STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS & BENEFITS
MEMBER GUIDEBOOK
FOR EMPLOYEES AND RETIREES
ENROLLED IN THE
SCHOOL EMPLOYEES’ HEALTH BENEFITS
PROGRAM
PLAN YEAR 2024
ADMINISTERED FOR THE DIVISION OF PENSIONS & BENEFITS BY
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
An online version of this guidebooks containing current updates is available for viewing at:
www.nj.gov/treasury/pensions/member-guidebooks.shtml Be sure to check the Division of
Pensions & Benefits Internet home page at: www.nj.gov/treasury/pensions for forms, fact
sheets, and news of any new developments affecting your health benefits.
NJ DIRECT
NJ EDUCATORS HEALTH PLAN
and
SEHBPMEMBER GUIDEBOOK
1
Contents
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................................................... 5
HORIZON BCBSNJMEMBER ONLINE SERVICES ..................................................................................................................... 6
MEMBER SERVICES .......................................................................................................................................................... 7
NJWELL RewardsProgram ................................................................................................................................................. 8
HEALTHBENEFITS PROGRAMELIGIBILITY ............................................................................................................................ 9
Local Education Employees .................................................................................................................................................... 9
Aggregate of Pension Membership Service Credit ............................................................................................................... 14
Eligible Dependents of Retirees ............................................................................................................................................ 14
Multiple Coverage under the SHBP/SEHBP is prohibited ...................................................................................................... 14
Enrolling in Retired Group Coverage .................................................................................................................................... 14
Medicare Part D ................................................................................................................................................................... 15
Medicare Eligibility ............................................................................................................................................................... 15
Coordination of benefits period ........................................................................................................................................... 16
When Medicare is primary ................................................................................................................................................... 16
Dual Medicare Eligibility ...................................................................................................................................................... 17
How to File a Claim If You Are Eligible for Medicare ............................................................................................................. 17
GENERALCONDITIONS OFTHEPLAN ................................................................................................................................. 18
Medical Need and Appropriate Level of Care ....................................................................................................................... 18
Health Care Fraud ................................................................................................................................................................ 18
Predetermination of Benefits ............................................................................................................................................... 22
Claims by Out-of-Network Provider Practices ...................................................................................................................... 23
Admissions for the Treatment of Substance Use Disorder (for NetworkService Only) .......................................................... 24
Experimental or Investigational Treatments ........................................................................................................................ 24
SEHBP BENEFITS ............................................................................................................................................................ 25
IN-NETWORK BENEFITS ................................................................................................................................................... 25
In-Network Copayments ....................................................................................................................................................... 26
Annual In-Network Coinsurance ........................................................................................................................................... 26
Annual In-Network Coinsurance Limit .................................................................................................................................. 26
Annual In-Network Out-of-Pocket Maximum ....................................................................................................................... 27
Active Employee Annual In-Network Out-of-Pocket Maximum ............................................................................................ 27
Retirees’ Annual In-Network Out-of-Pocket Maximum ........................................................................................................ 27
OUT-OF-NETWORK BENEFITS .......................................................................................................................................... 27
Out-of-Network Deductible .................................................................................................................................................. 28
Deductible Examples ..................................................................................................................................... 28
Out-of-Network Inpatient Deductible .................................................................................................................................. 29
Out-of-Network Coinsurance ................................................................................................................................................ 29
Out-of-Network Out-of-Pocket Maximum ............................................................................................................................ 29
COORDINATION OF BENEFITS ........................................................................................................................................... 30
GENERAL BENEFITS ......................................................................................................................................................... 31
Acupuncture ........................................................................................................................................................................ 31
Alcohol and Substance Abuse Treatment ............................................................................................................................. 31
Ambulance ........................................................................................................................................................................... 31
Audiology Services ............................................................................................................................................................... 32
Autism or OtherDevelopmental Disability ........................................................................................................................... 32
2
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Automobile-Related Injuries ................................................................................................................................................. 32
SEHBPMEMBER GUIDEBOOK
3
Biofeedback ......................................................................................................................................................................... 33
Birthing Centers ................................................................................................................................................................... 33
Blood ................................................................................................................................................................................... 33
Breast Reconstruction .......................................................................................................................................................... 33
Chiropractic Services ............................................................................................................................................................ 33
Congenital Defects ............................................................................................................................................................... 33
Dental Care .......................................................................................................................................................................... 33
Diabetic Self-Management Education .................................................................................................................................. 34
Dialysis ................................................................................................................................................................................. 34
Durable Medical Equipment and Supplies ............................................................................................................................ 34
Emergency Medical Services ................................................................................................................................................ 35
Urgent and After Hours Care ................................................................................................................................................ 35
Emergency Room ................................................................................................................................................................. 35
Federal Government Hospitals ............................................................................................................................................. 35
Gender Identity- Treatment to Affirm Gender Identity ........................................................................................................ 36
Gynecological Care and Examinations ................................................................................................................................. 36
Hearing Aids ......................................................................................................................................................................... 36
Hemophilia Treatment ......................................................................................................................................................... 36
Home HealthCare ................................................................................................................................................................ 36
Hospice CareBenefits ........................................................................................................................................................... 37
Immunizations ..................................................................................................................................................................... 37
Infertility Treatment............................................................................................................................................................. 38
Eligibility Requirements .................................................................................................................................. 38
Covered Expenses include ............................................................................................................................. 38
Exclusions ..................................................................................................................................................... 39
Lead Poisoning Screening and Treatment ............................................................................................................................ 39
Lithotripsy Centers ............................................................................................................................................................... 39
Lyme Disease Intravenous Antibiotic Therapy ....................................................................................................................... 39
Mammography .................................................................................................................................................................... 39
Mastectomy Benefits ............................................................................................................................................................ 40
Maternity/Obstetrical Care .................................................................................................................................................. 40
Maternity/Obstetrical Care for Child Dependents ................................................................................................................ 40
Mental or NervousConditions ............................................................................................................................................... 40
Newborn Home Visitation Program ..................................................................................................................................... 41
Nutritional Counseling ......................................................................................................................................................... 41
Organ Transplant Benefits ................................................................................................................................................... 41
Pain Management ............................................................................................................................................................... 42
Pap Smears .......................................................................................................................................................................... 42
Patient Controlled Analgesia (PCA) ....................................................................................................................................... 42
Physical Therapy/Occupational Therapy ............................................................................................................................... 42
Pre-Admission Hospital Review(In-Network and Out-of-Network) ....................................................................................... 43
Pre-Admission TestingCharges ............................................................................................................................................ 43
Prostate Cancer Screening (In-NetworkOnly) ....................................................................................................................... 43
Scalp Hair Prostheses ........................................................................................................................................................... 43
Second Surgical Opinion ....................................................................................................................................................... 43
Shock Therapy Benefits ........................................................................................................................................................ 43
Skilled Nursing Facility Charges ............................................................................................................................................ 43
Speech Therapy Benefit ........................................................................................................................................................ 44
Substance UseDisorder Treatment ...................................................................................................................................... 44
Surgical Services (Out-of-Network) ...................................................................................................................................... 45
Telemedicine ........................................................................................................................................................................ 46
Temporomandibular Joint Disorder (TMJ) and Mouth Conditions ......................................................................................... 46
Vision Care Benefits ............................................................................................................................................................. 46
Examples of Non-Covered Services ............................................................................................................... 52
4
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
RecoveryRight ...................................................................................................................................................................... 53
Submitting a Claim (In-Network) .......................................................................................................................................... 54
Submitting a Claim (Out-of-Network) .................................................................................................................................. 54
Filing Deadline (Proof of Loss) .............................................................................................................................................. 54
Itemized Bills are Necessary ................................................................................................................................................. 54
Foreign Claims ..................................................................................................................................................................... 55
Filling Out the Claim Form ................................................................................................................................................... 55
APPEALPROCEDURES ..................................................................................................................................................... 55
First Level Medical Appeal ............................................................................................................................. 56
Expedited Review (excluding appeals related to substance use disorder) ....................................................... 56
Second Level Medical Appeals (excluding certain appeals related to substance use disorder) ............................................ 57
Expedited Review of Second Level Medical Appeals (excluding appeals related to substance use disorder). 57
EXTERNAL APPEAL RIGHTS ................................................................................................................................................... 58
Standard External Appeals (excluding appeals related to substance use disorder) .......................................... 58
APPEAL RIGHTS EXCLUSIVE TO SUBSTANCE USE DISORDER ................................................................................................. 59
Substance Use Disorder First Level Appeal.................................................................................................... 59
Substance Use Disorder Second Level Appeal ............................................................................................... 59
Substance Use Disorder Appeals specific to Inpatient Care after the first 28 days ........................................... 60
Commission Appeal ....................................................................................................................................... 60
First Level Administrative Appeal ................................................................................................................... 61
Second Level Administrative Appeal ............................................................................................................... 61
Commission Appeal ....................................................................................................................................... 61
PRESCRIPTIONDRUGBENEFITS ........................................................................................................................................ 62
COBRA COVERAGE ......................................................................................................................................................... 63
COBRA Events ...................................................................................................................................................................... 63
Employer Responsibilities under COBRA ............................................................................................................................... 64
Employee Responsibilities under COBRA ............................................................................................................................... 64
Failure to Elect COBRA Coverage ......................................................................................................................................... 65
Termination of COBRACoverage .......................................................................................................................................... 65
APPENDIX I .................................................................................................................................................................... 65
APPENDIX II ................................................................................................................................................................... 67
Speech Therapy .................................................................................................................................................................... 73
APPENDIX III................................................................................................................................................................... 74
APPENDIX IV .................................................................................................................................................................. 82
APPENDIX V ................................................................................................................................................................... 84
Certification of Coverage ...................................................................................................................................................... 84
HIPAA Privacy ...................................................................................................................................................................... 84
APPENDIX VI .................................................................................................................................................................. 84
Protected Health Information .............................................................................................................................................. 84
Uses and Disclosures of PHI .................................................................................................................................................. 84
Restricted Uses ..................................................................................................................................................................... 85
Member Rights ..................................................................................................................................................................... 86
Questions and Complaints ................................................................................................................................................... 87
APPENDIX VII ................................................................................................................................................................. 88
Addresses............................................................................................................................................................................. 88
Telephone Numbers ............................................................................................................................................................ 88
General Publications ............................................................................................................................................................ 90
SEHBPMEMBER GUIDEBOOK
5
Member Guidebooks ............................................................................................................................................................ 90
An online version of this guidebooks containing current updates is available for viewing at:
www.nj.gov/treasury/pensions/member-guidebooks.shtml Be sure to check the Division of
Pensions & Benefits Internet home page at: www.nj.gov/treasury/pensions for forms, fact
sheets, and news of any new developments affecting your health benefits.
6
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
INTRODUCTION
The School Employees’ Health Benefits Program (SEHBP) was established in 2007. It offers
medical and prescription drug coverage to qualified local education public employees, retirees, and
eligible dependents. Local education employers must adopt a resolution to participate in the SEHBP.
The School Employees' Health Benefits Commission (SEHBC) is the executive organization
responsible for overseeing the SEHBP. The SEHBC includes the State Treasurer, the Commissioner
of the Department of Banking and Insurance, an appointee of the Governor, an appointee from New
Jersey School Board Association, three appointees from New Jersey Education Association, an
appointee from New Jersey State AFL-CIO, and a chairperson appointed by the Governor from
nominations submitted by the other members of the commission. The Director of the Division of
Pensions & Benefits is the Secretary to the SEHBC.
The School Employees’ Health Benefits Program Act is found in the New Jersey Statutes Annota ted,
Title 52, Article 14-17.46 et seq. Rules governing the operation and administration of the programare
found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The Division of Pensions & Benefits, specifically the Health Benefits Bureau and the Bureau of
Policy and Planning, is responsible for the daily administrative activities of the SHBPand the SEHBP.
Every effort has been made to ensure the accuracy of the Member Guidebook, which describes the
benefits provided in the contract with Horizon BCBSNJ. However, State law and the New Jersey
Administrative Code govern the SHBP and SEHBP. If there are any discrepancies between the
information presented in this booklet and/or plan documents and the law, regulations, or contracts, the
law, regulations, and contracts will govern. Furthermore, if you are unsure whether a procedure is
covered, contact your plan before you receive services to avoid any denial of coverage issues
that couldresult.
If, after reading this booklet, you have any questio ns, comments, or suggestions regarding this
material, please write to the Division of Pensions & Benefits PO Box 295, Trenton, NJ 08625 -0295,
call us at (609) 292-7524, or send an e-mail to pensi[email protected]
SEHBPMEMBER GUIDEBOOK
7
HORIZON BCBSNJ MEMBER ONLINE SERVICES
Horizon Blue Cross Blue Shield of New Jersey offers you an easy, secure and quick way to track your
health plan benefits and health information online.
Simply register at www.HorizonBlue.com/SHBP to have immediate access to health plan benefits
and health information online
1
. You can:
Chat or send a secure email.
Check claims status and payments.
Read Explanation of Benefits statements, and see any amount owed.
Tell Horizon BCBSNJifyouhave other health insurancecoverage.
Use our tools and resources to understand your plan and theinsuranceprocess.
Viewand print yourmember ID card.
View your benefitinformation.
Viewyourout-of-pocket expenses, authorizations, referrals and otheraccount information.
Access NJWELL
Connect with health and wellness programs
Check your HSA transactions and funding
Find a doctor, hospital or other health care professional
Have a telemedicine visit
Learn what’s new with your Horizon coverage
1
Not all HorizonBlue.com tools and services may be compatible with ev ery electronic dev ice or available with ev ery account.
For assistance with the registration process, please contact the eService Help Desk via email at
OnlineServices_HelpDesk@HorizonBlue.com or by calling 1-888-777-5075, Monday through
Friday, 7 a.m. to 6 p.m., Eastern Time.
You can also download the Horizon Blue app free by texting GetApp to 422-272 to get all theinformation you
need in the palm of your hand. There is no charge to download the Horizon Blue app, but rates from your
wireless provider may apply.
8
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
MEMBER SERVICES
When you call the number on your SHPB/SEHBP Horizon-BCBSNJ member ID card, Member
Services can help with all your health care needs: answering questions, solving issues, helping
with claims, finding care and give you information about local services for you and your family.
They can also refer you to the case management program to support members with complex
needs or who suffer from chronic health conditions. For questions related to these issues call
Member Services at 1-800-414-SHBP (7427).
Support for your medical care when you need it
The Horizon Case Management Program helps members with chronic conditions take better
care of their health, understand their care choices and improve their health. This program is
available at no added cost to eligible members with:
• Asthma.
• Chronic Kidney Disease (CKD).
• Chronic Obstructive Pulmonary Disease (COPD).
• Coronary Artery Disease (CAD).
• Diabetes.
• Heart Failure.
For more information, visit our website, chat or call:
Visit www.HorizonBlue.com/shbp
Click Chat Monday through Friday, 8 am to 6 pm, Eastern Time. -
Call 1-800-414-SHBP (7427), Monday through Friday, 8 am to 6 pm, Eastern Time.
SEHBPMEMBER GUIDEBOOK
9
NJWELL Rewards Program
Your benefits include NJWELL, a wellness program for eligible members and their covered spouses or
partners. Eligible members earn points toward an NJWELL Mastercard® Prepaid card valued at $250 by
completing activities, including an online health assessment, a biometric health screening, online activities,
preventive screenings and coaching between November 1 and October 31 each year. Visit
NJ.gov/NJWELL or www.HorizonBlue.com/NJWELL.
My Health Manager, powered by WebMD
®
My Health Manager is your personalized health guide. You can customize it to include news feeds,
articles and reminders, plus take advantage of an online health record that gives you and your family
the ability to store, manage and maintain health information in a centralized location.
My Health Manager also features these powerful tools:
NJWELL Rewards Program: link to your NJWELL Rewards page
WebMD's Symptom Checker: Answer a few simple questions and get information on
potential causes and treatments to discuss with your physician;
Hospital Quality Comparison Tool: Review diagnosis and procedure specific quality
rankings of hospitals;
Health Assessment Tool: Take an assessment that covers your current health conditions,
family health history, vital statistics, lifestyle and life events, among other factors;
Condition Centers: Tap into enhanced risk identification and management tools for conditions
ranging from allergies and asthma to depression and diabetes;
And much more: From health measurement trackers to tailored health improvement
programs, we provide all the tools you need.
Sign in or register to get started
My Health Manager is only available to registered members, please visit HorizonBlue.com/SHBP,
or the Horizon Blue app to Register or Sign in.
You are your own best health advocate. However, to get and stay healthy, it helps to
have some guidance. That’s why we offer My Health Manager, powered by WebMD
®
.
10
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
NJ DIRECT and the New Jersey Educators Health Plan
NJ DIRECT and the New Jersey Educators Health Plan (referred to as the ‘SEHBP plans’ through
this Guidebook) are administered for the Division of Pensions & Benefits by Horizon Blue Cross
Blue Shield of New Jersey (Horizon BCBSNJ). The SEHBP plans are self-funded. Funds for the
payment of claims and services come from funds supplied by the State, participating local
employers, and members. Refer to APPENDIX VII for more information on contacting the SEHBP
plans, the Division of Pensions & Benefits, and related health services. Except where noted, the
SEHBP plans follow the same policies and parameters.
All the SEHBP plans provide both in-network and out-of-network benefits.
In-network care is provided through a network of providers that includes internists, general
practitioners, pediatricians, specialists, and hospitals. Network providers offer a full range of
services that include well care and preventive services such as annual physicals, well-
baby/well-child care, immunizations, mammograms, annual gynecological examinations, and
prostate examinations. In-network services generally provide the highest level of benefits
available under the plan. Services may be subject to a copayment, coinsurance or in -network
deductible and coinsurance. For more information, refer to the IN-NETWORK BENEFIT section
of this Guidebook.
Out-of-network benefits provide reimbursement for expenses for eligible services rendered
for the treatment of illness and injury. Most out-of-network care is reimbursed at a percentage
of the reasonable and customary allowance after an annual deductible is met. Out-of-network
inpatient hospital admissions are subject to a separate inpatient deductible per admission for
most of the SEHBP plan options. For more information refer to the OUT -OF-NETWORK
BENEFITS section of this Guidebook. You can also sign in to www.HorizonBlue.com, to
validate your specific out-of-network benefits.
HEALTH BENEFITS PROGRAM ELIGIBILITY
ACTIVE EMPLOYEE ELIGIBILITY
Eligibility for coverage is determined by the School Employees’ Health Benefits Program (SEHBP).
Enrollments, terminations, changes to coverage, etc. must be presented through your employer to
the Division of Pensions & Benefits. If you have any questions concerning eligibility provisions, you
should contact the Division of Pensions & Benefits' Office of Client Services at (609) 292-7524, or
send e-mail to: pensions[email protected]
Local Education Employees
To be eligible for the SEHBP coverage you must be a full-time employee or an appointed or elected
officer receiving a salary from the board of education that participates in the SEHBP. Each
participating employer defines the minimum hours required for full-time by a resolution filed with the
Division of Pensions & Benefits, but it can be no less than 25 hours per week or more if required by
contract or resolution. 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).
SEHBPMEMBER GUIDEBOOK
11
The following local employees are also eligible for coverage.
Local Part-Time Employees — Part-time faculty members employed by a county or community
college that participates in the SEHBP are eligible for coverage 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 retired group coverage at their own expense provided they were covered up to the date
of retirement. See the Health Benefits Coverage for Part-Time Employees Fact Sheet for more
information.
ENROLLMENT
You are not covered until you enroll in the SEHBP. You must fill out a Health Benefits Program
Application and provide all the information requested. If you do not enroll all eligible members of your
family within 60 days of the time you or they first become eligible for coverage, you must wait until the
next Open Enrollment period. Open Enrollment periods generally occur once a year, usually during
the month of October. Information about the dates of the Open Enrollment period and effective dates for
coverage is announced by the Division of Pensions & Benefits.
ELIGIBLE DEPENDENTS
Your eligible dependents are your spouse, civil union partner or eligible same-sex domestic partner,
and your eligible children (as defined below).
Spouse — A person to whom you are legally married. A photocopy of the marriage certificate and
additional supporting documentation are required for enrollment.
Civil Union Partner — A person of the same sex with whom you have entered into a civil union. A
photocopy of the New Jersey Civil Union Certificate or a valid certification from another jurisdiction
that recognizes same-sex civil unions and additional supporting documentation are required for
enrollment. The cost of a civil union partner's coverage may be subject to federal tax (see your
employer or the Civil Unions and Domestic Partnerships Fact Sheet for details).
Domestic Partner — A person of the same sex with whom you have entered into a domestic
partnership as defined under Chapter 246, P.L. 2003, the Domestic Partnership Act. The domestic
partner of any State employee, State retiree, or an eligible empl oye e or retiree of a particip ati ng local public
entity that adopts a resolution to provide Chapter 246 health benefits, is eligible for coverage. A
photocopy of the New Jersey Certificate of Domestic Partnership dated prior to February 19, 2007(or
a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic
partners) and additional supporting documentation are required for enrollment. The cost of same-sex
domestic partner coverage may be subject to federal tax (see your employer or the Civil Unions and
Domestic Partnerships Fact Sheet for details).
Children — In compliance with the federal Patient Protection and Affordable Care Act (PPACA),
coverage is extended for children until age 26. This includes natural children under age 26 regardless
of the child’s marital, student, or financial dependency status. A photocopy of the child’s birth
certificate that includes the covered parent’s name is required for enrollment. (Non-custodial parents,
refer to the REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND
ENROLLMENT section of this Guidebook).
12
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
For a stepchild provide a photocopy of the child’s birth certificate showing the spouse/partner’s name
as a parent and a photocopy of marriage/partnership certificate showing the names of the
employee/retiree and spouse/partner.
Foster children and children in a guardian-ward relationship under age 26 are also eligible. A
photocopy of the child’s birth certificate and additional supporting legal documentation are required
with enrollment forms for these cases. Documents must attest to the legal guardianship by the covered
employee.
Refer to the REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND
ENROLLMENT section of this Guidebook.
Coverage for an enrolled child ends on December 31 of the year in which he or she turns age 26. See
the “COBRA” section, “Dependent Children with Disabilities” and “Over Age Children Until Age 31”
section of this Guidebook for continuation of coverage provisions.
Dependent Children with Disabilities — If a child is not capable of self-support when he or she
reaches age 26 due to mental illness, or developmental or 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 & Benefits, Health Benefits Bureau, 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 26, 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 or SEHBP, 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.
Over Age Children Until Age 31 — Certain children over age 26 may be eligible for coverage until
age 31 under the provisions of Chapter 375, P.L. 2005, as amended by Chapter 38, P.L. 2008. This
includes a child by blood or law who: is under the age of 31; is unmarried; has no dependent(s) of his
or her own; is a resident of New Jersey or is a full-time student at an accredited public or private
institution of higher education; and is not provided coverage as a subscriber, insured, enrollee, or
covered person under a group or individual health benefits plan, church plan, or entitled to benefits
under Medicare.
Under Chapter 375, an over age child does not have any choice in the selection of benefits but is
enrolled for coverage in exactly the same plan or plans (medical and/or prescription drug) that the
covered parent has selected. The covered parent or child is responsible for the entire cost of
coverage. There is no provision for dental or vision benefits.
Coverage for an enrolled over age child will end when the child no longer meets any one of the
eligibility requirements or if the required payment is not received. Coverage will also end when the
covered parent’s coverage ends. Coverage ends on the first of the month following the event that
makes the dependent ineligible or up until the paid through date in the case of non-payment. See the
Health Benefits Coverage of Children until Age 31 under Chapter 375 Fact Sheet for details.
SEHBPMEMBER GUIDEBOOK
13
SUPPORTING DOCUMENTATION REQUIRED FOR ENROLLMENT OF
DEPENDENT
The SEHBP is required to ensure that only eligible employees and retirees, and their dependents,
are receiving health care coverage under the program. Employees or retirees who enroll dependents
for coverage (spouses, civil union partners, domestic partners, children, disabled dependents, and
over age children continuing coverage) must submit supporting documentation in addition to the
enrollment application. For more information about the documentation a member must provide when
enrolling a new dependent for coverage, please refer to the REQUIRED DOCUMENTATION FOR
DEPENDENT ELIGIBILITY AND ENROLLMENT section of this Guidebook.
AUDIT OF DEPENDENT COVERAGE
Periodically, the Division of Pensions & Benefits performs an audit using a random sample of
members to determine if enrolled dependents are eligible under plan provisions. Proof of dependency
such as a marriage, civil union, or birth certificates, or tax returns are required. Coverage for ineligible
dependents will be terminated. Failure to respond to the audit will result in the termination of ALL
coverage and may include financial restitution for claims paid. Members who are found to have
intentionally enrolled an ineligible person for coverage will be prosecuted to the fullest extent of the
law.
MULTIPLE COVERAGE UNDER THE SHBP/SEHBP IS PROHIBITED
State statute specifically prohibits two members who are each enrolled in SHBP/SEHBP plans from
covering each other. Therefore, an eligible individual may only enroll in the SHBP/SEHBP as an
employee or retiree, or be covered as a dependent.
Eligible children may only be covered by one participating subscriber.
For example, a husband and wife both have coverage based on their employment and have children
eligible for coverage. One may choose Family coverage, making the spouse and children the
dependents and ineligible for any other SHBP/SEHBP coverage; or one may choose Single coverage
and the spouse may choose Parent and Child(ren) coverag e.
MEDICARE COVERAGE WHILE EMPLOYED
In general, it is not necessary for a Medicare-eligible employee, spouse, civil union or domestic
partner, or dependent child(ren) to be covered by Medicare while the employee remains actively at
work. However, if you or your dependents become eligible for Medicare due to End Stage Renal
Disease (ESRD), and the 30-month coordination of benefits period has ended, 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, below.
14
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
RETIREE ELIGIBILITY
The following individuals will be offered SEHBP Retired Group coverage for themselves and their
eligible dependents:
Full-time members of the Teachers' Pension and Annuity Fund (TPAF) and school board or
county college employees enrolled in the Public Employees' Retirement System (PERS) who
retire with less than 25 years of service credit from an employer that participates in the SEHBP;
Full-time members of the TPAF and school board or county college employees enrolled in the
PERS who retire with 25 years or more of service credit in one or more State or locally-
administered retirement systems or who retire on a disability retirement, even if their employer
did not cover its employees under the SEHBP. This includes those who elect to defer
retirement with 25 or more years of service credit in one or more State or locally-administered
retirement systems (see “Aggregate of Pension Membership Service Credit” below);
Full-time members of the TPAF or PERS who retire from a board of education,
vocational/technical school, or special services commission; maintain particip ation in the
health benefits plan of their former employer; and are eligible for and enrolled in Medicare
Parts A and B. A qualified retiree may enroll at retirement or when he or she becomes eligible
for Medicare;
Participants in the Alternate Benefit Program (ABP) eligible for the SEHBP who retire with at
least 25 years of credited ABP service or those who are on a long-term disability and begin
receiving a monthly lifetime annuity immediately following termination of employment; and
Part-time faculty at institutions of higher education that participate in the SEHBP if enrolled in
the SEHBP at the time of retirement.
Eligibility for SEHBP membership for the individuals listed in this section is contingent upon
meeting two conditions:
1. You must be immediately eligible for a retirement allowance from a locally -administered
retirement system (except certain employees retiring from a school board or community
college); and
2. You were a full-time employee and eligible for employer-paid medical coverage immediately
preceding the effective date of your retirement (if you are an employee retiring from a school
board with 25 or more years of service, you must have been eligible at the time you terminated
your employment), or a part-time State employee or part-time faculty member who is enrolled
in the SEHBP immediately preceding the effective date of your retirement.
This means that if you allow your active coverage to lapse (i.e. because of a leave of absence,
reduction in hours, or termination of employment) prior to your retirement or you defer your retirement
for any length of time after leaving employment, you will lose your eligibility for Retired Group health
coverage. This does not include former full-time employees enrolled in TPAF and PERS board of
education or county college who retire with 25 or more years of service.
Note: If you continue group coverage through COBRA (see the “COBRA” of this Guidebook) — or as a
dependent under othercoverage through a public employer— until your retirement becomes effective, you will
be eligible for retired coverage under the SEHBP.
Otherwise qualified employees whose coverage is terminated prior to retirement but who are later
approved for a disability retirement will be eligible for Retired Group coverage 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.
SEHBPMEMBER GUIDEBOOK
15
Aggregate of Pension Membership Service Credit
Upon retirement, a full-time, board of education employee, who has 25 years or more of service credit,
is eligible for State-paid health benefits under the SEHBP, subject to the applicable retiree
contribution, if any.
A retiree eligible for the SEHBP 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 non-concurrent.
For PERS or TPAF members, Out-of-State Service, U.S. Government Service, or service with a bi-
state or multi-state agency, requested for purchase after November 1, 2008, cannot be used to qualify
for any State-paid or employer-paid health benefits in retirement.
Eligible Dependents of Retirees
Dependent eligibility rules for Retired Group coverage are the same as for Active Group coverage
except for Chapter 334 domestic partners (described below) and the Medicare requirements (see
below). Chapter 334, P.L. 2005, provides that retirees from local entities (municipalities, counties,
boards of education, and county colleges) whose employers do not participate in the SHBP or
SEHBP, but who become eligible for SHBP or SEHBP coverage at retirement, may also enroll a
registered same-sex domestic partner as a covered dependent provided that the former employer’s
plan includes domestic partner coverage for employees. (Please refer to the RETIREE ELIGIBILITY
section of this Guidebook.)
Multiple Coverage under the SHBP/SEHBP is prohibited
State statute specifically prohibits two members who are each enrolled in SHBP/SEHBP plans from
covering each other. Therefore, an eligible individual may only enroll in the SHBP/SEHBP as an
employee or retiree, or be covered as a dependent.
Eligible children may only be covered by one participating subscriber.
For example, a husband and wife both have coverage based on their employment and have
children eligible for coverage. One may choose Family coverage, making the spouse and children
the dependents and ineligible for any other SHBP/SEHBP coverage; or one may choose Single
coverage and the spouse may choose Parent and Child(ren) coverage.
Enrolling in Retired Group Coverage
The Health Benefits Bureau is notified when you file an application for retirement with the Division of
Pensions & Benefits. If eligible, you will receive a letter inviting you to enroll in Retired Group
coverage. Early filing for retirement is recommended to prevent any lapse of coverage or delay of
eligibility.
If you do not submit a Retired Coverage Enrollment Application at the time of retirement, you will not
generally be permitted to enroll for coverage at a later date. See the Health Benefits Coverage –
Enrolling as a Retiree Fact Sheet for more information.
If you believe you are eligible for Retired Group coverage and do not receive an offering letter by the
date of your retirement, please contact the Division of Pensions & Benefits, Office of Client Services
at (609) 292-7524 or send an e-mail to pensions.[email protected]
Additional restrictions and/or requirements may apply when enrolling for Retired Group
coverage. Be sure to carefully read the “Retiree Enrollment” section of the Summary Program
Description.
16
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
MEDICARE COVERAGE
Medicare Parts A and B
IMPORTANT: A Retired Group member and/or dependent spouse, civil union partner, eligible same-
sexdomestic partner, or child who is 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
remainin SEHBP Retired Group coverage.
You will be required to submit documented evidence of enrollment in Medicare Part A and Part B when
you or your dependent becomes eligible for that coverage. Acceptable documentation includes a
photocopy of the Medicare card showing both Part A and Part B enrollment, or a letter from Medicare
indicating the effective dates of both Part A and Part B coverage. Send your evidence of enrollment to
the Health Benefits Bureau, Division of Pensions & Benefits, P.O. 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 Part A
and Part B, you and/or your dependents will be terminated from coverage. Upon submission of proof of
full Medicare coverage, your Retired Group coverage will be reinstated by the Health Benefits Bureau
on a prospective basis.
IMPORTANT: When coordinating benefits with Medicare, the secondary benefit under the SEHBP planis
supplemental to the Medicare payment. The SEHBP plan will consider the remaining Medicare
coinsurance and deductible as the allowable expense and apply the applicable copayments,
coinsurance, or deductible when appropriate. If a provider is not registered with or opts out of Medicare,
no benefits are payable under the SEHBP for the provider’s services, the charges would not be
considered under the medical plan, and the member will be responsible for the charges.
Medicare Part D
If you are enrolled in the Retired Group of the SEHBP and eligible for Medicare, you will be automatically
enrolled in Medicare Part D and the OptumRx Medicare Prescription Drug Plan.
Important: If you decide not to be enrolled in the OptumRx Medicare Prescription Drug Plan, you will
lose your prescription drug benefits provided by the SEHBP. In order to waive the OptumRx Medicare
Prescription Drug Plan, you must enroll in another Medicare Part D plan. To request that you not be
enrolled, you must submit proof of other Medicare Part D coverage to the Division of Pensions &
Benefits.
Medicare Eligibility
In most cases, a Retired Group member and/or dependent should enroll in Medicare Part A and Part B
coverage as soon as they become eligible. Otherwise, an individual can only enroll during Medicare’s
annual “General Enrollment Period” (January 1 through March 31) and late enrollment penalties may
apply (visit www.medicare.gov or contact Medicare at 1-800-633-4227 for more information).
A member may be eligible for Medicare for the following reasons:
Medicare EligibilitybyReason of Turning Age 65
A member (the retiree or covered spouse/partner) is considered to be eligible for Medicare by
reason of age fromthe 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 that is immediately prior to his/her 65th birthday.
SEHBPMEMBER GUIDEBOOK
17
The retired group health plan is the secondary payer;
Medicare Eligibility by Reason of Disability:
A member (the retiree or covered spouse/partner or dependent) who is under age 65 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 payer; or
Medicare EligibilitybyReasons of End Stage Renal Disease (ESRD)
A member usually becomes eligible for Medicare at age 65 or upon receiving Social Security
Disability benefits for two years. A member (the retiree or covered spouse/partner or
dependent) who is not eligible for Medicare because of age or disability may qualify because
of treatment for ESRD. When a person is eligible for Medicare due to ESRD, Medicare is the
secondary payer when:
The individual has group health coverage of their own or through a family member
(including a spouse/partner); or
The group health coverage is from either a current employer or a former employer. The
employer may be of any size (not limited to employers with more than 20 employees).
The rules listed below are known as the Medicare Secondary Payer (MSP) rules and are federal
regulations that determine whether Medicare pays first or second to the group health plan. Theserules
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 "coordi n ati o n
of
benefi ts"
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 payer. For members who became eligible for Medicare due solely to ESRD, 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. If you are eligible for Medicare by reason of ESRD and Medicare
is primary, you must enroll in Medicare A and B and submit proof of enrollment to the SEHBP. If you
do not enroll in Medicare A and B before the end of the coordination of benefits period, your SEHBP
coverage will be terminated. It is your responsibility to ensure that you file your application for Medicare
so that the Medicare effective date is on or before the date that the coordination of benefits period
ends.
18
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Dual Medicare Eligibility
When the member is eligible for Medicare because of age or disability and then becomes eligible for
Medicare because of ESRD:
If the health plan is primary because the member has active employment status, then the
group health plan continues to be primary for 30 months from the date of dual Medicare
entitlement; or
If the health plan is secondary because the member is not actively employed, then the
health plan continues to be the secondary payer. There is no 30-month coordination
period.
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:
You should provide the physician or provider with your identification number. This number
should be written on the Medicare Request for Payment (claim form) under "Other Health
Insurance;"
The physician or provider will then submit the Medicare Request for Payment to the
Medicare Part B carrier;
After Medicare has taken action, you will receive an Explanation of Benefits statement from
Medicare;
If the remarks section of the Explanation of Benefits contains the following statement, you
need not take any action: "This information has been forwarded to the Plan for their
consideration in processing supplementary coverage benefits;
If the statement shown above does not appear on the Explanation of Benefits, you should indicate
your SEHBP plan identification number and the name and address of the physician or provider in
the remarks section of the Explanation of Benefits with a completed claim form and send it to the
address on the claim form.
Out-Of-State
Physicians
or Providers:
The Medicare Request for Payment form should be submitted to the Medicare Part B carrier
in the area where services were performed. Call your local Social Security office for
information;
When you receive the Explanation of Benefits, indicate your identification number and the
name and address of the physician or provider in the Explanation of Benefits with a
completed claim form to the address on the claim form.
Retirees Enrolled in Medicare Who Move Outside the United States
Members who reside outside the United States must still maintain their Medicare coverage (Part A
and Part B) in order to be covered under Retired Group coverage; however, Medicare does not
cover services outside the United States. For members who reside outside the United States, the
SEHBP plan covers services as if the plan was primary.
Members, who reside outside the United States, even if they reside in a country with a national
health plan, should consider that if they travel outside their country of residence they will still need
coverage. In order to have coverage at any time in the future, the member must stay enrolled in the
SEHBP, since once a member terminates coverage they will not be reinstated.
SEHBPMEMBER GUIDEBOOK
19
GENERAL CONDITIONS OF THE PLAN
All benefits listed in this guidebook may be subject to limitations and exclusions as described in
subsequent sections. All pertinent parts of this guidebook should be consulted regarding a specific
benefit.
Even though a service or supply may not be described or listed in this guidebook, that does
not mean the service or supply is eligible for benefits under the SEHBP plans.
SEHBP plans will pay only for eligible services or supplies that meet the following conditions:
Are medically needed at the appropriate level of care (see below) for the medical condition.
(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.);
Are listed in the “Eligible Services and Supplies” section of this Guidebook;
Are ordered by an eligible provider for treatment of illness or injury;
Were provided while you or your eligible covered dependents were covered by a SEHBP
plan; and
Are not specifically excluded (listed in the “Charges Not Covered by the SEHBP plans”
section of this Guidebook).
When you use an out-of-network provider, all eligible services, supplies, tests, etc. prescribed by your
provider, including hospitalization, are reimbursed at a percentage of the reasonable and customary
allowance after deductibles and coinsurance have been met. The member is responsible for any
amount charged by the physician that is above and beyond the reasonable and customary allowance
in addition to deductibles and coinsurance.
Medical Need and Appropriate Level of Care
The medical need and appropriate level of care for any service or supply is determined by Horizon
BCBSNJ and must meet each of these requirements:
It is ordered by an eligible provider for the diagnosis or the treatment of an illness or injury;
The prevailing opinion within the appropriate specialty of the United States medical profession
is that it is safe and effective for its intended use; and
That it is the most appropriate level of service or supply considering the potential benefits and
possible harmto the patient.
Please refer to the “Experimental or Investigational Treatments” section of this Guidebook.
Health Care Fraud
Health care fraud is an intentional deception or misrepresentation that results in an unauthorized
benefit to a member or to some other person. Any individual who willfully and knowingly engages in
an activity intended to defraud the SEHBP will face disciplinary action that could include ter mination
of employment and may result in prosecution. Any member who receives monies fraudulently from a
health plan will be required to fully reimburse the plan.
20
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
PRECERTIFICATION OF BENEFITS
IN-NETWORK AND OUT-OF-NETWORK
A precertification is required for certain services and all inpatient admissions, excluding certain
admissions for treatment of substance use disorders in the first 180 days of the plan year. Failure to
obtain a precertification may result in benefits being denied. Participa ting physicians and hospitals
will obtain precertification on your behalf. Horizon BCBSNJ will conduct a review of any services that
were not precertified to determine eligibility. If you do not obtain precertification, payment may not be
made for services that are determined to be not medically appropriate.
SERVICES REQUIRING PRECERTIFICATION
Accidental Dental Injuries
Air Ambulance
Alcohol and Substance Abuse Specialty Services - See Substance Use Disorder Specialty
Services.
Applied Behavioral Analysis (ABA)
Cancer Clinical Trials
Durable Medical Equipment (DME) (see examples below)
Electric,
customized
or
motori zed
wheelch airs
and
scooters,
and
powered
accessori es;
Electric beds/Clinitron/powered hospital beds/air mattresses/powered accessories;
Enteral
formul a;
Bone stimulators;
Neurostimulators;
Lymphedema pumps;
External defibrillators;
Inpatient Admissions, including:
All acute care confinements, exclusive of maternities, including:
Surgical
admissi ons;
Medical
admissi ons;
Hospice
admissi on;
and
All Skilled
Nursing
Facility
(SNF)
confinem ents;
All Rehabilitation Facility confinements;
All
Sub-Acute
confinem ents;
and
Mental health and substance use disorder confinements including Residential, Partial
Hospitalizations, and Intensive Out-Patient Admissions.(See UTILIZATION MANAGEMENT)
SEHBPMEMBER GUIDEBOOK
21
Home Health Care Services
Home Hospice Services
Hyperbaric Oxygen Therapy
Infertility Services, including:
Gamete intrafallopian transfer;
In
vitro
fertilizati on;
Zygote intrafallopiantransfer;
Artificial
insemi nati on;
and
Hysterosalpingography.
Home Infusion (IV) Therapy
Lyme Disease Intravenous Antibiotic Therapy
Mental Health Specialty Services, including:
All Mental Health Confinements(including Residential, Partial Hospitalizations, and Intensive Out-
Patient Admissions;
Biofeedback.
Specific Medications administered in a physician's office or dialysis facility (review performed
by eviCore National)
Aranesp;
Epogen; and
Procrit.
Pain Management (Refer to the Pain Management section of this Guidebook for additional details.)
Private Duty Nursing in the Home (Inpatient PDN is ineligible)
Radiology (review services performed by eviCore)
CT/CTA Scans;
MRI/MRA;
Nuclear Medicine/Nuclear Cardiology;
PET and PET/CT Scans;
Echo Stress Tests; and
Diagnostic Left Heart Catheterization.
22
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Reconstructive Procedures that may be considered Cosmetic
Blepharoplasty/Canthopexy/Canthoplasty;
Excision
of
excessive
skin
due
to
weight
loss;
Rhinoplasty/rhytidectomy;
Pectus excavatum repair;
Breast reconstruction/enlargement;
Breast reduction/mammoplasty;
Lipectomy or excess fat removal;
Sclerotherapy or surgery for varicose veins;
Facial reconstruction or repairincluding:
Orthognathi c
surgery;
Bone grafts;
Osteotomies;
Surgical
manage me nt
of
temporom andi bul ar
joint;
Any other potentially cosmetic procedure.
Specialty Pharmaceuticals
Spinal Disk Surgeries, including but not limited to:
Percutaneo us
Laser
Discectomy;
Nucleoplasty; and
Spinal Fusion.
Substance Use Disorder Specialty Services:
All substance use disorder confinements, including residential and partial hospitalization
admissions (See UTILIZATION MANAGEMENT);
Intensive
Outpati ent
(IOP)
Treatment;
and
Office
Based
Opioid
Treatm ent
(OBOT)
Surgery for Morbid Obesity including but not limited to:
Gastroplasty;
Gastric Bypass; and
Bariatric
Procedures.
Therapy Services
Cognitive Therapy;
Occupational Therapy;
Physical Therapy; and
Speech Therapy.
Transplants
Lung;
Liver;
Heart;
Pancreas;
Autologo us
Bone
Marrow;
Cornea;
Kidney;
Autologous Chondrocyte Transplants; and
Uvulopal
atopharyngopl
asty
(UPPP).
SEHBPMEMBER GUIDEBOOK
23
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 & Benefits about coverage does not
constitute a predetermination of benefits. If the actual services rendered differ from those described
in the written request, the predetermi nati on of benefits will have no effect. A predetermi nati on is val i d
for one year from the date issued. All requests for written predeterminations must include all necessary
medical documentation and must be presented to Horizon BCBSNJ three to four weeks prior to the
services being rendered. If Horizon BCBSNJ requires additional medical information, the written
response may bedelayed.
UTILIZATION
MANAGEMENT
Medical Management and Review
Both in-network and out-of-network treatment is subject to Utilization Management (UM), a process
used to ensure that treatment is medically needed and provided at the appropriatelevel of care. When
the treatment is proposed by an in-network provider, the provider is responsible for the UM contact.
Benefits are payable for in-network treatment when they are provided by an in-network provider, the
UM organization has been notified to review the treatment, and the UM organization has approved
the treatment.
Out-of-network benefits that are actually payable will also depend on whether the patient or patient's
provider has or has not contacted the UM organi zati o n in regard to propose d medical treatment and
whether the UM organization agrees that the treatment is needed and at the appropriate level of care.
If the member is utilizing a non-participating physician, they should request their non-participating
physician to contact Utilization Management at the number listed on their ID card (1-800-664-2583).
If a member calls this number to request precertification, the UM organization’s Precertification
Department will request the phone number of the physician and will contact the physician to obtain the
clinical information needed in orderto reviewthe services requested.
For out-of-network benefits when the patient or physician has failed to contact the UM organization
at Horizon BCBSNJ, treatment will be considered not certified and expenses will not be applied to the
annual out-of-pocket maximum. However, if the treatment is ultimately determined to be eligible,
reimbursement will be made at the appropriate percentage of reasonable and customary allowances
after any deductible has been met.
REASONABLE AND CUSTOMARY ALLOWANCES
(For Out-of-Network Services)
Except where noted, the SEHBP plans cover only reasonable and customary allowances, which are
determined by a percentile of the FAIR Health national benchmark charge data or other nationally
recognized database. This schedule is based on actual charges by physicians nationally for a specific
service. In other instances, such as Ambulatory Surgery Centers (ASC’s) and the NJ Educators Health
Plan, the out-of-network allowance is derived froman alternatenationally recognized source; it’s based
on a percentage of the Centers for Medicare and Medicaid Services (CMS) allowance.
Sign into the Horizon-BCBSNJ member online services, www.HorizonBlue.com, to validate your
specific out-of-network benefits.
Please see the Out-of-Network allowance for all plans.
24
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
SEHBP Plan Option
Out-of-Network Allowance
NJ DIRECT10
90
th
Percentile of FAIR Health national
NJ DIRECT15
benchmark
NJ DIRECT1525*
NJ DIRECT2030*
NJ Educators Health Plan
200% of CMS
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select
oneof these twoplans as supplemental to Medicare.
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.
SEHBPMEMBER GUIDEBOOK
25
Admissions for the Treatment of Substance Use Disorder (for Network Service Only)
This section applies during the first 180 days of treatment per year whether the treatment is
inpatient or outpatient. Thereafter, inpatient treatment of substance use disorder is subject to
the above provisions governi ng hospital and other facility admissions.
If a member is admitted to facility for the treatment of substance use disorder, whether for a
scheduled admission or for an emergency admission, the facility must notify Horizon BCBSNJ
of the admission and initial treatment plan within 48 hours of the admission.
Horizon BCBSNJ will not initiate continued stay review, also known as concurrent review, with
respect to the first 28 days of the inpatient stay. Continued stay review may be required for
any subsequent days, but not more frequently than at two-week intervals. If Horizon BCBSNJ
determines continued stay is no longer a Medical Need and Appropriate Level of Care, Horizon
BCBSNJ shall provide written notice within 24 hours to the member and his or her provider
along with informati on regardin g appeal rights.
Experimental or Investigational Treatments
The SEHBP plans do not cover treatment that is considered experimental or investigational. Charges
in connection with such a service or supply are also not covered, except in the case of anapproved
clinical trial. For the purpose of this exclusion, a service or supply will be considered experimental
or investigational if Horizon BCBSNJ determines that one or more of the following is true.
1. The service or supply is under study or in a clinical trial to evaluate its toxicity, safety, or
efficacy for a particular diagnosis or set of indications. Clinical trials include but are not limited
to phase I, II, and III clinical trials, with the exception of approved cancer trials.
2. The prevailing opinion within the appropriate specialty of the United States medical profession
is that the service or supply needs further evaluation for a particular diagnosis or set of
indications before it is used outside clinical trials or other research settings. Horizon BCBSNJ
will determine this based on:
Published reports in authoritative medical literature; and
Regulations, reports, publications, and evaluations issued by US Government agencies
such as the Agency for Health Care Research and Quality, the National Institutes of
Health, and the federal Food and Drug Administration (FDA).
3. The provider's institutional review board acknowledges that the use of the service or supply is
experimental or investigational and subject to that board's approval.
4. The provider's institutional review board requires that the patient, parent, or guardian give an
informed consent stating that the service or supply is experimental or investigational, part of
a research project or study, or federal lawrequires such consent.
5. Research protocols indicate that the service or supply is experimental or investigational. This
item applies for protocols used by the patient's provider as well as for protocols used by other
providers studying substantially the same service or supply.
6. The service or supply is not recognized by the prevailing opinion within the appropriate medical
specialty as an effective treatment for the particular diagnosis or set of indications.
26
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
7. Additionally, if it is a drug, device, or other supply that is subject to FDA approval it will be
considered experimental and investigational if it:
Does not have FDA approval for sale and use in the United States (that is, for introducti on into
and distribution in interstate commerce); or
Has FDA approval only under the Treatment Investigational New Drug regulation or a
similar regulation; or
Has FDA approval, but is being used for an indication or at a dosa ge that is not an
acceptable off-label use. Horizon BCBSNJ will determine if a certain use is an accepted
off-label use based on published reports in peer-reviewed, authoritative medical literature
and entries in the following drug compendia: The American Medical Association Drug
Evaluations, the American Hospital Formulary Service Drug Information, and the United
States Pharmacopoeia Dispensing Information.
SEHBP BENEFITS
IN-NETWORK BENEFITS
You can benefit most from the SEHBP plans when you obtain your care from in-network providers.
Members have lower out-of-pocket costs when using in-network doctors and facilities or the BlueCard®
PPO network nationwide. As a Blue Cross and Blue Shield member, you take your healthcare benefits with
you when you are abroad. Throughthe Blue Cross Blue Shield Global Core program, you have access to
doctors and hospitals around the world. If you use out-of-network professionals or facilities, your out-of-
network costs may be higher.
In-network care is provided through a network of providers that includes internists, general practitioners,
specialists, pediatricians, and hospitals. No referrals are needed for visits to a specialist. If the physician
participates in the Horizon BCBSNJ Managed Care Network or the BlueCard® PPO network nationwide
or Horizon Care Online eligible services will be covered at the in- network level ofbenefits.
In-network hospital admissions are covered in full for most SEHBP plan options. If the physician does not
participate in the Horizon BCBSNJ Managed Care Network or the national network, the services will be
considered out-of-network. Contact your doctor to see if he or she participates in the Horizon BCBSNJ
Managed Care or national network.
To find current participating physicians in New Jersey contact Horizon BCBSNJ directly at 1-800-414-
SHBP(7427) or visit: www.horizonblue.com/shbp
SEHBPMEMBER GUIDEBOOK
27
In-Network Copayments
The SEHBP plans will pay, in most cases, the full cost after the copayment for physician office visits.
Copayments apply to in-network provider office visits, unless otherwise indicated, and vary by plan
option as outlined below:
SEHBP
Plan Option
PrimaryCare Office
Visit Copayment
Specialist Office Visit
Copayment
NJ Educators Health
Plan
$10
$15
NJ DIRECT10
$10
$10
NJ DIRECT15
$15
$15
NJ DIRECT1525
$15
$25
NJ DIRECT2030
$20
$30 for adults;
$20 for children to the end of
calendar year the child turns 26
The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select
oneof these twoplans as supplemental to Medicare.
Annual In-Network Coinsurance
For the NJ Educators Health Plan, NJ DIRECT10, NJ DIRECT15, NJ DIRECT1525 and NJ
DIRECT2030, select in-network services require the member to pay ten percent coinsurance instead
of a copayment until the in-network coinsurance limit is reached. In-network services and benefits
requiring coinsurance are durable medical equipment, ambulance transport, oxygen therapy,
outpatient private duty nursing, and some Prosthetics. In-network coinsurance paid by the member
is applied to the in- network coinsurance limit.
Annual In-Network Coinsurance Limit
Once the member reaches the in-network coinsurance limit (shown below), the SEHBP plans will pay
100 percent of the cost of covered in-network services that are subject to coinsurance for the balance
of the plan year.
SEHBP
Plan Option
Individual In-network
Coinsurance Limit
Family In-network
Coinsurance Limit
NJ DIRECT10 NJ
DIRECT15 NJ
DIRECT1525
$400
$1,000
NJ Educators Health Plan
$500
$1,000
NJ DIRECT2030
$800
$2,000
The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY availableto retirees that areMedicare eligible and select one
of these twoplans as supplemental to Medicare.
28
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Annual In-Network Out-of-Pocket Maximum
The Annual In-Network Out-of-Pocket maximum is the annual limit on the amount of cost-sharing
individuals or families are required to pay for covered in network health care expenses. In -network
copayments and coinsurance apply toward the annual in-network out-of-pocket maximum.
Active Employee Annual In-Network Out-of-Pocket Maximum
SEHBP
Plan Option
Individual In-network
Maximum Out-of-Pocket
Family In-network
Maximum Out-of-Pocket
NJ DIRECT10
$400
$1,000
NJ Educators Health Plan
$500
$1,000
NJ DIRECT15
$7,560
$15,120
Retirees’ Annual In-Network Out-of-Pocket Maximum
SEHBP
Plan Option
Individual In-Network
Maximum Out-of-Pocket
Family In-Network
Maximum Out-of-Pocket
NJ Educators Health Plan
$500
$1,000
NJ DIRECT1525
NJ DIRECT2030
$$8,03
9
$16,078
Note: The NJ Educators Health Plan is ONLYoffered to early retirees. The NJ DIRECT1525 and NJ DIRECT2030 Plans
areONLYoffered toMedicare eligible retirees thatselectoneofthese plansassupplemental toMedicare.
OUT-OF-NETWORK BENEFITS
SEHBP plans include an option for using out-of-network providers for services except most well-care,
routine/preventive and lab services. When you exercise this out-of-network option, you will be
responsible for deductibles, coinsurance based on the reasonable and customary fee schedule, and
any amount exceeding the reasonable and customary allowances for all services.
The out-of-network determination is based on the participating status of the provider such as the
physician, specialist, therapist, hospital/facility rendering the service. For example, if you utilize a non-
participating doctor and services are provided at an in-network hospital, the doctor will be paid at the
out-of-network level and the hospital will be paid at the in-network level.
If you do not contact your plan for prior certification for selected services, your claims may be paid at
the out-of-network level of benefits, if the services are deemed to be medically appropriate, and the
amount that you are required to pay will not apply to the out-of-network maximums. Please refer to
the SERVICES REQUIRING PRECERTIFICATION section of this Guidebook for additional
information.
SEHBPMEMBER GUIDEBOOK
29
Out-of-Network Deductible
The annual out-of-network deductible is the amount that the individual or family must meet before
covered out-of-network charges are paid by the plan. As shown below, the out-of-network deductible
varies depending on the plan option selected.
SEHBP
Plan Option
Individual Out-of-Network
Deductible
Family Out-of-Network
Deductible
NJ Educators
Health Plan
$350
$700 in total for all, but no more
than $350 per person
NJ DIRECT10 NJ
DIRECT15
NJ DIRECT1525**
$100
$250 in total for all, but no more
than $100 per person
NJ DIRECT2030**
$200
$500 in total for all members, but
no more than $200 per person
*Certain plans have a separate inpatient deductible per admission to out-of-network hospitals. See Out-of-Network
Inpatient Deductible.
**TheNJ DIRECT1525andNJ DIRECT2030 plansareONLYoffered to retirees thatareMedicareeligible andselectone
of these two plans as supplemental to Medicare.
The benefit year in which the deductible is measured runs from January 1 to December 31. However,
if treatment for an illness or injury is provided during the last three months of the year, the allowable
expenses that were applied toward the deductible may be allowed to “carry over” toward meeting the
deductible for the following year.
Deductible Examples:
Single Coverage – You incur an out-of-network doctor’s office visit in April and the allowable expense
is $100. This is your first claim of the year and no other calendar year deductible has been met;
therefore, the $100 allowable expense is applied to and satisfies the deductible for the following year.
Family Coverage/Aggregate – You and two covered family members incur an out-of-network
doctor’s office visit in May. The allowable expense is $85 per visit or $255 for all three visits. These
are your family’s first claims of the year and no other calendar year deductible has been met; therefore
$85 for the first two visits is applied toward the family deductible ($170) along with $80 from the third
visit ($250). The $250 family deductible is met for the current year.
Family Coverage/Individual – You or a family member incurs an out-of-network doctor’s office visit
in May of the current year and the allowable expense is $100. This is the first claim of the year and
no other calendar year deductible has been met. Therefore, the $100 allowable expense is applied
to and satisfies the individual deductible for the current year. The $100 allowable expense is also
applied toward the $250 family deductible for the current year.
Deductible Carryover – You incur an out-of-network doctor’s office visit in October and the allowable
expense is $90. This is your first claim of the year and no other calendar year deductible has been
met; therefore, the full $90 allowable expense is applied to the deductible for the current year. Since
this amount was applied in the last three months of the current year, the full $90 will carry over and
be applied toward meeting the deductible for the following year as well if you remain in the same plan.
30
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Out-of-Network Inpatient Deductible
The NJ DIRECT1525 and NJ DIRECT2030 have a separate inpatient deductible per admission to
out-of-network hospitals. The inpatient deductible varies by plan as shown below:
SEHBP Plan Option
Out-of-Network Inpatient Deductible (per admission)
NJ DIRECT1525
$200
NJ DIRECT2030
$500
* The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY offered to retirees that are Medicare eligible and select one
of these two plans as supplemental to Medicare.
Out-of-Network Coinsurance
The SEHBP plans will pay a percentage of the reasonable and customary allowance for eligible out-
of- network charges. You are required to pay the remaining percentage of the reasonable and
customary allowance (coinsurance) as well as the difference between the allowance and the
provider’s charges. As shown below, the coinsurance level varies by plan option. The out-of-network
coinsurance is applied toward the out-of-network, out-of-pocket maximum.
SEHBP Plan Option
Out-of-Network Coinsurance
NJ DIRECT10
20%
NJ DIRECT15
NJ DIRECT1525*
NJ DIRECT2030*
NJ Educators Health Plan
30%
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY offered to retirees that are Medicare eligible and select one
of these twoplans as supplemental to Medicare.
Out-of-Network Out-of-Pocket Maximum
When your out-of-network, out-of-pocket maximum for the year has been reached, the SEHBP plans
will pay 100 percent of the reasonable and customary allowance for eligible services. As shown below,
the out-of-network, out-of-pocket maximum varies by plan option.
SEHBP Plan Option
Individual
Out-of-Network
Out-of-Pocket Maximum
Family
Out-of-Network
Out-of-Pocket Maximum
NJ Educators Health Plan
NJ DIRECT10
NJ DIRECT15
NJ DIRECT1525
$2,000
$5,000
NJ DIRECT2030
$5,000
$12,500
The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select one
of these twoplans as supplemental to Medicare.
SEHBPMEMBER GUIDEBOOK
31
The member is responsible for any amount above the reasonable and customary allowance in
addition to deductible and coinsurance liability. Eligible services and pre-certified treatment count
toward the plan maximum out-of-pocket expense level. Expenses for ineligible services and charges
in excess of reasonable and customary allowances do not count toward your out-of-pocket maximums
and are your financial responsibility.
The in-network out-of-pocket expenses apply to the out-of-network out-of- pocket maximum under
NJ DIRECT10.
COORDINATION OF BENEFITS
For group plans that have a Coordination of Benefits (COB) provision, the following rules determine
which plan is primary:
If you, the active employee, is the patient, the SEHBP plan is primary for you. If your spouse/partner
is the patient, and covered under a health plan provide d through his or her employer as an active
employee, that plan is the primary plan for them;
If a member has coverage as an active employee and additional coverage as a retiree the coverage
through active employme nt is primary to retiree coverage;
When Medicare is involved (except for ESRD; see ESRD section of this Guidebook), the benefits of
the plan that covers an active employee and/or his or her dependents will be considered primary
before the benefits of a plan that covers a laid-off or a retired employee and his or her dependents;
If a dependent child is the patient and is covered under both parents' plans, the following birthday
rule will apply.
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 will be primary.
This birthday rule regulation affects all carriers and all contracts that 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;
If two or more plans cover a person as a dependent child of separated or divorced parents, benefits
for the dependent child will be determined in the following order.
The plan of the parent with custody is primary; followed by
The plan of the spouse/partner of the parent with custody of the child; then
The plan of the parent not having custody of the child.
If it has been established by a court order or judgment — Qualified Medical Child Support Order
(QMCSO) — that one parent has responsibility for the child's health care expenses, then the plan of
that parent is primary; or
If none of the rules listed above determine the order of benefits, the plan that has covered thepatient
for the longer period is the primary plan.
The SEHBP plans will provide its regular benefits in full when primary. As a secondary plan, the
SEHBP plan will provide reimbursement up to the plan’s regular benefit, which, when added to the
benefits underother group plans, will not exceed 100 percent of the member’s liability.
Please note: The COB rules described above may change if Medicare is involved. Please refer
to the Medicare sections of this Guidebook for more information.
32
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
GENERAL BENEFITS
This section lists the general treatments, services, and supplies that the SEHBP plans will consider.
Expenses for these services or supplies are subject to reasonable and customary allowances;
medical need and appropriate level of care; utilization review; the Schedule of Services and Supplies;
and benefit limitations and exclusions. Refer to the “Summary Schedule of Services and Supplies” of
this Guidebook. Select services require precertification (refer to the Services REQUIRING
PRECERTIFICATION section of this Guidebook for details). If a service is not listed, please conta c t
Horizon BCBSNJ directly to find out if it is covered.
The fact that an item or service is not listed below, does not automatically make the service or item
covered under the SEHBP plans.
Important Note: The recommendations and guidelines of the:
Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
United States Preventive Services Task Force;
Health
Resources
and
Services
Administration;
and
American Academy of Pediatric/Bright Futures Guidelines for Children and Adolescents;
as referenced throughout this Handbook may be updated periodically. The Plan is subject to updated
recommendations or guidelines that are issued by these organizations beginning on the first day of
the plan year, one year after the recommendation or guideline is issued.
For further information on preventative services, please visit:
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Acupuncture
Acupuncture treatment is covered when the services are for a diagnosis related to pain
management and are rendered by a Licensed Acupuncturist or Licensed Medical Doctor (M.D.,
D.O.). Acupuncture treatment is subject to maintenance and supportive care provisions.
Examples of acupuncture services that are not eligible under the SEHBP plans include weight loss
and smoking cessation.
Alcohol and Substance Abuse Treatment
See Substance Use Disorder Treatment Allergy Testing and Treatment
Most commonly used methods of allergy testing are covered. However, some methods are subject
to medical need at the appropriate level of care and will be reviewed before eligibility can be
determined.
Ambulance
Ambulance use for local emergency transport to the nearest facility equipped to treat theemergency
condition is covered subject to medical need at the appropriate level of care. If emergency air
transport is needed, it must be medically necessary and approved by having your physician call
Horizon BCBSNJ at 1-800-664-2583.
The SEHBP plans do not cover chartered air flights, non-emergency air ambulance, invalid coach,
transportation services, or other travel, lodging, or communication expenses of patients, providers,
nurses, or family members.
SEHBPMEMBER GUIDEBOOK
33
Audiology Services
Audiology services are covered when rendered by a physician or a licensed audiologist, when such
services are determined to be medically necessary and at the appropriate level of care. See
exclusions for hearing aids and hearing examinations.
Autism or Other Developmental Disability
Chapter 115, P.L. 2009, requires that the SEHBP provide:
Coverage for expenses incurred in screening and diagnosing autism or another developmental
disability;
Coverage for expenses incurred for medically necessary physical therapy, occupational therapy and
speech therapy services for the treatment of autism or another developmental disability;
Coverage for expenses incurred for medically necessary behavioral interventions (ABA therapy) for
individuals diagnosed with autism;
A benefit for the Family Cost Share portion of expenses incurred for certain health care services
obtained through the New Jersey Early Intervention System (NJEIS).
ABA therapy is not eligible for children with developmental diagnoses.
Horizon Behavioral Health must be contacted to pre-certify ABA services for autistic children.
Horizon BCBSNJ Utilization Management must be contacted for precertification by the provider
requesting occupational therapy, speech, and physical therapy services.
Automobile-Related Injuries
The SEHBP plans will provide secondary coverage to your mandatory New Jersey Personal Injury
Protection (PIP) unless the SEHBP plan has been elected as the primary coverage by or for the
employee covered under the SEHBP plan. This election is made by the named insured under the PIP
program and affects that member's family members who are not themselves the named insured under
another auto policy. The SEHBP plan may be primary for one member, but not for another if the
individuals have separate auto policies and have made different selections regarding primacy of
health coverage.
If the SEHBP 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 SEHBP plans.
Please note: If you elect to have the SEHBP plan as primary to PIP, prior notification to your SEHBP
plan is not required. Upon receipt of an auto-related claim, your SEHBP plan will request the
submission of written documentation, such as a copy of your policy declaration page, for verification
of your selection.
The SEHBP plans are some of several health insurance plans that provides benefits for automobile-
related injuries. If the covered employee has elected health coverage as primary, these plans may
coordinate benefits as they normally would in the absence of this provision.
If the SEHBP plan is secondary to PIP, the actual benefits payable will be the lesser of:
The remaining uncovered allowable expenses after PIP has provided coverage, subject to
medical need at the appropriate level of care and other provisions, after application of
deductibles and coinsurance; or
The actual benefits that would have been payable had theSEHBP plan been primary
34
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Biofeedback
Biofeedback to treat a medical or mental diagnosis is covered the same as any other general
condition.
Birthing Centers
As an alternative to conventional hospital delivery room care for low-risk maternity patients, the
SEHBP plans allow benefits for care in participating birthing centers. Services routinely provided by
the birthing centers including prenatal, delivery, and postnatal care, will be covered in full if the
delivery takes place at the center. If complications occur during labor, and delivery occurs in an
approved hospital because of the need for emergency or inpatient care, this care will also be covered
in full. Contact Horizon BCBSNJ at 1-800-414-SHBP (7427) to identify eligible birthing centers near
you.
Blood
Blood, blood products, blood transfusions, and the cost of testing and processing blood are covered.
The SEHBP plans do not pay for blood that has been donated or replaced on behalf of the patient.
Breast Reconstruction
If you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction
along with that mastectomy, the SEHBP plans will provide coverage for the following:
Reconstruction
of
the
breast
on
which
the
mastectomy
was
performed;
Prosthesis(es);
Surgery
and
reconstruction
of
the
other
breast
to
produce
a
symmetrical
appearance;
and
Physical complications at all stages of the mastectomy, including lymphedemas.
Chiropractic Services
There is a combined In-Network and Out-of-Network 30-visit maximum benefit per calendar year for
chiropractic services. 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. Chiropractic services are subject to a medical necessity review process.
Congenital Defects
Surgical procedures that are necessary to correct a congenital birth defect that significantly impairs
function are covered.
Dental Care
The SEHBP plans provide benefits for the removal of bony impacted molars, and will pay for the
treatment of accidental injuries, and treatment for mouth tumors if medically necessary. The SEHBP
plans may provide coverage for the treatment of accidental dental injuries. An accidental dental injury
is considered an injury to teeth (must be sound natural teeth) which is caused by an external factor
such as damage caused by being hit by a hockey puck or having teeth broken in a fall on the ice.
Breaking a tooth while chewing on food is not considered an accidental dental injury. Stress fractures
in teeth are very common and generally undetectable by X-ray. Stress fractures are often the cause
of tooth breakage. Treatment for this type of tooth breakage is considered a dental service and not
eligible for reimbursement. Dental services required as the result of medical conditions or medical
services rendered such as: radiation, chemotherapy and long-term use of prescription drugs are not
eligible. These dental services should be submitted to your Dental Plan.
SEHBPMEMBER GUIDEBOOK
35
Hospital and anesthesia charges incurred for dental services that are medically needed and at the
appropriate level of care are covered for severely disabled members and children when convincing
documentation is submitted in advance for the medical need for the hospitalization/anesthesia
services. Charges for the actual dental procedures would not be eligible for benefits.
Orthodontia is not covered.
Diabetic Self-Management Education
Benefits, limited to four visits per year, are included for expenses incurred for diabetes self-
management education to ensure that a person with diabetes is educated as to the proper self-
management and treatment of the member's condition.
Benefits for self-management education and education relating to diet shall be limited to medically
necessary visits upon:
The diagnosis of diabetes;
The
diagnosis
by
a physician
or nurse
provider/clinical
nurse
specialist
of a significant
change in your symptoms or conditions which necessitate changes in your self-
management; and
Determination by a physician or nurse provider/clinical nurse specialist that reeducation
or refresher education is necessary.
Diabetes self-management education is covered when provided by:
A physician, nurse provider, or clinical nurse specialist;
A health care professional such as a registered dietician that is recognized as a
Certified Diabetes
Educator
by the
American
Association
of Diabetes
Educators;
or
A registered pharmacist in New Jersey qualified with regard to management education for
diabetes by any institution recognized by the Board of Pharmacy of the State of New
Jersey.
Benefits are provided for expenses incurred for insulin pumps for the treatment of diabetes, if
recommended or prescribed by a physician or nurse provider/clinical nurse specialist.
Dialysis
Dialysis is covered when the services are provided and billed by an eligible hospital, by a freestanding
dialysis center, or by an eligible home health care agency. The facility must arrange 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. Ambulance
transportation/invalid coach service to and from dialysis sessions is not eligible for coverage.
Durable Medical Equipment and Supplies
Charges for the rental of durable medical equipment needed for therapeutic use are covered. The
SEHBP plans may cover the purchase of such items when it is less costly and more practical than
renting such items. The SEHBP plans do not cover the rental or purchase of any items that do not
fully meet the definition of durable medical equipment. For in- and out-of-network services, it is
recommended that costly durable medical equipment be approved by Horizon BCBSNJ prior to
purchase.
The SEHBP plans also covers eligible supplies including surgical dressings, blood and blood plasma,
artificial limbs, larynx and eyes, casts, Inherited Metabolic Disease medical food, certain non-
standard infant formula (under one year of age), splints, trusses, braces, crutches, respirator oxygen
and rental of equipment for its use.
Deluxe models of durable medical equipment items such as, but not limited to, wheelchairs are not
eligible for benefits.
36
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Emergency Medical Services
A medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson (including the parent of a minor child or guardian
of a disabled individual), who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in:
Placing the health of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
Serious impairment to bodily function; and/or
Serious dysfunction of bodily organ or part.
With respect to emergency services furnished in a hospital emergency department, Horizon BCBSNJ
shall not require prior authorization for the provision of such services if the member arrived at the
emergency medical department with symptoms that reasonably suggested an emergency condition
based on the judgment of a prudent layperson. All procedures performed during the evaluation (triage)
and treatment of an emergency medical condition shall be covered.
If you find yourself in an emergency and notification prior to treatment is not reasonably possible, go
directly to the nearest emergency facility. All such treatment received during the first 48 hours after
the onset of the medical emergency will be eligible for in-network benefits, regardless of whether such
treatment is received in or out of the service area or whether such treatment is furnished by a network
provider.
Urgent and After Hours Care
Urgent care is medically necessary care for an unexpected illness or injury that should be treated
within 24 hours but is not life threatening. It is medical care you can safely postpone until you can call
a physician. Examples of urgent care include fever, earache, cuts, sprains, and minor burns. In
instances like these, call your physician first for instructions. If your physician determines your
situation is a medical emergency, he or she will refer you directly to an emergency facility. If it is not
a medical emergency, your physician will tell you how to treat the problem yourself or make an
appointment to see you. Your physician or a covering physician should be available 24 hours a day,
every day.
Contact your physician for after-hours care or care that is required at night or on a weekend or holiday.
Again, your physician will provide instructionson howto treat your problem.
Emergency Room
Each time the member uses the hospital emerge ncy room, the member must pay a copaym ent. If the
member is admitted within 24 hours, the copayment amount is waived. There may also be additional
medical charges for out-of-network emergency rooms that may not be reimbursed in full.
Federal Government Hospitals
The SEHBP plans will pay for eligible charges in hospitals operated by the United States government
(Veterans Administration) as if they were member hospitals, regardless of their location, for eligible
charges for nonmilitary conditions.
The SEHBP plans 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:
Services are for treatment on an emergency basis for accidental injury from an external
cause; or
Services are provided in a hospital located outside of the United States and Puerto Rico.
SEHBPMEMBER GUIDEBOOK
37
Gender Identity- Treatment to Affirm Gender Identity
You are covered for management, consultation, counseling, hormones, and surgical services for
purposes of affirming your gender identity and/or gender transition (diagnostically this may be referred
to as gender dysphoria) when certain criteria are met
Gynecological Care and Examinations.
Gynecological care and examinations are eligible. The SEHBP plans provide coverage for one routine
gynecological examination per year that may include one routine Pap smear, when provided by a
gynecologist.
Hearing Aids
Coverage will be provided for medically necessary expenses incurred in the purchase of a hearing
aid for covered members who are 15 years old or younger. Coverage is provided for the purchase of
a hearing aid for each hearing impaired ear once in a 24-month period, when it is medically necessary
and prescribed by a licensed physician or audiologist.
Hemophilia Treatment
Hemophilia treatment is covered in an inpatient facility or outpatient facility. Home hemophilia
treatment will be considered when there is documented medical evidence that these services cannot
be performed in an outpatient facility.
Home Health Care
Home health care services and supplies are covered only if furnished by providers on a part -time or
intermittent basis, except when full-time or 24-hour service is needed on a short-term basis.
Precertification is required for these services.
The home health care plan must be established in writing by the member's provider within 14 days
after home health care starts and it must be reviewed by the member's provider at least once every
30 days.
Eligible home health services (subject to exclusions) provided by a home health care agency include:
Part-time skilled nursing services provided by or under the supervision of a registered
professional nurse (R.N.);
Physical therapy;
Occupational therapy;
Speech therapy;
Related treatment and services eligible for hospital benefits, except drugs and administration
of hemodialysis; and
Medical social services or part-time services by a home health care aide during the period
when you are receiving eligible skilled nursing care, physical therapy, or speech therapy
services.
A prior inpatient hospital stay is not required to qualify for home health care agency benefits but the
patient must be homebound and require skilled nursing care under a plan prescribed by an attending
physician.
The SEHBP plans do not cover:
Services furnished to family members, other than the patient;
Services provided by a companion;
Services
and
supplies
not
included
in the
home
health
care
plan;
or
Nursing home care or care that is maintenance care, supportive care, care to treat
deficiencies that are developmental in nature or are primarily custodial care in nature.
38
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Hospice Care Benefits
Benefits for hospice care must be provided according to a physician prescribed course of treatment
approved by the SEHBP plans with a confirmed diagnosis of terminal illness and a life expectancy of
six (6) months or less.
The following hospice services are covered:
Part-time professional nursing services of an R.N. or L.P.N.;
Home
health
care
aide
services
provided
under
the
supervision
of
an
R.N.;
Medical
care
rendered
by
a
hospice
care
program
physician;
Therapy services (including speech, physical and occupational therapies);
Diagnostic
services;
Medical and surgical supplies;
Durable medical equipment;
Prescribed drugs;
Oxygen and its administration;
Up to 10 days for respite care;
Inpatient acute care for related conditions;
Medical social services;
Psychological
support
services
to
the
terminally
ill
patient;
Family counseling related to the eligible person's terminal condition;
Dietician services; and
Inpatient room, board and general nursing services for related conditions.
No benefit consideration will be given for any of the following hospice care benefits:
Medical care rendered by the patient's private physician (would be paid separately under the
plan);
Volunteer services;
Pastoral services;
Homemaker services;
Food or home-delivered meals;
Non-authorized private-duty nursing services;
Dialysis treatment; or
Bereavement counseling.
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 -800-414-
SHBP (7427).
Immunizations
Immunizations provided by an in-network physician or contracted, New Jersey pharmacy are covered
under the SEHBP plans unless they are for travel outside the country or work-related. Well-child
immunizations for children less than 12 months of age are the only immunizations allowed out -of-
network.
SEHBPMEMBER GUIDEBOOK
39
Infertility Treatment
The SEHBP plans will follow the New Jersey State Mandate for Infertility.
Charges made for services related to diagnosis of infertility and treatment of infertility once a condition
of infertility has been diagnosed. Services include, but are not limited to: approved surgeries and other
therapeutic procedures that have been demonstrated in existing peer -reviewed, evidence- based,
scientific literature to have a reasonable likelihood of resulting in pregnancy (including microsurgical
sperm aspiration); laboratory tests; sperm washing or preparation; diagnostic evaluations; assisted
hatching; fresh and frozen embryo transfer; ovulation induction; gamete intrafallopian transfer (GIFT);
in vitro fertilization (IVF), including in vitro fertilization using donor eggs and in vitro fertilization where
the embryo is transferred to a gestational carrier or surrogate; zygote intrafallopian transfer (ZIFT);
artificial insemination; intracytoplasmic sperm injection (ICSI); and the services of an embryologist.
This benefit includes diagnosis and treatment of both male and female infertility.
Eligibility Requirements
Infertility services are covered for any abnormal function of the reproductive systems such that
the patient has met one of the following conditions:
•
a male
is
unable
to
impregnate
a female;
• a female with a male partner and under 35 years of age is unable to conceive after 12
months of unprotected sexual intercourse;
• a female with a male partner and 35 years of age and over is unable to conceive after
six months of unprotected sexual intercourse;
• a female without a male partner and under 35 years of age who is unable to conceive
after 12 failed attempts of intrauterine insemination under medical supervision;
• a female without a male partner and over 35 years of age who is unable to conceive
after six failed attempts of intrauterine insemination under medical supervision;
• partners are unable to conceive as a result of involuntary medical sterility;
• a person is unable to carry a pregnancy to live birth; or
•
a previous
determination
of
infertility
pursuant
to
the
law.
In vitro fertilization, gamete transfer and zygote transfer services are covered only:
If you have used all reasonable, less expensive and medically appropriate treatment and are
still unable to become pregnant or carry a pregnancy;
Up to four complete d egg retrievals combine d. Egg retrievals covered by another plan or the
member (outside of the SHBP/SEHBP) will not be applied toward the SHBP/SEHBP limit for
infertility services; and
If you are 45 years old or younger.
Covered Expenses include:
Where a live donor is used in the egg retrieval, the medical costs of the donor shall be covered
until the donor is released from treatment by the reproductive endocrinologist;
Intracytoplasmic sperm injections;
In vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where
the embryo is transferred to a gestational carrier or surrogate;
Prescription medications, including injectable infertility medications, are covered under the
SEHBP’s Prescription Drug Plans. Private freestanding prescription drug plans arranged by
local employer groups are required to be comparable to the SEHBP Prescription Drug Plans
and must provide coverage for infertility medications for covered members and donors;
Ovulation induction;
Surgery, including microsurgical sperm aspiration;
40
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Artificial Insemination;
Assisted Hatching;
Diagnosis and diagnostic testing; and
Fresh and frozen embryo transfers.
Exclusions
The following are specifically excluded infertility services:
Reversal of male and female voluntary sterilization;
Infertility services when the infertility is caused by or related to voluntary sterilization;
Non-medical costs of an egg or sperm donor. Medical costs of donors, including office visits,
medications, laboratory and radiological procedures and retrieval, shall be covered until the
donor is released from treatment by the reproductive endocrinologist;
Cryopreservation is not a covered benefit;
Any experimental, investigational, or unproven infertility procedures or therapies;
Payment for medical services rendered to a surrogate for purposes of childbearing where the
surrogate is not covered by the carrier’s policy or contract;
Ovulation kits and sperm testing kits and supplies;
In vitro fertilization, gamete intrafallopian tube transfer, and zygote intrafallopian tube transfer
for persons who have not used all reasonable less expensive and medically appropriate
treatments for infertility, who have exceeded the limit of four covered completed egg retrievals,
or are 46 years of age or older. Egg retrievals covered by another plan or the member (outside
of the SHBP/SEHBP) will not be applied toward the SHBP/SEHBP limit for infertility services;
and
Costs associated with egg or sperm retrieval not related to an authorized IVF procedure.
Lead Poisoning Screening and Treatment
Lead poisoning screening (in-network only; out-of-network screenings are not covered). Treatment is
eligible In-Network and Out-of-Network. No copayment applies to in-network screenings.
Lithotripsy Centers
Lithotri psy
services
are
covered
when
they
are
perform ed
in an
approved
hospital
or
lithotripsy
center.
For information regarding the eligibility of certain centers, please call 1-800-414-SHBP (7427).
Lyme Disease Intravenous Antibiotic Therapy
All intravenous antibiotic therapy for the treatment of Lyme disease requires precertification. When
intravenous therapy is determined to be medically appropriate, the supplies, cost of the drug, and
skilled nursing visits will be covered services. If services are not precertified and are determined not
to be medically necessary, the services will not be covered.
Mammography
Covers mammograms provided to a female member. Coverage is provided as follows:
One baseline mammography at any age; and
Age
40
and
older,
one
screeni ng
mamm ography
per
year.
SEHBPMEMBER GUIDEBOOK
41
Mastectomy Benefits
A hospital stay of at least 72 hours following a modified radical mastectomy and a hospital stay of at
least 48 hours is covered following a simple mastectomy unless the patient, in consultation with the
physician, determines that a shorter length of stay is medically needed and at the appropriate level
of care.
Maternity/Obstetrical Care
Medical care related to childbirth includes the hospital delivery and hospital stay for at least 48 hours
after a vaginal delivery or 96 hours after a cesarean section if the attending provider determines that
inpatient care is medically needed and at the appropriate level of care.
As mandated per P.L. 2019, Ch. 87- A non-medically indicated early elective delivery performed at a
hospital on a pregnant woman earlier than the 39th week of gestation, is not covered. “Non-medically
indicated early elective delivery” means the artificial start of the birth process through medical
interventions or other methods, also known as labor induction, or the surgical delivery of a baby via
a cesarean section for purposes or reasons that are not fully consistent with established standards
of clinical care as provided by the American College of Obstetricians and Gynecologists.
Services and supplies provided by a hospital to a newborn child during the initial covered ho spital
stay of the mother and child are covered as part of the obstetrical care benefits.
SEHBP plans also cover birthing center charges made by a provider for pre-natal care, delivery, and
post-partum care in connection with a member's pregnancy.
Professional charges billed by an eligible provider, related to the prenatal care, delivery and postnatal
care for home birth are covered.
Note: Providers do not routinely perform homebirths. The availability of a provider who performs home
births is not guaranteed.
Maternity/Obstetrical Care for Child Dependents
In some instances, SEHBP plans will pay bills related to the birth of a grandchild. In order for benefits
to be available, the mother must be enrolled as a covered child. Coverage for the grandchild ends
when the mother is discharged from the hospital. The grandparent may apply for dependent
coverage of the grandchild only if he or she obtains legal custody of the child.
Mental or Nervous Conditions
SEHBP plans cover the mental or nervous conditions the same way it would any other illness if
treatment is prescribed by an eligible provider and it is deemed to be medically needed and at the
appropriate level of care. Horizon Behavioral Health is responsible for the management of your
behavioral health benefit including treatment for mental/nervous conditions and substance use
disorder provided at all levels of care: in-patient, partial hospitalization, residential, intensive outpatient
(IOP), and individual or group outpatient treatment. Eligible providers of behavioral health care are
Psychiatrists (MD), Licensed Psychologists (PhD), Licensed Clinical Social Workers (LCSW),
Licensed Marriage and Family Therapists (LMFT), Associate Marriage & Family Therapist
(AMFT)Licensed Professional Counselors (LPC), and Certified (Psychiatric), Nurse Practitioners
working within the scope of their practice. Precertification (prior to treatment) is required for all
admissions and for some specialty services (in-network and out- of-network) including biofeedback,
and Intensive Outpatient (IOP) treatment. The precertification process will determine if the treatment
to be provided is medically appropriate and at the most appropriate level of care to fit your behavioral
health needs. Medical necessity determinations for mental health services are supported by the
Horizon Behavioral Health Medical Necessity criteria.
Effective February 1 2023, electroconvulsive therapy (ECT), transcranial magnetic stimulation
(TMS) and psychological testing rendered in an outpatient setting does not require an
authorization.
42
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Precertification is not required for routine, office based outpatient mental health servic es incurred on
or after January 1, 2013. Services may be reviewed at any time to determine the medical necessity of
the level of care being provided. Horizon may contact your treating provider to discuss your treatment
and the authorization requirement that will be applied. Authorization is required for coverage of any
treatment that Horizon determines is not consistent with usual treatment practices for your condition
based on the frequency of sessions, duration of treatment or other factors. You will b e advised if a
medical necessity review is conducted and services will require review and authorization.
The precertification process through Horizon Behavioral Health is available 24 hours-a-day, 7 days-
a-week by calling 1-800-991-5579. In addition to helping you navigate the precertification process,
Horizon Behavioral Health can help you find a provider, support your treatment and manage the
services you are receiving to ensure that they are appropriate for your behavioral health needs and
are supported by Horizon Behavioral Health medical necessity criteria. The absence of precertification
or authorization, when required, prior to services being rendered, may result in the denial of payment
for services.
Newborn Home Visitation Program
The program provides at least one home nurse visit in the newborn’s home within two weeks after
birth and no more than two additional visits during the newborn’s first three months of life. The visit
will be conducted by a registered nurse or advanced practice nurse. The program will improve
maternal health, infant health and development, and parenting skills. The visit will include a health
and wellness check of the newborn and an assessment of the physical and mental health of the
person who gave birth. The parent(s) will also receive support, including breastfeeding educationand
assistance in recognizing and coping with perinatal mood disorder. Once Horizon BCBSNJ is notified
of the pregnancy, the member will be notified of this benefit. Services are covered without out-of-
pocket costs when provided by an in-network registered nurse.
Nutritional Counseling
SEHBP plans allow three visits per year in-network only for nutritional counseling that is medically
needed and at the appropriate level of care. For eating disorder diagnoses only, there are no visit
limitations for services rendered in-network or out-of-network. Deductible and coinsurance applies to
services rendered out-of-network.
Occupational Therapy (See Physical Therapy)
Organ Transplant Benefits
Pre-approved services and supplies for the following types of transplants are covered:
Lung;
Liver;
Heart;
Pancreas;
Certain autologousbone marrow;
Cornea (pre-approval is not required in or out-of-network); and
Kidney (pre-approval is not required in or out-of-network).
Benefits only include surgical, storage and transportation services of the organ thatare directly related
to the donation and billed for by the hospital.
SEHBPMEMBER GUIDEBOOK
43
Pain Management
Pain management services are subject to current medical guidelines and policies. Pain management
therapy administered by a licensed physician must be supported by a comprehensive evaluation of
the patient and documentation of the rationale for treatment. The treatment of pain is multifaceted
and may include therapeutic exercises, activity modification, physical therapy, occupational therapy,
pharmacological interventions, behavioral health interventions, therapeutic and/or surgical
interventions. Treatment may not 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 goal. If treatment offers no appreciable improvement in the patient’s condition further
services may be considered maintenance and/or supportive care and will not be eligible for
reimbursement.
Horizon BCBSNJ contracts with eviCore Healthcare to review and authorize pain management
services. Monitored anesthesia rendered as part of pain management services must also be
authorized. Participating physicians will obtain prior authorization on your behalf. If you are using a
non-participating provider, it is your responsibility to ensure that authorization is obtained before
services are rendered. Your physician can contact eviCore Healthcare at 1-866-241-6603 to request
authorization. If you or your physician do not obtain prior authorization for pain management services,
those services will not be eligible for reimbursement. If services are rendered without the proper
authorization, benefits will be denied. A retroactive benefit review will not be conducted.
Pap Smears
Annual Pap smears provided by your participating OB/GYN are covered at the in -network level of
benefits. This benefit is limited to one Pap smear per year unless additional tests are medically
needed and at the appropriate level of care for diagnostic purposes. An annual Pap smear provided
out-of-network is covered, subject to any deductible and coinsurance.
Patient Controlled Analgesia (PCA)
Patient Controlled Analgesia (PCA) is covered when it is medically appropriate, prescribed by a
medical doctor, and provided under the guidance of one of the following:
Doctor;
Anesthesiologist; or
Approved home care agency.
Physical Therapy/Occupational Therapy
Therapy that is medically needed and at the appropriate level of care is covered based on one session
per day. A session of therapy is defined as up to one hour of therapy (treatment and/or evaluation) or
up to three therapy modalities provided on any given day.
Physicals (In-Network Only)
One routine physical examination for you and your eligible dependents is covered in -network each
year. In-network services that are considered preventive care under the Patient Protection and
Affordable Care Act will be covered with no out-of-pocket cost (no copayment) if you receive the
services from a participating health care professional and the sole reason for the visit is to receive
the preventive services as denoted by the procedure and diagnosis code reported on the claim.
Physicals for work-related purposes — other than employer-mandated physical examinations that
are a prerequisite for participation in an employer mandated physical fitness test required as a
condition of continuing employment — sports, or other similar reasons are not covered.
44
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Pre-Admission Hospital Review (In-Network and Out-of-Network)
All non-emergency hospital and other facility admissions must be reviewed by Horizon BCBSNJ
before they occur. You, the network hospital, or your provider must notify Horizon BCBSNJ and
request a Pre-Admission Review by phone or facsimile. Horizon BCBSNJ must receive the notice
and request at least 5 business days or as soon as reasonably possible before the admission is
scheduled to occur. For a maternity admission, such notice must be given to Horizon BCBSNJ at
least 60 days before the expected date of delivery, or as soon as reasonably possible, to obtain in-
network benefits.
Pre-Admission Testing Charges
Pre-admission diagnostic X-ray and laboratory tests needed for a planned hospital admission or
surgery are covered. SEHBP plans only cover these tests if the tests are done on an in -network
outpatient or out-of-hospital basis within seven days of the planned admission or surgery.
However, SEHBP plans do not cover tests that are repeated after admission or before surgery, unless
the admission or surgery is deferred solely due to a change in the member's health.
Prostate Cancer Screening (In-Network Only)
One routine office visit per year is covered for adult members, including a digital rectal examination
and a prostate-specific antigen test for adult male members over the age of 40.
Scalp Hair Prostheses
A benefit maximum of $500 in a 24-month period, per person, is covered for scalp hair prostheses
(wig) prescribed by a doctor, only if they are furnished in connection with hair loss resulting from:
Treatment of disease by radiation or chemicals;
Alopecia Universalis (totalis); or
Alopecia Areata.
Second Surgical Opinion
SEHBP plans provide coverage for a second physician's personal examination of a patient following
a recommendation for any eligible surgical procedure. SEHBP plans will pay for one consultation by
a qualified specialist physician.
If the second opinion specialist does not confirm the need for surgery, SEHBP plans will provide
coverage for one additional consultation if requested by the patient. SEHBP plans 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
SEHBP plans provide benefits for electroshock treatments, insulin shock treatments, and other similar
treatments. Benefits are also payable for anesthesia in connection with the shock treatment and for
all other eligible services performed on that day for the disorder.
Skilled Nursing Facility Charges
Room and board, including diets, drugs, medicines and dressings, and general nursing services in a
skilled nursing facility are covered.
For Medicare Primary Members — the eligible benefit days run concurrently with Medicare eligible
days. Once Medicare days are exhausted and the SEHBP plan becomes primary, Horizon BCBSNJ
will review continuing services for medical appropriateness and eligibility. Precertification is required
after Medicare benefits are exhausted or if Medicare does not allow benefits.
SEHBPMEMBER GUIDEBOOK
45
Speech Therapy Benefit
Speech therapy services provided by a qualified speech therapist are covered only as follows:
To restore speech after a loss of a demonstrated previous ability to speak or impairment of
a demonstrated previous ability to speak; or
To develop or improve speech after surgery to correct a defect that existed at birth and
impaired the ability to speak or would have impaired the ability to speak.
Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully
developed are not covered except for Autism and Pervasive Development Disorder (PDD).
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).
Substance Use Disorder Treatment
Horizon Behavioral Health is responsible for the management of your behavioral health benefit
including treatment for both mental/nervous conditions and substance use disorder at all levels of
care: inpatient, partial hospitalization, residential, intensive outpatient (IOP), individual, and group
outpatient treatment.
Except as explained below, for the treatment of substance use disorder, SEHBP plans cover the
treatment of substance use disorder the same way it would any other illness if treatment is prescribed
by an eligible provider and it is deemed to be medically needed and at the appropriate level of care.
Other than as stated below, precertification is required for certain inpatient admissions and for some
specialty care including Intensive Outpatient (IOP) Treatment and Office Based Opioid Treatment (in-
network and out-of-network) as noted on the SERVICES REQUIRING PRECERTIFICATION Section
of this Guidebook. The precertification process will determine if the treatment to be provided is
medically appropriate and at the most appropriate level of care to fit your behavioral health needs.
Substance use disorder treatment determinations are supported by the American Society of
Addictions Medicine (ASAM) guidelines. The precertification process through Horizon Behavioral
Health is available 24 hours-a-day, 7 days-a-week by calling 1-800-991-5579.
In addition to helping you navigate the precertification process, Horizon Behavioral Health can help
you find a provider, support your treatment, and manage the services you are receiving to ensure that
they are appropriate for your behavioral health needs and supported by the ASAM criteria. For
additional information or assistance regarding scheduled or emergency treatment related to substance
use disorder, you or your provider may call 1-800-9 91-5 579.
Precertification is not required for routine, office based outpatient substance use disorder services
incurred on or after January 1, 2013. Except as stated below for the treatment of substance use
disorder, services may be reviewed at any time to determine the medical necessity of the level of care
being provided. Horizon may contact your treating provider to discuss your treatment and the
authorization requirement that will be applied. Authorization is required for coverage of any treatment
that Horizon determines is not consistent with usual treatment practices for your condition based on
the frequency of sessions, duration of treatment or other factors. You will be advised if a medical
necessity review is conducted and services will require review and authorization. The absence of
precertification or authorization, when required, prior to services being rendered, may result in the
denial of payment for services.
The SEHBP plans provide benefits for the treatment of substance use disorder at in -network facilities
subject to the following:
a) the prospective determination of Medical Need and Appropriate Level of Care is made by the
member’s provider for the first 180 days of treatment during each year and for the balance
of the year the determination of Medical Need and Appropriate Level of Care is made by
Horizon BCBSNJ.
46
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
b) pre-authorization is not required for the first 180 days of inpatient and/or outpatient
treatment during each year but may be required for the balance of the year;
c) After the first 180 days, benefits are subject to UM requirements including medical
necessity, prior authorization, and retrospective review.
d) concurrent and retrospective review are not required for the first 28 days of inpatient
treatment, intensive outpatient and partial hospitalization services during each year but may
be required for the balance of the year;
e) concurrent and retrospective review are not required for the first 180 days of outpatient
treatment including outpatient prescription drugs, other than intensive outpatient treatment,
during each year but may be required for the balance of the year; and
f) If no in-network facility is available to provide inpatient services Horizon BCBSNJ shall
approve an in-plan exception 24 hours and provide benefits for inpatient services at an out-
of-network facility.
The first 180 days per year assumes 180 inpatient days whether consecutive or intermittent. Extended
outpatient services such as partial hospitalization and intensive outpatient are counted as inpatient
days. Any unused inpatient days may be exchanged for two outpatient visits.
Inpatient or outpatient treatment may be furnished as follows:
Care provided in a state licensed health care facility;
Care provided in a licensed detoxification facility;
Care provided at a licensed and state approved residential treatment facility, under a plan
which meets minimum standards of care; or
Care provided by an eligible, licensed behavioral health professional. Eligible providers of
behavioral health services are Psychiatrists (MD), Licensed Psychologists (PhD), Licensed
Clinical Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed
Professional Counselors (LPC), and Certified (Psychiatric) Nurse Practitioners working within
the scope of their practice.
Care provided at a substance use disorder facility if it carries out its stated purpose under all
relevant state and local laws, and it is either:
a) accredited for its stated purpose by The Joint Commission; or
b) approved for its stated purpose by Medicare; or
c) accredited by the Commission on Accreditation of Rehab Facilities (CARF); or
d) credentialed by Horizon Behavioral Health.
Surgical Services (Out-of-Network)
Multiple Procedures
If multiple procedures are performed during the same operative session, the procedure with
the highest Relative Value Unit (RVU) will be considered the primary procedure and the full
reasonable and customary allowance will be allowed for that primary procedure minus any
applicable member deductible and coinsurance liability. The RVU associated with the
procedure codes represents the time and skill involved in the performance of the procedure.
All eligible additional procedures performed in the same operative session will be considered
secondary procedures that are paid at 50 percent of the reasonable and customary allowance.
Bilateral Procedures
Bilateral procedures will be paid at 150 percent of the reasonable and customary allowance.
Services qualify as bilateral when anatomically there are two specific body parts that are being
operated upon during the same surgery 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.
SEHBPMEMBER GUIDEBOOK
47
Non-network assistant surgeons will be paid at the out-of-network level of benefits and
reimbursed based on 16 percent of the surgical allowance if the service is deemed medically
appropriate.
Telemedicine
You can access medical and behavioral health services through Horizon Care Online. To get care
from home and access confidential telemedicine services through Horizon CareOnline, sign in to
Horizonblue.com/SHBP, the Horizon Blue app or call 1-877-716-5657. Medicare primary members
are not eligible for this service.
See www.HorizonCareOnline.com for details. In addition, reimbursement for eligible services
performed by providers with the capability to render telemedicine is allowed at the in-network and out-
of-network level.
Temporomandibular Joint Disorder (TMJ) and Mouth Conditions
Medical and surgical services performed for the treatment of the jaw are covered. Services in relation to
the teeth in any manner are excluded. Charges for doctor's services or X-ray examinations for a
mouth condition are not eligible.
Charges for dental or orthodontic services for a TMJ diagnosis are not eligible. This exclusion applies
even if a condition requiring any of these services involves a part of the body other than the mouth,
such as treatment of TMJ or malocclusion involving joints or muscles by methods including but not
limited to crowning, wiring or repositioning of teeth and dental implants.
Vision Care Benefits
The SEHBP plans cover an annual routine eye examination by an in-network ophthalmologist or
optometrist. There are no benefits available for frames, lenses, or contact lenses. Contact lens fitting
examinations are also not covered. There is no out-of-network preventive vision care benefit.
Any visits to an ophthalmologist or optometrist for the diagnosis and treatment of a condition will be
eligible at the in-network and out-of-network level of benefits.
CHARGES NOT COVERED BY the SEHBP Plans
Even though a service or supply may not be described or listed in this guidebook, that does not make
the service or supply eligible for a benefit under this plan.
The following services and supplies are not covered:
Automobile accident-related injuries or conditions: Unless the SEHBP plan has been chosen
by the member as primary, the SEHBP plan does not pay for the treatment of injuries or
conditions related to an automobile accident if automobile insurance could have or should
have covered the treatment. This exclusion applies to, but is not limited to:
Existing motor vehicle insurance contracts;
Motor
vehicle
contracts
that
were
purchased
but
have
since
lapsed;
Motor vehicle insurance coverage that should have been purchased; and
Failure to make timely claims under a motor vehicle insurance policy;
Autopsy;
Car Seats;
Care
that
is
primaril y
custodi al
in
nature;
Chair and stair lifts;
48
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Charges above the reasonable and customary allowance or out-of-network plan allowance.
This includes all charges above the fixed dollar benefit limit for out-of-network acupuncture,
out-of-network chiropractic services, and out-of-network physical therapy services;
Charges billed by an Assisted Living Facility;
Charges for services or supplies not specifically covered under the plan;
Charges for services rendered by a member of the patient’s immediate family (including you,
your spouse/domestic partner, your child, brother, sister, or parent of you or your
spouse/domestic partner);
Charges for services rendered by a Birth Doula;
Charges for the completion of a claim form, photocopies of pertinent medical information, or
medical records;
Charges for services retained by the member, such as hiring an attorney or soliciting expert
medical testimony, in connection with an external review of an appeal or complaint. Note that
charges for experts retained by the plan (or the independent review organization with which
the plan contracts to conduct the external review) to conduct the external review of an adverse
benefit determination, are not borne by the member
Charges incurred prior to or in the course of a legal adoption;
Charges
that
should
have
been
paid
by
Medicare,
if Medicare
coverage
had
been
in
effect;
Chiropractic services beyond the combined In-Network and Out-of-Network 30-visit maximum
benefit per calendar year;
Cosmetic procedures — charges connected with curing a condition by cosmetic procedures.
This provision does not apply if the condition is due to an accidental injury that occurred while the
injured person is enrolled in the SEHBP plan. Among the services that are not covered are:
Removal of warts, with the exception of plantar warts;
Spider
vein
treatment;
and
Plastic surgery when performed primarily to improve the person's appearance;
Costs beyond the embryo transfer for a surrogate are not eligible;
Court ordered services or treatments;
Deluxe models of wheelchairs and other durable medical equipment;
Dental Care – other than accidental injury and extraction of bony impacted molars
Durable medical equipment or supplies that are specifically excluded from coverage. To
determine which equipment or supplies are eligible for coverage, call 1-800-414-SHBP (7427);
Educational or developmental services or supplies, or educational testing. This includes
services or supplies that are rendered with the primary purpose being to provide the person
with any of the following:
Training in the activities of daily living. This does not include training directly related to the
treatment of an illness or injury that resulted in a loss of a previously demonstrated ability
to perform those activities;
Instruction in scholastic skills such as reading and writing;
Preparation for an occupation;
Treatment for learning disabilities;
SEHBPMEMBER GUIDEBOOK
49
To promote development beyond any level of function previously demonstrated;
Assessments/testing of academic function; and
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 regardless of
where services are rendered. Rehabilitation programs that are primarily educational or
behavioral in nature;
Expenses for wilderness rehabilitation programs, diabetic camps, or other similar camps or
programs;
Experimental or investigational services or supplies and charges in connection with such
services or supplies, except in the case of an approved clinical trial. refer to the
Experimental or Investigational Treatments section of this Guidebook);
Eye care including:
Out-of-network examinations to determine the need for glasses or lenses of any type,
typically known as refraction examinations regardless of the diagnosis;
Lenses of any type except initial lens replacement for loss of the natural lens after cataract
surgery;
Eyeglasses and contact lenses regardless of the diagnosis, including but not limited to
Kerataconus; and
Low
vision
aids;
Eye surgery, such as radial keratotomy, Lasik procedures, or other refractive procedures
performed for any reason;
Foot conditions — charges for doctor's services for:
A weak, strained, flat, unstable, or imbalanced foot, metatarsalgia, or a bunion. However,
this exclusion does not apply to an open cutting operation;
One or more corns, calluses, or toenails. This exclusion does not apply to a charge for the
removal of part or all of a nail root and services connected with treating metabolic or
peripheral vascular disease;
Government
plan
charges
including
a
charge
for
a
service
or
supplies:
Furnished by or for the United States government;
Furnished
by
or
for
any
government,
unless
payment
is
required
by
law;
or
To the extent that the service or supply, or any benefit for the charge, is provided by any
law or government plan under which the member is or could be covered. This applies to
Medicare and "no-fault" medical and dental coverage when required in contracts by a
motor vehicle law or similar law.
Health
clubs
and
gym memberships;
See
HorizonbFi t/shbp
for
information
regarding
a fitness
reimbursement program
Hearing aids of any type (except as described under the “Hearing Aids” section of this
Guidebook);
Hearing examinations to determine the need for hearing aids or the need to adjust a hearing
aid, no matter what the cause of the hearing loss, except for members who are 15 years old
or younger please refer to the Hearing Aids section of this Guidebook;
Herbal, Alternative or Complementary medicine treatments;
Hot tubs, saunas, Jacuzzis or pools of any type;
50
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Hypnosis;
Immunizations and preventive vaccines when out-of-network (see exceptions under
“Immunizations” in this Guidebook);
Incidental Procedures — certain procedures are commonly performed in conjunction with
other procedures as a component of the overall service provided. An incidental procedure is
one that is performed at the same time as a more complex primary procedure and is
considered part of the primary procedure in order to successfully complete service;
Lab services performed out-of-network regardless of diagnosis, except for services that
require an authorization, have a Medical Policy or cannot be performed by an in -network
laboratory.
Legal fees;
Maintenance care — care that has reached a level where additional services will not
appreciably improve the condition;
Marriage counseling;
Medicare services rendered by providers who are not registered with or who opt -out of
Medicare;
Modifications to an auto to make it accessible and/or drivable;
Modifications to a home to make it accessible for a disabled/injured person;
Mouth conditions — charges for doctor's services or X-ray examinations for a mouth
condition. 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 Temporomandibular Joint
disorders (TMJ) or malocclusion involving joints or muscles by methods including, but not
limited to, crowning, wiring, or repositioning of teeth. See the “Glossary” in this Guidebook
for the definition of a mouth condition;
Nursing home care;
Over-the-counter supplies, supplements, vitamins, medications, or drugs that do not require a
prescription order under Federal law, even if the prescription is written by a physician. These
include, but are not limited to, aspirin, vitamins, lotions, creams, oils, formulas, liquid diets, and
dietary supplements;
Personal comfort or convenience items including telephone or television service, haircuts,
guest trays, or a private room during an inpatient stay;
Prescription drug charges or copayments. If your prescription drug plan does not provide
benefits for a particular drug, it does not mean that it will be eligible under S E H B P pl a n
benefits;
Private Duty Nursing (Inpatient). Private Duty Nursing (PDN) is covered subject to MCG
guidelines. Authorization is required. PDN is characterized by the performance of skilled
services by a licensed nursing professional (RN/LPN) in the member’s home typically to take
the place of continued in-patient treatment. PDN will be part of a written short term, home care
plan leading to the training of the primary care giver(s) to deliver those se rvices once the
member's condition is stabilized. PDN is not meant to replace a parent or caregiver, but is
meant to provide skilled support to the member at home when such services are medically
necessary to properly attend the member;
According to MCG guidelines, PDN is considered medically necessary for members who,
when the physician or specialist has agreed to a home care plan, the member meets MCG
medical necessity criteria and placement of the nurse in the home is done to meet the skilled
needs of the member only; not for the convenience of the family caregiver. Upon initial
discharge of a ventilator dependent member from an inpatient setting, up to 24 hours PDN
per day may be covered for a limited time to facilitate transition to home.
SEHBPMEMBER GUIDEBOOK
51
Thereafter, the hours will be determined by the member meeting specific MCG guidelines for
continued PDN services. Payment for any additional home nursing care is the sole
responsibility of the member/family;
Postage, handling and shipping fees;
Private rooms in a hospital. If you occupy a private room in a hospital or facility, you must pay the
difference between the private room rate and the average semiprivate room rate;
Preventive care/routine screening — unless otherwise indicated, the SEHBP plans’ out-of-
network coverage does not provide benefits for services or supplies that are considered to
be performed for any of the following:
Routine well-care as part of a routine examination;
Services and supplies that are provided for a diagnosis that does not indicate an illness
present at the time the service are rendered; and
Services
that
are
considered
preventive
or
screening
in
nature;
The following services are examples of out-of-network routine services that are not covered:
All immunizations/vaccinations including well-child immunizations/ vaccinations (except
for children under 12 months of age);
Flu shots/pneumonia vaccines;
Well-care annual physicals;
Cancer antigen tests that are performed because of a family history. Specific guidelines
apply to the eligibility of cancer antigen tests. Therefore, you may wish to request a pre-
determination of benefits prior to having services rendered;
Prostate Specific Antigen (PSA) as part of a routine examination or recommended due to a
family history of disease. Specific guidelines apply to the eligibility of PSA for non-routine
reasons;
Lab services performed outside of a facility regardless of diagnosis, except for services
that require an authorization, have a Medical Policy or can’t be rendered by an in-
network laboratory.
Repatriation (returning a traveler to his/her home when unable to continue with travel due to
medical reasons);
Self- or home-testing kits whether prescribed by a doctor or not;
Services for cosmetic surgery (or complications that result from such surgery) on any part of
the body except for reconstruction surgery following a mastectomy or when medically
necessary to correct damage caused by an accident, an injury, therapeutic surgery or to
correct a congenital defect;
Services or supplies that are not medically needed and/or not at the appropriate level of care
and charges in connection with such services or supplies. The fact that a physician may
prescribe, order, recommend, or approve a service or supply does not, in itself, make it
medically needed for the treatment and diagnosis of an illness or injury or make it a covered
medical expense;
Services that are commonly or customarily provided without charge to the patient. Even when
the services are billed, the SEHBP plans will not pay if they are usually not billed when there
is no coverage available;
Services and supplies prescribed or provided by an ineligible provider;
52
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Services or supplies that require prior authorization that are not authorized before services
are rendered;
Services rendered before the effective date of coverage or after the termination of coverage
date. However if the covered patient is hospitalized as an inpatient and coverage terminates
during the stay, that inpatient stay (as long as otherwise eligible) will be covered through to
discharge.
Services rendered or billed by an Assisted Living Facility;
Shoes that are not custom molded, are not attached to a brace, or can be purchased without
a prescription;
Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not
fully developed (Exceptions: Autism and Pervasive Developmental Disorder);
Sports physicals;
Supportive care — supportive care is defined as treatment for patients having reached
maximum therapeutic benefit in which periodic trials of therapeutic withdrawals fail to sustain
previous therapeutic gains. In some instances therapy may be clinically appropriate (such as
treatment of a chronic condition that requires supportive care) yet it would not be eligible for
reimbursement under the SEHBP plans;
Taxes on services/supplies;
Telephone consultations or provider charges for telephone calls except when rendered as
Telemedicine. See ‘Telemedicine’, under GENERAL BENEFITS.
Transport — Non-emergency transport via ambulance or transport by coach of any kind (by
land, air, or water;
Treatment of injuries sustained while committing a felony;
War charges for illness or injury due to an act of war. War means either declared or
undeclared, including resistance or armed aggression;
Weight loss programs such as Jenny Craig, Weight Watchers, and the cost of food associated
with them; and
Work-related injury or disease. This includes the following:
Injuries arising out of or in the course of work for wage or profit, whether or not you are
covered by a Workers' Compensation policy;
Disease caused by reason of its relation to Workers' Compensation law, occupational
disease laws, or similar laws; and
Work-related tests, examinations, or immunizations of any kind required by your work.
Work-related injuries will not be eligible for benefits under the SEHBP plans before or after
your Workers’ Compensation carrier has settled or closed your case.
This exclusion does not apply to employer-mandated physical examinations that are a
prerequisite for participation in an employer mandated physical fitness test required as a
condition of continuing employment. However, such employer mandated physical
examinations are covered in-network only.
Please note: If you collect benefits for the same injury or disease from both Workers' Compensation
and the SEHBP plans, you may be subject to prosecution for insurance fraud.
SEHBPMEMBER GUIDEBOOK
53
Examples of Non-Covered Services:
Example 1: A physician orders inpatient private duty nursing for a surgery patient. Since, while
confined in a hospital, nursing services are provided by the hospital, any charges for private duty
nursing will not be paid.
Example 2: A person is studying to become a therapist and is required by the school to enter therapy.
The treatment is intended to ensure that the new therapist is well-equipped to work with patients. The
treatment is not covered because it is primarily educational.
Example 3: A physician orders a drug that is FDA-approved but is not commonly used to treat the
particular condition. If the SEHBP health plan determines that the use is experimental, the plan will
not pay for the drug.
Example 4: A hospital routinely requires an assistant surgeon or Registered Nurse First Assistant
(RNFA) to be present at certain operations. The SEHBP plans will only pay for assistant
surgeons/RNFA’s that are determined to be medically necessary.
54
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
THIRD PARTY LIABILITY
Repayment Agreement
If you have received benefits from the SEHBP plans for medical services that are either auto-related
or work-related, Horizon BCBSNJ has the right to recover those payments. This means that if you
are reimbursed through a settlement, satisfied by a judgment, or other means, you are required to
return any benefits paid for illness or injury to the SEHBP plan. The repayment will only be equal to
the amount paid by the SEHBP 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.
Recovery Right
You are required to cooperate with Horizon BCBSNJ in recovering any amounts payable. Horizon
BCBSNJ may:
Assume your right to receive payment for benefits from the third party;
Require you to provide all information and sign and return all documents necessary to exercise
the SEHBP plan’s rights under this provision, before any benefits are provided under your
group's policy;
Require you to give testimony, answer interrogatories, attend depositions, and comply with all
legal actions which Horizon BCBSNJ may find necessary to recover money from all sources
when a third party may be responsible for damages or injuries.
SUBROGATION AND REIMBURSEMENT
Benefits payable as a result of any injuries claimed against any person or entity other than this Health
Plan are excluded from coverage under this Plan. If benefits are provided by this Plan that are
otherwise payable or become payable by any third party action against any person or entity, this Plan
is entitled to reimbursement only on the following terms and conditions:
In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of
the Member’s rights of recovery against any person or organization to the extent of the benefits
provided (“Member” includes any person receiving benefits hereunder including all
dependents). The Member shall execute and deliver instruments and papers and do whatever
else is necessary to secure such rights. The Member shall do nothing after loss to prejudice
such rights. The Member must cooperate with the Plan and/or any representatives of the Plan
in completing such forms and in giving such information surrounding any accident as the Plan
or its representatives deem necessary to fully investigate the incident;
The Plan is also granted a right of reimbursement from the proceeds of any recovery whether
by settlement, judgment, or otherwise. This right of reimbursement is cumulative with, and not
exclusive of, the subrogation right granted in the preceding paragraph, but only to the extent
of the benefits provided by the Plan;
The subrogation and reimbursement rights and liens apply to any recoveries made by the
Member as a result of the injuries sustained, including but not limited to the following:
Payments made directly by a third party, or any insurance company on behalf of a third
party, or any other payments on behalf of the third party;
Any payments or settlements, judgment or arbitration awards paid by any insurance
company under uninsured or underinsured motorist coverage, whether on behalf of a
Member or other person;
SEHBPMEMBER GUIDEBOOK
55
Any other payments from any source designed or intended to compensate a Member for injuries
sustained as the result of negligence or alleged negligence of a third party;
Any Workers’ Compensation award or settlement;
Any recovery made pursuant to no-fault insurance;
Any medical payments made as a result of such coverage in any automobile or
homeowners insurance policy; and the Plan shall recover the full amount of benefits provided
hereunder without regard to any claim of fault on the part of any Member, whether under
comparative negligence or otherwise.
WHEN YOU HAVE A CLAIM
Submitting a Claim (In-Network)
Generally, you will not have to submit any claim forms to Horizon BCBSNJ for reimbursement for
treatment from a network provider. You will simply pay the provider the required copayment amount
and the provider will submit claims directly to Horizon BCBSNJ for the appropriate reimbursement.
Submitting a Claim (Out-of-Network)
If you receive treatment out-of-network, claims must be submitted for reimbursement to:
Horizon BCBSNJ,
P.O. Box 820
Newark, NJ 07101-0820
All behavioral health and substance use disorder claims should be mailed to:
Horizon Behavioral Health
Horizon BCBSNJ
P.O. Box 10191
Newark, NJ 07101-3189
Filing Deadline (Proof of Loss)
Horizon BCBSNJ must be given written proof of a loss for which a claim is made under the SEHBP
plan. This proof must cover the occurrence, character, and extent of the loss. It must be furnished
within one year and 90 days of the end of the calendar year in which the services were incurred.
For example, if a service were incurred in the year 2024, you would have until March 31, 2026to file
the claim.
A claim will not be considered valid unless proof is furnished within the time limit shown above. If it
is not possible for you to provide proof within the time limit, the claim may be considered valid upon
appeal if the reason the proof was not provided in a timely basis was reasonable.
Itemized Bills are Necessary
You must obtain itemized bills from the providers of services for all medical expenses. The itemized
bills must include the following:
Name and address of provider;
Provider's
tax
identification
number;
Name of patient;
Date of service;
Diagnosis;
Type of service;
CPT 4 code; and
Charge for each service.
56
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Foreign Claims
Bills for services that are incurred outside of the United States must include an English translation
and the charge for each service performed. The exchange rate at the time of service should also be
indicated on the bill that is submitted for reimbursement.
Filling Out the Claim Form
Be sure to fill out the claim form completely. Include the identification number that appears on your
SEHBP plan identification card. Fill out all applicable portions of the claim form and sign it. A separate
claim form must be submitted for each individual and each time you file a claim.
MEDICARE CLAIM SUBMISSION
If a member is a New Jersey resident, has Medicare primary coverage, and receives care within New
Jersey, claims will be transmitted automatically from the Medicare carrier to the SEBHP plan.
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 SEHBP plan
claim form to Horizon BCBSNJ.
AUTHORIZATION TO PAY PROVIDER
The providers that participate with the SEHBP plans will be paid directly for eligible services. The
member will be paid for all services rendered by non-participating providers. Once payment has been
made to the member for services rendered, Horizon BCBSNJ will not have to pay the benefit again.
QUESTIONS ABOUT CLAIMS
If you have questions about a hospital claim, hospital benefits, a medical claim, or medical benefits
or if you need a claim form, call Horizon BCBSNJ at 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
“Appeal Procedures” section.
APPEAL PROCEDURES
SEHBP MEDICAL APPEAL PROCEDURE
Member appeals that involve medical judgment made by Horizon BCBSNJ are considered medical
appeals. An adverse benefit determination involving medical judgment is (a) a denial; or (b) a
reduction from the application of clinical or medical necessity criteria; or (c) a failure to cover an item
or service for which benefits are otherwise provided because Horizon BCBSNJ determines the item
or service to be experimental or investigational, cosmetic, or dental, rather than medical. Adverse
benefit determinations involving medical judgment may usually be appealed up to three (3) times as
outlined below:
• First Level Medical Appeal – The First Level Medical Appeal of an adverse benefit
determination;
• Second Level Medical Appeal – The Second Level Medical Appeal of an adverse benefit
determination available to you after completing a First Level Medical Appeal; and
• External Appeal – The third Level Medical Appeal of an adverse benefitdetermination, which,
at your request, would generally follow a Second Level Medical Appeal. An External Appeal
provides you the right to appeal to an Indepe ndent Review Organizati on (IRO).
SEHBPMEMBER GUIDEBOOK
57
An overview of the medical appeal procedure is provided below. An SEHBP Medical Appeals
Procedure brochure will be provided with every adverse benefit determination involving medical
judgment. The brochure provides a comprehensive description of the procedures.
First Level Medical Appeal
First Level Medical Appeals may be submitted in writing or verbally. Verbal appeals may be directed
to Horizon BCBSNJ Utilization Management at 1-888-221-6392. Written appeals may be sent to:
Horizon BCBSNJ
SEHBP Medical Appeals
P.O. Box 420
Mail Station PP 12E
Newark, NJ 07101-0420
The member, physician or other authorized representatives acting on behalf of the member, and with
the member’s written consent to pursue an appeal of any adverse benefit determination involving
medical judgment made by Horizon Blue Cross Blue Shield of New Jersey, have one (1) year
following the member’s receipt of the initial adverse benefit determination letter to request a Medical
Appeal.
To initiate a First Level Medical Appeal, the following information must be provided:
Name and address of the member or provider(s) involved;
Member’s identification number;
Date(s) of service;
Nature and reasonbehind your appeal;
Remedy sought; and
Clinical documentation to support your appeal.
First Level Medical Appeals will be reviewed and decided in the following time frames:
Standard First Level Medical Appeals are reviewed and decided within 15 calendar daysof
receipt; or
First Level Expedited (urgent and emergent) Medical Appeals aredecided as soon as possible
in accordance with the medical urgency of the case, but will not exceed 72 hoursfrom Horizon
BCBSNJ’s receipt of the appeal request.
The member will receive a letter documenting Horizon BCBSNJ’s First Level Medical Appeal decision.
The letter will include the specific reasons for the determination.
Expedited Review (excluding appeals related to substance use disorder)
Horizon BCBSNJ Medical Appeal procedures may be expedited in circumstances involving
urgent or emergent care.
First and Second Level Medical Appeals are automatically handled in an expedited manner for all
determinations regarding urgent or emergent care, an admission, availability of care, continued stay, or
health care services for which the claimant received emergency services but has not been discharged
from the facility. Furthermore, if you feel that the Horizon BCBSNJ decision will cause serious medical
consequences in the near future, you have the right to an Expedited Medical Appeal.
You also have the right to an Expedited Medical Appeal if in the opinion of a physician with knowledge
of your medical condition, your condition is as described above or that you will be subject to severe pain
that cannot be adequately managed without receiving the denied medical services. Expedited Medical
Appeals are initiated by calling a Horizon BCBSNJ Appeals Coordinator at 1-888-221-6392.
58
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Second Level Medical Appeals (excluding certain appeals related to substance use
disorder)
If you disagree with the First Level Medical Appeal decision, you have one (1) year following receipt
of Horizon BCBSNJ’s original determination letter to request a Second Level Medical Appeal. If y ou
wish to make a Second Level Medical Appeal, you may do so by sending your appeal in writing to
the following address:
Horizon BCBSNJ Appeals Department
Mail Station PP-12E
P.O. Box 420
Newark, NJ 07101-0420
You may also initiate a Second Level Medical Appeal by calling a Horizon BCBSNJ Appeals
Coordinator at 1-888-221-6392.
To initiate a Second Level Medical Appeal, the following information must be provided:
Name and address of the member or provider(s) involved;
Member’s identification number;
Date(s) of service;
Nature and reason behind your appeal;
Remedy
sought;
and
Clinical
documentati on
to
support
your
appeal.
If a Second Level Medical Appeal is received, it is submitted to the Horizon BCBSNJ Appeals
Committee. The Appeals Committee is made up of Horizon Medical Directors and staff, physicians
from the community, and consumer advocates. A smaller subcommittee reviews Expedited Second
Level Medical Appeals. The Appeals Coordinator will advise you of the date of your hearing. You
have the option of attending the hearing in person or via telephone conference. You may also elect
to have the Appeals Committee review and decide your Second Level Medical Appeal without your
appearance.
Second Level Medical Appeals will be reviewed and decided in the following time frames:
Standard Second Level Medical Appeals are reviewed and decided within 15 calendar days
of Horizon BCBSNJ’s receipt; or
Second Level Expedited (urgent and emergent circumstances, as previously described)
Medical Appeals are decided as soon as possible in accordance with the medical urgency of
the case, but will not exceed 72 hours from Horizon BCBSNJ’s receipt of your First Level
Medical Appeal request.
If you participate in the hearing, you will be notified of the Appeals Committee’s decision verbally by
telephone on the day of the hearing whenever possible. Written confirmation of the decision is sent
to you and/or your physician or other authorized representative who pursued the Second Level
Medical Appeal on your behalf. If you choose not to appear at the hearing, you will be notified of the
Appeals Committee’s decisions in writing within five (5) business days of the decision. Horizon
BCBSNJ’s letter will include the specific reasons for the determination. If Horizon BCBSNJ’s decision
is not in your favor, you have the right to pursue an External Appeal through an Independent Review
Organization (IRO).
Expedited Review of Second Level Medical Appeals (excluding appeals related to
substance use disorder)
If the circumstances previously described in the “Expedited Review” section apply in your case you
have the same right to an expedited review of your Second Level Medical Appeal.
SEHBPMEMBER GUIDEBOOK
59
EXTERNAL APPEAL RIGHTS
Standard External Appeals (excluding appeals related to substance use disorder)
If you are dissatisfied with the results of Horizon BCBSNJ’s internal appeals process, and you wish
to pursue an External Appeal with an Independent Review Organization (IRO), you must submit
a written request within four (4) months from your receipt of Horizon BCBSNJ’s final adverse benefit
determination of your Appeal. To initiate a Standard External Appeal, you should submit a written
request to the following address:
Horizon BCBSNJ Appeals Department
Mail Station PP-12E
P.O. Box 420
Newark, NJ 07101-0420
Upon receipt of your written request, a preliminary review will be conducted by Horizon BCBSNJ and
completed within five (5) business days to determine:
Your eligibility under your group health plan at thetime the service was requested or provided;
That the adverse benefit determination does not relate to your failure to meet eligibility
requirements under the terms of your group health plan (e.g. worker classification or
similar);
The internal appeals process has been exhausted (if required); and
You have provided all the information and forms required to process the external review.
After the completion of this preliminary review, written notification will be issued informing you of
Horizon BCBSNJ’s determination regarding the eligibility of your request for external review. If your
request for an external review meets the eligibility requirements, your appeal will be assigned to an
IRO by Horizon BCBSNJ. The IRO will notify you in writing of your request’s eligibility and acceptance
for external review. The IRO will reviewall of the information and documents received and will provide
its written final external review decision to the claimant and Horizon BCBSNJ within 45 days after the
IRO first received the request for the external review. Upon receipt of a final external review decisi o n
reversing an adverse benefit determination, Horizon BCBSNJ will provide coverage or payment for
the claim(s) or service(s) involved. If the final external review decision upholds the adverse benefit
determinati on, no further action is taken and the SEHBP plan Medical Appeal s Process is complete.
The Standard External Appeal rights described may be expedited in the following
circumstances:
The initial adverse benefit determination involving medical judgment concerns a medical condition
such that the completion of a Standard Internal Appeal would seriously jeopardize the life or health
of the member or would jeopardize the memb er’ s ability to regain maxi mum functi on, and the member has
filed a request for an Expedited Internal Appeal;
OR
The final adverse benefit determination (decision upon appeal) involving medical judgment concerns
a medical condition such that the completion of a Standard External Appeal would seriously jeopardize
the life or health of the member or would jeopardize the member’s ability to regain maximum function,
or if final adverse benefit determination involving medical judgment concerns an admission, availability
of care, continued stay or a health care item or service for which the member received emergency
services, but has not been discharged from the facility.
In instances of an expedited request, your request can be made by calling a Horizon BCBSNJ Appeals
Coordinator at 1-888-221-6392. For Expedited External Review requests, the final notice of the
decision must be provided as expeditiously as the member’s medical condition or circumstances
require, but in no event shall exceed 72 hours from the IRO’s receipt of the request for Expedited
External Review.
60
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
APPEAL RIGHTS EXCLUSIVE TO SUBSTANCE USE DISORDER
A Member (or a Provider acting for the Member, with the Member’s consent) may appeal an adverse
benefit determination with respect to substance use disorder.
The appeal process for adverse benefit determinations involving medical judgment with respect to
substance use disorder consists of the following:
(a) an internal review by Horizon BCBSNJ (a "Substance Use Disorder First Level Appeal"); and
(b) for appeals related to inpatient care beyond the first 28 days, a formal expedited external
review with the Independent Health Care Appeals Program at DOBI (a "Substance Use
Disorder External Appeal") followed by the option of an appeal to the Commission; and
(c) for all other substance use disorder appeals, a second level internal appeal as discussed
under the Second Level Medical Appeals section above; and
(d) an external appeal for appeals denied at the second level internal appeal.
(e)
Commi ssi o n
Appeal
as
detail ed
in
this
Guidebook.
Substance Use Disorder First Level Appeal
A member (or a provider acting for the member, with the member’s consent) can file a Substance Use
Disorder First Level Appeal by calling or writing Horizon BCBSNJ at the telephone number and
address in the First Level Medical Appeal section above. At the Substance Use Disorder First Level
Appeal, a member may discuss the adverse benefit determination directly with the Horizon BCBSNJ
physician who made it, or with the medical director designated by Horizon BCBSNJ.
To submit a Substance Use Disorder First Level Appeal, the member must include the following
information:
(1) the name(s) and address(es) of the member(s) or provider(s) involved;
(2) the member’s identification number;
(3) the date(s) of service;
(4) the details regarding the actions in question;
(5) the nature of and reason behind the appeal;
(6)
the
remedy
sought;
and
(7) the documentation to support the appeal.
First Level Appeals will be reviewed and decided in the time frames described in First Level Medical
Appeals above except First Level Medical Appeals related to inpatient care beyond the first 28 days
will be reviewed and decided within 24 hours of receipt. Horizon BCBSNJ will provide the member
and the provider with: (a) written notice of the outcome; (b) the reasons for the decision; and (c) if the
initial adverse benefi t determi nati on is uphel d, instructi ons for filing a Substance Use Disorder Secon d
Level Appeal.
Substance Use Disorder Second Level Appeal
This section applies to all substance use disorder appeals with the exception of appeals related to
inpatient care beyond the first 28 days. A member (or a provider acting for the member, with the
member’s consent) who is dissatisfied with the results of Horizon BCBSNJ's internal First Level
Appeal process with respect to an adverse benefit determination can pursue a Substance Use
Disorder Internal Second Level Appeal. The procedures for filing a Substance Use Disorder Second
Level Appeal are the same as in those set forth above in “Second Level Medical Appeal Rights".
SEHBPMEMBER GUIDEBOOK
61
Substance Use Disorder Appeals specific to Inpatient Care after the first 28 days
This section applies to all substance use disorder appeals related to inpatient care beyond the first
28 days. A member (or a provider acting for the member, with the member’s consent) who is
dissatisfied with the results of Horizon BCBSNJ's internal appeal process with respect to an adverse
benefit determination can pursue a Substance Use Disorder External Appeal, an expedited external
appeal with an IRO assigned by the DOBI. All appeals filed in accordance with th is paragraph must
be filed with the Independent Health Care Appeals Program in the New Jersey Department of Banking
and Insurance.
The IRO will complete its review of the Substance Use Disorder Second Level Appeal and issue its
decision in writing within 24 hours from its receipt of the request for the review.
Commission Appeal
Once all appeal options have been exhausted through Horizon BCBSNJ, the member may appeal to
the School Employees’ Health Benefits Commission (Commission). For information on how to request
a Commission Appeal, please refer to the Commission Appeal section of this Guidebook.
SEHBP PLANS ADMINISTRATIVE APPEAL PROCEDURE
The member or the member’s authorized representative may appeal and request that Horizon
BCBSNJ reconsider any claim or any portion(s) of a claim for which they believe benefits have been
erroneously denied based on the SEHBP plan’s limitations and/or exclusions. This appeal may be on
an administrative nature. Administrative appeals question plan benefit decisions such as whethera
particular service is covered or paid appropriately. Examples of Administrative Appeals include:
Visits beyond the 30-visit chiropracticlimit;
Benefits
beyond
the
reasona bl e
and
customary
allowance;
Routine Vision Services renderedout-of-network;
Benefits for a wig that exceed the $500/24 month limit;
Hearing Aid for a 60–year-old member.
Adverse benefi t determi nati o ns involving the applicati on of plan benefi ts may usually be appeal ed up
to three (3) times as outlined below:
First Level Administrative Appeal – The First Level Administrative Appeal of an adverse
benefit determination;
Second Level Administrative Appeal – The Second Level Administrative Appeal of an
adverse benefit determination available to you after completing a First Level Administrative
Appeal; and
Commission Appeal – The Third Level Administrative Appeal of an adverse benefit determination,
which, at your request, would generally follow a Second Level Administrative Appeal. A Commission
Appeal provides you the right to appeal to the School Employees’ Health BenefitsCommission.
An overviewof the administrative appeal process is provided below. A SEHBP Administrative Appeals
Procedure brochure will be provided with every administrative adverse benefit determination. The
brochure provides a comprehensive description of the procedures.
62
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
First Level Administrative Appeal
The member may request an administrative appeal by calling 1-800-414-SHBP (7427) or submitting
a written appeal to:
Horizon BCBSNJ
SEHBP Appeals
P.O. Box 820
Newark. NJ 07101
The member has one (1) year following your receipt of the initial adverse benefit determination letter
to request an Administrative Appeal.
The First Level Administrative Appeal should include the following information:
Name and address of the patient and theSEHBPplan member;
Member’s SEHBP plan identification number;
Date(s)
of service(s);
Provider’s
name
and
identifi cati on
number;
Physician’s name and identificationnumber;
The reason you think the claim/service should be reconsidered; and
All documentation supporting your appeal.
You will receive a written response to your First Level Administrative Appeal within 30 days. If you
are not satisfied with this written determination, a Second Level Administrative Appeal may be
requested.
Second Level Administrative Appeal
The member may request a Second Level Administrative Appeal within one (1) year following receipt
of the initial adverse benefit determination letter by calling 1-800-414-SHBP (7427), or by writing to
the address noted earlier. The member may also send an appeal via fax to 1-973-274-4599.
During the Second Level Administrative Appeal, Horizon BCBSNJ will review any additional evidence
the member wished to supply in support of the appeal. The member will receive a written
determination of the final decision within 30 days. This will complete the Horizon BCBSNJ appeal
options.
Commission Appeal
Once all appeal options have been exhausted through Horizon BCBSNJ, the member may appeal to
the School Employe es’ Health Benefi ts Commi ssi on (Commi ssi o n). If dissatisfi ed with a final Hori zo n
BCBSNJ decision on an admi nistrative
appeal ,
you have one (1) year from the date of final adverse
bene fi t
determi nati on letter to request a Commi ssi o n Appeal . Only the member or the member’s legal
representative may appeal, in writing, to the 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:
Appeals Coordinator
School Employees’ Health Benefits Commission
P.O. Box 299
Trenton, NJ 08625-0299
SEHBPMEMBER GUIDEBOOK
63
The member will be advised by the Commission how to arrange a hearing date, the date of the
hearing and the option to attend and appear before the Commission.
Notification of all Commission decisions will be made in writing to the member. 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 in writing to the Commission, within 45 days, 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 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. The member will be responsible for any
expenses involved in gathering evidence or material that will support the grounds for appeal. The
member will be responsible for any court filing fees or related costs that may be necessary duringthe
appeal process. If an attorney or expert medical testimony is required, the member will be responsible
for any fees or costs incurred.
If the recommendation is rejected, the administrative appeal process is ended. When the
administrative process is ended, further appeals may be made to the Superior Court of New Jersey,
Appellate Division.
PRESCRIPTION DRUG BENEFITS
The School Employees’ Health Benefits Commission require that all covered employees and
retirees have access to prescription drug coverage.
See the SHBP/SEHBP Prescription Drug Plans Member Guidebook for additional information on
prescription drug benefits and limitations.
Certain drugs that require administration in a physician’s office may be covered through your medical
plan (instead of your prescription plan) under the Specialty Pharmacy Program.
The SEHBPHealth Plans cover only prescription drugs administered while you are an inpatient in a
covered health care facility.
Please refer to the SHBP/SEHBP Prescription Drug Plans Member Guidebook for more information
regarding your prescription drug benefits.
Note: Oral Contraceptive coverage is available through this medical plan.
64
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
COBRA COVERAGE
CONTINUING COVERAGE WHEN IT WOULD NORMALLY END
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal 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 periods (see
“Duration of COBRA Coverage” in this Guidebook), and the member must pay the full cost of the
coverage plus an administrative fee.
Leave taken under the federal and/or State Family Leave Act is not subtracted from your COBRA
eligibility period.
Under COBRA, you may elect to enroll in any or all of the coverage s 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 "qualifyi ng event" (marriag e, birth or adopti on of a child, etc.) occurred within 60 days of the
COBRA event.
Open Enrollment — COBRA enrollees have the same rights to coverag e at Open Enrollme nt as are
available to active employees. This means that you or a dependent who elected to enroll under
COBRA are able to enroll, if eligible, in any medical, dental, or prescription drug coverage during the
Annual Open Enrollment Period regardless of whether you elected to enroll for the coverage when
you went into COBRA. This affords a COBRA enrollee the same opportunity to enroll for benefits
during the Annual Open Enrollment Period as an active employee. However, any time of non-
participation in the benefit is counted toward your maximum COBRA coverage period. If the State
Health Benefits Commission or School Employees’ Health Benefits Commission make changes to
any benefit plan available to active employees and/or retirees, those changes applyequally to COBRA
participants.
COBRA Events
Continuation of group coverage under COBRA is available if you or any of your covered dependents
who would otherwise lose coverage as a result of any of the following events:
Termination of employment (except for gross misconduct);
Death
of
the
member/reti ree;
Reducti o n
in
work
hours;
Leave of absence;
Divorce, legal separation, dissolution of a civil union or domestic partnership (makes
spouse/partner ineligible for further dependent coverage);
Loss of a dependent child's eligibility through the attainment of age 26; or
The employee elects Medicare as primary coverage. (Federal law requires active employees
to terminate their employer's health coverage if they want Medicare as their primary coverage.)
Note: Employees who at retirement are eligible toenroll in SEHBP Retired Group coverage cannot enroll for
health benefits coverage under COBRA.
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.
SEHBPMEMBER GUIDEBOOK
65
Cost
of COBRA
Coverage
If you choose to purchase COBRA benefits, you pay 100 percent of the cost of the coverag e plus a two
percent charge for administrative costs.
Duration
of COBRA
Coverage
COBRA coverage may be purchase d for up to 18 months if you or your depend ents become eligi bl e
because of termination of employment, a reduction in hours, or a leave of absence.
Coverage may be extende d up to 11 additi onal months,
for a total
of 29 months,
if you have
a Soc ial Securi ty
Administrati on approved disability (under
Title II or XVI of the Social
Security
Act) for a conditi on
that exi sted
when you enroll ed in COBRA
or began within the first 60 days of COBRA
coverage. Proof of Social Securi ty
Administrati on determi n ati o n must be submitted to the
Health
Benefi ts
Bureau
of the Division
of Pensi o ns
& Benefi ts within 60 days of the award or within 60 days of COBRA enroll ment. Coverage will cease either
at the end of your COBRA eligibility or when you obtain Medicare coverage, whichever comes first.
COBRA coverag e may be purchased by a depen dent for up to 36 months if he or she becomes eligi bl e
because of your death, divorce, dissolution of a civil union or domestic partnership, or a child
becomes ineligible for continued group coverage because of attaining age 26, or because you
elected Medicare as your primarycoverage.
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.
Employer Responsibilities under COBRA
The COBRA law requires employers to:
Notify you and your dependents of the COBRA provisions within 90 days of when you and
your dependents are first enrolled;
Notify you and your dependents of the right to purchase con tinued coverage within 14 days
of receiving notice that there has been a COBRA qualifying event that causes a loss of
coverage;
Send the COBRA Notification Letter and a COBRA Application within 14 days of receiving
notice that a COBRAqualifying event has occurred;
Notify the Health Benefits Bureau of the Division of Pensions & Benefits within 30 days of the
loss of an employee’s coverage; and
Maintain records documenting their compliance with the COBRAlaw.
Employee Responsibilities under COBRA
The law requires that you and/or your dependents:
Must notify your employer (if you are retired, you must notify the Health Benefits Bureau of
the Division of Pensions & Benefits) that a divorce, legal separation, dissolution of a civil union
or domestic partnership, or your death has occurred or that your child has reached age26 —
notification must be given within 60 days of the date the event occurred;
File a COBRA Application (obtained from your employer or the Health Benefits Bureau) within
60 days of the loss of coverage or the date of the COBRA Notice provided by your employer,
whichever is later;
Pay the required monthly premiums in a timely manner; and
Pay
premi ums,
when
billed,
retroacti ve
to
the
date
of
group
coverage
terminati o n.
66
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Failure to Elect COBRA Coverage
In consideri ng whether to elect continuati on of coverag e 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.
You should take into account that you have special enroll ment rights under federal law. You have the right
to request special enrollment in another group health plan for which you are otherwise eligible (such
as a plan sponsored by your spouse’s empl oyer) within 30 days of the date your group coverage ends.
You will also have the same special enrollment right at the end of the COBRA coverage periodif you
get the continuation of coverage under COBRA for the maximum time available to you.
Termination of COBRA Coverage
Your COBRA coverage will end when any of the following situations occur:
Your
eligibility
period
expires;
You fail to pay your premiums in a timely manner;
After
the
COBRA
event,
you
become
covered
under
another
group
insurance
program;
You voluntarily cancel your coverage;
Your employer drops out of the SEHBP; or
You become eligible for Medicare after you elect COBRA coverage. (This affects health
insurance only - not dental, prescription, or vision coverage.)
APPENDIX I
SPECIAL PLAN PROVISIONS
WORK-RELATED INJURY OR DISEASE
Work-related injuries or diseases are not covered under the SEHBP plans. This includes the
following:
Injuries arising out of or in the course of work for wage or profit, whether or not your injuries
are covered by a Workers' Compensation policy.
Disease caused by reason of its relation to Workers' Compensation law, occupational disease
laws, or similar laws.
Work-related tests, examinations or immunizations of any kind required by your work except
employer-mandated examinations that are a prerequisite for participation in an employer
mandated physical fitness test required as a condition of continuing employment.
Work-related injuries will not be eligible for benefits under your medical plan before or after
your Workers’ Compensati on carrier has settled or closed your case.
Please note: If you collectbenefits for the same injuryor disease from both Workers' Compensation
and your SEHBP plan, you maybe subject to prosecution for insurance fraud.
MEDICAL PLAN EXTENSION OF BENEFITS
If you or a dependent are disabled with a condition or illness at the time of your termination from the
SEHBP, you may qualify for an extension of benefits for this specific condition or illness. You do not
qualify for an extension of benefits if you currently have or are eligible for any other type of medical
coverage including but not limited to Medicare. If you feel that you may qualify for an extension of
benefits please contact Horizon BCBSNJ at 1-800-414-SHBP (7427) for assistance.
SEHBPMEMBER GUIDEBOOK
67
If the extension applies, it is only for eligible expenses relating to the disabling condition or illness. An
extension under the SEHBP plan will be for the time you or your dependent remains disabled from
any such condition or illness, but not beyond the end of the calendar year after the one in which your
coverage ends.
68
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
TERMINATION FOR CAUSE
If any of the following conditions exist, you may receive written notice that you will no longer be
covered under the SEHBP plan.
If, after reasonable efforts, the SEHBP plan and/or participating providers are unable to
establish and maintain a satisfactory, provider/patient relationship with you or you repeatedly
act in a manner which is verbally or physically abusive.
If you permit any person who is not authorized to use the identification card(s) issued to you.
You may be liable for the cost of any claims paid for services for an ineligibleindividual.
If you willfully furnish incorrect or incompl ete informati on in a statement made for the purpo s e
of effecting coverage.
If you abuse the system, including, but not limited to theft, damage to a participati ng provid e r’ s
property, or forgery of prescriptions.
Any action by the SEHBP plan under these provisions is subject to review in accordance with the
established appeals procedures. If an appeal is denied and the decision upheld, this action is subject
to appeal to the School Employees’ Health Benefits Commission. No benefits, other than for
emergencies, will be provided to the member and to any family members under the coverage as of
31 days after such written notice is given by the SEHBP plan. If the School Employees’ Health
Benefits Commission overrules the decision to terminate, benefits will be restored.
APPENDIX II
SUMMARY SCHEDULESOF SERVICES AND SUPPLIES
New Jersey statutes, administrative code, and agreements between the SEHBP and Horizon
BCBSNJ govern this plan. The following schedules of benefits are summary descriptions of plan
benefits and are not a complete listing. They do not describe all the limitations or conditions associated
with the coverage as described in other sections of this Guidebook. All pertinent pa rts of this
Guidebook should be consulted regarding a specific benefit. Health decisions should not be made on
the basis of the information provided in these schedules. Horizon BCBSNJ will administer the
coverage listed in the Schedule of Covered Services and Supplies, subject to the terms, conditions,
limitations, and exclusions stated within this Guidebook. 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. Certain services
are subject toprecertification.
SEHBPMEMBER GUIDEBOOK
69
SEHBP Plans ELIGIBLE SERVICES AND SUPPLIES
In-Network: The following copayments apply to in-network office and emergency room visits unless
otherwise indicated on the Summary Schedule of Services and Supplies. If the member is admitted
within 24 hours, the emergency room copayment is waived.
SEHBP PLAN OPTION
Primary Care
Office Visit
Copayment
Specialty Care Office Visit Copayment
Emergency
Room
Copayment
NJ DIRECT10
$10
$10
$25
NJ DIRECT15
$15
$15
$50
NJ Educators Health Plan
$10
$15
$125
NJ DIRECT1525*
$15
$25
$75
NJ DIRECT2030*
$20
$30 for adults;
$20 for children to end of year the child
turns 26
$125
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select
one of these two plans as supplemental to Medicare.
In-network coinsurance applies to the following services; ambulance transport, durable medical
equipment, some foot orthotics and prosthetics, oxygen therapy and outpatient private duty nursing.
The plan benefit for these services is 90 percent.
Out-of-network: Where indicated under “Out-of-Network” services in the following pages, the
reimbursement is 80 or 70 percent of the reasonable and customary or out-of-network allowance based
on the SEHBP plan option selected, unless otherwise indicated. Before out-of-network benefitsare paid,
the annual in-network deductible must be satisfied. Out-of-Network coverage for chiropracticservices,
acupuncture services and physical therapy services will be subject to a fixed dollar limit per visit.
SEHBP Plan Option
SEHBP Out-of-Network Benefit Level
(Unless otherwise indicated)
NJ DIRECT10
80%
Of the reasonable and customary allowance
after the deductible is satisfied
NJ DIRECT15
NJ DIRECT1525*
NJ DIRECT2030*-
70%
NJ Educators Health Plan
Of the reasonable and customary allowance
after the deductible is satisfied
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select one of
these two plans as supplemental to Medicare.
70
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
SEHBP Plans COVERED SERVICES
Acupuncture for Pain Management Only
In-Network................................................................................................100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance,
limited to $60 per visit
Alcohol or Substance Abuse Treatment (Inpatient) - See Substance Use Disorder Treatment
Alcohol or Substance Abuse Treatment (Outpatient) - See Substance Use Disorder Treatment
Allergy Testing
In-Network........................................................................................... 100 percent coverage
Out-of-Network ........................... 80/70/6 percent of the reasonable and customary allowance
Ambulance Services
In-Network............................................................................................. 90 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Ambulatory Surgery
In-Network........................................................................................... 100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Anesthesia
In-Network........................................................................................... 100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Biofeedback
In-Network........................................................................................... 100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Chiropractic Services (No Referral Required)
Combined In-Network and Out-of-Network 30 visit maximum benefit per calendar year
In-Network.......................... 100 percent coverage for maximum of 30 visits per calendar year
Out-of-Network ..................... 80/70percent of the reasonable and customary allowance, limited to
........................................ $35 per visit
Diagnostic X-Ray
In-Network........................................................................................... 100
percent
coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Dialysis Center Charges
In-Network.......................................................................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
SEHBPMEMBER GUIDEBOOK
71
Durable Medical Equipment
In-Network............................................................................................. 90 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Emergency Room
In-Network.................................. 100 percent coverage, after the emergency room copayment*
Out-of-Network** ........................ 100 percent coverage, after the emergency room copayment*
*For both in-network and out-of-network services, the copayment is waived if the patient is admitted due to
the emergent condition**The out-of-network benefitapplies if thepatient’s condition is non-emergent.
Hospital Charges
In-Network.......................................................................................... 1000 percent coverage
Out-of-Network ........................................ 80/70 percent coverage, subject to precertification
A separate inpatient deductible per inpatient hospital stay applies to NJ DIRECT1525, NJ DIRECT2030,
The standard deductible applies to the NJ DIRECT10 NJ DIRECT15 and the NJ Educators Health Plan.
Home Health Care
In-Network........................................................................................... 100
percent
coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Hospice Care
In-Network......................................................................................... 100 percent
coverage
Out-of-Network .......................... 80/70 percent of the reasonable and customary allowance
NOTE: Inpatient Hospice Care: A separate inpatientdeductible per inpatient hospital stay applies
to the NJ DIRECT1525 and NJ DIRECT2030. The standard deductible applies to NJ DIRECT10,
NJ DIRECT15 and the NJ Educators Health Plan.
Inherited Metabolic Disease Medical Foods
In-Network............................................................................................. 90 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Inpatient Physician Services
In-Network......................................................................................... 100 percent
coverage
Out-of-Network .......................... 80/70 percent of the reasonable and customary allowance
Laboratory Services
In-Network......................................................................................100 percent
coverage
Out-of-Network ................................................................. 80/70 fornon-routine services
Maternity/Obstetrical Care
In-Network....................................... 1000 percent coverage after a copayment for initial visit
Out-of-Network .......................... 80/70 percent of the reasonable and customary allowance
72
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Mental or Nervous Condition Treatment (Inpatient)
In-
Network
..........................................................................................
100
percent
coverage
Out-of-Network ...................................... 80/70 percent coverage, subject to precertification
A separate inpatient deductible per inpatient hospital stay applies to the NJ DIRECT1525 and NJ
DIRECT2030. The standard deductible applies to the NJ DIRECT10, NJ DIRECT15 and the NJ
Educators Health Plan.
Mental or Nervous Condition Treatment (Outpatient)
In-Network Office Visit ........................................................................... 100 percent coverage
In-Network Outpatient Visit ..................................................................... 100 percent coverage
Out-of-Network ............................... 80/70 percent of the reasonable and customary allowance
Nutritional Counseling
In-Network.................................................................... 100 percent coverage (3 visits per year)
Out-of-Network................................................................................................. No coverage*
*For eating disorder diagnoses only, there are no visit limitations for services rendered in-network
or out-of-network. Deductible and coinsurance applies to services rendered out-of-network.
Physical Therapy and Occupational Therapy
In-Network Office Visit .............................................................................100 percent coverage
In-Network Outpatient Visit ...................................................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance,
limited to $52 per visit.
Pre-Admission Testing
In-Network........................................................................................... 100percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Preventive Care
Under the Patient Protection and Affordable Care Act, some preventive care services are covered
with no out-of-pocket cost (no copayment), when you receive the services from an in-network health
care professional and the sole reason for the visit is to receive the preventive care services. If your
health care professional provides a preventive service as part of an office visit, you may be responsible
for cost sharing for the office visit if the preventive service is not the primary purpose of your visit or if
the provider bills you for the office visit separately from the preventive care.
Annual Routine Gynecological Care and Examination (limited to one per year)
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network ..................... 80/70/60 percent of the reasonable and customary allowance
Annual
Wellness
Visit
(Preventive
Care)
(limited
to
one
per
year)
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network .............................................................................................No coverage
SEHBPMEMBER GUIDEBOOK
73
Immunizations
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network .............................................................................................No coverage
Annual
Routine
Mammography
(limited
to
one
per
year)
In-Network ........................................................... 100percent coverage (no copayment)
Out-of-Network ............................. Coverage for one routine mammography is eligible at the
Out-of-Network level and is covered at 80/70percent of the reasonable and customary
allowance
PAP Smears
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network
......................................
…..80/70percent
of
the
reasona bl e
and
customary
allowance for an annual routine pap smear
Prostate Cancer Screening
In-Network...................................................................................... …..100 percent
coverage
Out-of-Network .............................................................................................No coverage
Well-Child Care
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network .............................................................................................No coverage
Well-Child Immunizations
In-Network ................................................................ 100 percent coverage (no copayment)
Out-of-Network (for children to age 12 months only) 80/70percent of the reasonable and
customary allowance
Private Duty Nursing (Outpatient)
In-Network............................................................................................. 90percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Second Surgical Opinion Charges (Voluntary)
In-Network................................................................................................100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Skilled Nursing Facility Charges
Combined In-Network and Out-of-Network Maximum of 120 Days
In-Network................................. 100percent coverage for up to 120 days per calendar year
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
up to 60 days per calendar year.
NOTE: A separate inpatient deductible per inpatient hospital stay applies to the NJ DIRECT1525
and NJ DIRECT2030. The standard deductible applies to the NJ DIRECT10, NJ DIRECT15 and
the NJ Educators Health Plan.
74
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Specialist Office Visits
In-Network............................................................................................ 100
percent coverage
Out-of-Network ................ 80/70percent of the reasonable and customary allowance
Specialized Non-Standard Infant Formula
In-Network............................................................................................. 90percent coverage
Out-of-Network........................80/70percent of the reasonable and customary allowance
Speech Therapy
In-Network................................................................................................100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Substance Use Disorder Treatment (Inpatient)
In-Network........................................................................................... 100
percent
coverage
Out-of-Network ....................................... 80/70percent coverage, subject to precertification
NOTE: A separate inpati ent deducti bl e per inpati ent hospital stay applies to the NJ DIRECT1525
and NJ DIRECT203 0. The standard deducti bl e applies to the NJ DIRECT10, NJ DIRECT15 and
NJ Educators Health Plan.
Substance Use Disorder Treatment (Outpatient)
In-Network........................................................................................... 100
percent
coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Surgical Services
In-Network......................................................................................100 percent
coverage
Out-of-Network......................... 80/70percent of the reasonable and customary allowance
Telemedicine*
In-Network......................................................................................... 100/ percent coverage
Out-of-Network .......................... 80/70percent of the reasonable and customaryallowance
Transplant Benefits
In-Network.......................................................................................... 100percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Vision Examination (routine exam limited to one per year)
In-Network..........................................................................................100 percent coverage
Out-of-Network .............................................................................................No coverage
SEHBPMEMBER GUIDEBOOK
75
APPENDIX III
GLOSSARY
Accidental Injury — Physical harm or damage done to a person as a result of a chance or
unexpected occurrence.
Active Group Member (subscriber) — An employee who has met the requirements for participation
and has completed a form constituting written notice of election to enroll for coverage for him or herself
and, if applicable, any eligible dependents. Also includes eligible employees or dependents who
continue coverage as a subscriber in the COBRAprogram.
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 reviewa 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 Health Benefits Commission may only be filed by a member or the member's
legal representative.
Benefit Period — The twelve-month period starting on January 1st and ending on December 31st.
The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins
on your coverage date. The last Benefit Period ends when you are no longer covered.
Calendar Year — A year starting January 1 and ending on December 31.
Case Manager — A person or entity designated by the plan to manage, assess, coordinate, direct,
and authorize the appropriate level of health care treatment.
Civil Union Partner — A person of the same sex with whom you have entered into a civil union. A
photocopy of the New Jersey Civil Union Certificate or a valid certification from another jurisdiction
that recognizes same-sex civil unions and additional supporting documentation are required for
enrollment. The cost of civil union partner coverage may be subject to federal tax (see your employer
or the Civil Unions and Domestic Partnerships Fact Sheet for details).
COBRA — Consolidated Omnibus Budget Reconciliation Act of 1985. This federal law requires
private employers with more than 20 empl oye es and all public employers to allow covered employees and
their dependents to remain on group insurance plans for limited time periods at their own expense
under certain conditions.
Coinsurance — The portion of an eligible charge which is the member's financial responsibility for
out-of-network services.
Coordination of Benefits — The practice of correlating the payments a plan makes with payments
provided by other insurance covering the same charges or expenses, so that (1) the plan with primary
responsibility pays first, (2) reimbursement does not exceed 100 percent of the actual expense, and
(3) the plan does not pay more than it would if no other insurance existed.
76
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Copayment — The fee charged to a member or patient to be paid directly to the participating provider
or network specialist at the time treatment is rendered for certain covered services.
Cosmetic Services — Services rendered to refine or reshape body structures or surfaces that are
not functionally impaired. They are to improve appearance or self-esteem, or for other psychological,
psychiatric or emotional reasons.
Covered Person (member) — An employee, retiree, or COBRA participant or a dependent of an
employee, retiree, or COBRA participant who is enrolled.
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 plan,
including those that are considered to be medically needed.
Dependent — A member's spouse, civil union partner, or same-sex domestic partner (as defined by
Chapter 246, P.L. 2003); and child(ren) under the age of 26. Children include natural, adopted, foster,
and stepchildren. If a covered child is not capable of self-support when he or she reaches age26 due
to mental illness, or developmental or physical disability, coverage may be continued subject to
approval.
Deductible — The portion of the first eligible charges submitted for payment in each calendar year
that the out-of-network portion of the SEHBP plan requires the member or covered dependent to pay.
Detoxification Facility — A health care facility licensed by the state as a detoxifi cati on facility for the
treatment of substance use disorder.
Domestic Partner — A person of the same sex with whom you have entered into a domestic
partnership as defined under Chapter 246, P.L. 2003, the Domestic Partnership Act. The domestic
partner of any State employee, State retiree, or an eligible employee or retiree of a participating local
public entity that adopts a resolution to provide Chapter 246 health benefits, is eligible for coverage.
A photocopy of the New Jersey Certificate of Domestic Partnership dated prior to February 19, 2007
(or a valid certification from another State or foreign jurisdiction that recognizes same -sex domestic
partners) and additional supporting documentation are required for enrollment. The costof same -sex
domestic partner coverage may be subject to federal tax (see your employer or the Civil Unions and
Domestic Partnerships Fact Sheet for details).
Durable Medical Equipment — Equipment determined to be:
Designed and able to withstand repeated use;
Made for and used primarily in the treatment of a disease or injury;
Generally
not
useful
in the
absence
of
an
illness
or
injury;
Suitable for use while not confined in a hospital;
Not for use in altering air quality or temperature; and
Not for exercise or training.
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:
Medically needed at the appropriate level of care for the medical condition;
Listed in covered services and supplies;
Ordered
by
a
doctor
(as
defined
by
the
SEHBP
plans)
for
treatment
of
illness
or
injury;
SEHBPMEMBER GUIDEBOOK
77
Not specificall y excluded (listed in the “Charges Not Covere d by the SEHBP plans” section);
and
Provided while you or your eligible family members were covered bythe SEHBPplans.
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:
Placing the health of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in seriousjeopardy;
Serious impairment to bodily function; and/or
Serious dysfunction of bodily organ or part.
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 local education public employer that participates in the School Employees’ Health
Benefits Program.
Facility Charges — Charges from an eligible medical institution such as a hospital, residential
treatment center, detoxification center, ambulatory or separate surgical center, dialysis center, or a
skilled nursing center.
Family or Medical Leave of Absence — A period of time of pre-determined length, approved by the
employer, during which the employee does not work, but after which the employee is expected to
return to active service. Any employee who has been granted an approved leave of absence in
accordance with the Family and Medical Leave Act of 1993 shall be considered to be active for
purposes of eligibility for covered services and supplies under your group's program.
Full Medicare Coverage — Enrollment in both Part A (Hospital Insurance) and Part B (Medical
Insurance) of the federal Medicare Program. State law requires that anyone who is enrolled in the
Retired Groupandis 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 or School Employees’
Health Benefits Program.
Gestational Carrier — A woman who has become pregnant with an embryo or embryos that are not
part of her genetic or biologic entity, and who intends to give the child to the biological parents after
birth.
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 that 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.
78
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Hospital — An approved institution that meets the tests of 1, 2, 3, 4, or 5, listed 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 init.
3. It is licensed as an ambul atory or separate surgical center. The center must mainly provide
outpatient surgical care and treatment.
4. It is an institution for the treatment of substance use disorder not meeting all the tests of (1)
or (2) but which is:
A licensed hospital; or
A licensed detoxification facility; or
A residential treatment facility that is approved by a state under a program that meets
standards of care equivalent to those of the Joint Commission on Accreditation of
Hospitals. (Educational services provided while at an approved treatment facility is not
eligible.)
5. It is a birth center that is licensed, certified, or approved by a departme nt of health or other
regulatory authority in the state where it operates or meets all of the following tests:
It is equipped and operated mainly to provide an alternative method of childbirth.
It is under the direction of a doctor;
It allows only doctors to perform surgery;
It requires an exam by an obstetrician at least once before delivery;
It offers prenatal and postpartum care;
It has at least two birthing rooms;
It has the necessary equipment and trained people to handle foreseeable emergencies.
The equipment must include a fetal monitor, incubator, and resuscitator;
It has the services of registered graduatenurses;
It does not allow patients to stay more than 24 hours;
It has written agreeme nts with one or more hospitals in the area that meet the tests listed above
in (1) or (2) and will immediately accept patients who develop complications or require
post-delivery confinement;
It provides for periodic reviewby an outside agency; and
It maintains proper medical records for each patient.
“Hospital” does not include a nursing home. Neither does it include an institution, or part of one,
that:
Is
used
mainly
as
a
place
for
convalescence,
rest,
nursing
care,
or
for
the
aged
or
drug
addicts;
Is used mainly as a center for the treatment and educati on of children with mental disorde rs
or learning disabilities; or
Provides home-like or custodial care.
SEHBPMEMBER GUIDEBOOK
79
Illness — Any disorder of the body or mind including substance use disorder.
Injury — Damage to the body.
Local Employee — For purposes of health benefits 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 25 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 — Care that 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 SEHBPplans.
Medical Need and Appropriate Level of Care — A service or supply that the SEHBP plan
determines meets each of these requirements:
It is ordered by a doctor for the diagnosis or the treatment of an illness or injury;
The prevailing opinion within the appropriate specialty of the United States medical profession
is that it is safe and effective for its intended use, and that its omission would adversely affect
the person's medicalcondition;
That it is the most appropriate level of service or supply considering the potential benefits and
harmto the patient; and
It is known to be effective in improving health outcomes (for new interventions, effectiveness
is determined by scientific evidence; then, if necessary, by professional standards; then, if
necessary, by expert opinion).
With respect to treatment of substance use disorder, the determination of Medical Need and
Appropriate Level of Care shall use an evidence-based and peer reviewed clinical tool as designated
in regulation by the Commissioner of Human Services.
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 SEHBP Retired Group coverage.
Member — An employee, retiree, COBRA enrollee or dependent who is enrolled under the SEHBP
plans.
80
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
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 use disorder.
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 conditi on involving one or more teeth, the tissue or structure around them, or the
alveolar process of the gums.
Off-Label Use — A drug not approved by the FDA for treatment of the condition in question or
prescribed at a different dosage than the approved dosage.
Out-of-Network Benefits — Benefits provided by the SEHBP plans when members do not use
network providers for their medical treatment or do not follow the managed care guidelines.
Out-of-Network Plan Allowance — An out-of-network plan allowance is used on the benefit
determination when valid reasonable and customary data is not available. The out-of-network
allowance is used to establish a reasonable level of reimbursement. One example is the allowance
for Ambulatory Surgery Centers (ASC’s). The out-of-network allowance used for ASC's is based on
a percentage of the Centers for Medicare and Medicaid Services (CMS) allowance. For the NJ
Educators Health Plan, the reasonable and customary allowance is based on 200% of CMS.
Participating Provider — A doctor or hospital which has a written agreement with the SEHBP plan to
provide care.
Precertification — A process by which the eligibility and medical appropriateness of services or
supplies is determined before services are rendered.
Primary Health Plan — A plan that 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 — The term is used to define an eligible provider and includes medical docto rs, dentists,
podiatrists, acupuncturists, psychologists, psychiatrists, physician assistants, nurse midwives,
licensed clinical social workers, licensed marriage and family therapists, licensed professional
counselors, board certified behavior analysts – doctoral (BCBA-D), board certified behavior analysts
(BCBA), ABA therapist credentialed by the National Behavior Analyst Certification Board (BACB) or
working under the direct supervision of a BCBA or BCBA-D, chiropractors, certified nurse
practitioners, clinical nurse specialists, Registered Nurse First Assistants (RNFA), physical therapists,
occupational therapists, optometrists, and audiologists who are properly licensed and are working
within the scope of their practice.
SEHBPMEMBER GUIDEBOOK
81
Reasonable and Customary —except where noted, SEBHP plans cover only reasonable and
customary allowances, which are determined by a percentile of the FAIR Health National benchmark
charge data or other nationally recognized database. This schedule is based on actual charges by
physicians nationally 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 are requiredto pay. In some instances
the out-of-network allowance is derived from an alternate nationally recognized source. One example
is Ambulatory Surgery Centers (ASC’s). The out-of-network plan allowance used for ASC’s is based
on a percentage of the Centers for Medicare and Medicaid Services (CMS) allowance. For the NJ
EducatorsHealth Plan, the reasonable and customary allowanceis based on 200% of CMS.
Residential Treatment Facility — A health care facility licensed by the State of New Jersey for
treatment of substance use disorder or meeting the same standards, if out-of-state.
Respite Care — Short-term or temporary care provided for the hospice patient in order to provide
relief, or respite to the family caregiver.
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 Retired Group coverage in the SEHBP for him/her self 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 in
Retired Group coverage for him/herself and, if applicable, any eligible dependents. Also includes a
surviving dependentchild of a deceased Retired Group member who had parent- child(ren) coverage,
providing he or she has completed a form constituting written notice of election to enroll in Retired
Group coverage.
School Employees’ Health Benefits Commission — The entity created by N.J.S.A. 52:14-17.46
and charged with the responsibility of overseeing the School Employee’s Health Benefits Program.
School Employees’ Health Benefits Program (SEHBP) — The SEHBP was established by Chapter
103, P.L. 2007. It offers medical and prescription drug coverage to qualified school employees and
retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the
SEHBP. The School Employees’ Health Benefi ts Program Act is found in the N.J.S.A. 52:14-1 7.4 6 et seq.
Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of
the New Jersey Administrative Code.
SEHBP Member — An individual who is either a School Employees’ Health Benefits Program 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 custodial, maintenance or supportive care as well as
assistance with daily living.
Specialty care — Services provided by a health care professional whose practice is limited to a
specific area of medicine (i.e. orthopedics, dermatology, physical therapy, chiropractic manipulation,
etc.).
Substance Use Disorder——The term as defined by the American Psychiatric Association in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and any subsequent editions.
Substance Use Disorder includes substance use withdrawal.
82
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Supportive Care — Care for patients that have 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 appropriate are not eligible for coverage
under the SEHBP plans.
Surgical Center — Also called a 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,
electro cauterization, tapping(paracentesis), administration of pneumothorax, endoscopy, or injection
of sclerosing solution.
Surrogate — A woman who carries an embryo that was formed from her own egg inseminated by
the sperm of a designated sperm donor.
Waiting Period — The period of time between enrollment in the health benefits program and the date
when you become eligible for benefits.
SEHBPMEMBER GUIDEBOOK
83
APPENDIX IV
REQUIRED DOCUMENTATION FOR DEPENDENTELIGIBILITY AND
ENROLLMENT
The School Employees’ Health Benefits Program (SEHBP) are required to ensure that only
employees, retirees, and eligible dependents receive coverage under the programs. Employees or
Retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners,
children) must submit supporting documentation in addition to the appropriate health benefits
application.
Dependent
Eligibility Definition
Required Documentation
Spouse
A person to whom you are
legally married.
A photocopy of the Marriage Certificate and
a photocopy of the front page of the
employee/retiree’s most recently filed tax
return* (Form 1040) that includes the spouse.
If filing separately, submit a copy of both
spouses’ tax returns.
Civil Union
Partner
A person of the same sex with
whom you have entered into a
civil union.
A photocopy of the New Jersey Civil Union
Certificate or a valid certification from another
jurisdiction that recognizes same- sex civil
unions and a photocopy of the front page of
the employee/ retiree’s most recently filed NJ
tax return* that includes the partner or a
photocopy of a recent (within 90 days of
application) bank statement or bill that
includes the names of both partners and is
received at the same address.
A person of the same sex with
whom you have entered into a
domestic partnership as defined
under Chapter 246, P.L. 2003,
A photocopy of the New Jersey Certificate of
Domestic Partnership dated prior to February
19, 2007 or a valid certificationfrom another
State of foreign jurisdiction that recognizes
same-sex domestic partners and a
photocopy of the front page of the
employee/retiree’s most recently filed NJ tax
return* that includes the partner or a
photocopy of a recent (within 90 days of
application) bank statement or bill that
includes the names of both partners and is
received at the same address.
the Domestic Partnership Act.
Domestic
Partner
The domestic partner of any
State employee, State retiree,
or any eligible employee/retiree
of a SHBP/SEHBP participating
local public entity, who adopts a
resolution to provide Chapter
246 health benefits, is eligible
for coverage.
*Note: On taxforms youmayblack out all financial information and all but the last 4 digits of any Social Security
numbers
Continued on next page
84
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
Required Documentation for Dependent Eligibility and Enrollment
Dependent
Eligibility Definition
Required Documentation
Children
A subscriber’s child until age 26,
regardless of the child’s marital,
student, or financial dependency
status – even if the young adult no
longer lives with his or her parents.
This includes a stepchild, foster
child, legally adopted child, or any
child
in a guardian-ward relationship
upon submitting required supporting
documentation.
Natural or Adopted Child – A photocopy
of the child’s birth certificate** showing the
name of the employee/retiree as a parent.
Step Child – A photocopy of the child’s birth
certificate showing the name of the
employee/retiree’s spouse or partner as a
parent and a photocopy of the marriage/
partnership certificate showing the names
of the employee/retiree andspouse/partner.
Legal Guardian, Grandchild, or Foster
Child – Photocopies of Final Court Orders
with the presiding judge’s signature and
seal. Documents must attest to the legal
guardianship by the covered employee.
Dependent
Children
With
Disabilities
If a covered child is not capable of
self-support when he or shereaches
age 26 due to mental illness or
incapacity, or a physical disability,
the child may be eligible for a
continuance of coverage.
See “Dependent Children with
Disabilities” in this Guidebook for
additional information. You will be
contacted periodically to verify that
the child remains eligible for
continued coverage.
Documentation for the appropriate “Child”
type (as noted above) and a photocopy of
the front page of the employee/retiree’s
most recently filed federal tax return* (Form
1040) that includes the child.
If Social Security disability has been
awarded, or is currently pending, please
include this information with the
documentation that is submitted.
Please note that this information is only
verifying the child’s eligibility as a
dependent. The disability status of the child
is determined through a separate process.
Certain children over age 26 may be
Documentation for the appropriate “Child”
Continued
Coverage for
Over Age
Children
eligible for continued coverage until
age 31 under the provisions of
Chapter 375, P.L. 2005. See “Over
Age Children until Age 31” in this
Guidebook for additional
type (as noted above), and a photocopy of
the front page of the child’s most recently
filed federal tax return* (Form 1040), and if
the child resides outside of the State of New
Jersey, documentation of full time student
information.
status
must
be submitted.
New Jersey residents can obtain records from the State Bureau of Vital Statistics and Registration Web site:
www.state.nj.us/health/vital/index.shtml To obtain copies of other documents listed on this chart, contact the
office of the Town Clerk in the city of the birth marriage, etc., or visit these Web sites: www.vitalrec.com or
www.studentclearinghouse.org
*Note: On tax forms, you may black out all financial information and all but the last 4 digits of any Social
Security numbers.
**Or a National Medical Support Notice (NMSN) if you are the non-custodial parent and are legally required to
provide coverage for the child as a result of the NMSN.
SEHBPMEMBER GUIDEBOOK
85
APPENDIX V
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
The SEHBP Health Plans meet the federal Health Insurance Portability and Accountability Act (HIPAA)
of 1996 requirements.
Certification of Coverage
A Certification of Coverage form, which verifies your SEHBP group health plan enrollment and
termination dates, is available through your payroll or human resources office, should you terminate
your coverage.
HIPAA Privacy
The SEHBP make every effort to safeguard the health information of their members and comply 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 the Notice of Privacy Practices
section of this Guidebook.
APPENDIX VI
NOTICE OF PRIVACY PRACTICES TO ENROLLEES IN THE NEW JERSEY
SCHOOL EMPLOYEES’ HEALTH BENEFITS PROGRAM
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Protected Health Information
School Employees’ Health Benefits Program (SEHBP) are required by the federal Health Insurance
Portability and Accountability Act (HIPAA) and State laws to maintain the privacy of any information
that is created or maintained and relates to your past, present, or future physical or mental health.
This Protected Health Information (PHI) includes information communicated or maintained in any
form. Examples of PHI are your name, address, Social Security number, birth date, telephone number,
fax number, dates of health care service, diagnosis codes, and procedu re codes. PHI is collected
through various sources, such as enrollment forms, employers, health care providers, federal and
State agencies, or third-party vendors.
The SEHBP are required by law to abide by the terms of this Notice. The SEHBP reserve the right to
change the terms of this Notice. If the SEHBP make material change to this Notice, a revised Notice will
be sent.
Uses and Disclosures of PHI
The SEHBP is permitted to use and to disclose PHI in order for our members to obtain payment for
health care services and to conduct the administrative activities needed to run programs without
specific member authorization. Under limited circumstances, we may be able to provide PHI for the
health care operations of providers and health plans. Specific examples of the ways in which PHI may
be used and disclosed are provided below. This list is illustrative only and not every use and disclosure
in a category is listed.
86
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
The SEHBP may disclose PHI to a doctor or a hospital to assist them in providing a member
with treatment.
The SEHBP may use and disclose member PHI so that our Business Associates may pay
claims fromdoctors, hospitals, and other providers.
The SEHBP receives PHI from employers, including the member's name, address, Social
Security number, and birth date. This enrollment information is provided to our Business
Associates so that they may provide coverage for health care benefits to eligible members.
The SEHBP and/or our Business Associates may use and disclose PHI to investiga te a
complaint or process an appeal by a member.
The SEHBP may provide PHI to a provider, a health care facility, or a health plan that is not
our Business Associate that contacts us with questions regarding the member's health care
coverage.
The SEHBP may use PHI to bill the member for the appropriate premiums and reconcile
billings we receive fromour Business Associates.
The SEHBP may use and disclose PHIfor fraud and abuse detection.
The SEHBP may allow use of PHI by our Business Associates to identify and contact our
members for activities relating to improving health or reducing health care costs, such as
information about disease management programs or about health-related benefits and
services or about treatment alternatives that may be of interest to them.
In the event that a member is involved in a lawsuit or other judicial proceeding, the SEHBP
may use and disclose PHI in response to a court or administrative order as provided by law.
The SEHBP may use or disclose PHI to help evaluate the performance of our health plans.
Any such disclosure would include restrictions for any other use of the information other than
for the intended purpose.
The SEHBP may use PHI in order to conduct an analysis of our claims data. This information
may be shared with internal departments such as auditing or it may be shared with our
Business Associates, such asour actuaries.
Except as described above, unless a member specifically authorizes us to do so, the SEHBP will
provide access to PHI only to the member, the member’s authorized representative, and those
organizations who need the information to aid in the conduct of business (our “Business Associates").
An authorization form may be obtained over the Internet at: www.nj.gov/treasury/pensions or by
sending an e-mail to: hi[email protected] A member may revoke an authorization at any
time.
Restricted Uses
PHI that contains genetic information is prohibited from use or disclosure by the Programs for
underwriting purposes.
The use or disclosure of PHI that includes psychotherapy notes requires authorization from
the member.
When using or disclosing PHI, the SEHBP will make every reasonable effort to limit the use or
disclosure of that information to the minimum extent necessary to accomplish the intended purpose.
The SEHBP maintain physical, technical, and procedural safeguards that comply with federal law
regarding PHI. In the event of a breach of unsecured PHI, the member will be notified.
SEHBPMEMBER GUIDEBOOK
87
Member Rights
Members of the SEHBP have the following rights regarding their PHI.
Right to Inspect and Copy: With limited exceptions, members have the right to inspect and/or obtain
a copy of their PHI that the SEHBP maintains in a designated record set which consists of all
documentation relating to member enrollment and the use of this PHI for claims resolution. The
member must make a request in writing to obtain access to their PHI. The member may use the
contact information foundat the end of this Notice to obtain a formto request access.
Right to Amend: Members have the right to request that the SEHBP amend the PHI that we have
created and that is maintained in our designated record set.
We cannot amend demographic information, treatment records or any other information created by
others. If members would like to amend any of their demographic information, please contact your
personnel office. To amend treatment records, a member must contact the treating physician, facility,
or other provider that created and/or maintains these records.
The SEHBP may deny the member's request if: 1) we did not create the information requested on the
amendment; 2) the information is not part of the designated record set maintained by the SHBP or
SEHBP; 3) the member does not have access rights to the information; or 4) we believe the
information is accurate and complete. If we deny the member’s request, we will provid e a written
explanation for the denial and the member's rights regarding the denial.
Right to an Accounting of Disclosures: Members have the right to receive an accounting of the
instances in which the SEHBP, or our Business Associates have disclosed member PHI. The
accounting will review disclosures made over the past six years. We will provide the member with the
date on which we made a disclosure, the name of the person or entity to whom we disclosed the PHI,
a description of the information we disclosed, the reason for the disclosure, and certain other
information. Certain disclosures are exempted from this requirement (e.g., those made for treatment,
payment or health benefits operation purposes or made in accordance with an authorization) and will
not appear on the accounting.
Right to Request Restrictions: The member has the right to request that the SEHBP place
restrictions on the use or disclosure of their PHI for treatment, payment, or health care operations
purposes. The SEHBP is not required to agree to any restrictions and in some cases will be prohibited
from agreeing to them. However, if we do agree to a restriction, our agreement will alwaysbe in writing
and signed by the Privacy Officer. The member request for restrictions must be in writing. A formcan
be obtained by using the contact information found at the end of this Notice.
Right to Restrict Disclosure: The member has the right to request that a provider restrictdisclosure
of PHI to the Program s or Business Associates if the PHI relates to services or a health care item for which
the individual has paid the provider in full. If payment involves a flexible spending account or health
savings account, the individual cannot restrict disclosure of informationnecessary to make thepayment
but may request that disclosure not be made to another program or health plan.
Right to Receive Notification of a Breach: The member has the right to receive notification in the
event that the Programs or a Business Associate discover unauthorized access or release of PHI
through a security breach.
Right to Request Confidential Communications: The member has the right to request that the
SEHBP communicate with them in confidence about their PHI by using alternative means or an
alternative location if the disclosure of all or part of that information to another person could endanger
them. We will accommodate such a request if it is reasonable, if the request specifies the alternative
means or locations, and if it continues to permit the SEHBP to colle ct premiums and pay claims under
the health plan.
88
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
To request changes to confidential communications, the member must make their request in writing,
and must clearly state that the information could endanger them if it is not communicated in confidence
as they requested.
Right to Receive a Paper Copyof the Notice: Members are entitled to receive a paper copy of this
Notice. Please contact us using the information at the end of this Notice.
Questions and Complaints
If you have questi ons or concerns, please contact the SEHBP using the informati on listed at the end
of this Notice.
If members think the SEHBP may have violated their privacy rights, or they disagree with a decision made
about access to their PHI, in response to a request made to amend or restrict the use or disclosure
of their information, or to have the SEHBP communicate with them in confidence by alternative means
or at an alternative location, they must submit their complaint in writing. To obtaina form for submitting
a complaint, use the contact information found at the end of this Notice. Members also may submit a
written complaint to the U.S. Department of Health and Human Services, 200 Independence Avenue,
S.W., Washington, D.C. 20201.
The SEHBP support member rights to protect the privacy of PHI. It is your right to file a complaint with
the SEHBP, or with the US Department of Health and Human Services.
Contact Office:
Division of Pensions & Benefits — HIPAA Privacy Officer
Address:
State of New Jersey
Department of the Treasury
Division of Pensions & Benefits
PO Box 295
Trenton, NJ 08625-0295
E-mail: hipaaform@treas.nj.gov
SEHBPMEMBER GUIDEBOOK
89
APPENDIX VII
HEALTH BENEFITS PROGRAM CONTACT INFORMATION
Addresses
SEHBP — Horizon Blue Cross Blue Shield of New Jersey
Mailing Address:
Horizon BCBSNJ
PO Box 820
Newark, NJ 07101-0820
Internet Address: www.horizonblue.com/shbp
Division of Pensions & Benefits — Health Benefits Bureau
Mailing Address:
Health Benefits Bureau
Division of Pensions & Benefits
PO Box 299
Trenton, NJ 08625-0299
Internet Address: www.nj.gov/treasury/pensions/
E-mail Address: pensions.nj@treas.nj.gov
Please indicate on all correspondence whether you are a SHBP or SEHBP member.
Telephone Numbers
SEHBP
Horizon Blue Cross Blue Shield of New Jersey ......................................... ..1-800-414-SHBP (7427)
Division of Pensions & Benefits:
Office of Client Services and Automated Information System ................................(609) 292-7524
TDD Phone (Hearing Impaired) ............................................................................. (609) 292-6683
State Employee Advisory Service (EAS) 24 hours a day .......................................... 1-866-327-9133
New Jersey State Police
Employee Advisory Program (EAP).................................................................1-800-FOR-NJSP
Rutgers University Personnel Counseling Service
Employee Advisory Program(EAP) .......................................................................(732)
932-7539
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)
90
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
New Jersey Department of Human Services
Pharmaceutical Assistance to the Aged and Disabled (PAAD) ................................ 1-800-792-9745
New Jersey Department of Health and Senior Services
Di visi on
of
Agi ng
and
Co m muni ty
Servi ces
................................................................ 1-800-792-882
0
Insurance Counseling
...........................................................................................
1-800-792-8820
Independe nt
Health
Care
Appeal s
Program
..............................................................
(609)
633-0660
Centers for Medicare and Medicaid Services
New Jersey Medicare — Part A and Part B ......................................................... 1-800-Medicare
SEHBPMEMBER GUIDEBOOK
91
HEALTH BENEFITS PROGRAM PUBLICATIONS
Fact sheets, guidebooks, and other publications are available for viewing or printing over the Internet
at: www.nj.gov/treasury/pensions
General Publications
Summary Program Description booklet — an overview of the SHBP and SEHBP
Plan Comparison Summary — Out-of-pocket cost comparison charts for State employees, local
government employees, local education employees, and all retirees.
Health Benefits Coverage - Enrolling as a Retire
Health Benefits Program and Medicare Parts A & B for Retirees
COBRA – The Continuation of Health Benefits
Termination of Employment through Resignation, Dismissal, or Layoff
Dental Plans – Active Employees
Health Benefits Retired Coverage under Chapter 330
Health Benefits Coverage Continuation for Over Age Children with Disabilities
Health Benefits Coverage for Part-Time Employees
SHBP Coverage for State Intermittent Employees
Dental Plans-Retirees
Health Benefit Coverage of Children until Age 31 under Chapter 375
Civil Unions and Domestic Partnerships
Member Guidebooks
SHBP Member Guidebook
SEHBP Member Guidebook
Horizon HMO Member Guidebook
Horizon HDHP Member Guidebook
Horizon OMNIA Member Guidebook Tiered-Network Plan
Prescription Drug Plans Member Guidebook
Employee Dental Plans Member Guidebook
Retiree Dental Plans Member Guidebook
92
NEW JERSEY DIVISION OF PENSIONS & BENEFITS
SEHBPMEMBER GUIDEBOOK
93
HB-0814b-1223
