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2018-2019POST-65 RETIREES BENEFITS GUIDE
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This past year has been very busy for METRO. We’ve continued to focus on taking care of our employees (past and present) by providing them with a benefits package that is competitive and affordable.
METRO is committed to covering the bulk of benefits costs; it’s up to each of you, as health care consumers, to make smart lifestyle and personal health decisions to help keep your costs down and sustain your health
As a part of the METRO family, our benefit programs are just one of the many ways METRO helps you take care of yourself and your family. Do your part to stay healthy! Be sure you and your family members take the time to schedule your appointments and visit your doctor.
Remember, higher cost doesn’t indicate higher quality of care, so choose the best combination of benefits for you and your family. The enrollment meetings allow you to talk to benefits professionals and ask questions about your health insurance. The benefits staff will be available to assist you with questions you may have concerning this process.
Making smart health care decisions starts at annual enrollment and lasts all year, and this year is an opportunity to start fresh and do great things. Please join me as we make 2018-2019 our best and healthiest year yet!
DEAR METRO RETIREES,
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PLAN AHEADEnroll for Medicare supplemental coverage between October 15 - December 7, 2018. Your Medicare supplemental coverage will go into effect January 1, 2019. See pages 4-6 for more information.
YOUR HEALTH PLANSPost-65 METRO retirees have two options for medical coverage:
• Via Benefits: Medical supplemental coverage through a marketplace
Visit www.my.viabenefits.com to explore your plan options, including rates, and enroll for Via Benefits online.
Learn more below >
• KelseyCare Advantage: Three plan options that grant benefits exclusively with Kelsey-Seybold providers
View your rates on page 13 and visit KelseyCare Advantage plan online at www.kelseycareadvantage.com/METRO.
See plan details on pages 7-10 >
VIA BENEFITSVia Benefits is designed to supplement Medicare coverage, and is available through the marketplace.
If you and your covered spouse decide to enroll in Medicare supplemental coverage through Via Benefits, you will receive $2,801 in a Health Reimbursement Account (HRA) each year you are enrolled.
However, if you go outside of Via Benefits for Medicare supplemental coverage, like choosing one of the KelseyCare Advantage plans, you will no longer receive the HRA contribution.
PAGE NUMBER
In This Guide
Your Health Plans 3
Via Benefits 3
Medicare Advantage/Supplement 4-6
KelseyCare Advantage Plans 7-10
Take an Active Role in Your Health 11
Your Dental Plans 12
Your 2018-2019 Rates 13
Contacts 14
If you or your dependents have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices about your prescription drug coverage. See separate legal notices for more details.
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MEDICARE OPEN ENROLLMENT CHANGE RULESPost-65 METRO retirees enrolled with Via Benefits have two options for medical coverage - Medicare Advantage and Medicare Supplement (Medicap) plans.
• Enrollment is passive for Medicare Plans.
• Medicare Advantage Plans
You may switch to a Medicare Advantage plan during the open enrollment period without any underwriting considerations. You can change between Medicare Advantage plans, or go from a Medigap to a Medicare Advantage plan.
• Medicare Supplement (Medigap) Plans
Depending on various factors (current carrier/plan, new carrier/plan, the state where you live, etc.), you may face underwriting in the event you want to change between Medigap plans, or go from a Medicare Advantage plan to a Medigap. In most cases, if you are enrolled in a Medigap plan, you will stay within that plan.
• Prescription Drug Plan (Part D Plan)
You may change your prescription drug plan during the open enrollment period without any underwriting considerations.
The Service Center will be open on Saturdays for appointments only for legacy participants between October 20 – December 1 from 9:00 a.m. to 7:00 p.m. EDT.
PEAK DAYS• Monday, October 15
• Tuesday, October 16
• Monday, November 26 through Friday, November 30
• Monday, December 3 through Friday, December 7
CUSTOMER SERVICE(855) 872-6806
• The open enrollment period is the busiest time of year.
• Monday and Tuesday are the busiest days of the week.
• Best time to call is typically in the afternoon or later in the week.
Hours of Operation:Monday - Friday, 8a.m. – 9p.m. EDT
MEDICARE ADVANTAGE/SUPPLEMENT
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MEDICARE ADVANTAGE OPEN ENROLLMENT PERIODFor participants enrolled through Via Benefits effective in 2019, a new Medicare Advantage open enrollment period will take place from January 1 –March 31, 2019. The open enrollment period provides an additional safeguard to participants that feel they enrolled in the wrong plan. This new Medicare Advantage open enrollment period will not help participants that did not enroll/missed their special enrollment period deadline.
The following changes are allowed during this time:
• Participant may switch from their current Medicare Advantage plan to a new Medicare Advantage plan.
• Participant may disenroll from their current Medicare Advantage plan, return to original Medicare and/or enroll into a stand-alone Prescription drug plan.
PART D PRESCRIPTION DRUG PLAN UPDATESFor 2019:
• The Initial Coverage Limit will increase from $3,750 to $3,820.
• You will enter the Coverage Gap, or Donut Hole, once the total cost of your prescriptions reach $3,820.
• You will exit the Coverage Gap, and reach the Catastrophic Coverage phase when the True Out-of-Pocket Threshold is met at $5,100.
• While in the Coverage Gap, you will pay 25% of the total cost of brand name drugs, and 37% of the total cost of generic drugs.
• The maximum Initial Deductible for Part D plans will increase to $415.
2019 ENHANCEMENTSVoluntary Product Offerings:
• Hearing aids
• Indemnity plans –Accident, Critical Illness, Hospital Indemnity
• Medical reimbursement plans –Metal Gap, Hybrid Accident/Critical illness
• Medical consultation services (PinnacleCare, Consumer Medical)
• Short-term medical plans
• Life Insurance
• Legal Services
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WEBSITE ENHANCEMENTS (VIA BENEFITS)• Expanded online enrollment for Medicare retirees/spouses.
• Approximately 70% of plans will now have online enrollment available during the open enrollment period.
• Upon checkout, you will be given step-by-step instructions to either complete the application online, or set an appointment to complete your enrollment over the phone.
• Medicare Beneficiary Identifier Updates:
• You may now enter Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN) online.
• You may update the existing HICN to the new MBI.
• Prescription Coverage Checkup Tool:
• You can update prescriptions to evaluate plan options for the new plan year.
• Allows you to more easily determine which plan may be best for you.
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If you are a Post-65 retiree and choose to become a KelseyCare Advantage member, you have three METRO plan options from which to choose – the Preferred, Preferred Rx or Preferred + Choice plans. The chart below shows the amount you will pay for the medical service listed.
PREFERRED PREFERRED RX PREFERRED + CHOICEInpatient Services
Inpatient Hospital Care(Including Transplant) $500 $500 $500
Inpatient Mental Health Care $500, 190 lifetime days $500, 190 lifetime days $500, 190 lifetime days
Skilled Nursing Facility Days 1-20: $0/day Days 21-100: $100/day Plan covers 100 days
Days 1-20: $0/day Days 21-100: $100/dayPlan covers 100 days
Days 1-20: $0/day Days 21-100: $100/dayPlan covers 100 days
Inpatient Services
You pay 100% of facility charges
You pay 100% of facility charges
You pay 100% of facility charges
$0 copay for physician services
$0 copay for physician services
$0 copay for physician services
10% coinsurance for Medicare-covered DME
10% coinsurance for Medicare-covered DME
10% coinsurance for Medicare-covered DME
20% coinsurance for orthotics/prosthetics
20% coinsurance for orthotics/prosthetics
20% coinsurance for orthotics/prosthetics
Home Health Care $0 copay for each Medicare-covered home care visit
$0 copay for each Medicare-covered home care visit
$0 copay for each Medicare-covered home care visit
Hospice care Paid by original Medicare Paid by original Medicare Paid by original Medicare
Outpatient Services
Doctor Office Visits (PCP) $0 $0 $0
Doctor Office Visits (Specialist) $15 $15 $15
Allergy Testing and Serum $0 $0 $0
Outpatient Services(Hospital) $175 $175 $175
Outpatient Services (Ambulatory Surgery Center) $175 $175 $175
Chiropractic Services $15 $15 $15
Podiatry Services $15 $15 $15
Outpatient Mental Health (Individual) $35 $35 $35
KELSEYCARE ADVANTAGE
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PREFERRED PREFERRED RX PREFERRED + CHOICE
Outpatient Services (Continued)
Outpatient Mental Health (Group) $20 $20 $20
Partial Hospitalization $35 per day $35 per day $35 per day
Outpatient Substance Abuse (Individual) $35 $35 $35
Outpatient Substance Abuse (Group) $20 $20 $20
Outpatient Surgery
$175 copay (ASC) $175 copay (ASC) $175 copay (ASC)
$175 copay (Hospital) $175 copay (Hospital) $175 copay (Hospital)
$175(I.E. CHEMO, DIAGNOSTIC SLEEP
STUDIES OR OBSERVATION STAY)
$175(I.E. CHEMO, DIAGNOSTIC SLEEP
STUDIES OR OBSERVATION STAY)
$175(I.E. CHEMO, DIAGNOSTIC SLEEP
STUDIES OR OBSERVATION STAY)
Ambulance Services $100 $100 $100
Emergency Care $50 $50 $50
Urgently Needed Care $50 $50 $50
Outpatient Rehab Services (Physical, Occupational or Speech Therapy)
$15 $15 $15
Outpatient Rehab Services - (CORF Services) $15 $15 $15
Outpatient Rehab Services - (Wound Care/Lymphedema) $15 $15 $15
Cardiac Rehab Services $25 $25 $25
Pulmonary Rehab Services $25 $25 $25
Durable Medical Equipment 10% coinsurance 10% coinsurance 10% coinsurance
Prosthetic Devices 20% coinsurance 20% coinsurance 20% coinsurance
Diabetic Monitoring Supplies 0% coinsurance 0% coinsurance 0% coinsurance
Diabetic Shoes and Inserts 20% 20% 20%
Diabetes Self-Monitoring Training $0 $0 $0
Diabetic Insulin Pump and Supplies 10% 10% 10%
Outpatient Diagnostic Tests and Therapeutic Services and Supplies
X-rays $0 $0 $0
Lab Services $0 $0 $0
Surgical Dressing/Supplies $0 $0 $0
Diagnostic Sleep Study(Non-Hospital Setting) $0 $0 $0
Cardiac Stress Test $25 $25 $25
CAT Scan $100 $100 $100
MRI or MRA $100 $100 $100
PET Scan $100 $100 $100
Radiation Therapy $25 $25 $25
Vision Care
Diagnostic and Treatment $15 $15 $15
After Cataract Surgery $0 for eye wear $0 for eye wear $0 for eye wear
Routine Exam $15 $15 $15
Hardware Not Covered Not Covered Not Covered
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PREFERRED PREFERRED RX PREFERRED + CHOICEPreventive Services
Abdominal Aortic Aneurysm Screening $0 $0 $0
Bone Mass Measurement $0 $0 $0
Colorectal Cancer Screening $0 $0 $0
HIV Screening $0 $0 $0
Immunizations $0 $0 $0
Mammography Screening $0 $0 $0
Pap Test, Pelvic Exams, Clinical Breast Exams $0 $0 $0
Prostate Cancer Screenings $0 $0 $0
Cardiovascular Disease Testing $0 $0 $0
Annual Wellness Visit $0 $0 $0
Diabetes Screening $0 $0 $0
Medical Nutrition Therapy $0 $0 $0
Smoking and Tobacco Use Cessation $0 $0 $0
Other Services
Renal Dialysis $25 $25 $25
Nutritional Therapy for Renal Disease $0 $0 $0
Part B Drugs 10% coinsurance(APPLIES TO PLAN LEVEL OOP MAX )
10% coinsurance(APPLIES TO PLAN LEVEL OOP MAX)
10% coinsurance(APPLIES TO PLAN LEVEL OOP MAX)
Additional Services
Plan Level Out-of-Pocket Maximum $3,400 $3,400
$3,400 (SEPARATE OUT-OF NETWORK OUT-
OF-POCKET MAXIMUM $6,700)
Dental Routine $25(MEDICARE DENTAL BENEFITS)
$25 (MEDICARE DENTAL BENEFITS)
$25 (MEDICARE DENTAL BENEFITS)
Hearing Services(Diagnostic/Treatment)
$0 (ONCE PER YEAR)
$0 (ONCE PER YEAR)
$0 (ONCE PER YEAR)
Hearing Services(Routine Exam) $15 $15 $15
Hearing Aid Fitting Evaluation $15 for fitting evaluation(ONCE EVERY TWO YEARS)
$15 for fitting evaluation(ONCE EVERY TWO YEARS)
$15 for fitting evaluation(ONCE EVERY TWO YEARS)
Hearing Aids $1,000 Limit (ONCE EVERY TWO YEARS)
$1,000 Limit (ONCE EVERY TWO YEARS)
$1,000 Limit (ONCE EVERY TWO YEARS)
Transportation$0
(LIMITED TO 20 ONE-WAY TRIPS PER CALENDAR YEAR)
$0 (LIMITED TO 20 ONE-WAY TRIPS PER
CALENDAR YEAR)
$0 (LIMITED TO 20 ONE-WAY TRIPS PER
CALENDAR YEAR)
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PREFERRED PREFERRED RX PREFERRED + CHOICE
Prescription Drug Coverage Preferred Pharmacy
Non-Preferred Pharmacy
Preferred Pharmacy
Non-Preferred Pharmacy
Preferred Pharmacy
Non-Preferred Pharmacy
Tier 1: Preferred Generic (30-day/90-day supply) $3/$7.50 $8/$24 $3/$7.50 $8/$24 $3/$7.50 $8/$24
Tier 2: Non-Preferred Generic (30-day/90-day supply) $30/$75 $40/$120 $30/$75 $40/$120 $30/$75 $40/$120
Tier 3: Preferred Brand(30-day/90-day supply) $30/$75 $40/$120 $30/$75 $40/$120 $30/$75 $40/$120
Tier 4: Non-Preferred Brand (30-day/90-day supply) $60/$150 $70/$210 $60/$150 $70/$210 $60/$150 $70/$210
Tier 5: Specialty Drugs (30-day or 90-day supply) 33% 33% 33% 33% 33% 33%
Retail/Mail-Order Prescriptions(90-day supply)
2.5 x copay/N/A
3 x copay/N/A
2.5 x copay/N/A
3 x copay/N/A
2.5 x copay/N/A
3 x copay/N/A
Additional Prescription Drug Services
Is There Gap Coverage YES YES YES
Discounts During Coverage GAP
Once $3,820 Total Drug Spend is met Tier 1 generics - ICL Copay All other Generic Drugs -37% All Brand Drugs - 25%
Tier 1 - Tier 5 Drugs (ALL Brands and Generics covered by KCA)
Once $3,820 Total Drug Spend is met Tier 1 generics - ICL Copay All other Generic Drugs - 37% All Brand Drugs - 25%
Pharmacy Deductible None None None
Government Discount Program for Brand Name drugs applies:
Reflected in the Discounts During Coverage GAP line item above
Yes - Once $3,820 Drug Spend is met – The member will continue to pay lesser of discounted cost or ICL copay Discount from manufacturer will accum to TrOOP
Reflected in the Discounts During Coverage GAP line item above
Initial Pharmacy Benefit Coverage Limits $3,820 $3,820 $3,820
Pharmacy Benefit OOP Threshold $5,100 $5,100 $5,100
Covered Excluded Drugs Not Covered Not Covered Not Covered
Out-of-Pocket Maximum Exclusions: Dental, Vision, Hearing, Transportation
Exclusions: Dental, Vision, Hearing, Transportation
Exclusions: Dental, Vision, Hearing, Transportation
*All drugs (generic and brand) over $600 are a 30-day supply.Note: Please refer to your Evidence of Coverage booklet for a legal, detailed description of your plan benefits.
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TAKE AN ACTIVE ROLE IN YOUR HEALTHKelseyCare Advantage members can access three Health Information Centers to provide free, up-to-date information on the prevention, early detection and treatment of illness. Find more information by calling the locations listed below:
• MAIN CAMPUS: (713) 442-0305
• FORT BEND CLINIC: (713) 442-9240
These centers are located at Kelsey-Seybold Clinic Main Campus, West Clinic and Fort Bend Medical and Diagnostic Center. Comprehensive resources include printed educational materials and health videos on a variety of health topics, reference books and health-related websites.
Health and wellness classes focus on disease prevention and the importance of health screenings, brain health, cholesterol management, diabetes management, healthy eating, hypertension and weight management. The Health Information Centers also provide patient support services such as the Breast Cancer Support Group, General Cancer Support Group, Diabetes Support Group, Pulmonary Fibrosis Support Group and Pulmonary Hypertension Support Group.
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DELTA CARE DHMO DELTA DENTAL PPO
Annual Deductible (Individual/Family) None $50/$150
Annual Maximum (Per Person) None $2,000
Orthodontic Schedule of fees* $1,000 lifetime maximum
Covered Services Delta Care DHMO Delta Dental PPO Plan Pays
Preventive Care (Deductible waived on PPO Plan, Includes Oral Examinations and Cleanings)
Schedule of fees* 100%
Fluoride Treatment (to age 19) No cost* 100%
Basic Dental Services(Extractions, Sealants, Periodontics, Endodontics, i.e. Dentures and Bridges)
Schedule of fees* 80%
Major Dental Services(Crowns, Cast Restorations, Prosthodontics, Implants - PPO only)
Schedule of fees* 50%
Orthodontic Services (to age 26) Schedule of fees* 50%
*Refer to your description of benefits for copays and limitations.
YOUR DENTAL PLANS
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YOUR 2018-2019
RATES2019 RETIREE MEDICAL MONTHLY RATES Retiree medical rates are due once per month (12 deductions per year), and are effective from January 1 through December 31, 2019.
PREFERRED PREFERRED RX PREFERRED + CHOICERetiree
ContributionMETRO
ContributionRetiree
ContributionMETRO
ContributionRetiree
ContributionMETRO
Contribution
Retiree only $56.21 $108.75 $103.32 $108.75 $136.70 $108.75
Retiree + spouse $221.17 $217.50 $315.39 $217.50 $382.15 $217.50
2018-2019 RETIREE DENTAL MONTHLY RATES Retiree dental rates are due once per month (12 deductions per year), and are effective from October 1, 2018, through September 30, 2019.
DELTA CARE DHMORetiree Monthly METRO Monthly
Retiree only $1.32 $8.16
Retiree + 1 $2.18 $13.45
Retiree + 2 $3.22 $19.95
DELTA DENTAL PPORetiree Monthly METRO Monthly
Retiree only $5.13 $31.49
Retiree + 1 $8.72 $53.54
Retiree + 2 $13.33 $81.89
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BENEFIT PROVIDER/GROUP # PHONE WEBSITE
Post-65 Retiree Medical Plans Via Benefits (855) 872-6806 www.my.viabenefits.com
Post-65 Retiree Medical Plans KelseyCare Advantage (713) 442-2273 www.kelseycareadvantage.com/METRO
Dental (PPO) Delta DentalGROUP # 75134 (800) 521-2651 www.deltadentalins.com
Dental (DHMO) Delta CareGROUP # 05134 (800) 422-4234 www.deltadentalca.org
Life Insurance Sun Life FinancialGROUP # 900763 (800) 247-6875 www.sunlife.com/us
401(A) and 457(B) Empower Retirement (800) 701-8255 https://participant.empower-retirement.com/participant/
Legal Insurance Texas Legal Protection PlanMASTER POLICY NO. 2004-100 (800) 252-9346 www.texaslegal.org
Auto, Home and Pet Insurance MetLife (800) 438-6388 www.metlife.com/mybenefits
METRO Credit Union Met Tran Federal Credit Union (713) 861-4780 www.mettranfcu.org
METRO Benefits Website N/A (713) 739-6060 http://metroretiree.benefitdomain.com
Username: retiree | Password: retiree
CONTACTS
RIDEMETRO.ORG1900 MAIN ST., P.O. BOX 61429HOUSTON, TX 77208-1429
THE FINE PRINTThe information contained in this summary should in no way be construed as a promise or guarantee of employment. The company reserves the right to modify, amend, suspend, or terminate any plan at any time for any reason. If there is a conflict between the information in this brochure and the actual plan documents or policies, the documents or policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates, policies and plan documents available from your Human Resources Office. This Benefits Enrollment Guide highlights recent plan design changes and is intended to fully comply with the requirements under the Employee Retirement Income Security Act (“ERISA”) as a Summary of Material Modifications and should be kept with your most recent summary plan description.
