Transit Employees Health and Welfare Plan Enrollment Guide and Summary of Health Benefits

Transcription

1 Transit Emplyees Health and Welfare Plan Enrllment Guide and Summary f Health Benefits Act Nw! If yu want t... enrll fr medical/visin and dental cverage change medical/visin and/r dental plan enrll r change supplemental MetLife life insurance cverage enrll r disenrll a dependent pt ut r cntinue pt ut f medical/visin and dental cverage level Cmpleted frms are due by May 29, Yur next chance t change yur benefit plan will be May N actin needed if... yu want t keep yur same medical/ visin and dental cverage yu d nt want t add r change dependents Fr Lcal 689 Members May 2015 Online enrllment nw available! See page 11 fr details 2015 Each year, yu must renew yur pt ut electin r yu will be returned t yur previus cverage Keep This Bklet fr Future Reference CareFirst PPO medical cverage is nly available t emplyees hired befre March 1, 2012 (Emplyees hired n r after March 1, 2012 are eligible t elect CareFirst PPO medical cverage after cmpleting 39 mnths f service frm the date f hire.)

2 Message frm the Bard f Trustees Once again it is that time f year when the Trustees f the Transit Emplyees' Health & Welfare Fund ( Fund ) invite yu t participate in Open Enrllment. Frm Mnday, May 4, 2015 until Friday, May 29, 2015 yu will have the pprtunity t: Review yur current benefit chices and make apprpriate changes; Enrll eligible dependents wh were nt enrlled when they first became eligible; Renew a prir pt-ut electin r pt-ut f the benefit prgram fr the first time; Elect additinal supplemental life insurance. Enrll a dmestic partner This year the fund has sme exciting new changes Visit ur new web site at Remember: Transit Emplyees Health & Welfare.rg Fr the first time, yu will be able t make yur pen enrllment changes n-line. Just lk t the upper right f the screen fr the Members Only link. Yu will be guided thrugh the registratin and enrllment prcess. Please try this ut and mst imprtant give us yur feedback. The nly way we can imprve yur experience is t learn frm yu. This is versin 1.0 and ver time we hpe t imprve the functinality. We hpe sn t be able t add the ability fr thse n self-pay t make payments n line r t schedule direct debits frm their bank. The web site prvides up t date infrmatin and yu can read abut pen enrllment and dwnlad many f the frms yu may need. Imprtant changes fr Change in Prescriptin Drug Carriers Effective January 1, 2015, we changed prescriptin drug carriers t Optum Rx fr Actives and pre Medicare Retirees and t United Health Care, Inc. fr Medicare retirees. Bth prgrams include limits n prescriptins fr cmpund medicatins and a step-therapy prgram. Mving Metr Watch fr this lg. Turn t page 13 and read mre abut ur effrts t help yu help yurself t imprve yur health and yur life. Cverage fr weight lss surgery This benefit has been added t the CareFirst PPO and BlueChice HMO plans. A reminder f last year s changes. Spusal Opt Out Credit Page 12 Prescriptin Safety Glasses Page 14. Imprved Retiree Dental Plan Page 15 New Supplemental Life Insurance Optins Page 17 The Affrdable Care Act cntinues t have direct and indirect impact n yur health care benefits and the benefits fr yur family and friends. Lk t ur web site fr infrmatin. If yu are satisfied with yur current benefit chices, n actin is required n yur part. Hwever, if yu have pted ut f Fund benefits fr 2014, yu must renew yur pt-ut again in If yu change yur benefit chices, yur actins will be effective July 1, Yu typically will nt receive yur new ID cards until early July. Sincerely, Bard f Trustees WMATA Shi (Shelley) Xie, Secretary Yetunde Olumide Dnna L Gaffney ATU Lcal 689 Jackie Lynn Jeter, Chair Esker Bilger Larry Lckley

3 Transit Emplyees Health and Welfare Plan Enrllment Guide and Summary f Health Benefits Table f Cntents Eligibility fr Yurself and Yur Dependents 3 Timing: When Yu Can Make Changes 5 Medical/Visin Benefit Chices 8 Statement f Grandfathered Status 10 Dental Benefit Chices 15 Vluntary Benefits 17 Key Cntacts fr Claims and Service Infrmatin 18 Active Emplyees Open Enrllment Frm 19 Active Cntributin Rates 21 Retiree Cntributin Rates 22 Retired Emplyees Open Enrllment Frm 23 D Yu Knw Wh Will Get Yur Death Benefit? If an emplyee r retired emplyee dies while eligible fr life and/r accidental death insurance benefits, the benefits are paid t the persn(s) named as beneficiary. Yu we it t yur family t make sure yur beneficiary designatins are up t date. Have yu had any changes in yur family, such as marriage, divrce, r children? All beneficiary changes must be made at the Health & Welfare ffice. 1

4 D Yu Have a Summary Plan Bklet? Active Full-Time and Part-Time Emplyees Health & Welfare Plan Chices Medical/visin Medical/Visin and dental V Medical/Visin Kaiser Permanente HMO medical and NVA visin BlueChice HMO medical and Davis Visin CareFirst PPO medical and Davis Visin 1 Dental (if yu elect medical/visin) CareFirst CIGNA DMO Autmatic Benefits V All active full-time and part-time emplyees receive these benefits: (See Summary Plan Bklet) Shrt Term Disability Lng Term Disability Life and Accident Insurance Vluntary Benefits A mre cmplete descriptin f eligibility and benefits can be fund in the Summary Plan Bklet. New bklets will be sent t yu shrtly. Yu can pick these up at the Health & Welfare ffice r request that the ffice mail ne t yu after they are available. Yu may purchase cverage by enrlling in these plans and paying the full cst: Supplemental Life Insurance Supplemental Orthdntic cverage (CareFirst) ING Universal Life Insurance 2 1 CareFirst PPO medical cverage is nly available t emplyees hired befre March 1, The Health & Welfare ffice is nt respnsible fr enrllment in this plan. If Yu Have Questins After reading this bklet, if yu have questins, please cntact the Health & Welfare ffice at (301) r visit us at 2701 Whitney Place, Suite 100, Frestville, MD Retired Emplyees Health & Welfare Plan Chices Medical/Visin and Dental Medical/Visin Kaiser Permanente HMO medical and NVA visin BlueChice HMO medical and Davis Visin CareFirst PPO medical and Davis Visin Dental: Single cverage under Delta Dental is autmatic. Yu may pt ut f single cverage r elect t cver yur spuse and dependents. 2

5 Eligibility fr Yurself and Yur Dependents Yur Eligibility fr Benefits Yu are cnsidered eligible fr benefits under the Health & Welfare Plan if designated as such in the Cllective Bargaining Agreement and successr Cllective Bargaining Agreements. Medical/visin and dental cverage is mandatry fr full-time emplyees unless yu have medical cverage frm anther surce. The fllwing grups are eligible fr cverage under the Plan: Full-time emplyees Part-time emplyees Emplyees wrking under the New Service Agreement Retired emplyees Surviving dependents f active and retired emplyees Emplyees n Military Leave and yur dependents will cntinue in the Plan until the last day f the mnth after the mnth yu wrked befre yu are called t duty. COBRA cntinuatin benefits will be available t yu and yur family afterwards. Effective Date f Cverage fr New Dependents Dependent Eligibility Yu may cver yur eligible dependents under yur medical/visin and dental cverage prvided the required dcumentatin is submitted and updated as necessary Yu cannt make changes directly with yur medical/ visin r dental prvider. T add r remve dependents yu must cme int the health and welfare Fund ffice r g t and make the changes n-line. A spuse can nly be remved prir t the next annual enrllment perid if the cuple divrces, if the spuse dies, r with evidence f ther cverage. A child can nrmally nly be remved prir t the next annual enrllment perid with evidence f ther cverage. T Enrll Yur Spuse Natural children Stepchildren Adpted children, children in placement fr adptin and children fr whm yu are appinted legal guardian Dmestic Partner This benefit is fully taxable t the emplyee RequireD Dcuments Marriage certificate if nt yur first spuse, then als divrce decree r death certificate. If married mre than tw years, yu must als prvide a cpy f yur mst recent tax return Birth certificate and scial security number yur name must appear n the birth certificate Birth certificate and scial security number the name f yur current spuse must appear n the birth certificate Original birth certificate, adptin and legal guardianship papers satisfactry t the Trustees Affidavit f Dmestic Partnership alng with dcumentatin f financial interdependence Registratin f Dmestic partnership if applicable Cverage Effective... First f the mnth fllwing the marriage and the Plan s receipt f all required dcumentatin. Cvered frm date f birth if the Plan is ntified within 30 days. Otherwise, first f the mnth fllwing date riginal dcumentatin is received by the Health & Welfare ffice (within 90 days). Same as spuse. Cvered frm the date f adptin r placement fr adptin. July 1st fllwing Open Enrllment r the first f the next mnth after all necessary dcumentin is prvided. Taxatin will begin at the same time. 3

6 4 T Enrll A Dependent Yu must prvide the scial security number fr each f yur eligible dependents. If yur dependent cannt btain a scial security number, he r she can apply t the Internal Revenue Service fr an individual taxpayer identificatin number. Yu must prvide an riginal birth certificate r riginal certificate f live birth t enrll children. The dcument must name the member r eligible spuse r eligible dmestic partner as a parent. Yu have a maxiumum f 90 days frm the date f marriage, birth, adptin, placement fr adptin r appintment as legal guardian t add yur new dependent. If yu miss the 90-day windw, yu must wait until the next scheduled May annual enrllment perid t make the change. The Plan will als prvide dependent cverage t a child if it is required t d s by a Qualified Medical Child Supprt Order that meets the natinal standards r the requirements established by the Trustees. A cpy f the sample language fr Medical Child Supprt Order may be btained frm the Health & Welfare ffice. Yur Eligible Dependents Include Yur: Spuse Dmestic Partner Dependent children under age 26 Children ver age 26 wh meet the requirements as a disabled dependent Unmarried children fr whm yu are the curt appinted guardian and wh meet the additinal requirements f the plan The Children Cvered Are Yur: Natural children Stepchildren Legally adpted children and children being placed fr adptin Children fr whm yu are appinted legal guardian T Enrll A Spuse Yu need an riginal state-issued marriage certificate t enrll a spuse. If yur frmer spuse was previusly enrlled in the Plan, yu will als need an riginal divrce decree r death certificate if married mre than tw years, yu must prvide a cpy f yur mst recent tax return. Legally married same sex cuples may enrll within 90 days f their marriage. T Enrll A Dmestic Partner Obtain the Affidavit f Dmestic Partnership frm the Health & Welfare Office. Cmplete and return the frm with all related dcumentatin t the Health & Welfare Office by May 29, The dmestic partner benefit is a taxable benefit t the emplyee. In additin t any additinal premium, yu will als pay additinal taxes each paycheck. This als applies t married same sex cuples. Spusal Opt Out Credit NW Available If yur spuse has ther insurance yu may be eligible fr a spusal pt ut credit See page 12 fr details Married Lcal 689 Members with Dual Cverage If tw Lcal 689 members f the same family are eligible fr separate cverage, they must cnslidate cverage with ne member electing family cverage. This saves mney and keeps all members csts dwn. The members decide which spuse will carry the family plan and which will waive cverage. If the family member is a child under age 26, the child r parent may elect separate cverage at any time If an active member is married t a retired member, the retired member shuld be named as a dependent n the active member s plan. Each Lcal 689 member remains entitled t their individual life insurance, shrt term disability, lng term disability and ther vluntary benefits. Members f Lcal 689 with a spuse with ther Authrity cverage shuld cntact the Health & Welfare ffice.

7 Timing: When Yu Can Make Changes The Health & Welfare Plan ffers several cverage ptins fr yu and yur family. If yu wuld like t change yur benefit plan, r enrll in the Plan, yu may d s this May with an effective date f July 1st. Yu may always enrll new dependents during the 30- r 90-day perid when they are first eligible. If nt, yu can nly enrll them during the annual enrllment in May f each year, with an effective date the fllwing July 1st. When yu have a new dependent as a result f birth, adptin r placement fr adptin, yu may be able t enrll yur dependent(s) in the Plan, even if yu d nt have family cverage at the time f the event. Yu must cntact the Health & Welfare ffice immediately. May 2015 MAY 29, 2015 July 1, 2015 May 2016 Enrllment perid if yu want t change yur benefit plan r enrll dependents in the Plan Enrllment frms due Effective date f enrllment and benefit plan changes Next chance t change yur benefit plan r enrll in the Plan Changes t Benefits Outside f Open Enrllment Generally, the enrllment decisins yu make this year will remain in place thrugh the next Open Enrllment in Hwever, if yu have a family status r wrk status change such as thse listed belw, and yu wish t change yur benefit electin, ntify the Health & Welfare ffice immediately. Generally, yu have 30 r 90 days in which t make a change t yur benefits after the date f the status event. Cmmn Wrk and Family Status Events Marriage Birth r adptin Divrce r annulment Death f yur spuse r eligible dependent child Change in yur full- r part-time status (see Yur Eligibility fr Benefits n page 3) Change in yur spuse s emplyer health insurance cverage Change in qualifying status f a dependent Issuance f a qualified Medical Child Supprt Order requiring cverage f a dependent child D I Have 30 Days r 90 Days t Make Changes? Depending n the type f change yu need t make t yur cverage, yu have 30 r 90 days in which t make a change as fllws: 30 Days t Make a Change T enrll fr Plan cverage if yu r a dependent lse ther health care cverage T enrll a newbrn, t be effective frm the date f birth, r t enrll a child adpted r placed fr adptin, t be effective frm the date f adptin r placement fr adptin. Change frm part-time t full-time r frm full-time t part-time r attaining 36 mnths f service beynd prbatin ÿ 90 Days t Make a Change V. T add a new dependent, t be effective the first day f the calendar mnth after yu prvide the necessary dcumentatin If yu and yur spuse divrce, yu must ntify this Plan immediately. If yu fail t remve yur divrced spuse frm yur Plan, yu may be liable fr any claims expense incurred by yur spuse after the date f the divrce. 5

8 Cst f Medical/Visin and Dental Benefits Csts fr the varius cverage ptins and levels are shwn in the 2015 rate sheet fund n pages 21 and 22 f this bklet. Yur premium cntributin fr medical/visin and dental cverage depends n which ptin yu select, and whether yu enrll fr single r family cverage. The Authrity pays mst f the premiums fr the ptins ffered. Yur ttal ut-fpcket cst fr care depends n which ptin yu select as well as the services and treatments yu and yur family need during the year. Payment f Health and Welfare Premiums If yu are currently wrking, yur prtin f the Health & Welfare cntributins will nrmally be deducted frm yur paycheck. Deductins nrmally ccur fur times per mnth in advance f the cverage mnth. If yu are nt currently wrking and are eligible fr benefits under the Cllective Bargaining Agreement, yu may cntinue yur cverage during perids f apprved leave by making timely mnthly payments directly t the Health & Welfare Fund. Yu will nt receive a bill. Failure t pay yur Health & Welfare cntributins by the first f the cverage mnth will result in terminatin f yur cverage. If yu are nt receiving a pensin check r a paycheck frm WMATA yu must pay the Health & Welfare Fund directly. If Yu Waive Medical Cverage Because f Other Medical Insurance Cverage... Yu may waive medical cverage fr yurself and yur dependents (including yur spuse) if yu have ther medical insurance cverage. Accrding t the Cllective Bargaining Agreement, Full-time Active emplyees are eligible t receive an annual payment f $1,500 frm the Premium Cnversin Plan instead f medical/visin and dental cverage under the Plan. Part-time Active emplyees wh chse nt t participate in the Health & Welfare Plan d nt receive a payment frm the Premium Cnversin Plan. New emplyees, wh elect the pt-ut ptin effective fr the first f a mnth ther than July 1, will receive a pr-rata share f the respective annual payment. Retired emplyees can terminate their cverage at any time, hwever, nce a retired emplyee cancels cverage, he r she can nly return under certain circumstances. Call the health and welfare ffice with questins. Yu must bring prf f ther nn-metro medical insurance t the Health & Welfare ffice every year. Except under limited circumstances, yu can nt change this electin until the next Open Enrllment perid, currently scheduled fr May I Opted Out Last Year. D I Need T D Anything? Yes, yu must renew yur pt-ut electin fr In the event yu r yur dependents lse the ther health care cverage, yu r yur dependents may be able t enrll in this plan. Yu must request enrllment within 30 days after the previus cverage ends. In additin t the supprting dcumentatin nrmally needed (described in the Eligibility fr Yurself and Yur Dependents sectin n page 3), yu must als prvide a Health Insurance Cverage Certificate frm yur frmer healthcare prvider as prf f previus health cverage. Cverage will be effective the first f the mnth fllwing cmpletin f the enrllment request. Call the Health & Welfare ffice immediately if yu have any questins. 6

9 COBRA Cntinuatin Cverage The Cnslidated Omnibus Recnciliatin Act f 1985 ( COBRA ) allws active emplyees, their spuses and dependents wh lse cverage under the Plan under certain circumstances called qualifying events t cntinue cverage n a self-pay basis fr up t 18 mnths (36 in certain situatins). The Health & Welfare ffice will ntify yu f the right t elect COBRA cntinuatin cverage and hw much the cverage will cst, which may change annually. Yu must ntify the Health & Welfare ffice within 60 days f the ntice r 60 days after yu lse cverage (whichever is later) if yu want t elect COBRA cntinuatin cverage. A cmplete descriptin f yur COBRA Rights & Respnsibilities is available in the Summary Plan Bklet. Abut Privacy and Dcumentatin The Health Insurance Prtability and Accuntability Act f 1996 (HIPAA), requires that the Health & Welfare Plan prtect the cnfidentiality f yur private health infrmatin. Once yu are enrlled in the Plan, the Health & Welfare ffice and the Bard f Trustees will nt use r further disclse infrmatin that is prtected by HIPAA (knwn as prtected health infrmatin r PHI ) except as necessary fr treatment, payment, healthcare peratins, r as permitted r required by law. In particular, they will nt, withut yur written authrizatin, use r disclse PHI fr emplyment-related actins and decisins r in cnnectin with any ther benefit r emplyee benefit plan f the Plan Spnsr. Under federal law, yu have certain rights with respect t yur prtected health infrmatin, including certain rights t see and cpy the infrmatin, receive an accunting f certain disclsures f the infrmatin, and under certain circumstances amend the infrmatin. Yu have the right t request reasnable restrictins n disclsure f infrmatin abut yu, and t request cnfidential cmmunicatins. Yu als have the right t file a cmplaint with the Plan r with the Secretary f the Department f Health and Human Services if yu believe yur rights have been vilated. If yu have questins abut the privacy f yur health infrmatin, r if yu wish t file a privacy vilatin cmplaint nce yu are cvered under the Plan, please cntact the Plan s Privacy Official at the Health & Welfare ffice address and phne number lcated n the back f this Guide. Medicaid and the Children s Health Insurance Prgram (CHIP) Offer Free r Lw-Cst Health Cverage t Children and Families If yu are eligible fr health cverage frm yur emplyer, but are unable t affrd the premiums, sme States have premium assistance prgrams that can help pay fr cverage. These States use funds frm their Medicaid r CHIP prgrams t help peple wh are eligible fr emplyer-spnsred health cverage, but need assistance in paying their health premiums. If yu r yur dependents are already enrlled in Medicaid r CHIP and yu live in a State listed belw, yu can cntact yur State Medicaid r CHIP ffice t find ut if premium assistance is available. If yu r yur dependents are NOT currently enrlled in Medicaid r CHIP, and yu think yu r any f yur dependents might be eligible fr either f these prgrams, yu can cntact yur State Medicaid r CHIP ffice r dial KIDS NOW r t find ut hw t apply. If yu qualify, yu can ask the State if it has a prgram that might help yu pay the premiums fr an emplyer-spnsred plan. Once it is determined that yu r yur dependents are eligible fr premium assistance under Medicaid r CHIP, yur emplyer s health plan is required t permit yu and yur dependents t enrll in the plan as lng as yu and yur dependents are eligible, but nt already enrlled in the emplyer s plan. This is called a special enrllment pprtunity, and yu must request cverage within 60 days f being determined eligible fr premium assistance. If yu have questins abut enrlling in yur emplyer Plan, yu can cntact the Department f Labr electrnically at r by calling tll-free EBSA (3272). As f January 31, 2014, the fllwing States ffer premium assistance prgrams: Alabama, Alaska, Arizna, Clrad, Flrida, Gergia, Idah, Indiana, Iwa, Kansas, Kentucky, Luisiana, Maine, Massachusetts, Minnesta, Missuri, Mntana, Nebraska, Nevada, New Hampshire, New Jersey, New Yrk, Nrth Carlina, Nrth Dakta, Oklahma, Oregn, Pennsylvania, Rhde Island, Suth Carlina, Suth Dakta, Texas, Utah, Vermnt, Virginia, Washingtn, West Virginia, Wiscnsin and Wyming. If yu live in ne f these States, yu shuld cntact its Medicaid r CHIP ffice fr further infrmatin as yu may be eligible. The cntact infrmatin fr Virginia is as fllws: VIRGINIA Medicaid and CHIP: Medicaid Website: Medicaid Phne: CHIP Website: CHIP Phne: T see if any mre States have added a premium assistance prgram since January 31, 2015, r fr mre infrmatin n special enrllment rights, yu can cntact either: U.S. Department f Labr U.S. Department f Health and Human Services Emplyee Benefits Security Administratin Centers fr Medicare & Medicaid Services EBSA (3272) , Ext

10 Yur Medical/Visin Benefit Plan Chices The Plan ffers bth active and retired emplyees the fllwing ptins fr medical (including prescriptin drugs) and visin cverage, including an pt-ut ptin fr Active Emplyees: Kaiser Permanente HMO medical and NVA visin BlueChice HMO medical and Davis Visin CareFirst PPO medical and Davis Visin Summary Cmparisn f Yur Medical/Visin Optins This chart summarizes sme key features f yur medical/visin plan ptins, s yu can cmpare ptins and select the best ne fr yur needs. A mre cmplete descriptin f benefits can be fund in materials prvided by the individual prviders. The Plan will als send yu a Health & Welfare Plan Summary Plan Bklet, which will further detail eligibility rules and benefits. Yu will receive a Summary f Benefits and Cverage fr each f the three plans ffered by the Plan as required by the Affrdable Care Act (health care refrm). It uses a standardized reprt t allw yu t cmpare yur benefit ptins. Pharmacy Benefits If yur medical plan is: Yur prescriptin drug prgram is: Retail Netwrk (30-day supply) Yur C-Payment is: Retail Nn-Netwrk (30-day supply) Mail Order (90-day supply) Kaiser Permanente HMO Kaiser Permanente Generic $5 Kaiser Pharmacy $10 Other Participating Netwrk Pharmacy Full cst f drug $10 Frmulary brand Nn-Frmulary $20 Kaiser Pharmacy $40 Other Participating Netwrk Pharmacy $30 Kaiser Pharmacy $60 Other Participating Netwrk Pharmacy Full cst f drug $40 Full cst f drug $60 CareFirst PPO BlueChice HMO Optimum Rx Active Particpants Pre-Medicare Retirees Generic $5 Full cst f drug $10 Frmulary brand $20 Full cst f drug $40 Nn-Frmulary $30 Full cst f drug $60 CareFirst PPO BlueChice HMO United Health Care Medicare Retirees Generic $5 Full cst f drug $10 Frmulary brand $20 Full cst f drug $40 Nn-Frmulary $30 Full cst f drug $60 Fr Medicare Eligible Retirees with high ut-f-pcket expenses, cpayments may be lwer than the nes nted abve. 8

11 Medical/Visin Plan Optins Cvered Services Kaiser PermaneNte HMO* BlueChice HMO CareFirst (PPO) In-Netwrk CareFirst (PPO) Out-Of-Netwrk** Annual Deductible Nne Nne Nne $300 individual $600 Family Office Visits $15 c-pay per visit $15 c-pay per visit $15 c-pay per visit Plan pays 75% f allwance after deductible Hspital Stays N charge N charge N charge (frm day 1 t 365) Plan pays 75% f allwance after deductible Outpatient Hspital Visits $15 c-pay per visit $15 c-pay per visit $15 c-pay per visit Plan pays 75% f allwance after deductible Surgery N charge N charge N charge Plan pays 75% f allwance after deductible X-Rays and Labs N charge N charge N charge Plan pays 75% f allwance after deductible Emergency Rm Care $50, waived if admitted $50, waived if admitted $50, waived if admitted $50, waived if admitted Plan pays 75% f allwance after deductible Preventive Services N charge N charge $15 c-pay per visit Plan pays 75% f allwance after deductible (birth t page 17) Mammgrams and Annual Pap Tests Mental Health Inpatient Care Mental Health Outpatient Care Substance Abuse Inpatient Care Substance Abuse Outpatient Care N charge N charge N charge Plan pays 75% f allwance after deductible N charge N charge N charge Plan pays 75% f allwance after deductible up t 45 days per calendar year N charge N charge N charge Plan pays 75% f allwance after deductible up t 40 visits, 60% after that N charge N charge N charge Plan pays 75% f allwance after deductible N charge N charge N charge Plan pays 75% f allwance after deductible Hspice Care N charge N charge N charge Plan pays 75% f allwance after deductible Chirpractic Care $15 c-pay per visit, up t 20 visits $15 c-pay per visit, up t 20 visits per calendar year $15 c-pay per visit Plan pays 75% f allwance after deductible Physical Therapy $15 c-pay per visit, up t 90 visits $15, c-pay per visit up t 30 visits per calendar year $15 c-pay per visit Plan pays 75% f allwance after deductible Weight Lss (including surgery) Limited cverage Limited cverage Limited cverage Nt Cvered * Benefits fr Kaiser enrllees wh are retired and Medicare-eligible differ in sme respects frm the benefits fr active emplyees and pre-medicare retirees. ** Remember, when yu see an ut-f-netwrk prvider fr care, the prvider may charge mre than the CareFirst allwance. If this is the case, yu are respnsible fr paying the balance in additin t yur cinsurance. 9

12 Medical/Visin Plan Optins Visin Plan Cverage NVA (included with Kaiser) DAVIS VISION (included with Bluechice) DAVIS VISION (included with CareFirst PPO) Visin Cverage (Active Emplyees) Exams thrugh HMO $15 discunted lenses and frames thrugh Natinal Visin Administratrs (NVA) Exams thrugh Davis Visin $15 c-pay. Opthalmlgist visits thrugh HMO $0 c-pay with referral frm PCP. Discunted frames and lenses thrugh Davis Visin One eye exam per calendar year; discunts n frames, lenses and cntacts when yu use a Davis Visin prvider Eye exam $15 Visin Cverage (Retired Emplyees) Exams thrugh HMO NVA discunts are nw available t retired emplyees and widws Exams thrugh Davis Visin $15 c-pay. Opthalmlgist visits thrugh HMO $0 c-pay with referral frm PCP. Discunted frames and lenses thrugh Davis Visin One eye exam per calendar year; discunts n frames, lenses and cntacts when yu use a Davis Visin prvider Eye Exams $15 c-pay $15 thrugh Davis Visin $0 thrugh HMO with referral frm PCP $15 c-payment at participating Davis Visin visin center Frequency Annually Annually Annually Frames Yu select any frame type frm a participating prvider and pay the whlesale price plus 50%. (Yu save because retail price is ften 3 times the whlesale cst.) Up t $70 retail Yu pay $40 Over $70 retail Yu pay $40 plus 90% f the amunt ver $70 Up t $70 retail Yu pay $40 Over $70 retail Yu pay $40 plus 90% f the amunt ver $70 Lenses Accrding t schedule, fr example, yur cst wuld be $31/pair fr single visin plastic lenses Yu pay Single $35 Bifcal $55 Trifcal $65 Yu pay Single $35 Bifcal $55 Trifcal $65 STATEMENT OF GRANDFATHERED status The Trustees believe that this Plan is a grandfathered health plan under the Affrdable Care Act, which permits us t preserve certain basic health cverage already in effect befre the law was passed. As with all grandfathered health plans, ur Plan des nt have t include certain cnsumer prtectins f the Affrdable Care Act that apply t ther plans (fr example, prvide preventative health services withut any cst sharing). Hwever, grandfathered health plans, like ur Plan, must cmply with certain ther cnsumer prtectins in the Affrdable Care Act (fr example, the extensin f cverage fr dependent children t age 26). Cntact the Health & Welfare ffice if yu have questins abut what it means fr a health plan t have grandfathered status and what might cause a plan t lse its grandfathered status. Yu may als cntact the U.S. Department f Labr s Emplyee Benefits Security Administratin (EBSA) at r The website includes a chart summarizing the prtectins that d and d nt apply t grandfathered health plans. 10

13 The Transit Emplyees Health & Welfare fund is nw n line Visit ur web site Use ur new member prtal and try ur new n-line enrllment Vest us n Facebk at 689 Mving Metr Try ur new On-line enrllment Anytime Medical Access wherever yu are n Visin yur hme cmputer Easy t use navigatin Explre yur plan f benefits Helpful vides Up t date news Wellness Infrmatin Frequently asked questins Easy access t the websites f benefit partners Supplemental Life Insurance Life Insurance Visit tday! Scan this Quick Respnse (QR) cde with yur smart phne. Yu can dwnlad a QR cde reader app frm yur app stre. During pen Enrllment G t the Member Prtal at T change yur benefit selectin T renew yur pt ut electin T enrll r disenrll a dependent. T change yur beneficiary Shrt-Term Disability Lng-Term Disability Dental 11

14 NEW SPOUSAL OPT OUT CREDIT AVAILABLE The new cllective bargaining agreement permits emplyees t receive a credit f up t $1,200 if their spuse pts ut f the Transit Emplyees Health & Welfare Plan s health insurance prgram. It can nly be used as a credit against medical and dental benefit expenses incurred as a Participant in the Plan. Yu must elect the spusal pt-ut ptin each year. Hw des it wrk? Up t $100 per mnth will be applied t reduce the cst f yur medical and dental insurance. It cannt be applied t reduce the cst f any supplemental life insurance yu may have elected r f any ther vluntary benefit. Example: Yur plan requires a mnthly cntributin f $80 tward single cverage and $208 tward family cverage. Here is hw the credit will wrk: Fr a family with nly emplyee and spuse cverage, the spusal pt-ut wuld change yur plan frm family t single (frm $208 t $80) and the credit wuld further reduce the mnthly cntributin fr single cverage ($80) t zer. Fr a family with emplyee, spuse and children cverage, the spusal pt-ut wuld nt change yur family plan cverage ($208), but it wuld reduce the $208 amunt yu pay t $108 (the maximum credit f $100 per mnth). This credit is available t emplyees and retirees, but cannt be cmbined with the emplyee pt-ut payment described elsewhere. This credit is available nly if the emplyee r retiree remains cvered in the Transit Emplyees Health and Welfare prgram. Yu can nly elect the spusal pt ut ptin during the annual pen enrllment perid, usually in May f each year. It will be effective fr yur premiums fr the fllwing July 1st. If yu have mre questins, please call the Health and Welfare Fund Office at

15 We ve Gt the Tls, Yu ve Gt the Pwer. Lcal 689 and TEHW are cmmitted t the 689 Mving Metr Wellness Prgram Missin Statement: We aim t empwer 689 members and their families by equipping them with infrmatin and tls needed t make small changes mving tward a healthier life. Every time time yu yu make a a healthy chice, yu harness yur pwer t t impact many aspects f f yur life: yur health, the length and quality f f yur yur life, life, yur bank accunt, yur wrk experience and and the the level level f f enjyment yu ll get get ut f f retirement! Here Here are are sme sme healthy chices yu yu can can start making tday: Eating Eating fruit fruit instead instead f f candy. candy. Taking the stairs instead f the Taking the stairs instead f the escalatr r elevatr. escalatr r elevatr. Taking a deep breath when yur stressed Taking a deep breath when yur stressed rather than bttling it up inside. rather than bttling it up inside. Prgram Features: - Fitness class pprtunities - Wellness fairs - Educatinal resurces fr healthy tpics like exercise, nutritin, stress management, and weight lss - Fun, healthy living challenges - Access t nline and smart phne based healthy living tls We ve teamed up up with with Virgin Pulse t t ffer eligible members access t t nline nline tls tls and and a a smartphne smartphne app app with with simple simple t t use use tls tls fr fr healthy healthy living.* living.* Be Be ne ne f f the the first first several several hundred members t enrll and receive a hundred members t enrll and receive a FREE Max pedmeter valued at $30! FREE Max pedmeter valued at $30! Enrll Enrll fr fr the the prgram prgram thrugh Virgin Pulse thrugh Virgin Pulse by visiting: by visiting: jin.virginpulse.cm/689mvingmetr jin.virginpulse.cm/689mvingmetr Getting a gd night s rest instead f Getting staying a up gd late night s t catch rest yur instead favrite f shw. staying up late t catch yur favrite shw. *Currently this feature is nly available t active 689 members *Currently eligible this feature fr benefits is nly thrugh available the t Transit active 689 Emplyee members Health eligible and fr benefits Welfare thrugh ffice. the Transit Emplyee Health and Welfare ffice. Learn mre by visiting Learn mre by visiting Like us n Facebk at 689 Mving Metr 13 Like us n Facebk at 689 Mving Metr

16 Safevisin Prescriptin Safety Glasses Available: Prescriptin Safety Glasses are nw available t ATU Lcal 689 members. If yu wrk in Maintenance r Cnstructin, yu are eligible fr Prescriptin Safety Glasses. These members are eligible fr this benefit nce a year, yu will need t cmplete an rder frm available at the Transit Emplyees Health & Welfare Plan ffice. Present the rder frm alng with a visin prescriptin (including pupil distance) frm yur ptician t the Transit Emplyees Health & Welfare Fund (TEHW). The basic benefit cnsists f a single visin and lined bifcals, is ffered at n cst t the members, hwever; members are respnsible fr the extras. Safety Glasses can be delivered directly t yur hme r t the TEHW ffice fr pick up. Am I eligible fr Safety Glasses? If yu wrk in Maintenance r Cnstructin, yu are eligible fr Prescriptin Safety Glasses. The members are eligible fr this benefit nce a year. Hw d I get the Safety Glasses? If yu are eligible, yu will need t cmplete an rder frm. The rder frms are available the Transit Emplyees Health & Welfare Plan ffice. Present the rder frm alng with their visin prescriptin (including pupil distance) frm their physician t the Transit Emplyees Health & Welfare Fund. What is the cst fr this benefit? The basic benefit, which includes single visin and lined bifcals, is ffered at n cst t the members. Hwever, members are respnsible fr the extras. Fr example: Prgressive (n line) Bifcals: $30.00; Scratch Resistant Cating: $25.00; Anti-Glare Cating: $35.00; Anti-Glare with TD2: $40.00; Black Hard case: $ Safety Glasses can be delivered directly t yur hme r t the Transit Emplyees Health & Welfare Office fr pick up. Where d the Safety glasses cme frm? We have an agreement with SafeVisin LLC frm St. Luis, MO ( t prvide made in the USA ANSI certified safety glasses. A representative frm the cmpany will be here the first three days f pen enrllment. Details will be made available n ur web site ( ) f 1 4/14/14 10:30 AM

17 Retired Emplyees Living Out f the Area The Plan s HMOs have limited benefit ptins fr thse persns wh live utside f the HMO s service areas. Retired emplyees shuld select the benefit plan that has facilities in the areas where they live. Otherwise, retired emplyees may be unable t receive prper medical treatment r may have t pay mre f the cst fr claims. Retired Emplyees wh live utside an HMO service area may be required t enrll in the CareFirst PPO ptin, which prvides cverage thrughut the United States. If Yu Are Eligible, Please Enrll in Medicare Parts A & B r Pay Mre Mney If yu r yur dependents becme eligible fr Medicare at age 65 r as a result f disability r End Stage Renal Disease, yu r yur dependent(s) can enrll in Medicare Part A and Part B. If yu d nt enrll in Medicare Part A and Part B, the Plan will nt pay the prtin f yur bills that Medicare wuld therwise pay. Yu will be respnsible fr the additinal payment. Dental Benefit Optins Dental health is imprtant t yur verall wellbeing. Dental insurance can help yu manage the cst f maintaining healthy teeth and gums. If yu elect medical/visin cverage, yu als get yur chice f dental cverage. If yu pted ut f medical/visin cverage, yu cannt elect dental cverage. The Health & Welfare Plan ffers the fllwing dental ptins: Active Emplyees CIGNA Dental Maintenance Organizatin (DMO) CareFirst withut rthdntic benefits CareFirst with rthdntic benefits Retired Emplyees Medicare will becme the primary payer and the Plan will be secndary t the extent permitted by law. Yu must prvide the Health & Welfare ffice with the infrmatin necessary t crdinate benefits with Medicare fr yu and yur dependent(s). Retired emplyees in Kaiser wh are eligible fr Medicare and have nt enrlled in Part B will have a surcharge added t their mnthly premium and deducted frm their pensin check. The surcharge amunt is subject t change. If yu fail t ntify the Health & Welfare ffice and it is later determined that yu r yur dependent were eligible fr cverage under Medicare, the Plan may recver frm yu the amunt f any claims paid in errr (including interest and cllectin csts). All retired emplyees receive individual dental cverage thrugh Delta Dental at a cst f $7.00 per mnth Retired emplyees can elect and purchase family Dental cverage with Delta Dental at a cst f $20.00 per mnth. Surviving Dependents Surviving Dependents can nly cntinue the cverage that was in effect when the member died 15

18 Summary Cmparisn f Yur Dental Optins This chart summarizes sme key features f yur dental plan ptins. A mre cmplete descriptin f benefits can be fund in materials prvided by the individual prviders. The Plan will als send yu a Health & Welfare Summary Plan Bklet, which will further detail eligibility rules and benefits. Dental Plan Optins CIGNA Dental DMO 1 CareFirst Dental CareFirst Dental with Orth Delta Dental fr Retirees Only 2 Annual Deductible Nne Nne Nne $100 per individual up t $300 family maximum Annual Benefit Maximum Nne $3,500 Individual $3,500 Individual (fr nn-rthdnic services) $1,500 Individual Preventive Services Exams Cleanings $0 N charge if service rendered by participating dentist 3 N charge if service rendered by participating dentist 3 60% f reasnable and custmary, n deductible Basic Restrative Services (Fillings) $0 20% f reasnable and custmary 20% f reasnable and custmary 60% f reasnable and custmary Majr Restrative Services Crwn (Prcelain/ Ceramic) $220 20% f reasnable and custmary 20% f reasnable and custmary 30% f reasnable and custmary Rt Canal Bicuspid $20 20% f reasnable and custmary 20% f reasnable and custmary 50% f reasnable and custmary Extractin Single Tth Partial Bny Impactin $5 $20 20% f reasnable and custmary 20% f reasnable and custmary 50% f reasnable and custmary Orthdntia 24 mnth treatment Adult $3,122 maximum ut-f-pcket cst per 24-mnth perid Nt cvered $1,000 lifetime maximum per persn Nt cvered Child $2,450 maximum ut-f-pcket cst per 24-mnth perid Crwns and Bridges 5 year replacement 10 year replacement 10 year replacement 30% f reasnable and custmary 1 If yu enrll in the CIGNA Dental Maintenance Organizatin (DMO), yu will need t select a dentist frm the CIGNA prvider listing and use him r her fr all f yur dental care needs. 2 Have yur dentist submit the claim frm t Delta Dental fr predeterminatin befre cmpleting treatment fr any care exceeding $ Nn-participating dentist, yu pay any amunt in excess f reasnable and custmary allwance. 16

19 Vluntary Benefits Supplemental Life Insurance Nw, fulltime active emplyees can elect $50,000 supplemental life insurance withut evidence f insurability. Yu can nw elect up t $400,000 in supplemental life insurance with evidence f insurability. The frms t enrll in the supplemental life insurance prgram will be available in the Transit Emplyees Health and Welfare Fund Office and nline at tehw.rg. Yu pay the full cst f this prgram. Premiums fr this supplemental cverage will be deducted frm yur pay. The new rates can be fund n the Rate Sheet n page 21 f this Guide. The rates are based n yur age. If yu elect $50,000 in supplemental life insurance and yu are 39 years ld, yu will pay $4.50 per mnth. After yu turn 40, yur rate increases t $5.00 per mnth. Plan Optins: $300,000 and $400,000 Status Basic Life Insurance Can Purchase Additinal Supplemental Life Insurance Active Full-Time Emplyees $50,000 Withut evidence f insurability $50,000 With evidence f insurability Up t $400,000 Active Part-Time Emplyees with Medical/Visin and Dental Cverage frm the H&W Plan Active Part-Time Emplyees withut Medical/Visin and Dental Cverage frm the H&W Plan $50,000 Withut evidence f insurability $50,000 With evidence f insurability Up t $400,000 $25,000 Withut evidence f insurability $35,000 Retired Emplyees $10,000 Nne Additinal Benefits Available t Lcal 689 Members Outside f the Health & Welfare Plan Universal Life Insurance Lcal 689 members wh are actively wrking are eligible t participate in a universal life insurance prgram. Yu pay the full cst f this prgram, which may be cntinued if yu leave WMATA fr any reasn. Optins available and rates fr cverage depend n yur persnal situatin. Yu may als insure yur spuse, dependent children and grandchildren, even if yu d nt participate. Premiums are paid thrugh payrll deductin. Fr additinal infrmatin, please call Natinal Grup Prtectin at Flexible Spending Accunt & Dependent Care Accunt Call WMATA benefits ffice at (see page 18) 17

20 Key Cntacts fr Claims and Service Infrmatin All questins regarding services and claims shuld be directed t yur insurance prvider as fllws: T Cntact Call SURF Kaiser Permanente HMO (301) (800) Natinal Visin with Kaiser HMO (800) BlueChice HMO (877) CareFirst PPO (877) Optimum Rx/United Healthcare Nn-Medicare (Active & Retired) Medicare (Retired) (866) (877) Davis Visin (800) CareFirst Dental (866) CIGNA DMO (Dental) (800) Delta Dental (Retirees nly) (800) www2.midatlanticdeltadental.cm Lng Term Disability Plan MetLife The Hartfrd (800) (800) Life and Accidental Death Insurance (800) press 2 Safevisin (314) Vluntary Universal Life (NGP) (800) WMATA Telephne Numbers Benefits Offices (Pensin) Medical Payrll Dependent Care/FSA (202) (202) (202) (202) ATU Lcal 689 (301) Transit Emplyees H & W Fund (301) Check the prvider directries r websites t verify that yur current primary care prvider is a netwrk prvider. The Plan will nt mail prvider directries. Hard cpies are available at the Health & Welfare ffice and frm the individual insurance prviders listed abve. Mre detailed benefit descriptins and cverage maps are als available at the Health & Welfare ffice. 18

21 D nt fill ut this frm if yu want t keep yur same medical/visin and dental cverage AND yu d nt want t add r drp dependents Emplyee N. E Daytime Phne: If yu want t: Add, remve r change dependents Change medical r dental plans Update life insurance beneficiary Please make a selectin frm the chart belw and return it t the Health & Welfare ffice. Active Emplyees Open Enrllment Frm Name Spuse s Name Des yur spuse wrk fr Metr? Y N SSN Spuse s SSN If yes, prvide spuse s Emplyee Number Medical/Visin (including Prescriptin Drugs) Dental Vluntary Benefits I nw have: Kaiser Permanente HMO and NVA Visin Single Cverage Family Cverage Spusal pt-ut BlueChice HMO and Davis Visn Single Cverage Family Cverage Spusal pt-ut CareFirst PPO and Davis Visin 1 Single Cverage Family Cverage Spusal pt-ut I want t change t: I nw have: CareFirst Single Cverage Family Cverage CareFirst with Orth Single Cverage Family Cverage CIGNA DMO Single Cverage Family Cverage I want t change t: Supplemental Life Frms are available nline at r the Health & Welfare Fund ffice Opt-ut I understand that an pt-ut is nt final until the necessary dcumentatin is prvided t the Health & Welfare ffice (See p. 6) Spusal Opt-ut I understand that an pt-ut is nt final until the necessary dcumentatin is prvided t the Health & Welfare ffice 1 CareFirst PPO medical cverage is nly available t emplyes hired befre March 1, (Emplyees hired n r after March 1, 2012 are eligible t elect CareFirst PPO medical cverage after cmpleting 39 mnths f service frm the date f hire.) Enrllment Deadline: May 29, 2015 This frm must be signed and returned t the Health & Welfare ffice at: 2701 Whitney Place, Suite 100 Frestville, MD If Yu Want t Add/DROP Dependents yu must fill ut the back f this frm and prvide it t the Health & Welfare ffice by May 29, (See page 3 f this Enrllment Guide.) Signature Date 19

22 If yu remve a dependent, please indicate the address separately, s that we may send them a COBRA ntice, if applicable. Dependents remved during pen enrllment d nt autmatically qualify fr COBRA cverage. Spuse Add Remve Emplyed by WMATA Yes N Additinal Inf: Name (Last, First, Mi) Scial Security Date f Birth Sex M F Child Add Remve Name (Last, First, Mi) Scial Security Date f Birth Sex M F Additinal Inf: Child Add Remve Name (Last, First, Mi) Scial Security Date f Birth Sex M F Additinal Inf: Child Add Remve Name (Last, First, Mi) Scial Security Date f Birth Sex M F Additinal Inf: Child Add Remve Name (Last, First, Mi) Scial Security Date f Birth Sex M F Additinal Inf: Must Prvide Dcumentatin t Health & Welfare Office (See page 3) Signature Date 20

23 Cntributins/Basic Rates Thrugh December 31, 2015 This page lists the csts fr the varius cverage ptins effective January 1, 2015 December 31, 2015 Cntributins fr Active Emplyees Medical/Visin Plan With CIGNA Dental With CareFirst Dental Full-Time Part-Time Full-Time Part-Time Kaiser Permanente Medical and NVA Visin Single Family $ $ $ $ $ $ $ $ BlueChice HMO Medical and Davis Visin* Single Family $ $ $ $ $ $ $ $ CareFirst PPO Medical and Davis Visin* Single Family $ $ $ $ $ $ $ $ Supplemental Orthdntic Single Family n/a n/a $ 8.92 $27.69 $ 8.92 $27.69 * CareFirst PPO medical cverage is nly available t emplyees hired befre March 1, (Emplyees hired n r after March 1, 2012 are eligible t elect CareFirst PPO medical cverage after cmpleting 39 mnths f service frm the date f hire.) Plan Optins: $300,000 and $400,000 MetLife Term Life Insurance Rates Age Band $10K $35K $50K $75K $100K $150K $200K $250K $300K $400K Less than 25 $0.50 $1.75 $2.50 $3.75 $5.00 $7.50 $10.00 $12.50 $15.00 $ $0.60 $2.10 $3.00 $4.50 $6.00 $9.00 $12.00 $15.00 $18.00 $ $0.80 $2.80 $4.00 $6.00 $8.00 $12.00 $16.00 $20.00 $24.00 $ $0.90 $3.15 $4.50 $6.75 $9.00 $13.50 $18.00 $22.50 $27.00 $ $1.00 $3.50 $5.00 $7.50 $10.00 $15.00 $20.00 $25.00 $30.00 $ $1.60 $5.60 $8.00 $12.00 $16.00 $24.00 $32.00 $40.00 $48.00 $ $2.60 $9.10 $13.00 $19.50 $26.00 $39.00 $52.00 $65.00 $78.00 $ $4.60 $16.10 $23.00 $34.50 $46.00 $69.00 $92.00 $ $ $ $6.80 $23.80 $34.00 $51.00 $68.00 $ $ $ $ $ $12.70 $44.45 $63.50 $95.25 $ $ $ $ $ $ $20.60 $72.10 $ $ $ $ $ $ $ $

24 Cntributins/Basic Rates Thrugh December 31, 2015 This page lists the csts fr the varius cverage ptins effective January 1, 2015 December 31, 2015 Retired Emplyees and Survivrs f Retirees Medical/Visin Plan Nrmal/Disability Medicare Survivrs f Retirees Survivrs f Retirees n Medicare Kaiser Permanente Medical and NVA Visin Single: Family: Family 1 Medicare Family 2 Medicare $ $ $ $ $ $ $ $ $ $ BlueChice HMO Medical and Davis Visin Single: Family: Family 1 Medicare Family 2 Medicare $ $ $ $ $ $ $ $ $ $ CareFirst PPO Medical and Davis Visin Single: Family: Family 1 Medicare Family 2 Medicare $ $ $ $ $ $ $ $ $ $ Survivrs f Active Emplyees Medical/Visin Plan With CIGNA Dental With CareFirst Dental Kaiser Permanente Medical and NVA Visin BlueChice HMO Medical and Davis Visin CareFirst PPO Medical and Davis Visin Single: Family: Single: Family: Single: Family: $ $ $ $ $ $ $ $ $ $ $ $ Supplemental Orthdntic Single: Family: $ 8.92 $ Retirees wh retire with an Early Pensin Medical/Visin Plan Age at retirement Age at retirement Age at retirement Pre- Medicare Medicare Pre- Medicare Medicare Pre- Medicare Medicare Kaiser Permanente Medical and NVA Visin Single: Family: $ $ $ $ $ $ $ $ $ Family 1 Medicare Family 2 Medicare $ $ $ $ $ $ BlueChice HMO Medical and Davis Visin Single: Family: $ $ $ $ $ $ $ $ $ Family 1 Medicare Family 2 Medicare $ $ $ $ $ $ CareFirst PPO Medical and Davis Visin Single: Family: $ $ $ $ $ $ $ $ $ Family 1 Medicare Family 2 Medicare $ $ $ $ $ $