Plan Description

The Plan uses the Blue Cross of California as the Preferred Provider Organization. Self-Funded PPO Plan’s health coverage meets the minimum value standard for the benefits it provides.

Eligibility Requirements

Primary Enrollee, spouse (includes domestic partner) and eligible dependent children to the end of the month dependent age 26.

Claims Procedures

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The Claims and Appeals procedures set forth below apply only to the Self-funded medical, mental health/substance use disorder, and prescription drug benefits.

Claims and appeals for insured benefits are governed by the rules of the specific insurance companies and HMOs. Copies of the applicable claims and appeals procedures for the HMO medical plan, Vision and Dental claims are available from Kaiser, Delta Dental and VSP.

Under the procedures set forth in the Plan and as is required by ERISA, if your claim for a health benefit is denied in whole or in part, you will receive a written explanation including the specific reasons for the denial.

You will be notified in writing of such denial within 90 days after receipt of such application or claim (in most situations, much earlier than 90 days). An extension of time not exceeding 90 days may be required in special circumstances. In many situations, there are delays because of information required by the Plan Office to process an application (such as a birth certificate and/or marriage certificate).

You then have the right to have the Board of Trustees review and reconsider your claim. If you have a question regarding the Plan or your benefit, you have the right to submit a letter to the Plan office seeking a response. The Plan will respond within a timely manner (within thirty days).