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1
Annual Enrollment
March 01 – March 30, 2007
State Health Plan NC SmartChoice SM
Blue Options SM PPO and Indemnity Plans
Overview for Retirees
2
Background of the State Health Plan
The State Health Plan: – Is mandated by general statute (Chapter 135). – Offers a health benefit plan to all state
employees, including teachers and retirees.– During the 2005/2006 legislative session the
NCSHP was given the authority to offer optional plans.
– Offered NC SmartChoiceSM in October 2006.
3
How Does the State Health Plan Work?
The State Health Plan has contracted with BCBSNC to use their provider Networks:
You should always verify that your provider participates in the Blue Options or Costwise Network before receiving care to avoid additional out-of-pocket costs.
NC SmartChoiceSM
PPO Plans
Indemnity Plans
Blue Options Network
CostWise Providers
Pharmacy Medco
4
Annual Enrollment
March 1 - 30 for the 2007/2008 benefit year. During annual enrollment you can:
1.) Switch plan options– Switch from the Indemnity plan to a PPO plan– Move from one PPO plan to another– Switch from a PPO plan to the Indemnity plan
2.) Change your coverage tier– (Retiree-only to retiree-children)
3.) Add or remove dependents
5
General Information
Members can call Customer Service at:
NC SmartChoiceSM
PPO Plans1-888-234-2416
New members and members changing plans will receive their NEW ID cards prior to the 07/01/2007 effective date
Only new members or members changing plans will receive a Benefit Booklet
1-800-422-4658 Indemnity Plans
6
Products
Four Choices for Eligible Members– NC SmartChoiceSM Blue OptionsSM PPO Plans – Copays for in-
network office visits. For other services coinsurance levels vary depending on plan selection.
– Indemnity Plan- Copay, deductibles and coinsurance for all services
Plan Health Plan Pays You PayPPO Basic 70% 30%PPO Standard 80% 20%PPO Plus 90% 10%Indemnity 80% 20%
Coinsurance
7
PPO Plans
8
NC SmartChoice SM
Blue Options SM PPO Plans
State retirees have 3 PPO options from which to choose
All 3 PPO options include a retiree-spouse tier
PPO PlansDeductible & Copays Price
Retiree Only Coverage
Family Coverage
PPO BasicHigher than
Std Plan $ No costReduced premium
PPO Standard
Between Basic and Plus Plans $$ No cost *
PPO PlusLower than Std Plan $$$ Retiree pays
Higher Premium
* Premiums for all other tiers on the Standard plan are less than the Indemnity plan rates.
9
PPO Plan Highlights
Copay only for most in-network (non-hospital based) physician office visits
Extensive in-state and out-of-state network No lifetime maximum Most annual physicals, copay only
10
Blue OptionsSM Network
PPO plans use the Blue OptionsSM Network
Open Access– No referral required for office visit to specialists.
Nationwide Coverage (Via BlueCardTM)– If you live or travel outside of North Carolina, you
can receive care from participating Blue Cross and Blue Shield (BCBS) providers at the same in-network benefit level.
Worldwide Coverage (Via BlueCardTM)
11
PPO Plans - Preventive Benefits
Routine physicals, eye exams, and hearing exams are covered every benefit year with no age restrictions (in-network only)
Screenings covered in and out-of-network– Gyn exam & cervical cancer screening– Ovarian cancer screening– Mammograms– Colorectal screening– Prostate screening
Copay for services received in physician office - otherwise subject to deductible & coinsurance
Labs are covered at 100% when performed alone Immunizations are covered at 100% when received
in-network
12
PPO Plans - Outpatient Services
Coverage level depends on where you receive services. Example: Sprained ankle
Please note: CT scans, MRIs, MRAs and PET scans are always deductible and coinsurance.
Doctor’s OfficeIn-Network
Primary Care Physician
Primary Copay $
Doctor’s OfficeIn-Network Specialist
Specialist Copay $$
Locations Other than Doctor’s Office (Hospital) or
Out-of-Network Providers
Deductible and Coinsurance $$
$
13
PPO Plans - Outpatient Services
Some physician practices are hospital-owned or operated and will bill your in-network office visit like an outpatient hospital visit instead.
Watch for yellow donut or red square icons!
14
Out-of-Network ServicesFor PPO Members
Some services are not covered out-of-network. You may be required to pay for charges over the allowed
amount, in addition to your copay or coinsurance. If your physician leaves the network, you have the option
of continuing care with your provider using the out-of-network benefits.
You may have to pay the provider and file a claim for reimbursement.
Emergencies are always covered as in-network. Anesthesiology and radiology are covered as in-
network when received as an inpatient at a participating hospital and when admitted by a participating physician.
15
Pre-Authorization of Services For PPO Members
You are responsible for pre-authorization of services received outside of North Carolina.
For a complete list of services that require pre-authorization, refer to your benefit booklet or call Customer Service.
16
PPO and Medicare
Routine Eye Exams are covered under PPO – not a Medicare benefit or indemnity plan benefit
Routine Physicals and Gynecological Exams are covered under PPO for copay only for most in-network. Not covered under Medicare benefit. Indemnity plan has $150 maximum then deductible and coinsurance.
Diabetic Supplies – covered under PPO for copay only. Indemnity plan deductible and coinsurance. Medicare does not cover syringes.
Office Visits – Copay only under PPO when see in-network provider. Deductible must first be met under both Indemnity and Medicare before receive benefit.
17
PPO and Medicare (cont.)
It’s free for retiree-only coverage Lower out-of-pockets costs – copay only for most in-network
office visits Lower premiums for dependent coverage Retiree-Spouse Tier Travel Outside of North Carolina and out-of-country – same in-
network benefits (BlueCard)
18
Extra Perks for PPO Members
Blue ExtrasSM
– Discounts on certain non-covered services, such as: cosmetic dentistry, lasik eye surgery, cosmetic surgery, massage therapy and alternative medicine
– Discounts on vitamins and herbal supplements– Earn prizes for physical activity
My Member Services– Protected online resource for managing health and
maximizing benefits– View claim status, check benefits summary, update policy
information, order new ID cards, change billing address For more information, visit www.shpnc.org
19
Indemnity Plan
20
Indemnity Plan Highlights
Pay copayment, plus deductible and coinsurance for all services
First $150 of preventive services covered at 100% Preventive services above $150, subject to
copayment, then deductible and coinsurance CostWise participating providers Retiree-spouse tier not available $5 million lifetime maximum
21
Indemnity Plan and Non-Participating Providers
Non-participating physicians Member responsible for the
difference between the CostWise charge and the out-of-network provider’s charges
22
Indemnity Plan and Non-Participating Hospitals
Non-participating hospitals
Member responsible for the difference between the in-network and the out-of-network charges
23
Indemnity Plan Preventive Benefits
Age restrictions on how often you can receive routine physicals
First $150 of preventive services covered at 100%
Preventive services above $150, subject to deductible and coinsurance
Immunizations covered at 100%
24
Benefit Differences Between The Plans
25
Covered Service Limits
• Physical Therapy, Occupational Therapy and Chiropractic - 30 combined visits per benefit year
• Speech Therapy – 30 visits per benefit year
• Home Health Care - 100 days per benefit year
• Chiropractic - $2000 limit per benefit year
PPO Plans Indemnity Plan
26
Mental Health and Substance Abuse Services
• Mental Health limited to 30 outpatient visits per benefit year/30 inpatient days per benefit year
• Substance Abuse – limited to $8,000 per benefit year/ $16,000 per lifetime
• Mental Health and Substance Abuse are unlimited.
• Prior authorization required for outpatient visits that exceed 26 per benefit year.
PPO Plans Indemnity Plan
27
– Allowed once a year for members 35 and older– Routine mammograms are covered at 100% when
performed alone, includes radiologist reading– When performed with another service or diagnostic (not
routine), mammograms are subject to coinsurance and deductible
Routine Mammograms
– Allowed once a year for members 40 and older– Mammogram and radiologist reading subject to copay,
deductible, and coinsurance – Can be included in the $150 preventive benefit
PPO Plans
Indemnity Plan
28
Chemotherapy Benefits
Benefits are based on service location
Always subject to copayment, deductible and coinsurance
PPO Plans
Indemnity Plan
29
Pharmacy Benefits
Copayments
PPO & Indemnity Plans
Generic $10
Preferred Brand
(no generic equivalent) $25
Preferred Brand
(generic equivalent)$40
Non-preferred Brand $50
PPO Plans - Diabetic supplies are covered under pharmacy with a copay
30
Diabetic Supplies
Covered under Pharmacy Benefit:• $10 copay for preferred brand for a 34-day
supply• $25 copay for non-preferred band for a 34-
day supply
Insulin-dependent:• 150 test strips per 34-day supply
Non-insulin dependent:• 50 test strips per 34-day supply
Additional test strips: • Covered under medical supply benefit,
subject to deductible and coinsurance
• Covered under Medical Supply Benefit, NOT the Pharmacy Benefit
• Subject to deductible and coinsurance
PPO Plans Indemnity Plan
31
Prescription Drug Incentive Programs
Waiver of copays for generic prescriptions– January 1, 2007 – March 31, 2007
Coverage of generic over-the-counter nicotine replacement patches
– No copay through March 31, 2007– $5 copay per prescription after March 31, 2007– Prescription required
32
Annual Enrollment
33
State Health Plan Rates
Rates for the 2007/2008 benefit year will be determined during the legislative session.
Based on market trends, it is likely that all plan options will experience an increase in rates
Potential rate increase should not change premium structure between plans
– PPO Basic Plan (70%/30%) will most likely still have lowest premium for dependent coverage
– PPO Plus Plan (90%/10%) will most likely still have highest premium for dependent coverage
Rates effective October 1, 2007
34
Member Responsibilitiesfor Annual Enrollment
Complete an Annual Enrollment Change Form: – Changing plans, adding dependents– Update personal information
Changes become effective July 1, 2007 Members who do not complete a change form will
remain on their current plan
Retirees
Change form to Retirement System by March 30
35
New State Health Plan Participants
Retirees can obtain enrollment kits beginning March 5th by calling Customer Service
Print kit from the State Health Plan Web site at:
www.shpnc.org
36
What if an employee is retiring?
Employees who retire prior to the effective date of 07/01/2007 should:
1. Send their Annual Enrollment Change Form to their HBR
2. And send their completed HM form to the State Retirement System
37
Effective Date of Changes/Coverage
The effective date is July 1 for:– Any changes made during
annual enrollment– New dependents added to
your plan– New State Health Plan
members
38
Annual Enrollment
• Health benefit year is from July 1 – June 30, at which time deductibles and coinsurance start over.
• Pre-existing condition waiting periods will apply to new members if they haven’t been continuously covered for 12 months or had a break of more than 63 days prior to effective date.
(This is different from last year.)
39
How to make changes to your plan
1. Complete a change form contained in your enrollment kit.
2. Keep PINK copy for your records. 3. Send the other 2 copies:
Retirees – to the Retirement System
Note: If you print your change form from the SHP Web site, complete the form and make 2 photocopies. Send the original along with 1 photocopy to the applicable location.
40
Resources
Customer Service Support Help Line 1-888-234-2416 PPO Plan 1-800-422-4658 Indemnity Plan
State Health Plan Web site: www.shpnc.org
Seniors’ Health Insurance Information Program (SHIIP)
1-800-443-9354 (toll free) 919-807-6900
41
Questions?