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:

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:

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. 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.

This program is totally voluntary and assures that the patient is receiving the most appropriate treatment. 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.

Once your treatment has begun, the Case Management process can be initiated by your provider through Anthem’s Utilization Management team by calling 800-274-7767.

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, and special pain control devices or medical equipment.

All types of pain management programs should be arranged and initiated by your provider with Anthem’s Utilization Management team by calling 800-274-7767 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.

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.

Revised 07/2024