Open Enrollment October 15-31, 2020 - 2021 Open Enrollment Medicare Outreach Webinar - NC.gov
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2021 Open Enrollment
Medicare Outreach Webinar
Open Enrollment
October 15-31, 2020
What We Will Cover Today
• 2021 Medicare Advantage Plan Change
• 2021 Plan Options
• Transition to Humana
• Medicare Advantage Perks
• 2021 Open Enrollment
• Plan Comparisons
• Medicare Advantage Refresher
• Humana
• 70/30 Plan (Blue Cross NC)
• Clear Pricing Project
• Premium Rates
2
2021 Medicare Advantage Plan Change!
• All members currently covered under
UnitedHealthcare (UHC) will be moved to
Humana for the 2021 benefit year, which
begins January 1, 2021.
• As of January 1, UHC will no longer
administer Medicare Advantage plans for
the Plan.
• The State Health Plan is committed to
making this transition as smooth as
possible for our members.
3
What is Changing and Why
• The State Health Plan’s contract with UHC is set to end December 31,
2020.
• As a result, the State Health Plan was required to conduct a competitive
bid process per state contracting and procurement rules for its Group
Medicare Advantage Plans.
• This process resulted in the Plan awarding the contract to Humana
effective January 1, 2021.
• Members currently in the UHC Medicare Advantage Plans will remain in
those plans until the end of 2020.
• This new contract has a potential cost savings of approximately $600
million over the 3-year contract period, which allows for a significant
reduction in Medicare-eligible dependent premiums for the 2021 plan
year—down to $4 for eligible dependents!
4
What is Changing and Why
• The State Health Plan’s website has 2
great videos available that discuss this
change and help members separate
myth from fact!
• The Plan is dedicated to making this a
smooth transition with as little
disruption for members as possible.
• The Plan’s website also provides a flier
for you to distribute to your providers
that explains our Medicare Advantage
Plans.
www.shpnc.org
5
Medicare Advantage Passive Network
• The Medicare Advantage Plans will continue to offer
a national “passive” network, which allows
members to continue seeing their current providers
regardless of being in or out of Humana’s network.
• Similar to what members are experiencing today, the
provider will need to be participating with Medicare
and agree to bill the Medicare Advantage plan
carrier.
• Humana is currently outreaching to providers to
ensure providers are aware our members are able to
seek services from out-of-network providers without
experiencing a higher out-of-pocket cost.
• If a provider is still resistant to filing a claim with
Humana, the member would need to pay for the
service and then file a paper claim with Humana for
reimbursement (less any applicable
copayment/coinsurance).
6
2021 Plan Offerings
• Medicare members will continue to have three State Health Plan
options to choose from for 2021:
• Humana Group Medicare Advantage (PPO) Base Plan
• Humana Group Medicare Advantage (PPO) Enhanced Plan
• The 70/30 Plan, administered by Blue Cross and Blue Shield of North
Carolina (Blue Cross NC)
• All current UnitedHealthcare members will be moved to the Humana
Group Medicare Advantage Base Plan for Open Enrollment. If they
take no action, they will be in the Base plan starting January 1,
2021.
• If you are currently on the Medicare Advantage Base Plan or the
70/30 Plan, you will REMAIN on that plan and do not need to take
action during Open Enrollment.
• If you are currently on the Medicare Advantage Enhanced Plan,
you will be moved to the Medicare Advantage Base Plan for the
2021 benefit year. If you would like to elect the Enhanced Plan for
2021, you will need to take action during Open Enrollment.
7
70/30 PPO State Health Plan Option
The Plan utilizes a third-party administrator or TPA that is
responsible for the provider network and processing your medical
claims. Our current TPA is Blue Cross and Blue Shield of NC.
Remember, your medical claims are paid by the state, not Blue
Cross.
The Plan also utilizes a pharmacy benefit manager or PBM that is
responsible for providing a pharmacy network and processing your
pharmacy claims. Our current PBM is CVS Caremark. Remember,
your pharmacy claims are paid by the state, not CVS.
8
State Health Plan Options for Medicare Primary Members
Humana is a Medicare Advantage Organization that contracts with
the Centers for Medicare and Medicaid Services (CMS) to
administer Medicare benefits on their behalf.
The Plan contracts with Humana to provide Group Medicare
Advantage plan options to our Medicare Primary members which
includes payment of claims.
9
Changes for 2021
Humana Group Medicare Advantage Base Plan
• There are no changes to benefits with this plan.
Humana Group Medicare Advantage Enhanced Plan Changes:
• A few copays have changed under the Enhanced plan:
• Primary Care Provider (PCP), Lab, Radiology, Inpatient Hospital, and
some prescription copays, to name a few.
• It will be important for members to review the benefit changes on the
Enhanced plan.
70/30 Plan Changes:
• Members who select a Clear Pricing Project Provider as their PCP will enjoy
a $0 copay! More details later in this presentation!
• Reduced copays for members who visit a Clear Pricing Project Specialist
• Preferred and non-preferred insulin will have a $0 copay for a 30-day
supply!
• Preventive services remain free!
102021 Plan Comparison – Medical Benefits
Humana Humana BCBSNC
Benefit
Base Enhanced 70/30*
Network Providers You can use in and out-of-network providers but You pay less when you use BCBSNC
must accept in Medicare and your insurance plan. provider network
Annual Medical Out-of- $4,000 $3,300 $5,900 In-network (Individual)
Pocket Maximum (In and Out-of-Network) (In and Out-of-Network) $16,300 Out-of-network (Family)
(Combined Medical & Pharmacy)
Annual Deductible $0 $0 $1,500 In-network (Individual)
$4,500 In-network (Family)
(Combined Medical & Pharmacy)
Primary Care Provider $20 copay $10 copay $0 for CPP PCP on ID Card
(PCP) – Office Visit $30 for non-CPP PCP on ID card
$45 for any other PCP
Specialist Office Visit $40 copay $35 copay $47 for CPP Specialist
$94 for other Specialists
Urgent Care $50 copay $40 copay $100 copay
Inpatient Hospitalization Days 1-10: $160/Day Days 1-10: $125/Day In-network: $337 copay plus 30%
Days 11+: $0/Day Days 11+: $0/Day coinsurance after deductible
Outpatient Surgery $250 copay $250 copay In-network: 30% coinsurance after
deductible
Ambulance $75 copay $75 copay 30% coinsurance after deductible2021 Plan Comparison – Medical Benefits, cont’d.
Humana Humana BCBSNC
Benefit
Base Enhanced 70/30*
Emergency Room $65 copay $65 copay Individual: $337 copay plus 30%
(Worldwide) (Worldwide) coinsurance after deductible
Lab Services $40 copay $10 copay If performed during PCP or
Specialist office visit, no
additional fee if in-network lab
used.
Diagnostic radiology $100 copay $100 copay In-network: 30% coinsurance after
services deductible
(such as MRIs, CT Scans)
Therapeutic Radiology $40 copay $40 copay In-network: 30% coinsurance after
Services (such as radiation deductible
treatment for cancer)
Durable Medical Equipment 20% coinsurance 20% coinsurance In-network: 30% coinsurance after
(such as oxygen) deductible
*When enrolled in the 70/30 Plan, cost-sharing amounts between you & the State Health Plan will vary. Medicare pays
benefits first and then the 70/30 Plan may help pay some of the costs that Medicare does not cover.
122021 Plan Comparison – Pharmacy Benefits
Humana Humana BCBSNC
Benefit
Base Enhanced 70/30*
Pharmacy Maximum $2,500 Individual $2,500 Individual $5,900 In-network (Individual)
$16,300 Out-of-network (Family)
(Combined Medical & Pharmacy)
Deductible $0 $0 $1,500 In-network (Individual)
$4,500 In-network (Family)
(Combined Medical & Pharmacy)
Retail Purchase from an In-Network Provider
Tier 1 $10 copay per 30-day supply $16 copay per 30-day supply
Tier 2 $40 copay per 30 $40 copay per 30-day $47 copay per 30-day supply
day supply supply
Tier 3 $64 copay per 30 $50 copay per 30-day
Ded/Coinsurance
day supply supply
Tier 4 25% coinsurance up to $100 per 30-day
$200
supply
Tier 5 N/A $350
Tier 6 N/A Ded/Coinsurance
Insulin $40 copay – Preferred Brand $0 (30-day supply)
(Novolog/Novolin) (30-day supply) Preferred or Non-Preferred14
What are Medicare Advantage Plans?
• A Medicare Advantage Plan, like the Humana Medicare Advantage plans offered by the
State Health Plan, are considered a Group Medicare Advantage Prescription Drug
Plan (MAPDP): A Medicare health plan choice may be an individual or group product.
• Private companies, like Humana, contract with Medicare to provide your Medicare Part A
and Medicare Part B benefits.
• With a Medicare Advantage Plan:
• You are still considered to be in the Medicare program.
• You keep same rights and protections as Original Medicare.
• They must cover all services Original Medicare covers.
• Members must have both Medicare Part A and Medicare Part B and continue to pay
Medicare premiums to be eligible for Medicare Advantage Plans. Part B premiums
are paid by member from Social Security benefits or directly to federal government.
• Zero dollar premiums on the Base Plan.*
• Significantly lower dependent premiums on Base and Enhanced Plan.
• No deductible.
• No referral for a Specialist.
*Keep in mind that if you do not have enough years of service to qualify for non-contributory coverage, or you
pay 100% of your coverage for other reasons, you are responsible for any premium owed.
15Medicare Advantage Plan Perks
• Simplicity – The Humana Medicare Advantage Plans provide one ID card
for medical services and prescription drugs.
• Remember – You are still considered to be in the Medicare program
• You use your Humana ID card – not your red, white and blue Medicare
card
• Predictability – The Humana Medicare Advantage Plans are copayment
driven meaning the majority of covered services have an established
copayment. This allows for you to know what your out-of-pocket costs will
be up front in most situations.
• The Humana Medicare Advantage Plans also provide extra services not
covered under Original Medicare.
• Wellness programs/SilverSneakers®
• Disease and Case Management
• Routine eye & hearing exams
• Hearing aids
16Network of Providers
• The Humana Medicare Advantage plans are considered National
Preferred Provider Organization (PPO) plans. They offer:
• Access to providers nationwide.
• Access to additional benefits at a lower cost and include an open
network.
• Copays or coinsurance remain the same, regardless of who you see
in- or out-of-network.
• Out-of-network providers must participate with Medicare and agree to
accept and file claims on member’s behalf.
17Humana Medicare Advantage Plans & Other Insurance
• With the Humana Medicare Advantage Plans there is no need for additional
coverage.
• Additional Medicare health plan coverage can cause you to be
disenrolled from your State Health Plan Humana Medicare Advantage
Plan.
• If already enrolled in another Medicare Advantage or Part D prescription
drug plan, your coverage with those plans will terminate unless you elect
not to enroll in one of the Humana Medicare Advantage Plans.
• If enrolled in a MAPDP, you cannot purchase a Medicare Supplement or
Medigap plan without you terminating your MAPDP.
18Medicare Advantage Plans & Other Insurance
• TRICARE® for Life (TFL) (TRICARE ® + Medicare)
• TFL beneficiaries can enroll in Medicare Advantage plans and
TFL will typically reimburse your copayments for services covered
by TFL.
• You cannot use Medicare or Medicare Advantage in a Military
Treatment Facility, like a VA Hospital.
• Other Insurance
• If covered by a Federal Employee Health Benefit Plan or another
former employer’s retiree group health plan, it is important to
check with them to ensure enrollment into one of these Medicare
Advantage plans will not disrupt coverage with them.
• Individual cancer, hospital indemnity, dental, vision, long-term
care insurance products will not have an effect on eligibility or
coverage under a Medicare Advantage plan.
19Humana Group Medicare Advantage Plans North Carolina State Health Plan for Teachers and State Employees
Humana Group Medicare Advantage PPO
At Humana, we are here to help you make the most of your benefits.
About Humana:
• Dedicated to communities around the country for more than 30 years
• Over 8.5 million Medicare members just like you, across all 50 states1
• Providing Medicare plans to beneficiaries since 1987
• Easily find a provider with our nationwide network of providers – over
760,000 providers and 3,300 hospitals
• In North Carolina, our provider network includes 6,822 Primary Care
Physicians (PCPs), 11,303 Specialists, and 92 hospitals
• Our Group Medicare Advantage PPO plans have earned 4‐Star or
higher quality ratings from the Centers for Medicare & Medicaid
Services (CMS) for 2019 and 2020.
1Humana Inc. 2019 Annual Report, February 2020
| 21What is a PPO?
Humana’s preferred provider organization (PPO)
• You will pay the same amount both in‐ and out‐of‐network for care
• No copayment for preventive care
• Out‐of‐pocket maximum
• Worldwide emergency coverage
| 22Providers
With your PPO plan, you will pay the same amount for in‐ and out‐of‐network
services.
• As a State Health Plan member, the in‐network
and out‐of‐network benefits are structured the
same for any member of this plan.
• This means you don’t need to find a new doctor.
• Similar to what you are experiencing today, as
long as your provider participates in Medicare
and agrees to bill Humana, you can continue
with the doctor you know and trust at no extra
cost ‐ even if they are out‐of‐network.
• If a provider is still resistant to filing a claim with
Humana, the member would pay for the service
and then file a paper claim with Humana for
reimbursement (less any applicable
copayment/coinsurance).
| 23Providers
With your PPO plan, you will pay the same amount for in‐ and out‐of‐network
services.
| 242021 Benefit Changes
Humana Group Medicare Advantage Base Plan
There are no changes to benefits with this plan.
Humana Group Medicare Advantage Enhanced Plan Changes:
A few copays have changed under the Enhanced plan listed in the below chart.
It will be important for members to review the benefit changes on the Enhanced plan.
2021 Enhanced Plan
Cost‐Share Decrease Cost‐Share Increase
Decrease PCP copay to $10 Increase Outpatient Radiology to $40
Decrease Lab copay to $10 Increase Radiation Therapy to $40
Decrease Inpatient Hospital copay to $125 Increase Tier 1 90‐day Rx copay to $24
Decrease Partial Hospitalization to $15 Increase Tier 2 30‐day Rx copay to $40
Increase Tier 2 90‐day Rx copay to $80
| 25Your PPO benefits – extra benefits
With your PPO plan, you will pay the same amount for in‐ and out‐of‐network
services.
Base Plan Enhanced Plan
Routine Vision Services • 100% after $40 copayment, • 100% after $35 copayment,
one routine exam per year one routine exam per year
Routine Podiatry Services • 100% after $40 copayment; • 100% after $35 copayment;
maximum of six visits per maximum of six visits per
year year
Routine Hearing Services • $0 copay for routine hearing exam, one per year
• $0 copay for fitting/evaluation, one per year
• $500 total allowance for hearing aids every three years
Private Duty Nursing • 20% coinsurance, $5,000 maximum benefit per year
COVID‐19 Testing • Testing and treatment for members with COVID‐19 diagnosis
will be covered at 100%
Health Essentials Kit • Kit includes over the counter items useful for preventing the
spread of COVID–19 and other viruses. Limited one per year.
| 26Virtual visits / telemedicine Connect with a provider or behavioral health professional1 virtually Your primary care provider and your specialist may offer virtual visits • Virtual visits connect you with your provider via telephone or video chat using your phone, tablet2 or laptop2 • Talk with a provider from the comfort of your home • Private, secure and confidential • Providers are available to treat many conditions, including allergies, fever, cold and flu symptoms, insect bites, stress, anxiety, depression and many others • Virtual visits may be able to address an expanded set of needs including changes to medicines, refills, ordering labs, test, screenings and help with management of chronic conditions. If you don’t have a primary care provider or if your PCP doesn’t offer virtual visits, you can use the “Find a doctor” tool on Humana.com or call the number on the back of your member ID card to get connected with a provider that offers this service. 1Behavioral health visits are by appointment. | 27 2Standard data rates may apply.
Your Pharmacy Coverage
What your pharmacy coverage includes: How you will be notified of changes:
• Generic, brand and specialty drugs • Drug List Change Letter
• Part D vaccines are covered 100%; • Welcome Kit Drug List
excludes foreign travel vaccines • Website Drug Lookup Resources
• Diabetic Supplies and Administration • Transition Fill Process
Supplies are covered 100%
• Mail Order Prescription Transfer
• Coverage for Cough and Cold, Weight
Loss, Fertility, Vitamins & Minerals
medications
• Access to over 66,000 national and
regional chains, including independent
local pharmacies
• Humana Specialty Pharmacy
| 28Humana Pharmacy
Rx Mail Delivery
Accuracy and safety
Free standard shipping in discreet, temperature‐controlled packaging
Convenience
No driving to the pharmacy or waiting in line*
Support you need
Learn how to set up a new account, start a new Rx and/or download the mobile
app by visiting HumanaPharmacy.com or calling 1‐800‐379‐0092 (TTY: 711),
Monday – Friday, 8 a.m. – 11 p.m. and Saturday, 8 a.m. – 6:30 p.m., Eastern time.
Reminders
Refill reminders by email, text or phone—you decide
*Other pharmacies are available in our network
| 29Diabetic Testing & Monitoring Supplies
• Preferred Diabetic Supplies and Administration
Supplies are covered 100%; supplies include
meters, test strips and lancets.
• Humana’s preferred insulin is Novolog and
Novolin at the Tier 2 copay.
• Humalog, Humulin, and Apidra are available at a
higher tier.
• Humana’s DME provider for Continuous Glucose
Monitoring Supplies/Sensors is CCS Medical.
| 30Health resources
• Case management
• Disease management
• Transplant management
• Health planning and support nurses
Humana member transition activities:
• Case Management Outreach to Diabetic Members
• High Risk Member Outreach:
• Transplants
• End‐Stage Renal Disease (ESRD)/Chronic Kidney Disease
(CKD)
• Disease/Case Management | 31In‐Home Health & Wellbeing Assessment
• A free, in‐home 45‐60 minute one‐on‐one health assessment with a doctor or nurse
practitioner.
• The doctor or nurse practitioner will:
• Check your blood pressure and other vital signs
• Take a brief health history
• Review any medications and over‐the‐counter vitamins and supplements you take
• Assess the safety of your home
• It is designed to help support, but not take the place of your regular
doctor’s care.
• You can talk about health concerns and ask questions that you haven’t
had time to ask before. It may also help Humana to identify any plan
programs and services that may be right for you.
• You can receive a reward when you complete a visit.
| 32A total health and physical activity program included in your plan at no extra cost.
SilverSneakers® gives you access to exercise equipment, group fitness classes and
social events at more than 17,000 nationwide locations.
Get moving with SilverSneakersLIVE and join thousands of other members from
the comfort of your home with our LIVE virtual classes and workshops. And since
it’s included in the SilverSneakers benefit, SilverSneakers LIVE is available at no
additional cost to members and offers virtual classes and workshops via Zoom.
A wellness program just for Humana members, included in your plan at no
extra cost. You’ll earn rewards that you can redeem for gift cards in the
Go365 Mall.
Redeem your rewards for gift cards in the Go365 Mall:
1) Online: Sign in at Go365.com/shop ‐OR‐ 2) Phone: Call 1‐866‐677‐0999 (TTY: 711)
Members must redeem the reward in the program year it is earned. Any rewards not redeemed
by 12/31 will expire. For a complete list of gift cards visit go365.com/shop.
| 33Humana Well Dine®
After your overnight inpatient stay in a hospital or skilled nursing facility,
you’re eligible for 2 meals per day for 7 days, up to 14 nutritious meals,
limited to 4 times per year delivered to your door at no additional cost to you.
Humana Well Dine meal plans
• Regular • Vegetarian
• Diabetic • Kosher
• Puree • Renal‐support
Advance care planning – MyDirectives
Use online tools to develop and share your healthcare choices
• Create a living will, medical power of attorney
• Make your choices known about resuscitation, life support, organ donation and
autopsy
• Your doctors and your family will know your exact wishes
• A simple way to share information with your doctor and family members
• Available to you at no additional cost
| 34What else does Humana offer you?
• Discounts on hearing aids, vision services, and dental
services
• Lifeline® Medical Alert Systems
• Meal Delivery Discount (Mom’s Meals®)
• Weight Management Discount (Jenny Craig®)
| 35Whether you prefer using a desktop, laptop Use the MyHumana Mobile app.
or smartphone, you can access your
healthcare information in one convenient
place.
• View your plan and coverage details
• Check the status of your claims
• View electronic versions of letters sent to
you
• Track your healthcare spending
• Find providers in your network
• Get tips for staying healthy
You will be able to activate your MyHumana account once you receive
your Humana member ID card. You will receive it in December, prior to
1/1/21. Go to our.humana.com/ncshp to register.
| 36SmartSummary®
An overview of your health benefits and health
spending on medical and prescriptions throughout
the year.
• Stay informed
• Clear and detailed financials
• Information you can share with your provider
• Prescription information
You can access your SmartSummary online with
your MyHumana account.
Go Green—update your member preferences to
receive your SmartSummary statement
electronically.
| 37Humana in your neighborhood
Asheville Location Greensboro Location
Skyland Plaza Westover Gallery of
1863 Hendersonville Road Shoppes
Suite 122 1420 Westover Terrace
Asheville, NC 28803 Suite C
Greensboro, NC 27408
Everyone is invited! Bring a friend or family member—
there is no cost to join in the fun!
• Help with your Humana plan
• Health and wellness
• Social and fun
• Virtual classes available online; visit the below link to
locate other centers nationwide as well as the
calendar of events:
https://www.humana.com/humana‐neighborhood‐centers
| 38Humana Member Welcome Kit
• Humana will send a Member Welcome Kit to all members
currently enrolled in the UHC Base or Enhanced plans, to be
received mid‐October.
• The Welcome Kit will include:
• Base and Enhanced Plan Medical and
Pharmacy Summary of Benefits
• PPO Plan Guidebook
• Abbreviated Prescription Drug Guide
• Go365 Program Flyer
• Educational Provider Flyer
Your enrollment kit is an important tool. The packet includes
information on your healthcare coverage along with extra
services included in your Humana plan.
| 39What to expect after enrollment
1 Enrollment confirmation 3 Medicare Health Survey
You will receive a letter after Humana will send you a
your enrollment information is postcard with instructions on
received, completed in the how to complete the survey.
Humana system and confirmed
by CMS. This will be received in 4 Evidence of Coverage (EOC)
December, prior to 1/1/21. Members will receive their
detailed benefit booklet in the
2 Humana member ID card mail.
You will receive your ID card in
December, prior to 1/1/21.
| 40Stay connected with Humana
You have a dedicated Customer Care team to help you with
anything related to your State Health Plan Humana plan.
1‐888‐700‐2263 (TTY: 711)
Monday – Friday, 8 a.m. – 9 p.m., Eastern time.
For more information:
• Refer to your Welcome kit, arriving mid‐October
• Visit our.humana.com/ncshp
• Call Humana Group Medicare Customer Care
team for anything related to your Humana plan at
1‐888‐700‐2263, Monday – Friday, 8 a.m. – 9 p.m.,
Eastern time
| 4170/30 PPO Plan
42Clear Pricing Project
• In 2019, the State Health Plan implemented the Clear Pricing Project
(CPP).
• Its goal was to ensure that members have this valuable benefit for years to
come, while bringing transparency to health care costs and addressing the
rising health costs that the Plan and members face each day.
• This effort resulted in more than 25,000 providers partnering with the Plan
for transparent and affordable health care.
• Plan members currently utilize the NC State Health Plan network, which
encompasses CPP providers and providers in the Blue Options Network to
ensure adequate access to health care.
• CPP providers have agreed to get rid of secret contracts, making health
care more affordable and transparent.
• In an effort to lower health care costs for members and to support CPP
providers, the Plan will be offering significant copay reductions for
members who visit a CPP provider in 2021.
4370/30 PPO Plan – Network
• As a State Health Plan member, you will have access to the North
Carolina State Health Plan Network, which is made up of providers who
signed up for the CPP, and Blue Cross NC’s Blue Options network.
• You may seek services from providers in the State Health Plan’s Network
or go to an out-of-network provider.
• However, when you use in-network providers, you’ll have wide access to
high quality providers, and pay less out-of-pocket.
• In-network providers are credentialed by Blue Cross NC, which means
you will receive the best of care and pay less out-of-pocket vs. going to an
out-of-network provider.
4470/30 PPO Plan
2021 Medical Benefits
2020 2021
Preventive Care $0 PCP / $0 Specialist
Primary Care Provider (PCP) Visit $45
CPP* PCP Visit (CPP PCP/Practice on ID Card) $30 $0
Non CPP* PCP Visit (Non CPP PCP/Practice on ID
$30
Card)
Specialist Visit $94
CPP* Specialist Visit $94 $47
Chiro/PT/OT/ST $72
CPP* Chiro/PT/OT/ST $72 $36
*Clear Pricing Project
4570/30 PPO Plan, cont’d.
2021 Medical Benefits, cont’d.
2020 2021
Annual Deductible (Medical/Rx combined) $1,500 Individual / $4,500 Family
Out-of-Pocket Maximum (Medical/Rx combined) $5,900 Individual / $16,300 Family
Urgent Care $100
Emergency Care $337 then 30% after deductible
Inpatient Hospital $337 then 30% after deductible
4670/30 PPO Plan, cont’d.
2021 Pharmacy Benefits
2020 2021
Tier 1 Generic $16
Tier 2 Preferred Brand and High Cost Generic $47
Tier 3 Non-preferred brand Ded/Coinsurance
Tier 4 Low Cost / Generic Specialty $200
Tier 5 Preferred Specialty $350
Tier 6 Non-Preferred Specialty Ded/Coinsurance
Preventive Medications $0
Preferred Diabetic Supplies $10
Preferred & Non-Preferred Insulin $47 $0
Annual Deductible (Medical and Rx combined) $1,500 Individual $4,500 Family
Out-of-Pocket Maximum (Medical and Rx combined) $5,900 Individual $16,300 Family
4770/30 PPO Plan
• The 70/30 Plan is a true out-of-pocket, ACA (Affordable Care Act)
compliant plan.
• You must meet the yearly $1,500 deductible for those medical services
and medications that are subject to the deductible.
• Once you’ve met the $1,500 deductible, you will pay 30% of all remaining
covered charges (after Medicare has paid - medical) up to the $5,900 out-
of-pocket maximum.
• Once the out-of-pocket maximum is met, covered medical and
pharmacy benefits will be paid at 100%.
Note: Your out-of-pocket maximum includes
copays, coinsurance and deductible.
70/30 PPO Plan is Secondary to Medicare
4870/30 Plan Deductible / Maximum Out of Pocket
Applied to Out-of-Pocket Maximum
Individual (Combined Medical &
Service
Deductible Pharmacy)
$1,500 $5,900
All Medical copays X
Includes office visits, urgent care, ER,
Inpatient/Outpatient Hospital
Deductible & 30% Coinsurance
• Facility based services X X
• Tiers 3 & 6 Rx’s X X
• Non-Preferred Diabetic Testing Supplies X X
Pharmacy Copays
• Tiers 1, 2, 4 & 5 X
• Preferred Diabetic Testing Supplies X
• Amounts applied to the individual deductible are also applied to the out-of-pocket maximum.
• After the individual deductible has been met, you will pay a 30% coinsurance until the total out-of-
pocket maximum has been met.
• ACA preventive services & preventive Rx’s covered at 100% are not subject to deductible or out-of-
pocket maximum.
4970/30 PPO Plan – Coordination of Benefits
Coordination of Benefits
Medicare
• If you elect the 70/30 Plan option, Medicare will be your primary coverage
• With the 70/30 Plan, charges left unpaid by Medicare are paid by the SHP
after your yearly deductible, coinsurance and copays are applied
• If you don’t have Medicare Part B, you will be responsible for what
Medicare Part B would have paid resulting in higher out-of-pocket costs
Medigap (Medicare Supplement) plan
• A Medigap plan is generally not needed when you have secondary
coverage to Medicare
• Medigap plans ONLY work with Original Medicare. They will not work with
Medicare Advantage plans
5070/30 PPO Plan – Coverage Out & About
• State Health Plan members are covered in all 50 States as well as
outside of the country for emergency and non-emergency services.
• Blue Cross Blue Shield Global Core (formally BlueCard Worldwide)
• Single point of contact for medical assistance (inpatient, outpatient and
professional):
• www.bcbsglobalcore.com
• Global Core Service Center: 1-800-810-2583 or Collect: 1-804-673-
1177, 24 hours a day, seven days a week.
• Outpatient/Doctor Care: Payment usually required up front.
Claim forms are located on the Global Core website or www.shpnc.org.
• Inpatient Care: Contact the Global Core Service Center to arrange direct
billing. Most cases you should not have to pay up front for inpatient care
except for any out-of-pocket expenses (i.e., deductible, copayment, etc.).
• Contact Blue Cross of NC for preauthorization.
51Open Enrollment, Rates, etc.
52Open Enrollment
Open Enrollment Period October 15-31, 2020
• Each year Open Enrollment provides the opportunity to make
changes:
• Change plans
• Opt in/out of the State Health Plan
• Add dependents
• Remove dependents
• If you opt out of the State Health Plan during Open
Enrollment, you may opt back into the State Health Plan
during any following Open Enrollment period or as a result of
a Qualifying Life Event.
• Should you opt out of the State Health Plan, we encourage
you to sign up for our electronic newsletter, Member Focus,
as you will not receive mailings from the Plan.
532021 Open Enrollment Action
• All current UHC members will be moved to the Humana Group Medicare
Advantage Base Plan for Open Enrollment. If they take no action, they will be
in the Base plan starting January 1, 2021.
• If you are currently on the Medicare Advantage Base Plan or 70/30 Plan, you
will REMAIN on that plan & do not need to take action during Open Enrollment.
• If you are currently on the Medicare Advantage Enhanced Plan, you will be
moved to the Base Plan for the 2021 benefit year. If you would like to elect the
Enhanced Plan for 2021, you will need to take action during Open Enrollment.
• All non-Medicare primary members, including non-Medicare primary
spouse/dependents, will be moved to the 70/30 Plan effective January 1, 2021.
• If spouse/dependents are not Medicare eligible:
• They have same options available to active employees/non-Medicare
members (80/20 PPO and 70/30 PPO Plan)
• They will be moved to the 70/30 PPO Plan for the 2021 benefit year, so
you will need to take action if you want them enrolled in the 80/20 Plan
and to reduce premiums in the 80/20 (premium reduction applies to non-
Medicare subscriber only)
• Failure to take action will result in dependent remaining on the 70/30 Plan
for 2021.
54Medicare Member Premiums
HUMANA GROUP MEDICARE ADVANTAGE (PPO) BASE PLAN
COVERAGE TYPE 2021 MONTHLY PREMIUM
Subscriber Only $0
Subscriber + Child(ren) $4.00
Subscriber + Spouse $4.00
Subscriber + Family $8.00
HUMANA GROUP MEDICARE ADVANTAGE (PPO) ENHANCED PLAN
COVERAGE TYPE 2021 MONTHLY PREMIUM
Subscriber Only $73.00
Subscriber + Child(ren) $146.00
Subscriber + Spouse $146.00
Subscriber + Family $219.00
70/30 PLAN
COVERAGE TYPE 2021 MONTHLY PREMIUM
Subscriber Only $0.00
Subscriber + Child(ren) $155.00
Subscriber + Spouse $425.00
Subscriber + Family $444.00
55Income-Related Monthly Adjustment Amount (IRMAA)
• Members with higher income levels are required to pay an adjusted
Medicare Part B premium plus an additional amount when enrolled in
Medicare Part D prescription drug coverage. The additional amount
is called Income-Related Monthly Adjustment Amount or IRMAA.
• Income level based on modified adjusted gross income, which is the
total of your adjusted gross income and tax-exempt interest income.
• IRMAA is mandated by Federal law and each amount is deducted
from your monthly Social Security payments.
• IRMAA will apply if individual income is over $87,000 or if married
(filing joint tax return) income is over $174,000.
• If enrolled in the Group Medicare Advantage plans with Humana,
higher income members may be subject to IRMAA.
56Disability
• If member becomes eligible for Medicare due to disability, it is very
important for them to enroll in both Medicare Part A and Medicare
Part B.
• Do not overlook accepting Medicare Part B. Many people fail to
accept the offer to retroactively purchase Medicare Part B.
• Read the AWARD Notice carefully.
• State Health Plan becomes SECONDARY to Medicare as of the
Medicare eligibility date.
• Claims will be reprocessed back to Medicare eligibility date.
• The State Health Plan will reduce their claims by the amount that
would have been paid under Medicare, paying the remaining
claim amount under the terms of the health benefit plan.
• As a result, if Medicare Part B is not taken, member will be
responsible for the amount that would have been paid by
Medicare Part B.
57Reminder – How to Make a Change for Open Enrollment
Enroll Online
• Visit the State Health Plan website and
click eBenefits in the blue box
• Then click the gold box for ORBIT
• Once you’re logged into ORBIT,
click State Health Plan Benefits
Enroll by Phone
• During Open Enrollment, the Plan’s
Eligibility and Enrollment Support Center
will offer extended hours.
M-F: 8 a.m. – 10 p.m.
Sat.: 8 a.m. – 5 p.m.
• Call 855-859-0966
58Important Phone Numbers
• ELIGIBILITY AND ENROLLMENT SUPPORT CENTER
855-859-0966
Extended hours during Open Enrollment:
Monday-Friday: 8 a.m.-10 p.m.
Saturdays: 8 a.m.-5 p.m.
• HUMANA CUSTOMER SERVICE
888-700-2263
• BLUE CROSS AND BLUE SHIELD OF NC
(BENEFITS, CLAIMS)
888-234-2416
• CVS CAREMARK
(70/30 PLAN PHARMACY BENEFITS)
888-321-3124
59Questions?
This presentation is for general information purposes only. If it conflicts with federal or state law, State Health Plan policy or your benefits booklet, those sources will control. Please be advised that while we
make every effort to ensure that the information we provide is up to date, it may not be updated in time to reflect a recent change in law or policy. To ensure the accuracy of, and to prevent the undue reliance
on, this information, we advise that the content of this material, in its entirety, or any portion thereof, should not be reproduced or broadcast without the express written permission of the State Health Plan.
www.shpnc.org
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