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INPATIENT
HOSPITAL BENEFITS
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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. No entity other than the Fund Office can
verify benefits and/or eligibility.
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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 -
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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. |
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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. |
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 $2,000 maximum per confinement. |
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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 -
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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. |
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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. |

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RETIRED
with
Medicare
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Medicare
will pay the majority of your hospital bill.
The Fund will pay the Medicare deductible and some co-
payments. |
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| EXTENDED
BENEFIT
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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.
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| 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.
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| OUTPATIENT
EMERGENCY CARE
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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:
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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. |
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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).

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| OUTPATIENT
SURGERY FACILITY
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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."
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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.
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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.
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| AUDIT
OF HOSPITAL CHARGES
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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.
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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. |
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HOSPITAL
EXPENSES NOT COVERED BY THIS PLAN
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Hospital
benefits are not payable for:
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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.)
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| 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.
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| 10. |
Any
part of a confinement for alcohol or drug abuse which begins prior to the
effective date of eligibility.
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| 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. |
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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.
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