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IBEW Local 40 NECA Plan

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The Kaiser HMO Plan

As a participant in this Plan, you are entitled to medical and prescription drug benefits under Kaiser provided you meet the eligibility requirements of the Plan.

Kaiser owns its own medical clinics and hospitals, and employs its own doctors. Kaiser may also contract with designated hospitals and Medical Groups. Under the Kaiser Plan, you can choose your own physician, and are encouraged to do so. You must live or work within the list of Kaiser zip codes to be eligible to enroll in the Kaiser Plan. You can use any Kaiser facility at any time and are not restricted to a particular Medical Group. There are specialist doctors within Kaiser and covered benefits are generally provided to you at no cost or for a fixed copayment.

Once enrolled, you can use any Kaiser facility. However, it is suggested that you choose a Kaiser facility closest to your home, or most convenient for you to receive most of your care.

Kaiser Plan benefits apply only when your care is provided, prescribed, or directed by a Kaiser physician except where specifically stated in emergency situations as described in the Kaiser descriptive literature. It is important to note that in order to receive covered benefits, you must use a Kaiser Plan facility to provide care for you and your dependent(s). Referrals to certain specialists may require a referral by your Kaiser doctor.

Complete benefits and information about the Kaiser Plan are described in their descriptive literature or call the Customer Service Call Center at (800) 464-4000. The services provided are summarized below.

Kaiser will provide you with complete descriptive literature after you enroll in the Kaiser HMO Plan, including an identification card. The medical facilities you must use are listed in the HMO brochure. Importantly, you must use the doctors and hospitals associated with Kaiser's HMO Plan

In the following sections, we have provided you with information about the Kaiser HMO Plan available through the Trust. However, this information is only a summary, included herein for easy reference. For complete information about the Kaiser HMO Plan, you should contact the Administrative Office or Kaiser and request that they send you complete descriptive literature about the Plan.

In Case of an Emergency

An emergency is a sudden, unforeseen illness or injury that requires immediate medical attention.

Emergency care and urgent care are available from Kaiser Permanente 24 hours a day, 7 days a week. All necessary care, emergency or otherwise, should be obtained at a Plan Facility, if possible. However, in certain situations Kaiser also covers emergency care obtained from non-Plan providers. This coverage is described below. You pay any copayments that normally apply to the services you receive.

If your condition is an emergency and you are unable to call or go to a Kaiser Permanente facility, call 911 or go to the nearest hospital. Please be aware, however, that Kaiser will not pay for 911 ambulance and other non-Kaiser Permanente emergency medical services in their Southern California Service Area unless the additional time required to reach a Kaiser Permanente facility would result in death, serious disability, or significant jeopardy to your condition. Refer to your Kaiser disclosure information for further details about your emergency care benefit.

 

Services Received at a Non-Planned Facility

To be eligible for this benefit, you must notify Kaiser Permanente within 48 hours after care begins (or as soon as reasonably possible). This benefit is provided only for emergency treatment required before your condition permits transfer to a Plan facility. Medically necessary special transportation is covered with prior approval from a Kaiser Plan Physician. Kaiser may arrange for your transfer to a Plan facility as soon as it is medically appropriate to do so. This benefit applies only to care that is a covered service under the Kaiser Plan Service Agreement.

Services Received at a Non-Planned Facility Outside of the Kaiser Service Area

Benefits are provided for immediate care needed because an unforeseen illness or injury occurs while you are outside the Kaiser Service Area, and services could not be delayed until you could get to a Plan Hospital or Plan Medical Office in the Service Area.

Services Received at a Non-Planned Facility Within the Kaiser Service Area

Benefits are provided for immediate care needed because of an unforeseen illness or injury if getting to a Kaiser Plan facility would have caused a delay resulting in death, serious disability, or significant jeopardy to your condition.

Student Coverage

In order to qualify for student coverage, the student must be:

  • Enrolled in an accredited institution.
  • Dependent upon subscriber for support.
  • Unmarried.

In addition, your employer determines the units and age limitations required.
Complete and return this form to your Union hall or Coast Benefits.