Download - Embracing a Healthy Lifestyle through the State Health Plan New Plan Options and Incentives for 2014
Why Are We Making Changes for 2014?
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• More choice for members. The Treasurer conducted a listening tour and the Plan conducted focus groups and surveys. The message was clear, members want more options.
• Encourage members to become more engaged in their health and take steps to live a healthier life.
• An engaged membership will help ensure that the State Health Plan remains financially stable in the years ahead.
Open Enrollment 2014
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Open Enrollment will be conducted October 1 – 31, 2013.
You must complete enrollment—otherwise, you and your covered family members will be
enrolled in the Traditional 70/30 Plan effective January 1, 2014.
Health Plan Options for 2014
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Enhanced 80/20 PlanNEW: Consumer-Directed Health Plan (CDHP) with
HRATraditional 70/30 Plan
• The current Standard 80/20 Plan with a new name to match the new features
• $0 ACA Preventive Services
• $0 ACA Preventive Medications
• New Wellness Incentives
•Reduced medical copay opportunities
• A new health plan option
• A high-deductible medical plan
• A Health Reimbursement Account (HRA) to help offset the deductible
• 85/15 Coinsurance
• $0 ACA Preventive Services/Medications
• CDHP Preventive Medication List ($0 deductible)
• New wellness incentives
• Additional HRA funds for visiting certain providers
• The current Basic 70/30 Plan with a new name
• No incentives available
• No $0 ACA (Affordable Care Act) Preventive Services/ Medications
A New Focus On Wellness
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Enhanced 80/20 PlanNEW: Consumer-Directed Health
Plan (CDHP) with HRATraditional 70/30
Plan
Wellness premium credits when:
• Subscriber completes a Health Assessment
• Subscriber attests for him/herself and spouse (if applicable) to not smoking
• Selecting a Primary Care Provider (PCP) for self and all dependents
• Additional wellness incentives
Wellness premium credits when:
• Subscriber completes a Health Assessment
• Subscriber attests for him/herself and spouse (if applicable) to not smoking
• Selecting a Primary Care Provider (PCP) for self and dependents
• Additional wellness incentives
• No incentives available
• No $0 ACA Preventive Services
• No $0 ACA Preventive Medications
The Traditional 70/30 Plan
• Traditional 70/30 Plan – There are no changes to the Plan’s benefits for 2014
• Copays and Deductibles – There will be no opportunities for copay reductions on the Traditional 70/30 Plan.
• Network Services – Members may visit any provider, but they will pay less when they go to a BCBSNC network provider
• Preventive Services – Copays still apply to preventive services.
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Traditional 70/30 Plan Benefit Highlights
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Coverage In-Network Out-of-Network
Annual Deductible $933 individual/$2,799 family $1,866 individual/$5,598 family
Coinsurance (after deductible is met)
30% of eligible expenses50% of eligible expenses plus 100% of amount above the allowed amount
Coinsurance Maximum (excludes deductible)
$3,793 individual/$11,379 family $7,586 individual/$22,758 family
Office Visits$35 copay for primary doctor$81 copay for specialists
50% after deductible
Preventive Care$35 copay for primary doctor$81 copay for specialists
Only certain services are covered
Inpatient Hospital$291 copay, then 30% after deductible
$291 copay, then 50% after deductible
Prescription Drugs (for 30-day supply)
Tier 1 $12 copay
Tier 2 $40 copay
Tier 3 $64 copay Specialty medications 25% up to $100 maximum per 30-day supply
Tier 1 $12 copay
Tier 2 $40 copay
Tier 3 $64 copaySpecialty medications 25% up to $100 maximum per 30-day supply
Monthly Premiums—Traditional 70/30Plan
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2014 Traditional Plan Premiums
Coverage Type Employee/ Retiree Monthly
Premium
Dependent Monthly Premium
Total Monthly Premium
Employee Only $0 N/A $0
Employee + Child(ren)
$0 $205.12 $205.12
Employee + Spouse
$0 $528.52 $528.52
Employeee + Family
$0 $562.94 $562.94
Reminder: Wellness premium credits are not offered under the Traditional Plan.
The Enhanced 80/20 Plan• New incentives to encourage members to manage their health
and lower their health care costs
• Preventive Care – No copays on Affordable Care Act (ACA ) preventive services or preventive medications.
• Primary Care Provider (PCP) – $15 PCP copay reduction.• If PCP is not available at the time of the appointment, the member may visit any
provider in the same practice and still receive the copay reduction
• If a member wants to change PCPs, they can go to their enrollment portal and select
a new PCP. The PCP change must be made before visiting the new PCP.
• Specialists – $10 Specialist copay reduction, choose a Blue Options
Designated provider
• Hospitals – $233 Inpatient Hospital copay avoidance (Blue Options)
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Enhanced 80/20 Plan Highlights in 2014
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Coverage In-Network Out-of-Network
Annual Deductible $700 individual/$2,100 family $1,400 individual/$4,200 family
Coinsurance (after deductible is met)
20% of eligible expenses40% of eligible expenses plus 100% of amount above the Plan’s allowed amount
Coinsurance Maximum (excludes deductible)
$3,210 individual/$9,630 family $6,420 individual/$19,260 family
Office Visits
$30 copay for primary doctor; $15 copay if the PCP on the ID card is utilized
$70 copay for specialists; $60 copay if a Blue Options Designated specialist is utilized
40% after deductible
Inpatient Hospital$233 copay, then 20% after deductible; copay avoided if a Blue Options Designated hospital is utilized
$233 copay, then 40% after deductible
Prescription Drugs (for 30-day supply)
Tier 1 $12 copay Tier 2 $40 copay Tier 3 $64 copay Specialty medications 25% up to $100 maximum per 30-day supply$0 for ACA Preventive Medications
Tier 1 $12 copay Tier 2 $40 copay Tier 3 $64 copay Specialty medications 25% up to $100 maximum per 30-day supply$0 for ACA Preventive Medications
Lower Your Health Care Costs with Wellness Incentives—The Enhanced 80/20 Plan
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Things you can do to reduce your costs…
Enhanced Plan Incentives
Visit the PCP listed on ID card Copay is reduced by $15
Visit a Blue Options Designated specialist Copay is reduced by $10
Get inpatient care in a Blue Options Designated hospital
$233 copay is avoided
Remember:
Get preventive services through an in-network provider in a non-hospital setting
100% coverage – this is provided at no cost to you
ACA preventive medication list100% coverage – this is provided at no cost to you
Who can be a Primary Care Provider?
• A Primary Care Provider can practice:• General / Family Medicine• Internal Medicine• Pediatrics, or• Obstetrics and Gynecology
• A Primary Care Provider can be:• Licensed Nurse Practitioners• Physician’s Assistants
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Specialty Providers cannot be selected as a PCP.
Wellness Premium Credits
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Wellness Activity How to Complete It When Members Can Take It
Subscriber selects a Primary Care Provider (PCP)A PCP must also be selected for each dependent covered on the State Health Plan.
Log into the eEnroll system to select a PCP.
If members have trouble contact 888-234-2416.
If you change your mind, you can select a different provider any time. (It takes 5 calendar days to update in the system)
Subscriber completes a confidential Health Assessment (HA)
Through the SHP website (www.shpnc.org), click on NC HealthSmart and log into Personal Health Portal.
If you completed a Health Assessment since Nov. 1, 2012, through the Personal Health Portal, it will count toward the premium credit.
Subscriber attests to being a non-smoker/commits to a cessation programand attests for spouse if applicable
During enrollment, Oct. 1-31, 2013.
Lower Your Premiums with Wellness Premium Credits—The Enhanced 80/20 Plan
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Complete up to Three Wellness ActivitiesBy October 31, 2013
Enhanced Plan Premium Credits
Subscriber attests to being a non-smoker/commits to a cessation program and attests for spouse if applicable
$20 per month
Subscriber (only) completes a confidential Health Assessment (HA)
$15 per month
Subscriber and covered dependents select a Primary Care Provider
$15 per month
Reduce your premium by up to… $50 per month
Monthly Premiums—Enhanced 80/20 Plan
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2014 Enhanced Plan Premiums
Coverage Type
Employee/ Monthly Premium
Dependent Monthly Premium
Total Monthly Premium
Wellness Premium Credits*
Net Monthly
Premium*
Employee Only
$63.56 N/A $63.56 $50.00* $13.56*
Employee + Child(ren)
$63.56 $272.80 $336.36 $50.00* $286.36*
Employee + Spouse
$63.56 $628.54 $692.10 $50.00* $642.10*
Employee + Family
$63.56 $666.38 $729.94 $50.00* $679.94*
*Assumes completion of three wellness activities
The Consumer-Directed Health Plan (CDHP) with HRAA different kind of health plan with two components
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Health Reimbursement Account (HRA)
High-Deductible Health Plan
• The Plan funds the members’ Health Reimbursement Accounts (HRA) annually
• $500 for employee only
• $1,000 for employee + 1
• $1,500 for employee + 2 or more dependents
• When HRA is depleted, the member must pay the remaining deductible & coinsurance
• Unused HRA funds roll to the following year
2• Covers the same services as
other Plan options through the same PPO network
• In-network: Deductible
$1,500 Individual/ $4,500 Family
• Out-of-Network: Deductible $3,000 Individual/ $9,000 Family
• After the deductible is met, 15% coinsurance
• The deductible applies to both Pharmacy and Medical expenses
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CDHP Highlights in 2014
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Coverage In-Network Out-of-Network
Plan-Provided HRA Contribution
$500 employee/retiree$1,000 employee/retiree + 1 dependent
$1,500 employee/retiree + 2 or more dependents
Annual Deductible $1,500 individual/$4,500 family $3,000 individual/$9,000 family
Coinsurance (after deductible is met)
15% of eligible expenses 35% of eligible expenses
Out-of-Pocket Maximum for medical and pharmacy (includes deductible)
$3,000 individual/$9,000 family$6,000 individual/$18,000 family
Office Visits(after deductible is met)
15% of eligible expenses; $15 added to HRA if the PCP on the ID card is utilized; $10 added to HRA if a Blue Options Designated specialist is utilized
35% of eligible expenses
Inpatient Hospital(after deductible is met)
15% of eligible expenses; $50 added to HRA if a Blue Options Designated hospital is utilized
35% of eligible expenses
ACA Preventive Medication List
$0 coinsurance, $0 deductible $0 coinsurance, $0 deductible
CDHP Preventive Medication List
15% coinsurance, $0 deductible 15% coinsurance, $0 deductible
Lower Member Health Care Costs with Wellness Incentives—CDHP
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Things you can do to reduce your costs…
CDHP Incentives
Visit the PCP listed on ID card $15 added to the HRA
Visit a Blue Options Designated specialist $10 added to the HRA
Get inpatient care in a Blue Options Designated hospital
$50 added to the HRA
Remember:
Get preventive care through an in-network provider in a non-hospital setting
100% coverage – this is provided at no cost to the member
ACA preventive medication list 100% coverage –no cost to the member
CDHP preventive medication list15% of eligible expense with no deductible
Example: CDHP Office Visit and Prescription
Present HRA ID Card at Office Visit. Total office visit $175 submitted to BCBSNC by provider.
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Claim processes in primary claims system and applies towards $1,500 deductible – EOB/EOP issued.
Claim automatically rolls over to HRA for adjudication - $175 remitted to provider-
Member picks up prescription at pharmacy and pays $65 because deductible has not been met.
Pharmacy claim automatically submitted to HRA. Member reimbursed $65.
At end of the month, $15 credited to member’s HRA for visiting PCP on ID Card.
Lower Premiums with Wellness Premium Credits—CDHP
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Complete up to Three Wellness Activities
By October 31, 2013
CDHPPremium Credits
Subscriber attests to being a non-smoker/commits to a cessation programand attests for spouse if applicable
$20 per month
Subscriber (only) completes a confidential Health Assessment (HA)
$10 per month
Subscriber selects a Primary Care Provider (and any covered dependents)
$10 per month
Reduce subscriber premium by … $40 per month
Monthly Premiums—CDHP
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2014 CDHP Premiums
Coverage Type
Employee Monthly Premium
Dependent Monthly Premium
Total Monthly Premium
Wellness Premium Credits*
Net Monthly
Premium*
Employee Only
$40.00 N/A $40.00 $40.00* $0*
Employee + Child(ren)
$40.00 $184.60 $224.60 $40.00* $184.60*
Employee + Spouse
$40.00 $475.68 $515.68 $40.00* $475.68*
Employee + Family
$40.00 $506.64 $546.64 $40.00* $506.64*
*Assumes completion of three wellness activities
Completing Open Enrollment
• Action must be taken during Open Enrollment:• Choose a health plan• Decide whom to cover• Complete wellness activities
• Remember, NC Flex Benefits enrollment in Oct. also.
• Online enrollment only – https://shp-login.hrtintouch.com
• Effective January 1, 2014 through December 31, 2014
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If you do not complete your enrollment by October 31, 2013, you, and any currently covered family members will be enrolled
in the Traditional 70/30 Plan effective Jan. 1, 2014.
Enrollment Instructions
eEnroll• All changes need to be done through the eEnroll system by logging in to the system at https://shp-login.hrintouch.com
• For assistance in navigating eEnroll members can call Benefitfocus Customer Service at 855-859-0966.
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NC FLEX – Vision Changes
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Plan 1 Basic Plan Exam and MaterialsNEW FOR 2014 Reduced premiums$20.00 co-pay on contact lens exam.
Increased frame allowance to $125 retailNew calendar year frequency.
Plan 2 Materials only No longer available
Plan 3 Enhanced Plan Enhanced Exam and materialsNEW FOR 2014 Reduced premiums$20.00 co-pay on contact lens exam.Increased frame allowance to $175 retailNew calendar year frequency.
NC FLEX – NEW Vision Benefit
• Core Wellness Exam• Annual Comprehensive Eye Exam• $20 copay• In-network providers only• Discounts on materials• No premium – but MUST enroll
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NC FLEX – NEW Group Term Life Option
• Employee and Spouse Coverage• Rates based on age of employee
• Employee and Child(ren) Coverage• Flat rate for child(ren) coverage
• If elected, premiums for Employee and Dependent(s) will be after-tax.
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NC Flex - Flexible Spending Accounts
• MUST re-enroll each year.• Employee-only contribution to reimburse yourself for eligible expenses
• Does not roll over• Not to be confused with HRA
• (Health Reimbursement Account)
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• Please READ your mail!
There will be 4 mailers sent to you to assist you in your decision.
• SHP Website• There will be 4 instructional videos posted to the Plan’s website.
• Premium Rate Calculator tool available online
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Resources for Members
Important Numbers
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• www.shp-login.hrintouch.com
• ELIGIBILITY AND ENROLLMENT for eEnroll855-859-0966
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• BLUE CROSS AND BLUE SHIELD OF NC (BENEFITS, CLAIMS and HRA) 888-234-2416