* Administering Health, Pension and Vacation Benefits For the Men and Women Who Help Build the Southwest *
Effective January 1, 2019, the Trust Fund introduced a new, enhanced Anthem Preferred Provider Organization (PPO). This plan replaced the UnitedHealthcare (UHC) Exclusive Provider Organization (EPO) and UHC PPO, Anthem PPO and all Health Maintenance Organizations (HMOs) in all states except the Kaiser HMO in California and Colorado. Under the enhanced Anthem PPO, prescription drug benefits are administered through Express Scripts (ESI), a pharmacy benefit administrator that is separate from your medical plan. Also, the Trust Fund made some changes to the Kaiser HMO and introduced new, enhanced UnitedHealthcare dental plan options, a copayment plan and a Dental Preferred Provider Organization (DPPO). These new UnitedHealthcare dental plans will replace all former dental plan options. Note that the copayment plan will not be available in New Mexico or Texas.
The plans available to you in 2019 depend on the state in which you live:
The Trust Fund offers the Kaiser HMO in California and Colorado because Kaiser:
The way your medical coverage will be affected in 2019 will depend on the plan you are currently in and the state in which you live. Find your current medical plan in the list below:
A PPO, or Preferred Provider Organization, is a group of providers (doctors, hospitals, labs and other healthcare facilities) that have contracted with Anthem to charge discounted fees for their services.
“In-network” providers are doctors, hospitals, labs and other healthcare facilities that have contracted with Anthem to charge discounted fees for their services. “Out-of-network” providers have no agreement with Anthem and may charge any amount they want, which may be significantly higher. Services received from an in-network provider will always cost you less. See the example below.
The following example shows the cost of in-network vs. out-of-network hospital care for an outpatient procedure and assumes the annual deductible has been met.
|
|
In-Network Hospital | Out-of-Network Hospital |
|---|---|---|
| Hospital expenses for a one-day outpatient hospital procedure | $10,000 (reflects PPO in-network discounted fee) | $15,000 (no discount) |
| Plan pays You pay |
$9,000 (90%) $1,000 (10%) |
$7,500 (50%) $7,500 (50%) |
In this example, you save $6,500 by using an in-network hospital.
If you were previously in the Anthem PPO, your out-of-pocket costs decreased under the new Anthem PPO. If you were previously in an EPO or non-Anthem PPO, your deductible and out-of-pocket maximum are higher under the new Anthem PPO; other benefits may have higher or lower costs. If you were previously in an HMO, you may pay more out-of-pocket under the new Anthem PPO. Anthem has online tools you can use to find the best care at the lowest cost.
With the Kaiser HMO, you choose a primary care physician (PCP) and can only see providers who participate in Kaiser’s network. The Anthem PPO is more flexible. It doesn’t require you to choose a PCP. It also offers out-of-network coverage for providers who aren’t in Anthem’s PPO network, although your out-of-pocket costs are greater when you use an out-of-network provider.
Also, the Anthem PPO is different in how it covers medical care. For most covered expenses, you pay a calendar year deductible before the PPO starts paying benefits. Then, you and the PPO share expenses (called “coinsurance”) until you reach the plan’s calendar year out-of-pocket maximum. At that point, the PPO pays 100% of covered expenses for the rest of the calendar year.
IMPORTANT: The PPO pays 100% of the cost of in-network routine preventive care (like your annual physical) and related lab fees and tests with no deductible.
The types of care under the Anthem PPO are the same as what was covered under the Trust Fund’s 2018 medical plans.
This is the amount that Anthem will use to determine benefit payments for care or services received from out-of-network providers who can charge any amount they wish to charge. You are responsible for paying any amounts over Anthem’s allowed amount for a given service or procedure.
Whether you can keep seeing your current provider and receive in-network benefits this year will depend mainly on where you live:
Visit anthem.com/ca to search for providers online, then:
You may also download Anthem’s mobile app from the App Store or Google Play and use the provider search tool, or call Anthem for help finding an in-network provider, at (833) 224-6930.
Ask your doctor to contact Anthem directly. Anthem will email an application packet to the doctor’s office. If the doctor returns the application to Anthem, they will initiate a credentialing review to ensure that the doctor meets their guidelines. This review takes 60 to 90 days to complete. Anthem does not guarantee the addition of any doctors, since acceptance into the network is dependent on the credentialing review and network needs.
See the Comparison of Medical Plan Benefits 2019 or the Summaries of Benefits and Coverage (SBCs) that contain information on the Anthem PPO. Also, you can call Anthem directly for coverage details or contact Participant Services at the Trust Fund at (213) 386-8590 or (800) 293-1370.
Anthem in-network providers can only charge you for copays or services not covered by the plan at the time of service. They cannot charge you deductible or coinsurance amounts until your claim is processed and Anthem’s Explanation of Benefits (EOB) is sent to you. For example, if you have an office visit with an Anthem PPO doctor, the doctor’s office cannot charge you for the deductible and 10% coinsurance until you receive your EOB. However, if the doctor performs a service not covered by the plan such as a Botox injection, the doctor’s office can charge you for that service at the time you receive it since it is not covered under the plan.
For most covered in-network services, the plan pays 90% of the discounted network charge. For most covered out-of-network services, the plan pays 50% of the allowed amount. This is the amount that the Anthem PPO allows as payment for care or services received from out-of-network providers. Your cost-share is determined using the allowed amount, not the total charge or billed amount. For details, see "What does the term “allowed charge” or “allowed amount” mean?" above.
Yes. Register to use the Anthem website at anthem.com/ca. You can then use the “Estimate Your Cost” tool to compare costs and quality for common procedures before you have those procedures/services performed.
No. You may see a specialist without the need for pre-approval or a referral. However, you receive the highest level of benefits by choosing an in-network specialist.
The Anthem PPO provides:
In addition, Anthem offers the following special services:
Call Anthem Member Services at (833) 224-6930 for more information or to register for these special services.
Telemedicine is a service that lets you see a US-based, board-certified doctor 24/7 via video chat on your phone, tablet or computer, through Anthem’s LiveHealth Online service. Use this service to diagnose common conditions—like a sore throat, headache, or the flu—or get answers to medical questions. Visit livehealthonline.com for more information and to enroll. You only need to pay a $5 copay for each LiveHealth Online visit.
Under the Anthem PPO, most common preventive services and tests are covered at 100% with no copay or deductible when received from an in-network provider. These include:
Visit anthem.com/ca for more information and a complete list of covered preventive care services.
The annual deductible under the Anthem PPO depends on whether you receive services in-network or out-of-network. The in-network deductible is $300 per person, with a maximum of $900 per family. For out-of-network services, the annual deductible is $500 per person, with a maximum of $1,500 per family.
Generally yes, but it depends on the service or care you are receiving. Eligible preventive care services received in-network are covered at 100% with no deductible. In addition, you do not have to pay the annual deductible before the plan starts paying outpatient prescription drug benefits or if you need ambulance services. However, for most other types of services and care, including doctor and specialist visits, you must meet the annual deductible before the plan starts paying benefits.
If you or your dependents are covered under a Trust Fund plan and another group medical plan, benefits will be coordinated between the plans on a “non-duplication” basis. It is not intended that you receive greater benefits than the actual allowable charges you incur. For details and rules for coordination of benefits, see the Health and Welfare Trust Summary Plan Description.
The annual out-of-pocket maximum under the Anthem PPO depends on whether you receive services in-network or out-of-network. Once you’ve met the annual individual out-of-pocket maximum, the plan will begin paying 100% of eligible charges for that individual. The annual medical in-network out-of-pocket maximum is $2,500 per person with a maximum of $5,000 per family. The annual outpatient prescription in-network out-of-pocket maximum is $1,000 per person with a maximum of $2,000 per family. There is no out-of-pocket maximum for out-of-network services, except for emergency care in an emergency room.
Yes. Emergency services are covered whether you use an in-network or out-of-network provider. However, out-of-network providers may charge for expenses that are not covered or charge more than the plan’s allowed charge and the charges will be paid at the out-of-network level if it’s deemed not to be a true emergency (see "What does the term “allowed charge” or “allowed amount” mean?" above). So it’s a good idea to receive in-network care whenever possible.
Yes. You’re covered through the BlueCard® program to get care anywhere in the United States and worldwide, as described in your Summary of Benefits and Coverage, but claims are processed at the out-of-network level. For more information, visit anthem.com/ca.
After you receive care from an in-network or out-of-network provider, you will receive an EOB statement from Anthem. This is not a bill. It’s a document showing the amount the provider charged, how much of that amount is allowable under the plan, how much the plan paid to the provider and the amount you owe the provider, if applicable. Your EOB statement will also show how much you’ve paid toward your annual deductible. EOBs are sent to you automatically when your provider files a claim for service. You can also see your EOBs online by registering at anthem.com/ca.
HealthGuide is Anthem’s new, enhanced customer service model. It provides tools to help you get the care that’s right for you and get more value from your benefits. Anthem offers specially trained health guides who can:
Call Anthem’s HealthGuide, at (833) 224-6930.
Kaiser HMO coverage will change as outlined below. The increase in the annual out-of-pocket maximum makes it the same as the Anthem PPO. With a new deductible being added to the Kaiser plan, members will begin to receive an Explanation of Benefits (EOB) statement monthly showing their deductible and out-of-pocket balance.
| Feature | Current Kaiser HMO | Kaiser HMO Effective January 1, 2019 |
|---|---|---|
|
Doctor office visit copays (decrease) |
CA: $20 CO: $20 plus 10% for procedures performed |
CA and CO: $10 |
|
Specialist office visit copays (decrease) |
CA: $40 CO: $30 plus 10% for procedures performed |
CA and CO: $20 |
|
Annual out-of-pocket maximum (increase) |
CA: $1,500 per person/ CO: $2,000 per person/ |
CA and CO: $2,500 per person/$5,000 family maximum |
|
Calendar year deductible for inpatient hospital, outpatient hospital and emergency room services (new) |
None |
CA and CO: $300 per person/ $600 family maximum |
|
Inpatient hospital, outpatient hospital and emergency room services |
CA and CO: various copays |
CA and CO: 10% after annual deductible |
|
Prescription drugs: Preferred Brand Retail — up to 30-day supply |
CA: $35 CO: $30 Preferred; |
CA and CO: $30 |
|
Prescription drugs: Preferred Brand Mail Order (decrease in CA) |
CA: $70 up to 100-day supply CO: $60 up to 90-day supply |
CA: $60 up to 100-day supply CO: $60 up to 90-day supply |
There are also improvements to prescription drug copays under the Kaiser HMO in California. Retail Preferred Brand, Non-Preferred Brand, and Specialty copays will decrease from $35 to $30 with no deductible (up to a 30-day supply). Mail order Preferred Brand and Non-Preferred Brand will decrease from $70 to $60 with no deductible (for up to a 100-day supply). Generic drug copays will continue to be $10.
The first difference relates to how each plan provides care. Under the Kaiser HMO, benefits are not paid for care provided from non-Kaiser network providers (except in cases of life-threatening emergency). Kaiser encourages members to choose a personal physician who will provide or coordinate all medical services. You’re free to change doctors within the Kaiser network any time, for any reason. In most cases, you’ll need to obtain a referral from your Kaiser personal physician to see a Kaiser specialist. You don’t need a referral for certain specialties, like obstetrics-gynecology, optometry, most psychiatry and substance abuse disorder treatment. With the Anthem PPO, you are not required to choose a primary care physician, and you can make an appointment directly with a specialist. You can also see providers outside Anthem’s network and receive benefits from the plan at the out-of-network level.
The second difference relates to your out-of-pocket costs for care. Under the Kaiser HMO, there is an annual deductible for certain services and you pay a flat copay for most covered services. For most covered services under the Anthem PPO, you must pay an annual deductible before the plan starts paying benefits. Then, you and the PPO share expenses (called “coinsurance”) until you reach the annual out-of-pocket maximum. At that point, the PPO pays 100% of covered expenses for the rest of the calendar year for the individual who reached the maximum. The Anthem PPO and the Kaiser HMO both pay 100% of the cost of in-network routine preventive care (like your annual physical) and related lab fees and tests, and no deductible applies to these services.
For 2019, there will be a new annual deductible under the Kaiser HMO for inpatient hospital stays, outpatient hospital visits and emergency room visits: $300 per person, with a maximum of $600 per family.
The annual out-of-pocket maximum under the Kaiser HMO will be $2,500 per person with a maximum of $5,000 per family—the same as it will be under the Anthem PPO.
In Southern Colorado, Kaiser members can use any pharmacy, not just Kaiser. For long-term drugs, you can use an outside pharmacy only once, then you must use a Kaiser pharmacy or the Kaiser mail order program. In other areas of Colorado and in California, you can use a Kaiser pharmacy or the Kaiser mail order program for long-term drugs.
If you are enrolled in the Anthem PPO, your prescription drug benefits are administered by Express Scripts (ESI). If you are enrolled in the Kaiser HMO, your prescription drug benefits are administered by Kaiser.
You may take your prescription to a pharmacy that participates in Express Scripts’ network (for example, national chains like Sav-On, Smith’s, Safeway, CVS; regional drug store chains; and thousands of independently-owned pharmacies). However, after two fills, you need to use the Express Scripts PharmacySM mail order service for drugs to be taken for 31 days or more. To determine if your prescription is covered, how much is covered, whether you need to get prior authorization before filling your prescription, or you have other questions about your prescriptions, contact Express Scripts at expressscripts.com or (800) 987-7836.
Yes. You may fill a long-term prescription drug at a participating retail pharmacy up to two times (an initial fill and one refill). After that, you must fill your prescription through the Express Scripts Pharmacy mail order service. If you continue filling the prescription at a retail pharmacy, you’ll pay the entire cost of the drug. (Long-term drugs are those prescribed by your doctor for ongoing conditions, such as high blood pressure or high cholesterol.)
When you fill your prescription by mail order, you can save up to 60% on the cost and your medication will be delivered to your home with free standard delivery.
To get started with mail order, call Express Scripts at (800) 987-7836. For most medications, they will contact your doctor and arrange for your first home delivery supply. Your medication will usually arrive within eight to 11 days after your prescription is received. Continue to use a participating retail pharmacy to fill prescriptions for short-term drugs, such as antibiotics.
If the drug you are taking is not on Express Scripts’ formulary, contact your doctor to discuss alternative/Preferred medications or request a formulary coverage review by calling Express Scripts’ Coverage Review Department at (800) 753-2851.
To set up mail order, download, complete and mail the Express Scripts Home Delivery Order Form.
Have your Anthem participating doctor write a new 90-day prescription and submit it to Express Scripts as soon as possible after December 31, 2018. Your physician can write an emergency short-term prescription, to fill at your local in-network retail pharmacy, to cover you while you are waiting for your mail order medications to arrive.
Yes. Depending on where you live, you will be offered the UHC copayment plan or the UHC Dental PPO (DPPO). You may also have the ability to choose between the two dental plans. See the chart below for details.
| If You… | Here’s What Will Happen… | |
|---|---|---|
| Reside in California or Nevada | You will be offered the UHC Select Managed Care Direct Compensation (DC) and the UHC DPPO to choose from during the next annual Open Enrollment. | |
| Reside in any state EXCEPT California or Nevada | You will be offered the UHC In-Network Only (INO) Plan* or, you can choose the UHC DPPO during the next annual Open Enrollment. | |
| Are not enrolled in any Southwest Carpenters Trust Fund dental plan as of October 31, 2018 | You will need to complete an enrollment form if you want to enroll in a dental plan effective January 1, 2019. | |
* Note that the UHC INO is not available in Alaska, Alabama, Arkansas, Connecticut, Georgia, Hawaii, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maryland, Maine, Missouri, Mississippi, Montana, New Mexico, North Carolina, North Dakota, Oklahoma, Texas and Vermont. If you live in any of these states, you will be enrolled automatically in the UHC DPPO for coverage effective January 1, 2019.
The new dental plans offer these enhancements over the current dental plans:
All of these UHC dental plans pay for diagnostic and preventive services at 100%.
For details on dental benefits, see Dental Plans.
Orthodontic treatment in progress is prorated based on the initial date of service and expected timeframe of the treatment. Banding charges and monthly fees incurred before the effective date with UnitedHealthcare are paid by your prior dental plan. UnitedHealthcare reviews the full cost of the case and the remaining treatment to be completed to calculate the benefit that will be paid over the remaining months of treatment.
If you are in the middle of an extensive treatment plan, a transition to a new carrier can be concerning. Often a pretreatment estimate was completed by your prior carrier. Ask your dentist to submit a similar pretreatment claim to UnitedHealthcare, listing the remaining services to be completed with any supportive x-rays or documentation. This gives UnitedHealthcare the opportunity to assist you with the transition before the work is completed. UnitedHealthcare also encourages provider nominations to its network and would be happy reach out to your dentist if he or she is not in their network. Nominations can be submitted online at myuhc.com or by calling the customer service number on your ID card.
No. Your vision benefits are not affected by the changes to your medical, prescription drug and dental plans. They will continue to be administered by UnitedHealthcare. You automatically have vision benefits if you are enrolled in a medical plan.
Generally, you can’t change your coverage other than during Open Enrollment unless you have a qualifying event (for example, marriage, divorce, birth or adoption of a child) or, if you are a Kaiser participant, you move outside of a Kaiser service area.
Your new ID card(s) were mailed to your home address on file. If you did not receive your ID cards, you may be able to print them from the Kaiser or Anthem website depending on which plan you are enrolled in effective January 1, 2019. Or, call Kaiser or Anthem directly to request them.
Our next annual Open Enrollment is in November 2019 for plan changes effective January 1, 2020. If you have moved out of the Kaiser Permanente Medical Plan service area, please contact the Trust Fund Office at (213) 386-8590 or (800) 293-1370.
Changes made during the upcoming Open Enrollment period take effect January 1, 2020.
No, unfortunately if you missed the annual Open Enrollment period you can no longer make changes until the next annual Open Enrollment period. The exception to this rule is if you move outside of your current Health Plan’s service area.
If you are eligible during the Open Enrollment period, you will receive a notice from the Administrative Office with instructions on how to enroll. Our next annual Open Enrollment period is November 2019, for plan changes effective January 1, 2020. If you have moved out of the Kaiser Permanente Medical Plan service area, please contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
No, parents are not eligible to enroll on your Health Plan. For more information contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
You are allowed to add or drop a dependent during the Plan year if you have a qualifying life event such as a birth, marriage, divorce or your spouse loses their coverage. If you are adding a dependent you will be required to complete an Enrollment Change Form, obtainable through the Administrative Office or this website. You must add or drop your dependents within 30 days of the qualifying life event.
In general, you can change your health plan provider once a year during the annual Open Enrollment period. However, depending on what state you live in, you may only have one medical and/or dental plan option. See Comparison of Medical Plan Benefits 2019. You can, however, change your medical primary care physician or your dental office during the calendar year.
No, as long as you are eligible for Plan benefits based on Active work hours these benefits are offered to you at no cost. If you lose coverage you will be offered COBRA Continuation of Coverage, which you will be required to submit monthly premiums to the Administrative Office to continue your healthcare.
Yes, this is considered a life event and you are eligible to add your dependent within 30 days from the birth. Contact the Administrative Office to obtain the Enrollment Forms to add your new dependent.
Yes, if you are the legal guardian or awarded legal custody of your siblings, they may be considered eligible dependents. For more information please contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
Yes, you can cover your dependent child up to the age of 26 if you have provided the Administrative Office with all the required documentation.
No, unfortunately if you missed the annual Open Enrollment period you can no longer make changes until the next annual Open Enrollment period. The exception to this rule is if you meet the 1,380 hours requirement for the current plan year, are enrolled in the Kaiser HMO in Colorado and move outside of Kaiser's service area.
Our next annual Open Enrollment is in November 2019 for plan changes effective January 1, 2020. If you have moved out of the Kaiser Permanente Medical Plan service area, please contact the Trust Fund Office at (213) 386-8590 or (800) 293-1370.
Changes made during the upcoming Open Enrollment period take effect January 1, 2020.
If you are eligible during the Open Enrollment period, you will receive a notice from the Administrative Office with instructions on how to enroll. Our next annual Open Enrollment period is November 2019, for plan changes effective January 1, 2020. If you have moved out of the Kaiser Permanente Medical Plan service area, please contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
In general, you can change your medical plan once a year during the annual Open Enrollment period. However, depending on what state you live in and your active status, you may only have one medical and/or dental plan option. See Comparison of Medical Plan Benefits 2019. You can, however, change your medical primary care physician or your dental office (if applicable) during the calendar year.
No, unfortunately if you missed the annual Open Enrollment period you can no longer make changes until the next annual Open Enrollment period. The exception to this rule is if you meet the 1,380 hours requirement for the current plan year, your agreement provides for contributions to the Gold Plan and you are enrolled in the Kaiser HMO in Colorado and move outside of Kaiser's service area.
No, parents are not eligible to enroll on your Health Plan. For more information contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
Yes, you can cover your dependent child up to the age of 26 if you have provided the Administrative Office with all the required documentation.
Yes, if you are the legal guardian or awarded legal custody of your siblings, they may be considered eligible dependents. For more information please contact the Administrative Office at (213) 386-8590 or (800) 293-1370.
Yes, this is considered a life event and you are eligible to add your dependent within 30 days from the birth. Contact the Administrative Office to obtain the Enrollment Forms to add your new dependent.
You are allowed to add or drop a dependent during the Plan year if you have a qualifying life event such as a birth, marriage, divorce or your spouse loses their coverage. If you are adding a dependent you will be required to complete an Enrollment Change Form, obtainable through the Administrative Office or this website. You must add or drop your dependents within 30 days of the qualifying life event.
Your new ID card(s) were mailed to your home address on file. If you did not receive your ID cards, you may be able to print them from the Kaiser or Anthem website depending on which plan you are enrolled in effective January 1, 2019. Or, call Kaiser or Anthem directly to request them.
No, as long as you are eligible for Plan benefits based on Active work hours these benefits are offered to you at no cost. If you lose coverage you will be offered COBRA Continuation of Coverage, which you will be required to submit monthly premiums to the Administrative Office to continue your healthcare.
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Benefit information varies by Active/Retired status and state. Please make a selection from each drop-down menu below:
La información sobre las prestaciones varía según su posición Activo / Jubilado y su estado. Por favor, haga una selección en cada menú desplegable a continuación: