Implementation of High Deductible Health Plans (HDHPs) in Your
As the North Carolina Medical Society Employee Benefit Plan (the NCMS
Plan) enters its eleventh year serving the physician practices of North
Carolina, we are pleased to report that beginning August 1, 2008, we will
offer 13 product choices to our participating practices. With seven PPO
products, five High Deductible Health Plans (HDHPs), and one product
blending an HDHP with a traditional PPO prescription drug copayment
benefit, medical practices across the state have numerous options to
choose from. All of our HDHP products are qualified to be paired with a
Health Savings Account (HSA). Any health product offered by the NCMS Plan
can be paired with a Health Reimbursement Account (HRA).
stated, HRAs are funded by employers on a tax-deductible basis on behalf
of their employees. A set amount of money is allocated for each employee
for use in covering eligible medical expenses subject to their health
plan's deductible or coinsurance. The money in an HRA is always owned by
the employer. HSAs are another option for paying qualified medical
expenses under an HDHP. These accounts can be funded by the employer
and/or employee on a tax-deductible or pre-tax basis and are completely
portable. Money deposited into an HSA by the employer or the employee is
immediately owned by the employee.
Currently, 22% of medical
practice employees covered by the NCMS Plan are enrolled in an HDHP. Some
with a tax-advantaged health account (an HSA or HRA) and some without.
While the traditional PPO plan still remains our most popular plan type,
the decision to offer an HDHP is becoming more common, and the NCMS Plan
makes it easy to add an HDHP as an option. In fact, NCMS Plan practices of
up to 50 enrolled employees have the ability to offer any two plans to
their employees. Groups of more than 50 enrolled employees can offer up to
As more groups offer HDHPs, the following suggestions
may be helpful in facilitating a smooth transition for your practice.
- Groups that successfully implement HDHPs take the necessary time for
communication and education of their employees. This can be done by
holding an informational meeting prior to open enrollment meetings. The
NCMS Plan staff or your Account Executive can be very helpful in this
- Many practices continue to offer a PPO plan in conjunction with an
HDHP. This is a popular solution resulting in physician and employee
- Many practices continue to pay 100% of the employee premium for the
HDHP and offer a PPO as a buy-up option.
- With the implementation of an HSA or an HRA partially funded by the
practice, employees will have assistance with reimbursement of eligible
out-of-pocket medical expenses.
We are committed to assisting you with a high level of customer
service. Please let us know if your practice would like further education
regarding HDHPs, HRAs, or HSAs. We welcome your questions and look forward
to serving you.
90-Day Rx Supply No Longer Requires 30-Day Supply First
Effective August 1, 2008, NCMS Plan members will no longer be required
to first fill a 30-day prescription before a 90-day supply of the same
prescription can be dispensed.
Prior to this change, the first
time an NCMS Plan member filled a prescription, only a 30-day supply would
be approved, even if a prescription for 90-days was presented at the
pharmacy. The intent was to first establish a record of the maintenance
drug, and then allow supplies of more than 30 days to be dispensed.
This change is likely to satisfy members prescribed a new
maintenance drug who want a 90-day supply from the outset.
eBenefitsNow: Your Online Tool for Plan Administration
Do you have 16 or more employees enrolled on your NCMS Plan health
plan? If so, you can use eBenefitsNow to take control of your benefits.
eBenefitsNow replaces the time-consuming paper-based benefit
enrollment with a comprehensive online benefit administration and
enrollment solution. It's secure, online, and paper free.
use eBenefitsNow to add new hires to your plan, make changes to employee
benefit elections, and instantly send all of your changes directly to the
NCMS Plan administrator, Blue Cross and Blue Shield of North Carolina. You
also eliminate faxing errors and improve accuracy by transmitting
information electronically. eBenefitsNow can even generate easy-to-use
reports for your employee census and benefit detail.
implementation of eBenefitsNow, visit www.eBenefitsNow.com/serviceagreement.html
and use access code: NC675899. Once you complete this agreement, a
representative from BenefitFocus will contact you to get your group setup
and to train you on how to use the system. There is no cost for your group
to use eBenefitsNow.
Want to check out a demo? Visit www.eBenefitsNow.com/start.
Feel free to customize and share this article with your employees in
your newsletter, on your intranet, by e-mail, or on a bulletin board.
Want a free MP3 player? How about a free soccer ball or radio for
your son or daughter?
The North Carolina Medical Society Employee
Benefit Plan has a physical activity and wellness incentive program called
Blue Points that gives you and your covered dependents an easy way to
record your physical activities and participation in wellness
activities--and rewards you with great prizes!
and lifestyle changes can greatly reduce the risk of cancer, heart
disease, diabetes and other health conditions. With BluePoints, just 30
minutes a day of physical activity like working in the yard, playing golf,
or walking the dog earns you points towards prizes like electronics,
sports equipment, clothing and more! You can also earn points for
enrolling in specific wellness programs and participating in wellness
activities like learning more about healthy cholesterol and blood pressure
All you have to do is record your activities online in
your Blue Points Activity Log. To access your Activity Log, visit www.bcbsnc.com/memberservices/
and log in or register for Member Services. At least 30 minutes of
activity a day or participation in a wellness activity earns you 10 points
for that day. Earn 250 points and select a prize. And, there are special
prizes for kids and teens.
For more information on online wellness
activities that qualify for Blue Points, log in to Member Services and
visit Health Programs. Sign up for the Get In Shape or Healthier Diet
online wellness program or calculate your Body Mass Index (BMI).
Remember, it's a good idea to check with your doctor before
starting any new activity. Ask your doctor to help you choose a fitness
plan that's right for you and your family.
Question: Some of my practice's employees have never had health
insurance before and have recently become eligible for benefits. How can I
best explain the difference between the deductible and coinsurance?
Answer: The deductible is the amount of allowable charges
for covered services that must be paid by the employee before the NCMS
Plan will assume any liability for the cost of any covered services. For
example, the PPO 1500-80 plan has an individual in-network deductible of
$1,500, so the employee would pay $1,500 for in-patient and out-patient
services before the NCMS Plan would pay any portion of the remaining
Coinsurance is simply a type of
"cost-sharing" that comes into play after the deductible has been met.
Once the deductible is met, the employee pays a percentage of the cost of
covered medical services as an out-of-pocket payment to the provider.
Using the previous example, the PPO 1500-80 plan would have the NCMS Plan
pay 80% of the cost and the employees pay the remaining 20% up to a given
All NCMS Plan health products have an
out-of-pocket maximum which upon being met, increases the plan benefits
(the NCMS Plan's payment) to 100% (excluding copayments).
Plan health products also have some deductible amount that must be met
within a given benefit period. It's important to remember that the
deductible does not include copayments, coinsurance, charges beyond the
allowed amount, or amounts for non-covered services.
note, PPO and HDHP/HRA family deductibles work differently. PPO
deductibles are individual; if one or more dependents are covered, each
covered person has an individual deductible and a maximum combined family
deductible (the individual deductible x 3). HDHP/HRA family deductibles
are aggregate. The employee (or individual) deductible applies if employee
selects "employee only" coverage; otherwise, the family deductible
applies. All covered family members contribute to the same family
deductible. Once the family deductible is reached, it is met for all
covered family members.
George Fanelli is an Account Service
Representative for the NCMS Plan. If you have a question you would like
answered in a future issue of CHOICES, e-mail George at firstname.lastname@example.org.
Practice Manager's Forum
High Deductible Health Plans and Provider Collection Policies
More than one-fifth of all employees covered by the NCMS Plan are now
enrolled in a High Deductible Health Plan (HDHP). That's nearly 3,400
physicians and medical practice employees across the state. What's even
more astounding is that the NCMS Plan has only been offering HDHPs since
August 2006. And this growth is likely to continue, if not escalate.
According to America's Health Insurance Plans, a Washington, D.C. trade
group, 6.1 million Americans were covered by a HDHP as of January, up from
438,000 in 2004.
For those unfamiliar with HDHPs, one significant
difference between a traditional PPO plan and a typical HDHP is that an
HDHP does not have copayments. Employees on HDHPs pay the allowable
charges for all services rendered in the provider's office. All of these
payments go toward the employee's deductible.
copayments, employees (i.e. your patients) will ask, "What will I have to
pay when I go to my doctor's office. I've always paid them my copayment
and that was it". You or your practice's employees probably deal with this
situation on a regular basis.
The NCMS Plan utilizes the Blue
Cross and Blue Shield of North Carolina (BCBSNC) network of providers. The
BCBSNC Provider Manual (The Blue Book) assists your practice with
understanding and administering the health insurance products and billing
guidelines. Section 3.11.2 of The Blue Book covers the specific issue:
HDHP collection policy.
The Blue Book advises that the limitation
on collection of estimated amounts are as follows:
- Physicians or professional providers may collect up to the lesser of
the member's estimated out-of-pocket costs or $50 for services received
in the provider's office.
- Hospitals and ancillary providers may collect up to the lesser of
the member's out-of-pocket costs or $500 for services rendered in the
hospital or outpatient facility.
The final determination of what the member owes is based on the claim
that is submitted and will be reflected on the Explanation of Payment
(EOP). Any refunds due to the member must be made within 45 days.
From the NCMS Plan's perspective, we want our (and your) covered
employees' experience with a HDHP to be positive and easy, yet we
understand that your practice has its own business interests to see
after...a difficult balance. We advocate that practices (especially those
with employees of their own on a HDHP) not collect anything at the point
of service from HDHP members and allow claims to process and bill the
member for allowable charges. Secondarily, we advocate that practices
collect a standard copayment for the office visit (say $20 or $25 for a
primary care visit, for example), or at least meet the guidelines
referenced from The Blue Book.
The NCMS Plan acknowledges that
medical practices have a difficult time these days on multiple fronts, but
the growth of HDHPs and the number of NCMS Plan members enrolled in HDHPs
from your practice, the practice across the street, or across town, may
cause you to take another look at your collection policies.
access BCBSNC's Provider Manual, The Blue Book, visit www.bcbsnc.com/providers/blue-book.cfm.
We'd be interested to know what you think about this topic. E-mail
Gary Bossert at email@example.com with
About the North Carolina Medical Society
As the largest physician organization in the state, the North Carolina
Medical Society (NCMS) is devoted to representing the interests of
physicians and protecting the quality of patient care. The NCMS Plan,
sponsored by the NCMS, is the only statewide employee benefits plan
designed specifically for North Carolina physicians.
information about many other benefits of NCMS membership, visit http://www.ncmedsoc.org/.