Embracing a Healthy Lifestyle through the State Health Plan
New Plan Options and Incentives for 2014
Why Are We Making Changes for 2014?
• 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.
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Open Enrollment 2014
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.
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Health Plan Options for 2014
Traditional 70/30 Plan
• The current Basic
70/30 Plan with a
new name
• No incentives
available
• No $0 ACA
(Affordable Care Act)
Preventive Services/
Medications
NEW: Consumer-Directed
Health Plan (CDHP) with
HRA
Enhanced 80/20 Plan
• The current Standard
80/20 Plan with a new
name to match the
new features
•
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
• $0 ACA Preventive
Services
• $0 ACA Preventive
Medications
• New Wellness
Incentives
• Reduced medical
copay opportunities
• Additional HRA funds for
visiting certain providers
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A New Focus On Wellness
Traditional 70/30
Plan
• No incentives
available
• No $0 ACA
Preventive
Services
• No $0 ACA
Preventive
Medications
Enhanced 80/20 Plan
NEW: Consumer-Directed Health
Plan (CDHP) with HRA
Wellness premium
credits when:
Wellness premium credits
when:
• Subscriber completes
a Health Assessment
• Subscriber attests for
him/herself and spouse (if
applicable) to not
smoking
• 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
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• Selecting a Primary Care
Provider (PCP) for self and
dependents
• Additional wellness
incentives
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
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 expenses
50% 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
Tier 1 $12 copay
Tier 1 $12 copay
Tier 2 $40 copay
Tier 2 $40 copay
Tier 3 $64 copay
Specialty medications 25% up to
$100 maximum per 30-day supply
Tier 3 $64 copay
Specialty medications 25% up to
$100 maximum per 30-day supply
Prescription Drugs
(for 30-day supply)
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Monthly Premiums—Traditional 70/30Plan
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.
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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
Coverage
Annual Deductible
In-Network
Out-of-Network
$700 individual/$2,100 family
$1,400 individual/$4,200 family
Coinsurance
(after deductible is met)
20% of eligible expenses
40% 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
$30 copay for primary doctor; $15 copay if
the PCP on the ID card is utilized
Office Visits
Inpatient Hospital
Prescription Drugs
(for 30-day supply)
$70 copay for specialists; $60 copay if a
Blue Options Designated specialist is
utilized
$233 copay, then 20% after deductible;
copay avoided if a Blue Options
Designated hospital is utilized
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
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40% after deductible
$233 copay, then 40% after
deductible
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
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 innetwork provider in a non-hospital setting
100% coverage – this is provided at
no cost to you
ACA preventive medication list
100% coverage – this is provided at
no cost to you
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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
Specialty Providers cannot be selected as a PCP.
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Wellness Premium Credits
Wellness Activity
Subscriber selects a
Primary Care Provider
(PCP)
How to Complete It
When Members Can Take It
A PCP must also be selected for
each dependent covered on the State
Health Plan.
Log into the eEnroll system If you change your mind, you
to select a PCP.
can select a different provider
any time. (It takes 5 calendar
If members have trouble
days to update in the system)
contact 888-234-2416.
Subscriber completes
a confidential
Health Assessment
(HA)
Through the SHP website
(www.shpnc.org), click on
NC HealthSmart and log
into Personal Health Portal.
Subscriber attests to
being a nonsmoker/commits to a
cessation program
and attests for spouse
if applicable
If you completed a Health
Assessment since Nov. 1,
2012, through the Personal
Health Portal, it will count
toward the premium credit.
During enrollment, Oct. 1-31,
2013.
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Lower Your Premiums with Wellness Premium Credits—
The Enhanced 80/20 Plan
Complete up to Three Wellness Activities
By October 31, 2013
Enhanced Plan
Premium Credits
Subscriber attests to being a nonsmoker/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…
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$50 per month
Monthly Premiums—Enhanced 80/20 Plan
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
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The Consumer-Directed Health Plan (CDHP) with HRA
A different kind of health plan with two components
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2
High-Deductible Health Plan
• 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
Health Reimbursement
Account (HRA)
• 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
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CDHP Highlights in 2014
Coverage
Plan-Provided HRA
Contribution
Annual Deductible
In-Network
$500 employee/retiree
$1,000 employee/retiree + 1 dependent
$1,500 employee/retiree + 2 or more dependents
$1,500 individual/$4,500 family
Coinsurance
15% of eligible expenses
(after deductible is met)
Out-of-Pocket Maximum
for medical and pharmacy $3,000 individual/$9,000 family
(includes deductible)
15% of eligible expenses; $15 added to HRA
Office Visits
if the PCP on the ID card is utilized; $10
(after deductible is met)
added to HRA if a Blue Options Designated
specialist is utilized
Inpatient Hospital
(after deductible is met)
ACA Preventive
Medication List
CDHP Preventive
Medication List
Out-of-Network
$3,000 individual/$9,000 family
35% of eligible expenses
$6,000 individual/$18,000
family
35% of eligible expenses
15% of eligible expenses; $50 added to HRA
if a Blue Options Designated hospital is
35% of eligible expenses
utilized
$0 coinsurance, $0 deductible
$0 coinsurance, $0 deductible
15% coinsurance, $0 deductible
15% coinsurance, $0
deductible
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Lower Member Health Care Costs with Wellness Incentives
—CDHP
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
$10 added to the HRA
specialist
Get inpatient care in a Blue Options
$50 added to the HRA
Designated hospital
Remember:
Get preventive care through an innetwork provider in a non-hospital
setting
ACA preventive medication list
CDHP preventive medication list
100% coverage – this is provided at
no cost to the member
100% coverage –no cost to the
member
15% of eligible expense with no
deductible
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Example: CDHP Office Visit and Prescription
Present HRA ID Card at Office
Visit. Total office visit $175
submitted to BCBSNC by provider.
Member picks up prescription at
pharmacy and pays $65 because
deductible has not been met.
Claim automatically rolls over
to HRA for adjudication - $175
remitted to provider-
Pharmacy claim automatically
submitted to HRA. Member
reimbursed $65.
Claim processes in primary claims
system and applies towards
$1,500 deductible – EOB/EOP
issued.
At end of the month, $15 credited
to member’s HRA for visiting PCP
on ID Card.
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Lower Premiums with Wellness Premium Credits
—CDHP
Complete up to Three Wellness
Activities
By October 31, 2013
CDHP
Premium Credits
Subscriber attests to being a nonsmoker/commits to a cessation program
and 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 …
20
$40 per month
Monthly Premiums—CDHP
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
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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
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.
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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
Plan 1 Basic Plan
Exam and Materials
NEW FOR 2014
Reduced premiums
$20.00 co-pay on contact lens exam.
Increased frame allowance to $125 retail
New calendar year frequency.
Plan 2 Materials only
No longer available
Plan 3 Enhanced Plan
Enhanced Exam and materials
NEW FOR 2014
Reduced premiums
$20.00 co-pay on contact lens exam.
Increased frame allowance to $175 retail
New calendar year frequency.
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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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Resources for Members
• 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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Important Numbers
• www.shp-login.hrintouch.com
• ELIGIBILITY AND ENROLLMENT for eEnroll
855-859-0966
•
• BLUE CROSS AND BLUE SHIELD OF NC
(BENEFITS, CLAIMS and HRA)
888-234-2416
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Thank you!
www.shpnc.org
www.nctreasurer.com
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