Your Medical Benefits
Eligibility:
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
PLEASE NOTE: The NVRH Preferred plan only covers services by Tier 1 Providers (NVRH Community Network Providers) and with prior approval for Tier 2 Providers (Dartmouth Hitchcock participating Network Providers). Services rendered by all other providers are not covered under the plan except emergency services, limited ancillary services such as lab, x-ray, anesthesia and certain specialties procedures approved by the Plan.
Summary of Benefits & Coverage (SBC)
Traveling Benefit
If a Covered Person is traveling out of state or out of country and requires emergency medical treatment from an Out-of-Network Provider (excluding when a Covered Person traveled to such location for the primary purpose of obtaining medical services, drugs or supplies), benefits shall be payable at Tier 1 Northeastern Vermont Regional Hospital In-Network Provider levels subject to Reasonable and Customary Charges.
Covered services for dependents who are full-time students residing outside the service area who receive services from participating providers will be covered at the Tier 3 benefit level. Covered emergency services for all Covered Persons traveling outside the service area will be covered at the Tier 1 benefit level.
DOCTOR ON DEMAND!
Helpful Resources
Carrier Service Contact
Health Plans Inc.
800-532-7575
Click here for log in instructions
Forms
Contributions & Rates
Prescription Drug Benefits
NVRH offers a prescription drug program through our in-house pharmacy and Express Scripts Inc (ESI).
Pharmacy Benefits for NVRH Preferred & Silver:
Retail Pharmacy Program Co-pay for up to a 30-day supply
Retail Pharmacy IN NETWORK:
- Generic: $15 Preferred Brand: $25 Non-Preferred Brand: $40
Retail Pharmacy Program Co-pay for up to a 90-day supply
NVRH Pharmacy:
- $5 flat rate co-payment
Mail Order Program Co-pay for up to a 90-day supply
IN NETWORK:
- Generic: $30 Preferred Brand: $50 Non-Preferred Brand: $80
Prescription drugs will be covered at 100% with no copay when combined Rx and Medical out of pocket exceeds $6,250 single/$12,500 per family.
Pharmacy Benefit for Bronze:
Preventive prescriptions are covered at copays. All other prescriptions will be covered after the tier 1 deductible ($3,000/$6,000) has been met. You will be responsible to pay the copayment listed per prescription drug. Once the tier 3 out of pocket maximum has been met ($6,250/$12,500) prescription drugs will be covered at 100%.
Retail Pharmacy Program Co-pay for up to a 30-day supply
IN NETWORK:
- Generic: $15 Preferred Brand: $25 Non-Preferred Brand: $40
Retail Pharmacy Program Co-pay for up to a 90-day supply
NVRH Pharmacy:
- $5 flat rate co-payment
Mail Order Program Co-pay for up to a 90-day supply
IN NETWORK:
- Generic: $30 Preferred Brand: $50 Non-Preferred Brand: $80
Helpful Resources
Carrier Service Contact
Express Scripts Inc, (ESI)
800-455-6906
Forms
Your Health Savings Account Benefits
•Employees are eligible to participate if enrolled in the HDHP.
•This account is 100% employee funded and contributions can be made with pre-tax payroll deductions, if elected.
•Employees will receive a Debit Card for their HSA & may use this card to pay for bills from providers & for prescription costs at retail & mail order pharmacies
•Employees can use Health Equity’s online feature & pay providers directly online as claims from HPI are sent to Health Equity. This feature allows employees to auto-substantiate by using this online feature & pay the provider before the bill arrives.
•Employees may also invest the funds in their HSA once their account has a balance of $2,000 in it. Instructions & more information are available on Health Equity’s website.
•Funds in an HSA rollover from one year to the next & can be taken with you when employment ends.
•Employees may contribute funds into an HSA as long as they are enrolled in a Qualified High Deductible Plan
•Employees may use funds from an HSA for any medical, dental or vision qualified expense (similar to the FSA), even if they are no longer enrolled in a Qualified High Deductible Plan in the future.
•Employees may contribute, in 2022, up to $3,650 if they are enrolled as a Single on the HDHP or up to $7,300 if they are enrolled with more than one person on their plan. There is a catch-up provision for employees who are over 55 of $1,000 regardless of the level at which they are enrolled.
NOTE: Employees who enroll in the HDHP & also elect to contribute to a Health Savings Account (HSA) may still elect a medical FSA, but will only be able to use funds for dental & vision expenses. This is an IRS Rule. This type of FSA is called a Limited Purpose FSA.
Helpful Resources
Carrier Service Contact
Health Equity
866-346-5800
Forms and Plan Documents
Your Dental Benefits
Eligibility:
NVRH offers 3 levels of dental coverage to eligible employees.
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Delta Dental Plans – Outline of Benefits & SPD’s
Contributions
Carrier Service Contact
Delta Dental
(800) 832-5700
Monday-Friday 8:00 am – 4:45 pm EST
Register as a Member to:
- Find a participating dentist
- Request for additional ID cards
- News and oral health education
Helpful Resources
Forms and Plan
Your Vision Benefits
VSP Primary EyeCare Plan
- Treatment for eye pain, or conditions like pink eye
- Tests to diagnose sudden vision changes
- Pictures of your eyes to detect and track eye conditions
- Exams to monitor cataracts
- Retinal Screenings
TruHearing is making hearing aids affordable by providing exclusive savings to all VSP Vision Care members. You can save up to $2,400 on a pair of digital hearing aids and savings on batteries through TruHearing.
Now you can manage your eye care needs at any time, and from anywhere. Access www.vsp.com from your smartphone.
View Exclusive Member Extras, like rebates, special offers and promotions totaling over $2,500 in savings.
- Up to $500 savings on LASIK
- Extra $20 to spend on featured frame brands.
Eligibility:
NVRH offers vision coverage through VSP to eligible employees.
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Contributions
Carrier Service Contact
VSP
(800) 877-7195
Monday-Friday 8:00 am-11:00 pm EST
Saturday 9:00 am – 8:00 pm EST
TruHearing 877-396-7194 9am -9pm EST
*For a full provider directory list, please register with the instructions below on the VSP website*
Helpful Resources
Your Flexible Spending Account Benefits
What is a Health Flexible Spending Account (FSA)?
A Health Flexible Spending Account (FSA) is a benefit that allows you to direct money to an account from your paycheck before taxes. You use the FSA money to pay for out-of-pocket health care costs, like co-pays, deductibles, dental work not covered by insurance, contacts, glasses, etc. You do not pay taxes on money directed to a Flexible Spending Account. You are saving for health care costs while saving money on taxes. The current annual maximum you may contribute to a Health FSA is $2,850.
How it works:
Equal amounts deducted from paycheck before taxes.
The annual amount you choose to contribute is deducted in equal amounts, per paycheck, for the calendar year (26 pay periods).
- For example, if you chose to contribute $1,200 for the year, the pre-tax deduction from your paycheck would be $46.15 for 26 pay periods.
Total amount available for immediate use.
Even though you are contributing to an FSA per pay period, the total annual maximum you choose is available for immediate use.
- For example, if you open a FSA in the amount of $1,000.00, and you incur healthcare expenses right away, you have the total amount of $1,000.00 to use immediately.
The Benefit Debit Card.
Our health plan issues a FSA Benefit Debit Card for the total FSA amount. You may use the Benefit Card to directly pay co-payments at doctors’ offices, at pharmacies (including the NVRH Pharmacy), or use it to pay any healthcare, dental, or eye care bills, etc. It’s extremely easy to use, and you avoid having to request a reimbursement from your account. Make sure to carry the Benefit Debit Card with you!
Carry-over FSA funds.
If you do not use all of money in your Flexible Spending Account in the calendar year, up to $550 may be carried over into the following year.
The Health FSA is an annual benefit. You must sign up for an FSA during open enrollment every year; or as a new employee when you are eligible for benefits.
Healthcare Reimbursement FSA
- The annual maximum amount you may contribute to this FSA is $2,850 per calendar year.
- Any unused FSA dollars at the end of the current plan year up to a $570 max may be rolled over into the following plan year to use for eligible medical expenses only. *Over-the-counter medications are not reimbursable through the FSA unless you have a prescription from your physician
Dependent Care FSA
The annual maximum amount you may contribute to this FSA is $5,000 per family or $2,500 (if you are married and file a separate tax return).
For dependent care, if you have an ongoing daycare payment and wish to receive automatic reimbursements to your account, the member can send a letter to Health Plans Inc. from the provider stating the dates of service and total cost for the year along with the Direct Deposit form located under Forms on the EBC. Health Plans Inc. will process the claim as of 1/1 and each time a deposit is made to the account, the member will automatically be reimbursed.
Eligibility
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Helpful Resources
Health Plans, Inc.
Attn: Flexible Spending Dept.
PO Box 5199
Westborough, MA 01581
800-343-7674 x8416
Forms and Additional Resources
Your Group & Voluntary Life Benefits
Eligibility:
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Contributions
Employer Paid Group Life Insurance Plan:
- NVRH pays for each eligible employee to have a Life Insurance benefit in the amount of 2 times annual salary.
- The coverage becomes effective on the 1st of the month following 30 days of employment.
- Benefits are reduced to 65% at age 70 and 50% at age 75. This limit takes effect on the first January 1 that occurs while you are that age, or take effect on the day you become insured if you are then age 70.
- Coverage may be converted within 31 days of employment termination/change in eligibility for reasons other than disability or retirement. Please see the Conversion Privilege section of the Summary Plan Design for details.
Optional Life Insurance Plan:
- Additional coverage is available to all full time and part time (with benefits) employees on the 1st of the month following 30 days of employment on a voluntary employee-paid basis.
- Coverage is available on each employee, their spouse and dependent children. An employee must enroll in coverage for themselves to cover their spouse and/or children. Dependent coverage begins from 14 days, and continues to age 26.
- Employees may purchase up to $300,000 on themselves, $25,000 on their spouse and $10,000 on their dependent child(ren) with no medical questions asked when initially eligible. Coverage may be purchased above these amounts, but will require Evidence of Insurability and approval from Sun Life.
Helpful Resources
Carrier Service Contact
Sun Life Financial
Phone: 800-247-6875
8:00am-8:00pm ET, Monday-Friday
Forms and Plan Documents
Your Disability Benefits
Eligibility:
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Short Term Disability:
- Eligible employees may receive benefits starting on the 15th day of continuous illness or injury and ending at 26 weeks, after which long term disability may apply.
- Benefit is 75% of weekly earnings
Filing your Claim by phone – refer to How to Submit a Telephonic Claim (brochure): POLICY#: 936190
Step 1: Call 877-932-7287 and select option 2 and initiate your short-term disability claim.
Step 2: Confirm with your doctor’s office that the FMLA Medical Certification, and Attending Physician’s Statement (APS), have been received, completed by the provider and returned to the appropriate carriers (FMLASource and Sun Life).
Step 3: Have your physician complete the Work Status Form and return the completed form to the HR Assists within 3-5 days of your tentative return to work date.
After you have initiated your claim, all inquiries or follow-up questions can be directed to Sun Life short-term disability client service number at 855-629-8811.
Eligibility:
Employees who work a minimum of 20 hours per week are eligible for benefits. Benefits-eligible employees are able to enroll on the first day of the month following 30 calendar days of employment.
Long Term Disability:
- Eligible employees may receive benefits starting after 26 weeks.
Definition of Disability
You are disabled when Sun Life Financial determines that:
- you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury;
- you are under the regular care of a doctor, and
- you have a 20% or more loss in weekly earnings due to the same sickness or injury.
Benefit Forms
Helpful Resources
Carrier Service Contact
Sun Life Financial
Phone: 800-247-6875
8:00am-8:00pm ET, Monday-Friday
Contributions
Short Term Disability:
NVRH pays 100% of the cost of coverage.
The weekly benefit amount is 75% of weekly earnings. Your payment may be reduced by deductible sources of income and in some cases by the income you earn while disabled.
Long Term Disability:
- NVRH pays for each eligible employee to have Long Term Disability coverage.
- You must be disabled, and have a loss of income for 180 calendar days before benefits begin to pay out.
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Benefits are 66.67% of basic monthly earnings, up to a maximum of $6,000 per month.
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Benefit duration is up to your normal retirement age under the Social Security Act. If you become disabled at or after 65, beneftis are payable according to an age-based schedule. Please refer to the Summary Plan Description above.
Family and Medical Leave Act (FMLA) and other federal and state mandated leaves of absence are administered by FMLASource on behalf of Northeastern Vermont Regional Hospital. FMLASource will help determine eligibility, notify the employee and NVRH management of leave status and tracking absences.
FMLA provides up to 12 weeks of unpaid, job protected leave for eligible employees for certain family and medical reasons.
Eligibility
Employees are eligible to take leave under FMLA, if they have worked for NVRH for 12 months and have worked for 1,250 hours over the previous 12 months. The months of employment are not required to be consecutive in order to qualify for FMLA leave.
When should a leave of absence be reported to FMLASource?
First, report your absence for leave to your manager, then call or email hrassist@nvrh.org .
Then contact FMLASource by either calling 877-462-3652 or go to www.fmlasource.com log in and click on Request a leave tab if/or when:
- You or an immediate family member is hospitalized for any amount of time
- You are incapacitated for more than three calendar days and are seeking treatment by a health care provider
- You will be absent periodically due to a chronic or permanent disabling condition of your own or of an immediate family member
- You are pregnant or missing work due to anything medically related to your pregnancy
- You are bonding with a newly born child or a recently placed adopted or foster child.
- You are caring for an immediate family member (spouse/domestic partner, parent or child) who is ill or injured.
- You are caring for an injured service member if the service member is your spouse, child, parent or “next of kin”. FMLA taken for this reason includes an entitlement of up to 26 weeks in a 12 month period
- You need to miss work due to a qualified exigency related to an immediate family member’s active service duty.
Once your FMLA Claim is approved, if you are going to be late or absent for any condition that has been approved for FMLA, you must personally notify your supervisor and contact FMLASource.
Employees who are currently on a continuous leave of absence must contact FMLASource and their supervisors if they:
- Require an extension of their current leave;
- Do not expect to return to work at all;
- Will be returning to work earlier than anticipated; or
- Have circumstances that have changed in any other respect.
Helpful Resources
FMLASource Contact Information:
Call: 877-462-3652
TDD: 800-697-0353
Fax: 877-309-0218
Website: www.fmlasource.com
Email: FMLACenter@FMLASource.com