Health benefits, including prescription, dental, and vision coverage, are effective September 1 for 10-month, full-time employees who begin working on that date. Coverage for 10-month full-time employees who are hired after September 1 and for all 12-month full-time employees is effective two months after their respective start dates.
Dependents' coverage is initiated on the same date as the employee's coverage. Eligible dependents include the employee's spouse (unless legally separated) and unmarried children up to 26 years of age who live with the employee in a regular parent-child relationship. Children's coverage normally ends on December 31 of the year they become 26. Upon resignation, termination, or retirement, coverage extends to approximately 30 days from the last day paid. Pamphlets and enrollment forms are available in the Benefits Office in the Division of Human Resources.
Part Time Employee Health Benefits
Chapter 172, P.L. 2003 provides part-time faculty members and employees at Montclair State University eligibility for enrollment for coverage in the State Health Benefits Program (SHBP), provided that the part-time employee is a member of a State administered retirement system. Under the law, the employee can enroll in NJ Direct 15 and the Employee Prescription Drug Plan. If an eligible employee or faculty member elects to enroll and purchase coverage, the employee or faculty member must pay the full cost of the coverage.
Part-Time Active Employee Eligibility
Eligibility for coverage is determined by the State Health Benefits Program (SHBP). Enrollments, terminations, changes to contracts, etc., must be processed through the MSU Benefit's Office.
To be eligible for coverage under the provisions of Chapter 172, an employee must be:
Part-time employees cannot be covered by the health benefits provided under Chapter 172, P.L. 2003, until enrolled in both a New Jersey State-administered retirement system and the SHBP. When eligible for enrollment in a retirement system, the University will provide you with the Part-Time Employees State Health Benefits Application. You must complete the application, providing all of the
information requested and submit it to the Benefit's Office in the Division of Human Resources (CO 314B). There is a two month waiting period before health benefits coverage begins.
Part-time employees may select both NJ Direct 15 and the Employee Prescription Drug Plan coverage, or NJ Direct 15 coverage only (part-time employees cannot enroll in only the Employee Prescription Drug Plan.)
Once enrolled in the SHBP, you will be billed monthly for the cost of your selected coverage. Rate charts showing the cost of coverage are available from the Benefit's office or on the SHBP's Internet home page at www.state.nj.us/treasury/pensions/shbp.htm.
For more information, contact the Benefit's Office at extension 4395.
Domestic Partnership Act
On January 12, 2004, Governor McGreevey signed the Domestic Partnership Act (DPA) into law. For those who meet the standards - including cohabitation and joint finances - the legislation provides domestic partners of New Jersey State workers eligibility to receive certain health care and retirement benefits. The bill also requires commercial health and dental insurers to extend eligibility for filing health insurance contracts to the individuals covered under the bill. Further, the legislation also makes available certain other rights that are given to married couples including: (i) protection against discrimination in housing and credit based on domestic partnership status; (ii) visitation rights for a hospitalized domestic partner and the rights to make medical or legal decisions on behalf of an incapacitated partner, (iii) an exemption from the personal income tax and the transfer of inheritance tax on the same basis as a spouse, and (iv) in certain circumstances, health and pension benefits similar to those provided to spouses. Moreover, pursuant to the DPA, domestic partners may now claim joint status for state tax purposes.
In order to obtain the benefits provided in the Domestic Partnership Act, those qualifying individuals would need to complete and file an Affidavit of Domestic Partnership with their local registrar and satisfy the following requirements: (i) both persons have a common residence and are otherwise jointly responsible for each other's common welfare; (ii) both persons agree to be jointly responsible for each other's basic living expenses during the domestic partnership; (iii) neither person is married or a member of another domestic partnership; (iv) neither person is related to the other by blood; (v) both persons are of the same-sex, or of opposite-sex whereby each person is each 62 years of age or older; (vi) both persons have chosen to share each other's lives in a committed relationship; and (vii) both persons are at least 18 years of age.
The fee for filing such an affidavit will be determined by the Commission of Health and Senior Services at a later date.
In accordance with the law, the bill takes effect on the 180th date after enactment, which is July 11, 2004.
NJ DIRECT 15
NJDIRECT 15 is administered for the SHBP by Horizon Blue Cross and Blue Shield of New Jersey (BCBSNJ). NJ DIRECT 15 is a preferred provider plan, which is a blend of an indemnity plan and a HMO. The plan has a network of doctors, hospitals, and other health care providers who offer medical care in cost-efficient ways. All providers undergo a credentialing procedure prior to becoming part of the network. The NJ DIRECT 15 network is available nationwide.
When enrolled in NJ DIRECT 15, the employee need not select a personal care physician, nor are referrals needed for in network care. When using network providers, a $15 co-payment is required, after which medical expenses are generally covered in full. There are no claim forms to file. In this way, NJ DIRECT 15 is very similar to an HMO. However, there is an important difference. A NJ DIRECT 15 participant also has the option to use a non-network provider (go out-of-network). When using doctors or hospitals outside the network, generally, NJ DIRECT 15 will pay 70 per cent of the eligible costs at a reasonable and customary level after the employee pays a required deductible. Claim forms are required for out-of-network services.
Occasionally, situations arise where an employee feels that his/her medical care or claims have not been properly handled by his/her health plan. The employee must try to resolve the problem directly with the administrator/carrier by telephone and then in writing. If the problem is not resolved, the employee then has the right to appeal the administrator’s/carrier’s decision by writing to the State Health Benefits Commission, P.O. Box 299, Trenton, NJ 08625.
Unified Provider Directory
The Unified Provider Directory, accessible through the Internet at the site indicated below, contains medical provider information currently included in the provider directories of each participating health plan in the State Health Benefits Program (SHBP). This consolidated information is in a uniform, easy-to-access format. Employees will no longer have to search through numerous provider directories to find the plan affiliations of their health care provider or hospital.
The service, which is updated monthly, displays timely and comprehensive information concerning health care providers and facilities that deliver their services through one or more of the SHBP’s managed-care plans. The site also includes PACE (Program of All-inclusive Care for the Elderly) providers who offer discounted services through the out-of-network services.
Employees may access the Unified Provider Directory through the SHBP homepage at:
The HMO Plans
Two Health Maintenance Organizations (HMOs) participate in the SHBP. They are licensed to provide services in specific territories (by county). The two HMO's offered are Aetna and Cigna Heathcare.
HMOs emphasize preventive care and provide coverage for physical exams, well-baby visits, immunizations, etc. Details on specific coverage, services, and fees vary by HMO. However, they generally work as follows. When the employee enrolls in an HMO, the employee selects a primary care physician from the list of providers in the HMO network to oversee health care. If the services of a specialist are required, the primary care physician arranges a referral. There are no deductibles to satisfy or claim forms to file, and the employee should not receive doctor or hospital bills. However, most HMOs require the employee to pay a small co-payment for doctor visits, emergency room visits, emergency room treatment, and other services. The employee must use the HMO network for health care services (other than for an emergency), or the HMO will not pay for the care.
Dental Care Programs
The State offers a choice of two dental care programs. Participation is optional, and for those employees electing dental coverage, there is a bi-weekly payroll deduction. The cost to the employee depends on the type of coverage selected. If an employee joins either program, he/she must remain a member for a minimum of 12 months. Upon resignation, termination, or retirement, coverage extends to approximately 30 days from the separation date. Pamphlets and enrollment forms are available in the Benefits Office in the Division of Human Resources. Employees may enroll or change programs during the annual open enrollment period held during the fall of each year.
Dental Expense Plan
The Dental Expense Plan provides coverage for oral exams; X-rays; oral prophylaxis, including scaling and polishing; repair of dentures (labor and supplies); restorative procedures (fillings, inlays, and crowns); palliative (emergency) treatment; extractions; endodontic services; space maintainers; oral surgery; apicetomy; and orthodontics for persons under age 19.
The Dental Expense Plan is administered by Aetna US Healthcare. Employees may call 877-238-6200 for more information.
This plan requires a deductible of $50 per family member to a maximum of $150 annually. The plan covers a maximum of $3000 in charges per person for each calendar year.
Levels of Reimbursement
100% Diagnostic and Preventive Procedures
80% Basic Services
65% Major Restorative Procedures
50% Prosthodontics and Periodontics
Eligible services include diagnostic-preventive procedures, radiographs, space maintainers, restoratives, endodontics, prosthodontics, oral surgery, orthodontics, periodontics, and fixed bridges. Eligible dependents are spouses (unless legally separated) and unmarried children under 23 years of age who live with the employee in a regular parent-child relationship. The bi-weekly deductions cover all eligible services except where a co-payment is specified.
New Jersey Dental Plan Organization (DPO)
The New Jersey Dental Plan Organization provides two options. Employees may select either a clinic or an individual dentist. A list of participating dental organizations is available in the Benefits Office in the Division of Human Resources. It is the employee's responsibility to verify that an individual dentist is a member of the plan.
Prescription Drug Program
The Prescription Drug Program covers the cost of prescription drugs for employees and eligible dependents for use outside of hospitals, nursing homes, or other institutions. The program covers drugs that, as required by federal law, can be dispensed only upon a written prescription order by a doctor.
The prescription drug program is administered by Caremark. Employees may call 866-881-5605 for more information.
For each prescription dispensed by a pharmacist, employees pay a $3 co-payment for generic drugs and a $10 co-payment for name brand drugs. Employees and their covered dependents who are using a prescription medication on an ongoing basis may utilize the prescription drug mail order program, which provides members with a three-month supply of their prescription medication. The employee need only make one co-payment for the three-month supply. Information on how this program works is available from the Benefits Office in the Division of Human Resources.
Vision Care Plan
Full-time employees and eligible dependents may receive a $40 reimbursement toward the cost of prescription eyeglasses with regular lenses, $45 reimbursement for glasses with bifocal lenses, or a $40 reimbursement for contact lenses. Eligible employees and their dependents may also receive a maximum reimbursement of $35 toward the cost of an eye examination given by an ophthalmologist or optometrist.
These reimbursements are available to each eligible employee and dependent once in every two-year period. Proper affidavit and submission of original receipts are required in order to receive payment. Vision care reimbursement forms are available from the Payroll Office.
Employees who are presently enrolled in the State Health Benefits Program may change their benefits provider only during the annual open enrollment period each fall. Employees who were previously eligible for health benefits coverage, but had elected not to accept health benefits, may choose to enroll in the health benefits program at that time.
Any changes in benefit coverage become effective January 1. Employees wishing to change coverage during the open enrollment period must contact the Benefits Office in the Division of Human Resources to obtain appropriate state-issued forms.
An employee and/or eligible dependents who lose benefits coverage as a result of a resignation, retirement, termination, approved unpaid leave status, death, divorce, or other covered event will be eligible to continue health, dental, prescription, and/or vision benefits by completing a COBRA application. Benefits may be continued for up to 18 months (and in some cases 36 months for dependents) whether or not the employee has other coverage. An employee electing COBRA coverage must send payments for continued coverage to the New Jersey Division of Pensions and Benefits. For eligibility or payment information contact the Benefits Office in the Division of Human Resources.