|
|
INPATIENT
HOSPITAL BENEFITS
|
|
Hospital benefits are provided to all eligible employees and
their eligible Dependents. The Fund uses the following PPO networks depending on
where you live:
IMPORTANT: Regardless of which PPO network applies to you,
your physician or hospital must contact the Fund Office when verification
of benefits and/or eligibility is needed. Verification of benefits and/or
eligibility can be obtained by contacting the Fund’s Information Center at (626)
356-1004
or 888-512-5279 and via the Fund’s website at
www.oefunds.org. No entity other than the Fund Office can
verify benefits and/or eligibility.
|
|
IMPORTANT This
benefit does not apply to inpatient care for mental health care or substance
abuse.
(See
Substance Abuse Treatment).
Payment is limited to the most common semi-private room rate.
Accommodation in an Intensive Care Unit, Neo-Natal Intensive Care Unit,
Pediatric Care Unit or Definitive Observation Unit for patients with serious
infectious diseases is paid at 2-1/2 times the semi-private room rate. Payment
for the Intensive Care Unit for the treatment of burns is limited to five times
the amount of the semi-private room rate.
When you are a registered hospital bed patient, the Fund provides the following
benefits: |
| ACTIVE |
PPO Contract Hospital
– The Fund will pay 90% of the contract amount. You are responsible for 10% of
the contract amount.
When you obtain care from a PPO participating hospital, you simply tell the
admitting/billing clerk you are an Operating Engineer Health & Welfare/Anthem
Blue Cross member (participants who reside in California or Nevada) or an AHF
member (participants who reside outside of California or Nevada). There is no
special paperwork, and the hospital will submit the claim forms directly to the
Fund Office.
Non-PPO Contract Hospital
-
When you obtain
care from a non-contract hospital the Fund will pay 70% of the covered charges
per confinement after satisfaction of the Calendar Year Deductible. You will be
responsible for the remaining balance.
 |
|
RETIRED
without
Medicare |
PPO Contract Hospital -
The Fund will pay 90% of the contract amount. You are responsible for 10% of the
contract amount.
When you obtain care from a PPO participating hospital, you simply tell the
admitting/billing clerk you are an Operating Engineer Health & Welfare/Blue
Cross Prudent Buyer/Anthem Blue Cross member (participants who reside in
California or Nevada) or an AHF member (participants who reside outside of
California or Nevada). There is no special paperwork, and the hospital will
submit the claim forms directly to the Fund Office.
Non-PPO Contract Hospital -
|
|
When you obtain care from a non-contract hospital the Fund will pay 70%
of the covered charges per confinement after satisfaction of the
Calendar Year Deductible. You will be responsible for the remaining
balance. |
|
|
RETIRED
with
Medicare
|
 |
Medicare will pay the majority of your hospital bill. The Fund will pay
the Medicare deductible and some co-payments.
|
|
| EXTENDED
BENEFIT
|
|
If
you or your Dependent are hospitalized at the time eligibility terminates, the
Fund will continue to provide hospital benefits only until you are discharged.
|
| PRE-ADMISSION
TESTING |
If
you or your eligible Dependents are going to be admitted as an in-patient to a hospital for
non-emergency care, you are encouraged to have as many of the tests required for
admission performed on an outpatient basis before your stay begins. This
is called Pre-Admission Testing. Charges for these tests will be paid at
100% of Reasonable and Customary with no deductible. Diagnostic testing is not
included in this benefit.
|
| OUTPATIENT
EMERGENCY CARE
|
|
If you do not become a registered bed patient, but incur hospital charges in
the Outpatient Department of a hospital for care that normally cannot
be performed in a doctor's office or laboratory:
|
 |
If the treatment
is related to an emergency medical condition,
the Fund's Fee-for-Service Plan will pay 70%
of the reasonable and customary charge after satisfaction of the
Calendar Year Deductible, if applicable. Examples of emergency treatment are broken bones, a
severe laceration, chest pain, poisoning, choking or convulsions.
If you use a
PPO contracting hospital, the Fund will pay 90% of the contract
amount. You are responsible for 10% of the contract amount.
|
|
|
If treatment in the emergency room is NOT emergency related,
the Fund’s
Fee-for-Service Plan will pay $15 for the emergency room visit and
70% of the maximum allowance on the X-Ray/Lab Schedule for any
necessary testing after satisfaction of the Calendar Year
Deductible, if applicable. Examples of non-emergency treatment are
sore throat, cold, flu, headache, aches or pains and dizziness.
NOTE: This benefit does not apply to care for substance abuse.
(See
Substance Abuse Treatment).
|
|
|
| OUTPATIENT
SURGERY FACILITY
|
|
Ambulatory surgery is surgery that is done without staying overnight in
the hospital. This surgery is sometimes called "same day surgery" or
"outpatient surgery." Ambulatory surgery may be done in the outpatient
department of a hospital, or in a special clinic known as an "Ambulatory
Surgery Center."
|
|
PPO Contracting Hospital/Facility
-
If you have outpatient surgery at a contracting hospital or
facility, your maximum out-of-pocket expense would be 10% of the
contract amount.
|
|
|
Non-PPO Contracting Hospital/Facility
-
When you have surgery done in the Outpatient Department of a
non-contracting Hospital or in a non-contracting Ambulatory
Surgery Center, the Fund’s Fee-for-Service Plan will pay 70% of
reasonable and customary charges. |
Ask your
doctor for an estimate of the facility's charge and consider whether or
not it would be less costly for you to be admitted to the hospital
overnight for your surgery.
Ambulatory Surgery Centers under contract with Anthem Blue Cross are
listed in the Anthem Blue Cross Directory or at
www.anthem.com . Ambulatory
Surgery Centers under contract with AHF are listed in the AHF Directory
of Participating Hospitals and Physicians which is available from the
Fund Office
or via their website at
www.ahfonline.org.
|
|
| AUDIT
OF HOSPITAL CHARGES
|
When
you are hospitalized, we urge you to review the itemized bill provided by the
hospital. If the hospital has
charged for something that was not provided, you should bring the matter to the
attention of the Fund Office immediately.
If the error is verified by the Fund's hospital auditor, you will receive 50% of
the amount saved by the Fund, up to a maximum of $1,000.
If the Fund Office discovers the error first or is contacted first by the
hospital, there will be no payment to the participant.
It is not necessary to audit a bill from a hospital under contract with the Fund
(Anthem Blue Cross or AHF). The itemized bill does not show the contract terms between the Fund and
the hospital. The contract terms
decide the amount to be paid by the Fund.
|
|
SKILLED NURSING FACILITY BENEFITS |
In addition to care in an acute general or specialized hospital, benefits will
be provided for care in a "Skilled Nursing Facility" (Convalescent Hospital).
Skilled Nursing Facility confinement will be covered for a maximum of 60 days
only if the following requirement is met:
You must be confined in an acute general hospital for at least 3 consecutive
days and then transferred to a Skilled Nursing Facility within 30 days. Your
doctor must certify that you need daily skilled nursing or rehabilitation
services.
The Fund's Fee-for-Service Plan will pay 70% of covered charges and the
deductible is waived.
This benefit does not apply to custodial care cases where the patient does not
require skilled nursing care.
FOR A BETTER BENEFIT - Eligible employees and their eligible Dependents can
obtain services in a Skilled Nursing Facility, when prescribed by a
physician, from PPO contract providers at several locations in Southern
California and Nevada. Under the PPO contract provisions, the Plan will pay 90%
of the
contracted rate which the provider has agreed to accept.
You have no co-payment - Skilled Nursing Facilities under contract with Anthem Blue Cross
are listed in the Anthem Blue Cross Directory or at
www.anthem.com . Skilled Nursing Facilities under contract with AHF are listed in the
AHF Directory of Participating Hospitals and Physicians which is available from
the Fund Office
or
via their website at
www.ahfonline.org. |
|
HOSPITAL
EXPENSES NOT COVERED BY THIS PLAN
|
Hospital
benefits are not payable for:
|
1. |
Confinements
as a result of a work-related injury or sickness |
| 2. |
Cosmetic
surgery, except operations necessary to repair or alleviate disfigurement due to an accident
while you are covered, or for treatment of a congenital defect in a dependent
child, or for breast reconstruction following mastectomy. |
| 3. |
A
hospital owned or operated by the United States Government, or with respect to
court-ordered care, or any care for which no charge is made that you are
required to pay. (Confinements at Veterans Administration hospitals are covered
only if the charges are for a non-service related illness or injury.)
|
| 4. |
Confinements
due to pregnancy of a dependent child (including childbirth, miscarriage and abortion). |
| 5. |
Confinements
in connection with the fitting or wearing of dentures or treatment of the teeth
or gums, except tumors and treatment of accidental injury to natural teeth and
fractures due to an accident occurring while covered by the Plan. |
| 6. |
Personal
items such as telephone or television charges, guest trays, personal care items,
slippers, etc. |
| 7. |
Private
Rooms. (Benefits would be paid according to the hospital's most common
semi-private room rate.) |
| 8. |
Charges for tests related to elective surgery made by a hospital, which are required for
admission as a registered bed patient which can be performed on an outpatient
basis, unless your attending physician or surgeon requires that such tests must be
done on an inpatient basis. |
| 9. |
Charges
made by a hospital during a hospitalization for non-emergency elective surgery
which are incurred prior to the date of surgery, except that if the attending
physician or surgeon requires that pre-admission testing must be done as an
inpatient, then such tests and the day(s) required for such tests will be
considered a covered expense.
|
| 10. |
Any
part of a confinement for alcohol or drug abuse which begins prior to the
effective date of eligibility.
|
| 11. |
Confinements
in connection with artificial insemination, in-vitro fertilization (IVF),
Zygote intrafallopian organ transfer (ZIFT), gamete
intrafallopian transfer (GIFT), intracytoplasmic sperm injection (ICSI),and similar
procedures, or the
reversal of elective sterilizations, including drugs used to treat infertility. |
| 12. |
Hospice
care. |
| 13. |
Expenses
incurred for the care of schizophrenia, chronic psychosis, organic psychosis,
and similar conditions unresponsive to therapeutic treatment, or expenses
incurred for mental or nervous disorders, unless such expenses are for the
treatment of substance abuse disorders or for the treatment of fetal alcohol
syndrome in a Dependent child age 16 or younger or the treatment of attention
deficit hyperactive disorder in a Dependent child. |
| 14. |
Custodial care or housekeeping care is not a covered expense.
Nursing homes are sometimes referred to as Skilled Nursing Facilities but they
are not the same. Nursing homes provide long term nursing care for persons who
are unable to care for themselves due to disability, senility, and/or old age.
This is considered to be “custodial” care. If you have questions regarding
nursing homes, please get in touch with the Fund Office.
|
|
|
