NEW JERSEY
STATE HEALTH BENEFITS PROGRAM

NJ PLUS MEMBER HANDBOOK
for Employees and Retirees

Administered by
Horizon Blue Cross Blue Shield of New Jersey

Plan Year 2006

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INTRODUCTION

The State Health Benefits Program (SHBP) was originally established in 1961. It offers medical, prescription drug, and dental coverage to qualified public employees and retirees, and their eligible dependents. The State Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article 17.25 et.seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.

The State Health Benefits Commission (SHBC) is the executive organization responsible for overseeing the State Health Benefits Program (SHBP). The SHBC includes the State Treasurer as the chairperson, the Commissioner of the Department of Banking and Insurance, the Commissioner of the Department of Personnel, a State employee representative chosen by the Public Employees’ Committee of the AFL-CIO, and a representative chosen by the New Jersey Education Association (NJEA), or their designated representatives. The Director of the Division of Pensions and Benefits is the Secretary to the SHBC. The Division of Pensions and Benefits, specifically the Health Benefits Bureau and the Bureau of Policy and Planning, is responsible for the daily administrative activities of the SHBP.

NJ PLUS is a point-of-service plan that provides both in-network managed care similar to an HMO plan and out-of-network care similar to a traditional indemnity plan.

In-network care is provided through the NJ PLUS network of providers which includes primary care physicians (PCP) internists, general practitioners, pediatricians, specialists, and hospitals. Network providers offer a full range of services that include well-care and preventive services such as annual physicals, well-baby/well-child care, immunizations, mammograms, annual gynecological examinations, and prostate examinations. In-network services are generally covered in full after a small copayment. In-network hospital admissions are covered in full.

Out-of-network benefits provide reimbursement for expenses for services rendered for the treatment of illness and injury. Most out-of-network care is usually reimbursed at 70 percent of the reasonable and customary allowance after an annual deductible is met.

NJ PLUS is self-funded. Funds for the payment of claims and services come from funds supplied by the State, participating local employers, and members. NJ PLUS is administered for the SHBP by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ).

An online version of this handbook containing current updates is available for viewing over the Internet at: www.state.nj.us/treasury/pensions/shbp.htm  Be sure to check the Division of Pensions and Benefits Internet home page at: www.state.nj.us/treasury/pensions  for SHBP related forms, fact sheets, and news of any new developments affecting the benefits provided under the SHBP.

Every effort has been made to ensure the accuracy of the NJ PLUS Member Handbook, which describes the benefits provided in the contract with Horizon BCBSNJ. However, State law and the New Jersey Administrative Code govern the SHBP. If there are discrepancies between the information presented in this handbook, and the law, regulations, or contract, the latter will govern.

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, call us at (609) 292-7524, or send e-mail to: pensions.nj@treas.state.nj.us

You may also refer to the following link for additional information on contacting the SHBP and its related health services.

SPECIAL PLAN PROVISIONS UNDER THE SHBP

WOMEN'S HEALTH AND CANCER RIGHTS ACT

Effective October 21, 1998, the State Health Benefits Commission adopted as policy, the federal mandate "Women's Health and Cancer Rights Act of 1998." The mandate requires that plans which cover mastectomies, must provide coverage for breast reconstruction surgery to produce a symmetrical appearance, prostheses, and treatment of any physical complications.

AUTOMOBILE-RELATED INJURIES

The SHBP will provide secondary coverage to Personal Injury Protection (PIP) unless you choose your SHBP plan as your primary insurer on your automobile policy. In addition, if your automobile policy contains provisions that make PIP secondary or as excess coverage to your health plan, then the SHBP will automatically be primary to your PIP policy. If you elect your SHBP plan as primary, this election may affect each of your family members differently.

When the SHBP is primary to your PIP policy, benefits are paid in accordance with the terms, conditions, and limits set forth by the SHBP health plan you have chosen. Your PIP policy would be a secondary payer to whom you would submit any bills unpaid by your SHBP plan. Any portions of unpaid bills would be eligible for payment under the terms and conditions of your PIP policy.

If your SHBP plan is secondary to the PIP policy, when applicable, the actual benefits payable will be the lesser of:

If you are enrolled in several health plans regardless of whether you have selected PIP as your primary or secondary coverage, the plans will coordinate benefits as dictated by each plan's coordination of benefits terms and conditions. You should consult the coordination of benefits provisions in your plan’s handbook and your PIP policy to assist you in making this decision.

Please note: There is no coordination of benefits for prescription drug expenses.

WORK-RELATED INJURY OR DISEASE

Work-related injuries or disease are not covered under the SHBP. This includes the following:

Please note: If you collect benefits for the same injury or disease from both Workers' Compensation and the State Health Benefits Program, you may be subject to prosecution for insurance fraud.

HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT

The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires group health plans to implement several provisions contained within the law or notify its membership each plan year of any provisions from which they may file an exemption. Self-funded, non-federal governmental plans may elect certain exemptions from compliance with HIPAA provisions on a year-to-year basis.

Mental Health Parity Act Requirements

The State Health Benefits Commission has filed an exemption from the mental health parity requirement with the federal Centers for Medicare and Medicaid Services for calendar year 2006. As a result, maximum annual and lifetime dollar limits apply to mental health benefits under NJ PLUS, except for biologically-based mental illness. Maximum annual and lifetime dollar limits for mental health benefits are outlined for NJ PLUS in this handbook and are also described in the SHBP Comparison Summary Chart.

All SHBP health plans meet or exceed the federal requirements with the exception of mental health parity for the Traditional Plan and NJ PLUS. Parity would require that the dollar limitations on mental health benefits are not lower than those of medical or surgical benefits.

Certification of Coverage

HIPAA rules state that if a person was previously covered under another group health plan, that coverage period will be credited toward any pre-existing condition limitation period for the new plan. This includes any prior group plan coverage that was in effect 90 days prior to the individual's effective date under the new plan. A Certification of Coverage form, which verifies your SHBP group health plan enrollment and termination dates, is available through your payroll or human resources office, should you terminate your coverage.

HIPAA Privacy

The State Health Benefits Program makes every effort to safeguard the health information of its members and complies with the privacy provisions of HIPAA, which requires that health plans maintain the privacy of any personal information relating to its members’ physical or mental health. See page 80 for the State Health Benefits Program’s Notice of Privacy Practices.

NOTICE OF PROVIDER TERMINATION

Any person enrolled in a managed care plan (HMO or NJ PLUS) must be provided with 90-days notice if that person’s Primary Care Physician (PCP) will be terminated from the provider network. If 90-day notice cannot be provided, the managed care plan must notify the member as soon as possible. The covered person may then choose another PCP or may change coverage to another participating health benefits plan. This provision does not apply if your PCP voluntarily terminates participation with the plan.

PURCHASE OF INDIVIDUAL INSURANCE COVERAGE

Employees, retirees, and their dependents may purchase individual, direct payment coverage from their State Health Benefits Program (SHBP) health plan carrier if their loss of group health coverage is due to any reason other than voluntary termination. Note: failure to pay required premiums is considered voluntary termination.

Before considering a policy, New Jersey residents who are not Medicare eligible, should first investigate coverage available under the provisions of the New Jersey Individual Health Coverage Program. Information about available policies can be obtained from the New Jersey Individual Health Coverage Board at the Department of Banking and Insurance. Carrier and rate information can be obtained by calling 1-800-838-0935 or at: www.njdobi.org

If you are Medicare eligible you may qualify for a Medigap policy. For more information, contact the State Health Insurance Assistance Program (SHIP) at 1-800-792-8820.

You will have 31 days from the end of your SHBP coverage to exercise your right to a direct payment policy.

MEDICAL PLAN EXTENSION OF BENEFITS

If you or a dependent are totally disabled with a condition or illness at the time of your termination from the SHBP and you have no other group medical coverage, you may qualify for an extension of benefits for this specific condition or illness. If you feel that you may qualify for an extension of benefits please contact Horizon BCBSNJ for assistance.

If the extension applies, it is only for expenses relating to the disabling condition or illness. An extension under any SHBP plan will be for the time you remain totally disabled from any such condition or illness, but not beyond the end of the calendar year after the one in which your coverage ends. During an extension there will be no automatic restoration of part or all of a lifetime benefit maximum.

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 of coverage for dependents.

TERMINATION FOR CAUSE

If any of the following conditions exist, you may receive written notice that you will no longer be covered under NJ PLUS.

Any action by NJ PLUS under these provisions is subject to review in accordance with the established appeals procedures. If an appeal is denied and the decision upheld, this action is subject to appeal to the State Health Benefits Commission. No benefits, other than for emergencies, will be provided to the member and to any family members under the coverage as of 31 days after such written notice is given by NJ PLUS.

If the State Health Benefits Commission sustains the termination by NJ PLUS, no further benefits are available from the day a completed application for a change of coverage to enroll in another health plan offered through the SHBP is received and processed by the Division of Pensions and Benefits, Health Benefits Bureau.

If the State Health Benefits Commission overrules the decision to terminate, benefits will be restored.

STATE HEALTH BENEFITS PROGRAM ELIGIBILITY

ACTIVE EMPLOYEE ELIGIBILITY

Eligibility for coverage is determined by the State Health Benefits Program (SHBP). Enrollments, terminations, changes to coverage, etc. must be presented through your employer to the SHBP. If you have any questions concerning eligibility provisions, you should call the Division of Pensions and Benefits' Office of Client Services at (609) 292-7524.

STATE EMPLOYEES

To be eligible for NJ PLUS State employee coverage, you must work full-time or be an appointed or an elected officer of the State of New Jersey (this includes employees of a State agency or authority and employees of a State college or university). For State employees, full-time normally requires 35 hours per week.

The following categories of State employees are also eligible for NJ PLUS coverage.

State Part-Time Employees — Part-time employees of the State and part-time faculty at institutions of higher education that participate in the SHBP are eligible for coverage under NJ PLUS and the Employee Prescription Drug Plan if they are members of a State-administered pension system. The employee or faculty member must pay the full cost of the coverage. Part-time employees will not qualify for employer or State-paid post-retirement health care benefits, but may enroll in the SHBP retired group at their own expense provided they were covered by the SHBP up to the date of retirement. See Fact Sheet #66, SHBP Coverage for State Part-Time Employees, for more information.

State Intermittent Employees — Certain intermittent State employees who have worked 750 hours in a Fiscal Year (July 1 - June 30) will be eligible for NJ PLUS and/or the Employee Prescription Drug Plan. Intermittent employees who maintain 750 hours of work per year continue to qualify for health benefits in subsequent years. See Fact Sheet #69, SHBP Coverage for State Intermittent Employees, for more information.

New Jersey National Guard — A member of the New Jersey National Guard who is called to State active duty for 30 days or more is eligible to enroll in NJ PLUS and the Employee Prescription Drug Plan at the State's expense. Upon enrollment, the member may also enroll eligible dependents. The Department of Military and Veteran's Affairs is responsible for notifying eligible members and for notifying the Division of Pensions and Benefits of members who are eligible.

LOCAL EMPLOYEES

To be eligible for NJ PLUS local employer coverage, you must be a full-time employee or an appointed or elected officer receiving a salary from a local employer (county, municipality, county or municipal authority, board of education, etc.) that participates in the SHBP. Each participating local employer defines the minimum hours required for full-time by a resolution filed with the SHBP, but it can be no less than an average of 20 hours per week. Employment must also be for 12 months per year except for employees whose usual work schedule is 10 months per year (the standard school year).

The following categories of local employees are also eligible for NJ PLUS coverage.

Local Part-Time Employees — A part-time faculty member employed by a county or community college that participates in the SHBP is eligible for coverage under NJ PLUS — and if provided by the employer the Employee Prescription Drug Plan — if they are members of a State-administered pension system. The faculty member must pay the full cost of the coverage. Part-time faculty members will not qualify for employer or State-paid post-retirement health care benefits, but may enroll in the SHBP retired group at their own expense provided they were covered by the SHBP up to the date of retirement. See Fact Sheet #66, SHBP Coverage for State Part-Time Employees, for more information.

ELIGIBLE DEPENDENTS

Your eligible dependents are your spouse or eligible same-sex domestic partner (as defined below) and/or your eligible unmarried children (as defined below).

Spouse — This is a member of the opposite sex to whom you are legally married. A photocopy of the marriage certificate is required for enrollment.

Domestic Partners — This is a same-sex domestic partner, as defined under Chapter 246, P.L. 2003, the Domestic Partnership Act, of any State employee, State retiree, or an eligible employee or retiree of a SHBP participating local public entity if the local governing body adopts 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).

Children — This includes your unmarried children under age 23 who live with you in a regular parent-child relationship, your children who are away at school, as well as divorced children living at home provided that they are dependent upon you for support and maintenance. If you are a single parent, divorced, or legally separated, your children who do not live with you are eligible if you are legally required to support those children — Affidavits of Dependency and legal documentation are required with enrollment forms for these cases. If a Qualified Medical Child Support Order (QMCSO) is issued for your child, the health plan of the parent named in the QMCSO will be the primary plan for that child. The employer must be notified of the QMCSO and a NJ State Health Benefits Program Application submitted electing coverage for the child within 60 days of the date the order was issued.

Stepchildren, foster children, legally adopted children, and children in a guardian-ward relationship are also eligible provided they live with you and are substantially dependent upon you for support and maintenance. Affidavits of Dependency and legal documentation are required with enrollment forms for these cases.

Coverage for an enrolled child will end when the child marries, enters into a domestic partnership, moves out of the household, turns age 23, or is no longer dependent on you for support and maintenance. Coverage for children age 23 ends on December 31 of the year in which they turn age 23 (see the COBRA section for continuation of coverage provisions).

Dependent Children with Disabilities — If a covered child is not capable of self-support when he or she reaches age 23 due to mental illness, mental retardation, or a physical disability, he or she may be eligible for a continuance of coverage. To request continued coverage, contact the Office of Client Services at (609) 292-7524 or write to the Division of Pensions and Benefits, Health Benefits Bureau, 50 West State Street, P. O. Box 299, Trenton, New Jersey 08625 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 for children with disabilities may continue only while (1) you are covered through the SHBP, and (2) the child continues to be disabled, and (3) the child is unmarried, and (4) the child remains dependent on you for support and maintenance. You will be contacted periodically to verify that the child remains eligible for continued coverage.

MEDICARE COVERAGE WHILE EMPLOYED

In general, it is not necessary for a Medicare-eligible employee, spouse, eligible same-sex domestic partner, or dependent child(ren) to be covered by Medicare while the employee remains actively at work. It is required that they enroll in both Parts A and B prior to retirement so that coverage will be effective at the time of retirement. However, if you or your dependents become eligible for Medicare due to End Stage Renal Disease (ESRD) you and/or your dependents must enroll in Medicare Parts A and B even though you are actively at work. For more information, see Medicare Coverage in the Retiree Eligibility section.

RETIREE ELIGIBILITY

The following individuals will be offered SHBP Retired Group coverage for themselves and their eligible dependents:

Eligibility for membership in the SHBP for the individuals listed in this section is contingent upon meeting two conditions:

1. You must be immediately eligible for a retirement allowance from a State- or locally-administered retirement system (except certain employees retiring from a school board or community college — or certain disability retirees); and

2. You were a full-time employee and eligible for employer-paid medical coverage immediately preceding the effective date of your retirement (if you are an employee retiring from a school board or community college under a deferred retirement with 25 or more years of service, you must have been eligible at the time you terminated your employment), or a part-time State employee or part-time faculty member who is enrolled in the SHBP immediately preceding the effective date of your retirement.

This means that if you allow your active coverage to lapse (i.e. because of a leave of absence, reduction in hours, or termination of employment) prior to your retirement or you defer your retirement for any length of time after leaving employment, you will lose your eligibility for health coverage under the Retired Group of the SHBP. (This does not include full-time TPAF retirees and PERS board of education or county college retirees with 25 or more years of service).

Employees whose coverage is terminated prior to retirement but who are later approved for a disability retirement will be eligible for coverage under the Retired Group of the SHBP beginning on the employee’s retirement date. If the approval of the disability retirement is delayed, coverage shall not be retroactive for more than one year.

Aggregate of Service Credit

Upon retirement, a full-time State employee, board of education, or county college employee who has 25 years or more of service credit, is eligible for State-paid health benefits under the SHBP. A full-time employee of a local government who has 25 years or more of service credit whose employer is enrolled in the SHBP and has chosen to provide post-retirement medical coverage to its retirees is eligible for employer-paid health benefits under the SHBP. Effective August 15, 2001, instead of having to meet the 25-year service credit requirement from a single State or locally-administered retirement system, a retiree under the SHBP may receive this benefit if the 25 years of service credit is from one or more State or locally-administered retirement systems and the time credited is nonconcurrent.

Eligible Dependents of Retirees

Dependent eligibility rules for Retired Group coverage are the same as for Active Group coverage except for the Medicare requirements.

Enrolling in the Retired Group of the SHBP

The SHBP is notified when you file an application for retirement with the Division of Pensions and Benefits. If eligible, you will receive a letter inviting you to enroll in the SHBP’s Retired Group coverage. Early filing for retirement is recommended to prevent any lapse of SHBP coverage or delay of eligibility.

Additional restrictions and/or requirements may apply when enrolling in the Retired Group of the SHBP. Be sure to carefully read the Retiree Enrollment section of the SHBP Summary Program Description (PDF file - size 356k - Requires Acrobat Reader).

MEDICARE COVERAGE

IMPORTANT: A Retired Group member and/or dependent(s) who are eligible for Medicare coverage by reason of age or disability must be enrolled in both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) to enroll or remain in SHBP Retired Group coverage.

You will be required to submit documentation of enrollment in Medicare Parts A and B when you become eligible for that coverage. Acceptable documentation includes a photocopy of your Medicare card showing both your Part A and B enrollment or a letter from Medicare indicating the effective dates of both your Parts A and B coverage. Send your evidence of enrollment to the Health Benefits Bureau, Division of Pensions and Benefits, PO Box 299, Trenton, New Jersey 08625-0299 or fax it to (609) 341-3407. If you do not submit evidence of Medicare coverage under both Parts A and B, you and/or your dependents will be terminated from the SHBP. Upon submission of proof of full Medicare coverage, your coverage will be reinstated by the SHBP.

IMPORTANT: If a provider is not registered with or opts out of Medicare, no benefits are payable under the SHBP for the provider’s services.

A Member May be Eligible for Medicare for the Following Reasons:

How to File a Claim If You Are Eligible for Medicare

When filing your claim, follow the procedure listed below that applies to you.

New Jersey Physicians or Providers:

Out-Of-State Physicians or Providers:

Retirees With Medicare Who Move Outside the United States

Medicare does not cover services outside the United States. For SHBP members who reside outside the United States, the Traditional Plan covers services as if the plan were primary.

Members who reside outside the United States must still maintain their Medicare coverage (Parts A and B) in order to be covered under the SHBP.

Members who reside outside the United States, even if they reside in a country with socialized medicine, should consider that if they travel outside their country of residence they will still need coverage. In order to have SHBP coverage at any time in the future, the member must stay enrolled in the SHBP, since once a member terminates coverage they will not normally be reinstated.

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. COBRA coverage is available for limited time periods (see Duration of COBRA Coverage), and the member must pay the full cost of the coverage plus an administrative fee.

Under COBRA, you may elect to enroll in any or all of the coverages you had as an active employee or dependent (health, prescription drug, 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 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 in any SHBP health plan and, if offered by your employer, SHBP prescription drug coverage during the SHBP Open Enrollment period regardless of whether you elected to enroll for the coverage when you went into COBRA. 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 the health insurance package available to active employees and 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:

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 COBRA Coverage

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

Duration of COBRA 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. Proof of Social Security Administration determination must be submitted within 60 days of the award or within 60 days of COBRA enrollment. 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 he or she becomes eligible because of your death, divorce, dissolution of a same-sex domestic partnership, or he or she becomes ineligible for continued group coverage because of marriage, entering into a domestic partnership, attaining age 23, or moving out of the household, or because you elected Medicare as your primary coverage.

If a second qualifying event — such as a divorce — 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.

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

Employer Responsibilities Under COBRA

The COBRA law requires employers to:

Employee Responsibilities Under COBRA

The law requires that you and/or your dependents:

Failure to Elect COBRA Coverage

In considering whether to elect continuation of coverage under COBRA, an eligible employee, retiree, or dependent (also known as a “qualified beneficiary” under COBRA law) should take into account that a failure to continue group health coverage will affect future rights under federal law.

Termination of COBRA Coverage

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

NJ PLUS

GENERAL CONDITIONS OF THE PLAN

All benefits listed in this handbook may be subject to limitations and exclusions as described in subsequent sections. All pertinent parts of this handbook should be consulted regarding a specific benefit.

Even though a service or supply may not be described or listed in this handbook, that does not make the service or supply eligible for a benefit under this plan.

Your Primary Care Physician (PCP) will ensure that your treatment is within the general conditions of the plan. However, if you go out-of-network you should know what will or will not be covered. The plan will pay only for eligible services or supplies that meet the following conditions:

When you go out-of-network, all services, supplies, tests, etc. prescribed by the out-of-network provider, including hospitalization, are reimbursed at 70 percent of the reasonable and customary allowance .

Medical Need and Appropriate Level of Care

The medical need and appropriate level of care for any service or supply as recommended by the treating physician is determined by NJ PLUS and must meet each of these requirements:

When there is a question as to medical need, the decision on whether the treatment is eligible for coverage will be made by NJ PLUS.

Reasonable and Customary Allowances (for Out-of-Network Services)

The plan covers only reasonable and customary allowances, which are determined by the Prevailing Healthcare Charges System (PHCS) fee schedule. This schedule is based on actual charges by physicians in a specific geographic area for a specific service. If your physician charges more than the reasonable and customary allowance, you will be responsible for the full amount above the reasonable and customary allowance in addition to any deductible and coinsurance you may be required to pay.

Experimental or Investigational Treatments

The plan does not cover treatment that is considered experimental or investigational. Charges in connection with such a service or supply are also not covered. For the purpose of this exclusion, a service or supply will be considered experimental or investigational if the claims administrator determines that one or more of the following is true.

The service or supply is under study or in a clinical trial to evaluate its toxicity, safety, or efficacy for a particular diagnosis or set of indications. Clinical trials include but are not limited to phase I, II, and III clinical trials, with the exception of approved cancer trials.

The prevailing opinion within the appropriate specialty of the United States medical profession is that the service or supply needs further evaluation for a particular diagnosis or set of indications before it is used outside clinical trials or other research settings. The claims administrator will determine this based on:

It is a drug, device, or other supply that is subject to FDA approval but:

Educational or Developmental Services or Supplies,
or Educational Testing

The plan does not cover services or supplies that are rendered with the primary purpose being to provide the person with any of the following:

In the case of a hospital stay, the  stay, services, and supplies are not covered to the extent that they are determined to be allocated to the scholastic education or vocational training of the patient.

Predetermination of Benefits

A predetermination for any service may be obtained in writing in advance of services being rendered. The written request will need to include the provider's name, address, and phone number, the diagnosis, a description of the services to be rendered, and the anticipated charges. Telephone contact with Horizon BCBSNJ or the Division of Pensions and Benefits about coverage does not constitute a predetermination of benefits. If the actual services rendered differ from those described in the written request, the predetermination of benefits will have no effect. A predetermination is valid for one year from the date issued.

Custodial, Maintenance, and Supportive Care

NJ PLUS does not provide coverage for services that are determined to be for custodial, maintenance, and/or supportive care. Custodial care relates to services that do not require the skill level of a nurse to perform. These services include, but are not limited to, assisting with activities of daily living, meal preparation, ambulation, cleaning, and laundry functions. Maintenance care is care that when provided does not substantially improve the condition. When care is provided for a condition that has reached maximum improvement and further services will not appreciably improve the condition, care will be deemed to be maintenance care and no longer eligible for reimbursement. Supportive care is treatment for patients having reached maximum therapeutic benefit in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains.

Regardless of whether they are medically necessary, custodial, maintenance, and/or supportive care are ineligible for reimbursement under NJ PLUS.

PRESCRIPTION DRUG BENEFITS

EMPLOYEE PRESCRIPTION DRUG PLAN

The Employee Prescription Drug Plan is offered to active State employees and their eligible dependents as a separate prescription drug plan. Local employers may also elect to provide the SHBP Employee Prescription Drug Plan to their employees as a separate prescription drug benefit.

The Employee Prescription Drug Plan is currently administered by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) through Caremark.

Plan Benefits

Employee Prescription Drug Plan benefits are available through a participating retail pharmacy or through the Caremark mail order and specialty pharmacy services.

For more information about the Employee Prescription Drug Plan, copayment amounts, and specific benefits, see the Employee Prescription Drug Plan Member Handbook which is available from your employer, from the Division of Pensions and Benefits, or at the SHBP home page at: www.state.nj.us/treasury/pensions/shbp.htm

PRESCRIPTION DRUG BENEFITS PROVIDED
THROUGH SHBP HEALTH PLANS

The State Health Benefits Commission requires that all participating employees and retirees have access to prescription drug coverage.

Employee Prescription Drug Reimbursement Plan for NJ PLUS Members

Active employees whose employer does not offer a separate prescription drug plan have prescription drug coverage through the Employee Prescription Drug Reimbursement Plan for NJ PLUS. The Employee Prescription Drug Reimbursement Plan is accepted at most pharmacies nationwide. These pharmacies have agreed to provide prescription drugs at a discounted price to plan members. When you use a participating pharmacy, most claims can be submitted electronically to the plan for consideration.

Prescriptions written by your in-network PCP or a specialist with PCP referral will be reimbursed the applicable percentage of the discounted price.

Prescriptions written by an out-of-network provider are reimbursed the applicable percentage of the discounted price after satisfying your deductible.

After your NJ PLUS out-of-pocket maximum has been reached (see Coinsurance ), you will be reimbursed 100 percent of the eligible pharmacy price under the Employee Prescription Drug Reimbursement Plan.

A mail order service is also available through the Employee Prescription Drug Reimbursement Plan for NJ PLUS for active employees (including COBRA participants) who do not have a separate prescription drug plan through their employer. The mail order service is administered by Horizon Blue Cross Blue Shield of New Jersey through the mail service pharmacy owned and operated by Caremark. Members may order maintenance prescriptions by mail or online from www.caremark.com

Specialty pharmacy services also apply — for details see “Specialty Pharmacy Services“

Using a pharmacy that does not participate in the plan may result in higher out-of-pocket costs. If you have a prescription filled at a non-participating pharmacy or forget to present your Employee Prescription Drug Reimbursement Plan identification card, you will need to submit a completed claim for reimbursement.

Some prescription drugs are covered by the Employee Prescription Drug Reimbursement Plan only in certain quantities.

RETIREE PRESCRIPTION DRUG COVERAGE

Retirees enrolled in NJ PLUS have access to a separate Retiree Prescription Drug Plan that includes retail pharmacy, mail order, and specialty pharmacy services. The plan is administered by Horizon Blue Cross Blue Shield of New Jersey through Caremark, and features a three-tiered design.

Based on the design adopted at the time the plan was implemented, effective January 1, 2006, copayment amounts for a 30-day supply are set at $8 for generic drugs (Tier I), $16 for preferred brand name drugs (Tier II), and $33 for all other brand name drugs (Tier III) when purchased at a participating retail pharmacy. You may purchase up to a 90-day supply of medication at a pharmacy when prescribed by your provider, by paying the applicable copayments (31- to 60-day supply — two copayments, 61- to 90-day supply — three copayments).

Mail order copayments for up to a 90-day supply are $8 for generic drugs, $25 for preferred brand name drugs, and $41 for all other brand name drugs.

Specialty pharmacy services also apply — for details see “Specialty Pharmacy Services“

Effective January 1, 2006, there is a $1,000 annual maximum in prescription drug copayments per person. Once a person has paid $1,000 in copayments, that person is no longer required to pay any prescription drug copayments for the remainder of the calendar year.

Note: The copayment and plan maximum amounts listed above may increase each year based upon a “set cost sharing formula” that is a part of the plan design.

A majority of pharmacies participate with Caremark, however, some do not have agreements with Caremark and are not a part of the Retiree Prescription Drug Plan. When using a non-participating pharmacy, you will be asked to pay the full cost of the prescription drug to the pharmacist and file a claim with Caremark for reimbursement. The reimbursement will be based on the participating pharmacy allowance rather than the actual charge(s) paid.

Some prescription drugs are covered by the Retiree Prescription Drug Plan only in certain quantities.

COORDINATION OF BENEFITS

Almost all group insurance plans, including NJ PLUS, provide for the coordination of benefits (COB). 

Please note: The COB rules may change if Medicare is involved. Please refer to the Medicare section for more information.

For group plans that do have a COB provision, the following rules determine which is the primary plan.

NJ PLUS will provide its regular benefits in full when it is the primary plan. As a secondary plan, NJ PLUS will provide reimbursement up to its regular benefit which when added to the benefits under other group plans will not exceed 100 percent of the eligible charges.

If you enroll in NJ PLUS and your spouse or eligible domestic partner has primary coverage through another plan, your spouse/partner’s visits to his or her primary care physician (PCP), under NJ PLUS, are covered in full after the appropriate copayment. Office visits to PCPs are covered under NJ PLUS as if NJ PLUS were the primary plan. All other services are subject to regular COB rules.

If your spouse or eligible domestic partner is referred to a NJ PLUS specialist or goes to an in-network obstetrician/gynecologist, chiropractor, or optometrist or ophthalmologist for an annual vision examination, your spouse or domestic partner need only give the provider the appropriate copayment plus any assistance required in completing claim forms to submit the charge to the spouse/partner’s primary coverage. His or her plan will pay its benefit first, and NJ PLUS will cover the balance to the provider according to the in-network rules. If the visit is to an out-of-network provider, normal COB rules apply.

Please note: No individual can receive benefits under more than one NJ PLUS contract. There is no coordination of benefits for yourself or for any of your dependents if you and your spouse or eligible domestic partner, through separate employment, have selected NJ PLUS as your plan.

PLAN BENEFITS

IN-NETWORK BENEFITS

You can benefit most from NJ PLUS when you use in-network benefits which means obtaining your care from network providers and having your care managed by your primary care physician (PCP). When you are treated in-network, you are covered for treatment of illness or injury as well as well-care and preventive services. The plan will pay, in most cases, the full cost after an appropriate copayment per visit (see copayment information). Certain services, such as durable medical equipment, private duty nursing services, outpatient mental health care, prescription drugs, and ambulance services are paid at 90 percent. When your out-of-pocket amounts total $400 per individual/$1,000 per family, the plan will pay 100 percent of the reasonable and customary allowance for these services.

Your PCP manages the level of care you receive by referring you to the appropriate network specialists and hospitals. If your PCP determines that you require specialty care, he or she will refer you to a NJ PLUS specialist. If your PCP determines you require hospitalization, then s(he) will refer you to a NJ PLUS hospital and arrange for admission. If the specialty care or hospital service needed cannot be provided by a network specialist or hospital, then the patient will be referred to an appropriate non-network specialist or hospital. In the event this occurs, with the approval of NJ PLUS, the benefits can, in certain circumstances, be provided at the in-network level.

Selecting a Primary Care Physician (PCP)

When you enroll in NJ PLUS, you and each covered family member must select a PCP from the NJ PLUS Provider Network. Each family member may select his or her own PCP from NJ PLUS participating family practitioners, internists, general practitioners, and pediatricians. Patients may visit any participating obstetrician/gynecologist, chiropractor, or participating ophthalmologist/optometrist for related treatment without a referral from their PCP. (See the Summary of Covered Services and Supplies for limits on chiropractic care and vision care/annual eye examinations.)

How to Access Information That Will Help You Choose a PCP

The SHBP offers the Unified Provider Directory (UPD). Updated monthly, the UPD is available over the Internet and contains medical provider information for all of the SHBP's participating health plans. This information is in a uniform, easy to use format and displays timely and comprehensive information concerning health care providers and facilities that deliver their services through NJ PLUS. The site can be reached through the SHBP home page at: www.state.nj.us/treasury/pensions/shbp.htm In addition, you may also access the NJ PLUS Provider Directory on the Horizon Blue Cross Blue Shield of New Jersey Web site at: www.horizonblue.com

If you do not have Internet access, contact Horizon Blue Cross Blue Shield of New Jersey for provider information at 1-800-414-SHBP (7427).

OUT-OF-NETWORK BENEFITS

NJ PLUS includes an option for using out-of-network providers. When you use out-of-network providers, NJ PLUS covers hospital and other medical services similar to traditional or indemnity plans. When you exercise this out-of-network option, you incur an annual deductible and a coinsurance requirement of 30 percent of reasonable and customary allowances, and any amounts exceeding the reasonable and customary allowances. NJ PLUS out-of-network benefits do not cover well-care or preventive care. If you use an out-of-network provider, all services, supplies, tests, etc. ordered by that provider will be paid at the out-of-network level. If your out-of-network provider contacts NJ PLUS for authorization prior to referring you to a network hospital for inpatient services, you may be eligible for in-network benefits for the facility fees.

Deductibles

NJ PLUS has two separate deductibles. There is an annual deductible that each member must meet before an out-of-network charge is paid. There is also a deductible of $200 for each inpatient out-of-network hospital stay.

The annual individual deductible for out-of-network services is $100. The actual maximum deductible amount varies with the level of coverage that you elect:

The benefit year in which the deductible is measured runs from January 1 to December 31. However, if treatment for an illness or injury is provided during the last three months of the year, the eligible charges that were applied toward the deductible may be counted toward meeting the deductible for the following year.

For example: you are charged $100 for an October 3, 2005 doctor's office visit. This is your first claim of the year and no other calendar year deductible has been met; therefore, the full $100 charge is applied to the deductible for 2005. Since this amount was applied in the last three months of 2005, the full $100 will be applied towards meeting the 2006 deductible.

If you are enrolling in the SHBP for the first time because your employer has decided to join, previously paid charges in the current calendar year can be used to meet the deductible requirements for NJ PLUS. You must submit documentation to NJ PLUS showing charges used to meet the deductible.

Coinsurance

NJ PLUS will pay 70 percent of the reasonable and customary allowance for eligible out-of-network charges. You are required to pay the other 30 percent of the cost of eligible out-of-network charges up to the point at which your out-of-pocket amount for the year totals $2,000 per individual or $5,000 per family. Once the $2,000 out of pocket amount has been reached, the plan will pay 100 percent of the reasonable and customary allowance for that individual. Since the coinsurance applies to each person in your family, the actual amount you are required to pay each year will depend on the number of dependents on your coverage. Expenses for ineligible services and charges in excess of reasonable and customary allowances do not count toward your out-of-pocket maximums. Additionally, only preauthorized treatments count toward the NJ PLUS maximum out-of-pocket expense level.

UTILIZATION MANAGEMENT

Both in-network and out-of-network treatment is subject to Utilization Management (UM), a process used to ensure that treatment is medically needed and at the appropriate level of care.

Benefits are payable for in-network treatment when they are provided by an in-network provider, the UM organization has been notified to review the treatment, and the UM organization has approved the treatment. Benefits would also be paid on this basis to an out-of-network provider in those instances where the patient is referred to an out-of-network provider by their PCP and it is authorized by NJ PLUS.

For out-of-network benefits when the patient has failed to contact the UM organization, treatment will be considered as unauthorized and expenses will not be applied to the annual out-of-pocket maximum (see appeal procedures). However, if the treatment is eligible, reimbursement will be made at 70 percent of reasonable and customary allowances if the deductible has been met.

OVERALL BENEFIT MAXIMUMS

For in-network services there is no lifetime benefit maximum.

For out-of-network services, there is a lifetime maximum benefit of $1,000,000 for diagnosis and treatment of illness and injuries, with an automatic limited restoration feature. Once the maximum lifetime benefit has been paid out, at the start of each calendar year, any previously unused portion of a covered person's maximum will be carried over and $2,000 or the lesser amount needed to restore the full maximum will also be made available for benefits for that covered person.

If your coverage under NJ PLUS ends and begins again at a later date, your individual lifetime maximum benefit resumes at the same level it was when your coverage ended.

Mental Health Maximums

The maximum benefits for non-biologically-based mental or nervous conditions are listed on page 56. NJ PLUS also contains a unique automatic restoration provision, which can restore benefits issued for non-biologically-based mental illnesses. This special restoration of benefits is in addition to the restoration provision for the overall plan lifetime benefit maximum. This provision is applicable in the calendar year immediately following the initial calendar year in which benefits are paid for mental illness. The patient must be a covered person at the beginning of the year the restoration begins. The maximum that may be restored in a calendar year is $2,000. The amount restored will be the lesser of $2,000 or the amount that will bring the total lifetime benefits to $50,000. A maximum restoration of $50,000 is available for the lifetime of the patient. Services for mental and nervous disorders, that are non-biologically-based, have a $15,000 annual maximum/$50,000 lifetime maximum with a $2,000 automatic restoration provision for all in-network or out-of-network services.

SUMMARY OF COVERED SERVICES AND SUPPLIES

SPECIFIC COVERAGE AREAS

This section lists the various treatments, services, and supplies that NJ PLUS will consider. Expenses for these services or supplies are subject to reasonable and customary allowances; medical need and appropriate level of care; utilization review; the Schedule of Covered Services and Supplies; and benefit limitations and exclusions.

Acupuncture

Acupuncture treatment is covered when the services are for a diagnosis related to pain management and are rendered by a Licensed Acupuncturist or Licensed Medical Doctor (M.D., D.O.). Acupuncture treatment is subject to maintenance and supportive care provisions.

Examples of acupuncture services that are not eligible under NJ PLUS include weight loss and smoking cessation.

Alcoholism and Substance Abuse

NJ PLUS covers the treatment of Alcoholism and Substance Abuse the same way it would any other illness, if such treatment is prescribed by an eligible provider and it is deemed to be medically needed and at the appropriate level of care. If you need care, you must contact NJ PLUS directly. You do not need a referral from your PCP for this care. For scheduled or emergency treatment relating to substance abuse, or alcoholism, you or your provider should call 1-800-991-5579. You must obtain a pre-treatment authorization for all in-network admissions. If you choose to receive your care out-of-network, you should also call NJ PLUS for pre-treatment authorization so that your coinsurance amounts, for these services, are applied to your out-of-pocket maximum.

Inpatient or outpatient treatment may be furnished as follows:

Psychotherapy to treat alcohol or substance abuse is covered under mental health and is subject to the annual and lifetime maximum benefits.

Allergy Testing and Treatment

Most commonly used methods of allergy testing are covered. However, some methods are subject to medical need at the appropriate level of care review before eligibility can be determined. This includes, but is not limited to, the following tests:

Ambulance

Ambulance use for local emergency transport to the nearest eligible facility equipped to treat the emergency condition is covered subject to medical need at the appropriate level of care. If emergency air transport is needed, it must be precertified by calling NJ PLUS at 1-800-414-SHBP (7427).

NJ PLUS does not cover chartered air flights, non-emergency air ambulance, invalid coach, transportation services, or other travel, lodging, or communication expenses of patients, providers, nurses, or family members.

Audiology Services

Audiology services are covered when rendered by a physician or a licensed audiologist, when such services are determined to be medically medical needed and at the appropriate level of care. Pre-approval is required for these services to be considered at the in-network level of benefits. See exclusions for hearing aids and hearing examinations.

Automobile-Related Injuries

NJ PLUS will provide secondary coverage to your mandatory New Jersey Personal Injury Protection (PIP) unless NJ PLUS has been elected as the primary coverage by or for the employee covered under this contract. This election is made by the named insured under the PIP program and affects that member's family members who are not themselves the named insured under another auto policy. NJ PLUS may be primary for one member, but not for another if the persons have separate auto policies and have made different selections regarding primacy of health coverage.

NJ PLUS is secondary to automobile insurance coverage. However, if the automobile insurance contains provisions which made the automobile insurance coverage secondary or excess to NJ PLUS, NJ PLUS will be primary.

If NJ PLUS is primary to PIP or other automobile insurance coverage, benefits are paid in accordance with the terms, conditions, and limits set forth in your contract and only for those services normally covered under NJ PLUS.

Please note: If you elect to have NJ PLUS as primary to PIP, prior notification to Horizon BCBSNJ is not required. Upon receipt of an auto related claim, Horizon BCBSNJ will request the submission of written documentation, such as a copy of your policy declaration page, for verification of your selection.

If NJ PLUS is one of several health insurance plans which provide benefits for automobile related injuries and the covered employee has elected health coverage as primary, these plans may coordinate benefits as they normally would in the absence of this provision.

Please note: There is no coordination of benefits for prescription drug expenses.

If NJ PLUS is secondary to PIP, the actual benefits payable will be the lesser of:

Biofeedback

Biofeedback to treat a medical or biologically-based mental illness diagnosis is covered the same as any other general condition. Mental health diagnoses that are considered non-biologically-based in nature will be subject to the mental health plan maximums under NJ PLUS.

Birthing Centers

As an alternative to conventional hospital delivery room care for low-risk maternity patients, NJ PLUS pays for care in birthing centers under contract with Horizon BCBSNJ. Services routinely provided by the birthing centers, including prenatal, delivery, and postnatal care, will be covered in full if the delivery takes place at the center. If complications occur during labor and delivery occurs in an approved hospital because of the need for emergency or inpatient care, this care will also be covered in full. Contact NJ PLUS at 1-800-414-SHBP (7427) to identify eligible birthing centers near you.

Blood

Blood, blood products, blood transfusions, and the cost of testing and processing blood are covered. NJ PLUS does not pay for blood which has been donated or replaced on behalf of the patient.

Breast Reconstruction

If you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction along with that mastectomy, NJ PLUS will provide coverage for the following:

Chiropractic Services

There is a 30-visit benefit maximum for chiropractic services per person per calendar year. The chiropractor must be licensed, the services must be appropriate for the diagnosed condition(s), and must fall within the scope of practice of a chiropractor in the state in which he or she is practicing.

No referral is needed for the in-network level of coverage.

Congenital Defects

Surgical procedures that are necessary to correct a congenital birth defect, which significantly impairs function, including dental procedures, are covered.

Dental Care

NJ PLUS provides benefits for the removal of bony impacted molars, and will pay for the treatment of accidental injuries, and treatment for mouth tumors if medically necessary.

NJ PLUS may provide coverage for the treatment of accidental dental injuries. You must have been covered by NJ PLUS at the time the injury occurred. An accidental dental injury is considered an injury to teeth (must be sound natural teeth) which is caused by an external factor such as damage caused by being hit by a hockey puck or having teeth broken in a fall on the ice.

The treatment and replacement must occur within 12 months of the accident. A treatment plan must be submitted. If it is determined that treatment cannot be reasonably completed within 12 months, this time limit may be extended.

Breaking a tooth while chewing on food is not considered an accidental dental injury. Examples of ineligible dental services include, but are not limited to, breaking a tooth on a popcorn seed, olive pit, or on a bone in a piece of meat.

Stress fractures in teeth are very common and generally undetectable by X-ray. Stress fractures are often the cause of tooth breakage. Treatment for this type of tooth breakage is considered a dental service and not eligible for reimbursement under NJ PLUS.

Hospital and anesthesia charges incurred for dental services that are medically needed and at the appropriate level of care are covered for severely disabled members and children who can submit convincing documentation for the medical need for the hospitalization/anesthesic services. Charges for the actual dental procedures would not be eligible for benefit under NJ PLUS.

Diabetic Self-Management Education

Benefits, limited to four visits per year, are included for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of the member's condition.

Benefits for self-management education and education relating to diet shall be limited to medically necessary visits upon:

Diabetes self-management education is covered when provided by:

Benefits are provided for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse provider/clinical nurse specialist:

Dialysis

Dialysis is covered when the services are provided and billed by an eligible hospital, by a freestanding dialysis center, or by an eligible home health care agency. The facility must make arrangements for training, equipment rental, and supplies on behalf of the patient. Home dialysis will be considered when there is documented evidence that the services cannot be performed in an outpatient facility.

Durable Medical Equipment and Supplies

Charges for the rental of durable medical equipment needed for therapeutic use are covered. NJ PLUS may cover the purchase of such items when it is less costly and more practical than renting such items. NJ PLUS does not cover the rental or purchase of any items which do not fully meet the definition of durable medical equipment. For in- and out-of-network services it is recommended that costly durable medical equipment be approved by NJ PLUS prior to purchase.

NJ PLUS also covers eligible supplies including surgical dressings, blood and blood plasma, artificial limbs, larynx and eyes, casts, Inherited Metabolic Disease medical food, certain non-standard infant formula (under one year of age), splints, trusses, braces, crutches, respirator oxygen and rental of equipment for its use.

Emergency Medical Services

A medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

With respect to emergency services furnished in a hospital emergency department, NJ PLUS shall not require prior authorization for the provision of such services if the member arrived at the emergency medical department with symptoms that reasonably suggested an emergency condition based on the judgment of a prudent layperson, regardless of whether the hospital was affiliated with NJ PLUS. All procedures performed during the evaluation (triage) and treatment of an emergency medical condition shall be covered by NJ PLUS.

If you find yourself in an emergency situation, and notification prior to treatment is not reasonably possible, go directly to the nearest emergency facility. All such treatment received during the first 48 hours after the onset of the medical emergency will be eligible for in-network benefits, regardless of whether such treatment is received in or out of the service area or whether such treatment is furnished by a network provider. You must notify your PCP and/or NJ PLUS of the medical emergency within those 48 hours. Your PCP must then authorize the continuation of any necessary medical services in order for any such treatment received after those first 48 hours to continue being eligible for in-network benefits. This means if you are admitted to the hospital through the emergency room, you must notify your PCP and/or NJ PLUS of the emergency and get authorization for treatment and hospital days beyond the first 48 hours. If you do not notify your PCP and/or NJ PLUS within 48 hours, you will not receive in-network benefits.

Urgent and After Hours Care

Urgent care is medically necessary care for an un­ex­pect­ed illness or injury that should be treated within 24 hours, but is not life-threatening. It is medical care you can safely post­pone until you can call your Primary Care Physician (PCP). Examples of urgent care include fever, earache, cuts, sprains, and minor burns. In instances like these, call your PCP first for instructions. If your PCP determines your situation is a medical emergency, he or she will refer you directly to an emer­gen­cy facility. If it is not a medical emergency, your PCP will tell you how to treat the problem yourself or make an ap­point­ment to see you. Your PCP or a covering physician is available 24 hours a day, every day.

Contact your PCP for after hours care or care that is required at night or on a weekend or holiday. Again, your PCP will provide instructions on how to treat your problem.

If you go directly to an emergency facility for urgent or after hours care and your situation is not a medical emergency, your care will not be covered at the in-network level of benefits.

Away From Home Care

Under NJ PLUS you are covered for urgent care when traveling or away from home. Urgent care is medically needed and at the appropriate level of care for an unexpected illness or injury, not a life threatening condition, but one that should be treated before you return home. If you are traveling out of the service area and need urgent care, call NJ PLUS at 1-800-414-SHBP (7427) before receiving care from a local doctor. If you are unable to contact NJ PLUS before receiving care, call within 48 business hours of receiving care.

When you call NJ PLUS before receiving care or within 48 business hours, eligible, medically needed and appropriate level of care services will be paid at the in-network level of benefits. Any necessary follow-up care must be performed or referred by your PCP to receive the in-network level of benefits. Follow-up care that is not performed or referred by your PCP will be paid at the out-of-network level of benefits.

For all medical emergencies, present your NJ PLUS identification card to the hospital representative at the time of treatment. The identification card contains all necessary emergency instructions.

Emergency Room

Each time the member uses the hospital emergency room, the member must pay a copayment as designated in the Summary Schedule of Services and Supplies . If the member is admitted within 24 hours, the copayment amount is waived.

Federal Government Hospitals

NJ PLUS will pay for eligible charges in hospitals operated by the United States government (Veterans Administration and Department of Defense) as if they were member hospitals, regardless of their location, for eligible charges for nonmilitary conditions.

NJ PLUS will pay hospitals operated by the United States government for nonmilitary patients (i.e., patients other than military retirees and their dependents and dependents of active duty military personnel) for eligible charges only if:

Home Health Care

Home health care services and supplies are covered only if furnished by providers on a part-time or intermittent basis, except when full-time or 24-hour service is needed on a short-term basis. Pre-approval of a skilled need is required for these services.

The home health care plan must be established in writing by the member's provider within 14 days after home health care starts and it must be reviewed by the member's provider at least once every 60 days.

Eligible home health services provided by a home health care agency include:

A prior inpatient hospital stay is not required to qualify for home health care agency benefits but the patient must be homebound and require skilled nursing care under a plan prescribed by an attending physician.

NJ PLUS does not cover:

Home Hemophilia Treatment

Home hemophilia treatment will be considered when there is documented medical evidence that these services cannot be performed in an outpatient facility.

Hospice Care Benefits

Benefits for hospice must be provided according to a physician prescribed course of treatment approved by NJ PLUS with a confirmed diagnosis of terminal illness and a life expectancy of six (6) months or less.

The following hospice services are covered:

No benefit consideration will be given for any of the following hospice care benefits:

Inpatient benefits for hospice patients are provided at the same level as those provided for non-hospice patients. For more information on hospice care, please call NJ PLUS at 1-800-414-SHBP (7427).

Hospital-Based Weight Loss Programs

Hospital-based weight loss programs may be eligible for a patient diagnosed with morbid obesity. For in-network level benefits, the provider should obtain authorization from NJ PLUS. For out-of-network services, call NJ PLUS at 1-800-414-SHBP (7427) to verify eligibility prior to enrolling in a hospital-based weight loss program.

Immunizations

Immunizations are covered under NJ PLUS at the in-network level of benefits unless they are for travel outside the country or work-related. Well-child immunizations for children less than 12 months of age are the only immunizations allowed at the out-of-network level.

Infertility Treatment

The State Health Benefits Program has established Assisted Reproductive Technology (ART) benefits that were effective as of July 1, 2000, for members of the Traditional Plan, NJ PLUS, and Aetna. See Appendix IV for plan details.

Lithotripsy Centers

Lithotripsy services are covered when they are performed in an approved hospital or lithotripsy center. For information regarding the eligibility of certain centers, please call NJ PLUS at 1-800-414-SHBP (7427).

Lyme Disease Intravenous Antibiotic Therapy

All intravenous antibiotic therapy for the treatment of Lyme Disease must be pre-certified by NJ PLUS. When intravenous therapy is determined to be medically appropriate, the supplies, cost of the drug, and skilled nursing visits will be covered services.

To pre-certify intravenous therapy for treatment of Lyme Disease, your provider should call NJ PLUS at 1-800-414-SHBP (7427). The State Health Benefits Program’s policy on Lyme Disease treatment is found in Appendix IV.

Mastectomy Benefits

A hospital stay of at least 72 hours following a modified radical mastectomy and a hospital stay of at least 48 hours is covered following a simple mastectomy, unless the patient in consultation with his physician, determines that a shorter length of stay is medically needed and at the appropriate level of care.

Maternity/Obstetrical Care

Medical care related to childbirth includes the hospital delivery and hospital stay for at least 48 hours after a vaginal delivery or 96 hours after a cesarean section if the attending provider determines that inpatient care is medically needed and at the appropriate level of care.

Services and supplies provided by a hospital to a newborn child during the initial covered hospital stay of the mother and child is covered as part of the obstetrical care benefits.

NJ PLUS also covers birthing center charges made by a provider for pre-natal care, delivery, and post-partum care in connection with a member's pregnancy.

Maternity/Obstetrical Care for Child Dependents

In some instances, NJ PLUS will pay bills related to the birth of a grandchild. In order for benefits to be available, all of the following must apply:

Coverage for the grandchild ends when the mother is discharged from the hospital. The grandparent may apply for coverage of the grandchild under the SHBP only if (s)he obtains legal custody of the child.

Mental or Nervous Conditions and Substance Abuse

NJ PLUS covers treatment for mental or nervous conditions and for substance abuse, including group therapy. If you need care you must contact NJ PLUS directly. You do not need a referral from your PCP for this care. For a scheduled or emergency mental health, substance abuse, or alcoholism hospitalization, you or your provider must call 1-800-991-5579. You must obtain pre-treatment authorization for all in-network admissions. If you choose to receive your care out-of-network, you must also call NJ PLUS for certification in order for your coinsurance for these services to be applied to your out of pocket maximum.

When the Care Manager authorizes a member's treatment for mental or nervous conditions, or substance abuse, coverage will be provided at the in-network level of benefits. Payment will be made at a reduced level, or may not be approved if the Care Manager does not manage, assess, coordinate, direct, and authorize a member's treatment for mental or nervous conditions and substance abuse before expenses are incurred. The Care Manager will review and determine if services rendered were medically needed and at the appropriate level of care.

A member may receive covered treatment as an inpatient in an eligible hospital or a substance abuse facility. The member may also receive covered treatment at an eligible hospital or outpatient substance abuse center, or from any eligible provider, psychologist or licensed clinical social worker.

Services rendered for the treatment of a biologically-based mental illness are treated like any other illness and are not subject to the mental health maximums. Biologically-based mental illness includes, but is not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, and pervasive developmental disorder or autism.

Nutritional Counseling

NJ PLUS allows three visits per year for nutritional counseling that is medically needed and at the appropriate level of care. The nutritional counseling must be prescribed by a NJ PLUS network provider.

Organ Transplant Benefits

Pre-approved services and supplies for the following types of transplants are covered:

Benefits include surgical, storage and transportation services which are directly related to the donation of the organ and billed for by the hospital.

Pain Management

Pain management services are covered subject to Horizon BCBSNJ’s guidelines. Pain management therapy must be supported by a comprehensive evaluation of the patient, the rationale for treatment must be well documented, and treatment must include a comprehensive program that is multifaceted and may include education, rest, therapeutic exercises, activity modification, physical therapy, occupational therapy, pharmacological interventions, mental health and behavioral interventions, therapeutic and injection interventions, and surgical interventions, if needed. Treatment will not always achieve complete elimination of a patient’s pain. In such cases, an increase in a patient’s level of function and teaching the patient strategies to cope with residual pain will be the aim. If treatment reaches a point at which no appreciable improvement in the patient’s condition is anticipated, services will be considered maintenance and/or supportive care (see page 19) and will not be eligible for reimbursement.

Pap Smears

Annual Pap smears provided by your PCP or a participating OB/GYN are covered at the in-network level of benefits. An annual Pap smear provided out-of-network is covered, subject to any deductible and coinsurance.

Patient Controlled Analgesia (PCA)

Patient Controlled Analgesia (PCA) is covered when it is medically appropriate, prescribed by a medical doctor, and provided under the guidance of one of the following:

Physical Therapy

Physical therapy that is medically needed and at the appropriate level of care is covered based on one session per day. A session of physical therapy is defined as up to one hour of physical therapy (treatment and/or evaluation) or up to three physical therapy modalities provided on any given day.

Pre-Admission Hospital Review

To obtain in-network benefits all non-emergency hospital and other facility admissions must be reviewed by NJ PLUS before they occur. You or the network hospital or your provider must notify NJ PLUS and request a Pre-Admission Review by phone or facsimile. NJ PLUS must receive the notice and request at least 5 business days or as soon as reasonably possible before the admission is scheduled to occur. For a maternity admission, such notice must be given to NJ PLUS at least 60 days before the expected date of delivery, or as soon as reasonably possible, to obtain in-network benefits.

Pre-Admission Testing Charges

Pre-admission diagnostic X-ray and laboratory tests needed for a planned hospital admission or surgery are covered. NJ PLUS only covers these tests if the tests are done on an outpatient or out-of-hospital basis within seven days of the planned admission or surgery.

However, NJ PLUS does not cover tests that are repeated after admission or before surgery, unless the admission or surgery is deferred solely due to a change in the member's health.

Preventive Care

Preventive care services, except mammograms, an annual Pap smear, and certain immunizations, are not covered out-of-network. In-network benefits for certain covered services and supplies relating to preventive care including related diagnostic X-rays and laboratory tests are provided. The covered preventive care benefits are as follows:

Private Duty Nursing

Private duty professional nursing is only available under very strict standards. Private duty nursing will only be covered under extraordinary circumstances upon evidence of a clear and convincing objective need.

Private duty nursing must be ordered by a doctor; and provided by one of the following:

Private duty nursing will not be covered if the care is:

Scalp Hair Prostheses

A benefit maximum of $500 in a 24 month period, per person, is covered for scalp hair prostheses prescribed or authorized by a doctor, only if they are furnished in connection with hair loss resulting from:

Second Surgical Opinion

NJ PLUS provides coverage for a second physician's personal examination of a patient following a recommendation for any eligible surgical procedure. The plan will pay for one consultation by a qualified specialist physician.

If the second opinion specialist does not confirm the need for surgery, NJ PLUS will provide coverage for one additional consultation if requested by the patient. The plan also will provide coverage for any diagnostic X-rays, laboratory tests, or diagnostic surgical procedures required by the physicians performing the consultations.

Shock Therapy Benefits

NJ PLUS provides benefits for electroshock treatments, insulin shock treatments, and other similar treatments. All treatment provided for a non-biologically-based mental illness will be counted towards the annual and lifetime mental health maximums. Benefits are also payable for anesthesia in connection with the shock treatment and for all other eligible services performed on that day for the disorder.

Skilled Nursing Facility Charges

Room, board, including diets, drugs, medicines and dressings and general nursing service in a skilled nursing facility are covered.

Speech Therapy Benefit

Speech therapy services provided by a qualified speech therapist are covered only as follows:

Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully developed are not covered under NJ PLUS.

In addition, speech therapy services will be considered eligible for a period of one year for children with a documented medical history of multiple cases of Otitis Media and one or more myringotomy(ies).

Surgical Services

Temporomandibular Joint Disorder (TMJ) and Mouth Conditions

Medical and surgical services performed for the treatment of the jaw are covered. Services in relation to the teeth in any manner are excluded. Charges for doctor's services or X-ray examinations for a mouth condition are not eligible.

Charges for dental or orthodontic services for a TMJ diagnosis are not eligible. This exclusion applies even if a condition requiring any of these services involves a part of the body other than the mouth, such as treatment of TMJ or malocclusion involving joints or muscles by methods including but not limited to crowning, wiring or repositioning of teeth and dental implants.

Vision Care Benefits (In-Network Only)

NJ PLUS covers an annual eye examination by a participating ophthalmologist or optometrist. You do not need a referral from your PCP for this annual routine examination. Any visits to an ophthalmologist or optometrist other than for the annual examination will be covered at the in-network level only when you have a referral from your PCP. There are no benefits available for frames, lenses, or contact lenses. There is no out-of-network preventive vision care benefit.

CHARGES NOT COVERED BY THE PLAN

Even though a service or supply may not be described or listed in this handbook, that does not make the service or supply eligible for a benefit under this plan.

The following services and supplies are not covered by NJ PLUS:

Examples of Non-Covered Services:

Example 1: A physician orders inpatient private duty nursing for a surgery patient. Since private duty nursing is not covered under the plan while confined in a hospital, because these nursing services are provided by the hospital, the charges for private duty nursing will not be paid.

Example 2: A person is studying to become a therapist and is required by the school to enter therapy. The treatment is intended to ensure that the new therapist is well-equipped to work with patients. The treatment is not covered because it is primarily educational.

Example 3: A physician orders a drug that is FDA-approved but is not commonly used to treat the particular condition. If the plan determines that the use is so new it is experimental, the plan will not pay for the drug.

Example 4: A hospital routinely requires an assistant to be present at certain operations. Other hospitals do not have that requirement. The plan will not pay for the assistant unless it can be demonstrated that the service was medically necessary.

THIRD PARTY LIABILITY

Repayment Agreement

If you have received benefits from NJ PLUS for medical services that are either auto-related or work-related, NJ PLUS has the right to recover those payments. This means that if your medical expenses are reimbursed through a settlement, satisfied by a judgement, or other means, you are required to return any benefits paid for illness or injury to NJ PLUS. The repayment will only be equal to the amount paid by NJ PLUS.

This provision is binding whether the payment received from the third party is the result of a legal judgment, an arbitration award, a compromise settlement, or any other arrangement, whether or not the third party has admitted liability for the payment.

Recovery Right

You are required to cooperate with NJ PLUS in recovering any amounts payable. NJ PLUS may:

WHEN YOU HAVE A CLAIM

SUBMITTING A CLAIM

IN-NETWORK

Generally you will not have to submit any claim forms to NJ PLUS for reimbursement for treatment from your Primary Care Physician (PCP) or any other network provider. You will simply pay the provider the required copayment amount and the provider will submit directly to NJ PLUS for the appropriate reimbursement.

OUT-OF-NETWORK

If you receive treatment out-of-network, claims must be submitted to the appropriate NJ PLUS address. Participating out-of-network Horizon BCBSNJ providers will file medical claims directly. If you do not use a participating provider you must submit the claim for reimbursement.

All mental health and substance abuse claims should be mailed to:

NJ PLUS
199 Pomeroy Road
Parsippany, New Jersey 07054
Phone: 1-800-991-5579

All other claims should go to one of the following addresses.

The three letters that appear on your NJ PLUS ID card before your identification number — the alpha prefix — is the indicator that determines where you should send your claims.

If your alpha prefix is NJP, send your claims to:

NJ PLUS
Horizon Blue Cross Blue Shield of New Jersey
P.O. Box 820
Newark, New Jersey 07101-0820
Phone: 1-800-414-SHBP (7427)

If your alpha prefix is HHP, send your claims to:

Empire Health Choice
P.O. Box 5049
Middletown, New York 10940-5049
Phone: 1-800-228-4708

If your alpha prefix is FLP (see note below), send your claims to:

Blue Cross Blue Shield of Florida
National Account Service Company
P.O. Box 2988
Jacksonville, FL 32232
Phone: 1-800-414-SHBP (7427)

Note: If your alpha prefix is FLP and Medicare is your primary coverage, send your claims to the NJ PLUS New Jersey address for NJP prefixes listed above.

Filing Deadline - Proof of Loss

NJ PLUS must be given written proof of a loss for which a claim is made under the plan. 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 2006, you would have until March 31, 2008, to file the claim.

A claim will not be considered valid unless proof is furnished within the time limit shown above. 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 medical expenses. The itemized bills must include the following:

Foreign Claims

Bills for services that are incurred outside of the United States must include an English translation and the charge for each service performed. The exchange rate at the time of service should also be indicated on the bill that is submitted for reimbursement.

Filling Out the Claim Form

Be sure to fill out the claim form completely. Include the identification number that appears on your NJ PLUS identification card. Fill out all applicable portions of the claim form and sign it. A separate claim form must be submitted for each individual and each time you file a claim.

MEDICARE CLAIM SUBMISSION

If a member is a New Jersey resident, has Medicare primary coverage, and receives care within New Jersey, claims will be transmitted automatically from the Medicare carrier to NJ PLUS.

If a member resides in another state and has Medicare primary coverage, the member will have to submit a copy of the Medicare Explanation of Benefits, an itemized bill, and a completed NJ PLUS claim form to Horizon BCBSN).

AUTHORIZATION TO PAY PROVIDER

The medical expense coverage provided by NJ PLUS is not assignable. However, the member (or a qualified dependent in case of the member's death) can, with the agreement of NJ PLUS, request that payment of any benefit for eligible charges payable to the member, instead be paid directly to the provider of service or supplies. Once payment is made to the provider at the member's request, NJ PLUS will not have to pay the benefit again. This direct payment is done as a courtesy to our member and is not an assignment of benefits. In order for benefits to be payable directly to a non-participating provider, the member must authorize this direction of payment by completing the appropriate section of the claim form.

The providers that participate with any Blue Cross Blue Shield plan will be paid directly for eligible services.

QUESTIONS ABOUT CLAIMS

If you have questions about a hospital claim, hospital benefits, a medical claim, or medical benefits or if you need a claim form, call 1-800-414-SHBP (7427).

If for any reason the claim is not eligible, you will be notified of its ineligibility within 90 days of receipt of your claim. To request a review of the claim, you should follow the instructions described in the Claim Appeal Procedures section.

APPENDIX I

SUMMARY SCHEDULE OF SERVICES AND SUPPLIES

New Jersey statutes, administrative code, and agreements between the SHBP and Horizon BCBSNJ govern this plan. The following schedule of benefits is a summary description of plan benefits. It is not complete and does not describe all the limitations or conditions associated with the coverage as described in prior sections. All pertinent parts of this handbook should be consulted regarding a specific benefit. Health decisions should not be made on the basis of the information provided in this schedule.

Horizon BCBSNJ will administer the coverage listed in this Schedule of Covered Services and Supplies, subject to the terms, conditions, limitations, and exclusions stated within this booklet.

Services and supplies provided by a Primary Care Physician (PCP), which the member selected to coordinate overall health care, or through a referral by a member's PCP are covered at the in-network level.

Services and supplies provided by an out-of-network provider or a provider not referred to or coordinated by a PCP or Care Manager are covered at the out-of-network level. Most services are subject to a reasonable and customary fee allowance.

Please note: The fact that a doctor may prescribe, order, recommend, or approve a service or supply does not, in itself, make it medically needed for the treatment and/or diagnosis of an illness or injury or make it a covered medical expense.

All treatment for mental or nervous conditions, substance abuse or alcoholism, for both the in-network and out-of-network levels of coverage, must be preapproved and coordinated by the care manager.

YOUR SHARE OF COSTS

Copayments

Copayments apply to in-network services unless otherwise indicated.

Coinsurance

In-Network

 Unless otherwise indicated, eligible charges are covered in full, after applicable copayment.

Out-of-Network

 30 percent of covered charges.

Maximum Out-of-Pocket

In-Network 

 $400 per year/individual coinsurance only.
  $1000 per year/family coinsurance only.

Out-of-Network  

 $2,000 per year/individual.
  $5,000 per year/family.

Note: The Maximum Out-of-Pocket cannot be met with:

•     Non-Covered Charges.

•     Deductibles.

•     Copayments.

•     Amounts above the reasonable and customary allowance.

Deductible/Out-of-Network (see Deductibles)

$100 Member
$250 Family and Parent/Child ($100 for you, $100 for spouse, eligible domestic partner, or one child, and $50 for a third person)

Hospital Admission Deductible

Out-of-Network

 $200 per admission.

MAXIMUM PLAN BENEFITS

In-Network Unlimited. Applies to all covered services and supplies.
Out-of-Network $1,000,000. Applies to all covered services and supplies.

MENTAL HEALTH MAXIMUMS

For Non-Biologically-Based Mental Illnesses

In-Network and   
Out-of-Network
(Combined Maximum)

$15,000 per calendar year/ $50,000 lifetime.

ELIGIBLE SERVICES AND SUPPLIES

Covered Services

Acupuncture for Pain Management Only
In-Network 
100 percent coverage
Out-of-Network  
70 percent coverage

Inpatient Alcohol or Substance Abuse
In-Network
100 percent coverage
Out-of-Network 70 percent coverage, subject to $200 hospital deductible

Outpatient Alcohol or Substance Abuse
In-Network 100 percent coverage (no copayment)
Out-of-Network 70 percent coverage

Allergy Testing and Treatment
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Ambulance Services
In-Network 90 percent coverage
Out-of-Network 70 percent coverage

Ambulatory Surgery
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Anesthesia
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Biofeedback for General Conditions
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Biofeedback for Non-Biologically-Based Mental Illnesses
In-Network 90 percent coverage up to Mental Health Maximums
Out-of-Network 70 percent coverage up to Mental Health Maximums

Chiropractic Services (No Referral Required)
In-Network 100 percent coverage for maximum of 30 visits per calendar year
Out-of-Network 70 percent coverage for maximum of 30 visits per calendar year

Diagnostic Laboratory
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Diagnostic X-ray
In-Network 100 percent coverage (copayment at a facility other than a hospital)
Out-of-Network 70 percent coverage

Dialysis Center Charges
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Durable Medical Equipment
In-Network 90 percent coverage
Out-of-Network 70 percent coverage

Emergency Room
In-Network 100 percent coverage, after a $25.00 copayment* (if reported within 48 hours).
70 percent coverage (if not reported within 48 hours
Out-of-Network 100 percent coverage, after a $25.00 copayment* (if reported within 48 hours).
70 percent coverage (if not reported within 48 hours)
*For both in- and out-of-network services the $25 copayment amount is waived if admitted.

Hospital Charges
In-Network 100 percent coverage, subject to pre-approval
Out-of-Network 70 percent coverage, subject to hospital deductible

Home Health Care Agency
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Hospice Care
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Inherited Metabolic Disease Medical Foods
In-Network 90 percent coverage
Out-of-Network 70 percent coverage

Inpatient Physician Services
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Maternity/Obstetrical Care
In-Network 100 percent coverage after a $5.00 copayment for initial visit.
Out-of-Network 70 percent coverage

Non-Biologically-Based Mental or Nervous Conditions
•     Inpatient
In-Network 100 percent coverage for up to 25 days per benefit period. Additional services will be covered at 90 percent, subject to the annual/lifetime maximum.
Out-of-Network 50 days per calendar year at 50 percent subject to a $200 deductible per confinement and the annual/lifetime maximums.
•     Outpatient
In-Network 90 percent coverage, subject to the annual/lifetime maximum.
Out-of-Network 70 percent coverage, subject to the annual/lifetime maximum.
•     Inpatient Medical Visits
In-Network 100 percent coverage, subject to the annual/lifetime maximum.
Out-of-Network 70 percent coverage, subject to the annual/lifetime maximum.

Nutritional Counseling
In-Network 100 percent coverage (3 visits per year)
Out-of-Network No coverage.

Physical Therapy
In-Network 100 percent coverage
Out-of-Network 70 percent coverage.

Pre-Admission Testing
In-Network 100 percent coverage
Out-of-Network 70 percent coverage.

Preventive Care
•     Gynecological Care and Examinations (Routine)
In-Network 100 percent coverage, no referral is required.
Out-of-Network No coverage for routine care. Care for treatment of a diagnosed condition is covered at 70 percent coverage
•     Mammography
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage.
•     PAP Smears
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage (annual only).
•     Routine Physicals and Immunizations
In-Network 100 percent coverage.
Out-of-Network No coverage.
•     Well-Child Care
In-Network 100 percent coverage.
Out-of-Network No coverage.
•     Well-Child Immunizations
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage, if under 12 months of age.
•     Prostate Cancer Screening
In-Network 100 percent coverage.
Out-of-Network No coverage.

Private Duty Nursing
In-Network 90 percent coverage.
Out-of-Network 70 percent coverage.

Second Surgical Opinion Charges (Voluntary)
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage.

Skilled Nursing Facility Charges
In-Network 100 percent coverage for up to 120 days per calendar year.
Out-of-Network 70 percent coverage for up to 60 days per calendar year.

Specialist Services
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

Specialized Non-Standard Infant Formula
In-Network 90 percent coverage.
Out-of-Network 70 percent coverage

Speech Therapy
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage

Surgical Services
In-Network 100 percent coverage.
Out-of-Network 70 percent coverage

Transplant Benefits
In-Network 100 percent coverage
Out-of-Network 70 percent coverage

APPENDIX II

UTILIZATION REVIEW APPEAL PROCEDURE

If you are not satisfied with any utilization review decision, including but not limited to hospitalization admission denials or a reduction of benefits payable, you or your provider may appeal such decision by writing to NJ PLUS. A nurse reviewer will collect any additional medical information required and submit the case to a NJ PLUS appeal physician designated by NJ PLUS. This physician will review the case with the reviewer who made the initial decision. The appeal physician may discuss the case with your provider. You or your provider will be notified of the appeal recommendation.

You (or a provider acting on your behalf and with your consent) may appeal any administrative and utilization management determinations made by NJ PLUS with respect to its coverage. These determinations involve benefit issues — including denials, terminations, or other limitations of covered services and supplies.

First Level Appeal

You initiate the appeal process by calling 1-800-414-SHBP (7427) to receive instructions on how to submit a written appeal. All First Level Appeals must be made within 12 months from the date you were notified of the original determination.

A provider initiates an appeal by writing to the provider services representative or NJ PLUS Utilization Department. All pertinent information will be reviewed by a NJ PLUS Medical Director and a decision will be made on the appeal.

A First Level Appeal must be submitted in writing, dated and signed, with the following information:

Second Level Appeal

If either you or your provider is not satisfied with the determination made on your First Level Appeal, you can file a Second Level Appeal before other health care professionals selected by NJ PLUS who were not involved in the initial determination. You or your provider will receive notification of the final determination of the Second Level Appeal, the reasons therefore and instructions for filing an external appeal.

External Appeal

If you are dissatisfied with the results of NJ PLUS internal appeal process, you or your legal representative can appeal in writing to the State Health Benefits Commission. The right to such an appeal is contingent upon full compliance with both stages of the NJ PLUS internal appeal process.

APPENDIX III

CLAIM APPEAL PROCEDURES

You or your authorized representative may appeal and request that your health 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 might question eligibility or 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.

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.

If dissatisfied with a final health plan decision on a medical appeal, only the member or the member's legal representative (this does not include the provider of service) may appeal, in writing, to the State Health Benefits Commission. If the member is deceased or incapacitated, the individual legally entrusted with his or her affairs may act on the member's behalf. Request for consideration must contain the reason for the disagreement along with copies of all relevant correspondence and should be directed to the following address:

Appeals Coordinator
State Health Benefits Commission
PO Box 299
Trenton, NJ 08625-0299

Notification of all Commission decisions will be made in writing to the member. If the Commission approves the member's appeal, the decision is binding upon the health plan. If the Commission denies the member's appeal, the member will be informed of further steps he or she 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 (ALJ) will hear the case and make a recommendation to the Commission, which the Commission may adopt, modify, or reject. If the recommendation is rejected, the administrative appeal process is ended. When the administrative process is ended, further appeals will 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. You will be responsible for any court filing fees or 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.

APPENDIX IV

STATE HEALTH BENEFITS PROGRAM
MEDICAL TREATMENT POLICIES

INFERTILITY TREATMENT

The following State Health Benefits Program (SHBP) Assisted Reproductive Technology (ART) benefits were effective as of July 1, 2000, for members of the Traditional Plan, NJ PLUS, and Aetna HMO.

[In Vitro Fertilization (IVF), Embryo Transfer (ET), Zygote Intrafallopian Transfer (ZIFT), Gamete Intrafallopian Transfer (GIFT)]

All services must be provided at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetrics and Gynecology.

Eligible Services

Examples of some of the related services that would be covered within the three attempts include initial consultation, office visits, cost of the drug(s), laboratory and/or radiologic procedures, testicular sperm aspiration (TESA) and percutaneous epididymal sperm aspiration (PESA) and the process of cryopreservation of embryos4 although not the storage costs.   These procedures would all be subject to the member's deductible and coinsurance or copayment requirements and any lifetime Major Medical Benefit maximum.

In addition, any necessary ovum or sperm donor costs would be covered, including but not limited to office visits, costs of drugs, laboratory and/or radiologic procedures, retrieval, cryopreservation, etc. but not including costs for transportation, lodging, or any compensation.

An attempt is recorded based on the criteria as defined regardless of whether fertilization or transfer is successful.  This is also true whether or not the pregnancy goes to term, results in a live birth, or if it results in an ectopic pregnancy. 

Ineligible Services

Services or procedures that are not eligible for separate or additional reimbursement since they are considered part of another more global service or procedure include, but are not limited to:

Medical management fees, cycle management fees, administrative fees, and/or professional management fees billed in addition to office visits.

The following services are considered investigational and therefore ineligible for benefit:5 

Notes

1 IVF is In Vitro Fertilization which is a four step procedure.  1) Eggs produced by administering fertility drugs (gonadotropins) are 2) retrieved from the woman's body and 3) fertilized by sperm in a laboratory dish.  The resulting embryos are 4) transferred by catheter to the uterus.

2 ZIFT is Zygote Intrafallopian Transfer in which eggs are fertilized by sperm in a laboratory dish and resulting embryos are transferred to the woman's fallopian tubes from which they travel naturally to the uterus.

3 GIFT is Gamete Intrafallopian Transfer wherein, following hormonal stimulation of egg production, a mixture of sperm and eggs is transferred, using a minor surgical procedure, to the fallopian tubes, where fertilization may occur.

4 Cryopreservation is freezing of embryos after a previous ART cycle for later thawing and transferal to the uterus without the need for repeat stimulation and retrieval during subsequent cycles.

5 This list is not all inclusive and does not include all investigational services and procedures.  Denials are not limited to those on this list.

LYME DISEASE INTRAVENOUS ANTIBIOTIC THERAPY

All intravenous antibiotic therapy for the treatment of Lyme Disease must be pre-certified by Horizon BCBSNJ or the claims will be denied, whether or not the care was medically needed and appropriate to the level of care. When intravenous therapy is pre-certified to be medically needed and appropriate, the supplies, cost of the drug, and skilled nursing visits will be covered services.

To pre-certify intravenous therapy for treatment of Lyme Disease, please call Horizon BCBSNJ at 1-800-664-BLUE (2583).

Diagnosis

All testing should be initiated by antibody capture immunoassay, enzyme-linked immunosorbent assay (ELISA), or immunoflourescence assay (IFA) as "screening" tests. Because these tests are generally sensitive, specimens negative by ELISA or IFA need not be further tested since the diagnosis of Lyme disease can virtually be excluded. However, specimens that are positive, minimally reactive, or equivocal by ELISA or IFA should be confirmed by Western blots because of their relatively low specificity.6 If early Lyme Disease is suspected clinically despite a negative antibody titer, serological investigations (starting with ELISA or IFA) should be repeated approximately 2 to 4 weeks later since 60 percent of infected individuals may test negative at the early stage.  Antibiotic therapy may prevent an increase in specific antibodies and seroconversion may even occur after antibiotic therapy.

IgM Western blot is considered positive if two of the following three bands are present: 24 Da (OspC), 39 kDa (BmpA), and 41 kDa (Fla). IgG Western blot is considered positive if five of the following 10 bands are present: 18 kDa, 21 kDa (OspC), 28 kDa, 30 kDa, 39 kDa, 41 kDa (Fla), 45 kDa, 58 kDa (not GroEl), 66 kDa, and 93 kDa.

Serological findings are dependent on disease duration and clinical manifestation.

Early Localized Lyme Disease (Erythema migrans rash)

    Covered Treatment: Early localized Lyme Disease should be treated with oral antibiotic therapy, preferably a 21-day course of doxycycline or amoxicillin, not intravenous therapy. [Patients intolerant to those oral medications may be treated with cefuroxime axetil (oral), clarithromycin (oral), or azithromycin (oral).]7 Intravenous therapy is not appropriate unless oral medications are not tolerated.  If intravenous antibiotic therapy must be used, 14 days of antibiotic therapy is equivalent to 21 days of oral doxycycline.8

Early Disseminated Lyme Disease  (Erythema migrans rash with multiple lesions,

migratory joint pains and brief arthritis attacks, meningitis, cranial neuritis (usually facial palsy), carditis (usually AV nodal block))

  1. Medical certification of early disseminated disease (disseminated infection with cardiac and neurological problems);  

  2. Symptomatic pregnant women with failed course of oral antibiotics.

Covered Treatment: Early disseminated disease is treated with oral antibiotics (doxycycline 100 mg. twice a day or amoxicillin 500 mg. three times a day for 21 days). 

All intravenous therapy for treatment of Lyme Disease must be pre-certified by Horizon BCBSNJ. When intravenous therapy is determined to be medically appropriate, the supplies, cost of the drug, and skilled nursing visits will be covered services.

Pulse therapy, pulse treatment with Imipenem, therapy with Vancomycin, and diagnostic tests involving urine antigen and urine and serum polymerase chain reaction (PCR) are to be considered investigational.

Late/Chronic Disease Lyme Arthritis
and Late/Chronic Disease Neuroborreliosis  (Persistent infection with prolonged arthritis attacks, chronic encephalomyelitis, chronic axonal polyradiculopathy, acrodermatitis chronica atrophicans)

In order to be considered medically appropriate, the following criteria must be met where applicable:

Covered Treatment: may be treated with up to 30 days of intravenous antibiotic therapy.

A second or extended course of intravenous therapy must be pre-certified by Horizon BCBSNJ at its sole discretion prior to extending the course of therapy. There must be sufficient objective evidence, including objective clinical and laboratory findings, of new or extended manifestations of the disease. The plan administrator may require a consultation with an appropriate specialist.

Note: Requests for more than 30 days require clinical/laboratory documentation of the need.

A second course of intravenous therapy is warranted for any one of the following indications:

Extended intravenous therapy beyond 30 days as a second course may be approved only if there is:

Examples of cases where an extension or repeat course of intravenous therapy may be medically appropriate include: a patient who had left knee arthritis and received treatment only to develop neurologic disease or arthritis of another joint after termination of treatment; a patient who had treatment of established Lyme Disease in the past and now develops new findings with increasing reactivity with Borrelia Burgdorferi as indicated by expansion of the immunologic reactivity with new bands on Western blot.

Notes

6 In the early stage of the disease (localized or even disseminated), there may be isolated IgM reactivity to ELISA or IFA, or in a minority of patients, there may only be an IgG response. Therefore, both IgM and IgG Western blots are recommended in the early stage.

7 Note: cefuroxime axetil, clarithromycin, and azithromycin have been studied only in early, localized Lyme Disease, and azithromycin has been shown to be inferior to amoxicillin.

8 "Ceftriaxone compared with doxycycline for the treatment of acute disseminated Lyme Disease." New England Journal of Medicine 1997.  337:289-94.

9 Single photon emission computed tomography (SPECT) scanning in and of itself is not suitable to establish the diagnosis of Lyme Disease. It is, however, useful to evaluate regional cerebral blood flow and is to be covered by the plan administrator for patients suspected of Late/Chronic Neuroborreliosis. SPECT scanning has been reported to show at six months that perfusion abnormalities improve in patients with Lyme encephalopathy after a one-month course of intravenous ceftriaxone. Therefore, it may be helpful to demonstrate whether a patient with suspected Lyme Disease actually has encephalopathy and may be helpful to follow response to therapy. SPECT scanning is not required in all patients and should only be used as an adjunct to other diagnostic tests when there is uncertainty as to the patient's diagnosis or response to therapy.

10 PCR testing of CSF and synovial fluid are to be covered by the plan administrator for patients suspected of Late/Chronic Lyme Disease.   Coverage for PCR testing for other uses or fluids will be determined by the plan administrator.

11 A persistently positive PCR in spinal fluid should be interpreted with caution. It's not really known what it means. In conjunction with other clinical/laboratory data, it may help support the need for a second course of antibiotics. In and of itself, it would not mandate therapy.

12 It would be reasonable to extend or repeat treatment if a patient had a persistently positive CSF PCR and ongoing symptoms.

APPENDIX V

GLOSSARY

Accidental Injury — Physical harm or damage done to a person as a result of a chance or unexpected occurrence.

Active Group Member — An employee who has met the requirements for participation and has completed a form constituting written notice of election to enroll for coverage in the SHBP for him or herself and, if applicable, any eligible dependents. Also includes eligible employees or dependents who continue SHBP coverage as a subscriber in the SHBP's COBRA program.

Activities of Daily Living — Day-to-day activities, such as dressing, feeding, toileting, transferring, ambulating, meal preparation, and laundry functions.

Allowable Expense — The allowance for charges for services rendered or supplies furnished by a health care provider that would qualify as a covered expense.

Ambulatory Surgical Center — An accredited ambulatory care facility licensed as such by the state in which it operates to provide same-day surgical services.

Appeal — A request made by a member, doctor, or facility that a carrier review a decision concerning a claim. Administrative appeals question plan benefit decisions such as whether a particular service is covered or paid appropriately. Medical appeals refer to the determination of need or appropriateness of treatment or whether treatment is considered experimental or educational in nature. Appeals to the State Health Benefits Commission may only be filed by a member or the member's legal representative.

Benefit Period — The twelve-month period starting on January 1st and ending on December 31st. The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins on your coverage date. The last Benefit Period ends when you are no longer covered.

Biologically-Based Mental Illness — Diagnosed conditions including schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive compulsive disorder, panic disorder, and pervasive developmental disorder or autism.

Blue Card Program — A national Blue Cross Blue Shield (BCBS) electronic claims billing program through which participating hospitals and doctors can transmit bills for BCBS plan members to any BCBS-administered health insurance program.

Calendar Year — A year starting January 1 and ending on December 31.

Case Manager — A person or entity designated by Horizon BCBSNJ to manage, assess, coordinate, direct, and authorize the appropriate level of health care treatment.

COBRA — Consolidated Omnibus Budget Reconciliation Act of 1985. This federal law requires private employers with more than 20 employees and all public employers to allow covered employees and their dependents to remain on group insurance plans for limited time periods at their own expense under certain conditions.

Coinsurance — The portion of an eligible charge which is the member's financial responsibility for out-of-network services.

Coordination of Benefits — The practice of correlating the payments a plan makes with payments provided by other insurance covering the same charges or expenses, so that (1) the plan with primary responsibility pays first, (2) reimbursement does not exceed 100 percent of the actual expense, and (3) the plan does not pay more than it would if no other insurance existed.

Copayment — The fee charged to a member or patient to be paid directly to the PCP or network specialist at the time treatment is rendered for certain covered services.

Cosmetic Services — Services rendered to refine or reshape body structures or surfaces that are not functionally impaired. They are to improve appearance or self-esteem, or for other psychological, psychiatric or emotional reasons.

Covered Person — An employee, retiree, or COBRA participant or a dependent of an employee, retiree, or COBRA participant who is enrolled in NJ PLUS.

Coverage — The plan design of payment for medical expenses under the program.

Custodial Care — Services that do not require the skill level of a nurse to perform. These services include but are not limited to assisting with activities of daily living, meal preparation, ambulation, cleaning, and laundry functions. Custodial care services are not eligible for coverage under NJ PLUS, including those that are considered to be medically needed.

Deductible — The portion of the first eligible charges submitted for payment in each calendar year that the out-of-network portion of NJ PLUS requires the member or covered dependent to pay.

Dependent Coverage — Coverage of an eligible family member of an enrolled member.

Detoxification Facility — A health care facility licensed by the state it is in as a detoxification facility for the treatment of alcoholism and/or substance abuse.

Domestic Partner — Domestic partner SHBP coverage is only available to State employees/retirees and to Local/Educational employees/retirees whose employer has adopted a resolution to participate in health benefits coverage under Chapter 246, P.L. 2003, the Domestic Partnership Act.  Under the Act, a domestic partner is defined for SHBP eligibility as a person of the same sex with whom the employee or retiree has entered into a domestic partnership by registering with the local registrar and receiving a Certificate of Domestic Partnership from the State of New Jersey (or a valid certification from another jurisdiction that recognizes same-sex domestic partners, civil unions, or similar same-sex relationships). The cost of domestic partner coverage may be subject to federal tax (see your employer or Fact Sheet #71, Benefits Under the Domestic Partnership Act, for more information).

Durable Medical Equipment — Equipment, which is designed and able to withstand repeated use and is customarily used to serve a member with a medical condition.

Eligible Services and Supplies — These are the charges that may be used as the basis for a claim. They are the charges for certain services and supplies to the extent the charges meet the terms as outlined below:

Eligible Dependent — A member's spouse or same-sex domestic partner (as defined by Chapter 246, P.L. 2003) and unmarried child(ren) under the age of 23 who lives with and is substantially dependent upon the member for support. Children include natural, adopted, foster, and stepchildren. If a covered child is not capable of self-support when he or she reaches age 23 due to mental illness, mental retardation, or a physical disability, coverage under the SHBP may be continued.

Emergency — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or a guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

Claims will be paid for emergency services furnished in a hospital emergency department if the presenting symptoms reasonably suggested an emergency condition as would be interpreted by a prudent layperson. All procedures performed during the evaluation (triage) and treatment of an emergency condition will be covered.

Employer — The State, or a local public employer which participates in the State Health Benefits Program.

Facility Charges — Charges from an eligible medical institution such as a hospital, residential treatment center, detoxification center, ambulatory or separate surgical center, dialysis center, or a skilled nursing center.

Family or Medical Leave of Absence — A period of time of pre-determined length, approved by the employer, during which the employee does not work, but after which the employee is expected to return to active service. Any employee who has been granted an approved leave of absence in accordance with the Family and Medical Leave Act of 1993 shall be considered to be active for purposes of eligibility for covered services and supplies under your group's program.

Full Medicare Coverage — Enrollment in both Part A (Hospital Insurance) and Part B (Medical Insurance) of the federal Medicare Program. State law requires that anyone who is enrolled in the Retired Group and is eligible for Medicare must enroll in both Parts A and B of the Medicare Program in order to be covered in the State Health Benefits Program.

Government Hospital — A hospital which is operated by a government or any of its subdivisions or agencies. This includes any federal, military, state, county, or city hospital.

Home Health Care Agency — A provider which mainly provides skilled nursing care and therapeutic services for an ill or injured person in the home under a home health care program designed to eliminate hospital stays. To be eligible for reimbursement it must be licensed by the state in which it operates, or be certified to participate in Medicare as a home health care agency.

Hospice — A provider that renders a health care program which provides an integrated set of services designed to provide comfort, pain relief and supportive care for terminally ill or terminally injured people under a hospice care program.

Hospital — An approved institution that meets the tests of 1, 2, 3, 4, or 5 below:

  1. It is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Hospitals and Medicare approved.
  2. It (a) is legally operated, (b) is supervised by a staff of doctors, (c) has 24-hour-a-day nursing service by registered graduate nurses, and (d) mainly provides general inpatient medical care and treatment of sick and injured persons by the use of the medical, diagnostic, and major surgical facilities in it.
  3. It is licensed as an ambulatory or separate surgical center. The center must mainly provide outpatient surgical care and treatment.
  4. It is an institution for the treatment of alcoholism not meeting all the tests of (1) or (2) but which is:
  1. It is a birth center that is licensed, certified, or approved by a department of health or other regulatory authority in the state where it operates or meets all of the following tests:

“Hospital” does not include a nursing home. Neither does it include an institution, or part of one, that:

Hospital-Based Weight Loss Programs — Hospital-based weight loss programs may be eligible for a patient diagnosed with morbid obesity. For in-network level benefits, the provider should obtain authorization from NJ PLUS. For out-of-network services, call NJ PLUS at 1-800-414-SHBP (7427) to verify eligibility prior to enrolling in a hospital-based weight loss program.

Illness — Any disorder of the body or mind of a covered person.

Injury — Damage to the body of a covered person.

Local Employee — For purposes of SHBP coverage, a local employee is a full-time employee receiving a salary and working for a Participating Local Employer. Full-time shall mean employment of an eligible employee who appears on a regular payroll and who receives salary or wages for an average number of hours specified by the employer, but not to be less than 20 hours per week. It also means employment in all 12 months of the year except in the case of those employees engaged in activities where the normal work schedule is 10 months. In addition, for local coverage, employee shall also mean an appointed or elected officer of the local employer, including an employee who is compensated on a fee basis as a convenient method of payment of wages or salary but who is not a self-employed independent contractor compensated in a like manner. To qualify for coverage as an appointed officer, a person must be appointed to an office specifically established by law, ordinance, resolution, or such other official action required by law for establishment of a public office by an appointing authority. A person appointed under a general authorization, such as to appoint officers or to appoint such other officers or similar language is not eligible to participate in the program as an appointed officer. An officer appointed under a general authorization must qualify for participation as a full-time employee.

Local Employer — Government employers in New Jersey, including counties, municipalities, townships, school districts, community colleges, and various public agencies or organizations.

Maintenance Care — Maintenance care is care that when provided does not substantially improve the condition. When care is provided for a condition that has reached maximum improvement and further services will not appreciably improve the condition, care will be deemed to be maintenance care and no longer eligible for reimbursement. Maintenance care services, even those that are considered to be medically needed, are not eligible for coverage under NJ PLUS.

Medical Need and Appropriate Level of Care — A service or supply that Horizon BCBSNJ determines meets each of these requirements:

Medicare — The federal health insurance program for people 65 or older, people of any age with permanent kidney failure, and certain disabled people under age 65. Medical coverage consists of two parts: Part A is Hospital Insurance Benefits and Part B is Medical Insurance Benefits. A Retired Group member and/or spouse who are eligible for Medicare coverage by reason of age or disability must be enrolled in Parts A and B to enroll or remain in SHBP Retired Group coverage.

Member — An employee, retiree, or dependent who is enrolled under NJ PLUS.

Mental or Nervous Condition — A condition which manifests symptoms which are primarily mental or nervous, whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and regardless of cause, basis or inducement, for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or nervous conditions include, but are not limited to, psychoses, neurotic and anxiety disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems. Mental or nervous condition does not include substance abuse or alcoholism.

Morbid Obesity — A body mass index (BMI) greater than 40kg/m2, or a BMI greater than 35kg/m2 with associated life-threatening or disabling co-morbidities including, but not limited to, coronary heart disease, diabetes, hypertension, or obstructive sleep apnea.

Mouth Condition — A condition involving one or more teeth, the tissue or structure around them, or the alveolar process of the gums.

Off-Label Use — A drug not approved by the FDA for treatment of the condition in question or prescribed at a different dosage than the approved dosage.

Out-of-Network Benefits — Benefits provided by NJ PLUS when members do not use network providers for their medical treatment or do not follow the managed care guidelines, i.e., go directly to a network specialist without obtaining a referral from the Primary Care Physician.

Participating Hospital — A health care facility licensed by the State it is in to provide hospital care and services or any U.S. Government-operated hospital which has an agreement with Blue Cross Blue Shield to provide hospital care both to a) the Blue Cross plan's subscribers and b) other Blue Cross plans' subscribers through the Blue Card Program.

Participating Provider — A doctor or hospital which has a written agreement with their local Blue Cross Blue Shield plan to provide care to both that plan's members and other Blue Cross Blue Shield plan members.

Point of Service — A plan that provides managed care to its members through its own network of providers. The plan also provides reimbursement to members for services rendered by non-network providers at a lower reimbursement rate and subject to a calendar year deductible. In a point of service plan, you must choose a Primary Care Physician to manage your healthcare.

Primary Care Physician — A participating provider who provides basic healthcare services to, and arranges specialized services for, those members who select that provider as their Primary Care Physician (PCP).

Primary Health Plan — A plan which pays benefits for a member's covered charge first, ignoring what the member's secondary plan pays. A secondary health plan then pays the remaining unpaid expenses in accordance with the provisions of the member's secondary health plan.

Provider — Under the SHBP, the term is used to define an eligible provider and includes medical doctors, dentists, podiatrists, acupuncturists, psychologists, psychiatrists, nurse midwives, licensed clinical social workers, licensed marriage and family therapists, licensed professional counselors, chiropractors, certified nurse practitioners, clinical nurse specialists, physical therapists, occupational therapists, optometrists, and audiometrists who are properly licensed and are working within the scope of their practice.

Public Employer — A federal, state, county, or municipal government, authority, or agency; a local board of education; or a state or county university or college.

Reasonable and Customary — The plan makes payments based on the reasonable and customary allowance for supplies and services in a specific geographic area. The reasonable and customary allowance is the general level of charges made by others in the area for like services or supplies as determined by the Prevailing Healthcare Charges System (PHCS). This schedule is updated on a semi-annual basis. Reasonable and customary allowances are based on actual charges by physicians in a specific geographical area for specific services.

Residential Treatment Facility — A health care facility licensed, certified, or approved by the State of New Jersey for treatment of alcoholism or substance abuse or meeting the same standards, if out-of-state.

Retired Group Member — An eligible retiree of a state-administered or local public pension fund who has met the requirements for participation and has completed a form constituting written notice of election to enroll for coverage in the Retired Group of the SHBP for him/herself and, if applicable, any eligible dependents. Also includes a surviving spouse of a deceased Retired Group member who has met the requirements for and has completed a form constituting written notice of election to enroll for coverage in the Retired Group of the SHBP for him/herself and, if applicable, any eligible dependents. Also includes a surviving dependent child of a deceased Retired Group member who had parent-child(ren) coverage, providing he or she has completed a form constituting written notice of election to enroll for coverage in the Retired Group of the SHBP.

SHBP Member — An individual who is either a SHBP Active Group, Retired Group, or COBRA participant, and their dependents.

Skilled Nursing Facility — A facility which is approved by either the Joint Commission on Accreditation of Health Care Organizations or the Secretary of Health and Human Services and provides skilled nursing care and services to eligible persons. The skilled nursing facility provides a specific type of treatment that falls midway between a hospital that provides care for acute illness and a nursing home that primarily provides assistance with daily living.

State Biweekly Employee — For purposes of SHBP coverage, state biweekly employee shall mean a full-time employee of the State, or an appointed or elected officer, paid by the State's centralized payroll system whose benefits are based on a biweekly cycle. Full-time normally requires 35 hours per week.

State Health Benefits Commission (Commission) — The entity created by N.J.S.A. 52:14-17.27 and charged with the responsibility of establishing and overseeing the State Health Benefits Program.

State Health Benefits Program (SHBP) — The SHBP was originally established by statute in 1961. It offers medical, prescription drug, and dental coverage to qualified public employees and retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the SHBP and its plans. The State Health Benefits Program Act is found in the N.J.S.A. 52:17.25 et.seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.

State Monthly Employee — For purposes of SHBP coverage, state monthly employee shall mean a full-time employee of the State, or an appointed or elected officer, whose benefits are based on a monthly cycle and whose payroll system is autonomous (not paid by the State's centralized payroll system). Full-time shall mean the usual full-time weekly schedule for the particular title, which normally requires 35 hours per week.

State Monthly Employer — Employers whose benefits are based on a monthly cycle and whose payroll system is autonomous (not paid by the State's centralized payroll system). This includes state colleges and universities and participating independent state commissions, authorities, and agencies such as:

Substance Abuse — The abuse or addiction to drugs or controlled substances, not including alcohol.

Supportive Care — Care for patients having reached the maximum therapeutic benefit in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains. Supportive care services, even those that are considered to be medically needed, are not eligible for coverage under NJ PLUS.

Surgical Center — Also termed as surgicenter. An ambulatory-care facility licensed by a state to provide same-day surgical services.

Surgical Procedure — This includes cutting, suturing, treatment of burns, correction of fracture, reduction of dislocation, manipulation of joint under general anesthesia, application of plaster casts, electrocauterization, tapping (paracentesis), administration of pneumothorax, endoscopy, or injection of sclerosing solution.

Waiting Period — The period of time between enrollment in the State Health Benefits Program and the date when you become eligible for benefits.

APPENDIX VI

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

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

Click this link to view the SHBP Notice of Privacy Practices

EFFECTIVE DATE: APRIL 14, 2003

STATE HEALTH BENEFITS PROGRAM
CONTACT INFORMATION

ADDRESSES

Our Mailing Address is:
The State Health Benefits Program
Division of Pensions and Benefits
PO Box 299
Trenton, NJ 08625-0299
                                                                                                

Our Internet Address is: 
www.state.nj.us/treasury/pensions/shbp.htm

Our E-mail Address is :
pensions.nj@treas.state.nj.us

TELEPHONE NUMBERS

Division of Pensions and Benefits:
Office of Client Services (609) 292-7524
TDD Phone (Hearing Impaired) (609) 292-7718

Horizon Blue Cross Blue Shield of New Jersey:
1-800-414-7427 (SHBP)

State Employee Advisory Service (EAS):
(609) 292-8543

Rutgers University Personnel Counseling Service (EAP):
(732) 932-7539

New Jersey State Police

Employee Advisory Program (EAP):
(856) 234-5652
(908) 231-1077
(609) 633-3718
1-800-FOR-NJSP

University of Medicine and Dentistry of New Jersey (EAP):
(973) 972-5429

New Jersey Department of Banking and Insurance
Individual Health Coverage Program Board 1-800-838-0935
Consumer Assistance for Health Insurance (609) 292-5316  (Press 2)
                                                                                                                   

New Jersey Department of Human Services
Pharmaceutical Assistance to the
Aged and Disabled (PAAD) 		 1-800-792-9745

New Jersey Department of Health and Senior Services
Division of Aging and Community Services 1-800-792-8820
Insurance Counseling 1-800-792-8820
Independent Health Care Appeals Program (609) 633-0660

Centers for Medicare and Medicaid Services 1-800-Medicare
New Jersey Medicare - Part A. Not Available
New Jersey Medicare - Part B Not Available

HEALTH BENEFITS PROGRAM PUBLICATIONS

The publications and fact sheets available from the Division of Pensions and Benefits provide information on a variety of subjects. Employees and retirees can obtain copies of these publications by contacting their employers or by contacting the Division of Pensions and Benefits.

Fact sheets and other publications are also available for viewing or downloading over the Internet at: www.state.nj.us/treasury/pensions

General Publications

Health Benefits Program Summary Program Description booklet (PDF file - size 356k - Requires Acrobat Reader)

Health Benefits Program Comparison Summaries - Plan comparison chart.

SHBP Fact Sheets

Fact Sheet #11, Enrolling in Health Benefits Coverage When you Retire.

Fact Sheet #23, The Health Benefits Programs and Medicare Parts A & B for Retirees.

Fact Sheet #25, Employer Responsibilities under COBRA.

Fact Sheet #26, Health Benefits Options upon Termination of Employment.

Fact Sheet #30, The Continuation of Health Benefits Coverage Under COBRA.

Fact Sheet #37, Employee Dental Plans.

Fact Sheet #47, Retired Health Benefits Coverage Under Chapter 330 - PFRS & LEO.

Fact Sheet #51, Continuing Health Benefits Coverage for Overage Children with Disabilities.

Fact Sheet #60, Voluntary Furlough Program.

Fact Sheet #66, Health Benefits Coverage for State Part-Time Employees.

Fact Sheet #69, SHBP Coverage for State Intermittent Employees.

Fact Sheet #71, Benefits Under the Domestic Partnership Act.

Fact Sheet #73, Retiree Dental Expense Plan.

SHBP Member Handbooks

Traditional Plan Member Handbook

HMO member handbooks are available from the individual HMOs (see Summary Program Description for contact information — PDF file - size 356k - Requires Acrobat Reader).

Employee Prescription Drug Plan Member Handbook — PDF file - size 268k - Requires Acrobat Reader).

Employee Dental Plans Member Handbook

Retiree Dental Expense Plan Member Handbook — PDF file - size 218k - Requires Acrobat Reader).

To download a PDF version of this handbook, click here - size 288K
(Requires Acrobat Reader available free from Adobe.)

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Division of Pensions and Benefits
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Trenton, NJ 08625-0295

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Last Updated: April 1, 2009