AHF was created by several
Health and Welfare Funds, including Operating Engineers, to help reduce the cost
of health care. The Fund has contracted with doctors and hospitals through the
organization known as Affiliated Health Funds (AHF). Your freedom of choice is
retained with this arrangement. You may continue to select the doctors and
hospitals of your choice. However, choosing doctors and hospitals from the
AHF contract network will result in less out-of-pocket expense to you. The
AHF program requires no enrollment. If you are not enrolled in an HMO plan and
you are eligible, you are automatically part of the AHF program.
AHF is currently the
secondary network for members who reside in California and Nevada. (Anthem Blue
Cross/Anthem Blue Cross Blue Shield are the primary networks)
AHF is the primary network
for members who reside outside of California and Nevada, although most
contracted providers are located within California and Nevada.
The Fund has contracted with
doctors and hospitals through the organization known as Affiliated Health Funds
(AHF). Your freedom of choice is retained with this arrangement. You may
continue to select the doctors and hospitals of your choice. However,
choosing doctors and hospitals from the AHF contract network will result in less
out-of-pocket expense to you. The AHF program requires no enrollment. If
you are not enrolled in an HMO plan and you are eligible, you are automatically
part of the AHF program.
AHF
HOSPITAL BENEFITS
When you are a
registered bed patient in an AHF participating hospital, the Fund provides
the
following benefits,with the exception of
psychiatric and substance abuse treatment:
ACTIVE-INPATIENT
The Plan will pay 90% of the Contract Amount after satisfaction of the Calendar
Year Deductible. You are responsible for 10% of the
Contract Amount and any amount applied toward the Calendar Year Deductible.
RETIRED-INPATIENT
Non-Medicare
-
The Plan will pay 90% of the Contract Amount after satisfaction of the Calendar
Year Deductible. You are responsible for 10% of the
Contract Amount and any amount applied toward the Calendar Year Deductible*.
Medicare - Medicare will pay the majority of your hospital bill.The Fund will pay the Medicare deductible and co-payments.
*Does
not apply to psychiatric or substance abuse admissions.
When
you obtain care from an AHF participating hospital, you
simply tell the admitting/billingclerk you are an Operating Engineer and
an AHF member.There is no
special paperwork, and the hospital will submit the claim forms directly to the
Fund Office.
IMPORTANT:
When a
member, spouse or dependent has other group insurance coverage (including
Medicare) which is the primary carrier, these AHF benefits are not payable.
The Plan pays normal benefits as the secondary carrier.
DIRECTORY:
AHF’s Directory of
Participating Hospitals, Physicians, Physical Therapists and Chiropractors is no longer available in printed form. Please visit www.AHFonline.org to see the
complete Directory. If necessary, you can print specific pages or sections of
the Directory from their website.
AHF
DOCTOR/PHYSICIAN
Under the AHF contract provisions,
the Plan will pay 90% of the
Contract Amount minus any applicable
co-payment or Calendar Year Deductible. Services not covered by the Plan are
your responsibility.
When
you make an appointment, be sure to ask if the doctor is still part of the AHF network.
If you have questions about this, call the Fund Office.
The current Calendar Year Deductible for AHF services (Other than CA/NV
residents) is $350.00 per individual, with a $1,050.00 per family maximum.
The current Calendar Year Deductible for AHF services (CA/NV residents) is
$500.00 per individual, with a $1,500.00 per family maximum.
When
a member, spouse or dependent has other group insurance coverage (including
Medicare) which is the primary carrier, the AHF benefits are not
payable. The Plan pays normal
benefits as the secondary carrier.
Enrollment is not necessary - but please advise the doctor that you are in the AHF
program.
COMPARISON
TO NORMAL PLAN BENEFITS
NORMAL
PLAN BENEFIT EXAMPLE:
A bill for medical services totals $800.00. The Plan has an allowance for those
services of $600.00. The doctor in this case has charged more than the Plan
allows. The $500.00 annual deductible is applied to the $600.00 allowed amount,
leaving a balance of $100.00 which is paid at 70%. The Fund pays
$70.00. The out-of-pocket expense to the member in this case is $730.00.
AHF BENEFIT EXAMPLE:
NormalFee-for-
Service
Plan
AHF
Program
Doctor's Charge
$ 800.00
$ 800.00
Plan Allowance
$ 600.00
$ 500.00
Deductible
$ 500.00
$ 350.00
Plan Payment
$ 70.00
$ 135.00
Your Out-of-Pocket
$
730.00
$ 365.00
AHF
PHYSICAL THERAPISTS
Current provisions in the
Plan provide for
payment of $15 per
visit for the services of a physical therapist with a maximum of 26
visits per calendar year in combination with acupuncture,
biofeedback and chiropractic care. Refer to
“Alternative Therapy”.
Under the AHF contract provisions, the Plan will pay 50% of the Contract
Amount after satisfaction of the Calendar Year Deductible, as
applicable. Any balance
remaining after the Fund payment & your co-payment/deductible
responsibility will be written-off by the provider.
IMPORTANT: Physical Therapy is
part of the Fund's "Alternative Therapy" benefit and applies to any
combination of contract and non-contract providers. For example, if you
have already visited a chiropractor for 10 visits during the year, you
will only be entitled to 16 additional physical therapy visits.
No enrollment is
necessary - but
please advise the therapist that you are in the AHF program.
Physical therapists under contract with AHF are listed in the AHF
Directory of Participating Hospitals and Physicians which is available
from the Fund Office
or via their website at
www.AHFONLINE.org.
DURABLE
MEDICAL EQUIPMENT
Eligible participants and
their eligible dependents can obtain durable medical equipment and oxygen, when prescribed by a
physician, from contract providers at several locations in Southern California and Nevada.
Under the AHF contract provisions, the Plan will pay 90% of the Contract
Amount minus any applicable co-payment or Calendar Year Deductible.
Services not covered by the Plan are your responsibility.
Simply present your Health & Welfare Identification Card along with your
doctor's prescription. Trained medical equipment specialists will make
certain that you are provided with the prescribed equipment, and will
make any necessary adjustments. Repairs or exchanges of rented
equipment will also be done by contract providers.
Durable
Medical Equipment Locations
For
delivery of durable medical equipment and other home health needs, you may
contact Apria Healthcare or Equipnet.You
or your physician may call the toll-free numbers and arrangements will be made
to provide the requested service.Delivery
is free of
charge.
Apria Healthcare Inc.
(800) 277-4288
Durable medical equipment includes
items such as wheelchairs, walkers, hospital beds, breathing equipment, crutches
and many other items.
NOTE:These AHF benefits for Durable Medical Equipment are not available for
participants who are enrolled in the Kaiser Permanente, Health Net or Health
Plan of Nevada HMO programs.
HEARING
AIDS
Eligible
participants and their eligible dependents can obtain hearing care service and
hearing aids at a reduced cost from the Beltone Corporation.
Beltone offers a nationwide network of Hearing Aid Centers. To locate the
Beltone Hearing Aid center nearest you, call (800-235-8663) or click
here for a list of the Beltone Hearing Centers participating in the
Affiliated Health Funds (AHF) program.
AHF
LIMITATIONS
IMPORTANT:
1.
If you obtain services from an AHF provider that are not covered by the Plan, benefits will not be paid. You will be
responsible to pay for those charges.
2.
If your doctor sends you outside his office to a
specialist or for x-rays or lab tests, you will need to find out if that
provider has a contract with AHF. The Fund will have to provide normal
Plan benefits if the provider is not contracted with AHF, and you may incur some
out-of-pocket expense.
3.
Hospitals do not always have their own pathology labs, radiologists, or
emergency room doctors on staff. These types of providers will lease space and
operate out of the hospital: they DO NOT always have a contract with AHF. In
this case the Fund will have to provide normal Plan benefits and you may incur
some out-of-pocket expense. (This does not apply to non-emergency care in the
hospital's emergency room (see outpatient emergency
care).
