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OPERATING ENGINEERS
TRUST FUNDS

Medical Coverage

In this Section:

  1. Medical Benefits
  2. LiveHealth Online
  3. Hospital Benefits
  4. Medical and Hospital Benefit Exclusions
  5. Member Assistance Program (MAP)
  6. Mental Health and Substance Abuse Benefits
  7. Prescription Drug Benefits
  8. Vision Benefits
  9. Dental Benefits

For Active and Retired Participants, Excluding Medicare Retirees.

Types of Medical Coverage Available

The Fund offers two types of medical coverage:

  • Preferred Provider Organization (PPO)
  • Health Maintenance Organization (HMO)

Preferred Provider Organization (PPO)

The PPO is available to all Participants. This is a network of hospitals, doctors, physical therapists, chiropractors and hearing aid suppliers who offer services at a special contracted rate. The Plan’s PPO is Anthem Blue Cross nationwide.

When you use hospitals and doctors in the PPO network, you will have lower deductibles and co-payments. You may use hospitals and doctors outside of the network, but your out-of-pocket costs will be higher. This non-network PPO benefit was formerly called the “Fee-for-Service Plan”.

The PPO program requires no enrollment. If you are not enrolled in an HMO, you are automatically part of the PPO. You cannot use PPO providers if you are enrolled in an HMO. If you or your Dependents have primary coverage with another plan, you may choose PPO providers but the Plan will coordinate benefits as outlined in Coordination of Benefits.

Health Maintenance Organization (HMO)

Currently, the Plan offers three HMOs:

  • Kaiser Permanente
  • Anthem Blue Cross
  • Health Plan of Nevada (limited to Nevada Participants)

The Kaiser and Anthem Blue Cross HMOs are available to Active Participants and non-Medicare Retirees.

Health Plan of Nevada is available to all Active and Retired Participants. An HMO is an organization to whom the Fund pays a fee to provide medical coverage to you and your dependents. Except for small copayments and non-covered items, you make no direct payment for medical treatment. You must enroll to be covered under an HMO.

Deductibles

The following calendar year deductibles apply:

Type of Plan Calendar Year Deductible
PPO Network $250 per person/ $750 per family
PPO Non-Network $500 per person/ $1,500 per family
HMO None charged by the HMO. Claims submitted for services not covered by the HMO, but covered by the PPO plan, are subject to the PPO Non-Network Deductible

The deductibles under the PPO plan do not apply to:

  • Inpatient Hospital Confinement
  • Pre-admission Testing
  • Outpatient hospital or ambulatory surgery center charges incurred in connection with a surgical procedure
  • Emergency Ambulance Transport (ground and air)
  • Home health agency charges
  • Birthing Center charges
  • Covered expenses for Eligible Individuals for whom Medicare is primary
  • Preventative health services as required by applicable federal law and regulations

Deductible Waiver

In the event an individual eligible for benefits under the Plan had no covered medical expenses submitted to or paid by the Plan for a calendar year, the deductible for the immediately following calendar year will be waived. This deductible waiver is only available to individuals who were eligible for the entire calendar year immediately preceding the calendar year for which the deductible is being waived and will not apply to Medicare Primary Retirees or dependents of Retirees that are Medicare Primary.

Out-Of-Pocket Calendar Year Maximums

The maximum out-of-pocket amount you and your family pay for covered expenses each calendar year:

Type of Plan Calendar Year Out-of-Pocket Maximum
PPO Network $3,000 per person/ $6,000 per family
PPO Non-Network $6,000 per person/ $12,000 per family
CVS Caremark – Rx Network $3,600 per person/ $7,200 per family
HMO
Kaiser Permanente $1,500 per person/ $3,000 per family
Anthem Blue Cross $1,500 per person/ $3,000 for two family members/ $4,500 for three or more family members
Health Plan of Nevada $6,000 per person/ $12,000 per family

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 both the patient and the physician. It will not be imposed by the Fund unless the patient and the physician both agree to it.

Case Management can help with a wide variety of complex and potentially expensive health care problems including burns, spinal cord injuries, cancer, stroke, cardiovascular disease, AIDS, organ transplants, chronic infections or disease, and pain management. The case management team can also assist in arranging hospice care. The program assures that the patient is receiving the most appropriate
treatment. If you agree to case management, the Plan may pay for certain benefits that would not otherwise be covered by the Plan.

This program is totally voluntary. Its purpose is to benefit the patient and is provided as part of the benefit plan so there is no additional cost to the patient.

If you or a family member has a medical condition that may qualify for this program, you should contact a Case Management Representative at the Fund Office before, or as soon as, the patient enters the hospital or before beginning any other complex treatment.

Pain Management Programs

Pain Management programs are covered by the Fund when Medically Necessary. These types of services include, but are not limited to:

  • Comprehensive inpatient and outpatient pain management programs
  • Implantable spinal pain management devices
  • Special pain control devices or medical equipment

All types of pain management programs should be arranged and initiated by the Case Management Department prior to the beginning of service. You must submit a complete description of the program or therapy, along with an estimate of the related costs and all medical records relating to the patient’s disorder and reason for medical necessity, to the Fund’s Case Management Department.

Personal Injury Liability

If you or your covered dependents are injured by someone else (for example, in an automobile collision or a slip and fall accident) the Fund will pay benefits on medical claims arising from the injury only if you do BOTH of the following:

  • Sign a lien or agreement in a form acceptable to the Fund Office in which you acknowledge and agree that the Fund has the right to all or a portion of damages you collect for your injuries to the extent of the benefit the Fund paid. The lien applies to all amounts you recover for your injuries, including amounts you collect from your own insurance (for example, 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 to collect damages for
    your injuries.
  • Reimburse the Fund for the benefits it paid from any settlement or judgment you collect for those injuries. If you do not reimburse the Fund as required, future benefit payments will be withheld and applied to the amount you owe until the full amount is reimbursed. You are required to file a claim with the third party insurance. If you fail to do so, you will be responsible to pay the bills you incurred as a result of the injury. The Fund will not pay these bills.

Worker’s Compensation Policy

The Fund does not cover expenses in connection with work-related injuries or illnesses whether or not the Employee has Worker’s Compensation Insurance through their employer or makes a claim for Worker’s Compensation benefits. No benefits are payable from the Fund, even if the work-related injury occurred in the past and the case has already been closed.

Overpayments

If an overpayment occurs in connection with a claim for benefits, the Fund Office is required to recover the over-payment regardless of the reason for the overpayment.

The Trustees expect immediate payment. However, if that is not possible, a schedule of payments may be arranged with the Fund Office and, if that is not acceptable, the Fund Office is required to offset the payment of future claims against the overpaid amount until complete recovery is made.

If you have an existing over-payment with the Fund Office, you cannot enroll in an HMO until the over-payment has been recovered in full by the Fund.

Care in a Foreign Country

Medical claims incurred in foreign countries are covered by the Fund for treatment that is approved, legal and accepted practice in the United States. If you are planning to obtain non-emergency medical treatment in a foreign country, you should get pre-approval from the Fund Office, otherwise the claim may be denied.

The Plan covers only medical services and supplies reasonably necessary for the care and treatment of bodily injury or sickness. Whether such services or supplies are reasonably necessary is determined by the Trustees based on the opinions and decisions of recognized medical authorities and the U.S. Food and Drug Administration.

PPO Plan Benefits

The following is a brief outline of the benefits available under the PPO Plan. Further details of the benefits covered, exclusions and limitations can be found in the pages that follow and in the Rules and Regulations of the Plan.

PPO Plan Benefits (Professional Services)
Professional Services PPO Network PPO Non-Network
Office Visits Plan pays 90% of the Contract Rate after a $20 co-payment Plan pays a maximum of $15 per visit
Hospital Visits Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary Charges
Surgical Facility Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Lab and X-Ray Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Therapy: Acupuncture, Chiropractic & Physical Therapy
  • Chiropractic: Plan pays 50% of the Contract Rate;
  • Acupuncture and Physical Therapy: Plan pays 90% of the Contract Rate after a $20 co-payment per visit.

Acupuncture and Chiropractic services have a combined limit of 26 visits per year.

Plan pays a maximum of $15 per visit

Acupuncture and Chiropractic services have a combined limit of 26 visits per year

Speech Therapy Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges up to a maximum of $15
Routine Physicals Plan pays 90% of the Contract Rate up to a maximum of $175 for one annual routine physical. Plan pays 70% of Reasonable and Customary charges up to a maximum of $150 for one annual routine physical
Surgeon Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Assistant Surgeon Plan pays 90% of the Contract Rate for second surgeon, assistant surgeon, second assistant surgeon, and physician assistant. Plan pays 70% of Reasonable and Customary charges for second surgeon, assistant surgeon, second assistant surgeon, and physician assistant.
Anesthetist Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Deductible $250 per individual per calendar year; maximum $750 per family (Applicable to most services) $500 per individual per calendar year; maximum $1,500 per family (Applicable to most services)
Annual Out-of-Pocket Maximum: Medical and Pediatric Dental & Vision $3,000 per individual;
$6,000 per family per calendar year
$6,000 per individual;
$12,000 per family per calendar year
Annual Out-of-Pocket Maximum: Rx $3,600 per individual;
$7,200 per family per calendar year
Not Applicable

 

PPO Plan Benefits (Hospital Services)
Hospital Services PPO Network PPO Non-Network
Inpatient Care:
Semi-Private Room and Miscellaneous Charges
Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Outpatient Care Plan pays 90% of the Contract Rate Plan pays a maximum of $15 for Emergency Room Visit;
70% of Reasonable and Customary charges for Lab and X-Ray charges
Emergency Room Care: Non-Emergency Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Emergency Room Care: Emergency Related Surgical Facility Plan pays 90% of the Contract Rate Plan pays 90% of Reasonable and Customary charges
Inpatient Psychiatric Care Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Inpatient and Outpatient Alcohol and Substance Abuse Care (covered through MHN) Plan pays 90% of the Contract Rate Plan pays 70% of Reasonable and Customary charges
Skilled Nursing Facility Plan pays 90% of the Contract Rate with a 60-day maximum per confinement Plan pays 80% of Reasonable and Customary charges with a 60-day maximum per confinement

 

PPO Plan Benefits (Other Services)
Other Services PPO Network PPO Non-Network
Ambulance Emergency Transport:
Plan pays 80% of the Contract
Rate (deductible waived) Non-Emergency Transport:
Plan pays 80% of the Contract
Rate (deductible applies)Transport Between In-Network
Hospitals:

Plan pays 100% of the Contract
Rate. The deductible is waived
Emergency Transport:
Plan pays 80% of Reasonable and
Customary charges (deductible
waived)
Non-Emergency Transport:

Plan pays 70% of Reasonable and
Customary charges (deductible
applies)Transport between In-Network
Hospitals:

N/A
Durable Medical
Equipment
Plan pays 90% of the Contract
Rate, not to exceed purchase
price
Play pays 70% of Reasonable and
Customary charges, not to exceed
purchase price
Prosthetic Appliances Plan pays 90% of the Contract
Rate
Plan pays 70% of Reasonable and
Customary charges

Revised 01/2020

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