The Health & Welfare Plan provides three choices for medical care—two HMO plans and one POS plan. Effective April 13, 2020, new hires are eligible to enroll in the HMO adnPOS plans. For more information on eligible dependents, visit the Eligibility page.
All three plans offer coverage for:
PLAN COMPARISON AT A GLANCE
|Point-of-Service (POS)||Health Maintenance Organization (HMO)|
|Options||CareFirst PPO||Kaiser Permanente or BlueChoice|
A POS is a type of managed care plan that is a hybrid of HMO and PPO plans. Like and HMO, participants designate an in-network physician to be their primary care provider. But like a PPO, participants may visit preferred providers at a contracted rate, or visit out-of-network providers and pay Coinsurance for covered services.
|Must visit providers in the HMO and select a primary care physician to coordinate care.|
|The Plan Pays||Generally, POS covered services are paid at 100% of the Allowance. Out-of-network covered services are paid at 75% of the Allowance, and then you are required to pay the difference between the billed amount and the amount paid by the Plan.||The full cost for covered services, minus your Co-payment.|
|You Pay||A Co-payment or a percentage of the cost (your Coinsurance). If you visit an out-of-network provider, you are also responsible for paying the amount, if any, that the provider charges that is more than the POS Allowance.||A Co-payment for services, if applicable.|
|Deductible||None for POS providers. For out-of-network providers, $300 per individual or $600 per family.||None|
|Filing Claims||The POS provider will file claims for you. You may have to file claims if you use an out-of-network provider.||The HMO provider will file claims for you.|
What’s the Difference between an HMO and POS
A POS is a network of healthcare providers (doctors, specialists, hospitals, laboratory facilities, etc.) who agree to provide health care services at contracted rates for employees. The POS rate is called “the Allowance.” When you visit a provider in the POS network (an “in-network provider”), there is no deductible and many services are covered at 100% of the Allowance. Under a POS plan you do not need to have a primary care physician. You have the flexibility to see any doctor or specialist in the network without a referral. POS providers generally accept a range of insurance benefits, so they may not be familiar with the benefits you have under the Health & Weflare Plan.
HMOs provide health care services through a system of healthcare network facilities. Through an HMO, you select a primary care physician who becomes familiar with your individual health status and medical needs, then treats you or refers you to specialists in the HMO, when necessary. An HMO generally has lower out-of-pocket costs than a POS. If you elect an HMO, you can only see physicians associated with the HMO plan. HMO providers generally are staff providers (i.e., they work for Kaiser Permanente), so they will know your benefits well.
The Trustees believe that this Plan is a “grandfathered health plan” under the Affordable Care Act, which permits us to preserve certain basic health coverage already in effect before the law was passed. As with all grandfathered health plans, our Plan does not have to include certain consumer protections of the Affordable Care Act that apply to other plans (for example, provide preventive health services without any cost sharing). However, grandfathered health plans, like our Plan, must comply with certain other consumer protections in the Affordable Care Act (for example, the extension of coverage for dependent children to age 26). Contact the Health & Welfare Plan if you have questions about what it means for a health plan to have grandfathered status and what might cause a plan to lose its grandfathered status. You may also contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) at 800-444-3272 or www.dol.gov/ebsa/healthreform. The website includes a chart summarizing the protections that do and do not apply to grandfathered health plans.