JERSEY STATE HEALTH BENEFITS PROGRAM
COMPARISON SUMMARY FOR
LOCAL GOVERNMENT AND LOCAL EDUCATION EMPLOYEES
ALL LOCAL AND STATE RETIREES
for Plan Year 2006
Health Benefits Program Comparison Summary provides an easy
way for local employees and all retirees
to compare the benefits of the various plans offered by the State
Health Benefits Program by summarizing what benefits each plan provides
for a specified service.
The State Health
Benefits Program offers three types of plans:
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.
combines managed care with the option to get reimbursed for services
performed out of the NJ PLUS network of physicians, hospitals
Choose a benefit category to view the chart.
Compare the services provided by the SHBP plans.
plan benefits offered by the Traditional Plan, NJ PLUS, and participating
HMOs are the same for all local active employees and all retirees.
to Use the Charts
wanting to know more about what their plan offers, the charts can
be a handy quick reference guide to the services currently offered
by your health plan. The Comparison Summary 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.
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.
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
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
plans under the SHBP are fully compliant with the provisions of
the federal Health Insurance Portability and Accountability Act.
NJ PLUS and the Traditional Plan are also fully compliant except
in the area of mental health parity. A waiver has been filed with
the appropriate federal agency.
see how various HMOs are rated, see the NJ Department of Health
and Senior Services'
2004 New Jersey HMO
Report: Compare Your Choices.
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
To be eligible
for benefits supplemental to Medicare under the SHBP, both Parts
A and B of Medicare must be obtained when retired members
and their dependents 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
State Health Benefits Program and Medicare Parts A and B for Retirees.
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.
Medicare Part D Information
current prescription drug benefit plans meet the Medicare Part D
standards. The State will be sharing the savings it receives under
Medicares Part D rules by reducing plan year 2006 premiums
applicable to prescription drug plans. Most Medicare eligible retirees
and/or their Medicare eligible dependents need not enroll in Medicare
Part D. Some members who qualify for limited-income subsidy programs
may find it beneficial to enroll in Medicare Part D. However, once
you enroll in Medicare Part D, your SHBP retired group prescription
drug benefits will be terminated for you and your dependents.
Drug Coverage for Retirees
have prescription drug coverage included in their SHBP plan. Prescription
drug copayment amounts are shown in
this comparison chart.
enrolled in an HMO plan should contact the HMO directly for
details about their prescription drug coverage.
enrolled in the Traditional Plan or NJ PLUS have access to a
separate prescription drug card plan that includes retail pharmacies
and a mail order service. The plan features a three-tiered copayment
design - Tier I for generic drugs, Tier II for preferred
brand name drugs, and Tier III for all other brand name
drugs. For plan year 2006, the prescription drug plan out-of-pocket
maximum has been set at $1,000. Once a person has paid $1,000 in
copayments in the calendar year, that person is no longer required
to pay any prescription drug copayments for the remainder of the