Insurance Education
Part #2
Health Plan Options
Health Plan Options
Choices
• State


Health Plan
Standard Plan
Savings Plan
• HMOs


BlueChoice HealthPlan*
(available statewide)
CIGNA HMO*
*Must live or work in service area
Insurance Education
Part #2
Health Plan Options
Standard Plan
and
Savings Plan
(Features the Plans have in Common)
State Health Plan (SHP)
Standard Plan
and
Savings Plan
Standard Plan and Savings Plan
(common to both)
•
Network providers
•
•
Out-of-network
benefits
Rx network
providers
•
Mental health and
substance abuse
benefits
•
Medi-Call/APS
pre-authorization
requirements
•
BlueCard Program
•
Preventive benefits
SHP Standard Plan
and Savings Plan
Provider Network and
BlueCard Advantage
• Freedom
of choice
• Worldwide coverage
• Easy access to medically
necessary care
• Providers file claims
• Subscriber pays deductible
and coinsurance
SHP Standard Plan
and Savings Plan
(cont.)
• Subscribers
not balance-billed for
charges over allowed amount
(negotiated pricing)
• SHP ID card (Preferred Provider
Organization, or PPO, logo located
in bottom corner of ID card)
• National PPO organization
coverage
• Worldwide coverage
• Call 800-810-BLUE
SHP Standard Plan
and Savings Plan
Non-network Benefits
• Freedom
of choice (will
receive higher level of
benefits when using
network providers)
• Worldwide coverage
• Easy access to medicallynecessary care
SHP Standard Plan
and Savings Plan
(cont.)
• Subscriber
may have to file
claims
• Subscriber pays deductible
and higher coinsurance
maximum
• Subscriber can be balancebilled (provider can charge
more than allowed amount
no negotiated pricing for
non-network services)
SHP Standard Plan
and Savings Plan
Preventive Benefits
(must follow Plan guidelines)
• Mammography
• Pap
testing
Test
• Well-child care
• Routine colonoscopy
• Worksite health screening
(available to HMO subscribers as
well)
SHP Standard Plan
and Savings Plan
Mammography Testing
• 100
percent coverage for
routine, four-view
mammograms, according to
Plan guidelines
• Performed at participating
mammography facilities
SHP Standard Plan
and Savings Plan
(cont.)
• Ages
35-39 (one routine
mammogram during those years)
• Ages 40-74 (one routine
mammogram every 12 months)
• Deductible and coinsurance apply
to diagnostic mammograms
SHP Standard Plan
and Savings Plan
Pap Test
• No
deductible or coinsurance
• Subscriber free to choose provider
• One Pap Test each year for
covered females, ages 18 through
65
• For routine and diagnostic Pap
Tests
• Pays lab costs only - routine office
visit NOT covered
SHP Standard Plan
and Savings Plan
Well-child Care Benefits
• Well-child



checkups
Five visits for children
younger than 1 year old
Three visits for children 1
year and older
One visit per year for
children age 2 through 18
SHP Standard Plan
and Savings Plan
(cont.)
• 100
percent benefit for
regular check-ups provided
by network providers
• 100 percent benefit for
covered immunizations,
according to recommended
schedule (catch-up provision
for delayed or missed
immunizations through age
18)
SHP Standard Plan
and Savings Plan
(cont.)
• Covered




immunizations
Diphtheria-Tetanus-Pertussis
(DTP)
Polio
Hepatitis A and B
Haemophilus (Hib)
SHP Standard Plan
and Savings Plan
(cont.)
• Additional






covered immunizations
Measles-Mumps-Rubella
Chicken pox
Pneumoccocal vaccine (Prevnar)
HPV (Human Papilomavirus)
Influenza
Meningococcal
SHP Standard Plan
and Savings Plan
Routine Colonoscopies
• One
routine colonoscopy every 10
years for subscribers age 50 and
older
• Subject to deductible and
coinsurance
• Diagnostic colonoscopy subject to
deductible and coinsurance
SHP Standard Plan
and Savings Plan
Prevention Partners
(State Employee Wellness Program)
• Worksite
screening available to
employees and spouses covered
by State Health Plan or HMO/POS

Subscriber/spouse pays $15 for
screening
SHP Standard Plan
and Savings Plan
(cont.)

One screening a year, per eligible
SHP subscriber and covered spouse
•
•
$15 per eligible subscriber
For active and retired subscribers
and their spouses
Whose primary coverage is one of
state’s health plans and
• Is not eligible for Medicare
•
SHP Standard Plan
and Savings Plan
Screening Benefits
•
•
•
•
•
Chemistry profile
(BUN, Glucose)
Hemogram
(Hemoglobin)
Health risk appraisal
Blood pressure
check
Height and weight
measurement
•
•
•
Lipid profile
(cholesterol)
Confidential
personal report
Confidential,
personal
consultation about
results upon
request
SHP Standard Plan
and Savings Plan
Retail Rx Maintenance Network
•
•
•
•
•
•
Visit www.eip.sc.gov
Choose your category
Go to online directories
Select “State Health Plan Retail
Maintenance Network”
Plan administrator -- Medco
Medco Customer Service: 800-7113450
SHP Standard Plan
and Savings Plan
My Rx Choices
May help SHP subscribers pay less for
long-term prescriptions
 Locate lowest-cost prescriptions
using Medco’s online cost comparison
tool
 Access “My Rx Choices” online to
compare drug costs by visiting:
www.Medco.com

See Insurance Benefits Guide for details
SHP Standard Plan
and Savings Plan
Medi-Call
(state managed care)
• State Health Plan’s utilization
review program for medical/
surgical benefits
• Ensures subscriber and covered
family members receive
appropriate medical care in most
beneficial, cost-effective manner
SHP Standard Plan
and Savings Plan
(cont.)
• Some
Call

services requiring a Medi-
Provider may call for subscriber;
however, subscriber has
responsibility for calling Medi-Call
for pre-authorization
SHP Standard Plan
and Savings Plan
(cont.)
• Some





services include
All inpatient admissions
Emergency admissions within 48
hours or next business day
All outpatient surgery in hospital or
ambulatory surgical center
Hospice services
Home health care services
SHP Standard Plan
and Savings Plan
(cont.)




Skilled nursing service
In-vitro fertilization procedures
Call during first trimester of
pregnancy
MRI, MRA, CT or PET scan
• Consult
Insurance Benefits Guide
for complete listing of services
requiring a Medi-Call
SHP Standard Plan
and Savings Plan
(cont.)
• Penalties
contacted


if Medi-Call not
$200 penalty (penalty does not
apply to coinsurance maximum)
Charges for services not preauthorized by Medi-Call do not
apply toward deductible or
coinsurance maximum
SHP Standard Plan
and Savings Plan
Medi-Call
Columbia:
803-699-3337
SC, nationwide and Canada:
800-925-9724
SHP Standard Plan
and Savings Plan
Mental Health/Substance
Abuse
• Administered
by APS
• Coverage for medically
necessary treatment of
mental health and substance
abuse conditions
• Same coinsurance, deductible
and out-of-pocket amounts
as for physical conditions
SHP Standard Plan
and Savings Plan
(cont.)
• Must
use participating
provider or no benefits paid
• Can nominate provider for
network
SHP Standard Plan
and Savings Plan
(cont.)
• Inpatient/outpatient


care
Pre-authorization required before
receiving care
Call APS: 800-221-8699
• Outpatient
treatment beyond 10
visits must be reviewed for
medical necessity
SHP Standard Plan
and Savings Plan
Tobacco Cessation Benefits
• Free
& Clear Program,
administered by APS
• Free for subscribers and
covered dependents
SHP Standard Plan
and Savings Plan
Contact Free & Clear
to participate at:
866-QUIT-4-LIFE
(866-784-8454)
Insurance Education
Part #2
SHP Standard Plan
Standard Plan
Deductibles and Coinsurance
Annual Deductible
$350 individual
• $700 family
•
Coinsurance In-network
Coinsurance Out-of-network
•
Plan pays
80%
•
Plan pays
60%
•
Subscriber pays
20%
•
Subscriber pays
40%
Coinsurance Maximum
Coinsurance Maximum
•
$2,000 individual
•
$4,000 individual
•
$4,000 family
•
$8,000 family
Standard Plan
Per-occurrence Deductibles
$125 emergency room visit (waived
if admitted)
• $75 out-patient hospital service
(some exceptions apply)
• $10 per office visit
• Do not apply toward annual
deductibles or coinsurance
maximums
•
Standard Plan
Prescription Drug Program
Pharmacy Network
• Must
use participating network
pharmacy
• Most major pharmacies nationwide
and many independent pharmacies
in SC
• Show State Health Plan ID card
• List of participating pharmacies on
EIP Web site
Standard Plan
Prescription Drug Program
Participating Retail Pharmacy
•
•
•
(up to 31-day supply)
$10 tier one
$25 tier two
$40 tier three
Mail-Order Pharmacy
•
•
•
(up to 90-day supply)
$25 tier one
$62 tier two
$100 tier three
Standard Plan
Prescription Drug Program
Facts
• Annual
copayment maximum
of $2,500 per person
• Coordination of benefits
Standard Plan
(cont.)
• “Pay

the Difference”
If generic brand drug is available
and subscriber or doctor chooses
brand name, subscriber responsible
for difference in price between the
allowable charge for name brand
and generic brand, plus generic
brand copayment
Standard Plan
(cont.)


“Pay the difference” does not apply
to $2,500 out-of-pocket maximum
Generic copayment does apply to
out-of-pocket maximum
Insurance Education
Part #2
Savings Plan
Health Savings Accounts
(HSA)
and
Limited-use Medical
Spending Accounts
Savings Plan
Choice for Subscribers Who:
Want lower premiums
 Are willing to take more
responsibility for their
healthcare
 Want to save for major medical
expenses through Health
Savings Account

Savings Plan
Annual Deductible
• $3,000
individual
• $6,000 family (no embedded
deductible)
Savings Plan
Rules
• Subscriber
pays 100 percent of
allowable charges for medical
costs


In-network provider: SHP
allowance applies toward
deductible
Out-of-network provider: SHP
allows only what Plan would have
allowed if subscriber used innetwork provider
Savings Plan
(cont.)
• No
per-occurrence
deductibles
• Reimbursement for annual
flu shot
• Annual physical to include
specific services
• Eligible to contribute to
Health Savings Account
(HSA)
Savings Plan
(cont.)
• Subscriber
pays 100 percent of
allowable charges for prescription
costs


Must use in-network pharmacies
only to pay negotiated rate
Negotiated rate not available when
using out-of-network pharmacies
Savings Plan
Coinsurance
In-network Coinsurance
Plan pays
80%
• Subscriber pays
20%
• Coinsurance Maximum
 $2,000 individual
 $4,000 family
•
Out-of-network Coinsurance
•
•
•
Plan pays
60%
Subscriber pays
40%
Coinsurance Maximum
 $4,000 individual
 $8,000 family
Savings Plan
Restrictions and Exclusions
• Chiropractic

Limited to $500 per person (after
deductible)
• Rx


payments
drug benefits exclude
Drugs for erectile dysfunction
Non-sedating antihistamines
Health Savings Accounts
(HSA)
Health Savings Account Facts
Tax-sheltered investment accounts
used to pay qualified medical
expenses
• Money rolls over from year-to-year
 Cannot be covered by another health
plan, including Medicare or Medical
Spending Account
•
Health Savings Accounts
(cont.)
Contributions to HSA allowed only
when participating in high-deductible
health plan (i.e. SHP Savings Plan)
 Spouse and dependents do not need to
be covered by SHP Savings Plan to be
eligible to receive claims
reimbursement for covered services

Health Savings Accounts
(cont.)
Contributions payroll deducted and
tax-free
• If contributions direct-deposited, can
deduct on tax return
• Keep receipts in event of an IRS audit
 Tax-free for qualified medical
expenses
•
Health Savings Accounts
(cont.)
•
If HSA funds used for non-qualified
medical expenses,


Amount is included in income and
IRS penalty applies unless subscriber
• Becomes disabled
• Enrolls in Medicare
• Dies
• More
HSA information on IRS Web
site: www.irs.gov
Health Savings Accounts
(cont.)
•
•
HSA account does NOT advance
money
Annual HSA contributions for 2008
limited to:


$2,900 for individual
$5,800 for family
• Catch-up
provision for individuals
age 55 and older allows additional
$900 for 2008
Health Savings Accounts
(cont.)
• $1/mo
(payroll deducted)
administrative fee (FBMC)



HSA funds earn interest and are tax
free
HSA portable when employment
ends
Subscriber must complete
“authorization packet” received
from NBSC to activate account
Health Savings Accounts
(cont.)
•
How to access funds from HSA



Free VISA® debit card from NBSC
Checks provided - $.35 fee per check
written
$1/month or $10/yearly administrative
fee until balance reaches $2,500
(NBSC)
“Limited Use” Medical
Spending Accounts (MSA)
“Limited Use” MSA Facts

Can use for vision and dental
expenses only (maximum
$5,000)


$3.50 per month administrative
fee applies
Must be continuously employed
for one year to enroll
“Limited Use” Medical
Spending Accounts (MSA)
(cont.)
• “Use
it or lose it” (funds do not roll
over as with HSA)
• Claims must be incurred by March
15th grace period and submitted by
March 31st
• Not eligible for EZ REIMBURSE®
Card
Insurance Education
Part #2
My Insurance
Manager
BCBS of South Carolina
www.southcarolinablues.com
My Insurance Manager
BCBS of South Carolina
(www.southcarolinablues.com)
My Insurance Manager’s Features
• Review
claims via BCBS Web site
• View and print Explanation of
Benefits (EOB)
• See amount paid toward deductible
and coinsurance maximum
• Secure E-mail customer service
questions
• View up-to-date provider directory
• Request new ID card
Insurance Education
Part #2
Health Insurance
Options
Health Maintenance
Organizations
(HMOs)
Health Maintenance
Organizations (HMOs)
Rules
•
•
•
Subscribers must choose
primary care physician (PCP)
Referral required for most
specialty care
You must live or work in HMO
service area
Health Maintenance
Organizations (HMOs)
(cont.)
•
•
•
Provide qualified emergency service
out-of-network
No non-emergency out-of-network
benefits
Read HMO materials carefully before
making health plan selection
Insurance Education
Part #2
BlueChoice
HealthPlan
BlueChoice HealthPlan
(available in all South Carolina counties)
Features
•
Annual deductible



Amount subscriber pays before HMO
begins paying (deductible does not
apply to PCP charges)
$250 individual
$500 family
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)
•
After subscriber pays annual
deductible and copayment, plan pays
90 percent of allowable charges
subscriber pays 10 percent, which
applies to coinsurance maximum
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)
•
Hospital copayments



$100 outpatient hospital copay
$125 emergency copay
$200 inpatient hospital copay
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)

Physical therapy, speech therapy and
occupational therapy



Covered after annual deductible met
Plan pays 90 percent of allowable
charges; subscriber pays 10 percent
Limit per plan year: 20 visits per type of
“therapy”
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)
•
Coinsurance maximum




Most an individual or family will pay for
covered services
Excludes deductibles and copays
$1,500 individual
$3,000 family
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)

Physician copays




Plan pays 100 percent of allowable
charges after copay
$15 PCP and OB-GYN copay
$30 specialist copay
$35 urgent care copay
• Human
organ transplant lifetime
maximum

$350,000 per person
BlueChoice HealthPlan
(available in all South Carolina counties)
(cont.)
• Tobacco
cessation benefits
available


Free for subscribers and covered
dependents, age 18 and older
Contact Free & Clear at:
866-Quit-4-Life
(866-784-8454)
BlueChoice HealthPlan
(available in all South Carolina counties)
Network Only
Retail Pharmacy
(up to 31-day supply)
•
•
•
•
$7 generic brand
$35 preferred brand
$55 non-preferred brand
$100 specialty pharmaceuticals
Mail Order
(up to 90-day supply)
•
•
•
$14 generic brand
$70 preferred brand
$110 non-preferred brand
Insurance Education
Part #2
CIGNA HMO
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
Features
• Annual
deductible: none
• HMO pays 80 percent of
allowable charges
• Subscriber pays 20 percent -applies toward coinsurance
maximum
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
(cont.)
• Coinsurance




maximum
$2,000 for individual
$4,000 for family
Most an individual or family will pay
for covered services
Includes inpatient/outpatient
hospital copays
•
•
$250 outpatient hospital copay
$500 inpatient hospital copay
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
(cont.)
• $100

emergency room copay
HMO pays 100 percent of allowable
charges after subscriber pays
copay
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
(cont.)
•
Plan pays 100 percent of allowable
charges after subscriber pays




$15 PCP and OB-GYN copay
$30 specialist copay
$30 outpatient mental health and
substance abuse copay
$50 urgent care copay
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
(cont.)

Short-term rehabilitation therapy and
chiropractic services


$30 specialist copay
Limit per year -- 20 visits
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
Network Only
Retail Pharmacy
(up to 31-day supply)



$7 generic brand
$25 preferred brand
$50 non-preferred brand
Mail Order
(up to 90-day supply)
•
•
•
$14 generic brand
$50 preferred brand
$100 non-preferred brand
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
CIGNA Quit Today Tobacco
Cessation Program
SM
• Beginning
January 1, 2008,
available to subscribers and
covered dependents
• Free
• Enroll


Call 866-417-7848 or
Visit CIGNA’s Web site
www.myCIGNA.com
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
Strength and ResilienceSM Stress
Management Program
• Free
to subscribers and covered
dependents
• Includes:



Stress risk assessment
Up to six coaching sessions during
first six months
Unlimited calls to coach
CIGNA HMO
(available in all South Carolina counties except: Abbeville, Aiken,
Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
(cont.)
• To


enroll
Call 866-417-7848 or
Visit CIGNA’s Web site:
www.myCIGNA.com
Insurance Education
Part #2
Active Employee
Health Plan
Premiums
Active Employee Monthly
Health Premiums
SHP
Savings
Plan
Employee only
$
9.28
Employee/spouse
Employee/children
Full family
$ 72.56
$ 20.28
$108.56
CIGNA
HMO
Employee only
Employee/spouse
Employee/children
Full family
$136.30
$390.94
$288.66
$577.34
SHP
Standard
Plan
You Pay
$ 93.46
$
$237.50
$142.46
$294.58
$144.04
$ 49.00
$201.12
You Pay
Blue-Choice
HMO
$36.30
$290.94
$188.66
$477.34
0.00
$129.60
$380.50
$282.14
$566.48
You Pay
$29.60
$280.50
$182.14
$466.48