Teachers’ and State Employees’ Comprehensive Major Medical Plan www.shpnc.org Frequently Asked Questions (FAQs) for Retirees, about the PPO and Indemnity plan for Annual Enrollment 2007/2008 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 enrollment. 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 members. 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 coverage. 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- network. 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 www.shpnc.org. You can also print an Explanation of Benefits from My Member Services. 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 year. 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. INDEMNITY PLAN FAQs 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 coinsurance. 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 covered.
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