Medical
Once you establish initial eligibility, your options for health plan coverage are the Comprehensive Health Plan (self-funded by the Plan), Kaiser Foundation Health Plan (northern California and Hawaii), Health Net, HMSA or United Healthcare (UHC).
Please consider your Plan selection carefully. The selection you make will remain in effect for you and your eligible family members for twelve months unless you have a Special Enrollment event. Once each year you have the opportunity to change your Medical coverage, however you must remain in the plan you selected for a minimum of 12 months unless you choose an HMO and later move out of the HMO plan's service area or otherwise have a Special Enrollment event. Any change in plans will be effective on the first day of the second month following the date the enrollment form is received by the Trust Fund Office.
If you select the Comprehensive Plan, using Providers in the Anthem Blue Cross network of participating providers in California or Blue Card providers in other states will maximize Plan benefits. This list changes from time to time so please contact, the trust Fund Office Claims Department at (800) 251-5013 to verify that the providers are still in the network.
The following summary is intended only as a general description of Plan benefits. For a complete description of benefits and Plan exclusions and limitations, please refer to your Summary Plan Description.
Choice of Physicians
- Members may use the providers of their choice.
Deductible per Calendar Year
Out-of-pocket expense limit per Calendar Year (applies to comprehensive medical benefits only)
Hospital Services and Supplies (Pre-authorization required for admissions)
- Accommodations, including CCU and ICU
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of the Allowed Charge.
- Ancillary services and supplies Outpatient treatment rooms Convalescent hospital services (up to 100 days per confinement)
Doctor Visits
- Office visits
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of covered expenses incurred.
- Home visits
- Visits while you are in the hospital
Surgery(Pre-authorization required for out-patient surgery if you are not eligible for Medicare)
- Surgery
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of Allowed Charge.
- Anesthesia and its administration Second surgical opinion
- Hospital services and supplies for out-patient surgery
Preventive Care
The Plan's preventive care guidelines have been modified and expanded to reflect requirements of the Affordable Care Act (also known as "health care reform"). Preventive care services that are required under health reform are payable at 100%, with no deductible when received from a Contract Provider. Preventive care services from a Non-Contract Provider are not covered except immunizations, colorectal cancer screening including colonoscopy and an annual exam for Retiree and Spouse (Fund pays 80%)
Please see the following Government website for a complete description of covered preventive care or call the Fund Office with any questions you have. http://www.healthcare.gov/law/about/provisions/services/lists.html
Emergency Services
- Physician services
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of the Allowed Charge.
- Emergency room use, supplies, ancillary services, drugs, and medicines
Transplants(Pre-authorization required)
- Organ procurement and transportation
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of covered expenses incurred.
- Surgery
- Follow-up care
- Immunosuppresant drugs
Mental Health Inpatient treatment (covered the same as any other illness)
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 80% of the Allowed Charge.
- Outpatient treatment - up to 26 visits per calendar year (not subject to out-of-pocket limit) Fund pays 50% of covered expenses
Additional Services and Supplies Ambulance service
- Contract Provider: The Fund pays 80% of the negotiated contract rate.
- (Exception: laboratory services billed by a free-standing contract laboratory are paid at 100% of contract rate)
- Non-contract Provider: The Fund pays 80% of the Allowed Charge.
- Outpatient diagnostic laboratory and radiology services Physical and occupational therapy or chiropractic services (up to 40 visits per year - combined maximum)
- Medical equipment and supplies (prior authorization recommended)
- Artificial limbs and eyes, crutches, casts, braces Orthotics
- Acupuncture (up to 16 visits per treatment series) Speech therapy Blood Transfusions Oxygen and rental of equipment for its administration
Schedule II will not apply to any Retired Employee who retired on or after January 1, 2007.
The following summary is intended only as a general description of Plan benefits. For a complete description of benefits and Plan exclusions and limitations, please refer to your Summary Plan Description.
Choice of Physicians
- Members may use the providers of their choice.
Deductible per Calendar Year
Out-of-pocket expense limit per Calendar Year (applies to comprehensive medical benefits only)
- Contract medical providers is $5,000/person/calendar year; $11,000/family/calendar year
Hospital Services and Supplies (Pre-authorization required for admissions, if you are not eligible for Medicare)
- Accommodations, including CCU and ICU
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
Doctor Visits
- Office visits
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
- Home visits while you are in the hospital
Surgery(Pre-authorization required for out-patient surgery)
- Surgery
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
- Anesthesia and its administration Second surgical opinion Hospital services and supplies for out-patient surgery
Preventive Care
The Plan's preventive care guidelines have been modified and expanded to reflect requirements of the Affordable Care Act (also known as "healthcare reform"). Preventive care services that are required under health reform are payable at 100%, with no deductible when received from a Contract Provider. Preventive care services from a Non-Contract Provider are not covered except immunizations, colorectal cancer screening including colonoscopy and an annual exam for Retiree and Spouse (Fund pays 80%).
Emergency Services
- Physician services
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
- Emergency room use, supplies, ancillary services, drugs, and medicines
Transplants(Pre-authorization required)
- Organ procurement and transportation
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
- Surgery
- Follow-up care
- Immunosuppresant drugs
Mental Health Inpatient treatment (covered the same as any other illness)
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
Additional Services and Supplies
- Ambulance service
- Contract Provider: The Fund pays 75% of the negotiated contract rate.
- (Exception: laboratory services billed by a free-standing contract laboratory are paid at 100% of contract rate)
- Non-contract Provider: The Fund pays 75% of the Allowed Charge.
- Outpatient diagnostic laboratory and radiology services Physical and occupational therapy or chiropractic services (up to 40 visits per year - combined maximum)
- Medical equipment and supplies (prior authorization recommended)
- Artificial limbs and eyes, crutches, casts, braces Orthotics
- Acupuncture (up to 16 visits per treatment series)
- Speech therapy
- Blood Transfusions
- Oxygen and rental of equipment for its administration
The Medicare + Choice program offered by Kaiser is called Kaiser "Senior Advantage". Current Kaiser retirees who become eligible for Medicare must enroll in Kaiser's "Senior Advantage" program. Only those who were in Kaiser and eligible for Medicare prior to January 1, 1995 may elect to remain in the Medicare Cost plan.
The HMO Medicare + Choice programs are based on a contractual agreement between the HMO and Medicare where Medicare pays a fixed monthly premium directly to the HMO on behalf of its enrolled participants. In turn, participants must receive ALL services exclusively through the HMO.
Enroll Through the Operating Engineers for Added Advantage
Retirees and spouses who enroll in one of the Medicare + Choice plans through the Operating Engineers plan, instead of on their own, will have several important advantages.
- You can return to the Comprehensive Health Plan once in a twelve month period during the enrollment periods allowed by Medicare. [Note to Surviving Spouses: If you return to the Comprehensive Health Plan, you must purchase prescription drug coverage and medical coverage. Your monthly premium will increase by $90.]
- You will have unlimited prescription drug benefits; the Medicare + Choice plans offered to the public have annual limits for prescriptions. However, it is important to understand that your prescriptions must be obtained through the HMO. You will no longer have prescription drug benefits through the Trust Fund’s plan administered by Caremark.
- You will continue to have Vision Care through Vision Service Plan for Schedule I only and Chemical Dependency Benefits under the Operating Engineers Comprehensive Health Plan. Chiropractic, Podiatry and Physical Exam benefits are provided through the HMO Plans subject to their limitations. Note: Vision Care coverage is also available to you through the HMO Plans regardless of whether you are covered under Schedule I or Schedule II. [Note. This does not apply to Surviving Spouses who are not eligible for these benefits.]
Each Retiree and Each Spouse Can Decide on Options
Because choosing your doctor is so important to you, the Board will allow each retiree eligible for Medicare and each spouse eligible for Medicare to individually select one of the four plans. The husband and wife can both select the same plan or each may select a different plan.
More Coverage for Less Cost
The Board of Trustees is offering these "Medicare + Choice" plans because they will save you and the Fund money. There are small co-payments for certain services under the Senior Advantage plan [$15 for each office visit and $10-$20 for covered prescription drugs] but there will be no remaining charges for you to pay, as there often are under the Comprehensive Health Plan after Medicare and the Fund pay their share of your expenses.
Retirees without Medicare
If you are not Medicare eligible, you are eligible for Kaiser Foundation Health Plan. You must live within 30 miles of a Kaiser facility to enroll in Kaiser.
When you become eligible for Medicare, Kaiser will require you to enroll in their Medicare + Choice program known as "Senior Advantage." Only those participants who were in Kaiser and already eligible for Medicare prior to January 1, 1995 may elect to remain with the Kaiser Medicare Cost plan. The Trust Fund also offers other HMO "Medicare + Choice" plans for Medicare eligible retirees, spouses and surviving spouses. Special rules apply to these plans. Please call the Trust Fund Office if you are eligible for Medicare and would like to receive information about the Medicare + Choice plans.
The HMO Medicare + Choice programs are based on a contractual agreement between the HMO and Medicare where Medicare pays a fixed monthly premium directly to the HMO on behalf of its enrolled participants. In turn, participants must receive ALL services exclusively through the HMO.
Enroll Through the Operating Engineers for Added Advantage
Retirees and spouses who enroll in one of the Medicare + Choice plans through the Operating Engineers plan, instead of on their own, will have several important advantages.
- You can return to the Comprehensive Health Plan once in a twelve month period during the enrollment periods allowed by Medicare. [Note to Surviving Spouses: If you return to the Comprehensive Health Plan, you must purchase prescription drug coverage and medical coverage. Your monthly premium will increase by $90.]
- You will have unlimited prescription drug benefits; the Medicare + Choice plans offered to the public have annual limits for prescriptions. However, it is important to understand that your prescriptions must be obtained through the HMO. You will no longer have prescription drug benefits through the Trust Fund’s comprehensive plan administered by Caremark.
- You will continue to have Vision Care through Vision Service Plan for Schedule I only and Chemical Dependency Benefits under the Operating Engineers Comprehensive Health Plan. Chiropractic, Podiatry and Physical Exam benefits are provided through the HMO Plans subject to their limitations. Note: Vision Care coverage is also available to you through the HMO Plans regardless of whether you are covered under Schedule I or Schedule II. [Note. This does not apply to Surviving Spouses who are not eligible for these benefits.]
Each Retiree and Each Spouse Can Decide on Options
Because choosing your doctor is so important to you, the Board will allow each retiree eligible for Medicare and each spouse eligible for Medicare to individually select one of the four plans. The husband and wife can both select the same plan or each may select a different plan.
More Coverage for Less Cost
The Board of Trustees is offering these "Medicare + Choice" plans because they will save you and the Fund money. There are small co-payments for certain services [$5 for each office visit and $5 for generic or $10 for brand name prescription drugs] but there will be no remaining charges for you to pay, as there often are under the Comprehensive Health Plan after Medicare and the Fund pay their share of your expenses.
Summary of Benefits The following summary is intended only as a general description of Plan benefits. For a complete description of benefits and Plan exclusions and limitations, please refer to the Health Net "Evidence of Coverage.
Choice of Physicians Members must use specified Medicare Advantage Network Providers. No benefits will be paid for services received outside the Network except for emergency services.
Plan Maximum None
Your Copayments:
Inpatient Hospital Services $250 per admission
Skilled Nursing Facility No charge for days 1-20; $25 per day for days 21-100, maximum of 100 days
Physician Office Visits $5 per visit / $20 for Specialist
Emergency RoomIn-Area $65, waived if admitted Out-of-Area $65, waived if admitted
Ambulance $50
Outpatient Surgery $50 per surgery
Lab Services No Charge
X-rays, Imaging Procedures No Charge
Mental Health: Inpatient $100 per admission, lifetime benefit maximum is 190 days Outpatient $20 per individual visit / $5 per group visit
Home Health Care No Charge
Durable Medical Equipment (DME) 20%
Chiropractic Care $15 per visit, limited to 12 visits per year for Routine Chiropractic Care; $20 for Medicare covered chiropractic treatment (no limit on number of visits for Medicare covered chiropractic treatment)
The HMO Medicare + Choice programs are based on a contractual agreement between the HMO and Medicare where Medicare pays a fixed monthly premium directly to the HMO on behalf of its enrolled participants. In turn, participants must receive ALL services exclusively through the HMO.
Enroll Through the Operating Engineers for Added Advantage
Retirees and spouses who enroll in one of the Medicare + Choice plans through the Operating Engineers plan, instead of on their own, will have several important advantages.
- You can return to the Comprehensive Health Plan once in a twelve month period during the enrollment periods allowed by Medicare. [Note to Surviving Spouses: If you return to the Comprehensive Health Plan, you must purchase prescription drug coverage and medical coverage. Your monthly premium will increase by $90.]
- You will have unlimited prescription drug benefits; the Medicare + Choice plans offered to the public have annual limits for prescriptions. However, it is important to understand that your prescriptions must be obtained through the HMO. You will no longer have prescription drug benefits through the Trust Fund’s comprehensive plan.
- You will continue to have Vision Care through Vision Service Plan for Schedule I only and Chemical Dependency Benefits under the Operating Engineers Comprehensive Health Plan. Chiropractic, Podiatry and Physical Exam benefits are provided through the HMO Plans subject to their limitations. Note: Vision Care coverage is also available to you through the HMO Plans regardless of whether you are covered under Schedule I or Schedule II. [Note. This does not apply to Surviving Spouses who are not eligible for these benefits.]
Each Retiree and Each Spouse Can Decide on Options
Because choosing your doctor is so important to you, the Board will allow each retiree eligible for Medicare and each spouse eligible for Medicare to individually select one of the four plans. The husband and wife can both select the same plan or each may select a different plan.
More Coverage for Less Cost
The Board of Trustees is offering these "Medicare + Choice" plans because they will save you and the Fund money. There are small co-payments for certain services [$15 for each office visit and $10 for generic or $20 for brand name prescription drugs] but there will be no remaining charges for you to pay, as there often are under the Comprehensive Health Plan after Medicare and the Fund pay their share of your expenses.
Summary of Benefits The following summary is intended only as a general description of Plan benefits. For a complete description of benefits and Plan exclusions and limitations, please refer to the Plan's Benefits Summary and "Evidence of Coverage".
Choice of Physicians Members must use specified Medicare Advantage Network Providers. No benefits will be paid for services received outside the Network except for emergency services.
Plan Maximum None
Your Copayments:
Inpatient Hospital Services $100 per admission
Skilled Nursing Facility No charge for days 1-20;
$25 per day for days 21-100, maximum of 100 days
Physician Office Visits $5 per visit / $20 for Specialist
Emergency RoomIn-Area $65, waived if admitted Out-of-Area $65, waived if admitted
Ambulance $50
Outpatient Surgery $50 per surgery
Lab Services No Charge
X-rays, Imaging Procedures No Charge
Mental Health: Inpatient $100 per admission, lifetime benefit maximum is 190 days Outpatient $20 per individual visit / $5 per group visit
Home Health Care No Charge
Durable Medical Equipment (DME) 20%
Chiropractic Care $15 per visit, limited to 12 visits per year for Routine Chiropractic Care; $20 for Medicare covered chiropractic treatment (no limit on number of visits for Medicare covered chiropractic treatment)
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