These questions and answers are for general information purposes only. This information does not create an employment contract between the employee and the agency. This information does not create any contractual rights or entitlements. The agency reserves the right to revise the content of this information, in whole or in part. No promises or assurances, whether written or oral, which are contrary to or inconsistent with the terms of this paragraph create any contract of employment. This information does not constitute tax or legal advice.
State Health Plan Savings Plan
Q. What is the Savings Plan?
A. An alternative to the Standard Plan, the Savings Plan is a high deductible health plan (HDHP), a type of health plan that, when combined with a Health Savings Account, provides health insurance coverage and a tax-free way to save for unreimbursed, qualified medical expenses, now and in the future. The Savings Plan and the Health Savings Account each has its own set of eligibility rules. More information about the Savings Plan and the Health Savings Account may be found in the Insurance Benefits Guide.
Q. Who is eligible to enroll in the SHP Savings Plan?
A. Anyone eligible to enroll in a health plan offered by PEBA Insurance Benefits may enroll in the Savings Plan. A subscriber who is enrolled in the Savings Plan and also covered by another type of health insurance (including Medicare) may not contribute to a Health Savings Account. Refer to the FAQ page of our website for more information on Health Savings Accounts.
Q. What are the premiums?*
A. Rates for active subscribers are:
- Subscriber/spouse: $77.40
- Subscriber/children: $20.48
- Full Family: $113.00
*Rates for local subdivision employees may vary. To verify your rates, contact your benefits office.
Q. What is the annual deductible, the amount the subscriber must pay before the plan begins to pay benefits?
- $3,000 for subscriber-only coverage
- $6,000 for family coverage (this includes subscriber/spouse, subscriber/children and full family)
There is no individual deductible if more than one family member is covered. The family deductible is not considered met for any covered individual until total covered medical expenses exceed $6,000.
For example: Even if one member of the family has $3,001 in covered medical expenses, he will not begin receiving benefits, other than preventive benefits, until covered family members’ total covered medical expenses exceed $6,000.
For example: If the subscriber has $1,000 in expenses, the spouse has $3,001 in expenses and a child has $2,000 in expenses, all family members will begin receiving benefits.
For example: If one covered family member has $6,001 in covered medical expenses, all family members will begin receiving benefits.
Q. Are there per-occurrence deductibles under the Savings Plan?
Q. How do I pay my medical expenses?
A. A subscriber can pay medical expenses as follows:
Consult your tax advisor or the IRS for additional information on taxation of these accounts.
- A subscriber can pay them out-of-pocket, just as she would pay any expenses.
- Eligible subscribers may open a Health Savings Account and pay expenses from that account. Refer to the FAQs on Health Savings Accounts.
Q. What applies toward the annual deductible?
A. The same kinds of costs that apply toward the deductible under the Standard Plan, such as allowed amounts for covered medical services. Under the Savings Plan, the allowed amounts for covered prescription drugs also apply toward the deductible. (Refer to the question, "How are prescription drugs covered under the Savings Plan?", for more information.) Charges for non-covered services or non-covered drugs do not count toward the deductible. Keep in mind you must use a participating provider to ensure you will not be billed more than the allowed amount. You must use a participating pharmacy for your prescription drug purchases to be covered. Like medical services, a higher percentage of the cost of your mental health and substance abuse services will be covered if you use a network provider.
Participating providers submit claims to the Savings Plan's third-party administrator, BlueCross BlueShield of South Carolina. If your deductible has not been met, allowed amounts for covered expenses will be credited to it.
Q. What will the plan pay after my deductible is met?
A. After you have met your deductible, the Savings Plan will pay coinsurance:
- 80 percent of the allowed amount for covered care and prescription drugs given by providers in the network.
- 60 percent of the allowed amount for covered medical care given by providers outside the network. There are no benefits for prescription drug purchases out of network.
Q. After the deductible has been met, what is the coinsurance maximum — the amount in coinsurance one has to pay before one is no longer required to pay coinsurance?
A. Once the deductible has been met, your share of the allowed amount will apply toward your coinsurance maximum.
- If you have subscriber-only coverage, and:
- You use network providers, you will have to pay 20 percent of the allowed amount for the covered care and drugs you receive, up to a maximum of $2,000.
- You use providers outside the network, you will have to pay 40 percent of the allowed amount for the covered care you receive, up to a maximum of $4,000.
- If you have family coverage, and:
- You use network providers, you will have to pay 20 percent of the allowed amount for the covered care and drugs you receive, up to a maximum of $4,000.
- You use providers outside the network, you will have to pay 40 percent of the allowed amount for the covered care you receive, up to a maximum of $8,000.
Q. What are the additional benefits under the Savings Plan?
A. In addition to the benefits covered under the Standard Plan, this plan offers preventive benefits at no cost. They include:
- The allowed amount for a yearly flu immunization for each eligible participant. If the member does not go to a network physician, he may be billed for the difference between the charge and the allowed amount.
- Access to a 24-hour nurseline, through which registered nurses provide personal, immediate assistance to subscribers. The toll-free number is listed on the back of your Health Plan ID card and on the cover of the self-care handbook.
- A copy of a monthly newsletter and a self-care handbook.
Children age 18 and younger receive the Well Child Care benefits and women receive the mammogram and Pap test benefits that are offered to those enrolled in the Standard Plan. In addition, Savings Plan participants age 19 and older may receive an annual physical exam (given by a network provider in his office) that includes:
- A preventive, comprehensive examination
- A complete urinalysis, if coded as a preventive screening
- A preventive EKG
- A fecal occult blood test, if coded as a preventive screening
- A general health laboratory panel blood work, if coded as a preventive screening
- A preventive lipid panel once every five years (for testing cholesterol and triglycerides)
Note: These tests will only be covered if your physician sends them to a network provider. Refer to your Insurance Benefits Guide for additional information on State Health Plan benefits.
Q. How are prescription drugs covered under the Savings Plan?
- Subscribers pay 100 percent of the SHP’s allowed amount for drugs purchased at a participating retail pharmacy or through Express Scripts’ mail-order pharmacy service.
- Eligible expenditures for covered drugs are then transmitted to the Savings Plan’s third-party administrator, BlueCross BlueShield of South Carolina, and applied to the deductible.
- After the deductible has been met, the subscriber will continue to pay 100 percent of the allowed amount for drugs at a participating retail pharmacy or through the mail-order pharmacy service. You will be reimbursed for 80 percent of the allowed amount by the third-party administrator, BlueCross BlueShield of South Carolina.
- If your doctor prescribes, or you request, a brand-name drug and an equivalent generic drug is available, only the plan’s allowed amount for the generic drug will apply toward your deductible. After you have met your deductible, your coinsurance for the cost for the generic drug, 20 percent of the allowed amount, will apply toward your coinsurance maximum. This policy will apply, even if the doctor prescribes the medication as “Dispense as Written” or “Do Not Substitute.”
For example, the allowed amount for the brand-name drug, as a 10 mg capsule would be $150 for a 30-day supply. A generic equivalent would cost $50. If you purchase the brand name drug instead of the generic, you would pay $150, but only $50 would apply toward your deductible, if you have not met your deductible.
If you have met your deductible, whether you buy the brand-name drug or the generic drug, you will be reimbursed for 80 percent of the allowed amount for the generic drug ($40). Twenty percent of the allowed amount for the generic drug ($10) will apply toward your coinsurance maximum.
Non-sedating antihistamines and drugs for erectile dysfunction are not covered.
Q. What is not covered under the Savings Plan?
A. In addition to the same exclusions and limitations under the Standard Plan, the Savings Plan will not cover:
- Non-sedating antihistamines (drugs for allergies and colds that don’t cause drowsiness)
- Drugs to treat erectile dysfunction
Also, under the Savings Plan, chiropractic benefits are limited to $500 a year for each covered person after the deductible is met, and manual therapy is limited to one per visit per person. Refer to your Insurance Benefits Guide for additional information on State Health Plan exclusions and limitations.
Q. Can the premiums for the Savings Plan be paid pretax?
A. Active employees’ premiums are deducted before an employee pays taxes through the MoneyPlu$ Pretax Group Insurance Premium Feature, just as they are now with the other health plans that PEBA Insurance Benefits offers. Retirees, survivors and COBRA subscribers pay their health insurance premiums on an after-tax basis.
Q. If I die, will my family members covered under the Savings Plan be able to remain under this plan?
A. Yes, provided they are eligible to continue their coverage under the Savings Plan. Otherwise, they will be allowed to switch to another health plan.
If your coverage is funded by your employer, health insurance premiums for your surviving, covered spouse or child will be waived for one year.