Selecting Health Coverage Through The
State Health Plan
Please print or type in black ink.
Section A.
FIRST NAME
Tell us about yourself.
MI
LAST NAME
SSN
DATE OF BIRTH
MAILING ADDRESS
MEMBER ID
CITY
Marital status:
Section B.
STATE
COUNTY
SINGLE
MARRIED
ZIP CODE
GENDER
MALE
WIDOWED
Optional Retirement Program
Legislative Retirement System
SEPARATED
ST CON OFF
DEDUCT OFF
ST CURRENT
ST RETRO
RET . DATE
DCT. CURRENT
DEDUCT RETRO
EFF. DATE
TOTAL
TOTAL
RSD USE ONLY
Consolidated Judicial Retirement System
FEMALE
DIVORCED
Please check appropriate box for eligibility.
Teachers' and State Employees' Retirement System
TELEPHONE NO.
Disability Income Plan of North Carolina
Surviving Spouse
Section C.
Please indicate the reason you are updating your coverage.
Please check one of the following and comply with the special instructions.
I am choosing coverage for the first time as a new retiree or recipient of extended short-term or long-term disability
benefits. Complete all sections except Section F.
I have existing coverage, but I want to choose my coverage for the 2007-2009 plan year during Annual Enrollment
(March 1 through March 30, 2007). Complete all sections.
I want to cancel or decline coverage for myself. The only other sections you need to complete are Sections F and J.
I have existing coverage, but I want to change who in my family is covered. Skip to Section E.
Section D.
Please
check one:
Section E.
Please
check one:
Please check the type of coverage you desire, if applicable.
Indemnity
Plan
PPO 70/30 Plan
SM
(NC SmartChoice Basic)
PP0 80/20 Plan
SM
(NC SmartChoice Standard)
PPO 90/10 Plan
SM
(NC SmartChoice Plus)
Please choose which family members you will cover.
RETIREE
ONLY
RETIREE AND CHILD(REN)
Spouse not included
RETIREE AND SPOUSE
Children not included
RETIREE AND FAMILY
Spouse and dependent
children, if any, included.
Note: For the Indemnity plan, the rate for RETIREE AND SPOUSE is the same rate as RETIREE AND FAMILY.
Please continue to the next page.
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Page 1 of 3
SSN
Section F.
Please give the events that caused you to modify your coverage, if applicable
If adding, changing, or canceling coverage, please give the event that caused your change and its date (mm-dd-yyyy).
Annual Enrollment
Death
Foster child
Other coverage
Student
No longer student
Marriage
Newborn
Max student age 26
Separation
Step/Adopted
Max child age 19
Divorce
Other (Specify:)
Section G.
Please list any family members to be added, continued, or removed from coverage.
For anyone added or removed from coverage, be sure to give the reason in Section F.
SPOUSE
ADD OR CONTINUE
FIRST NAME
REMOVE
MI LAST NAME
Gender
SSN
MALE
FEMALE
DATE OF BIRTH
ELIGIBLE FOR
MEDICARE?
YES
NO
CHILDREN (You must attach documentation to prove legal guardianship or custody for children not added by birth or marriage.)
ADD OR CONTINUE
FIRST NAME
REMOVE
MI LAST NAME
Gender:
SSN
MALE
FEMALE
DATE OF BIRTH
IF CHILD IS OVER 19:
STUDENT
HANDICAPPED
NATURAL
STEPCHILD
ADD OR CONTINUE
FIRST NAME
FOSTER
REMOVE
MI LAST NAME
ADOPTED
Gender:
SSN
ELIGIBLE FOR MEDICARE?
MALE
FEMALE
DATE OF BIRTH
YES
NO
IF CHILD IS OVER 19:
STUDENT
HANDICAPPED
NATURAL
STEPCHILD
ADD OR CONTINUE
FIRST NAME
FOSTER
REMOVE
MI LAST NAME
ADOPTED
Gender:
SSN
ELIGIBLE FOR MEDICARE?
MALE
FEMALE
DATE OF BIRTH
YES
NO
IF CHILD IS OVER 19:
STUDENT
HANDICAPPED
NATURAL
STEPCHILD
ADD OR CONTINUE
FIRST NAME
FOSTER
REMOVE
MI LAST NAME
ADOPTED
Gender:
SSN
ELIGIBLE FOR MEDICARE?
MALE
FEMALE
DATE OF BIRTH
YES
NO
IF CHILD IS OVER 19:
STUDENT
HANDICAPPED
NATURAL
STEPCHILD
ADD OR CONTINUE
FIRST NAME
FOSTER
REMOVE
MI LAST NAME
ADOPTED
Gender:
SSN
ELIGIBLE FOR MEDICARE?
MALE
FEMALE
DATE OF BIRTH
YES
NO
IF CHILD IS OVER 19:
STUDENT
HANDICAPPED
NATURAL
STEPCHILD
FOSTER
ADOPTED
ELIGIBLE FOR MEDICARE?
YES
NO
Please continue to the next page.
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Page 2 of 3
SSN
Section H.
List yourself and any other persons who are eligible for Parts A and B of Medicare.
Medicare Parts A and B are required to continue the same level of coverage when you or dependents become Medicare eligible.
YOURSELF
Are you eligible for Medicare?
FIRST NAME
YES
NO
If YES, then please give the following:
MI LAST NAME
ELIGIBILITY IS DUE TO:
AGE
MEDICARE CLAIM NO.
DISABILITY
DATES OF ENROLLMENT
PART A
PART B
RENAL DISEASE
If eligibility is due to renal disease, please give the date that dialysis began
OTHERS
Is anyone you listed in Section G eligible for Medicare?
FIRST NAME
YES
MI LAST NAME
ELIGIBILITY IS DUE TO:
AGE
NO
If YES, then please give the following:
MEDICARE CLAIM NO.
DISABILITY
DATES OF ENROLLMENT
PART A
PART B
RENAL DISEASE
If eligibility is due to renal disease, please give the date that dialysis began
Section I.
Please complete if you or your dependents are covered by another group health policy.
Coverage type:
Self only
POLICY NUMBER
Parent/Child(ren)
Self/Spouse
POLICY HOLDER'S NAME
Family
SSN
Effective date:
DATE OF BIRTH
NAME OF INSURANCE COMPANY
NAME OF EMPLOYER PROVIDING THE POLICY
ADDRESS OF INSURANCE COMPANY
ADDRESS OF EMPLOYER
CITY
Section J.
STATE
ZIP
CITY
STATE
ZIP
Please authorize with your signature. Unsigned forms cannot be processed.
I hereby elect coverage under the plan listed above for myself and eligible family dependents listed, if any, and I agree that the
information provided is correct. I further agree that I/we shall abide by the provisions of the Agreement of the plan in which I/we
are enrolling. I hereby authorize the Retirement System, until I revoke by written notice, to deduct from my benefit payment the
retiree contribution, if any, required for the above indicated coverage. I authorize any licensed physician, medical practitioner,
hospital, clinic, or other medically related facility, insurance company, or other organization or institution that has any records or
knowledge of the health of myself or any other covered member of my family to exchange such information with the plan I have
selected. I certify by my signature that I have completed pages 1, 2, and 3 of this form.
Desired effective date of change, if applicable (mm-01-yyyy):
Signature _________________________________________________________________________ Date ________________
Section K.
Please submit this form by mail or fax.
This form is also available online at www.myncretirement.com.
• You may mail the completed form(s) to the address below.
• You may fax the completed form(s) to (919) 508-5350
Thank you.
N.C. Department of State Treasurer, Retirement Systems Division
325 North Salisbury Street, Raleigh, North Carolina 27603-1385
(919) 733-4191 in the Raleigh area or (877) 733-4191 toll free
www.myncretirement.com
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This page is intentionally blank. Please continue to the Guides.
Guides to Selecting Health Coverage
Through the State Health Plan
Guide A.
Am I or my dependents eligible for coverage?
Am I eligible for coverage?
If you belong to the Teachers' and State Employees'
Retirement System, the Consolidated Judicial Retirement
System, or the Legislative Retirement System, and have five
(5) or more years of retirement membership service credit,
and you were hired prior to October 1, 2006, you are eligible
for coverage if:
first full month of benefits. Please consult your employer about
the date your prior health insurance coverage will end.
• You are a retiree. Under current law, the State pays for all of
your individual coverage.* Your coverage is effective the first
day of the next month following the effective retirement date.
For example, if your effective date of retirement is July 1, 2007,
your retired group health coverage will be effective August 1,
2007. If you are actively serving at the time you enter
retirement, your System employer provides coverage for the
thirty (30) days following the effective retirement date. If you
begin coverage when first available to you as a retiree, there
are no pre-existing condition clauses, but you should be
careful not to cancel prior-retirement coverage too soon.
If you are a member of the Local Governmental Employees'
Retirement System, you should check with your employer
about the availability of health insurance coverage, if any, for
its retirees.
• You are receiving extended short-term or long-term
disability benefits through the Disability Income Plan of North
Carolina (DIPNC) and you have met the requirement of having
five (5) or more years of retirement membership service. Under
current law, the State pays for all of your individual coverage.*
However, if you have not met the retirement membership
requirement, you are eligible for coverage, but the cost of the
coverage is entirely your responsibility. If you are receiving
DIPNC benefits under transitional clauses, you are eligible for
coverage, but the cost of the coverage is entirely your
responsibility. Regardless, your coverage is effective the first
of the following month if your disability benefit period begins
between the 1st and the 14th of the month. If your benefit
period begins between the 15th and the 31st of the month,
your coverage is effective the first of the month following the
Guide B.
If you are retired under the Optional Retirement Program, you
are also eligible for coverage, provided you met the
requirement of having five (5) years of membership service
under the Optional Retirement Program. Under current law, the
State pays for all of your individual coverage.*
Is my family eligible for coverage?
If you are eligible for health insurance coverage, then your
spouse and your eligible dependents are also eligible for
coverage. An eligible dependent child can be covered until age
19 or until age 26, if a full-time student. Eligible dependents
include your natural children, your children through marriage,
or your adopted and foster children. However, you are
responsible for the cost of the coverage for any dependents
covered.
What happens to my dependents' coverage at my death?
If you were providing your spouse and/or eligible dependents
with health insurance at the time of your death, then they are
eligible for continued coverage (child coverage would continue
based on the conditions above) after your death. At that time,
they would be wholly responsible for the cost of the coverage.
Please inform your spouse and eligible dependents to
immediately report your death to the Retirement Systems
Division with a death certificate. If they want to continue
coverage, they must also submit an Form HM at that time; they
will later be contacted with further instructions.
*The enhanced coverage offered through the 90/10 PPO plan
is available at additional cost.
Does the cost of my coverage change? When do my choices become effective?
What impact does Medicare have on the cost of coverage?
If you are receiving disability benefits, or if you are a retiree
under the age of 65, the cost of coverage begins at a certain
rate. Under current provisions, the rate decreases when you
become eligible for Medicare. You will only notice this
decrease if you choose a level of coverage in which you pay
part of the cost.
Under current provisions, the rates also decrease when your
spouse or dependents become eligible for Medicare. Please
be sure they too apply for Medicare as soon as they are
eligible. At any time your spouse or dependents become
eligible for Medicare, you must inform the Retirement Systems
Division by completing a new Form HM, available at
www.myncretirement.com.
You must apply for Medicare coverage, both Parts A (hospital
coverage) and B (medical coverage) through the Social
Security Administration, as soon as you are eligible, in order to
maintain the same level of coverage you enjoyed prior to
becoming eligible for Medicare. To learn about applying for
Medicare, visit www.medicare.gov or call 1-800-MEDICARE.
Part A of Medicare is free, but Part B is not.
When you begin coverage, you will choose (a) one of four
plans to cover you (or your family) and (b) whether to provide
coverage for your spouse and/or dependents. You may drop
and add eligible dependents from coverage at any time by
completing another Form HM. However, a pre-existing
condition waiting period may apply if there is no qualifying
Please continue to the next page.
What if I change my mind about the coverage I want?
GUIDES
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Guide B.
(Continued)
event. The change can be made as early as the first day of the
month following the date the form is signed. However, Form
HM should be submitted to the Retirement Systems Division
by the 10th of the month in order for the change to be
processed on the first day of the following month. You have a
choice among four health plans: the Indemnity plan and three
PPO plans. See Guides C and G for a comparison of these.
You will have a period of time each year (annual enrollment) in
which you may change between the four plans offered.
The information in Guides B, E, G, is provided to you on behalf
of the State Health Plan. Please contact State Health Plan
Customer Services at 1-800-422-4658 with any questions you
may have about the Idemnity plan or 1-888-234-2416 for the
PPO plans. The Retirement Systems Division cannot provide
further information about these plans or guide you in choosing
one.
You have a choice among four plans. This choice includes the
three preferred provider organization (PPO) plans and the
Indemnity plan. First you should consider if you prefer the
PPO or Indemnity.
What are the key features of the PPO plans?
As a NC SmartChoiceSM Blue OptionsSM PPO member you will
receive services at reduced out-of-pocket costs when you use
in-network providers. Also, you decide when to visit a
specialist and whether to select a provider from in-network or
out-of-network. Referrals are never required for visits to your
provider even when you use an out-of-network provider.
PPO Plan Name
Guide C.
What type of plan is best for me, one of the PPO plans or the Indemnity plan?
The State Health Plan has contracted with Blue Cross Blue
Shield to use their BlueOptions® program. The BlueOptions®
program has contracted with most primary care physicians,
specialists, and hospitals in North Carolina.
In-network
providers are located in all 100 counties in North Carolina. If
you are not a NC resident or frequently travel outside of North
Carolina, you can receive care from any participating Blue
Cross Blue Shield provider at the same in-network benefit level
through the BlueCard® program. This program also provides
you with worldwide coverage. To find out if your provider
participates in the BlueOptions® program you can visit the
State Health Plan at www.shpnc.org and click on “Find a
Doctor,” or you can call 1-800-810-BLUE (2583) for
out-of-state providers.
Sample
Plan coDeductible insurance
Compared
to other
PPO
SmartChoice
SM
Basic
$600
70%
lowest cost
SmartChoice
SM
Standard
$300
80%
mid cost
SmartChoice
SM
Plus
$150
90%
highest cost
What are the key features of the Indemnity plan?
The Indemnity plan offers the traditional coverage. At each
office visit and specialist visit, you pay a copay and then you
pay the remainder of the bill for that visit and each visit there
after until the cumulative amount you have paid for treatment
reaches a certain limit (your deductible) for that plan year.
After you reach your deductible, your health insurance pays a
percentage of the remaining bill and you pay the rest (these
percentages are called plan coinsurance and member
coinsurance, respectively). You pay the coinsurance for each
treatment until you reach another limit (coinsurance
maximum).
How else can the PPO and Indemnity plans be compared?
Comparatively the monthly cost to you (premiums) for
dependents under the Indemnity plan is more than the basic
and standard PPO plans, but less than the PPO Plus plan.
You may prefer a PPO plan if:
• You want to cover your spouse only, at a rate that is not the
same as covering your entire family.
• You are looking for reduced premiums because you cover
more than just yourself.
• You want lower out-of-pocket costs each time you seek care.
• You want your health insurance to offer less restrictive
coverage for wellness and preventative health.
The three available PPO plans are chiefly differentiated by
their copays, deductibles and coinsurance rates. Higher
deductibles and lower (plan-paid) coinsurance means lower
monthly costs (lower premiums) for you, but possibly higher
portions of your medical bill for which you are responsible
(higher out-of-pocket costs). In contrast, lower deductibles and
higher (plan-paid) coinsurance mean higher monthly costs to
you, but possibly lower out-of-pocket costs and visits.
You may prefer the Indemnity plan if:
• You already have a relationship with a physician who is
out-of-network under the PPO plan
Premiums for health insurance coverage are paid one month in
advance. For example, a deduction from the January benefit is
for coverage effective for the month of February. If you are
receiving a disability benefit or receiving a retirement benefit,
your premiums are automatically deducted from your benefit
check. If the premiums for which you are responsible exceed
the amount of your benefit, then the North Carolina State
Health Plan will bill you directly each month for the total
premiums. If you are covered on the basis of being a spouse
or dependent of a deceased member, you may have the
premiums deducted from a survivor's benefit you are receiving
from the Retirement System. Or, the State Health Plan will bill
you directly. Under all cases, premiums are not tax-deferred.
Guide D.
For a detailed comparison of all plans, see Guide G. For a
quote of all current rates, see Guide E. If you have questions
regarding which plan to choose, please contact State Health
Plan Customer Services at 1-800-422-4658 for the Idemnity
plan or 1-888-234-2416 for the PPO plans.
How will I pay for additional premiums not paid by the State?
Please continue to the next page.
GUIDES
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Guide E. What are the monthly premiums for Plan Year 2007/2009?
Plan Year 2007-2009
Preferred Provider Organization (PPO) Plans
70/30 PPO Plan
90/10 PPO Plan
80/20 PPO Plan
SM
SM
SM
Indemnity Plan
SmartChoice
SmartChoice
SmartChoice
Basic
Plus
Standard
Before you are Medicare eligible, and before your spouse or dependents, if any, are eligible:
October 1, 2007 - June 30, 2009
Retiree
Retiree + Child(ren)
Retiree + Spouse
Retiree + Family
$0
$223.00
$534.88
$534.88
$0
$150.66
$388.18
$413.46
$0
$200.36
$461.64
$489.44
$43.98
$269.78
$564.22
$595.52
$0
$200.36
$461.64
$489.44
$33.48
$259.28
$553.72
$585.06
$0
$152.52
$344.64
$372.44
$43.98
$215.86
$432.36
$463.68
$0
$152.52
$344.64
$372.44
$33.48
$205.36
$421.86
$453.18
After you are Medicare eligible, but your spouse or dependent(s), if any, are not:
Retiree
Retiree + Child(ren)
Retiree + Spouse
Retiree + Family
$0
$223.00
$534.88
$534.88
$0
$158.18
$395.70
$420.98
Before you are Medicare eligible, but after your spouse or dependent(s) are:
Retiree
Retiree + Child(ren)
Retiree + Spouse
Retiree + Family
$0
$169.52
$406.52
$406.52
$0
$107.18
$281.84
$307.10
After you are Medicare eligible, and your spouse and dependents are too:
Retiree
Retiree + Child(ren)
Retiree + Spouse
Retiree + Family
$0
$169.52
$406.52
$406.52
$0
$114.70
$289.34
$314.62
For more information, visit the State Health Plan on the web at www.shpnc.org or call 1-800-422-4658 contact State
Health Plan Customer Services at 1-800-422-4658 for the Idemnity plan or 1-888-234-2416 for the PPO plans.
The Retirement Systems Division cannot provide additional information about these plans or guide you in choosing one.
Guide F.
Whom can I contact with questions?
Contact the Retirement Systems Division at the address or
number below, or visit online at www.myncretirement.com, if
you have questions about (a) your enrollment under the retiree
group, (b) determining your or your family member's eligibility
under the retiree group of the State Health Plan or (c) which
premium rate you will pay.
Please continue to the next page.
Contact the State Health Plan Customer Services if you have
questions about: (a) which plan to choose, (b) a specific claim,
(c) your coverage as a spouse or dependent of a deceased
member (d) insurance cards or benefits booklets, or (e) finding
a provider. Indemnity plan members call 1-800-422-4658. NC
SM
SmartChoice
Blue OptionsSM PPO members call
1-888-234-2416.
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Guide G.
What are the plan choices offered by the North Carolina State Health Plan for the Plan Year 2007/2009?
The Retirement Systems Division cannot provide further information about these plans or guide you in choosing one.
Preferred Provider Organization (PPO) Plans
Plan Year 2007-2009
October 1, 2007- June 30, 2009
Plan Design Feature
Lifetime Maximum
Annual Deductible (Ind/Fam)
Plan Coinsurance
Primary Care
Specialist
Urgent Care
70/30 PPO Plan
SM
SmartChoice Basic
80/20 PPO Plan
SM
SmartChoice Standard
90/10 PPO Plan
SM
SmartChoice Plus
(Indemnity Plan)
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
$5 million
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
$300/$900*
$600/$1800*
$150/$450*
$300/$900*
80%
60%
90%
70%
$450/$1350
80%
Coinsurance Maximum (Ind/Fam)
Physician Office
Visits
Indemnity Plan
$2,000/$6,000
$25 plus D&C (see notes below)
$25 plus D&C
--
$600/$1800* $1,200/$,3600*
70%
50%
$2,500/$7,500 $5,000/$15,000 $1.750/$5,250 $3,500/$10,500 $1,000/$3,000 $2,000/$6,000
$25
$50
$75
Covered after D&C
Covered after D&C
$75
$20
$40
$50
Covered after D&C
Covered after D&C
$50
$15
$30
$50
Covered after D&C
Covered after D&C
$50
Inpatient copay
$150, then D&C
$200, then D&C
$150, then D&C
$100, then D&C
Outpatient Hospital and Ambulatory
Surgical Center copay
$75, then D&C
D&C
D&C
D&C
Emergency Room copay
$150, then D&C
$250, then D&C
$200, then D&C
$150, then D&C
Wellness Benefits (annual)
$150
Generic Rx copay
Preferred Rx copay
Prescription (no generic equivalent)
Drug Benefits Preferred Rx copay
(generic equivalent)
Non-preferred Rx copay
$10
$30
$10
$30
$10
$30
$10
$30
$40
$40
$40
$40
$50
$50
$50
$50
Per benefits
Not covered
Per benefits
Not covered
Per benefits
Not covered
• D&C stands for deductible and coinsurance.
• For the PPO options, in most cases, there are no deductibles for physician office visits. Only the copayment applies. Some in-network hospital owned/operated practices
may be subject to deductible and co-insurance. Please call your physician or see the Provider Directory to determine if his/her practice is hospital owned or operated.
• For the PPO Options, for Wellness/Preventative Health Coverage, please refer to the Summary of Benefits provided by the State Health Plan.
• NC HealthSmart, the State Health Plan's healthy living initiative, is available at no additional cost, but those eligible for Medicare are not eligible for the initiative.
• The current drug benefit does not change under any of the plans, except for diabetic supplies. Diabetic supplies are covered under the PPO plans for a copayment.
For more information, see Guides E and F for complete contact information. Thank you.
GUIDES
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