Hospital Benefits

The following describes the hospital benefits provided to participants in the PPO plan.

If you are enrolled in an HMO and are not a Medicare Retiree, please refer to HMO Enrollees. If you are a Medicare Retiree, please refer to Medicare Retirees in an HMO Plan.

Eligibility and Benefit Verification: When verification of benefits and/or eligibility is needed, your physician or hospital must contact the Fund Office Member Services Department at (866) 400-5200. No other entity can verify benefits and/or eligibility.

Inpatient Benefits

When you or an eligible Dependent are a registered hospital bed patient, the Fund provides the benefits outlined below. Payment is limited to the most common semi-private room rate, subject to the following:

• PPO Network Hospital:

The Fund will pay 90% of the Contract Rate.

If either you or your Dependent is hospitalized at the time eligibility terminates, the Plan will continue to provide hospital benefits only until you or your dependent are discharged.

When you obtain care from a PPO network hospital, you simply tell the admitting/billing clerk that you are an Operating Engineers Health & Welfare Fund Participant and have Anthem Blue Cross. The hospital will submit the claim directly to Anthem Blue Cross for you.

• PPO Non-Network Hospital:

The Fund will pay 70% of Reasonable and Customary charges for the first 180 days of confinement.

Pre-Admission Testing

If either you or your eligible Dependent is going to be admitted as an in-patient for non-emergency care, you should have as many of the tests required for admission performed on an outpatient basis before the hospital stay begins. Charges for these tests will be paid at 100% of the Contract Rate (PPO Network provider), or 100% of Reasonable and Customary charges (PPO Non-Network provider). Diagnostic testing is not included in this benefit.

Outpatient Emergency Care

If you do not become a registered bed patient and incur hospital charges in the Outpatient Department of a hospital for care that normally cannot be performed in a doctor’s office or laboratory, the Plan will provide the following coverage:

If the treatment is related to an emergency medical condition (such as, emergency treatment of broken bones, a severe laceration, chest pain, poisoning, choking or convulsions):

• PPO Network Hospital: The Plan will pay 90% of the Contract Rate after satisfaction of the PPO Network deductible.
• Non-PPO Hospital: The Plan will pay 90% of Reasonable and Customary charges after satisfaction of the PPO Non-Network deductible.

If the treatment is NOT related to an emergency medical condition (such as, a sore throat, cold, flu, headaches, aches or pains and dizziness):

• PPO Network Hospital: The Plan will pay 90% of the Contract Rate, subject to a $20 co-payment per visit, after satisfaction of the deductible.
• Non-PPO Hospital: The Plan will pay a maximum of $15 for the emergency room visit after satisfaction of the deductible and 70% of Reasonable and Customary charges for any necessary testing, after satisfaction of the deductible.

Outpatient Surgery Facility

Ambulatory surgery is surgery that is done without staying overnight in the hospital. Ambulatory surgery may be done in the outpatient department of a hospital or in a special facility known as an “Ambulatory Surgery Center”.

Ambulatory Surgery Centers in the Anthem Blue Cross network can be found at www.anthem.com or by calling the Fund Office.

Skilled Nursing Facility

Confinement in a Skilled Nursing Facility is covered, but benefits are limited to a maximum of 100 days of confinement beginning with the first day of admission, and provided:

1. You must be confined in an acute general hospital for at least 3 consecutive days and then transferred to a Skilled Nursing Facility within 30 days.
2. Your doctor must certify that you need daily skilled nursing or rehabilitation services. Skilled Nursing Facilities in the Anthem Blue Cross network can be found at www.anthem.com or by calling the Fund Office.

Hospital Expenses Not Covered by the Plan

Hospital benefits are NOT payable for:

1. Confinement as a result of a work related injury or illness.
2. Cosmetic surgery, except operations necessary to repair or alleviate disfigurement due to an accident or treatment of a congenital defect in a Dependent Child or for breast reconstruction following mastectomy.
3. Confinement in a hospital owned or operated by the U.S. Government, or with respect to court-ordered care, or any care for which you are not required to pay. Confinements at Veterans Administration hospitals are covered only if the charges are for a non-service related illness or injury.
4. Confinements in connection with the fitting or wearing of dentures or treatment of the teeth or gums, except tumors and treatment of accidental injury to natural teeth and fractures due to an accident occurring while covered by the Plan.
5. Personal items such as telephone or television charges, guest trays, personal care items, slippers, etc.
6. Private rooms. Benefits would be paid according to the hospital’s most common semi-private rate.
7. Charges for tests related to elective surgery made by a hospital which are required for admission as a registered bed patient which can be performed on an outpatient basis, unless your attending physician or surgeon requires that such tests must be done on an inpatient basis.
8. Charges incurred at a hospital during a hospitalization for non-emergency elective surgery which are incurred prior to the date of surgery, except that if the attending physician or surgeon requires that pre-admission testing must be done as an inpatient then such tests and the day(s) required for such test will be considered a covered expense.
9. Confinements that begin prior to the effective date of eligibility.
10. Confinements in connection with artificial insemination, in-vitro fertilization (IVF), Zygote intrafallopian organ transfer (ZIFT), gamete intrafallopian transfer (GIFT), intracytoplamic sperm injection (ICSI), and similar procedures, or the reversal of elective sterilizations including drugs used to treat infertility.
11. Hospice care.
12. Custodial care or housekeeping care. Nursing homes are sometimes referred to as Skilled Nursing Facilities but they are not the same. Nursing homes provide long term nursing care for persons who are unable to care for themselves due to disability, senility, and/or old age. This is considered to be “custodial” care.

Audit of Hospital Charges

When you are hospitalized, you are urged to review the itemized bill provided by the hospital. If the hospital has charged for something that was not provided, you should contact the Fund Office immediately. If the error is verified by the Plan’s hospital auditor, you will receive 50% of the amount saved by the Plan up to a maximum of $1,000.

Revised 12/2022