VSP stands for Vision Service Plan which has been contracted by the UFCW & Employers Benefits Trust (the“UEBT” or “Plan”) to administer vision care benefits (for those participants with vision coverage). The highest benefits are paid when you use a VSP provider. To locate a list of VSP providers visit www.vsp.com or call (800) 877-7197.

Under the PPO Plan, you may use any provider for your medical care. However, the UEBT pays a higher level of benefit and your deductible is lower when you use a provider within the PPO network. You save money because the UEBT has negotiated rates with PPO providers. In addition, there are no claim forms to file when you use a PPO provider. You should always verify that your provider is a contracted provider in the PPO network at the time you make an appointment for services and before services are received. Even if they have been a PPO provider in the past, the provider may have changed and not informed you. Also, you should verify that any specialist or facility referred by your PPO primary care physician is also a PPO provider, otherwise you will pay a higher level of out-of-pocket costs for their services.

From the Trust Fund website go to the “Resources” tab and choose “Find A Provider” from the drop down menu. Under the “Blue Shield of California” section click the “Find a Doctor inside California” and follow the instructions for finding a Blue Shield provider.

“HMO” stands for “Health Maintenance Organization.” An HMO is an organization of healthcare providers, including hospitals and diagnostic centers. With an HMO plan, a Participant must select a primary care physician who is a member of the HMO network. In most cases, the participant must obtain a referral from their primary care physician to see a specialist. HMO’s only provide coverage for in-network care by in-network providers.

“PPO” stands for “Preferred Provider Organization.” Participants covered under a PPO Plan are free to use any provider. However, there may be significantly higher out-of-pocket expenses when using an out-of-network provider. Participants are not required to obtain referrals to visit a specialist healthcare provider.

Generally, you can expect to receive a check seven (7) business days after the Trust Fund Office receives a completed Sick-Leave claim form and any other required information.

Coinsurance is the percentage of the Covered Expense that you pay. The Plan pays the balance of the Covered Expenses after your Deductible is met. Coinsurance applies to services that are subject to the Deductible which must be satisfied before the Plan pays its portion of the Covered Expense. Coinsurance levels are higher for non-PPO services. Use PPO providers to lower your out-of-pocket expenses.

No. Prior authorization for physical therapy is not required. However, all physical therapy must be medically necessary as defined by the Plan. The Plan will cover up to 30 physical therapy visits without requiring any further action from the Participant. If the physical therapy treatments exceed 30 visits for the same injury or condition, continuing treatments are subject to review for continued medical necessity. Blue Shield will notify the physical therapy provider that treatments beyond 30 are subject to review for medical necessity. If it is determined that a PPO provider’s physical therapy treatments past 30 visits are not medically necessary, the patient will not be billed. If a non-PPO provider provides physical therapy treatments above 30 visits that are found to not meet medical necessity, however, the patient may be billed by the non-PPO provider for the treatments beyond 30 visits that are not covered by the Plan.

The cost of having tests done at a PPO hospital can be significantly higher than those performed at a free-standing PPO x-ray or lab facility. Search your PPO network website for a freestanding x-ray/lab facility near you.

Accident letters help the Plan identify those situations when a third party may be responsible for your medical care expenses. Car accidents and Workers’ Compensation injuries are two very common examples of when accident letters are necessary.

Yes, if your enrolled Spouse/Domestic Partner has access to health care coverage through his or her own current or former employer, he/she must enroll in that coverage and choose the highest benefit option available that is most comparable to the UEBT Active Plan, without regard to the cost of the other plan. If he/she does not enroll in the other coverage offered through his or her current or former employer, benefits for your Spouse/Domestic Partner under the UEBT Active Plan will be reduced (by 60%) and will not be subject to any out-of-pocket maximum, even if you use a PPO provider.

The general guidelines are to select the benefit option under the other insurance that most closely matches the UEBT Active Plan levels in the following categories: Coinsurance, Out-of-Pocket maximum, and Deductible. If the plans offered through your Spouse/Domestic Partner’s Employer have a lower benefit, then your Spouse/Domestic Partner must enroll in the highest level plan available that most closely resembles the UEBT Active Plan under which you are covered.

If your Spouse/Domestic Partner is not offered other group coverage, you must submit documentation to the Trust Fund Office on official letterhead from your Spouse’s/Domestic Partner’s Employer that confirms that group health insurance is not offered or available to your Spouse/Domestic Partner. If your Spouse/Domestic Partner is offered coverage but is unable to enroll until that plan’s next Open Enrollment, the UEBT Active Plan will provide a one-time grace period until that other plan’s effective date of coverage. In that case, you are required to provide documentation from that plan or the Employer stating that immediate enrollment is not possible, the date of the next Open Enrollment, and the effective date of coverage. During this grace period, benefit payments through the UEBT Active Plan will not be reduced.

Yes, if a Dependent child is eligible for coverage under the UEBT Active Plan, you can enroll the Dependent child without enrolling your Spouse/Domestic Partner.

No. Your Spouse/Domestic Partner is not required to enroll you and your Dependent children under their plan.

No. Dependent children enrolled in the UEBT Active Plan are not required to enroll in other Employer provided coverage.

The premiums for Kaiser HCP and PD are the same as the PPO HCP and PD options, respectively. The Dependent child premium for all plan options are calculated on a per child rate up to a maximum of 3 children, after which no additional premiums are required.

Yes. Up to 36 months of COBRA coverage is offered.

No, legal guardianship alone is not enough to establish eligibility for your grandchild. The UEBT Active Plan will provide coverage for a natural child, step-child, adopted child, a child who has been placed with you for adoption, or a foster child.

Your Spouse/Domestic Partner is required to take coverage available to them through their Employer that is most comparable to the coverage provided by the UEBT Active Plan. Therefore, in this situation, your Spouse would be required to enroll for Medical coverage. You will be required to submit documentation, on the Employer’s letterhead, stating that the Dental and/or Vision coverage is not available from that Employer.

Yes. Blue Shield of California PPO providers have agreed to accept Blue Shield’s contracted rate as payment in full for covered services. However, you are responsible for your annual calendar year Deductible and Coinsurance amounts.

Yes, the Deductible and Coinsurance apply to primary care office visits for the treatment of an illness or injury, or a specialist visit. The Deductible does not apply to preventive care, screenings and immunizations. The Deductible is waived for chiropractic/acupuncture visits, however, the services are subject to a copay.

No. Non-preferred drug copayments will not be reimbursed through the HRA unless an exception was approved by OptumRx (formally Catamaran) to use the non-preferred drug.

Yes. OptumRx is available for calls from Participants regarding the Market Priced Drug program 24 hours a day, 7 days a week, at 1-866-635-6906.

Yes. To be considered for an exception, your doctor must complete and submit an exception request form to OptumRx, which is available on the Trust Fund website under the “Resources” and “Forms” tab.

You may appeal the denial to the Board of Trustees. All appeals received will be reviewed and decided in accordance with the applicable laws and the UEBT Active Plan’s claims and appeals procedures.

Yes.

No. In order to be eligible for dual coverage, both Members must (1) be enrolled in the HCP plan option, (2) cover the same Dependents under each plan, and (3) be enrolled with the same carrier (Kaiser or Blue Shield).

No.

Yes.

Members who are eligible on their own but also eligible as a Dependent child will receive the higher level of benefits available (generally as a Dependent).

Dual covered Members meeting all the Plan’s eligibility requirements will be provided 100% network coverage and will not be subject to Coinsurance, Copayments, or Deductibles. This 100% benefit does not apply to non-network services or non-preferred prescription drug co-payments.

Yes.

When outside of California, you should use a Blue Card provider to have the highest level of benefits for non-emergency services. You can find in-network providers in California, nationwide and globally on the Trust Fund website under the “Find a Provider” tab, or you can call Blue Shield at the number on the back of your Blue Shield card: (800) 810-2583. If you have an emergency while you are traveling, you should go to the nearest facility for treatment. Expenses related to true emergencies are paid at the Out-of-Area benefit level, subject to the PPO Coinsurance and PPO Deductible amounts.

Your next opportunity to enroll your eligible Dependents will be at the next Open Enrollment, unless you or your Dependents have a qualifying event that would provide you or your Dependents with “Special Enrollment Rights” outside of Open Enrollment.

“Special Enrollment Rights “are as follows: if you acquire a new Dependent as a result of marriage, birth, adoption, or placement for adoption, Domestic Registration, you may have the right to enroll your Dependent in the UEBT Active Plan outside of Open Enrollment. You may also have the right to specially enroll your Dependents into the UEBT Active Plan outside of Open Enrollment if he or she loses other health insurance coverage.

Generally, once Open Enrollment is over, you may not make any additional enrollment or carrier changes. That means you may not change the number of Dependents covered under the UEBT Active Plan or make any changes in carriers if otherwise eligible to do so, unless under special circumstances (e.g., you have Special Enrollment Rights). If you didn’t participate in Open Enrollment, you are required to complete an Annual Verification to confirm your personal and family information and update any changes before you will be eligible for self-only coverage. Failure to participate in Open Enrollment or Annual Verification will result in the denial of all of your claims until you participate.

No. If a Surviving Spouse/Domestic Partner becomes covered under another Active or Retiree group health plan while also covered under the UEBT Retiree Plan, coverage under the UEBT Retiree Plan will be terminated and the Surviving Spouse will not be able to re-enroll in UEBT Retiree Plan in the future.

Yes. A Surviving Spouse/Domestic Partner who opts out of the UEBT Retiree Plan while already covered by other group health coverage may re-enroll in the UEBT Retiree Plan when the other group coverage terminates. The request for re-enrollment in the UEBT Retiree Plan must be received within 60 days of losing the other coverage or during the next Open Enrollment period for the UEBT Retiree Plan. If these timelines are not met the Surviving Spouse/Domestic Partner will not be able to re-enroll in the UEBT Retiree Plan in the future.

The Trust Fund Office requires documentation on the employer’s letterhead confirming health insurance is not available to your Spouse/Domestic Partner or working Dependent child.

You should contact your working Dependent child or Spouse’s/Domestic Partner’s employer(s) and/or former employer(s) to ask about available coverage.

Yes, you are required to enroll in the group health plan offered by your current employer.

No. If you opt out of the UEBT Retiree Plan, you can only request re-enrollment if you lose your other group coverage.

You must contact the Fund Office within 60 days of your Spouse/Domestic Partner losing that other coverage, or at the first Open Enrollment following the loss of coverage, in order to re-enroll your Spouse/Domestic Partner in the UEBT Retiree Plan. If you do not meet these timelines, your Spouse/Domestic Partner will never be allowed to re-enroll in the UEBT Retiree Plan.

Yes, if a Dependent child is eligible for coverage under the UEBT Retiree Plan, the Retiree can enroll the Dependent child without enrolling their Spouse/Domestic Partner. The Retiree is not required to enroll their Spouse/Domestic Partner. For retirements on and after March 1, 2013, the Retiree must have at least 25 Benefit Accrual Credits (BACs) under the Pension Plan to cover Dependent children under the UEBT Retiree Plan.

No, you must enroll yourself in the coverage, but you are not required to cover your Dependent Spouse/Domestic Partner or children.

No. If you drop UEBT Retiree Plan coverage for any reason other than being covered by other group health coverage, you will not be able to re-enroll in the UEBT Retiree Plan. Individual coverage does not preserve your right to re-enroll in the UEBT Retiree Plan. However, enrollment in coverage through the Covered California Healthcare Market Place will preserve your right to re-enrollment at a later date in the UEBT Retiree Plan.

Student Certification documentation is required each school period. The Student Certification form must be received within 60 days of the beginning of the semester or quarter. If the Student Certification form is not received timely, your child will not have coverage and you will have to wait until the next Open Enrollment period to enroll your child.

Full-time student status is based on the definition established by the accredited institution that your child is attending.

Yes. However, in the event the student does not return to school as indicated in the intent letter, coverage will be terminated back to the end date of the last student certification and the Retiree must repay any claims paid by the UEBT Retiree Plan during the period of ineligibility.

Yes, up to 36 months.

When you enroll a Dependent child age 19 through 23 during Open Enrollment, you will be given information about the Student Certification requirements and documentation you must provide by the deadline before enrollment can be completed.

The premiums for Kaiser Coverage under the UEBT Retiree Plan are the same as the UEBT Retiree PPO plan and are based on years of credited service and Medicare eligibility status. Note that non-Medicare Retirees will pay the same premium without regard to whether they have individual-only coverage or if they cover one or more Dependents, whereas a Medicare Retiree will pay a per-enrolled-person premium.

This does not apply to Self-Pay Retirees. For the UEBT Retiree plan details please reference your Open Enrollment information or contact the Trust Fund Office.

No, legal guardianship alone is not enough to establish eligibility for your grandchild. The UEBT Retiree Plan will provide coverage for a natural child, step-child, adopted child, a child who has been placed with you for adoption, or a foster child.

Typically, yes. If a primary plan pays more than the UEBT Retiree Plan would have paid if it were the primary plan, the patient is responsible for the patient’s portion due under the primary plan. Contact your primary plan for more information.

This depends on your primary plan’s reason for the denial. For instance, if your primary plan denied the claim for untimely filing, there may not be any benefit paid under the UEBT Retiree Plan if it was also untimely filed under the UEBT Retiree Plan. If the primary plan denied the claim because the service is a plan exclusion, but the service is covered under the UEBT Retiree Plan, the UEBT Retiree Plan would process the claim as primary. If the primary plan denied the claim because the service was not authorized, you should appeal to the primary plan.

Amounts you are required to pay for Deductibles and Coinsurance by your primary plan do not count towards the deductible and out-of-pocket maximum limits under the UEBT Retiree Plan. Only amounts required to be paid by you under the UEBT Retiree Plan apply to your UEBT Retiree Plan out-of-pocket maximum.

Yes. Blue Shield of California PPO providers have agreed to accept Blue Shield’s contracted rate as payment in full for covered services. However, if you are covered by Medicare and the Blue Shield allowable charge is less than the Medicare allowable charge, the provider may bill you for the balance, up to the Medicare allowable charge.

No. Pregnancy benefits are not covered under the UEBT Retiree Plan.

No, office visits require a $20 copay per visit. The Deductible does not apply to the office visit. However, if other services are provided as part of the office visit, such as lab or x-rays, the Deductible or Coinsurance applies to those services.

No, not at this time. However, the Board of Trustees reserves the right to increase or terminate benefits at a future date.

No. Health Net is only available to a Medicare Retirees whose Spouse/Domestic Partner and eligible Dependent children are also Medicare-eligible.

If you have filled a prescription for a non-preferred medication you will receive a letter from OptumRx identifying the non-preferred medication, the preferred alternative medication, and the cost to you if you choose to continue to receive the non-preferred medication.

If you are enrolled in Kaiser the MPD program does not apply to you.

Yes. To be considered for an exception, your doctor must complete and submit the exception request form to OptumRx, which is available on the Trust Fund website under the “Resources” and “Forms” tab.

You may appeal the denial to the Board of Trustees. All appeals received will be reviewed and decided in accordance with the applicable laws and the follow the Plan’s normal claims and appeals procedures.

Yes, it is still $100 per person.

If you are enrolled in Kaiser Senior Advantage you receive your Prescription Benefits through Kaiser and there is no deductible.

Dual coverage refers to two married individuals or Domestic Partners who meet all the Plan’s eligibility requirements, and as a result, are provided 100% network coverage and will not be subject to Coinsurance, Copayments, or Deductibles. This 100% benefit does not apply to non-network services or non-preferred prescription drug Copayments.

Dual Coverage applies when both Participants are covered as employees by the UEBT Active Plan, when both are covered as Retirees under the UEBT Retiree Plan, or when one is covered by the UEBT Retiree Plan and one is covered by the UEBT Active Plan, if the following requirements are met: both must be (1) enrolled with the same carrier, (2) have authorized premiums at the same level, and (3) if an Active member(s), must elect (and participate in) the Health Care Partnership (HCP) Plan option.

Yes.

Yes, but only if the Active Member and Spouse are enrolled in the Kaiser HCP plan.

Yes, but only if the Active Member and Spouse are enrolled in the Kaiser HCP plan.

No. There is no dual coverage under this scenario and standard non-duplication of benefit rules apply. There is no reimbursement of Kaiser Copayments.

No.

Yes.

Members who are eligible under the Standard Plan on their own but also eligible as a Dependent child will receive the higher level benefits available (generally as a Dependent).

Yes, if you apply for re-enrollment within 60 days of losing Tri-Care coverage, or at the next Open Enrollment.

Yes. The Surviving Spouse may opt back in if proof of the loss of coverage is provided to the UEBT Retiree Plan within 60 days of loss of coverage, or at the next Open Enrollment.

No. You do not have to elect dual dental coverage in order to have dual medical coverage. If dual dental coverage is desired, however, and you have elected dual coverage for your medical plan, then you must also elect dual coverage for your dental plan.

Yes, a Retiree and/or Spouse/Domestic Partner can enroll in the UEBT Retiree Plan due to loss of other coverage but must provide proof (evidence of other group coverage) and request to re-enroll within 60 days of the loss of other coverage or at the next Open Enrollment. If proof of loss of coverage and a request to enroll is not provided within 60 days of losing coverage, or the next Open Enrollment after losing coverage, the Spouse/Domestic Partner will not be able to reenroll in the UEBT Retiree Plan.

Yes.

This does not apply to Self-Pay Retirees. For UEBT Retiree plan details please reference your Open Enrollment information or contact the Trust Fund Office.

Yes, the PPO out-of-pocket maximum is $3,000 per person / $9,000 per family.

Yes. Due to non-duplication of benefits, the Indemnity Medicare plan provides limited medical reimbursement. You may wish to purchase your own INDIVIDUAL Medicare Supplemental plan to help offset these claims expenses. Please note that the main benefit provided to Medicare Indemnity participants is the Prescription Drug coverage. It is VERY important that if you buy your own individual Medicare Supplemental plan, it MUST NOT have prescription drug (Part D) coverage. Members who purchase individual Part D coverage will be dropped from the UEBT Retiree Plan prescription drug coverage.