Annual Enrollment

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State Health Plan NC SmartChoice SM Blue
Options SM PPO and Indemnity Plans Overview for
Retirees

• Annual Enrollment
• March 01 March 30, 2007

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Background of the State Health Plan

• The State Health Plan
• Is mandated by general statute (Chapter 135).
• Offers a health benefit plan to all state
  employees, including teachers and retirees.
• During the 2005/2006 legislative session the
  NCSHP was given the authority to offer optional
  plans.
• Offered NC SmartChoiceSM in October 2006.

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How Does the State Health Plan Work?

• The State Health Plan has contracted with BCBSNC
  to use their provider Networks

NC SmartChoiceSM PPO Plans
Blue Options Network
Indemnity Plans
CostWise Providers
Medco
Pharmacy

• You should always verify that your provider
  participates in the Blue Options or Costwise
  Network before receiving care to avoid additional
  out-of-pocket costs.

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Annual Enrollment

• March 1 - 30 for the 2007/2008 benefit year.
• During annual enrollment you can

• 1.) Switch plan options
• Switch from the Indemnity plan to a PPO plan
• Move from one PPO plan to another
• Switch from a PPO plan to the Indemnity plan
• 2.) Change your coverage tier
• (Retiree-only to retiree-children)
• 3.) Add or remove dependents

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General Information

• Members can call Customer Service at

NC SmartChoiceSM PPO Plans
1-888-234-2416
1-800-422-4658
Indemnity Plans

• New members and members changing plans will
  receive their NEW ID cards prior to the
  07/01/2007 effective date
• Only new members or members changing plans will
  receive a Benefit Booklet

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Products

• Four Choices for Eligible Members
• NC SmartChoiceSM Blue OptionsSM PPO Plans
  Copays for in-network office visits. For other
  services coinsurance levels vary depending on
  plan selection.  
• Indemnity Plan- Copay, deductibles and
  coinsurance for all services

•  
•    

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• PPO Plans

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NC SmartChoice SM Blue Options SM PPO Plans

• State retirees have 3 PPO options from which to
  choose

• All 3 PPO options include a retiree-spouse tier

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PPO Plan Highlights

• Copay only for most in-network (non-hospital
  based) physician office visits
• Extensive in-state and out-of-state network
• No lifetime maximum
• Most annual physicals, copay only

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Blue OptionsSM Network

• PPO plans use the Blue OptionsSM Network
• Open Access
• No referral required for office visit to
  specialists.
• Nationwide Coverage (Via BlueCardTM)
• If you live or travel outside of North Carolina,
  you can receive care from participating Blue
  Cross and Blue Shield (BCBS) providers at the
  same in-network benefit level.
• Worldwide Coverage (Via BlueCardTM)

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PPO Plans - Preventive Benefits

• Routine physicals, eye exams, and hearing exams
  are covered every benefit year with no age
  restrictions (in-network only)
• Screenings covered in and out-of-network
• Gyn exam cervical cancer screening
• Ovarian cancer screening
• Mammograms
• Colorectal screening
• Prostate screening
• Copay for services received in physician office -
  otherwise subject to deductible coinsurance
• Labs are covered at 100 when performed alone
• Immunizations are covered at 100 when received
  in-network

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PPO Plans - Outpatient Services

• Coverage level depends on where you receive
  services. Example Sprained ankle

• Please note CT scans, MRIs, MRAs and PET scans
  are always deductible and coinsurance.

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PPO Plans - Outpatient Services

• Some physician practices are hospital-owned or
  operated and will bill your in-network office
  visit like an outpatient hospital visit instead.

• Watch for yellow donut or red square icons!

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Out-of-Network ServicesFor PPO Members

• Some services are not covered out-of-network.
• You may be required to pay for charges over the
  allowed amount, in addition to your copay or
  coinsurance.
• If your physician leaves the network, you have
  the option of continuing care with your provider
  using the out-of-network benefits.
• You may have to pay the provider and file a claim
  for reimbursement.
• Emergencies are always covered as in-network.
• Anesthesiology and radiology are covered as
  in-network when received as an inpatient at a
  participating hospital and when admitted by a
  participating physician.

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Pre-Authorization of Services For PPO Members

• You are responsible for pre-authorization of
  services received outside of North Carolina.
• For a complete list of services that require
  pre-authorization, refer to your benefit booklet
  or call Customer Service.

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PPO and Medicare

• Routine Eye Exams are covered under PPO not a
  Medicare benefit or indemnity plan benefit
• Routine Physicals and Gynecological Exams are
  covered under PPO for copay only for most
  in-network. Not covered under Medicare benefit.
  Indemnity plan has 150 maximum then deductible
  and coinsurance.
• Diabetic Supplies covered under PPO for copay
  only. Indemnity plan deductible and coinsurance.
  Medicare does not cover syringes.
• Office Visits Copay only under PPO when see
  in-network provider. Deductible must first be
  met under both Indemnity and Medicare before
  receive benefit.

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PPO and Medicare (cont.)

• Its free for retiree-only coverage
• Lower out-of-pockets costs copay only for most
  in-network office visits
• Lower premiums for dependent coverage
• Retiree-Spouse Tier
• Travel Outside of North Carolina and
  out-of-country same in-network benefits
  (BlueCard)

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Extra Perks for PPO Members

• Blue ExtrasSM
• Discounts on certain non-covered services, such
  as cosmetic dentistry, lasik eye surgery,
  cosmetic surgery, massage therapy and alternative
  medicine
• Discounts on vitamins and herbal supplements
• Earn prizes for physical activity

• My Member Services
• Protected online resource for managing health and
  maximizing benefits
• View claim status, check benefits summary, update
  policy information, order new ID cards, change
  billing address
• For more information, visit www.shpnc.org

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• Indemnity Plan

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Indemnity Plan Highlights

• Pay copayment, plus deductible and coinsurance
  for all services
• First 150 of preventive services covered at 100
• Preventive services above 150, subject to
  copayment, then deductible and coinsurance
• CostWise participating providers
• Retiree-spouse tier not available
• 5 million lifetime maximum

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Indemnity Plan and Non-Participating Providers

• Non-participating physicians
• Member responsible for the difference between the
  CostWise charge and the out-of-network providers
  charges

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Indemnity Plan and Non-Participating Hospitals

• Non-participating hospitals
• Member responsible for the difference between the
  in-network and the out-of-network charges

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Indemnity Plan Preventive Benefits

• Age restrictions on how often you can receive
  routine physicals
• First 150 of preventive services covered at 100
• Preventive services above 150, subject to
  deductible and coinsurance
• Immunizations covered at 100

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• Benefit Differences Between The Plans

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Covered Service Limits
PPO Plans
Indemnity Plan

• Physical Therapy, Occupational Therapy and
  Chiropractic - 30 combined visits per benefit
  year
• Speech Therapy 30 visits per benefit year
• Home Health Care - 100 days per benefit year

• Chiropractic - 2000 limit per benefit year

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Mental Health and Substance Abuse Services
PPO Plans
Indemnity Plan

• Mental Health limited to 30 outpatient visits per
  benefit year/30 inpatient days per benefit year
• Substance Abuse limited to 8,000 per benefit
  year/ 16,000 per lifetime

• Mental Health and Substance Abuse are unlimited.
• Prior authorization required for outpatient
  visits that exceed 26 per benefit year.

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Routine Mammograms

• Allowed once a year for members 35 and older
• Routine mammograms are covered at 100 when
  performed alone, includes radiologist reading
• When performed with another service or diagnostic
  (not routine), mammograms are subject to
  coinsurance and deductible

PPO Plans

• Allowed once a year for members 40 and older
• Mammogram and radiologist reading subject to
  copay, deductible, and coinsurance
• Can be included in the 150 preventive benefit

Indemnity Plan
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Chemotherapy Benefits
PPO Plans

• Benefits are based on service location
• Always subject to copayment, deductible and
  coinsurance

Indemnity Plan
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Pharmacy Benefits
PPO Plans - Diabetic supplies are covered under
pharmacy with a copay
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Diabetic Supplies
PPO Plans
Indemnity Plan

• Covered under Pharmacy Benefit
• 10 copay for preferred brand for a 34-day supply
• 25 copay for non-preferred band for a 34-day
  supply
• Insulin-dependent
• 150 test strips per 34-day supply
• Non-insulin dependent
• 50 test strips per 34-day supply
• Additional test strips
• Covered under medical supply benefit, subject to
  deductible and coinsurance

• Covered under Medical Supply Benefit, NOT the
  Pharmacy Benefit
• Subject to deductible and coinsurance

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Prescription Drug Incentive Programs

• Waiver of copays for generic prescriptions
• January 1, 2007 March 31, 2007
• Coverage of generic over-the-counter nicotine
  replacement patches
• No copay through March 31, 2007
• 5 copay per prescription after March 31, 2007
• Prescription required

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• Annual Enrollment

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State Health Plan Rates

• Rates for the 2007/2008 benefit year will be
  determined during the legislative session.
• Based on market trends, it is likely that all
  plan options will experience an increase in rates
• Potential rate increase should not change premium
  structure between plans
• PPO Basic Plan (70/30) will most likely still
  have lowest premium for dependent coverage
• PPO Plus Plan (90/10) will most likely still
  have highest premium for dependent coverage
• Rates effective October 1, 2007

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Member Responsibilitiesfor Annual Enrollment

• Complete an Annual Enrollment Change Form
• Changing plans, adding dependents
• Update personal information

• Changes become effective July 1, 2007
• Members who do not complete a change form will
  remain on their current plan

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New State Health Plan Participants

• Retirees can obtain enrollment kits beginning
  March 5th by calling Customer Service
• Print kit from the State Health Plan Web site at
  www.shpnc.org

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What if an employee is retiring?

• Employees who retire prior to the effective date
  of 07/01/2007 should
• Send their Annual Enrollment Change Form to their
  HBR
• And send their completed HM form to the State
  Retirement System

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Effective Date of Changes/Coverage

• The effective date is July 1 for
• Any changes made during annual enrollment
• New dependents added to your plan
• New State Health Plan members

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Annual Enrollment

• Health benefit year is from July 1 June 30, at
  which time deductibles and coinsurance start
  over.
• Pre-existing condition waiting periods will apply
  to new members if they havent been continuously
  covered for 12 months or had a break of more than
  63 days prior to effective date.

• (This is different from last year.)

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How to make changes to your plan

• Complete a change form contained in your
  enrollment kit.
• Keep PINK copy for your records.
• Send the other 2 copies
• Retirees to the Retirement System
• Note If you print your change form from the SHP
  Web site, complete the form and make 2
  photocopies. Send the original along with 1
  photocopy to the applicable location.

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Resources

• Customer Service Support Help Line
• 1-888-234-2416 PPO Plan
• 1-800-422-4658 Indemnity Plan
• State Health Plan Web site www.shpnc.org
• Seniors Health Insurance Information Program
  (SHIIP)
• 1-800-443-9354 (toll free)
• 919-807-6900

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• Questions?