The Medical Plans

Employees that have at least three years of service after their probationary period are eligible for the CareFirst PPO Plan. This plan utilizes the CareFirst PPO network of healthcare providers—doctors, specialists, hospitals, laboratory facilities, etc.—who have agreed to provide health care services at a contracted rate for employees. When you visit a provider in the PPO network, there is no deductible to meet and many services are covered at 100% of the negotiated price minus any co-payment

Under this plan you do not need to see a primary care physician. You have the flexibility to see any doctor or specialist in the network without a referral. If you see an out-of-network provider, you will still receive benefits for covered services. However, your out-of-pocket costs are generally greater and you will have to meet an annual deductible before benefits are paid. If the out-of-network provider charges more than the PPO negotiated price, you are responsible for paying the difference between the out-of-network provider cost and the PPO’s contracted price.

The Health & Welfare Plan has copies of PPO directories to help you find an in-network provider near you. Or, you can find a provider on the internet by visiting CareFirst.

On its website, CareFirst also offers online Explanations of Benefits (EOBs) and other helpful tools and resources. Read more about online EOBs.

Coinsurance vs. Copayments

When you are required to share the cost for services by paying a percentage, your share is called "Coinsurance." For example, if a service is covered at 75%, your Coinsurance would be 25%.

A Co-payment is a flat fee for covered services. Some HMO, PPO and Prescription Drug services require a co-payment.

This managed health care plan provides your health care services through a system of healthcare facilities known as an HMO. Through the Kaiser Permanente HMO, you select a primary care physician who becomes familiar with your health status and medical needs. You are then treated or referred to specialists in the HMO when necessary.

Depending on the provider you see and the services you receive, the Kaiser Permanente HMO Plan generally has lower out-of-pocket costs than the CareFirst PPO plan. If you elect this plan, you can only see the physicians that are associated with the HMO to receive benefits.

This managed health care plan provides your health care services through a system of healthcare facilities known as an HMO. Through the HMO, you select a primary care physician who becomes familiar with your health status and medical needs. You are then treated or referred to specialists in the HMO when necessary.

Depending on the provider you see and the services you receive, the CareFirst BlueChoice HMO Plan generally has lower out-of-pocket costs than the CareFirst PPO plan. If you elect this plan, you can only see the physicians that are associated with the HMO to receive benefits.

CareFirst offers online Explanations of Benefits (EOBs) and other helpful tools and resources on its website. Read more about online EOBs.

Your Medical Benefits
Covered ServicesKaiser Permanente HMO*BlueChoice HMOCareFirst (PPO) In-NetworkCareFirst (PPO) Out-Of-Network**
Annual Deductible None   None   None   $300 individual/$600 Family
Office Visits $15 co-pay per visit $15 co-pay per visit $15 co-pay per visit Plan pays 75% of Allowance after Deductible
Hospital Stays No charge No charge No  charge Plan pays 75% of Allowance after Deductible
Outpatient Hospital Visits $15 co-pay per visit $15 co-pay per visit $15 co-pay per visit Plan pays 75% of Allowance after Deductible
Surgery No charge No charge No charge Plan pays 75% of Allowance after Deductible
X-Rays and Labs No charge No charge No charge Plan pays 75% of Allowance after Deductible
Emergency Room Care $50, waived if admitted $50, waived if admitted $50, waived if admitted $50, waived if admitted
Preventive Services No charge $15 co-pay per visit $15   co-pay per visit Plan pays 75% of Allowance (birth to age 17)
Mammograms and Annual Pap Tests No charge No charge No charge No  charge
Mental Health Inpatient Care No charge No charge No charge Plan pays 75% of Allowance after Deductible
Mental Health Outpatient Care No charge No charge No charge Plan pays 75% of Allowance after Deductible
Substance Abuse Inpatient Care No charge No charge No charge Plan pays 75% of Allowance after Deductible
Substance Abuse Outpatient Care No charge No charge No charge Plan pays 75% of Allowance after Deductible
Hospice Care No charge No charge No charge Plan pays 75% of Allowance after Deductible
Chiropractic Care $15 co-pay per visit, up to 20 visits $15 co-pay per visit, up to 20 visits per Calendar year $15 co-pay per visit Plan pays 75% of Allowance after Deductible
Physical Therapy $15 co-pay per visit, up to 90 visits $15,   co-pay per visit up to 30 visits per calendar year $15 co-pay per visit Plan pays 75% of Allowance after Deductible
Weight Loss (including surgery) Limited coverage Not Covered Not Covered Not Covered

* Benefits for Kaiser enrollees who are retired and Medicare-eligible differ in some respects from the benefits for active employees and pre-Medicare retirees

** Remember, when you see an out-of-network provider for care, the provider may charge more than the CareFirst Allowance. If this is the case, you are responsible for paying the   balance in addition to your Coinsurance

Covered medical services must be medically necessary as determined under the rules of the plan. Cosmetic procedures and experimental procedures are generally not covered. In addition, some medical services may be excluded, limited or require prior authorization for medical necessity. Refer to the benefit booklet from your carrier or contact your carrier for more details.

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FAQs

Who do I call if I want to change doctors?

To change doctors you should call your health care provider (e.g., CareFirst, Kaiser etc.) or visit them online.

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