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State Employee Health Plans:
(a) The plans are as follows:
(1) an Indemnity-type plan with the common mental health and substance abuse, prescription drug, vision, and wellness benefits;
(2) a Point of Service (POS) plan with the common mental health and substance abuse, prescription drug, vision, and wellness benefits;
The State will provide the current State Employee's Wellness Program to all covered employees and retirees (but not dependents) enrolled in one (1) of the four (4) health plans. The State and VSEA and VTA will continue to discuss and pursue Wellness initiatives and options that would enhance the current Wellness Program. These initiatives and options, if mutually-agreed to by the parties, will be incorporated into the Wellness Program.
Except as required to effectuate the health care plan changes referenced above, the provisions of Article 42 of the 1999-2001 Agreement shall be incorporated into this Agreement.
(b) Prescription Drugs. The prescription drug benefit for the Total Choice, Health Guard PPO (if applicable) and Select Care POS Plans shall implement the following. There shall be an initial deductible of twenty-five dollars ($25.00) per patient for each year. Commencing on January 1, 2019, the initial deductible will increase to fifty dollars ($50.00). As is currently the case, the State may select the Pharmacy Benefits Manager, who shall implement the terms of this section in accordance with its contract with the State. The Pharmacy Benefits Manager shall, in accordance with industry standards, categorize (and may subsequently recategorize) prescription drugs into three (3) tiers: generic, preferred brand and non-preferred brand. There shall be a co-payment by the patient on each prescription of ten percent (10%) for generic drugs, twenty percent (20%) for preferred brands, and forty percent (40%) for non-preferred brands. If there is no effective generic or preferred alternative to it, the co-pay for non-preferred brands shall be twenty percent (20%).
There shall be a maximum out-of-pocket for the patient, in addition to the deductible, of six hundred seventy-five dollars ($675.00), effective January 1, 2009, and seven hundred fifty dollars ($750) effective January 1, 2010. Co-payments made at the forty percent (40%) rate for non-preferred brands shall not be counted toward the maximum out-of-pocket limit (i.e., there shall be no maximum out-of-pocket limit for co-payments made at the forty percent (40%) rate for non-preferred brands). The maximum out-of-pocket shall apply to all co-payments made at the ten percent (10%) or twenty percent (20%) rate. The maximum out-of-pocket limit shall also apply to all co-payments made for Specialty drugs at the forty percent (40%) rate.
Effective January 1, 2019, the prescription drug formulary, formerly referred to as "the list" shall change to the standard national formulary of the Pharmacy Benefits manager and the State shall have the authority to authorize the Pharmacy Benefits manager to apply reasonable quality and cost measures such as prior authorization and drug quantity management. The Pharmacy Benefits Manager shall annually thereafter, provide a proposed list of the division of drugs into tiers prior to the implementation of such drug list. The parties will meet, review and discuss the list promptly. The parties must consider each other's positions in good faith. During any year, the Pharmacy Benefits Manager may bring forward revisions for discussion and review in accordance with this paragraph.
(c) Study Committee. The parties shall utilize the Benefits Advisory Committee, with equal membership by the State and its unionized employees (VSEA and VTA), for the purpose of reviewing all issues related to health care and prescription drugs, and recommending changes to the bargaining committees. The parties shall also establish a special study committee to evaluate the current health plans, and make recommendations to the bargaining committees of the State and employees for sustainable savings in the health care plans.
(d) The State of Vermont, through LiveWell Vermont, the State Employee Wellness Program, may offer influenza inoculations to permanent and temporary employees, regardless of whether they are members of the State Employee Health Plan(s), which shall be paid for by the Plan. However, the costs to provide such inoculations to non-members of the State Employee Health Plan(s) shall not exceed twelve thousand dollars ($12,000) per Fiscal Year.
(1) Not later than March 31 of each Fiscal Year, the State shall provide VTA with the following information for that year:
(i) Number of participants who received the inoculation;
(ii) Total costs of the inoculation (including totals for vaccinations, staff time, overhead, etc.); and
(iii) Name of vendor contracted to provide vaccinations and the amount paid for the contract.
Premium Share: The State shall pay eighty percent (80%) of the premium cost of each plan and the employee or retiree will pay the remaining twenty percent (20%).
Insurance Pools: If the State of Vermont is required by the Vermont Legislature to institute any insurance plan or pool, and the state employees' health plans are required to participate in such plan or pool, and the plan or pool:
(a) includes a membership larger than the groups currently covered by the state employees' health plans; or
(b) alters the structure of the state's current health plan offerings or their operating foundations; or
(c) has an impact on plan benefits; or
(d) increases premium rates;
the State and VTA agree to a limited contract reopener for the purpose of negotiating the impacts of such change. Both parties shall retain all statutory impasse rights.
Commencing on January 1, 2013, the SelectCare Health Insurance Plan employee co-payments that were fifteen dollars ($15.00) will increase to twenty dollars ($20.00). Commencing on January 1, 2019, the SelectCare Health Insurance Plan employee co-payments for non-specialist office visits that were twenty dollars ($20.00) will increase to twenty-five dollars ($25.00) and specialist office visit that were twenty dollars ($20.00) will increase to thirty dollars ($30.00). SelectCare emergency room visit co-payments that were fifty dollars ($50.00) will increase to seventy-five dollars ($75.00). SelectCare magnetic resonance image (MRI) co-payments will be thirty dollars ($30.00) Commencing on January 1, 2021, there shall be a maximum out-of-pocket limit of one thousand five hundred dollars ($1500.00) for a single person coverage or three thousand dollars ($3000.00) for a two (2) person or family coverage.
Effective, January 1, 2023, plan members shall be entitled to a one thousand five hundred dollar ($1,500,00) hearing aid benefit for each ear in a sixty (60) month period.
Eligibility/Enrollment: For purposes of this Article, "Plan" means any approved health plan in which the employee is enrolled.
(a) Eligibility requirements: Minimum hours working requirement for eligibility for permanent part-time employees shall be as follows: to be eligible for membership in a Plan, an employee must be certified by the appointing authority as being expected to work at least one thousand forty (1040) hours per year in their position. The Commissioner of Human Resources may require a certificate from any appointing authority as appropriate to ascertain that any employee, or group of employees, initially meets and continues to meet this eligibility requirement. An employee who is not certified as meeting the eligibility requirement expressed herein shall not be allowed to join a Plan, and any employee initially certified as meeting the minimum working hours requirement may stay in a Plan only so long as the reasonable expectation of working at least one thousand forty (1040) hours per calendar year continues. No membership will be terminated under this section without reasonable notice and an opportunity for hearing before the Commissioner of Human Resources. Permanent part-time employees in an inactive status (i.e., a regular or irregular layoff due to seasonal needs or lack of work) who continue to meet Plan eligibility requirements may remain in the Plan, but they shall be responsible for payment of the entire premium in advance of the due date to the Department of Human Resources, Benefits Division. For purposes of continued participation in the Plan, employees under this section shall be governed by the same rules provided for employees in unpaid, non-medical leave of absence status.
For purposes of this article, "due date" for an employee refers to each date on which the State pay date falls and on which the payroll deduction of premium would normally be made. For a retiree, "due date" shall be the first day of each month. Failure of the member to render required payments under this article in advance of the due date shall result in automatic cancellation of membership in a Plan.
(b) Open Enrollment Period: There shall be an annual open enrollment period for State Employee Health Plans every November. Coverage shall be effective on the first day of January following the open enrollment period. Initial premium deductions shall be taken in the pay check for the pay period which includes January 1, each year.
(c) Enrollment Eligibility of New Hires and New Dependents: Newly hired employees shall be eligible to enroll in any of the Plans between their first and 60th day of employment. Employees can enroll newborn or newly acquired dependents within sixty (60) days of birth, adoption, marriage, legal civil union, or bona fide domestic partnership. Enrollments in any of the Plans shall be in accordance with the rules of the Plans.
(d) Enrollment Form: All Plan applicants shall be required to fill out and sign an eligibility/enrollment form provided by the Department of Human Resources.
(e) Enrollment Exceptions: For purposes of this subsection, the term "spouse" shall be synonymous with legal civil union partner or bona fide domestic partner. Except in the case of new hire, marriage, legal civil union, bona fide domestic partnership, childbirth or adoption, divorce, dissolution of a legal civil union or a bona fide domestic partnership, death of a spouse, or spouse's job loss, enrollment will not be permitted outside the open enrollment period. An employee covered by one of the Plans shall not be allowed to change Plans outside the open enrollment period except in case of a permanent change of residence of such employee to a service area not covered by the managed care plan in which the employee is enrolled.
(f) Eligibility for Health Coverage - RIF: An employee who is laid off on or after July 1, 1992, pursuant to the provisions of Reemployment Rights, may elect to continue membership in their Plan, upon advance payment of the regular percentage contribution to the cost of the Plan, during the first six (6) full pay periods next following the effective date of separation, provided the employee retains reemployment rights under the Reemployment Rights Article. This provision shall not apply to any employee who is subsequently returned to layoff status after having accepted a reemployment offer. An employee who accepts the offer under Section 8(d) of the Reemployment Rights Article to displace and become a temporary employee shall be eligible for membership in their Plan under the above, until such employee declines a single mandatory offer of reemployment.
Thereafter, former employees who remained as members of the Plan shall be eligible to remain in the Plan so long as they continue to make required payment of the entire premium in advance of the due date to the Department of Human Resources, Benefits Division. This benefit and privilege shall continue for the period of RIF status, not to exceed two (2) years from the effective date of separation. Any member under this section who drops or loses health insurance coverage, either voluntarily or by failing to pay the premium, shall not be eligible to re-enroll in the insurance plan during the remainder of their RIF status (although such former members may elect to be covered, in accordance with Plan rules, upon return to active State service through exercise of RIF rights). An employee who returns to active employment after a layoff shall not be eligible to enroll in any plan other than the plan in which the employee was enrolled at the time (s)he left active employment. All eligible dependents at the time of re-enrollment shall be eligible for coverage.
(g) Eligibility for Health Coverage - Leave of Absence (LOA) Status:
(1) Non-medical LOA: Members on an approved, unpaid leave of absence (non-medical) may remain in their Plan for the period of the approved leave, plus extensions, so long as they continue to make required payment of the entire premium in advance of the due date to the Department of Human Resources, Benefits Division. Any member under this Section, who drops or loses coverage, either voluntarily or by failing to pay the premium, shall not be eligible to re-enroll in any Plan during the remainder of their period of leave of absence status, and may not rejoin the Plan upon return to active status until an open enrollment period arises.
(2) Medical LOA: Members on an approved, unpaid leave of absence granted for medical reasons may remain in their Plan for the period of the approved leave, plus any extensions, so long as they continue to make required payment of their share of the premium, as provided herein, in advance of the due date, to the Department of Human Resources, Benefits Division. During the first twelve (12) months of medical leave of absence, the State will continue to pay eighty percent (80%) of the premium, and the member will be responsible to pay the remaining twenty percent (20%). After twelve (12) months (which may be continuous, or an aggregate of leave time granted for a given illness or condition) a member may stay in their Plan for the remaining period of the medical leave of absence, plus extensions, so long as they continue to make payment of the entire premium in advance of the due date to the Department of Human Resources, Benefits Division. Any member under this Section, who drops or loses coverage, either voluntarily or by failing to pay the premium as required herein, shall not be eligible to reenroll in a Plan during the remainder of their leave of absence status and may not rejoin a Plan upon return to active status until an open enrollment period arises.
(3) Paid LOA: Members on an approved, paid leave of absence may remain in a Plan for the period of approved paid leave. In any such case the employee's share of the premium will continue to be deducted from the employee's pay. Members in said status who elect to drop out of a Plan while on a paid leave shall be ineligible to re-enroll in a Plan upon return to active service until an open enrollment period arises.
(4) Military LOA: As permitted under benefit plan rules and/or the contract, an employee who returns to active employment after an unpaid military leave of absence shall not be eligible to enroll in any plan other than the plan in which the employee was enrolled at the time (s)he left active employment. All eligible dependents at time of re-enrollment shall be eligible for coverage.
(5) Legislative LOA: Employees on leave of absence to serve in the General Assembly of the State of Vermont shall retain insurance coverage hereunder and the State shall continue to pay eighty percent (80%) of the premium cost during such leave. The employee shall continue to pay their twenty percent (20%) share of the premium.
(h) Students: Students shall be covered for an additional sixty (60) days following the date of graduation. Students shall be required once per year to provide certification that they are a full-time student.
(i) The Plan shall provide coverage in compliance with the requirements of 8 V.S.A § 4089d (providing for extended coverage for certain dependent children).
SELF INSURANCE
Nothing herein shall prevent the State from self-insuring the terms of coverage or from contracting with an insurance company to provide substantially equivalent coverage.
PRE-TAX PREMIUM PAYMENT
The State will offer a pre-tax premium payment plan permitted under Section 125 of the Internal Revenue Code.
FLEXIBLE SPENDING ACCOUNT
The parties agree that the State shall have the right to use State Employee Health Plan funds to cover the administrative costs of operating the medical and dependent care flexible spending account programs.
PLAN ADMINISTRATION
(a) The State will keep a record of any surplus or deficit in Plan funds and will report its existence to VTA.
(b) Any surplus, including that portion attributable to the State's percentage of premium payment, shall remain with the State Employee Health Plan Fund and shall not be expended for any non-Fund purposes without mutual agreement.
(c) The State will give written notice to VTA of its intent to apply any State Employee Health Plan Fund surplus to premium reduction, new benefits or continued accumulations, or, in case of an anticipated deficit, of the necessity to raise premiums. The State will give at least forty-five (45) calendar days written notice to VTA over any proposed premium increase. At the request of VTA, the State will consult and discuss the proposed premium increase for a period not exceeding thirty (30) calendar days from the date of such notice by the State, after which the State may implement its decision, whether or not the parties have bargained to genuine impasse. The statutory impasse procedure shall not apply.
(d) The State will consult with VTA concerning the method of funding for any newly recognized benefit.
(e) VTA shall have a reasonable opportunity (not less than thirty (30) days) to review any subsequently drafted plan booklet prior to publication.
(f) The VTA will encourage employees and retirees with problems or questions concerning the administration of health care claims to directly raise those concerns with the Benefits Division of the Department of Human Resources. The Benefits Division will work cooperatively with employees or retirees to resolve such questions. If such questions or concerns are not resolved and the VTA becomes involved in the issue, the Benefits Division shall work cooperatively with the VTA to seek a resolution.[2]
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