For a better benefit for

California Residents see Blue Cross, and

Non-California Residents see AHF.

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.  

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 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:  

KIDNEY DIALYSIS

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

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. 

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:  

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.

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 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'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.  

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.  

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 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.

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.  

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:  

The Fund will not pay for these supplies:

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.  

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:

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.