State Health Plan NC SmartChoice PPO

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State Health Plan NC SmartChoice PPO Indemnity
Plans

• Health Benefits Representative Training

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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
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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 physicians 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 setting
• Indemnity 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
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
  provider
• Who 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?

Good News!
An array of tools and services are available to
eligible members through NC HealthSmart.
Services are at no additional cost..and its
easy!

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

• NC HealthSmart, the State Health Plans
• 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 members 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?