Benefits at a Glance

Eligibility for Medical, Rx, Mental Health/Substance Abuse begins first day of month following hire date or benefits eligibility date

MEDICAL COVERAGE
 

FLETCHER ALLEN PREFERRED MEDICAL PLAN

FLETCHER ALLEN PREFERRED PLUS MEDICAL PLAN

In-Network Coverage

Out-Of-Network Coverage

Plan Description

May use only in-network providers.

May use both in-network and out-of-network providers.

Use network providers and receive the in-network level of benefits.

Use out-of-network providers, receive the out-of-network level of benefits based on usual and customary charges.

Annual Deductible
 

Includes Coinsurance?
Includes Copays?

(Does not apply to co-pays or pharmacy services)

$250single/
$750 family

Yes
No

$250single/
$750 family

Yes
No

$500 single/
$1,500 family

Yes
No

Annual Out-of-Pocket Maximum

Includes Deductible?
Includes Coinsurance?
Includes Co-pays?

$1,500 single /
$4,500 family

Yes
Yes
No

$1,500 single /
$4,500 family

Yes
Yes
No

$2,000 single /$6,000 family

Yes
Yes
No

Lifetime Maximum Benefit

Unlimited

Unlimited

Unlimited

Pre-Existing Condition Limit

None

None

None

(Office Visits) Preventive Care

Covered at 100%

Covered at 100%

Not Covered

X-ray and Laboratory Services (Preventive)

Covered at 100%

Covered at 100%

Not Covered

Office Visit - Primary Care

$10 co-pay per office visit

$10 co-pay per office visit

You pay 30% after deductible

Office Visit - Specialist Care

Office Surgery (Specialist)

Second Opinion

$25 co-pay per office visit

$25 co-pay per office visit

You pay 30% after deductible

Maternity - Confirm pregnancy

Prenatal/Postnatal Visits

$10 co-pay for first office visit
Remaining visits covered 100%

$10 co-pay for first office visit
Remaining visits covered 100%

You pay 30% after deductible

Hospice

Covered at 100%

Covered at 100%

You pay 30% after deductible

Routine Vision Exam

(One visit every 24 months)

Covered at 100%

Covered at 100%

 Not Covered

Outpatient Physical, Speech and Occupational Therapy

$10 co-pay for FAHC Provider only, per office visit

$25 co-pay per office visit

(up to 30 visits per year)

$10 co-pay for FAHC  Provider only, per office visit

$25 co-pay per office visit

(up to 30 visits per year)

You pay 30% after deductible

Chiropractic Care**

Plan pays $15
per visit after $25 co-pay

(up to 12 visits
per year)

Plan pays $15
per visit after $25 co-pay

(up to 12 visits
per year)

Plan pays $15
per visit after $25 co-pay

(up to 12 visits
per year)

Urgent Care / Fanny Allen WICC

$25 co-pay plus coinsurance if applicable

$25 co-pay plus coinsurance if applicable

$25 co-pay plus coinsurance if applicable

Emergency Room

$50 co-pay (waived if admitted) plus coinsurance if applicable

$50 co-pay (waived if admitted) plus coinsurance if applicable

$50 co-pay (waived if admitted) Plus coinsurance if applicable
co-pay

Hospital Inpatient Care*

Outpatient Surgery             (doctor and hospital fees)

Outpatient CT/MRI/Nuclear Scans 

(X-Ray and Laboratory Services (Diagnostic)

After the deductible is met, FAHC charges are subject to 5% coinsurance and other provider's charges are subject to 10% coinsurance up to the annual out-of-pocket maximum.

After the deductible is met. FAHC charges are subject to 5% coinsurance and other provider's charges are subject to 10% coinsurance up to the annual out-of-pocket maximum.

 You pay 30% after deductible

Skilled Nursing Facility
(up to 120 days per year)

You pay 10% after deductible

You pay 10% after deductible

You pay 30% after deductible

Home Health Care

You pay 10% after deductible

You pay 10% after deductible

You pay 30% after deductible

External Prosthetic Devices

You pay 20% after deductible

You pay 20% after deductible

You pay 30% after deductible

Durable Medical Equipment

You pay 20% after deductible

You pay 20% after deductible

You pay 30% after deductible

Infertility Treatment AI, IUI, IVF

You pay 50% coinsurance.  Services are exempt from annual deductible and do not count toward annual out of pocket maximum. $15,000 Lifetime Maximum Benefit

Must be a FAHC Provider

You pay 50% coinsurance.  Services are exempt from annual deductible and do not count toward annual out of pocket maximum. $15,000 Lifetime Maximum Benefit

Must be a FAHC Provider

Not Covered

Mental Health / Substance Abuse

Inpatient*

After the deductible is met, Fletcher Allen charges are subject to 5% coinsurance and other providers' charges are subject to 10% coinsurance, up to the annual out-of-pocket maximum.

After the deductible is met, Fletcher Allen charges are subject to 5% coinsurance and other providers' charges are subject to 10% coinsurance, up to the annual out-of pocket maximum.

After deductible is met, you pay 30% coinsurance on the remaining charges, up to the annual out-of-pocket maximum
 

Outpatient
(office visit)

$10 co-pay per visit

$10 co-pay per visit

After deductible is met, you pay 30% coinsurance on the remaining charges, up to the annual out-of-pocket maximum
 

Outpatient
(group therapy)

$10 co-pay per visit

$10 co-pay per visit

After deductible is met, you pay 30% coinsurance on the remaining charges, up to the annual out-of-pocket maximum

Prescription Drug

Retail Pharmacy
(up to 30-day supply)

When using a Fletcher Allen Pharmacy, you can get a 90 day supply for a 60 day copayment.

$10 generic co-pay
$25 preferred co-pay
$45 non-preferred co-pay
Infertility: 50% coinsurance; maxium annual benefit of $2,000

$10 generic co-pay
$25 preferred co-pay
$45 non-preferred co-pay
Infertility: 50% coinsurance; maxium annual benefit of $2,000

You pay 50% no deductible

Mail Order Delivery
(up to 90-day supply)

$20 generic co-pay
$50 preferred co-pay
$90 non-preferred co-pay

$20 generic co-pay
$50 preferred co-pay
$90 non-preferred co-pay

Not covered

* All inpatient hospital admissions require Prior Authorization and Continued Stay Review.

**Chiropractic Providers - There is not a defined network of Chiropractors. Fletcher Allen employees and their dependents can utilize the chiropractor of their choice!  

***Benefits  - This is a benefit plan outline of the Fletcher Allen Preferred and Fletcher Allen Preferred Plus Medical Plan benefits; it does not include every detail of the Plan.  Please refer to your "Summary Plan Document" 

Explanation of out-of-network benefits

Calculations regarding out-of-network benefits will be based on the usual and customary (U&C) allowance. In many cases, the U&C allowance will be lower, therefore your out-of-pocket costs could be higher. You will be responsible for any differences between the U&C allowance and the provider's fee. This could be a significant cost to you and will not be credited toward your deductible nor your out-of-pocket maximum. Please consider this fact when making your decision to use an out-of-network provider.

Fletcher Allen Health Care
Summary of Benefits for The Pre-65 Retiree
Benefits Comprehensive
Annual Deductible
Individual
Family
None
None
Annual Out-Of-Pocket Maximum
Individual
Family
None
None
Pre-Existing Condition Limitation Not Applicable
Lifetime Maximum Unlimited
Your Plan Pays
Office Visit
Illness/Injury
100% up to 20 visits per year
Preventive Care
Office Visit
100% (including lab and x-ray)
Independent X-Ray and Lab 100%
Prescription Drugs Not Covered
Emergency:
Doctors Office
Emergency Room / Urgent Care Facility
Ambulance

100%
100%
100%
Hospital Inpatient:
Hospital Inpatient
Doctors Visits
Pre-Admission Certification/Continued Stay Review(1)

100%  up to 120 days per admission
100%
Patient must get approval
Outpatient Surgical Facility 100%
Surgery
Surgeons Fees
Second Opinion Consultation

100% 
100%
Outpatient Rehabilitation
Includes Physical Therapy, Occupational &
Chiropractic Therapy (2)
100% up to 30 visits per calendar year
Special Services
Skilled Nursing Facility
Home Health Care
Hospice - Inpatient
Hospice - Outpatient

100%  up to 120 days per admission
100%  up to 120 days per admission
100%  up to 120 days per admission
100%
Durable Medical Equipment 80% 
External Prosthetic Appliances 100%
Mental Health
Inpatient
Outpatient

100% up to 120 days per admission
100% up to 20 visits per year
Alcohol & Drug Abuse Rehabilitation
Inpatient
Outpatient

100% up to 120 days per admission
100% up to 20 visits per year
Group Therapy Subject to Mental Health, Alcohol or Drug Abuse
outpatient maximums and limitations
Vision Care Not Covered
  1. All inpatient hospital admissions require Pre-Admission Certification and Continued Stay Review. If your admission/stay is not authorized there may be reduction or denial of coverage.
  2. 2 - Speech therapy, which is not restorative in nature, will not be covered.
Summary of Benefits for The POST-65 Retiree
Benefits Comprehensive
Annual Deductible
Individual
Family

None
None
Annual Out-Of-Pocket Maximum
Individual
Family

None
None
Pre-Existing Condition Limitation Not Applicable
Lifetime Maximum Unlimited
Your Plan Pays
Office Visit
Illness/Injury/Allegery Treatment
100%
Preventive Care
 
Not Covered
Independent X-Ray and Lab 100%
Prescription Drugs Not Covered
Emergency:
Doctors Office
Emergency Room / Urgent Care Facility
Ambulance

100%
100%
100%
Hospital Inpatient
Doctors Office
Pre-Admission Testing
100%
100%
100%
Outpatient Surgical Facility 100% 
Surgery
Surgeons Fees
Second Opinion Consultation

100%
100%
Outpatient Rehabilitation
Includes Physical Therapy, Occupational &
Chiropractic Therapy (1)
100% up to 30 visits per calendar year
Special Services
Skilled Nursing Facility
Home Health Care
Hospice - Inpatient
Hospice - Outpatient

100% up to 100 days per year
100% unlimited
Not Covered
Not Covered
Durable Medical Equipment 100%
External Prosthetic Appliances 100%
Mental Health
Inpatient
Outpatient

100%
100%
Alcohol & Drug Abuse Rehabilitation
Inpatient
Outpatient

100%
100%
Group Therapy 100%
Vision Care Not Covered

(1) Speech therapy that is not restorative in nature will not be covered.

Privacy Statement (PDF version)

Notice of Privacy Practices of FAHC’s Self-Insured Health Plans Administered by Vermont Managed Care

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Legal Duty

The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes requirements on health plans concerning the use and disclosure of Protected Health Information. This document is a Notice of Privacy Practices (“Privacy Notice”) of Fletcher Allen Health Care’s (“FAHC’s”) Self-Insured Plans (collectively referred to as the “Plan” or “we”) that is being provided to you as a participant in the Plan. Protected Health Information (sometimes referred to as “PHI”) means information relating to your past, present or future health or medical condition, the provision of health care to you, or payment for the provision of health care to you. The Plan is administered by Vermont Managed Care (“VMC”), and PHI also includes records that VMC maintains about your coverage and claims as the Plan’s administrator.

The Plan is required by federal law to maintain the privacy of your Protected Health Information, and to provide you with this Privacy Notice to describe how Protected Health Information about you may be used and disclosed and your rights regarding your PHI, including how you may obtain access to your PHI. Access to and disclosure of the information described in this Privacy Notice applies to the Plan, and to PHI maintained by FAHC or VMC on behalf of the Plan, but it does not apply to information that is maintained by FAHC as an employer. Please read the notice carefully, and file it for future reference.

Uses and Disclosures of PHI

The privacy rules allow the use and disclosure of your health information without your authorization as described below. With the exception of uses for the purposes of treatment, only the “minimum necessary” amount of health information will be used or disclosed by the Plan, as defined under the HIPAA rules.

Primary Uses and Disclosures of PHI

Treatment

Includes providing, coordinating, or managing health care by one or more health care providers. For example, the Plan may share health information about you with physicians who are treating you.

Payment

Includes activities by the Plan, other plans, or providers to obtain payment, make coverage and eligibility determinations and provide reimbursement for health care. For example, we might also use your information to coordinate benefits, to examine medical necessity, and to issue explanations of benefits to the person who subscribes to the health plan in which you participate.

Health Care Operations

Includes activities such as wellness and risk assessment programs, quality assessment and improvement activities, customer service, internal grievance resolution, case management, and similar activities, as defined by HIPAA. For example, we may use your information to process a claim or resolve a grievance that you may have with the Plan.

As Required or Permitted by Law

Please see the next section titled “Other allowable uses or disclosures of your health information.”

Plan Sponsor

Disclosures to FAHC for plan administration functions. For example, FAHC may seek information to evaluate future changes to your benefit plan or to obtain bids for reinsurance.

Business Associates

Disclosures to individuals and entities (called “Business Associates”) in order to perform various functions on behalf of the Plan or to provide certain types of services (such as member service support, utilization management, subrogation, or pharmacy benefit management), including VMC as Plan Administrator, pursuant to a Business Associate agreement.

Other Providers or Health Plans

Disclosures to assist health care providers in connection with their treatment or payment activities, or to assist other health plans or providers in connection with certain of their health care operations such as quality assurance, or accreditation, certification, licensing or credentialing.

To You or with Your Authorization

Disclosures to you, as described in the Individual Rights section of this notice.

Other Allowable Uses or Disclosures of Your PHI

Treatment Alternatives

Disclosure to you to provide information about treatment alternatives or other health-related benefits and services.

Public Health Activities
  • Disclosures made in the good-faith belief that releasing your health information is necessary to prevent or lessen a serious and imminent threat to public or personal health or safety, if made to someone reasonably able to prevent or lessen the threat (including disclosures to the target of the threat).
  • Disclosures to public health authorities to prevent or control disease or report child abuse or neglect or for public health investigations.
  • Disclosures to the Food and Drug Administration to collect or report adverse events or product defects.
Victims of Abuse, Neglect, or Domestic Violence

Disclosures to government authorities, including protected services agencies authorized by law to receive reports of abuse, neglect, or domestic violence, as required by law or if you agree or we believe that disclosure is necessary to prevent serious harm to you or potential victims. (You will be notified of the Plan’s disclosure if informing you will not put you at further risk.)

Judicial and Administrative Proceedings

Disclosures in response to a court or administrative order, subpoena, discovery request, or other lawful process. (The Plan may be required to notify you of the request, or receive satisfactory assurance from the party seeking your health information that efforts were made to notify you or to obtain a qualified protective order concerning the information.)

Law Enforcement Purposes

Disclosures to law enforcement officials required by law or pursuant to legal process, or to identify a suspect, fugitive, witness, or missing person; disclosures about a crime victim if you agree or if disclosure is necessary for immediate law enforcement activity; disclosure about a death that may have resulted from criminal conduct; and disclosure to provide evidence of criminal conduct on the Plan’s premises.

Health Oversight Activities

Disclosures to health agencies for activities authorized by law (audits, inspections, investigations, or licensing actions) for oversight of the health care system, government benefits programs for which health information is relevant to beneficiary eligibility, and compliance with regulatory programs or civil rights laws.

Specialized Government Functions

Disclosures about individuals who are Armed Forces personnel or foreign military personnel under appropriate military command; disclosures to authorized federal officials for national security or intelligence activities; and disclosures to correctional facilities or custodial law enforcement officials about inmates.

HHS Investigations

Disclosures of your health information to the Department of Health and Human Services (HHS) to investigate or determine the Plan’s compliance with the HIPAA privacy rule.

Coroners, Medical Examiners, Funeral Directors, and Organ Donation

Disclosures to a coroner or medical examiner for purposes of identifying you after you die, determining cause of death, or to perform other duties authorized by law. We also might disclose, as authorized by law, information to funeral directors so that they may carry out their duties on your behalf. Further, we might disclose PHI to organizations that handle organ, eye, or tissue donation and transplantation.

Research

Disclosures for the purpose of conducting research when an institutional review board or privacy board has: (1) reviewed the research proposal and established protocols to ensure the privacy of the information; and (2) approved the research.

Workers’ Compensation

Disclosures made to comply with workers’ compensation laws and other similar programs that provide benefits for work-related injuries or illnesses.

To Family and Friends

Disclosures with your agreement, (or without your agreement if you are unavailable to agree such as in a medical emergency situation), to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care.

Individual Rights

Except as described in this notice, other uses and disclosures of your Protected Health Information will be made only with your written authorization. You may revoke your authorization as permitted by the privacy rules. However, you cannot revoke your authorization with respect to disclosures the Plan has already made in reliance on your authorization. You have the following rights with respect to your Protected Health Information the Plan maintains. These rights are subject to certain limitations.

Review Your Protected Health Information

You have the right to inspect and obtain a copy of your Protected Health Information, except you do not have the right to copies of psychotherapy notes or information compiled for civil, criminal, or administrative proceedings. You must make a request in writing to obtain access to your Protected Health Information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the address at the end of this notice. If you request copies, we might charge you a reasonable fee for each page, and postage if you want the copies mailed to you. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot reasonably do so. If you request an alternative format, we might charge a cost-based fee for providing your Protected Health Information in that format. If you prefer, we will prepare a summary or an explanation of your PHI, but we might charge a fee to do so. We might deny your request to inspect and copy your PHI in certain limited circumstances. Under certain conditions, our denial will not be reviewable. If this event occurs, we will inform you in our denial that the decision is not reviewable. If you are denied access to your information and the denial is subject to review, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person performing this review will not be the same person who denied your initial request.

Request to Restrict Your Protected Health Information

You have the right to ask the Plan to restrict the use and disclosure of your Protected Health Information to carry out Treatment, Payment, or Health Care Operations, except for uses or disclosures required by law. We are not required to agree to a requested restriction, but if we do, we will abide by the agreement (except in an emergency). Any agreement to a request for additional restrictions must be in writing and signed by a person authorized to make such an agreement. We will not be liable for uses and disclosures made outside of the requested restriction unless the agreement to restrict is in writing. We may end the agreement to the requested restriction by notifying you in writing.

You may request a restriction by writing to the Plan using the information listed at the end of this notice. In your request you must describe: (1) the information for which you want to limit our use and disclosure; and (2) how you want to limit our use and/or disclosure of the information.

Receive Confidential Communications

If you believe that a disclosure of all or part of your PHI may endanger you, you have the right to request that we communicate with you in confidence about your Protected Health Information. This means that you may request that we send you information by alternative means, or to an alternate location. The Plan must accommodate your request if: it is reasonable, specifies the alternative means or alternate location, and specifies how payment issues (premiums and claims) will be handled. You may request such confidential communications by writing to the Plan using the information listed at the end of this notice

Amend Your Health Information

You have the right to request an amendment to your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons. If your request is denied, we will provide you with a written explanation. You may respond with a statement of disagreement, which will be appended to the information you wanted to amend. If the Plan accepts your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Receive an Accounting of Disclosures

You have the right to a list of certain disclosures the Plan has made of your Protected Health Information going back six years from the date of your request, but not for disclosures made prior to April 14, 2003. You do not have a right to receive an accounting of any disclosures made:

  • For Treatment, Payment, or Health Care Operations;
  • To you about your own health information;
  • Incidental to other permitted or required disclosures;
  • Where authorization was provided;
  • For national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances; and
  • As part of a “limited data set” (health information that excludes certain identifying information).

You may request an accounting by submitting your request in writing using the information listed at the end of this notice. Your request may be for disclosures made up to 6 years before the date of your request, but in no event, for disclosures made prior to April 14, 2003.

Paper Copy of This Notice

You are receiving this notice by mail. This Privacy Notice will also be posted on the FAHC Web site at www.fahcpreferred.org Even if you agree to receive this notice on the web site, or by electronic mail (e-mail), you are entitled to receive a paper copy as well. Please contact the Plan using the information listed at the end of this notice to obtain this notice in written form. If the e-mail transmission has failed, and we are aware of the failure, then it will provide a paper copy of the notice to you. When exercising these rights, please put your request in writing and send it to Vermont Managed Care, Privacy Officer, PO Box 1150, Burlington, Vermont 05402-1150

Other Relevant Information Regarding Your PHI and This Privacy Notice

State Law

HIPAA Privacy Regulations generally do not “preempt” (or take precedence over) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, to the extent state law applies, the privacy laws of a particular state, or other federal laws, rather than the HIPAA privacy rules, might impose a privacy standard under which we will be required to operate.

Changes to Privacy Policies

The Plan must abide by the terms of the Privacy Notice currently in effect. This notice takes effect on April 14, 2003. However, the Plan reserves the right to change the terms of its privacy policies as described in this notice at any time, and to make new provisions effective for all PHI that the Plan maintains. This includes PHI that was previously created or received, not just PHI created or received after the policy is changed. If changes are made to the Plan’s privacy policies described in this notice, you will be provided with a revised Privacy Notice by mail.  Copies of the most current Privacy Notice  may be obtained at any time by calling the Vermont Managed Care Customer Service Department or by viewing the Fletcher Allen Preferred website at www.fahcpreferred.org

Questions or Complaints

If you have any questions about the Plan’s privacy policies or your rights under HIPAA, please write to Vermont Managed Care, PO Box 1150, Burlington, VT 05402-1150.

If you believe your privacy rights have been violated, you may complain to the Plan and to the Secretary of Health and Human Services. You will not be retaliated against for filing a complaint.

To file a complaint with the Plan, please describe your complaint in a letter addressed to Vermont Managed Care, PO Box 1150, Burlington, VT 05402-1150 or Call 802-847-4862 or toll free at 1-866-582-6836.

To file a complaint with the U.S. Secretary of Health and Human Services use the HIPAA Complaint Submission Form at cms.hhs.gov/hipaa/hipaa 2 or by mail to: HIPAA Complaint, 7500 Security Blvd., C5-24-04, Baltimore, MD 21244.

NOTICE EFFECTIVE DATE:  April 14, 2003
Revised 1/1/2011

FAP Administrative Documents