Welcome to this presentation about our annual enrollment for the upcoming benefit year. We will provide you with an overview of both the North Carolina Smart Choice PPO plans and the traditional Indemnity plan. Just sit back and watch, as the slides will proceed automatically. If you’ve already seen this presentation, and you’d like to skip ahead to review slides that are important to you, just click on the slide title of your choice in the listing t o the left. Now, let’s get started!
First, I would like to provide you with a little background on the State Health Plan. The State Health Plan is mandated by general statute to offer health coverage for all eligible state employees and retirees. In 2005 we were given authority to offer optional plans along with the mandated plan. In October 2006 we first offered the NC SmartChoice PPO plans.
The State Health Plan has contracted with Blue Cross and Blue Shield of North Carolina to use their provider networks. The PPO plans use the Blue Options provider network, and the Indemnity plan uses CostWise participating providers. The State Health Plan has also contracted with Medco as the pharmacy admnistrator. It is important to verify with your provider that he or she participates in your network before you receive care. That way, you’ll save money by avoiding additional out-of-pocket costs.
Annual enrollment for the upcoming benefit year is from March 1st- March 30 th . During annual enrollment you can switch from the Indemnity plan to one of the PPO plans, move from one PPO plan to another, or move from a PPO plan to the Indemnity plan. Also, during annual enrollment you can change your coverage tier or add or remove dependents. Annual enrollment is also a great time to review and update your personal information, especially if you have had any changes.
The State Health Plan has two customer service numbers. For PPO questions you should call 1-888-234-2416 and for Indemnity questions you should call 1-800-422-4658. Representatives are available on both lines to help you with any questions you may have during annual enrollment. Please note that new members and members changing plans will receive their new ID cards prior to the July 1, 2007 effective date. Keep in mind that only new members and members making changes will receive new ID cards and benefit booklets this year.
Again this year, you have four plan options --- three PPO office visit copay plans and the traditional deductible and coinsurance Indemnity plan. PPO Basic is a 70/30 coinsurance plan; PPO Standard is a 80/20 coinsurance plan; PPO Plus is a 90/10 coinsurance plan; and then there’s the traditional indemnity plan, which is also an 80/20 coinsurance plan. You should carefully review all of your plan options and choose the plan that best meets the needs of you and your family. We will talk about each product in more detail as we proceed with the presentation.
Now, let’s review the PPO plans.
You have 3 PPO options from which to choose: First, there’s the PPO Basic Plan. This plan has higher copays and deductibles, but the premiums are the lowest of the three plans. There’s no cost for retiree-only coverage, and the family plan has a reduced premium. Next, there’s the PPO Standard Plan. This plan provides coverage at levels between the basic and plus plans. Again, there’s no cost for retiree-only coverage and the premiums for the Standard PPO plan are less than the indemnity plan for all of the coverage types. Finally, there’s the PPO Plus Plan. This plan has the lowest deductibles and copay amounts and that’s why it costs a little more. You have to contribute towards retiree-only coverage, and you’ll pay a bit more for family coverage under this plan. All three of the PPO Plans have a retiree/spouse option which is not available on the Indemnity plan. This means that you do not have to pay the full cost for family coverage when you just want to cover your spouse.
Now let’s review some of the highlights of the PPO plans. First, you only pay a copay for most in-network physician office visits. You have access to one of the largest and most extensive provider networks, both in-state and out-of-state. Also, there is no lifetime maximum on any of these plans. Finally, routine physicals are covered every year for all PPO members regardless of their age and usually only cost a copay.
As we mentioned a little earlier, the PPO plans use Blue Cross and Blue Shield of North Carolina’s Blue Options network. With these plans, you have Open Access to Blue Options providers. That means that you do not need a referral from your primary care physician in order to visit a specialist. Also, when you travel or if you live outside of North Carolina, you can receive care from participating Blue Cross and Blue Shield providers at the in-network benefit level nationwide! This nationwide coverage among Blue Cross and Blue Shield plans is called BlueCard. Remember to carry your ID card at all times, as your ID card links you to the BlueCard program and ensures that you get in-network benefits if you visit in-network providers. Your ID card also provides you with coverage in more than 200 countries around the world via the BlueCard Worldwide. For more information about BlueCard, see the brochure in your enrollment kit or on the State Health Plan Web site.
The PPO plans have a strong emphasis on preventive care. In fact, routine physicals, eye exams and hearing exams are covered in-network every benefit year with no age restrictions. In addition, GYN exams, Ovarian cancer and Cervical cancer screenings, Mammograms, and Colorectal and Prostate screenings are all covered both in and out-of-network. In most cases, you pay only a copay for in-network preventive services received in physician’s office. Preventive services not received in a provider’s office are subject to deductible and coinsurance. Labs are covered at 100% when performed alone even when performed outside of a provider’s office. If you receive lab work as part of your in-network office visit then you will pay just your office visit copay. Also, immunizations are covered at 100% when received in-network.
Let’s talk about outpatient services for a moment. Your level of coverage depends on where you receive services. For example -- say you sprain your ankle and want to have a doctor take a look at it. If you visit your in-network primary care physician’s office, you would just pay your primary care copay. If you visit an in-network specialist, you’ll still just pay a copay, but it will be at the specialist level. When services are performed from a location other than a doctor’s office -- in a hospital, for example -- you will pay a deductible and coinsurance. You’ll also pay the deductible and coinsurance if you visit an out-of-network provider. Please note that regardless of location CT scans, MRIs, MRAs and PET scans are always subject to deductible and coinsurance.
Here’s another thing to remember about outpatient services. Some physician practices are hospital-owned or operated. Instead of charging you a copay for an in-network office visit, these practices typically bill office visit services as an outpatient hospital visit instead. As a result, these services are subject to the deductible and coinsurance. To determine if your physician’s practice is hospital-owned or operated, you can click on the “Find a Doctor” link from the State Health Plan Web site. Here’s an example, using a fictitious provider. If there is a yellow donut icon next to your provider’s name, then you may have to pay deductible and coinsurance for your in-network office visit. If there is a red square next to your provider’s name, then you definitely WILL have to pay the deductible and coinsurance for services. If you are unsure as to what you should pay, you can call Customer Service or your provider’s office.
Here are a few important things to remember regarding out-of-network services for PPO members. First, there are some services that are not covered out-of-network. Be sure to check your benefit booklet or call Customer Service to make sure your service is covered by out-of-network providers. Secondly, if you choose to receive out-of-network services, you may be required to pay for charges over the in-network’s allowed amount for those services in addition to the deductible and/or coinsurance. One of the advantages of having a PPO plan is that if your physician leaves the network, you will have the option of continuing care with your provider using your out-of-network benefits. However, you may have to pay that out-of-network provider up front and then file your own claim for reimbursement. * Finally, emergencies and urgent care are always covered as in-network as are anesthesiology and radiology when admitted by a participating provider at a participating hospital.
There’s one rule you have to follow with these PPO plans. You must receive pre-authorization for certain services. For example, you are responsible for pre-authorization of services received outside of North Carolina and from out-of-network providers in North Carolina . For a complete list of services that require pre-authorization, refer to your benefit booklet or call Customer Service.
If you are a retiree and Medicare Primary, it is important for you to understand how the PPO plans and Medicare coordinate. Under the PPO plans routine eye exams are covered. This is not a benefit under Medicare or the Indemnity plan. Routine physicals and GYN exams are covered under the PPO plans. These services are not covered under Medicare. Under the Indemnity plan these services would count towards your $150 preventive care benefit. If you had already used your $150 preventive benefit then these procedures would then be subject to deductible and coinsurance under the Indemnity plan. Diabetic supplies including syringes, are covered under the PPO plans for a copay only under the pharmacy benefit, while under the Indemnity plan deductible and coinsurace are charged for diabetic supplies. Medicare does not cover syringes at all. When you see an in-network provider for an office visit, under the PPO plan the only cost will be your copay. Under the Indemnity plan and Medicare you must first meet your deductible before you receive any benefits.
Some more benefits of having one of the PPO plans along with Medicare is, it’s free. As a retiree if you just want to cover yourself on either the PPO basic or the PPO standard, there is no charge. The PPO plans also allow you to have lower out-of-pocket expenses since for most in-network office visits you will only have to pay a copay as opposed to deductible and coinsurance under Medicare and the Indemnity plans. If you cover dependents, the PPO plans offer lower premiums for dependent coverage. Another nice feature of the PPO plans is that if you want to cover just your spouse then there is a premium for covering just your spouse. This is different from the Indemnity plan where if you wanted to cover your spouse you would have to pay the same premium as if you were covering your whole family. Also the PPO plans, have an extensive out-of-state network. When you travel outside of North Carolina you can still receive the same in-network benefits including low copayment when you seek care from an in-network provider out-of-state.
As a PPO member you are eligible for some additional perks. The first is called the Blue Extras program -- which gives you discounts on certain non-covered services. As a PPO member you can receive discounts on cosmetic dentistry, lasik eye surgery, cosmetic surgery, massage therapy and alternative medicine. You may also receive discounts on vitamins and herbal supplements and can earn prizes for physical activity. The other perk is My Member Services, which is a protected online resource for managing your health and maximizing your benefits. My Member Services allows you to view claim status, check your benefits summary, update your policy information, order new ID cards, change your billing address and much more. For more information on these programs - or to register for My Member Services - visit the State Health Plan Web site at www.shpnc.org.
Now I would like to provide you with a brief overview of the Indemnity plan.
The indemnity plan is a traditional product where members must pay a copay, deductible and coinsurance for all services. The only exception is for preventive services. The first $150 of preventive care each benefit year will be paid at 100%, and you won’t have to pay the deductible or coinsurance. Preventive services above the $150, however, will be subject to copayments, and the deductible and coinsurance. Remember to visit CostWise participating providers to avoid additional out-of-pocket costs. The retiree-spouse tier is not available on the Indemnity plan, and note that this plan has a $5 million lifetime maximum.
If you are an Indemnity plan member and you visit a physician who does not participate as a CostWise provider, you will pay more for services. In addition to your copayment, deductible and coinsurance, you’ll also be responsible for the difference between the CostWise charge for that service and the out-of-network provider’s charges -- even if you have received prior authorization for those services.
Remember -- Participating doctors on the Indemnity plan in NC that have an agreement with BCBSNC are called CostWise providers. The State Health Plan contracts with hospitals directly. If you are an Indemnity plan member and you visit a HOSPITAL that does not participate with the State Health Plan, you will pay more for those services. In addition to your copayment, deductible and coinsurance, you’ll also be responsible for the difference between what the State Health Plan would pay an in-network hospital for that same service and the out-of-network hospital’s charges -- even if you have received prior authorization for those services.
On the Indemnity plan, there are age restrictions on how often you can receive routine physicals. Check the Indemnity plan benefit booklet for details. This benefit booklet is available for you to view online at the State Health Plan Web site. As we mentioned a moment ago, each year on the Indemnity plan you receive a $150 preventive care benefit, which means the first $150 of preventive care each benefit year is not subject to the deductible and coinsurance. Preventive services above the $150, however, will be subject to the deductible and coinsurance. Finally, immunizations are always covered at 100%.
Next, I would like to discuss some of the benefit differences between the PPO plans and the Indemnity plan.
Let’s look at therapy first. With the PPO plans, you will have a combined visit limit of 30 visits per benefit year for physical therapy, occupational therapy and chiropractic services. Speech therapy has a separate visit limit of 30 visits per benefit year. In addition, home health care has a limit of 100 days per benefit year. Under the Indemnity plan, chiropractic care is limited to $2,000 per benefit year.
With the PPO plans, mental health coverage is limited to 30 outpatient visits per benefit year and 30 inpatient days per benefit year. In only some very specific cases, members may receive prior approval for more than 30 outpatient mental health visits per benefit year. Substance abuse treatment on the PPO plans is limited to $8,000 per benefit year and $16,000 per lifetime. With the Indemnity plan, the outpatient mental health and substance abuse visits are unlimited. However, members must receive prior authorization if they receive more than 26 outpatient visits per benefit year.
Now for a word about routine mammogram benefits. On the PPO Plans, members can begin receiving coverage for one routine mammogram per year at age 35. Routine mammograms are covered at 100% on the PPO plans when performed alone. Coverage includes the radiologist reading. But -- if the mammogram is received along with another service, such as a bone density scan, or if the mammogram is diagnostic, (which means it is not routine), then it will be subject to the deductible and coinsurance. On the Indemnity plan, members can begin receiving coverage for one routine mammogram per year at age 40. Routine mammograms and the radiologist reading are always subject to copays, deductible and coinsurance unless the mammogram is part of the annual $150 preventive benefit. Any preventive charges over $150 per benefit year are subject to deductible and coinsurance.
Now let’s look at chemotherapy benefits. For PPO members, what you’ll pay for chemotherapy services is based on the location you choose to receive the service. If a PPO member receives chemotherapy in an in-network physician’s office, then the most he or she will have to pay is a copay if they have an office visit in addition to their chemo. But if the PPO member receives chemotherapy in an outpatient hospital setting, at a hospital-owned facility or out-of-network, then services will be subject to deductible and coinsurance. On the Indemnity plan, chemotherapy is always subject to a copayment, plus the deductible and coinsurance.
The pharmacy benefit is the same for both the PPO and Indemnity plans. The only difference is that under the PPO plans, diabetic supplies, including test strips, are covered under the pharmacy benefit for a copayment.
Diabetic supplies, including syringes, lancets and test strips, are part of the pharmacy benefit on the PPO plans. This means you only pay your pharmacy copayment for a 34-day supply. Preferred brand test strips are covered for $10 and non-preferred for $25. If you are insulin dependent, then you can receive 150 test strips per 34-day supply. Otherwise, you will receive 50 test strips per 34-day supply. If you need more than the 34-day supply limit, you can receive additional test strips under the medical supply benefit. These additional supplies will be subject to deductible and coinsurance. On the Indemnity plan, diabetic supplies are always covered as part of the medical supply benefit and NOT the pharmacy benefit. This means you can’t get your diabetic supplies with a copayment, but they are subject to the deductible and coinsurance.
The North Carolina State Health Plan is pleased to announce two pharmacy programs that will save you money if you choose generic drugs. The first is the waiver of pharmacy copayments for all generic prescriptions. This program runs through March 31 st . The second program provides coverage for generic over-the-counter nicotine replacement patches. If you’ve thought about quitting smoking, this program could help you do it. Through March 31 st you can get the generic patches for free, and after March 31 st , they will only cost you $5 per prescription. You must receive a prescription for the nicotine patches from your provider to take advantage of this program.
Now let’s go through the important things to know about this year’s annual enrollment.
The rates for the upcoming benefit year for all plans will be determined during this legislative session by the General Assembly. Based on market trends, it is likely that all of the plans will have some sort of a rate increase. However, the rating among the plans will probably NOT change the premium structure between plans, which means that the PPO Basic Plan will still have the lowest premiums for dependent coverage and the PPO Plus Plan will have the highest premiums for dependent coverage. Included in your enrollment kit is the rate sheet for this benefit year. Even though the rates for the upcoming benefit year are not yet known, it should help guide you in your selection. If there is a rate increase, it will not go into effect until October 1, 2007.
It is very important that you complete the Annual Enrollment Change Form in your enrollment kit if you want to make any changes in your coverage or to update your personal information such as your address. You will need to return your completed change form to the Retirement System. Lines 1, 2 and 14 on the change form are required in order to process your changes. Any changes you make during annual enrollment will become effective on July 1 st . If you do not complete a change form , you will remain in your current plan option.
If you are already enrolled in the State Health Plan, you should have already received your enrollment kit in the mail. If you are eligible but not currently enrolled in the State Health Plan and you would like to become a member, there are several different ways you can obtain an enrollment kit. Beginning March 5 th , you can call Customer Services at the numbers listed at the end of this presentation to request a kit --- or you can print an enrollment kit from the State Health Plan Web site at: www.shpnc.org.
If you are retiring prior to July 1, 2007, you should send your Annual Enrollment Change Form to your HBR. Also send your completed HM form to the State Retirement System.
The effective date for any changes you make during annual enrollment is July 1, 2007. If you are adding new dependents to your plan --- or if you are a new State Health Plan member, your coverage and the coverage for your dependents will also be effective on July 1 st .
The benefit year for the State Health Plan is July 1 st through June 30 th . At the beginning of each benefit year, deductibles and coinsurance start over. If you are new to the State Health Plan but not a new retiree or adding a new dependent, a pre-existing condition waiting period may apply in limited circumstances. Pre-existing condition waiting periods will only apply if you haven’t been continuously covered for 12 months – or if you had a break in coverage of more than 63 days prior to the effective date. It is important that you complete line 14 on your change form to give you and / or your dependents credit for any prior coverage. This will help to either eliminate or reduce the pre-existing condition waiting period if it applies.
If you are making changes during annual enrollment, you will need to complete the change form located in your enrollment kit. You should keep the pink copy for your records and send the other 2 copies to the Retirement System if you are a retiree. If you print your change form from the State Health Plan Web site, complete the form and make 2 photocopies. Send the original along with 1 photocopy to the appropriate location based on your status.
Do you need more information about the health plans? Do you have questions about annual enrollment? We have several resources to help you. Customer service representatives are available during annual enrollment to assist you with questions regarding benefits and enrollment. You can call the Customer Service line toll-free at 1-888-234-2416 for PPO questions or 1-800-422-4658 for Indemnity questions. You can also visit the State Health Plan Web site at www.shpnc.org or contact SHIIP toll free at 1-800-443-9354 or local at 919-807-6900. Remember, the annual enrollment period is March 1st to March 30th, 2007.
Thank you for viewing the 2007/2008 annual enrollment training for the North Carolina State Health Plan. At this time we’ll open the floor for any questions you may have.
Annual Enrollment March 01 – March 30, 2007 State Health Plan NC Smart Choice SM Blue Options SM PPO and Indemnity Plans Overview for Retirees