health plan options insurance education part #2. health plan options choices state health plan ...

Health Plan Options

Insurance Education Part #2

Health Plan Options

Choices• State Health Plan

Standard Plan Savings Plan

• HMOs BlueChoice HealthPlan*

(available statewide) CIGNA HMO*

*Must live or work in service area

Health Plan OptionsStandard Plan

and Savings Plan

(Features the Plans have in Common)


State Health Plan (SHP)Standard Plan and Savings Plan

• Network providers

• Out-of-network benefits

• BlueCard Program

• Preventive benefits

• Rx network providers

• Mental health and substance abuse benefits

• Medi-Call/APS pre-authorization requirements

Standard Plan and Savings Plan(common to both)

Provider Network and

BlueCard Advantage• Freedom of choice• Worldwide coverage• Easy access to medically necessary care

• Providers file claims• Subscriber pays deductible and coinsurance

SHP Standard Plan and Savings Plan

(cont.)

• Subscribers not balance-billed for charges over allowed amount (negotiated pricing)

• SHP ID card (Preferred Provider Organization, or PPO, logo located in bottom corner of ID card)

• National PPO organization coverage

• Worldwide coverage• Call 800-810-BLUE


Non-network Benefits• Freedom of choice (will receive higher level of benefits when using network providers)

• Worldwide coverage• Easy access to medically-necessary care



(cont.)

• Subscriber may have to file claims

• Subscriber pays deductible and higher coinsurance maximum

• Subscriber can be balance-billed (provider can charge more than allowed amount no negotiated pricing for non-network services)


Preventive Benefits (must follow Plan guidelines)• Mammography testing• Pap Test• Well-child care• Routine colonoscopy• Worksite health screening (available to HMO subscribers as well)

Mammography Testing• 100 percent coverage for routine, four-view mammograms, according to Plan guidelines

• Performed at participating mammography facilities


(cont.)

• Ages 35-39 (one routine mammogram during those years)

• Ages 40-74 (one routine mammogram every 12 months)

• Deductible and coinsurance apply to diagnostic mammograms


Pap Test• No deductible or coinsurance• Subscriber free to choose provider• One Pap Test each year for covered females, ages 18 through 65

• For routine and diagnostic Pap Tests

• Pays lab costs only - routine office visit NOT covered


Well-child Care Benefits• Well-child checkups

Five visits for children younger than 1 year old

Three visits for children 1 year and older

One visit per year for children age 2 through 18


(cont.)

• 100 percent benefit for regular check-ups provided by network providers

• 100 percent benefit for covered immunizations, according to recommended schedule (catch-up provision for delayed or missed immunizations through age 18)


(cont.)

• Covered immunizations Diphtheria-Tetanus-Pertussis (DTP)

Polio Hepatitis A and B Haemophilus (Hib)



(cont.)

• Additional covered immunizations Measles-Mumps-Rubella Chicken pox Pneumoccocal vaccine (Prevnar) HPV (Human Papilomavirus) Influenza Meningococcal

Routine Colonoscopies• One routine colonoscopy every 10 years for subscribers age 50 and older

• Subject to deductible and coinsurance

• Diagnostic colonoscopy subject to deductible and coinsurance


Prevention Partners

(State Employee Wellness Program)

• Worksite screening available to employees and spouses covered by State Health Plan or HMO/POS Subscriber/spouse pays $15 for screening


One screening a year, per eligible SHP subscriber and covered spouse• $15 per eligible subscriber• For active and retired subscribers

and their spouses • Whose primary coverage is one of

state’s health plans and• Is not eligible for Medicare

(cont.)


• Chemistry profile (BUN, Glucose)

• Hemogram (Hemoglobin)

• Health risk appraisal

• Blood pressure check

• Height and weight measurement

• Lipid profile (cholesterol)

• Confidential personal report

• Confidential, personal consultation about results upon request

Screening Benefits


Retail Rx Maintenance Network• Visit www.eip.sc.gov• Choose your category• Go to online directories• Select “State Health Plan Retail Maintenance Network”

• Plan administrator -- Medco • Medco Customer Service: 800-711-3450


My Rx Choices May help SHP subscribers pay less for long-term prescriptions

Locate lowest-cost prescriptions using Medco’s online cost comparison tool

Access “My Rx Choices” online to compare drug costs by visiting:

www.Medco.com

See Insurance Benefits Guide for details


Medi-Call (state managed care)• State Health Plan’s utilization review program for medical/ surgical benefits

• Ensures subscriber and covered family members receive appropriate medical care in most beneficial, cost-effective manner



(cont.)

• Some services requiring a Medi-Call Provider may call for subscriber; however, subscriber has responsibility for calling Medi-Call for pre-authorization


(cont.)

• Some services include All inpatient admissions Emergency admissions within 48 hours or next business day

All outpatient surgery in hospital or ambulatory surgical center

Hospice services Home health care services

(cont.) Skilled nursing service In-vitro fertilization procedures Call during first trimester of pregnancy

MRI, MRA, CT or PET scan

• Consult Insurance Benefits Guide for complete listing of services requiring a Medi-Call



(cont.)

• Penalties if Medi-Call not contacted $200 penalty (penalty does not apply to coinsurance maximum)

Charges for services not pre-authorized by Medi-Call do not apply toward deductible or coinsurance maximum

Medi-CallColumbia:

803-699-3337SC, nationwide and Canada:

800-925-9724


Mental Health/Substance Abuse

• Administered by APS• Coverage for medically necessary treatment of mental health and substance abuse conditions

• Same coinsurance, deductible and out-of-pocket amounts as for physical conditions


• Must use participating provider or no benefits paid

• Can nominate provider for network

(cont.)


• Inpatient/outpatient care Pre-authorization required before receiving care

Call APS: 800-221-8699• Outpatient treatment beyond 10 visits must be reviewed for medical necessity

(cont.)


Tobacco Cessation Benefits• Free & Clear Program, administered by APS

• Free for subscribers and covered dependents



Contact Free & Clear to participate at:866-QUIT-4-LIFE(866-784-8454)

SHP Standard Plan


Coinsurance Out-of-network• Plan pays 60%

• Subscriber pays 40%

Coinsurance Maximum• $4,000 individual

• $8,000 family

Annual Deductible• $350 individual• $700 family

Coinsurance In-network• Plan pays 80%

• Subscriber pays 20%

Coinsurance Maximum• $2,000 individual

• $4,000 family

Deductibles and Coinsurance

Standard Plan

Per-occurrence Deductibles• $125 emergency room visit (waived if admitted)

• $75 out-patient hospital service (some exceptions apply)

• $10 per office visit• Do not apply toward annual deductibles or coinsurance maximums

Standard Plan

• Must use participating network pharmacy

• Most major pharmacies nationwide and many independent pharmacies in SC

• Show State Health Plan ID card• List of participating pharmacies on EIP Web site

Prescription Drug Program Pharmacy Network

Standard Plan

Participating Retail Pharmacy(up to 31-day supply)

• $10 tier one • $25 tier two• $40 tier three

Mail-Order Pharmacy(up to 90-day supply)

• $25 tier one • $62 tier two• $100 tier three

Prescription Drug Program

Standard Plan

Prescription Drug Program Facts

• Annual copayment maximum of $2,500 per person

• Coordination of benefits

Standard Plan

• “Pay the Difference” If generic brand drug is available and subscriber or doctor chooses brand name, subscriber responsible for difference in price between the allowable charge for name brand and generic brand, plus generic brand copayment

(cont.)

Standard Plan

“Pay the difference” does not apply to $2,500 out-of-pocket maximum

Generic copayment does apply to out-of-pocket maximum

(cont.)

Standard Plan

Savings Plan Health Savings Accounts

(HSA)and

Limited-use Medical Spending Accounts


Choice for Subscribers Who: Want lower premiums Are willing to take more responsibility for their healthcare

Want to save for major medical expenses through Health Savings Account

Savings Plan

Annual Deductible• $3,000 individual• $6,000 family (no embedded deductible)

Savings Plan

Rules• Subscriber pays 100 percent of allowable charges for medical costs In-network provider: SHP allowance applies toward deductible

Out-of-network provider: SHP allows only what Plan would have allowed if subscriber used in-network provider

Savings Plan

• No per-occurrence deductibles

• Reimbursement for annual flu shot

• Annual physical to include specific services

• Eligible to contribute to Health Savings Account (HSA)

(cont.)

Savings Plan

(cont.)

• Subscriber pays 100 percent of allowable charges for prescription costs Must use in-network pharmacies only to pay negotiated rate

Negotiated rate not available when using out-of-network pharmacies

Savings Plan

In-network Coinsurance• Plan pays

80%• Subscriber pays

20%• Coinsurance Maximum

$2,000 individual $4,000 familyOut-of-network Coinsurance

• Plan pays60%

• Subscriber pays40%

• Coinsurance Maximum $4,000 individual $8,000 family

Coinsurance

Savings Plan

Restrictions and Exclusions • Chiropractic payments

Limited to $500 per person (after deductible)

• Rx drug benefits exclude Drugs for erectile dysfunction Non-sedating antihistamines

Savings Plan

Health Savings Account Facts• Tax-sheltered investment accounts used to pay qualified medical expenses

• Money rolls over from year-to-year Cannot be covered by another health plan, including Medicare or Medical Spending Account

Health Savings Accounts (HSA)

Contributions to HSA allowed only when participating in high-deductible health plan (i.e. SHP Savings Plan)

Spouse and dependents do not need to be covered by SHP Savings Plan to be eligible to receive claims reimbursement for covered services

(cont.)

Health Savings Accounts

• Contributions payroll deducted and tax-free

• If contributions direct-deposited, can deduct on tax return

• Keep receipts in event of an IRS audit Tax-free for qualified medical expenses

(cont.)


• If HSA funds used for non-qualified medical expenses, Amount is included in income and IRS penalty applies unless subscriber

• Becomes disabled• Enrolls in Medicare• Dies

(cont.)


• More HSA information on IRS Web site: www.irs.gov

(cont.)

• HSA account does NOT advance money

• Annual HSA contributions for 2008 limited to: $2,900 for individual $5,800 for family

• Catch-up provision for individuals age 55 and older allows additional $900 for 2008



(cont.)

• $1/mo (payroll deducted) administrative fee (FBMC) HSA funds earn interest and are tax free

HSA portable when employment ends

Subscriber must complete “authorization packet” received from NBSC to activate account

• How to access funds from HSA Free VISA® debit card from NBSC Checks provided - $.35 fee per check

written $1/month or $10/yearly administrative

fee until balance reaches $2,500 (NBSC)

(cont.)


“Limited Use” MSA Facts Can use for vision and dental expenses only (maximum $5,000) $3.50 per month administrative

fee applies Must be continuously employed

for one year to enroll

“Limited Use” Medical Spending Accounts (MSA)

(cont.)

• “Use it or lose it” (funds do not roll over as with HSA)

• Claims must be incurred by March 15th grace period and submitted by March 31st

• Not eligible for EZ REIMBURSE® Card

“Limited Use” Medical Spending Accounts (MSA)

My InsuranceManager

BCBS of South Carolinawww.southcarolinablues.com


My Insurance Manager’s Features • Review claims via BCBS Web site• View and print Explanation of Benefits (EOB)

• See amount paid toward deductible and coinsurance maximum

• Secure E-mail customer service questions

• View up-to-date provider directory • Request new ID card

My Insurance ManagerBCBS of South Carolina

(www.southcarolinablues.com)

Health Insurance Options

Health Maintenance Organizations

(HMOs)


Rules• Subscribers must choose primary care physician (PCP)

• Referral required for most specialty care

• You must live or work in HMO service area

Health Maintenance Organizations (HMOs)

(cont.)

• Provide qualified emergency service out-of-network

• No non-emergency out-of-network benefits

• Read HMO materials carefully before making health plan selection

Health Maintenance Organizations (HMOs)

BlueChoice HealthPlan


Features• Annual deductible

Amount subscriber pays before HMO begins paying (deductible does not apply to PCP charges)

$250 individual $500 family

BlueChoice HealthPlan(available in all South Carolina counties)

• After subscriber pays annual deductible and copayment, plan pays 90 percent of allowable charges subscriber pays 10 percent, which applies to coinsurance maximum

(cont.)


• Hospital copayments $100 outpatient hospital copay $125 emergency copay $200 inpatient hospital copay

(cont.)


Physical therapy, speech therapy and occupational therapy Covered after annual deductible met Plan pays 90 percent of allowable

charges; subscriber pays 10 percent Limit per plan year: 20 visits per type of

“therapy”

(cont.)


• Coinsurance maximum Most an individual or family will pay for

covered services Excludes deductibles and copays $1,500 individual $3,000 family

(cont.)


Physician copays Plan pays 100 percent of allowable

charges after copay $15 PCP and OB-GYN copay $30 specialist copay $35 urgent care copay

(cont.)


• Human organ transplant lifetime maximum $350,000 per person

• Tobacco cessation benefits available Free for subscribers and covered dependents, age 18 and older

Contact Free & Clear at:

866-Quit-4-Life (866-784-8454)

(cont.)


Retail Pharmacy (up to 31-day supply)

• $7 generic brand • $35 preferred brand • $55 non-preferred brand• $100 specialty pharmaceuticals

Mail Order (up to 90-day supply)

• $14 generic brand• $70 preferred brand• $110 non-preferred brand

Network Only


CIGNA HMO


Features• Annual deductible: none• HMO pays 80 percent of allowable charges

• Subscriber pays 20 percent --applies toward coinsurance maximum

CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

(cont.)

• Coinsurance maximum $2,000 for individual $4,000 for family Most an individual or family will pay for covered services

Includes inpatient/outpatient hospital copays• $250 outpatient hospital copay• $500 inpatient hospital copay

CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

(cont.)

• $100 emergency room copay HMO pays 100 percent of allowable charges after subscriber pays copay

CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

• Plan pays 100 percent of allowable charges after subscriber pays $15 PCP and OB-GYN copay $30 specialist copay $30 outpatient mental health and

substance abuse copay $50 urgent care copay

(cont.)


Short-term rehabilitation therapy and chiropractic services $30 specialist copay Limit per year -- 20 visits

(cont.)


Mail Order (up to 90-day supply)

• $14 generic brand • $50 preferred brand • $100 non-preferred brand

Network Only

Retail Pharmacy (up to 31-day supply)

$7 generic brand $25 preferred brand $50 non-preferred brand


• Beginning January 1, 2008, available to subscribers and covered dependents

• Free• Enroll

Call 866-417-7848 or Visit CIGNA’s Web site

www.myCIGNA.com

CIGNA Quit TodaySM Tobacco Cessation Program


Strength and ResilienceSM Stress Management Program• Free to subscribers and covered dependents

• Includes: Stress risk assessment Up to six coaching sessions during first six months

Unlimited calls to coach


• To enroll Call 866-417-7848 or Visit CIGNA’s Web site:

www.myCIGNA.com

(cont.)


Active Employee Health Plan Premiums


SHP

Savings Plan

SHP Standard

Plan

You Pay

Employee only $ 9.28 $ 93.46 $ 0.00

Employee/ spouse $ 72.56 $237.50 $144.04 Employee/ children $ 20.28 $142.46 $ 49.00 Full family $108.56 $294.58 $201.12

CI GNA

HMO

You Pay Blue-Choice

HMO You Pay

Employee only $136.30 $36.30 $129.60 $29.60 Employee/ spouse $390.94 $290.94 $380.50 $280.50 Employee/ children $288.66 $188.66 $282.14 $182.14

Full family $577.34 $477.34 $566.48 $466.48

Active Employee Monthly Health Premiums

Active Employee Monthly Health Premiums

health plan options insurance education part #2. health plan options choices state health plan ...

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