The Health & Welfare Plan provides three choices for medical care—two HMO plans and one PPO plan. To enroll in the PPO program, you need to have at least three years of service beyond your probationary period. New hires must elect one of the HMO options. For more information on eligible dependents, visit the Eligibility page.
All three plans offer coverage for:
PLAN COMPARISON AT A GLANCE
|Preferred Provider Organization (PPO)||Health Maintenance Organization (HMO)|
|Options||CareFirst PPO||Kaiser Permanente or BlueChoice|
|Description||A PPO is a network of preferred providers. You 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.|
|Restrictions||Available at Open Enrollment only to employees 36 months after completing their probationary period.||Available at conclusion of probationary period.|
|The Plan Pays||Generally, PPO 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 PPO Allowance.||A Co-payment for services, if applicable.|
|Deductible||None for PPO providers. For out-of-network providers, $300 per individual or $600 per family.||None|
|Filing Claims||The PPO 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 PPO
A PPO 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 PPO rate is called “the Allowance.” When you visit a provider in the PPO network (an “in-network provider”), there is no deductible and many services are covered at 100% of the Allowance. Under a PPO 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. PPO 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 PPO. 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.
While you are collecting Workers’ Compensation, you are not eligible to receive short-term disability benefits from the Plan. However, you are eligible to apply for long-term disability benefits six months after your injury. Any long-term disability benefit you receive will be reduced by your Workers’ Compensation and other forms of income. For many reasons, it is to your advantage to apply for long-term disability benefits. Call the Health & Welfare Plan office if you have any questions.