Cigna Medical Claim Forms

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					  School Employees Health Benefits Program (SEHBP)
                   Medical Plans


Health Insurance Plans


Below are descriptions of the two types of plans offered by SEHBP effective
April 1, 2008. Click below to access the SHBP’s “A Guide to Choosing a SHBP
Health Plan” and “SEHBP Plan Comparison Summary”. Both documents provide
detailed coverage information about the Preferred Provider Organization (PPO)
and Health Maintenance Organizations (HMOs). Please note that health
insurance is available to new employees only if they work 35 or more hours per
week.

For the guide, click below

       http://www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/hb0505
.pdf

For the comparison chart, click below:

      http://www.state.nj.us/treasury/pensions/hb_open_enrollment_2009/hb-
0798-local-ed-comparison-booklet.pdf

For a network of providers go to the insurance company links under the PPO and
HMO descriptions.

The PPO and HMOs are managed care plans, meaning that they provide
coverage for preventive care such as annual checkups and screening tests, well-
baby visits, and immunizations, in the hope of avoiding serious illness and more
costly treatment.



Preferred Provider Organization (PPO)
The PPO plan is administered for the SEHBP by Horizon Blue Cross Blue Shield
of New Jersey (800-414-7427). The PPO offers 2 options – NJ DIRECT10 and
NJ DIRECT15. Both plans provide both in-network and out-of-network medical
care. Members may see any physician, nationwide, and do not need to select a
Primary Care Physician (PCP) for in-network care, nor obtain a referral to visit a
specialist.
To locate a provider go to Horizon’s web site for the SEHBP:

www.horizon-bcbsnj.com/shbp/getting_care/provider_directory.html


If the physician does not participate in Horizon’s network, the services will be
considered out-of-network. Out-of-network benefits provide reimbursement for
eligible services for the treatment of illness or injury. Out-of-network care is
reimbursed at the reasonable and customary allowances after the deductible is
met.

To file a claim for an out-of-network provider, click below to print a claim form.

http://www.horizon-
bcbsnj.com/SiteGen/Uploads/Public/horizon_bcbsnj/pdf/shbp/2642.pdf


NJ DIRECT10 and NJ DIRECT15 offer different copayments and coinsurances
as shown below:

                                   NJ Direct10           NJ Direct15

In-Network Co-payment                      $10                  $15

Out-of-Network Benefit                     80%                  70%

Emergency Room Co-payment                  $25                  $50

For out-of-network services, the reimbursement is either 80% or 70% of the
reasonable and customary costs after an annual individual deductible of $100
and an annual family deductible of $250 is met. The in-network out-of-pocket
maximum is $400 for an individual and $1,000 for a family. The out-of-network
out-of-pocket maximum is $2,000 for an individual and $5,000 for a family. (note:
For 2009 only, the maximum is $400 not $2000 as specified.)

NJ Direct Handbook

For more details about the plans, click on the guide or comparison chart above,
or go to NJ Direct Handbook:

www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/njdirectbk.pdf


Pre-Certification
Pre-Certification is required for certain services. See pages 14-16 of the
handbook for services requiring pre-certification and the procedure for obtaining
pre-certification approval.



Health Maintenance Organization (HMO)
A HMO provides complete coverage, including wellness and preventive care for
medical services provided by participating providers. All services, except
emergencies, are coordinated through a PCP who, when necessary, will refer
you to a specialist in the HMO network. Electronic referrals are used by the
HMOs, and services rendered without a referral will not be paid by the HMO.

HMOs have no deductibles or claim forms to file. You are required to pay a $10
co-payment for PCP visits or referred specialist visits. There are no out-of-
network benefits under an HMO plan. Aetna and Cigna offer an HMO. For more
details about the plans, go to:

Aetna
www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/aetna-
handbook.pdf

Cigna
www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/cigna-handbook.pdf


To find a provider, click above on the SHBP Unified Provider Directory above or
go to either Aetna or Cigna:

      Aetna         www.aetna.com/statenj/      (800 – 782-8365)

      Cigna         www.cigna.com              (800 – 564-7642)


What do the plans cover?

To find out what each plan covers, check out the Comparison guide for
information about hospital stays, physician services, emergency room services,
out of pocket costs, prescriptions, eye exams, etc. Or, for more detailed
information, go to the Summary Plan Description at the following site:

http://www.state.nj.us/treasury/pensions/epbam/exhibits/handbook/hb0505.pdf
Who is covered?

        You as the employee. Employees hired after 5/21/2010 must work 35
         hours or more per week to be eligible.
        Your spouse / civil union partner
        Unmarried children under the age of 23 who live with you in a regular
         parent-child relationship, are away at school, or are divorced children
         living at home provided they are dependent upon you for support and
         maintenance. For children who are covered prior to turning age 23, the
         coverage continues through the end of the calendar year in which they
         turn 23. Coverage for an enrolled child will end when the child marries,
         enters into a civil union partnership, moves out of the household, turns
         age 23, obtains coverage under the SHBP as an employee, or is no longer
         dependent on you for support.
        Children up to age 26. A child is defined as an enrollee’s child until age
         26, regardless of the child’s marital, student, or financial dependency even
         if the child no longer lives with the enrollee. A child is not eligible if he/she
         is eligible to enroll in employer base coverage.

Coverage of children to Age 31. Click below for information about purchasing
medical coverage for over age children.

http://www.state.nj.us/treasury/pensions/epbam/exhibits/factsheets/fact74.pdf


Chapter 89, P.L. 2008 mandated that the SHBP and SEHBP conduct a
continuous review to ensure that only eligible employees and retirees, and their
dependents, are receiving coverage under the program. Please click below for a
list of dependents and the eligibility definition for each group. Also click below for
the documentation you must provide when you enroll an eligible dependent.

http://www.state.nj.us/treasury/pensions/shbp-sehbp-required-documentation-
chart.pdf


When does the medical coverage start?

There is a waiting period of 2 months following your date of hire before your
SEHBP health benefits coverage begins, provided you submit a completed NJ
State Health Benefits Program Application. Your enrolled eligible dependent's
coverage is effective the same date as yours. Full-time faculty members who
begin employment on September 1 receive coverage immediately.

Q.       How much will I pay for health insurance?
A.    You will pay 1.5% of your base salary each pay period.

Q.     My spouse has family coverage through the SHBP at Rutgers University.
Can I enroll in family coverage through Brookdale?

A.    No, you cannot enroll your family. Chapter 2, P.L. 2010 prohibits duplicate
coverage.

Q.    My spouse covers our family. Can I enroll in the health waiver program
and collect a stipend for waiving coverage?

A.    No. By being enrolled under family coverage at Rutgers and electing the
waiver stipend at Brookdale, you will have duplicate coverage and will have to
choose one coverage.

Q.    I submitted the health waiver forms after May 21, 2010. How much will my
waiver be?

A.   The most an employee who waives coverage will receive is 25% of the
amount saved by the employer or $5,000, whichever is less.

Q.    How many hours do I need to work each week to be eligible for health
insurance?

A.     Any employee hired after May 21, 2010 must work 35 hours per week to
be eligible.


Will the amounts against the lifetime maximum, mental lifetime maximum
under the traditional plan and out of network NJ Plus follow me under NJ
DIRECT10 or NJ DIRECT15?

The maximums will follow participants to NJ DIRECT10 and 15 for out-of-network
only.


What is the in-network out of pocket maximum for NJ DIRECT10 & 15?

Your co-payments and coinsurance will be applied to the $400 individual out-of-
pocket maximum and the $1,000 family out of pocket maximum.


Will the network co-payments and coinsurance payments apply to the out-
of-network out-of-pocket maximum?

They will apply under NJ DIRECT10, but not under NJ DIRECT15.
Under NJ DIRECT, I don’t need a referral. However, the Plan Comparison
Summary states that I need pre-certification for certain services. What is a
pre-certification?

Pre-certification requires that employees (or the treating doctor/facility) receive
prior authorization from Horizon to determine medical necessity before certain
services are performed. If you are using a network doctor or facility, the provider
will coordinate the in-network pre-certification. For out-of-network services, the
employee or the provider on behalf of the employee will have to contact Horizon.

Some examples of these services include inpatient admissions, reconstructive
procedures, durable medical equipment purchase, etc. Call Horizon at 800-414-
7427 for a list of the services.


Do I need to choose a primary care physician (PCP)?

If you are enrolling in the Aetna or Cigna HMO, you will need to pick a PCP. You
do not need to select a PCP if you are enrolling in NJ DIRECT.


Do I need referrals to go to a specialist?

You will need a referral if you are in Aetna or Cigna. Most referrals can be done
electronically.

You do not need referrals if you are in NJ DIRECT. However, pre-certification is
required for certain in-network and out-of-network services.


Member Benefits Online System (MBOS)

Now you can access pension information about your Public Employees
Retirement System (PERS) account, pension plans, Designation of beneficiary,
etc.

All employees may access information about their State Health Benefits
Program.

Click below for information about MBOS and the four steps to register.

http://www.state.nj.us/treasury/pensions/mbos_webx.htm
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