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2021 Health Care Benefits

Dartmouth-Hitchcock (D-H) offers you a choice of three medical plan options—the ElevateHealth HSA Plan, the ElevateHealth HRA Plan, and the Choice Health Plan. Deciding which plan to choose is a personal and financial decision. To help you choose, we have outlined some similarities and differences between the plans.

  • ElevateHealth Plans: ElevateHealth is an insurance partnership of Dartmouth-Hitchcock (D-H), Elliot Health System, and Harvard Pilgrim Health Care. Employees who enroll in one of the two ElevateHealth plans can expect care from a network of providers and facilities primarily located in New Hampshire and Vermont where most D-H employees and their families are seeking care today; however, coverage is not provided for service outside the ElevateHealth network. The only exception to this provision is in the event of an emergency situation or a service that is not provided at the facilities in the ElevateHealth network which is medically necessary.
  • Choice Health Plan: The Dartmouth-Hitchcock Health Choice Health Plan, administered by Health Plans, Inc., offers a national network of providers. In the Choice Health Plan, you have access to the Harvard Pilgrim network of providers. If you choose to see a provider that is out-of-network, you will be responsible for the out-of-network deductible, coinsurance, and plan provisions.

The following sections describe the benefits available for each plan.

Medical, prescription drug, and dental plan employee contributions

Bi-weekly premiums shown here are for non-tobacco users with the ElevateHealth Plan with HSA and HRA Choice Health Plans. Additional premiums or premium adjustments may apply.

Medical and prescription drug plan employee contributions

FTE 0.75 or greater

Salary range Covered Cost
Base salary $0 to $49,999 Employee $38.87
  Employee and Children(s) $58.29
  Employee and Spouse $81.60
  Family $107.63
Base salary $50,000 to $149,999 Employee $57.86
  Employee and Children(s) $86.80
  Employee and Spouse $121.52
  Family $160.29
Base salary $150,000 or greater Employee $86.59
  Employee and Children(s) $129.87
  Employee and Spouse $181.83
  Family $239.84

FTE 0.5-0.74

Covered Cost
Employee $125.86
Employee and children $192.60
Employee and spouse $266.97
Family $350.99

Dental plan employee contributions

Premiums shown are for FTE 0.5 to 1.0.

Covered Basic Enhanced
Employee $2.58 $5.69
Employee and children $10.85 $21.68
Employee and spouse $10.85 $21.68
Family $20.66 $40.80

Additional premiums

  • Tobacco use premium: The employee contributions shown are for non-tobacco users only. If you or a covered dependent use tobacco, a $15 tobacco user premium will be added to your contribution each pay period.
  • Spouse premium: If you choose to cover your spouse under a D-H health care plan, your 2021 health care contributions will be twice the standard premium if your spouse has access to group-sponsored health insurance coverage through their own employer. This does not apply if your spouse is employed and eligible for benefits at D-H, Alice Peck Day, Cheshire Medical Center, or New London Hospital.
  • Salary level premium: All salary-based insurance premiums, such as medical insurance, life and disability buy-up insurance, may increase or decrease based on salary adjustments throughout the calendar year. For example, medical insurance premiums are based on salary levels. If an employee has an adjustment in salary, the premium and/or benefit level change will take effect within two pay periods of the date in which Human Resources receives the change.

Medical plans

These tables summarize the costs associated with each medical plan. "Single" = Employee only coverage. "Family" = all other coverage levels.

ElevateHealth HSA Plan

Plan features Preferred providers ElevateHealth network
Deductible Single: $1,400
Family: $2,800
Single: $1,400
Family: $2,800
Co-insurance 10% after deductible 30% after deductible
Preventative care Covered 100% Covered 100%
Out-of-pocket maximum Single: $2,200 Family: $4,400 (Includes RX drugs)  
D-H annual HSA or HRA contribution Employees earning less than $150,000 that are enrolled in, and eligible for, the HSA or HRA will receive an employer contribution. The contribution amount is based on your salary tier and HSA / HRA effective date.

ElevateHealth HRA Plan

Plan features Preferred providers ElevateHealth network
Deductible Single: $1,400
Family: $2,800
Single: $1,400
Family: $2,800
Co-insurance 10% after deductible 30% after deductible
Preventative care Covered 100% Covered 100%
Out-of-pocket maximum Single: $2,200 Family: $4,400 (Includes RX drugs)  
D-H annual HSA or HRA contribution Employees earning less than $150,000 that are enrolled in, and eligible for, the HSA or HRA will receive an employer contribution. The contribution amount is based on your salary tier and HSA / HRA effective date.

Choice Health Plan

Plan features In-network Out-of-network
Deductible Single: $2,000
Family: $4,000
Single: $4,000
Family: $8000
Co-insurance 30% after deductible 50% after deductible
Preventative care Covered 100% 50% after deductible
Out-of-pocket maximum Single: $3,400
Family: $6,800
(Includes RX drugs)
Single: $5,600
Family: $11,200
(Includes RX drugs)
D-H annual HSA or HRA contribution Employees earning less than $150,000 that are enrolled in, and eligible for, the HSA or HRA will receive an employer contribution. The contribution amount is based on your salary tier and HSA / HRA effective date.

Pharmacy benefits

These table show the costs, deductibles and relevant pharmacy location information for pharmacy benefits. "Single" = Employee only coverage. "Family" = all other coverage levels.

ElevateHealth HSA plan

Days supply Locations Benefits
30 days
  • D-H pharmacy
  • Cheshire Medical Center pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
  • Select CVS retail pharmacies
Subject to deductible and 10% co-insurance
30 days All other retail pharmacies Subject to deductible and 30% co-insurance
90 days
  • D-H pharmacy
  • D-H pharmacy mail order
  • Cheshire Medical Center pharmacy
Subject to deductible and 10% co-insurance
90 days
  • OptumRx Mail Service Pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
Subject to deductible and 30% co-insurance
90 days All other retail pharmacies Not available

ElevateHealth HRA plan

Days supply Locations Benefits
30 days
  • D-H pharmacy
  • Cheshire Medical Center pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
  • Select CVS retail pharmacies
  • Generics: $10
  • Brand: 30% co-insurance up to $100
  • Specialty: 50% co-insurance up to $200
30 days All other retail pharmacies
  • Generics: $15
  • Brand: 40% co-insurance up to $100
  • Specialty: 60% co-insurance up to $200
90 days
  • D-H pharmacy
  • D-H pharmacy mail order
  • Cheshire Medical Center pharmacy
  • Generics: $30
  • Brand: 30% co-insurance up to $300
90 days
  • OptumRx Mail Service Pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
  • Generics: $45
  • Brand: 40% co-insurance up to $300
90 days All other retail pharmacies Not available

Choice Health Plan

Days supply Locations Benefits
30 days
  • D-H pharmacy
  • Cheshire Medical Center pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
  • Select CVS retail pharmacies
Subject to deductible and 10% co-insurance
30 days All other retail pharmacies Subject to deductible and 30% co-insurance
90 days
  • D-H pharmacy
  • D-H pharmacy mail order
  • Cheshire Medical Center pharmacy
Subject to deductible and 10% co-insurance
90 days
  • OptumRX mail service pharmacy
  • The Pharmacy in Bennington and Manchester, Vermont
  • Colonial Pharmacy, New London, New Hampshire
Subject to deductible and 30% co-insurance
90 days All other retail pharmacies Not available

Vision coverage

Dartmouth-Hitchcock offers vision coverage for eyewear through DeltaVision. DeltaVision is supported by the EyeMed Vision Care network, with over 88,000 providers at over 27,000 locations nationwide, including private practitioners and the most popular optical retail outlets.You can search for providers at EyeMed. (On the Find an eye doctor page, choose Access Network in the Network box.)

Our medical plan continues to cover your routine eye exams under preventive services and the DeltaVision plan can be used to cover your frames and lenses. The plan provides the following in-network benefits:

  • Frames: You have a $130 allowance every 24 months, then 20% off the balance.
  • Lenses: You pay only a $10 co-pay for standard plastic lenses, including bifocal and trifocal, the plan pays the balance. Available once every 12 months. Additional co-pays apply to other lens options, like UV coating, tinting, and scratch resistance.
  • Contacts: You have a $130 allowance every 12 months (in lieu of spectacle lenses). In addition to the allowance, you also receive 15% off any balance payable for non-disposable contacts.
  • Laser Vision Correction - Lasik or PRK: You get 15% off retail price or 5% off promotional price.
Members Cost
Employee Only $2.21
Employee and child(ren) $4.17
Employee and spouse $4.30
Family $6.50

Dental plans

Dartmouth-Hitchcock offers two dental options for you and your eligible dependents through Northeast Delta Dental.

Plan features Basic Enhanced
Deductible Single: $50; Family: $150 Single: $25; Family: $75
Preventive care 100%, no deductible (2 annual cleanings) 100%, no deductible (2 annual cleanings)
Basic restorative care:
Fillings, extractions, root canals
Plan pays 50%, after deductible Plan pays 80%, after deductible
Major restorative care:
crowns, dentures, bridges
Plan pays 50%, after deductible Plan pays 50%, after deductible
Orthodontia Plan pays 50%, no deductible, lifetime maximum benefit of $2,000 per covered member Plan pays 50%, no deductible, lifetime maximum benefit of $2,000 per covered member
Annual maximum benefit $1,000 per covered member $1,500 per covered member

Reimbursement accounts

Dartmouth-Hitchcock offers reimbursement accounts to help employees cover health care costs.

  • Health Care Reimbursement Account (HCRA)

    The HCRA is a pre-tax savings account available to employees who waive health care coverage or enroll in the ElevateHealth HRA plan. The HCRA can be used to pay for eligible health care, dental, or vision care expenses that are not covered by insurance, for you and your eligible dependents.The maximum amount you may contribute to your HCRA is $2,750 each calendar year. Once you sign up for the HCRA, you will receive a personalized debit card from HealthEquity to use when paying for your eligible health care expenses.
    Note: You may not use your HSA, HRA, or HCRA to pay for, or be reimbursed for, over-the-counter medications unless prescribed by a provider.

  • Dependent Care Reimbursement Account (DCRA)

    The DCRA is a pre-tax savings account that may be used to pay for eligible elder and child care expenses. You may only use this account if you utilize day care or elder care services so that you and your spouse can work, obtain gainful employment, or attend school full time. It is important to note that your day care or elder care provider must furnish you with his/her Social Security Number (SSN) or Tax Identification Number (TIN) in order to receive reimbursement for your expenses. IRS regulations limit the amount you may contribute to any DCRA to $5,000 for your family (or $2,500 if married and filing separate tax returns) per calendar year.

In order to qualify for reimbursement, expenses must be incurred for the care of “eligible dependents” who the IRS defines as:

  • A child under the age of 13, or a child of any age who is physically or mentally incapable of self-care
  • Your opposite sex spouse, if physically or mentally incapable of self-care and living in your home for more than 50% of the year
  • Any other dependent (including your same sex spouse) who is physically or mentally incapable of self-care who meets specific criteria. For more details about who qualifies as eligible dependents under the DCRA, refer to IRS Publication 503, titled Child and Dependent Care Expenses, which is available by calling the IRS at 800.829.1040 or at IRS.gov.
  • Note: You can only participate in the DCRA if you earn less than the highly compensated limits. The limit for 2021 is $130,000.

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