Blue Cross Blue Shield Vermont: The Vermont Health Partnership

The Vermont Health Partnership

The Vermont Health Partnership is a point-of-service plan. It has two levels of benefits for most services--Preferred and Standard. When you use your Primary Care Physician or another in-network doctor, you receive Preferred benefits. This means lower out-of-pocket costs for you. With this program, you do not need a referral from your primary care physician before you seek care from another provider. You need prior approval for some services in order to get any benefits at all. If you use an out-of-network provider, you need written prior approval from BCBSVT to get Preferred Benefits. If you do not get this approval, you may receive Standard Benefits for some services, but you will share in the higher cost of your care through higher out-of-pocket costs (deductibles, coinsurance, etc.). For some services, including those on our prior approval list, the Vermont Health Partnership does not offer Standard Benefits at all. You must follow managed care guidelines to receive benefits.

More information about the Vermont Health Partnership appears below:

Urgent and Emergency Care with the Vermont Health Partnership
Office Visits with the Vermont Health Partnership
Hospital Admission with the Vermont Health Partnership
Mental Health and Substance Abuse Treatment with the Vermont Health Partnership
Exclusions to Vermont Health Partnership Coverage
Precertification Program
Our Better Beginnings Program
Vision Care with The Vermont Health Partnership

Our Precertification Program

You or the hospital must call us to receive certification for your inpatient admission. Calling us will protect you from having to pay for unnecessary and noncovered stays. Call (800)922-8778.

The phone number to call for mental health or substance abuse treatment admissions is (800)395-1356.

Urgent and Emergency Care with the Vermont Health Partnership

The Vermont Health Partnership has guidelines for urgent care and emergency care. In both cases, you may need quick care. "Urgent" care means health care services that are necessary to treat a condition or illness that if not treated within 24 hours presents a serious risk of harm. We call your problem an "emergency" if going without care right away might put your health in danger.

If you need urgent care, call your primary care physician or another network doctor. VHP primary care physicians are on call or have coverage 24 hours a day, seven days a week. After hours, you may have to leave a message with an answering service. Your doctor or a covering doctor will return your call. A provider will see you within 24 hours of when you ask for urgent care. For some urgent problems, your doctor can treat you in the office. Other times, you may have to go to the emergency room. Your doctor will tell you what to do. If you have an urgent problem when you are outside of the service area, call your primary care physician as soon as possible and he or she will help you get approval for care.

In emergencies, you need care right away. An emergency occurs when a person with average knowledge of health and medicine expects the condition or illness, if not treated immediately, to result in serious harm to your physical or mental health.

Emergencies might include:


		•	broken bones
		•	heart attack
		•	choking

You will receive care right away in an emergency. In an emergency, go straight to the emergency room-whether you are in Vermont or out of the area. If necessary, call 911 or an ambulance. You do not need to call your primary care physician first. But remember: we don't cover the emergency room charge if we determine that you could have safely received care somewhere else. You may want to call your primary care physician to check on the medical necessity of your visit.

Office Visits with the Vermont Health Partnership
Use your primary care physician for most care. This physician will provide you with preventive care and most of the other care you need. When you need care from another provider, such as a specialist, your primary care physician will direct you to a network provider. (You don't need a written referral.) When network providers cannot provide the care you need, your doctor will help you get prior approval for out-of-network care. If you follow these guidelines, you will receive Preferred benefits. You will only pay a modest co-payment each time you go to the doctor. For office-based mental health and substance abuse treatment and vision care, you must use special networks in order to get benefits.

Hospital Admission with the Vermont Health Partnership
When you need to go into the hospital for a scheduled stay, make sure to get the following authorizations:


		•	a preadmission review from BCBSVT (call 800-922-8778) to make sure we consider your admission medically necessary
		•	any prior approvals necessary for the particular services you need

If you follow these guidelines, the Vermont Health Partnership will provide you with Preferred benefits and you will pay only your inpatient co-payment, if applicable. (Some groups have no inpatient co-payment and care is covered at 100% of the BCBSVT allowed price. Check your Outline of Coverage for your co-payment.) If you use an out-of-network hospital and you don't get prior approval, you may receive only Standard benefits. Higher out-of-pocket costs will apply. If the service you need is on our prior approval list and you don't get prior approval, you will have to pay for services yourself. Please check your contract materials carefully before a scheduled inpatient stay.

If you go into the hospital for an emergency or maternity condition, you may call us for approvals after your admission--preferably within 48 hours after you enter the hospital. For mental health and substance abuse admissions, we have different procedures.

Mental Health & Substance Abuse Treatment
with the Vermont Health Partnership
You don’t need to see your primary care physician before getting mental health or substance abuse treatment. Instead, call our mental health and substance abuse network, Merit Behavioral Care (MBC) of Vermont. Dial 1-800-395-1356. MBC will consider your condition and may grant prior approval for you to seek care. You must use an MBC network provider to receive benefits. MBC will help you find the right provider for your needs

We have ensured that you can find care easily in the network. There should be an outpatient facility within a 30-minute drive from your home. There should be an inpatient facility within a 60-minute drive.

Remember, we only provide mental health or substance abuse benefits when MBC approves your care. Check your Contract for details. To look for a mental health provider in the MBC network, visit our Find a Doctor site. Please check your certificate for details on what is not covered.

Better Beginnings Program
Better Beginnings helps babies get the best start in life by providing their parents with educational materials, such as popular books and CPR classes. We also cover skilled nursing and housekeeping visits to help parents after their babies leave the hospital. Throughout a pregnancy, our nurses keep in touch with a mom-to-be to ensure she's getting the best possible care and the benefits to cover it. To join the program, a member should call our customer service department during the first trimester of her pregnancy. Our Better Beginnings representative will then mail her a starter kit.

Vision Care with the Vermont Health Partnership

Your contract may include benefits for a vision exam or vision materials. If so, you should use a Vision Service Plan provider for care. To find a provider in your area, visit Vision Service Plan's web site.