BENEFITS GUIDE FOR PENSIONERS - Nashville.gov
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2023 BENEFITS GUIDE FOR PENSIONERS
This guide provides an overview of your benefits. Keep it handy in case you have benefits questions during the year. Important contacts are listed on the back cover. If you need more detail than this guide provides, contact Metro Human Resources at (615) 862-6700 or visit nashville.gov/hr. Table of Contents 2023 Benefit Plan Rates 1 Benefit Basics 2 Medical 4 Dental 16 Vision 18 Life Insurance 20 Notices 21 Important contacts back cover
2023 BENEFIT PLAN RATES PER MONTH
If you were hired on or after January 1, 2013, OR you were a non-vested employee rehired after that
date, the amount you pay for your medical premiums may be different than the amount shown below. The
premiums you pay will depend on the number of years you worked for Metro. If you were hired/re-hired
after January 1, 2013, contact Metro Human Resources to find out how much you will pay each month for
your medical insurance.
MEDICAL
All family members WITH Medicare A & B: Medicare Advantage
Pensioner with Medicare A & B $31.24
Pensioner and spouse/partner both with Medicare A & B $62.48
Pensioner, spouse/partner, child(ren) all with Medicare A & B $93.72
Pensioner and one child both with Medicare A & B $62.48
All family members WITHOUT Medicare: PPO HRA Plan
Single $232.00 $227.00
Pensioner + child(ren) (no spouse coverage) $338.00 $332.00
Family $620.00 $610.00
Family members with AND without Medicare A & B: PPO HRA Plan
Pensioner with Medicare A & B +
$360.00 $370.00
spouse/partner without Medicare A & B
Pensioner without Medicare A & B +
$360.00 $370.00
spouse/partner with Medicare A & B
Pensioner with Medicare A & B +
$256.00 $286.00
child(ren) without Medicare A & B
Three family members covered
$488.00 $513.00
(two of them with Medicare A & B)
Pensioner without Medicare A & B +
$360.00 $370.00
one child with Medicare A & B
DENTAL
Flexible Plan Limited Plan
Single Metro provides single dental coverage at no cost to you
Family $39.44 $50.22
VISION
Basic Plan Enhanced Plan
Single $2.95 $4.66
Family $9.02 $14.88
1
BENEFIT BASICS
ELIGIBILITY
Pensioner
Metro pensioners eligible for an Early or Normal
service pension when their employment ends are
eligible to enroll in benefits.
Dependents
You may enroll your eligible dependents in your
medical, dental and vision insurance at the time
you go on pension or within 60 days of an eligible
change in status. Eligible dependents include
your:
» Legally recognized spouse, while not divorced
or legally separated
» Domestic partner (documentation will be
required proving you’ve shared a primary
residence for the last 365 days and you are
financially interdependent upon one another)
Opting Out of Benefits
» Dependent child(ren) from birth up to age 26 if
he/she: Disability and Service pensioners and
• Is your or your domestic partner’s child by Survivors who can enroll in other medical
birth, legal adoption, legal guardianship or and/or dental coverage may opt out of Metro’s
court order who may or may not reside in your insurance coverage.
home the majority of the time on an annual Pensioners who wish to preserve their future
basis right to re-enroll in Metro’s plans must provide
• Is your stepchild proof of other non-Medicare coverage —
• Is a foster child living in your residence in either an insurance card in the pensioner’s
accordance with a Foster Care Placement, name or a letter from the other insurance
which means and is defined as the supervised company. If you opt out and later lose your
adoption period prior to final adoption, as non-Metro medical or dental coverage or
approved by a court of competent jurisdiction have an eligible change in status, you have 60
calendar days to re-enroll in Metro’s medical
• Is a dependent child(ren) over age 26, if
or dental plan.
coverage under Metro benefits has been
continuous and he/she is incapable of Additionally, Service pensioners and Survivors
self-sustaining employment by reason of may opt out of Metro’s coverage at any time
intellectual or physical disability; contact without proof of other coverage, but by doing
Human Resources for details so, you will never be allowed to re-enroll in
Metro’s plans.
The following are not eligible for Metro benefits:
» Foster children (placed in the home for care but
not adoption)
» Ex-spouses or ex-domestic partners, except as
allowed under COBRA
» Parents of the pensioner or spouse/domestic
partner
2
WHEN COVERAGE BEGINS
AND ENDS Medicare Coverage
If you become eligible for Medicare while you
Coverage is effective the day your pension benefit are still actively employed with Metro and
becomes effective. Your coverage will end when you are enrolled in Metro’s employee medical
your pension ends or when you die. Your spouse/ insurance, you are not required by Metro
domestic partner and dependent children may be to enroll in Medicare Parts A & B. However,
eligible to continue their coverage if they receive a once you are a Metro pensioner or you are
Survivor pension benefit. a covered dependent on another Metro
pensioner’s medical insurance, Metro requires
CHANGING YOUR BENEFITS you and your dependents to enroll in Medicare
Parts A & B as soon as you first become
The benefits you choose at the time of your eligible — regardless of other coverage you
pension or during Annual Enrollment remain in have or your employment status.
effect for the entire plan year, unless you have an You must notify Metro Human Resources
eligible change in status such as: immediately as soon as you or your
» Marriage or divorce dependents are enrolled in Medicare Part B.
» Birth or adoption of a child Once you and all your covered dependents
» Change in job status for you or your dependent are eligible for Medicare Parts A & B, you will
» Loss of coverage for you or your dependent automatically be moved into Metro’s Medicare
Advantage plan.
» Death of a covered eligible dependent
If you do not enroll in Medicare Part B
You must notify Metro Human Resources and
when it is first offered to you, you will
provide documentation within 60 calendar days of
no longer be eligible for Metro’s medical
an eligible change in status to make a change in
insurance benefits.
your benefit elections. Not notifying Metro Human
Resources timely may prevent you from adding
a dependent or may require you to pay family
premiums for the remainder of the plan year when
a dependent is no longer eligible.
For a complete list of eligible changes in status
and instructions on changing your benefit
elections, contact Metro Human Resources.
Metro pensioners may NOT add dependents
during Annual Enrollment and may only add
dependents within 60 days of an eligible change
in status.
3
MEDICAL
Understanding Your Options
Metro offers medical coverage to eligible pensioners and their covered
dependents as shown below. Follow the blue or orange color schemes
in the Medical section of this guide to learn more about your options.
If you or any of your
If you and all your covered
covered dependents are
dependents are eligible for
NOT yet eligible for
Medicare Parts A & B:
Medicare Parts A & B:
The medical plan available You have a choice
to you is the of medical plans:
MEDICARE PPO
ADVANTAGE with BlueCross BlueShield (BCBS)
— OR —
PLAN HRA PLAN
insured by Humana with Cigna
Learn more starting on page 5. All family members must be
enrolled in the same plan.
Learn more starting on page 8.
Once you are enrolled in If, during the year, you and
Metro’s Medicare Advantage all your covered dependents
plan, DO NOT enroll in become eligible for Medicare,
another Medicare Advantage you MUST enroll in Parts A & B,
plan. If you do, you will be AND you will automatically be
disenrolled from Metro’s plan. moved into Metro’s Medicare
Advantage plan.*
* Note to HRA Plan members:
Any money remaining in your
HRA Fund will be forfeited
when you are moved to the
Medicare Advantage plan.
4
Medicare Advantage
The Medicare Advantage plan is only available if Telehealth
the pensioner and all covered dependents have
For minor illnesses and concerns, telehealth
Medicare Parts A & B. If one covered person in the
may be a convenient option for seeking care. A
family is not yet eligible for Medicare Parts A & B,
telehealth visit is done over your smartphone,
your Metro coverage must be provided through the
tablet or computer. You and your provider will be
PPO or HRA Plan, as described starting on page 8.
able to see each other and talk via webcam on
The Medicare Advantage plan offers these each person’s device.
features:
If your provider is in Humana’s network and offers
» $10 office visits (for both primary care and telehealth through their office, Humana will cover
specialist care) these visits at a $0 copay for primary care visits
» No annual deductible and $10 copay for specialist visits.
» No referral required to see a specialist
» 100% coverage for hospital care Hearing Benefits
» 100% coverage for most preventive care Medicare Advantage members receive a hearing
» $1,000 per member annual out-of-pocket benefit through their plan, as well as discounts
maximum (Once you spend this amount on through several providers. Call the number on
medical care, plan pays 100% for the rest of your ID card for details.
the year; you continue to pay prescription drug
copays.)
» Out-of-network coverage (same coverage as in- Finding a Humana Provider
network as long as provider accepts Medicare For a list of network providers
and agrees to bill Humana*) and other plan details, visit
* Even if your medical provider will not agree to bill Humana https://our.humana.com/metro-gov.
directly, you can still see that provider and file a claim Or call Humana at (888) 899-0102.
with Humana yourself for reimbursement, and you will
receive in-network benefits.
Preventive Care
Under the Medicare Advantage plan, preventive
care is covered at 100% with no benefit limit.
Prescription Drugs
The Medicare Advantage plan includes coverage
for prescription drugs, as shown in the chart on
pages 6-7. Visit https://our.humana.com/metro-
gov for a list of participating retail, home delivery
and mail order pharmacies. Or call Humana
at (888) 899-0102. Certain drugs may require
preauthorization or step therapy, and quantities of
some drugs may be limited.
5
MEDICAL
MEDICARE ADVANTAGE BENEFITS … AT A GLANCE
In-Network
Annual Deductible $0
Annual Out-of-Pocket Maximum $1,000/individual
Medical Services
You pay $0
Well Care/Preventive Care (includes Pap smears, mammograms, pelvic exams,
prostate exams, bone mass exams)
Office Visits
» Primary Care Physician $10 copay
» Specialist $10 copay
» In-office Procedures (surgery, consultation, $10 copay
allergy injections)
Hospital (inpatient) You pay $0 (unlimited days)
Hospital (outpatient) You pay $0 or $10 copay, depending on service
Ambulatory Surgery Center You pay $0
Outpatient Diagnostic You pay $0 or $10 copay, depending on service
Ambulance $100 copay (rules apply)
$50 copay
Emergency Room
(copay waived if admitted within 72 hours)
Mental Health/Substance Abuse
» Outpatient $10 copay
» Inpatient (preauthorization required) You pay $0
(190-day lifetime maximum in psychiatric hospital)
Rehabilitation (physical, occupational, speech) $10 copay
Skilled Nursing Facility You pay $0 (rules apply)
Home Health Care You pay $0
Routine Hearing Exam $10 copay
Hearing Aid Benefit $200 allowance every 2 years
Routine Vision Exam $10 copay
Diabetic Vision Exam You pay $0
Eyewear $100 allowance per year
Dental Care $100 allowance per year
6
MEDICARE ADVANTAGE BENEFITS … AT A GLANCE
In-Network
Prescription Drugs
1-month Supply
» Generic $10 copay
» Brand name $20 copay
3-month supply (maintenance drugs)
» At Humana’s mail order pharmacy You pay 2 times the above copays
» At in-network retail pharmacies You pay 3 times the above copays
Medicare Advantage Extras
Medicare Advantage members have access to these programs and discounts. For more details about
these benefits, including important rules, visit https://our.humana.com/metro-gov. Or call Humana at
(888) 899-0102.
SilverSneakers® Fitness Program Personal Health Coaching
» Includes free membership at a participating » For weight management, nutrition, exercise,
fitness center back care, and blood pressure and blood sugar
management
Post-Discharge Benefit
The following benefits are available after an Acupuncture
inpatient stay in a hospital or nursing facility: » Covers up to 20 Medicare-covered sessions
» Well Dine® food program – delivers 28 pre- per year for $10 copay/session
cooked frozen meals to your home Chiropractic
» Transportation – covers 12 one-way trips » Covers Medicare-covered visits for $10 copay/
» In-home personal care – provides 4 hours a session
day, up to 8 hours per discharge
7
MEDICAL
PPO
The PPO, which stands for preferred provider Prescription Drugs
organization, is administered by BlueCross
You may purchase a one-month supply at any
BlueShield (BCBS). It is an 80/20 coinsurance
pharmacy. If you take medication for an ongoing
plan, which means most non-preventive services
condition, you can save money (pay two copays
are covered at 80% when you use BCBS network
instead of three) by asking your provider to write
providers. Additionally:
your prescription for a three-month supply. You
» Limited preventive care is covered at 100% must use a pharmacy in the BCBS Retail90 Plus
(up to $750 per year) for members ages 7 and Network or BCBS mail order program to fill a
older; for members under age 7, the coverage is three-month supply.
80%. See below for more details.
Visit bcbst.com/members/metro-gov for a list of
» Office visits are covered at 80% after a $20
pharmacies in the BCBS Retail90 Plus network, or
(PCP) or $30 (specialist) copay.
for details on mail order.
» There is no deductible if you use network
providers. Telehealth
» Out-of-network care is covered at a lower benefit If your provider is in BCBS’s network and offers
amount, as shown in the chart on pages 12-13. telehealth through their office, BCBS will cover
» If you reach the out-of-pocket maximum, you these visits at the same cost as an in-person in-
continue to pay copays but no coinsurance for network visit. If you seek telehealth from an out-
the rest of the year. of-network provider, your visit will be covered at
Preventive Care the out-of-network level.
Under the PPO, the following are covered as Hearing Benefits
preventive care services:
PPO members can save 30%-60% on hearing
» Annual preventive health exam aids. Visit bcbst.com/blueaccess and view the
» Childhood immunizations Blue365 Discounts page.
» Blood pressure screening
» Flu and pneumonia shots
» Tetanus-diphtheria (Td) booster Finding a BCBS Provider
» Other recommended adult immunizations and
For a list of network providers and other plan
immunizations not completed in childhood
details, visit bcbst.com/members/metro-gov.
» X-rays and lab associated with preventive care Or call BCBS at (800) 367-7790.
» Vision and hearing screenings performed by the
physician during the preventive health exam BCBS negotiates with its network providers to
get you discounted rates for medical services,
The following are NOT covered as preventive care supplies and prescription drugs. This helps
services but instead covered at the normal benefit lower your out-of-pocket costs when you use
level of 80% in-network or 60% out-of-network: network providers.
» Prostate screening
» Routine Pap smears
» Well-woman exams
» Routine mammograms
» Colorectal cancer screening
8HRA Plan
The HRA Plan, which is administered by Cigna, combines traditional medical coverage with a Metro-funded
Health Reimbursement Account (HRA) Fund. Here is how the plan works:
HRA Fund*
Each year you are enrolled in the plan (as long as the pensioner is not eligible for Medicare Parts
A & B), Metro puts money in a Health Reimbursement Account (HRA) Fund to help you pay eligible
medical and prescription drug expenses: $1,100/single coverage, $2,200/pensioner + child(ren) or
$2,200/family coverage.
You use your HRA Fund first during the year to pay for medical and prescription drugs costs. There are
no copays; you pay the full discounted cost of the product or service using your HRA Fund.
Deductible
If you use all your HRA Fund during the year, you are responsible for If you don’t use
paying the full discounted costs of your medical and prescription drug all your HRA Fund
claims until you have met your share of the deductible ($450/single, during the year,
$900/pensioner + child(ren) or $900/family). remaining funds
will roll over to your
2024 HRA Fund
Coinsurance and reduce your
share of your 2024
Once you have met your share of the deductible, the plan begins to pay deductible. This
a percentage of the cost, as shown in the chart on pages 12-13. money is yours to
spend on future
eligible expenses
Out-of-Pocket Maximum as long as you
remain enrolled in
If you reach the annual out-of-pocket maximum, which includes amounts
the HRA Plan.
paid toward the deductible and coinsurance, the plan pays 100% — and
you pay nothing — for covered services for the rest of 2023.
* If the pensioner becomes eligible for Medicare Parts A & B Continued on next page
while enrolled in the HRA Plan, you will no longer receive HRA
dollars from Metro. However, you can still earn HRA dollars by
participating in certain Cigna programs, as described on page
14. If a covered dependent becomes eligible for Medicare Parts A
& B but the pensioner does not, Metro will continue to make HRA
contributions as described above.
9MEDICAL
HRA Plan continued
Preventive Care Telehealth
All of the following preventive care services are Cigna offers a variety of ways to connect with a
covered at 100%, with no copay or coinsurance: doctor through your phone or computer:
» Annual preventive health exam
» Childhood immunizations Your own provider
» Blood pressure screening If your provider is in Cigna’s network and offers
» Flu and pneumonia shots telehealth through their office, Cigna will cover
these visits at the same cost as an in-person visit.
» Tetanus-diphtheria (Td) booster
» Other recommended adult immunizations and Cigna’s network of providers
immunizations not completed in childhood
Cigna has a wide network of providers who
» X-rays and lab services associated with
offer virtual/telehealth services. Simply visit
preventive care
myCigna.com, or call the number on the back
» Vision and hearing screenings performed by the of your Cigna ID card.
physician during the preventive health exam
» Prostate screening MDLIVE
» Routine Pap smears Cigna has partnered with MDLIVE to give you access
» Well-woman exams to board-certified doctors for the following needs:
» Routine mammograms » Primary care – routine and preventive care,
» Colorectal cancer screening receive orders for blood work and screenings at
local facilities
Prescription Drugs » Urgent care – a convenient alternative to
Under the HRA Plan, there are no copays. You urgent care centers and the emergency room
will use your HRA Fund to pay the full discounted » Behavioral health – talk therapy for issues
cost of your prescriptions. If you use all your HRA such as anxiety, stress, depression and grief
Fund, you are responsible for paying the full cost (see page 11 for more details)
of your prescriptions until you meet the plan’s » Dermatology – care for common skin, hair and
deductible, as shown on pages 12-13. nail concerns
You may fill prescriptions for a one-month Log onto myCigna.com and click “Talk to a
supply at any pharmacy. You can only purchase doctor.” Select the type of care you need, and
a three-month supply at pharmacies in Cigna’s your cost will be displayed. Or call MDLIVE at
maintenance medication program, which includes (888) 726-3171.
most retail chain, big box and grocery store
pharmacies, but does NOT include CVS or Publix.
Your cost is always based on a discounted
(or prenegotiated) amount, saving you money.
However, Cigna’s maintenance medication and
mail order programs offer greater discounts.
Visit myCigna.com to see a list of participating
pharmacies, or call (800) 244-6224. You are
encouraged to shop pharmacies to find the
lowest cost on prescriptions.
10Behavioral Health
Challenges to mental well-being come in many » Get unlimited confidential support 24/7/365
forms, and so do the ways you can get help. for one monthly rate via your behavioral health
Cigna offers a wide range of support tools and benefits.
services that range from mindfulness apps to text- » If needed, your coach can add a licensed
based therapy to in-person and virtual counseling. therapist or psychiatrist to your care team
Below is an overview of some of those services; within days.
more details and access are available by logging
onto myCigna.com. Apps
Cigna has partnered with Happify (soon to be
Counseling through Cigna’s Behavioral
Twill) and iPrevail to offer you free access to these
Health network
normally paid interactive apps:
As an HRA Plan member, you have access to » Twill is a self-directed program with science-
a giant network of behavioral health providers. based games guided meditations, designed to
Simply visit myCigna.com to search for a help defeat negative thoughts, reduce stress
provider. Or call the number on the back of and anxiety, and boost overall well-being.
your Cigna ID card. Both in-person and virtual
» iPrevail provides on-demand coaching.
counseling is available.
Complete an assessment, receive a program
If you need care immediately, you can search for tailored to your needs, and get connected to a
Fast Access Providers, which guarantee an initial peer coach.
appointment within five business days and a
callback within one business day.
MDLIVE virtual counseling
MDLIVE’s therapists and psychiatrists are trained
to use virtual technology to treat many behavioral
health conditions.
» Schedule visits at times that work for you,
Not sure which behavioral health
including evenings and weekends. service you need?
» See the same provider each visit or change Here are two ways to find out:
whenever you’d like. 1. View an interactive digital guide at
» Have prescriptions sent directly to your local CignaBehavioralPrograms.com/ctbh.
pharmacy. 2. Take a brief quiz. Your answers will help
identify the most appropriate care for your
Ginger specific needs. Log onto myCigna.com.
Ginger’s 24/7 coaching services are a first line of Under the Wellness dropdown, choose
defense for overcoming a range of challenges and “Mental Health Support.” Follow the
stressors — from improving sleep or relationships, prompts.
to managing anxiety and depression.
» Chat with a trained behavioral health coach
within seconds.
11MEDICAL
PPO & HRA PLAN BENEFITS … AT A GLANCE
PPO
In-Network Out-of-Network3
(Blue Network P)
Metro-Funded Health
N/A N/A
Reimbursement Account (HRA)
Your Share of the Deductible $0 $200/single, $600/family
Coinsurance Maximum $1,000/single, $2,000/family $5,000/single, $10,000/family
Annual Out-of-Pocket Maximum $1,000/single, $2,000/family $5,000/single, $10,000/family
Medical Services After deductible, plan pays… (unless otherwise noted)
Well Care/Preventive Care 100% up to $7501, then 80% 60%1
Office Visit - Primary Care Physician2 80% after $20 copay 60% after $20 copay
Office Visit - Specialist2 80% after $30 copay 60% after $30 copay
In-office Procedures (surgery,
80% after office visit copay 60% after office visit copay
consultation, allergy injections)
Maternity
» Prenatal Care $20 copay for initial visit $20 copay for initial visit
» Delivery 80% 60%
Hospital (inpatient) 80% 60%
60% or 80%; see evidence
Outpatient Surgery 80%
of coverage for details
Outpatient Diagnostic 80% after $20 copay 60% after $20 copay
Emergency Room 80% after $100 copay (copay waived if admitted)
Ambulance 80% 80%
Rehabilitation (physical,
80% 60%
occupational, speech)
Skilled Nursing Facility 80% (certain rules apply) 60% (certain rules apply)
Home Health Care 80% (certain rules apply) 60% (certain rules apply)
Mental Health/Substance Abuse
» Outpatient 80% after $20 copay 60% after $20 copay
» Inpatient 80% (preauthorization required) 60% (preauthorization required)
Routine Hearing & Vision Exams 100% covered if performed during preventive care exam
Diabetic Vision Exam 80% 60%
Eyewear 80% after cataract surgery 60% after cataract surgery
Prescription Drugs No deductible, you pay…
1-month Supply
» Generic $10 copay
» Brand name $30 copay
3-month Supply (maintenance drugs) 2x above copays (through certain retail pharmacies and mail order; see page 8)
12HRA Plan
In-Network
Need More Help?
Out-of-Network3
(Open Access Plus) Cigna One Guide® gives
you access to a real, live
$1,100/single, $2,200/family $1,100/single, $2,200/family person who can help you
$450/single, $900/family $450/single, $900/family understand your options
and determine which plan
$700/single, $1,400/family $4,550/single, $9,100/family is a better fit for you. They
$1,150/single, $2,300/family $5,000/single, $10,000/family can help you find the best
provider for your needs, find
After deductible, plan pays… (unless otherwise noted)
ways to lower your costs,
100%; no deductible 70% resolve problems and more.
90% 70% Download the One Guide
app at myCigna.com or
90% 70%
call 1-888-806-5042.
90% 70%
1
Screening colonoscopies,
90% 70% mammograms, PSA tests and Pap
exams are covered at 80% after
office visit copay (in-network) and
90% 70% 60% after office visit copay (out-of-
network) but are not included in the
90% 70% $750 well-care benefit limit.
90% 70%
2
Primary Care Physicians include
pediatricians, family and general
90% 90% practitioners, internists and OB/
GYNs. Specialists include physicians
90% 90% highly trained in specific areas
such as cardiology, dermatology,
90% 70% neurology, podiatry, oncology and
specialized OB/GYNs.
90% (certain rules apply) 70%
3
If you use an out-of-network provider
90% (certain rules apply) 70% (certain rules apply) and charges exceed the Maximum
Allowable Charge (MAC), you will be
responsible for the difference. In-
90% 70% network providers have agreed not
to exceed MAC.
100% covered if performed during preventive care exam
90% 70% Note: To view a complete copy
90% after cataract surgery 70% after cataract surgery of the plan documents and
provisions, go to nashville.gov/hr.
After deductible, plan pays…
90% of discounted cost 90% of discounted cost
70% of discounted cost 70% of discounted cost
Same as above (through certain retail pharmacies and mail order; see page 10)
13MEDICAL
Attention HRA Plan Members:
Earn additional HRA dollars!
Want to reduce your share of the deductible and
total out-of-pocket expenses? Participate in any
of these programs each year and earn dollars to
be added to your HRA Fund. Only employees,
pensioners and their spouses/domestic partners
who are covered under the HRA Plan are eligible
to earn incentive dollars. Visit myCigna.com or
call (800) 244-6224 for details.
Take a Health Risk Assessment
earn $100/person
This online questionnaire is short, confidential and
provides you with a personalized health profile
to help you take steps toward better health. Your
individual answers will not be shared with anyone
at Metro.
Participate in a Chronic Health
Condition Support Program
earn $100/person
If you live with a chronic condition, such as heart
disease, diabetes, COPD, asthma, depression, low
back pain, osteoarthritis or weight complications,
Cigna health coaches help you better manage
your condition.
Participate in a Lifestyle
Management Program
earn $50/program up to $100/person
Cigna health coaches provide personalized
support for lifestyle behaviors such as tobacco
cessation, stress management and weight loss.
Participate in Healthy Pregnancies,
Healthy BabiesSM Program
earn up to $150
This program helps you and your baby stay
healthy during your pregnancy. Earn $150 if you
enroll by the end of your first trimester ($75 by the
end of your second trimester).
14HELP ME CHOOSE
Need help choosing between the PPO and HRA Plan? Here’s how the plans compare.
PPO HRA PLAN
Yes; for limited services.
Free preventive care? In-network, plan pays 100% Yes. In-network, plan pays 100%
up to $750/year, then 80%
Yes. Each year, Metro puts $1,100/single
Metro-Funded Health or $2,200/family in an HRA Fund for you to
Reimbursement No spend on eligible medical and pharmacy
Account (HRA) Fund? expenses and help you meet your
deductible.*
Out-of-network only: Yes; your share after HRA Fund pays:
Deductible?
$200/single; $600/family $450/single; $900/family
No. HRA Fund pays first. Then you pay full
Yes. You pay copay
Office visit copays? discounted cost until deductible is met,
+ coinsurance
then you pay 10% in-network.
Telehealth office Yes, if your provider offers
Yes; see page 10
visit covered? telehealth; see page 8
No. HRA Fund pays first. Then you pay full
Prescription drug
Yes discounted cost until deductible is met,
copays?
then you pay 10% (generic) or 30% (brand).
Coinsurance
Plan pays 80%; you pay 20% Plan pays 90%; you pay 10%
(in-network)?
Plan pays 80%; you pay 20%
Inpatient hospital Plan pays 90%; you pay 10% until you
until you reach the plan’s
coverage? reach the plan’s out-of-pocket maximum
out-of-pocket maximum
Pre-negotiated
Yes Yes
discounted rates?
Plan pays 100% after you
Plan pays 100% after you spend
Annual out-of-pocket spend $1,000/single or
$1,150/single or $2,300/family
maximum? $2,000/family; you continue
(deductible + coinsurance)
to pay copays
Incentives for healthy
No Yes; see page 14
behaviors?
Premiums for
See page 1 to compare See page 1 to compare
coverage?
* If you don’t spend all your HRA Fund during the year, remaining funds roll over to the next year and are yours to use toward
eligible expenses, as long as you remain enrolled in the HRA Plan.
15DENTAL
Dental coverage, offered through BlueCross BlueShield of Tennessee (BCBS), covers a wide range of
preventive and restorative services. You have two choices for coverage: the Flexible Plan or the Limited Plan.
How the Dental Plans Work
Under the Flexible Plan, you can see any dentist
you choose, but benefits are highest when you
use providers in the BCBS DentalBlue network.
Network providers have agreed not to exceed
reasonable and customary (R&C) limits, which
are based on the usual fees charged by providers
in your geographic area. You have the flexibility
to see an out-of-network provider, but if the
provider’s charges exceed R&C limits, you will be
responsible for paying the difference.
Under the Limited Plan, benefits are paid
according to a schedule of benefits, which shows
your cost per service when you see a network
provider. If you use an out-of-network provider, no
benefits are paid.
For a list of providers and other important plan
details, including the Limited Plan schedule of
benefits, visit bcbst.com/members/metro-gov, HELP ME CHOOSE
or call (800) 367-7790. Both plans use the same network, called
DentalBlue, but the Limited Plan has higher
Pre-determination of Benefits monthly premiums. Below are several ways
If your dentist recommends treatment that is the plans differ:
expected to cost $200 or more, your dentist can » The Flexible Plan covers implants and TMJ
request a predetermination of benefits. This helps treatment; the Limited Plan does not.
you avoid surprises by letting you know how much » The Flexible Plan has a $1,000 annual
will be covered before you receive treatment. benefit maximum; the Limited Plan does
not have a maximum annual benefit.
» The Limited Plan offers greater benefits for
orthodontia.
» The Limited Plan does NOT cover out-
of-network treatment, but the Flexible
Plan does. So if your dentist is not in the
DentalBlue network and you don’t want to
change to an in-network dentist, choose
the Flexible Plan.
16DENTAL BENEFITS … AT A GLANCE
Flexible Plan Limited Plan
In-Network1
In-Network Only1
(out-of-network coverage
(no out-of-network coverage)
available)
$75/person
Annual Deductible $0
$225/family
See schedule of benefits
Plan pays…
for cost by service2
Preventive/Diagnostic
(2 exams/cleanings every 12 months, 100%; no deductible 100% for most services
x-rays, sealants, fluoride)
Basic Restorative 100% for some services;
(fillings, extractions, oral surgery, 80%; no deductible you pay flat fee for
root canals, periodontics) other services
Major Restorative You pay flat fee for most
50% after deductible
(crowns, bridges, dentures, implants) services; implants not covered
50% after annual deductible
Orthodontia You pay flat fee for
and one-time $100 orthodontia
(child and adult) most services
deductible
Lifetime Orthodontia Maximum $1,000/person See schedule of benefits2
TMJ (temporomandibular joint) 50% after annual deductible
Not covered
Treatment and $100 annual TMJ deductible
Lifetime TMJ Maximum $750/person N/A
$1,000/person
Annual Benefit Maximum N/A
(excludes orthodontia, TMJ)
1
If there is no network provider
within a 30-mile radius of your
home, you may use an out-of-
network provider and receive in-
network benefits. Contact BCBS for
instructions.
2
View the Limited Plan schedule of
benefits at bcbst.com/members/
metro-gov.
17VISION
Vision coverage, offered through National Vision Administrators (NVA), covers eye exams, frames, lenses
and contacts. You have two choices for vision coverage: the Basic Plan or the Enhanced Plan.
How the Vision Plans Work
You receive the highest benefits when you use NVA’s network of providers. The network includes many
independent optometrists, ophthalmologists and opticians, as well as national retail optical providers,
such as Walmart and Visionworks. For a list of network providers, visit e-nva.com (user name: metro;
password: vision1). You are responsible for any costs over the reimbursed or allowed amount shown in
the chart on the next page.
HELP ME CHOOSE
The Enhanced Plan has higher employee
premiums but offers higher benefits for:
» Standard progressive and polycarbonate
lenses – covered at 100% (Basic Plan
does not cover)
» Contact lenses – pays up to $140 with no
copay (Basic Plan pays up to $125 after
a $10 copay)
18VISION BENEFITS … AT A GLANCE
Basic Plan Enhanced Plan
In-Network Out-of-Network In-Network Out-of-Network
Deductible $0 $0
You pay Plan pays You pay Plan pays
Exams
$10 copay up to $45 $10 copay up to $45
Lenses You pay: Plan pays: You pay: Plan pays:
» Single Vision $10 copay Up to $40 $25 copay Up to $40
» Bifocals $10 copay Up to $60 $25 copay Up to $60
» Trifocal $10 copay Up to $80 $25 copay Up to $80
» Lenticular $10 copay Up to $80 $25 copay Up to $80
Lens Options Plan pays: Plan pays:
» Scratch-resistant
100% Up to $5 100% Up to $5
Coating
» Standard
Not covered Not covered 100% Up to $35
Progressives
» Polycarbonate Not covered Not covered 100% Up to $10
Plan pays up to Plan pays up to Plan pays up to Plan pays up to
Frames
$1301
$50 $1501 $50
Contacts (in lieu of frames/lenses)
Plan pays up to
Plan pays up to Plan pays up to Plan pays up to
» Elective $125 after
$125 $1401 $140
$10 copay1
Plan pays Plan pays up to Plan pays Plan pays up to
» Medically Necessary
100% $210 100% $210
Fit/Follow-up You pay: Plan pays: You pay: Plan pays:
» Standard Daily Wear $20 copay Up to $20 $20 copay Up to $20
» Extended Daily Wear $30 copay Up to $30 $30 copay Up to $30
Exams, contact fit every 12 months;
Exams, contact fit, lenses, frames
Covers… lenses, frames and contacts
and contacts every 12 months
every 24 months
1
In many cases, NVA offers a discount on amounts exceeding retail allowance; ask your network provider.
19LIFE INSURANCE
Basic Life Beneficiary
As a retired Metro employee, Metro provides you You may change your beneficiary at any time
with $10,000 of basic term life insurance at no by completing a new form with Metro Human
cost to you. See the life insurance policy located Resources. When you experience an eligible
on Metro Human Resources’ website for more change in status (such as with a marriage,
information concerning your life insurance benefits. divorce or death) you should consider updating
your beneficiary at that time. You may also name
Supplemental Life different beneficiaries to receive your basic life
Pensioners are not eligible to enroll in and supplemental life benefits.
supplemental term life insurance. However, if you
were previously enrolled as an active employee, Conversion and Portability Rights
you may elect to continue your supplemental term At retirement, you have the option to convert to
life coverage as a pensioner under an individual an individual life policy in $1,000 increments up
policy at the lesser of $20,000 or the amount that to $40,000 (which is the difference between the
is in force prior to retirement (at least $10,000). $50,000 active employee amount and $10,000
The decision to continue your supplemental pensioner benefit). You must make written
life coverage must be made at the time you are application and payment of premium to the life
signing your pension application paperwork. insurance company within 31 days from the date
you are notified by Metro. For more information,
Waiver of Premium contact the life insurance company.
If you are under the age of 60 and you become
totally disabled according to the life insurance
carrier’s standards (not Metro’s), you may apply for
the waiver of premium for basic life, supplemental
life and dependent life benefits and have your
premiums waived as long as you continue to be
disabled. You must apply within 12 months of the
date you became disabled. If approved, your pre-
retirement level of benefits may remain in effect
until you are age 70 as long as you continue to
meet the life insurance carrier’s criteria.
If you qualify for the waiver of premium, this is
a free benefit to you. If you are denied for the
waiver of premium benefit, you have 30 days from
the date of the denial to appeal the insurance
company’s decision. If your appeal is denied,
or you elect not to appeal the denial, you may
convert to an individual policy; however, you must
make written application and payment of premium
within 31 days from the time the insurance
company denies your waiver of premium
application. To appeal or convert, you must
contact the life insurance company directly.
20NOTICES
COBRA Continuation Coverage
If you or your dependents lose your eligibility for
health care coverage for certain reasons, you
will be allowed to continue coverage for a certain
period of time under COBRA provisions. Your
dependents have the right to continue coverage
even if you do not elect to continue your own
coverage. Metro does not pay for coverage under
COBRA; you or your dependent will pay 100% of
the cost plus a 2% administration fee.
You or your dependents are eligible for COBRA
continuation if coverage ends because:
» You die Women’s Health Provisions
» You get divorced or legally separated No matter which medical plan option you choose,
» Your dependent child becomes ineligible for your hospital coverage for childbirth will be for the
coverage same minimum number of days, as required by
federal law.
If you or your dependents qualify for COBRA,
» If your baby is delivered vaginally, you may stay
you will be mailed a packet with rate information
in the hospital at least 48 hours (two days) after
and payment instructions from Metro’s COBRA
the birth
administrator.
» If you have a cesarean section, you may stay in
Coordination of Benefits the hospital at least 96 hours (four days) after
the birth
Regardless of which medical plan you elect, you
must be sure to notify your insurance carrier if » If the attending physician believes you need
your dependents receive health coverage outside a longer stay, you may receive benefits for
of Metro’s plan (for example, through your spouse/ additional days if your doctor obtains pre-
domestic partner’s insurance plan at work or by authorization from the insurance company. On
qualifying for Medicare). the other hand, if you and your doctor agree
that, in your case, the minimum number of days
If your dependent has coverage elsewhere, a is not necessary, you may be released from the
process called coordination of benefits (COB) hospital earlier.
comes into play. COB simply means that benefits
are coordinated between your dependent’s Under the Women’s Health and Cancer Rights Act
coverage under your Metro plan and another plan. of 1998, all health plans that provide mastectomy
This process ensures that benefit payments are coverage are also required to provide coverage for:
not duplicated and helps hold down the rising » Reconstruction of the breast on which the
cost of health insurance. mastectomy has been performed
» Surgery and reconstruction of the other
breast to produce a symmetrical (balanced)
appearance
» Prostheses (artificial replacements) and physical
complications at all stages of the mastectomy,
including lymphedemas
21IMPORTANT CONTACTS
Plan Carrier Website Phone
Medicare
Humana our.humana.com/metro-gov (888) 899-0102
Advantage
BlueCross
PPO bcbst.com/members/metro-gov (800) 367-7790
BlueShield (BCBS)
HRA Plan Cigna myCigna.com (800) 244-6224
BlueCross
Dental bcbst.com/members/metro-gov (800) 367-7790
BlueShield (BCBS)
Vision NVA e-nva.com (user name: metro; password: vision1) (800) 672-7723
Life Insurance Prudential prudential.com/mybenefits (877) 232-3619
Metro Human
General nashville.gov/hr (615) 862-6700
Resources
HIPAA Notice of Privacy Practices
This notice governs Metro’s privacy practices for Metro’s medical plans and the flexible spending
accounts and can be found at nashville.gov/hr. For copies of the other carriers’ privacy notices,
contact the carrier directly.
Summary of Benefits and Coverage
In accordance with the Affordable Care Act, you can find the Summaries of Benefits and Coverage
(SBC) for both the PPO and HRA Plan in your Annual Enrollment packet or on the Human
Resources website at nashville.gov/hr.
Grandfathered Plan Status
Metro’s medical plans are considered “grandfathered plans” under the Affordable Care Act. A
grandfathered health plan can preserve certain basic health coverage that was already in effect when
that law was enacted, and your plan may not include certain consumer protections of the Affordable
Care Act that apply to other plans.
If the information in the guide differs from the official plan documents, the plan documents will govern.
This guide does not constitute an offer of employment or a promise to provide any particular benefit.
Metro Nashville reserves the right to change its employee benefits program at any time. For more
information, call Metro Human Resources at (615) 862-6700.You can also read
