State Health Plan NC SmartChoice PPO
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Transcript of 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.
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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
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Benefit Year
The benefit year runs from 7/1 – 6/30 each year.
Deductibles and coinsurance begin each benefit year
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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.
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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
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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
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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
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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
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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
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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
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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
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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.
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Additional PPO Benefits
Routine Eye Exams
Routine Hearing Exams
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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
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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
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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
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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%
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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
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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
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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
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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
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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
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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
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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
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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
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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.*
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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
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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
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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
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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.
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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
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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!
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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.
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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
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Questions?