SHBP EMPLOYEE DENTAL PLANS MEMBER HANDBOOK

THE DENTAL EXPENSE PLAN
AND
THE DENTAL PLAN ORGANIZATIONS

FOR STATE EMPLOYEES AND PARTICIPATING LOCAL EMPLOYEES

October 2004

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SECTION ONE

GENERAL INFORMATION

INTRODUCTION

State law and the New Jersey Administrative Code govern the SHBP. Although every effort has been made to ensure the accuracy of this publication, if there are discrepancies between the information presented here and the law, or regulations, the latter will govern.

This booklet describes the dental benefit plans that are available under the SHBP Employee Dental Plans to eligible full-time employees of the State, State universities and colleges, employees of certain independent State agencies, and eligible employees of a local government or local education employer that participates in the SHBP and that adopts the SHBP Employee Dental Plans by resolution. Before making any enrollment decision, you should carefully review the standards of eligibility and the conditions, limitations, and exclusions of the coverage under each plan. The complete terms of the SHBP Employee Dental Plans are described in the Dental Expense Plan contract and the Dental Provider Organization contracts with amendments.

If, after reading this booklet, you have any questions, comments, or suggestions regarding this material please write to the Division of Pensions and Benefits, PO Box 295, Trenton, NJ 08625-0295, e-mail us at: pensions.nj@treas.state.nj.us or call us at (609) 292-7524.

DENTAL PLANS

The SHBP provides a choice between two different types of plans:

• The Dental Expense Plan is a traditional indemnity plan that allows you to obtain services from any dentist. After you satisfy the $50 annual deductible (the deductible applies to non-preventive services only), you are reimbursed a percentage of the reasonable and customary charges for the services that are covered under the plan. This plan is administered under a contract between the State Health Benefits Commission (SHBC) and Aetna Life Insurance Company (Aetna).
  
  
• The Dental Plan Organizations are individual prepaid plans offering services through a network of dental providers. You may enroll in one of several Dental Plan Organizations (DPOs). To obtain services, you must use a dentist who is a member of the DPO you selected. The cost for most services are prepaid, but certain services require an additional copayment. You will not be covered for services if you go to a dental provider who is not a member of your DPO, unless referred by a DPO dentist.

Levels of Coverage

There are four levels of coverage:

• Single: covers the employee only
  
  
• Member and spouse or domestic partner: covers the employee and his/her spouse or an eligible same-sex domestic partner
  
  
• Parent and child: covers the employee and all enrolled eligible children
  
  
• Family: covers employee, spouse or eligible same-sex domestic partner, and all enrolled eligible children

Dental Plan Premiums

State Employees — The cost for participation in the SHBP Employee Dental Plans is shared by the State and participants. Premium payments are made through payroll deductions. For a current list of rates and payroll deduction schedules, please see your benefits administrator. Employee premiums can be paid on a pre-tax basis through participation in the Premium Option Plan (POP) of the State's IRC Section 125 Program, Tax$ave. Participation in POP is automatic unless you specifically decline enrollment. Note: Tax$ave POP members are not permitted to drop coverage within a calendar year unless a qualifying event occurs, see Appendix C for more information on Tax$ave.

Local Employees — The cost of dental plan coverage for employees of a participating local employer, will vary based upon the policies of that employer in regard to health benefit costs and any labor agreements between the employer and the unions representing the employee. Employees of a participating local employer should see their Human Resources Representative or Benefits Administrator for more information.

ELIGIBILITY AND ENROLLMENT

Eligibility

The SHBP Employee Dental Plans are available to full-time State employees, appointed or an elected officers of the State of New Jersey, full-time employees of a local employer (county, municipality, school board, etc.) that elects by resolution to provide the Employee Dental Plans to its employees, and the eligible dependents of these employees. Generally, you are considered to be a full-time employee if you are employed for at least 35 hours per week on a 10 or 12 month basis and have completed the required waiting period, howeve, local employees should consult their Human Resources Representative or Benefits Administrator to determine the specific requirements of their employer.

Enrollment in a dental plan is optional. If you do not enroll when first eligible, you will have the option to enroll each year during the annual SHBP Open Enrollment Period.

In deciding whether to enroll and which plan to choose, you should consider the differences in out-of-pocket costs, the covered services between the Dental Expense Plan and a DPO, and the degree of flexibility that you may want in selecting a dentist. You should also recognize that you must remain in any plan you select for at least 12 months.

Eligible Dependents

If you enroll, you may also enroll the following dependents:

• Your spouse or an eligible same-sex domestic partner.*
  
  *Chapter 246, P.L. 2003, the Domestic Partnership Act, defines a domestic partner as a person of the same sex to whom an employee or retiree has entered into a domestic partnership and received a New Jersey Certificate of Domestic Partnership through application to a local registrar. For SHBP eligibility, the employee must be a State employee, State retiree, or an eligible employee or retiree of a SHBP participating local public entity if the local governing body has adopted a resolution to provide Chapter 246 health benefits. A photocopy of the New Jersey Certificate of Domestic Partnership (or a valid certification from another jurisdiction that recognizes same-sex domestic partners, civil unions, or similar same-sex relationships) is required for enrollment. The cost of same-sex domestic partner coverage may be subject to federal tax (see your employer or Fact Sheet #71, Benefits Under the Domestic Partnership Act, for details).
  
  
• Your unmarried children (including step-children, legally adopted children, foster children, and legal wards) under the age of 23 who are substantially dependent upon you for support and maintenance and who:
  
  
• live with you in a normal parent-child relationship; or
  
  
• reside at school but who have a permanent domicile with you and whom you support; or
  
  

• do not live with you, but whom you are legally required to support. Proof of the legal requirement of support is necessary.

Ineligible dependents are as follows:

• A child age 23 or over at the time of enrollment. A child's eligibility ends on December 31 of the year in which the child reaches age 23.
  
  
• A child who no longer resides with you in a parent/child relationship.
  
  
• A child who does not live with you and you are not legally required to support.
  
  
• A married child. Eligibility ends on the date of the marriage.
  
  
• A child who is on active duty in the armed forces of any country.
  
  
• Any dependent who is eligible for dental coverage through active service in the armed forces of any country.
  
  
• Any dependent who is already covered by the SHBP Employee Dental Plans as an employee or a dependent of another employee. For example, if you and your spouse (or divorced or separated spouse) are both covered as employees, a child can only be listed as a dependent on one coverage.
  
  
• A divorced spouse.
  
  
• A former same-sex domestic partner where the domestic partnership has been disolved.

Enrollment

In the description of enrollment procedures, this booklet makes reference to biweekly employees, monthly employees, and local employees.

• Biweekly employees are paid through the State's Centralized Payroll Unit with benefits provided on a biweekly pay period basis.
  
  
• Monthly employees are employees of State universities and colleges, independent State agencies, and State legislators and aides. Their benefits are provided on a calendar-month basis.
  
  
• Local employees are employees of a county, municipality, school board, etc. Their benefits are provided on a calendar-month basis.

A new employee must submit a completed SHBP Employee Dental Plans Application to his or her Human Resources Representative within 60 days of employment. If you do not enroll within 60 days of employment, you must wait to enroll during the Annual Open Enrollment Period. See "When Coverage Begins" for effective dates of coverage.

If you do not enroll because of other coverage and you lose that coverage, you can be enrolled providing you submit a completed application to your Human Resources Representative within 60 days of the event. A copy of your spouse's, eligible same-sex domestic partner's, and/or dependent's Certificate of Continued Coverage must be submitted with the NJ State Health Benefits Program Application or SHBP Employee Dental Plans Application. Coverage will be effective the first day of the payroll period in which the event occurs if you are a biweekly employee. For monthly and local employees, the coverage will be effective on the date of the event.

Enrolling Dependents

You may enroll your eligible dependents when you enroll, or during any SHBP Open Enrollment Period. See "When Dependent Coverage Begins" for effective dates of coverage.

If you have a new dependent, you may enroll the dependent effective the date you acquired the dependent provided you submit a completed application within 60 days of the dependents's eligibility. If you do not enroll the new dependent within 60 days, you must wait until the annual Open Enrollment Period.

If you do not enroll an eligible dependent because of other coverage and that coverage is lost, you can enroll that dependent providing you submit a completed application within 60 days of the event. A copy of your spouse's, eligible same-sex domestic partner's, and/or dependent's Certificate of Continued Coverage must be submitted with the NJ State Health Benefits Program Application or SHBP Employee Dental Plans Application. Coverage for that dependent will be effective the first day of the payroll period in which the event occurs if you are a biweekly employee. For monthly and local employees, the coverage will be effective on the date of the event.

Dual Dental Plan Enrollment is Prohibited

Two employees who are married to each other (or registered same-sex domestic partners) and who are both SHBP members are prohibited from obtaining duplicate coverage in the SHBP Employee Dental Plans. You and your spouse/domestic partner may belong to a SHBP Employee Dental Plan as an employee or as a dependent but not as both.

For example, if two employees are married to each other, each may elect to enroll for single coverage only under any of the SHBP Employee Dental Plans, or one employee may enroll the other dependent if the other person waives their dental plan coverage.

Furthermore, two employees cannot each enroll the same children as dependents under their SHBP Employee Dental Plans.

When Coverage Begins

Upon enrollment, coverage for you and your enrolled eligible dependents will begin as follows:

• If you enroll at the time you begin employment, your coverage begins approximately two months after the start of your employment. If you are paid through the State's Centralized Payroll Unit, your coverage begins on the first day of your fifth payroll period. If you are not paid through the State's Centralized Payroll Unit, (i.e. a monthly or local employee) your coverage begins on the 61st day of employment. (Note: see orthodontic exception.) Coverage for enrolled eligible dependents is effective the same date as your coverage.
  
  
• If you enroll during the Open Enrollment Period, your coverage begins on the established Open Enrollment Period effective date.
  
  
• If you enroll under the provisions described above because of loss of other coverage, your SHBP Employee Dental Plan coverage begins on the first day of the payroll period in which the event occurs if you are a biweekly employee, provided an application was submitted within 60 days of the loss of coverage. For monthly and local employees, coverage will begin the date of the event. You will be responsible for paying the appropriate premiums.
  
  
• If you enroll under the Dental Expense Plan, your coverage for any eligible orthodontic expense becomes effective only after you have been employed full-time for 10 months. If you elect a Dental Plan Organization (DPO), your coverage for eligible orthodontic expense becomes effective when your dental coverage begins.

When Dependent Coverage Begins

• If you enroll a dependent when you enroll as a new employee, the dependent's coverage begins when your coverage begins.
  
  
• If you add a new dependent and submit a completed application within the 60-day period before or after a qualifying event (birth, marriage, adoption, loss of coverage due to a dependent's change of employment, etc.), the dependent's coverage begins on the first day of the payroll period in which the event occurs if you are a biweekly employee. For monthly and local employees, the coverage will be effective on the date of the event.
  
  
• For those dependents not added when eligible but whom you wish to add during the annual Open Enrollment Period, the dependent's coverage begins on the effective date established for the Open Enrollment Period.

Change of Coverage

• You may change from one plan to another only during the annual Open Enrollment Period.
  
  
• You must also remain in a plan for 12 months before you can transfer to another plan during the next annual Open Enrollment Period.
  
  
• You may cancel your coverage at any time after 12 months of participation (unless enrolled in the Tax$ave POP).
  
  
• You may cancel coverage for a dependent at any time after the dependent's 12 months of participation (unless enrolled in the Tax$ave POP).
  
  
• If you enroll in a Dental Plan Organization (DPO), you may change your DPO only during the annual Open Enrollment Period, or when your DPO cannot provide you a dental provider within 30 miles of your home.

When Coverage Ends

Dental Expense Plan and DPO coverage ends:

• If you are no longer eligible due to a change in your employee eligibility status; or
  
  
• you fail to make the required payments for your enrollment; or
  
  
• you voluntarily terminate coverage after 12 months of participation (unless enrolled in the Tax$ave POP).

When Dependent Coverage Ends

Dental expense plan and DPO coverage for your dependents ends:

• When a dependent is no longer eligible; or
  
  
• when your coverage ends; or
  
  
• you voluntarily terminate the dependent's coverage after 12 months of participation (unless enrolled in the Tax$ave POP).

EXTENSION OF COVERAGE PROVISIONS

If Eligibility Ends While Undergoing Treatment

Dental Expense Plan only:

If coverage for you or a dependent is terminated, the coverage will be extended to cover the following procedures for 30 days following the end of the coverage:

• An appliance or modification of an appliance for which the impression was taken while the person was covered.
  
  
• A crown or restoration for which a tooth was prepared while the person was covered.
  
  
• Root canal therapy for which the pulp chamber was opened while the person was covered.

Dental Provider Organizations only:

If coverage for you or a dependent is terminated, the coverage will be extended to cover the following procedures for 30 days following the end of the coverage:

• An appliance or modification of an appliance for which the impression was taken while the person was covered.
  
  
• A crown or restoration for which a tooth was prepared while the person was covered.
  
  
• Root canal therapy for which the pulp chamber was opened while the person was covered.

If DPO Terminates Participation in the SHBP

If your DPO leaves the SHBP Employee Dental Plans you will be given the opportunity to join another SHBP Employee Dental Plan. For services that have already begun prior to plan termination including a full course of orthodontic treatment, coverage for those services for you and your dependents will be extended at no additional cost to you except for the remaining portion of the copayment that has not yet been paid.

For Children Over the Age of 23

A child over the age of 23 who is incapable of self-support due to mental illness, mental retardation, or physical disability, may be continued for coverage provided the child had been enrolled prior to reaching age 23 and the disability occurred before age 23. You must prove the child is incapable of self-support and the continuation of coverage must be approved by the State Health Benefits Program (SHBP). To request continued coverage, call or write the Division of Pensions and Benefits, Health Benefits Bureau, for a Continuance for Dependent With Disabilities form. The form and proof of the child's condition must be given to the Division no later than 31 days after the date coverage would normally end. Since coverage for children ends on December 31 of the year they turn 23, you have until January 31 to file the Continuance for Dependent With Disabilities form. Coverage may continue only while (1) you are still covered through the SHBP, (2) the child is disabled, and (3) the child is unmarried. The Division will contact you periodically to verify that the covered child remains eligible for continued coverage.

Leave Of Absence

If you are on an authorized leave with pay, your coverage is automatically continued.

If you are on an authorized leave without pay, you may continue your coverage for up to six biweekly pay periods or three months. You must pay the entire cost (employee and employer contributions) in advance except in the case of Workers' Compensation, Family Leave, and Furlough. In these cases, you pay only the cost of the employee contribution.

EXTENSION PROVISIONS FOR DENTAL BENEFITS

COBRA COVERAGE

Continuing Coverage When it Would Normally End

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federally regulated law that gives employees and their eligible dependents the opportunity to remain in their employer's group coverage when they would otherwise lose coverage because of certain qualifying events. COBRA coverage is available for limited time periods, and the member must pay the full cost of the coverage plus an administrative fee.

Leave taken under the federal and/or State Family Leave Act is not subtracted from your COBRA eligibility period.

Under COBRA, you may elect to enroll in any or all of the coverages you had as an active employee or dependent (health, prescription, dental, and vision). You may also change your health or dental plan when enrolling in COBRA. You may elect to cover the same dependents that you covered while an active employee, or delete dependents from coverage — however, you cannot add dependents who were not covered while an employee except during the annual Open Enrollment period (see below) or unless a "qualifying event" (marriage, birth or adoption of a child, etc.) occurs within 60 days of the COBRA event.

COBRA enrollees have the same rights to coverage at Open Enrollment as are available to active employees. This means that you or a dependent who elected to enroll under COBRA are able to enroll, if eligible, in any SHBP medical, dental, or prescription drug coverage during the SHBP Open Enrollment Period regardless of whether you elected to enroll for the coverage when you went into COBRA. This affords a COBRA enrollee the same opportunity to enroll for benefits during the SHBP Open Enrollment Period as an active employee. However, any time of non-participation in the benefit is counted toward your maximum COBRA coverage period. If the State Health Benefits Commission makes changes to any benefit plan available to active employees and/or retirees, those changes apply equally to COBRA participants.

COBRA Events

Continuation of group coverage under COBRA is available if you or any of your covered dependents would otherwise lose coverage as a result of any of the following events:

• Termination of employment (except for gross misconduct).
  
  
• Death of the member.
  
  
• Reduction in work hours.
  
  
• Leave of absence.
  
  
• Divorce, legal separation, or dissolution of a domestic partnership.
  
  
• Loss of a dependent child's eligibility through independence (moving out of household), the attainment of age 23, or marriage.

The occurrence of the COBRA event must be the reason for the loss of coverage for you or your dependent to be able to take advantage of the provisions of the law. If there is no coverage in effect at the time of the event, there can be no continuation of coverage under COBRA.

Cost of Coverage

If you choose to purchase COBRA benefits, you pay 100 percent of the cost of the coverage plus a 2 percent charge for administrative costs.

Duration of Coverage

COBRA coverage may be purchased for up to 18 months if you or your dependents become eligible because of termination of employment, a reduction in hours, or a leave of absence.

Coverage may be extended up to 11 additional months, for a total of 29 months, if you have a Social Security Administration approved disability (under Title II or XVI of the Social Security Act) for a condition that existed when you enrolled in COBRA or began within the first 60 days of COBRA coverage. Coverage will cease either at the end of your COBRA eligibility or when you obtain Medicare coverage, whichever comes first.

COBRA coverage may be purchased by a dependent for up to 36 months if (s)he becomes eligible because of your death or divorce, or (s)he becomes ineligible for continued group coverage because of marriage, attaining age 23, or moving out of the household, or because you elected Medicare as your primary coverage.

If a second qualifying event occurs during the 18-month period following the date of any employee's termination or reduction in hours, the beneficiary of that second qualifying event will be entitled to a total of 36 months of continued coverage. The period will be measured from the date of the loss of coverage caused by the first qualifying event.

Employer Responsibilities Under COBRA

The COBRA law requires employers to:

• notify you and your dependents of the COBRA provisions when you and your dependents are first enrolled;
  
  
• notify you, your spouse or eligible domestic partner, and your children of the right to purchase continued coverage when they become aware of a COBRA event that causes a loss of coverage;
  
  
• send the COBRA Notification Letter and a COBRA Application within 14 calendar days of receiving notice that a qualifying event has occurred; and
  
  
• maintain records documenting their compliance with the COBRA law.

Employee Responsibilities Under COBRA

The law requires that you and your dependents:

• notify your employer that a divorce, legal separation, or death has occurred or that your child has married, moved out of your household, or reached age 23 - notification must be given within 60 days of the date the event occurred;
  
  
• file a COBRA application within 60 days of the loss of coverage or the date of the COBRA Notice provided by your employer, whichever is later;
  
  
• pay the required monthly premiums when billed in a timely manner and retroactive to the COBRA effective date.

Termination of COBRA Coverage

Your COBRA coverage through the SHBP will end when any of the following situations occur:

• your eligibility period expires;
  
  
• you fail to pay your premiums in a timely manner;
  
  
• after the COBRA event, you become covered under another group insurance program (unless a pre-existing clause applies);
  
  
• you voluntarily cancel your coverage.

APPEAL PROCEDURES

You or your authorized representative may appeal and request that your dental plan reconsider any claim or any portion(s) of a claim for which you believe benefits have been erroneously denied based on the plan's limitations and/or exclusions. This appeal may be of an administrative or medical nature. Administrative appeals question plan benefit decisions such as whether a particular service is covered or paid appropriately. Medical appeals refer to the determination of medical need, appropriateness of treatment, or experimental and/or investigational procedures.

The following information must be given at the time of each inquiry.

• Name(s) and address(es) of patient and employee;
  
  
• employee's identification number;
  
  
• date(s) of service(s);
  
  
• provider's name and identification number;
  
  
• the specific remedy being sought; and
  
  
• the reason you think the claim should be reconsidered.

If you have any additional information or evidence about the claim that was not given when the claim was first submitted, be sure to include it.

Any member of the Dental Expense Plan who disagrees with a final decision of Aetna may request, in writing, that the matter be considered by the State Health Benefits Commission. Requests for consideration must be directed to the Appeals Coordinator, State Health Benefits Commission, PO Box 299, Trenton, NJ 08625-0299 and must contain the reason for the disagreement and a copy of all relevant correspondence. Appeals are considered at regular monthly meetings of the Commission. It is the responsibility of the member to provide the Commission with any medical or other information that the Commission may require in order to make a decision.

Any member of a DPO who disagrees with a determination of the appropriateness of a procedure made by a DPO or any member of a DPO who feels that the DPO has violated the terms and conditions of its contract with the SHBP may request, in writing, that the matter be considered by the State Health Benefits Commission. Such an appeal can only be considered after the member has exhausted the DPO's grievance process.

Upon request, your DPO will supply you with its grievance procedures. Requests for consideration must be directed to the Appeals Coordinator, State Health Benefits Commission, PO Box 299, Trenton, NJ 08625-0299 and must contain the reason for the disagreement and a copy of all relevant correspondence and supporting documentation. Appeals are considered at regular monthly meetings of the Commission.

Notification of all Commission decisions will be made in writing to the member. If the Commission denies the member's appeal, the member will be informed of further steps (s)he may take in the denial letter from the Commission. Any member who disagrees with the Commission's decision may request within 45 days in writing to the Commission that the case be forwarded to the Office of Administrative Law. The Commission will then determine if a factual hearing is necessary. If so, the case will be forwarded to the Office of Administrative Law. An Administrative Law judge will hear the case and make a recommendation to the Commission, which the Commission may adopt, modify, or reject. If a factural hearing is not necessary, the administrative appeal process involving the Commission is ended. When the administrative process is completed, further appeals may be made to the Superior Court of New Jersey, Appellate Division.

If your case is forwarded to the Office of Administrative Law, you will be responsible for the presentation of your case and for submitting all evidence. You will be responsible for any expenses involved in gathering evidence or material that will support your grounds for appeal. If you take your appeal to Superior Court, you will be responsible for any court filing fees or similar related costs that may be necessary during the appeal's process. If you require an attorney or expert medical testimony, you will be responsible for any fees or costs incurred.

HIPAA PRIVACY

The SHBP Employee Dental Plans make every effort to safeguard the health information of its members and complies with the privacy provisions of the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA requires health plans to maintain the privacy of any personal information relating to its members' physical or mental health. See Appendix D for the State Health Benefits Program's Notice of Privacy Practices.

AUDIT OF DEPENDENT COVERAGE

Periodically, the SHBP performs an audit using a random sample of members to determine if dependents are eligible under plan provisions. Proof of dependency such as a marriage certificate or birth certificate is required. Coverage for ineligible dependents will be terminated. Failure to respond to the audit will result in the termination from coverage of dependents.

SECTION TWO

THE DENTAL EXPENSE PLAN

The Dental Expense Plan is an indemnity plan that will reimburse you for a portion of the expenses you, and your enrolled dependents, incur for dental care provided by dentists or physicians licensed to perform dental services in the state in which they are practicing. Not all dental services are eligible for reimbursement, and some services are eligible only up to a limited amount. (For example, orthodontic services are reimbursed differently than other services.) Diagnostic/preventive and orthodontic services, are not subject to the deductible. For all other services, a deductible amount must be met before expenses are reimbursed. You are responsible for making the full payment of all charges to your dentist.

The Dental Expense Plan has been established by the State as a self-funded plan. The State currently contracts with Aetna to act as the administrative agent for the Plan.

As a Dental Expense Plan member you may be able to take advantage of a special Aetna network of participating dental providers. In this network, participating dental providers contract with Aetna for a discounted fee schedule. When you use a participating dental provider, you only pay the provider any applicable deductible and the appropriate coinsurance based on the discounted fee, thereby reducing your out-of-pocket cost. In many cases the participating dental provider will submit the claims directly to Aetna, eliminating the necessity of your filing claim forms. To find out if your provider participates in the discounted network, call Aetna at 1-877-238-6200.

Deductibles

Diagnostic/preventive and orthodontic services are not subject to a deductible amount. For other services, the first $50 of covered expenses that you or your dependent(s) incur in a calendar year is not eligible for reimbursement. However, if there are four or more members of your family in the Plan, no additional deductibles are charged after any three members have each met their $50 deductible.

Reasonable and Customary Charges

The Dental Expense Plan covers only that part of a provider's charge for a service or supply that is reasonable and customary. Generally speaking, a charge by your dentist, or by any other provider of services or supplies, is considered reasonable and customary if it doesn't exceed the prevailing charge for the same service or supply made by similar providers in the same geographic area. It may differ from the actual amount that your dentist charges. You are responsible for the amount the dentist charges above the reasonable and customary allowances.

Levels of Reimbursement

After a person meets his or her $50 deductible (if applicable), the costs of all other eligible services for that person are reimbursed at a percentage of the reasonable and customary charge for the service (except where certain limits apply and subject to benefit maximums). The reimbursement percentages are as follows:

100% Diagnostic and Preventive (No deductible applicable)

80% Basic Services

65% Major Restorative

50% Periodontics and Prosthodontics

50% Orthodontics (No deductible applicable; separate $1000 lifetime benefit maximum)

A general description of each category of services is provided below. Refer to "Services That are Eligible for Reimbursement" for any limitations that may apply to the services described below.

Diagnostic and Preventive services are precautionary services and are intended to maintain oral health and reduce the effects of tooth decay or gum disease which could lead to an increased need for more costly restorative services. They include the following:

• Oral Evaluations (includes comprehensive, periodic, limited, and specialist oral evaluations)
  
  
• Prophylaxis (cleaning of the teeth, including scaling and polishing procedures)
  
  
• Fluoride Treatments (topical application of fluoride for children under age 19)
  
  
• X-rays (limitations may apply)
  
  
• Laboratory and other Diagnostic Tests

Basic Services include:

• Emergency Treatment (Palliative only)
  
  
• Space Maintainers (i.e., passive appliances – can be fixed or removable)
  
  
• Simple Extractions
  
  
• Surgical Extractions
  
  
• Oral Surgery
  
  
• Anesthesia Services
  
  
• Basic Restorations (i.e., amalgam restorations and resin restorations)
  
  
• Endodontics (i.e., treatment of diseases of the dental pulp, including root canal and associated therapy)
  
  
• Repairs to removable dentures

Major Restorative services include those services that restore existing teeth. These services are utilized only if a tooth can not be restored with an amalgam, acrylic, synthetic porcelain, or composite filling restoration. Inlays/Onlays/Crowns are typical examples of major restorative services.

Periodontal services include those services involving the maintenance, reconstruction, regeneration and treatment of the supporting structures surrounding teeth, including bone, gum tissue, and root surfaces.

Prosthodontic services include both removable and fixed dentures (bridges) replacing missing teeth.

Orthodontic services correct abnormalities in tooth position (malposition) or abnormal bite (malocclusion), using appliances such as retainers or braces.

Annual Benefit Maximum

The most the plan will pay for any one person in any one calendar year is $3,000. This maximum applies to all eligible services except orthodontic, which has a separate $1,000 lifetime benefit maximum.

How Payments Are Made

Normally, reimbursements will be made to the Dental Expense Plan subscriber. The Plan subscriber may, however, authorize Aetna to send the reimbursement directly to the dental provider by completing the appropriate part of the claim form.

Additionally, whenever a law or court order requires the payment of dental expense benefits under the Plan to be made to a person or facility other than the Plan subscriber, the payment will be made to that person or facility upon proper notification (letter and a copy of the order/law).

Filing Deadline - Proof of Loss

Aetna must be given written proof of a loss for which a claim is made under the coverage. This proof must cover the occurrence, character, and extent of the loss. It must be furnished within one year and 90 days of the end of the calendar year in which the services were incurred. For example, if a service were incurred in the year 2004, you would have until March 31, 2006, to file the claim.

A claim will not be considered valid unless proof is furnished within the above time limit. If it is not possible for you to provide proof within the time limit, the claim may be considered valid upon appeal if the reason the proof was not provided in a timely basis was reasonable.

Itemized Bills are Necessary

You must obtain itemized bills from the providers of services for all dental expenses. The itemized bills must include the following:

• Name and address of provider
  
  
• Provider's tax identification number
  
  
• Name of patient
  
  
• Date of service
  
  
• Diagnosis
  
  
• Type of service
  
  
• CPT 4 code
  
  
• Charge for each service

Predetermination of Benefits

Predetermination allows you to know what services are covered and what payments will be made for treatment before the work is done. If you or one of your dependents are likely to incur dental expenses over $300, it is strongly recommended that you ask your dentist to file for predetermination of benefits.

This feature of the Dental Expense Plan ensures that both you and the dentist will know in advance what part of the dentist’s charges the Plan will pay. If possible, treatment should be completed within 90 days of receiving the approved predetermination.

The predetermination of benefits provision of the Dental Expense Plan is important because under the alternate procedures provision, Aetna has the right to pay the reasonable and customary amount for the method of treatment that is proper and is economically sound (see Charge Limits). If you and the dentist decide you want a more costly treatment method, you are responsible for the charges beyond those for the less costly, appropriate treatment.

Here’s How It Works

Predetermination of benefits will help you avoid surprises. Most dentists are familiar with predetermination procedures, but if not, they should call Aetna at 1-877-238-6200.

If your dentist submits a treatment plan for predetermination of benefits and then alters the course of treatment, Aetna will adjust its payments accordingly. If the dentist makes a major change in the treatment plan, he/she should send in a revised plan.

DENTAL BENEFITS AT A GLANCE

SERVICES THAT ARE ELIGIBLE FOR REIMBURSEMENT

(Please see the Glossary for definition of terms.)

• Oral evaluations (limited to once per 6 month interval). Emergency or limited oral evaluations are covered, limited to one evaluation per patient, per year. Covered at 100%.
  
  
• X-rays. (horizontal bitewing X-rays limited to one series of up to 4 films per six month interval; vertical bitewing X-rays limited to one series of up to 8 films per 12 month interval; set of full mouth X-rays limited to once per 36 month interval; no more than 18 films per set of full mouth periapical X-rays).
  
  
• Oral prophylaxis, including scaling (not including scaling performed by a periodontist) and polishing (limited to once per 6 month interval).
  
  
• Topical application of fluoride for children under age 19 limited to once per 6 month interval. · Sealants (limited to once per lifetime for permanent molars of eligible dependent children under the age of 19 years).
  
  
• Prosthodontic procedures (the replacement of an existing removable prosthetic appliance is covered only after a 5 year period measured from the date on which the appliance was previously placed).
  
  
• Periodontic procedures (reimbursement for periodontal surgical procedures, usually provided for a specific quadrant, is limited to one surgical-type procedure every 36 months). Reimbursement for periodontal scaling and root planing procedures per specific quadrant is limited to one procedure per 12 month interval.
  
  
• Periodontal surgical procedures, usually provided for specific quadrants, are subject to a reduced reimbursement when the number of diseased teeth in a quadrant are less than 4. Additional reduction in benefits may apply, when multiple types of procedures are provided in the same quadrant, at the same appointment.
  
  
• Restorative procedures, including fillings, inlays, onlays, and crowns (the replacement of a crown is covered only after a 5 year period measured from the date on which the crown was previously placed).
  
  
• Emergency palliative treatment.
  
  
• Extractions of teeth.
  
  
• Endodontic services, such as pulpotomy and root canal therapy.
  
  
• Space maintainers.
  
  
• Oral surgery for surgical extractions, treatment of fractures, removal of lesions of the mouth, and alveolectomy.
  
  
• Apicoectomy.
  
  
• General anesthesia (including conscious sedation coverage) when medically necessary and in connection with covered oral and periodontal surgical procedures.

Charge Limits on Services

Two or more services may each be suitable for the dental care of a specific condition, under usual dental practice. If a charge is incurred for one of these services, Aetna may consider the charge to have been incurred for the other service which would have produced a professionally acceptable result, as determined by Aetna, and may pay only the lower of the two services.

Services That Are Not Eligible for Reimbursement

• Any orthodontic service prior to the employee attaining 10 months of employment or for any member over 19 years of age (see the separate section for special coverage for orthodontic service).
  
  
• Gold restorations other than crowns, inlays, and onlays.
  
  
• Any service or item not reasonably necessary for the dental care of the patient.
  
  
• Endosteal, subperiosteal and transosteal tooth implants, protective devices such as athletic mouth guards, plaque control, or myofunctional therapy.
  
  
• A charge in connection with appliances, restorations, or procedures needed to alter vertical dimensions or restore occlusion, or for the purpose of splinting or correcting attrition, abrasion, or erosion.
  
  
• Crowns, inlays, and onlays if used in splinting procedures during periodontal treatment.
  
  
• A service for cosmetic purposes.
  
  
• Any charge for a supply that is normally for home use such as toothpaste, toothbrushes, water-pick, or mouthwash.
  
  
• A dental examination when required as a condition of employment by an employer, a government agency, or the terms of a labor agreement.
  
  
• Charges not reasonably necessary made to produce a professionally acceptable result.
  
  
• A service or supply due to a war or any act of war.
  
  
• A service not furnished by a dentist or physician licensed to provide the dental service, except for a service performed by a licensed dental hygienist under the direction of a dentist.
  
  
• A service rendered by a provider that is beyond the scope of the provider's license.
  
  
• A charge made by a dentist for a failure of the patient to keep an appointment.
  
  
• A charge for the completion of any claim forms.
  
  
• A charge in connection with any procedure started before the patient was eligible for reimbursement in this plan; except that a procedure will not have been considered to have started with an oral prophylaxis or a diagnostic procedure.
  
  
• Any service or supply other than those specifically covered under this plan.
  
  
• Any service or supply which is furnished or made available to a patient or financed by federal, State, or local government, including Medicare or a like program, Workers' Compensation law or a similar law, any automobile no-fault law, or any other program or law under which the patient is or could be covered, whether or not the patient makes any claim or receives compensation under it.
  
  
• Any charge incurred after the patient is no longer covered, except in the case of an Extension of Coverage.
  
  
• Any charge for a service that is more than the reasonable and customary dental charge.
  
  
• Any charge for a service rendered by a member of the patient’s immediate family (including you, your spouse or domestic partner, your child, brother, sister, or parent of you or your spouse or domestic partner).
  
  
• Any charge for a service rendered by a member of the patient's immediate family (including you, your spouse or domestic partner, your child, brother, sister, or parent of you or your spouse or domestic partner).
  
  
• Charges for sterilization or asepsis.

ORTHODONTIC SERVICES

Certain charges for orthodontic procedures are eligible if:

• You have been a full-time employee for at least 10 months.
  
  
• The orthodontic treatment is for a child covered under the Dental Expense Plan who is less than 19 years old.
  
  
• The procedure involves the use of active appliances to move teeth in order to correct the faulty position of teeth (malposition) or abnormal bite (malocclusion).
  
  
• The service or supply is part of a treatment plan submitted by the dentist and ap- proved by Aetna with an estimate of the benefits that are payable.
  
  
• The service or supply is furnished before the end of the estimated duration of the treatment as recorded in the treatment plan.
  
  
• An active appliance for the procedure is inserted while the person is eligible for benefits in this plan.

Orthodontic Benefits

Eligible orthodontic services will be covered at a 50 percent coinsurance level, up to a lifetime benefit maximum of $1,000. There is no deductible for orthodontic services.

Orthodontic Charges That Are Not Eligible

Charges that are eligible for coverage under the regular dental care portion of the plan.

• Charges for an orthodontic procedure started prior to the day on which the person became covered under the plan or eligible for orthodontic benefits.
  
  
• Charges not reasonably necessary for orthodontic care.
  
  
• Any charges incurred for orthodontic procedures or treatment begun on or after the date the person attains age 19.
  

If you and your dependents are also covered for dental expenses by other plans, certain rules apply that determine which plan provides the primary coverage and how much each plan will reimburse you. The purpose of these rules is to prevent a combined reimbursement from both plans that exceeds the expenses that you actually incur. Although there may be special cases not described here, the basic determination of which plan provides primary coverage is as follows:

• The employee's primary dental coverage is provided by the DPO.
  
  
• If your spouse or eligible same-sex domestic partner is enrolled as your dependent and is also covered by a dental plan through his or her employer, your spouse's oe domestic partner's primary coverage is through the dental plan offered by his or her employer.
  
  
• If your children are enrolled as dependents in your plan and your spouse's or eligible same-sex domestic partner's plan, their primary coverage is provided by the dental plan of the parent whose birthday falls earlier in the year. If your spouse's or domestic partner's plan does not follow this rule, then the rule in the other plan or program will determine the order of benefits.
  
  
• In the case of a separation, divorce, dissolution of a domestic partnership, or parents who are not married, the primary coverage for a child is provided in this order: by the plan of the parent who is legally responsible for the dental expenses of the child; by the plan of the parent with custody of the child; by the plan of the spouse or domestic partner of the parent with custody of the child; or by the plan of the noncustodial parent.

SECTION THREE

THE DENTAL PLAN ORGANIZATIONS

A Dental Plan Organization (DPO) is similar to a medical Health Maintenance Organization (HMO) plan. The full cost for most services is prepaid to your dentist, but certain services require an additional copayment from you. Also, if you choose a more expensive treatment than deemed appropriate by your dental provider, you must pay the extra cost. Further, you will not be covered for services if you go to a dentist who is not a member of your DPO, unless referred by your DPO dentist.

• There are many Dental Plan Organizations in the SHBP Employee Dental Plans. Among these organizations, there are two types of plans – Dental Center and Individual Practice Associations (IPA). Dental Centers employ a group of dentists and technicians who are located at a central office. In a Dental Center Plan, you do not have the option to select a particular dentist unless permitted by the Dental Center.
  
  
• An Individual Practice Association (IPA) consists of a network of participating dentists who work in their own offices. If you choose an IPA, you must select a specific dentist in the IPA who will treat you and your dependents.

Some DPOs offer both a dental center and a list of participating dentists, thereby giving you the option of selecting a center or a particular dentist.

The DPO is responsible for providing all of the services that are listed as covered in this booklet. If the participating dentist that you have selected does not provide a specific service, then the DPO must refer you to another participating dentist located within 10 miles of your dentist’s office (or 20 miles for orthodontic service). If you agree, the DPO may also refer you to a dentist located beyond these limits.

• If the DPO dentist refers you to another dentist and that referral is approved by the DPO, then you will have the same coverage for the service as if you had been treated by your dentist. However, if you select an outside dentist on your own, the service you receive will not be covered.
  

CONSIDERATIONS IN CHOOSING A DPO

• Obtain a list of DPOs and participating dentists from your benefits administrator. If you choose a dentist rather than a Dental Center, check with the DPO and the dentist to be sure that the dentist is a member of the DPO, services SHBP Employee Dental Plan members, and will accept you as a new patient.
  
  
• If you choose a dentist, you should also check with the dentist to make sure that he or she plans to stay in the DPO. If the dentist leaves, you will then have to select another dentist in that DPO.
  
  
• You should also check to determine that the DPO dentist or center could serve the needs of your entire family and whether the days and hours of operation are convenient for you and your family.
  
  
• If your dentist leaves the DPO, and there are no other dentists in the DPO within 30 miles of your home, you may switch to another dental plan (either another DPO or the Dental Expense Plan).

COORDINATION OF BENEFITS WITH OTHER INSURANCE PLANS

There is no coordination of benefits between any two SHBP Employee Dental Plans because no individual is eligible for coverage in more than one SHBP Employee Dental Plan.

If you and your dependents are also covered for dental expenses by other plans, certain rules apply that determine which plan provides the primary coverage and how much each plan will reimburse you. The purpose of these rules is to prevent a combined reimbursement from both plans that exceeds the expenses that you actually incur. Although there may be special cases not described here, the basic determination of which plan provides primary coverage is as follows:

• The employee’s primary dental coverage is provided by the DPO.
  
  
• If your spouse or eligible same-sex domestic partner is enrolled as your dependent and is also covered by a dental plan through his or her employer, your spouse’s or domestic partner's primary coverage is through the dental plan offered by his or her employer.
  
  
• If your children are enrolled as dependents in your plan and your spouse’s or eligible same-sex domestic partner's plan, their primary coverage is provided by the dental plan of the parent whose birthday falls earlier in the year. If your spouse’s or domestic partner's plan does not follow this rule, then the rule in the other program will determine the order of benefits.
  
  
• In the case of a separation, divorce, or the dissolution of a domestic partnership, the primary coverage for a child is provided in this order: by the plan of the parent who is legally responsible for the dental expenses of the child; by the plan of the parent with custody of the child; by the plan of the spouse or domestic partner of the parent with custody of the child; or by the plan of the noncustodial parent.

COVERED SERVICES

The following is a list of covered services and, if applicable, copayments. Copayment means what you must pay for the service. Some of these terms may be unfamiliar to you. Please see the Glossary.

Orthodontics

(Treatment plan maximum of 24 months)

1. Patient under 18 years of age at the start of treatment — Class I, II, and III malocclusion (copayment required of $1,000 or 50% of bill, whichever is less).

2. Patient 18 years of age or over at the start of treatment — Class I, II, and III malocclusion (copayment required of $1,750 or 50% of bill, whichever is less). Includes Invisalign as an optional treatment procedure — this procedure may fall under the "More Expensive Services" option and as such, the member choosing this option would be responsible for the difference between Invisalign charges and the standard adult orthodontic charge.

Services That Are Not Covered By the DPO

• A service started before the person became a covered individual under the plan.
  
  
• A service covered under any medical or surgical or major medical plan (including a health maintenance organization) provided by the employer.
  
  
• Replacement of lost, stolen, or damaged prosthodontic devices within two years of the date of initial installation.
  
  
• A service not reasonably necessary for the dental care of a covered individual or provided solely for cosmetic purposes.
  
  
• Providing supplies of a type normally intended for home use, such as toothpaste, toothbrushes, waterpicks, and mouthwash.
  
  
• A service required because of war or an act of war.
  
  
• A service made available to a covered individual or financed by the federal government or a state or local government. This includes the federal Medicare program and any similar federal program, any Workers' Compensation law or similar law, any automobile no-fault law, or any other program or law under which the covered individual is, or could be, covered. The exclusion is applicable whether or not the covered individual receives the service, makes a claim or receives compensation for the service, or receives a recovery from a third party for damages.
  
  
• A service not furnished by a dentist. This is not applicable to a service performed by a licensed dental hygienist under the supervision of a dentist.
  
  
• General anesthesia, except when medically necessary in connection with covered oral and periodontal surgery procedures.
  
  
• Hospitalization.
  
  
• Any dental implant including any crowns, prostheses, devices, or appliances attached to implants.
  
  
• Experimental procedures.
  
  
• Appliances, restorations, and procedures to alter vertical dimension and/or restore occlusion, including temporomandibular joint dysfunction, except oral splints.
  
  
• Procedures not listed.

More Expensive Services

A covered individual may elect a more expensive procedure than an appropriate procedure recommended by the DPO. The covered individual shall pay any copayment required for the less expensive procedure plus the difference in cost between the two procedures on the basis of the reasonable and customary dental charges for the procedures.

Emergency Services — Out-of-Area

Emergency Treatment is defined as, "when a covered SHBP member or dependent is at least 50 miles from home, any necessary service or procedure which is rendered as the direct result of an 'unforeseen' occurrence and requires immediate, urgent action or remedy". Examples are, acute pain, bleeding, fractured tooth, broken filling, broken front tooth broken denture, and lost or loose crown. The reimbursement shall be at the full amount of the charge up to a maximum of $100 per episode.

SECTION FOUR

APPENDIX A

GLOSSARY

APPENDIX B

AVAILABLE DENTAL PLANS (see note below)

*If a county is listed as not served, there are an insufficient number of dental providers within the county for the respective DPO network. For specific areas of service, contact the DPO or see your benefits administrator for a list of dental providers for each DPO.

APPENDIX C

TAX$AVE

Tax$ave is a benefit program defined by Section 125 of the federal Internal Revenue Code that allows eligible New Jersey State employees to use pre-tax dollars to pay for qualified medical, dental, and dependent care expenses and thereby increase their take-home pay. The pre-tax deduction effectively reduces the salary on which taxes are computed by the amount of the health, dental, or dependent care deduction.

Your participation in the SHBP Employee Dental Plans may be affected by two components of Tax$ave — the Unreimbursed Medical Spending Account and the Premium Option Plan (POP).

Unreimbursed Medical Spending Accounts

If you elect to establish an Unreimbursed Medical Spending Account under the Tax$ave Program, a predetermined amount is deducted from your pre-tax salary each pay period and set aside in your account. Then, any eligible out-of-pocket expense (copayments, deductibles, coinsurances) that you make in the SHBP Employee Dental Plans can be paid from that account. This saves you tax dollars by allowing you to pay these expenses using your pre-tax income.

Premium Option Plan

The Premium Option Plan (POP) allows eligible New Jersey State employees to make payments for basic health and dental premiums on a pre-tax basis and thereby increase their take-home pay. Any increase in take-home pay will depend on the medical and/or dental plan selected and the level of coverage (single, member and spouse, parent and child(ren) or family).

As a State employee enrolled in the SHBP Employee Dental Plans you are automatically enrolled in the POP— since you share in the premium cost of the dental plan program with the State through payroll deductions — unless you decline enrollment at the time you first become eligible for health and dental plan coverage or during the Tax$ave Open Enrollment period (see "Declining POP").

Effect of POP Participation on Dental Program Rules and Procedures

The Tax$ave Program is strictly regulated by the Internal Revenue Service (IRS) because of the tax advantages provided under the POP. IRS rules require that for an employee covered by the POP, payroll deductions for medical and/or dental plan benefits remain the same for the entire plan year. Therefore, no coverage level changes can be made to your dental plan enrollment that would result in a change in the amount of your dental plan deduction unless a "qualifying event" occurs. If a qualifying event does occur (see below), you may make a change by submitting a completed dental plan application to your employer within 60 days of a qualifying event or during the annual Tax$ave Open Enrollment period.

Qualifying Events:

• A marriage (you may enroll your spouse and any other eligible dependents).
  
  
• Addition of an eligible dependent due to birth, adoption, or legal guardianship.
  
  
• A change in family status involving the loss of eligibility of a family member (separation, divorce, death, child marries, no longer lives at home, or is no longer eligible due to age).
  
  
• A move outside an HMO service area.
  
  
• The termination of your employment for ay reason, including retirement.
  
  
• An approved unpaid leave of absence (you may elect enrollment in the POP upon return to active employment).
  
  
• A change in your spouse's or eligible dependent's employment status resulting in their loss of health and/or dental coverage.
  
  
• A child, under the age of 23, has divorced and moves back into your household and is dependent upon you for support and maintenance.
  
  
• Such other events that may be determined to be appropriate and in accordance with applicable IRS regulations.

Declining POP

Since enrollment is automatic for employees with medical or dental plan deductions, a newly hired employee who does not want to participate in the POP may decline participation by completing a Declination of Premium Option Plan form that can be obtained from the employee's Human Resources Representative or Payroll clerk.

Domestic Partners and Tax$ave

The Internal Revenue Service does not recognize a New Jersey same-sex domestic partner as a dependent for tax purposes in the same manner that it recognizes a spouse or dependent children of an employee. Therefore, your employer may have to treat the same-sex domestic partner SHBP benefit as federally taxable.

As a result, a same-sex domestic partner must be able to qualify as a “tax dependent” of the employee for federal tax filing purposes — under Internal Revenue Code Section 152 — before an out-of-pocket medical expense incurred by the same-sex domestic partner can be reimbursed under the Unreimbursed Medical Spending Account and before any premiums that the employee pays for the same-sex domestic partner coverage can be made on a pre-tax basis under the Premium Option Plan. See IRS Tax Topic 354 - Dependents for additional information on the requirements for establishing dependent status for federal tax purposes.

If the same-sex domestic partner is not a “qualified tax dependent” of the employee, the domestic partner's SHBP coverage is considered federally taxable and the employee cannot be reimbursed under the Unreimbursed Medical Spending Account for any out-of-pocket medical expense incurred by the domestic partner, nor make pre-tax payments for the cost of the domestic partner's coverage under the Premium Option Plan. (Pre-tax dollars may still be used to pay for the employee's portion of the cost of his or her own and dependent children's coverage.)

The same-sex domestic partner SHBP benefit is not subject to New Jersey State income tax. If you live outside of New Jersey, you should check with your State's tax agency to determine if the same-sex domestic partner SHBP benefit is subject to state taxes.

Additional information about the New Jersey Domestic Partnership Act can be found in Fact Sheet #71, Benefits Under the Domestic Partnership Act.

For More Information

Fact Sheet #44, Tax$ave, outlines the Tax$ave Program and may be obtained from your benefits administrator or from the Division of Pensions and Benefits.

You can also visit the Division of Pensions and Benefits’ Tax$ave Internet page at: www.state.nj.us/treasury/pensions/taxsave.htm

APPENDIX D

NOTICE OF PRIVACY PRACTICES TO ENROLLEESIN THE NEW JERSEY STATE HEALTH BENEFITS PROGRAM

Protected Health Information

The State Health Benefits Program (SHBP) is required by the federal Health Insurance Portability and Accountability Act (HIPAA) and State laws to maintain the privacy of any information that is created or maintained by the SHBP that relates to your past, present, or future physical or mental health. This Protected Health Information (PHI) includes information communicated or maintained in any form. Examples of PHI are your name, address, Social Security number, birth date, telephone number, fax number, dates of health care service, diagnosis codes, and procedure codes. PHI is collected by the SHBP through various sources, such as enrollment forms, employers, health care providers, federal and State agencies, or third-party vendors.

The SHBP is required by law to abide by the terms of this Notice. The SHBP reserves the right to change the terms of this Notice. If the SHBP makes material change to this Notice, a revised Notice will be sent.

SHBP Uses and Disclosures of PHI

The SHBP is permitted to use and to disclose PHI in order for our members to obtain payment for health care services and to conduct the administrative activities needed to run the SHBP without specific member authorization. Under limited circumstances, we may be able to provide PHI for the health care operations of providers and health plans. Specific examples of the ways in which PHI may be used and disclosed are provided below. This list is illustrative only and not every use and disclosure in a category is listed.

• The SHBP may disclose PHI to a doctor or a hospital to assist them in providing a member with treatment.
  
  
• The SHBP may use and disclose member PHI so that our Business Associates may pay claims from doctors, hospitals, and other providers.
  
  
• The SHBP receives PHI from employers, including the member's name, address, Social Security number, and birth date. This enrollment information is provided to our Business Associates so that they may provide coverage for health care benefits to eligible members.
  
  
• The SHBP and/or our Business Associates may use and disclose PHI to investigate a complaint or process an appeal by a member.
  
  
• The SHBP may provide PHI to a provider, a health care facility, or a health plan that is not our Business Associate that contacts us with questions regarding the member's health care coverage.
  
  
• The SHBP may use PHI to bill the member for the appropriate premiums and reconcile billings we receive from our Business Associates.
  
  
• The SHBP may use and disclose PHI for fraud and abuse detection.
  
  
• The SHBP may allow use of PHI by our Business Associates to identify and contact our members for activities relating to improving health or reducing health care costs, such as information about disease management programs or about health-related benefits and services or about treatment alternatives that may be of interest to them.
  
  
• In the event that a member is involved in a lawsuit or other judicial proceeding, the SHBP may use and disclose PHI in response to a court or administrative order as provided by law.
  
  
• The SHBP may use or disclose PHI to help evaluate the performance of our health plans. Any such disclosure would include restrictions for any other use of the information other than for the intended purpose.
  
  
• The SHBP may use PHI in order to conduct an analysis of our claims data. This information may be shared with internal departments such as auditing or it may be shared with our Business Associates, such as our actuaries.

Except as described above, unless a member specifically authorizes us to do so, the SHBP will provide access to PHI only to the member, the member's authorized representative, and those organizations who need the information to aid the SHBP in the conduct of its business (our "Business Associates"). An authorization form may be obtained over the Internet at www.state.nj.us/treasury/pensions, by e-mailing hipaaform@treas.state.nj.us, or by calling the Division of Pensions and Benefits at (609) 777-4355. A member may revoke an authorization at any time.

When using or disclosing PHI, the SHBP will make every reasonable effort to limit the use or disclosure of that information to the minimum extent necessary to accomplish the intended purpose. The SHBP maintains physical, technical and procedural safeguards that comply with federal law regarding PHI.

Member Rights

Members of the SHBP have the following rights regarding their PHI:

Right to Inspect and Copy: With limited exceptions, members have the right to inspect and/or obtain a copy of their PHI that the SHBP maintains in a designated record set which consists of all documentation relating to member enrollment and the SHBP's use of this PHI for claims resolution. The member must make a request in writing to obtain access to their PHI. The member may use the contact information found at the end of this Notice to obtain a form to request access.

Right to Amend: Members have the right to request that the SHBP amend the PHI that we have created and that is maintained in our designated record set.

We cannot amend demographic information, treatment records or any other information created by others. If members would like to amend any of their demographic information, please contact your personnel office. To amend treatment records, a member must contact the treating physician, facility, or other provider that created and/or maintains these records.

The SHBP may deny the member's request if: 1) we did not create the information requested on the amendment; 2) the information is not part of the designated record set maintained by the SHBP; 3) the member does not have access rights to the information; or 4) we believe the information is accurate and complete. If we deny the member's request, we will provide a written explanation for the denial and the member's rights regarding the denial.

Right to an Accounting of Disclosures: Members have the right to receive an accounting of the instances in which the SHBP or our Business Associates have disclosed member PHI. The accounting will review disclosures made over the past six years or back to April 14, 2003, whichever period is shorter. We will provide the member with the date on which we made a disclosure, the name of the person or entity to whom we disclosed the PHI, a description of the information we disclosed, the reason for the disclosure, and certain other information. Certain disclosures are exempted from this requirement (e.g., those made for treatment, payment or health benefits operation purposes or made in accordance with an authorization) and will not appear on the accounting.

Right to Request Restrictions: The member has the right to request that the SHBP place restrictions on the use or disclosure of their PHI for treatment, payment, or health care operations purposes. The SHBP is not required to agree to any restrictions and in some cases will be prohibited from agreeing to them. However, if we do agree to a restriction, our agreement will always be in writing and signed by the Privacy Officer. The member request for restrictions must be in writing. A form can be obtained by using the contact information found at the end of this Notice.

Right to Request Confidential Communications: The member has the right to request that the SHBP communicate with them in confidence about their PHI by using alternative means or an alternative location if the disclosure of all or part of that information to another person could endanger them. We will accommodate such a request if it is reasonable, if the request specifies the alternative means or locations, and if it continues to permit the SHBP to collect premiums and pay claims under the health plan.

To request changes to confidential communications, the member must make their request in writing, and must clearly state that the information could endanger them if it is not communicated in confidence as they requested.

Questions and Complaints

If you have questions or concerns, please contact the SHBP using the information listed at the end of this Notice.

If members think the SHBP may have violated their privacy rights, or they disagree with a decision made about access to their PHI, in response to a request made to amend or restrict the use or disclosure of their information, or to have the SHBP communicate with them in confidence by alternative means or at an alternative location, they must submit their complaint in writing. To obtain a form for submitting a complaint, use the contact information found at the end of this Notice.

Members also may submit a written complaint to the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.

The SHBP supports member rights to protect the privacy of PHI. It is your right to file a complaint with the SHBP or with the U.S. Department of Health and Human Services.

Contact Office: The State Health Benefits Program—HIPAA Privacy Officer

Address:
State of New Jersey
Department of the Treasury
Division of Pensions and Benefits
Bureau of Policy and Planning
PO Box 295
Trenton, NJ 08625-0295

Telephone: (609) 777-4355

Fax: (609) 341-3410

E-mail: hipaaform@treas.state.nj.us

APPENDIX E

CONTACT INFORMATION
DIVISION OF PENSIONS AND BENEFITS

MAILING ADDRESSES:

Division of Pensions and Benefits
Office of Client Services
PO Box 295
Trenton, NJ 08625-0295

State Health Benefits Commission
Division of Pensions and Benefits
PO Box 299
Trenton, NJ 08625-0299

On all correspondence, be sure to include your Social Security number and a daytime telephone number.

TELEPHONE NUMBERS:

Division of Pensions and Benefits,
Office of Client Services — (609) 292-7524

Telephone Counselors available 8:30 a.m. to 4:00 p.m., Monday through Friday (except holidays).

TDD Phone (Hearing Impaired) — (609) 292-7718

COUNSELING SERVICES:

Division of Pensions and Benefits
Office of Client Services
50 West State Street, First Floor
Trenton, NJ

Counselors are available by appointment Monday through Friday from 7:40 AM to 3:40 PM.
Counseling appointments can be made online at: www.state.nj.us/treasury/pensions

E-mail the Division of Pensions and Benefits at:

Division of Pensions and Benefits Internet home page:

To download a PDF version of this handbook, click here. Size 144K (Requires Acrobat Reader available free from Adobe.)

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