Embracing a Healthy Lifestyle through the State Health Plan
New Plan Options and Incentives for 2014
Agenda
• Why are we Making Changes for 2014?
• New Plan Options for 2014
• Introducing New Wellness Incentives
• Open Enrollment for 2014
• Additional Resources
2
Why Are We Making Changes for 2014?
• The State Health Plan is providing more choice for members. The
Treasurer conducted a listening tour across the state last year and
the Plan has conducted various focus groups and surveys and the
message has been clear, members have stated that they want more
options.
• Many of the changes and new choices are designed to encourage
members to become more engaged in their health and take steps to
live a healthier life.
• The Plan also believes an engaged membership will help ensure that
the State Health Plan remains financially stable in the years ahead.
3
Health Plan Options for 2014
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
•
•
The current Basic 70/30
Plan with a new name
A Health Reimbursement
Account (HRA) to help offset
the deductible
•
No incentives available
•
No $0 ACA Preventive
Services
•
No $0 ACA Preventive
Medications
•
$0 ACA Preventive Services
•
$0 ACA Preventive
Medications
•
85/15 Coinsurance
New Wellness Incentives
•
$0 ACA Preventive Services
•
$0 ACA Preventive
Medications
•
CDHP Preventive Medication
List ($0 deductible)
•
New wellness incentives
•
•
Reduced medical copay
opportunities
Traditional 70/30 Plan
• Additional HRA funds for
visiting certain providers
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.
4
A New Focus On Wellness
Enhanced 80/20 Plan
NEW: Consumer-Directed Health
Plan (CDHP) with HRA
• Wellness premium credits when:
• Subscriber completes a Health
Assessment
• Subscriber attests for him/herself
and spouse (if applicable) to not
smoking...or to being in a
smoking cessation program
• Wellness premium credits when:
• Subscriber completes a Health
Assessment
• Subscriber attests for him/herself
and spouse (if applicable) to not
smoking...or to being in a smoking
cessation program
•
Selecting a Primary Care
Provider (PCP) for self and all
dependents
• Additional wellness incentives
• $15 copay reduction for utilizing
the PCP (or someone in that
practice) listed on the ID card
• $10 specialist copay reduction
for utilizing a Blue Options
Designated Specialist
• $0 inpatient hospital copay for
utilizing a Blue Options
Designated Hospital
•
Selecting a Primary Care Provider
(PCP) for self and dependents
• Additional wellness incentives
• $15 added to the HRA when the
PCP (or someone in that practice)
listed on the ID card is seen
• $10 added to the HRA when a
Blue Options Designated
Specialist is seen
• $50 added to the HRA when a
Blue Options Designated Hospital
is utilized for inpatient services
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Traditional 70/30 Plan
• No incentives available
• No $0 ACA Preventive Services
• No $0 ACA Preventive
Medications
Wellness Premium Credits
Wellness Activity
How to Complete It
When Members Can Take It
Subscriber selects a
Primary Care
Provider (PCP)
Log into the BEACON/eEnroll system to
select a PCP. If members have trouble
locating a provider, they can contact
888-234-2416.
Subscribers don’t have to wait until
October to choose a PCP. They can
choose one NOW. If they change their
mind, they 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 State Health Plan website
(www.shpnc.org), click on NC
HealthSmart and member logs into
Personal Health Portal. Health
Assessments can also be completed by
telephone at 800-817-7044.
A new shorter assessment is NOW
available on the Personal Health Portal.
If the member has completed a Health
Assessment since Nov. 1, 2012, through
the Personal Health Portal, it will count
toward the premium credit. Members
may also complete the HA during Open
Enrollment via the enrollment portal.
Subscriber attests to
being a nonsmoker/commits to a
cessation program
and attests for
spouse if applicable
Through the online enrollment system.
For instructions, go to the State Health
Plan website (www.shpnc.org), click on
Important Forms under “Quick Links”
and select Enroll in a plan.
During enrollment, Oct. 1-31, 2013.
To quit smoking, the Plan offers
assistance through QuitlineNC.
Members can access online at
www.QuitlineNC.org or call 800-QUITNOW (800-784-8669)
A PCP must also be
selected for each
dependent covered on the
State Health Plan.
6
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.
7
What Is a Blue Options Designated Provider?
• Blue Options Designated providers meet BCBSNC criteria for:
• Delivering quality health outcomes
• Cost effectiveness
• Accessibility by members
• The Blue Options Designated provider network includes hospitals and certain
types of specialists:
• General Surgery
• Ob-Gyn
• Gastroenterology
• Orthopedics
• Cardiology
• Neurology
To find a Designated Blue Options provider, members may go online to www.shpnc.org and
click on Member Services, then on “Find a Doctor or Facility” or call 888-234-2416
8
The Enhanced 80/20 Plan
• An enhanced version of the current Standard 80/20 Plan, except
• New name – The Enhanced 80/20 Plan
• New incentives to encourage members to manage their health and lower their health care
costs
• Preventive Care – There will be no copays on Affordable Care Act (ACA ) preventive
services or preventive medications.
• Primary Care Provider (PCP) – To receive a $15 PCP copay reduction, a PCP must be
selected by Oct. 31, 2013.
• If the selected 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. A new ID card with the PCP’s information will be mailed to the member. The PCP
change must be made before visiting the new PCP.
• Providers* - When a specialist or hospital is needed, members have the option to select a Blue
Options Designated Provider:
• Specialists – To receive a $10 Specialist copay reduction, choose a Blue Options
Designated provider
• Hospitals – To avoid a $233 Inpatient Hospital copay, select a Blue Options Designated
Hospital
*Members may visit any provider in the BCBSNC Blue Options network and be considered “in-network”. The additional
rewards are tied to the incentives outlined above and throughout this presentation.
9
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 any covered dependents selects
a Primary Care Provider
$15 per month
Reduce your premium by up to…
$50 per month
10
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
Your copay is reduced by $15
Visit a Blue Options Designated specialist Your copay is reduced by $10
Get inpatient care in a Blue Options
Designated hospital
Your $233 copay is not applied
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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ACA Preventive Medications
Drug or Drug Category
Criteria
Aspirin (to prevent cardiovascular events)-Generic
OTC 81mg and 325mg
Men ages 45 to 79 years and women ages 55 to 79
years
Fluoride – Generic OTC and prescription products
Children older than 6 months of age through 5 years
old
Folic Acid – Generic OTC and prescription products
0.4 – 0.8 mg
Iron Supplements – Generic OTC and prescriptions
products
Women through age 50 years
Children ages 6 to 12 months who are at risk for
iron deficiency anemia
Smoking Cessation – Generic OTC patches and gum
Members must contact QuitlineNC for OTC product
coverage
Vitamin D – Generic OTC and prescription products
Men and Women ages ≥ 65 who are at increased
risk for falls
Women’s Preventive Services & contraception
coverage
1) Barrier contraception- i.e. caps, diaphragms
2) Generic hormonal contraception
3) Emergency contraception
4) Implantable medications
5) Intrauterine contraception
Women through age 50
You must have a Prescription for these medication to have them covered at 100%
12
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 not applied 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
The Consumer-Directed Health Plan (CDHP) with HRA
A different kind
of health plan
with two
components

High-Deductible Health Plan

Health Reimbursement
Account (HRA)
• Covers the same services as other
Plan options through the same PPO
network
• The Plan funds the members’ Health
Reimbursement Accounts (HRA)
annually
• The deductible is higher than other
Plan options, but the coinsurance is
lower
• HRA funding is based on the
number of family members covered
• In-network: $1,500 Individual/
$4,500 Family
• Out-of-Network: $3,000 Individual/
$9,000 Family
• After the deductible is met, the
member only pays the 15%
coinsurance
• The deductible applies to both
Pharmacy and Medical expenses
• If the member reaches his or her
deductible and coinsurance out-ofpocket maximum, the Plan pays
100% of the covered expenses for the
rest of the benefit year (medical and
pharmacy)
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• $500 for employee/retiree only
• $1,000 for employee/retiree + 1
$1,500 for employee/retiree + 2
or more dependents
• HRA funds are used to pay a portion
of the members’ deductibles &
coinsurance
• Once the HRA is depleted, the
member must pay the remaining
deductible & coinsurance
• Incentives available to add value to
HRA
• Unused HRA funds are available the
following year
The Consumer-Directed Health Plan (CDHP)
A High Deductible Health Plan is exactly what it says –
A plan with a high front-end deductible.
•
After meeting the deductible the member pays a 15% coinsurance on all innetwork medical and pharmacy benefits except ACA preventive services and ACA
preventative medications, which are covered at 100%.
• The pharmacy and medical deductible and out-of-pockets are shared.
• An additional CDHP preventive medication list is covered with no deductible
meaning the member is subject to 15% of eligible expense only.
15
Consumer Directed Health Plan (CDHP): Pharmacy Benefits
The Deductible Does Not Apply to Every Medication
• Under the Affordable Care Act, many ACA preventive
medications are paid at 100%
• Medications on the CDHP Preventive medication are subject to
15% coinsurance with no deductible. Example of medications
include those used to treat heart disease or stroke, asthma,
and diabetes.
These 2 different medication lists will be
posted online at www.shpnc.org.
16
How The HRA Helps The Member Meet Their Deductible
Coverage Type
HRA Pays
You Pay
Total Deductible
Employee Only
Remaining Deductible $1,000
In-Network
$1,500
First $500
Out-of-Network
Remaining Deductible $2,500
$3,000
Employee + One
Family Member
In-Network
Remaining Deductible $2,000
First $1,000
Out-of-Network
Remaining Deductible $5,000
$3,000*
$6,000
Employee + Two or more
Family Members
In-Network
Out-of-Network
Remaining Deductible $3,000
First $1,500
Remaining Deductible $7,500
$4,500*
$9,000
*The HRA is a pooled account and is available to whichever family member needs it first. It is possible for one family member to use
all the funds before another family member has a claim.
17
How the Consumer-Directed Health Plan with HRA Works
Member presents
HRA ID Card at Office
Visit Total office visit of
$175 submitted to
BCBSNC by provider
#6
#1
Member's Individual Deductible
At end of the
month, $15
credited to
member’s HRA for
visiting PCP on ID
Card
#5
Claim processes in
primary claims
system and applies
towards $1,500
deductible –
EOB/EOP issued
Pharmacy claim
automatically
submitted to HRA
Member reimbursed
$65
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
#4
#2
#3
Beginning Deductible
Office Visit
Rx
Remaining Deductible
$1,500
($175)
($65)
$1,260
HRA Account
First Medical Cost of the Year
Beginning Balance
$500
Office Visit
($175)
Rx
($65)
Remaining HRA Balance
$260
PCP Incentive Reward
$15
New HRA Balance
$275
To monitor HRA balance and claim’s payments,
members may go online to www.shpnc.org and
click on My Member Services.
18
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 …
19
$40 per month
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 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 100% coverage – this is provided at
provider in a non-hospital setting
no cost to the member
100% coverage – this is provided at
no cost to the member
15% of eligible expense with no
deductible
ACA preventive medication list
CDHP preventive medication list
20
CDHP Highlights in 2014
Coverage
Plan-Provided HRA
Contribution
Annual Deductible
In-Network
Out-of-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
$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
21
The Traditional 70/30 Plan
• Traditional 70/30 Plan – The new name for the current 70/30 Basic Plan;
there are no changes to the Plan’s benefits for 2014
• Copays and Deductibles – The copays and deductibles on the
Traditional 70/30 PPO plan are the same as they are today on the 70/30
Basic Plan. 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.
22
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)
23
Monthly Premiums—Enhanced 80/20 Plan
2014 Enhanced Plan Premiums
(Active Employees and Non-Medicare Primary Members)
Coverage Type
Employee/
Retiree Monthly
Premium
Dependent
Monthly
Premium
Total Monthly
Premium
Wellness
Premium
Credits*
Net Monthly
Premium*
Employee/Retiree Only
$63.56
N/A
$63.56
$50.00*
$13.56*
Employee/Retiree +
Child(ren)
$63.56
$272.80
$336.36
$50.00*
$286.36*
Employee/Retiree +
Spouse
$63.56
$628.54
$692.10
$50.00*
$642.10*
Employee/Retiree +
Family
$63.56
$666.38
$729.94
$50.00*
$679.94*
*Assumes completion of three wellness activities
24
Monthly Premiums—CDHP
2014 CDHP Premiums
(Active Employees and Non-Medicare Primary Members)
Coverage Type
Employee/
Retiree Monthly
Premium
Dependent
Monthly
Premium
Total Monthly
Premium
Wellness
Premium
Credits*
Net Monthly
Premium*
Employee/Retiree Only
$40.00
N/A
$40.00
$40.00*
$0*
Employee/Retiree +
Child(ren)
$40.00
$184.60
$224.60
$40.00*
$184.60*
Employee/Retiree +
Spouse
$40.00
$475.68
$515.68
$40.00*
$475.68*
Employee/Retiree +
Family
$40.00
$506.64
$546.64
$40.00*
$506.64*
*Assumes completion of three wellness activities
25
Monthly Premiums—Traditional 70/30Plan
2014 Traditional Plan Premiums
(Active Employees and Non-Medicare Primary Members)
Coverage Type
Employee/ Retiree
Monthly Premium
Dependent Monthly
Premium
Total Monthly Premium
Employee/Retiree Only
$0
N/A
$0
Employee/Retiree +
Child(ren)
$0
$205.12
$205.12
Employee/Retiree + Spouse
$0
$528.52
$528.52
Employee/Retiree + Family
$0
$562.94
$562.94
Reminder: Wellness premium credits are not offered under the Traditional Plan.
26
Completing Open Enrollment
• Action must be taken during Open Enrollment—October 1–31, 2013:
• Choose a health plan
• Decide whom to cover
• Complete wellness activities
• Remember, NC Flex Benefits enrollment in Oct. as well.
• Online enrollment only – through the eEnroll or BEACON platform,
depending on your agency
• Choices are effective from 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.
27
Enrollment Instructions
BEACON
• Employee Self Service (ESS), available on the BEACON website at
https://mybeacon.nc.gov. Select the “My Benefits” link to begin
enrollment.
• For instructions, click on the “Read Before Beginning Online
Enrollment” link.
• Members without ESS access may contact BEST Shared Services at
919-707-0707 (in Raleigh) or 866-622-3784 (statewide) to complete
enrollment by phone.
eEnroll
• All changes need to be done through the eEnroll system by logging in
to the system at https:// shp-login.hrintouch.com to enroll. For
assistance in navigating eEnroll members can call Benefitfocus
Customer Service at 855-859-0966.
28
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 in
September
• Enrollment tour will be conducted across the state in
October, more information will be included in one of your
mailers
• Sign up for our monthly electronic newsletter, Member
Focus, which can be done by visiting the Plan’s website
29
Important Numbers
• ELIGIBILITY AND ENROLLMENT for eEnroll Agencies
855-859-0966
• BEST SHARED SERVICES: BEACON
919-707-0707
• BLUE CROSS AND BLUE SHIELD OF NC (BENEFITS,
CLAIMS and HRA)
888-234-2416
• EXPRESS SCRIPTS (PHARMACY QUESTIONS for
Active/Non-Medicare Retirees)
800-336-5933
30
Thank you!
www.shpnc.org
www.nctreasurer.com
31