2020 - 2021 BENEFITS GUIDE · 2020-02-21 · 4. Dental – Firms with 1-5 enrolling subscribers must have 100% participation. Firms with 6 or more may have 75% participation in dental

2020 - 2021 BENEFITS GUIDE

04/01/2020 - 03/31/2021

We've Got You Covered

A Note for All Members, The North Bay Builders Exchanges Insurance Trust (NBBE) is a partnership between many local North Coast and Bay Area Builders Exchanges and employers. NBBE was formed in order to simplify the complexities of healthcare by offering one complete program focusing on quality options and affordable solutions. Our program offers:

• Freedom of choice – Anthem and Kaiser medical, as well as dental, vision, life and disability options

• Extensive doctor, hospital and medical providers • Guaranteed rates • Dedicated service and support • Educational resources • Cobra/Cal-Cobra Administration

Each year, the NBBE teams work diligently to continue to evaluate our plans in light of changing healthcare regulations, rising healthcare costs, and changes within the company. It is our commitment to find the right plans for all members. With this in mind, we encourage all members to take an active role in their health and healthcare related spending decisions by making well-informed decisions, taking full advantage of the programs being offered such as preventive care, generic prescription alternatives, mail order prescriptions (maintenance drugs only) and utilizing in-network providers. With the information and tools in this guide and related resources, we hope to help you be well today and work toward a healthy and secure future. If you have any questions about your benefits, eligibility, and/or how to enroll, contact the NBBE Benefits Desk at [email protected] or (949) 681-9052. In Good Health,

North Bay Builders Exchanges Insurance Trust

mailto:[email protected]

Group Requirements As an active member in any participating Exchange/Association your company is eligible to enroll in the exclusive group insurance program contracted through the North Bay Builders Exchanges Insurance Trust (NBBE). ELIGIBILITY REQUIREMENTS

1. Member firms are eligible to enroll in the group insurance program within the first 60 days after Exchange/Association membership activation date.

2. After the activation date, a member firm may have an effective participation date upon one of the following:

• During the first 60 days of meeting Exchange/Association membership eligibility; • During the Open Enrollment period, if the Exchange/Association eligibility membership

has been met; • Within 60 days of no longer being subject to a collective bargaining agreement; • Within 60 days of non-renewal with a competitive carrier.

3. Medical – 75% or more of all eligible employees of firms with three (3) or more enrolling subscribers must enroll; 100% of enrollment is required for two (2) person firms. Additionally, firms with 2 or fewer enrolling subscribers have limited plan choices to only 1 carrier and 1 plan option.

4. Dental – Firms with 1-5 enrolling subscribers must have 100% participation. Firms with 6 or more may have 75% participation in dental plan. Dental plans are available on a “stand-alone” basis for all size groups.

5. Vision – When vision is the only plan being offered, 100% of all eligible employees must enroll. In all other cases, vision enrollment must match medical enrollment.

6. Basic Group Life – 100% Employer paid benefit and 100% of all eligible employees must enroll. 7. Optional Group Life – Individual coverage with no group requirements. Requires individual

underwriting approval.

All eligible member firms must be in business a minimum of one full calendar quarter and submit a DE-9C, proof of payroll, or other accepted official ownership documents. Wage information is required to determine eligibility of part-time, temporary, or seasonal employees. Firms that are terminated for non-payment or cancel their medical, dental, vision or life coverage must wait a minimum of 12 months before they can re-enroll with any NBBE Exchange/Association Health Plan and then may do so only during an Open Enrollment period.

Here’s some important information you should know.

The benefits in this summary are effective 04/01/2020 through 03/31/2021. This guide is an overview and does not provide a complete description of all benefits provisions. For more detailed information, please refer to your plan benefits guide or summary plan descriptions (SPDs). The plan benefits guide determine how all benefits are paid.

A list of plan contacts is included at the back of this guide

INSIDE THIS GUIDE Are you eligible for benefits? .................................................................................................................................. 1

Compare our medical plans .................................................................................................................................... 2

Choosing a medical plan ......................................................................................................................................... 3

Medical .................................................................................................................................................................... 4

Prescription Drugs ................................................................................................................................................... 7

Know where to go ................................................................................................................................................... 9

Dental .................................................................................................................................................................... 10

Vision ..................................................................................................................................................................... 13

Life and AD&D ....................................................................................................................................................... 15

Need help? ............................................................................................................................................................ 17

Plan contacts ......................................................................................................................................................... 18

Important plan notices & documents ................................................................................................................... 19

Notes ..................................................................................................................................................................... 21

Medicare Part D Notice: If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see the Annual Notices for more details.

1

Who is eligible for benefits? Regular full-time employee working 20 hours or more per week.

List of eligible dependents

● Legally married spouse (including same-sex spouse) ● Domestic Partners (must complete the enrollment form and provide supporting documents) ● Natural, adopted, or step children up to age 26 ● Tax dependents over age 26 who are disabled and dependent on you for support ● Children named in a Qualified Medical Child Support Order (QMCSO) as defined by federal law

Family members such as parents, grandparents and siblings who are not tax dependents as described above are not eligible for coverage.

When to enroll Plan members can enroll in benefits as a new hire or during the annual open enrollment period. Benefits become effective on the first day of the month following one of the waiting periods below, depending on the employer’s waiting period policy:

• First of the month following date of hire • First of the month following 30 days, or • First of the month following 60 days

During plan members’ initial eligibility period or during the annual open enrollment period, they will need to complete and return the 2020 Employee Enrollment Form to the NBBE Benefits Desk. If you miss the enrollment deadline, they’ll need to wait until the next open enrollment (the one time each year that you can make changes to your benefits for any reason).

Changing benefits

Outside of open enrollment, plan members may be able to add or remove dependents or change benefits options if they have a qualifying life. Changes must be submitted within 31 days. Eligible qualifying events include:

● change in legal marital status ● change in number of dependents or dependent eligibility status ● change in employment status that affects eligibility for you, your spouse, or dependent child(ren) ● change in residence that affects access to network providers ● change in your health coverage or your spouse’s coverage due to your spouse’s employment ● change in an individual’s eligibility for Medicare or Medicaid ● court order requiring coverage for your child ● “special enrollment” event under the Health Insurance Portability and Accountability Act (HIPAA),

including a new dependent by marriage, birth or adoption, or loss of coverage under another health insurance plan

● event allowed under the Children’s Health Insurance Program (CHIP) Reauthorization Act (you have 60 days to request enrollment due to events allowed under CHIP).

2

Comparing medical plans North Bay Builders Exchanges offers different medical plans for different needs and budgets. Here's an overview of how each type of plan works.

PPO

Preferred Provider Option • Anthem Medical PPO Plan - Premier PPO 500 ● Anthem Medical PPO Plan - Standard PPO 1000 ● Anthem Medical PPO Plan - Value 1500

All of the Anthem Blue Cross PPO plans give flexibility and choice, for a price. Anthem Blue Cross offers plan members access to a large network of physicians who agree to discount their fees for services. Under these plans, you are not required to select a primary care physician (PCP) and can access different physicians and specialist at your own discretion.

They can go to any doctor without a referral, but will pay a larger share of the cost if they are not in the plan's network. Plan members would need to meet an annual deductible before the plan starts paying for some services.

HMO

Health Maintenance Organization ● Kaiser Medical HMO Plan - Platinum HMO 0/15 ● Kaiser Medical HMO Plan - Gold HMO 250/25 ● Kaiser Medical HMO Plan - Gold HMO 500/30 ● Kaiser Medical HMO Plan - Silver HMO 1650/55 ● Kaiser Medical HMO Plan - Bronze HMO 6300/65

We also offer HMO plans through Kaiser Permanente to plan members. Kaiser’s network is unique as the insurance company employs hospitals, doctors, and nurses which members would receive all treatment from, except in case of an emergency.

An HMO gives more predictable costs but less flexibility. Plan members pay a copay for most services, but all care must be received within the HMO network. Out-of-network care is not covered except in an emergency. Plan members may need to meet a deductible before the plan starts to pay. The primary care physician (PCP) will manage routine care, referrals, and hospital stays.

EPO

Exclusive Provider Option ● Anthem Medical EPO Plan

With the EPO plan through Anthem Blue Cross, plan members must use in-network providers. Out-of-network care isn't covered, except for some emergency care. Plan members generally pay a copayment for each office visit. Members are not required to select a primary care physician and you don't need a referral to see a specialist. Authorization may need to be obtained from Anthem before receiving types of care.

HDHP High Deductible Health Plan ● Anthem Medical HSA 3000 Plan ● Kaiser Medical Bronze HDHP HMO 6900/0

A HDHP is the only plan with a Health Savings Account (HSA) funded by tax-free dollars. The HSA helps pay for eligible healthcare expenses using tax-free dollars. Plan members can visit any provider, but if members stay in-network, they save more of their HSA dollars for future healthcare needs.

The HDHP allows members to visit any doctor choosing from a large network of providers. Members may also go out-of-network but note; will be sharing more of the cost. Kaiser HDHP lets members self-refer to certain specialists.

The HDHP has differences from the traditional PPO or HMO in that members pay the annual deductible amount before coverage begins for all services except in-network preventive care services (covered at 100%). Once the deductible has been satisfied, traditional health coverage kicks in.

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Choosing a medical plan Choosing a new medical plan? Check out these tips first.

● CHECK THE NETWORK– Do plan members prefer specific doctors or hospitals? Visit the plan's website to find out if they are in-network. If not, you'll pay a bigger share of the cost.

● EVALUATE NEEDS– Do plan members... visit a chiropractor? ...have frequent doctor or urgent care visits? ...get ongoing tests? ...take medications? ...have surgery planned? Compare these costs under each plan.

● THE BOTTOM LINE– How much is the premium? Is there a deductible? Can you offset expenses with a tax-free account such as an HSA? Each of these factors can affect your true cost of healthcare.

● WORDS TO KNOW– Understanding these terms will help better understand and compare plans.

DEDUCTIBLE The amount of healthcare costs you have to pay for with your own money before your plan will start to pay anything.

COINSURANCE After the deductible (if applicable), you and the plan share the cost. For example, if the plan pays 70%, your coinsurance share of the cost is 30%. You are billed for your coinsurance after your visit.

COPAY A set fee you pay instead of coinsurance for some healthcare services, for example, a doctor's office visit. You pay the copay at the time you receive care.

OUT-OF-POCKET MAXIMUM Protects you from big medical bills. Once costs "out of your own pocket" reach this amount, the plan pays 100% of most eligible expenses for the rest of the plan year.

IN & OUT-OF-NETWORK In-network services will always be the lowest cost option. Out-of-network services will cost more, or may not be covered. Check your plan's website to find doctors, hospitals, labs, and pharmacies that belong to the network.

BALANCE BILLING In-network providers are not allowed to bill more than the plan's allowable charge, but out-of-network providers are. For example, if the provider fee is $100 but the plan allows only $70, an out-of-network provider may bill YOU the extra $30. This is called balance billing.

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Medical ANTHEM BLUE CROSS

Anthem Premier Classic PPO 500

Anthem Standard PPO 1000

Anthem Value Classic PPO 1500

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Creditable Coverage Yes Yes Yes Medical Deductible Individual/Family

$500/$1,500 $1,000/$3,000 $2,000/$6,000 $1,500/$4,500 $3,000/$9,000

Pharmacy Deductible

$150 brand name/member (max 3/family)



Out-of-Pocket Maximum Individual/Family

$4,500/$9,000 $15,000/$30,000 $5,500/$11,000 $15,000/$30,000 $6,350/$12,700 $15,000/$30,000

Primary provider office visit $20 copay

40% after deductible

$30 copay 40% after deductible


Specialist office visit $20 copay




Chiropractic care (30 visits/year) $20 copay




Acupuncture (20 visits/year) $20 copay




Preventive care No Charge 40% after deductible

No Charge 40% after deductible

No charge 50% after deductible

Basic Lab/X-Ray 20% after deductible






MRI/CT/PET 20% after deductible






Urgent care $20 copay




Emergency room $250 copay (waived if admitted); then, 20% after deductible

$250 copay (waived if admitted); then, 20% after deductible

$250 copay (waived if admitted); then, 30% after deductible

Hospitalization

$500 copay/admission (max $1,000/per day for out-of-network)

$500 copay/admission $500 copay/admission







Ambulance 20% after deductible 20% after deductible 30% after deductible

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Medical

ANTHEM BLUE CROSS Anthem EPO 1000 Anthem PPO – HSA 3000 In-Network Out-of-Network In-Network Out-of-Network Creditable Coverage No No Medical Deductible Individual/Family

$1,000/$3,000 Not covered $3,000/$6,000 $6,000/$12,000

Pharmacy Deductible

None Not covered None


$5,500/$11,000 Not covered $6,350/$12,700 $20,000/$40,000

Primary provider office visit

$20/visit, deductible waived

Not covered 20% after deductible 40% after deductible

Specialist office visit $20/visit, deductible waived


Chiropractic care (30 visits/year)



Acupuncture care (20 visits/year)



Preventive care No copay, deductible waived

Not covered No copay, deductible waived 40% after deductible

Basic Lab/X-Ray 20% after deductible Not covered 20% after deductible 40% after deductible

MRI/CT/PET 20% after deductible Not covered 20% after deductible 40% after deductible

($800 max/procedure) Urgent care $20/visit, deductible

waived Not covered 20% after deductible 40% after deductible

Emergency room 20% after deductible 20% after deductible 20% after deductible

Hospitalization 20% after deductible Not covered 20% after deductible 40% after deductible

Ambulance 20% after deductible 20% after deductible 20% after deductible

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Medical

KAISER PERMANENTE Platinum HMO

0/15 Gold HMO

250/25 Gold HMO

500/30 Silver HMO

1650/55 Bronze HDHP HMO 6900/0

Bronze HMO 6300/65

In-Network In-Network In-Network In-Network In-Network In-Network Creditable Coverage Yes Yes Yes Yes Yes No

Medical Deductible Individual/Family

$0 $250/$500 $500/$1,000 $1,650/$3,300 $6,900/$13,800 $6,300/$12,600

Pharmacy Deductible

None None None $350/$700 Medical Deductible

Applies $500/$1,000


$4,500 / $9,000 $7,800 / $15,600

$7,000 / $14,000

$7,800/ $15,600 $6,900 / $13,800 $7,800 / $15,600

Primary provider office visit $15 copay $25 copay $30 copay $55 copay (no

deductible) $0 after

deductible $65 copay after

deductible

Specialist office visit $30 copay $50 copay $35 copay $80 copay (no

deductible) $0 after


deductible

Chiropractic care Not Covered Not Covered

$15 per visit; 20 visits/year combined

with acupuncture

$15 per visit; 20 visits/year combined

with acupuncture

Not Covered Not Covered

Preventive care No Copay No Copay No Copay

No charge

(no deductible)

No charge

(no deductible)

No charge

(no deductible)

Basic Lab/X-Ray Lab:$15 X-Ray: $30 copay per

encounter

Lab: $25 X-Ray: $65 copay

per encounter


per encounter


per encounter after deductible

Lab & X-Ray: $0 after

deductible

Lab: $40 copay per encounter

X-Ray: 40% after deductible

MRI/CT/PET $75 copay per procedure $275 copay $300 copay after


deductible $0 after

deductible 40% after deductible

Skilled Nursing Facility (up to 100 days per benefit)

$150/day up to 5 days per

admission


admission after deductible

$300/day up to 5 days per admission

after deductible 40% after deductible

$0 after deductible


Urgent care $15 copay $25 copay $30 copay $55 per visit no deductible

$0 after deductible

$65 per visit after deductible

Emergency room

(waived if admitted) $150 copay $250 copay

after deductible

$250 copay after deductible


$0 after deductible


Hospitalization $250/day up to a maximum of $1,250 per admission


admission after deductible

$600/day up to 5 days per admission

after deductible 40% after deductible

$0 after deductible


Outpatient surgery $125/procedure $340 copay $600 copay after deductible


$0 after deductible


Ambulance $150 copay/trip

$250 copay after

deductible

$250 copay after deductible


$0 after deductible 40% after

deductible

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Prescription Drugs ANTHEM BENEFITS Access Anthems pharmacy tool using the mobile app. Using your smartphone or other mobile device, you are able to:

• Find in-network pharmacies • Compare retail prescription medication cost at individual local pharmacies • Get personalized reminders to ensure you’re following your doctor’s treatment plan • Track your order status or quickly refill and renew prescriptions • Get drug interactions, manage medications and view claim history • Research potential side effects and view other important drug information

KAISER BENEFITS Once you’ve registered using kp.org/registernow, download the app. You can also call or go online and Kaiser will help with transitioning prescriptions to the Kaiser Permanente pharmacy of your choice. Use your kp.org user ID and password to activate the app. You can easily:

• Refill most prescriptions • Find a pharmacy near you

Anthem Prescription Drug Coverage

Anthem Premier Classic PPO 500 Anthem Value Classic 1500/ Anthem

Standard PPO 1000 In-Network Out-of-Network In-Network Out-of-Network

Deductible $150 brand name/member (max 3/family) $250 brand name/member (max 3/family) Retail (30 day supply) Generic

Tier 1a: $5 copay Tier 1b: $20 copay

Rx deductible waived

Tier 1a: $5 copay + 50% Tier 1b: $20 copay + 50%


Tier 1a: $5 copay Tier 1b: $20 copay


Tier 1a: $5 copay + 50% Tier 1b: $20 copay +

50% Rx deductible waived

Brand Formulary $40 copay after Rx deductible

$40 copay + 50% after Rx deductible $40 copay after Rx deductible

$40 copay + 50% after Rx deductible

Brand Non-Formulary $60 copay after Rx deductible

$60 copay + 50% after Rx deductible

$75 copay after Rx deductible $75 copay + 50% after Rx deductible

Specialty Drugs 30% up to $250 after Rx deductible

30% up to $250 after deductible + 50%

30% up to $250 after Rx deductible

30% up to $250 after deductible + 50%

Mail Order (90 day supply)

Generic Brand Formulary Brand Non-Formulary Specialty

$12.50 - $50 copay $120 copay $180 copay

30% Rx deductible waived for Tier 1

Not covered

12.50 - $50 copay $120 copay $225 copay

30% Rx deductible waived for Tier 1

Not covered

Prescription Drugs Continued

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Anthem Prescription Drug Coverage

Anthem EPO 1000 Anthem PPO – HSA 3000 In-Network Out-of-Network In-Network In-Network

Deductible $0 Not Covered $0

Retail (30 day supply) Generic Tier 1a: $5 copay

Tier 1b: $20 copay Not Covered

$10 copay 40% up to $250 copay/fill

(compound and specialty drugs not covered)

Brand Formulary $40 copay $30 copay Brand Non-Formulary $60 copay $50 copay Specialty Drugs 30% up to $250 copay/fill 30% up to $150 copay/fill


Generic Brand Formulary Brand Non-Formulary Specialty

$12.50-$50 copay $120 copay $180 copay

50%

Not Covered

$10 copay $60 copay

$100 copay 30% up to $300 copay/fill

Not Applicable

Kaiser Prescription Drug Coverage

Platinum HMO

0/15 Gold HMO

250/25 Gold HMO

500/30 Silver HMO

1650/55 Bronze HDHP HMO 6900/0

Bronze HMO 6300/65

In-Network In-Network In-Network In-Network In-Network In-Network

Deductible None None None $350 / $700 Combined with

Medical ($6,900/$13,800)

$500 / $1,000

Retail (30 day supply)

Generic $5 copay $15 copay $15 copay $20 (no deductible)

$0 after deductible

$18 after deductible

Brand-Name Formulary $15 copay $50 copay $50 copay $75 after deductible 40% up to $500

after deductible

Specialty Drugs 10% copay up to $250 maximum

20%/Rx up to $250 maximum



40% up to $500 after deductible


Generic $10 copay $30 copay $30 copay $60 (no deductible)

$0 after deductible


Brand-Name $30 copay $110 copay $100 copay $150 after deductible


9

Know where to go

ER or urgent care?

The emergency room shouldn’t be the first choice unless there’s a true emergency.

Consider urgent care for... Go to the emergency room for...

Symptoms, pain or conditions that require quick medical attention but do not require hospital care, such as: - Earache - Sore throat - Rashes - Sprains - Broken fingers or toes - Flu - Fever up to 104 degrees

Serious or life threatening conditions that require immediate treatment that you can get only at a hospital, such as: - Chest pain or severe abdominal pain - Trouble breathing - Loss of consciousness - Severe bleeding that can't be stopped - Large broken bones - Major injuries from a car crash, fall or other accident - Fever above 104 degrees

Other non-emergency care options

Our medical plans offer plenty of options when you need care or advice, but it’s not an emergency: 24/7 NurseLine

Anthem Plan Participants You can call any time to talk to a registered nurse about your health concerns. You can get answers to questions, whether you’re sick or not. A nurse can help you decide where to go if your doctor isn’t available – just call the number on your ID card.

Get a Video House Call

Anthem Plan Participants Anthem members can video chat with a doctor from the comfort of their own homes, without an appointment. LiveHealth Online provides 24/7 access to U.S. board-certified physicians. Your Anthem plan includes benefits for video visits using LiveHealth Online, so you’ll just pay your share of the costs —usually $49 or less for medical doctor visits, and a 45-minute therapy or psychiatry session usually costs the same as an office visit. Physicians can treat a host of common illnesses quickly and effectively through a real-time video visit. They can even send prescription orders to your local pharmacy. For more information, visit livehealthonline.com.

Video Visit Appointment Kaiser Participants Follow these steps to see your doctor without the trip to the doctor’s office.

1. Download the Kaiser app 2. Login to your kp.org account 3. Find your scheduled video visit

appointment a. Select the “upcoming” tab on the

appointment screen b. Select your scheduled visit to see

your doctor c. Press the “join now” if you are

within the 15 minute appointment window

10

Dental – Anthem Plan Comparison Anthem Blue Cross dental plans are available on a “stand-alone: basis for all size groups and are a valuable addition to your firms benefits package. The plans cover the following services when they are provided by a licensed dentist and when necessary and customary, as determined by the standards of generally accepted dental practices. The chart on the following pages identify the primary covered services.

If you have current group dental insurance when joining the NBBE program you may select any plan. If you do not have current group dental insurance when joining the NBBE program then you must select the Value plan with a 12 month wait for major services for your first year. After your group plan has been in place for 12 months you may request the 12 month waiting period for major services be removed and during the next open enrollment period you may select any available plan.

The Voluntary Plan (100% paid for by plan member with no employer contribution) must have a minimum of 5 participants in order to be offered.

Dental coverage provides periodic preventive care, and if there’s a problem, helps with the cost of dental work.

11

Dental

Anthem Premier (4001) Dental Plan5 Anthem Standard (3000) Dental Plan In-network Out-of-network1,2 In-network Out-of-network1,2 Annual deductible

None $50 per insured person /

up to $150 family (3x individual)

$25 per insured person / up to $75 family (3x

individual)


individual)

Annual plan maximum $2,500 per insured person $1,500 per insured person $2,500 per insured person $1,500 per insured person

Diagnostic and preventive

Covered 100%, deductible waived




Basic services

Fillings 10% after deductible 20% after deductible 10% after deductible 20% after deductible

Root canals 10% after deductible 20% after deductible 10% after deductible 20% after deductible

Periodontics 10% after deductible 20% after deductible 10% after deductible 20% after deductible

Endodontics, oral surgery

10% after deductible 20% after deductible 10% after deductible 20% after deductible

Major services3

Crowns 40% after deductible 50% after deductible 40% after deductible 50% after deductible

Bridgework 40% after deductible 50% after deductible 40% after deductible 50% after deductible

Dentures 40% after deductible 50% after deductible 40% after deductible 50% after deductible

Orthodontia services

Orthodontia (child only)4

50% deductible waived


Not covered Not covered

Lifetime maximum $2,000 $1,500 Not covered Not covered

1Reimbursement based upon 90% of FAIR Health (Usual, Customary, & Reasonable - UCR) 2Reimbursement based upon maximum allowable charge (MAC). MAC determined in one of following ways: out-of-network dental fee schedule/ rate developed by Anthem, information provided by a third-party vendor that shows comparable costs for dental services, in-network dentist fee schedule. Reimbursement is based upon a percentage of these amounts. 3Subject to a 12 month waiting period, which may be waived with proof of prior GROUP dental coverage. 4Child orthodontic coverage begins at age 8 and runs through age 18. This means the child must have been banded between the ages of 8 and 19 in order to receive coverage. If dependents are covered up to age 26, they can continue to receive coverage, but they must have been banded before age 18. 5 To offer Premier Dental plan, firm must have 6 or more enrollees

12

\ Dental Continued

Anthem Value (2000) Dental Plan Anthem Voluntary (1000) Dental Plan In-network Out-of-network1,2 In-network Out-of-network1,2 Annual deductible $50 per insured person /

up to $150 family (3x individual)


individual)


individual)


individual)

Annual plan maximum $2,000 per insured person $1,000 per insured person $1,000 per insured person $1,000 per insured person

Diagnostic and preventive





Basic services

Fillings 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Root canals 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Periodontics 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Endodontics, oral surgery 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Major services3

Crowns 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Bridgework 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Dentures 50% after deductible 50% after deductible 50% after deductible 50% after deductible

Orthodontia services

Orthodontia (child only)4





Lifetime maximum $1,000 $1,000 $1,0003 $1,0003

1 Reimbursement based upon 90% of FAIR Health (Usual, Customary, & Reasonable - UCR) 2 Reimbursement based upon maximum allowable charge (MAC). MAC determined in one of following ways: out-of-network dental fee schedule/ rate developed by Anthem, information provided by a third-party vendor that shows comparable costs for dental services, in-network dentist fee schedule. Reimbursement is based upon a percentage of these amounts. 3 Subject to a 12 month waiting period, which may be waived with proof of prior GROUP dental coverage. 4 Child orthodontic coverage begins at age 8 and runs through age 18. This means the child must have been banded between the ages of 8 and 19 in order to receive coverage. If dependents are covered up to age 26, they can continue to receive coverage, but they must have been banded before age 18. 5 To offer Premier Dental plan, firm must have 6 or more enrollees.

13

Vision Vision coverage helps with the cost of eyeglasses or contacts. But even if you don’t need vision correction, an annual eye exam checks the health of your eyes and can even detect more serious health issues such as diabetes, high blood pressure, high cholesterol, and thyroid disease.

Anthem Vision Plan VSP Vision Plan

In-network Out-of-network In-network Out-of-network Frequency

Examination 1 x every 12 months from last date of service

In-network limitations apply

1 x every 12 months from last date of service


Frames 1 x every 24 months from last date of service




Eyeglass lenses 1 x every 12 months from last date of service




Contacts (elective) 1 x every 12 months from last date of service




Benefit

Routine Eye Exam $10 copay Up to $45 allowance $10 copay Up to $45 allowance

Frames $120 allowance, then 20% off any remaining balance

Up to $47 allowance $120-$140 allowance,

then 20% off remaining balance

Up to $70 allowance

Single vision lenses $25 copay Up to $45 allowance $25 copay Up to $30 allowance

Bifocal lenses $25 copay Up to $65 allowance $25 copay Up to $50 allowance

Trifocal lenses $25 copay Up to $85 allowance $25 copay Up to $65 allowance

Contacts (elective) $120 allowance, then 15% off remaining balance

Up to $105 allowance $120 allowance, up to $60

for fitting & evaluation Up to $105 allowance

Contacts (elective

disposable) $120 allowance Up to $105 allowance $120 allowance, up to $60

for fitting & evaluation Up to $105 allowance

Contacts ( non-elective) No Charge Up to $250 allowance

$120 allowance, up to $60 for fitting & evaluation

Up to $105 allowance

Note: Exam/Lenses/Contact – once every 12 months; frames – once every 24 months. Anthem’s Blue View Vision network also includes convenient retail locations that include: 1-800- CONTACTS, Lens Crafters, and most Pearle Vision.

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Vision Continued

The Voluntary Blue View Vision plan is available for all active full-time owners and plan member. The minimum enrollment period is 12 months. The benefits are the same as the group plan but the rates are higher. This is a voluntary individual plan, paid 100% by the plan member through a payroll deduction.

Voluntary Blue View Vision

In-network Out-of-network Frequency

Examination 1 x every 12 months from last date of service In-network limitations apply

Frames 1 x every 24 months from last date of service In-network limitations apply

Eyeglass lenses 1 x every 12 months from last date of service In-network limitations apply

Contacts (elective) 1 x every 12 months from last date of service In-network limitations apply

Benefit

Routine Eye Exam $10 copay Up to $45 allowance

Frames2 No co-pay applies Up to $47 allowance

Single vision lenses1 $25 copay Up to $45 allowance

Bifocal lenses1 $25 copay Up to $65 allowance

Trifocal lenses1 $25 copay Up to $85 allowance

Contacts3 (elective) $120 allowance, then 15% off remaining balance Up to $105 allowance

Contacts3 (elective

disposable) $120 allowance Up to $105 allowance

Contacts3 ( non-elective) No co-pay applies Up to $250 allowance

1All lenses include a $25 materials co-pay that is applied once per service year toward your lenses or contacts. 2Frame of your choice covered up to $120. Plus, 20% off any out-of-pocket costs. 3 Contacts may be chosen instead of prescription glasses. An allowance of $120 will be provided towards the cost of your contact lenses. Fitting, evaluation, materials, and two follow-up visits are $55. Premium contact lenses have a fitting benefit of a 10% discount. Any costs exceeding the allowance are the responsibility of the patient. Contact lens frequency is the same as lenses. Under this plan, if you choose, you will be eligible for a frame 24 months after the last date of obtaining contacts. 4 Lenses for Children Under the Age of 19. In addition to the standard lens allowance, Blue View Vision covers polycarbonate lenses for children under the age of 19. Polycarbonate lenses are now becoming the industry standard for children due to safety reasons. “Transitions” lenses are also included for children under 19. 5 Services from a Blue View Network Doctor or Retail Specialist. Blue View Vision offers you additional savings of up to 40% on extra eyewear, certain non-prescription sunglasses and other popular accessories. There is no limit to the number of purchases you can make using this great savings opportunity – even after you’ve exhausted your covered vision benefits. 6 Laser Vision Correction Surgery. Blue View members pay a discounted amount per eye for LASIK Vision correction.

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Life and AD&D Life insurance can fill a number of financial gaps for a family recovering from the death of a loved one. Without enough life insurance, many families have to reduce their standard of living after the loss of an income. Consider your current and future financial needs when evaluating how much coverage you need. The most common short and long-term financial needs include:

● Medical bills and funeral expenses ● Living expenses for the surviving family (housing, food, clothing, utilities, etc.) ● Large expenses, e.g., college education, or home mortgage ● Taxes and debts that need to be settled.

Make sure that you have named a beneficiary for your life insurance benefits, and update it if your family or marital status changes.

Company-provided coverage

Basic Life and AD&D

Basic Life Insurance pays your beneficiary a lump sum if you die. AD&D (Accidental Death & Dismemberment) provides another layer of benefits to either you or your beneficiary if you suffer from loss of a limb, speech, sight, or hearing, or if you have a fatal accident. The company pays the full cost for your basic life and accidental death and dismemberment insurance coverage; you pay nothing. Coverage is provided through Anthem Blue Cross.

ANTHEM BASIC LIFE AND AD&D PLAN - ALL ELIGIBLE PLAN MEMBERS

Basic Life $5,000, $10,000 and $25,000

Basic AD&D $5,000, $10,000 and $25,000

The $50,000 benefit is only available for member firms with 6 or more enrolled owners/plan members.

Benefits Age Reduction

For both Basic and Voluntary Life and AD&D

Beginning at age 65, your life insurance benefits will be reduced by 40% of your benefit amount. Benefits age reduction applies to your coverage as well as any spouse coverage. See table below:

Age Reduction (ADEA graded age reductions apply for insured’s over age 65)

Age % of Pre-Age Benefit Paid 65-69 60% 70-74 35% 75-79 25%

Age % of Pre-Age Benefit Paid 80-84 15% 85-89 10% 90+ 5%

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Voluntary coverage

Voluntary Life

Voluntary Life Insurance allows you to purchase additional life insurance to protect your family's financial security. Coverage is available for your spouse and/or child (ren) if you purchase coverage for yourself.

ANTHEM VOLUNTARY LIFE AND AD&D PLAN

Employee Increments of $10,000 up to Lesser of 5 x covered annual earnings or $300,000.

Spouse Increments of $10,000 up to Lesser of 50% of employee amount or $100,000.

Child(ren) Increments of $2,500 up to Lesser of 50% of employee amount or $10,000.

Your AD&D benefit and your spouse’s AD&D benefit, if elected, is equal to your voluntary life benefit amount, if loss is due to accident or injury. AD&D coverage does not apply to children.

Evidence of Insurability Requirements

An owner/plan member must complete the Medical Questionnaire on all amounts. If the response is “yes” to any of the questions or if this is not the Initial Offering of optional life coverage by the company to the owners/employees, Anthem requires a full statement of health approval before coverage can take effect. An owner/plan member’s spouse must submit a Statement of Health form to Anthem, and Anthem must approve it before a spouse can be covered.

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Need help?

Get help with your benefits however you feel most comfortable. You have many different ways to get answers to your questions and assistance with coverage and claims issues. Use the resources on the following pages freely!

Get to know your benefits portal Gives you 24/7 access to general benefits information and benefits-related documents and forms.

More information coming soon!

Say hello to your benefit advocate Reach out to your benefits advocate for personal and confidential assistance with general benefits questions; eligibility and coverage; finding a network provider; coverage changes due to life events such as marriage, a new child, or divorce; and health care claim or billing issues (when warranted).

Email: [email protected] Phone: 949.681.9052

Make friends with mobile apps Stay informed while you're on the go! Many of your benefits plans offer apps that provide personalized information about your benefits coverage and individual usage.

Download the Anthem Blue Cross app to your smartphone to access these tools on the go: - Store member ID card - Estimate costs you can plan ahead - Find a doctor or urgent care and get

directions. View ratings and reviews - Check copays, deductibles and more - Securely send a receive messages about your

plan

Download the Kaiser Permanente app to your smartphone to access these tools on the go: - View most lab test results - Refill most prescriptions - Email your doctor’s office with non-urgent

questions - Schedule and cancel routine appointment - Print vaccination records for school, sports,

and camps - Use tools to help you manage your coverage

and costs - Manage a family members health care

Contribution questions? Contact your employer for any contribution related questions.


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Plan contacts

Plan type Provider Phone Web Policy # Medical Kaiser

Permanente 800.464.4000 www.kp.org 231224 & 603780

Medical Anthem Blue Cross

800.877.8288 www.anthem.com 277158

Dental Anthem Blue Cross

877.567.1804 www.anthem.com ACA0564121

Vision Anthem Blue Cross

866.723.0515 www.anthem.com 1702250011

Vision Vision Service Plan 800.877.7195 www.vsp.com 12335317

Life and AD&D Anthem Blue Cross

800.552.2137 www.anthem.com 2771580001

24/7 NurseLine Anthem Blue Cross

800.337.4770 N/A N/A

LiveHealthOnline Anthem Blue Cross

1.888.548.34.32 Livehealthonline.com N/A

Bay Area Builders Exchange

Scott Leary 510.483.8880 [email protected] N/A

Marin Builders Association

Paula Krause 415.462.1220, ext. 104

[email protected] N/A

Central Coast Builders Association

Christie Cromeens 831.758.1624 [email protected] N/A

NBBE Benefits Advocate

Alliant Insurance Services

949.681.9052 [email protected] N/A

North Coast Builders Exchange

Cindy Womack 707.542.9502 [email protected] N/A

Customer Service/Eligibility

Julie Mayo 916.486.1262 ext 116

[email protected] N/A

http://www.kp.org/

http://www.anthem.com/



http://www.vsp.com/







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Important plan notices & documents

Health plan notices

These notices must be provided to plan participants on an annual basis and are available HERE.

Medicare Part D Notice Describes options to access prescription drug coverage for Medicare eligible individuals

Women's Health and Cancer Rights Act

Describes benefits available to those that will or have undergone a mastectomy

Newborns' and Mothers' Health Protection Act

Describes the rights of mother and newborn to stay in the hospital 48-96 hours after delivery

HIPAA Notice of Special Enrollment Rights

Describes when you can enroll yourself and/or dependents in health coverage outside of open enrollment

HIPAA Notice of Privacy Practices

Describes how health information about you may be used and disclosed

Notice of Choice of Providers

Notifies you that your plan requires you to name a Primary Care Physician (PCP) or provides for you to select one

Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP)

Describes availability of premium assistance for Medicaid eligible dependents

COBRA continuation coverage

You and/or your dependents may have the right to continue coverage after you lose eligibility under the terms of our health plan. Upon enrollment, you and your dependents receive a COBRA Initial Notice that outlines the circumstances under which continued coverage is available and your obligations to notify the plan when you or your dependents experience a qualifying event. Please review this notice carefully to make sure you understand your rights and obligations.

Plan documents

Important documents for our health plan are available. Paper copies of these documents and notices are available if requested. If you would like a paper copy, please contact your employer.

SUMMARY PLAN DESCRIPTIONS

The legal document for describing benefits provided under the plan as well as plan rights and obligations to participants and beneficiaries.

https://alliantbenefits.cld.bz/2019-2020nbbeannualnotice

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SUMMARY OF BENEFITS AND COVERAGE

A document required by the Affordable Care Act (ACA) that presents benefits plan features in a standardized format. ● Kaiser Medical HMO Plan - Bronze HMO 6300/65 ● Kaiser Medical HMO Plan - Silver HMO 1650/55 ● Kaiser Medical HMO Plan - Platinum HMO 0/15 ● Kaiser Medical HMO Plan - Gold HMO 250/25 ● Kaiser Medical HMO Plan - Bronze HDHP 6900/0 ● Kaiser Medical HMO Plan - Gold HMO 500/30 ● Anthem Medical PPO Plan - Standard PPO 1000 ● Anthem Medical PPO Plan - Value 1500 ● Anthem Medical PPO Plan - HSA 3000 ● Anthem Medical PPO Plan - Premier PPO 500 ● Anthem Medical EPO Plan

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Notes ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Notes ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Notes ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Revised 02/04/2020

Documents

2020 - 2021 BENEFITS GUIDE · 2020-02-21 · 4. Dental – Firms with 1-5 enrolling subscribers must have 100% participation. Firms with 6 or more may have 75% participation in dental