JERSEY STATE HEALTH BENEFITS PROGRAM
COMPARISON SUMMARY FOR MEMBERS
January 1, 2003
The rates on this chart are effective until July 1, 2004
with the exception of Prescription Drug Copayments
which changed on January 1, 2004
Employees and Retirees:
Health Benefits Program Comparison Summary provides an
easy way for employees and retirees
to compare the benefits of the various plans offered by the
State Health Benefit Program by summarizing what benefits
each plan provides for a specified service.
Health Benefits Program offers three types of plans:
Traditional Plan reimburses
you for the cost of hospitalization, doctor visits, surgery,
various medical services, and supplies. There are no restrictions
in choosing a physician. The Traditional Plan does not cover
preventive or wellness care (with the exception of mammography
and Pap tests).
Maintenance Organization (HMO) provides complete
coverage, including wellness and preventive care for medical
services provided by affiliated physicians and hospitals.
PLUS combines managed care with the option to get
reimbursed for services performed out of the NJ PLUS network
of physicians, hospitals or laboratories.
plan benefits offered by the Traditional Plan, NJ PLUS, and
participating HMOs are the same for active employees and retirees.
wanting to know more about what their plan offers, the charts
(provided below) can be a handy quick reference guide to the
services currently offered by your health plan. The Program
Comparison Chart can also be a very useful tool if you are
a new SHBP member or a SHBP member who is considering a different
health plan. Although the chart contains a lot of information,
using the following helpful hints can make reading this chart
you are looking for how a specific service is covered
— locate the service that you are inquiring about using
the categories listed below, follow horizontally across
the chart and compare how that particular service is covered
by the various health plans. Determine which plan provides
the best coverage for the services that you or your family
you are looking for general plan information offered by
the SHBP — locate the name of the plan using the
links listed above. The "Service Area", in the
second row of the chart, lists what states and/or counties
are covered under that particular plan. The specific services
offered by that plan are listed in the table under the plan
name — the table is cross-referenced with the left or right
hand column of the chart, which contains a listing of all
of the basic services.
are considering a managed care plan (an HMO or NJ PLUS) contact
your doctor’s office to see if they participate in any of
those plans you have selected. You can also use the
SHBP Unified Provider Directory available on the Internet.
The Unified Provider Directory lists the most current participating
physicians from all of the SHBP plans in one convenient, easy-to-use
Program Comparison Summary outlines many of the coverage
options provided under the New Jersey State Health Benefits
Program. For more information about the available health plans,
or eligibility in the SHBP, see the Summary Program Description
booklet. The Summary Program Description is available
from your employer, the Division of Pensions and Benefits,
or over the Internet.
plans under the SHBP are fully compliant with the provisions
of the federal Health Insurance Portability and Accountability
Act. The NJ PLUS and Traditional plans are also fully compliant
except in the area of mental health parity. A waiver has been
filed with the appropriate federal agency.
rates on these charta are effective until July 1, 2004
Choose a benefit category to view the chart.
Compare the services provided by the SHBP plans.
see how various HMOs are rated, see the
NJ Department of Health and Senior Services'
2003 New Jersey HMO
Report: Compare Your Choices.
to Frequently Asked Questions Related to Group Members
is the best plan in the SHBP?
There is no single best plan. The answer to this question
depends on the personal situation of the member.
factors should I consider when I decide which plan to take?
There are several factors you should consider, evaluate,
and compare to arrive at the decision as to which plan you
should take. They include:
family size and age of children;
health of family members - any significant (costly) problems;
medication being used on an ongoing basis;
other health insurance available from your spouse or Medicare;
prescription drug plan;
cost of the plan to you;
importance of complete freedom of choice in selecting
whether your doctors are in a particular managed care
plan (NJ PLUS or HMO);
the design of the health plans, that is, what they will
and will not cover; and
what plans provide coverage where you and your covered
do I call with a question about a claim or whether a particular
medical service is covered?
Call your health plan member services department.
SHBP/Medicare Information for Retirees
of a health care plan is a personal decision based on your needs
and the needs of your family. No one plan is best for everyone.
The charts in this fact sheet provide an easy way to compare the
benefits of the various plans offered by the State Health Benefits
Program (SHBP) by summarizing what benefit each plan provides for
a specified service. You can look at the services that are important
to you and determine which plan provides the best coverage for those
services. If you are considering a plan other than the Traditional
Plan, check with your doctor’s office to see if the doctor participates
in that plan, or you can use the SHBP
Unified Provider Directory available on the Internet. The Unified
Provider Directory lists participating providers from all the SHBP
plans in one easy-to-use data base.
and the SHBP
chart describes benefits available to members and their dependents.
The benefits listed were selected as those most likely to be of
interest to you. To be eligible for benefits supplemental to Medicare
under the SHBP, both Parts A and B of Medicare must be obtained
when retired members become eligible. The SHBP will not pay for
benefits which should have been paid for by Medicare. For additional
information see Fact Sheet #23, The
Traditional Plan and Medicare Parts A and B.
Medicare is Your Primary Payer
For the Traditional
Plan and NJ PLUS out-of-network coverage, claims are first submitted
to Medicare and then depending where services are provided, unreimbursed
expenses may be sent to your SHBP plan by the Medicare carrier for
further reimbursement. The member may still have out-of-pocket expenses
such as deductibles and costs above reasonable and customary allowances.
Under HMOs and the in-network NJ PLUS plan, this coordination of
benefits also occurs but is handled by the HMO or NJ Plus provider
and/or the plan, so that benefits and procedures remain the same
for enrollees regardless of Medicare eligibility. Enrollees simply
pay their normal co-payments to the provider. The deductibles and
coinsurance required by Medicare will be paid in full by your health
If the claim is one where our plan does not receive the claim information
automatically, you must submit the claim directly to your plan along
with a copy of the Medicare Evidence of Insurability statement.
Prescription Drug Coverage
- Presecription Drug copayments effective January 1, 2004
All SHBP health
plans include prescription drug coverage for all retirees.
enrolled in the Traditional Plan or NJ PLUS receive prescription
drug benefits through the Retiree Prescription Drug Plan administered
by AdvancePCS. As of January 1, 2004, the following copayment amounts
are applied to prescriptions purchased through the Retiree Prescription
Pharmacy - up to a 90-day supply copayment amounts
- 30 days
- 60 days
- 91 days
Order - up to a 90-day suply copyament amounts
- 90 days
Also effective January 1, 2004, the annual maximum for prescription
drug copayments has changed to $474 per person. Once a person has
paid $474 in copayments in a calendar year, that person is no longer
required to pay any prescription drug copayments for the remainder
of that calendar year.
plans provide a prescription drug card benefit with copayments
of $5 for generic drugs, $10 for "preferred" brand name
drugs, and $20 for all other brand name drugs, when purchased at
a participating retail pharmacy and prescribed by your Primary Care
Physician (PCP) or a provider to whom your PCP has referred you.
Mail order programs are also be available. See the chart or contact
your HMO for more information.