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SHBP Info and Stats

The Department of Community Health administers the State Health Benefit Plan (SHBP). The SHBP provides health coverage to nearly 700,000 state employees, teachers, retirees and dependents. Teachers and school personnel represent 72 percent and retirees comprise about 18 percent of the covered lives.

Six operating units within the SHBP process and manage the information necessary for member coverage and claim payments. The units and responsibilities are as follows:

• Plan Management determines benefit Plan design and negotiation of vendor contracts and compliance.
• Clinical Services oversees the vendors clinical and quality operations, as well as, assists members and providers with questions related to clinical coverage issues that include, but are not limited to, medical/surgical procedures, wellness, disease management, behavioral health, transplants, durable medical equipment and pharmacy management.
• Communications provides information to both payroll locations and members on the plan’s workings and changes.
• Employer Services assists employer and agencies research and solve any employee problems and to assist employers with SHBP Bills and training issues
• Member Services applies the eligibility regulations and assists members with their issues and problems and efficiently process member changes and payroll deductions.
• Vendor Program Management provides oversight and monitoring of vendor performance, member correspondence and eligibility appeals.

CIGNA and UnitedHealthCare each offer SHBP members the following options:

• Health Reimbursement Arrangement (HRA)*
• High Deductible Health Plan (HDHP)*
• Preferred Provider Organization (PPO)
• Health Maintenance Organization (HMO)
• Medicare Advantage Private Fee For Service (MAPFFS) - Retirees Only 

HRA - a consumer driven health plan option where SHBP puts cash in your account each year and you choose how you spend your health care dollars.

HDHP - provides coverage for members for a low monthly premium. In return for the lower premiums, members must meet a larger deductible before the Plan pays benefits. This Option may also be coupled with a Health Savings account that may provide members with investment opportunities. This savings account may be available through the State Personnel Administration (SPA) if your flexible benefits are administered by them or through an independent financial institution.

PPO - provides coverage for in-network at 90 percent and out-of-network services at 60 percent of allowed amounts.

HMO members must use network providers to have their expenses paid. Services performed in a physician’s office are paid at 100 percent after the member pays a nominal co-payment. Other services are paid at 90 percent after satisfying the annual deductible.

MAPFFS - plan offered to retirees who are 65 or older who are enrolled in Medicare Parts A and B. 

Retiree Coverage – retirees may elect to change options only during the annual retiree option change period or when they become eligible for Medicare. Retirees who drop the coverage may not pick up the coverage at a later date.  Retirees can only add dependents if they experience a qualifying event. 

In addition to the 10 options offered to active members, retirees enrolled in Part A and B Medicare may choose from two Medicare Advantage Plans.

* Prescription drug benefits for all options (except HRA and HDHP) include a three tiered co-payment structure to encourage use of generics and preferred brands to control costs while giving members choice.

* HRA, HDHP and PPO members may select from a broad network of providers to receive in-network benefits. They also may use providers who are not in the network but will receive benefits at a lower level. Out of network services may result in balance billing to members.

State Health Benefit Plan Enrollment (October 1, 2009)

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