or public exchange such as in state or federal Health Insurance Marketplace.
  2. Long-term care (LTC) services.
  3. Cosmetic surgery/services, ear piercing, hair removal or other similar cosmetic procedures, unless the surgery or procedure is necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease. “Cosmetic surgery” means any procedure that is directed at improving the patient’s appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease.
  4. Funeral and burial expenses.
  5. Massage therapy to improve general health.
  6. Custodial care.
  7. Babysitting and child care expenses.
  8. Costs for sending a problem child to a school for benefits that the child may receive from the course of study and/or disciplinary methods.
  9. Health club or fitness program dues.
  10. Social activities, such as dance lessons and swimming lessons to improve general health.
  11. Cosmetics, toiletries, toothpaste, etc.
  12. Vitamins, food supplements, diet food, even if prescribed by a physician.
  13. Uniforms or special clothing, such as maternity clothing.
  14. Automobile insurance premiums.
  15. Transportation expenses except in certain circumstances where transportation is necessary to receive medical care.
  16. Marijuana and other controlled substances that are in violation of federal laws, even if prescribed by a physician.
  17. Premiums paid through salary reduction contributions under the terms of a Code Section 125 plan or any plan that provides for premium payment with pre-tax dollars.
  18. Over-the-Counter drugs and medicine unless prescribed by a health care provider or physician.
Reminder:  In no event are premiums for individual health insurance payable, whether purchased in the individual insurance market or in a Health Insurance Marketplace.

Eligible Medical Expenses

You are covered for expenses you incur for most, but not all, medical services and supplies.  The expenses for which you are covered are called “eligible medical expense.”  Eligible Medical Expenses are determined by the Plan Administrator or its designee, and are limited to those that are:

  1. “Medically Necessary,” but only to the extent that the charges are “Allowed Charges” (as those terms are defined in the Definitions chapter of this document); and
  2. Not services or supplies that are excluded from coverage (as provided in the Exclusions chapter of this document); and
  3. Not services or supplies in excess of the overall Annual Maximum Plan Benefit or any maximums on specific Plan benefits as shown in the Schedule of Medical Benefits and
  4. For the diagnosis or treatment of an injury or illness (except where preventive services are payable by the Plan as noted in the Schedule of Medical Benefits in this document).

Generally, the Plan will not reimburse you for all Eligible Medical Expenses.  Usually, you will have to satisfy some Deductibles and pay some Coinsurance, or make some Copayments toward the amounts you incur that are Eligible Medical Expenses.  However, once you have incurred a maximum Out-of-Pocket each calendar year no further Coinsurance and/or co-pays with PPO providers will be applied for that calendar year.

Non-Eligible Medical Expenses

The Plan will not reimburse you for any expenses that are not Eligible Medical Expenses.  That means you are responsible for paying the full cost of all expenses that are not determined to be Medically Necessary, determined to be in excess of the Allowed Charge, not covered by the Plan, or payable on account of a penalty because of failure to comply with the Plan’s Utilization Review requirements as described later in this document.

 

Schedule of Medical Benefits

Utilization Review

NOTE:  If you are a Retiree or a Retiree’s Dependent that is eligible for Medicare or if this Plan is the secondary payer of your benefits (see Coordination of Benefits) the requirements for Utilization Review/Prior authorization (described below) and Care Counseling do not apply to you.

Purpose of the Utilization Review Program

Your Plan is designed to provide you and your eligible family members with financial protection from significant health care expenses.  The development of new medical technology and procedures and the ever-increasing cost of providing health care may make it difficult for the Fund to afford the cost of maintaining your plan.

To enable your Plan to provide coverage in a cost-effective way, your Plan has adopted a Utilization Review program designed to help control increasing health care costs by avoiding unnecessary services or services that are more costly than others that can achieve the same result.  By doing this, the Fund is better able to afford to maintain the Plan and all its benefits.  If you follow the procedures of the plan’s Utilization Review program, you may avoid some Out-of-Pocket costs. However, if you don’t follow these procedures, your Plan provides reduced benefits, and you’ll be responsible for paying more out of your own pocket.

Management of the Utilization Review Program

The Plan’s inpatient Utilization Review Program is administered by an independent professional Utilization Review Company operating under a contract with the Plan (hereafter referred to as the UM Company).  The name, address and telephone number of the UM Company appears in the Quick Reference Chart.

The health care professionals in the UM Company focus their review on the necessity and appropriateness of Hospital stays and the necessity, appropriateness and cost-effectiveness of proposed medical or surgical services.  In carrying out its responsibilities under the Plan, the UM Company has been given discretionary authority by the Plan Administrator to determine if a course of care or treatment is medically necessary with respect to the patient’s condition and within the terms and provisions of this Plan.
Elements of the Utilization Review Program
The Plan’s Utilization Review Program consists of:

  1. Prior Authorization (pre-service) review: review of proposed health care services before the services are provided;
  2. Concurrent (continued stay) review: ongoing assessment of the health care as it is being provided, especially (but not limited to) inpatient confinement in a hospital or health care facility or continued duration of healthcare services;
  3. Second and third opinions: consultations and/or examinations designed to take a second, and when required, a third look at the need for certain elective health care services; and
  4. Retrospective (post-service) review: review of health care services after they have been provided.

Restrictions and Limitations of the Utilization Review Program  (Very Important Information)

  1. The fact that your Physician recommends surgery, hospitalization, confinement in a Health Care Facility, or that your Physician or other Health Care Provider proposes or provides any other medical services or supplies doesn’t mean that the recommended services or supplies will be an eligible expense or be considered medically necessary for determining coverage under the Medical Plan.
  2. The Utilization Review Program is not intended to diagnose or treat medical conditions, validate eligibility for coverage, or guarantee payment of Plan benefits. The UM Company’s certification that a service is medically necessary doesn’t mean that a benefit payment is guaranteed.  Eligibility for and actual payment of benefits are subject to the terms and conditions of the Plan as described in this document.  For example, benefits would not be payable if your eligibility for coverage ended before the services were rendered or if the services were not covered by the Plan either in whole or in part.
  3. All treatment decisions rest with you and your Physician (or other Health Care Provider). You should follow whatever course of treatment you and your Physician (or other Health Care Provider) believe to be the most appropriate, even if the UM Company does not certify the proposed surgery/treatment/service or admission as medically necessary or as an eligible expense.  However, the benefits payable by the Plan may be affected by the determination of the UM Company.
  4. With respect to the administration of this Plan, the Fund, the Claims Administrator and the UM Company are not engaged in the practice of medicine, and none of them takes responsibility either for the quality of health care services actually provided, even if they have been certified by the UM Company as medically necessary, or for the results if the patient chooses not to receive health care services that have not been certified by the UM Company as medically necessary.
Information Needed Whom to Contact
Utilization Review for Inpatient Hospitalizations, and PPO Network for the Medical Plan(for Active Employees, Retirees who are not eligible for Medicare and eligible Dependents enrolled in the Blue Cross Network (PPO) or the Blue Cross Advantage Network (APPO).

  • Provides prior authorization for inpatient Hospital admissions (except routine childbirth or emergency) for eligible Participants
  • Additions/Deletions of Network Providers (Always check with the Network before you visit a provider to be sure they are still contracted and will give you the discounted price)
  • Compare the costs charged by different Anthem Blue Cross Network providers at www.anthem.com/ca

This PPO network is not available to Medicare eligible Retirees or their Dependents that are eligible for Medicare.

Anthem Blue Cross
21555 Oxnard Street
Woodland Hills, CA 91367
1-800-274-7767
For help finding network providers (PPO Physician, specialist, hospital or other Health Care Practitioner), see www.anthem.com/ca (or call the Trust Fund Office). Be sure to choose “Large Group Plan” under plan type and “Blue Cross PPO (Prudent Buyer)” under select a plan.Anthem Blue Cross – Network Provider Finder
With the Find a Doctor online tool, it’s simple to look for doctors who are part of either your current PPO Prudent Buyer network or a part of the newly added Advantage PPO network. Follow the directions in the attached document in either of your two Anthem network options.CAUTION: Use of a non-PPO network hospital, facility or Health Care Practitioner could result in you having to pay a substantial balance on the provider’s billing (see definition of “Balance Billing” in the Definition chapter of this document).
Medical Plan Networks

  • Medical Network Provider Directory
  • Additions/Deletions of Network Providers

 

Blue Card

(for indemnity medical Plan Participants outside of California)

  • Help finding contracted Blue Card providers
  • Preauthorization for hospital admissions or surgery
Anthem Blue Cross
1-800-810-2583
Website: www.bluecares.com
Use the following directions:
There are certain states/geographic areas where selecting a “PPO” provider is not an option. If that occurs, please choose “Traditional” and follow the prompts. Although “Traditional” providers do not participate in a Blue Card network, they have agreed to perform services at special discounted rates for Blue Card members. You should go to a “Traditional” provider only if there are no Blue Card PPO providers in your area.
  • To access Anthem’s Advantage Provider Network:
  1. Log in to anthem.com (Note: If you log in as a member, your personal information will be shown including physicians and facilities within your chosen network).
  2. If you do not have your user information or log in as a member on the anthem.com homepage, go to Useful Tools on the right, and select Find a Doctor.
  3. Under Search as a Guest, click on Search by selecting a plan/network.
  4. In the Find a Doctor section, click on your preferred choices (type of doctor, state and select plan/network, which is Advantage PPO).
  5. Advantage PPO will be shown under the heading Medical (Employer-Sponsored) and listed as Advantage PPO (Note: You will have to scroll down through many network options).
  6. When you are within the Advantage PPO area you will be asked for various categories (doctor, hospital, physician name etc.) so enter those tabs accordingly, add your location and press search.

Either a list of providers will populate on the screen for you to choose from or your specific choice will be shown as in or out of the network.

 

  • To access Anthem’s Prudent Buyer Provider Network:
  1. Log in to anthem.com (Note: If you log in as a member, your personal information will be shown including physicians and facilities within your chosen network).
  2. If you do not have your user information or log in as a member on the anthem.com homepage, go to Useful Tools on the right, and select Find a Doctor.
  3. Under Search as a Guest, click on Search by selecting a plan/network.
  4. In the Find a Doctor section, click on your preferred choices (type of doctor, state and select plan/network, which is Blue Cross PPO (Prudent Buyer) – Large Group).
  5. Advantage PPO will be shown under the heading Medical (Employer-Sponsored) and listed as Blue Cross PPO (Prudent Buyer) – Large Group (Note: You will have to scroll down through many network options).
  6. When you are within the Blue Cross PPO (Prudent Buyer) – Large Group area you will be asked for various categories (doctor, hospital, physician name etc.) so enter those tabs accordingly, add your location and press search.

Either a list of providers will populate on the screen for you to choose from or your specific choice will be shown as in or out of the network.

 

 HMO Medical Plan

(for Active/Retired participants and eligible Dependents who live in the Kaiser service area and are enrolled in the Kaiser (HMO) or the Kaiser/Smart Choices (HMO))

  • ID Cards
  • Retail Network Pharmacies
  • Mail Order (Home Delivery) Pharmacy
  • Prescription Drug Information
  • Referrals and prior authorizations
  • Mental Health and Chemical Dependence Providers
  • Claims and Appeals
  • Smart Choices Healthy Rewards Program Educational Requirements for Kaiser Participants
  

Kaiser Permanente (Group #602697)
Northern California Region
1950 Franklin Street
Oakland, CA 94612

Toll Free: 1-800-464-4000

Website: www.kp.org

Smart Choices/Healthy Rewards Educational Requirements:

www.kp.org/healthylifestyles