The State Health Benefits Program
(SHBP) was created in 1961 to provide health insurance coverage for State employees.
In 1964, the Program was made available to employees of city, county, and educational
and public agencies. The State and Local Group components of the SHBP are administered
separately. Since July 1997, the Local Group has been experience-rated in two
groups — Education employers and others. The SHBP also provides coverage to
eligible retirees.
The State Health Benefits Commission (SHBC) is the executive organization responsible for overseeing the State Health Benefits Program (SHBP). The SHBC includes the State Treasurer as the chairperson, the Commissioner of the Department of Banking and Insurance, the Commissioner of the Department of Personnel, a State employee representative chosen by the Public Employees’ Committee of the AFL-CIO, and a representative chosen by the New Jersey Education Association (NJEA), or their designated representatives. The Director of the Division of Pensions and Benefits is the Secretary to the SHBC. The Division of Pensions and Benefits, specifically the Health Benefits Bureau and the Bureau of Policy and Planning, is responsible for the daily administrative activities of the SHBP.
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State
Health Benefits Program Component Plans
Available
Medical Plans
General
Information
The SHBP
offers two types of medical plans.
Two Preferred Provider Organizations are available:
Two Health Maintenance Organizations, or HMOs, are also available:
- CIGNA HealthCare
- Aetna HMO
All four plans are self-funded, which means that the money paid out for benefits comes directly
from a SHBP fund supplied by the State, participating local employers, and member
premiums.
NJ DIRECT 10 replaces the Traditional Plan. It is available to:
- Employees and retirees of Local Education employers and Local Government employers; and
- State retirees who pay the full cost of retired SHBP coverage or who attained 25 years of service on or before June 30, 2007 or retired on a disability retirement on or before July 1, 2007.
NOTE: NJ DIRECT10 is not being offered to active State employees.
NJ DIRECT 15 replaces NJ PLUS. It is available to ALL employees and retirees.
Resolution to Offer Only One Option of the Preferred Provider Organizations — Local Employers ONLY
Local government and local education employers may adopt a resolution to offer only one option of the PPOs offered — NJ DIRECT15 OR NJ DIRECT10 — to members at their employing location. A copy of this resolution is provided below: Resolution to Offer Only One Option of the Preferred Provider Organization — NJ DIRECT15 OR NJ DIRECT10 (Local Government and Education Employers).
Both NJ DIRECT10 and NJ DIRECT15 are similar in design to the old NJ PLUS plan. They both provide in-network and out-of-network medical care.
NJ DIRECT differs from NJ PLUS in that NJ DIRECT is available nationwide, you are not required to choose a primary care physician, and you do not need a referral for in-network services.
For members still covered under the old plans*, the SHBP
will continue to offer the Traditional Plan and the NJ PLUS Plan (for Traditional Plan and NJ PLUS information, click here),
but only two Health Maintenance Organizations, or HMOs, will be offered — CIGNA HealthCare and Aetna HMO.
*Certain State employees covered by labor contracts that are not yet ratified will remain in the Traditional Plan or NJ PLUS until new contracts are settled and may not change plans at this time. These employees include State Police (law enforcement officers), some Department of Corrections employees and some State Judiciary employees. Employees in these bargaining groups who are enrolled in AmeriHealth, Health Net, or Oxford will be automatically assigned to NJ PLUS, unless they submit a SHBP Application to enroll in another medical plan. For Traditional Plan and NJ PLUS information, click here.
Employee Contribution Required (As of July 2007)
Employees enrolled in the SHBP for health and/or prescription drug coverage will be required to contribute 1.5% of their annual base salary, effective July 7, 2007 for State biweekly employees and July 1, 2007 for State monthly employees. For employees of these groups paid on a ten-month basis, the contribution change is effective September 1, 2007. Additional labor bargaining groups may be added to the list of employees affected by these changes as pending labor contracts are settled.
The contribution amount (not the percentage, e.g., 1.5% of a $20,000 salary is $300; 1.5% of a $40,000 salary is $600) will change any time there is a change in an employee’s base annual salary. The contribution is the same regardless of the medical plan or level of coverage that is selected.
Waiver of SHBP Medical and Prescription Coverage
Employees will be permitted to waive their SHBP medical and prescription coverage to avoid the 1.5% contribution from salary — provided they have other health care coverage. Employees may also add dependents who have lost health coverage to their current coverage through August 31, 2007. An SHBP State Waiver form and a SHBP Application are required to be submitted through the employer to the SHBP.
Available
Medical Plan for Part-time Employees of the State and Part-time Faculty Members
at Public Institutions of Higher Education
Part-time
employees of the State of New Jersey and part-time faculty members employed at
New Jersey public institutions of higher education (New Jersey State colleges,
State universities, or county community colleges) who are eligible for SHBP coverage
under Chapter 172, P.L. 2003, are limited to enrollment in the NJ DIRECT15 medical
plan and the Employee Prescription Drug Plan.
Available
Medical Plan for Intermittent State Employees
Certain
intermittent State employees who have worked a minimum of 750 regular pay status hours within the previous fiscal year (i.e., June 26, 2006 - June 24, 2007 for Fiscal Year 2007) are eligible for enrollment in NJ DIRECT15 and the Employee Prescription
Drug Plan (effective July 1, 2004). Intermittent employees who maintain 750
hours of work per fiscal year will receive coverage for the next fiscal year (at
least through the period covered by the labor contract in effect).
Intermittent State employees who meet the minimum pay status hours outlined above must also be covered under the labor contract between the CWA and the State of New Jersey that committed the State to provide SHBP coverage to intermittent employees.
Employers must certify that their intermittent employees have at least 750 regular pay status hours in the prior fiscal year to qualify for coverage in subsequent years. The Human Resource Offices of the Department of Labor and the Department of the Treasury will re-certify eligibility of every intermittent employee with SHBP coverage each year.
Available
Medical Plan for National Guard Members Called to State Active Duty
National
Guard members who are called to State active duty for 30 days or more are eligible
for enrollment in NJ DIRECT15 and the Employee Prescription Drug Plan at the State's
expense. Members can also enroll eligible dependents at the State's expense. The Department of Military and Veteran's Affairs is responsible for notifying eligible members and for notifying the Division of Pensions and Benefits of members who are eligible.
State Health Benefits Program Benefits under the Domestic Partnership Act
Effective
July 10, 2004, under the Domestic Partnership Act, State Health Benefits Program
benefits are extended to eligible same-sex domestic partners of State employees and retirees.
Local public employers participating in the SHBP are permitted to extend SHBP
benefits to their employees and retirees through resolution or ordinance. There
are certain conditions that must be met in order for the domestic partner of an
enrolled member to be eligible for SHBP coverage.
SHBP
members must be made aware of the possible federal tax implications of covering
a domestic partner under the SHBP (see Fact
Sheet #71, Benefits under the Domestic Partnership Act.)
For
additional information about the Domestic Partnership Act and its impact on State-administered
retirement system pension and benefit issues, including coverage under the State
Health Benefits Program, please refer to Fact
Sheet #71, Benefits under the Domestic Partnership Act.
State Health Benefits Program Benefits under the Civil Union Law
Effective February 19, 2007, Chapter 103, P.L. 2006 establishes Civil Unions, which are designed to provide the same legal rights and financial benefits currently available to married heterosexual couples to same-sex couples who enter into a civil union. For more information about this legislation, please visit the Civil Unions page on the Division's Web site.
NJ direct10 and nJ direct15 — A Brief Introduction
Both NJ DIRECT 15 and NJ DIRECT10 are administered for the SHBP by Horizon Blue Cross Blue Shield
of New Jersey (Horizon BCBSNJ). Both plans are available nationwide. Members are not required to choose a primary care physician and do not need a referral for IN-NETWORK services under either plan.
In-Network Benefits
When a member sees a physician who participates in the Horizon BCBSNJ Managed Care Network, the member will only pay the appropriate copayment for eligible services.
Members living outside of New Jersey can utilize physicians participating in the national Blue Cross Blue Shield network; the member will only pay the appropriate copayment for eligible services.
If the physician does not paricipate in the Horizon BCBSNJ Managed Care Network or national BCBS network, the services will be considered out-of-network.
Members should contact their doctor to see if he or she participates in the Horizon BCBSNJ Managed Care or national network. To find current participating physicians in New Jersey, members should consult theSHBP Unified Provider Directory. To find a participating physician outside of New Jersey, members should contact Horizon BCBSNJ directly.
Certain services, like inpatient admissions*, reconstructive procedures,
durable medical equipment purchases, specialty pharmaceuticals, hospice, and home health care, require pre-certification from Horizon BCBSNJ in order to be paid at in-network benefit levels.
Services that require a pre-certification but are not precertified will be paid at out-of-network benefit levels and will not count toward out-of-pocket maiximums.
*In-network hospital admissions are covered in full as long as they are precertified If they are not precertified, they will be paid at out-of-network benefit levels and will not count toward out-of-pocket maiximums.
Out-of-Network Benefits
Out-of-network benefits allow members to utilize any licensed physician, but they are required to file a claim form with Horizon BCBSNJ. Most eligible out-of-network care is reimbursed at the applicable percentage of “reasonable and customary” allowances after a member’s annual deductible is met. Out-of-network hospital admissions are also subject to a deductible.
NJ DIRECT Copayments and Deductibles
The in-network copayment for most services(3) is $10 in NJ DIRECT10 and $15 in NJ DIRECT15. Once the in-network out-of-pocket cost for coinsurance(4) totals $400 per individual or $1,000 per family, those covered benefits are paid at 100 percent through the remainder of the calendar year. Only precertified treatment counts toward the maximum out-of pocket expense level.
For both NJ DIRECT10 and NJ DIRECT15 the annual deductible for out-of-network services is $100 for single coverage; $200 ($100 per person) for member/spouse-partner or parent/child coverage, and an aggregate family deductible of $250 for family coverage, or parent/children coverage (more than two individuals). There is also a $200 deductible for each out-of-network inpatient hospital stay(2).
After deductibles are met, covered out-of-network claims are paid at the applicable percentage of the "reasonable and customary" allowance. In addition, the member is responsible for the full cost of any services over the "reasonable and customary" allowance or costs not otherwise covered by the plan.
Once the out-of-pocket cost for coinsurance totals $2,000 per individual or $5,000 per family, covered benefits are paid at 100 percent of the "reasonable
and customary" allowance through the remainder of the calendar year. Only pre-certified treatment counts toward the maximum out-of-pocket expense level.
For more information about NJ DIRECT1O AND NJ DIRECT 15, please consult the NJ
DIRECT Member Handbook.
The
HMO Plans - A Brief Introduction
There
are now two Health Maintenance Organizations, or HMOs, that participate in the
SHBP — CIGNA HealthCare and Aetna HMO. Both have expanded their networks and now provide services nationwide.
AmeriHealth, Health Net, and Oxford are no longer part of the State Health Benefits Program (SHBP), effective April 1, 2008.
Members who enroll in an HMO must select a Primary Care Physician (PCP) from a group of participating providers contracted by the HMO. All services,
except emergencies, are coordinated through the chosen PCP.
Members may either contact the plan they choose or view the “Unified Provider Directory” to find a participating provider.
The member's PCP will refer the member to a specialist who participates in the HMO network when a specialist's care is required. Both HMOs now offer electronic referrals which facilitate the use of specialists.
HMOs have no deductibles or claim forms to file, but members are required to pay a copayment for visits to their PCP or a referred specialist.
HMO Copayments
For local education or local government employees, and all retirees, the HMO copayment for services provided by a participating physician is $10.
For State employees the HMO copayment for services provided by a participating physician is $15.
More
detailed information and an explanation of benefits of the HMOs, including HMO
performance reports, plan descriptions, and plan standards, are available beginning
on page 14 of the SHBP Summary Program
Description. Each HMO also provides its own handbook.
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Available
Prescription Drug Plan
Active
Employee Prescription Drug Coverage
The
SHBP Employee Prescription Drug Plan is offered to eligible, active State of New
Jersey employees and their dependents as a separate drug plan. Local employers
may also elect to provide the SHBP Employee Prescription Drug Plan to their employees
as a separate prescription drug benefit.
Under
the Program, members receive a prescription drug card that entitles them to pay
only $3.00 for generic drugs or $10.00 for brand name drugs per prescription or
refill.*
A
mail order feature is also available for members requiring maintenance prescription
drugs. Under the Mail Order Program, up to a 90 day supply of a generic or brand
name drug can be obtained with a payment of $5 and $15, respectively.
Effective July 7, 2007 for State biweekly employees and July 1, 2007 for State monthly employees, the structure of the prescription drug benefit has been modified to include a third tier of copayments. The copayment for each 30 day supply purchased at a retail pharmacy will remain $3 for generic drugs and $10 for brand name prescription drugs without generic equivalents. The new third tier will include a $25 copayment for brand name drugs where a generic equivalent is available, for a 30 day supply purchased at a retail pharmacy.
The mail order prescription drug copayments, for up to a 90-day supply, will remain $5 for generic drugs and $15 for brand name drugs without generic equivalents. The third tier mail order copayment will be $40 for brand name drugs where a generic equivalent is available.
These copayments
will remain in effect through 2008.
Note: In certain circumstances of intolerance or the therapeutic failure of a drug's generic equivalent, a member may be able to receive a third tier brand name drug where a generic equivalent is available for the lower second tier copayment for a brand name drug without generic equivalent. (See "Third Tier Copayment Exception" in the Employee Prescription Drug Plan Member Handbook.)
The
State Prescription Drug Plan is currently administered by Horizon Blue Cross
Blue Shield of New Jersey (Horizon BCBSNJ) through
CVS/Caremark.
More
detailed information concerning the SHBP Employee Prescription Drug Plan is available
on pages 28-30 in the SHBP Summary
Program Description, and in the SHBP
Employee Prescription Drug Plan Member Handbook.
Retiree
Prescription Drug Coverage
Retirees enrolled in the NJ DIRECT have access
to a separate prescription drug card plan that includes a mail order service.
The plan features a three-tiered design. More information about the program is
available in the NJ
DIRECT Member Handbook.
The
SHBP HMOs provide retirees with prescription benefits through the use of a prescription
drug card. There are co-payments when using an HMO drug card that vary by plan
and that will not exceed $42 per prescription if prescribed by the member's PCP
or a provider to whom a member has been referred by a PCP. To learn specific details
of this benefit provided by each HMO, the member can refer to the plan description
found in the SHBP Summary Program
Description.
The
New Jersey SHBP Employee Dental Plans
The
New Jersey SHBP Employee Dental Plans are available to eligible full-time State
employees, full-time employees of a local employer (county, municipality, school
board, etc.) that elects by resolution to provide the Employee Dental Plans to
its employees, and the eligible dependents of these employees. The program provides
a choice between two different plans, the Dental Expense Plan and Dental Provider
Organizations (DPOs). A comparison of these types of plans is found in Fact
Sheet #37, State Employee Group Dental Program. More detailed information
is available in the State
Employee Group Dental Program booklet.
Please
note that there is one application, the New
Jersey SHBP Employee Dental Plans Application, for full-time State
employees, full-time employees of a local employer (county, municipality, school
board, etc.) that elects by resolution to provide the Employee Dental Plans to
its employees, and the eligible dependents of these employees.
Local
employers wishing to initiate participation in the SHBP Employee Dental Plans
should click here for more information about how to
elect to participate in the SHBP Employee Dental Plans, including the completion
of the Resolution
for SHBP Dental Plan Participation.
The
Dental Expense Plan is a traditional indemnity plan that allows a member to obtain
services from any dentist. After the member satisfies a $50 deductible, the member
is reimbursed for a percentage of the reasonable and customary charges for the
services that are covered under the plan. The Dental Expense Plan has a network
of participating providers who offer discounted services. Employees save money
by using these providers. This plan is administered under a contract between the
State Health Benefits Commission (SHBC) and Aetna Dental. For more information,
please see the Employee
Dental Plans Member Handbook.
The
Dental Plan Organizations,
or DPOs, are individual companies offering dental services through contracts with
a network of dental providers. A DPO member selects a DPO dentist, and the cost
of most diagnostic and preventive services is covered in full, although certain
services require an additional co-payment. The DPOs operate much like Health Maintenance
Organizations in that they will not cover services provided by an out-of-network
provider unless there was a proper referral. You must use a dentist who is a member
of the DPO you selected or be referred by your DPO dentist. For more information,
please see the Employee
Dental Plans Member Handbook.
The
cost of participation in either plan is shared equally by the State and the employee.
Premium payments are made through payroll deductions. Employee premiums can be
paid on a pretax basis through participation in the Premium Option Plan (POP)
of the State's IRC Section 125 Program, Tax$ave.
Participation in the POP is automatic unless the employee specifically declines
enrollment.
Retiree
Dental Expense Plan
The SHBP also offers a Retiree Dental Expense
Plan to retirees enrolled in, or eligible to enroll in, the Retired Group of the
SHBP. Employers should inform employees who are nearing retirement about this
plan.This plan is self-insured by the State and is administered for the SHBP by
Aetna Dental.
Most retirees
pay the full cost of the Retiree Dental Expense Plan (the plan is offered
with the understanding that the State will bear no costs for it.) Under certain
circumstances, local public employers pariticipating in the SHBP may elect to
share the cost of coverage for their retirees through the adoption of the provisions
of Chapter 48, P.L. 1999. The following links are made available so that employers
can provide additional information about the Retiree Dental Expense Plan to their
eligible employees:
Fact
Sheet #73, Retiree Dental Expense Plan
Retiree
Dental Expense Plan Rates
Retiree
Dental Expense Plan Member Handbook
Retiree
Dental Expense Plan Rates for 2008
The
costs of the Retiree Dental
Expense Plan are reflected in the charts below. In 2008, there are different rates for each retiree group below:
Employer
Enrollment in the State Health Benefits Program
The
State Health Benefits Program is open to all local employers who elect to participate
by completing the Resolution to Authorize
Participation in the SHBP.
Employers can enroll in the medical plan only or medical
plan and prescription drug program. However,
an employer enrolling only in the medical plan must offer a uniform, stand-alone
prescription drug plan to all eligible employees in order to be in compliance
with the SHBP.
To
enroll in the SHBP, the employer must submit a completed resolution a minimum
of sixty days (preferably 75 or more days) prior to the desired entry date. You
can obtain the resolution and enrollment packet by calling the Health Benefits
Bureau at (609) 777-4154. This packet will include:
These
resolutions must be completed by the location's Certifying Officer and returned
to the Health Benefits Bureau a minimum of 60 days prior to the effective date
of coverage. Submission of the resolutions at least 75 - 90 days ahead of the
effective date will ensure that sufficient time is available to process all applications
from the employer's employees, retirees, and COBRA participants.
State
or Employer-paid Coverage at Retirement, for Members with a Total of 25 or More
Years of Nonconcurrent Pension Credit in Multiple Pension Funds
Under
a recent law (Chapter 209, P.L. 2001), members who accumulate a total of 25 or
more years of nonconcurrent pension credit in multiple pension funds may be eligible
for State or employer-paid coverage at retirement, as long as they meet the following
requirements:
- Retire and collect
a benefit from each membership;
- Have
25 or more years of nonconcurrent service credit total;
- Retire
from the last membership after the effective date of this law (August 15, 2001);
- Be
eligible for employer-paid health benefits coverage immediately prior to retirement
or separation from the last contributing employer in the retirement system, for
retirees of the State, school boards, county colleges, or participating
local employers who have agreed by resolution to pay for the coverage of their
retirees (see below), and;
- Notify
the Division of Pensions and Benefits that they have a total of 25 or more years
of nonconcurrent service in more than one public retirement system in New Jersey.
The
Division of Pensions and Benefits is not able to identify members who are eligible
for State or employer-paid coverage at retirement under this law. Members must
be able to identify that they are eligible, and then notify the Division.
Local
Employers Other Than Boards of Education and County Colleges
Under
Chapter 209, P.L. 2001, local employers may, by adopting and submitting a resolution
to the Division of Pensions and Benefits, pay for the post-retirement medical
benefits of their employees if the employee:
- retired
on a disability pension, or;
- retired
after 25 or more years of nonconcurrent service credit in one or more State- or
locally-administered retirement systems, with a period of service of up to
25 years with the employer at the time of retirement, with the years of service
determined by the employer through a resolution, or;
- retired
and reached the age of 65 years or older with 25 years or more of nonconcurrent
service credit in one or more State or locally-administered retirement systems
and a period of service of up to 25 years with the employer at the time
of retirement, with the years of service determined by the
employer through a resolution, or;
- retired
and reached the age of 62 years or older with at least 15 years of service with
the employer.
Local employers wishing
to initiate participation in the SHBP Employee Dental Plans should complete and
mail a
Resolution
for SHBP Dental Plan Participation to the Division of Pensions and Benefits.
Local
government employers have some degree of flexibility in defining which employees
qualify for post-retirement medical benefits under another law, Chapter
48, P.L. 1999.
In regard to Chapter
209, P.L. 2001, a local government employer may specify the number of years
an employee must work for the employer in order to be eligible for the employer-paid
retired SHBP coverage outlined above, by filing a resolution with the Division.
Employers may also file a resolution specifying post-retirement coverage, if any,
for an eligible member's dependents, or for an eligible member's surviving spouse,
upon the death of the member.
Employer
Enrollment in the SHBP Employee Dental Plans
Local
employers wishing to initiate participation in the SHBP Employee Dental Plans
should complete and mail a
Resolution
for SHBP Dental Plan Participation to the Division of Pensions and Benefits.
The resolution must be completed
by the location's Certifying Officer and returned to the Health Benefits Bureau
a minimum of 60 days prior to the effective date of coverage. Submission of the
resolutions at least 75 - 90 days ahead of the effective date will ensure that
sufficient time is available to process all applications from the employer's employees,
retirees, and COBRA participants.
Termination
of Employer Participation
Voluntary
Termination
When
an employer chooses to terminate participation in the SHBP, a completed Termination
Resolution must be submitted by the employer to the State Health Benefits
Commission for approval. A minimum of 60 days notice (preferably 75 or more
days) is required in order to effect the termination process. When an employer
terminates participation, the coverage of all its employees, retirees, and COBRA
participants is also terminated unless the retirees are covered by specific legislation
that permits them to continue SHBP participation upon the termination of their
former employer.
An
employer choosing to terminate participation in the NJ SHBP Employee Dental Plans
must submit a completed Resolution
for SHBP Dental Plan Termination to
the State Health Benefits Commission for approval. A minimum of 60 days
notice (preferably 75 or more days) is required in order to effect the termination
process.
Termination
for Nonpayment
A participating
employer will be considered in default if premiums are not paid within 31 days
of the date they are due. At that point, coverage will terminate for all employees
and dependents. When an employer defaults on payment, the Division of Pensions
and Benefits notifies the Office of the Attorney General and the Division of Local
Government or the Department of Education, as appropriate, that the employer has
failed to meet its obligations to the State of New Jersey. When the coverage is
terminated, the employer must notify all employees and retirees of the termination
of their coverage. Premiums will continue to accumulate with interest penalties.
