Health
The City of Fall River offers Health Insurance plans to employees, retirees, and surviving spouses through Blue Cross Blue Shield of Massachusetts. Participants who wish to obtain more information on the plans can stop by Human Resources or view the summaries of benefits through the links provided below.
The City offers active employees and non-Medicare eligible retirees two plans based on their service area. Members residing in in the six New England states are eligible for Network Blue New England Options v.5, which includes a tiered hospital network.
Any non-Medicare eligible retirees and their survivors residing outside the New England area will need to enroll in the Blue Care Elect Deductible (PPO) Plan. Blue Care Elect is significantly more expensive than Network Blue New England with little difference in benefits–it is only available to our members that reside outside Massachusetts and Rhode Island. All members living in Massachusetts and Rhode Island must enroll in Network Blue New England. You can view the minor differences between the plans here.
Advantages of the HMO Blue New England Options Deductible v.5 Plan:
Lower premiums than plan designs with a similar level of benefits (when using Enhanced Benefits Tier providers).
The ability for members to control out-of-pocket costs through provider choice.
A plan design that’s easy to understand and use.
How does the HMO Blue New England Options Deductible v.5 Plan work?
Hospitals in Massachusetts are grouped into three benefit levels or tiers based on how they scored on cost and quality benchmarks. When members get care, the amount they pay is based on which tier their hospital is in.
All ER/urgent care services and out of state (Rhode Island) hospital services will process under the Enhanced benefit tier. Primary Care Providers are not tiered under our plan.
Enhanced Benefits Tier (most affordable, $) – No deductible applies–Includes Massachusetts hospitals that meet the standards for quality and are low cost relative to the Blue Cross Benchmark.
Standard Benefits Tier (premium cost, $$) – $250 per member/$750 per family deductible applies–Includes Massachusetts hospitals that meet the standards for quality and are moderate cost relative to the BCBS benchmark and hospitals that do not meet the standards for quality but are low or moderate cost relative to the BCBS benchmark. Also includes providers without sufficient data for measurement on one or both benchmarks. To ensure members have provider access in certain geographic areas, the Standard Benefits Tier includes some providers whose scores would otherwise put them in the Basic Benefits Tier.
Basic Benefits Tier (cost plus, $$$) $250 per member/$750 per family deductible applies, with much higher copays after the deductible is satisfied–Includes Massachusetts hospitals that are high cost relative to the BCBS benchmark that do not meet the standards for quality or are high cost relative to the BCBS benchmark. Please view the Hospital Tiers for a better idea of how this might impact you. Benefit Differential – Hospital Facilities Only
High Tech Imaging
Enhanced Tier: $50 copay, not subject to deductible
Standard Tier: $50 copay, deductible applies first
Basic Tier: $100 copay, deductible applies first
Outpatient Surgery/ Inpatient Hospital Treatment
Enhanced Tier: $300 copay, not subject to a deductible.
Standard Tier: $300 copay, deductible applies first
Basic Tier: $700 copay, deductible applies first
EFFECTIVE 7/1/2015: DIAGNOSTIC X-RAYS AND LABS ARE NO LONGER SUBJECT TO THE PLAN YEAR DEDUCTIBLE.
Blue Cross Blue Shield of Massachusetts offers our employee an array of benefits, such as the Blue Care Line, a 24/7 toll-free telephone number which can be accessed by calling 1-888-247-BLUE (2583). A specially trained registered nurse is available to answer your health questions. BC/BS also offers Weight Loss and Fitness Benefits. For more information or to download forms, log on to www.bcbsma.com and click on the “My Wellbeing” tab.
For specific questions about your plan or any claims please call Blue Cross Member Services at 1-800-782-3675.
Effective 7/1/2018 Active and non-Medicare members enrolled in Network Blue or Blue Care Elect will have prescription coverage through MaxorPlus, an independent Pharmacy Benefit Manager (PBM), instead of Blue Cross Blue Shield of Massachusetts. Participating with MaxorPlus will give the City and employees greater access and control over our prescription drug plan while potentially saving millions over the length of the contract.
Members will have the same copays ($10/$25/$50 for one month of retail or $20/$50/$110 for three months of mail order) with access to a larger drug formulary and can continue to use their regular retail pharmacy or participate in the MaxorPlus mail order program at a reduced copay. Please view this Maxor FAQ for more information about the program. Members will also still have access to and are encouraged to take advantage of the $0 copay Fall River Meds program through CanaRx.
Please click here for a breakdown of tiered prescriptions which apply to both the HMO and PPO.
What do the tiers mean?
Tier 1: Generic Medication
Tier 2: Brand Name Medication
Tier 3: Specialty Medication
Both plans are eligible for Fitness and Weight Loss Benefits. Please click the corresponding links for more information.
Fitness Benefit
Weight Loss Benefit
Medex 2 Plan Summary with Blue Medicare Rx PDP Summary.
Blue Medicare RX is administered by CVS Caremark for the New England Joint Enterprise that Blue Cross Blue Shield of Massachusetts co-manages under the Medicare Contract S2893 and is a prescription drug plan (PDP) that complies with the CMS Medicare rules and regulations for a PDP. Please see 2018 3 Tier Select Comp Formulary for a list of covered medications.
Medex 2 with Medicare RX (PDP) is a Medicare supplement designed for retired employees age 65 or older (or retired employees that qualify for Medicare Part B before the attainment of age 65.
Frequently Asked Questions about Medicare and supplemental insurance.
Any members of the Blue Medicare RX (PDP) should contact CVS Caremark at 1-800-875-0867 for more information about their medications or to set up a 90-day supply through the mail.
Effective 1/1/2019 the Blue Medicare RX (PDP) coverage included with Medex will change to Humana. Members will still have their Medex Medicare coverage through Blue Cross Blue Shield of Massachusetts but will use their new Humana card at their regular retail pharmacy or can take advantage of the Humana mail order program for prescriptions through mail. Members will still be able to use the free Fall River Meds program. Members that need any help at all with their prescription coverage can contact Retiree First, a firm that specializes in municipal retiree health and drug programs, at 508-300-9697.
Open Enrollment
All employees, retirees, and survivors will be notified about the 2019 open enrollment period (for changes effective 7/1/2019) sometime in March 2019.
Please feel free to contact the Human Resources department if you have any questions.
Other Resources
To find out how medical information about you may be used and disclosed and how you can get access to this information please review this Notice of Privacy Practices.
Transparency of Coverage Notice – Machine-Readable Files
Under the Patient Protection and Affordable Care Act (ACA), non-grandfathered group medical plans and health insurers are required to provide cost information in three machine-readable files. The following plans are not required to provide this information: (1) grandfathered plans, (2) excepted benefits such as stand-alone dental and vision benefits and most EAPs, (3) account-based plans such as Health Reimbursement Arrangements, Health Savings Accounts, and health Flexible Spending Accounts, (4) retiree only plans (fewer than two participants who are current employees), (5) expatriate plans, and (6) short-term, limited duration insurance. In fulfillment of this requirement, below is the link to the BCBSMA website containing the required machine-readable files:
BCBS – https://transparency-in-coverage.bluecrossma.com/
These files contain the following required information:
1. An in-network rate file that includes cost information for all covered services except for prescription drug. The file must include certain information on network negotiated reimbursement rates by billing codes.
2. Cost information for out-of-network providers by billing code. The file must include allowed amounts and billed charges for covered services furnished by an out-of-network provider during the 90-day time period that begins 180 days before publication of the file.
3. Negotiated rates and historical net prices for prescription drugs (in and out of network). After regulations were issued in November 2020, Congress enacted the Consolidated Appropriations Act of 2021 (CAA), which also contains a drug reporting requirement. The requirement for public disclosure in a machine-readable file for prescription drugs, which is required by the November 2020 regulations, is being delayed while regulators consider whether the prescription drug machine-readable file requirement remains appropriate.