Affiliated Health Funds (AHF)

	Contract Hospital Benefit
	Directory of Contract Providers
	Contract Physician Benefit
	Contract Physical Therapists
	Contract Medical Equipment
	Hearing Aids
	AHF Plan Limitations

AFFILIATED HEALTH FUNDS (AHF)

AHF was created by several Health and Welfare Funds, including Operating Engineers, to help reduce the cost of health care. The Fund has contracted with doctors and hospitals through the organization known as Affiliated Health Funds (AHF). Your freedom of choice is retained with this arrangement. You may continue to select the doctors and hospitals of your choice. However, choosing doctors and hospitals from the AHF contract network will result in less out-of-pocket expense to you. The AHF program requires no enrollment. If you are not enrolled in an HMO plan and you are eligible, you are automatically part of the AHF program.

NOTE: WITH THE EXCEPTION OF DURABLE MEDICAL EQUIPMENT these AHF benefits are not available to participants enrolled in the Kaiser, Health Net or Health Plan of Nevada HMO programs.

AHF HOSPITAL BENEFITS

When you are a registered bed patient in an AHF participating hospital, the Fund provides

the following benefits, with the exception of psychiatric and substance abuse treatment:

ACTIVE

Paid according to the negotiated contract. You are responsible for 10% of the hospital's charge, up to $500. You could save $1,500 or more!*

RETIRED

Non-Medicare - Paid according to the negotiated contract. You are responsible for 10% of the hospital's charge not to exceed half of the AHF contract allowance, up to $2,000. You save 10% of the bill or more. There is NO deductible. *

Medicare - Medicare will pay the majority of your hospital bill. The Fund will pay the Medicare deductible and co-payments.

*Does not apply to psychiatric or substance abuse admissions.

When you obtain care from an AHF participating hospital, you simply tell the admitting/billing clerk you are an Operating Engineer and an AHF member. There is no special paperwork, and the hospital will submit the claim forms directly to the Fund Office.

IMPORTANT: When a member, spouse or dependent has other group insurance coverage (including Medicare) which is the primary carrier, these AHF benefits are not payable. The Plan pays normal benefits as the secondary carrier.

DIRECTORY:

The AHF Directory of Participating Hospitals and Physicians is issued and mailed to eligible participants in Spring of each year and is also available by calling the Fund Office and requesting one.

AHF DOCTOR/PHYSICIAN

Under the AHF contract provisions, the Plan will pay the contract rate which the doctor has agreed to accept. You have no co-payment. You must, however, pay for any services not covered by the Plan.

When you make an appointment, be sure to ask if the doctor is still part of the AHF network. If you have questions about this, call the Fund Office.

If you use the doctor under contract, the Plan will waive the annual deductible which currently is $250.00 per person per calendar year, with a $750.00 per family maximum.

When a member, spouse or dependent has other group insurance coverage (including Medicare) which is the primary carrier, the AHF benefits are not payable. The Plan pays normal benefits as the secondary carrier.

No enrollment is necessary - but please advise the doctor that you are in the AHF program.

COMPARISON TO NORMAL PLAN BENEFITS

NORMAL PLAN BENEFIT EXAMPLE:

A bill for medical services totals $500.00. The Plan has an allowance for those services of $400.00. The doctor in this case has charged more than the Plan allows. The $250.00 annual deductible is applied to the $400.00 allowed amount, leaving a balance of $150.00 which is paid at 80%. The Fund pays $120.00. The out-of-pocket expense to the member in this case is $380.00.

AHF BENEFIT EXAMPLE:
	Normal Fee-for- Service Plan	AHF Program
Doctor's Charge	$ 500.00	$ 500.00
Plan Allowance	$ 400.00	$ 300.00
Deductible	$ 250.00	$ 0.00
Plan Payment	$ 120.00	$ 300.00
Your Out-of-Pocket	$ 380.00	$ 0.00

AHF PHYSICAL THERAPISTS

Current provisions in the Plan provide for payment of $35 per visit for the services of a physical therapist with a maximum of 26 visits per calendar year in combination with acupuncture, biofeedback and chiropractic care. Refer to “Alternative Therapy”.

However, under the AHF contract provisions, the Plan will pay the contracted rate, which the physical therapist has agreed to accept. You have no co-payment.

IMPORTANT: Physical Therapy is part of the Fund's "Alternative Therapy" benefit and applies to any combination of contract and non-contract providers. For example, if you have already visited a chiropractor for 10 visits during the year, you will only be entitled to 16 additional physical therapy visits.

If you use the physical therapist under contract, the Plan will waive the annual deductible which currently is $250.00 per person per calendar year, with a $750.00 per family maximum.

And, no enrollment is necessary - but please advise the therapist that you are in the AHF program.

Physical therapists under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available from the Fund Office.

DURABLE MEDICAL EQUIPMENT

Eligible participants and their eligible dependents can obtain durable medical equipment and oxygen, when prescribed by a physician, from contract providers at several locations in Southern California.

Under the AHF contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no co-payment .

Simply present your Health & Welfare Identification Card along with your doctor's prescription. Trained medical equipment specialists will make certain that you are provided with the prescribed equipment, and will make any necessary adjustments. Repairs or exchanges of rented equipment will also be done by contract providers at no charge.

Durable Medical Equipment Locations

For delivery of durable medical equipment and other home health needs, you may contact Apria Healthcare or Equipnet. You or your physician may call the toll-free numbers and arrangements will be made to provide the requested service. Delivery is free of charge.

	Apria Healthcare Inc.	(800) 277-4288
	Equipnet, Inc.	(800) 366-0232

Durable medical equipment includes items such as wheelchairs, walkers, hospital beds, breathing equipment, crutches and many other items.

NOTE: These AHF benefits for Durable Medical Equipment are not available for participants who are enrolled in the Kaiser Permanente and Health Net HMO program.

HEARING AIDS

Eligible participants and their eligible dependents can obtain hearing care service and hearing aids at a reduced cost from the Beltone Corporation.

Beltone offers a nationwide network of Hearing Aid Centers. To locate the Beltone Hearing Aid center nearest you, call (800-235-8663) or click here for a list of the Beltone Hearing Centers participating in the Affiliated Health Funds (AHF) program.

AHF LIMITATIONS

IMPORTANT:	1.	If you obtain services from an AHF provider that are not covered by the Plan, benefits will not be paid. You will be responsible to pay for those charges.
	2.	If your doctor sends you outside his office to a specialist or for x-rays or lab tests, you will need to find out if that provider has a contract with AHF. The Fund will have to provide normal Plan benefits if the provider is not contracted with AHF, and you may incur some out-of-pocket expense.
	3.	Hospitals do not always have their own pathology labs, radiologists, or emergency room doctors on staff. These types of providers will lease space and operate out of the hospital: they DO NOT always have a contract with AHF. In this case the Fund will have to provide normal Plan benefits and you may incur some out-of-pocket expense, however, no deductible will be taken from those charges. (This does not apply to non-emergency care in the hospital's emergency room (see outpatient emergency care).)