NEW JERSEY STATE HEALTH BENEFITS PROGRAM
COMPARISON SUMMARY FOR
LOCAL GOVERNMENT, LOCAL EDUCATION EMPLOYEES,
ALL RETIREES,
(AND STATE EMPLOYEES NOT UNDER NEW LABOR AGREEMENTS EFFECTIVE JULY 2007)

Effective for Plan Year 2007

Dear Employees and Retirees:

The State Health Benefits Program Comparison Summary provides an easy way for employees and retirees to compare the benefits of the various plans offered by the State Health Benefits Program by summarizing what benefits each plan provides for a specified service.

The State Health Benefits Program offers three types of plans:

COMPARISON SUMMARY CHARTS

1. Choose a benefit category to view the chart.

2. Compare the services provided by the SHBP plans.

HOW TO USE THE CHARTS

For members wanting to know more about what their plan offers, the charts can be a handy quick reference guide to the services currently offered by your health plan. The Comparison Summary chart can also be a very useful tool if you are a new SHBP member or a SHBP member who is considering a different health plan. Although the chart contains a lot of information, using the following helpful hints can make reading this chart easier.

If you are considering a managed care plan (NJ PLUS or an HMO) contact your doctor's office to see if they participate in any of those plans you have selected. You can also use the SHBP Unified Provider Directory available on the Internet. The Unified Provider Directory lists the most current participating physicians from all of the SHBP plans in one convenient, easy-to-use data base.

The SHBP Comparison Summary outlines many of the coverage options provided under the New Jersey State Health Benefits Program. For more information about the available health plans, or eligibility in the SHBP, see the Summary Program Description booklet.

NOTE: All plans under the SHBP are fully compliant with the provisions of the federal Health Insurance Portability and Accountability Act. NJ PLUS and the Traditional Plan are also fully compliant except in the area of mental health parity. A waiver has been filed with the appropriate federal agency.

To see how various HMOs are rated, see the NJ Department of Health and Senior Services'
2005 New Jersey HMO Performance Report: Compare Your Choices.

COPAYMENT AMOUNTS

Note: State Employees covered under the labor agreements between the State and the CWA, AFSCME, and IFPTE, which became effective July 2007, should refer to the State Employee version of this comparison chart.

Local Government/Education Employees, All Retirees,
and State Employees not covered under the labor agreements effective July 2007.

• For the 2007 plan year, copayments for Local Government/Education Active Group members, all Retirees (and State Active Group members not covered under the agreements above), enrolled in NJ PLUS or an HMO (Aetna, AmeriHealth, CIGNA, Health Net and Oxford) are $10 for primary doctor visits and visits to a specialist. The copayment for a visit to an emergency room is $25. The emergency room copayment is waived if you are admitted to the hospital.
  
  
• The copayments for Local Government/Education Active Group members (and State Active Group members not covered under the agreements above) enrolled in the SHBP Employee Prescription Drug Plan for each 30 day supply purchased at a retail pharmacy is $3 for generic drugs and $10 for brand name prescription drugs. Mail order copayments for up to a 90-day supply is $5 for generic drugs and $15 for brand name prescription drugs.
  
  
• All retirees have prescription drug coverage included in their SHBP plan. Prescription drug copayment amounts are shown in this comparison chart.

DUAL HMO ENROLLMENT IS PROHIBITED

State statute specifically prohibits two employees/retirees who are married to each other or who are eligible, certified domestic partners and who are both enrolled in the SHBP from enrolling under any two of the SHBP’s HMO plans. One member may belong to a SHBP HMO as an employee or as a dependent but not as both.

For example, if two members are married to each other, or are eligible, certified domestic partners, each may elect to enroll for single coverage under any of the HMO plans, or one employee can enroll the other as a dependent under a SHBP HMO if the other person has the Traditional Plan or NJ PLUS coverage.

Furthermore, two SHBP members cannot both cover the same children as dependents under any two SHBP HMO plans.
In cases of divorce, dissolution of a domestic partnership, or single parent coverage of dependents, there is no coordination of benefits under two HMO plans

COVERAGE OF CIVIL UNION AND DOMESTIC PARTNERS

The Civil Union Law, Chapter 103, P.L. 2006, established civil unions for same-sex couples in the State of New Jersey. The law also extends SHBP benefits to same-sex civil union partners of State employees, Local Government and Educational employees, and retirees of these employers in the same manner as those benefits are available to an employee's or retiree's spouse. This law became effective on February 19, 2007.

A civil union partner is defined for SHBP benefits eligibility as a person of the same sex to whom the eligible employee or retiree has entered into a civil union as recognized under Chapter 103. The Civil Union Law extends health benefits to all eligible civil union couples; therefore, there is no additional resolution or approval required by an employer as is required under the earlier Domestic Partnership Act.

The New Jersey Domestic Partnership Act, Chapter 246, P.L. 2003, established certain rights and responsibilities for domestic partners in the State of New Jersey. The law also extends SHBP benefits to same-sex domestic partners of State employees and retirees and permits local employers that participate in the SHBP to extend those same domestic partner benefits to their employees and retirees.

A domestic partner is defined for eligibility in the SHBP as a person of the same sex with whom you have entered into a domestic partnership and received a New Jersey Certificate of Domestic Partnership dated prior to February 19, 2007 (or a valid certification from another jurisdiction that recognizes same-sex domestic partners).

In order for you to be eligible for Member & Domestic Partner SHBP coverage, you must be an employee or retiree of the State of New Jersey or an employee or retiree of a SHBP participating local employer that has adopted a resolution to participate in Chapter 246, P.L. 2003, the Domestic Partnership Act.

The cost of civil union partner or domestic partner coverage may be subject to federal tax (see your employer or Fact Sheet #75, Civil Unions, or Fact Sheet #71, Benefits Under the Domestic Partnership Act, for more information). If covering a civil union partner or domestic partner as a dependent, you must attach a photocopy of your Civil union Certificate or Certificate of Domestic Partnership to your SHBP enrollment application.

EXTENDED COVER AGE FOR OVER AGE CHILDREN UP TO AGE 30

Under the provisions of Chapter 375, P.L. 2005, certain over age children may elect coverage with the SHBP from the time their dependent coverage eligibility would normally end until their 30th birthday. The SHBP covered parent is responsible for the full cost of this extended coverage and will be billed on a monthly basis.

Qualifications and Requirements

Under the provisions of Chapter 375, P.L. 2005, certain over age children may be eligible for coverage under the State Health Benefits Program (SHBP) until age 30.

This includes a child by blood or law who:

• is under the age of 30;
• unmarried;
• has no dependent(s) of his or her own;
• is a resident of New Jersey or is a full time student at an accredited public or private institution of higher education; and
• is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.

Under Chapter 375, an over age child does not have any choice in the selection of benefits but is enrolled for coverage in exactly the same plan or plans (medical and/or prescription drug) that the covered parent has selected. There is no provision for eligibility for dental or vision benefits.

The covered parent is responsible for the entire cost of Chapter 375 coverage (which may be more expensive than other coverage options available to some dependents such as continuation through COBRA).

Additional information is available in Fact Sheet #74, SHBP Coverage Of Children To Age 30. The fact sheet, along with the Chapter 375 Enrollment Application and information about rates can be obtained on our Web site at: www.state.nj.us/treasury/pensions/shbp.htm or by calling the Division of Pensions and Benefits.

AUDIT OF DEPENDENT COVERAGE

Periodically, the SHBP performs an audit using a random sample of members to determine if dependents are eligible under plan provisions. Proof of dependency such as a marriage certificate or a birth certificate is required. Coverage for ineligible dependents will be terminated. Failure to respond to the audit will result in the termination of dependents from your coverage and may include financial restitution for claims paid.

HEALTH CARE FRAUD

Health care fraud is an intentional deception or misrepresentation that results in an unauthorized benefit to a member or to some other person. Any individual who willfully and knowingly engages in an activity intended to defraud the New Jersey State Health Benefits Program will face disciplinary action that could include termination of employment and may result in prosecution. Any member who receives monies fraudulently from a health plan will be required to fully reimburse the plan.

INFORMATION FOR RETIREES

Your choice of a health care plan is a personal decision based on your needs and the needs of your family. No one plan is best for everyone. The charts in this fact sheet provide an easy way to compare the benefits of the various plans offered by the State Health Benefits Program (SHBP) by summarizing what benefit each plan provides for a specified service. You can look at the services that are important to you and determine which plan provides the best coverage for those services. If you are considering a plan other than the Traditional Plan, check with your doctor’s office to see if the doctor participates in that plan, or you can use the SHBP Unified Provider Directory available on the Internet. The Unified Provider Directory lists participating providers from all the SHBP plans in one easy-to-use data base.

Medicare and the SHBP

To be eligible for benefits supplemental to Medicare under the SHBP, both Parts A and B of Medicare must be obtained when retired members and their dependents become eligible. The SHBP will not pay for benefits which should have been paid for by Medicare. For additional information see Fact Sheet #23, The State Health Benefits Program and Medicare Parts A and B for Retirees.

If Medicare is Your Primary Payer

For the Traditional Plan and NJ PLUS out-of-network coverage, claims are first submitted to Medicare and then depending where services are provided, unreimbursed expenses may be sent to your SHBP plan by the Medicare carrier for further reimbursement. The member may still have out-of-pocket expenses such as deductibles and costs above reasonable and customary allowances.

Under HMOs and the in-network NJ PLUS plan, this coordination of benefits also occurs but is handled by the HMO or NJ Plus provider and/or the plan, so that benefits and procedures remain the same for enrollees regardless of Medicare eligibility. Enrollees simply pay their normal co-payments to the provider. The deductibles and coinsurance required by Medicare will be paid in full by your health plan.

If the claim is one where our plan does not receive the claim information automatically, you must submit the claim directly to your plan along with a copy of the Medicare Evidence of Insurability statement.

Prescription Drug Coverage for Retirees

All retirees have prescription drug coverage included in their SHBP plan. Prescription drug copayment amounts are shown in this comparison chart.

Important Medicare Part D Information

The SHBP’s current prescription drug benefit plans meet the Medicare Part D standards. The State will be sharing the savings it receives under Medicare’s Part D rules by reducing plan year 2006 premiums applicable to prescription drug plans. Most Medicare eligible retirees and/or their Medicare eligible dependents need not enroll in Medicare Part D. Some members who qualify for limited-income subsidy programs may find it beneficial to enroll in Medicare Part D. However, once you enroll in Medicare Part D, your SHBP retired group prescription drug benefits will be terminated for you and your dependents.