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 availability of 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.
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 the appropriate 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 the appropriate 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, 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 all plans but Aetna Freedom10 and NJ DIRECT10 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, Aetna Freedom15, 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.
Preferred Provider Organization (PPO) — A Brief Introduction
The Preferred Provider Organization (PPO) plans are administered for the SHBP/SEHBP by Aetna and 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.
Click here for a list of PPO Plans
In-Network Benefits
When a member sees a physician who participates in-network, the member will only pay the appropriate copayment for eligible services.
Members living outside of New Jersey can utilize physicians participating in-network; the member will only pay the appropriate copayment for eligible services.
If the physician does not paricipate in the network, the services will be considered out-of-network.
Members should contact their doctor to see if he or she participates in the network. For specific details on in-network services, members should contact their plan.
Out-of-Network Benefits
Out-of-network benefits allow members to utilize any licensed physician, but they are required to file a claim form. 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, members should contact their plan .
Click here for PPO Copayments and Deductibles
Under 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.
Health Maintenance Organization Plans (HMO) — A Brief Introduction
The Health Maintenence Organization (HMO) plans have networks that provide services nationwide.
Click here for a list of HMO Plans
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, members should contact their plan.
Click here for HMO Copayments
HMO plans require copayments for routine services such as office visits, use of emergency rooms, etc.
High Deductible Health Plans — A Brief Introduction
The SHBP/SEHBP High Deductible Health Plans (HDHP) combine medical benefits, that include prescription drugs, with a tax-advantaged Health Savings Account (HSA).
Click here for a list of HDHP plans
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 entire 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.
Click here for High Deductible Health Plans (HDHP) Costs
* HD4000 plans are not offered to SEHBP active employees.
Note: Medicare eligible Retirees cannot enroll in a High Deductible Health Plan.
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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 have access to a separate prescription drug card plan that includes a mail order service. The plan features a three-tiered design. Copayments vary by plan. More information about the benefit is available from the plans.
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