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MATERNITY
BENEFITS
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| Maternity
benefits are provided for the pregnancy of a dependent spouse or female
Operating Engineer on the same basis as any other illness or disability.
There are no benefits available for any charges related to the pregnancy
or suspected pregnancy of a dependent daughter, including miscarriage and
abortion.
If you are pregnant on the date eligibility terminates, benefits for hospital
and obstetrical care will be payable as if eligibility had not terminated for a
period of up to 90 days after the end of the pregnancy. In other words, the Fund
will pay for the delivery of the child (physician and hospital) even though the
employee previously lost eligibility.
However, charges for the dependent baby will not be covered under this
special provision.
There are no benefits available for services
related to artificial insemination or in-vitro fertilization.
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PHYSICIAN |
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Through
the Fund's Fee-for-Service Plan, the Fund
will pay 70%
of the allowed amount listed in the Surgical Schedule toward the Doctor's
charges for "Total OB Care." The Fund does NOT pre-pay medical benefits in
maternity cases. Payments are made after the birth of the child. Fees for
anesthesia will be
reimbursed at 70%
of the Scheduled Benefit after satisfaction of the
Calendar Year Deductible,
if applicable.
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MIDWIFE |
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Through the
Fund's Fee-for-Service Plan, the
fund does cover the services of Licensed Midwives at 80% of the Reasonable and
Customary fee for their service after satisfaction of
the Calendar Year Deductible, if applicable.
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BIRTHING CENTERS
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Birthing
centers provide an alternative to hospital delivery.
They are often separate from a hospital and provide a homelike
environment. The Plan provides
maternity benefits for birthing centers.
Charges are paid at 100% of the reasonable and customary fees, with a $1,200
maximum per delivery,
and the Calendar Year Deductible will be waived.
The $1,200 benefit includes the baby's hospital charges.
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CARE OF NEWBORNS
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All hospital services and supplies necessary for the care of a newborn child
during hospital confinement, including routine nursery care, will be paid in
accordance with the hospital benefits described below.
The employee must be eligible at the time of service in order for
these benefits to be provided.
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VOLUNTARY
STERILIZATION
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The Fund will cover Voluntary Sterilization. It will not cover the reversal
of voluntary sterilization.
Benefits for the surgical procedure
are paid at
70%
of the listed amount in the Surgical Schedule after satisfaction of
the Calendar Year Deductible,
if applicable.
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ADOPTION
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The
Fund will provide medical and hospital benefits toward charges for the birth of
a child who is in the process of being legally adopted by the participant.
The Fund will NOT cover the birth mother's charges.
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REQUIREMENTS:
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Adoption
proceedings usually take about 6-12 months before the adoption becomes final.
Therefore, the Fund will require a copy of documents from the attorney
handling the adoption or from the court showing that the adoption is in
progress.
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The child will be covered from the day he or she begins to live with the
employee. The Fund cannot
consider any child as an eligible dependent unless he or she is living with the
employee. |
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FETAL
MONITORING
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Pre-term
fetal monitoring is not covered by the Plan because it is not considered to be
medically necessary by the American Board of Obstetricians & Gynecologists.
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HOSPITAL |
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Click
here to read about your hospital benefits.
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FOR A BETTER BENEFIT |
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Eligible employees
and their
eligible dependent
spouse can obtain maternity benefits from PPO contract providers at several
locations in Southern California and Nevada. Under the PPO contract provisions,
the Plan will pay 90% of the contracted rate
(minus any co-payment) after satisfaction of the Calendar Year Deductible, if
applicable.
Simply present your Health & Welfare Identification Card.
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 on AHF's website.
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NEWBORNS'
AND MOTHERS' HEALTH PROTECTION ACT (NMHPA)
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| This
Plan complies with a federal law that prohibits restricting benefits for any
hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a normal vaginal delivery, or less than 96
hours following a cesarean section. However, Federal law generally does not
prohibit the mother's or newborn's attending provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96
hours as applicable). In any case, this Plan does not require that a health care practitioner
obtain authorization from the Plan (or its utilization review company) for
prescribing a length of stay up to 48 hours (or 96 hours following a cesarean
section). |
