Please note: This summary is a brief description of Carpenters Health and Plan Rules and Regulations, including any amendments, will be the basis
A Health Maintenance Organization
(HMO) that provides prepaid medical, drug, vision and hearing aid benefits to Participants enrolled in this Plan with a guaranteed payment of these benefits. Participants must live within the Service Area.
Phantom COB (Coordination of Benefits)
Phantom COB does not apply
Annual out of Pocket Limits
Limit on co-payments Per person - $1,500 Per family - $3,000
Shown for each service
Plan Lifetime Maximum
Choice of Physicians
Members choose a Physician on staff at a Kaiser Permanente facility located in their service area. Routine, preventive, and specialist care are provided at Kaiser Permanente facilities or by Kaiser con- tract providers.
Plan A & R Comparison
Welfare Plan benefits. In all cases, the for the payment of any benefits.
The Indemnity Plan is a comprehensive benefit plan with an annual deductible and a limit on your annual out of pocket for covered expenses. After the out of pocket limit is reached each year, the Plan will pay 100% of covered expenses for the remainder of the calendar year.
Phantom COB: If the participant’s spouse is employed and the employer offers in- surance, the spouse must elect coverage. If he or she declines coverage, the Indem- nity Plan will pay up to 20% of covered medical bills. The Fund will estimate the benefits of the other group plan at 80% of expenses incurred and will coordinate its benefits with the estimated benefits.
Per person: PPO: $100, Non-PPO: $200 Maximum deductible Per family: PPO: $200, Non-PPO: $400
For Contract Providers, $1,000 per per- son, not to exceed $2,000 per family. There is no Out of Pocket Maximum for Non-Contract Provider charges.
Once annual deductible is satisfied and until the out of pocket limit is met, the Plan pays PPO at 90% of contract rates and Non-PPO at 70% of Allowed Charg- es for all benefits unless otherwise indi- cated.
Members may use the providers of their choice; however to receive maximum benefits, members must use PPO/contract providers.
Inpatient: Subject to deductibles and out of pocket limits. Benefits reduced by 25% if utilization review is not obtained. Outpatient: Subject to deductibles and out of pocket limits. PPO - 90% Non-PPO
70%; however, if there was no choice
in the hospital used due to an Emergency and patient was admitted from the Emer- gency Room, the benefit is 90% of Al- lowed Charges.