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/billingclerk 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:
AHF’s Directory of
Participating Hospitals, Physicians, Physical Therapists and Chiropractors is no longer available in printed form. Please visit www.AHFonline.org to see the
complete Directory. If necessary, you can print specific pages or sections of
the Directory from their website.
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:
NormalFee-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).)
