retiree active - mpiphp...the information in this summary plan description (spd) for the motion...

Summary Plan DeScriPtion

DecemBer 2015

active mpi health planretiree

health plan

For information regarding pension benefits, please contact theMotion Picture Industry Pension Plan at the California Plan Office number listed above.

California (Main) Office11365 Ventura Blvd., P.O. Box 1999

Studio City, CA 91614-0999

Main Phone: 855.ASK.4MPI (855.275.4674) Main Fax: 818.508.4714

New York Office145 Hudson St., Suite 6A

New York, NY 10013-2103

Main Phone: 212.634.5252 Main Fax: 212.634.4952

Website: www.mpiphp.org

retiree Summary Plan DeScriPtionDecember 2015

The Retiree Plan maintains administrative offices in California and New York. Our California Plan Office maintains records pertaining to your eligibility and processes claims for benefits. Please address any inquiry, claim or correspondence to the California Plan Office (our main Health Plan Office) and remember to include the Participant’s Social Security or Participant identification number.

MOTION PICTURE INDUSTRY HEALTH PLANFOR RETIRED ParticipantS

Summary Plan Description

Dear Eligible Retirees and Survivors,

The Motion Picture Industry Health Plan (“MPIHP” or the “MPI Health Plan”) consists of two plans: (1) the Motion Picture Industry Health Plan for Active Participants (the “Active Plan”) and (2) the Motion Picture Industry Health Plan for Retired Participants. We are pleased to welcome you into the Motion Picture Industry Health Plan for Retired Participants (the “Retiree Plan” or the “Plan”) and to provide you with this guide to the comprehensive Retiree Plan available to you and your eligible dependents.

Through your participation, you have an extensive package of benefits that includes medical, hospital, prescription drug, vision, dental and life insurance coverage. In addition, our contracted Wellness Program offers you preventive screenings and educational programs.

You may choose from among several options: the Retiree Plan offers our Preferred Provider Organization (PPO), which provides medical and hospital coverage throughout the country; residents of California may, instead, select a Health Maintenance Organization (HMO) plan offered through Health Net Seniority Plus® or Kaiser Permanente Senior Advantage®. If you select an HMO for your health benefits, the Evidence of Coverage or Schedule of Benefits/Coverage you receive upon enrollment with the Retiree Plan or with this Summary Plan Description will become part of your Summary Plan Description. There are also two dental plan options: Delta Dental PPO (available nationwide) and DeltaCare® USA (available to those who reside in California).

Under the Retiree Plan’s umbrella of benefits, there are various provider networks available to you depending upon the options you select. A list of the members of the network(s) you may choose from will be provided upon your request at no cost to you. Information on the provider network members, e.g., doctors, hospitals, etc., is also available on the respective network websites (see inside back cover for a complete list of the website addresses).

This Summary Plan Description (SPD) includes important information to help you understand and appropriately access your benefits. As much as possible, it is written in plain language. However, for legal reasons, we must sometimes use insurance industry and legal terms or phrases. For your reference, we have created a Glossary of Terms, located at the back of this SPD on page 116.

This Summary Plan Description explains the Retiree Plan, its restrictions and responsibilities. We make no recommendations regarding the use of any of the options offered but provide this information for you to select the plans most suited to your needs. For your convenience, we have included comparison charts on pages 18-22 for medical and hospital benefits and on page 83 for dental plans.

If you have selected the PPO medical and hospital benefits provided by the Retiree Plan, benefit details are included in this Summary Plan Description. If you have selected an HMO, only a summary is included in this SPD (in the section entitled Health Plan Alternatives); you may obtain more comprehensive information regarding the benefits available to you by referring to your Evidence of Coverage or by contacting the HMO plan directly.

Throughout this Summary Plan Description, you will find phone numbers, addresses, and websites to get additional information and answers to your questions regarding the benefits offered. Please don’t hesitate to contact us or the provider networks directly.

Thank you for your participation.

The Board of Directors Motion Picture Industry Health Plan

2015 Board Officers

Chairperson Mr. Michael Rosenfeld

Vice-Chairperson Ms. Laura Legge

Secretary Mr. Michael Miller

Vice-Secretary Mr. Ronald Kutak

2015 Board Members

Mr. Patric Abaravich

Mr. Aric Ackerman

Ms. Helayne Antler

Mr. Mark Badagliacca

Ms. Krysten Brennan

Mr. Ed Brown

Mr. Michael Campolo

Mr. Tommy Cole

Mr. Chuck Cortez

Mr. Thom Davis

Mr. Steve Dayan

Mr. Bruce Doering

Ms. Colleen Donahue

Mr. John Ford

Ms. Nicole Gustafson

Mr. Tom Inman

Mr. Sheldon Kasdan

Mr. Ronald Kutak

Mr. Hank Lachmund

Ms. Laura Legge

Mr. Matthew Loeb

Ms. Carol Lombardini

Mr. Michael Messina

Mr. Michael Miller

Ms. Diane Mirowski

Ms. Catrice Monson

Mr. Wes Ponsford

Mr. Michael Rosenfeld

Mr. Scott Roth

Mr. Ted Rubin

Mr. Joseph Scudiero

Ms. Carole Stepp

CHIEF EXECUTIVE OFFICERDavid Asplund

CHIEF MEDICAL OFFICER Kerry R. Clark, MD

legal counselsMitchell, Silberberg & Knupp, LLP

Short & ShepherdSpivak Lipton LLP

Wohlner, Kaplon, Cutler, Halford & Rosenfeld, P.C.

consultants Cheiron

Rael & Letson Consultants and Actuaries

MOTION PICTURE INDUSTRY HEALTH PLAN

Board of Directors

The information in this Summary Plan Description (SPD) for the Motion Picture Industry Health Plan for Retired Participants is effective for covered services received on or after December 1, 2015 and supersedes and replaces all simi-lar information previously issued. A separate SPD is available for the Motion Picture Health Plan for Active Participants.

The Retiree Plan is operated under the provisions of an Agreement and Declaration of Trust, and all benefits provided are subject to the terms of the Trust, this Summary Plan Description and the Group Master Contracts (including The Union Labor Life Insurance Company; Anthem® Blue Cross; Health Net®; Kaiser Permanente®; Delta Dental PPO; DeltaCare® USA; Express Scripts® , and Vision Service Plan®) which collectively constitute the Retiree Plan documents. The contracts have been issued to the Chief Executive Officer on behalf of the Directors. The terms of these documents will prevail in the interpretation of questions concerning any subject matter covered in this SPD.

The nature and extent of benefits provided by the Retiree Plan and the rules governing eligibility are determined solely and exclusively by the Directors of the Retiree Plan. The Directors shall also have full discretion and authority to interpret the Retiree Plan and to decide any factual questions related to eligibility for and the extent of benefits provided by the Retiree Plan. Such interpretations are final and binding on Participants, their dependents and providers.

Employees of the MPI Health Plans have no authority to alter benefits or eligibility rules. Any interpretations or opinions given by employees of the MPI Health Plan are not binding upon the Directors and cannot enhance or change such benefits or eligibility rules. In accordance with the terms of the Trust Agreement, the Directors reserve the right to change the nature and extent of benefits provided by the Retiree Plan and to amend the rules governing eligibility at any time.

While intended to remain in effect indefinitely, the benefits described in this Summary Plan Description can only be provided as long as the parties to the collective bargaining agreements continue to require contributions into the Trust (see page 3) sufficient to underwrite the cost of the benefits. Should contributions cease and the reserves be expended, the Directors would no longer be obligated to furnish coverage. These are not guaranteed lifetime benefits. Benefits can be changed or terminated at any time by the Directors.

SUMMARY PLAN DESCRIPTION

For Retired Participants

False or Fraudulent ClaimsAny Participant, dependent or provider who submits any false or fraudulent claim or information to the Retiree Plan may be subject to criminal penalties, including a fine or imprisonment or both, as well as damages in a civil action under California, federal or other applicable law. Furthermore, the Board of Directors reserves the right to impose such restrictions upon the payment of future benefits to any such Participant, dependent or provider as may be necessary to protect the Retiree Plan, including the deduction from such future benefits of amounts owed to the Plan because of payment of any false or fraudulent claim.

Are you a former Participant of any other health plan that merged into the Motion Picture Industry Health Plan? If so, it is important that you carefully review any appendix included with this Summary Plan Description (SPD) which addresses your particular situation. That appendix may contain special rules that are different from the rules contained in the main SPD. If there is any conflict between the terms of the appendix and the main SPD, the terms of the appendix will govern.

Retirement Certification Page 3The Motion Picture Industry Health Plan for Retired Participants is a separate plan to provide benefits for you following your retirement from the Motion Picture Industry. Employers make special contributions for this purpose during your working years, and no premium payment is required from you. Eligibility for Retiree Plan benefits is based on hours worked prior to retirement.

Eligible Dependent Family MembersPage 5Documentation must be submitted to the Plan Office by the Participant for any dependent for whom enrollment is requested to determine eligibility. Birth certificates, marriage certificates, spousal coordination of benefit forms and/or other forms of documentation (e.g., divorce/custody documents) are required to make this determination.

Medical and Dental Plan SelectionPage 6You have a choice of medical/hospital and dental plans. In addition, you will receive vision benefits through Vision Service Plan and prescription drug benefits through Express Scripts.

Open EnrollmentPage 8The Open Enrollment period occurs throughout the month of July each year for Plan enrollment effective August 1. During Open Enrollment, you may change your medical/hospital and/or dental coverage. Please note: Enrollment in the MPIHP/ Anthem Blue Cross Plan and/or the Delta Dental PPO dental plan is open all year.

Surviving Spouse CoveragePage 14The Retiree Plan will extend coverage to your surviving spouse, if you die while an eligible retiree, for the periods specified under the “Surviving Dependents” section on page 14.

MedicarePage 37If you or your eligible dependents are eligible for Medicare for any reason, including disability, reaching age 65, amyotrophic lateral sclerosis (ALS), or End Stage Renal Disease (ESRD), whether or not you have retired and applied for Social Security benefits, you must enroll in Medicare Part A and Part B benefits at your Social Security office. This is vitally important to you because your benefits with the Retiree Plan will not duplicate any such benefits you or your eligible dependents are legally entitled to receive.

Life InsurancePage 95A $2,000 life insurance policy is payable in full to your beneficiary in the event of your death from any cause while you are covered under the Retiree Plan.

Things to Remember• You MUST notify the Retiree Plan if you or your

dependent(s) have other group health insurance coverage as MPI will need that information to determine the order of benefits.

• You MUST notify the Plan Office in writing whenever you have a change of address, get married, get divorced, have a baby, etc.

• Important: if one or more of your dependents have an address that is different than yours, it is necessary that you notify the Plan as soon as this information is available.

• Be sure you have a current set of Health and Pension Plan Beneficiary Enrollment Forms on file at the Plan Office.

Please call us at 855.ASK.4MPI (855.275.4674) for a Change of Address Form or new Beneficiary Forms. Remember, there are separate Beneficiary Forms for the MPI Health Plan and the Pension Plan. Many of the forms are also available on our website: www.mpiphp.org.

HIgHLIgHTS

For Retired Participants

CONTENTS

1 Plan Eligibility 3 Basic Requirements for Plan Eligibility 5 Dependent Eligibility 6 Medical and Dental Plan Selection 7 Benefit Identification Cards 8 Forms 9 Self-Payment - COBRA 12 Dependent Continuation Coverage 14 Surviving Dependents

15 Health Plan Options 17 Health Plan Options Summary 18 Retiree Medical Plan Benefit Comparison At-A-Glance 23 MPIHP/Anthem Blue Cross PPO Health Plan Option 24 Hospital Expense Benefits 26 Health Plan Services 28 Claims Submission Guidelines 35 Coordination of Benefits 41 MPI Health Plan Benefits and Limitations 48 Non-Covered Services and Items 50 Preauthorization 51 Claims Appeals Procedures 54 UCLA Health-MPTF Health Centers 57 OptumHealth Behavioral Solutions 61 Health Plan Alternatives 63 Health Net 71 Kaiser Permanente

81 Dental Plan Options 82 Dental Plan Options 83 Dental Plans Comparison 84 Delta Dental PPO 91 DeltaCare USA

93 Additional Health Benefits 95 Life Insurance 97 Prescription Drug Benefit 103 Vision Services 105 The Wellness Program

107 The Plan 109 The Plan Defined 109 Participating Unions 109 Participating Employers 110 Employee Retirement Income Security Act of 1974 (ERISA) 113 Board of Directors

115 Resource Information 116 Glossary of Terms 119 Index

121 Health Benefits Appendix 124 Retired Former East Coast Local 600 (644)/666 Welfare Fund Participants 126 Retired Former East Coast Local 700 Welfare Fund Participants 128 Optional East Coast Plan - Oxford 136 Retired Former East Coast Local 52 Welfare Fund Participants 138 Retired Former East Coast Local 161 Welfare Fund Participants

Important Contact Information(Inside Back Cover)

TAbLE OF CONTENTS

Summary Plan Description for Retired ParticipantsDetailed contents of each major Summary Plan Description section are listed on the title page of that section. A subject index is located at the back of this Summary Plan Description on page 119.

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plan eligibilityThis section of the Summary Plan Description provides comprehensive information on the requirements to become and remain an eligible Participant of the Motion Picture Industry Health Plan for Retired Participants, including information on eligibility extensions and retiree health coverage. It details basic requirements for eligibility for you and for your dependents and survivors of eligible Participants.

CONTENTS

3 Basic Requirements for Plan Eligibility 3 The Trust 3 Basic Requirements 3 Effective Date of Benefits 3 Total and Permanent Disability 4 Eligibility Notification 4 Duration of Eligibility 4 Benefit Changes Upon Retirement 4 Work After Retirement

5 Dependent Eligibility 5 Eligible Dependents 5 Divorce Notification Requirements 6 Medical and Dental Plan Selection 6 Your Plan Options 6 Medical Plan Selection for the Newly Eligible 6 Dental Plan Selection for the Newly Eligible

7 Benefit Identification Cards 7 Benefit Cards – MPIHP/Anthem Blue Cross/ Dental/Prescription 7 Benefit Cards – HMO Plans 7 Benefit Cards – Dental 8 Forms 8 Beneficiary/Enrollment Form 8 Benefit Selection Form 8 Open Enrollment 8 Required Dependent Documentation 8 Change of Address

9 Self-Payment – COBRA 9 What is COBRA Coverage? 9 Who is Entitled to Elect COBRA? 9 Requirements for COBRA Coverage 9 Electing COBRA Continuation Coverage 10 Coverage Provided Through COBRA 10 Core and Non-Core Benefits 10 Cost of COBRA Continuation Coverage 10 Duration of COBRA Continuation Coverage 10 Open Enrollment 10 Termination of COBRA Continuation Coverage Self-Payment 11 Keep Your Address Current 11 If You Have Questions 11 Plan Contact Information 11 Coverage Conversion Alternatives 11 Marketplace Alternatives

12 Dependent Continuation Coverage 12 Student Eligibility 12 Required Student Documentation 12 Handicapped or Physically Incapacitated Dependents 13 Spouse and Dependent Children 13 Qualified Medical Child Support Orders

14 Surviving Dependents 14 Surviving Spouse 14 Surviving Dependent Children

3

bASIC REqUIREMENTS FOR PLAN ELIgIbILITY

Retirement CertificationTo establish eligibility for Retiree Plan benefits, you must contact the Motion Picture Industry Pension Plan at 855.ASK.4MPI (855.275.4674). If you qualify for Retiree Plan benefits, the Pension Plan will verify the number of hours and Qualified Years you have accrued and the age at which you will be eligible. If you are eligible for enrollment in the Retiree Plan, you will automatically be sent an enrollment packet.

The TrustThe Motion Picture Industry Health Plan for Retired Participants (the “Retiree Plan” or the “Plan”) maintains a separate Trust to provide benefits for you following your retirement from the Motion Picture Industry. Employers make special contributions for this purpose during your working years and no premium payment is required from you as a retiree. The assets of the Retiree Plan are not available for payment of benefits under the Motion Picture Industry Health Plan for Active Participants (the “Active Plan”); likewise, the assets of the Active Plan are not available for payment of benefits under the Retiree Plan.

Basic RequirementsYour eligibility for Retiree Plan benefits, with the exception of a total and permanent disability retirement, is not dependent upon your qualifying for retirement under the provisions of the Motion Picture Industry Pension Plan (the “MPI Pension Plan” or the “Pension Plan”). The rules governing the Retiree Plan and the rules governing the Pension Plan are similar but separate. You will qualify for Retiree Plan benefits provided:1. You have retired from the Motion Picture Industry; and2. You meet the Qualified Years/hours/minimum age

requirements outlined in the next section; and3. Your retirement from the Industry has been certified by

the Motion Picture Industry Pension Plan.

Please note: 1. “Qualified Year” is any year in which you worked at

least 400 hours for which contributions were made to the Retiree Plan. Please be aware that your Retiree Plan Qualified Years may be more than your Pension Plan Qualified Years if you incurred a “break in service” under the Pension Plan.

2. If you believe that you lost one or more Qualified Years as a result of service in the United States military, you may request additional credit toward establishing eligibility for Retiree Plan benefits by filing a written appeal. Upon receipt of your appeal, the Benefits/Appeals Committee will determine whether it is reasonably certain that military service, which qualifies under the terms of the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), prevented you from obtaining one or more Qualified Years toward your Retiree Plan benefits eligibility, and if so, the Benefits/Appeals Committee may credit you with one or more additional Qualified Years (see page 51 for instructions for filing an appeal).

Effective Date of BenefitsThe effective date of your Retiree Plan benefits is determined by the number of Qualified Years and hours you have, as well as the age at which you retire. While it is possible that you may retire and receive pension benefits at an earlier age, you will not be entitled to Retiree Plan benefits until the effective dates listed below.

Your active life insurance benefit will remain in effect as long as you would have been eligible in the Active Plan.1. With 15 Qualified Years and 20,000 Hours, the earliest

your Retiree Plan benefits will commence is on the 1st of the month following your 62nd birthday. To qualify, you must have earned at least three Qualified Years after the attainment of age 40, and earned at least one Qualified Year in any of the years commencing with the Plan Year 2000 through 2015.

2. With 20 Qualified Years and 20,000 Hours, the earliest your Retiree Plan benefits will commence is on the 1st of the month following your 62nd birthday.

3. With 30 Qualified Years and 55,000 Hours, the earliest your Retiree Plan benefits will commence is on the 1st of the month following your 61st birthday.

4. With 30 Qualified Years and 60,000 Hours, the earliest your Retiree Plan benefits will commence is on the 1st of the month following your 60th birthday.

Total and Permanent DisabilityIf you meet the requirements set forth below, you will be entitled to Retiree Plan benefits effective on the date of your disability retirement, regardless of your age.

You may retire under this provision if you have a minimum of 10 Qualified Years and 10,000 Hours for which contributions have been paid to the Retiree Plan, are totally and permanently disabled at the time of your retirement, AND1. You are eligible to retire and have retired under the

disability pension provisions of the Motion Picture Industry Pension Plan, or

2. You meet the requirements for a Motion Picture Industry Pension Plan disability pension but are not entitled to a Social Security Disability Award only because you are over-age. You will be entitled to Retiree Plan benefits effective on the date of your certification as being totally and permanently disabled by the MPI Health Plan’s Medical Review Department, or

3. You meet all of the requirements for such a disability pension but are not a Participant in the Motion Picture Industry Pension Plan.

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Eligibility NotificationWhen MPIHP is notified of your retirement, you will be sent information and materials relevant to your participation in the Retiree Plan. For the newly eligible retiree, you will be given a choice of medical/hospital and dental plans, which are described in individual sections of this Summary Plan Description.

Duration of EligibilityAs a Retiree, eligibility for the Retiree Plan lasts for your lifetime, provided there are sufficient funds available in the Trust to continue to provide these benefits. Please note that your eligible dependents may be entitled to continue coverage upon your death (see the Surviving Dependents section of this SPD on page 14 for additional information). The Directors reserve the right to alter and amend the level and nature of the benefits provided. A separate Trust is maintained for the Retiree Plan, and there is no guarantee of continued funding of that Trust. Should the reserves be expended, the Directors would no longer be obligated to furnish coverage.

Benefit Changes Upon RetirementWhile many of your benefits under the Retiree Plan remain the same as when you were in the Active Plan, there are important differences, including:• Medicare becomes your primary coverage upon first

becoming eligible for any reason (see page 37 for details).• Substance abuse and mental health benefits under the

Retiree Plan through OptumHealth Behavioral Solutions are as follows: the co-payment is $5; out-of-network hospitalization is not covered; hospitalization for psychiatric care is limited to the 1st through 14th day of confinement over the patient’s lifetime. Admission for alcoholism, narcotic addiction or abuse is limited to the 1st through 3rd day of confinement over the patient’s lifetime (see page 57).

• Prescription Drug Benefits Co-payment amounts change (see page 97).

• Life insurance benefits are reduced from $10,000 to $2,000. You may elect, at your expense, to convert from $500 up to $8,000 of your Active Plan group life insurance to a private policy with The Union Labor Life Insurance Company, without undergoing a physical examination. If you are interested in this conversion, contact MPI Participant Services at 855.ASK.4MPI (855.275.4674) immediately upon the termination of your Active Plan group life insurance. (see page 95)

• Dependent children are covered only until age 19 unless they satisfy the requirements for being a full-time student (see page 12), in which case coverage may continue until attainment of age 23, or graduation, whichever comes first.

Note: The Directors retain the right to change the Retiree Plan benefits in their sole discretion, and any changes made after you retire will apply to you and your eligible dependents.

Work After RetirementIf you re-qualify for eligibility in the Active Plan on the basis of hours worked after the date of your retirement certification under the MPI Pension Plan, you will be transferred to the Active Plan on the first date of the subsequent eligibility period. Any Active Plan premiums must be paid in a timely manner. When earned Active Plan benefits are exhausted, you will immediately be returned to the Retiree Plan.

Any questions you may have regarding information included in the Summary Plan Description concerning eligibility should be directed to:

Participant Services CenterAttn: Eligibility

Motion Picture Industry Health PlanP.O. Box 1999


855.ASK.4MPI (855.275.4674)

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Eligible DependentsIn order to enroll a dependent(s) in the Retiree Plan, application must be made and the required documentation submitted to the Plan Office in order to determine eligibility for any dependent you want to enroll. Birth certificates, marriage certificates, spousal Coordination of Benefits Forms and/or other forms of documentation (e.g., divorce/custody documents) are required for the Plan Office to make this determination.

It is extremely important that you are aware of how coverage for your eligible dependents is affected by primary and secondary insurance requirements (see pages 37 and 38 for additional information regarding spouse Coordination of Benefits for Participants in the MPIHP/ Anthem Blue Cross Health Plan Option).

Your eligible dependents are:• Your lawful spouse;• Your unmarried biological children who have not reached

age 19 (23 if a full-time student);• Any unmarried legally adopted children, or children placed

with you for adoption, who have not reached age 19 (23 if a full-time student);

• Any unmarried stepchild, foster child, and/or any child for whom you (the Participant) are legal guardian. In each case, the child must live with you in a parent-child relationship, be dependent upon you for support and maintenance, and must not have reached age 19 (23 if a full-time student);

• Any child required to be recognized under a Qualified Medical Child Support Order (QMCSO).

dependent eligibility

Please be aware that in order to enroll a dependent(s) in the Retiree Plan, application must be made and documents must be submitted to the Plan Office by the Participant to determine eligibility for ALL dependents.

The following is a summary of the general dependent eligibility rules. It is important to note, however, that a spouse shall not be eligible for MPI Health Plan benefits if such person is required by the Retiree Plan to be enrolled in a health plan offered by the spouse’s employer and is not enrolled (see the Coordination of Benefits section, starting on page 35).

Divorce Notification RequirementsYou must notify the Retiree Plan immediately in the event of a divorce and submit a copy of the final decree of divorce as soon as possible. A spouse from whom you are divorced is not eligible for benefits under the Retiree Plan as of the first day of the month following the date on which the final decree of dissolution of marriage or divorce is entered. However, the divorced spouse may elect COBRA, as described on page 9. If you fail to timely notify the Retiree Plan in writing of a change in your marital status and the Retiree Plan pays a claim for your former spouse for services rendered after eligibility ends, you and your former spouse will be held personally liable for reimbursement to the Retiree Plan for benefits paid, as well as any additional expenses, including attorneys’ fees and costs incurred by the Retiree Plan as a result of your statements, actions or failure to timely notify the Retiree Plan. The amount of any such overpayment may be deducted from the benefits to which you or your former spouse would otherwise be entitled.

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* MPI coverage offered to residents living throughout the country.** MPI coverage offered to residents living in California only.

Medical Plan Selection for the Newly Eligible When you first become eligible for the Retiree Plan, you will be automatically enrolled in the Motion Picture Industry Health Plan/Anthem Blue Cross PPO Plan (“MPIHP/Anthem Blue Cross” or the “MPIHP/Anthem Blue Cross PPO Plan”).

If you select one of the Health Maintenance Organizations (HMOs) – Health Net or Kaiser Permanente – your coverage with that plan will be effective on the first of the month following the Plan Office’s receipt of your completed Enrollment Form. Until your HMO coverage is effective, you will be covered by the MPIHP/Anthem Blue Cross PPO Plan.

If you are already covered under Health Net or Kaiser Permanente through some other group or individual plan, you can be enrolled in that plan on the first day you become eligible under the Retiree Plan. The medical/hospital plan you select will remain the same unless you select a different plan during Open Enrollment (held in July of each year).

Please note: It is extremely important for Participants and/or their eligible dependents who become eligible for Medicare for any reason to enroll in Medicare Parts A and B immediately. Failure to do so can result in substantial out-of-pocket expenses on medical claims, and/or termination of your HMO enrollment.

Your life insurance, dental, vision and prescription drug benefits will not be affected by your choice of medical/ hospital plan.

With the exception of hearing aids and The Wellness Program, Participants enrolled in an HMO plan are not eligible for any medical or hospital benefits other than those provided for under the HMO plan. The Wellness Program is available only in southern California. However, printed educational/information materials are available to all Participants.

Dental Plan Selection for the Newly Eligible When you first become eligible for benefits and the Plan Office receives your completed Beneficiary/Enrollment Form, you will automatically be enrolled in the Delta Dental PPO Plan. If you choose to select the prepaid dental plan DeltaCare USA, your coverage under that plan will be effective the first of the month following the Plan Office’s receipt of your completed Enrollment Form. Until your prepaid dental coverage is effective, you will be covered by the Delta Dental PPO Dental Plan.

Your dental plan selection will remain in effect unless you select a different plan during Open Enrollment (held in July of each year).

MEDICAL AND DENTAL PLAN SELECTION

As a Participant in the Retiree Plan, you have prescription drug and vision benefits, in addition to a choice of medical/hospital and dental plans. You will find comparisons between the various plans and descriptions of each in this Summary Plan Description (SPD). The Directors make no recommendations regarding the use of any of the options offered but provide this information for you to select the plans most suited to your needs. Note: If you or your dependent(s) are covered by any other group health plan, please carefully read the Coordination of Benefits section of this SPD.

Your Plan OptionsYou may select only one medical/hospital plan and one dental plan.

Medical/Hospital Plans Dental Plans

Motion Picture Industry Health Plan/ Anthem Blue Cross PPO Plan*

Health Net HMO Plan**

Kaiser Permanente HMO Plan**

Delta Dental PPO Plan*

DeltaCare USA DMO Plan**

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Medical/Hospital Plans Dental Plans

Motion Picture Industry Health Plan/ Anthem Blue Cross PPO Plan*

Health Net HMO Plan**

Kaiser Permanente HMO Plan**

Delta Dental PPO Plan*

DeltaCare USA DMO Plan**

bENEFIT IDENTIFICATION CARDS

Benefit Cards - MPIHP/Anthem Blue Cross/ Dental/PrescriptionIf you select the MPIHP/Anthem Blue Cross PPO Plan, Anthem Blue Cross will send you a benefit identification card.

If you need additional cards, please e-mail your request to MPIHP’s Participant Services Center at [email protected] or call toll-free 855.ASK.4MPI (855.275.4674).

Benefit Cards - HMO PlansIf you select an HMO plan, your medical/hospital benefit cards will be issued directly from that plan: Health Net or Kaiser Permanente, whichever you choose. Your prescription drug benefit cards will be sent to you from the Plan Office.

Benefit Cards - DentalDental enrollment information is provided on the identification cards issued by the Plan Office. If you select the prepaid dental plan, an additional dental benefit card will be issued directly from DeltaCare USA.

To request an HMO benefit card, call your chosen plan:

Health Net: 800.522.0088Kaiser Permanente: 800.464.4000

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Beneficiary/Enrollment FormUpon qualifying for Retiree Plan benefits, you will be sent a Beneficiary/Enrollment Form that is required to be completed to request enrollment for you and your eligible dependents and to designate a beneficiary(ies) of your life insurance. You must complete and return this Enrollment Form to the Plan Office. Benefit cards will not be issued, and no claims can be paid until your enrollment is completed.

Benefit Selection FormFor the newly eligible retiree, a Benefit Selection Form to enroll in your choice of medical/hospital and dental plans will be sent upon qualification for Retiree Plan benefits. If the Plan Office does not receive your completed form, you will be automatically enrolled in the MPIHP/Anthem Blue Cross Plan and the Delta Dental PPO Plan.

Open EnrollmentThe Open Enrollment period for plan enrollment occurs throughout the month of July each year, with any plan changes effective August 1. During Open Enrollment, you may change your medical/hospital and/or dental coverage. Please note: enrollment in the MPIHP/Anthem Blue Cross PPO Plan and/or the Delta Dental PPO plan is open all year.

Benefit Selection Forms are available upon request and at www.mpiphp.org. If you do not return this form timely, you will remain in your previously selected medical/hospital and dental plans.

Required Dependent DocumentationIn addition to the completion of the Beneficiary/Enrollment Form, documentation must be submitted to the Plan Office to determine eligibility for coverage of all dependents you wish to enroll. Copies of birth certificates, marriage certificates, spousal Coordination of Benefits Forms (see page 35 for additional information) and/or other forms of documentation (e.g., divorce/custody documents) are required to make this determination.

It is important that both the MPI Health Plan and the MPI Pension Plan are notified of any changes. You must complete new Beneficiary/Enrollment Forms and submit all required documentation. If your dependents change or you want to change your beneficiary(ies), contact the the Plan Office immediately, and you will be sent new forms. Revised Beneficiary/Enrollment Forms received on behalf of a deceased Participant will not be accepted.

Change of AddressIt is your responsibility to ensure that the Plan Office has your correct address. If your address changes, you should notify the Plan Office in writing by submitting a signed Change of Address Form that can be obtained from the Plan Office or online at mpiphp.org. If you notify the Plan Office of an address change in any other way, including by marking on a claim form that your address has changed, and you are a Participant in the Motion Picture Industry Pension Plan, you will be authorizing both the MPI Health Plan and the MPI Pension Plan to update your records to reflect your new address.

Important: if one or more of your dependents have an address that is different than yours, it is necessary that you notify the Plan as soon as this information is available. Always let the Plan know when a dependent has other insurance coverage as MPI will need that information to determine the order of benefits.

FORMS

Many of the Retiree Plan’s Forms are available on our website at www.mpiphp.org. You may also stop by the Plan Office to pick them up, or call us at 855.ASK.4MPI (855.275.4674), and we will mail you the form you need.

The Social Security or Participant identification number and signature of the Participant are required to change an address. For your protection, address changes will not be taken over the telephone.

98

What is COBRA Coverage?COBRA coverage is a continuation of Retiree Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this section. After a qualifying event occurs and any required notice of that event is properly provided to the Plan Office, COBRA coverage must be offered to each person losing Retiree Plan coverage who is a “qualified beneficiary.” Your spouse and other dependents could become qualified beneficiaries entitled to elect COBRA if coverage under the Retiree Plan is lost because of the qualifying event (certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail below). Under the Retiree Plan, qualified beneficiaries who elect COBRA must pay for COBRA coverage.

Who is Entitled to Elect COBRA?For Spouse and ChildrenCOBRA continuation coverage is available to an eligible spouse and other dependents if coverage would otherwise end because of any of the following:• Death of a Participant.• Divorce.• The dependent child is no longer considered a dependent as

defined by the Retiree Plan. For example, he or she marries, reaches the maximum age limit for coverage, or is no longer a full-time student.

Requirements for COBRA CoverageThe Plan Office is responsible for administering COBRA coverage. In order to have the option to elect COBRA coverage after a divorce or in the case of a child ceasing to be eligible under the Retiree Plan, you and/or a family member must notify the Plan Office in writing no later than 60 days after the coverage would end.

Your notice must be sent to:

Electing COBRA Continuation CoverageOnce the Plan Office receives the notice of a qualifying event, the qualified beneficiary(ies) will be sent a COBRA Election Form. Each qualified beneficiary will have an independent right to elect COBRA. Parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Retiree Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COVERAGE.

SELF-PAYMENT - CObRA

This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of group health coverage under the Retiree Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA coverage, when it may become available to you and enrolled members of your family, and what you need to do to protect their right to receive it.

The right to COBRA coverage was created by federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to your spouse and dependent children, if they are covered under the Retiree Plan, when they would otherwise lose their group health coverage under the Retiree Plan. This section does not fully describe COBRA coverage or other rights under the Retiree Plan. For additional information about your rights and obligations under the Retiree Plan and under federal law, you should review all the provisions of this Summary Plan Description or contact the Motion Picture Industry Health Plan office, which is the Retiree Plan administrator. The Retiree Plan provides no greater COBRA rights than what COBRA requires — nothing in this section is intended to expand your rights beyond COBRA’s requirements.

Participant Services Center Attn: Eligibility

Motion Picture Industry Health Plan P.O. Box 1999


1110

Qualified beneficiaries who are entitled to elect COBRA may do so even if they have other group health plan coverage or are entitled to Medicare benefits on or before the date on which COBRA is elected. However, a qualified beneficiary’s COBRA coverage will terminate automatically if, after electing COBRA, he or she becomes entitled to Medicare benefits or becomes covered under other group health plan coverage (but only after any applicable pre-existing condition exclusions of that other plan have been exhausted or satisfied).

Coverage Provided Through COBRAIf you choose COBRA coverage, you will be entitled to the same health coverage that you had when the event occurred that caused your health coverage under the Retiree Plan to end. However, under COBRA, you must now pay for that coverage. If there is a change in the health coverage provided by the Retiree Plan to similarly-situated Retiree Plan Participants and their families who have not experienced a COBRA qualifying event, the same change will be made in your COBRA continuation coverage.

Core and Non-Core BenefitsYour right to continued health care coverage includes the “Non-Core Benefits.” This package includes medical, hospitalization, prescription drug, vision and dental coverage. However, for a lower premium payment, you may elect to continue “Core Benefits,” which include medical, hospitalization and prescription drug coverage only. Neither of these rates includes life insurance.

Cost of COBRA Continuation CoverageThe amount you must pay for COBRA coverage will be due monthly. The Retiree Plan charges the full cost of coverage for similarly-situated Retiree Plan Participants and families, plus an additional 2% (for a total charge of 102%).

The Plan Office will notify you of the cost of the coverage and of any monthly COBRA premium amount charges at the time you receive your notice of entitlement to COBRA coverage. The cost of COBRA coverage may be subject to future increases during the period it remains in effect.

There will be an initial grace period of 45 days to pay the first amount due, retroactive to the date your coverage would have otherwise ended, starting with the date COBRA coverage is elected. Please note that your eligibility status cannot be verified and claims will not be paid until your payment is received. If this payment is not made timely, COBRA continuation coverage will cease to be available.

After you make your first COBRA payment, future payments are due on the first day of the month for that coverage period. If payment is not received by the due date, your coverage will be immediately suspended. If payment is received within 30 days after the due date, your coverage will be reinstated retroactively to the first day of the coverage period. MPI cannot verify your eligibility status for service providers until payment has been received. However, providers will be told that you are in the COBRA election period and that, if you pay for COBRA coverage, your coverage will be retroactive. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.

If payment of the amount due is not received by the Plan Office by the end of the applicable grace period, COBRA continuation coverage will terminate.

Following each payment, you will receive confirmation of the coverage period and when your next payment is due. Payments can be made on a monthly basis or for multiple months in advance.

Duration of COBRA Continuation CoverageCOBRA continuation coverage can continue for up to 36 months, depending on the COBRA qualifying event.

36 Months (Eligible Spouse and Dependents Only)COBRA continuation coverage for your eligible spouse and dependents continues for up to a total of 36 months from the date that any one of the following COBRA qualifying events occurs:• Your death• Your divorce• Your dependent child ceases to be eligible for Retiree Plan

coverage. For example, he or she marries, reaches the maximum age limit, or is no longer a full-time student.

Open EnrollmentThe Open Enrollment period occurs every year during the month of July. During that time, you may change your medical/hospital or dental coverage, your coverage type, add or delete qualified beneficiaries, or change your coverage between family and individual. Any changes made during the Open Enrollment period become effective on August 1st of that year.

Alternate Recipients Under Qualified Medical Child Support Orders (QMCSOs)A covered retiree’s child who is receiving benefits under the Retiree Plan pursuant to a QMCSO received by the Retiree Plan during the covered retiree’s Period of Eligibility with the Retiree Plan is entitled to the same rights to elect COBRA as an eligible dependent child of the covered retiree.

Termination of COBRA Continuation Coverage Self-PaymentOnce COBRA continuation coverage has been elected, it may be cut short (terminated) on the occurrence of any of the following events:• The first day of the month for which the COBRA premium

is not paid timely,• The date on which the Retiree Plan is terminated,• The date, after the date of the COBRA election, on which a

dependent(s) first becomes covered by another group health plan, and that plan does not contain any legally applicable exclusion or limitation with respect to a pre-existing condition that the covered person may have, or

• The date, after the date of the COBRA election, on which a dependent(s) first becomes entitled to Medicare due to disability, reaching age 65 or End Stage Renal Disease (ESRD).

COBRA coverage ends on the earlier of the date that:• Any of the above-listed events occurs, or• The COBRA period (36 months) ends.

1110

Keep Your Address CurrentIn order to protect your family’s rights, you must notify the Plan Office of any changes in the addresses, phone numbers or e-mail addresses of family members. You should keep a copy, for your records, of any notices you send to the Plan Office.

If You Have QuestionsIf you have questions about COBRA continuation coverage, contact the Plan Office. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting your health plan, you may contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) or visit the EBSA website, www.dol.gov/ebsa. Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa.

Plan Contact InformationYou may obtain information about the Retiree Plan and COBRA coverage from:

Your COBRA rights are subject to change. Coverage will be provided only as required by law. If the law changes, your rights will change accordingly.

Coverage Conversion AlternativesIf you exhaust the option for continuation coverage or do not wish to extend benefits under COBRA continuation coverage, you may still obtain coverage for yourself and your family by conversion to an individual policy. The cost of these benefits depends upon the family members to be covered. If you would like additional information regarding this option, please contact the medical/hospital plan in which you are currently enrolled.

Marketplace AlternativesThere may be other coverage options for your spouse or dependents. They may be able to buy coverage through the Health Insurance Marketplace, e.g., Covered California. In the Marketplace, they could be eligible for a tax credit that lowers their monthly premiums right away, and they can see what their premium, deductibles, and out-of-pocket costs will be before they make a decision to enroll. Being eligible for COBRA does not limit eligibility for coverage for a tax credit through the Marketplace.


Motion Picture Industry Health PlanP.O. Box 1999


855.ASK.4MPI (855.275.4674) FAX: 818.766.1229

1312

Student Eligibility If your unmarried child is dependent upon you for primary support and is a full-time student in an accredited school or college, the child may remain eligible for coverage until attainment of age 23. To be recognized by the Retiree Plan, a school or college attended must be fully accredited (approved by the State Department of Education or recognized for veterans’ training, and accredited with one of the regional associations granting accreditation to schools throughout the country).

If the school or college is based on a quarterly system, the child must attend at least three quarters per year and carry a minimum of ten units per quarter. If the school or college is based on a semester system, the child must attend at least two semesters per year and carry a minimum of 12 units per semester.

If enrolled in a trade, technical or adult education school, the student must be in attendance 25 hours or more per week. Students attending school to acquire a high school diploma are required to attend classes 20 hours or more per week.

The student’s eligibility for benefits will begin on the first of the month of the session in which the student is enrolled full-time and will cease as of the first of the month following graduation, or the first of the month following the student’s withdrawal, bringing the total number of units or hours carried to below full-time. The Participant is required to supply the Plan Office with the withdrawal date. Students who finish school in the spring session will be covered through August, provided the Participant is still eligible for benefits. In no event will eligibility for benefits extend beyond the first of the month following the student’s 23rd birthday.

Student eligibility for continued coverage is also subject to the Coordination of Benefits rules discussed on page 35.

If a student has a serious injury or an illness that prevents him/her from attending school and this injury or illness is certified by a physician, coverage may be continued at six (6) month intervals, not to exceed one year.

Required Student Documentation To maintain uninterrupted eligibility for a student until age 23, the Participant must complete and submit to the Plan Office, a Student Certification Form or other documentation acceptable to the Retiree Plan, such as schedule of classes showing the number of units or hours, final grades or transcripts. Failure to

comply with this requirement will result in the denial of claims submitted and a demand for reimbursement of any claims paid by the Retiree Plan on behalf of the child. Always make sure that the student has an up-to-date address on file with the Plan.

An enrolled dependent child who ceases to meet the Retiree Plan’s definition of “dependent” may be able to continue coverage by self-payment through COBRA.

Handicapped or Physically Incapacitated DependentsAn eligible dependent child whose coverage would otherwise terminate due to attainment of limiting age will continue to be considered an eligible dependent if they have a physical or mental disability (for example, cerebral palsy, mental retardation, autism, bipolar disorder) and because of that disability are incapable of self-sustaining employment and independent care and maintenance. The status and condition of the dependent MUST be certified at least annually by the attending physician. The provisions regarding coordination of benefits, including Medicare and Medicaid and, if married, spousal coordination of benefits will apply to the dependent. Please see the coordination of benefits section of this SPD for further information.

This provision will only apply if the Retiree Plan is provided with written evidence of such incapacity by the later of:1. The 31st day after attainment of the limiting age, or2. The 31st day after the Participant is notified of the

ineligibility of the dependent.

The statement from the attending physician must include the diagnosis, the date of the commencement of the incapacity and the expected date of recovery. Proof of the continued existence of such incapacity must be furnished to the Plan Office annually.

Children who reach age 19 prior to the Participant’s initial eligibility in either the Active Plan or the Retiree Plan, whichever is earlier, are not entitled to coverage under this provision.

Important: if one or more of your dependents have an address that is different than yours, it is necessary that you notify the Plan as soon as this information is available. Always let the Plan know when a dependent has other insurance coverage as MPI will need that information to determine the order of benefits.

DEPENDENT CONTINUATION COvERAgE

1312

Spouse and Dependent Children If your covered spouse and/or any dependent children lose coverage due to any of the following events, your spouse or dependent children may purchase COBRA continuation coverage for up to 36 months:1. Death of the Participant;2. Divorce; or3. The dependent child is no longer considered a dependent

as defined by the Retiree Plan.For information, see the COBRA section of this SPD on page 9.

Qualified Medical Child Support Orders (QMCSOs) Pursuant to federal law, the Retiree Plan is obligated to honor the terms of a QMCSO providing continued health care coverage for your children. A QMCSO is an order, decree, judgment, or administrative notice (including a settlement agreement) issued by a domestic relations court or other court of competent jurisdiction, or through an administrative process established under state law which has the force and effect of law in that state, which meets the requirements of Section 609 of ERISA.

Note: To qualify for COBRA coverage, the Plan Office must be notified no later than 60 days after coverage would end.

An eligible dependent spouse from whom you are not yet divorced cannot be removed from your coverage.

1514

Surviving SpouseAs a Retiree, if you die while covered under the Retiree Plan and you have been married for less than two years, the Retiree Plan will extend coverage to your eligible surviving spouse for a period of six months, without cost.

As a Retiree, if you die while covered under the Retiree Plan and you have been married for more than two years, and if your retirement certification was based on:• 15 Qualified Years and 20,000 Hours requirement – your

eligible surviving spouse will continue to be eligible for his/her lifetime (or until remarriage), provided you are at least age 62 at the time of your death. If you die before reaching age 62, your surviving spouse will receive one year of extended coverage for each Qualified Year that you have earned.

• 20 Qualified Years and 20,000 Hours requirement – your eligible surviving spouse will continue to be eligible for his/her lifetime (or until remarriage), provided you are at least age 62 at the time of your death. If you die before reaching age 62, your surviving spouse will receive one year of extended coverage for each Qualified Year that you have earned.



• 10 Qualified Years and 10,000 Hours/Total and Permanent Disability requirement - your eligible surviving spouse will receive one year of extended coverage for each Qualified Year that you have earned.

In the event that your eligible surviving spouse should remarry or otherwise lose coverage before 36 months have passed since your death, your spouse may have the option to continue coverage by self-payment through COBRA for the remainder of the 36-month period. For information, see the COBRA section of this SPD on page 9.

Surviving Dependent ChildrenIn addition to the above, any eligible children you have at the time of your death will continue coverage until they cease to qualify as eligible dependents.

If your eligible surviving dependent children lose coverage before 36 months have passed since your death, they may have the option to continue coverage by self-payment through COBRA for the remainder of the 36-month period.

For information, see the COBRA section of this SPD on page 9.

Any questions you have regarding these provisions may be directed to:

SURvIvINg DEPENDENTS


Motion Picture Industry Health Plan P.O. Box 1999


855.ASK.4MPI (855.275.4674) FAX: 818.766.1229

15

1514

HEALTH PLAN OPTIONSAs a Retired Participant, you have an extensive package of benefits available to you, and you have choices within that package. In order to make decisions appropriate to your needs, it is in your best interest to take time to familiarize yourself with your medical and hospital benefit options. The Plan Options Summary and Medical Plan Benefit Comparison Chart provided in the following pages offer you factual information to help you identify the most appropriate benefits for your individual circumstances.

CONTENTS

17 Health Plan Options Summary 17 Services Provided to California residents 17 Services Provided to non-California residents

18 Retiree Medical Plan Benefit Comparison At-A-Glance

23 MPIHP/Anthem Blue Cross PPO Health Plan Option 24 Hospital Expense Benefits 24 General Information 24 Skilled Nursing/Extended Care Facility 24 Emergency Outpatient Care 24 Inpatient Care 24 Balance Billing 25 Childbirth 25 Medicare 25 Surgical Centers 25 Hospital Care/Admissions 25 Services Not Covered 25 Information of Note 26 Health Plan Services 26 Covered Services 26 Second Surgical/Medical Opinion 26 Services Not Covered 27 Experimental and Investigational Exclusion 27 Preauthorization 28 Claim Submission Guidelines 28 Submission and Payment of Claims 30 Coordination of Benefits 30 Allowable Amount 31 Physician Services 32 Schedule of Allowable Amount 33 Co-Payment

33 Yearly Out-of-Pocket Maximum for Comprehensive Medical Benefits 33 Overpayments 34 Billing Errors 34 Stop Payment or Replacement of a Benefit 35 Coordination of Benefits 35 Order of Benefit Determination 35 Payment Priority 37 EPO, HMO, POS and PPO Coordination 37 Medicaid Coverage Coordination 37 Medicare Coordination of Benefits 39 Claims Involving Third Party Liability 40 Workers’ Compensation 41 MPI Health Plan Benefits & Limitations 41 Acupuncture 41 Alcoholism/Chemical Dependency 41 Ambulance 41 Artificial Cervical and Lumbar Discs 41 Aquatic Therapy 42 Birth Control Devices 42 Bone Mineral Density Measurement 42 Cardiac Rehabilitation 42 Case Management 42 Chiropractic Treatment 42 Colonoscopy 42 Cosmetic Surgery 42 Dental Treatment 42 Medical Services Provided by Dentists 43 Dermatology 43 Diabetes Supplies and Insulin 43 Diagnostic Imaging and Laboratory Tests 43 Durable Medical Equipment 43 Emergency Hospital Admissions 43 Emergency Room Treatment

15

1716

43 Food Allergy Testing 43 Fundus Photography 43 Genetic Testing 44 Hearing Aids 44 Home Hospice Care 44 Home Intravenous Therapy 44 Immunizations/Vaccinations 44 Lens Replacement Following Cataract Surgery 44 Mammography 44 Maternity Benefits 45 Mental Health and Chemical Dependency 45 Nursing Care 45 Nutrition Counseling 45 Nutritional Support 46 Physical Examinations 46 Physical/Occupational/Aquatic/Osteopathic Manipulative Therapies (Outpatient) 46 Podiatry 46 Prostheses and Braces 46 Reconstructive/Cosmetic Surgery 47 Sclerotherapy 47 Skin Cancer

47 Speech Therapy 47 Transplants 47 Venipuncture for Medical Procedures 47 Weight Control 47 Wigs/Hair Pieces 48 Non-Covered Services and Items 50 Preauthorization 51 Claims Appeals Procedures 54 UCLA Health-Motion Picture & Television Fund Service Area 54 Pediatric and Maternity Services 54 Selecting a Provider/Scheduling an Appointment 54 Using an Out-of-Network Provider 54 UCLA Health-MPTF Health Centers Service Area ZIP Codes 55 Third Party Liability Questionnaires 55 UCLA Health-MPTF Health Centers 57 OptumHealth Behavioral Solutions

61 Health Plan Alternatives 63 Health Net Seniority Plus 71 Kaiser Permanente Senior Advantage

1716

As a Retired Participant, you have an extensive package of benefits available to you, and you have choices within that package. In order to make decisions appropriate to your needs, it is in your best interest to take time to familiarize yourself with your medical and hospital plan options.

The Benefit Comparison chart for Medicare eligible retirees provided on the following pages offers you factual information to help you identify the the most appropriate benefits for your individual circumstances. It is provided for your information only. The Retiree Plan makes no recommendations regarding the use of any of the options offered.

The Board of Directors retains the right to interpret and apply the Retiree Plan, and any interpretation of the Retiree Plan is final and binding upon Participants, their dependents, and providers of services. The Directors also reserve the right to alter and amend the level and nature of benefits provided.

If you are in doubt about coverage of a certain service or are seeking review of a claim that has already been processed by the Plan, we suggest you write to the Plan Office for clarification, requesting a written response rather than obtaining information over the telephone.

Employees of the MPI Health Plan have no authority to alter benefits or eligibility rules. Any interpretations or opinions given by employees of the MPI Health Plan are not binding upon the Directors and cannot enhance or change such benefits or eligibility rules.

(see Claims Appeals Procedures, page 51)

Eligible Participants• If you or your eligible dependents are entitled to

Medicare for any reason, the payment of your claims is explained under the section entitled “Medicare Coverage Coordination” on page 37.

• If you or an eligible family member has other employer group health insurance available to them, please see the section Coordination of Benefits on page 35.

• See the sections entitled Workers’ Compensation on page 40 and MPI Health Plan Benefits and Limitations on page 41 for important exclusions and limitations on Retiree Plan benefits.

• Dental, life insurance, prescription drug, and vision benefits and The Wellness Program are not impacted no matter which medical/hospital plan you select.

Plan Options Available to California ResidentsIf you reside in California, you may elect coverage under the Motion Picture Industry Health Plan/Anthem Blue Cross PPO Plan, the Health Net Seniority Plus HMO plan, or the Kaiser Permanente Senior Advantage HMO plan. Benefits provided under the MPIHP/Anthem Blue Cross PPO Plan are described in detail in this Summary Plan Description. Benefits provided under the Health Net and Kaiser plans are summarized in their respective sections of this Summary Plan Description.

Due to the initial processing time when enrollment in either the Health Net or Kaiser Permanente plan is selected, during the first month of your initial selection of Health Net or Kaiser Permanente, you will be covered under the MPIHP/Anthem Blue Cross PPO Plan. Coverage under Health Net or Kaiser Permanente will commence on the first day of the second month after the effective date of your initial selection. Please note that if you are already covered under the HMO you have selected through some other group or individual plan, you will be enrolled in the HMO from the first day of eligibility.

Non-California ResidentsParticipants residing outside California will be enrolled in the BlueCard® PPO Program.

HEALTH PLAN OPTIONS SUMMARY

As to the determination of non-covered services and items, the Retiree Plan does not imply that the services and items are not beneficial for the health management of the patient, nor do we wish to interfere with the patient/provider relationship. Rather, we are administering the Retiree Plan in accordance with its terms.

In accessing your benefits, please remember that, although a physician may recommend or prescribe a service or supply, this does not, of itself, establish or require coverage by the Retiree Plan.

1918

Health Care Benefits

MPIHP/ Anthem Blue Cross

Health Net Seniority Plus* California Only

Kaiser Permanente Senior Advantage*

California Only

Out-of-Network Coverage • Yes, as indicated below• Balance billing could occur• Reimbursement is based on the

allowable amount, which may be less than the provider’s charges

• Only for a medical emergency • Only for a medical emergency

Annual Deductible • None • None • None

Medicare Coordination • Benefits below are before coordination with Medicare (see page 37)

• Generally, co-pays apply and coinsurance is covered by the Retiree Plan

• Benefits below are after coordination with Medicare

• Benefits below are after coordination with Medicare

Annual Out-of-Pocket Maximum • In-network: $1,000 per person• Includes coinsurance;

does not include co-pays • Out-of-network: unlimited, except for an emergency admission

• $3,400 per person• Includes coinsurance and co-pays

• $1,500 per person up to $3,000 per family

• Includes coinsurance and co-pays

Hospital Services

• Room and Board• Intensive Care• Ancillary Services• Semi-Private Room

• In-network: 10% coinsurance plus $100 per admission

• Out-of-network: 50% coinsurance plus $100 per admission

• When Medicare is primary, there will be no coverage under the Retiree Plan once the Medicare coverage is exhausted

• No charge • No charge

Extended Care• Room and Board in a

Skilled Nursing Facility• Other Services and Supplies

• In-network: 10% coinsurance • Out-of-network: 50% coinsurance• Plan coverage ends after

- 90 days for Participants - 60 days for dependents

• No charge (up to 100 days per admission )

• No charge (up to 100 days per admission) (see Evidence of Coverage)

RETIREE MEDICAL PLAN BENEFIT COMPARISON AT-A-GLANCE

1918





California Only

Emergency Services Within or Outside Service Area

• 10% coinsurance plus $100 co-pay plus balance of charged amount for out-of-network providers (waived if admitted to a hospital)

• All covered services when medically necessary anywhere in the world from any licensed physician, surgeon or general hospital

• Out-of-network: hospital facility allowable amount

• $20 co-pay (waived if admitted to a hospital)

• All covered services when medically necessary anywhere in the world from any licensed physician, surgeon or general hospital

• $20 co-pay (waived if admitted to a hospital)

• All covered services when medically necessary anywhere in the world from any licensed physician, surgeon or gen-eral hospital

Professional Benefits• Physician Visits:

– Hospital/Office – Surgeon – Assistant Surgeon – Per visit co-pays applies to

office visits

• UCLA Health-MPTF Health Centers: $5 co-pay

• In-network in UCLA Health-MPTF Health Centers area: 10% coinsurance plus $30 co-pay

• In-network: out of UCLA Health-MPTF Health Centers area: 10% coinsurance plus $15 co-pay

• Out-of-network in UCLA Health-MPTF Health Centers area: 50% coinsurance plus $30 co-pay

• Out-of-network out of UCLA Health-MPTF Health Centers area: 50% coinsurance plus $15 co-pay

• No co-pay for inpatient visits

• $15 co-pay for office visits• No charge for inpatient visits

• $15 co-pay for office visits• No charge for inpatient visits

• Urgent Care Visits • Same as physician visits • $20 co-pay • $5 co-pay

• Anesthesia (Note that anesthesiologist can be out-of-network even when the hospital and surgeon are in-network)

• In-network: 10% coinsurance• Out-of-network: 50% coinsurance

• In-network: No charge • In-network: No charge

2120





California Only

Professional Benefits (continued)

• Ambulance Services (including air ambulance)

• Emergency: 10% coinsurance• Non-emergency and medically

necessary: - In-network: 10% coinsurance - Out-of-network: 50% coinsurance

• Emergency: No charge• Non-emergency: No charge, prior

approval is required

• Emergency: No charge• Non-emergency: No charge, prior

approval is required

• Laboratory Tests and Diagnostic Imaging

• In-network: 10% coinsurance• Out-of-network: 50% coinsurance

• No charge • In-Network: No charge

• Injectable Drugs (Outpatient) • Many covered under the Prescription Drug Benefit through Express Scripts (see Prescription Drug Benefit section on page 97)

• Allergy Shots and Injectable Drugs not covered by Express Scripts - In-Network: 10% Coinsurance - Out-of-Network: 50% Coinsurance

• No charge for most injectable drugs, allergy shots or allergy tests

• Also covered through Express Scripts (see Express Scripts Prescription drugs Benefits section on page 97)

• No charge for most injectable drugs, including allergy tests

• Also covered through Express Scripts (see Express Scripts Prescription drugs Benefits section on page 97)

• Eye Examinations • $20 co-pay for routine eye examina-tion and corrective lenses are covered through VSP (see Vision Service Plan section on page 103)

• Non-routine same as physician visit

• $15 co-pay per visit• Routine exams are also covered through

VSP at a $20 co-pay (see Vision Service Plan section on page 103)

• $15 co-pay per visit

• Routine exams are also covered through VSP at a $20 co-pay (see Vision Service Plan section on page 103)

• Chiropractic Service • In-network: No charge• Out-of-network: Maximum allowable

amount and other limitations apply (see Benefits and Limitations section on page 41)

• Maximum of 20 visits per calendar year for both in- and out-of-network

• $5 co-pay per visit• Maximum of 20 visits per calendar year

(see page 64)


• Maximum of 20 visits per calendar year (see page 72)


2120





California Only

Professional Benefits (continued)• Physical Examination (annual)

• For adults: applicable co-pay and coinsurance apply:

➢ Reside in LA County: Must use a UCLA Health-MPTF Health Center provider

➢ Reside outside of LA County: Annual exam covered up to $300

• For children (i.e., under age 18) applicable co-pays and coinsurance apply


• Physical Therapy • Same as physician visits• Out-of-network: Maximum allowable

amount and other limitations apply (see Benefits and Limitations section on page 41)

• Maximum of 16 visits per calendar year per injury; 2nd injury needs approval; visit limit applies to both in- and out-of-network

• No charge • $15 co-pay per visit

Home Health Services• Physician Home Visits

• Same as physician visits • $15 co-pay • No charge

• Home Health Nurse • No co-pay• Coinsurance applies


• Hospice (In-home only)

• No charge • $15 for preliminary consultative visit • No charge

Maternity Benefits • Physician visits: applicable coinsurance plus at least one physician co-pay

• Hospital services: applicable coinsurance and co-pay

• No coverage for dependent children

• $15 co-pay per visit• No charge in hospital


• No charge in hospital

2322





California Only

Professional Benefits (continued) Family Planning Services• Vasectomy

• Not covered • Not covered • Not covered

• Tubal Ligation • Not covered • Not covered • Not covered

• Elective Abortion • Covered under specific conditions. (see page 44 for limitations)

• No charge for medically necessary abortion

• Elective abortion not covered

• $15 co-pay when outpatient

• No charge if inpatient

• Intrauterine Device (IUD) (provided in a physician’s office)

• UCLA Health-MPTF Health Centers: $5 co-pay

• In-network in UCLA Health-MPTF Health Centers area: 10% coinsurance plus $30 co-pay

• In-network: out of UCLA Health- MPTF Health Centers area: 10% coinsurance plus $15 co-pay

• Out-of-network in UCLA Health- MPTF Health Centers area: 50% coinsurance plus $30 co-pay

• Out-of-network out of UCLA Health-MPTF Health Centers area: 50% coinsurance plus $15 co-pay

• Not covered • $15 co-pay per visit

• No charge per prescription

Mental Health Outpatient • In-network: $25 co-pay per visit (see page 57)

• Out-of-network: 50% coinsurance

• $15 co-pay per visit • $15 co-pay visit• $7 co-pay per visit for group therapy

Mental Health Inpatient • In-network: No charge• Out-of-network: $100 per admission,

then 50% coinsurance (see page 58)



2322

MPIHP/Anthem Blue Cross* Health Plan OptionAs a retired Participant, you have the option of selecting comprehensive medical and hospital coverage available through the MPIHP/Anthem Blue Cross PPO Plan option. You should become familiar with the limitations, as well as opportunities to save out-of-pocket costs by using network providers.

IN CALIFORNIA:The hospital PPO network in California is provided by Anthem Blue Cross, and the benefits are administered by the MPI Health Plan.

The comprehensive medical PPO network in California is provided by Anthem Blue Cross, and the benefits are administered by the MPI Health Plan.

OUTSIDE CALIFORNIA:The hospital PPO network outside California is provided by the BlueCard Program, and the benefits are administered by the MPI Health Plan and BlueCard.

The comprehensive medical PPO network outside of California is provided by the BlueCard Program, and the benefits are administered by the MPI Health Plan and BlueCard.

The plan of benefits, including covered procedures and processes and non-covered services, is provided on the following pages. Please note that the MPI Health Plan utilizes internal policies and procedures in coordination with Anthem Blue Cross to determine coverage and benefits under the Retiree Plan. We encourage all retired Participants to review this section thoroughly.

MPIHP/ANTHEM bLUE CROSS PPO HEALTH PLAN OPTION

* Anthem Blue Cross is the trade name of Blue Cross of California, an independent licensee of the Blue Cross Association. ANTHEM® is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

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HOSPITAL ExPENSE bENEFITSBenefits are provided for hospitalizations when reasonable and necessary for the treatment of illness or injury. Hospitalizations related to mental disorders, as listed in the International Classification of Diseases, are administered by OptumHealth Behavioral Solutions (see page 57).

The term “hospital” means an institution or facility which is primarily engaged in providing diagnostic, medical and surgical health care services for the care and treatment of sick and injured individuals on an inpatient and outpatient basis. The hospital provides these services under clinical direction of licensed medical doctors and with 24-hour-a-day nursing care by licensed and/or registered nurses, as well as care provided by other health care professionals. The term hospital does not include any institution or part of an institution which is used principally as a rest facility, nursing facility or facility for the aged, or for the care and treatment of substance abuse or for psychiatric treatment.

MPIHP/Anthem Blue Cross PPO Health Plan Option

General InformationClaims for Services Rendered in CaliforniaFor hospital admission for you or your covered dependents, present your benefit card. If you do not have your benefit card with you at the time, provide the following information:• Anthem Blue Cross Group number: 277163M002• Plan Code: 040• Certificate Number (“MPI” plus the Participant’s Social

Security number)

Claims for services received outside of California should be submitted to the local Blue Cross/Blue Shield office. For information on BlueCard providers nationwide, call 800.810.BLUE (2583).

Skilled Nursing/Extended Care FacilityThe benefits described under inpatient care are available in an Anthem Blue Cross contracting skilled nursing/extended care facility or Medicare-approved extended care facility if admitted within 30 days of a minimum three-day stay in a licensed general hospital.

The maximum covered length of stay is 90 days for a Participant and 60 days for a covered dependent.

For more information, call the MPI Health Plan, 855.ASK.4MPI (855.275.4674).

In no event will the terms “convalescent hospital” or “extended care facility” include any institution or part thereof which is used primarily as a rest facility (including nursing facility or facility for the aged). Custodial care is not covered (see Case Management, page 42).

Emergency Outpatient CareCovered hospital emergency room charges, including all covered services performed in the emergency room, are paid at 90% of the allowable amount, less a $100 co-pay if not admitted. (If admitted to the hospital, the $100 emergency room co-pay is waived.)

Some hospitals operate clinics within their facility. That allows them to separate treatment areas for true emergencies from those for lower acuity medical issues. When a Participant is seen in one of these clinics, rather than in the emergency department, the covered benefit for a clinic visit is the same as for a doctor’s office visit.

Inpatient CareBenefits for inpatient care at Anthem Blue Cross contracting hospitals include:• Room Charge (semi-private)• Intensive Care• Nursery Expenses

• Other charges - supplies, medication, diagnostic x-rays and laboratory tests, operating room, anesthesia supplies, physiotherapy, and inhalation therapy required in connection with the conditions being treated (see Hospital Care/ Admissions, page 25).

Balance BillingWhen a Participant uses an out-of-network provider for covered services, the provider can bill the Participant for the difference between the billed charges and the allowable amount determined by the Plan. Charging this difference is referred to as balance billing.

Emergency treatment rendered in facilities other than a licensed acute care hospital, such as urgent care centers and after hours centers, will be paid under the comprehensive medical benefit (see page 31).

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Information of Note• Certain other services supplied by hospitals are

not covered by your hospital benefit but may be included as covered medical expenses under your comprehensive medical benefit. These may include doctor, surgeon, and anesthesiologist charges, as well as certain special surgical or orthopedic supplies and ambulance service.

• Coordination of benefits (COB) will apply in all situations in which the patient has other group health coverage.


ChildbirthThe Retiree Plan complies with federal law that prohibits the restriction of benefits for a mother or newborn child in connection with childbirth to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a Cesarean section. The law also prohibits a plan from requiring a health care practitioner to obtain authorization from the Retiree Plan for prescribing a length of stay which is less than that legal minimum.

As a result, covered expenses include bed and board and other necessary services and supplies for a mother and her newborn child for up to 48 hours following a normal vaginal delivery and up to 96 hours following a Cesarean section. No authorization is needed from the Retiree Plan in order to be covered for these amounts of time.

MedicareWhen you or your dependents are entitled to Medicare benefits, your hospital expenses will be handled as follows:• Present your hospital benefit card and Medicare card to

obtain admission to the hospital.• The hospital will bill Anthem Blue Cross and Medicare

directly. No benefits will be payable under the Retiree Plan for eligible Medicare benefits that are not paid because you did not enroll, qualify or submit claims for Medicare coverage. This same rule applies if your doctor or hospital does not submit bills to Medicare on your behalf. Medicare will not pay benefits for care received outside the United States. Contact your Social Security Office for more information on Medicare benefits.

For more information concerning Medicare, see page 37.

Surgical CentersTo determine in advance whether a non-hospital surgical center is contracted with Anthem Blue Cross, contact:

For surgical centers in California:• MPI Health Plan, 855.ASK.4MPI (855.275.4674)• www.anthem.com/ca

For surgical centers outside of California:• Anthem Blue Cross, 800.810.BLUE (2583)• www.anthem.com/ca

Surgical suites and surgery centers that are out-of-network are subject to a special payment schedule. Benefits for covered services will be 25% of the surgical allowance payable at 50%.

Hospital Care/AdmissionsThe Retiree Plan has contracted with Anthem Blue Cross to obtain reduced costs through the Anthem Blue Cross network of preferred provider hospitals in California and for out-of-state residents, with the BlueCard Program throughout the United States. Receiving services at lower fees enables the Retiree Plan to provide 90% coverage, less a $100 co-pay, for covered services received from a preferred provider.

For out-of-network hospitals, the Retiree Plan will pay 50% of the allowable amount, less a $100 co-pay, for covered services, and you will be responsible for the balance. If, however, you are admitted to an out-of-network hospital through the emergency room, the Retiree Plan will pay 90% of the allowable amount, less your $100 co-pay. (If admitted to the hospital, the $100 emergency room co-pay is waived.) These charges can be used to satisfy your $1,000 in-network out-of-pocket maximum.

Be sure to verify in advance whether the hospital is an Anthem Blue Cross preferred provider hospital or contracted through the BlueCard program. To obtain this information:

For preferred provider network hospitals in California• MPI Health Plan, 855.ASK.4MPI (855.275.4674)• www.anthem.com/caFor preferred provider network hospitals outside

of California:• Anthem Blue Cross, 800.810.BLUE (2583)• www.anthem.com/ca

Services Not CoveredThe following is a summary of some services which are not covered:• Industrial illness or injury, including any illness or injury

arising out of and in the course of your employment• Hospitalization for cosmetic surgery, except for restoration

of congenital malformation or for the repair of accidental injury which occurred while covered, or for reconstructive surgery following a mastectomy

• Hospitalization for a dependent child’s pregnancy• Hospitalization for custodial care• Hospitalization not reasonable and necessary for the

treatment of a covered illness or injury• Hospitalization in connection with any treatment or

procedure which is not covered under the Comprehensive Medical Benefits of the Retiree Plan.

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HEALTH PLAN SERvICES

The Plan provides benefits for specific medical services that have been approved by the Retiree Plan Board of Directors. Comprehensive medical benefits cover reasonable and necessary medical services in connection with the diagnosis and treatment of any non-industrial illness or injury.


Covered ServicesIn order for a service to be covered, it must be a service for which the Retiree Plan has established a benefit, and the service must be medically necessary and reasonable. To determine if a particular service is medically necessary and reasonable, the Retiree Plan independently reviews the claim and makes a decision as to whether the nature of the services provided and the amount charged is appropriate for the specific diagnosis under the indicated clinical circumstances.

“Medically necessary” means procedures, treatments, supplies,

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