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NEW JERSEY STATE HEALTH BENEFITS PROGRAM
COMPARISON SUMMARY FOR MEMBERS

Effective January 1, 2003
The rates on this chart are effective until July 1, 2004
with the exception of Prescription Drug Copayments for retirees
which changed on January 1, 2004

Dear Employees and Retirees:

The State 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.

The State Health Benefits Program offers three types of plans:

The 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).

A Health Maintenance Organization (HMO) provides complete coverage, including wellness and preventive care for medical services provided by affiliated physicians and hospitals.

NJ PLUS combines managed care with the option to get reimbursed for services performed out of the NJ PLUS network of physicians, hospitals or laboratories.

All individual plan benefits offered by the Traditional Plan, NJ PLUS, and participating HMOs are the same for active employees and retirees.

For members 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 easier.

If 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 may need.

If 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.

If you 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 data base.

The SHBP 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.

NOTE: All 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.

COMPARISON SUMMARY CHARTS
The rates on these charta are effective until July 1, 2004

1. Choose a benefit category to view the chart.

2. Compare the services provided by the SHBP plans.

To see how various HMOs are rated, see the

NJ Department of Health and Senior Services'

2003 New Jersey HMO Performance Report:
Compare Your Choices.

Answers to Frequently Asked Questions Related to Group Members

What 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.

What 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 medical provider;
  • 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 dependents live.

Whom 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

Your choice 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.

Medicare and the SHBP

This comparison 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.

If 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 plan.

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.

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 Drug Plan:

Retail Pharmacy - up to a 90-day supply copayment amounts
Supply Generic Preferred Brand All Other Brands
01 - 30 days $6 $13 $26
31 - 60 days $12 $26 $52
61 - 91 days $18 $39 $78
Mail Order - up to a 90-day suply copyament amounts
Supply Generic Preferred Brand All Other Brands
01 - 90 days $6 $19 $32


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
.

HMO 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.

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Division of Pensions and Benefits
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Last Updated: February 18, 2004