Operating Engineers Health & Welfare Fund

Surgery-Related Benefits

 

Surgeon

Anesthesia

Assistant Surgeon

Cosmetic Surgery

 


SURGERY-RELATED BENEFITS

Through the Fund’s Fee-for-Service Plan, the physician’s fee for inpatient surgery, surgery done at the doctor's office, or surgery done on an outpatient basis will be paid at 70% of the amount listed in the SURGICAL SCHEDULE, after satisfaction of the Calendar Year Deductible, if applicable.  Follow-up care is included in the surgery charge if applicable.

 

EXAMPLE:

Surgeon's Charge $ 1,000.00
Allowed Amount    800.00
Fund's Payment    560.00
Employee's Out-of-Pocket Expense    440.00

 

The complete SURGICAL SCHEDULE is too lengthy to publish.  If you require information on a specific surgery, please call or write the Fund Office for the details you require.  You must have the Current Procedural Terminology (CPT) code or the Health Care Financing Administration's Common Procedure Coding System (HCPCS) code of the procedure performed.  The complete SURGICAL SCHEDULE is available from the Fund Office upon request.

ANESTHESIA

Through the Fund’s Fee-for-Service Plan, fees for anesthesia services will be reimbursed at 70% of the Surgical Schedule. The Fund’s allowed amount is based on the procedure performed, complications, and the amount of time involved after satisfaction of the Calendar Year Deductible, if applicable.

 

EXAMPLE:

Anesthesiologist's Charge $ 700.00
Allowed Amount from Schedule    600.00
Fund's Payment    420.00
Employee's Out-of-Pocket Expense    280.00

 

ASSISTANT SURGEON

If the procedure REQUIRES one or more assistant surgeons, the assistant surgeon will be reimbursed through the Fund's Fee-for-Service Plan with a total payment for all assistant surgeons at 20% of the amount allowed for the primary surgeon, after satisfaction of the Calendar Year Deductible, if applicable.  If the only assistant is a Registered Nurse First Assistant (RNFA) or Physician’s Assistant (PA), reimbursement will be at a total of 10% of the allowed amount for the surgery, after satisfaction of the Calendar Year Deductible, if applicable.

EXAMPLE:

Surgery Allowance $ 1,000.00
Assistant Surgeon's Charge    500.00
Allowed Amount    200.00
  
(20% of Surgery Allowance)
  Fund's Payment 140.00
Member's Out-of-Pocket Expense      860.00

 

 

COSMETIC SURGERY

The term "Cosmetic Surgery" means surgery which is performed merely for the purpose of improving the appearance of an individual.

The Fund does NOT cover Cosmetic Surgery unless the surgery is being done to repair or alleviate disfigurement resulting from an accident which occurred while the patient was eligible in the Plan, or for the correction of a congenital defect in a Dependent child, or for breast reconstruction following cancer-related mastectomy.
 

FOR A BETTER BENEFIT

Eligible employees and their eligible dependents can obtain surgical services, 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 90% of the contract amount (minus any copayment) after satisfaction of the Calendar Year Deductible, if applicable.

Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

Providers under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com . Providers under contract with AHF are listed in the AHF Directory of Participating Hospitals and Physicians which is available via their website at www.AHFONLINE.org