The SHBP will offer two types of medical plans: NJ DIRECT 15, a Preferred Provider Organization (PPO), administered by Horizon Blue Cross Blue Shield of NJ and Aetna and Cigna Health Maintenance Organizations (HMOs).
Q – Can I continue my coverage in the Traditional Plan?
No. The Traditional Plan and NJ PLUS will be replaced by NJ DIRECT 15 (PPO).
Q – What is the difference between a Preferred Provider Organization (PPO) and a Health Maintenance Organization (HMO)?
A PPO and HMO are both Managed Care Plans. Managed Care Plans provide coverage for preventive care, such as annual check-ups, screening tests, well-baby visits, and immunizations in the hope of avoiding serious illness and more costly treatment. Services are monitored for medical necessity and appropriate levels of care. A PPO is designed to provide affordable health care while maintaining flexibility for its members, who do not have to use the services within the network, but are encouraged to do so. If members go outside the network, they are still covered, but must pay a deductible and contribute a higher co-payment. When an HMO manages your healthcare, they usually require you to use doctors and hospitals that belong to its network. If you utilize a doctor or hospital that does not belong to the network, the care you receive usually will not be paid unless the care was pre-authorized or for emergency care.
Q – What do these medical plan changes mean for me?
Employees enrolled in the Traditional Plan or NJ PLUS will automatically be enrolled in NJ DIRECT 15. Employees enrolled in AmeriHealth, Health Net or Oxford HMO plans will automatically be enrolled in NJ DIRECT 15. Employees enrolled in Aetna or Cigna HMOs will remain in these plans.
Q – Can I select a different plan?
Yes. If you wish to elect a plan other than the one in which you will automatically be enrolled, you must complete a SHBP Enrollment Application during the Special Open Enrollment Period.
Q – When is the Special Open Enrollment Period?
January 28th – February 15th, 2008.
Q – What is the effective date of coverage?
April 1 2008.
Q – What changes can I make during the Special Open Enrollment?
Medical Plan changes only. You cannot add dependents, change coverage levels, or make changes to your dental or prescription drug plans during the Special Open Enrollment.
Q – Will I receive a new medical identification card?
Yes. New ID cards will be mailed in March, 2008.
Q – Can I waive my medical coverage?
Yes. To waive medical coverage, you must complete a SHBP Enrollment Application and check the appropriate box to waive coverage and also complete a Waiver/Reinstatement Form.
Q – Will there be another Open Enrollment Period this year?
Yes. The next Open Enrollment is October 1 – 31, 2008. During this Open Enrollment you can make changes to your medical, prescription drug and dental plans. Changes made become effective January 1, 2009.
Q – What is the benefit of enrolling in the NJ DIRECT 15 (PPO)?
Members will have the option of using in-network or out-of-network benefits. In-network – if the physician participates in the Horizon BCBSNJ Managed Care Network, members will only pay the $15.00 co-payment for eligible services. Members living outside of New Jersey can utilize physicians participating in the National Blue Cross Blue Shield Network. If the physician does not participate in the Horizon BCBSNJ Managed Care or National Networks, the services will be considered out-of-network. Out-of-network benefits allow you to utilize any licensed physician; however you are required to file a claim form with Horizon BCBSNJ. Most out-of-network care is reimbursed at 70% of reasonable allowances after the annual deductible is met. The out-of-network co-insurance is 30%.
Q – Are referrals required for NJ DIRECT 15 in-network services?
No. Referrals are no longer required for in-network treatment.
Q – What is the deductible for NJ DIRECT 15 out-of-network benefits?
The annual deductible for out-of-network services is $100. for single coverage; $200. ($100. per person) for member/spouse, member/same sex partner or parent/child coverage, and an aggregate family deductible of $250. for family coverage or parent/children coverage (more than two individuals). There is also a $200. deductible for each out-of-network inpatient hospital stay.
Q –What are the maximum out-of-pocket costs?
The maximum out-of-pocket in-network costs are $400. for an individual and $1,000. for a family. The maximum out-of-pocket out-of-network costs are $2,000. for an individual and $5,000. for a family. Once the out-of-pocket allowances are met, covered benefits are paid at 100% of the reasonable and customary amounts through the remainder of the calendar year.
Q – How many HMO plans are available for employees?
Two: Aetna and Cigna HMOs. AmeriHealth, Health Net and Oxford are no longer part of the NJ State Health Benefits Plan (SHBP).
Q – Did Aetna and Cigna HMOs expand their networks?
Yes. Both Aetna and Cigna have expanded their networks and will now provide services nationwide.
Q – If I enroll in an HMO, am I required to select a Primary Care Physician (PCP)?
Yes. When you enroll in an HMO you must select a Primary Care Physician (PCP) from a group of participating providers contracted by the HMO. All services, except emergencies, are coordinated through your PCP. If you require the care of a specialist, your PCP will refer you to a specialist who participates in the HMO network.
Q – Are referrals required for the Aetna and Cigna HMO plans?
Yes. Both Aetna and Cigna now offer electronic referrals, which facilitates the use of specialists.
Q – Will I have deductibles and claims forms to file for Aetna and Cigna HMO plans?
No. There are no deductibles or claims to file, however you are required to pay a co-payment of $15.00 for visits to your PCP or a referred specialist.
Q – What is the premium rate for medical coverage in NJ DIRECT 15, Aetna and Cigna HMOs?
The medical contribution is 1.5% of salary regardless of the plan (PPO or HMO) or level of coverage (single, member/spouse, member and same sex partner, parent and child or family).
Q - How can I obtain additional information?
A comprehensive guide to plan choices, Unified Provider Directory and other information will be available prior to the Special Open Enrollment Period. You can also obtain information at: