Your CareFirst plan and other benefits: updates and answers

CSSP's new CareFirst plan was written with adult vision coverage included in the medical plan. CareFirst has since told us that its system cannot support adult vision coverage attached to the medical plan in that way. We know this has caused confusion, and we have been pressing CareFirst to honor the plan as written.

As of October 2, we expect CareFirst to require a separate vision plan, with coverage starting November 1, 2026, the earliest date CareFirst says it can put that plan in place. We are pushing back on the cost, because it should not be paid by employees. If needed, Positively Partners will cover the cost.

We will update this answer, and share enrollment details, as soon as the vision plan is confirmed.

You can use your HRA for eligible vision expenses. The HRA covers eligible expenses under IRS Section 213(d) across medical, dental, and vision care, separate from what the CareFirst medical plan covers. Keep your receipts, and contact Ameriflex if you are unsure whether a specific vision expense qualifies. More on using the HRA for vision

Two changes may be affecting you. CSSP moved from a grandfathered plan to a new CareFirst plan with its own coverage rules. In addition, the pharmacy benefit manager (PBM), which manages prescription coverage for the plan, updates its formulary from time to time as new medications become available and costs change, and often at the start of a new plan year. When a change affects a medication you take, the PBM notifies you before it takes effect.

As a result, you may be asked for a prior authorization before the pharmacy can fill a medication, or need a new one because of the plan change. In some cases the plan may prefer a different medication. Your prescriber and Ask Bennie can help you understand your options. Read the full explanation

Prior authorization is a health plan's process for reviewing certain medications, procedures, or services before agreeing to cover them. The plan confirms that the treatment meets its requirements for medical necessity and appropriate use. Most health plans use it, so it has become a routine part of how insurance works.

A prior authorization requirement is not a denial. It usually means your provider needs to send the plan more information. Watch a short explainer video

You may. Because CSSP's new CareFirst coverage is a different medical plan, the coverage rules and prior authorization requirements for certain services or medications may also be different. This can include changes to the formulary, preferred medications, or the clinical criteria used to decide whether a medication, procedure, treatment, or other service needs advance approval. An authorization approved under the previous plan may not automatically apply under the new plan.

Prior authorization is CareFirst's process for reviewing certain planned services or medications to confirm they meet the plan's requirements for medical necessity and appropriate use. Your provider may need to submit updated clinical information, such as your diagnosis, treatment history, or the reason a particular medication or service is recommended. Prior authorization does not guarantee that a service will ultimately be covered or paid.

If you had an authorization under the previous plan, contact your treating provider before your next appointment, procedure, or refill. They can confirm whether a new authorization is required and submit the necessary information. Ask Bennie can also help you understand the process or troubleshoot an issue.

Start by contacting your provider to confirm whether a new prior authorization is needed under your current CareFirst plan. You can also contact Ask Bennie for help with pharmacy questions, coverage questions, claims, and prior authorizations.

If you have tried both and are still stuck, contact us at hr@cssp.org or 617-843-3064, option 2. We will advocate on your behalf.

Your CareFirst plan documents describe covered services and in-network and out-of-network costs. Because coverage and cost can depend on the specific provider or service, Ask Bennie can also help you understand your benefits, find an in-network provider, review your deductible or copay, or confirm whether a particular service is covered.

Review the full plan summary for the new CareFirst medical plan

Yes. Telemedicine is billed as a standard primary care or specialist office visit. You have access 24 hours a day, 365 days a year, to board-certified doctors for non-emergency conditions such as colds and flu, allergies, sore throats, sinus or ear infections, rashes, and minor prescription refills, right from your phone, computer, or tablet.

There are differences between CSSP's previous CareFirst plan and the new plan. For details on deductibles, copays, coinsurance, and in-network and out-of-network costs, review the side-by-side comparison and the plan summary below. If you have questions about how the plan applies to a specific service or provider, Ask Bennie can help you interpret your coverage.

• Side-by-side plan comparison
• CareFirst BluePreferred PPO Essential Platinum Plan Summary

No. The previous plan was discontinued, so there are differences between the two plans. Review the side-by-side comparison

The CareFirst BluePreferred PPO Essential Platinum Plan Summary lists services and in-network and out-of-network costs.

CSSP introduced a Health Reimbursement Arrangement, or HRA, for the September 1, 2026 to August 31, 2027 plan year. The HRA is funded by CSSP and gives employees enrolled in CSSP's medical plan funds to use toward eligible health care expenses.

The full annual amount is available at the start of the plan year:

• Employee only: $500
• Employee plus child or spouse: $750
• Family: $1,000

The HRA can be used for eligible expenses under IRS Section 213(d) across medical, dental, and vision care. Examples include eligible out-of-pocket costs for medical, dental, and vision care, prescriptions, medical equipment and devices, and over-the-counter medications.

Because eligibility depends on the specific expense, keep your receipts and supporting documentation, and contact Ameriflex if you are unsure whether an expense qualifies.

Yes, as long as the expense is eligible. CSSP expanded the HRA to cover eligible IRS Section 213(d) expenses across medical, dental, and vision care. That is separate from whether a particular vision service is covered by the CareFirst medical plan itself.

Please rely on the updated HRA guidance shared in September, and contact Ameriflex if you have questions about a specific vision expense.

Yes. The HRA covers eligible expenses incurred on or after September 1, 2026. If you paid an eligible expense out of pocket before your Ameriflex debit card arrived, you can submit it to Ameriflex for reimbursement.

Ameriflex provides a debit card you can use for eligible expenses. Keep your receipts, since Ameriflex may ask for documentation to verify that an expense is eligible.

If you don't have your card with you, or you choose to pay out of pocket, you can request reimbursement through the Ameriflex participant portal. Debit cards are mailed directly by Ameriflex and are expected to arrive about 7 to 10 business days after they are issued.

Follow the New User Registration steps on the Ameriflex participant portal login page.

Unused HRA funds do not roll over to the next plan year. You will, however, have 90 days after the plan year ends on August 31, 2027 to submit reimbursement requests for eligible expenses incurred between September 1, 2026 and August 31, 2027.

In other words, the expense must happen during the plan year, and you have an extra 90 days afterward to submit the claim.

Ask Bennie is CSSP's benefits concierge. Bennie can help with questions about your medical, dental, and vision coverage, claims, deductibles and copays, pharmacy benefits, providers, enrollment, ID cards, and more, including finding an in-network provider or confirming whether a procedure is covered.

For HRA questions, contact Ameriflex. For anything unresolved, or if you want to share feedback, contact Positively Partners at hr@cssp.org or 617-843-3064, option 2.

Ask Bennie can help you get an ID card, find your member ID, or resolve enrollment information that is missing or pending.

Bennie has partnered with Positively Partners for more than three years, and the service challenges in onboarding CSSP have surprised us. Bennie has been slow to grant employees access to its app and to issue the benefits guide. Adam has escalated these concerns to Bennie's Chief Operating Officer, and Bennie is working to resolve them and provide access immediately.

We expect access no later than the middle of next week (the week of October 5). We will post an update on this page as soon as it is available.

Contact us. Email hr@cssp.org or call 617-843-3064, option 2, and tell us what you asked, when, and what happened. We will follow up with Bennie, CareFirst, or Ameriflex on your behalf and keep you informed. Hearing about these problems directly is how we can advocate for you.

When the Affordable Care Act (ACA) became law in 2010, it changed many of the rules governing health insurance. Plans that already existed on March 23, 2010 were allowed, under certain conditions, to keep operating under some pre-ACA rules. These became known as "grandfathered" plans. CSSP's previous CareFirst medical plan was a grandfathered plan.

CSSP was able to offer that plan to eligible employees for many years, and its strong coverage made it worth keeping for as long as CareFirst offered it. Grandfathered status, however, does not require a carrier to keep a plan available indefinitely. When CareFirst discontinued the plan, CSSP needed to choose coverage from the health insurance market that applies to the organization today.

That market runs through DC Health Link. Health insurance law groups employers into markets by size. In the District, small employers, generally those with 1 to 50 employees, get small-group coverage through DC Health Link's small-business marketplace. CSSP falls within this small-group market. You may know DC Health Link mainly as a place where individuals buy insurance, but it also operates the marketplace for small employers.

Moving to DC Health Link does not mean you were moved to individual health insurance, and DC Health Link is not your insurance company.

CSSP continues to offer employer-sponsored health coverage to eligible employees and to contribute toward its cost. CSSP's leadership selects the plan the organization offers. DC Health Link has some oversight of the plan and serves as the channel that gives CSSP access to the new CareFirst plan.

Once it was clear the existing plan would no longer be available, Bennie and Positively Partners worked together to identify CSSP's options and help the leadership team understand the differences among them.

This is a particularly difficult health insurance market. Premiums continue to rise, and many employers are finding that higher costs don't necessarily bring richer coverage. We explored multiple options with Bennie, weighing coverage, employee costs, provider access, and overall value.

Those options and their tradeoffs were presented to CSSP's leadership, who are responsible for selecting the plan the organization offers. After considering the alternatives, the leadership team chose the CareFirst plan they believe offers the best available balance for CSSP and its employees.

The previous plan was unusual: its grandfathered status let it continue for many years under an older set of insurance rules. Moving to DC Health Link brings CSSP into today's small-group health insurance market.

That gives CSSP's leadership the ability to evaluate the plans available in the small-group marketplace over time, rather than staying tied to a single legacy plan. Plans in today's market are also subject to the current requirements and consumer protections that apply to ACA-compliant small-group coverage.

That doesn't mean every feature of the new plan is better. The previous CareFirst plan offered high-quality coverage, and there are differences. We are committed to helping you understand what those differences mean for you and your family.

To prepare for open enrollment, your information needed to be added to the DC Health Link system in advance, and that triggered some automated emails. No action was needed in response to those emails.

No. DC Health Link is the District's health insurance marketplace. CareFirst is the insurance carrier for the plan selected by CSSP's leadership.

No. This remains employer-sponsored group health coverage. CSSP makes coverage available to eligible employees and contributes toward the cost.