Comprehensive Wellness Initiative Overview
In April 2009, Senate Bill 287 became law (Session Law 2009-16). Contained in the Law is a section about the Comprehensive Wellness Initiative (CWI) for members of the State Health Plan for Teachers and State
Employees (Plan). This initiative was developed to encourage Plan members to make healthier lifestyle choices. It also provides supports to assist Plan members to quit using tobacco and maintain a healthy weight.
Starting July 1, 2010, members will be enrolled in the 70/30 Basic Plan unless they meet the requirements for enrollment in the 80/20 Standard Plan, based on compliance with the tobacco cessation component. A weight management component will be added to the requirements for the 80/20 Standard Plan beginning July 1, 2011. The CWI applies to active employees, retirees, COBRA participants and dependents whose primary health coverage is provided by the Plan. The CWI does not apply to members with Medicare as their primary coverage.
Members who wish to enroll in the 70/30 Basic Plan do not complete an Attestation Form*. Members who wish to enroll or remain in the 80/20 Standard Plan must complete an Attestation Form each Plan year. If requesting exemption, the member must obtain a completed Physician Certification Form each year to enroll in the 80/20 Standard Plan. (See “Exemptions” below for details.)
* An Attestation Form is a legally binding document that subscribers must complete each year to enroll in the 80/20 Standard Plan.
Tobacco Cessation Component
Tobacco Cessation Supports
Weight Management Component
Weight Management Supports
Please direct any questions about the Comprehensive Wellness Initiative to the Customer Services Department at 1-888-234-2416. In December, members will receive the PharmacyWise newsletter which will outline enhanced benefits and other NC HealthSmart resources for members.
Notice to Plan Members:
A federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, sets forth certain requirements for group health plans. HIPAA also permits state and local governmental employers that sponsor health plans to elect to exempt their plan from these requirements for any part of the plan that is “self-funded” by the employer, rather than provided through a health insurance policy. The State Health Plan is self-funded. In order to implement its comprehensive wellness initiative, the State of North Carolina has elected to exempt the State Health Plan from the HIPAA rules prohibiting discrimination against individual participants and beneficiaries based on health status related factors, including health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, insurability, and disability. The exemption from these Federal requirements will be in effect for state fiscal year 2011 beginning July 1, 2010 through June 30, 2011. The election may be renewed for subsequent plan years. State law, G.S. § 95-28.2 prohibits discrimination against individuals based on lawful use of lawful products during nonworking hours. However, much like federal law, the State statute provides an exemption to that prohibition where differential premium and cost sharing rates are actuarially justified, the Plan provides written notice of the differential rates, and the State contributes an equal amount of health premium dollars on behalf of each employee. Although members will not lose their health coverage as a result of the Comprehensive Wellness Initiative, the State Health Plan provides for certification and disclosure of creditable coverage for covered employees and their dependents who lose coverage under the Plan. The certificate provides evidence that you were covered under this Plan, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer’s health plan, or if you wish to purchase an individual health insurance policy.
Starting July 1, 2010, members will be enrolled in the 70/30 Basic Plan unless they meet the requirements for enrollment in the 80/20 Standard Plan, based on compliance with the tobacco cessation component. A weight management component will be added to the requirements for the 80/20 Standard Plan beginning July 1, 2011. The CWI applies to active employees, retirees, COBRA participants and dependents whose primary health coverage is provided by the Plan. The CWI does not apply to members with Medicare as their primary coverage.
Members who wish to enroll in the 70/30 Basic Plan do not complete an Attestation Form*. Members who wish to enroll or remain in the 80/20 Standard Plan must complete an Attestation Form each Plan year. If requesting exemption, the member must obtain a completed Physician Certification Form each year to enroll in the 80/20 Standard Plan. (See “Exemptions” below for details.)
* An Attestation Form is a legally binding document that subscribers must complete each year to enroll in the 80/20 Standard Plan.
Tobacco Cessation Component
Tobacco Cessation Supports
Weight Management Component
Weight Management Supports
Exemptions
Subscribers who attest to qualifying for exemption at enrollment must obtain a Physician Certification Form. The completed form must include a dated physician, nurse practitioner or physician assistant’s signature, as well as the tobacco cessation and/or weight management program start date(s). Members should keep the original, completed certification form for their records, as the Plan may request it at any time. Upon the Plan’s request, the member will have fifteen (15) business days to submit the completed form to maintain their eligibility for enrollment in the 80/20 Standard Plan. If the form is not submitted within 15 business days, members will be notified of the consequences outlined in the “Consequences and Appeal Rights” section below.Consequences and Appeal Rights
Members, who refuse testing, do not submit a completed Physician Certification Form within fifteen (15) business days of request, or fail the tobacco use or BMI tests will be moved to the 70/30 Basic Plan for the rest of the Plan year. The move to the 70/30 Basic Plan will include all covered family members. Those members will forfeit any coinsurance and deductible(s) already paid under the 80/20 Standard Plan and will only be eligible to enroll in the 70/30 Basic Plan for the following Plan year. Members may not appeal the stated consequences if they refuse testing or do not submit a Physician Certification Form within fifteen (15) business days of the Plan’s request. Members may appeal the stated consequences based on test results. Instructions on the appeal process will be provided to the member at the time of testing.Please direct any questions about the Comprehensive Wellness Initiative to the Customer Services Department at 1-888-234-2416. In December, members will receive the PharmacyWise newsletter which will outline enhanced benefits and other NC HealthSmart resources for members.
| Click here to access our Member Feedback e-mail if you have a question or concern. Your input will be reviewed and used to expand/clarify the information on the Comprehensive Wellness Initiative. Individual responses will not be possible. If you have specific benefit questions, you may contact Customer Service at 1-888-234-2416. |
A federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, sets forth certain requirements for group health plans. HIPAA also permits state and local governmental employers that sponsor health plans to elect to exempt their plan from these requirements for any part of the plan that is “self-funded” by the employer, rather than provided through a health insurance policy. The State Health Plan is self-funded. In order to implement its comprehensive wellness initiative, the State of North Carolina has elected to exempt the State Health Plan from the HIPAA rules prohibiting discrimination against individual participants and beneficiaries based on health status related factors, including health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, insurability, and disability. The exemption from these Federal requirements will be in effect for state fiscal year 2011 beginning July 1, 2010 through June 30, 2011. The election may be renewed for subsequent plan years. State law, G.S. § 95-28.2 prohibits discrimination against individuals based on lawful use of lawful products during nonworking hours. However, much like federal law, the State statute provides an exemption to that prohibition where differential premium and cost sharing rates are actuarially justified, the Plan provides written notice of the differential rates, and the State contributes an equal amount of health premium dollars on behalf of each employee. Although members will not lose their health coverage as a result of the Comprehensive Wellness Initiative, the State Health Plan provides for certification and disclosure of creditable coverage for covered employees and their dependents who lose coverage under the Plan. The certificate provides evidence that you were covered under this Plan, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer’s health plan, or if you wish to purchase an individual health insurance policy.
