Health and Welfare Summary Plan Description
I. DEFINITIONS
The following terms have the meaning set forth below, unless the defined meaning is plainly inapplicable.
ACA means, collectively, the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152.
Active Coverage means coverage provided to an Active Employee, and any other coverage that is expressly treated as Active Coverage.
Active Employee means an Employee who has satisfied the initial eligibility requirements of Section 3.2 and continues to be eligible under Sections 3.3 or 3.4.
Blue Shield means Blue Shield of California, an independent member of the Blue Shield Association.
Blue Shield HMO means the HMO made available to Participants under Article IX that is maintained by Blue Shield.
Board means the Board of Trustees of the trust.
Child means theEmployee's, the Employee's Spouse's or Domestic Partner�s, natural child, stepchild, legally adopted child, foster child, or other child for whom the Employee, Spouse, or Domestic Partner has been appointed legal guardian or is required to provide dependent coverage pursuant to a QMCSO under Section Section 5.3; provided, however, that any such individual shall be so treated only through the month in which the individual attains age 26.
COBRA Coverage means a Covered Individual's continuation of Plan coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. No. 99-272, as generally provided in Article VII.
Collective Bargaining Agreement means any collective bargaining agreement entered into by Local 6 and SFECA that provides for contributions to the trust, as it may be amended from time to time. (See Appendix A for a list of the Collective Bargaining Agreements in effect as of the Effective Date.)
Contribution Agreement means an Employer's agreement to contribute to the Plan pursuant to a Collective Bargaining Agreement, Subscription agreement or the Reciprocal Agreement. (See Appendix A for a list of the Contribution Agreements in effect as of the Effective Date.)
Covered Charge means a charge described in Section 8.9.
Covered Employment means, except as expressly provided otherwise, service as an Employee, any Military Service described in Section 6.8, and any Qualified Trustee Service; provided, however, that any service as a responsible management employee (RME) and responsible management official (RMO) shall be excluded.
Covered Individual means any Participant or covered Dependent.
Custodial Care means treatment, services or confinement that could be rendered safely and reasonably by a person not medically skilled, and which are designed mainly to help the patient with activities of daily life, including personal care, homemaking services, moving the patient, acting as companion or sitter and supervising medication that can ordinarily be self-administered.
Dependent means an Employee's Spouse, Domestic Partner and any Child.
Domestic Partner means a Participant's spousal equivalent under the laws of a state, county, city or other municipality, and for whom an official certification of registration of domestic partnership has been submitted to the Plan Office. In order to effectuate enrollment of a Domestic Partner, the Plan Office must receive (i) proof of Domestic Partner status in the form of an official certification of registration of domestic partnership and (ii) either (a) an "affidavit of dependency" for tax purposes or (b) advance remittance of at least six months of taxes that the Plan Office determines are due on any additional imputed federal taxable income to the Participant, including the Employer's portion of such taxes. The Plan shall treat the effective date of a Participant's domestic partnership as if it were the date of marriage. (See, for example, the Special Enrollment provisions of Section 6.4, which also applies to Domestic Partners.) The term "divorce" or "dissolution" in this Plan is deemed to include the legal termination of a domestic partnership.
Effective Date means February 1, 2023.
EISB means the Electrical Industry Service Bureau, Inc., the entity engaged by the Board to serve as the Plan's contract administrator for day-to-day Plan administration.
Employee means an individual performing work requiring contributions to the Plan under a Contribution Agreement.
Employer means an employer that is obligated to contribute to the Plan under a Contribution Agreement.
ERISA means the Employee Retirement Income Security Act of 1974, as amended.
ESRD means end-stage renal disease.
Experimental or Not Generally Accepted means, subject to the exceptions described below, and regardless of any claimed therapeutic value, experimental or investigational, limited to research by the FDA, the American Medical Association (Diagnostic and Therapeutic Technology Assessment) or the Office of Medical Application of Research of the National Institute of Health Office of Technology Association, or is not generally accepted by specialists in that particular field of medicine, as determined by the Plan's medical review consultant and/or an independent medical reviewer. If a treatment has not been addressed by one of the organizations listed in the preceding sentence, the Plan may determine if a treatment is Experimental or Not Generally Accepted based on the advice of its medical review department and/or an independent medical reviewer or other medical experts. For this purpose, "Generally Accepted" means treatment or service that (i) has been accepted as the standard of practice according to the prevailing opinion among experts as shown by (or in) articles published in authoritative, peer-reviewed medical and scientific literature, (ii) is in general use in the medical community and (iii) is not under continued scientific testing or research as a therapy for the particular injury or sickness which is the subject of the claim.
Exception 1: Certain FDA Approved Drugs Prescribed for Unapproved Purposes. Coverage is provided for an FDA-approved drug that is used to treat a life threatening condition for which the FDA has not approved the drug's use, if the drug has been recognized for treatment of that condition by the American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information or the United States Pharmacopeia Dispensing Information, Volume I, "Drug Information for the Health Care Professional." "Life-threatening," for this purpose, means either (or both) diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted, and diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival.
Exception 2: Certain Suspected Physical Causes of Autistic Symptoms. Coverage is provided for alternative treatment of a condition suspected of playing a role in the expression of symptoms of autism, limited to $3,000 per calendar year. This treatment is considered experimental, and not an essential health benefit within the meaning of the ACA, and therefore can be subject to an annual benefit maximum. The alternative treatments currently include:
- vitamin supplementation therapy;
- oral secretin therapy;
- chelation;
- hyperbaric oxygen therapy;
- cranio-sacral therapy;
- fibroblast growth factor therapy;
- live cell and stem cell therapy;
- anti-fungal therapy;
- antibiotic therapy; and
- naltexone therapy.
FDA means the U.S. Food and Drug Administration.
HIPAA means the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
HMO means, in the general context, a health maintenance organization and, in the specific context, either or both the Blue Shield HMO or the Kaiser HMO.
Hospital means an institution that:
- is primarily engaged in providing, by or under the supervision of Physicians, in-patient diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation of injured, disabled or sick persons;
- maintains clinical records on all patients;
- has bylaws in effect with respect to its staff of Physicians;
- has a requirement that every patient be under the care of a Physician;
- provides 24-hour nursing service rendered or supervised by a registered professional nurse;
- has in effect a hospital utilization review plan;
- is licensed pursuant to any state or agency of the state responsible for licensing hospitals; and
- has accreditation under one of the programs of the Joint Commission on Accreditation of Hospitals. The term does not include an institution, or that part of an institution, used mainly for nursing care, rest care, convalescent care, care of the aged, Custodial Care or educational services.
Hour Bank means the system of accounting, as described in Section 3.1, for a Participant's monthly hours of Covered Employment and corresponding Employer contributions received for those work hours for purposes of determining eligibility for Plan coverage.
IBEW means the International Brotherhood of Electrical Workers.
Illness means a bodily disorder, infection or disease, including all related symptoms and recurrent conditions resulting from the same causes.
Injury means physical harm sustained to the body as the direct result of an accident, affected solely through external means, and all related symptoms and recurrent conditions resulting from the same accident.
Kaiser HMO means the HMO made available to Participants under Article IX that is maintained by Kaiser Foundation Health Plan, Inc.
Local 6 means the International Brotherhood of Electrical Workers, Local 6.
Medically Necessary means that the treatment must be, and Medical Necessity refers to a treatment that is, ordered by a Physician or Other Accredited Provider to diagnose or treat an Injury or Illness, and be:
- generally recognized as effective and essential to the treatment of the Injury or Illness for which it is ordered;
- appropriate for the symptoms and consistent with the diagnosis; and
- the appropriate level of care, and which (i) is provided in the most appropriate setting, based on the diagnosis and condition, (ii) could not have been omitted without an adverse effect on the Covered Individual's condition or the quality of medical care, (iii) is based on generally recognized and accepted standards of medical practice in the United States, and (iv) is neither:
- Experimental or Not Generally Accepted or primarily limited to research in its application to the Injury or Illness;
- primarily for scholastic, educational, vocational or developmental training;
- primarily for the comfort, convenience or administrative ease of the Covered Individual, Physician or Other Accredited Provider or member of his or her family or caretaker; nor
- Custodial Care.
Medicare means the benefits provided under Title XVIII of the Social Security Amendments of 1965.
Mental Health Parity and Addiction Equity Act means the federal law (Pub. L. 110-343) that disallows health plans that provide mental health or substance use disorder benefits from inposing less favorable benefit limitations on those benefits than on medical and surgical benefits.
Monthly Coverage Payment means a monthly payment that a Covered Individual must make to the Plan in order to maintain coverage for a month.
NECA means the National Electrical Contractors Association, Incorporated.
No Surprises Act means the law included in the Consolidated Appropriations Act of 2021, Pub. L. No. 116-260, that generally prohibits surprise balance billing by certain out-of-network providers for certain categories of services.
Other Accredited Provider means a Physician's assistant, nurse practitioner, midwife or nurse midwife, who provides medical care within the scope of a license or certificate.
Participant means an Employee, Retiree who is covered under the Plan.
Pension Plan means the Northern California Electrical Workers Pension Plan.
Physician means a duly licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) authorized to perform medical or surgical services within the lawful scope of his or her practice, and any other health care provider having substantially equivalent status under state law. Chropractor, occupational therapist, and physical therapist are examples of health care providers that do not meet the definition of Physician.
Plan means this San Francisco Electrical Workers Health & Welfare Plan.
Plan Office means the administrative office of the Plan, which is currently managed by EISB.
Preventive Care means items or services required to be covered without cost-sharing (copayment or coinsurance charges) when delivered by an in-network provider. (See Section 8.9 for examples.) A comprehensive list can be found at: www.HealthCare.gov/center/regulations/prevention.html and additional information regarding the U.S. Preventive Services Task Force recommended services receiving grades A or B is located at www.uspreventiveservicestaskforce.org.
Qualified Trustee Service means those hours of service by an Employee (not to exceed seven per day) that would have constituted covered employment under a Collective Bargaining Agreement but for the Employee's service as a Trustee of the Trust of the Northern California Electrical Workers Pension Trust. Such hours shall be treated under this definition as if they were performed.
Reasonable and Customary means falling within the common range of fees billed by a majority of health care providers for a covered procedure in a given geographic region, or which is justified based on the complexity or the severity of treatment for a specific case, as determined from time to time by the Board. For this purpose, "region" means a county or greater area that is necessary to obtain a representative cross-section of the usual charges made. The Plan applies a widely-used claims data base at the 90th percentile to determine Reasonable and Customary (that is, the charge may not exceed the amounts normally charged by 90% of the Physicians in the data base in a particular geographical area).
Reciprocal Agreement means the Electrical Industry Health and Welfare Reciprocal Agreement, effective as of 1996, as it may be amended from time to time. (Check with the Plan Office for any recent changes to the Reciprocal Agreement.)
Regular Retiree means a Retiree who has met the requirements of Section 4.1(a)
Retiree means an IBEW member in good standing who formerly, but no longer, performs services in the electrical industry.
Self-Funded PPO means the coverage option describing benefits paid directly by the Plan, as set forth in Article VIII.
SFECA means the San Francisco Electrical Contractors Association, Inc.
Spouse means an Employee's legal spouse under State law (if recognized by federal law).
Subscription Agreement means a written agreement, other than a collective bargaining agreement, between the Board and an employer to provide Plan coverage for the employer's employees, and which shall set forth the terms and conditions for participation in the Plan.
Trust means the San Francisco Electrical Workers Health & Welfare Trust, as established under the Trust Agreement
Trust Agreement means the trust agreement establishing the >Trust, as it may be amended from time to time.
Trustee means any member of the Board.