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Health Benefits Summary Information
Health Benefits
Health, dental and prescription drug coverage becomes effective 60 days after an employee's hire date. Employees hired as of September 1st under a 10 month contract are entitled to have their health benefits start effective September 1st provided they start work at the beginning of the contract year. Employee's eligible dependents' coverage becomes effective on the same day. Eligible dependents include the employee's spouse and unmarried children up to 23 years of age who live with the employee in a regular parent-child relationship. The employee's child's coverage ends on December 31 of the year that they reach the age of 23. In December of the year that they turn 23, the children will receive information concerning coverage through COBRA plus coverage through Chapter 375 for children up to age 31. All new full-time employees must complete the State Health Benefits Application to enroll in the health insurance or in order to waive the opportunity to enroll. If you do not enroll within 60 days of employment, you must wait to enroll during the annual open enrollment period. The open enrollment is held every October for an effective date of January 1 of the new year.
Employees will be able to make a choice between a Preferred Provider Organization (PPO) and two Health Maintenance Organizations (HMOs). An explanation of the two types of plans follows:
NJ DIRECT15
The Preferred Provider Organization (PPO) is NJ DIRECT15. NJ DIRECT15 is administered by Horizon Blue Cross Blue Shield of New Jersey. The NJ DIRECT15 Plan provides in-network care and out-of-network care. With NJ DIRECT15, in-network providers are available nationwide, you do not have to select a primary care physician, and you do not need a referral to see a specialist.
In-Network Services NJ DIRECT15
If a doctor participates in the Horizon BCBSNJ Managed Care Network, members will only pay the usual copayment for eligible services. Members who live outside of New Jersey can utilize doctors who participate in the national Blue Cross Blue Shield network. To find out if a doctor is part of the Managed Care Network, go to the Unified Provider Directory which can be found at http://www.state.nj.us/treasury/pensions/shbp.htm. You can also go directly to the website at www.horizonblue.com/shbp to check your doctor’s participation.
Out of Pocket Expenses for In-Network Care
Deductible (individual) |
$0 deductible; $15 dollar co-pay for doctor’s office visit; $50 emergency room |
Deductible (Family Maximum) |
$0 deductible; $15 dollar co-pay for doctor’s office visit; $50 emergency room |
Maximum Out of Pocket (Individual) |
$400 per calendar year (coinsurance only) |
Maximum Out of Pocket (Family) |
$1,000 per calendar year (coinsurance only) |
Out of Network Services NJ DIRECT15
If the doctor does not participate in the aforementioned networks, the services will be considered out-of-network. Out-of-network care is subject to an annual deductible and then the claim will be paid at 70% of the reasonable and customary charges. Please review the table that follows for out of pocket costs.
Out of Pocket Expenses for Out of Network Care
Deductible (individual) |
$100 per calendar year |
Deductible (Family Maximum) |
$250 per calendar year |
Hospital Inpatient |
$200 per hospital stay |
Maximum Out of Pocket (Individual) |
$2,000 per calendar year (coinsurance only) |
Maximum Out of Pocket (Family) |
$5,000 per calendar year (coinsurance only) |
Once the out of pocket costs for coinsurance totals $2,000.00 per individual or $5,000.00 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.
Health Maintenance Organizations (HMOs)
The two HMO plans that will be available to active employees are Aetna HMO and Cigna Healthcare. You will select a Primary Care Provider (PCP) when you enroll in the HMO, referrals will be necessary in order to access specialist services, and there will be no out-of-network coverage. The PCP will coordinate your health care and provide you with electronic referrals when needed. Both HMO plans provide services nationwide. HMOs have no deductibles or claim forms to file. You will pay the usual copayment for an office visit to your PCP or referred specialist.
You must you receive care from a doctor that participates with the HMO. To find out if a doctor is part of the Aetna HMO or the Cigna HMO, go to the Unified Provider Directory which can be found at http://www.state.nj.us/treasury/pensions/shbp.htm.
New Jersey Plus (Police Unions)
New Jersey Plus is a point of service plan that is a blend of a traditional indemnity plan and an HMO. It provides managed care to its members through its own network of providers. It also offers out-of-network benefits, which provide reimbursement to providers and members for expenses for services, rendered for the treatment of illness and injury. Claim forms are required for out-of-network services. Preventative services and well-care are not covered when you go out-of-network.
Unified Provider Directory
The Unified Provider Directory, accessible through the Internet link at http://www.state.nj.us/treasury/pensions/shbp.htm contains medical provider information currently included in the provider directories of each of the State Health Benefits Program's (SHBP) participating health plans. This consolidated information is in a uniform, easy-to-access format. Members will no longer have to search through numerous provider directories to find the plan affiliations of their health care provider or hospital.
The service, which is updated monthly, displays timely and comprehensive information concerning health care providers and facilities that deliver their services through one or more of the SHBP's managed-care plans.
Prescription Drug Plan
The Prescription Drug Program covers the cost of prescription drugs for employees and eligible dependents for use outside of hospitals, nursing homes, or other institutions. The program covers drugs which, as required by Federal Law, can be dispensed only upon a written prescription order by a doctor. Click here for the prescription claim form.
For each prescription dispensed by the pharmacist, employees pay a co-payment.
Click here to review the schedule for prescription co-payments.
Employees and their covered dependents who are using a prescription medication on an ongoing basis may utilize the prescription drug mail order program. This program provides members with a three-month supply of their prescription medication. The employee need only make one co-payment for the three-month supply.
To Apply for the Health and Prescription Plans
Complete the Health Insurance Enrollment Form and submit it to the office of Human Resources. If you do not want to enroll in health insurance and/or prescription drug coverage, it is necessary to complete the health insurance enrollment form plus a waiver form in order to avoid the 1.5% wage contribution.
If you are enrolling as Parent/Child, please complete an Affidavit of Dependency Form along with the enrollment form. You may also call us at extension 2283 to obtain a form.
