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Coverage in the State Health Benefits Program (SHBP) is available to all full time employees. Coverage for the employee and eligible dependents (eligible dependents include the employee's spouse (unless legally separated) or same-sex civil union partner and unmarried children up to 23 years of age who live with the employee in a regular parent-child relationship). The effective dates for enrollment in the State Health Benefits Program are as follows:
- 10-month employees who begin their employment on September 1 are eligible for immediate enrollment in the SHBP.
- 10-month employees whose employment starts on a date other than September 1 and employees hired in 12-month positions are eligible for enrollment in the SHBP 60 days after employment.
All unaligned employees as well as those who are represented by the American Federation of Teachers(AFT), Communications Workers of America(CWA) and the International Federation of Professional and Technical Engineers(IFPTE) will pay 1.5% of their base salary toward the cost of their Health and/or Prescription Drug plan coverage.
A.
NJ Direct15 (Available as of 04/01/08)
NJ Direct15 is a Preferred Provider Organization (PPO) administered by Blue Cross and Blue Shield of NJ. This PPO plan provides both in-network and out-of-network medical care. NJ Direct 15 is available nationwide and members do not have to choose a primary care physician and they do not need referrals for in-network services.
If the physician participates in the Horizon BCBSNJ Managed Care Network, members will only pay the appropriate copayment for eligible services (certain services may also require pre-certification from Horizon BCBSNJ). Members living outside of New Jersey can utilize physicians participating in the national Blue Cross Blue Shield network. If the physician does not participate in the Horizon BCBSNJ Managed Care or national networks, the services will be considered out-of-network. Out-of-network benefits allow you to utilize and licensed physician, however you are required to file a claim form with Horizon BCBSNJ. This plan is not available to employees represented by the Fraternal Order of Police (FOP) or by the Police Benevolent Association (PBA).
B.
The HMO Plans
There are two Health Maintenance
Organizations that participate in the SHBP as of April 1, 2008, Aetna and Cigna Healthcare provide
services through their nationwide networks.
HMO's emphasize preventative care
and provide coverage for physical exams, well-baby visits, immunizations,
etc. Details on specific coverage, services, and fees vary by HMO. However,
they generally work as follows. When you enroll in an HMO, you select
a primary care physician from the list of providers in the HMO network
to oversee your health care. If the services of a specialist are required,
your primary care physician refers you to one. As an HMO member, there
are no deductibles to satisfy or claim forms to file, and you should
not receive doctor or hospital bills. However, HMO's require you
to pay a small co-payment ($15) for doctor visits, emergency room visits,
emergency room treatment, and other services. You must use the HMO network health care services (other than for an emergency), or the HMO will
not pay for the care.
C.
NJ PLUS (No Longer Available to employees as of 04/01/08 (except those representented by the FOP and PBA)
NJ PLUS is administered
for the SHBP by Horizon Blue Cross and Blue Shield of New Jersey (BCBSNJ).
NJ PLUS is a point-of-services plan, which is a blend of the Traditional
Plan and an HMO. The plan has a network of doctors, hospital, and other
health care providers who offer medical care in cost-efficient ways.
All providers undergo a credentialing procedure prior to becoming part
of the network. The NJ PLUS network covers all of New Jersey and Delaware,
parts of Pennsylvania, and New York.
When you enroll in NJ PLUS, you
select a personal care physician (PCP) to oversee your medical care.
When you use this doctor or other network providers, you pay a $15 co-payment after which your medical expenses are generally covered
in full. There are no claim forms to file. It this way, NJ PLUS is very
similar to an HMO. But there is an important difference. As a NJ PLUS
participant, you have the option to use a non-network provider (go out-of-network).
When using doctors or hospitals outside the network, generally, NJ PLUS
will pay 70% of the eligible costs at a reasonable and customary level
after the member pays a required deductible. Claim forms are required
for out-of-network services, and preventative services and well-care
are not covered out-of-network.
D.
Appeals
Occasionally, situations arise
where a member feels that his or her medical care or claims have not
been properly handled by his or her health plan. The member must try
to resolve the problem directly with the administrator/carrier by telephone
and then in writing. If the problem is not resolved, the member then
has the right to appeal the administrator's/carrier's decision by writing
to the State Health Benefits Commission.
E.
Open Enrollment
Once employees have enrolled in
health benefits programs, they may change plans during the annual open
enrollment period, held during the month of October. The effective date
of any change will be January 1st of the following year.
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