STATE HEALTH BENEFITS PROGRAM

SHBP

The information covered by this section of the Manual is very extensive.  Each of the items listed below is a link to a specific topic discussed concerning the State Health Benefits Program.  It may be helpful to begin reading the "Introduction" to this section and continue through the description of the several Plans offered by SHBP in order to get an overview of the program.  

Specific topics can be accessed through the links below, and any necessary forms will be accessible from there.

CONTENTS

AVAILABLE HANDBOOKS

Introduction

Summary Program Description

SHBP Component Plans

Employee Prescription Drug Plan

Available medical plans

Dental Provider List

The Traditional Plan

Dental Provider Organization Booklet

NJ PLUS

NJ Plus Member Handbook

HMO Plans

The Traditional Plan Member Handbook

Available Prescription Drug Plan


NJ State Dental Program

Employer Participation

Employer Enrollment

SHBP Main Page

SHBP Financial

COBRA-HIPAA Information

COBRA Rates

SHBP Employee Support Tasks

Chapter 48 Resolution (Paying for Retirees)

Termination of Employer Participation

Employee Support Tasks

Enroll Eligible Employees

Determine Eligibility

Have Employee Complete SHBP Application

Employer Certifies Application

Enrollment of Eligible Dependents

Effective Dates of Coverage

Timetable for SHBP Enrollment

Timetable for SHBP Termination

Open Enrollment Periods

Changes in Coverage and Family Status

While on Leaves of Absence

Approved Leaves of Absence for Illness

Approved Leave of Absence Other than Illness

Family Leave Act (federal and state)

Furlough

Workers' Compensation

Suspension from Employment

Upon Return From a Leave:

Re-enrollment

Military leave

Suspension

Change of Status (full-time v. part-time)

Waivers of Coverage (Municipalities Only)

Identification Cards

Monthly Reports

Reporting Changes

Needed Forms

Collect and Remit Premium Payments

Local Group

State Monthly

State Biweekly

Individual Retirees

COBRA Members

Overpayments and Shortages

Local Employer Late Payments

Premium Delay

Review and Reconcile Reports

Part B Medicare Premium Reimbursements

Part A Medicare Premium Reimbursements

Local Employer Payment of Retiree Coverage Under Chapter 48

How Plan Rates Are Set

Surcharge for Non-Participating School Districts

 

Introduction

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 is the executive organization responsible for overseeing the State Health Benefits Program. The Commission includes the State Treasurer, the Commissioner of Banking and Insurance, and the Commissioner of Personnel or their designated representatives. State law and the New Jersey Administrative Code govern the SHBP. The Division of Pensions and Benefits, specifically the Health Benefits Bureau, is responsible for the daily administrative activities of the SHBP.

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State Health Benefits Program Component Plans

Available Medical Plans

The SHBP offers three types of medical plans - the Traditional Plan, NJ PLUS Plan, and a number of Health Maintenance Organizations (HMOs). NJ PLUS, the Traditional Plan, and three HMOs: Horizon HMO, CIGNA Healthcare, and Aetna US Healthcare are self-funded, which means that the money paid out for benefits comes directly from a SHBP fund supplied by the State, participating local employer, and member premiums.

The Traditional Plan - a Brief Introduction

The Traditional Plan is administered for the SHBP by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). This plan allows participants the freedom of choice to use any properly licensed provider, as defined by the plan, for covered medical services.

The plan pays only for diagnosis and treatment of illness or injury. It does not pay for preventive treatment (except for mammongraphies) such as immunizations, physical exams, screening tests, and well-care physician visits.

The Traditional Plan has three components: Basic benefits (hospitalization), extended basic benefits (medical-surgical/professional), and major medical benefits.

The plan reimburses member expenses after the member pays a required deductible of $100 per calendar year (medical expenses only) with a maximum out-of-pocket expense of $400 per calendar year coinsurance, plus $100 deductible per individual. Eligible expenses are paid at 80% of "reasonable and customary fees" for each covered member. The member is generally responsible for a paying 20% in coinsurance.

More detailed information and an explanation of benefits of the Traditional Plan is available on page 26 of the SHBP Summary Program Description, and in The Traditional Plan Member Handbook.

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NJ PLUS - a Brief Introduction

NJ PLUS is a "point of service plan," administered for the SHBP by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), that is a hybrid of the Traditional Plan and an HMO.

In-Network Services:

When members enroll in NJ PLUS, they are encouraged to select a primary care physician (PCP) to oversee their medical care for themselves and eligible family members. When members use their PCP, they are only responsible for a $5.00 payment per visit. There are no claim forms to fill out. If they need to see a specialist or seek hospital care, the PCP will issue a referral to a participating provider for a $5 co-payment per visit and coordinate hospital care through the NJ PLUS hospital network. Coordinating medical services using the PCP in this manner is considered the in-network benefits of the NJPLUS plan.

Out-of-Network Services:

In addition to the in-network benefits of NJ PLUS, members have the freedom to access any eligible provider or hospital for the treatment of illness or injury, similar to the Traditional Plan benefit. If members exercise the option to use non-network physicians, specialists, hospitals, or other eligible providers, generally NJ PLUS will pay 70% of the "reasonable and customary" rate of eligible expenses after members pay the required $100 annual, per person, deductible. Claim forms are only required for out-of-network services.

More detailed information and an explanation of benefits of NJ PLUS is available in the SHBP Summary Program Description, and in The NJ Plus Member Handbook.

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The HMO Plans - a Brief Introduction

There are numerous Health Maintenance Organizations that participate in the SHBP. They are licensed to provide services in specific territories (by county), with all HMOs covering all New Jersey residents.

HMOs emphasize preventive care and provide coverage for physical exams, well-baby visits, immunizations, etc. The payment for each doctor visit is $5.00 and members are not required to fill out any claim forms. If members need to see a specialist or seek hospital care, the PCP will issue a referral to a participating provider for a $5 CO-payment per visit, and coordinate hospital care through the HMO's hospital network. The exception is Physicians Health Services (PHS) which does not require their members to get referrals to see participating specialists.

Members must use the HMO network for health care services (other than in a medical emergency), or the HMO will not pay for the care.

More detailed information and an explanation of benefits of the HMO's, including HMO performance reports, plan descriptions, and plan standards, is available beginning on page 10 of the SHBP Summary Program Description. Each HMO also provides their 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 $1.00 for generic drugs or $5.00 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 $1 and $5, respectively.

The State Prescription Drug Plan is currently administered through Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) through Merck-Medco, L.L.C., and its affiliate, PAID Prescriptions, L.L.C. The is a stand-alone plan and should not be confused with the prescription drug components of the various medical plans in the SHBP.

More detailed information concerning the SHBP Employee Prescription Drug Plan is available on pages 4-5 in the SHBP Summary Program Description, and in the SHBP Employee Prescription Drug Plan booklet.

Retiree Prescription Drug Coverage:

Effective January 1, 2000, retirees enrolled in the Traditional Plan or NJ PLUS 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 Traditional and NJ PLUS plan descriptions in the SHBP Summary Program Description.

The SHBP HMO's provide retirees with prescription benefits through the use of a prescription drug card. Co-payments when using an HMO drug card vary by plan, but cannot exceed $10 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 beginning on page 11.

The New Jersey State Dental Program

The State Employee Group Dental Program is available to eligible full-time employees of the State, State universities and colleges, and certain independent agencies. The program provides a choice between two different plans, the Dental Expense Plan and Dental Provider Organizations (DPO's). A comparison of these types of plans is found in Fact Sheet #37, "State Employee Group Dental Plan." More detailed information is available in the "State Employee Group Dental Program" booklet. 

A New Jersey State Dental Benefits Application must be completed by the employee and certified by the employer for enrollment to become effective. Click here for a copy of the Dental Plan Application.

The Dental Expense Plan is a traditional indemnity plan that allows a member to obtain services from any dentist. After the member satisfies a $25 deductible, the member is reimbursed for 80% 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 by the Prudential Healthcare, a member company of Aetna/US Healthcare, under contract with the State Health Benefits Commission (SHBC).

The Dental Plan Organizations, or DPO's, are individual prepaid plans offering services through a network of dental providers. The cost for most services is prepaid, but certain services require an additional CO-payment The DPO operates 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.

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 POP is automatic unless the employee specifically declines enrollment.

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EMPLOYER PARTICIPATION

Employer Enrollment

The State Health Benefits Program is open to all local employers who elect to participate by completing resolution HB-80-180-793

Also, see the "Benefits of Choosing the State Health Benefits Program, An Employer Reference Guide". 

Employers can enroll into the medical plans only or medical plans 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 may obtain the resolution and enrollment packet by calling the Health Benefits Bureau at (609) 633-7564. This packet will include:

-- A Resolution to Authorize Participation in the SHBP 

-- A Resolution to Elect Delay Premium Option  

-- Current Rate Charts

-- Memo and resolution regarding Chapter 48, P.L. 1999 -- optional participation.*

*Chapter 48, P.L. 1999 provides eligible participating local employers considerable flexibility in defining which employees qualify for post-retirement medical benefits by using the age and service requirements of the local government laws NJSA 40A:10-23.

It allows an eligible local employer to negotiate payment obligations for post-retirement medical coverage with its employees or their labor representatives.

Click here to download a copy of the Chapter 48 Resolution.

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 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 it's employees, retirees, and COBRA participants are also terminated unless the retirees are covered by specific legislation that permits them to continue SHBP participation upon the termination of their former employer.

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.

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