FAQ

  1. What is a Preferred Provider Organization (PPO)?
    In a PPO arrangement, providers are under contract to provide medical services at lower than usual fees in return for prompt payment and a certain volume of patients.
    • There is freedom of choice among in-network providers, including specialists. No referrals are required for specialist office visits.
    • When in-network providers are used, out-of-pocket expenses are lower and no claims forms are required.
  2. How is a PPO different from an HMO?
    PPO plans differ from the traditional HMO plans in the following way:
    PPO HMO
    PPO members are not required to choose a primary care physician. HMO members must choose a primary care physician (PCP).
    PPO members can refer themselves to specialists. HMO members must get a referral from their PCP in order to see a specialist.
    PPO members are not required to stay within the PPO network, but there is usually a strong financial incentive to do so. HMOs provide no coverage for care received from non-network physicians.
  3. Who is eligible to enroll in the Blue OptionsSM PPO plans?
    If you are an employee who works a minimum of 30 hours per week, a teacher, State retiree, or a COBRA participant, you are eligible to enroll in the Blue OptionsSM PPO plans. If you are an NC Health Choice (CHIP) member, you are not eligible to enroll in the Blue OptionsSM PPO plans. Permanent part-time employees who work between 20 and 29 hours per week are also eligible; however, they are responsible for paying the full premium cost.
  4. If I currently have other coverage and choose not to enroll in the PPO during the enrollment period, can I enroll next year during annual enrollment? What if I don't have other coverage?
    If you choose to enroll during a later annual enrollment period, coverage limitations and/or a waiting period may be required. You will be given credit for your previous coverage that may be used to satisfy PPO plan's waiting period. Proof of prior coverage will be requested as verification. If you don't have coverage under another plan and apply during the next annual enrollment, you may be subject to the entire waiting period before certain services are covered under the plan. Please be sure to meet with your Benefits Counselor if you have questions.
  5. Can members who have TRICARE as primary enroll in the Blue OptionsSM PPO plans?
    After carefully evaluating the benefits, if you feel that the Blue OptionsSM PPO plans are more cost-effective for you, TRICARE primary members are eligible to enroll.
  6. How are the Blue OptionsSM PPO Plans coordinated with TRICARE coverage?
    Blue OptionsSM PPO plans coverage is always primary when coordinated with TRICARE while you are an active employee.
  7. I am 65, still working, and thinking about enrolling in the Blue OptionsSM PPO plan. How does Medicare coordinate with the PPO plans?
    While you are actively employed and eligible for Medicare, the PPO plan is treated as primary coverage. Because there is no cost, you should still enroll in Part A of Medicare. When you retire, it is recommended that you enroll in Medicare Part B. At the point of retirement, Medicare will become primary coverage and the PPO plan will be the secondary payer. If you choose not to enroll in Medicare, the PPO plan will treat claims as if you are covered by Medicare, possibly reducing coverage.
  8. Can I order an ID card online?
    Yes, this is one of the benefits you will receive as a Blue OptionsSM PPO plan member. You can order an ID card online by registering with My Member Services here.
  9. Can I obtain claim information online?
    Yes, this is one of the benefits you will receive as a Blue OptionsSM PPO plan member. You can view your claim information online by registering with My Member Services at www.shpnc.org. You can also print an Explanation of Benefits from My Member Services.
  10. I've tried to contact the PPO plan by e-mail through a Blue Cross and Blue Shield of North Carolina (BCBSNC) e-mail address, but I've received no response. Am I using the correct e-mail address?
    Blue OptionsSM PPO plan questions can be sent via e-mail to: ppo.inquiries@shpnc.org. This mailbox is maintained by the State Health Plan, rather than by BCBSNC.

Network of Providers Questions (Blue OptionsSM)

  1. What network of providers do I have access to?
    If you choose one of the PPO plans, you will have access to the Blue Cross and Blue Shield Blue OptionsSM network of providers. If you receive services outside of this network, you will still have coverage, but your benefits will be reduced and you will have to pay more out-of-pocket. The Blue OptionsSM network includes about 90% of the primary care physicians in the state, 97% of the hospitals in the state, and participating providers in all 100 counties of North Carolina. Members who reside or travel outside of North Carolina will be able to receive in-network coverage through the extensive Blue Card network of providers.
  2. Are network providers available in all 100 counties?
    Yes. If you choose one of the PPO plans, you will use the Blue Cross and Blue Shield of North Carolina Blue OptionsSM network of providers. The Blue OptionsSM network includes about 90% of the primary care physicians in the state, 97% of the hospitals in the state, and participating providers in all 100 counties of North Carolina. Members who reside or travel outside of North Carolina will be able to receive in-network coverage through the extensive Blue Card network of providers.
  3. What is the greatest distance I may have to travel to receive care from a primary care physician or a specialist?
    Blue Cross and Blue Shield of North Carolina (BCBSNC), through its Physician Advisory Group and Quality Improvement Committee, has established standards that limit the driving distance a member must travel to receive the services of an in-network provider. The standards are different for counties that are highly populated or highly urbanized. The driving distance for more populated counties is less than for counties that are not as populated. The following counties are considered highly urbanized counties: Cumberland, Durham, Forsyth, Gaston, Guilford, Mecklenburg, New Hanover and Wake counties. All other counties in North Carolina are considered low-urbanized counties.
    The driving distance standards are listed below and are based on the type of provider.
    Adult and Pediatric Primary Care Providers:
    High- Urbanized Counties One provider within 15 miles
    Low- Urbanized Counties One provider within 30 miles

    Ob/Gyn Providers:
    High- Urbanized Counties One provider within 15 miles
    Low- Urbanized Counties One provider within 30 miles

    Specialist MD – High Volume and non-MD Specialist Providers: MDs who contract with BCBSNC in the specialties of allergy, cardiovascular disease, dermatology, gastroenterology, general surgery, hematology/oncology, neurology, ophthalmology, orthopedic surgery, otolaryngology (ear, nose and throat) and urology.
    High- Urbanized Counties One provider within 30 miles
    Low- Urbanized Counties One provider within 60 miles

    Specialist MD – Low Volume Providers: MDs who contract with BCBSNC in specialties not designated as high volume.
    High- Urbanized Counties One provider within 45 miles
    Low- Urbanized Counties One provider within 85 miles
  4. Is my provider a Blue OptionsSM provider?
    In order to find out which providers participate in the Blue OptionsSM Network, please visit the State Health Plan Web site, or simply ask your physician if he or she is a participating provider in the Blue OptionsSM network.
  5. I noticed on the online provider directory that some providers have a yellow circle or a red square. What do the symbols mean?
    If a provider has a yellow circle on the directory, it means the doctor MAY bill for services as outpatient services; subject to the deductible and co-insurance. If the provider has a red square, services WILL be billed as outpatient services; subject to the deductible and coinsurance.
    If the services are provided by a facility that is hospital owned, the covered member should inquire as to whether or not the deductible and coinsurance will apply to the visit. For example, although Duke University Health Care has primary care providers, services may actually be billed as outpatient visits; subject to the deductible and coinsurance. On the other hand, the majority of UNC Health Care System physicians are also primary care providers, but services billed are only subject to the copay. There are exceptions to how services are billed. This is just one example. When making provider selections, be sure to visit the on-line directory. Click on the yellow circle or red square for details on how services are billed based on the specific provider.
  6. If my participating provider terminates from the network, what should I do if I still want to use him or her?
    You may continue to use your physician if he or she terminates from the network, but out-of-network deductibles and coinsurances will apply.
  7. What happens if my provider drops out of the network during the middle of a treatment plan?
    If a provider drops out of the network during treatment for a special on-going condition such as pregnancy, services are still covered for possibly up to a 90-day period or more depending on plan rules and utilization management. The covered member should contact 1-888-234-2416 to discuss continuation of care.
  8. How will I know if my provider terminates from the Blue OptionsSM network?
    Participating providers are required to give a 30–60 day notice of termination from the network. Once the termination is received and processed, members will receive a notice advising them that their physician will no longer be participating as of the date they requested, and indicating that the member should begin seeking alternative physicians.

Blue OptionsSM PPO Plan Option Benefits Questions

  1. What do the percentages on the benefit summary represent?
    The percentages on the benefit summary represent the amount of money the plan will pay towards your allowed charges.
  2. Does the office visit copay count toward the deductible?
    Office visit copays do not count toward meeting the annual deductible.
  3. If I satisfy the deductible for in-network benefits, will the amount apply to the out-of-network deductible?
    In-network deductible amounts met do not apply to the out-of-network deductible limit. Amounts paid to satisfy out-of-network deductibles do; however, they apply towards in-network deductible requirements. The same rules apply toward meeting out-of-pocket limits (coinsurance maximums).
  4. If I have an outpatient surgical procedure, do I have to pay an office visit copay in addition to the deductible and coinsurance?
    No, a copay is not required. Only the deductible and coinsurance are required.
  5. How will I know when my services are subject to deductibles and coinsurance?
    Your level of coverage depends on the location where the service is provided (i.e. physician's office, facility, hospital).
    • Copayments apply when services are received in an in-network physician's office.
    • Deductible and coinsurance apply when services are performed outside of the physician's office, and when performed in a hospital owned or operated physician's office or when services are provided by an out-of-network provider in the office.
    • Outpatient lab & mammography are covered at 100% when performed alone by an in-network provider.
    • Outpatient lab & mammography are subject to coinsurance and deductible when performed with another service, or when performed by an out of network provider.
    Examples of services received in conjunction with a routine mammogram that are subject to coinsurance and deductible are diagnostic x-ray, nuclear medicine, ultrasound, emergency room, cardiology, stress test, and MRI.
  6. I am unclear about how preventive and wellness benefits work. How many services can I receive for one copay, and what is subject to the coinsurance and deductible?
    The initial copay covers services received during a primary care physician visit. Additional services such as mammograms and lab work, even if received outside of the doctor's office, are also covered under the initial copay. If more services are required, such as x-rays, EEG or an EKG, they may be covered at 100% if performed in a physician's office. If the services are performed in an outpatient clinic setting, they may be subject to the deductible and coinsurance.
  7. What if my doctor sends me to another location for lab work. Are the lab services covered?
    If recommended lab services originate from a primary care physician visit and the physician is NOT part of a hospital-owned practice, the lab services are covered at 100%; otherwise, they may be subject to the deductible and coinsurance.
  8. Are there network providers for prosthetics? How often can a prosthetic be fitted or adjusted and how is it covered?
    Network providers are available for prosthetics. Prosthetics are covered with deductible and coinsurance. More information about covered prosthetics can be obtained by contacting the PPO plan customer service line or reviewing the medical policy located on the BCBSNC Web site [see Medical Policies below].
  9. What if I use up my 30 chiropractic visits during the year. Are there any exceptions, and will the plan approve more visits?
    If the 30 visits are used up, covered members may take advantage of the Blue ExtrasSM program, which offers discounts on chiropractic services.
  10. I'm having a baby: Do I have to pay a copay every time I go for a prenatal visit. And, how are hospital and delivery charges handled?
    There is an initial copay charge for the pregnancy diagnosis (the first visit); visits thereafter are covered at no charge. The remaining maternity visit charges are covered by one global fee subject to the inpatient copay, deductible and coinsurance upon hospital admission/delivery. Charges include prenatal, delivery and postnatal care as well as circumcision. Please note: You must add your newborn to the plan within 30 days of birth to avoid pre-existing condition limitations and/or waiting periods.
  11. What if I need more than one eye exam per year. For example, a diabetic may require more than one eye exam.
    Diabetics typically need more than one eye exam per year. The first routine eye exam is covered under the in-network wellness benefits with a copay. The plan allows for more than one exam when deemed medically necessary, and those eye exams are also covered with the copay. Non-routine eye exams are covered with a specialist copay when seen by an in-network provider.
  12. I understand that routine eye exams are covered in-network with just the copay. What is included in the routine eye exam. Can the provider write a prescription for contacts and/or glasses during the routine eye exam visit. Where should I get the prescription filled?
    Routine eye exams include glaucoma screening, measurement for contact lenses or glasses and a prescription, if necessary. Hardware such as glasses and/or contact lenses are not covered. However, you can receive a 30% discount on eyewear and hard contact lenses and a 15% discount on disposable contacts at in-network providers with dispensaries.
  13. Are residential treatment centers for mental health services (for example, an over-night facility) covered by the Blue OptionsSM PPO plan?
    Residential treatment centers are covered for substance abuse treatment, but not for mental health services. ValueOptions should be consulted for more information about coverage details and limitations.
  14. I am diabetic and I understand there are some changes to how supplies are covered.
    Diabetic supplies including test strips, lancets and syringes are covered by the pharmacy benefit copay. Preferred brand diabetic supplies are covered with a $10 copay. Non-preferred brand diabetics supplies are covered with a $30 co-pay. If a covered member is using a non-preferred brand of test strips, the Blue OptionsSM PPO plan will send the member a free glucometer as an incentive to use a preferred test strip brand.
  15. I use an insulin pump rather that injecting insulin. Is the pump covered?
    Insulin pumps are covered under durable medical equipment provisions. See Medical Policies section below.
  16. How is kidney dialysis covered. What if I receive in-home dialysis services?
    Dialysis services are provided in an outpatient setting and are always covered by the deductible & coinsurance. In-home dialysis services are also covered with the deductible and coinsurance.
  17. If I am admitted into the hospital and my care includes anesthesiology and radiology services, will I have to pay out-of-network fees if the physician was not an in-network provider?
    Inpatient services such as anesthesiology and radiology will always be covered as in-network, whether performed by in or out-of-network providers, as long as services were provided at a participating hospital and you were admitted by a participating physician.
  18. What if I am traveling, have an emergency, and I am rushed to the nearest hospital. Will I have to pay out-of-network fees for my services if the hospital does not participate in the network?
    No. Emergencies are always covered as in-network services.
  19. What constitutes an emergency?
    An emergency is the sudden or unexpected onset of a condition of such severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of an individual or with respect to a pregnant woman, the health of the pregnant woman or her unborn child in serious jeopardy; serious physical impairment to bodily functions; serious dysfunction of any bodily organ or part; or death.
    • Heart attacks, strokes, uncontrolled bleeding, poisonings, major burns prolonged loss of consciousness, spinal injuries, shock, and other severe, acute conditions are examples of emergencies.
  20. How are diabetic supplies covered under the Blue OptionsSM PPO plans?
    Diabetic supplies, including test strips, are covered as a pharmacy benefit under the Blue OptionsSM PPO plans. This means that you only have to pay a copay for diabetic supplies.
  21. Once I meet my out-of-pocket maximum for out-of-network services, will I still be responsible for any difference between the billed amount and the allowable amount if I go out-of-network?
    Yes. Once you meet your out-of-pocket maximum for out-of-network services, you will still be responsible for any charges above the allowed amount.
  22. Do any of the services provided under the PPO plans have visitation limits?
    Yes. The following services have visit limits under the PPO plans:
    • Chiropractic – 30 visits per benefit year
  23. Isn't it better to cover my dependents on the BCBSNC Blue Advantage® plan?
    It may or may not be better for you to cover your dependents on Blue Advantage®. If you are covering one male child or one female child under the age of 19, and that child does not have any pre-existing conditions, Blue Advantage® could offer cost savings for you. If you are covering more than one child, with or without pre-existing conditions, the PPO may be a better option for you. Blue Advantage® uses medical underwriting in calculating the rate you must pay for coverage; whereas the PPO plans do not use individual medical underwriting when calculating rates.
  24. What is the age limit for covered dependents?
    Unmarried dependent child(ren) are covered to age 19 or to age 26 if a full-time student at an accredited school.
  25. Will the PPO plans provide vision coverage?
    Coverage is provided for one routine eye exam per benefit year for your primary care copay when the provider is in the Blue OptionsSM network. Routine eye exams are not covered out-of-network. You must let the provider know that you are a Blue OptionsSM member when you arrive for your visit. In addition, you will receive discounts on eyewear from participating providers with dispensaries.
  26. What is certification?
    Certain health care services you receive must be certified in order for you to receive benefits. In-network, providers are required to obtain any required certifications on your behalf, except for in-network services received outside of North Carolina. Out-of-network providers, however, are not obligated to obtain any needed certification. When the provider is not required or obligated to get certification on your behalf, the responsibility falls on you, the member, to contact the State Health Plan for certification of services or supplies. Certification is the determination by the State Health Plan that an admission, availability of care, continued stay, or other services, supplies or drugs have been reviewed and, based on the information provided, satisfy the State Health Plan requirements for medically necessary services and supplies, appropriateness, health setting, level of care and effectiveness.
  27. What is a certification penalty?
    A certification penalty is charged to a PPO member, when certification of service is the member's responsibility and certification is not obtained. This penalty will reduce your allowed charges by 25% before your deductible and coinsurance are applied.
  28. Does the North Carolina State Health Plan cover the Shingles vaccine?
    Yes.  The vaccine is covered at 100%.  You are, however, responsible for the office visit copayment if it is administered by your provider.
  29. What if my doctor’s office doesn’t have the Shingles vaccine?
    Your doctor may write you a prescription to buy the Shingles vaccine at a pharmacy.  You then take the Shingles vaccine to your doctor for him or her to administer.  The Shingles vaccine must be kept frozen until it’s used.  You will have to pay full price at the pharmacy, but will be reimbursed by the State Health Plan.  To receive reimbursement, you will need to complete and return a Medical Claim Form.  Medical Claim Forms are available on our Web site here or by calling Customer Service at 1-888-234-2416.
  30. What if Medicare is my primary coverage?
    The vaccine isn’t covered by Medicare.  Ask your provider to file the Shingles vaccine directly with the State Health Plan.
  31. Should I consider getting the Shingles vaccine?
    Ask your provider if it is medically appropriate for you to receive the Shingles vaccine.

Retiree Questions

  1. Where should retirees send their enrollment forms?
    Enrollment forms for retirees should be returned to:
    NC Department of State Treasurer, Retirement Systems Division
    325 North Salisbury Street
    Raleigh, NC 27603-1385
  2. As a Medicare primary retiree, what are the benefits of the Blue OptionsSM PPO plans?
    As a Medicare primary member, the Blue OptionsSM PPO plans will save you on your out-of-pocket expenses. Examples are:
    • Lower Premiums – Premiums for dependent coverage are lower for the Blue OptionsSM PPO plans.
    • Spouse-Only Coverage - The Blue OptionsSM PPO plans offer a fourth level of coverage, Employee & Spouse, for members who only have a spouse to cover.
    • Travel Outside of North Carolina and the United States – Coverage is provided for travel outside of North Carolina and the United States at the in-network level of coverage through the extensive BlueCard® network of providers under the Blue OptionsSM PPO plans. Medicare does not provide coverage outside the United States except under limited circumstances.
    • Diabetic Supplies (Syringes, Lancets & Test Strips) - Covered as a pharmacy benefit for only a copay under the Blue OptionsSM PPO plans. Medicare does not cover syringes.
    • Routine Physicals and Gynecological (GYN) Exams – Covered for only a copay when services are provided by a participating Blue OptionsSM in-network physician under the Blue OptionsSM PPO plans. Medicare does not cover routine annual physicals and gynecological exams
    • Routine Eye Exams - Covered for one routine eye exam per benefit period when services are provided by a participating Blue OptionsSM provider under the Blue OptionsSM PPO plans. Medicare does not cover routine eye exams.

Blue OptionsSM, BlueCard & BlueExtras

  1. I have heard the terms Blue OptionsSM, BlueCard®, and Blue ExtrasSM, what are they exactly?
    Blue OptionsSM is BCBSNC's network of preferred providers that the State Health Plan (SHP) has contracted with to provide the PPO plan options. The BlueCard® program links participating health care providers and the independent Blue Cross and Blue Shield Plans across the country and abroad with a single electronic process for professional, outpatient and inpatient claims processing and reimbursement. The program allows members obtaining health care services while out of town to receive the same benefits of their Blue Cross plan and access out-of-town providers' savings. In most cases, providers bill claims directly to their local Plans without requiring up-front payment from the member. The Blue ExtrasSM is a free value-added program that compliments the PPO health insurance plan by providing discounts on everything from vitamins and supplements, to massage therapy and laser vision correction. It's a gateway to saving money and taking charge of your health.
  2. What other services are available through the Blue ExtrasSM program?
    The Blue ExtrasSM program offers generous discounts on services such as hearing aids, cosmetic surgery, nutrition and fitness, holistic medicine (acupuncture, for example), vitamin programs, LASIK surgery and many others. Discount percentages vary depending on the services.
  3. What is "My Member Services"?
    One of your member benefits is access to My Member Services, a protected online resource for help in managing your health and maximizing your benefits. On My Member Services, you can:
    • View your claim status
    • Check your benefits summary
    • Update your policy information
    • Order new ID cards
    • Change your billing address