NEW JERSEY STATE HEALTH BENEFITS PROGRAM
COMPARISON SUMMARY FOR
LOCAL GOVERNMENT AND LOCAL EDUCATION EMPLOYEES
AND
ALL LOCAL AND STATE RETIREES

Effective for Plan Year 2006

Dear Employees and Retirees:

The State 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:

COMPARISON SUMMARY CHARTS

1. Choose a benefit category to view the chart.

2. Compare the services provided by the SHBP plans.

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

How to Use the Charts

For members 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.

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 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.

NOTE: All 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.

To see how various HMOs are rated, see the NJ Department of Health and Senior Services'
2004 New Jersey HMO Performance Report: Compare Your Choices.

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

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.

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.

Important Medicare Part D Information

The SHBP’s current prescription drug benefit plans meet the Medicare Part D standards. The State will be sharing the savings it receives under Medicare’s 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.

Prescription Drug Coverage for Retirees

All retirees have prescription drug coverage included in their SHBP plan. Prescription drug copayment amounts are shown in this comparison chart.

Retirees enrolled in an HMO plan should contact the HMO directly for details about their prescription drug coverage.

Retirees 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 calendar year.