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 for the purchase of your hearing aid (prescription required), or for repairs and batteries, subject to satisfaction of the Calendar Year deductible.  

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. Contact the Fund's Case Management Department for assistance in coordinating this type of care.

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 for treatment within 90 days of a hospital confinement of at least 3 days.

FOR A BETTER BENEFIT - Eligible Employees and their eligible Dependents can obtain home health care services, when prescribed by a physician, from PPO contract providers in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no copayment. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

Home Health Agencies under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com. Home Health Agencies under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available from the Fund Office. 

Through the Fund’s Fee-for-Service Plan, fees for most immunizations will be reimbursed at 80% of the reasonable and customary charge after satisfaction of the calendar year deductible, if applicable. For the flu shot benefit see page 54.

Infertility or sterility, which is the inability to procreate, is not in itself 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 diagnostic services necessary to determine if you are infertile or sterile. However, the Fund will NOT pay for services performed to treat the infertility or sterility.

KIDNEY DIALYSIS

Through the Fund's Fee-for-Service Plan, kidney dialysis will be paid at 80% of the reasonable and customary charges after satisfaction of the calendar year deductible, if applicable.

Through the Fund's Fee-for-Service Plan, fees for laboratory tests or x-rays (such as a blood test, pap smear, PSA test, chest x-ray, mammogram, MRI (open or closed), MRA, PET scan, CAT scan, etc...) will be reimbursed at 80% of the X-ray/Lab Schedule after satisfaction of the Calendar Year deductible, if applicable.  Laboratory tests or x-rays must be medically necessary. 

X-ray/Diagnostic Imaging and laboratory services under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com. X-ray/Diagnostic Imaging and laboratory services under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available from the Fund Office.   

An “organ” is a somewhat independent part of the body that performs a special function or functions. 

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, if the following conditions are met:

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.

Immunosuppressant drugs are covered under the Plan’s Prescription Drug benefit.

The Plan does not consider a bone marrow transplant to be an organ transplant. Benefits are available according to normal Plan provisions. IMPORTANT: Due to the complexity and expense related to organ transplants, please contact the Fund’s Case Management Department for coordination of services and a full explanation of your coverage.

Foot Orthotics are external devices, other than casts, made specially for each individual person to support or correct a diseased or injured foot. Through the Fund’s Fee-for-Service Plan the Fund will pay 80% up to a $72 maximum per person, per foot after satisfaction of the calendar year deductible, if applicable. Through the Fund’s PPO Plan the Fund will pay 100% of the contract amount up to a $90 maximum per person, per foot. Casting is paid under surgery benefits.

Foot Orthotics are covered only once every 12 months for adults and once in a period of 6 months for children under age 19 or up to age 26 if a full-time student. All foot orthotics must be custom made and molded to the patient’s foot. Custom made foot orthotics are covered when prescribed by a physician and prepared by a qualified health professional.

FOR A BETTER BENEFIT – Eligible employees and their eligible Dependents can obtain foot othotics, when prescribed by a physician, from PPO contract providers at several locations in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate up to $90 per foot. Any balance between the contract amount and the Fund’s payment is the patient’s responsibility. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

Through the Fund's Fee-for-Service Plan, fees for oxygen and rental of equipment for administration of oxygen will be reimbursed at 80% of the reasonable and customary charge after satisfaction of the calendar year deductible, if applicable.  You must have a prescription from your physician.    

FOR A BETTER BENEFIT – Eligible employees and their eligible Dependents can obtain oxygen and equipment for administration of oxygen, when prescribed by a physician, from PPO contract providers at several locations in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no copayment. Simply present you Health & Welfare Identification Card along with your doctor's prescription.

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

If the Pain Management Program you intend to use meets the requirements of this benefit under the Rules and Regulations of the Plan, the Fund will pay the appropriate benefit for each type of service rendered. If you require these services please contact the Case Management Department at (626) 356-3519. 

Under the PPO contract provisions, the Plan will pay the contracted rate which the doctor has agreed to accept. You typically have no copayment. You must, however, pay for any services not covered by the Plan. And, for consultations, you are responsible for any contractual amount which exceeds the Plan’s $150 consultation maximum.

Through the Fund’s Fee-for-Service Plan physician’s fees for office visits are paid at 100% up to a maximum of $35 per visit after satisfaction of the calendar year deductible, if applicable. There is a limit of 50 visits per calendar year. 

The benefit for an initial consultation with a specialist is paid at 100% up to a maximum of $150 after satisfaction of the calendar year deductible, if applicable. The Fund can only pay for one consultation per medical condition and you must be referred to the specialist by another physician or other appropriate medical professional for an opinion or advice regarding a specific medical condition. The request for consultation or referral must be documented in your medical record and the consulting physician must provide a written report to the referring physician. If these requirements are not met, then charges for an initial consultation with a physician will be paid at 100% up to a maximum payment of $35 after satisfaction of the calendar year deductible, if applicable or the PPO contracted rate.

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 after satisfaction of the calendar year deductible, if applicable.

COMPARISON OF FEE-FOR-SERVICE PLAN BENEFITS vs. PPO PLAN BENEFITS

Fee-for-Service Plan Benefit Example:

A bill for medical services is in the amount of $600. The Plan has an allowance for those services of $400. The doctor in this case has charged more than the Plan allows. The $250 calendar year deductible is applied to the $400 allowed amount leaving a balance of $150 which is paid at 80%. The Fund pays $120. The out-of-pocket expense to the employee in this case is $480.

PPO Benefit Example:

A bill for medical services is in the amount of $600. The PPO contract physician has agreed to accept the contracted rate of $400 for those services. The Fund pays $400. The out-of-pocket expense to the participant is $ .00.

FOR A BETTER BENEFIT - Eligible employees and their eligible Dependents can obtain physician care and services from PPO contract physicians at several locations in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no copayment. Simply present your Health & Welfare Identification Card.

Physicians under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com Physicians under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available from the Fund Office.

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 through the Fund's Fee-for-Service Plan 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 after satisfaction of the calendar year deductible, if applicable.

A second artificial limb to replace an initial artificial limb may be covered if approved by the Fund's Case Manager.

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.

The Fund will pay for physician charges incurred in connection with a routine physical exam, up to a maximum payment of $150 per person every two years after satisfaction of the calendar year deductible, if applicable. The physical exam can be performed by the physician of your choice. Any charges in excess of $150 are not paid by the Fund, including charges from PPO contract providers.

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

FOR A BETTER BENEFIT - Eligible employees and their eligible Dependents can obtain speech therapy, when prescribed by a physician, from PPO contract providers at several locations in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no copayment. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

Speech Therapists under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com. Speech Therapists under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available from the Fund Office.

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

SUBSTANCE ABUSE/CHEMICAL DEPENDENCY TREATMENT: The Plan will provide a MAXIMUM benefit for the treatment of alcohol or drug abuse (drug rehab or alcohol rehab) 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 services.

Supplies are items that are medically necessary for the therapeutic treatment of an illness or injury. 

Through the Fund's Fee-for-Service Plan, 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, if applicable..  

The Fund will not pay for these supplies:

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