Retiree Health & Welfare
Health & Welfare Plan
Glossary of Terms
Active Employee, Active Participant or Participant
Any person who, by reason of their employment, meets the eligibility requirements for participation in the Plan.
Allowed Amount or Allowed Charges
The amount established by the Plan as the amount payable for benefits covered by the Plan.
Ambulatory Surgical Center
A freestanding outpatient surgical facility. It must be licensed as an outpatient clinic according to state and local laws and must meet all requirements of an outpatient clinic providing surgical services. It must also meet accreditation standards of the Joint Commission on Accreditation of Health Care Organizations or the Accreditation Association of Ambulatory Health Care.
Assignment of Benefits
An authorization to the Plan to pay the Physician, hospital or other provider of service directly for the benefits received.
The Plan accepts an assignment of benefits for all services except the following:
- Prescription drugs
- Vision benefits if benefits are received from a Physician other than a Vision Service Plan provider.
- Certain health care providers as designated by the Trustees. At your request, the Fund Office will provide a complete list of providers to whom you cannot assign benefits. You should check with the Fund Office to see if the plan allows benefit assignment to the Hospital, Doctor or other provider treating you.
A facility equipped and operated solely as a setting for prenatal care, delivery and immediate postpartum care for patients with low risk pregnancies.
A Birthing Center may be free-standing, Hospital-based or Hospital associated. It must be licensed under the direction of an MD or DO specializing in obstetrics and gynecology. It shall provide skilled nursing services under the direction of an RN or certified nurse midwife in the delivery and recovery rooms and have a written agreement with an area Hospital for immediate transfer in case of emergency.
A program in which a coordinator works with the patient, his or her Physician, his or her family, and the Plan to decide on an appropriate treatment plan. Case Management is generally used in cases of catastrophic or chronic sickness or injury.
A registered nurse who has gained the special knowledge and skills of midwifery in an educational program accredited by the American College of Nurse-Midwives and who is licensed in the State of California by the Board of Registered Nursing as a Nurse Midwife.
The amount a PPO Network provider has agreed to accept as the total charge. PPO Network providers cannot bill you for covered charges in excess of the Contract Rate.
Coordination of Benefits
The method of dividing responsibility for payment among the health plans that cover an Eligible Individual so that the total of all reasonable expenses for covered services will be paid.
Co-payment or Coinsurance
Any amount you are responsible to pay after the Fund has provided benefits. This is your portion of the cost of care and is also called your “out-of-pocket” expense.
Surgery which is performed merely for the purpose of improving the appearance of the individual.
The amount of covered expenses you must pay before the Plan begins to pay. Deductibles may be higher when you use non-network providers.
A Dentist licensed to practice dentistry in the state or county in which he or she renders treatment and is not the spouse, child, brother, sister or parent of the Participant or the Participant’s Dependent.
A dental technician who is licensed to make and fit dentures without the supervision of a Dentist. A Denturist is not responsible for making any type of diagnosis or carrying out any other treatment (e.g., removing teeth). Denturists are not licensed to practice in every state.
Individuals who meet the Plan’s requirement to be covered by the Plan as a result of their relationship to the Participant. See pages 9-12.
Dental Health Maintenance Organization (DHMO)
An organization which contracts with the Plan to provide complete, pre paid-dental coverage for Plan participants and their Dependents. The Plan has contracts with United Concordia and Delta Dental.
Doctor or Physician
A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Certified Nurse Practitioner, Licensed Professional Counselor, Licensed Professional Physical Therapist, Midwife, Occupational Therapist, Optometrist (O.D.), Physiotherapist, Psychiatrist, Psychologist (PhD), Speech Language Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license. A Physician cannot be the employee or the employee’s Dependent or any person who is the Spouse, parent, child, brother or sister of the employee or the employee’s Dependents.
A surgery which is not a matter of life or death – a surgery which can be performed at any time. It does not include any surgery which must be performed immediately in order to protect the health and life of a person.
Participants and each of their eligible Dependents.
Emergency Medical Condition
A medical condition manifesting itself by acute symptoms of severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual in serious jeopardy; or
- Serious impairment of bodily functions; or
- Serious dysfunction of any bodily organ or part.
- Any treatment which is not recognized by the American Medical Association and the California Medical Association as having medical significance or therapeutic value to the patient;
- Any course of treatment making use of devices or drugs not yet approved by the U.S. Food and Drug Administration;
- Drugs approved by the U.S. Food and Drug Administration used in a course of treatment which is not generally accepted medical practice or which is not covered by Medicare.
Health Maintenance Organization (HMO)
An organization which contracts with the Plan to provide complete pre-paid medical coverage for Plan Participants. The Plan has contracts with Kaiser, Anthem Blue Cross and Health Plan of Nevada HMOs.
Home Health Agency
An organization or agency which meets the requirements for participation as a “Home Health Agency” under Medicare.
Only an institution which meets the following requirements:
- Maintains a permanent full-time facility for bed care of five or more resident patients; and
- Has a Physician in regular attendance; and
- Continuously provides 24-hour-a-day nursing service by Registered Nurses; and
- Is primarily engaged in providing diagnostic and therapeutic facilities for medical and surgical care of injured and sick persons on a basis other than as a rest home, nursing home, Skilled Nursing Facility, a place for the aged or a place for drug addicts, and is operating lawfully in the jurisdiction where it is located;
- Is recognized by the Board of Trustees by name, on a specific basis, and is primarily operated in providing Physician-related inpatient medical treatment of alcoholism, chemical dependency or mental health services.
Procedures or treatments that have progressed to limited use on humans, but which are not widely accepted as proven effective procedures with the organized medical community.
A bill from a provider of service which has a breakdown for each specific service rendered and an individual price for each service. The itemized bill is provided for each individual patient. The Plan will accept itemized billing as long as all of the information indicated above is provided, as well as:
- The Participant’s name
- The patient’s name
- The Participant’s Social Security Number or Operating Engineers Identification Number (OEID)
- The diagnosis, place of service
- The provider’s name, address, National Provider Identifier (NPI), and Federal Tax ID Number
Medically Necessary procedures, supplies, equipment or services are those considered to be:
- Appropriate and necessary for the diagnosis or treatment of the medical condition;
- Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease;
- Provided for the diagnosis or direct care and treatment of the medical condition;
- Within standards of good medical practice within the organized medical community;
- Not primarily for your convenience, or for the convenience of your physician or another provider;
- Not more costly than an equivalent service or sequence of services that is medically appropriate and is likely to produce equivalent therapeutic or diagnostic results in regard to the diagnosis or treatment of the patient’s illness, injury, or condition;
- The most appropriate procedure, supply, equipment or service which can safely be provided. The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
- There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
- Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable.
- Is not conducted for research purposes, unless as part of a covered clinical trial;
- It is the most appropriate supply or level of care needed to provide safe and adequate care. Also, the site of the service must be the most appropriate due to the inherent clinical condition of the patient or to the nature of the services provided.
A health plan offered by private insurers approved by Medicare. Medicare pays these companies to cover all of your Medicare benefits:
- Part A: Hospital benefits
- Part B: Professional services
- Part D: Prescription drug benefits
Often times, these health plans offer services and benefits beyond traditional Medicare.
A physical condition in which the Eligible Individual has a Body Mass Index (BMI) greater than, or equal to, 30 and has serious medical conditions.
Operating Engineer Identification Number (OEID)
A randomly generated number used to identify the Active or Retired Participant and his/her Dependents as reflected on the Participant’s Anthem Blue Cross or Fund issued ID card.
A Dentist with additional specialist training in correcting defects in the teeth and is board eligible to practice orthodontia in his/her state.
PPO Plan Dentist
Any Dentist contracted with the Plan, or one of the Plan’s contracted dental PPO insurers to provide dental services and supplies at a fixed rate.
The Rules and Regulations of the Operating Engineers Health and Welfare Fund for Active Employees and the Rules and Regulations of the Operating Engineers Health and Welfare Fund for Retired Employees.
Preferred Provider Organization (PPO)
An organization consisting of a network of providers which has contracted with the Plan to provide benefits at certain prices. Services from PPO network providers give you the best value for your health dollar. The Plan uses Anthem Blue Cross as the medical PPO nationwide.
Qualified Medical Child Support Order (QMCSO)
An order by a court resulting from a divorce which designates one parent to pay for a child’s health coverage and which meets all of the federal legal requirements for this type of order.
Reasonable Charge/Reasonable and Customary Charge
For covered services performed by a provider participating in the PPO Network, the maximum Reasonable and Customary Charge will be the Contract Rate that the provider has agreed to accept as reimbursement for the provided covered services from the PPO Network. For covered services performed by a provider not participating in the PPO Network, the maximum Reasonable and Customary Charge will be based on the applicable PPO Network non-participating provider rate or fee schedule, an amount negotiated by the PPO Network or a third party vendor which has been agreed to by the non-participating provider, an amount derived from the total charges billed by the non-participating provider, an amount based on information provided by a third party vendor, or an amount based on reimbursement or cost information from the Centers for Medicare and Medicaid Services (CMS).
Important: Because the PPO Network (Anthem Blue Cross) may change its determination of what is a Reasonable and Customary Charge for any particular treatment or service at any time, you should check with both the provider of service and Anthem before you consent to receive treatment or service from a Non-PPO Network Provider. Ask both the provider of service and Anthem what the maximum allowed amount is for the treatment or service you are requesting. Neither Anthem nor the Fund will give notice of these changed calculations; so it is very important that you inquire about them. You should do this even if you have had the same treatment or procedure in the past, because Anthem may have changed the maximum allowed amount since your last treatment. A change in what Anthem considers to be Reasonable and Customary Charge and what will be the maximum allowed amount for a treatment or service could mean a change in hundreds or even thousands of dollars in your out-of-pocket cost.
A registered graduate nurse who does not ordinarily reside in the Participant’s home and is not the spouse, parent, brother or sister of the Participant or the Participant’s Dependent.
Retiree/Retired Participant/Retired Employee
Any person who, by reason of their retirement, meets the eligibility requirements for participation in the Plan. A Medicare Retiree is a Retiree who is either under or over age 65 and eligible for Medicare.
Schedule of Dental Procedures
The description of dental procedures and the maximum amounts payable as set forth by the Board of Trustees as amended from time to time.
Skilled Nursing Facility
An institution which is primarily engaged in providing inpatients with: (1) skilled nursing care and related services for patients who require medical or nursing care, or (2) rehabilitation services for the rehabilitation of injured, disabled or sick persons, which meets all of the following requirements:
- Is regularly engaged in providing skilled nursing care to sick and injured persons under 24-hour-a-day supervision of a Physician and surgeon (MD) or graduate Registered Nurse (RN)
- Has available at all times the services of a Physician and surgeon (MD) who is a staff member of a general hospital
- Has on duty 24 hours a day a graduate Registered Nurse (RN), Licensed Vocational Nurse (LVN), or skilled practical nurse, and has a graduate Registered Nurse (RN) on duty at least eight hours per day
- Is not, other than incidentally, a place for custodial care, a place for the aged, a place for drug addicts, a place for alcoholics, a hotel, or a similar institution
- Complies with all licensing and other legal requirements, and is recognized as a “Skilled Nursing Facility” by the secretary of Health and Human Services of the United States in accordance with the Social Security Amendments Act of 1965
A legal Spouse, including same-sex Spouse. Same-sex or opposite sex domestic partners do not qualify as a Spouse.
With respect to an Active Participant, prevention by reason of bodily injury or sickness from engaging in any occupation for wages or profit, and with respect to a Dependent, prevention by reason of bodily injury or sickness, from engaging in normal activities.