Hospital Benefits

Anthem Blue Cross Contract Providers

Inpatient Hospital Care

Pre-Admission Testing

Outpatient Emergency Care

Outpatient Surgery Facility

Audit of Charges

Skilled Nursing Facility Benefits

Hospital Expenses Not Covered

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:

	California – Anthem Blue Cross Prudent Buyer Plan
	Nevada – Anthem Blue Cross and Blue Shield PPO
	All Other States – Affiliated Health Funds (AHF)

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. 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 according to the negotiated contract. You are responsible for 10% of the hospital’s charge. Your co-payment will not exceed $500 per confinement.1 The deductible is waived.

If an active employee or eligible Dependent is re-hospitalized within 90 days with the same illness, it will be considered one continuous hospital stay unless you or your eligible Dependent return to work full time for 7 days between hospital stays, recover completely or are hospitalized on the later day for something completely different. This means there would be no additional copayment over and above the $500 maximum per confinement.

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 -

If you live within 20 miles of a PPO contract hospital and you use a non-contracted hospital in your area, the Fund will pay 70% of the covered charges per confinement and you will be responsible for the remaining balance. The deductible is waived.

If there is no contract hospital within 20 miles of your home, the Fund will pay 80% of the first $10,000 of allowed charges and 100% thereafter, per confinement and the deductible is waived.

RETIRED

without

Medicare

PPO Contract Hospital - The Fund will pay according to the negotiated contract. You are responsible for 10% of the hospital’s charge. Your co-payment will not exceed one-half of the covered expenses or $2,000, whichever is less. This represents a savings of 10% or more to the retired employee who uses a contract hospital.

If a retired employee or eligible Dependent is re-hospitalized within 90 days with the same illness, it will be considered one continuous hospital stay unless you or your eligible Dependent recover completely or are hospitalized on the later day for something completely different or your eligible Dependent returns to work full time for 7 days between hospital stays. This means there would be no additional copayment over and above the $2,000 maximum per confinement.

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 -

	If you live within 20 miles of a PPO contract hospital and you use a non-contracted hospital in your area, the Fund will pay only 70% of the covered charges, per confinement after satisfaction of the calendar year deductible and you will be responsible for the remaining balance.
	If there is no contract hospital within 20 miles of your home, the Fund will pay 80% of the allowed charge per confinement after satisfaction of the calendar year deductible.

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 80% of the reasonable and customary charge after satisfaction of the annual 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, payment is made according to the negotiated contract. You are responsible for 10% of the hospital’s charge.

If treatment in the emergency room is NOT emergency related, the Fund’s Fee-for-Service Plan will pay $35 for the emergency room visit and 80% 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, your maximum out-of-pocket expense would be 10% of the contract allowance.
	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 90% of the first $1,000 of Reasonable and Customary charges and 60% of the remaining allowable charges for the hospital or ambulatory surgery center.

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. If your surgery is performed while inpatient at a contracting hospital, your maximum out-of-pocket expense would be $500 for Active Employees or, for Retired Employees, 10% of the hospital's charge not to exceed one-half of the covered expenses or $2,000, whichever is less.

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.

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 an "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 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 80% 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 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.

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.