1. 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.

2. 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

3. 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.

4. APPROVED DEPENDENT VERIFICATION DOCUMENTS
SPOUSE
BIOLOGICAL CHILD(REN)
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
PAGE 1 OF THE MOST CURRENT YEAR TAX RETURN LISTING THE CHILD(REN) OR A COPY OF THE BIRTH CERFITICATE

5. APPROVED DEPENDENT VERIFICATOIN DOCUMENTS
ADOPTED CHILD(REN)/LEGAL GUARDIANSHIP
FOSTER CHILD(REN)
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
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.

6. 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

7. 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

8. TRADITIONAL 70/30 PLAN CURRENT BASIC 70/30 WITH A NEW NAME
NO INCENTIVES AVAILABLE
NO $0 ACA PREVENTIVE SERVICES AND MEDICATIONS

9. FOCUS ON WELLNESS ENHANCED 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

10. 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

11. FOCUS ON WELLNESS NEW: 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

12. 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

13. 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.

14. WELLNESS TRADITIONAL 70/30 PLAN
NO INCENTIVES AVAILABLE
NO $0 ACA PREVENTIVE SERVICES
NO $0 ACA PREVENTIVE MEDICATIONS

15. 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

16. THE ENHANCED 80/20 PLAN WHAT’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.

17. 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

18. 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

19. 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

20. 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 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 mg – 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

21. ENHANCED 80/20 PLAN HIGHLIGHTS IN 2014
COVERAGE
IN-NETWORK
OUT-OF-NETWORK
ANNUAL 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
(FOR 30 DAY SUPPLY)
TIER 2 $40 COPAY
TIER 3 $64 COPAY
SPECIALTY MEDICATIONS 25% UP TO $100 MAXIMUM PER
30-DAY SUPPLY $0 FOR ACA PREVENTIVE MEDICATIONS

22. QUESTIONS ON THE ENHANCED 80/20 PLAN?

23. THE CONSUMER DIRECTED HEALTH PLAN WITH HEALTH REIMBURSEMENT ACCOUNT (HRA)

24. 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.)

25. 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

26. 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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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

33. 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.

34. 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

35. CDHP HIGHLIGHTS IN 2014 COVERAGE 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 FAMILY
FOR MEDICAL AND PHARMACY
(INCLUDES DEDUCTIBLE)
OFFICE VISITS
15% OF ELIGIBLE EXPENSES: $15 ADDED TO HRA
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
(AFTER DEDCUTIBLE IS MET)
IF A BLUE OPTIONS DESIGNATED HOSPITAL IS
UTILIZED
ACA PREVENTIVE MEDICATIONS
$0 COINSURANCE, $0 DEDUCTIBLE
CDHP PREVENTIVE MEDICATIONS
15% COINSURANCE, $0 DUCTIBLE
15% COINSURANCE, $0 DEDUCTIBLE

36. QUESTIONS ABOUT CDHP?

37. THE TRADITIONAL 70/30 PLAN

38. TRADITIONAL 70/30 PLAN The new name for the current 70/30 Basic Plan.
No plan changes for 2014.
Copays and deductibles still apply.

39. TRADITIONAL 70/30 PLAN BENEFIT HIGHLIGHTS
COVERAGE
IN-NETWORK
OUT-OF-NETWORK
ANNUAL 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
ONLY CERTAIN SERVICES ARE COVERED
INPATIENT HOSPITAL
$291 COPAY, THEN 30% AFTER DEDUCTIBLE
$291 COPAY, THEN 50% AFTER DEDUCTIBLE
PRESCRIPTION DRUGS
TIER 1 $12 COPAY
(FOR 30 DAY SUPPLY)
TIER 2 $40 COPAY
TIER 3 $64 COPAY
SPECIALTY MEDICATIONS 25% UP TO $100
MAXIMUM PER 30-DAY SUPPLY

40. 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

41. QUESTIONS?