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 Options Standard Plan and Savings Plan (Features the Plans have in Common) Insurance Education Part #2

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 BLUE SHP Standard Plan and Savings Plan

Non-network Benefits Freedom of choice (will receive higher level of benefits when using network providers) Worldwide coverage Easy access to medically- necessary care SHP Standard Plan and Savings Plan

SHP Standard Plan and Savings Plan (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)

SHP Standard Plan and Savings Plan 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 SHP Standard Plan and Savings Plan

(cont.) Ages (one routine mammogram during those years) Ages (one routine mammogram every 12 months) Deductible and coinsurance apply to diagnostic mammograms SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

(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) SHP Standard Plan and Savings Plan

(cont.) Covered immunizations  Diphtheria-Tetanus-Pertussis (DTP)  Polio  Hepatitis A and B  Haemophilus (Hib) SHP Standard Plan and Savings Plan

SHP Standard Plan and Savings Plan (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 SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

 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.) SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

Retail Rx Maintenance Network Visit Choose your category Go to online directories Select “State Health Plan Retail Maintenance Network” Plan administrator -- Medco Medco Customer Service: SHP Standard Plan and Savings Plan

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: See Insurance Benefits Guide for details SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

SHP Standard Plan and Savings Plan (cont.) Some services requiring a Medi- Call  Provider may call for subscriber; however, subscriber has responsibility for calling Medi-Call for pre-authorization

SHP Standard Plan and Savings Plan (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 SHP Standard Plan and Savings Plan

SHP Standard Plan and Savings Plan (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-Call Columbia: SC, nationwide and Canada: SHP Standard Plan and Savings Plan

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 SHP Standard Plan and Savings Plan

Must use participating provider or no benefits paid Can nominate provider for network (cont.) SHP Standard Plan and Savings Plan

Inpatient/outpatient care  Pre-authorization required before receiving care  Call APS: Outpatient treatment beyond 10 visits must be reviewed for medical necessity (cont.) SHP Standard Plan and Savings Plan

Tobacco Cessation Benefits Free & Clear Program, administered by APS Free for subscribers and covered dependents SHP Standard Plan and Savings Plan

SHP Standard Plan and Savings Plan Contact Free & Clear to participate at: 866-QUIT-4-LIFE ( )

SHP Standard Plan Insurance Education Part #2

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 Insurance Education Part #2

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 pays80% Subscriber pays20% Coinsurance Maximum  $2,000 individual  $4,000 family Out-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.) Health Savings Accounts

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.) Health Savings Accounts More HSA information on IRS Web site:

(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 Health Savings Accounts

(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.) Health Savings Accounts

“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 Insurance Manager BCBS of South Carolina Insurance Education Part #2

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 customer service questions View up-to-date provider directory Request new ID card My Insurance Manager BCBS of South Carolina (

Health Insurance Options Health Maintenance Organizations (HMOs) Insurance Education Part #2

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 Insurance Education Part #2

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.) BlueChoice HealthPlan (available in all South Carolina counties)

Hospital copayments  $100 outpatient hospital copay  $125 emergency copay  $200 inpatient hospital copay (cont.) BlueChoice HealthPlan (available in all South Carolina counties)

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.) BlueChoice HealthPlan (available in all South Carolina counties)

Coinsurance maximum  Most an individual or family will pay for covered services  Excludes deductibles and copays  $1,500 individual  $3,000 family (cont.) BlueChoice HealthPlan (available in all South Carolina counties)

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.) BlueChoice HealthPlan (available in all South Carolina counties) 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 ( ) (cont.) BlueChoice HealthPlan (available in all South Carolina counties)

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 BlueChoice HealthPlan (available in all South Carolina counties)

CIGNA HMO Insurance Education Part #2

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

Short-term rehabilitation therapy and chiropractic services  $30 specialist copay  Limit per year visits (cont.) CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

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

Beginning January 1, 2008, available to subscribers and covered dependents Free Enroll  Call or  Visit CIGNA’s Web site CIGNA Quit Today SM Tobacco Cessation Program CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

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

To enroll  Call or  Visit CIGNA’s Web site: (cont.) CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)

Active Employee Health Plan Premiums Insurance Education Part #2

Active Employee Monthly Health Premiums