North Carolina's State Health Plan encourages its enrollees to engage in "healthy goal" activities.
Over 665,000 active employees, retirees and their dependents (including teachers and government employees) receive coverage as of 2011 through the North Carolina State Health Plan, according to that office. Employees have the option to enroll in one of two preferred provider organization (PPO) plans, and they can also apply for insurance coverage for their children through NC Health Choice.
PPO Plans
North Carolina State Health Plan offers a basic or standard option. The basic plan has lower monthly premiums, but employees are responsible for more out-of-pocket medical expenses. It is a 70/30 plan, meaning that they pay 30 percent of the costs of covered services. Employees pay 20 percent of costs in the 80/20 standard plan. In-network deductibles are $200 to $600 lower in the standard plan in comparison to the basic option, according to 2010-2011 rates. A copay is required for employees receiving care from primary physicians, urgent care facilities and chiropractors. Copays are also required to receive short-term rehabilitation therapy and office-based mental health services. Emergency care, inpatient services, outpatient hospital care and more comprehensive mental health services are subject to the deductible.
Prescription Coverage
Prescription drug benefits are the same in both the basic and standard olans, according to the 2010-2011 benefits summary. Employees pay $10 for a month's supply of generic medications. Their out-of-pocket costs for preferred-brand drugs with no available generic is $35 for a 30-day supply and $55 for non-preferred brands. However, employees must pay the generic copay and the difference in cost between the generic and brand-name drug if they take a brand drug that has an available generic. Specialty drugs are subject to a 25 percent coinsurance up to a maximum of $100 for each monthly supply.
Preventive Services
The State Health Plan offers members several preventive benefits including coverage for immunizations, annual physicals, gynecological exams, hearing exams and prostate testing. Screens for colorectal, cervical and ovarian cancer are also covered. Female employees age 35 and up are eligible for one mammogram per year. Well-baby benefits cover required immunizations and wellness visits for members' children up to two years of age. Members can also receive online and phone support from health coaches to encourage them to meet healthy goals including weight loss, exercise and stress management.
NC Health Choice
Members who cannot afford to pay for insurance for their children through the State Health Plan can apply for NC Health Choice. This program offers coverage for children when parents can't afford insurance but do not qualify for Medicaid. Formerly handled through the State Health Plan, NC Health Choice is administered through the state's Division of Medical Assistance as of July 2010. Members accepted into the program can obtain primary health coverage in addition to dental, vision and hearing benefits for their kids. The NC Health Choice program follows Medicaid's benefits structure.
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