|
TYPES
OF MEDICAL COVERAGE AVAILABLE
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| The
Trustees offer four types of medical coverage: |
FEE-FOR-SERVICE
simply means that the Plan reimburses you or the provider for expenses
incurred in the treatment of illness or injury. The specified amount
allowed in accordance with the rules of the Plan is paid either to you or a
provider of service after the annual deductible is satisfied. |
A PREFERRED PROVIDER ORGANIZATION (PPO) is a network of hospitals, doctors, labs, surgical
centers, hearing aid centers, chiropractors and physical
therapists who offer services to Engineers at a rate contracted with the Fund. You
may choose from any provider on the list and you do not have to enroll in a
special plan to use them.
The Fund provides two different PPO networks depending on where
you live:
 | California Residents
- the PPO network is provided through the Anthem Blue Cross Prudent Buyer
Plan; |
| Nevada Residents -
the PPO network is provided through the Anthem Blue Cross and Blue Shield PPO; |
| All other states -
the PPO network is provided through Affiliated Health Funds (AHF). |
You cannot use PPO providers if you are enrolled in an HMO, with the exception
of
hearing aid related services.
If you have primary coverage with another plan (including Medicare), you
may choose PPO providers but the Fund will coordinate benefits as usual.
|
| HEALTH
MAINTENANCE ORGANIZATIONs (HMOs) are paid a fee by the Fund to provide
medical coverage to you and your family. Except for some small co-payments
and non-covered items, you make no direct payment to the HMO for medical treatment.
The Trustees presently have contracts with three (3) HMOs: Kaiser
Permanente, Health Net, and Health Plan of Nevada. |
| PLAN
"M" FOR RETIREES WITH MEDICARE enables retired participants
and/or their spouses to obtain a limited program of benefits from the Fund for a
reduced fee. When you join a Medicare HMO (any one you choose) in your
area, you must obtain all of your medical and hospital care from the HMO. The
Fund's "M" Plan will provide benefits only for hearing aids,
chiropractic care, dental care, and death benefits. You cannot enroll in a Medicare HMO if you live outside the
HMO's service area, if you have End-Stage Renal Disease (ESRD), if you do not
have Part B Medicare, or if you are currently receiving Medicare Hospice
benefits. |
|
HEALTH
MAINTENANCE ORGANIZATIONS (HMOs)
KAISER,
HEALTH NET, HEALTH PLAN OF NEVADA
|
| Eligible
participants living within certain geographical areas have a choice of other
Health Plans in addition to the Fee-for-Service medical and hospital plan.
Enrollment is held when you first become eligible and at the beginning of
each year.
|
| 1. |
Kaiser-
Permanente Health Plan
|
This
option is available only to participants who live in areas of Southern
California where
Kaiser facilities exist. If you
choose this option, you and all of your eligible dependents will be covered
under the Kaiser Plan for hospital, medical and prescription drug services.
If
you enroll your family in the Kaiser Plan, you must remain in the
plan for one
full year. You will not be
permitted to change your selection until the Fund's open enrollment period which
will be held once each year during January.
If coverage stops for you or any covered family member because of loss of
eligibility, you and/or the family member may enroll in Kaiser's Conversion
Plan. Conversion Plan information
is available through the Kaiser Membership Service Department.
To assist you, each Kaiser Medical Center has a Membership Service Department.
The Membership Service representatives are there to answer any questions
or solve any problems you may have. Their
telephone number is (800) 464-4000.
|
| 2. |
Health
Net
|
This option is available only to participants who live in areas where Health
Net facilities exist. If you choose this option, you and all of your
eligible dependents will be covered under the Health Net Plan for
hospital, medical and prescription drug services.
If you enroll your family in the Health Net Plan, you must remain in the plan for
one full year. You will not be permitted to change your
plan until
the Fund's open enrollment period which will be held once each year during
January.
If coverage stops for you or any covered family member because of loss of
eligibility, you and /or the family member may enroll in a Health Net Conversion
Plan upon written request. Direct your request to:
|
|
|
Health Maintenance Network
of
Southern California
PO
Box 9103
Van
Nuys, CA 91409
If
you have a question or problem, call or write your Health Net Coordinator at
your medical group. If you call Health Net directly, their number is
1-800-522-0088.
|
| 3. |
Health Plan of
Nevada
|
This option is available only to participants who live in areas where
Health Plan of Nevada facilities exist. If you choose this option, you and your
eligible dependents will be covered under the Health Plan of
Nevada for hospital, medical and prescription drug services.
If
you enroll your family in the Health Plan of Nevada, you must remain in the plan
for one full year. You will not be permitted to change your
plan selection
until the Fund's open enrollment period,
which will be held once each year during January.
If you have any questions about Health Plan of Nevada,
contact the
Member Services Department at (800) 777-1840.
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|
|
If
you choose to
be covered under any of these plans,
you must complete the appropriate enrollment form which may be obtained from the
Pasadena Fund Office.
If you require additional information about these options, contact the
Pasadena Fund Office.
Continued enrollment in any one of
the HMO's depends upon continued eligibility in the Health & Welfare
Plan. If you lose eligibility, you must re-enroll in the HMO Program
when you regain eligibility. Re-enrollment after loss of eligibility is
not automatic.
If you are dissatisfied with your HMO plan you may request that the Trustees
waive the one year enrollment requirement; however you must remain in the HMO
plan until the end of an eligibility quarter.
NOTE: Regardless of which Health
Plan option you choose, you and your family will continue to be covered under
the Fund's Life Insurance*, vision care, accidental death and dismemberment*,
dental benefits and hearing aid programs. (*Active eligibles only).
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|
IF
YOU ARE ENROLLED IN AN HMO
THESE BENEFITS ARE AVAILABLE:
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|
Type of Service |
HMO |
Operating
Engineers Plan
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|
Physician care
|
All HMO's under contract provide physician's
services in accordance with their regulations. There is a co-payment
for office visits.
|
No coverage provided. |
|
Hospital
|
All HMO's under contract provide hospital
services in accordance with their regulations.
|
No coverage provided. |
|
Lab/X-ray
|
All HMO's under contract provide lab and x-ray
services in accordance with their regulations.
|
No coverage provided. |
|
Chiropractor
|
Limited coverage Provided.
|
No coverage provided.
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Durable Medical
Equipment
|
Kaiser, Health Net and Health Plan of Nevada.
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No coverage provided.
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|
Prescription Drugs
|
Kaiser, Health Net and Health Plan of Nevada provide prescription
services in accordance with their regulations.
|
No coverage provided. |
|
Dental
|
No Coverage provided. |
Provided by O.E. Plan through the Dental Plan, through United Concordia or
Delta Dental
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|
Routine Vision
Care
|
No coverage provided. |
Provided by O.E. Plan through Vision Service Plan (VSP).
|
|
Hearing Aids
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No coverage provided. |
Provided by O.E. Plan
|
|
Orthotics
|
Kaiser and Health Plan
of Nevada provide limited coverage
|
No coverage provided.
|
|
|
DEDUCTIBLE
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|
There are two (2) types of Calendar Year Deductible:
In-Network (Contract): Calendar Year Deductible of $350 for each
family member with a maximum of $1,050 per family.
Out-of-Network (Non-Contract): Calendar Year Deductible of $500
for each family member with a maximum of $1,500 per family.
The deductible
does not apply to: |
1. |
Active
eligible individuals who were eligible from January through
December
in the previous year but did not submit any claims. |
2. |
Birthing
Center charges.
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|
3.
|
Participants
with Medicare as their primary insurance.
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|
4.
|
Home
health agency charges incurred after a hospital stay.
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|
5.
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Pre-admission
testing when performed on an outpatient basis.
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IMPORTANT: |
|
1.
|
|
If an Active participant or any other Active eligible individual
who has been eligible from January through December of the preceding
calendar year submits no claim for payment or processing,
Calendar Year Deductibles will not be applied during the following year.
If a claim submitted during the previous year was denied for some reason
or applied to a
Calendar Year Deductible,
then the Calendar Year Deductibles
would not be waived the following year. |
|
|
|
| 2. |
HOWEVER, claims you submit to the Fund Office for services not covered by the
HMO (such as hearing aids), ARE SUBJECT TO THE $500 OUT-OF-NETWORK (Non-PPO)
CALENDAR YEAR DEDUCTIBLE.
|
|
|
|
| 3. |
You must submit your claims to the Fund Office in order for them to be applied
to the Calendar Year Deductibles. |
|
| 4. |
Deductibles are taken from the contract or allowed amounts, not the charged
amount. For example: |
| |
|
Office Visit Charge |
= $50.00
|
|
| |
|
Fund's Allowance
|
= $15.00
|
|
| |
|
Deductible Applied |
- $15.00
|
|
| |
|
Fund's Payment |
= $ .00
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ANNUAL OUT OF POCKET MAXIMUMS |
|
Effective with dates of services January 1,
2011 and after, once the amount you have paid for covered expenses during the
calendar year reaches the In-Network or Out-of-Network maximum, the Plan will
pay:
| 100% of allowed contract charges for
In-Network services for the remainder of the calendar year, and |
| 100% of allowed usual and customary
charges for Out-of-Network services for the remainder of the calendar year.
|
The amount you have to pay before the Plan
begins paying 100% is lower if you use Contract (In-Network) providers than it
is if you use Non-Contract (Out-of-Network) providers. The following chart
shows the In-Network and Out-of-Network maximums for an individual and family:
|
CALENDAR YEAR MAXIMUM |
IN-NETWORK |
OUT-OF-NETWORK |
|
Individual
|
$3,000
|
$6,000 |
|
Family
|
$6,000
|
$12,000 |
The amounts you pay for services prior to
the annual Out-of-Pocket Maximum taking effect are separate for In-Network and
Out-of-Network services.
The following amounts you pay do not
accumulate toward the Out-of-Pocket Maximums:
| Amounts applied to the individual and
family Calendar Year Deductibles (In-Network & Out-of-Network),
|
| Amounts you pay for services not
covered by the Plan, |
| Amounts in excess of allowed contract
charges (In-Network), |
| Amounts in excess of allowed usual and
customary charges (Out-of-Network), |
| Charges in excess of the Plan benefit
maximum (such as hearing aid(s), alcohol/substance abuse treatment, routine
physical examinations, etc.). |
|
| |
|
CALENDAR YEAR MEDICAL MAXIMUM |
|
The
Fund provides a calendar year maximum of $400,000 for each eligible Employee and
each eligible Dependent who reside in California or Nevada. Once
the maximum is reached, the Fund will not pay any further benefits for services
or supplies on account of you or your Dependent for the remainder of the
calendar year.
The
Fund Office will monitor each person’s medical expenses and any person
approaching the calendar year maximum will be assisted with enrollment in one of
the Plan’s HMOs for the remainder of that calendar year.
On
January 1 of each year, the person may go back into the Fee-for-Service/PPO plan
if desired.
|
|
PERSONAL
INJURY LIABILITY
(Including Automobile Accident
)
|
|
If
you are injured by someone else, e.g. in an automobile collision, or a slip-and-fall accident, and you have medical claims because of the injuries, the Fund
will pay benefits on those claims only if you do the following: You must sign a
lien in the form provided by the Fund Office in which you acknowledge that the
Fund has the right to any damages you collect for your injuries to the extent of
the benefits the Fund pays. You
must also reimburse the Fund from any settlement or
judgment you collect for those injuries for the benefits The Fund paid . The
lien applies to all amounts you recover for your injuries including
amounts you collect from your
own insurance, e.g. uninsured motorist coverage on your automobile policy.
The Trustees
may reduce the amount of the lien if you have to pay an attorney to sue the
person that injured you. You should
contact the Fund Office for more details about reducing the amount of a lien.
|
|
WORK-RELATED
ILLNESS/INJURY
|
|
The
Fund DOES NOT COVER ANY
expenses in connection with work-related injuries or
illnesses
whether or not the employee has Workers' Compensation insurance. Even if the work-related injury occurred a long time ago, and
the case has already been closed, NO BENEFITS ARE PAYABLE.
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HOW TO FILE A CLAIM
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|
Hospital and Medical Benefits
Generally,
hospitals do not require claim forms. They submit their own itemized claims in
an acceptable format. Claim forms for medical benefits may be obtained from any
Union Office or the Fund Office. All completed claims should be sent to the
Fund Office for processing. All benefit checks including your Explanation of
Benefits (EOB) will be issued by the Fund Office.
When you use PPO
providers, the providers will file the claim for you.
The Fund will
accept hospital expense claims and medical expense claims for up to 12 months
after the date of service. Hospital and medical claims older than these
specified times will not be paid.
If you receive
pre-approved treatment outside of the United States, submit a detailed,
translated hospital bill, which includes the number of days hospitalized, lab
work done, drugs administered, diagnosis and type of treatment given, to the
Fund Office.
Before submitting
a claim form, be sure it is filled out properly. To avoid delays in the
processing of your claims, follow these steps:
1. Complete
your portion of the form. If you want the Fund to pay your doctor directly,
sign the authorization to pay the benefits to the physician and check the
appropriate box for assignment. Sign the authorization to release information.
2. Have
the person providing services complete the rest of the form.
3. Check
the claim form to be certain that all applicable portions of the form are
completed. Be sure your bills are itemized. The following information should
be indicated on the bills or claim form submitted:
|
Your name and
Social Security number or Health Care ID number (HCID) |
|
The patient’s
name and address, date of birth and relationship to you |
|
The date of
service |
|
If you have
coverage under any other group hospital or surgical plan, the name of the
insurance company providing your other group coverage and the policy number of
this coverage. |
|
The CPT-4 codes
(the codes for physician services and other health care services found in the
“Current Procedural Terminology, 4th Edition”, as maintained and
distributed by the American Medical Association) |
|
The ICD-9 codes
(the diagnosis codes found in the “International Classification of Diseases, 9th
Edition”, as maintained and distributed by the U.S. Department of Health and
Human Services) |
|
The billed
charge(s) |
|
The number of
units (for anesthesia and certain other claims) |
|
The Federal
taxpayer identification number (TIN) of the provider |
|
The billing name
and address |
|
If services were
rendered because of an accident, the date and place of injury, including
details (i.e. auto accident, fall, etc.) |
|
Mail your claim
form or have your doctor mail it with your itemized bills to the Fund Office
|
You must submit a
separate claim form for each dependent.
If you have any
questions about your claim, call the Fund Office at (626) 356-1004. |
|
Prescription Drug Benefits
If you use a non-participating retail pharmacy for your
prescription drugs, you need to file a Prescription Drug Claim Form as provided
by the Fund Office. You must pay full price for the prescribed item and submit the claim form to the Fund Office for
reimbursement.
For a better benefit see the Prescription Drug Programs section of this website
or page 83 of the Plan Benefit Booklet.
Following are the
steps for filing a prescription drug claim form:
1.
Request an itemized bill from the pharmacy showing
the following information for each prescription:
|
Prescription
number |
|
Date of sale |
|
Name of the
physician who issued the prescription |
|
Patient’s name |
|
Cost of the
prescription |
|
National Drug
Code (NDC) number for the drug |
2. Complete
the claim form. Make sure you include your name and Social Security number, the
patient’s name, address, date of birth, and relationship to you, your billing
address and the policy number and insurance company name for any other group
coverage you have.
3. Attach the itemized bill to the claim form and
submit it to the Fund Office. |
|
Dental Benefits
Claim forms for
dental benefits may be obtained from any Union Office or the Fund Office. All
completed claims should be sent to the Fund Office for processing. All benefit
checks including your Explanation of Benefits (EOB) will be issued by the Fund
Office.
When you use
Operating Engineers Panel Dentists, each panel dentist has a supply of claim
forms and will file the claim for you.
To file a claim
for non-Panel dentist claims, follow these steps:
1. Complete
and sign Part 1 before you visit the dentist. Make sure you include your name
and Social Security number, the patient’s name, address, date of birth, and
relationship to you, your mailing address and the policy number and insurance
company name for any other group coverage you have.
2. Have
the dentist complete Part 2 of the claim form and return it to the Fund Office. |
|
Vision Benefits
If you use the Vision Service Plan (VSP) for your vision care needs you will not
need to file a claim form. You will pay the amount due from you at the end of
the visit and your provider will take care of billing VSP for the remainder.
If you use a non-VSP provider, you will need to request a copy of
the bill showing the amount of the eye examination and send it to:
Vision Service Plan
Attention: Non-Member Doctor Claims
P.O. Box 997100
Sacramento, CA 95899-7100
Be sure to include the participant’s name, mailing address Social Security
number, HCID#, the patient’s name, relationship to the participant and date of
birth. |
|
Hearing Aid Benefit
NOTE: A
prescription for a hearing aid is required.
To file a claim
for hearing aid benefits, follow these steps:
1. Get
a claim form from any Union Office or the Fund Office.
2. Complete
your portion of the claim form. Make sure you include your name and Social
Security or HCID number, the patient’s name, address, date of birth, and relationship to
you, your mailing address and the policy number and insurance company name for
any other group coverage you have.
3. Have
your physician complete the providers portion of the claim form.
4. Send
the claim form with an itemized bill showing the cost of the hearing aid device
to the Fund Office. The ear in which the hearing aid was placed must also
be specified. |
|
Life Insurance and Accidental Death and
Dismemberment Benefits
Life Insurance and
Accidental Death and Dismemberment claim forms are available from the Fund
Office. Provide a copy of the death certificate, and if appropriate, evidence
of the accidental nature of the death, to the Fund Office. In the event of
dismemberment, notify the Fund Office promptly. A claim form will be sent to
you.
For further
details, contact the Death Benefits Department at (626) 356-1062. |
|
Weekly Disability Benefit (So. Nevada Only)
Disability forms are available from the Nevada Fund Office, the Pasadena Fund
Office, the Las Vegas District Office of the I.U.O.E., Local 12 or via the
‘Forms’ section of this website, accessible from the main page. You and your
physician must complete the form and return it to the Pasadena Fund Office for
processing. |
|
Note: For
services rendered by providers contracting with the Trustees, such as United
Concordia Dental Plan or the various HMO'S, the requirements are different and you should get in
touch with them if you require information on submitting a claim for
reimbursement.
|
CASE
MANAGEMENT |
| Case
Management is a process by which a coordinator works with the patient, the
family
and the attending physician to develop an appropriate
treatment plan and to identify and suggest alternatives to
traditional inpatient hospital care. The alternative treatment plan must be
accepted by the patient and the attending physician before it is put in place.
Case Management is used to monitor complex and potentially
expensive health care problems.
Case Management services also provide help to participants with
complicated illnesses.
This voluntary program assures that you or your dependents
are receiving the most appropriate treatment when medical care is necessary.
If you agree to Case Management, the Plan may pay
for certain benefits through the Case Management Program that would not otherwise
be covered by the Plan. All
requests for Case Management are kept strictly confidential
in accordance with state and federal laws.
Examples of the type of cases that are appropriate for
this program include severe traumatic injury such as burns
and spinal cord injury, cancer, stroke, cardiovascular disease, AIDS,
organ transplants, chronic infections or diseases, and pain management.
|
If you or a family member have a serious or complicated medical problem and
need assistance, get in touch with the Fund's Information Center and ask to
speak to a Case Management Representative before, or as soon as, the patient
enters the hospital for acute care. |
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