STATE HEALTH BENEFITS PROGRAM
PLAN MEMBER HANDBOOK
for Employees and Retirees
Horizon Blue Cross Blue Shield of New Jersey
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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. 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.
The Traditional Plan is an indemnity plan that provides reimbursement of expenses for treatment of illness and injury. The Traditional Plan is self-funded. Funds for the payment of claims and services come from funds supplied by the State, participating local employers, and members.
The Traditional Plan is administered for the SHBP by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). This plan allows you to use any eligible licensed provider, as defined by the plan, for covered medical services. The plan pays only for the diagnosis and treatment of illness or injury. It does not pay for preventive treatment such as immunizations, physical exams, screening tests, and well-care visits to doctors.
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 Traditional Plan 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: firstname.lastname@example.org
You may also refer to the following link for 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.
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 the Traditional Plan, except for biologically-based mental illness. Maximum annual and lifetime dollar limits for mental health benefits are outlined for the Traditional Plan 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.
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.
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.
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.
To be eligible for Traditional Plan 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 employees are not eligible for coverage under the Traditional Plan.
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.
State Employees Enrolled On or After July 1, 2003 — Certain State employees who enroll in the SHBP on or after July 1, 2003 are not eligible for coverage under the Traditional Plan. This group includes State employees as determined by union contract and all non-aligned State employees as provided under Chapter 119, P.L. 2003. See your human resources representative for information about your union affiliation.
To be eligible for Traditional Plan 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 employees are not eligible for coverage under the Traditional Plan.
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.
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 Partner — 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.
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:
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 singleState 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).
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:
This applies to a member who is the retiree or covered spouse/same-sex domestic partner and is at least 65 years of age.
A member is considered to be eligible for Medicare by reason of age from the first day of the month during which he or she reaches age 65. However, if he or she is born on the first day of a month, he or she is considered to be eligible for Medicare from the first day of the month which is immediately prior to his/her 65th birthday.
The retired group health plan is the secondary plan.
This applies to a member or dependent who is under age 65.
A member is considered to be eligible for Medicare by reason of disability if they have been receiving Social Security Disability benefits for 24 months.
The retired group health plan is the secondary plan to Medicare when the member is the subscriber, is under age 65, and is retired, or when the dependent is covered under Medicare and not covered under any active employer group plan.
A member usually becomes eligible for Medicare at age 65 or upon receiving Social Security Disability benefits for two years. A member who is not eligible for Medicare because of age or disability may qualify because of treatment for End Stage Renal Disease (ESRD). When a person is eligible for Medicare due to ESRD, Medicare is the secondary payer when:
The rules listed above, known as the Medicare Secondary Payer (MSP) rules are federal regulations that determine whether Medicare pays first or second to the group health plan. These rules have changed over time.
As of January 1, 2000, where the member becomes eligible for Medicare solely on the basis of ESRD, the Medicare eligibility can be segmented into three parts: (1) an initial three-month waiting period; (2) a "coordination of benefits" period; and (3) a period where Medicare is primary.
Three-month waiting period
Once a person has begun a regular course of renal dialysis for treatment of ESRD, there is a three-month waiting period before the individual becomes entitled to Medicare Parts A and B benefits. During the initial three-month period, the group health plan is primary.
Coordination of benefits period
During the "coordination of benefits" period, Medicare is secondary to the group health plan coverage. Claims are processed first under the health plan. Medicare considers the claims as a secondary carrier. For members who became eligible for Medicare due solely to ESRD after 1996, the coordination of benefits period is 30 months.
When Medicare is primary
After the coordination of benefits period ends, Medicare is considered the primary payer and the group health plan is secondary.
Dual Medicare Eligibility
When the member is eligible for Medicare because of age or disability and then becomes eligible for Medicare because of ESRD:
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.
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 (see below) or unless a "qualifying event" (marriage, birth or adoption of a child, etc.) occurs within 60 days of the COBRA event.
COBRA enrollees have the same rights to coverage at Open Enrollment as are available to active employees. This means that you or a dependent who elected to enroll under COBRA are able to enroll 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.
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:
TRADITIONAL PLAN BENEFITS
USING THIS HANDBOOK
How to Determine Available Benefits
The Traditional Plan provides benefits in three distinct categories: Basic Benefits, Extended Basic Benefits, and Major Medical Benefits. The medical services you receive may fall into any or all of these three categories. Therefore, you should review all three categories of benefit descriptions in this handbook to determine which benefits are covered for a specific service. For example, when using the hospital emergency room, covered expenses would be found under the Basic Benefits, Extended Basic Benefits, and Major Medical Benefits sections of this handbook.
All benefits listed in this handbook may be subject to limitations and exclusions as described in subsequent sections.
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.
GENERAL CONDITIONS OF THE PLAN
The plan will pay only for eligible services or supplies, which:
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 Horizon BCBSNJ 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 Horizon BCBSNJ.
Reasonable and Customary Allowances
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.
Educational or Developmental Services or Supplies, or Educational Testing
The Traditional 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
The Traditional Plan 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 the Traditional Plan.
Traditional Plan members and their covered dependents are eligible to take advantage of increased savings by using a special Blue Cross Blue Shield (BCBS) program. In this program, participating providers contract with BCBS plans throughout the country. When you use a participating provider, the Traditional Plan pays the provider. You pay the provider your 20 percent coinsurance based on a contracted fee and applicable deductible amounts, thereby reducing your out-of-pocket cost. Participating providers submit all claims directly to the BCBS plan, eliminating the necessity of claim forms.
To find out if your provider participates in the program, or to identify participating providers, call 1-800-414-SHBP (7427) or contact the local BCBS plan in the area where you reside.
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.
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 Traditional Plan 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 the Traditional Plan. 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, and you will be reimbursed the applicable percentage of the discounted price after satisfying your deductible.
After your Traditional Plan 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 the Traditional Plan 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 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 the Traditional Plan 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 the Traditional Plan, provide for the coordination of benefits(COB).
Please note: The COB rules may change if Medicare is involved. Please refer to the Medicare section that begins on page 10 for more information.
For group plans that do have a COB provision, the following rules determine which is the primary plan.
Under the birthday rule, the plan covering the parent whose birthday falls earlier in the year will have primary responsibility for the coverage of the dependent children. For example, if the father's birthday is July 16 and the mother's birthday is May 17, the mother's plan would be the primary plan for the couple's dependent children because the mother's birthday falls earlier in the year. If both parents have the same birthday, the plan covering the parent for the longer period of time will be primary.
This birthday rule regulation affects all carriers and all contracts which contain COB provisions. It applies only if both contracts being coordinated have the birthday rule provision. If only one contract has the birthday rule and the other has the gender rule (father's contract is always primary), the contract with the gender rule will prevail in determining primary coverage.
The Traditional Plan will provide its regular benefits in full when it is the primary plan. As a secondary plan, the Traditional Plan will provide a reduced amount which when added to the benefits paid by the other group plan will equal up to 100 percent of the eligible allowable expense.
Please note: No individual can receive benefits under more than one Traditional Plan contract. There is no coordination of benefits for major medical services for yourself or for any of your dependents if you and your spouse or eligible domestic partner, through separate employment, have selected the SHBP Traditional Plan as your plan.
Bills for eligible inpatient care provided by a hospital are paid based on the contracted rates or reasonable and customary allowance. If you or a covered family member is admitted to a Horizon BCBSNJ participating hospital in New Jersey, the hospital will electronically transmit the bill to Horizon BCBSNJ. If you enter an out-of-state hospital that has a contract with another local Blue Cross Blue Shield plan, the hospital will send the bill electronically through the Blue Card Program, which will forward it to Horizon BCBSNJ for payment. If you use a non-participating eligible hospital in or outside of New Jersey that does not have a contract with the local Blue Cross Blue Shield plan, you or the hospital should send the bill to Horizon BCBSNJ.
To qualify for benefits under the Traditional Plan, hospital charges must be considered eligible and must be provided in a SHBP eligible facility.
Coverage in the Hospital
The hospital benefits portion of the Traditional Plan covers up to 365 days in a hospital per calendar year. When an individual is hospitalized, (s)he begins working against the 365-day maximum. If (s)he is released from the hospital but is readmitted in the same calendar year, (s)he continues to work against that year's 365-day maximum. At the beginning of the next calendar year, the 365 benefit days renew or start over, provided that the individual was released from the hospital and has not been readmitted for the same or related conditions for at least 90 days.
After the 365-day maximum has been reached for a particular person, coverage under hospital benefits stops. Medically-needed hospital expenses can continue to be covered under the Major Medical portion of the plan subject to the total lifetime maximum.
IMPORTANT: If an individual requires extensive, long-term hospitalization, Voluntary Case Management should be considered.
Alcohol and Substance Abuse Benefits - Inpatient
Eligible alcohol and substance abuse treatment services are covered like any other general illness under the plan.
Eligible Services and Supplies
The following services and supplies provided during inpatient care are eligible under the hospitalization portion of the Traditional Plan when included as part of the hospital bill.
The following facility charges performed in an outpatient department and billed by the hospital are eligible under the hospitalization portion of the Traditional Plan (physician charges and other professional fees related to these services may or may not have an Extended Basic Benefit component).
OTHER SERVICES PAID UNDER BASIC BENEFITS
As an alternative to conventional hospital delivery room care for low-risk maternity patients, the hospitalization portion of the Traditional Plan pays for care provided in birthing centers under contract to Horizon BCBSNJ. Services routinely provided by the birthing centers, including prenatal, delivery, and postnatal care, will be covered in full under the Basic Benefits portion of the plan, 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. If the delivery does not occur at the center, or if the care of the patient transfers to a hospital maternity program, all expenses incurred at the center for prenatal care will be considered under the Major Medical portion of the plan.
Contact Horizon BCBSNJ at 1-800-414-SHBP (7427) to identify eligible birthing centers near you. If you do not reside in New Jersey, call your local Blue Cross Blue Shield plan for eligible birthing centers it has under contract.
Dental Benefits - Inpatient
Dialysis is covered when the services are provided and billed by an eligible hospital, by a separate dialysis center, or by an eligible home health 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.
If the dialysis center is not under contract with Horizon BCBSNJ, the charges will be considered under the Major Medical portion of the plan.
Federal Government Hospitals
The Traditional Plan will pay hospitals operated by the United States government (Veterans Administration and Department of Defense) as if they were participating hospitals, regardless of their location, for eligible charges for nonmilitary conditions.
The Traditional Plan 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 Agency Benefits
The hospitalization portion of the Traditional Plan covers home health visits as long as the circumstances meet plan guidelines. Members receiving home health care must be home-bound and must require skilled nursing care, physical therapy, occupational therapy, or speech therapy under a plan prescribed by an attending physician and approved by Horizon BCBSNJ. Eligible home health services provided by an approved participating home health agency include:
Up to 60 visits are available within 61 days per occurrence. Every three home health care visits by a participating Horizon BCBSNJ home health care agency reduces your available inpatient days by one (1). A prior inpatient hospital stay is not required to qualify for home health agency benefits, however, your provider must contact Horizon BCBSNJ at 1-800-664-BLUE (2583) in order to certify benefits through a participating agency prior to services being rendered. Benefits are not available for services rendered by a non-participating home health care agency.
Home health care services that are deemed "custodial" by Horizon BCBSNJ will not be eligible for benefits under the Traditional Plan. Custodial services are primarily services rendered that do not require the skill level of a nurse for performance. These services include but are not limited to activities of daily living(ADLs): such as bathing, meal preparation, dressing, feeding, aiding in ambulation, cleaning, and laundry functions. Services that are rendered by a nurse or home health aide that have been determined by Horizon BCBSNJ to be maintenance or supportive care are also not eligible for benefits. Services provided by a companion are not eligible for benefits.
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 care must be provided according to a physician prescribed course of treatment approved by Horizon BCBSNJ 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.
Hospice care benefits are not limited to or counted against the benefit days available under the hospitalization portion of the Traditional Plan. 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 Horizon BCBSNJ at 1-800-664-BLUE (2583).
Hospital charges related to mastectomy services are covered as follows, unless the patient and physician determine that a shorter stay is medically appropriate:
Mental Health Benefits - Inpatient
Up to 20 inpatient days for the treatment of non-biologically-based mental, psychoneurotic or personality disorders are covered. These days are renewed every calendar year provided that the patient has not been readmitted to the hospital for at least 90 days for related illnesses.
Once the 20 inpatient benefit days have been exhausted, any additional inpatient days and all in-hospital medical services will be considered under the Major Medical portion of the Traditional plan, subject to the deductible, coinsurance, and annual and lifetime mental health maximum benefits. Please refer to page 43 for more information on available Major Medical Benefits for mental health conditions.
Services rendered for the treatment of a biologically-based mental illness are treated like any other illness and are not subject to the 20-day maximum. 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.
Obstetrical Care Benefits - Inpatient
Hospital and delivery charges related to the mother's obstetrical care and the newborn child's and mother's initial stay in the hospital are covered. The plan will provide coverage for a minimum of 48 hours of inpatient care for the mother and newly born child following a vaginal delivery and up to 96 hours following a cesarean section. If a doctor orders care beyond the 48/96 hours, medical records will be required to determine continued medical need.
In some instances, the plan will also 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 he or she obtains legal custody of the child.
The following human organ transplant procedures are eligible for coverage only with prior written pre-certification by Horizon BCBSNJ:
The following human organ transplant procedures are eligible for coverage without pre-certification by Horizon BCBSNJ:
If your physician has recommended a human organ transplant procedure, call 1-800-414-SHBP (7427) to obtain information on pre-certification.
Services billed by an approved hospital that participates in the Blue Quality Centers for Transplants (BQCT) network for human organ transplant procedures are covered. The plan also provides coverage for the cost of transportation and storage services related to organ only when billed by a BQCT network hospital. Transportation and lodging for the donor or recipient is not eligible.
If you choose to use a hospital that is not participating in the BQCT network, you may be responsible for 20 percent of some charges, in addition to amounts charged by providers that are in excess of the reasonable and customary allowance.
In the absence of other group insurance coverage, charges incurred by the organ donor that are directly related to the transplant will be considered for coverage under this plan.
Benefits are available for surgical services in connection with eligible human organ transplants when provided by and billed by a physician.
Diagnostic tests that would normally be a part of a hospital stay will also be paid by the plan if they are performed on an outpatient basis by a hospital that participates in the Horizon BCBSNJ pre-admission testing program.
Pre-admission testing is covered at 100 percent only if you are scheduled for admission to a participating hospital for treatment of the diagnosed condition that made the pre-admission test(s) necessary. The testing will also be covered if the admission is postponed or canceled for one of the following reasons:
Pre-admission testing performed at a nonmember facility is not covered under hospital benefits. It will, however, be covered under the Major Medical portion of the plan.
If you occupy a private room in a hospital, you must pay the difference between the private room rate and the average semiprivate room rate.
Skilled Nursing Facility
A skilled nursing facility is a specific type of treatment center that falls between a hospital (which provides care for acute illness) and a nursing home (which primarily provides custodial, maintenance, and/or supportive care).The Traditional Plan does not pay for nursing home care. Hospitalization coverage does, however, cover up to 30 days of care in a skilled nursing facility when it is under a plan prescribed by a doctor and approved by Horizon BCBSNJ. The plan's payment to the member skilled nursing facility will be accepted as payment in full. Room and board charges beyond 30 days are not covered under Major Medical Benefits. Any charges, other than room and board charges, not eligible under the hospitalization coverage, will be considered under the Major Medical portion of the plan.
You may be transferred to a member skilled nursing facility directly from your home or from a hospital if your physician prescribes that you need skilled care, therapeutic services, and treatment for your illness or injury.
Surgical Centers/Ophthalmic Surgical Centers
If surgical procedures are provided in an eligible surgical center instead of a hospital, the hospitalization portion of the plan will provide 100 percent coverage for facility charges as long as you are admitted and discharged within a 24-hour period and the center is under contract with any Blue Cross Blue Shield Plan.
The following criteria must be met for the facility fees at any surgical center to be covered.
Ophthalmic Surgical Centers — Facility charges for certain services provided by an outpatient ophthalmic surgical center as an alternative to hospital inpatient or outpatient surgery are covered. Only the following cataract surgical procedures are eligible.
EXTENDED BASIC BENEFITS
Extended Basic Benefits include a specific set of covered professional services and supplies billed by a doctor that are paid according to a fee schedule on a “first-dollar basis.” This means that the charge, if eligible, is paid according to a fee schedule at 100 percent with no deductible considered. The remaining amount above the level of the fee schedule would then be considered at 80 percent of the reasonable and customary allowance with a deductible under the Major Medical portion of the plan.
Eligible Services and Supplies
Specific amounts payable under Extended Basic Benefits are shown below:
If you are covered in the SHBP Active Group as a full-time employee and meet the income limitations below, the Traditional Plan will pay 100 percent of the doctor's bills for certain basic benefit services, such as surgery, anesthesia, and inpatient medical charges. This provision does not apply to members of the SHBP Retired Group.
Gross annual income means salary, wages, business profits, interest, dividends, and income from all sources. In determining if the 100 percent benefit is available, the plan administrator will consider gross annual income in the calendar year before the service was rendered.
In both instances, the 100 percent payment provision is subject to all other plan provisions, such as medical need and reasonable and customary allowances. You are responsible for notifying the plan when you qualify for service benefits within 90 days of the service.
MAJOR MEDICAL BENEFITS
The Traditional Plan includes coverage for Major Medical services provided by doctors and other medical professionals. The provider must meet the SHBP definition of a doctor, hospital, or other approved provider for services to be covered.
Services and Supplies
The following services are included under the Major Medical portion of the Traditional Plan.
Note: Prescription drug coverage is not available through the Traditional Plan if a separate authorized prescription drug plan, including the SHBP Employee Prescription Drug Plan, is offered through the employer.
The maximum amount that will be paid for any one person during a 24-month period is $500.
MAJOR MEDICAL PAYMENTS
The Major Medical portion of the plan has an annual deductible which means that it is your responsibility to pay the first portion of any eligible medical bills each year.
The deductible amount varies depending on the type of employer for which you work.
State Employees — The deductible amount varies depending on the contract agreement between the labor union that represents you as an employee and the State.
For all non-aligned employees of the State of New Jersey and State colleges and universities; and for State employees and employees of State colleges and universities covered by a collective bargaining agreement that has agreed to provide for higher deductible amounts, the annual deductibles are as follows:
1The total deductible for dependents adds up to $250 combined per year.
See your Human Resources Representative to determine your union affiliation.
Local Government/Education Employees, Certain State Employees, and All Retirees — For employees of a SHBP participatingLocal Government employer (county, municipality, municipal or local authority, etc.) or Local Board of Education; State employees who are not affected by the contract agreements that provide for higher deductible amounts; and all retirees enrolled in the SHBP, the annual deductibles are as follows:
2If two children each have $50 in bills, the $100 deductible for other family members has not been reached. If one child has $110 in eligible bills, then the $100 deductible for other family members has been reached and eligible charges for treatment of your spouse or other children would be eligible for payment at 80 percent of the reasonable and customary allowance.
Deductibles — Terms and Conditions
Expenses for ineligible services and charges in excess of reasonable and customary allowances do not count toward your deductibles.
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, those eligible charges that were applied toward a deductible may be counted toward meeting the deductible for the following year.
Additionally, if two or more family members are injured in the same accident, then your family must meet only one deductible. For instance, you are a local employee and your house is damaged in a tornado and three of your family members are treated by a physician at a cost of $50 each in eligible charges, for a total of $150. The $100 deductible has been met, and the other $50 will be considered under the Major Medical portion of the plan.
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 the Traditional Plan. You must submit documentation to Horizon BCBSNJ showing the eligible charges used to meet the deductible.
For example:You work for a city that is joining the SHBP on July 1. Your employer's prior insurance plan had a deductible of $200 and you have already paid $200 for yourself and $100 for one child. When you join the SHBP on July 1, you will be considered to have met the deductible for yourself and for other family members for that calendar year.
Under the Major Medical portion of the Traditional Plan, you are required to pay 20 percent of the cost of eligible reasonable and customary charges until you reach your out-of-pocket maximum (the point at which the eligible charges for the year total $2,000 after deductibles). Once an individual reaches his or her $2,000 ceiling, the plan will pay 100 percent of the reasonable and customary allowance for treatment that is medically needed. 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.
Example 1: You have employee only coverage.
Example 2: You have employee and spouse coverage.
Example 3: You have family coverage.
LIFETIME BENEFIT MAXIMUMS
Major Medical Maximums
The individual lifetime maximum for all benefits paid under the Major Medical portion of the Traditional Plan is $1,000,000 subject to 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 the Traditional Plan 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 Traditional Plan 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 $20,000. A maximum restoration of $20,000 is available for the lifetime of the patient. Services for mental and nervous disorders, that are non-biologically-based, have a $10,000 annual maximum/$20,000 lifetime maximum with a $2,000 automatic restoration provision for all services.
The Traditional Plan will provide secondary coverage to Personal Injury Protection (PIP) unless the plan has been elected as primary coverage by or for the employee covered under this contract. This election is made by the named insured under the auto insurance PIP program and affects that member's family members who are not themselves the named insured under another auto policy. The Traditional Plan 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.
The Traditional Plan is normally secondary to automobile insurance coverage. However, if the automobile insurance contains provisions which made the automobile insurance coverage secondary or excess to the Traditional Plan, the Traditional Plan will be primary.
If the Traditional Plan 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 the Traditional Plan.
Please note: If you elect to have the Traditional Plan 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 the Traditional Plan 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 the Traditional Plan is secondary to PIP, when applicable, the actual benefits payable will be the lesser of:
SPECIFIC COVERAGE AREAS
In order to be eligible for reimbursement all services must be medically needed at the appropriate level of care and meet all other plan provisions.
Acupuncture treatment is covered when the services are for the treatment of pain, documented by a diagnosis, and 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 the Traditional Plan include weight loss and smoking cessation.
Alcohol and Substance Abuse Treatment
Alcohol and substance abuse treatment is covered like any other illness. The following alcohol and substance abuse treatment services are covered when they are provided by an eligible residential treatment facility to a member who is being treated as an inpatient, outpatient, or when they are provided as aftercare by an eligible detoxification facility.
Psychotherapy to treat alcohol or substance abuse is covered under the mental health benefit and is subject to the annual and lifetime maximum benefits.
Most commonly used methods of allergy testing are covered. However, some methods are subject to medical need and appropriateness review before eligibility can be determined. This includes, but is not limited to, the following tests.
Ambulance use for local emergency transport to the nearest eligible facility equipped to treat the emergency condition is covered.
The Traditional Plan does not cover chartered air flights, non-emergency air ambulance, invalid coach, transportation services, or other travel, lodging, or communication expenses of patients, practitioners, nurses, or family members.
Biofeedback to treat a medical illness or a biologically-based mental illness is covered like any other general condition under Major Medical Benefits. Biofeedback to treat non-biologically-based mental or psychiatric conditions will be attributed to mental health and will be subject to the mental health benefit maximums.
Blood, blood products, blood transfusions, and the cost of testing and processing blood are covered. The Traditional Plan does not pay for blood which has been donated or replaced on behalf of the patient.
If you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction along with that mastectomy, Major Medical Benefits will provide coverage for the following:
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.
Surgical procedures necessary to correct congenital birth defects, which significantly impair function, including dental procedures, are covered.
Dental care under the Traditional Plan is very limited. The plan will pay a basic benefit for the removal of bony impacted molars (see Impacted Teeth), and will pay for the treatment of accidental injuries (see below), and treatment for mouth tumors if medically needed and at the appropriate level of care.
Extended Basic Benefits coverage will pay for professional fees for covered dental services, including anesthesia, whether performed in a hospital or a dental office.
There is no additional coverage through Major Medical Benefits toward the removal of bony impacted molars and impacted bicuspids.
Accidental Dental— The Major Medical portion of the Traditional Plan may provide coverage for the treatment of accidental dental injuries. You must have been a covered person at the time the accident occurred. Accidental dental 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.
Breaking a tooth while chewing on food is not considered accidental dental. 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 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 the Traditional Plan.
The Major Medical portion of the Traditional Plan may also provide coverage for dental prostheses to replace accidentally injured teeth, if the treatment and replacement 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.
Diabetic Self-Management Education
Diabetes self-management education is covered when the services are provided by one of the following:
Eligible educational services for Traditional Plan members that have been diagnosed with diabetes include:
Hospital-Based Weight Loss Programs
Hospital-based weight loss programs may be eligible for benefits for a patient diagnosed with morbid obesity. Call Horizon BCBSNJ at 1-800-414-SHBP (7427) to verify eligibility prior to enrolling in a hospital-based weight loss program.
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. See Appendix III for plan details.
Lithotripsy services are covered when they are performed in an approved hospital or lithotripsy center. The approved centers in New Jersey are:
Information regarding out-of-state approved lithotripsy centers may be obtained by calling the Horizon BCBSNJ Customer Service 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 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.
To pre-certify intravenous therapy for treatment of Lyme Disease, please call Horizon BCBSNJ at 1-800-664-BLUE (2583). The State Health Benefits Program’s policy on Lyme Disease treatment is found in Appendix III.
Coverage of screening mammographies is mandated by law and is an exception to the general rule that well care is not covered under the Traditional Plan. Routine mammography is covered as follows:
Mental Health Treatment
Mental health treatment by any of the following providers working within the scope of their licenses is covered if the treatment is determined to be medically needed and the patient has not reached the annual or lifetime benefit maximums (see Mental Health Maximums):
Services rendered for the treatment of a biologically-based mental illness are treated like any other illness and are not subject to plan 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.
Orthopedic shoes that are attached to a brace are covered. All other orthopedic shoes are not eligible for reimbursement.
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 and will not be eligible for reimbursement.
Coverage of Annual Pap smears, mandated by law, as ordered by a woman’s physician are eligible for coverage, subject to deductible and coinsurance. The office visit, laboratory costs associated with the Pap smear, and any necessary confirmatory tests are covered.
Patient Controlled Analgesia (PCA)
Patient Controlled Analgesia (PCA) is covered when it is prescribed by a medical doctor and provided under the guidance of one of the following:
Physical therapy that is medically needed at the appropriate level of care, that is not determined to be maintenance or supportive 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.
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 furnished in connection with hair loss resulting from:
Second Surgical Opinion
The Major Medical portion of the Traditional Plan provides coverage for a second physician's personal examination of a patient following a recommendation for any eligible surgical procedures. The plan will pay for one consultation by a qualified specialist physician.
If the second opinion specialist does not confirm the need for surgery, the Major Medical portion of the Traditional Plan 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
Basic (first-dollar) benefits are payable for charges for electroshock treatments, insulin shock treatments, and other similar treatments given for mental, psychoneurotic, or personality disorder and then Major Medical Benefits apply. 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. There is a limit of 12 shock treatments in each calendar year for each eligible person.
Speech Therapy Benefits
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 is not covered under the Traditional Plan.
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).
If multiple procedures are performed during the same operative session, the procedure with the highest Relative Value Unit will be considered the primary procedure and the full reasonable and customary allowance will be allowed for that primary procedure minus any applicable deductible and coinsurance liability. The Relative Value Unit associated with the procedure codes represents the time and skill involved in the performance of the procedure. All additional procedures performed in the same operative session will be secondary procedures paid at 50 percent of the reasonable and customary allowance.
Bilateral procedures will be paid at 150 percent of the reasonable and customary allowance for one procedure. Services qualify as bilateral when anatomically there are two specific body parts such as ears, eyes, knees, breasts, and kidneys. A lesion on the right arm and a lesion on the left arm would not qualify as bilateral since the skin is one body organ.
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.
Voluntary Case Management
The State Health Benefits Program provides voluntary case management services to Traditional Plan members. It is often more cost effective and convenient for a case manager to be involved in the coordination of care for a critically/catastrophically ill member in some situations. This service is purely voluntary. You do not have to take advantage of it.
By utilizing the services of a case manager, your medically appropriate care is coordinated and managed to provide the most cost-effective approach for the completion of long-term care goals.
For the patient's family, the primary advantage of case management is the additional flexibility and support provided by the case manager. Sometimes it is possible for the patient to be treated at home or in an alternate setting, such as a rehabilitation center or hospice, with additional services or home health assistance.
Some conditions that typically benefit from the services of a case manager are as follows:
Services that would be considered for case management are identified in various ways.
While the claims administrator may suggest that case management is appropriate for a particular case, the claims administrator is not responsible for initiating case management. Once it has been agreed that the patient can benefit from case management services, the case manager and the patient's physician will plan a course of treatment to provide the most efficient and cost effective quality care possible.
If you would like more information about Voluntary Case Management, please call Horizon BCBSNJ at 1-800-664-BLUE (2583).
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 the Traditional Plan:
In the case of a hospital stay, the length of the stay and hospital 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.
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.
Examples of Non-Covered Services:
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
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 needed and at the appropriate level of care.
THIRD PARTY LIABILITY
If you have received benefits from the Traditional Plan for medical services that are either auto-related or work-related, the Traditional Plan 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 the Traditional Plan. The repayment will only be equal to the amount paid by the Traditional Plan.
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.
You are required to cooperate with the Traditional Plan in recovering any amounts payable. The Traditional Plan may:
WHEN YOU HAVE A CLAIM
FILING A CLAIM
Filing Deadlines - Proof of Loss
Horizon BCBSNJ must be given written proof of a loss for which a claim is made under the coverage. This proof must cover the occurrence, character, and extent of the loss. It must be furnished within one year and 90 days of the end of the calendar year in which the services were incurred. For example, if a service were incurred in the year 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 indicated 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:
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 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. The claim mailing address, which is noted on the back of the claim form, is as follows:
New Jersey State Health
Horizon Blue Cross Blue Shield of New Jersey
PO Box 1609
Newark, New Jersey 07101-1609
SUBMITTING A CLAIM
All New Jersey hospitals file claims directly with Horizon BCBSNJ. Out-of-state hospitals that participate with the local Blue Cross Blue Shield (BCBS) plan will file the claim for you through the Blue Card Program. If you have services out-of-state at a non Blue Card hospital or out of the country, you are responsible for submitting an itemized bill and a completed claim form to Horizon BCBSNJ.
Providers in the Participating Provider network will file claims directly with Horizon BCBSNJ. Out-of-state providers that participate in the local BCBS plan will file medical claims with Horizon BCBSNJ through the Blue Card Program. Many other providers will also file medical claims as a service to their patients. If they do not, you are responsible for submitting an itemized bill and a completed claim form to Horizon BCBSNJ.
Medicare Claims and Other Coverage
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 Horizon BCBSNJ.
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 Traditional Plan claim form to Horizon BCBSNJ.
If the member has primary coverage with another carrier, the member must include a copy of the Explanation of Benefits from the other carrier, an itemized bill, and a completed Traditional Plan claim form to Horizon BCBSNJ.
Horizon Blue Cross Blue Shield of NJ participates in a program that uses nationwide contracting provider arrangements with all Blue Cross Blue Shield plans. This program allows SHBP participants the use of out-of-state hospitals and doctors. Participants of the SHBP may utilize the services of all hospitals and doctors across the nation who contract with independent Blue Cross Blue Shield Plans.
Authorization to Pay Provider
The medical expense coverage provided by the Traditional Plan is not assignable. However, the member (or a qualified dependent in case of the member's death) can, with the agreement of Horizon BCBSNJ, 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, Horizon BCBSNJ 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 BCBS plan will be paid directly for eligible services.
QUESTIONS ABOUT CLAIMS
If you have questions about a hospital claim, hospital benefits, a medical claim, 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.
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.
This section lists the types of charges Horizon BCBSNJ will pay for covered services or supplies according to all provisions, including but not limited to medical need and medical appropriateness, the Schedule of Covered Services and Supplies, benefit limitations, and plan exclusions.
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.
The plan will provide the coverage listed in this Schedule of Covered Services and Supplies, subject to the terms, conditions, limitations, and exclusions stated within this booklet.
BASIC ( HOSPITALIZATION ) BENEFITS
|Benefit Period||365 days of inpatient care per Benefit Period|
|Every two days in a member skilled nursing facility or every three home care visits will count as one benefit day for inpatient care.|
|Renewal Interval||Benefit Period is renewed when 90 days without care as a related inpatient in a hospital have elapsed.|
|Inpatient Hospital Services||100 percent up to 365 days for a semi- private room. Day 366+ subject to deductible and 20 percent coinsurance|
|Skilled Nursing Facility Charges||100 percent for up to 30 days|
|Ambulatory Surgical Center||100 percent for facility charges|
|Home Health Agency Care||100 percent for up to 60 visits within 61 days, per occurrence|
|Hospice Care||100 percent|
|Accidental Injury||100 percent for facility charges|
|Inpatient Alcohol and Substance Abuse||100 percent, same as general inpatient benefit|
|Inpatient Mental or Nervous Conditions||100 percent for up to 20 inpatient days per calendar year. Expenses beyond 20 days are paid under Major Medical Benefits subject to annual and lifetime maximums, deductible, and coinsurance. (For biologically-based mental illnesses, coverage is the same as for any other medical condition.)|
|Pre-admission Testing||100 percent|
|Organ Transplants||100 percent for organ transplants at an approved participating facility. Non-participating facilities are covered at 80 percent subject to deductible and coinsurance. Prior authorization is required except for cornea and kidney transplants|
|EXTENDED BASIC (MEDICAL-SURGICAL) BENEFITS|
|Bony Impacted Molars and Bicuspids||Subject to a $264
Benefit Period maximum for the removal ($105 for the first tooth
and $53 for each of the next three teeth)
Please note: The remaining charge is the member's responsibility if there is no dental insurance coverage available. It is not eligible for benefit under Major Medical Benefits.
|Chemotherapy||Subject to a $500 Benefit Period maximum|
|Newborn Well-Care||Subject to a $42
Benefit Period maximum while both mother and child are hospitalized.
Please note: The remaining charge is the member's responsibility. It is not eligible under Major Medical Benefits.
|Pathology||Subject to a $25 Benefit Period maximum.|
|Physical Therapy||Subject to a $50 Benefit Period maximum.|
|Physician Services for Surgical Procedures||Subject to a fixed amount for specific surgical procedures.|
|Cesarean Section||Subject to a $651 first dollar benefit per procedure.|
|Vaginal Delivery||Subject to a $420 first dollar benefit per procedure.|
|Total Hysterectomy||Subject to a $578 first dollar benefit per procedure.|
|D&C||Subject to a $126 first dollar benefit per procedure.|
|Appendectomy||Subject to a $368 first dollar benefit per procedure.|
|Repair Inguinal Hernia||Subject to a $315 first dollar benefit per procedure.|
|Radioactive Isotope Studies||Subject to a $125 Benefit Period maximum.|
|Radioactive Isotope Therapy||Subject to a $500 Benefit Period maximum.|
|Radium, Radioactive Isotope (sealed sources) or Radon Therapy||Subject to a $150 Benefit Period maximum.|
|Shock Therapy||Subject to a 12 Shock Treatment Benefit Period up to a fixed schedule amount.|
|X-rays (diagnostic)||Subject to a $125 Benefit Period maximum.|
|X-ray Therapy||$500 Benefit Period maximum for X-ray therapy performed outside a hospital.|
|MAJOR MEDICAL BENEFITS|
|Coinsurance||20 percent of reasonable and customary allowance of eligible expense.|
$2,000 in claims for each member, the Traditional Plan pays 100 percent
of covered services.
Note: The Out-of-Pocket Maximum cannot be met with:
|State Employees subject to plan changes||$250
per covered person.
$500 per Member and Spouse/Domestic Partner, Parent and Child, or Family.
|Local Employees||$100 per covered person.|
|State Employees not subject to plan changes, and All Retirees||$200
per Member and Spouse/Domestic Partner,
Parent and Child, or Family.
|Common Accident Deductible||If two or more covered persons in the same family are injured in the same accident, only one deductible will be applied in a benefit period to the covered services and supplies resulting from the accident.|
|Fourth Quarter Deductible Carry-over||Covered services and supplies incurred within the last 3 months of a benefit period which were applied against the deductible but did not satisfy the deductible may be carried over and applied against the deductible for the following benefit period.|
|Prior Carrier Deductible Carry-over||The prior carrier deductible carry-over applies only to new groups joining the SHBP. Charges for covered services and supplies which satisfied any portion of a deductible required for the final benefit period under the employer's prior major medical group contract will be applied to satisfy all or any portion of the initial deductible required under this program.|
|Major Medical Lifetime Maximum||One million dollars per covered person with an automatic limited restoration feature. At the start of each benefit period, any of the covered person's previously used part of a maximum will then be restored for future charges up to the lesser of (a) $2,000 or (b) the amount needed to restore the full maximum. If the covered person's coverage ends under the Traditional Plan and begins again at a later date, the lifetime maximum benefit resumes at the same level it was when the coverage ended.|
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:
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.
HEALTH BENEFITS PROGRAM
MEDICAL TREATMENT POLICIES
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.
Consultations with infertility specialists and/or at comprehensive infertility centers are covered. Under the Traditional Plan and NJ PLUS out-of-network, screening tests such as HIV, routine PAP, hepatitis panels, etc., which may be required prior to infertility treatments will not be covered expenses. Under HMO and NJ PLUS in-network, those expenses will be covered.
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.
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).
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))
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.
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.
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.
Basic Benefits — That portion of the Traditional Plan that provides coverage for eligible hospital (facility) charges. Basic Benefits are paid according to a "first-dollar" basis either in full or at a specific fee schedule. Also known as hospitalization benefits.
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 for those members taking advantage of the Voluntary Case Management Program.
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.
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.
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 the Traditional Plan.
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 the Traditional Plan, 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 Major Medical portion of the Traditional Plan 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 (s)he 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.
Extended Basic Benefits — That portion of the Traditional Plan that provides coverage for eligible medical-surgical (professional) charges such as X-rays and lab tests and surgical expenses. Extended Basic Benefits are paid on a "first-dollar" basis according to a specific fee schedule.
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. These charges are generally paid under the Basic Benefits (hospitalization) portion of the Traditional Plan.
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.
First-Dollar Basis — A provision of a benefit plan that provides reimbursement for incurred health care costs "from the first eligible dollar" with no deductible.
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:
(5) 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:
Hospitalization Benefits — Benefits provided under a policy for hospital charges incurred by an insured person because of an illness or injury. Also known as Basic Benefits.
Illness — Any disorder of the body or mind of a covered person.
Indemnity Plan — A plan that allows members to choose any eligible provider and hospital for service and receive reimbursement for designated covered services. Payments can be made either to enrollees or directly to health providers. This type of plan is also referred to as fee-for-service. The Traditional Plan is an indemnity plan.
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 the Traditional Plan.
Major Medical Benefits — The supplemental program for health insurance that provides a reimbursement of eligible expenses beyond the Basic Benefits. The program normally provides for a deductible and coinsurance formula for specific services (generally involving major illnesses and injuries). Full reimbursement is often provided once the expenses paid by the individual reach a certain level. Although the maximums that limit total benefits are usually substantial, maximums are generally specified and mean that most policies do not provide completely unlimited protection. Limits on particular services, such as psychiatric care, may also be specified.
Medical Need and Appropriate Level of Care — A service or supply that Horizon BCBSNJ determines meets each of these requirements:
Medical-Surgical or Professional Benefits — Basic Benefits under the Traditional Plan for professional charges such as X-rays and lab tests and surgical expenses toward the doctor's operating fees. Medical-surgical benefits are paid on a set fee schedule and remaining eligible charges are then automatically considered under the Major Medical portion of the plan. Also known as Extended Basic Benefits.
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 the Traditional Plan.
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.
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.
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, 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 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 (s)he 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 the Traditional Plan.
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.
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.
EFFECTIVE DATE: APRIL 14, 2003
Please review it carefully.
Click this link to view the SHBP Notice of Privacy Practices.
STATE HEALTH BENEFITS PROGRAM CONTACT INFORMATION
|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 email@example.com|
|Division of Pensions and Benefits:|
|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
|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)
|New Jersey Department of Health and Senior Services|
|Division of Aging and Community Services||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
New Jersey Medicare - Part B
STATE 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
|State Health Benefits Program Summary Program Description booklet (PDF file - size 356k - Requires Acrobat Reader)|
|State Health Benefits Program Comparison Summary - Plan comparison chart.|
SHBP Fact Sheets
Fact Sheet #11, Enrolling in the State Health Benefits Program When you Retire.
|Fact Sheet #23, The State Health Benefits Program 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 New Jersey State Health Benefits Program Coverage Under COBRA.|
|Fact Sheet #37, SHBP Employee Dental Plans.|
Fact Sheet #47, SHBP Retired Coverage Under Chapter 330 - PFRS & LEO.
|Fact Sheet #51, Continuing SHBP Coverage for Overage Children with Disabilities.|
|Fact Sheet #60, Voluntary Furlough Program.|
Fact Sheet #66, SHBP 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
|SHBP NJ PLUS Member Handbook|
a PDF version of this handbook, click
here - size 289K
(Requires Acrobat Reader available free from Adobe.)
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