Level C Benefits for 2024
Professional Musicians Local 47 and Employers Health and Welfare Fund offers one Kaiser Permanente plan to Level C eligible participants, and their dependents, who reside in California.
Participants that qualify for Level C may waive the Kaiser Permanente medical plan and enroll in the Dental/Vision Only plan.
Review the benefit summary carefully.
The following Summary of Benefits & Coverages (“SBC”) contain the same information as the Benefit Summaries. However, they are provided in a different format that is required by the Affordable Care Act (“ACA”) to allow members to compare various plans.
Level C Benefit Summaries
Medical Coverage
Kaiser Permanente
High Deductible HMO - HSA Qualified Plan
$30 Office Visit co-pay / $3,200 / $6,400 Deductible – 30% of some services
Kaiser Permanente Enrollment Guide
High Deductible HMO Benefit Summary
High Deductible HMO SBC
High Deductible HMO Evidence of Coverage
Kaiser Permanente Value Story
Coronavirus Information
Disclosure Part 2
Machine-Readable Files Notice
Life and Accidental Death and Dismemberment Coverage
Prudential Financial
Prudential Financial underwrites life and Accidental Death and Dismemberment coverage. This benefit covers the participant only. Dependents are not eligible for this benefit.
Prudential Life Certificate
Life Application/Beneficiary Form
Dental & Vision Coverage Only Plan
DENTAL COVERAGE OPTION 1:
Delta Dental DeltaCare DHMO
DHMO Benefit Summary
DHMO Evidence of Coverage
Delta Dental’s Mobile App & Online Services
Coronavirus Information
DENTAL COVERAGE OPTION 2:
Delta Dental PPO
PPO Benefit Summary
PPO Evidence of Coverage
Delta Dental’s Mobile App & Online Services
Coronavirus Information
CALIFORNIA RESIDENTS ONLY
EyeMed
Benefit Summary - coming soon
Level C Rates
Rates are valid through December 31, 2024
Kaiser Permanente
High Deductible HMO - HSA Qualified Plan
$30 Office Visit co-pay / $3,200 / $6,400 Deductible – 30% of some services
Kaiser Permanente HD HMO
Member Only
$155.00
Member +1
$706.00
Family
$1,220.00
Dental & Vision Coverage Only
THE RATES LISTED BELOW ARE ANNUAL
DeltaCare HMO + EyeMed Vision
Member Only
$60
Member +1
$288.00
Family
$516.00
Delta Dental PPO + EyeMed Vision
Member Only
$600
Member +1
$1,308.00
Family
$2,148.00
Level C Enrollment Form
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th).
NOTE: Submitting an enrollment application is not proof of enrollment.