Health Insurance Program(s)
As employees of the State of North Carolina, UNC Health Care employees enjoy the Health Insurance options available to all NC State Employees. There are three options for coverage, all designed and overseen by the NC State Legislature and the State Health Plan governing body. Plans are administered by Blue Cross / Blue Shield of North Carolina. The available plans are as follows:
State Health Plan Preferred Provider Organization (PPO)
The State Health Plan's Preferred Provider Organization (PPO) plans offer comprehensive major medical coverage and prescription drug benefits. There are three levels of PPO coverage:
- Traditonal 70/30 Plan
- Enhanced 80/20 Plan
- Consumer-Directed Health Plan
The three PPO plan options employ the same network; the difference between the plans is in the premiums (the cost per month) and the Copay, Deductible and Coinsurance rates (the cost per visit). To receive the maximum coverage under the PPO plans, you must see in-network providers. In-network provider lists are available by clicking here (www.SHPNC.org) (select "Find a Doctor").
|Eligibility||Premiums||Preventive Care Benefits|
|Enrollment||Deductibles, Coinsurance & Copays||Claims|
|Cost||Prescription Drug Benefits||Questions|
All permanent employees who work 30 hours per week or more are eligible for coverage. Spouses and legally dependent children up to age 26 are also eligible. Permanent employees who work 20 to 29 hours are eligible for coverage, but must pay higher monthly premiums.
You must enroll within 30 days of hire, of a qualifying family status change or of the termination of another medical plan. You may be subject to certain waiting periods if you enroll after the 30-day period. There is one annual enrollment period during which employees may enroll or make changes to their plan; the annual enrollment is typically held in the fall. UNC Health Care is an agency that provides “only online enrollment”. Paper forms are not accepted.
The State pays the monthly premium for regular, 30+ hour employees enrolled in SmartChoice Basic. The State pays a majority of the premium for the SmartChoice plans also. Additonal premiums are paid by UNC Health Care for dependent coverage ( Health Insurance Special Pay, restricted to employees, click here first if viewing from home). Coverage for dependents and/or a spouse is available and paid for by the employee. Regular employees working 20 to 29 hours may enroll. See premium rates below.
Premiums for the plan are paid through a combination of employer and employee contributions as a pre-tax payroll deduction. Click here to view the monthly premiums for the plans.
Premiums are paid on a biweekly basis - half of the employee’s monthly contribution is deducted from the first two paychecks of each month. (There are two months per year in which there is a third paycheck, making a total of 26 paychecks for the year. No deductions are taken from the third paycheck of a month.) Please note that premiums are paid one month in advance.
Deductibles, Coinsurance & Copays
A Deductible is the portion of any claim that is not covered by the insurance provider. In other words, the employee is responsible for all health care expenses each plan year until the Deductible is met. Each covered dependent has an Individual Deductible, but if the Family Deductible is met then the deductible for all covered family members is considered met.
For the State Health Plan PPO options, the amount of the deductible varies depending on the plan elected and whether the service is received from in- or out-of-network providers. Click here to view information about the deductible.
Coinsurance may refer to Plan Coinsurance or Member Coinsurance, and it refers to the percentage of the health care expenses that each is responsible for once the Deductible is met. For example, if the Plan Coinsurance is 80%, then the plan will pay 80% of the health care expense incurred, and the remaining 20% becomes the Member Coinsurance that the employee must pay. All State Health Plan options include a Coinsurance Maximum, which is the maximum out-of-pocket amount that the employee will pay during the plan year for Member Coinsurance charges. Once the Individual or Family Coinsurance Maximum is met, the Plan Coinsurance effectively increases to 100%.
For the State Health Plan PPO options, the Plan Coinsurance and Coinsurance Maximum amounts vary depending on the plan elected and whether the service is received from in- or out-of-network providers. Click here to view the details about the Coinsurance.
A Copay is a flat dollar amount paid for a medical service by an insured person. Copays are necessary for all Prescription Drug services and most other services including Physician Office Visits. Copay expenses are not counted towards a member’s Deductible or Coinsurance.
Employees participating in the PPO plans pay only a Copay for in-network physician office visits. For these visits, charges are not subject to deductibles or coinsurance. The Copay amounts for the PPO plans vary by type of service and the plan elected. Click here to view information about the Copay.
Prescription Drug Benefits
The State Health Plan prescription benefits cover prescription drugs, self administered injectable medications and insulin. For the PPO Plans, diabetic test supplies are also available through the pharmacy benefit. Prescription drug Copays vary depending on the type of drug and are required for each 30-day supply.
In some instances the member will be required to pay the difference between the Plan’s actual cost of the brand name drug and the amount the Plan would have paid for the generic equivalent in addition to the generic copay. Click here to view information about Prescription Drugs.
- Routine Physical Exam
- Routine Hearing Evaluation
- Well-Baby and Well-Child Care
- Gynecological Exam, including Cervical Cancer Screening
- Ovarian Cancer Screening
- Screening Mammograms
- Colorectal Screening
- Prostate Screening
For a complete list of benefits, restrictions and exclusions please refer to the Benefits Booklet for your chosen plan (available at www.SHPNC.org). Some PPO plan benefits are covered only when received from an in-network provider and usage limitations may apply.
All claims must be filed within 18 months from the date of service. Claim forms may be found on the Forms page (http://hr.intranet.unchealthcare.org/forms) and is restricted to employees.
Claims for prescription drugs should be submitted to Medco. Call 800-336-5933 for details. All other claims should be mailed to Claims Processing Contractor, PO Box 30025, Durham, NC 27702-3025
All appeals must be submitted within 60 days of receiving a denial or benefits decision.
If you elect to have your premiums paid on a before tax basis, your health benefit coverage can only be changed (dependents added or removed) during the annual enrollment period or when one of the following events occurs:
- You change your legal marital status, which includes marriage, death of spouse, divorce, legal separation, or annulment.
- Your dependents change due to birth, adoption, placement for adoption, or death of the dependent.
- You, your spouse, or your dependents terminate or commence employment.
- You, your spouse, or your dependents reduce or increase their hours of employment.
- Your dependents cease or commence to satisfy the requirements for coverage due to attainment of age or student status.
- You, your spouse, or your dependents are entitled to coverage under Part A or Part B of Medicare, or Medicaid.
- You, your spouse, or your dependents commence or return from an unpaid leave of absence such as Family and Medical Leave or military leave.
- You receive a court order to provide coverage for your child(ren).
- There is a substantial change (at least $50 per month) in the premiums and/or benefits in the plan covering dependents. Example: Spouse covers dependent child(ren) and the cost of spouse’s coverage increases at least $50 per month, dependents can be added to the State Health Plan.
- The employee stops the withholding of premiums from their pay.
When one of these events occurs, you must complete an online change within 30 days of the event. If however, you do not inform the Employee Benefits Office within 30 days, you must wait until the next annual enrollment to make the coverage change. Whenever you report a change due to a qualifying event, your premium deduction will be on a pre-tax basis.
Employees who stop the withholding of premiums and terminate coverage on their dependents may only re-enroll their dependents if one of the above status changes occur or at the next annual enrollment.
For questions about premiums, deductions, enrollment and changes to your election, please contact the Benefits Office at email@example.com or call 919 966-2027.
If you have questions about State Health Plan benefits, processing a claim form, or have experienced problems in receiving a reimbursement, please contact Blue Cross / Blue Shield at the address listed below.
Additional information can be found on the State Health Plan Web site, www.SHPNC.org.
Blue Cross and Blue Shield of North Carolina
PO Box 30111
Durham, NC 27702-3111