Allowance or Allowable Expense or Allowable Charges is the amount that the PPO network recognizes as the appropriate charge by a provider for eligible health care expenses under the Plan. Providers in the PPO network used by the Plan have agreed to charge no more than the Allowable Expense. If you use Providers who are not in the network, you are responsible for charges that are greater than the Allowable Expense.
Cafeteria Plan is a benefits plan that that allows Participants a choice in designing his or her own benefit package by selecting different types and/or levels of benefits that are funded with nontaxable employer dollars.
COBRA stands for Consolidated Omnibus Budget Reconciliation Act of 1985. Through COBRA, you and/or your dependents can continue your health care benefits if you experience certain qualifying events that would otherwise cause you to lose your coverage under the Plan.
Once you satisfy your Deductible, if any, the Plan will pay a portion of the Allowable Charges you incur for eligible health care expenses. The remaining portion of the allowable charge is your share or “Coinsurance” amount. Coinsurance applies to Participants in the PPO Plan.
Collective Bargaining Agreement is a written agreement between a union and an employer that requires the employer to make contributions to the Plan on behalf of its employees.
Co-payment is a fixed dollar amount that you must pay for certain services provided by the Plan.
Deductible is the amount you (and/or your family) must pay in medical expenses each year before the Plan will pay benefits for eligible health care expenses. HMO Participants are not required to meet a Deductible.
Health Maintenance Organization or HMO is a group of doctors and other medical professionals that offer care through the network for a flat monthly rate with no Deductibles. However, only visits to professionals within the HMO network or referred by a network provider are covered by the policy. All visits to specialists or for other care need a referral from your HMO physician in order to be covered. A primary physician within the HMO handles referrals. A Dental Health Maintenance Organization or DHMO is a network of dentist and dental specialist that operates like an HMO. Maintenance Medications are medications that you take on a regular basis to treat a chronic condition such as diabetes, high blood pressure or high cholesterol.
New Service Agreement is the Supplemental Agreement, a collective bargaining agreement between METRO and ATU Local 689.
Open Enrollment Period is the period that occurs every year in May. The current bargaining agreement permits you to change your benefit selections (i.e., switch to a different medical plan or dental plan, or enroll a dependent that you did not enroll within the required time frames when they first became eligible) during the Open Enrollment Period.
Out-of-Pocket Maximum is the maximum amount of Coinsurance plus Deductible that you must pay for any allowable health care costs that are not covered by the Plan. Once you exceed the maximum, the Plan will pay 100% of your eligible medical expenses for the remainder of the calendar year.
Preferred Provider Organization (PPO) is a network of providers that agree to accept the Plan’s allowable charge for a particular medical service as payment in full. If you participate in the CareFirst PPO, you cannot be billed more than the allowable charge for a medical service when you visit a provider that participates in the PPO.
PHI or “Protected Health Information” is information that the Plan has created or received regarding your health or payment for your health. It includes both your medical records and personal information such as your name, Social Security Number, address, and other identifying information.
For various legitimate reasons, some members may have difficulty providing necessary documentation. In this case, it is important that you apply for coverage within the time periods outlined for each plan. Only then will the merits of your unique situation be considered. Contact the Health and Welfare office for more information.