NC STATE HEALTH PLAN

• The North Carolina State Health Plan’s Board of Trustees approved proposals to change the plan year and offer new health plan options for state employees.

IMPORTANT CHANGES

• Plan year changes to calendar year effective January 1, 2014

• New 85/15 High Deductible plan offer• The addition of surcharges and incentives

to employee only premiums• Premium increase of 3.57%• ACA

DEPENDENT ELIGIBILITY REMINDER

• Open Enrollment is the time to add and drop dependents

• Outside of OE, there must be a qualifying event to add/drop dependents and those changes must be made within 30 days of the event

• It is very important that dependent verification documentation be maintained on all dependents.

APPROVED DEPENDENT VERIFICATION DOCUMENTS

SPOUSE• PAGE 1 OF THE MOST

CURRENT YEAR TAX RETURN LISTING THE SPOUSE OR:

• MARRIAGE CERTIFICATE PLUS A CURRENT UTILITY BILLING STATEMENT LISTING THE EMPLOYEE AND SPOUSE OR DESIGNATION OF SPOUSE AS PRIMARY BENEFICIARY ON THE EMPLOYEE’S LIFE INSURANCE

BIOLOGICAL CHILD(REN)• PAGE 1 OF THE MOST

CURRENT YEAR TAX RETURN LISTING THE CHILD(REN) OR A COPY OF THE BIRTH CERFITICATE

APPROVED DEPENDENT VERIFICATOIN DOCUMENTS

ADOPTED CHILD(REN)/LEGAL GUARDIANSHIP

• PAGE 1 OF THE MOST CURRENT YEAR TAX RETURN LISTING THE CHILD(REN) OR

• COURT DOCUMENTS SIGNED BY A JUDGE SHOWING THAT THE EMPLOYEE HAS ADOPTED THE CHILD OR HAS LEGAL GUARDIANSHIP OR

• PAPERS FROM THE ADOPTION AGENCY SHOWING INTENT TO ADOPT

FOSTER CHILD(REN)• STATE OF NORTH CAROLINA

CERTIFICATION IDENTIFYING THE CHILD BY NAME AND SETTING FORTH ALL RELEVANT ASPECTS OF THE RELATIONSHIP. THE CERTIFICATION OF DEPENDENT ELIGIBILITY FORM (P4) AND A COPY OF A DOCUMENT THAT ESTABLISHES A BONA-FIDE FOSTER CHILD RELATIONSHIP ARE REQUIRED.

ENHANCED 80/20 PLAN

• THE CURRENT STANDARD 80/20 PLAN WITH A NEW NAME TO MATCH THE NEW FEATURES

• $0 ACA PREVENTIVE SERVICES AND MEDICATIONS

• NEW WELLNESS INCENTIVE WITH REDUCED MEDICAL COPAY OPPORTUNITIES

NEW: CONSUMER-DIRECTED HEALTH PLAN (CDHP) WITH HRA

• A NEW HEALTH PLAN OPITION• A HIGH-DEDUCTIBLE MEDICAL PLAN• A HEALTH REIMBURSEMENT ACCOUNT TO HELP

OFFSET THE DEDUCTIBLE• 85/15 COINSURANCE• $0 ACA PREVENTIVE SERVICES AND MEDICATIONS• CDHP PREVENTIVE MEDICATION LIST WITH $0

DEDUCTIBLE• NEW WELLNESS INCENTIVES

TRADITIONAL 70/30 PLAN

• CURRENT BASIC 70/30 WITH A NEW NAME• NO INCENTIVES AVAILABLE• NO $0 ACA PREVENTIVE SERVICES AND

MEDICATIONS

FOCUS ON WELLNESSENHANCED 80/20 PLAN

• 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 COVERED DEPENDENTS

WELLNESS 80/20 PLAN

• 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

– $233 INPATIENT COPAY IS WAIVED IF YOU UTILIZE A BLUE OPTIONS DESIGNATED HOSPITAL

FOCUS ON WELLNESSNEW: 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

– SELECTING A PRIMARY CARE PROVIDER (PCP) FOR SELF AND ALL COVERED DEPENDENTS

WELLNESS CDHP WITH HRA

• ADDITIONAL WELLNESS INCENTIVES– $15 ADDED TO 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

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.

WELLNESS TRADITIONAL 70/30 PLAN

• NO INCENTIVES AVAILABLE

• NO $0 ACA PREVENTIVE SERVICES

• NO $0 ACA PREVENTIVE MEDICATIONS

CURRENT LIST OF BLUE OPTIONS DESIGNATED HOSPITALS

• ALAMANCE REGIONAL MEDICAL CENTER • ALLEGHANY COUNTY MEMORIAL HOSPITAL • ANGEL MEDICAL CENTER • ASHE MEMORIAL HOSPITAL • BERTIE MEMORIAL HOSPITAL • BLADEN COUNTY HOSPITAL • BLUE RIDGE REGIONAL HOSPITAL • BLOWING ROCK HOSPITAL • CALDWELL MEMORIAL HOSPITAL • CAROLINAS MEDICAL CENTER UNIVERSITY • CATAWBA VALLEY MED CTR • CENTRAL CAROLINA HOSPITAL • CHARLES A CANNON JR MEMORIAL HOSP • CHATHAM HOSPITAL • DAVIE COUNTY HOSPITAL • D L P PERSON MEMORIAL HOSPITAL LLC • DOSHER MEMORIAL HOSPITAL • FIRSTHEALTH MONTGOMERY MEM HOSP • FIRSTHEALTH MOORE REGIONAL • FRYE REGIONAL MEDICAL CTR • GRANVILLE MEDICAL CENTER

• HARRIS REGIONAL HOSPITAL • HAYWOOD REGIONAL MEDICAL CENTER • HIGH POINT REGIONAL HOSPITAL • HIGHLANDS CASHIERS HOSPITAL • HUGH CHATHAM MEMORIAL HOSPITAL • LEXINGTON MEMORIAL HOSPITAL • MARG R PARDEE MEMORIAL HOSPITAL • MARTIN GENERAL HOSPITAL • MOSES H CONE MEMORIAL HOSPITAL • NEW HANOVER REGIONAL MEDICAL CENTER • NORTH CAROLINA BAPTIST HOSPITAL • OUR COMMUNITY HOSPITAL • PENDER MEMORIAL HOSPITAL • PIONEER COMMUNITY HOSP OF STOKE • PUNGO DISTRICT HOSPITAL • REX HOSPITAL • ROWAN REGIONAL MEDICAL CENTER INC • SAMPSON REGIONAL MED CTR • ST LUKES HOSPITAL • SWAIN COUNTY HOSPITAL • THE MCDOWELL HOSPITAL • THE OUTER BANKS HOSPITAL INC • TRANSYLVANIA COMMUNITY HOSPITAL • UNC HOSPITALS • VIDANT CHOWAN HOSPITAL • WASHINGTON COUNTY HOSPITAL • YADKIN VALLEY COMMUNITY HOSPITAL • WAKEMED RALEIGH CAMPUS

THE ENHANCED 80/20 PLANWHAT’S NEW?

• New Name – The Enhanced 80/20 Plan• New Incentives to encourage members to manage their

health and lower their healthcare costs– Preventive Care – There will be no copays on ACA preventive services

or preventive medications– Primary Care Provider (PCP) – To receive a $15 PCP copay reduction, a

PCP must be selected by the end of the open enrollment period• 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 PCP’s, they can contact the Benefits Office for

assistance. A new ID card with the new PCP’s information will be mailed to the member. The PCP change must be made before visiting the new PCP.

THE ENHANCED 80/20 PLAN

• Providers- When a specialist or hospital is needed, members have the option to select a Blue Options Designated Provider– Specialist – 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

LOWER PREMIUMS WITH WELLNESS PREMIUM CREDITS 80/20 PLAN

• MUST BE COMPLETED BY OCTOBER 31, 2013

• Receive a $20 per month premium credit if you attest to being a non-smoker/commits to a cessation program and attest for spouse if applicable

• Receive a $15 per month premium credit if you complete a confidential Health Assessment (HA) on State Health Plan website

• Receive a $15 per month premium credit if you and all covered dependents select a Primary Care Provider

LOWER YOUR HEALTH CARE COSTS WITH WELLNESS INCENTIVES 80/20 PLAN

• Reduce your copay by $15 when you visit the PCP listed on your ID card

• Reduce your copay by $10 when you visit a Blue Options Designated specialist

• Your $233 copay is not applied when you get inpatient care in a Blue Options Designated Hospital

ACA PREVENTIVE MEDICATIONS• YOU MUST HAVE A PRESCRIPTION FOR THESE MEDICATIONS TO HAVE

THEM COVERED AT 100%• ASPIRIN (TO PREVENT CARDIOVASCULAR EVENTS)- GENERIC OTC 81mg and 325mg – Men

ages 45-79 and women ages 55-79• Fluoride – Generic OTC and prescription products – Children older than 6 months through 5

years• Folic Acid – Generic OTC and prescription products 0.4-0.8mg – Women through age 50• Iron Supplements – Generic OTC and prescriptions products – Children ages 6-12 months

who are at risk for iron deficiency anemia• Smoking Cessation – Generic OTC and patches and gum – Members must contact QuitlineNC

for OTC product coverage• Vitamin D – Generic OTC and prescription products – Men and Women age 65+ who are at

increased risk for falls• Women’s Preventive Services & Contraception Coverage – Women through age 50

ENHANCED 80/20 PLAN HIGHLIGHTS IN 2014

COVERAGE IN-NETWORK OUT-OF-NETWORKANNUAL DEDUCTIBLE $700 INDIVIDUAL / $2100 FAMILY $1400 INDIVIDUAL / $4200 FAMILY COINSURANCE 20% OF ELGIBLE EXPENSES 40% OF ELIGIBLE EXPENSES PLUS 100% OF AMOUNT (AFTER DEDUCTIBLE IS MET) ABOVE THE PLAN'S ALLOWED AMOUNT COINSURANCE MAXIMUM $3210 INDIVIDUAL / $9630 FAMILY $6420 INDIVIDUAL / $19260 FAMILY(EXCLUDES DEDUCTIBLE) OFFICE VISITS $30 COPAY FOR PRIMARY DOCTOR; $15 COPAY IF THE PCP 40$ AFTER DEDUCTIBLE ON THE ID CARD ID UTILIZED $70 COPAY FOR SPECIALISTS $60 COPAY IF THE BLUE OPTIONS DESIGNATED SPECIALIST IS UTILIZED INPATIENT HOSPITAL $233 COPAY, THEN 20% AFTER DEDUCTIBLE; COPAY NOT $233 COPAY, THEN 40% AFTER DEDUCTIBLE APPLIED IF A BLUE OPTIONS DESIGNATED HOSPITAL IS UTILIZED PRESCRIPTION DRUGS TIER 1 $12 COPAY TIER 1 $12 COPAY(FOR 30 DAY SUPPLY) TIER 2 $40 COPAY TIER 2 $40 COPAY TIER 3 $64 COPAY TIER 3 $64 COPAY SPECIALTY MEDICATIONS 25% UP TO $100 MAXIMUM PER SPECIALTY MEDICATIONS 25% UP TO $100 MAXIMUM PER 30-DAY SUPPLY $0 FOR ACA PREVENTIVE MEDICATIONS 30-DAY SUPPLY $0 FOR ACA PREVENTIVE MEDICATIONS

QUESTIONS ON THE ENHANCED 80/20 PLAN?

THE CONSUMER DIRECTED HEALTH PLAN WITH HEALTH REIMBURSEMENT ACCOUNT

(HRA)

HIGH-DEDUCTIBLE HEALTH PLAN

• Covers the same service as other Plan options through the same PPO network.

• The deductible is higher than other Plan options, but the coinsurance is lower.

• After the deductible is met, the member only pays the 15% coinsurance.

• The deductible applies to both Medical Claims and Prescriptions.

• If the member reaches the deductible and coinsurance maximum, the Plan pays 100% of the covered expenses for the rest of the benefit year. (Medical and prescriptions.)

HEALTH REIMBURSEMENT ACCOUNT (HRA)

• The Plan funds the members’ Health Reimbursement Accounts (HRA) annually.

• HRA funding is based on the number covered:– $500 for employee only– $1000 for employee plus 1– $1500 for employee plus 2 or more

HEALTH REIMBURSEMENT ACCOUNT(HRA)

• HRA funds are used to pay a portion of the member’s deductible and coinsurance

• Once the HRA is depleted, the member must pay the remaining deductible and coinsurance

• Incentives available to add value to HRA• Unused HRA funds are available the following

year

CDHP

• Instead of copays, members will have to meet a deductible. After meeting the deductible the member pays a 15% co-insurance on all in-network medical and pharmacy benefits except ACA preventive services and ACA preventive medications, which are covered at 100%.

• Pharmacy and Medical deductibles and out-of-pockets are shared.

• An additional CDHP preventive medication list is covered with no deductible…member will only have to pay the 15% co-insurance expense.

CDHP: PHARMACY BENEFITS

• Under the Affordable Care Act many ACA preventive medications are paid at 100%

• There will be an ACA preventive medication list posted on the State Health Plan website.

• Medications on the CDHP Preventive medication list are subject to 15% coinsurance with no deductible.

• There will be a CDHP preventive medication list posted to the State Health Plan website.

HERE’S HOW IT WORKS!

• Medical Claims– Provider or member submits medical claim to

BCBSNC– Claim processes in BCBSNC system and payment

and/or explanation of benefits (EOB) is issued to the provider and/or member.

– Claim processes in HRA system and if funds are available, a check is issued to the provider and/or member.

Here’s How it Works!

• Pharmacy Claims– Member pays for discounted prescription (non-

preventive prescription) in full– Pharmacy claims are submitted by the pharmacy

benefit manager on a bi-weekly basis to the HRA system

– Pharmacy claims process in the HRA system and if funds are available, a check is issued to the member.

CDHP: MEMBER RESPONSIBILITIES

• Present Member ID card to provider/pharmacy at time of service

• Monitor HRA balances and claim payments through My Member Services, which is accessible on the Plan’s website.

• Pay provider for any deductible and coinsurance not covered by the HRA – Best practice is to allow the claim to adjudicate in both BCBSNC’s system and the HRA system prior to remitting payment to the provider – Some providers may require payment at the time of service. In this case, claims will be paid to the member.

CDHP: Wellness Incentives

• MUST BE COMPLETED BY OCTOBER 31, 2013

• Receive a $20 per month premium credit if you attest to being a non-smoker/commit to a cessation program and attest for spouse if applicable

• Receive a $10 per month premium credit if you complete a confidential Health Assessment (HA) on State Health Plan website

• Receive a $10 per month premium credit if you and all covered dependents select a Primary Care Provider

CDHP: WELLNESS INCENTIVES

• $15 added to HRA when you visit the PCP listed on ID card.

• $10 added to HRA when you visit a Blue Options Designated specialist

• $50 added to your HRA when you get inpatient care in a Blue Options Designated hospital.

CDHP: THINGS TO REMEMBER

• Preventive care through an in-network provider in a non-hospital setting is covered at 100% - provided at no cost to member

• ACA preventive medication list – covered at 100% - provided at no cost to member

• CDHP preventive medication list – member pays 15% of eligible expense with no deductible

CDHP HIGHLIGHTS IN 2014COVERAGE IN-NETWORK OUT-OF-NETWORK

ANNUAL DEDUCTIBLE $1500 INDIVIDUAL / $4500 FAMILY $3000 INDIVIDUAL / $9000 FAMILY CONINSURANCE 15% OF ELGIBLE EXPENSES 35% OF ELIGIBLE EXPENSES(AFTER DEDUCTIBLE IS MET) OUT-OF-POCKET MAXIMUM $3000 INDIVIDUAL/ $9000 FAMILY $6000 INDIVIDUAL / $18000 FAMILYFOR MEDICAL AND PHARMACY (INCLUDES DEDUCTIBLE) OFFICE VISITS 15% OF ELIGIBLE EXPENSES: $15 ADDED TO HRA 35% OF ELIGIBLE EXPENSES(AFTER DEDUCTIBLE IS MET) IF PCP ON THE ID CARD IS UTILIZED; $10 ADDED TO HRA IF A BLUE OPTIONS DESIGNATED SPECIALIST IS UTILIZED INPATIENT HOSPITAL 15% OF ELIGIBLE EXPENSES; $50 ADDED TO HRA 35% OF ELIGIBLE EXPENSES(AFTER DEDCUTIBLE IS MET) IF A BLUE OPTIONS DESIGNATED HOSPITAL IS UTILIZED ACA PREVENTIVE MEDICATIONS $0 COINSURANCE, $0 DEDUCTIBLE $0 COINSURANCE, $0 DEDUCTIBLE CDHP PREVENTIVE MEDICATIONS 15% COINSURANCE, $0 DUCTIBLE 15% COINSURANCE, $0 DEDUCTIBLE

QUESTIONS ABOUT CDHP?

THE TRADITIONAL 70/30 PLAN

TRADITIONAL 70/30 PLAN

• The new name for the current 70/30 Basic Plan.

• No plan changes for 2014.• Copays and deductibles still apply.

TRADITIONAL 70/30 PLAN BENEFIT HIGHLIGHTS

COVERAGE IN-NETWORK OUT-OF-NETWORKANNUAL DEDUCTIBLE $933 INDIVIDUAL / $2799 FAMILY $1866 INDIVIDUAL / $5598 FAMILY CONINSURANCE 30% OF ELIGIBLE EXPENSES 50% OF ELIGIBLE EXPENSES PLUS 100% OF (AFTER DEDUCTIBLE IS MET) AMOUNT ABOVE ALLOWED AMOUNT OUT-OF-POCKET MAXIMUM $3793 INDIVIDUAL/ $11379 FAMILY $7586 INDIVIDUAL / $22758 FAMILY(EXCLUDES DEDUCTIBLE) OFFICE VISITS $35 COPAY FOR PRIMARY DOCTOR 50% AFTER DEDUCTIBLE $81 COPAY FOR SPECIALISTS PREVENTIVE CARE $35 COPAY FOR PRIMARY DOCTOR ONLY CERTAIN SERVICES ARE COVERED $81 COPAY FOR SPECIALISTS INPATIENT HOSPITAL $291 COPAY, THEN 30% AFTER DEDUCTIBLE $291 COPAY, THEN 50% AFTER DEDUCTIBLE PRESCRIPTION DRUGS TIER 1 $12 COPAY TIER 1 $12 COPAY(FOR 30 DAY SUPPLY) TIER 2 $40 COPAY TIER 2 $40 COPAY TIER 3 $64 COPAY TIER 3 $64 COPAY SPECIALTY MEDICATIONS 25% UP TO $100 SPECIALTY MEDICATIONS 25% UP TO $100 MAXIMUM PER 30-DAY SUPPLY MAXIMUM PER 30-DAY SUPPLY

ANNUAL ENROLLMENT

• EVERYONE WILL BE MOVED TO THE 70/30 PLAN• Action must be taken during Open Enrollment—October 1–31, 2013:

Choose a health plan other than 70/30• Decide whom to cover • Complete wellness activities • Send dependent verification to the Benefits Office

• Remember, NC Flex Benefits enrollment in Oct. as well. • Online enrollment only – through the eEnroll • Choices are effective from January 1, 2014 through December 31, 2014

QUESTIONS?