State Health Plan NC SmartChoice PPO

State Health Plan NC SmartChoice PPO &

Indemnity Plans

Health Benefits Representative Training

08/10/10Confidential and Proprietary2

Background of the State Health Plan

The State Health Plan is mandated by Chapter 135 of NCGS to offer 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.


Products

Four Choices for Eligible Members NC SmartChoiceSM Blue OptionsSM PPO Plans

PPO Basic 70/30 PPO Standard 80/20 PPO Plus 90/10

Indemnity Plan Members should choose the plan that best meets

their needs


Benefit Year

The benefit year runs from 7/1 – 6/30 each year.

Deductibles and coinsurance begin each benefit year


Who is eligible to enroll in the NC State Health Plan?

All State employees working a minimum of 30 hours per week, teachers, State retirees and COBRA participants are eligible to enroll in the State Health Plan PPO options or the Indemnity Plan.


Annual Enrollment

Annual Enrollment for the State Health Plan NC SmartChoiceSM PPO and Indemnity plans March 1st – March 30, 2007

Members opportunity to: Elect to have coverage with the SHP Switch between the PPO plans, move from the Indemnity plan to one

of the PPO plans, or move from one of the PPO plans to the Indemnity plan

Update personal information (Name, address, birthdate, SSN) Add/remove dependent(s)

Health Benefit Representative (HBR) Support/Help Line 1-800-422-5249 - Benefit Questions 1-800-245-7319 – Membership / Billing Questions

State Health Plan Website www.shpnc.org


How Does the State Health Plan Work?

The State Health Plan has contracted with BCBSNC to use their Blue Options Network for the NC SmartChoiceSM PPO plans and the Indemnity plan uses Costwise participating providers

Employees should always verify that their provider participates in the Blue Options Network if they are a PPO member or that their provide participates with Costwise if they are an Indemnity member to avoid additional out-of-pocket costs


Indemnity Plan Highlights

Traditional product $5 million lifetime maximum Copayment plus deductible and coinsurance for

office visits, specialists visits, urgent care, and outpatient hospital visits

First $150 of preventative services covered at 100% after copayment, then deductible and coinsurance

Employee-spouse tier not available on the Indemnity Plan

Costwise participating providers


Indemnity Plan Benefits

20%Coinsurance

$15 copay then ded & coinsurancePhysician Office Visits

$75 copay then ded & coinsuranceOutpatient Hospital

$150 copay then ded & coinsuranceInpatient Hospital

$200 copay then ded & coinsuranceEmergency Room

First $150 covered after copay then deductible & coinsurance

Wellness

$10 Generic

$25 Preferred Brand

$40 Preferred Brand w/ Generic Equiv.

$50 Non-Preferred Brand

Prescription Drug

$350 / $1050Deductible


About the NC SmartChoiceSM PPO Plans

State Employees have 3 PPO options from which to choose NC SmartChoiceSM Basic

No cost for employee-only coverage; reduced premiums for family coverage

Members have higher copays, coinsurance and deductibles NC SmartChoiceSM Standard

Coverage at levels between basic and plus plans No cost for employee-only coverage; premiums for all other tiers

are less than Indemnity rates NC SmartChoiceSM Plus

Members pay out-of-pocket for employee-only coverage and higher premiums for family coverage

Members have lower copays, coinsurance and deductibles

All 3 options include an employee-spouse tier


PPO Plan Highlights

Copay only for most in-network non-hospital based physician office visits

Deductible and coinsurance for most hospital based physician office visits

Extensive in-state network Extensive out-of-state network No lifetime maximum Most annual physicals for copay only


PPO Plan Highlights (cont.)

Reduced out-of-pocket costs when using in-network providers

Referrals never required An employee-spouse tier A richer “buy-up” plan option Reduced premium plan option for dependent

coverage Routine eye and hearing exams No annual dollar cap for preventive benefits


Outpatient Services – PPO Plans

Coverage level is dependent on service location. Copayment required for services received at an in-network

physician’s office. Deductible and coinsurance required when service

performed outside of physician office, at an out-of-network physician office, or in a hospital owned or operated physicians practice.

Yellow donut – Provider may be subject to outpatient hospital benefit charges

Red Square – Provider always subject to deductible and coinsurance

Please Note – CT scans, MRIs, MRAs and PET scans are always subject to deductible and coinsurance.


Additional PPO Benefits

Routine Eye Exams

Routine Hearing Exams


PPO Extras

Blue ExtrasSM

Discounts on certain non-covered services. Services include: 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


PPO and NC Flex

Superior Vision in most cases PPO member will not need to elect

for higher option

Health Care Reimbursement PPO members need to evaluate their contributions Members may not need to set aside as much

money since most in-network office services are not subject to deductible and coinsurance


Benefit Comparison

PPO Plans Lifetime max -- Unlimited Office visits – copay only

for most in-network Specialist visits – copay

only for most in-network Urgent care – copay only Outpatient hospital – only

deductible & coinsurance Preventive – covered

annually - no dollar maximum Employee-spouse tier Routine Eye Exam 30 mental health office visits

per benefit year

Indemnity Plan Lifetime max -- $5 million Office visits – copay plus

deductible & coinsurance Specialist visits – copay plus

deductible & coinsurance Urgent care – copay plus

deductible & coinsurance Outpatient Hospital – copay

plus deductible & coinsurance Preventive – age limit

restrictions No employee-spouse tier No routine eye exam Unlimited mental health office

visits requires prior auth after 26 visits


Preventive Benefits

PPO Plans Routine physicals covered every benefit

year with no age restrictions Routine physicals covered in-network only

except for screenings 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 a non-hospital, in-network physician office, otherwise deductible & coinsurance labs are covered at 100% when

performed alone Immunizations – copay when received

with office visit otherwise 100% Routine eye exams- annually Routine hearing exams- annually

Indemnity Plan Age restrictions on how often can

receive routine physicals First $150 per benefit year at 100%

after copay - then deductible & coinsurance

Charges over $150 subject to deductible & coinsurance

Immunizations – 100%


Mammograms

PPO Plan Benefits Allowed once a year for members 35 and older Routine mammograms are covered at 100% when performed

alone Radiologist reading covered at 100% Mammograms are subject to coinsurance and deductible when

performed with another service (Diagnostic mammograms are subject to deductible and

coinsurance)Indemnity Plan Benefits Allowed once a year for members 40 and older Charges beyond $150 preventive benefit are subject to copay,

deductible, and coinsurance Radiologist reading includes copay, deductible, and

coinsurance


Mental Health and Substance Abuse Services

PPO Plans Mental Health-

30 visits per benefit year/ 30 inpatient days per benefit year

Substance Abuse- $8,000 per benefit year/ $16,000 per lifetime

Indemnity Plan Mental health and Chemical

Dependency- unlimited, prior authorization required for more than 26 visits per benefit year


Other Services with Visit Limits

PPO Plans Physical Therapy /

Occupational Therapy / Chiropractic – 30 combined visits per benefit year

Speech Therapy – 30 visits

Home health Care- 100 days per benefit year

Indemnity Plan Chiropractic - $2000 per

benefit year


Benefits when Receiving Chemotherapy

PPO Plan Benefits are based on service location and if chemotherapy

is provided along with a MD visit Copay only if you see an in-network provider at the same

time of receiving treatment Covered 100% if only receiving treatment and no provider

visit Subject to deductible and coinsurance if receiving care in an

in-network outpatient hospital settingIndemnity Plan Always subject to deductible and coinsurance


Maternity Benefits

PPO and Indemnity Plan Copay for initial visit to diagnose pregnancy All other visits bundled into delivery Delivery charged as an inpatient hospital with a

copay, deductible and coinsurance


Prescription Drugs for Both PPO and Indemnity Plan

$50Non-preferred Brand

$40Preferred Brand

(generic equivalent)

$25Preferred Brand

(no generic equivalent)

$10Generic

Copayments

PPO Plans - Diabetic supplies are covered under pharmacy

for a copay


Diabetic Supplies

PPO Plans Pharmacy Benefit

test strips, lancets, and syringes copay only

$10 copay for preferred brand diabetic supplies

$25 copay for non-preferred brand diabetic supplies

34-day supply limit 150 test strips for insulin

dependent members 50 test strips for non-insulin

dependent members Additional supplies

Any amount over the 34-day supply limit are then covered under the medical supply benefit which are subject to deductible and coinsurance

Indemnity Plan Medical Supply Benefit

Test strips, lancets, and syringes deductible and coinsurance apply


Prescription Drugs- Incentive Program

Waiver of copays for generic prescriptions January 1, 2007 – March 31, 2007

Coverage of generic over-the-counter nicotine replacement patches Ongoing program No copay through March 31, 2007 $5 copay after March 31, 2007


Rates

Rates for the 2007/2008 benefit year have not been established Rates 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 70/30 PPO plan will most likely still have lowest premium for

dependent coverage 90/10 will most likely still have highest premium for dependent

coverage

*Unfortunately the actual rates and benefits for both the PPO plans and the Indemnity plan will not be made available until after annual enrollment. We apologize for the difficulties presented by the current timing and will do our best to assist our members.*


TRICARE Supplement Plan

Provides TRICARE beneficiaries an additional choice

Pays close to 100% of members out-of-pocket costs for TRICARE covered services

The State of North Carolina pays employee only coverage

Can enroll dependents at a lower rate


TRICARE Supplement Plan Highlights

No plan deductible No coinsurance Guaranteed acceptance No pre-existing condition limitations Use any TRICARE or Medicare authorized civilian providerWho is Eligible?

Military Retirees Retired Reservists, Guardsmen Spouses and Unmarried Dependent Children Former Spouses


How to enroll in the TRICARE Supplement Plan?

Confirm eligibility and Military ID card information by calling DEERS (Defense Enrollment Eligibility Reporting System) 1-800-538-9552

Existing SHP members should complete the Change Form to cancel their membership

Complete an ASI TRICARE Supplement Enrollment Form


HBR Responsibilities

Conducting annual enrollment meetings with their employees. (A standard presentation will be available on the SHP Web site at www.shpnc.org.)

Process applications and send as soon as received.

Forward communications to employees. Be available for employee questions, direct

employees as needed to Customer Service and the SHP Website.


General Information

Customer Service Representatives are available during annual enrollment to assist members with questions regarding benefits and enrollment.

Members can call Customer Service at: 1-888-234-2416 (For PPO) 1-800-422-4658 (For Indemnity)

New Members or members changing plans will receive their NEW ID card prior to the 07/01/2007 effective date.

Only new members or members changing plans will receive a benefit booklet with a detailed description of their healthcare plan.

HBR Hotline: 1-800-422-5249 – Benefit Questions 1-800-245-7319 – Membership / Billing Questions


NC HealthSmart

Do employees ask you about…. Preventive care benefits, managing stress, losing weight, medication management, or generally being healthy?

*Members whose primary health insurance is through the NC State Health Plan (PPO or Indemnity) and who are not on Cobra are eligible for NC HealthSmart.

An array of tools and services are available to eligible* members through NC HealthSmart. Services are at no additional cost…..and it’s easy!

Good News!


NC HealthSmart

NC HealthSmart, the State Health Plan’s healthy living initiative, aims to:

empower healthy members* to stay healthy; and help those with chronic disease or disease risk factors better manage their health.

*Members whose primary health insurance is through the NC State Health Plan (PPO or Indemnity) and who are not on Cobra are eligible for NC HealthSmart.


NC HealthSmart Tools & Services…

Health Coaches - 24 hours a day/7 days a week-1-800-817-7044

Specially trained health care professionals ready to talk with members on a variety of conditions and lifestyle issues such as stress management. Health Risk Assessment (HRA) Members will get a Personal Action Plan after taking the assessment. They can

take online at www.shpnc.org or call 1-800-817-7044 Health Education Programs and Tools Access to a telephone audio library with over 475 topics, free videos and printed information that can be sent to a member’s home NC HealthSmart Website, www.shpnc.org featuring WebMD Web-based programs to help members in changing health behaviors such as stopping smoking and more.

Worksite Wellness Programs Tools to support the member in joining or starting a program at work


Questions?

Documents

State Health Plan NC SmartChoice PPO