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Annual Enrollment

March 01 – March 30, 2007

State Health Plan NC SmartChoice SM

Blue Options SM PPO and Indemnity Plans

Overview for Retirees

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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.

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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

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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

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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

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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

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PPO Plans

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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.

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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

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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)

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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

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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 $$

$

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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!

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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.

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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.

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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.

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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)

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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

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Indemnity Plan

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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

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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

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Indemnity Plan and Non-Participating Hospitals

Non-participating hospitals

Member responsible for the difference between the in-network and the out-of-network charges

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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%

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Benefit Differences Between The Plans

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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

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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

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– 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

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Chemotherapy Benefits

Benefits are based on service location

Always subject to copayment, deductible and coinsurance

PPO Plans

Indemnity Plan

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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

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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

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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

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Annual Enrollment

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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

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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

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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

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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

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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

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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.)

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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.

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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

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Questions?