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MATERNITY
BENEFITS
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Maternity
benefits are provided for the pregnancy of a dependent spouse or female
Operating Engineer on the same basis as any other illness or disability.
There are no benefits available for any charges related to the pregnancy
or suspected pregnancy of a dependent daughter, including miscarriage and
abortion.
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PHYSICIAN |
| The
Fund will pay 100% of the allowed amount listed in the Surgical Schedule toward
the Doctor's charges for "Total O.B. Care." The Fund does NOT pre-pay
medical benefits in maternity cases. Payments
are made after the birth of the child. Fees
for anesthesia will be reimbursed at 80% of the Scheduled Benefit.
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MIDWIFE |
| The
Fund covers the services of Licensed Midwives at 80% of the Usual and
Customary fee for their service.
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HOSPITAL |
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When
you are a registered hospital bed patient, the Fund provides the following
benefits:
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(ACTIVE) |
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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.
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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. |
For
a better benefit, see Affiliated Health Funds.
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| (RETIRED) |
| 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.
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| 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.
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For a better benefit, see Affiliated Health Funds.
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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.
If you are pregnant on the date eligibility terminates, benefits for hospital
and obstetrical care will be payable as if eligibility had not terminated for a
period of up to 90 days after the pregnancy terminates.
However, charges for the dependent baby will not be covered.
There are no benefits available for services related to artificial insemination
or in-vitro fertilization.
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BIRTHING
CENTERS
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Birthing
centers provide an alternative to hospital delivery.
They are normally separate from a hospital and provide a homelike
environment. The Plan provides
maternity benefits for birthing centers. Charges
are paid at 100% of the usual and customary fees, with a $1,200 maximum per
delivery, and the deductible will be waived.
The $1,200 benefit includes the baby's hospital charges.
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CARE
OF NEWBORNS
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| All
hospital services and supplies necessary for the care of a newborn child during
hospital confinement, including routine nursery care, will be paid in accordance
with the hospital benefits described above.
The member must be eligible at the time the baby is born in order for these benefits
to be covered.
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VOLUNTARY
STERILIZATION
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The
Fund will cover Voluntary Sterilization. It
will not cover the reversal of voluntary sterilization.
Benefits for the surgical procedure are paid at 100% of the listed amount in the
Surgical Schedule after satisfaction of the annual deductible.
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ADOPTION
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The
Fund will provide medical and hospital benefits toward charges for the birth of
a child who is in the process of being legally adopted by the participant.
The Fund will NOT cover the birth mother's charges.
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REQUIREMENTS:
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Adoption
proceedings usually take about 6 months before the adoption becomes final.
Therefore, the Fund will require a copy of documents from the attorney
handling the adoption or from the court showing that the adoption is in
progress.
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The child will be covered from the day he or she begins to live with the
participant. The Fund cannot
consider any child as an eligible dependent unless he or she is living with the
participant. |
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FETAL
MONITORING
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Pre-term
fetal monitoring is not covered by the Plan because it is not considered to be
medically necessary by the American Board of Obstetricians & Gynecologists.
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NEWBORNS'
AND MOTHERS' HEALTH PROTECTION ACT (NMHPA)
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| This
Plan complies with federal law that prohibits restricting benefits for any
hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a normal vaginal delivery, or less than 96
hours following a cesarean section. However, Federal law generally does not
prohibit the mother's or newborn's attending provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96
hours as applicable). In any case, plans may not require that a health care practitioner
obtain authorization from the Plan (or its utilization review company) for
prescribing a length of stay not in excess of 48 hours (or 96 hours). |
