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OPERATING ENGINEERS
TRUST FUNDS

Health Maintenance Organizations (HMOs)

Kaiser, Anthem Blue Cross and Health Plan of Nevada

Eligible Employees living within certain areas may choose to enroll and be covered by an HMO instead of the PPO medical and hospital plan. The Kaiser and Anthem Blue Cross Plans are available only to Active Participants and non-Medicare Retired Participants. Health Plan of Nevada is available to all Active and Retired Participants residing in Nevada.

Employees may enroll upon becoming eligible and at the beginning of each calendar month.

The following HMOs are offered by the Fund:

HMO Eligible Employees Conversion Information* Contact for Questions
Kaiser Permanente
Health Plan
Residents of areas where Kaiser facilities exist Kaiser Membership Services
(800) 464-4000
Kaiser Membership Services
(800) 464-4000
Anthem Blue Cross Residents of areas where Anthem Blue Cross facilities exist Anthem Blue Cross
(800) 522-0088
Anthem Blue Cross
(800) 522-0088
Health Plan of Nevada Residents of Nevada HPN Membership Services Department
(800) 777-1840
HPN Membership Services Department
(800) 777-1840

*If coverage stops for you or any of your covered dependents because of loss of eligibility, you and/or your dependents may enroll in the HMO’s conversion plan.

HMO Rules

  1. If you want to be covered by one of these HMOs, you must complete the appropriate enrollment form and submit it to the Fund Office. For information and forms, contact the Fund Office.
  2. If you have an existing overpayment with the Fund, you cannot enroll in an HMO. The Fund will have to recover the overpayment in full from you before your HMO enrollment can be accepted.
  3. Continued enrollment in an HMO depends on continued eligibility in the Health and Welfare Plan. If you lose eligibility, you must re-enroll in the HMO when you regain eligibility. Re-enrollment after loss of eligibility is not automatic.

With the exception of the COBRA Core Plan, you and your family will continue to be covered under the Fund’s Life Insurance (Active Employees only), vision care, Accidental Death & Dismemberment (Active Employees only), dental benefits and hearing aid programs regardless of which Health Plan option you choose.

Operating Engineers Health & Welfare Fund HMO Benefit Summary

The following is a brief description of the benefits available under the HMO plans. Please refer to each plan’s brochure for a complete benefit description, as well as their plan exclusions and limitations. A copy of this material is available from the fund office or the HMO directly.

HMO Benefit Summary
Item Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Deductible
None
None
None
Calendar Year Maximum
None
None
None
Annual Out-of-Pocket Maximum $1,500 per person;
$3,000 for two or more family members
$1,500 per person;
$3,000 for two family members;
$4,500 for three or more family members
$6,000 per person;
$12,000 per family

 

HMO Benefit Summary (Professional Services)
Professional Services Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Office Visits $25 co-pay per visit $25 co-pay per visit $5 co-pay per visit
Hospital Visits $250 co-pay per admission $250 co-pay per admission Inpatient: $300 co-pay per admission;
Outpatient: $200 co-pay per surgery
Lab and X-Ray $10 co-pay per service
No Charge
$5 co-pay per service (lab);
$10 per service (x-ray)
Alternative Therapy: Acupuncture, Biofeedback, Chiropractic, Physical Therapy (PT) $25 co-pay per visit (see Kaiser’s Summary of Benefits for details) $25 co-pay per visit $5 co-pay per visit for PT and chiropractic (see HP of Nevada’s Summary of Benefits for details.)
Speech Therapy $25 co-pay per visit $25 co-pay per visit $5 co-pay per visit
Routine Physicals $25 co-pay per visit $25 co-pay per visit $5 co-pay per visit
Surgeon
No charge
No charge
$100 per surgery (hospital);
$50 per surgery (surgical facility)
Assistant Surgeon
No charge
No charge
No Charge
Assistant Surgeon
No charge
No charge
No Charge
Anesthetist
No charge
$35 co-pay per occurrence $100 co-pay per surgery
Urgent Care Services $25 co-pay per visit $35 co-pay per visit $20 co-pay per visit

 

HMO Benefit Summary (Hospital Services)
Hospital Services Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Inpatient Care Semi-private Room and Miscellaneous Charges $250 co-pay per admission $250 co-pay per admission $300 co-pay per admission
Outpatient Care Emergency Room Care $100 co-pay per visit; waived if admitted $100 co-pay per visit; waived if admitted $150 co-pay per visit; waived if admitted
Surgical Facility $250 co-pay per occurrence $250 co-pay per occurrence $50 co-pay per surgery
Inpatient Psychiatric Care $250 co-pay per admission $250 co-pay per admission $300 co-pay per admission
Inpatient Alcohol and Substance Abuse Care
  • $250 co-pay per admission for detoxification;
  • $100 co-pay per admission for transitional residential recovery services;
  • Maximum of 60 days per calendar year, not to exceed 120 days in any 5 year period
$250 co-pay per admission for detoxification only $300 co-pay per admission
Skilled Nursing Facility Maximum of 100 days per benefit period (2/1-1/31) $250 co-pay per admission;
Maximum of 100 days per calendar year
$300 co-pay per admission; waived if admitted from an acute care facility; Maximum of 100 days per calendar year

 

HMO Benefit Summary (Other Services)
Other Services Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Ambulance $50 co-pay per trip $50 co-pay per trip $150 co-pay per trip
Hearing Aids
Not covered
Not covered
$0 co-pay
Durable Medical Equipment No charge, including diabetic testing supplies
No charge
$0 co-pay subject to maximum
Prosthetic Appliances
No charge
No charge
$750 co-pay per device; subject to maximum benefit

 

HMO Benefit Summary (Prescription Drugs)
Prescription Drug Procurement Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Contract Prescription Card Walk-in (30 day supply) For generic drugs at Kaiser pharmacies, you pay:

  • $10 for up to a 31 day supply;
  • $20 for a 100 day supply

For brand name drugs at plan pharmacies, you pay:

  • $25 for up to a 31 day supply;
  • $50 for a 100 day supply
At contract pharmacies, you pay:

  • $10 for a generic drug on the Anthem Blue Cross recommended drug list (RDL);
  • For a RDL brand name drug, you pay $30;
  • For a drug not listed on the RDL, you pay 50% of the drug cost
At contract pharmacies, you pay:

  • $7 for a Tier I drug;
  • For a Tier II drug with NO generic equivalent you pay $30;
  • For a Tier III drug you pay $50 per prescription
Mail Order (90 day supply) For generic drugs, you pay:

  • $10 for up to a 30 day supply;
  • $20 for a 31 to 100 day supply
You pay twice the applicable co-pay as outlined above You pay 2.5 times the applicable co-pay as outlined above

 

HMO Benefit Summary (Vision Care)
Vision Care Kaiser Plan Anthem Blue Cross Plan Health Plan of Nevada
Eye Examination $25 co-pay per visit $25 co-pay per visit Through Vision
Service Plan (VSP)
Eye Lenses/Frames Through VSP:

  • $25 co-pay
  • Lenses covered once every 24 months
  • Frames covered once every 24 months

For the Member Only: Extra pair of glasses or lenses every 24 months for a $65 co-pay

Through VSP:

  • $25 co-pay
  • Lenses covered once every 24 months
  • Frames covered once every 24 months

For the Member Only: Extra pair of glasses or lenses every 24 months for a $65 co-pay

Through VSP:

  • $25 co-pay
  • Lenses covered once every 24 months
  • Frames covered once every 24 months

For the Member Only: Extra pair of glasses or lenses every 24 months for a $65 co-pay

Optional Limited Coverage Retiree Plan (Plan L)

The Fund offers a lower-cost plan for Retired Participants. Plan L enables Retired Participants to obtain medical and hospital coverage elsewhere at the Participant’s cost. For example, Participants may already be covered by Medicare or their spouse’s employment-related health coverage. Under Plan L, all of the Participant’s medical and hospital care must be obtained through Medicare or the other plan. The Fund will not provide secondary coverage. The Fund will only cover prescription drugs, dental, vision, hearing aids and death benefits.

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