When skilled nursing service or home health care is required in the home, it is always wise to check with the Fund Office to determine if the situation qualifies for coverage.  Situations that require housekeeping and meal preparation are not covered even if nursing has been "prescribed" by a doctor. Contact the Fund's Case Management Department for assistance in coordinating this type of care.

Skilled nursing service and home health care must be ordered by a medical doctor and the duties to be performed by the nurse(s) must be described.  Home health care must be provided by a licensed home health agency.

Home health care and registered nurse visits will be combined.  The Fund will pay a maximum of $70.00 per visit with a limit of 10 visits per year for treatment within 90 days of a hospital confinement of at least 3 days.

FOR A BETTER BENEFIT - Eligible Employees and their eligible Dependents can obtain home health care services, when prescribed by a physician, from PPO contract providers in Southern California and Nevada. Under the PPO contract provisions, the Plan will pay the contracted rate which the provider has agreed to accept. You have no copayment. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

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

Through the Fund’s Fee-for-Service Plan, fees for most immunizations will be reimbursed at 70% of the reasonable and customary charge after satisfaction of the Calendar Year Deductible, as applicable. See above for the Flu Shot benefit.

FOR A BETTER BENEFIT - Eligible employees and their eligible dependents can obtain immunizations, 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 for the immunization. Your co-payment will be 10% of the contract amount. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

   

Infertility or sterility, which is the inability to procreate, is not in itself a bodily illness; therefore treatment is generally NOT covered by the Plan.

If infertility or sterility is caused by an organic illness, the treatment of the underlying illness would be covered by the Plan.

The Fund will pay for the initial exam and diagnostic services necessary to determine if you are infertile or sterile. However, the Fund will NOT pay for services performed to treat the infertility or sterility.

KIDNEY DIALYSIS

Through the Fund's Fee-for-Service Plan, kidney dialysis will be paid at 70% of the reasonable and customary charges after satisfaction of the Calendar Year Deductible, as applicable.

FOR A BETTER BENEFIT - Eligible employees and their eligible dependents can obtain kidney dialysis, 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 a $20 co-payment after satisfaction of the Calendar Year Deductible, as applicable. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

An “organ” is a somewhat independent part of the body that performs a special function or functions. 

The Fund will cover all expenses related to the transplantation of an organ, including patient screening, organ procurement and transportation of the organ, patient and/or donor, surgery for the patient and donor, follow-up care in the home or a hospital, if the following conditions are met:

This transplant benefit is available only if the transplant recipient is eligible with the Plan.

THIS BENEFIT IS NOT AVAILABLE FROM THE FUND FOR A PARTICIPANT ENROLLED IN AN HMO PROGRAM. Donor-related expenses will only be covered if the donor has no other health insurance coverage for the transplant procedure.

In no case will the Fund cover expenses for transportation of surgeons or family members. If the individual is covered by Medicare and the Fund provides the secondary coverage for that individual, no benefits will be provided by the Fund unless the transplant center program is approved by Medicare.

Immunosuppressant drugs are covered under the Plan’s Prescription Drug benefit.

The Plan does not consider a bone marrow transplant to be an organ transplant. Benefits are available according to normal Plan provisions. IMPORTANT: Due to the complexity and expense related to organ transplants, please contact the Fund’s Case Management Department for coordination of services and a full explanation of your coverage.

Foot Orthotics are external devices, other than casts, made specially for each individual person to support or correct a diseased or injured foot. Through the Fund’s Fee-for-Service Plan the Fund will pay 70% up to a $72 maximum per person, per foot after satisfaction of the Calendar Year Deductible, as applicable. Through the Fund’s PPO Plan the Fund will pay 100% of the contract amount up to a $90 maximum per person, per foot after satisfaction of the Calendar Year Deductible, as applicable. Casting is paid under surgery benefits.

Foot Orthotics are covered only once every 12 months for adults and once in a period of 6 months for children under age 19 or up to age 26 if a full-time student. All foot orthotics must be custom made and molded to the patient’s foot. Custom made foot orthotics are covered when prescribed by a physician and prepared by a qualified health professional.

FOR A BETTER BENEFIT – Eligible employees and their eligible dependents can obtain foot orthotics, 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 the contracted rate up to $90 per foot after satisfaction of the Calendar Year Deductible, as applicable. Any balance between the contract amount and the Fund’s payment is the patient’s responsibility. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

  

Through the Fund's Fee-for-Service Plan, fees for oxygen and rental of equipment for administration of oxygen will be reimbursed at 70% of the reasonable and customary charge after satisfaction of the Calendar Year Deductible, as applicable.  You must have a prescription from your physician.    

FOR A BETTER BENEFIT – Eligible employees and their eligible dependents can obtain oxygen and equipment for administration of oxygen, 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 after satisfaction of the Calendar Year Deductible, as applicable. Your co-payment will be 10% of the contract amount. Simply present you Health & Welfare Identification Card along with your doctor's prescription.

Pain Management programs are covered by the Fund but are subject to a limited benefit.  Pain Management programs include comprehensive in-patient and out-patient programs, implantable spinal pain management devices, special pain control devices and medical equipment, epidural steroid injections, nerve blocks and electrotherapy (TEXS).

If the Pain Management Program you intend to use meets the requirements of this benefit under the Rules and Regulations of the Plan, the Fund will pay the appropriate benefit for each type of service rendered. If you require these services please contact the Case Management Department at (626) 356-3519. 

Under the PPO contract provisions, the Plan will pay 90% of the contract amount.  You will be responsible for a $20 co-payment per office visit after satisfaction of the Calendar Year Deductible, if applicable and you will have to pay for any services not covered by the Plan. For consultations, you are responsible for any contractual amount which exceeds the Plan’s $150 consultation maximum.

Through the Fund’s Fee-for-Service Plan physician’s fees for office visits are paid at 100% up to a maximum of $15 per visit after satisfaction of the Calendar Year Deductible, if applicable. There is a limit of 50 visits per calendar year. 

Under the PPO contract provisions, the benefit for an initial consultation with a specialist is paid at 90% of the contract amount minus a $20 co-payment after satisfaction of the Calendar Year Deductible, as applicable. The Fund can only pay for one consultation per medical condition and you must be referred to the specialist by another physician or other appropriate medical professional for an opinion or advice regarding a specific medical condition. The request for consultation or referral must be documented in your medical record and the consulting physician must provide a written report to the referring physician. If these requirements are not met, then charges for an initial consultation with a physician will be processed as a regular office visit after satisfaction of the Calendar Year Deductible.

Through the Fund’s Fee-for-Service Plan physician’s fees for an initial consultation will be paid at 70% of reasonable charges up to a maximum payment of $150 after satisfaction of the Calendar Year Deductible, if applicable. The Fund can only pay for one consultation per medical condition and you must be referred to the specialist by another physician or other appropriate medical professional for an opinion or advice regarding a specific medical condition. The request for consultation or referral must be documented in your medical record and the consulting physician must provide a written report to the referring physician. If these requirements are not met, then charges for an initial consultation with a physician will be processed as a regular office visit with a maximum payment of $15 after satisfaction of the Calendar Year Deductible, if applicable.  

Under the PPO contract provisions the Plan will pay 90% of the contract amount for physician’s visits to the hospital while you are a registered bed patient after satisfaction of the Calendar Year Deductible, if applicable. Charges for follow-up care after surgery which is already included in the surgeon’s fee will not be covered.

Through the Fund’s Fee-for-Service Plan physician’s visits to the hospital while you are a registered bed patient are paid at 70% of reasonable and customary charges after satisfaction of the Calendar Year Deductible, if applicable. Charges for follow-up care after surgery which is already included in the surgeon’s fee will not be covered.

Under the PPO contract provisions, the benefit for a physician’s house call is 90% of the contract amount after satisfaction of the Calendar Year Deductible, if applicable.

Through the Fund’s Fee-for-Service Plan fees for a physician’s house call will be paid at 70% of reasonable and customary charges after satisfaction of the Calendar Year Deductible, if applicable

COMPARISON OF FEE-FOR-SERVICE PLAN BENEFITS vs. PPO PLAN BENEFITS

Fee-for-Service Plan Benefit Example:

A bill for surgical services is in the amount of $2,500. The Plan has an allowance for those services of $1,200. The doctor in this case has charged more than the Plan allows. The $300 Calendar Year Deductible is applied to the $1,200 allowed amount leaving a balance of $900, which is paid at 70%. The Fund pays $630. The out-of-pocket expense to the employee in this case is $1,870.

PPO Benefit Example:

A bill for surgical services is in the amount of $2,500. The PPO contract physician has agreed to accept the contracted amount of $800 for those services. The Fund pays $720 (90% of the contracted amount). The out-of-pocket expense to the participant is $80.

FOR A BETTER BENEFIT - Eligible employees and their eligible dependents can obtain physician care and services from PPO contract physicians 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.

The Fund will pay for physician charges incurred in connection with a routine physical exam once per year. 

Under the PPO contract provisions the Plan will pay 90% of the contract amount up to a maximum payment of $175 after satisfaction of the Calendar Year Deductible, if applicable.

Through the Fund’s Fee-for-Service Plan charges for a routine physical exam are paid at 70% of reasonable and customary charges up to a maximum payment of $150 after satisfaction of the Calendar Year Deductible, if applicable.

Note: The Fund does not provide benefits for therapy or educational programs to correct the developmental problems of a child or learning disabilities such as autism, dyslexia and similar problems.

FOR A BETTER BENEFIT - Eligible employees and their eligible Dependents can obtain speech therapy, 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 the contracted rate which the provider has agreed to accept. You have no copayment. Simply present your Health & Welfare Identification Card along with your doctor’s prescription.

Speech Therapists under contract with Anthem Blue Cross are listed in the Anthem Blue Cross Directory or at www.anthem.com. Speech Therapists 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

No benefits are available for any type of psychiatric or mental health care which is not due to alcohol or drug abuse.

SUBSTANCE ABUSE/CHEMICAL DEPENDENCY TREATMENT: The Plan will provide a MAXIMUM benefit for the treatment of alcohol or drug abuse (drug rehab or alcohol rehab) of $5,000 in 12 consecutive months with a lifetime maximum of $7,500. These maximums are for any combination of inpatient, outpatient, day treatment and counseling services.

Supplies are items that are medically necessary for the therapeutic treatment of an illness or injury. 

Through the Fund's Fee-for-Service Plan, fees for supplies that are covered by the Plan will be reimbursed at 70% of the reasonable and customary charge after satisfaction of the Calendar Year Deductible, if applicable.

The Fund will not pay for these supplies:

The Fund does not cover nutritional supplements, special food, liquid or powdered food supplements.

Through the Fund’s Fee-for-Service Plan office visits to the physician are reimbursed at 100% up to a maximum of $15 after satisfaction of the Calendar Year Deductible, if applicable.  Charges for lab tests will be reimbursed at 70% of the X-Ray/Lab Schedule after satisfaction of the Calendar Year Deductible, if applicable.

FOR A BETTER BENEFIT - Eligible employees and their eligible dependents can obtain weight control program 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.