PPO SmartChoice Standard Plan
PPO Medical Plan Provided by:
The North Carolina State Health Plan
Customer Service Number:(888) 234-2416

Under the PPO plan, you have the freedom to see any provider, and you benefit from using in-network providers with lower out of pocket costs. The PPO in-network providers contract with the health plan for lower reimbursement rates, which is a direct savings to you. In addition, many routine services, such as physician visits, can be obtained with only a co-pay. PPO Providers are available in all 100 counties in North Carolina, in addition to an extensive out of state network.

You also have the flexibility to see a specialist at any time. Referrals are never required. As a PPO member, you also have access to NC HealthSmart, the State Health Plan’s healthy living initiative.

You also have the freedom to see a medical provider out of the PPO network. You are responsible for any amount the medical provider charges beyond what the plan reimburses. You are also responsible for any claim forms and certification required for treatment.

PPO SmartChoice Standard

Benefit Overview In-Network Out-of-Network
Benefit Year Deductible $600 Individual
$1800 Family
$1200 Individual
$3600 Family
Co-Insurance Maximum
(does not include deductible)
$2750 Individual
$8250 Family
$5500 Individual
$16500 Family
Lifetime Maximum Unlimited Unlimited
Plan Co-Insurance 20% of eligible expenses after deductible 40% of eligible expenses after deductible & the difference between the allowed amount & the charged amount.

Medical Services

Primary care $25* Copay 40% coinsurance after deductible
Specialist $60* Copay 40% coinsurance after deductible
Urgent Care $75 Copay $75 Copay
Emergency Room $200 Copay plus 20% coinsurance after deductible $200 Copay plus 20% coinsurance after deductible
Inpatient $200 Copay then 20% coinsurance after deductible $200 Copay then 40% coinsurance after deductible
Outpatient Hospital & Ambulatory Surgical Center 20% coinsurance after deductible 40% coinsurance after deductible
Preventative Care $25* Copay -Primary Care
$60* Copay-Specialist
Not Covered**
Physical / Occupational / Speech Therapies $45* Copay - office services

20% coinsurance after deductible-outpatient hospital
40% coinsurance after deductible
Routine Eye Exam (covered until 12/31/2009) $25 Copay Not Covered

$45* Copay -specialist
30 visit limit per benefit period

40% coinsurance after deductible

Mental Health / Chemical Dependency

Office Services $45 Copay 40% Coinsurance
Outpatient Services 20% coinsurance after deductible 40% Coinsurance after deductible
Inpatient Services $200 copayment then 20% coinsurance after deductible $200 copayment then 40% coinsurance after deductible
Prior authorization is required after visit 26 - combined in & out-of-network office visits.

* PPO Options: In-Network hospital owned or operated practices may be subject to deductible & coinsurance. Please call your physician or see the Provider Directory to determine if your physician's practice is hospital owned or operated.
** The following preventative care benefits are available both in- & out-of-network: gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening & prostate specific antigen tests.
*** Also, NC HealthSmart, the SHP healthy living initiative, is available at no additional cost to all eligible State Health Plan members. (COBRA, Medicare eligibles & TRICARE enrollees are not eligible for NC HealthSmart).

Waiting Period for Preexisting Conditions
Employees or dependents not enrolling when first eligible may have a 12-month waiting period for preexisting conditions. A preexisting condition is defined as a condition, disease, illness or injury diagnosed and treated within six months prior to the effective date of coverage. Health care services determined to be related to a preexisting condition are not covered during the waiting period.

You must complete and return the Enrollment Application or Change Form to the Benefits Office within 30 days of a family status change in order to avoid a 12-month waiting period for preexisting conditions.

Credit for Prior Health Coverage
Credit toward the 12-month waiting period for preexisting conditions may be given for the time enrolled in previous health coverage if no more than 63 days have elapsed between the termination date of the prior health coverage and the enrollment date in the State Health Plan.

The State Health Plan will apply credit toward the waiting period for preexisting conditions by using more than one health coverage when an individual's prior health coverage does not completely cover the 12-month waiting period for preexisting conditions. The time span between the two previous health coverages cannot exceed 63 days.

If health coverage was withheld under a previous employer because of a probationary period, the State Health Plan will not count this time period toward the 63-day time limit. The State Health Plan, however, will apply the probationary time period toward the 12-month waiting period for preexisting conditions. Credit will be given for prior coverage even if the other coverage is still in effect.