Enroll
Eligible Employees
The employer benefits representative
should enroll eligible employees as soon as possible so their
applications can be processed and the necessary information can
be provided to the insurance carrier prior to the effective date
of coverage. Generally, enrollment is effective approximately
60 days after the date of hire. The effective date of coverage
for State biweekly employees is determined by the payroll schedule
of Centralized Payroll, but will also be approximately 60 days
after hire.
The four employer responsibilities
in enrollment are:
- To determine
employee eligibility;
- To ensure and assist the eligible
employee to complete the appropriate Health Benefits Application;
- To certify
and submit the Health Beneifts Application to the Division
of Pensions and Benefits in a timely manner; and
- To provide new employee with with
written notification of the requirements
of the federal COBRA and HIPAA laws.
1.
Determine Eligibility
Eligibility for Coverage, State
Employees
To be eligible for coverage, a State
employee must meet the "actively at work" requirements,
and work full-time or be an appointed or elected officer of the
State of New Jersey.
For State employees, "full-time"
means the normal full-time weekly schedule for the particular
title held; 35 hours per week is normally required for "full-time"
status.
Any newly appointed or elected official is required to work a minimum of 35 hours per week to be considered "full-time" and eligible for coverage under the SHBP.
Under Chapter 172, P.L.
2003, certain part-time employees of the State
of New Jersey, and part-time faculty members at New Jersey public
institutions of higher education (State colleges, State universities,
and county community colleges), who are members of a State-administered
retirement system, are eligible for enrollment for coverage in
the State Health Benefits Program. (See below
for details).
Certain State intermittent employees are also eligible for SHBP coverage, see below.
Eligibility for Coverage, Local
Employees
To be eligible for local employer
SHBP/SEHBP coverage, a local employee must appear on regular payroll
and work full-time or be an appointed
or elected officer receiving a salary.
Any newly appointed or elected official is required to work a minimum of 35 hours per week to be considered "full-time" and eligible for coverage under the SHBP/SEHBP.
Certain part-time
local employees — part-time faculty members at New Jersey
county community colleges — are now eligible for SHBP coverage,
see below.
In the case of local employer coverage,
the average number of hours per week required for a local employee
to have "full-time" status shall be prescribed
by the governing body of the participating employer.
In order for an employee of a local employer hired after May 21, 2010 to be
eligible for coverage under the SHBP/SEHBP, he or she will be required to work a minimum number of hours per week as determined by resolution of the governing body of the local employer but in no instance will the minimum hours be less than 25.
Any employee or officer of the local employer or the State who met the minimum work hour requirements prior to May 21, 2010 will be eligible for continued coverage under the SHBP/SEHBP provided there is no break in the employee’s service or reduction in work hours.
Resolution
to establish the number of hours constituting "full-time"
status.
Full-time also means employment
for 12 months per year, except in the case of employees whose
regular and normal work schedule is contractually established
at 10 months per year.
Appointed or Elected Officials:
An appointed or elected officer of a local employer who is compensated
on a fee basis as the method of payment of wages or salary, but
who is not a self-employed
independent contractor compensated on a fee basis, may also
be eligible for local employee coverage. To qualify for coverage
as an appointed officer, a person must be appointed to an office
specifically established by law, ordinance, resolution, or another
official action required by law as a method of establishing a
public office by an appointing authority.
An individual appointed under a general
authorization, that is, the specific office to which the person
is appointed has not been established by law, ordinance, resolution,
or another official action required by law to establish a public
office by an appointing authority, is not eligible to participate
in the program as an appointed officer. An officer appointed under
a general authorization must qualify for participation in the
SHBP/SEHBP as a full-time employee.
Eligibility for Coverage, State
Part-time Employees and Part-time Faculty Members Employed at
NJ Public Institutions of Higher Education (NJ State Colleges,
State Universities, and County Community Colleges)
Chapter 172, P.L. 2003, effective
January 1, 2004, extends eligibility for enrollment for coverage
in the SHBP/SEHBP to some part-time
employees of the State of New Jersey and part-time faculty members
employed at New Jersey public institutions of higher education
(New Jersey State colleges, State universities, or county community
colleges), as long as they are members of a State-administered
retirement system.
Part-time employees of the Palisades
Interstate Parkway Commission, the New Jersey Building Authority,
and the New Jersey Commerce and Economic Growth Commission are
also eligible.
Eligible part-time employees may
enroll in a SHBP/SEHBP medical plan and corresponding Prescription Drug Plan,
or a medical plan only, and must pay the full cost of coverage for the
level of coverage selected. The SHBP/SEHBP determines whether an employee is eligible for coverage.
Part-time employees who enroll in
the SHBP/SEHBP will be billed monthly for the cost of the coverage selected.
There are separate
rate charts listing the cost of this coverage.
Employees eligible for this
coverage should use the appropriate Part-time
Employees Group — Health Benefits
Application to enroll. Otherwise, employers should follow
the same steps for SHBP/SEHBP enrollment as for other employees eligible
for SHBP/SEHBP coverage.
For more information about coverage
for part-time employees, please see Fact
Sheet #66, Health Benefits Coverage for Part-time Employees.
Available
Medical Plan for Intermittent State Employees
Certain
intermittent State employees who have worked a minimum of 750 regular pay status hours within the previous fiscal year (i.e., July to June) are eligible for enrollment in NJ DIRECT15 and the Employee Prescription
Drug Plan. Intermittent employees who maintain 750
hours of work per fiscal year will receive coverage for the next fiscal year (at
least through the period covered by the labor contract in effect).
Intermittent State employees who meet the minimum pay status hours outlined above must also be covered under the labor contract between the CWA and the State of New Jersey that committed the State to provide SHBP coverage to intermittent employees.
Employers must certify that their intermittent employees have at least 750 regular pay status hours in the prior fiscal year to qualify for coverage in subsequent years. The Human Resource Offices of the Department of Labor and the Department of the Treasury will re-certify eligibility of every intermittent employee with SHBP coverage each year.
Full-time Status and Eligibility
for Coverage: Sabbaticals, Approved Leaves of Absence, and Multiple
Public Positions—State and Local Employees
A State or local employee who is
on sabbatical or an approved leave absence will have "full-time"
status and be eligible for coverage if the compensation paid is
50 percent or more of the salary granted just prior to the leave
and the period of eligibility terminates with the end of the fiscal
year.
An employee holding multiple public
positions at the same time will be considered "full-time"
if the employee satisfies the definition of full-time in any one
of the positions he or she holds.
State and Local Employee Ineligibility
for SHBP/SEHBP Coverage
State and local employees who are
ineligible for coverage include:
- Those who have less than two
months of continuous service;
- Those who are employed on a short-term,
seasonal, intermittent or emergency basis;
- Those who are paid an hourly rate; and
- Those who are not on payroll.
State statute specifically prohibits two members who are each enrolled in the SHBP/SEHBP plans from covering each other. Therefore, an eligible individual may only enroll in the SHBP/SEHBP as an employee or retiree, or be covered as a dependent.
Eligible children may only be covered by one participating subscriber.
For example, a husband and wife both have coverage based on their employment and have children eligible for coverage. One may choose Family coverage, making the spouse and children the dependents and ineligible for any other SHBP/SEHBP coverage; or one may choose Single coverage and the spouse may choose Parent and Child(ren) coverage.
New Jersey State Legislators and
SHBP Coverage
Chapter 308, P.L. 2003, signed into
law on January 14, 2004, prohibits members of the State Legislature
who elect health coverage from their legislative position from
having primary health insurance coverage from another public employer.
Chapter 308, P.L. 2003 applies to
members of the State Legislature who are at the same time employed
by or take employment with another public employer in New Jersey
that provides health benefits coverage. In such cases, the member
must waive his or her health coverage from the other public employment
in order to retain the health coverage through employment in the
State Legislature; or, the member may waive health benefits coverage
through the legislative position and accept primary coverage from
the other public employer.
For
more information, please see the the SHBP letter regarding Chapter
308, P.L. 2003.
1. Have Employee Complete a Health Benefits
Application
Eligible employees must complete
the appropriate application.
Those
part-time State employees who are eligible for SHBP/SEHBP coverage (see
above) should complete the appropriate application.
Failure to complete an application or neglecting
to add an eligible family member when first becoming eligible
for coverage will delay enrollment until the next Open Enrollment
period.
2. Employers should check for completeness,
accuracy, and any required attachments.
3. Employer Certifies Application
The employer certification portion
of the Health Benefits Application is
located on the upper right corner of the form. All completed applications
must be certified by the employer and mailed to the Health Benefits
Bureau. (When completing the
employer certification portion of the Part-time Employees Group
— Health Benefits Application, for
part-time faculty members eligible for coverage under Chapter
172, P.L. 2003, Certifying Officers of New Jersey State
colleges, State universities and county community colleges should
use the same union code as for other adjunct faculty members.)
4. Employer Provides Written Notification
of Federal COBRA and HIPAA Requirements, and Other Federal Health
Insurance Regulations
Under federal law, employers are
required to notify all employees and dependents enrolling
in their health plan of the provisions of the federal
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
and the Health Insurance Portability and Accountability
Act (HIPAA) of 1996.
The COBRA and HIPAA notifications
are intended to inform employees of their rights and obligations
under these federal laws, and must be distributed to all new employees
and their dependents enrolling in the SHBP within 90 days of enrollment.
The initial COBRA notification and HIPAA notification must be
addressed to the employee and dependents and mailed to the address
furnished by the employee. The employer must keep a record of
the notification. The chart below shows the specific forms and
documents that an employer must provide to newly enrolled employees
and dependents:
|
For COBRA Notification:
For HIPAA Notification:
|
The federal Consolidated Omnibus
Budget Reconciliation Act (COBRA) of
1985 requires that most employers sponsoring group health
plans offer employees and their eligible dependents the opportunity
to temporarily extend their group health coverage in certain instances
where coverage under the plan would otherwise end. For SHBP/SEHBP participants, COBRA is not a separate
health program; it is a continuation of SHBP/SEHBP coverage under the
provisions of the federal law.
Click here for more information about
COBRA.
The Health Insurance Portability
and Accountability Act of 1996 (HIPAA) is a federal law that
includes important new protections for millions of working Americans
and their families who have preexisting medical conditions, or
might suffer discrimination in health coverage based on a factor
that relates to an individual's health. This Act requires health
plans, such as the SHBP/SEHBP, to maintain the privacy of any personal
information relating to its members' physical or mental health.
Click here for more information
about HIPAA.
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Enrollment
of Eligible Dependents
Enrollment of dependents normally
occurs when the employee enrolls. If the employee fails to enroll
a dependent when first eligible (at initial enrollment or
within 60 days of becoming a dependent), then the employee will
have to wait until the annual Open Enrollment period to add them
to coverage. The only exceptions to this rule would be in cases
covered by the federal Health Insurance
Portability and Accountability Act (HIPAA).
An employee's eligible dependents
are his or her spouse, and children under age 26. Effective January 1, 2011, coverage of a member's children was extended through December 31 of the year in which a child turns 26, in compliance with the federal Patient Protection and Affordable Care Act (ACA).
Under the ACA, a ‘child” is defined as an enrollee’s child until age 26, regardless of the child’s marital, student, or financial dependency status – even if the young adult no longer lives with his parents. A photocopy of the child’s birth certificate that includes the covered parent’s name must be submitted, along with the application (and additional supporting documentation for foster or stepchildren).
Please note that under the provisions of Chapter 375, P.L. 2005, as amended by Chapter 38, P.L. 2008, certain over age children may be eligible for coverage until age 31. For information about continuing Health Benefits coverage for over age children until age 31, please click here.
Dependent coverage includes children
who are away at school. If the employee is divorced, the children
who do not live with the parent are still eligible for coverage
if the employee is legally required to support these children.
A copy of the divorce decree or court order must be submitted
with the enrollment application to provide proof of dependent
status in cases where the children do not reside with the covered
employee. (Please
see note below regarding overage children
with disabilities and SHBP/SEHBP coverage; for information about continuing coverage for over age children until age 31, please click here.)
Stepchildren, foster children, and
legally adopted children are also eligible for coverage, provided
they live with the employee and are dependent upon the employee
for support and maintenance. Affidavits of Dependency and
legal documentation, including recent court orders, guardianship
papers, adoption papers, etc. are required with enrollment forms
for these cases. Click here for a copy of an Affidavit
of Dependency.
Effective
Dates of SHBP/SEHBP Coverage
There is a waiting period of approximately
2 months (60 days) following an employee's date of hire before
SHBP/SEHBP coverage becomes effective. (For exceptions,
see below.)
The timely submittal of the correct
Health Benefits Enrollment Application, properly completed and signed,
to the Division's Health Benefits Bureau is very important, allowing
the employee's coverage to start immediately following the
two-month waiting period. (See Timetables
below.)
SHBP Coverage for State Employees
SHBP coverage for the State biweekly
employee begins on the first day of the employee's fifth
payroll period. The exact date of coverage for State biweekly
employees will be determined by the payroll schedule issued by
the State's Centralized Payroll.
SHBP coverage for the State employee
paid on a monthly basis begins on the first day following
two months of employment. A State monthly employee who starts
employment on May 14 will have a SHBP coverage effective date
of July 14.
SHBP/SEHBP Coverage for Employees of
Participating Local Employers
Coverage for the employee of
a participating local employer begins on the first day following
two months of employment. For example: if the employee starts work on June
14, SHBP/SEHBP begins on August 14 (assuming that the employee's properly
completed and signed SHBP Enrollment Application has been
submitted in a timely manner).
There are three exceptions to this
effective date of coverage rule, which can be found in the Health Benefits Summary Program Description
- If an employee had at least two
months of service on the date the employer joins SHBP/SEHBP, coverage
starts on the date the employer enters the program;
- If an employee has an annual
contract, is paid on a 10-month basis, and begins work
at the beginning of the contract year, coverage begins on September
1 (see SHBP/SEHBP Coverage Effective Dates
for Ten-month Employees below);
- If an employee was enrolled in
the SHBP/SEHBP with a previous employer and the employee's
coverage is still in effect on the day work begins with the
current employer (COBRA coverage excluded), coverage begins
immediately so there is no break in coverage.
SHBP/SEHBP Coverage Effective Dates
for Ten-month Employees
SHBP/SEHBP coverage begins on the first
of the month in which employment began, for employees of local
and State monthly employers working under a ten-month contract
who begin employment at the start of the school year. In such
cases, the two months preceding the first of the month in which
the contract began are regarded as the two-month waiting period.
For example, a teacher who starts
working for a school district at the beginning of the school year
in September, under a ten-month contract, will have SHBP/SEHBP coverage
effective as of September 1, with the preceding July and August
regarded as the two-month waiting period.
For State biweekly employees working
under a ten-month contract who begin employment at the start of
the school year, SHBP coverage will begin on the first day of
the pay period closest to September 1, with the four preceding
pay periods regarded as the two-month waiting period.
Timetables for
SHBP/SEHBP Enrollment
Timetable
for Enrollment in the SHBP/SEHBP for Local and State
Monthly Employers |
Date of Hire |
Date Forms
Must be Received at the Division of Pensions and Benefits |
Date Coverage
Begins |
January 1 - 31 |
February 5 |
March 1 - 31 |
February 1 - 28* |
March 5 |
April 1 - 28 ** |
March 1 - 31 |
April 5 |
May 1 - 31 |
April 1 - 30 |
May 5 |
June 1 - 30 |
May 1 - 31 |
June 5 |
July 1 - 31 |
June 1 - 30 |
July 5 |
August 1 - 30 |
July 1 - 31 |
August 5 |
September 1 - October 1 ** |
August 1 - 31 |
September 5 |
October 1 - 31 |
September 1 - 30 |
October 5 |
November 1 - 30 |
October 1 - 31 |
November 5 |
December 1 - 31 |
November 1 - 30 |
December 5 |
January 1 - 31 |
December 1 - 31 |
January 5 |
February 1 - March 1 ** |
* February 29 during leap
years. |
** Since all months are not
of equal length, there may be a difference in the "Date
Coverage Begins" for certain employees. For example,
if an employee began employment on July 31, coverage
is not effective until October 1, the first day after
the completion of 2 full months. Months are calculated
from date to date (i.e., Jan. 1 to Feb. 1 constitutes
one full month). If you have a question about a specific
employee, contact the Division of Pensions and Benefits,
Health Benefits Bureau. |
SHBP/SEHBP Coverage Upon Termination
of Employment, Ten-month Employees
For the purposes of BOTH State and
local employee coverage:
An employee paid under a 10-month
contract that starts work at the beginning of the school year
and terminates service with the employer at the end of that school
year, will be entitled to a full year's coverage comparable to
that of any employee paid on a 12-month basis, AS LONG AS THE
FOLLOWING IS TRUE: The employee has worked for the number
of months prescribed by the contract or arrangement with the employer
for that school year.
This means that SHBP/SEHBP coverage for
ten-month employees and their dependents will continue during
the summer months subsequent to the end of the school year (July
and August), provided that any contributions or Premiums are made as required by the State or local employer.
For example, a teacher with a ten-month
contract who begins employment at the start of the school year
in September and then terminates employment on the last day of
school in June will have coverage continue through the months
of July and August immediately following the end of that school
year.
Please note, however, that when the
termination of employment at the end of the school year is because
of the member's July 1 retirement, coverage under the active group
ends August 1, at which time eligiblity for coverage under the retired group
becomes effective.
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Timetables for
SHBP/SEHBP Termination
|
Timetable
for Termination in the SHBP/SEHBP
for Local and State Monthly Employers* |
|
Date of
Termination** |
Date Forms
Must be Received at the Division of Pensions and Benefits |
Date Coverage
Ends |
| January 6 - February 5 |
February 5 |
March 1 |
| February 6 - March 5 |
March 5 |
April 1 |
| March 6 - April 5 |
April 5 |
May 1 |
| April 6 - May 5 |
May 5 |
June 1 |
| May 6 - June 5 |
June 5 |
July 1 |
| June 6 - July 5 |
July 5 |
August 1 |
| July 6 - August 5 |
August 5 |
September 1 |
| August 6 - September 5 |
September 5 |
October 1 |
| September 6 - October 5 |
October 5 |
November 1 |
| October 6 - November 5 |
November 5 |
December 1 |
| November 6 - December 5 |
December 5 |
January 1 |
| December 6 - January 5 |
January 5 |
February 1 |
*The coverage ending dates in
this chart apply to State monthly dental coverage, and State monthly
and local employer medical and prescription drug coverage, including
all local employer stand-alone prescription plans.
**Please Note:
The
Transmittal of Deletions form indicates that coverage termination
is effective the first of the month following the first full
month for which no salary was paid; however, deletions received
between the first and the fifth of the previous month will also
take effect on the first of the month that follows. Termination
due to a member's death always take effect on the first
of the month following the member's date of death.
Open
Enrollment Periods
An annual Open Enrollment period is held for all eligible State employees and local participating employees. The Open Enrollment period is normally during the month of October; however, specific dates are announced in advance by the Health Benefits Bureau.
Coverage changes made during the Open Enrollment period are effective the first biweekly payroll period of the new plan year for State employees paid through the State's Centralized Payroll Unit, and January 1 of the new plan year for all other State and local employees.
If making changes during the Open Enrollment, completed health benefits applications must be returned to the employee's human resources representative or payroll officer by the deadline indicated in the Open Enrollment announcement materials.
The annual Open Enrollment period is the employee's opportunity to make changes to the coverage provided to themselves and any dependents. During the Open Enrollment period, employees may:
- Enroll in any of the medical, prescription, and/or dental plans offered for which the employee is eligible, if not previously enrolled;
- Change to another eligible medical, prescription, and/or dental plan (dental plans require a minimum enrollment of 12 months);
- Add eligible dependents who have not previously enrolled (including over age children eligible under Chapter 375, P.L. 2005); and
- Delete dependents (this can also be done at any time during the year).
For
State Employees
Special Open Enrollment Periods are occasionally conducted
because of changes that occur during the plan year that impact
employees' coverage or cost. When these changes occur, the State
Health Benefits Commission/School Employees' Health Benefits Commission will authorize a special Open Enrollment.
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Changes
in Coverage and Family Status
Generally, active employees cannot change
their plan, level of coverage, or dependent coverage until the next Open
Enrollment period. There are exceptions when an employee may change
coverage. These exceptions are:
- An employee who marries or enters into a civil union or same-sex domestic partnership may
enroll their spouse/partner and/or newly eligible dependent children.
A health benefits application must be filed within 60 days of the marriage/partnership.
- When the birth or adoption
of a child occurs, a health benefits application must be filed within 60
days of the birth or adoption. Adoption requires additional legal
documentation filed with application.
- When a change in family
status involving the loss of a family member occurs (divorce,
death, child
turns age 26*, see below for exceptions ).
- The employee is on a leave
of absence and cannot afford to pay for coverage. Coverage can
be reduced from family to single or parent and child while employee
is on the leave. When the employee returns to work, coverage
can be increased back to family coverage.
- An employee's spouse/partner loses
health benefit coverage; the employee has 60 days from the date
of the loss of coverage to add a spouse/partner to his or her coverage.
The enrollment application must
be accompanied by the spouse/partner's HIPAA certification form showing
the date coverage was lost.
Coverage changes involving the addition
of dependents are effective retroactively to the date of the event
of eligibility, if the health benefits application is filed within 60
days of the event. Active employees may decrease dependent
coverage at any time. Deletions of dependent coverage are effective
on a timely or prospective basis, that is, when they are processed
by the Health Benefits Bureau.
*A dependent child covered under
an employee's SHBP/SEHBP health plan
becomes ineligible for continued coverage on December 31 of
the year in which (s)he turns 26 years of age.
However, an over age
child who is disabled due to mental illness, mental retardation,
or a physical disability and dependent upon a member for support,
can remain covered as a dependent if the child's disabled status
is approved by the SHBP/SEHBP. See Fact Sheet #51, Continuing
Health Benefits Coverage for Over Age Children with Disabilities for
more information.
Under Chapter 375, P.L. 2005, members may extend SHBP coverage for their over age children until age 31 as long as specific conditions are met. The covered parent is responsible for the entire cost of coverage for the eligible dependent, and will be billed directly for the coverage cost. For more information, see Fact Sheet #74, Health Benefits Coverage of Children until Age 31 Under Chapter 375, P.L. 2005.
Employer's
Responsibilities under Leaves of Absence
The employer has responsibilities
to:
- Advise employees of the status
of their health benefits if they take a leave of absence.
- Let employees know that they may
reduce coverage level (for financial reasons) while on leave
and increase it again when they return.
- Provide employee and/or dependents
with a specific COBRA
Notice when a COBRA event
occurs.
- Maintain records that demonstrate
your compliance with the COBRA law.
- Advise employees of the status
of their health benefits when they return from a leave of absence.
- Provide Open Enrollment information
to employees on a leave of absence.
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Leave
of Absence without Pay for Illness
An employee can continue health coverage
while on an approved leave of absence without pay for illness. State biweekly employee coverage will be
provided by the State for the first six biweekly pay periods following
the last day the employee would normally be covered. Coverage
may be obtained for an additional 20 biweekly pay periods provided
the employee pays the full cost of the coverage.
State monthly employee
coverage would be provided by the State for the first three months
following the last day the employee would normally be covered.
Coverage may be continued for an additional nine months provided
the employee pays the full cost of the coverage. If an employer
does not extend coverage for the three-month period, the employee
may only elect to continue coverage for a maximum of nine months.
Local public employers may provide for payment of the first three months of approved sick leave with the employee being able to extend coverage by prepayment for an additional nine months. If the employer does not extend coverage for the three-month period, the employee may elect to continue coverage for a maximum of nine months only. The employer may not discriminate against any eligible employee or groups of employees.
Certain local educational agencies
may agree to adopt the provisions of Chapter 127, P.L. 1989. Chapter
127 applies only to eligible employees of local boards of education,
regional boards of education, county colleges, educational service
commissions, jointure commissions, county special services school
districts, county vocational-technical school districts, or any
boards or commissions under the authority of the Commissioner
of Education or State Board of Education.
Chapter 127 permits the employer to continue to pay for the coverage
of an employee granted an approved leave of absence (with or without
pay) for up to a two-year period, provided that the employee has
worked for the location for at least three years.
Contact the Health Benefits Bureau at the Division of Pensions
and Benefits, PO Box 299, Trenton, NJ 08626-0299 to obtain a copy
of the Chapter 27 resolution.
Leave
of Absence without Pay for Reasons Other Than Illness
An employee who is permitted to take
an approved leave of absence for reasons other than illness, family
leave, or furlough, may continue health coverage under the SHBP/SEHBP
for up to nine months or 20 biweekly pay periods. The full cost
of the coverage must be paid to the employer in advance. If the
employee remains on leave beyond the time for which coverage has
been purchased, then the Active Group coverage will terminate.
The coverage may be extended under
COBRA for a period not to exceed the 18 months, including
the total leave time. However, leave that qualifies under the
Federal or State Family Leave Act is not deducted from the total
COBRA eligibility period.
Family
Leave
An employee who is taking family
leave is entitled under the State Family Leave Act (NJFLA) to
continue 12 weeks of health care coverage in any 24 month period
at the expense of his or her employer while on family leave. This
includes all health care benefits, including Prescription Drug,
Dental, and Vision Care benefits if the employer provides them.
State Family Leave is defined as leave from employment to provide
care for the birth or adoption of a child, or the serious illness
of a child, parent, or spouse.
The Federal Family Leave Act (FMLA)
has benefits similar to the State Family Leave Act with the exception
that the federal act also requires that leaves of up to 12 weeks
in any 12 month period be permitted for the employee's own serious
illness.
Leave usually counts for both State
and federal entitlements, except in the instance where an employee
could be eligible for up to 24 weeks of leave in one year under
certain circumstances. An employee could request a leave for maternity
and then childcare leave. The leave for maternity, which qualifies
as personal illness, counts toward the FMLA. The employee would
still be entitled to an additional 12 weeks under the NJFLA to
care for the newborn child.
To be eligible for family leave,
an employee must be employed for at least 12 months. Family leave
can be taken on a continuous or intermittent basis, or by way
of a reduced leave schedule under the conditions of the law.
In cases where the employee has a
deduction, the employer must make arrangements with the employee
on family leave to receive direct payment for the required employee
contribution. If the Division of Pensions and Benefits does not
receive full payment from the employer, then the employee's benefit
coverage will be terminated under the termination provisions of
the SHBP/SEHBP.
The time an employee spends on federal
or State family leave will not count as part of the
COBRA eligibility period, should an employee receive approval
from his or her employer to extend the leave.
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Furlough
If an employee takes an approved
furlough, the SHBP/SEHBP coverage will continue at the employer's expense.
The employee must remit in advance the employee portion of premiums
normally paid, if any.
A State employee eligible for a voluntary
furlough extension beyond the 30 days allowed will be treated
as an exceptional case. The employee will have to pay the full
cost of coverage for his or her extended furlough days in 10-day
increments, or drop the coverage for the entire furlough extension
benefit period(s) in which the employee takes a furlough day.
Workers'
Compensation
An employee who has a Workers' Compensation
award pending or has received an award of periodic benefits may
have coverage continue and may continue the coverage of dependents.
The employee must pay the employer, in advance, that portion of
the premiums that would normally be paid, if any.
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Suspension
An employee who is suspended from
employment is not eligible for benefits. If coverage is terminated
as a result of suspension, the employee's only options for continuing
group coverage are through COBRA
or conversion to an individual, direct payment coverage from his
or her SHBP/SEHBP health plan carrier. See the Summary Program Description for a more extended discussion.
If the suspension is for "gross
misconduct," the employee will not be eligible for coverage
through COBRA. Since the federal COBRA law does not precisely
define "gross misconduct", the employer should seek
legal counsel before denying continuation of benefits through
COBRA. (In light of this lack of precision in defining terms,
some employers choose to simply offer continuation through COBRA
regardless of the terms of termination.)
Employer's
Responsibility for an Employee
Who Returns from a Leave of Absence
The employer must advise an employee,
upon returning from an approved leave of absence, as to the status
of the health benefit coverage for the employee and eligible dependents.
- If coverage lapsed during
the leave of absence, the employee must complete a health benefits
application to reinstate health benefit coverage (including
prescription and dental coverage, if applicable). The employer
must certify the date the employee returned to work on the application.
- Coverage becomes effective on
the date the employee returns to work if the employee is a State
monthly or local employee. If the employee is a State biweekly,
coverage will be effective on the first day of the pay period
in which the employee returned to work.
- If an employee reduced coverage
levels while on an approved leave, the employee may return
to the former level of coverage upon returning to work.
- If an employee is on leave
during an Open Enrollment period, the employee may elect
to make coverage changes upon returning to work. The employer
must advise the employee that he or she must complete and submit
an application within 60 days of returning to work; the effective
date of these changes will be the date the employee returned
to work.
- If an employee's coverage was
terminated during a leave, or the employee purchased
COBRA coverage while on leave, the employee must file a
new application within 60 days of the first day the employee returns to work.
Return
from Military Leave
An employee, upon returning from
a military leave without pay, may enroll and receive appropriate
coverage by completing and forwarding the appropriate application within 60 days after the date of return to
active full-time employment. Any eligible dependents may, of course,
be included.
If a Local group or State
monthly employee applies for coverage immediately upon returning
from the military leave of absence, the coverage is effective
on the first day of the month of return. Coverage for State
biweekly employees is effective on the first day of the pay
period of return. No benefits are available prior to the actual
date of return to active employment.
In the event a dependent of an
employee is discharged from military service, the employee
may enroll such dependent for appropriate coverage within 60 days
of discharge. Coverage will be effective the date of return to
dependency upon the employee.
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Return
from Suspension
When an employee returns from a suspension
which was long enough to terminate coverage, the effective date
for reinstatement would be the same as if the member returned
from a leave of absence. If a court order or administrative ruling
canceled the suspension and required the retroactive reinstatement
of the employee's benefits, coverage will be reinstated retroactively,
provided that a copy of the court order or ruling is submitted
with the appropriate application. If the employee pays for any portion of health benefits
coverage, then the employee must pay the back payments to the
employer.
Changes
in Status
Part-time
Employment
When an employee changes from active
full-time employment to part-time employment, the employee's coverage
in the SHBP will be terminated, unless the
employee is eligible for SHBP coverage as a State part-time employee
or a part-time faculty member employed at a New Jersey public
institution of higher education, see above. The employee may
continue coverage under the federal
COBRA program. Should employment resume to full-time status,
the employee must reestablish eligibility for coverage and wait
2 months before coverage will become effective.
Dependent Eligibility
Dependent children are covered under
their parent's enrollment until December 31 of the calendar year
in which they reach age 26*, at which time coverage will cease. The child will
not be given notice of coverage ending. If the dependent child
intends to continue coverage under COBRA,
the employee must notify the employer of this qualifying event.
An application should
be submitted noting the removal of the over age child from the
member's coverage. Two exceptions are outlined below:
Chapter 375 — Over Age Children until Age 31
Under Chapter 375, P.L. 2005, certain over age children may be eligible for coverage under the SHBP/SEHBP until age 31. This includes a child by blood or law who:
- is under the age of 31;
- unmarried;
- has no dependent(s) of his or her own;
- is a resident of New Jersey or is a full time student at an accredited public or private institution of higher education; and
- is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
The covered parent is responsible for the entire cost of dependent coverage under Chapter 375, and will be billed directly by the SHBP/SEHBP for the coverage cost. For more information, please see Fact Sheet #74, Health Benefits Coverage of Children until Age 31 under Chapter 375, P.L. 2005.
Over Age Dependent with Disabilities
A dependent child who is physically
or mentally incapable of self-support at the end of the calendar
year in which age 26 is reached may continue coverage under the
plan while remaining incapacitated and unmarried, subject to the
coverage remaining in effect.
The employee must request a Continuance
of Enrollment for an Eligible Dependent with Disabilities
from the Health Benefits Bureau. This form is to be completed
by the employee and the dependent's physician. This form must
be submitted to the Health Benefits Bureau no later than January
31st of the year following the calendar year in which the child
reaches age 26. To request a Continuance of Enrollment
for an Eligible Dependent with Disabilities form, the
member must contact the Division of Pensions and Benefits, Active
Health Benefits Group, in writing, prior to November of the year
in which the disabled dependent reaches age 26. See
Fact Sheet #51, Continuing
Health Benefits Coverage for Over Age Children with Disabilities for more
information.
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Waivers
of Coverage
Waiver for State Monthly, State Biweekly Employees
State employees are permitted to waive their SHBP medical and prescription coverage provided they have other health care coverage of their own or as a dependent. State employees who waive coverage can thereby avoid the contribution of a percentage of the premiums for health and/or prescription drug coverage required under Chapter 78, P.L.2011 .
There is no additional annual payment, or incentive, to State employees who waive SHBP medical and prescription coverage.
A State
Health Benefits Program Coverage Waiver/Reinstatement Form and an application must be submitted through the employer to the SHBP in order to waive SHBP medical and prescription coverage.
To reinstate coverage under the SHBP,
a State employee must once again complete a State
Health Benefits Program Coverage Waiver/Reinstatement Form along with an application.
The member must notify the SHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage. Reinstatement will be effective immediately following the loss
of the employee's other health plan coverage. Reinstatement will be effective immediately following the loss
of the employee's other health plan coverage.
Waiver for Local Government/Education Employers
Local Government/Education Employers that participate in the SHBP/SEHBP, or in another group health plan, may permit
an employee to waive the health benefits coverage offered by the
employer (local government/education employer),
if the employee is eligible for any other employer provided health care coverage of their own or as a covered dependent.
The local government/education employer may then pay the employee an annual amount,
or incentive, which cannot be more than 25% of the amount saved
by the local government/education employer or $5,000, whichever is less, because
of the employee's waiver of health plan coverage. The employing
local government/education location establishes
what the annual amount payable to an employee choosing to waive
the health benefits coverage will be.
The decision of the local government/education employer to allow its employees to
waive coverage, and the amount of the incentive to be paid, cannot be subject to the collective bargaining process.
An employee who has waived
coverage under the provisions of this law may immediately resume
health coverage under his or her employer's health plan in the
event that the other health care coverage is terminated, provided the member notifies the SHBP/SEHBP within 60 days of the loss of the other coverage and provides proof of loss of that coverage.
Historical Note: Chapter 259, P.L. 1995 originally
allowed only municipalities to permit employees to waive their
group health benefits in exchange for an agreed-upon incentive;
through Chapter 189, P.L. 2001 municipal authorities were also
included. The above waiver provisions now extend to county colleges
through Chapter 3, P.L. 2003. Chapter 3 also expanded the waiver
provisions by allowing employees to waive employee health care
coverage if they are eligible for any other coverage, not
just in the case where they are eligible for dependent coverage
through a spouse's plan. Chapter 92, P.L. 2007 (Section 48) extends to all local public employers the current authorization to provide financial incentives to employees who waive coverage under the SHBP if the employee is eligible for other health care coverage. Chapter 2, P.L. 2012 changed the waiver incentive for local government/education employers to either 25% of the amount saved by the employer or $5,000, whichever is less.
To Waive SHBP/SEHBP Coverage
Employees of county colleges, municipalities,
and municipal authorities participating in the
SHBP/SEHBP who wish to waive coverage in order to receive an incentive
must file a Health
Benefits Coverage Waiver/Reinstatement Form along
with the appropriate application.
Reinstatement of Coverage
To reinstate coverage under the SHBP/SEHBP,
an employee must complete a Health Benefits Coverage Waiver/Reinstatement Form
along with the appropriate application.
The member must notify the SHBP/SEHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage. Reinstatement will be effective immediately following the loss
of the employee's other health plan coverage.
Note: Any local government/education employer contemplating exercising its right
to offer a cash incentive to waive health benefits should discuss
the federal income tax consequences of such an action on its employees
with legal counsel knowledgeable in federal and state tax matters, especially with regard to employee benefits plans. If a cash incentive provided by an employer
is not part of an Internal Revenue Code Section 125 plan, the
health benefits provided to its other employees may be subject
to federal taxes.
Identification
Cards
Identification cards for SHBP/SEHBP medical, prescription drug, and dental plans are issued from
the plan's claims administrators or carriers directly to the employees.
These cards are mailed to the employee's home address, and
should be carefully reviewed for accuracy. If the identification
card has an error in the spelling of the name or ID
number, advise the employee to call the Office of Client Services
at (609) 292-7524. If there is an error in the listing of the Primary
Care Physician or primary dentist, the employee should contact
the insurance carrier immediately. The contact number for
each provider appears on the card itself.