2021 Open Enrollment Medicare Outreach Webinar

Open Enrollment October 15-31, 2020

What We Will Cover Today• 2021 Medicare Advantage Plan Change • 2021 Plan Options

• Transition to Humana• Medicare Advantage Perks

• 2021 Open Enrollment• Plan Comparisons• Medicare Advantage Refresher• Humana• 70/30 Plan (Blue Cross NC)• Clear Pricing Project• Premium Rates

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2021 Medicare Advantage Plan Change!• All members currently covered under

UnitedHealthcare (UHC) will be moved to Humana for the 2021 benefit year, which begins January 1, 2021.

• As of January 1, UHC will no longer administer Medicare Advantage plans for the Plan.

• The State Health Plan is committed to making this transition as smooth as possible for our members.

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What is Changing and Why

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• The State Health Plan’s contract with UHC is set to end December 31, 2020.

• As a result, the State Health Plan was required to conduct a competitive bid process per state contracting and procurement rules for its Group Medicare Advantage Plans.

• This process resulted in the Plan awarding the contract to Humana effective January 1, 2021.

• Members currently in the UHC Medicare Advantage Plans will remain in those plans until the end of 2020.

• This new contract has a potential cost savings of approximately $600 million over the 3-year contract period, which allows for a significant reduction in Medicare-eligible dependent premiums for the 2021 plan year—down to $4 for eligible dependents!

What is Changing and Why

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• The State Health Plan’s website has 2 great videos available that discuss this change and help members separate myth from fact!

• The Plan is dedicated to making this a smooth transition with as little disruption for members as possible.

• The Plan’s website also provides a flier for you to distribute to your providers that explains our Medicare Advantage Plans.

www.shpnc.org

Medicare Advantage Passive Network• The Medicare Advantage Plans will continue to offer

a national “passive” network, which allows members to continue seeing their current providers regardless of being in or out of Humana’s network.

• Similar to what members are experiencing today, the provider will need to be participating with Medicare and agree to bill the Medicare Advantage plan carrier.

• Humana is currently outreaching to providers to ensure providers are aware our members are able to seek services from out-of-network providers without experiencing a higher out-of-pocket cost.

• If a provider is still resistant to filing a claim with Humana, the member would need to pay for the service and then file a paper claim with Humana for reimbursement (less any applicable copayment/coinsurance).

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2021 Plan Offerings• Medicare members will continue to have three State Health Plan

options to choose from for 2021:• Humana Group Medicare Advantage (PPO) Base Plan• Humana Group Medicare Advantage (PPO) Enhanced Plan• The 70/30 Plan, administered by Blue Cross and Blue Shield of North

Carolina (Blue Cross NC)• All current UnitedHealthcare members will be moved to the Humana

Group Medicare Advantage Base Plan for Open Enrollment. If they take no action, they will be in the Base plan starting January 1, 2021.

• If you are currently on the Medicare Advantage Base Plan or the 70/30 Plan, you will REMAIN on that plan and do not need to take action during Open Enrollment.

• If you are currently on the Medicare Advantage Enhanced Plan, you will be moved to the Medicare Advantage Base Plan for the 2021 benefit year. If you would like to elect the Enhanced Plan for 2021, you will need to take action during Open Enrollment.

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The Plan also utilizes a pharmacy benefit manager or PBM that is responsible for providing a pharmacy network and processing your pharmacy claims. Our current PBM is CVS Caremark. Remember,

your pharmacy claims are paid by the state, not CVS.

The Plan utilizes a third-party administrator or TPA that is responsible for the provider network and processing your medical

claims. Our current TPA is Blue Cross and Blue Shield of NC. Remember, your medical claims are paid by the state, not Blue

Cross.

70/30 PPO State Health Plan Option

State Health Plan Options for Medicare Primary Members

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The Plan contracts with Humana to provide Group Medicare Advantage plan options to our Medicare Primary members which

includes payment of claims.

Humana is a Medicare Advantage Organization that contracts with the Centers for Medicare and Medicaid Services (CMS) to

administer Medicare benefits on their behalf.

Changes for 2021Humana Group Medicare Advantage Base Plan

• There are no changes to benefits with this plan. Humana Group Medicare Advantage Enhanced Plan Changes:

• A few copays have changed under the Enhanced plan:• Primary Care Provider (PCP), Lab, Radiology, Inpatient Hospital, and

some prescription copays, to name a few.• It will be important for members to review the benefit changes on the

Enhanced plan.70/30 Plan Changes:

• Members who select a Clear Pricing Project Provider as their PCP will enjoy a $0 copay! More details later in this presentation!

• Reduced copays for members who visit a Clear Pricing Project Specialist• Preferred and non-preferred insulin will have a $0 copay for a 30-day

supply!• Preventive services remain free!

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2021 Plan Comparison – Medical BenefitsBenefit Humana

BaseHumana

EnhancedBCBSNC

70/30*Network Providers You can use in and out-of-network providers but

must accept in Medicare and your insurance plan.You pay less when you use BCBSNC

provider network

Annual Medical Out-of-Pocket Maximum

$4,000(In and Out-of-Network)

$3,300(In and Out-of-Network)

$5,900 In-network (Individual)$16,300 Out-of-network (Family)(Combined Medical & Pharmacy)

Annual Deductible $0 $0 $1,500 In-network (Individual)$4,500 In-network (Family)

(Combined Medical & Pharmacy)

Primary Care Provider (PCP) – Office Visit

$20 copay $10 copay $0 for CPP PCP on ID Card$30 for non-CPP PCP on ID card

$45 for any other PCP

Specialist Office Visit $40 copay $35 copay $47 for CPP Specialist$94 for other Specialists

Urgent Care $50 copay $40 copay $100 copay

Inpatient Hospitalization Days 1-10: $160/Day Days 11+: $0/Day

Days 1-10: $125/Day Days 11+: $0/Day

In-network: $337 copay plus 30% coinsurance after deductible

Outpatient Surgery $250 copay $250 copay In-network: 30% coinsurance after deductible

Ambulance $75 copay $75 copay 30% coinsurance after deductible

2021 Plan Comparison – Medical Benefits, cont’d.Benefit Humana

BaseHumana

EnhancedBCBSNC

70/30*

Emergency Room $65 copay(Worldwide)

$65 copay(Worldwide)

Individual: $337 copay plus 30% coinsurance after deductible

Lab Services $40 copay $10 copay If performed during PCP or Specialist office visit, no

additional fee if in-network lab used.

Diagnostic radiology services

(such as MRIs, CT Scans)

$100 copay $100 copay In-network: 30% coinsurance after deductible

Therapeutic RadiologyServices (such as radiation

treatment for cancer)

$40 copay $40 copay In-network: 30% coinsurance after deductible

Durable Medical Equipment(such as oxygen)

20% coinsurance 20% coinsurance In-network: 30% coinsurance after deductible

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*When enrolled in the 70/30 Plan, cost-sharing amounts between you & the State Health Plan will vary. Medicare pays benefits first and then the 70/30 Plan may help pay some of the costs that Medicare does not cover.

2021 Plan Comparison – Pharmacy BenefitsBenefit Humana

BaseHumana

EnhancedBCBSNC

70/30*Pharmacy Maximum $2,500 Individual $2,500 Individual $5,900 In-network (Individual)

$16,300 Out-of-network (Family)(Combined Medical & Pharmacy)

Deductible $0 $0 $1,500 In-network (Individual)$4,500 In-network (Family)

(Combined Medical & Pharmacy)

Retail Purchase from an In-Network Provider

Tier 1 $10 copay per 30-day supply $16 copay per 30-day supply

Tier 2 $40 copay per 30 day supply

$40 copay per 30-day supply

$47 copay per 30-day supply

Tier 3 $64 copay per 30 day supply

$50 copay per 30-day supply Ded/Coinsurance

Tier 4 25% coinsurance up to $100 per 30-day supply $200

Tier 5 N/A $350

Tier 6 N/A Ded/Coinsurance

Insulin $40 copay – Preferred Brand (Novolog/Novolin) (30-day supply)

$0 (30-day supply)Preferred or Non-Preferred

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What are Medicare Advantage Plans?• A Medicare Advantage Plan, like the Humana Medicare Advantage plans offered by the

State Health Plan, are considered a Group Medicare Advantage Prescription Drug Plan (MAPDP): A Medicare health plan choice may be an individual or group product.

• Private companies, like Humana, contract with Medicare to provide your Medicare Part A and Medicare Part B benefits.

• With a Medicare Advantage Plan:• You are still considered to be in the Medicare program.• You keep same rights and protections as Original Medicare.• They must cover all services Original Medicare covers.• Members must have both Medicare Part A and Medicare Part B and continue to pay

Medicare premiums to be eligible for Medicare Advantage Plans. Part B premiums are paid by member from Social Security benefits or directly to federal government.

• Zero dollar premiums on the Base Plan.*• Significantly lower dependent premiums on Base and Enhanced Plan.• No deductible.• No referral for a Specialist.

*Keep in mind that if you do not have enough years of service to qualify for non-contributory coverage, or you pay 100% of your coverage for other reasons, you are responsible for any premium owed.

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Medicare Advantage Plan Perks• Simplicity – The Humana Medicare Advantage Plans provide one ID card

for medical services and prescription drugs.• Remember – You are still considered to be in the Medicare program• You use your Humana ID card – not your red, white and blue Medicare

card• Predictability – The Humana Medicare Advantage Plans are copayment

driven meaning the majority of covered services have an established copayment. This allows for you to know what your out-of-pocket costs will be up front in most situations.

• The Humana Medicare Advantage Plans also provide extra services not covered under Original Medicare.• Wellness programs/SilverSneakers®

• Disease and Case Management • Routine eye & hearing exams• Hearing aids

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Network of Providers• The Humana Medicare Advantage plans are considered National

Preferred Provider Organization (PPO) plans. They offer:

• Access to providers nationwide.

• Access to additional benefits at a lower cost and include an open network.

• Copays or coinsurance remain the same, regardless of who you see in- or out-of-network.

• Out-of-network providers must participate with Medicare and agree to accept and file claims on member’s behalf.

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Humana Medicare Advantage Plans & Other Insurance• With the Humana Medicare Advantage Plans there is no need for additional

coverage.

• Additional Medicare health plan coverage can cause you to be disenrolled from your State Health Plan Humana Medicare Advantage Plan.

• If already enrolled in another Medicare Advantage or Part D prescription drug plan, your coverage with those plans will terminate unless you elect not to enroll in one of the Humana Medicare Advantage Plans.

• If enrolled in a MAPDP, you cannot purchase a Medicare Supplement or Medigap plan without you terminating your MAPDP.

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Medicare Advantage Plans & Other Insurance• TRICARE® for Life (TFL) (TRICARE ® + Medicare)

• TFL beneficiaries can enroll in Medicare Advantage plans and TFL will typically reimburse your copayments for services covered by TFL.

• You cannot use Medicare or Medicare Advantage in a Military Treatment Facility, like a VA Hospital.

• Other Insurance

• If covered by a Federal Employee Health Benefit Plan or another former employer’s retiree group health plan, it is important to check with them to ensure enrollment into one of these Medicare Advantage plans will not disrupt coverage with them.

• Individual cancer, hospital indemnity, dental, vision, long-term care insurance products will not have an effect on eligibility or coverage under a Medicare Advantage plan.

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HumanaGroup Medicare Advantage PlansNorth Carolina State Health Plan for Teachers and State Employees

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Humana Group Medicare Advantage PPOAt Humana, we are here to help you make the most of your benefits.

About Humana:• Dedicated to communities around the country for more than 30 years

• Over 8.5 million Medicare members just like you, across all 50 states1

• Providing Medicare plans to beneficiaries since 1987

• Easily find a provider with our nationwide network of providers – over 760,000 providers and 3,300 hospitals

• In North Carolina, our provider network includes 6,822 Primary Care Physicians (PCPs), 11,303 Specialists, and 92 hospitals

• Our Group Medicare Advantage PPO plans have earned 4‐Star or  higher quality ratings from the Centers for Medicare & Medicaid Services (CMS) for 2019 and 2020.

1Humana Inc. 2019 Annual Report, February 2020

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What is a PPO?Humana’s preferred provider organization (PPO)

• You will pay the same amount both in‐ and out‐of‐network for care

• No copayment for preventive care

• Out‐of‐pocket maximum

• Worldwide emergency coverage

• As a State Health Plan member, the in‐network and out‐of‐network benefits are structured the same for any member of this plan. 

• This means you don’t need to find a new doctor. 

• Similar to what you are experiencing today, as long as your provider participates in Medicare and agrees to bill Humana, you can continue with the doctor you know and trust at no extra cost ‐ even if they are out‐of‐network.

• If a provider is still resistant to filing a claim with Humana, the member would pay for the service and then file a paper claim with Humana for reimbursement (less any applicable copayment/coinsurance).

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ProvidersWith your PPO plan, you will pay the same amount for in‐ and out‐of‐network services. 

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ProvidersWith your PPO plan, you will pay the same amount for in‐ and out‐of‐network services. 

Humana Group Medicare Advantage Base PlanThere are no changes to benefits with this plan. 

Humana Group Medicare Advantage Enhanced Plan Changes:A few copays have changed under the Enhanced plan listed in the below chart.It will be important for members to review the benefit changes on the Enhanced plan.

2021 Benefit Changes

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2021 Enhanced PlanCost‐Share Decrease Cost‐Share Increase

Decrease PCP copay to $10 Increase Outpatient Radiology to $40Decrease Lab copay to $10 Increase Radiation Therapy to $40Decrease Inpatient Hospital copay to $125 Increase Tier 1 90‐day Rx copay to $24Decrease Partial Hospitalization to $15 Increase Tier 2 30‐day Rx copay to $40

Increase Tier 2 90‐day Rx copay to $80

Base Plan Enhanced PlanRoutine Vision Services • 100% after $40 copayment, 

one routine exam per year• 100% after $35 copayment, 

one routine exam per yearRoutine Podiatry Services • 100% after $40 copayment; 

maximum of six visits per year

• 100% after $35 copayment; maximum of six visits per year

Routine Hearing Services • $0 copay for routine hearing exam, one per year• $0 copay for fitting/evaluation, one per year• $500 total allowance for hearing aids every three years

Private Duty Nursing • 20% coinsurance, $5,000 maximum benefit per year

COVID‐19 Testing • Testing and treatment for members with COVID‐19 diagnosis will be covered at 100%

Health Essentials Kit • Kit includes over the counter items useful for preventing the spread of COVID–19 and other viruses. Limited one per year.

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Your PPO benefits – extra benefitsWith your PPO plan, you will pay the same amount for in‐ and out‐of‐network services. 

Your primary care provider and your specialist may offer virtual visits• Virtual visits connect you with your provider via telephone or video chat using your phone, tablet2 or laptop2

• Talk with a provider from the comfort of your home• Private, secure and confidential• Providers are available to treat many conditions, including allergies, fever, cold and flu symptoms, insect bites, stress, anxiety, depression and many others

• Virtual visits may be able to address an expanded set of needs including changes to medicines, refills, ordering labs, test, screenings and help with management of chronic conditions.

If you don’t have a primary care provider or if your PCP doesn’t offer virtual visits, you can use the “Find a doctor” tool on Humana.com or call the number on the back of your member ID card to get connected with a provider that offers this service.

1Behavioral health visits are by appointment.2Standard data rates may apply.

Virtual visits / telemedicineConnect with a provider or behavioral health professional1 virtually

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• Generic, brand and specialty drugs

• Part D vaccines are covered 100%; excludes foreign travel vaccines

• Diabetic Supplies and Administration Supplies are covered 100%

• Coverage for Cough and Cold, Weight Loss, Fertility, Vitamins & Minerals medications

• Access to over 66,000 national and regional chains, including independent local pharmacies

• Humana Specialty Pharmacy

What your pharmacy coverage includes:

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• Drug List Change Letter

• Welcome Kit Drug List

• Website Drug Lookup Resources

• Transition Fill Process

• Mail Order Prescription Transfer

How you will be notified of changes:

Your Pharmacy Coverage

Humana PharmacyRx Mail Delivery

Accuracy and safetyFree standard shipping in discreet, temperature‐controlled packaging

ConvenienceNo driving to the pharmacy or waiting in line*

Support you needLearn how to set up a new account, start a new Rx and/or download the mobile app by visiting HumanaPharmacy.com or calling 1‐800‐379‐0092 (TTY: 711), Monday – Friday, 8 a.m. – 11 p.m. and Saturday, 8 a.m. – 6:30 p.m., Eastern time.

RemindersRefill reminders by email, text or phone—you decide

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*Other pharmacies are available in our network

• Preferred Diabetic Supplies and Administration Supplies are covered 100%; supplies include meters, test strips and lancets.

• Humana’s preferred insulin is Novolog and Novolin at the Tier 2 copay.

• Humalog, Humulin, and Apidra are available at a higher tier. 

• Humana’s DME provider for Continuous Glucose Monitoring Supplies/Sensors is CCS Medical. 

Diabetic Testing & Monitoring Supplies

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Health resources

• Case management• Disease management• Transplant management• Health planning and support nurses

Humana member transition activities:

• Case Management Outreach to Diabetic Members

• High Risk Member Outreach:

• Transplants• End‐Stage Renal Disease (ESRD)/Chronic Kidney Disease (CKD)

• Disease/Case Management

In‐Home Health & Wellbeing Assessment• A free, in‐home 45‐60 minute one‐on‐one health assessment with a doctor or nurse 

practitioner.

• The doctor or nurse practitioner will:• Check your blood pressure and other vital signs• Take a brief health history• Review any medications and over‐the‐counter vitamins and supplements you take• Assess the safety of your home

• It is designed to help support, but not take the place of your regular doctor’s care.

• You can talk about health concerns and ask questions that you haven’t had time to ask before. It may also help Humana to identify any plan     programs and services that may be right for you.

• You can receive a reward when you complete a visit.

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A total health and physical activity program included in your plan at no extra cost.

SilverSneakers® gives you access to exercise equipment, group fitness classes and social events at more than 17,000 nationwide locations. 

Get moving with SilverSneakersLIVE and join thousands of other members from the comfort of your home with our LIVE virtual classes and workshops. And since it’s included in the SilverSneakers benefit, SilverSneakers LIVE is available at no additional cost to members and offers virtual classes and workshops via Zoom.

Redeem your rewards for gift cards in the Go365 Mall:1) Online: Sign in at Go365.com/shop  ‐OR‐ 2) Phone: Call 1‐866‐677‐0999 (TTY: 711)

A wellness program just for Humana members, included in your plan at no extra cost. You’ll earn rewards that you can redeem for gift cards in the Go365 Mall.

Members must redeem the reward in the program year it is earned. Any rewards not redeemed by 12/31 will expire. For a complete list of gift cards visit go365.com/shop.

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Humana Well Dine®After your overnight inpatient stay in a hospital or skilled nursing facility, you’re eligible for 2 meals per day for 7 days, up to 14 nutritious meals, limited to 4 times per year delivered to your door at no additional cost to you.Humana Well Dine meal plans•  Regular •  Vegetarian•  Diabetic •  Kosher•  Puree •  Renal‐support

Advance care planning – MyDirectivesUse online tools to develop and share your healthcare choices• Create a living will, medical power of attorney• Make your choices known about resuscitation, life support, organ donation and autopsy

• Your doctors and your family will know your exact wishes• A simple way to share information with your doctor and family members• Available to you at no additional cost

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What else does Humana offer you?

• Discounts on hearing aids, vision services, and dental services

• Lifeline® Medical Alert Systems

• Meal Delivery Discount (Mom’s Meals®)

• Weight Management Discount (Jenny Craig®)

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Whether you prefer using a desktop, laptop or smartphone, you can access your healthcare information in one convenient place. 

• View your plan and coverage details• Check the status of your claims• View electronic versions of letters sent to you

• Track your healthcare spending• Find providers in your network• Get tips for staying healthy

You will be able to activate your MyHumana account once you receive your Humana member ID card. You will receive it in December, prior to 1/1/21. Go to our.humana.com/ncshp to register.

Use the MyHumana Mobile app. 

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SmartSummary®An overview of your health benefits and health spending on medical and prescriptions throughout the year.• Stay informed• Clear and detailed financials• Information you can share with your  provider• Prescription information

You can access your SmartSummary online with your MyHumana account.

Go Green—update your member preferences to receive your SmartSummary statement electronically.

Humana in your neighborhood

Everyone is invited! Bring a friend or family member—there is no cost to join in the fun!• Help with your Humana plan• Health and wellness• Social and fun• Virtual classes available online; visit the below link to locate other centers nationwide as well as the calendar of events:

https://www.humana.com/humana‐neighborhood‐centers

Asheville LocationSkyland Plaza1863 Hendersonville Road Suite 122Asheville, NC 28803

Greensboro LocationWestover Gallery of Shoppes1420 Westover TerraceSuite CGreensboro, NC 27408

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Humana Member Welcome Kit

Your enrollment kit is an important tool. The packet includes information on your healthcare coverage along with extra services included in your Humana plan.

• Humana will send a Member Welcome Kit to all members currently enrolled in the UHC Base or Enhanced plans, to be received mid‐October.

• The Welcome Kit will include:• Base and Enhanced Plan Medical and Pharmacy Summary of Benefits

• PPO Plan Guidebook• Abbreviated Prescription Drug Guide• Go365 Program Flyer• Educational Provider Flyer

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What to expect after enrollment

Enrollment confirmationYou will receive a letter after your  enrollment information is received, completed in the Humana system and confirmed by CMS. This will be received in December, prior to 1/1/21.

Humana member ID cardYou will receive your ID card in December, prior to 1/1/21.

Medicare Health SurveyHumana will send you a postcard with instructions on how to  complete the survey.

Evidence of Coverage (EOC) Members will receive theirdetailed  benefit booklet in themail.

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Stay connected with Humana

You have a dedicated Customer Care team to help you with anything related to your State Health Plan Humana plan.

1‐888‐700‐2263 (TTY: 711)Monday – Friday, 8 a.m. – 9 p.m., Eastern time.

For more information:• Refer to your Welcome kit, arriving mid‐October• Visit our.humana.com/ncshp• Call Humana Group Medicare Customer Care

team for anything related to your Humana plan at 1‐888‐700‐2263,Monday – Friday, 8 a.m. – 9 p.m., Eastern time

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70/30 PPO Plan

Clear Pricing Project• In 2019, the State Health Plan implemented the Clear Pricing Project

(CPP).• Its goal was to ensure that members have this valuable benefit for years to

come, while bringing transparency to health care costs and addressing the rising health costs that the Plan and members face each day.

• This effort resulted in more than 25,000 providers partnering with the Plan for transparent and affordable health care.

• Plan members currently utilize the NC State Health Plan network, which encompasses CPP providers and providers in the Blue Options Network to ensure adequate access to health care.

• CPP providers have agreed to get rid of secret contracts, making health care more affordable and transparent.

• In an effort to lower health care costs for members and to support CPP providers, the Plan will be offering significant copay reductions for members who visit a CPP provider in 2021.

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70/30 PPO Plan – Network• As a State Health Plan member, you will have access to the North

Carolina State Health Plan Network, which is made up of providers who signed up for the CPP, and Blue Cross NC’s Blue Options network.

• You may seek services from providers in the State Health Plan’s Network or go to an out-of-network provider.

• However, when you use in-network providers, you’ll have wide access to high quality providers, and pay less out-of-pocket.

• In-network providers are credentialed by Blue Cross NC, which means you will receive the best of care and pay less out-of-pocket vs. going to an out-of-network provider.

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70/30 PPO Plan

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2021 Medical Benefits2020 2021

Preventive Care $0 PCP / $0 Specialist

Primary Care Provider (PCP) Visit $45

CPP* PCP Visit (CPP PCP/Practice on ID Card) $30 $0Non CPP* PCP Visit (Non CPP PCP/Practice on ID Card) $30

Specialist Visit $94

CPP* Specialist Visit $94 $47

Chiro/PT/OT/ST $72

CPP* Chiro/PT/OT/ST $72 $36

*Clear Pricing Project

70/30 PPO Plan, cont’d.

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2021 Medical Benefits, cont’d.2020 2021

Annual Deductible (Medical/Rx combined) $1,500 Individual / $4,500 FamilyOut-of-Pocket Maximum (Medical/Rx combined) $5,900 Individual / $16,300 FamilyUrgent Care $100 Emergency Care $337 then 30% after deductibleInpatient Hospital $337 then 30% after deductible

70/30 PPO Plan, cont’d.

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2021 Pharmacy Benefits2020 2021

Tier 1 Generic $16

Tier 2 Preferred Brand and High Cost Generic $47

Tier 3 Non-preferred brand Ded/Coinsurance

Tier 4 Low Cost / Generic Specialty $200

Tier 5 Preferred Specialty $350

Tier 6 Non-Preferred Specialty Ded/Coinsurance

Preventive Medications $0

Preferred Diabetic Supplies $10

Preferred & Non-Preferred Insulin $47 $0

Annual Deductible (Medical and Rx combined) $1,500 Individual $4,500 Family

Out-of-Pocket Maximum (Medical and Rx combined) $5,900 Individual $16,300 Family

70/30 PPO Plan

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• The 70/30 Plan is a true out-of-pocket, ACA (Affordable Care Act) compliant plan.

• You must meet the yearly $1,500 deductible for those medical services and medications that are subject to the deductible.

• Once you’ve met the $1,500 deductible, you will pay 30% of all remaining covered charges (after Medicare has paid - medical) up to the $5,900 out-of-pocket maximum.

• Once the out-of-pocket maximum is met, covered medical and pharmacy benefits will be paid at 100%.

Note: Your out-of-pocket maximum includes copays, coinsurance and deductible.

70/30 PPO Plan is Secondary to Medicare

70/30 Plan Deductible / Maximum Out of Pocket

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Service

Applied to Individual Deductible

$1,500

Out-of-Pocket Maximum (Combined Medical &

Pharmacy)$5,900

All Medical copaysIncludes office visits, urgent care, ER, Inpatient/Outpatient Hospital

X

Deductible & 30% Coinsurance• Facility based services• Tiers 3 & 6 Rx’s• Non-Preferred Diabetic Testing Supplies

X XX

X XX

Pharmacy Copays• Tiers 1, 2, 4 & 5• Preferred Diabetic Testing Supplies

XX

• Amounts applied to the individual deductible are also applied to the out-of-pocket maximum.• After the individual deductible has been met, you will pay a 30% coinsurance until the total out-of-

pocket maximum has been met.• ACA preventive services & preventive Rx’s covered at 100% are not subject to deductible or out-of-

pocket maximum.

70/30 PPO Plan – Coordination of Benefits

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Coordination of Benefits

Medicare• If you elect the 70/30 Plan option, Medicare will be your primary coverage• With the 70/30 Plan, charges left unpaid by Medicare are paid by the SHP

after your yearly deductible, coinsurance and copays are applied• If you don’t have Medicare Part B, you will be responsible for what

Medicare Part B would have paid resulting in higher out-of-pocket costs

Medigap (Medicare Supplement) plan• A Medigap plan is generally not needed when you have secondary

coverage to Medicare• Medigap plans ONLY work with Original Medicare. They will not work with

Medicare Advantage plans

70/30 PPO Plan – Coverage Out & About

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• State Health Plan members are covered in all 50 States as well as outside of the country for emergency and non-emergency services.

• Blue Cross Blue Shield Global Core (formally BlueCard Worldwide)• Single point of contact for medical assistance (inpatient, outpatient and

professional):• www.bcbsglobalcore.com• Global Core Service Center: 1-800-810-2583 or Collect: 1-804-673-

1177, 24 hours a day, seven days a week. • Outpatient/Doctor Care: Payment usually required up front.

Claim forms are located on the Global Core website or www.shpnc.org.• Inpatient Care: Contact the Global Core Service Center to arrange direct

billing. Most cases you should not have to pay up front for inpatient care except for any out-of-pocket expenses (i.e., deductible, copayment, etc.).

• Contact Blue Cross of NC for preauthorization.

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Open Enrollment, Rates, etc.

Open Enrollment Period• Each year Open Enrollment provides the opportunity to make

changes:• Change plans• Opt in/out of the State Health Plan• Add dependents• Remove dependents

• If you opt out of the State Health Plan during Open Enrollment, you may opt back into the State Health Plan during any following Open Enrollment period or as a result of a Qualifying Life Event.• Should you opt out of the State Health Plan, we encourage

you to sign up for our electronic newsletter, Member Focus, as you will not receive mailings from the Plan.

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Open Enrollment October 15-31, 2020

2021 Open Enrollment Action

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• All current UHC members will be moved to the Humana Group Medicare Advantage Base Plan for Open Enrollment. If they take no action, they will be in the Base plan starting January 1, 2021.

• If you are currently on the Medicare Advantage Base Plan or 70/30 Plan, you will REMAIN on that plan & do not need to take action during Open Enrollment.

• If you are currently on the Medicare Advantage Enhanced Plan, you will be moved to the Base Plan for the 2021 benefit year. If you would like to elect the Enhanced Plan for 2021, you will need to take action during Open Enrollment.

• All non-Medicare primary members, including non-Medicare primary spouse/dependents, will be moved to the 70/30 Plan effective January 1, 2021.

• If spouse/dependents are not Medicare eligible:• They have same options available to active employees/non-Medicare

members (80/20 PPO and 70/30 PPO Plan)• They will be moved to the 70/30 PPO Plan for the 2021 benefit year, so

you will need to take action if you want them enrolled in the 80/20 Plan and to reduce premiums in the 80/20 (premium reduction applies to non-Medicare subscriber only)

• Failure to take action will result in dependent remaining on the 70/30 Plan for 2021.

Medicare Member Premiums

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HUMANA GROUP MEDICARE ADVANTAGE (PPO) BASE PLANCOVERAGE TYPE 2021 MONTHLY PREMIUM

Subscriber Only $0Subscriber + Child(ren) $4.00Subscriber + Spouse $4.00Subscriber + Family $8.00

HUMANA GROUP MEDICARE ADVANTAGE (PPO) ENHANCED PLANCOVERAGE TYPE 2021 MONTHLY PREMIUM

Subscriber Only $73.00Subscriber + Child(ren) $146.00Subscriber + Spouse $146.00Subscriber + Family $219.00

70/30 PLANCOVERAGE TYPE 2021 MONTHLY PREMIUM

Subscriber Only $0.00Subscriber + Child(ren) $155.00Subscriber + Spouse $425.00Subscriber + Family $444.00

Income-Related Monthly Adjustment Amount (IRMAA)

• Members with higher income levels are required to pay an adjusted Medicare Part B premium plus an additional amount when enrolled in Medicare Part D prescription drug coverage. The additional amount is called Income-Related Monthly Adjustment Amount or IRMAA.

• Income level based on modified adjusted gross income, which is the total of your adjusted gross income and tax-exempt interest income.

• IRMAA is mandated by Federal law and each amount is deducted from your monthly Social Security payments.

• IRMAA will apply if individual income is over $87,000 or if married (filing joint tax return) income is over $174,000.

• If enrolled in the Group Medicare Advantage plans with Humana, higher income members may be subject to IRMAA.

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Disability• If member becomes eligible for Medicare due to disability, it is very

important for them to enroll in both Medicare Part A and Medicare Part B.

• Do not overlook accepting Medicare Part B. Many people fail to accept the offer to retroactively purchase Medicare Part B.• Read the AWARD Notice carefully.

• State Health Plan becomes SECONDARY to Medicare as of the Medicare eligibility date.• Claims will be reprocessed back to Medicare eligibility date. • The State Health Plan will reduce their claims by the amount that

would have been paid under Medicare, paying the remaining claim amount under the terms of the health benefit plan.

• As a result, if Medicare Part B is not taken, member will be responsible for the amount that would have been paid by Medicare Part B.

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Reminder – How to Make a Change for Open Enrollment

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Enroll Online• Visit the State Health Plan website and

click eBenefits in the blue box• Then click the gold box for ORBIT• Once you’re logged into ORBIT,

click State Health Plan Benefits

Enroll by Phone• During Open Enrollment, the Plan’s

Eligibility and Enrollment Support Center will offer extended hours.

M-F: 8 a.m. – 10 p.m. Sat.: 8 a.m. – 5 p.m.

• Call 855-859-0966

Important Phone Numbers

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• ELIGIBILITY AND ENROLLMENT SUPPORT CENTER855-859-0966Extended hours during Open Enrollment:Monday-Friday: 8 a.m.-10 p.m.Saturdays: 8 a.m.-5 p.m.

• HUMANA CUSTOMER SERVICE888-700-2263

• BLUE CROSS AND BLUE SHIELD OF NC(BENEFITS, CLAIMS)888-234-2416

• CVS CAREMARK (70/30 PLAN PHARMACY BENEFITS)888-321-3124

www.shpnc.orgwww.nctreasurer.com

Questions?

Photo credits: Thinkstock Images

This presentation is for general information purposes only. If it conflicts with federal or state law, State Health Plan policy or your benefits booklet, those sources will control. Please be advised that while we make every effort to ensure that the information we provide is up to date, it may not be updated in time to reflect a recent change in law or policy.  To ensure the accuracy of, and to prevent the undue reliance on, this information, we advise that the content of this material, in its entirety, or any portion thereof, should not be reproduced or broadcast without the express written permission of the State Health Plan.