Operating Engineers Health & Welfare Fund

Hospital Benefits

 

Inpatient Hospital Care

Pre-Admission Testing

Outpatient Emergency Care

Outpatient Surgery Facility

Audit of Charges

Convalescent/Skilled Nursing Care

Nursing Homes

Hospital Expenses Not Covered

Zip Code List

 


INPATIENT HOSPITAL BENEFITS

  

When you are a registered hospital bed patient, the Fund provides the following benefits:  
ACTIVE 
bullet

If you live within 20 miles of an AHF contract hospital but you use a non-contracted hospital: The Fund will pay 70% of the covered charges and you will be responsible for 30% of the hospital's charge plus any non-covered charges.  The deductible is waived.

 

bullet

If you live beyond 20 miles from an AHF contract hospital: The Fund will pay 80% of the first $10,000 of allowed charges, and 100% thereafter, per confinement, and the deductible is waived.

 

           If you are re-hospitalized within 90 days with the same
           illness, it would be considered a continuation of your
           previous stay.

          

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

 

 RETIRED 

without

 Medicare 

bullet

If you live within 20 miles of an AHF contract hospital but you use a non-contracted hospital: The Fund will pay 70% of the covered charges after satisfaction of the deductible and you will be responsible for 30% of the hospital's charge plus any non-covered charges.

 

bullet

If you live beyond 20 miles from an AHF contract hospital: The Fund will pay 80% of the allowed charge per confinement after satisfaction of the deductible.
 

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

RETIRED
with
Medicare

bullet

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

 

IF YOUR HOME ADDRESS ZIP CODE APPEARS ON THE ZIP CODE LIST, THERE IS AN AHF CONTRACTED HOSPITAL WITHIN APPROXIMATELY 20 MILES OF YOUR HOME.  IF YOU CHOOSE NOT TO USE THE CONTRACTED HOSPITAL, BENEFITS WILL BE PAID AS DESCRIBED ABOVE. 

Payment is limited to the most common semi-private room rate.  Intensive Care Unit is paid at 2 1/2 times the semi-private room rate.

 

NOTE:    This benefit does not apply to care for substance abuse. (See Psychiatric/ Substance Abuse Treatment)

 

 

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

 

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 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 Usual 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:

 

bullet

If the treatment is emergency related, the Fund will pay 80% of the usual and customary charge after satisfaction of the annual deductible .  Examples of emergency treatment are broken bones, a severe laceration, chest pain, poisoning, choking or convulsions.

bullet

If treatment in the emergency room is NOT emergency related, the Fund will pay $35.00 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 annual deductible.  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 Psychiatric/ Substance Abuse Treatment)


 

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

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." "Same day surgery" may be done in the outpatient department of a hospital, or in a special clinic known as an "Ambulatory Surgery Center."

When you have surgery done in the Outpatient Department of a hospital or in an Ambulatory Surgery Center, the Fund will pay 90% of the first $1,000 of Usual 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 an AHF contracting hospital, your maximum out-of-pocket expense would be $500 for Active participants or 10% to $2,000 for Retired participants.  If your surgery is performed while outpatient at an AHF contracting hospital, your maximum out-of-pocket expense would be 10% of the hospital's charge.

 

 

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 reimbursement to the participant.

It is not necessary to audit a bill from a hospital under contract with the Fund (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.

 

 

CONVALESCENT HOSPITAL 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.  The Fund 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.

 

NURSING HOMES

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.

Custodial care or housekeeping care is not a covered expense.  Nursing homes are sometimes referred to as convalescent homes but they are not the same.  If you have questions regarding nursing homes, please get in touch with 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 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 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, etc.
7.

Private Rooms. (Benefits would be paid according to the hospital's most common semi-private room rate.)

8. Charges for tests, for 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 stipulates 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 stipulates 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 and similar procedures, or the reversal of elective sterilizations.

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.

 

ZIP CODE LIST

If your home address appears below, there is an AHF-Contracted hospital within approximately 20 miles of your home.

  85614

 

 

92101

thru

92199

92801

thru

92830

85622

 

 

92201

thru

92203

 

 

 

85629

 

 

92210

93001

thru

93099

85641

 

 

92223

 

 

 

85652

 

 

92234

thru

92236

93101

thru

93199

85701

thru

85751

92240

 

 

 

     

92253

93203

 

 

89004

and

89005

92255

93217

 

 

89009

   

92258

93220

thru

93221

89014

thru

89016

92260

thru

92264

93223

 

 

89030

thru

89099

92270

93235

 

 

89101

thru

89136

92276

93241

 

 

 

 

 

92282

93244

 

 

90001

thru

90099

93247

 

 

90101

thru

90199

92301

93250

 

 

90201

thru

90299

92305

93257

thru

93258

90301

thru

90399

92307

and

92308

93263

 

 

90401

thru

90499

92316

thru

92318

93265

 

 

90501

thru

90599

92320

thru

92322

93267

 

 

90601

thru

90699

92324

thru

92326

93270

thru

93271

90701

thru

90799

92329

93274

thru

93278

90801

thru

90899

92334

thru

92337

93286

thru

93287

90901

thru

90999

92339

thru

92342

93291

 

 

     

92345

and

92346

 

 

 

91001

thru

91099

92352

93301

thru

93399

91101

thru

91199

92354

 

 

 

91201

thru

91299

92358

and

92359

93401

thru

93412

91301

thru

91399

92368

and

92369

93420

thru

93424

91401

thru

91499

92371

thru

92378

93429

and

93430

91501

thru

91599

92382

93433

and

93434

91601

thru

91699

92385

93442

thru

93445

91701

thru

91799

92391

thru

92394

93448

and

93449

91801

thru

91899

92399

93453

thru

93457

91901