How the Medical Plans Work
The Health and Welfare Plan offers three options for medical care: two HMO plans and one PPO plan.
All three plans provide coverage for:
- Medical services, including office visits, hospitalization and surgery, preventative care, mental health services, and substance abuse treatment.
- Prescription drugs.
- Vision Care.
What is the Difference Between PPO and HMO?
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Preferred Provider Organization (PPO)
Preferred Provider Organization (PPOs) plans offers reduced costs when you utilize healthcare providers within the plan’s network, including doctors and hospitals. There’s no deductible to fulfill, and many services are covered at 100% of the allowance.
Opting for the PPO plan means you’re not required to choose a primary care physician. You retain the flexibility to consult any doctor or specialist within the network without needing a referral.
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Health Maintenance Organizations (HMOs)
Health Maintenance Organizations (HMOs) are managed healthcare programs that offer health care services through a network of healthcare facilities. Within an HMO, you choose a primary care physician who becomes acquainted with your health status and medical requirements. This physician then either provides treatment or directs you to specialists within the HMO network as needed.
Coinsurance vs. Copay
A copayment is a predetermined fee that an insurance policyholder is required to pay for a particular service covered by their insurance plan. In contrast, coinsurance represents a percentage of the total cost of a service. While copayments and coinsurance are utilized in distinct circumstances, they both constitute expenses linked to your insurance coverage.
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Coinsurance
When you’re required to contribute a portion of the service cost by paying a percentage, your share is termed “Coinsurance.” For instance, if a service is covered at 75%, your Coinsurance would be 25%.
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Copayments
A Co-payment is a flat fee for covered services. Some HMO, PPOs, and Prescription Drug Services require a co-payment.
- Kaiser Permanente HMO Plan
- Preferred Provider Organization (PPO)
- CareFirst Blue Choice HMO Plan
- Medical Benefit Comparison
- Limitation and Exclusions
- No Surprises Act
Kaiser Permanente HMO Plan
This managed healthcare plan offers your medical services through a network of healthcare facilities called an HMO. With the Kaiser Permanente HMO, you choose a primary care physician who gets to know your health status and medical requirements. When necessary, you’re either treated by this physician or referred to specialists within the HMO.
Compared to the CareFirst PPO plan, the Kaiser Permanente HMO Plan typically entails lower out-of-pocket expenses, depending on the provider and services rendered. Opting for this plan restricts you to seeing physicians affiliated with the HMO to avail of benefits.
Preferred Provider Organization (PPO)
This plan utilizes the CareFirst POS 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 higher, and you must 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.
You can locate an in-network provider near you by visiting CareFirst’s directory.
CareFirst also provides online Explanations of Benefits (EOBs) along with various other helpful tools and resources on its website. For further information regarding online EOBs, click here.
CareFirst Blue Choice HMO Plan
This managed health care plan delivers health services via a network of participating healthcare facilities. You choose a primary care physician who becomes acquainted with your health status and medical requirements. Subsequently, you receive treatment or referrals to participating HMO facilities as needed.
The CareFirst Blue Choice HMO Plan typically entails lower out-of-pocket expenses compared to the CareFirst POS plan, contingent upon the provider you visit and the services you undergo. Opting for the HMO plan necessitates consulting in-network physicians affiliated with the HMO to avail benefits.
CareFirst also provides online Explanations of Benefits (EOBs) along with various other helpful tools and resources on its website. For further information regarding online EOBs, click here.
Medical Benefit Comparison
Your Medical Benefits
| Covered Services | Kaiser Permanente HMO* | Blue Choice HMO | CareFirst PPO | CareFirst (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 | The plan pays 75% of the Allowance after the deductible. |
| Hospital Stays | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Outpatient Hospital Visits | $15 co-pay per visit | $15 co-pay per visit | $15 co-pay per visit | The plan pays 75% of the Allowance after the deductible. |
| Surgery | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| X-Rays and Labs | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Urgent Care | $15 co-pay | No charge | $15 co-pay | $15 co-pay |
| Emergency Room Care | $50, waived if admitted | $50, waived if admitted | $50, waived if admitted | $50, waived if admitted |
| Preventive Services | No charge | No charge | No charge | The plan pays 75% of the 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 | The plan pays 75% of the Allowance after the deductible. |
| Mental Health Outpatient Care | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Substance Abuse Inpatient Care | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Substance Abuse Outpatient Care | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Hospice Care | No charge | No charge | No charge | The plan pays 75% of the Allowance after the deductible. |
| Chiropractic Care | $15 co-pay per visit, up to 20 visits per calendar year | $15 co-pay per visit, up to 20 visits per calendar year | $15 co-pay per visit | The plan pays 75% of the Allowance after the deductible. |
| Physical Therapy | $15 co-pay per visit for up to 90 visits per calendar year | $15, co-pay per visit to 30 visits per calendar year | $15 co-pay per visit | The plan pays 75% of the Allowance after the deductible. |
| Weight Loss (Including surgery) | Limited Coverage | Limited coverage*** | Limited coverage*** | Not covered |
*Benefits for retired Kaiser enrollees who are eligible for Medicare differ in certain aspects from the benefits available to active employees and retirees who haven’t reached Medicare age yet.
**Please note, if you choose to seek care from an out-of-network provider, they may charge more than the POS Allowance. In such instances, you will be responsible for paying the balance in addition to your coinsurance.
***Surgical benefits are exclusively accessible at Centers of Blue Distinction.
Limitation and Exclusions
Medical services covered by the plan must be deemed medically necessary according to the plan’s guidelines. Typically, cosmetic and experimental procedures are not included. Moreover, certain medical services may either be excluded, subject to limitations, or necessitate prior authorization based on medical necessity.
For further information, consult the benefits booklet provided by your carrier or get in touch with them directly.
No Surprises Act
As of 2022, The Federal No Surprises Act protects consumers from balance billing or surprise bills from healthcare providers. Click here to learn the basics about these new protections and to see some examples of how they safeguard consumers.
Continuing Your Coverage
The plan provides an excellent option to maintain your benefits at favorable rates during periods of leave, throughout retirement, and for your survivors in the event of your death.
You and your dependents may be eligible to continue coverage under COBRA in certain circumstances. Specifically, your children can maintain coverage under COBRA once they no longer qualify as dependents.
To maintain your coverage while on leave or under COBRA, you must ensure timely monthly payments to the Health & Welfare Plan. You bear full responsibility for paying your monthly premiums.
- Continuation Coverage under the Collective Bargaining Agreement
- COBRA Continuation Coverage
- Qualifying Events
- Notifying the Plan About a Qualifying Event
Continuation Coverage under the Collective Bargaining Agreement
The Plan currently allows active employees who are not actively working due to specified reasons, such as Sick Leave, Workers’ Compensation, FMLA, and Long-Term Disability, to maintain their participation in the Health and Welfare Plan current active employee premium rates.
It is crucial for you to be aware of your Health and Welfare contributions status and to make timely premium payments to the Health and Welfare Plan. Premium payments are due on the first of each month. It is your responsibility to ensure your Health and Welfare premium payments are made on time. The Plan is not obligated to send notice of delinquent payments or invoices. Failure to make timely payments will result in the termination of your coverage under the Plan.
COBRA Continuation Coverage
If your coverage under the Health and Welfare Plan ends due to a “qualifying event” (as outlined below), you and your covered dependents may qualify to continue your health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
By making monthly payments, you and your dependents can maintain the same medical coverage (including prescription drugs and vision) and dental coverage you had before your coverage ended. Alternatively, you may choose to continue your medical coverage while opting out of dental coverage. The duration of your COBRA Continuation Coverage can extend up to 36 months, depending on the qualifying event that led to the loss of your coverage. If retirement is the qualifying event, you also have the option to maintain your active dental coverage.
Qualifying Events
To be eligible to elect COBRA, you and your dependents must experience a loss of coverage due to any qualifying events listed in the chart below. You and your dependents may be eligible for COBRA if you lose coverage due to any of the following qualifying events.
| Qualifying Event | Who May Purchase | Eligibility | Notification Requirements |
|---|---|---|---|
| Termination – Employee terminated for a reason other than gross misconduct (including retirement) | Employee, spouse, and dependent children | 18 months | METRO will notify the Health and Welfare Plan |
| Reduction in hours -Employee’s reduction in hours worked (making employee ineligible for coverage or the same coverage under the Plan) | Employee, spouse and/or dependent children | 18 months | METRO will notify the Health and Welfare Plan |
| Eligibility for Social Security Disability Employee becomes eligible for disability through Social Security at some time before 60th day of COBRA and disability last until the end of the 18-month COBRA period. | Employee, spouse and/or dependent children | 11 months in addition to the 18 months |
Notifying the Plan About a Qualifying Event
The health and welfare plan must be informed of your qualifying event for you to elect COBRA coverage.
WMATA is required to notify the Health and Welfare Plan in the event of your termination of employment, reduction of hours, or death.
As an employee or covered dependent, you are responsible for notifying the Health and Welfare Plan within 30 days from the date you lost coverage due to certain qualifying events:
- Divorce or legal separation from your spouse
- Changes in eligibility status for your dependents
