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Plan A California Health Net HMO Medical Options
Medical Procedure
Health Net

HMO Plan
Annual Deductible
None
Annual Co-Payment Limit on Allowable Charges Plan pays 100% after co-payments reach $1,500 in a year ($4,500 for a family)
Overall Lifetime Maximum
None
Hospital
Inpatient
 You pay $400 per admission
Outpatient
 Plan pays 100%
Extended Care Facility (Skilled Nursing) You pay $400 per admission, 100 days maximum
Physician Services
Office Visits
 You pay $20 per visit
Routine Physical
Adults
Not Covered (You pay $20 for periodic health evaluation)
Children
(up to age 6)
You pay $20 per visit (no charge for well-baby care up to 24 months)
Children
(age 6 to 17)
You pay $20 per visit, age 2 and older
Inpatient Surgery
 Plan pays 100%
Outpatient Surgery
 Plan pays 100% (You pay $20 for office visit)
Hospital Visits
 Plan pays 100% inpatient, You pay $20 for outpatient
Diagnostic X-Ray and Lab Plan pays 100% (You pay $20 for office visit)
CAT Scans & MRI's Plan pays 100% when medically necessary
Durable Medical Equipment Plan pays 100%
Casts, Splints, Trusses, Braces & Crutches Plan pays 100%
Home Nursing Care You pay $20 per visit after 31st visit
Chiropractic Care
Not covered
Physical Therapy Plan pays 100%; maximum of 60 days per medical condition
Speech Therapy Plan pays 100%; maximum of 60 days per medical condition
Maternity Care Same as any other illness
Psychiatric Care -
Inpatient
 Plan pays 100% inpatient; 30 days maximum
Outpatient
 You pay $30 per visit; 20 visits per year maximum, unlimited visits for severe conditions
Substance Abuse -
You may choose between coverage under the Beat It! Program or your HMO, or a combination of both, as follows (See California Fee-for-Service Plan A for details on Beat It!):
Inpatient
 Plan pays 100%; 30 days maximum
Outpatient
 You pay $15 per group session, or $30 per individual session; 20 visit per year maximum
Prescription Drugs Must be obtained at a participating HMO pharmacy
Short-term (outpatient)
 You pay $10 per generic and $25 per brand name, and $35 per non-preferred prescription
Maintenance (30 day supply or more thru the Mail Order)
 Mail order - you pay 2 co-pays per prescription for a 90-day supply
Hearing Aids
Not covered
Emergency Room Care You pay $35 (co-payment waived if admitted to hospital)

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The information contained on this website is intended to provide only highlights of the benefits available under the Sheet Metal Workers Trust Funds' plans and plans of benefits. Complete details about the plans are contained in the governing plan documents. In the event of any inconsistency between the information on this website and the official plan documents, the terms of the plan documents, as interpreted by the plan's Board of Trustees in its sole and absolute discretion, will control. The respective Boards of Trustees of the plans reserve the right to amend, modify, or terminate all or part of the plans at any time, subject to applicable law.