retiree_faqs by niusheng11


									                    Teachers’ and State Employees’ Comprehensive Major Medical Plan

 Frequently Asked Questions (FAQs) for Retirees, about
   the PPO and Indemnity plan for Annual Enrollment

What is annual enrollment?
Annual enrollment is the only time during the benefit year when members are
allowed to make changes to their plan. Annual enrollment allows members to:
1. Switch plan options
     move from the Indemnity Plan to the PPO plan
     change from the 90/10 PPO plan to the 80/20 PPO plan
     move from the PPO plan to the Indemnity plan
2. Add / remove dependents
3. Update personal information

When is annual enrollment?
Annual enrollment for the 2007 / 2008 benefit year, is from March 1st through
March 30th, 2007. All changes made during annual enrollment will become
effective July 1, 2007.

I received my annual enrollment kit, what do I need to do?
If you wish to make any changes in your coverage or update your personal
information such as your address you should complete the Annual Enrollment
Change form located in your kit.
            You will need to return your completed change form by March 30,
               2007 to the Retirement System:
                   o NC Department of State Treasurer
                       Retirement System Division
                       325 North Salisbury Street
                       Raleigh, NC 27603-1385
            Lines 1, 2, and 14 on the change form are required in order to
               process your changes.
            Any changes you make during annual enrollment will become
               effective on July 1, 2007. If you do nothing, you will remain in your
               current plan.
How can I reach someone when calling Customer Service?
If you are unable to reach the correct person or cannot get through a ll of the
prompts when calling Customer Service, you can remain silent. The automated
system will try 3 times to get you to enter your information. After 3 failed
attempts the system will then take you directly to a Customer Service agent.
Pressing zero or pound will start the automated system over.

What are the rates for 2007/2008 benefit year?
The rates for the 2007/2008 benefit year have not been established and will be
determined during this year’s legislative session. Based on the market trends, it
is likely that all plan options will experience a rate increase. The potential rate
increase should not change the premium structure between plans, therefore the
70/30 PPO plan will still most likely have the lowest premium for dependent
coverage and the 90/10 PPO plan will most likely have the highest premium for
dependent coverage. Unfortunately the actual rates and benefits for both the
PPO plans and the Indemnity plan will not be made available until after annual

We know that this timing is difficult. That’s why the State Health Plan is
recommending, as one of our top legislative priorities, a switch to a calendar year
benefit period. Future enrollments would then take place in the fall (rather than
the spring), after the General Assembly has passed the budget – and new
premiums and benefit changes have been determined.

The State Health Plan is committed to affordability and choice. We apologize for
the difficulties presented by the current timing and will do our best to assist our

What are the KEY differences between the Indemnity plan and
the NC SmartChoiceSM Blue Options SM PPO plans?
The KEY differences are:

      With the NC PPO plans, State members will save on their medical costs
       by avoiding deductibles and coinsurance for most in-network physician
       office visits.

      The PPO plans provide choice. State members have three PPO plan
       options, with varying levels of coverage to choose from.

      With the PPO plans, State members have the option of covering
       themselves and their spouses without having to pay for full family

      The PPO plans offer reduced premiums for dependent coverage.
      On the Indemnity plan members have to pay deductible and coinsurance
       for preventive care except for the first $150 of preventive care per benefit
       year. As a result, members have to choose which preventive service(s)
       they want covered at 100% under their preventive benefit. For the PPO
       plans, such choices are unnecessary. Costs are usually less because the
       member is only paying the copay when receiving preventive services in-

      On the PPO plans, members pay only a copay for both an annual physical
       and mammogram when provided in-network.

PPO Plans

If during annual enrollment, I choose a PPO plan and later
decide that I do not like it, can I switch plans?
You will only be able to switch plans during your next enrollment period. You
have to remain in the plan that you choose until the next benefit year. If a
qualifying event occurs during the plan year, changes may only be made within
the same plan option. For example, a newborn may be added to your coverage
as a qualified status change, but you cannot switch to a different plan option.

Can I obtain claim information online?
Yes, this is one of the benefits you receive as a PPO plan member. You can view
your claim information online by registering with My Member Services at You can also print an Explanation of Benefits from My Member

What network of providers do I have access to?
If you choose one of the PPO plans, you will have access to the Blue Cross and
Blue Shield Blue OptionsSM network of providers. If you receive services outside
of this network, you will still have coverage, but your benefits will be reduced and
you will have to pay more out-of-pocket. The Blue OptionsSM network includes
about 90% of the primary care physicians in the state, 97% of the hospitals in the
state, and participating providers in all 100 counties of North Carolina. Members
who reside or travel outside of North Carolina will be able to receive in-network
coverage through the extensive Blue Card network of providers.

What happens if my provider drops out of the network during
the middle of a treatment plan?
If a provider drops out of the network during treatment for a special on-going
condition such as pregnancy, services are still covered for possibly up to a 90-
day period or more depending on pla n rules and utilization management. The
covered member should contact Customer Service at 1-888-234-2416 to discuss
continuation of care.
I am unclear about how preventive and wellness benefits work.
How many services can I receive for one copay, and what is
subject to the coinsurance and deductible?
The initial copay covers services received during a primary care physician visit.
Mammograms and lab work, when received alone outside of the doctor's office,
are also covered under the initial copay. If more services are required, such as
x-rays, an EEG or an EKG, they may be covered at 100% if performed in a
physician's office. If the services are performed in an outpatient clinic setting,
they may be subject to the deductible and coinsurance.

What if my doctor sends me to another location for lab work.
Are the lab services covered?
If recommended lab services originate from a primary care physician visit and the
physician is NOT part of a hospital-owned practice, the lab services are covered
at 100% when received alone; otherwise, they may be subject to the deductible
and coinsurance.

Do chiropractic visits count towards the 30-visit limit for therapy
per benefit year?
Chiropractic visits count toward the thirty total visits allowed per plan year for
therapy services, along with outpatient physical and occupational therapy visits.
The total combined number of visits allowed for these services is 30 per benefit

I understand that routine eye exams are covered in-network with
just the primary care copay. What is included in the routine eye
exam? Can the provider write a prescription for contacts and/or
glasses during the routine eye exam visit? Where should I get
the prescription filled?
Routine eye exams include glaucoma screening, measurement for contact
lenses or glasses and a prescription, if necessary. Hardware such as glasses
and/or contact lenses are not covered. However, you can receive a 30% discount
on eyewear and hard contact lenses and a 15% discount on disposable contacts
at in-network providers with dispensaries.

Are there visit limits for mental health services?
Yes, outpatient mental health is limited to 30 visits per benefit year. Inpatient
mental health has a separate visit limit of 30 inpatient days per benefit year.
Only in very limited circumstances members will be able to receive more than 30
outpatient visits per benefit year.

How are diabetic supplies covered under the PPO plans?
Diabetic supplies including test strips, lancets and syringes are covered by the
pharmacy benefit copay. Preferred brand diabetic supplies are covered with a
$10 copay for a 34-day supply. Non-preferred brand diabetics supplies have a
$25 copay for a 34-day supply. Insulin dependent members can receive up to
150 test strips per 34-day supply and non-insulin dependent members can
receive up to 50 tests per 34-day supply. If a member needs additional test
strips they can be purchased through their medical supply benefit. Medical
supplies are subject to deductible and coinsurance.

What constitutes an emergency?
An emergency is the sudden or unexpected onset of a condition of such severity
that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention
to result in any of the following: placing the health of an individual or with respect
to a pregnant woman, the health of the pregnant woman or her unborn child in
serious jeopardy; serious physical impairment to bodily functions; serious
dysfunction of any bodily organ or part; or death.

      Heart attacks, strokes, uncontrolled bleeding, poisonings, major burns
       prolonged loss of consciousness, spinal injuries, shock, and other severe,
       acute conditions are examples of emergencies.

Routine Physical and Screening Procedures
The Indemnity plan provides its members with a $150 preventive benefit per
benefit year (July 1 - June 30). The indemnity plan will pay 100 percent of
allowable charges up to the $150 maximum after the copayment. Preventive
services that exceed the $150 preventive benefit are subject to deductible and

The $150 preventive benefit may be applied to     the   following services:
    Routine physicals                                 Hearing tests
    Pap smears                                        Routine blood and urine tests
    Breast, colon, rectal and                         Occult blood tests
      prostate exams                                   Chest x-rays
    Blood pressure checks                             Thyroid studies
    Mammograms                                        Tuberculosis tests
    Electrocardiograms

On the Indemnity plan can I receive a physical every year?
General health checkups that are medically necessary for the maintenance and
improvement of an individual's health and screening procedures, including
mammograms,* are limited as follows (a "year" is defined as 365 days):

      Unlimited well visits for children from birth up to one (1) year
      Three (3) well visits for children between the ages of one (1) and two (2)
      One (1) visit each year (365 days must pass between visits) for children
       between the ages of two (2) and seven (7)
      One (1) visit every three (3) years (1,095 days between visits) for
       individuals between seven (7) and thirty-nine (39) years of age
      One (1) visit every two (2) years (730 days between visits) between forty
       (40) and forty-nine (49) years of age
      One (1) visit every year (365 days between visits) for individuals forty (40)
       years and older The Indemnity plan DOES NOT pay benefits for physical
       examinations, tests, and reports

Routine physical examinations performed as part of employment, insurance,
legal, school, camp, travel, athletic or governmental requirements are not

To top