welcome to 2016 Annual Enrollment! OCTOBER 15 NOVEMBER 18, 2015

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1 welcome to 2016 Annual Enrollment! OCTOBER 15 NOVEMBER 18, 2015 The purpose of this guide is to help you take a closer look at the five health plan options available to you and show you what s changing, so you can decide which plan to choose for 2016 your best choice for 2016 may be different from the coverage you have now. Visit for State Health Plan information. FOR MEDICARE RETIREES

2 please read this guide to understand important changes for 2016 There are significant changes to cost sharing (how much you pay when you need care) and premiums (how much you pay for coverage each month) under the Medicare Advantage Enhanced Plans, and under the Traditional 70/30 Plan, starting January 1, IMPORTANT: Premiums for the Medicare Advantage Enhanced Plans will increase for As a result, all members enrolled in a Medicare Advantage Enhanced Plan will be moved to their carrier s Humana or UnitedHealthcare (UHC) Medicare Advantage Base Plan. To remain in your current Medicare Advantage Enhanced Plan, you must enroll in that Plan during Annual Enrollment. WHAT YOU CAN DO DURING ANNUAL ENROLLMENT The choices you make during Annual Enrollment stay in effect from January 1, 2016 through December 31, Annual Enrollment is your chance to: Review your State Health Plan coverage, change your coverage, and/or add or drop dependents, if you d like. Choose State Health Plan coverage for the first time. WHAT YOU NEED TO DO Take a close look at the five health plan options available to you your best choice for 2016 may be different than the coverage you have now. If you wish to elect or remain in a Medicare Advantage Enhanced Plan for 2016 you must take action during Annual Enrollment and select the Medicare Advantage Enhanced Plan you wish to enroll in. If you wish to remain in your Medicare Advantage Base Plan or the Traditional 70/30 Plan for 2016 no action during Annual Enrollment is required. Enroll any time from October 15 through November 18, 2015 either online or by phone to make any coverage changes for See How to Enroll (page 1) for details. A legislative change that was effective July 1, 2015 allows retirees and surviving spouses to disenroll from the State Health Plan without having a Qualifying Life Event. This means that retirees and surviving spouses can: Drop their State Health Plan coverage during the Plan year without a Qualifying Life Event. Disenroll dependents from State Health Plan coverage during the Plan year without a Qualifying Life Event.

3 a look at your options For 2016, the State Health Plan will continue offering you five health plans options: The Humana Medicare Advantage Base Plan; The Humana Medicare Advantage Enhanced Plan; The UnitedHealthcare Medicare Advantage Base Plan; The UnitedHealthcare Medicare Advantage Enhanced Plan; and The Traditional 70/30 PPO Plan. HOW TO ENROLL You can enroll in or change your plan online or by phone: To enroll online, visit the State Health Plan s website ( and click Enroll Now and select Log into eenroll through ORBIT. To enroll by phone during Annual Enrollment, call , Monday Friday from 8 a.m. 8 p.m. Remember to note for your records the date and time of your call, and the person you spoke with. As you enroll, make sure to: Review your dependent information and make changes, if needed. Review the benefits you ve selected. Print your confirmation statement for your records, or ask your phone representative for your reference case number. WHAT S INSIDE Medicare Advantage Plans...2 the Traditional 70/30 Plan State Health Plan comparison monthly premiums...9 1

4 Medicare Advantage Plans The State Health Plan offers four group Medicare Advantage Plan options that are customized for our retirees. To enroll in a Medicare Advantage Plan, you must have Medicare Part A and Medicare Part B in place. You continue to pay the Part A premium (if required) and the Part B premium. The convenience of the Medicare Advantage Plan is that you get all of your coverage through one insurance company (Humana or UnitedHealthcare) and enjoy the following features: No deductible and predictable copays An out-of-pocket limit, which includes copays and coinsurance this is the most you must pay in a calendar year before the plan pays 100% of covered expenses Access to Preferred Provider Organization (PPO) networks nationwide One ID card for both medical and prescription drug coverage Medicare Part D prescription drug coverage, even in the coverage gap (the donut hole ) Preventive care coverage at no cost to you Disease management, a nurse help line, the SilverSneakers Fitness Program, and vision and hearing benefits. When enrolled in a Medicare Advantage Plan, you are still in the Medicare program, but you do not have Original Medicare. By enrolling in a Medicare Advantage Plan, you are choosing to receive your Medicare Part A and Medicare Part B benefits through a private carrier, Humana or UnitedHealthcare. When you enroll in a Medicare Advantage Plan, you cannot use Medicare Supplement Insurance (Medigap) to pay for out-of-pocket costs, such as copays and coinsurance. Since all Medicare Advantage Plans provide Medicare Part D prescription drug coverage, you do not need a stand-alone Medicare Part D Plan. HUMANA AND UNITEDHEALTHCARE (UHC) MEDICARE ADVANTAGE BASE PLANS WHAT S NEW FOR 2016? The Humana Medicare Advantage Base Plan will offer two new routine preventive care benefits for You may see changes to the drug formulary under the Humana and UHC plans. Be sure to compare any drugs you take now with your plan s 2016 formulary to see if there will be changes in how your drugs will be covered. Please call Humana or UHC to discuss the formulary changes. If you re already in a Medicare Advantage Base Plan and wish to stay in that plan for 2016, no action during Annual Enrollment is required. The benefits you receive through the Humana or UHC Medicare Advantage Base Plans are identical, though there may be slight differences in the prescription drugs that are covered by each plan and the pharmacies that participate in each plan s network. 2

5 If you are a retiree for whom the State of North Carolina pays 100% of the cost of coverage based on your years of service, you will not pay a monthly premium for coverage under the Medicare Advantage Base Plans. However, you must pay a monthly premium to cover eligible family members. You also need to pay your premium(s) for Medicare Part A (if any) and Medicare Part B. HUMANA AND UNITEDHEALTHCARE (UHC) MEDICARE ADVANTAGE ENHANCED PLANS WHAT S NEW FOR 2016? Monthly premiums for both the Humana and UHC Medicare Advantage Enhanced Plans will increase beginning January 1, See page 9 for 2016 rates. Cost sharing (which is how much you pay when you need care) under the Humana and UHC Medicare Advantage Enhanced Plans for certain covered services will change beginning January 1, See pages 6 and 7 for details. All members currently enrolled in a Medicare Advantage Enhanced Plan will be moved to the Medicare Advantage Base Plan of the same carrier (Humana or UHC) because of premium increases and plan changes for To remain in a Medicare Advantage Enhanced Plan, you must enroll in that plan during Annual Enrollment. You pay a monthly premium for coverage under a Medicare Advantage Enhanced Plan. You must also pay a monthly premium to cover eligible family members. And, you pay for Medicare Part A (if any) and Medicare Part B. Like the Medicare Advantage Base Plans, the Medicare Advantage Enhanced Plans have an out-of-pocket limit, no deductible, prescription drug coverage, and fixed copays. You pay less from your wallet when you need care under a Medicare Advantage Enhanced Plan. But, you pay more to have coverage under these plans. The chart below shows changes to some key plan features under the Humana and UHC Medicare Advantage Enhanced Plans for See pages 5 7 for a comparison of all five plans. PLAN FEATURE Out-of-Pocket Maximum Primary Care Physician Visit Emergency Room Visit 2015 HUMANA ENHANCED PLAN 2016 HUMANA ENHANCED PLAN 2015 UHC ENHANCED PLAN 2016 UHC ENHANCED PLAN $2,600 $3,300 $2,600 $3,300 $10 copay $15 copay $10 copay $15 copay $50 copay $65 copay $50 copay $65 copay PRESCRIPTION DRUG PART D RETAIL (UP TO A 31-DAY SUPPLY) Tier 1 $7 copay $7 copay $5 copay $10 copay Tier 2 $35 copay $33 copay $30 copay $35 copay Tier 3 $50 copay $50 copay $40 copay $50 copay 3

6 the Traditional 70/30 Plan WHAT S NEW FOR 2016? Cost sharing (which is how much you pay when you need care) under the Traditional 70/30 Plan will change beginning January 1, See page 5 for details. If you re already in the Traditional 70/30 Plan and wish to stay in that plan for 2016, no action is required during Annual Enrollment. Under this Plan, Original Medicare is the primary payer for your hospital and medical insurance. That means that Medicare pays for your health care first. Then, after you meet your annual deductible, the Traditional 70/30 Plan pays its share toward your eligible expenses, up to the amount that would have been paid if the State Health Plan provided your primary coverage. You pay any copays or coinsurance, as applicable. The Traditional 70/30 Plan includes prescription drug coverage. Under this plan, you receive care from providers in the Blue Cross and Blue Shield of North Carolina Blue Options network. You can also go out-of-network for coverage, but your deductibles, copays, and coinsurance will be higher. If you are a retiree for whom the State of North Carolina pays 100% of the cost of coverage based on your years of service, you will not pay a monthly premium for coverage under the Traditional 70/30 Plan. However, you will pay a monthly premium to cover eligible family members. You must also pay premiums for Medicare Part A (if any) and Medicare Part B. The chart below shows changes to some key plan features under the Traditional 70/30 Plan for See pages 5 7 for a comparison of all five plans. PLAN FEATURE /30 TRADITIONAL PLAN /30 TRADITIONAL PLAN Out-of-Pocket Maximum Primary Care Physician Visit Emergency Room Visit $3,793 individual; $11,379 family $4,282 individual; $12,846 family $35 copay $39 copay $291 copay/deductible/coinsurance $329 copay/deductible/coinsurance PRESCRIPTION DRUG PART D RETAIL (UP TO A 31-DAY SUPPLY) Tier 1 $12 copay $15 copay Tier 2 $40 copay $46 copay Tier 3 $64 copay $72 copay 4

7 2016 State Health Plan comparison MEDICAL AND HOSPITAL BENEFITS Use of Network Providers Annual Deductible Annual Out-of- Pocket Maximum or Coinsurance Maximum Physician Services Emergency Room (copay waived if admitted) Inpatient Hospital Outpatient Hospital Outpatient Surgery Diagnostic Procedures (e.g., CT, MRI) Skilled Nursing Facility SilverSneakers Fitness Program TRADITIONAL 70/30 PLAN* You pay less when you use BCBSNC network providers Individual: $1,054 in-network $2,108 out-of-network Family: $3,162 in-network $6,324 out-of-network A coinsurance maximum applies for this plan; it does not include your payments toward your deductible or your copays Individual: $4,282 in-network $8,564 out-of-network Family: In-network: $12,846 in-network $25,692 out-of-network Primary Care:... $39 copay Specialist:... $92 copay Preventive Care:.... $39 copay In-network: $329 copay plus 30% coinsurance after deductible In-network: $329 copay plus 30% coinsurance after deductible In-network: 30% coinsurance after deductible In-network: 30% coinsurance after deductible In-network: 30% coinsurance after deductible In-network: 30% coinsurance after deductible Not covered HUMANA AND UNITEDHEALTHCARE MEDICARE ADVANTAGE BASE PLANS Use any Medicare-participating provider who accepts the carrier s Medicare Advantage Plan; in-network and out-ofnetwork benefits are the same $0 An out-of-pocket maximum applies for these plans; it includes your copays and your share of coinsurance $4,000 Primary Care:...$20 copay Specialist:...$40 copay Preventive Care:....$0 $65 copay Days 1-10:...$160/day Days 11+:...$0 $125 copay $250 copay $100 copay Days 1-20:....$0 Days :...$50/day Included * Cost-sharing amounts between you and the State Health Plan will vary if you enroll in the Traditional 70/30 Plan. Medicare pays benefits first. Then, the Traditional 70/30 Plan may help pay some of the costs that Medicare does not cover. 5

8 MEDICAL AND HOSPITAL BENEFITS (Continued) Use of Network Providers HUMANA MEDICARE ADVANTAGE ENHANCED PLAN Use any Medicare-participating provider who accepts the Humana Medicare Advantage Plan; in-network and out-ofnetwork benefits are the same Annual Deductible $0 $0 Annual Out-of-Pocket Maximum or Coinsurance Maximum An out-of-pocket maximum applies for this plan; it includes your copays and your share of coinsurance $3,300 UNITEDHEALTHCARE MEDICARE ADVANTAGE ENHANCED PLAN Use any Medicare-participating provider who accepts the UnitedHealthcare Medicare Advantage Plan; in-network and out-of-network benefits are the same An out-of-pocket maximum applies for this plan; it includes your copays and your share of coinsurance $3,300 Physician Services Primary Care:...$15 copay Specialist:...$35 copay Preventive Care:....$0 Primary Care:...$15 copay Specialist:...$35 copay Preventive Care:....$0 Emergency Room (copay waived if admitted) Inpatient Hospital $65 copay $65 copay Days 1-10:...$160/day Days 11+:...$0 Outpatient Hospital $100 copay $100 copay Outpatient Surgery $175 copay $250 copay Diagnostic Procedures (e.g., CT, MRI) Skilled Nursing Facility SilverSneakers Fitness Program $100 copay $100 copay Days 1-20:....$0 Days :...$50/day Included Days 1-10:...$150/day Days 11+:...$0 Days 1-20:....$0 Days :...$50/day Included Copays may vary by place of service. More detailed information on these cost-sharing amounts will be available in the documents sent by your assigned plan. PRESCRIPTION DRUG COVERAGE Individual Prescription Drug Out-of-Pocket Maximum TRADITIONAL 70/30 PLAN $3,294 $2,500 HUMANA AND UNITEDHEALTHCARE MEDICARE ADVANTAGE BASE PLANS RETAIL (UP TO 30-DAY SUPPLY IN-NETWORK) (UP TO 31-DAY SUPPLY IN-NETWORK) Tier 1 Drugs $15 copay $10 copay Tier 2 Drugs $46 copay $40 copay Tier 3 Drugs $72 copay Note: If generic is available, member pays generic copay plus the difference between the plan s cost for the brand name drug and the generic drug, not to exceed $100 per 30-day supply for the brand medication $64 copay Tier 4 Drugs 25% coinsurance, up to $100 25% coinsurance, up to $100 Tier 5 Drugs 25% coinsurance, up to $132 Not applicable 6

9 PRESCRIPTION DRUG COVERAGE (Continued) TRADITIONAL 70/30 PLAN MAINTENANCE DRUGS (UP TO 90-DAY SUPPLY IN-NETWORK) Tier 1 Drugs $45 copay $24 copay Tier 2 Drugs $138 copay $80 copay HUMANA AND UNITEDHEALTHCARE MEDICARE ADVANTAGE BASE PLANS Tier 3 Drugs $216 copay Note: If generic is available, member pays generic copay plus the difference between the plan s cost for the brand name drug and the generic drug, not to exceed $100 per 30-day supply for the brand medication $128 copay Tier 4 Drugs* 25% coinsurance, up to $300 25% coinsurance, up to $300 Tier 5 Drugs 25% coinsurance, up to $396 Not applicable * Certain Tier 4 drugs are available in a 90-day supply. Some specialty drugs are limited to a 30- or 31-day supply, as applicable. Individual Prescription Drug Out-of-Pocket Maximum RETAIL (UP TO 31-DAY SUPPLY) HUMANA MEDICARE ADVANTAGE ENHANCED PLAN $2,500 $2,500 Tier 1 Drugs $7 copay $10 copay UNITEDHEALTHCARE MEDICARE ADVANTAGE ENHANCED PLAN Tier 2 Drugs $33 copay $35 copay Tier 3 Drugs $50 copay $50 copay Tier 4 Drugs 25% coinsurance, up to $100 25% coinsurance, up to $100 Tier 5 Drugs Not applicable Not applicable MAINTENANCE DRUGS (UP TO 90-DAY SUPPLY) Tier 1 Drugs $14 copay $20 copay Tier 2 Drugs $66 copay $70 copay Tier 3 Drugs $100 copay $100 copay Tier 4 Drugs 25% coinsurance, up to $200* 25% coinsurance, up to $200 Tier 5 Drugs Not applicable Not applicable * Certain Tier 4 drugs are available in a 90-day supply. Some specialty drugs are limited to a 31-day supply. All of the plans provide prescription drug coverage. Therefore, you DO NOT need to enroll in a separate Medicare Part D prescription drug plan if you enroll in a State Health Plan option. Also note, the in-network pharmacies and drug formularies may vary by carrier (Humana or UnitedHealthcare). Thus, as you make your plan decision for 2016, be sure to compare and understand how the medications you use are covered through each carrier s formulary. Contact Humana at , UnitedHealthcare at , or Express Scripts (for the Traditional 70/30 Plan) at to get more information. 7

10 OUTREACH EVENTS COMING TO A LOCATION NEAR YOU! The State Health Plan is holding informational meetings in September and October to tell you about your 2016 health plan options, review changes to cost sharing and premiums under the Medicare Advantage Enhanced Plans and the Traditional 70/30 Plan, and help you make the best choice for The meeting schedule is included in the Health Plan Options & Outreach Events Schedule booklet, which was sent to your home mailbox. You can also find the list of meeting dates and times on the State Health Plan website ( LEGAL NOTICES Notice of Grandfather Status The State Health Plan believes the Traditional 70/30 Plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to Customer Service at You may also contact the U.S. Department of Health and Human Services at As a plan grandfathered under the Affordable Care Act, cost sharing for preventive benefits will continue as it does currently and will be based on the location where the service is provided. Notice Regarding Mastectomy-Related Services As required by the Women s Health and Cancer Rights Act of 1998, benefits are provided for mastectomy related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. For more information, contact Customer Service at This booklet provides a brief summary of plan benefits. Refer to the applicable benefit plan summary for more detail, which will be mailed by each carrier this fall. In the event of a discrepancy between the information in this booklet and the plan benefits booklet, the information provided in the plan benefits booklet will govern. 8

11 2016 monthly premiums The premiums shown below apply to retirees for whom the State of North Carolina pays 100% of the cost of coverage based on years of service, where the retiree and dependents are eligible for Medicare. Keep in mind that if you do not have enough years of service to qualify for noncontributory coverage, you are responsible for any premium owed. The premium owed will be billed to you or deducted from your pension check. To find all rates for all plans, go to HUMANA AND UNITEDHEALTHCARE MEDICARE ADVANTAGE BASE PLANS TRADITIONAL 70/30 PLAN COVERAGE TYPE MONTHLY PREMIUM COVERAGE TYPE MONTHLY PREMIUM Retiree Only $0.00 Retiree + Child(ren) $ Retiree + Spouse $ Retiree + Family $ Retiree Only $0.00 Retiree + Child(ren) $ Retiree + Spouse $ Retiree + Family $ HUMANA AND UNITEDHEALTHCARE MEDICARE ADVANTAGE ENHANCED PLANS COVERAGE TYPE MONTHLY PREMIUM Retiree Only $66.00 Retiree + Child(ren) $ Retiree + Spouse $ Retiree + Family $ Some people with higher annual incomes must pay an additional amount to Social Security when they enroll in a Medicare plan that provides Medicare Part D prescription drug coverage (e.g., a Medicare Advantage Plan). If you have higher income, federal law requires an adjustment to premiums for Medicare Part B (medical insurance) and Medicare prescription drug coverage. This additional amount is called the income-related monthly adjustment amount or IRMAA. This extra amount, if applicable, is deducted from your Social Security check. If you have questions about this extra amount, please contact Social Security at

12 State Health Plan Eligibility and Support Center 100 Benefitfocus Way Charleston, SC FIRST CLASS MAIL PRESORTED U.S. POSTAGE PAID Raleigh, NC Permit No. 786 YOUR ENROLLMENT DECISION GUIDE FOR 2016 STATE HEALTH PLAN ANNUAL ENROLLMENT! ANNUAL ENROLLMENT: OCTOBER 15 NOVEMBER 18, 2015 CONTACT US Enrollment Questions: Humana: UnitedHealthcare: Blue Cross and Blue Shield of NC: SHP110