The Fund, working with Anthem Blue Cross and HMC HealthWorks® (HMC), provides a special program for routine knee and hip joint replacement surgeries. This program is available only to Indemnity PPO Medical Plan Participants.
You will pay much lower out-of-pocket costs when you go to a Designated Hospital or routine knee or hip joint replacement surgery. You can access a list of Designated Hospitals in the drop down below or by calling HMC at 844-751-4530.
Allowed Amounts for Hospital Charges
Click on the drop down arrow to find out more about allowed amounts for hospital charges
The plan’s allowed amount for hospital charges incurred for routine knee and hip joint replacement surgeries is $35,000. Regardless of how much a hospital charges, the plan’s payment on your behalf is based on the lesser of the hospital’s charge or $35,000.
Hospital charges for these surgeries typically include the cost for the hospital stay and the devices and materials needed for the replacement. The $35,000 allowed amount does not apply to charges from surgeons or other providers involved in your care.
To keep knee and hip joint replacement hospital costs within the $35,000 allowed amount, you have access to many well-known hospitals and surgical facilities in California. These “designated facilities” are highly respected for the quality of their orthopedic surgical facilities, patient care, and cost effectiveness. Click here for a list of Knee / Hip Designated Hospitals.
How You and the Plan Share Costs for Routine Knee/Hip Replacement
Click on the drop down arrow to find out more about cost sharing for knee/hip replacement surgeries.
- If you have your knee or hip replacement surgery at a Designated Facility, you will have no out-of-pocket costs beyond your annual deductible and your coinsurance. You need to meet your annual deductible and pay your share of coinsurance (both payable from your Health Reimbursement Account balance, if any). After you reach the plan’s annual medical out-of-pocket maximum, the plan pays 100% of the remaining charges—the Designated Facility has agreed to limit its charges to $35,000.
- If do not have your knee or hip replacement surgery at a Designated Facility, your out-of-pocket costs may be extremely high. In addition to paying your annual deductible and your share of coinsurance, you must also pay any charges above the $35,000 allowed amount. Charges above the allowed amount will not count towards your annual medical out-of-pocket maximum. In addition, the plan’s annual medical out-of-pocket maximum will not limit your costs that exceed the allowed amount. You cannot use your Health Reimbursement Account balance to pay charges that exceed the allowed amount.
Watch Out! Not all Anthem Blue Cross PPO hospitals are Designated Facilities. Because your costs may be so much higher if you do not use a Designated Facility, it’s important to understand what you may pay before you or your covered family members have knee or hip joint replacement surgery. CONTACT THE FUND OFFICE AS SOON AS YOU BEGIN PLANNING ONE OF THESE PROCEDURES. Also note, if Anthem Blue Cross receives a precertification request that indicates you or a covered family member may need a knee or hip replacement, the program administrator will contact you by mail and/or by phone to explain your options.