Presentation on theme: "Welcome and introductions."— Presentation transcript:
1 Welcome and introductions. We appreciate you being here today and hope to equip you with the knowledge to help you understand the changes that are to take place for your 2014 health benefit options.Embracing a Healthy Lifestyle through the State Health Plan New Plan Options and Incentives for 2014
2 Agenda Why are we Making Changes for 2014? New Plan Options for 2014 Introducing New Wellness IncentivesOpen Enrollment for 2014Additional ResourcesToday’s presentation is about changes to the State Health Plan for active employees and non-Medicare Primary retirees.
3 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.Before we get into the details, let’s talk about why these changes are being made.First and foremost, 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.As you’ll see, 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.
4 Health Plan Options for 2014 Enhanced 80/20 PlanNEW: Consumer-Directed Health Plan (CDHP) with HRATraditional 70/30 PlanThe current Standard 80/20 Plan with a new name to match the new features$0 ACA Preventive Services$0 ACA Preventive MedicationsNew Wellness IncentivesReduced medical copay opportunitiesA new health plan optionA high-deductible medical planA Health Reimbursement Account (HRA) to help offset the deductible85/15 Coinsurance$0 ACA Preventive Services$0 ACA Preventive MedicationsCDHP Preventive Medication List ($0 deductible)New wellness incentivesAdditional HRA funds for visiting certain providersThe current Basic 70/30 Plan with a new nameNo incentives availableNo $0 ACA Preventive ServicesNo $0 ACA Preventive MedicationsLet’s take a quick look at all of the options that will be available in We will go into more detail about each plan in a few minutes.The Enhanced 80/20 Plan is mostly the same as our current Standard 80/20 Plan but with a $0 copay for ACA preventive services received in a physician’s office and $0 copay for ACA preventive medications. Besides the name change, the big difference is that we are adding several wellness incentives to the Plan to lower member out-of-pocket costs.The Consumer-Directed Health Plan, or CDHP, is the NEW option for It provides coverage through a high-deductible medical plan with 85/15 coinsurance after the deductible is met, and it includes a Health Reimbursement Account, or HRA, to help offset the deductible. The State Health Plan provides funds for the HRA. It also includes ACA preventive medications at $0 copay. In addition medications on the CHDP preventative medication list have a $0 deductible. The CDHP also includes several wellness incentives.The current Basic 70/30 Plan will also continue to be available, but the name is changing to the Traditional 70/30 Plan.Before we go on, it’s important to understand that, because we have new options, non-Medicare primary members must choose a Plan and complete enrollment during the October enrollment period. Otherwise, they and their covered family members will be enrolled in the Traditional 70/30 Plan effective January 1, 2014.Open Enrollment will be conducted October 1 – 31, You must complete enrollment—otherwise, you and your covered family members will be enrolled in the Traditional 70/30 Plan effective January 1, 2014.
5 NEW: Consumer-Directed Health Plan (CDHP) with HRA A New Focus On WellnessEnhanced 80/20 PlanNEW: Consumer-Directed Health Plan (CDHP) with HRATraditional 70/30 PlanWellness premium credits when:Subscriber completes a Health AssessmentSubscriber attests for him/herself and spouse (if applicable) to not smoking...or to being in a smoking cessation programSelecting a Primary Care Provider (PCP) for self and all dependentsAdditional 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 HospitalWellness premium credits when:Subscriber completes a Health AssessmentSubscriber attests for him/herself and spouse (if applicable) to not smoking...or to being in a smoking cessation programSelecting a Primary Care Provider (PCP) for self and dependentsAdditional 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 servicesNo incentives availableNo $0 ACA Preventive ServicesNo $0 ACA Preventive MedicationsNow, a little more about the new incentives. Starting in 2014, money-saving opportunities are included in the Enhanced 80/20 Plan and the CDHP to encourage members to focus on their health and well-being. Notice that these incentives are offered through the Enhanced Plan 80/20 Plan and the CDHP only. The Traditional 70/30 Plan does NOT have them. The amount of each incentive depends on whether members are in the Enhanced Plan 80/20 or the CDHP, and we’ll show you the amounts a little later when we describe each plan.The first incentive is a lower premium. Unlike the Traditional Plan 70/30 Plan, the Enhanced Plan 80/20 Plan and CDHP both require a premium for employee coverage. However, members can lower their premium for the Enhanced Plan 80/20 or eliminate it entirely for the CDHP by completing certain wellness activities before the end of Open Enrollment.The first wellness activity that will lower your premium is to select a primary care provider—also known as a PCP.The second is to take an online health assessment that asks questions about your current health and lifestyle. Federal law prohibits the Plan from using your personal information to discriminate against you in any way or from giving this information to your employing agency/school or other unauthorized third party, except as allowed by law.The third wellness activity that will lower your premium is to attest that you do not smoke, or if you do smoke, that you will join a cessation program. If applicable, you will also need to attest for your spouse.Members can do as many or as few of these three wellness activities as they want. The more you do, the more premium credits you’ll receive and the lower your premium will be.And there will be more opportunities to save money with additional wellness incentives that come with the plan.
6 Wellness Premium Credits Wellness ActivityHow to Complete ItWhen Members Can Take ItSubscriber selects a Primary Care Provider (PCP)A PCP must also be selected for each dependent covered on the State Health Plan.Log into the BEACON/eEnroll system to select a PCP. If members have trouble locating a provider, they can contactSubscribers 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 confidentialHealth 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 atA 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 non-smoker/commits to a cessation programand attests for spouse if applicableThrough 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 or call 800-QUIT-NOW ( )There’s no need to wait until Open Enrollment for members get started on the wellness activities. You can do two of the activities now—selecting a PCP and completing the Health Assessment—before Open Enrollment even begins.To complete the Health Assessment, go to the State Health Plan website and access your Personal Health Portal through NCHealthSmart. The health assessment is shorter now and only takes about 5 minutes to complete! When you’re done, NCHealthSmart will automatically transfer your answers to the enrollment system to qualify you for the premium credits.All of these activities must be completed by 10/31/2013 to qualify for the wellness premium credits.NOTE: Smokers will need to commit to participation in a smoking cessation program by Jan. 1, 2014.
7 Who can be a Primary Care Provider? A Primary Care Provider can practice:General / Family MedicineInternal MedicinePediatrics, orObstetrics and GynecologyA Primary Care Provider can be:Licensed Nurse PractitionersPhysician’s AssistantsNot all network physician’s assistants and licensed nurse practitioners are listed in the PCP tool. If you are unable to find one, you can select a physician from the practice and receive both the premium credit and the copay reduction when visiting a provider in that practice.It takes 5 calendar days to process a PCP change---keep that in mind.Specialty Providers cannot be selected as a PCP.
8 What Is a Blue Options Designated Provider? Blue Options Designated providers meet BCBSNC criteria for:Delivering quality health outcomesCost effectivenessAccessibility by membersThe Blue Options Designated provider network includes hospitals and certain types of specialists:General SurgeryOb-GynGastroenterologyOrthopedicsCardiologyNeurologyBlue Options Designated providers have been chosen by Blue Cross and Blue Shield of North Carolina based on criteria for quality health outcomes, cost effectiveness and accessibility by members. They include hospitals and specialists in many fields.To find a Designated Blue Options provider, members may go online to and click on Member Services, then on “Find a Doctor or Facility” or call
9 The Enhanced 80/20 PlanAn enhanced version of the current Standard 80/20 Plan, exceptNew name – The Enhanced 80/20 PlanNew incentives to encourage members to manage their health and lower their health care costsPreventive 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 reductionIf 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 providerHospitals – 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.Now let’s look at each of the health plan options, and how much you can save by taking advantage of the wellness incentives.We’ll start with the Enhanced 80/20 Plan. As a reminder, this plan is similar to the current Standard 80/20 Plan; the main differences are that we’re changing the name and adding the incentives we just talked about as well as providing 100% coverage for in-network preventive services received in a non-hospital setting.So like the Standard Plan, the Enhanced 80/20 Plan is a preferred provider organization administered by Blue Cross and Blue Shield of North Carolina.You can go to any doctor or hospital in the BCBSNC network or go out of network. However, if you stay in network, your deductibles, copays and coinsurance will be lower.Remember, if you elect a PCP after Oct. 31, you do not receive the premium credit NOR will you be able to receive the copay reduction at the office visit.
10 Complete up to Three Wellness Activities Lower Your Premiums with Wellness Premium Credits— The Enhanced 80/20 PlanComplete up to Three Wellness ActivitiesBy October 31, 2013Enhanced PlanPremium CreditsSubscriber attests to being a non-smoker/commits to a cessation programand attests for spouse if applicable$20 per monthSubscriber (only) completes a confidentialHealth Assessment (HA)$15 per monthSubscriber and any covered dependents selects a Primary Care ProviderReduce your premium by up to…$50 per monthAnd here’s how the wellness incentives work under the Enhanced 80/20 Plan, and how much you can save. These are the three wellness activities we discussed earlier that earn you premium credits—and how much each activity will lower your premium:Members can save $20 a month if you (and your spouse, if he or she is enrolled) attest to not smoking or commit to a quitting program$15 a month if you complete a confidential Heath Assessment (just the member needs to complete), andAnother $15 a month if you select a PCP for yourself and each family member you enroll in the Enhanced 80/20 Plan.Remember, you can do one, two or all three of the Plan’s wellness activities. If you do all three, you will lower your premium by $50 a month.NOTE: Smokers will need to commit to participation in a smoking cessation program by Jan. 1, 2014.
11 Lower Your Health Care Costs with Wellness Incentives—The Enhanced 80/20 Plan Things you can do toreduce your costs…Enhanced PlanIncentivesVisit the PCP listed on ID cardYour copay is reduced by $15Visit a Blue Options Designated specialistYour copay is reduced by $10Get inpatient care in a Blue Options Designated hospitalYour $233 copay is not appliedRemember:Get preventive services through an in-network provider in a non-hospital setting100% coverage – this is provided at no cost to youACA preventive medication listAnd here’s what you can save by taking advantage of the additional incentives that will become available in 2014.You can save $15 on you copay if you use your PCPYou’ll save $10 on your copay by using a Blue Options Designated specialistAnd you can save the entire inpatient copay of $233 if you choose a Blue Options Designated hospital when you need to be admitted to a hospitalThe lower copay amounts that you’ll pay for doing any of these things will be listed on their plan ID card. Be sure to point that out at the time of your visit.You will save the full cost of preventive care if you use an in-network provider in a non-hospital setting—in other words, you will pay nothing.
12 ACA Preventive Medications Drug or Drug CategoryCriteriaAspirin (to prevent cardiovascular events)-Generic OTC 81mg and 325mgMen ages 45 to 79 years and women ages 55 to 79 yearsFluoride – Generic OTC and prescription productsChildren older than 6 months of age through 5 years oldFolic Acid – Generic OTC and prescription products 0.4 – 0.8 mgWomen through age 50 yearsIron Supplements – Generic OTC and prescriptions productsChildren ages 6 to 12 months who are at risk for iron deficiency anemiaSmoking Cessation – Generic OTC patches and gumMembers must contact QuitlineNC for OTC product coverageVitamin D – Generic OTC and prescription productsMen and Women ages ≥ 65 who are at increased risk for fallsWomen’s Preventive Services & contraception coverage 1) Barrier contraception- i.e. caps, diaphragms 2) Generic hormonal contraception 3) Emergency contraception 4) Implantable medications 5) Intrauterine contraceptionWomen through age 50 This is a list of the Affordable Care Act medications covered at 100%.Remember you must have a prescription from your PCP and have these filled at the pharmacy to receive them covered at 100%.You must have a Prescription for these medication to have them covered at 100%
13 Enhanced 80/20 Plan Highlights in 2014 CoverageIn-NetworkOut-of-NetworkAnnual Deductible$700 individual/$2,100 family$1,400 individual/$4,200 familyCoinsurance (after deductible is met)20% of eligible expenses40% of eligible expenses plus 100% of amount above the Plan’s allowed amountCoinsurance Maximum (excludes deductible)$3,210 individual/$9,630 family$6,420 individual/$19,260 familyOffice Visits$30 copay for primary doctor; $15 copay if the PCP on the ID card is utilized$70 copay for specialists; $60 copay if a Blue Options Designated specialist is utilized40% after deductibleInpatient Hospital$233 copay, then 20% after deductible; copay not applied if a Blue Options Designated hospital is utilized$233 copay, then 40% after deductiblePrescription Drugs (for 30-day supply)Tier 1 $12 copayTier 2 $40 copayTier 3 $64 copaySpecialty medications 25% up to $100 maximum per 30-day supply$0 for ACA Preventive MedicationsFOR REFERENCEBefore we move on to the next plan, here’s a brief summary of the Enhanced 80/20 Plan’s benefits. Because it’s important that you understand certain insurance terms that are used here and apply to all plan options, let’s review them.First, the annual deductible, which is the dollar amount members must pay for certain covered services each year before the Plan pays any benefits, is the same amount it has been. If one or more dependents are covered, the subscriber and their dependents each have an individual deductible—plus there’s a combined family deductible. There are also separate deductibles for in-network and out-of-network services. Amounts applied to the out-of-network deductible are credited to the in-network deductible. However, amounts applied to the in-network deductible are not credited to the out-of-network deductible.Next is coinsurance, which applies to certain services after members have satisfied the deductible amount. As you can see, the coinsurance is lower when visiting in-network providers; also, in-network providers will not bill more than the amount allowed by the plan for the services you receive. However, when using out-of-network providers, you need to be sure to pay attention to the costs. If the provider’s charges exceed the allowed amount, you are responsible for their coinsurance PLUS the charge over the allowed amount.The annual coinsurance maximum is the most members will pay in coinsurance each year under the Enhanced or Traditional Plan. Once you hit the coinsurance maximum, the Plan pays 100% of your coinsurance for covered expenses for the rest of the benefit year. Premiums, deductibles and copays do NOT count toward the coinsurance maximum.Copay amounts in the chart are the amounts you pay for office visits and prescription drugs. A copay is a flat dollar amount usually required at the time of service for these and certain other services. Copays do NOT count toward the annual deductible.
14 The Consumer-Directed Health Plan (CDHP) with HRA High-Deductible Health PlanHealth Reimbursement Account (HRA)A different kind of health plan with two componentsCovers the same services as other Plan options through the same PPO networkThe deductible is higher than other Plan options, but the coinsurance is lowerIn-network: $1,500 Individual/ $4,500 FamilyOut-of-Network: $3,000 Individual/ $9,000 FamilyAfter the deductible is met, the member only pays the 15% coinsuranceThe deductible applies to both Pharmacy and Medical expensesIf the member reaches his or her deductible and coinsurance out-of- pocket maximum, the Plan pays 100% of the covered expenses for the rest of the benefit year (medical and pharmacy)The Plan funds the members’ Health Reimbursement Accounts (HRA) annuallyHRA funding is based on the number of family members covered$500 for employee/retiree only$1,000 for employee/retiree + 1 $1,500 for employee/retiree or more dependentsHRA funds are used to pay a portion of the members’ deductibles & coinsuranceOnce the HRA is depleted, the member must pay the remaining deductible & coinsuranceIncentives available to add value to HRAUnused HRA funds are available the following yearNext, we’ll talk about the new Consumer-Directed Health Plan, or CDHP. This Plan is not like any we’ve offered in the past.It’s made up of two components: a high-deductible health plan and a Health Reimbursement Account, also known as an HRA.The high-deductible plan covers the same services as the Enhanced and Traditional Plans, through the same BlueCross BlueShield network. But as its name suggests, the deductible is higher. However, members are given a HRA with funds to assist you with meeting that deductible.As with the Enhanced and Traditional Plans, if members meet the deductible, Plan benefits begin—members pay only a small coinsurance percentage (15%) and the Plan pays the rest of your eligible expenses. There are no copays on this Plan.The Plan also includes an out-of-pocket maximum. This is the maximum amount members would pay in a year for both the deductible and coinsurance. When they reach the annual out-of-pocket maximum, the Plan pays 100% for covered services for the rest of the year.While having to meet a high deductible under this plan may sound a little scary, the second component of the CDHP, your HRA, helps you get there. Here’s how.At the start of 2014, the State Health Plan will set up a HRA with a balance. The beginning balance amount of the account will depend on the number of family members covered under your Plan:$500 for subscriber only$1,000 for subscriber plus one family member$1,500 for subscriber plus two or more family membersWhen you see a doctor or fill a prescription, the bill is paid from your HRA. For example, if a member has employee-only coverage under the CDHP, this means their HRA will start with $500 in The member goes to a doctor who charges $75 for the visit. The $75 will come from the HRA, which will leave a balance of $425. If you go to another doctor who charges $50, the HRA balance will drop to $375, but so far the member has paid nothing out-of-pocket. If the balance is depleted before meeting the deductible, then the member will start paying the bills themselves until they satisfy the remaining deductible amount. If you they don’t go to any more doctors and have unused HRA funds at the end of the year, they’ll continue to be available the following year—at which time the State Health Plan will replenish their account with additional funding.One last point about your HRA--Some agencies or employers allow employees to contribute to Flexible Spending Accounts, or FSAs. It may sound similar, and it’s also used to pay health care bills, but an FSA is not the same as an HRA. You can have both, but your claims processed under your medical benefit will automatically draw from the HRA account. If members have funds in the HRA, they really should use that first before using their FSA account as funds can’t be placed back into either account.
15 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 in-network 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.Three other points:After meeting the deductible you will pay a 15% coinsurance on all in-network medical and pharmacy benefits except ACA preventive services and ACA preventative medications, which are covered at 100%.Because the pharmacy benefit is “integrated” with the medical benefit, thepharmacy 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.
16 Consumer Directed Health Plan (CDHP): Pharmacy Benefits The Deductible Does Not Apply to Every MedicationUnder 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.The CDHP preventive medication list will be posted the Plan’s website.These 2 different medication lists will be posted online at
17 How The HRA Helps The Member Meet Their Deductible Employee OnlyOut-of-NetworkRemaining Deductible $2,500$1,500Remaining Deductible $1,000First $500In-Network$3,000Total DeductibleHRA PaysYou PayEmployee + One Family MemberRemaining Deductible $5,000$3,000*Remaining Deductible $2,000$6,000First $1,000Employee + Two or more Family MembersRemaining Deductible $7,500$4,500*Remaining Deductible $3,000$9,000First $1,500Coverage TypeThe order in which claims are processed determines which claims are reimbursed from the HRA. For example, if you have 2 children on your plan that both go to the doctor the same week, which ever claim is processed first through BCBSNC’s system will be the first claim considered by the HRA. Claims are generally processed in a first in, first out basis, not a date of service basis.*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.
18 How the Consumer-Directed Health Plan with HRA Works #1Member presents HRA ID Card at Office Visit -Total office visit of $175 submitted to BCBSNC by providerClaim processes in primary claims system and applies towards $1,500 deductible – EOB/EOP issuedClaim 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 metPharmacy claim automatically submitted to HRAMember reimbursed $65At end of the month, $15 credited to member’s HRA for visiting PCP on ID Card#6#2#5#3This slide is a day-in-the-life of a member explaining how the HRA works.Step 1 – Member presents Member ID card to provider/pharmacy at time of serviceStep 2 - Provider submits medical claim to BCBSNCStep 3 – Claim processes in HRA system and if funds are available, a check is issued to the provider and/or member – (The member will not receive a copy of an EOB when the check goes to the provider.)Step 4 – Member pays for discounted prescription (non-preventive prescription) in full.Step 5 – Pharmacy claims are submitted by the pharmacy benefit manager on a bi- weekly basis to the HRA system for adjudication and a check is issued to the member.Step 6 – At the end of the month, $15 is credited to HRA for visiting PCP on ID card.Don’t forget you are responsible to 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 payment will be made to the member.For NC Flex/FSA users, it’s important to note here that they can use their FSA for Rx purchases, but it’s still going to come out of the HRA and they’re still going to get reimbursed, so members really should not use their FSA until their HRA has been depleted.To monitor HRA balance and claim’s payments, members may go online to and click on My Member Services.#4
19 Lower Premiums with Wellness Premium Credits—CDHP Complete up to Three Wellness ActivitiesBy October 31, 2013CDHPPremium CreditsSubscriber attests to being a non-smoker/commits to a cessation programand attests for spouse if applicable$20 per monthSubscriber (only) completes a confidentialHealth Assessment (HA)$10 per monthSubscriber selects a Primary Care Provider (and any covered dependents)Reduce subscriber premium by …$40 per monthAs mentioned earlier, new wellness incentives are available under the CDHP as well as under the Enhanced 80/20 Plan. So here again are the three wellness activities we discussed earlier that earn premium credits. And here’s how much each one will lower your monthly premium if members enroll in the CDHP:$20 a month if you (and your spouse, if applicable) attest to not smoking or commit to a quitting program$10 a month if you complete a confidential Heath Assessment, and$10 a month if you select a PCP for yourself and each family member enrolled in the CDHP.Although the activities are the same, you may notice the credits are slightly lower than those on 80/20 Enhanced Plan. That is because the premium is lower and the deductible is higher. And remember, you can do one, two or all three of these wellness activities. If members do all three, you’ll bring the cost of your CDHP premium down to zero.This plan includes a $40 premium. However, if all activities are completed, the subscriber-only premium would be $0.This plan will have the lowest dependent premiums of all three plans.NOTE: Smokers will need to commit to participation in a smoking cessation program by Jan. 1, 2014.
20 Lower Member Health Care Costs with Wellness Incentives—CDHP Things you can do toreduce your costs…CDHP IncentivesVisit the PCP listed on ID card$15 added to the HRAVisit a Blue Options Designated specialist$10 added to the HRAGet inpatient care in a Blue Options Designated hospital$50 added to the HRARemember:Get preventive care through an in-network provider in a non-hospital setting100% coverage – this is provided at no cost to the memberACA preventive medication listCDHP preventive medication list15% of eligible expense with no deductibleWith the CDHP, members can also take advantage of the additional incentives that will become available in 2014.First, you’ll receive free preventive care if you use an in-network provider in a non-hospital setting.In addition, the State Health Plan will increase the balance in their HRA if you use certain doctors and hospitals.It will increase $15 each time you use your PCPIt will increase $10 if you use a Blue Options Designated specialistAnd it will increase $50 if you choose a Blue Options Designated hospital if you need to be admitted to a hospital
21 CDHP Highlights in 2014 Coverage In-Network Out-of-Network Plan-Provided HRA Contribution$500 employee/retiree$1,000 employee/retiree + 1 dependent$1,500 employee/retiree + 2 or more dependentsAnnual Deductible$1,500 individual/$4,500 family$3,000 individual/$9,000 familyCoinsurance (after deductible is met)15% of eligible expenses35% of eligible expensesOut-of-Pocket Maximum for medical and pharmacy (includes deductible)$6,000 individual/$18,000 familyOffice Visits(after deductible is met)15% of eligible expenses; $15 added to HRA if the PCP on the ID card is utilized; $10 added to HRA if a Blue Options Designated specialist is utilizedInpatient Hospital15% of eligible expenses; $50 added to HRA if a Blue Options Designated hospital is utilizedACA Preventive Medication List$0 coinsurance, $0 deductibleCDHP Preventive Medication List15% coinsurance, $0 deductibleHere is a brief summary of the Consumer-Directed Health Plan that shows the share of the cost for various services.
22 The Traditional 70/30 PlanTraditional 70/30 Plan – The new name for the current 70/30 Basic Plan; there are no changes to the Plan’s benefits for 2014Copays 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 providerPreventive Services – Copays still apply to preventive services.And finally, the third Health Plan option for 2014—the Traditional 70/30 Plan.As a reminder, this plan is the same as the current 70/30 Basic Plan; only the name is changing.So like the Basic Plan, it is a preferred provider organization administered by Blue Cross and Blue Shield of North Carolina.You can go to any doctor or hospital in the BCBSNC network or go out of network. However, if you stay in network, your deductibles, copays and coinsurance will be lower.Most importantly, wellness incentives are not offered under this plan. While members are encouraged do things like complete a Health Assessment and choose a primary care provider, the employee premium, which is already zero, won’t be affected. Neither will the copays—regardless of whether or not you use your PCP or a Blue Options Designated provider.Unlike the Enhanced Plan and the CHDP where preventive care is covered at 100%, under the Traditional Plan, most preventive care will have copays and deductibles
23 Traditional 70/30 Plan Benefit Highlights CoverageIn-NetworkOut-of-NetworkAnnual Deductible$933 individual/$2,799 family$1,866 individual/$5,598 familyCoinsurance (after deductible is met)30% of eligible expenses50% of eligible expenses plus 100% of amount above the allowed amountCoinsurance Maximum (excludes deductible)$3,793 individual/$11,379 family$7,586 individual/$22,758 familyOffice Visits$35 copay for primary doctor$81 copay for specialists50% after deductiblePreventive CareOnly certain services are coveredInpatient Hospital$291 copay, then 30% after deductible$291 copay, then 50% after deductiblePrescription Drugs (for 30-day supply)Tier 1 $12 copayTier 2 $40 copayTier 3 $64 copaySpecialty medications 25% up to $100 maximum per 30-day supplyHere is a brief summary of the Traditional Plan’s benefits that shows the share of the cost for various services.Remember – if subscribers take no action during the October enrollment period, they will be enrolled in the Traditional 70/30 Plan.
24 Monthly Premiums—Enhanced 80/20 Plan 2014 Enhanced Plan Premiums(Active Employees and Non-Medicare Primary Members)Coverage TypeEmployee/ Retiree Monthly PremiumDependent Monthly PremiumTotal Monthly PremiumWellness Premium Credits*Net Monthly Premium*Employee/Retiree Only$63.56N/A$50.00*$13.56*Employee/Retiree + Child(ren)$272.80$336.36$286.36*Employee/Retiree + Spouse$628.54$692.10$642.10*Employee/Retiree + Family$666.38$729.94$679.94*Now let’s look at your premiums. These apply to active employees and non-Medicare primary members effective January 1, 2014, under the Enhanced Plan. It shows how much you pay without any wellness premium credits and with maximum wellness premium credits.An online premium calculator will be available at the State Health Plan website in September. Members will be able to compare the premiums of all of the plans, with and without wellness premium credits.*Assumes completion of three wellness activities
25 Monthly Premiums—CDHP 2014 CDHP Premiums(Active Employees and Non-Medicare Primary Members)Coverage TypeEmployee/ Retiree Monthly PremiumDependent Monthly PremiumTotal Monthly PremiumWellness Premium Credits*Net Monthly Premium*Employee/Retiree Only$40.00N/A$40.00*$0*Employee/Retiree + Child(ren)$184.60$224.60$184.60*Employee/Retiree + Spouse$475.68$515.68$475.68*Employee/Retiree + Family$506.64$546.64$506.64*Here are the premiums for active employees and non-Medicare primary members effective January 1, 2014, under the CDHP. It too shows how much you pay without any wellness premium credits and with maximum wellness premium credits applied.Note that family coverage premiums are lower under this plan than under either the Enhanced or Traditional Plan.*Assumes completion of three wellness activities
26 Monthly Premiums—Traditional 70/30Plan 2014 Traditional Plan Premiums(Active Employees and Non-Medicare Primary Members)Coverage TypeEmployee/ Retiree Monthly PremiumDependent Monthly PremiumTotal Monthly PremiumEmployee/Retiree Only$0N/AEmployee/Retiree + Child(ren)$205.12Employee/Retiree + Spouse$528.52Employee/Retiree + Family$562.94Here are the premiums for active employees and non-Medicare primary members effective January 1, 2014, under the Traditional Plan.As a reminder, there is no premium for employee-only coverage. However, there will be approximately a 1.04 percent increase in dependent premiums for 2014.Also, wellness premium credits are not offered under this Plan.Reminder: Wellness premium credits are not offered under the Traditional Plan.
27 Completing Open Enrollment Action must be taken during Open Enrollment—October 1–31, 2013:Choose a health planDecide whom to coverComplete wellness activitiesRemember, NC Flex Benefits enrollment in Oct. as well.Online enrollment only – through the eEnroll or BEACON platform, depending on your agencyChoices are effective from January 1, 2014 through December 31, 2014Remember, you must take action during Open Enrollment! If members do not complete their enrollment by October 31, 2013, they and any covered family members will be enrolled in the Traditional 70/30 Plan effective January 1, 2014.All enrollments will be online – through the Benefitfocus or BEACON platform, depending on your agency/employer.The choices you make will remain in effect from January 1, 2014, through December 31, Members may not switch plans or coverage type (for example, employee only) unless you experience a qualifying life event, such as marriage, birth, death or retirement. (You can find a complete list of qualifying life events in your Benefits Booklet, which is available online at the State Health Plan website.)Members can enroll themselves only or any eligible family members.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.
28 Enrollment Instructions BEACONEmployee 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 (in Raleigh) or (statewide) to complete enrollment by phone.eEnrollAll 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 atHere are the websites and telephone numbers for the different Enrollment Agencies.
29 Resources for Members Please READ your mail! There will be 4 mailers sent to you to assist you in your decision.SHP WebsiteThere will be 4 instructional videos posted to the Plan’s website.Premium Rate Calculator tool available online in SeptemberEnrollment tour will be conducted across the state in October, more information will be included in one of your mailersSign up for our monthly electronic newsletter, Member Focus, which can be done by visiting the Plan’s websiteTake advantage of these additional resources to help you in making an informed decision.
30 Important NumbersELIGIBILITY AND ENROLLMENT for eEnroll AgenciesBEST SHARED SERVICES: BEACONBLUE CROSS AND BLUE SHIELD OF NC (BENEFITS, CLAIMS and HRA)EXPRESS SCRIPTS (PHARMACY QUESTIONS for Active/Non-Medicare Retirees)Or call one of these numbers for some additional assistance.
31 Thank you!Thank you. Does anyone have any questions?