IMPORTANT NOTICE

TO:                  ALL PARTICIPANTS

SUBJECT:       NEW CONTRACT PROVIDER NETWORK IN NEVADA

Effective April 1, 2008 the Fund will no longer contract with Affiliated Health Funds (AHF) in Nevada.  The new Preferred Provider Organization (PPO) in Nevada will be the Anthem Blue Cross & Blue Shield PPO.

Your freedom of choice is retained with this arrangement.  You may continue to select the doctors and hospitals of your choice.  However, choosing doctors and hospitals from the Anthem Blue Cross & Blue Shield PPO participating network will result in less out-of-pocket expense to you. 

The Trustees have incentives in the plans to encourage participants to use contract providers. These are the same incentives that were in effect when AHF was the contracted network. Those incentives are described below:

INPATIENT HOSPITAL BENEFITS - ACTIVE PLAN

Blue Cross Hospital - The Fund will pay according to the negotiated contract rate.  You are responsible for 10% of the hospital's charge. Your co-payment will not exceed $500 per confinement.  The deductible is waived.

Non-Blue Cross Hospital -

1.      If you live within 20 miles of a Blue Cross contract hospital and you use a non-Blue Cross contract hospital in your area, the Fund will pay only 70% of the covered charges, per confinement and you will be responsible for 30% of the hospital's charge plus any non-covered charges.  The deductible is waived.

2.      If there is no Blue Cross contract hospital within 20 miles of your home, the Fund will pay 80% of the first $10,000 of allowed charges and 100% thereafter, per confinement, and the deductible is waived.

INPATIENT HOSPITAL BENEFITS - RETIREE PLAN (Non-Medicare Participants)

Blue Cross Hospital - The Fund will pay according to the negotiated contract rate.  You are responsible for 10% of the hospital's charge. Your co-payment will not exceed one-half of the covered expenses, or $2,000, whichever is greater.

This represents a savings of 10% or more to the retired member who uses a Blue Cross hospital.

Non-Blue Cross Hospital -

1.      If you live within 20 miles of a Blue Cross contract hospital and you use a non-Blue Cross hospital in your area, the Fund will pay only 70% of the covered charges, per confinement, after satisfaction of the calendar year deductible and you will be responsible for 30% of the hospital's charge plus any non-covered charges.

2.      If there is no Blue Cross contract hospital within 20 miles of your home, the Fund will pay 80% of the allowed charges per confinement after satisfaction of the calendar year deductible. 

HOSPITAL EMERGENCY ROOM SERVICES - ACTIVE AND RETIREE PLANS

If the treatment is emergency related and you use the emergency room facilities of a non-Blue Cross hospital, the Fund will pay 80% of the usual and customary charges after satisfaction of the calendar year deductible. 

If the treatment is emergency related and you use the emergency room facilities of a Blue Cross contract hospital, the Fund will pay 90% of the allowed amount.  This represents a savings of 10% to the member who uses the emergency room facilities of a Blue Cross hospital.

If the treatment in the emergency room is NOT emergency related, the Fund will pay $35 for the emergency room visit and 80% of the maximum allowance on the X-RAY/LAB SCHEDULE for any necessary testing.  Examples of non-emergency treatment are sore throat, cold, flu, headache, aches or pains and dizziness.

OUTPATIENT SURGICAL FACILITY - ACTIVE AND RETIREE PLANS

Blue Cross Hospital – If you have outpatient surgery at a Blue Cross contract hospital or ambulatory surgery center, your maximum out-of-pocket expense will be 10% of the hospital’s contract amount.  The deductible is waived.

Non-Blue Cross Hospital - If you have outpatient surgery done at a non-Blue Cross hospital or ambulatory surgery center, the Fund will pay 90% of the first $1,000 of usual and customary charges and 60% of the remaining allowable charges for the hospital or ambulatory surgery center.  The deductible is waived.

You should decide whether your surgery will be done on an outpatient or inpatient basis after reviewing the estimated charges with the hospital.

PHYSICIAN SERVICES - ACTIVE AND RETIREE PLANS

Blue Cross Physician - Under the Blue Cross contract the doctor has agreed to limit the fee for service to a specific allowed amount.  If you choose a Blue Cross doctor, the Fund will pay the contracted rate in full. You have no co-payment if you use a Blue Cross doctor.  You must, however pay for any services not covered by the Plan.

 

Non-Blue Cross Physician - Physician’s fees for office visits to non-Blue Cross physicians are paid at a maximum of $35 per visit after satisfaction of the calendar year deductible.  There is a limit of 50 visits per calendar year.

If the Health & Welfare Fund provides the secondary benefits for you because of Medicare or other group insurance coverage, Blue Cross benefits will not be available.  Your claims will be paid in accordance with Plan rules relating to coordination of benefits.

The Blue Cross program is not a mandatory program and you are not prohibited from using the services provided by any physician or hospital.  You still have the freedom of choice.  You do not need to enroll or sign any application.  You may use a Blue Cross provider at any time.

Enclosed with this notice you will find a Blue Cross directory of participating providers for Nevada.  To see the most current contracting provider information, please visit Blue Cross’ website at www.anthem.com. Should you need to find doctors in California, visit www.anthem.com/ca (after 4/1/08) or you can contact the Fund Office for an alternate directory.

You will also receive a new eligibility identification card in the next few days which contains the Anthem Blue Cross & Blue Shield PPO information.

If you should have any questions regarding Blue Cross, please contact the Fund Office.

BOARD OF TRUSTEES

OPERATING ENGINEERS HEALTH & WELFARE FUND