Medical Plans

How Your Medical Plans work

The Health & Welfare Plan provides three choices for medical Care two HMO plans and one PPO plan.

All three plans offer coverage for:

  • Medical services include office visits, hospitalization and surgery, wellness care, mental health treatment, and substance abuse treatment.
  • Prescription drugs.
  • Vision Care.
 

What’s the Difference Between a PPO and an HMO?

  • Preferred Provider Organization (PPO)

    A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network; there is no Deductible to meet. Many services are covered at 100% of the Allowance.

    If you choose to be covered under the PPO plan, you do not have to select a primary care physician. You have the flexibility to see any doctor or specialist in the network without a referral.

  • Health Maintenance Organizations (HMOs)

    Health Maintenance Organizations (HMOs) are managed healthcare programs that 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 health status and medical needs, then treats you or refers you to the specialist in the HMO when necessary.

Coinsurance vs. Copayments

  • Coinsurance

    When you must share the cost of services by paying a percentage, your share is called “Coinsurance.” For example, if a service is covered at 75%, your Coinsurance would be 25%.

  • 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

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 select this plan, you can only see the physicians associated with the HMO to receive benefits.

Preferred Provider Organization (PPO)

Effective April 13, 2020, all employees are eligible for the PPO Plan. 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. Suppose the out-of-network provider charges more than the PPO negotiated price. In that case, you are responsible for paying the difference between the out-of-network provider cost and the PPO’s contracted price.

You can find an in-network provider near you by visiting CareFirst.

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

CareFirst Blue Choice HMO Plan

This managed health care plan provides your health care services through a system of healthcare facilities known as an HMO. You select a primary care physician who becomes familiar with your health status and medical needs through the HMO. 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 Blue Choice HMO Plan generally has lower out-of-pocket costs than the CareFirst POS plan. If you select this plan, you can only see the physicians 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.

Medical Benefit Comparison

Your Medical Benefits

Covered ServicesKaiser Permanente HMO*Blue Choice HMOCareFirst PPOCareFirst (PPO) Out-Of-Network**
Annual DeductibleNoneNoneNone$300 individual/$600 Family
Office Visits$15 co-pay per visit$15 co-pay per visit$15 co-pay per visitThe plan pays 75% of the Allowance after the deductible.
Hospital StaysNo chargeNo chargeNo chargeThe 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 visitThe plan pays 75% of the Allowance after the deductible.
SurgeryNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
X-Rays and LabsNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
Urgent Care$15 co-payNo 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 ServicesNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance (birth to age 17)
Mammograms and Annual Pap TestsNo chargeNo chargeNo chargeNo charge
Mental Health Inpatient CareNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
Mental Health Outpatient CareNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
Substance Abuse Inpatient CareNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
Substance Abuse Outpatient CareNo chargeNo chargeNo chargeThe plan pays 75% of the Allowance after the deductible.
Hospice CareNo chargeNo chargeNo chargeThe 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 visitThe 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 visitThe plan pays 75% of the Allowance after the deductible.
Weight Loss (Including surgery)Limited CoverageLimited coverage***Limited coverage***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 POS Allowance. If this is the case, you are responsible for paying the balance in addition to your coinsurance.
***Surgical benefits are available only at Centers of Blue Distinction.

Limitation and Exclusions

Covered medical services must be medically necessary as determined under the plan’s rules. 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 benefits booklet from your carrier or contact your carrier for more details.

No Surprises Act

You may have heard stories from friends or news about balance bills or surprise bills from health care providers. Starting in 2022, a new law went into effect – the federal No Surprises Act – that protects you from many types of surprise bills. Click here to find out the basics about the new protections and some examples of how they can protect consumers.

Learn more

Continuing Your Coverage

The plan offers a great option to continue your benefits at favorable rates during periods of leave, during retirement, and for your survivors if you should die.

You and your dependents may be eligible to continue coverage under COBRA in certain other circumstances. Your children can continue coverage under COBRA when they no longer qualify as dependents.

To continue your coverage while on leave or under COBRA, you must make timely monthly payments to the Health & Welfare Plan. You are fully responsible for your money premiums during continued coverage, including COBRA.

 

Continuation Coverage under the Collective Bargaining Agreement

The Plan currently permits active employees who are not actively at work for specified reasons- such as Sick Leave, Workers’ Compensation, FMLA, and Long-Term Disability to continue their participation in the Health & Welfare Plan at the rates paid by active employees.

If the Health & Welfare Plan does not receive timely notification of your change in status, it is essential that you know the status of your Health & Welfare contributions and make timely payments to the Health & Welfare Plan. Payments are due on the first of the month. It is your responsibility to make your Health & Welfare payments on time. The Plan is not required to send you notice of delinquent payments, nor is it required to send you an invoice. If you do not make your payment on time, your coverage under the Plan will end.

While you may be eligible for COBRA if you are dropped from continuation coverage under the Collective bargaining agreement, the cost of COBRA is much greater.

COBRA Continuation Coverage

Suppose your coverage under the Health & Welfare Plan ends due to a “qualifying event” (see below). In that case, you and your covered dependents may be eligible to continue your health care coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

By making monthly payments, you and your dependents may continue the same medical (including prescription drugs and vision) and dental coverage you had before your coverage ended. You may also choose to continue your medical but not your dental coverage. Your COBRA Continuation Coverage can last for up to 18, 29, or 36 months, depending on the qualifying that resulted in your loss of coverage. If the qualifying event is retirement, you also have the choice to continue your active dental coverage.

Qualifying Events

To be eligible to elect COBRA, you and your dependents must lose coverage due to any qualifying events shown in the chart on the next page.

Notifying the Plan About a Qualifying Event

The health and welfare plan must be notified of your qualifying event for you to elect COBRA.

Your employer must notify the Health & Welfare Plan in the event of your termination of employment, reduction of your hours, or death.

As an employee or qualified beneficiary, you are responsible for providing the Health & Welfare Plan notice within 60 days of the date you would have lost coverage for certain qualifying events:

  • Your divorce or legal separation from your spouse
  • Your dependent’s change in eligibility for
Qualifying EventWho May PurchaseEligibilityNotification Requirements
Termination – Employee terminated for a reason other than gross misconduct (including retirement)Employee, spouse, and dependent children18 monthsMETRO will notify the Health & 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 children18 monthsMETRO will notify the Health & 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 children11 months in addition to the 18 months 
 

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