For Non-Medicare Retirees and Dependents
Kaiser |
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Physician Care & Outpatient Services | Hospital Inpatient & Outpatient | Preventive Health Services | Mental/Nervous Condition |
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Deductible | In Network | Out of Network 1 |
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Maximum of two deductibles per family per year | $200 per person | $200 per person |
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Lifetime Maximum | $1,000,000 | $1,000,000 | |
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Coinsurance Maximum | $10,000 | Does Not Apply |
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1. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges2, and benefits will be reduced by 20% if you do not receive prior authorization.
2 For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
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Physician Care & Outpatient Services |
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Visits to Primary Care Physician (PCP) | 90% of contract rate2, after deductible. | 70% of usual, customary & reasonable3, after deductible. |
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Visits to Dr. Other than PCP | 90% of contract rate2, after deductible. | 70% of usual, customary & reasonable3, after deductible. |
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Diagnostics, X-Ray, Lab | 90% of contract rate2, after deductible. | 70% of usual, customary & reasonable3, after deductible. |
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Gynecological Visits | 90% of contract rate2, after deductible. | 70% of usual, customary & reasonable3, after deductible. |
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| $1,500 maximum benefit per calendar year |
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Physical Therapy | 90% of contract rate2, after deductible. | 70% of usual, customary & reasonable3, after deductible. |
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Durable Medical Equipment | 90% of contract rate2, after deductible. | 80% of usual, customary & reasonable3, after deductible. |
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1. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges.
2. For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
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Hospital Inpatient & Outpatient |
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Room & Board | 90% of contract rate 2, after deductible | 70% of semi-private rate 3 after deductible |
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Misc. Hosp. Charges, Surgery, Anesthesia | 90% of contract rate 2, after deductible | 70% of usual, customary & reasonable 3, after deductible |
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Intensive Care | 90% of contract rate 2, after deductible, if emergency.
50% of contract rate 2, after deductible, if non-emergency. | 70% of usual, customary & reasonable 3, after deductible, if emergency.
50% of usual, customary & reasonable 3, after deductible, if non-emergency. |
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Home Health | 90% of contract rate 2, after deductible. | 80% of usual, customary & reasonable 3, after deductible |
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| 100 Visit Maximum Per Year |
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Hospice
Inpatient or Outpatient | 80% of usual, customary & reasonable 3, after deductible | 80% of contract rate 2, after deductible. |
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1. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges.3
2. For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
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Preventive Health Services |
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Well Baby Care
8 visits from birth to second birthday | 90% of contract rate, after deductible, for office visit
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(Out of Area paid at 80% of usual, customary & reasonable 3). | |
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| $850 maximum including medically necessary immunizations. |
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Routine Exam
One exam per year ages 2-19 and over 65.
One exam every two years ages 20-64. | 90% of contract rate 2, after deductible. | Not covered 1
(Out of Area paid at 80% of usual, customary & reasonable 3). |
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| $100 maximum not including medically necessary immunizations. |
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Immunizations | 100% of contract rate 2. | Not covered 1
(Out of Area paid at 80% of usual, customary & reasonable 3). |
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1. Out of area preventive health services: if you live more than 30 miles away from the nearest network provider, services still must be provided by your primary care physician. The visit is covered at 80% of usual, customary & reasonable3, after the deductible. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.
2. For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
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1. Out of area Hearing Aids, Audiology: if you live more than 30 miles away from Sacramento Ear, Nose and Throat, pre-authorization is required for the initial audiology visit. If authorized, the visit is covered at 80% of usual, customary, and reasonable, after the deductible. If hearing aids are needed, your audiology report must be sent to Sacramento Ear, Nose and Throat so the hearing aids can be authorized. Hearing aids are covered at 80% of usual, customary, and reasonable, after deductible, up to $1,000 per ear. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%.
2. For retirees eligible for Medicare, this Plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
4. Annual hearing aid maintenance check is required. If you fail to obtain this annual maintenance check, the Fund will not pay for replacement of hearing aids.
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Mental/Nervous Conditions 4
For only Medicare retirees and dependents who have selected the Union Labor Life Insurance Co. Plan |
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Inpatient | 50% of contract rate 2, no deductible | 50% of usual, customary & reasonable 3, no deductible
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| 30 Day Yearly Maximum |
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Outpatient | 50% of contract rate 2, no deductible | 50% of usual, customary & reasonable 3, no deductible
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| 20 Visit Yearly Maximum 5 |
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Counseling Benefit 4
For all Medicare retirees and dependents |
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Family Counseling, grief counseling, outpatient counseling, etc. | 50% of contract rate 2, no deductible. | 50% of usual, customary & reasonable, no deductible. |
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| 20 Visit Yearly Maximum 5 |
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1. Only in-network benefits count toward the $10,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out of area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual and customary charges, and will be reduced by 20% if you do not receive prior authorization.
2. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Benefits are based upon Medicare’s explanation of benefits and payable up to the contract rate or Medicare’s allowance, whichever is less.
3. For retirees eligible for Medicare, this plan’s benefits will be coordinated with Medicare. Whether or not the provider accepts Medicare assignment, benefits are based upon Medicare’s explanation of benefits and payable up to usual, customary and reasonable or Medicare’s allowance, whichever is less.
4. Mental/nervous and counseling claims do not count towards the out-of-pocket maximum. Mental/nervous and counseling claims do not go towards, and are never eligible for, 100% coverage.
5. Annual 20 visit limit applies to mental/nervous and counseling benefits combined.
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