The State Health Benefits Program (SHBP) was established in 1961. It offers medical and prescription drug coverage to qualified State and local government public employees, retirees, and eligible dependents; and dental coverage to qualified State and local government/education public employees, retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the SHBP.
The State Health Benefits Commission (SHBC) is the executive organization responsible for overseeing the SHBP.
The State Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17.25 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The School Employees' Health Benefits Program (SEHBP) was established in 2007. It offers medical and prescription drug coverage to qualified local education public employees, retirees, and eligible dependents. Local education employers must adopt a resolution to participate in the SEHBP.
The School Employees' Health Benefits Commission (SEHBC) is the executive organization responsible for overseeing the SEHBP.
The School Employees' Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 14-17.46 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The Division of Pensions and Benefits, specifically the Health Benefits Bureau and the Bureau of Policy and Planning, are responsible for the daily administrative activities of the SHBP and the SEHBP.
BACK
TO TOP
State
Health Benefits Program and School Employees' Health Benefits Program Component Plans
Available
Medical Plans
General
Information
The following medical plans* are offered to most State employees**, participating local government and local education employees, and all retirees.
- NJ DIRECT — administered by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) — offers four PPO plans: NJ DIRECT10**, NJ DIRECT15, NJ DIRECT1525, and NJ DIRECT2030.
- Aetna and Cigna each offer three HMO plans: Aetna HMO, Cigna HealthCare HMO, Aetna1525, Cigna1525, Aetna2030, and Cigna2030.
- In addition, NJ DIRECT, Aetna, and Cigna each also offer High Deductible Health Plans (HDHP).
- State and local government employees may select from six HDHP choices: NJ DIRECT HD4000, Aetna HD4000, Cigna HD4000, NJ DIRECT HD1500, Aetna HD1500, and Cigna HD1500.
- Local education employees may select from three HDHP choices: NJ DIRECT HD1500, Aetna HD1500, and Cigna HD1500.
Note: Retirees cannot enroll in the HD1500 plans; Medicare eligible retirees cannot enroll in any HDHP plan or in Aetna2030; retirees who are eligible for Medicare and enroll in Aetna HMO are covered under the Aetna Medicare Plan (HMO).
* Local Employers may limit the number of plans available to their employees.
** State employees cannot participate in NJ DIRECT10. Eligible State and Intermittent employees and New Jersey National Guard enrollees are restricted to enroll in NJ DIRECT15 and/or the Employee Prescription Drug Plan.
All SHBP/SEHBP plans are self-funded, which means that the money paid out for benefits comes directly
from a SHBP/SEHBP fund supplied by the State, participating local employers, and member
premiums.
Resolution to Limit the Selection of Medical Plans
Local government and local education employers may adopt a resolution to limit the medical plans offered through the SHBP or SEHBP.
Plan Choice
The availabilityof plans offered to eligible employees may be limited by local employers through the binding collective bargaining process. However, local employers must offer at least one plan from each Category of Plans for a minimum of four plans.
| Category 1: |
NJ DIRECT10, NJ DIRECT15, Aetna HMO, Cigna HealthCare HMO |
| Category 2: |
NJ DIRECT1525, Aetna1525, Cigna1525 |
| Category 3: |
NJ DIRECT2030, Aetna2030, Cigna2030 |
| Category 4*: |
NJ DIRECT HD4000**, NJ DIRECT HD1500, Aetna HD4000**, Aetna HD1500, Cigna HD4000**, Cigna HD1500 |
* Medicare eligible Retirees cannot enroll in a Category 4 plan or Aetna2030.
** HD4000 plans are not offered to SEHBP active employees. |
The local employer may, through its sole discretion, impose the provisions of a binding collective bargaining agreement on those employees who have no majority representation for collective bargaining purposes. The local employer may, through the collective bargaining process, offer employees all, a combination of plans, or one plan from each of the four categories of plans. The plans offered may be different for each baragining group.
Employee Contribution Required (As of July 2011)
Under Chapter 78, P.L. 2001, employee contributions for health benefits are required at a specified percentage of the health benefits/prescription drug premiums for a salary range, but not less than 1.5% of salary (as previously required under Chapter 2, P.L. 2010).
For employees employed as of the contribution's effective date (June 28, 2011) the percentage of premium requirement is implemented in a four-year phase-in at contribution levels of 1/4, 1/2, 3/4, and the full amount of the contribution rate during the phase-in years.
For State employees the phase-in period began as of July 1, 2011
For Local government and local education employees the first year phase in begins upon the expiration of the collective negotiations agreement in effect as of June 28, 2011.
For new employees hired on or after June 28, 2011, or after the expiration of a collective negotiations agreement that was in force on June 28, 2011, the employees contribute (without any phase-in) at the full amount of the required contribution rate.
Calculation charts and worksheets reflecting the phase-in of contribution levels for employees employed on the contribution's effective date who will pay 1/4, 1/2, 3/4, and the full amount of the contribution rate during the phase-in years are available on the Division of Pensions and Benefits' Web site.
Waiver of Medical and Prescription Coverage
State employees may waive SHBP medical and prescription drug coverage and will not have to pay the required health benefits contribution, provided that they are covered under a spouse's or partner's employer provided health benefits coverage. SHBP coverage may be resumed if the spouse's or partner's dependent coverage is no longer in effect. An SHBP Waiver form and a Health Benefits Application are required to be submitted through the employer to the SHBP.
An employer other than the State participating in the SHBp or SEHBP may allow an employee who is covered as a dependent under a spouse's or partner's employer provided health benefits coverage, to waive SHBp or SEHBP health benefits coverage and be reimbursed up to 25 percent of the amount saved by the employer or $5,000, whichever is less. SHBP/SEHBP coverage may be resumed if the spouse's or partner's dependent coverage is no longer in effect. The decision of an employer to allow its employees to waive coverage and the amount of consideration to be paid are not subject to collective bargaining. An SHBP/SEHBP Waiver form and a Health Benefits Application for Local Government Employees or a Health Benefits Application for Local Education Employees 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, may enroll in a SHBP/SEHBP medical
plan and the Employee Prescription Drug Plan, and must pay the full cost of coverage for the
level of coverage selected.
Medical Plan Coverage 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., July 1 to June 30) are eligible for enrollment in NJ DIRECT15 and the Employee Prescription
Drug Plan. Intermittent employees who maintain 750
hours of work per fiscal year will receive coverage for the next fiscal year.
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.
Medical Plan Coverage 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.
SHBP/SEHBP Benefits under the Civil Union Law
Chapter 103, P.L. 2006 establishes New Jersey 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, see Fact Sheet #75, Civil Unions.
SHBP/SEHBP Benefits under the Domestic Partnership Act
Under the New Jersey Domestic Partnership Act, SHBP
benefits are extended to eligible same-sex domestic partners of State employees and retirees.
Local public employers participating in the SHBP/SEHBP are permitted to extend
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/SEHBP coverage.
SHBP/SEHBP
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.
NJ direct Plans (PPO) — A Brief Introduction
The NJ DIRECT plans (NJ DIRECT10, NJ DIRECT15, NJ DIRECT1525, NJ DIRECT2030) are administered for the SHBP/SEHBP by Horizon Blue Cross Blue Shield
of New Jersey (Horizon BCBSNJ). 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 the plans.
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. For specific details on in-network services, see the NJ DIRECT Member Handbook.
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. For specific details on out-of--network benefits, see the NJ DIRECT Member Handbook.
NJ DIRECT Copayments and Deductibles
In-Network
NJ DIRECT in-network benefits require copayments for routine services such as office visits, use of emergency rooms, etc.
- NJ DIRECT10 copayments for in-network visits to a primary doctor or a network specialist are $10.
- NJ DIRECT15 copayments for in-network visits to a primary doctor or a network specialist are $15.
- NJ DIRECT1525 copayments for in-network visits to a primary doctor are $15 and visits to a network specialist are $25.
- NJ DIRECT2030 copayments for in-network visits to a primary doctor are $20 and visits to a network specialist are $20 for children and $30 for adults.
Out-of-Network
NJ DIRECT out-of-network benefits require that an annual deductible be met. Deductibles are listed in the NJ DIRECT Member Handbook and the Plan Comparison charts produced by the Division of Pensions and Benefits.
After dudctibles are met, covered services are reimbursed subject to coinsurance based on the "reasonable and customary" allowance for the service.
- Most NJ DIRECT10 out-of-network services are reimbursed at 80% of the "reasonable and customary" allowance after annual deductibles are met.
- Most NJ DIRECT15, NJ DIRECT1525, and NJ DIRECT2030 out-of-network services are reimbursed at 70% of the "reasonable and customary" allowance after annual deductibles are met.
Under NJ DIRECT out-of-network benefits, your out-of-pocket expenses may substantially increase because you will be charged for any portion of the fee that is above the "resonable and customary" amount allowed by the plan for payment to a provider for a particular service.
For example, if a physician's charge for a surgical procedure is $500 and the "reasonable and customary" allowance is $400, you are responsible for the $100 difference in addition to any coinsurance and deductible amounts.
Aetna and Cigna Plans (HMO) — A Brief Introduction
The Aetna and Cigna HMO plans have networks that provide services nationwide.
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.
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 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.
For specific details HMO plan benefits, see the Aetna or Cigna Member Handbooks.
HMO Copayments
Aetna HMO and Cigna HealthCare HMO require copayments for routine services such as office visits, use of emergency rooms, etc.
For most State Employees, Aetna HMO and Cigna HealthCare HMO copayments for visits to a primary doctor and visits to a referred specialist are $15.
- For most local government, local education, and all retirees, Aetna HMO/Aetna Medicare Plan (HMO) and Cigna HealthCare HMO copayments for visits to a primary doctor and visits to a referred specialist are $10.
- Aetna 1525 and Cigna1525 copayments for visits to a primary doctor are $15 and visits to a referred specialist are $25.
- Aetna2030 and Cigna2030 copayments for visits to a primary doctor are $20 and visits to a referred specialist are $20 for children and $30 for adults.
High Deductible Health Plans — A Brief Introduction
The SHBP/SEHBP High Deductible Health Plans (NJ DIRECT HD1500, NJ DIRECT4000, Aetna HD1500, Aetna HD4000, Cigna HD1500, Cigna HD4000) combine HDHP medical benefits, that include prescription drugs, with a tax-advantaged Health Savings Account (HSA).
Under a HDHP, members must pay an annual deductible before the medical plan pays for any covered health care costs. Only services that are covered by the plan count toward the annual deductible. Eligible preventive services normally covered at 100 percent and are not subject to the deductible.
Once the annual deductible is met, members pay a percentage of the covered health care costs (coinsurance) and your health plan pays the rest — up to any out-of-pocket maximum.
The Health Savings Account (HSA) is a pre-tax personal savings account funded by the member (and employer for the HDHP 1500 plans). HSA funds may be used to pay for qualified medical expenses not covered through your health plan including deductibles, coinsurance, dental or vision care, and other costs as outlined by the IRS.
High Deductible Health Plans (HDHP) Costs
- NJ DIRECT HD4000, Aetna HD4000, and Cigna HD4000 require that an annual in-network deductible* ($4,000 individual/$8,000 family) be met followed by an in-network out-of-pocket maximum ($1,000 individual/$2,000 family)**.
- NJ DIRECT HD1500, Aetna HD1500, and Cigna HD1500 require that an annual in-network deductible* ($1,500 individual/$3,000 family) be met followed by an in-network out-of-pocket maximum ($1,000 individual/$2,000 family).
- Most NJ DIRECT HD4000 and NJ DIRECT HD1500 out-of-network services are reimbursed at 60% of the "reasonable and customary" allowance after annual deductibles are met.
* The entire deductible must be met before any benefits are paid.
** HD4000 plans are not offered to SEHBP active employees.
Note: Medicare eligible Retirees cannot enroll in a High Deductible Health Plan.
BACK
TO TOP
Available
Prescription Drug Plans
Active
Employee Prescription Drug Coverage
The
SHBP/SEHBP Prescription Drug Plans are 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/SEHBP Prescription Drug Plans to their employees
as a separate prescription drug benefit. For specific details about the Prescription Drug Plans, see the SHBP/SEHBP Prescription Drug Plans Member Handbook.
The
Prescription Drug Plans are administered for the SHBP and SEHBP by Medco Health Solutions, Inc., the pharmacy benefit manager for all eligible members.
Detailed information concerning the SHBP/SEHBP Prescription Drug Plans are available in the SHBP Summary
Program Description, and in the SHBP/SEHBP Prescription Drug Plans Member Handbook.
Retiree
Prescription Drug Coverage
Retirees enrolled in the NJ DIRECT plan 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 benefit is
available in the NJ
DIRECT Member Handbook.
The
Aetna and Cigna plans provide retirees with prescription benefits through the use of a prescription
drug card. There are copayments when using an HMO drug card that vary by plan. More information about the benefits is available in the Aetna and Cigna Member Handbooks.
The
SHBP Employee Dental Plans
The
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 types of plans, the Dental Expense Plan and Dental Provider
Organizations (DPOs). A comparison of the types of plans is found in Fact
Sheet #37, Employee Dental Plans. More detailed information
is available in the Employee Dental Plans Member Handbook.
Please
note that there is one application, the 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 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 Plan Organizations
(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 copayment. 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
Dental Expense Plan is a traditional indemnity plan that allows a member to obtain
services from any dentist. After the member satisfies a 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
cost of participation in either plan is shared equally by the State and the employee.
Premium payments are made through payroll deductions.
Retiree
Dental Expense Plan
The SHBP offers a Retiree Dental Expense
Plan to retirees enrolled in, or eligible to enroll in, the Retired Group of the
SHBP/SEHBP. Employers should inform employees who are nearing retirement about this
plan.The 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 participating in the SHBP/SEHBP 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