Operating Engineers Health & Welfare Fund

Medical Benefits

Acupuncture

Alternative Therapy

Ambulance

Artificial Insemination

Attention Deficit Disorder

Blood

Cataract Surgery

Chemotherapy

Chiropractor

Durable Medical Equipment

Flu shots

Hearing Aids

Home Health Care

Infertility

Injections

In Vitro Fertilization

Kidney Dialysis

Laboratory

Mental Health

Organ Transplants

Orthotics

Oxygen

Pain Management Programs

Physical Therapy

Physician Care

Physician's Assistant

Preventive Care

Prosthetic Appliances

Psychiatric Treatment

Registered Nurse

Routine Physical

Speech Therapy

Sterility

Substance Abuse

Supplies

Weight Control

Wigs

X-rays

 


MEDICAL BENEFITS

 

ACUPUNCTURE

See Alternative Therapy.

 

ALTERNATIVE THERAPY

Alternative therapy includes acupuncture, biofeedback, chiropractic care and physical therapy.

Acupuncture is a covered expense only when performed by a medical doctor or state Certified Acupuncturist.  The only exception applies to the state of Nevada where it is also a covered expense when performed by a Doctor of Traditional Chinese Medicine.

BENEFIT:  Any combination of acupuncture, biofeedback, chiropractic visits and physical therapy will be paid at a maximum of $35 per visit with a combined limit of 26 visits per calendar year. 

If the acupuncturist performs physical therapy and acupuncture on the same day, the Fund will allow a maximum of $35 for all combined services on that day.

Chiropractic visits for dependent children under 16 years of age are not covered by the Plan. 

If you are enrolled in an HMO which does not cover chiropractic visits, this type of treatment will be reimbursed at $35 per visit through the Fund's "fee-for-service" Plan after satisfaction of the calendar year deductible.
 

AMBULANCE SERVICE

If it is medically necessary, professional ambulance service to the nearest hospital for care and treatment of the injury or sickness will be reimbursed at 80% of the reasonable and customary charges after satisfaction of the calendar year deductible.  Air ambulance service is also covered when medically necessary to transport a patient to the closest.

Transportation for the patient's convenience from the hospital to home is not a covered expense.

ARTIFICIAL INSEMINATION

The Fund does NOT cover any charges related to artificial insemination.

 

BLOOD - Donation and Storage

The Fund will provide benefits for blood donation and storage ONLY if your medical condition requires a transfusion.  The benefit is limited to the Red Cross charge per unit to have your own blood processed.  The Red Cross telephone number is (800) 843-2949.

 

CATARACT SURGERY
In addition to the normal surgical benefits you may also be eligible for eye glasses at the time of surgery.

These items are obtained through the Vision Service Program.
CHEMOTHERAPY
Chemotherapy is covered by the Fund at 80% of the Usual and Customary Charge after satisfaction of the annual deductible.  
CHIROPRACTIC/PHYSICAL THERAPY

See Alternative Therapy.

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

 

DURABLE MEDICAL EQUIPMENT

Rental or purchase of a wheelchair, hospital-type bed, iron lung or other durable medical equipment, including shower benches, used exclusively for the therapeutic treatment of injury or sickness, will be reimbursed at 80% of the reasonable and customary charge, not to exceed the reasonable purchase price.  If you must have durable medical equipment for a long period of time and the rental price is expected to exceed the purchase price, you should consider purchasing the equipment right away.  A doctor's prescription is required.

Examples of Expenses Not Covered - Benefits will not be payable for:
1. Handrails 5. Pools (Therapy)
2. Wheelchair Batteries or any other Batteries 6. Air Conditioners
3. Over-bed Tables 7. Special Auto Equipment, such as van lifts.
4. Hot Tubs 8. Exercise equipment (treadmill, rowing machine, etc.)

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

 
FLU SHOTS
Participants aged 65 and older are entitled to reimbursement for a maximum of two flu shots per calendar year which will be paid up to a maximum of $10.00 each, subject to satisfaction of the Calendar Year deductible..
HEARING AID BENEFIT

When you and your dependents are eligible for the medical and hospital benefits provided by the Fund, you are also eligible for hearing aid benefits.  This hearing aid benefit is also available to those eligible members who are enrolled in Kaiser, Health Net, or Health Plan of Nevada.

The Fund will pay a maximum of $1,000.00 for the purchase of your hearing aid, or for repairs and batteries, subject to satisfaction of the Calendar Year deductible.  

You are entitled to benefits for new hearing aids or repairs once every three years. 

For a better benefit see AHF.

HOME HEALTH CARE/REGISTERED NURSE

When skilled nursing service or home health care is required in the home, it is always wise to check with the Fund Office to determine if the situation qualifies for coverage.  Situations that require housekeeping and meal preparation are not covered even if nursing has been "prescribed" by a doctor.

Skilled nursing service and home health care must be ordered by a medical doctor and the duties to be performed by the nurse(s) must be described.  Home health care must be provided  by a licensed home health agency.

Home health care and registered nurse visits will be combined.  The Fund will pay a maximum of $70.00 per visit with a limit of 10 visits per year.  

INFERTILITY/STERILITY

Infertility or sterility, which is the inability to procreate, is not in itself considered a bodily illness; therefore, treatment is generally NOT covered by the Plan.

If infertility or sterility is caused by an organic illness, the treatment of the underlying illness would be covered by the Plan.  

The Fund will pay for the initial exam and the diagnostic services necessary to determine the cause of the infertility.  However, the Fund will NOT pay for services performed strictly for the purpose of becoming pregnant.  

Some of these non-covered services are:  

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ARTIFICIAL INSEMINATION

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LOW TUBAL TRANSFERS

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IN-VITRO FERTILIZATION (see next section)

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FERTILITY DRUGS

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EMBRYO TRANSPLANT

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GAMETE INTRAFALLOPIAN TRANSFER (GIFT)

IN-VITRO FERTILIZATION
The Fund does NOT cover any charges related to In-Vitro Fertilization unless the direct cause of the infertility is testicular cancer.  In that case, the Fund will provide a benefit of $6,000 per program, or $3,000 per "cycle" with a limitation of two cycles of treatment.

KIDNEY DIALYSIS

Kidney dialysis is covered by the Fund at 80% of the reasonable and customary charges after satisfaction of the calendar year deductible.   

   

LABORATORY AND X-RAY

Fees for laboratory tests or x-rays (such as a blood test, PSA test, chest x-ray, mammogram, MRI, CT scan, etc...) will be reimbursed at 80% of the X-ray/Lab Schedule after satisfaction of the Calendar Year deductible.  Laboratory tests or x-rays must be medically necessary. 

 

ORGAN TRANSPLANTS

The Fund will cover all expenses related to the transplantation of an organ, including patient screening, organ procurement and transportation of the organ, patient and/or donor, surgery for the patient and donor, follow-up care in the home or a hospital, UP TO A MAXIMUM OF $100,000.00, if the following conditions are met:  

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The transplant cannot be considered experimental or investigational by the American Medical Association; and

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The patient must be admitted to a transplant center program which is approved by  Medicare or the appropriate state in which the center is located.

This transplant benefit is available only if the transplant recipient is eligible with the Plan.  THIS BENEFIT IS NOT AVAILABLE FROM THE FUND FOR A PARTICIPANT ENROLLED IN AN HMO PROGRAM.  Donor-related expenses will only be covered if the donor has no other health insurance coverage for the transplant procedure.

In no case will the Fund cover expenses for transportation of surgeons or family members.  If the individual is covered by Medicare and the Fund provides the secondary coverage for that individual, no benefits will be provided by the Fund unless the transplant center program is approved by Medicare.

Immuno-suppressant drugs are covered under the Plan's Prescription Drug benefit and are not counted toward the $100,000 limit.

The Plan does not consider a bone marrow transplant to be an organ transplant.  Benefits are available according to normal Plan provisions for the hospital and medical care, however, due to the complexity and expense, please refer to Case Management.

ORTHOTICS
Orthotics are external devices, other than casts, made specially for each individual person to support or correct a diseased or injured foot.  The Fund will pay 80% to a $90.00 maximum per foot.  Casting is paid under surgery benefits.  
OXYGEN

Fees for oxygen and rental of equipment for administration of oxygen will be reimbursed at 80% of the reasonable and customary charge.  You must have a prescription from your physician.

     For a better benefit see AHF.

 

PAIN MANAGEMENT SERVICES

Pain Management programs are covered by the Fund but are subject to a limited benefit.  Pain Management programs include comprehensive inpatient and outpatient programs, implantable spinal pain management devices, special pain control devices and medical equipment, epidural steroid injections, nerve blocks and electrotherapy (TEXS). 

All Pain Management programs must be pre-authorized by the Case Management Department before starting the program.  The Case Manager will require a complete description of the program or therapy, a cost estimate, and all medical records related to the disorder being treated.  (Pre-Authorized Information Form)

PHYSICIAN CARE

Physician's fees for office visits are paid at a maximum of $35.00 per visit.  There is a limit of 50 visits per calendar year.

The benefit for an initial consultation with a specialist is a maximum of $150.00. The Fund can only pay for one consultation per illness and you must be referred to the specialist by your primary physician.

The benefit for physician's visits to the hospital while you are a registered bed patient is 80% of the reasonable and customary charge.  Charges for follow-up care after surgery which is already included in the surgeon's fee will not be covered.  

The benefit for a physician's house call is 80% of the reasonable and customary charge.

All of these reimbursements are subject to satisfaction of the Calendar Year deductible.

    

For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

PHYSICIAN'S ASSISTANT

The physician's assistant will be reimbursed at 10% of the amount allowed for the surgeon, after satisfaction of the Annual Deductible, not to exceed his charge.  NOTE: This benefit is available only in cases when the physician's assistant takes the place of an assistant surgeon in major surgeries.  

PREVENTIVE HEALTH CARE FOR CHILDREN
Benefits are provided for routine examinations and immunizations of dependent children through 6 years of age.  Routine eye exams for children would be covered only through the Vision Service Plan.  
PROSTHETIC APPLIANCES

A prosthetic appliance is an artificial replacement for a missing body part, such as an artificial leg. If a natural limb or eye was lost while the patient was eligible under the Plan, the fee for the initial prosthetic appliance will be reimbursed at 80% of the reasonable and customary charge.

In the event a dependent child requires replacement of a prosthesis due to growth, each replacement prosthesis will be a covered expense.

Repairs and replacements of prosthetic appliances are subject to approval by the Board of Trustees.  

PSYCHIATRIC/SUBSTANCE ABUSE TREATMENT

No benefits are available for any type of psychiatric or mental health care which is not due to alcohol or drug abuse.

The Plan will provide a maximum benefit for the treatment of alcohol or drug abuse of $5,000 in 12 consecutive months, with a lifetime maximum of $7,500.  These maximums are for any combination of inpatient, outpatient, day treatment and counseling service.

The benefits for substance abuse treatment will be paid as follows:

Inpatient (hospital) - 90% of allowed charges if confined to an AHF contract hospital; 80% of allowed charges if beyond 20 miles of AHF contract hospital; or 70% of allowed charges if within 20 miles of AHF contract hospital to the maximum described above.  There is no deductible applied to the hospital benefit for Active participants.

Outpatient Counseling - (Only for alcohol/drug abuse, fetal alcohol syndrome in a dependent child 16 or younger, or mental/nervous disorders directly related to bodily injury caused by physical trauma) - $35.00 per visit to the maximum described above  with a maximum of 50 visits per calendar year.  The annual deductible will apply in this case.

Day Treatment - $100 per day after the annual deductible has been satisfied to the maximum described above.

IMPORTANT:  No benefits will be provided for psychotherapy or counseling claims which are alcohol/drug related unless there is evidence of a detoxification program sometime during the previous 12 months.

No benefits are payable if the alcohol or drug problem is "pre-existing." A "pre-existing" condition is an illness or condition for which the patient received treatment or took prescribed drugs or medicines prior to the effective date of his eligibility.

No benefits will be provided for 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.

Attention Deficit Disorders - Behavioral counseling and psychotherapy are not covered.  However, the psychotherapeutic drugs, lab testing and physician visits to monitor the drug therapy are covered by the Plan.  Refer to Lab/X-ray, Physician Care and Prescription Drugs.  

ROUTINE PHYSICAL EXAM  BENEFIT

The Fund will pay for doctor, x-ray and laboratory charges incurred in connection with a routine physical exam, only for Active participants, up to a maximum payment of $150.00 per person every two years subject to satisfaction of the Calendar Year deductible.  The physical exam can be performed by the physician of your choice .  Any charges in excess of $150.00 are not paid by the Fund, including charges from AHF contract providers.

This Routine Physical Exam benefit will not be payable for:

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Diagnosis or treatment of any injury or illness.

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Examination of the teeth, gums or eyes.

Claims for diagnosis of a suspected illness or injury are paid according to Plan provisions for the services provided.

Dental exams are paid under the Dental Plan provisions.

Eye exams are paid under the Vision Plan provisions.  

SPEECH THERAPY

The Fund will pay $65.00 per visit after satisfaction of the calendar year deductible, with a limit of 52 visits per year for speech therapy, only if the following conditions are met:  

  1. The patient must have had normal speech for his or her age, which was lost or significantly impaired due to sickness or injury, and

  2. The therapy must be given by, or under the direct supervision of, a certified and licensed Speech Pathologist.  

NOTE: The Fund does not provide benefits for therapy or educational programs to correct the developmental problems of a child, for learning disabilities such as dyslexia, and similar problems.

SUPPLIES

Supplies are items that are medically necessary for the therapeutic treatment of an illness or injury.  Fees for supplies that are covered by the Plan will be reimbursed at 80% of the reasonable and customary charge after satisfaction of the calendar year deductible.  

Some examples of covered supplies are:  

splints

rib belts

jobst stockings

ostomy supplies (available through the contract Prescription Drug Program)

enteral and g-tube feeding supplies

knee, neck and back braces - only if needed for all regular and customary activities to promote healing a stability after injury or surgery

orthopedic shoes only if attached to a brace or to prevent amputation for severe diabetics

The Fund will not pay for these supplies:

ace bandages

heating pads

back pads or cushions

incontinence pads or diapers

sports braces or supports

nutritional supplements

THERAPEUTIC INJECTIONS

Fees for therapeutic injections will be reimbursed at 80% of the reasonable and customary charge.

NOTE:
  B-12 injections and immunizations for anyone over 6 years of age are not a covered expense.  

 

WEIGHT CONTROL PROGRAMS

The Fund will cover most of the charges for weight control programs (except prescription weight control drugs) if the patient meets these requirements:

  1. The patient must be 100 pounds over the top weight for "large frame" individuals using the Metropolitan Life Insurance Company Height/Weight Tables.

  2. The patient must have remained "morbidly obese" for five (5) consecutive years.  This must be documented in the patient's medical records.

  3. The patient must be 15-50 years of age if not diabetic, and 15-40 years of age if diabetic.

  4. The patient must have a serious medical complication of obesity, such as:

uncontrolled diabetes

uncontrolled hypertension

Pickwickian Syndrome (or hypoventilation) - a reduced rate and 
depth of breathing

crippling degenerative joint disease requiring a need for 
replacement of the hip or knee.

Office visits to the physician are reimbursed at $35 after satisfaction of the calendar year deductible.  Charges for lab tests are reimbursed according to the X-Ray/Lab Schedule.

The Fund does not cover nutritional supplements, special food, liquid or powdered food supplements, or weight loss medications.

 

WIGS AND HAIRPIECES FOR 
CHEMOTHERAPY PATIENTS  
The cost of wigs and hairpieces for patients undergoing chemotherapy treatment will be paid up to a maximum of $ 100.00.