Important Basics About The Plan, page 1

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	Types of Coverage
	Fee for Service
	Affiliated Health Funds (AHF)
	Kaiser Permanente HMO
	Health Net
	Health Plan of Nevada
	HMO Comparison
	Deductible
	Calendar Year Medical Maximum
	Lifetime Maximum
	Accidents & 3rd Party Liability
	Work-related Illness/Injury
	Claim Form Policy
	Case Management

TYPES OF MEDICAL COVERAGE AVAILABLE

The Trustees offer four types of medical coverage:

FEE-FOR-SERVICE simply means that the Plan reimburses you or the provider for expenses incurred in the treatment of illness or injury. The specified amount allowed in accordance with the rules of the Plan is paid either to you or a provider of service after the annual deductible is satisfied.

A PREFERRED PROVIDER ORGANIZATION (PPO) is a network of hospitals, doctors, labs, surgical centers, hearing aid centers, chiropractors and physical therapists who offer services to Engineers at a rate contracted with the Fund. You may choose from any provider on the list and you do not have to enroll in a special plan to use them.

The Fund provides two different PPO networks depending on where you live:

California Residents - the PPO network is provided through the Anthem Blue Cross Prudent Buyer Plan;

Nevada Residents - the PPO network is provided through the Anthem Blue Cross and Blue Shield PPO;

All other states - the PPO network is provided through Affiliated Health Funds (AHF).

You cannot use PPO providers if you are enrolled in an HMO, with the exception of the chiropractic and hearing aid network. If you have primary coverage with another plan (including Medicare), you may choose PPO providers but the Fund will coordinate benefits as usual.

HEALTH MAINTENANCE ORGANIZATIONs (HMOs) are paid a fee by the Fund to provide medical coverage to you and your family. Except for some small co-payments and non-covered items, you make no direct payment to the HMO for medical treatment. The Trustees presently have contracts with three (3) HMOs: Kaiser Permanente, Health Net, and Health Plan of Nevada.

PLAN "M" FOR RETIREES WITH MEDICARE enables retired participants and/or their spouses to obtain a limited program of benefits from the Fund for a reduced fee. When you join a Medicare HMO (any one you choose) in your area, you must obtain all of your medical and hospital care from the HMO. The Fund's "M" Plan will provide benefits only for hearing aids, chiropractic care, dental care, and death benefits. You cannot enroll in a Medicare HMO if you live outside the HMO's service area, if you have End-Stage Renal Disease (ESRD), if you do not have Part B Medicare, or if you are currently receiving Medicare Hospice benefits.

HEALTH MAINTENANCE ORGANIZATIONS (HMOs)

KAISER, HEALTH NET, HEALTH PLAN OF NEVADA

Eligible participants living within certain geographical areas now have a choice of other Health Plans in addition to the Fee-for-Service medical and hospital plan. Enrollment is held when you first become eligible and at the beginning of each year.

1.	Kaiser- Permanente Health Plan	This option is available only to participants who live in areas of Southern California where Kaiser facilities exist. If you choose this option, you and all of your eligible dependents will be covered under the Kaiser Plan for hospital, medical and prescription drug services. If you enroll your family in the Kaiser Plan, you must remain in the plan for one full year. You will not be permitted to change your selection until the Fund's open enrollment period which will be held once each year during January. If coverage stops for you or any covered family member because of loss of eligibility, you and/or the family member may enroll in Kaiser's Conversion Plan. Conversion Plan information is available through the Kaiser Membership Service Department. To assist you, each Kaiser Medical Center has a Membership Service Department. The Membership Service representatives are there to answer any questions or solve any problems you may have. Their telephone number is (800) 464-4000.
2.	Health Net	This option is available only to participants who live in areas where Health Net facilities exist. If you choose this option, you and all of your eligible dependents will be covered under the Health Net Plan for hospital and medical services. Prescription drug benefits are available through the Fund's regular prescription drug program. If you enroll your family in the Health Net Plan, you must remain in the plan for one full year. You will not be permitted to change your selection until the Fund's open enrollment period which will be held once each year during January. If coverage stops for you or any covered family member because of loss of eligibility, you and /or the family member may enroll in a Health Net Conversion Plan upon written request. Direct your request to:
		Health Maintenance Network of Southern California PO Box 9103 Van Nuys, CA 91409 If you have a question or problem, call or write your Health Net Coordinator at your medical group. If you call Health Net directly, their number is 1-800-522-0088.
3.	Health Plan of Nevada	This option is available only to participants who live in areas where Health Plan of Nevada facilities exist. If you choose this option, you and your eligible dependents will be covered under the Health Plan of Nevada for hospital, medical and prescription drug services. If you enroll your family in the Health Plan of Nevada, you must remain in the plan for one full year. You will not be permitted to change your selection until the Fund's open enrollment period which will be held once each year during January. If you have any questions about Health Plan of Nevada, contact the Member Services Department at (800) 777-1840.

If you choose to be covered under any of these plans, you must fill out the appropriate enrollment card which must be obtained from the Fund Office. If you require additional information about these options, contact the Fund Office.

Continued enrollment in any one of the HMO's depends upon continued eligibility in the Health & Welfare Plan. If you lose eligibility, you must re-enroll in the HMO Program when you regain eligibility. Re-enrollment after loss of eligibility is not automatic.

A member who is dissatisfied with the HMO may request that the Trustees waive the one year enrollment requirement, however he must remain in the HMO until the end of an eligibility quarter.

NOTE: Regardless of which Health Plan option you choose, you and your family will continue to be covered under the Fund's Life Insurance*, vision care, accidental death and dismemberment*, dental benefits and hearing aid programs. (*Active eligibles only).

IF YOU ARE ENROLLED IN AN HMO
THESE BENEFITS ARE AVAILABLE:

	HMO	Operating Engineers Plan
Physician care	All HMO's under contract provide physician's services in accordance with their regulations. There is a co-payment for office visits.	No coverage provided.
Hospital	All HMO's under contract provide hospital services in accordance with their regulations.	No coverage provided.
Lab/X-ray	All HMO's under contract provide lab and x-ray services in accordance with their regulations.	No coverage provided.
Chiropractor	Limited coverage Provided.	Provided by O.E. Plan
Durable Medical Equipment	Kaiser, Health Net and Health Plan of Nevada.	No coverage provided.
Prescription Drugs	Kaiser, Health Net and Health Plan of Nevada provide prescription services in accordance with their regulations.	Drug benefit for Health Net participants provided by O.E. Plan. Diabetic needles & supplies provided by O.E. Plan.
Dental	No Coverage provided.	Provided by O.E. Plan through Dental Plan or DeltaCare.
Routine Vision Care	No coverage provided.	Provided by O.E. Plan through Vision Service Plan (VSP) and Spectera.
Hearing Aids	No coverage provided.	Provided by O.E. Plan
Orthotics	Kaiser and Health Plan of Nevada provide limited coverage	Provided by O.E. Plan for Health Net participants

DEDUCTIBLE

There is a calendar year deductible of $250 for each family member with a maximum of $750 per family. The deductible does not apply to:

1.	Services provided through the Plan's PPO programs.
2.	Hospital charges as a registered bed patient (Active only).
3.	Outpatient surgical facility charges.
4.	Convalescent hospital room and board charges incurred after a hospital stay.
5.	Home health agency charges incurred after a hospital stay.
6.	Active eligible individuals who were eligible from January through December in the previous year but did not submit any claims.
7.	Birthing Center charges.
8.	Pre-admission testing when performed on an outpatient basis.
9.	Participants with Medicare as their primary insurance.

IMPORTANT:

1.	If an Active participant or any other Active eligible individual who has been eligible from January through December of the preceding calendar year submits no claim for payment or processing, no deductible is applied during the following year. If a claim submitted during the previous year was denied for some reason or applied to the deductible, then the deductible would not be waived the following year.
2.	If you are enrolled in an HMO, the HMO will not charge you with a deductible. HOWEVER, claims you submit to the Fund Office for services not covered by the HMO (such as chiropractic care), ARE SUBJECT TO THE $250 DEDUCTIBLE.



3.	You must submit your claims to the Fund Office in order for them to be applied to the yearly deductible.

4.	Deductible is taken from the allowed amount, not the charged amount. For example:

		Office Visit Charge	= $50.00
		Fund's Allowance	= $35.00
		Deductible Applied	- $35.00
		Fund's Payment	= $ .00

CALENDAR YEAR MEDICAL MAXIMUM

The Fund provides a calendar year maximum of $400,000 for each eligible Employee and each eligible Dependent who reside in California or Nevada. Once the maximum is reached, the Fund will not pay any further benefits for services or supplies on account of you or your Dependent for the remainder of the calendar year.

The Fund Office will monitor each person’s medical expenses and any person approaching the calendar year maximum will be assisted with enrollment in one of the Plan’s HMOs for the remainder of that calendar year.

On January 1 of each year, the person may go back into the Fee-for-Service/PPO plan if desired.

LIFETIME MAXIMUM

The Fund provides a lifetime maximum of $2,250,000 for each eligible member and each eligible dependent. Once the maximum is reached, benefits will be automatically reinstated up to $1,000, each subsequent January 1.

When you or your dependent has received $2,250,000 in benefits, you may apply for reinstatement of the full maximum by furnishing evidence of good health to the Fund. Get in touch with the Fund Office for the appropriate information.

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.

click here: Calendar Year Medical Maximum

PERSONAL INJURY LIABILITY
(Including Automobile Accident )

If you are injured by someone else, e.g. in an automobile collision, or a slip-and-fall accident, and you have medical claims because of the injuries, the Fund will pay benefits on those claims only if you do the following: You must sign a lien in the form provided by the Fund Office in which you acknowledge that the Fund has the right to any damages you collect for your injuries to the extent of the benefits the Fund pays. You must also reimburse the Fund from any settlement or judgment you collect for those injuries for the benefits The Fund paid . The lien applies to all amounts you recover for your injuries including amounts you collect from your own insurance, e.g. uninsured motorist coverage on your automobile policy. The Trustees may reduce the amount of the lien if you have to pay an attorney to sue the person that injured you. You should contact the Fund Office for more details about reducing the amount of a lien.

WORK-RELATED ILLNESS/INJURY

The Fund DOES NOT COVER ANY expenses in connection with work-related injuries or illnesses whether or not the employee has Workers' Compensation insurance. Even if the work-related injury occurred a long time ago, and the case has already been closed, NO BENEFITS ARE PAYABLE.

HOW TO FILE A CLAIM

Hospital and Medical Benefits

Generally, hospitals do not require claim forms. They submit their own itemized claims in an acceptable format. Claim forms for medical benefits may be obtained from any Union Office or the Fund Office. All completed claims should be sent to the Fund Office for processing. All benefit checks including your Explanation of Benefits (EOB) will be issued by the Fund Office.

When you use PPO providers, the providers will file the claim for you.

The Fund will accept hospital expense claims and medical expense claims for up to 12 months after the date of service. Hospital and medical claims older than these specified times will not be paid.

If you receive pre-approved treatment outside of the United States, submit a detailed, translated hospital bill, which includes the number of days hospitalized, lab work done, drugs administered, diagnosis and type of treatment given, to the Fund Office.

Before submitting a claim form, be sure it is filled out properly. To avoid delays in the processing of your claims, follow these steps:

1. Complete your portion of the form. If you want the Fund to pay your doctor directly, sign the authorization to pay the benefits to the physician and check the appropriate box for assignment. Sign the authorization to release information.

2. Have the person providing services complete the rest of the form.

3. Check the claim form to be certain that all applicable portions of the form are completed. Be sure your bills are itemized. The following information should be indicated on the bills or claim form submitted:

	Your name and Social Security number or Health Care ID number (HCID)
	The patient’s name and address, date of birth and relationship to you
	The date of service
	If you have coverage under any other group hospital or surgical plan, the name of the insurance company providing your other group coverage and the policy number of this coverage.
	The CPT-4 codes (the codes for physician services and other health care services found in the “Current Procedural Terminology, 4^th Edition”, as maintained and distributed by the American Medical Association)
	The ICD-9 codes (the diagnosis codes found in the “International Classification of Diseases, 9^th Edition”, as maintained and distributed by the U.S. Department of Health and Human Services)
	The billed charge(s)
	The number of units (for anesthesia and certain other claims)
	The Federal taxpayer identification number (TIN) of the provider
	The billing name and address
	If services were rendered because of an accident, the date and place of injury, including details (i.e. auto accident, fall, etc.)
	Mail your claim form or have your doctor mail it with your itemized bills to the Fund Office

You must submit a separate claim form for each dependent.

If you have any questions about your claim, call the Fund Office at (626) 356-1004.

Prescription Drug Benefits

If you use a non-participating retail pharmacy for your prescription drugs, you need to file a Prescription Drug Claim Form as provided by the Fund Office. You must pay full price for the prescribed item and submit the claim form to the Fund Office for reimbursement. For a better benefit see page 70.

Following are the steps for filing a prescription drug claim form:

1. Request an itemized bill from the pharmacy showing the following information for each prescription:

	Prescription number
	Date of sale
	Name of the physician who issued the prescription
	Patient’s name
	Cost of the prescription
	National Drug Code (NDC) number for the drug

2. Complete the claim form. Make sure you include your name and Social Security number, the patient’s name, address, date of birth, and relationship to you, your billing address and the policy number and insurance company name for any other group coverage you have.

3. Attach the itemized bill to the claim form and submit it to the Fund Office.

Dental Benefits

Claim forms for dental benefits may be obtained from any Union Office or the Fund Office. All completed claims should be sent to the Fund Office for processing. All benefit checks including your Explanation of Benefits (EOB) will be issued by the Fund Office.

When you use Operating Engineers Panel Dentists, each panel dentist has a supply of claim forms and will file the claim for you.

To file a claim for non-Panel dentist claims, follow these steps:

1. Complete and sign Part 1 before you visit the dentist. Make sure you include your name and Social Security number, the patient’s name, address, date of birth, and relationship to you, your mailing address and the policy number and insurance company name for any other group coverage you have.

2. Have the dentist complete Part 2 of the claim form and return it to the Fund Office.

Vision Benefits

If you use VSP or United Healthcare Vision (UHC) providers, you will not need to file a claim form. You will pay the amount due from you at the end of the visit and your provider will take care of billing VSP or UHC for the remainder.

If you use a non-VSP or non-UHC provider, you will need to request a copy of the bill showing the amount of the eye examination and send it to:

Vision Service Plan
Attention: Non-Member Doctor Claims
P.O. Box 997100
Sacramento, CA 95899-7100

United Healthcare Vision Claims Department
P.O. Box 30978
Salt Lake City, UT 84130

Be sure to include the participant’s name, mailing address and Social Security number and the patient’s name, relationship to the participant and date of birth.

Hearing Aid Benefit

NOTE: A prescription for a hearing aid is required.

To file a claim for hearing aid benefits, follow these steps:

1. Get a claim form from any Union Office or the Fund Office.

2. Complete your portion of the claim form. Make sure you include your name and Social Security or HCID number, the patient’s name, address, date of birth, and relationship to you, your mailing address and the policy number and insurance company name for any other group coverage you have.

3. Have your physician complete the providers portion of the claim form

4. Send the claim form with an itemized bill showing the cost of the hearing aid device to the Fund Office. The ear in which the hearing aid was placed must also be specified.

Life Insurance and Accidental Death and Dismemberment Benefits

Life Insurance and Accidental Death and Dismemberment claim forms are available from the Fund Office. Provide a copy of the death certificate, and if appropriate, evidence of the accidental nature of the death, to the Fund Office. In the event of dismemberment, notify the Fund Office promptly. A claim form will be sent to you.

For further details, contact the Death Benefits Department at (626) 356-1062.

Weekly Disability Benefit (So. Nevada Only)

Disability forms are available from the Fund Office or the Las Vegas District Office of the I.U.O.E., Local 12. You and your physician must complete the form and return it to the Fund Office for processing.

Note: For services rendered by providers contracting with the Trustees, such as United Concordia Dental Plan or the various HMO'S, the requirements are different and you should get in touch with them if you require information on submitting a claim for reimbursement.

CASE MANAGEMENT

Case Management is a process by which a coordinator works with the patient, the family and the attending physician to develop an appropriate treatment plan and to identify and suggest alternatives to traditional inpatient hospital care. The alternative treatment plan must be accepted by the patient and the attending physician before it is put in place.

Case Management is used to monitor complex and potentially expensive health care problems. Case Management services also provide help to participants with complicated illnesses.

This voluntary program assures that you or your dependent are receiving the most appropriate treatment when medical care is necessary. If you agree to Case Management, the Plan may pay for certain benefits through the Case Management Program that would not otherwise be covered by the Plan. All requests for Case Management are kept strictly confidential in accordance with state and federal laws.

Examples of the type of cases that are appropriate for this program include severe traumatic injury such as burns and spinal cord injury, cancer, stroke, cardiovascular disease, AIDS, organ transplants, chronic infections or diseases, and pain management.

If you or a family member have a serious or complicated medical problem and need assistance, get in touch with the Fund's Information Center and ask to speak to a Case Management Representative before, or as soon as, the patient enters the hospital for acute care.

Important Basics About the Plan