Operating Engineers Health & Welfare Fund

Important Basics About the Plan

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COORDINATION OF BENEFITS  
WITH MEDICARE  
FOR RETIRED MEMBERS AND SPOUSES

When you or your dependent becomes 65 years of age, you are also eligible for Medicare benefits.  It is important that you enroll promptly in the Medicare program because Medicare will become your primary insurance and the Health & Welfare Fund will be your secondary insurance.

   How do I enroll in the Medicare program?

If you are approaching age 65 you are not automatically enrolled in Medicare unless you have filed an application and established eligibility for a monthly Social Security benefit.

If you have not applied for Social Security benefits, you must file a Medicare application form during the three-month period prior to the month of your birthday for coverage to begin during the month you reach age 65.  Call or write your nearest Social Security office 90 days before your 65th birthday and ask for an application.

If you fail to enroll during this period, you will have to wait until the beginning of the next calendar year to enroll and you will have to pay an additional 10% per year on your Part B premium.  Also, the Fund will pay only 20% toward your medical claims.

How do I submit my claims to the Fund Office?

The Fund Office cannot provide benefits on your claims without Medicare's Explanation of Benefits.  You must submit this Explanation of Benefits from Medicare along with the complete itemized bill or payment cannot be made.
What is a Medicare Explanation of Benefits?

After you or the doctor or supplier sends in a medical insurance claim, Medicare will send you a notice called an "Explanation of Medicare Benefits" to tell you the decision on the claim.  This notice shows what services were covered, what charges were approved, how much was credited to your yearly deductible, and the amount Medicare paid for each service.
Why should I enroll in the Retiree Health and Welfare 
Plan if I am already covered by Medicare?

There are many things that Medicare does not cover completely and others that Medicare does not cover at all.  The difference would normally be paid out of your pocket.  You would pay an annual deductible plus at least 20% of every doctor bill.  You would pay a deductible for admission to the hospital and a co-payment for every hospital day over 60 days.  You would pay all of the cost for prescription drugs, eyeglasses (in most cases), ambulance service (except in an emergency), hearing aids and dental care.

If you are enrolled in the Retiree Health and Welfare Plan, some of your out-of-pocket expenses will be reimbursed by the Plan.  For example, Medicare does not cover prescription drug charges.  If you obtain your prescription drugs from the Fund's Contract Prescription Provider, you will pay a small co-payment per prescription. (This co-payment is subject to change.)  The Fund Office will reimburse you for all other prescription drugs at 80% of the reasonable and customary charge.
What will the Fund Office pay if I am eligible for 
Medicare but choose not to enroll?

If  you are eligible for Medicare but choose not to enroll in Part B, the Fund Office will estimate that Medicare would have covered 80% of your claims, and the Fund will pay only 20%.  Therefore, it is very important that you enroll in Medicare, both Part A and Part B, as soon as you become eligible.
Will the Fund Office pay the entire balance on my 
doctor's bill after Medicare pays?

NO.  The maximum allowance on any claim involving Medicare will be the amount approved by Medicare.  The Fund will pay the difference between Medicare's allowance and Medicare's payment, including the Medicare deductible,  but the Fund cannot pay more than the maximum Plan benefit.

*USE MEDICARE PROVIDERS WHO ACCEPT ASSIGNMENT*
Doctors and suppliers can now sign agreements to become Medicare-participating doctors and suppliers.  This means they have agreed in advance to accept assignment on all Medicare claims. 

When doctors and suppliers "accept assignment", it means they agree to accept the Medicare-approved amount as their charge.  This could save you some out-of-pocket expense.  For example, the doctor may charge $100, but the Medicare-approved amount is $70.  The doctor would be required to write off the $30 difference.  You cannot be charged for that amount.

The names and addresses of Medicare-participating doctors and suppliers are listed in the "Medicare- participating Physician/Supplier Directory."  This directory is available for review in all Social Security offices and in most hospitals.  You can also obtain the directory free of charge from your Medicare carrier.  The Medicare carrier will send a copy to you.

The Fund will provide regular Plan benefits for services not covered by Medicare, but only if the services are covered by the Plan.  This would include hearing exams, hearing aids, chiropractors' services and flu shots.