NJ State Health Benefits Program 2015 Open Enrollment LOCAL GOVERNMENT Employers Presented by Roseann Whypp Pensions Benefits Specialist www.state.nj.us/treasury/pensions
2015 Open Enrollment Overview Health Benefits Representatives Jennifer Moyer, Aetna Katherine Impellizzeri, Aetna Christopher Lowry, Horizon Blue Cross and Blue Shield of NJ 2015 Annual Open Enrollment Eligibility and Applications Eligibility for Enrollment Eligible Dependents Required Documentation Applying for Coverage NJWELL Year 2 2
2015 Open Enrollment Overview State Health Benefits Program 2015 Benefit Information Medical Benefits Prescription Drug Benefits Dental Benefits Status Changes When Coverage Ends Terminating Dependents COBRA Chapter 375 Annual Open Enrollment Processing and Timeframes Identification Cards EPIC 3
2015 Annual Open Enrollment Eligibility
Eligibility for Enrollment Active Local Government Employees To be eligible for health benefits coverage, a regular local employee must appear on regular payroll and work full time. The number of hours per week required for a local employee to have "full time" status shall be set by the location s governing body. The minimum number of hours for employees hired after May 21, 2010 cannot be less than 25 hours. Newly appointed or elected officials are required to work a minimum of 35 hours per week to be considered "full time" and eligible for coverage under the SHBP/SEHBP. Any employee or official who met the minimum work hour requirements prior to May 21, 2010 will be eligible for continued coverage under the SHBP provided there is no break in the employee s service or reduction in work hours. 5
Employees Ineligible for Coverage Active Local Government Employees Employees who are ineligible for coverage include: those who have less than two months of continuous service those who are employed on a short term, seasonal, intermittent or emergency basis those who are paid an hourly rate those who are not on payroll 6
Other Eligibility Issues Active Local Government Employees State statute specifically prohibits two members who are each enrolled in the 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. The husband may elect Family coverage, covering the wife and children as his dependents, making them ineligible for any other SHBP/SEHBP coverage; or the husband may choose Single coverage and the wife may choose Parent and Child(ren) coverage. 7
Eligible Dependents Active Local Government Employees Legal Spouse Civil Union Partner Domestic Partner Chapter 256, P.L. 2003 Local Public Entities must adopt Resolution to provide Chapter 256 health benefits. Children Naturally Legally Adopted Legal Guardianship Stepchild under the age of 26 Regardless of child s marital status, educational status, residency or financial dependency on the subscriber. 8
Dependent Children with Disabilities Active Local Government Employees Dependent children with disabilities may be able to continue on parent s medical insurance after age 26. Parent must be enrolled through SHBP. Child is disabled and not capable of self support. Child must be unmarried and not in a civil union or domestic partnership. Child must be substantially dependent on parent for support and maintenance. Child must live with parent. Child must be a covered dependent through SHBP and disabled prior to age 26. Parent must complete a Continuance for Dependent with Disabilities form and submit it by January 31 st after the child ages off (end of the calendar year which the child reaches age 26). Approval is subject to review of the documentation provided and may be subject to periodic reevaluations. For new locations: If child is over 26 we will allow the child to enroll in the coverage at the time the location enrolls with the SHBP. Employer must submit a letter to SHBP stating the child was covered under the employer s private plan. See Fact Sheet #51 for more information. 9
Required Documentation for Dependents Active Local Government Employees Legal Spouse Marriage certificate AND front page of the most recent Federal tax return (Form 1040). If no tax form is available, proof of joint debt or ownership is required Joint debt is a bill that includes the names of husband and wife received at the same address. Joint ownership is a bank statement dated within the last 90 days that includes the names of husband and wife received at the same address. Civil Union Partner Civil Union certificate, and front page of member s most recent NJ State tax return that includes partner or proof of joint debt or ownership. Domestic Partner Domestic Partner certificate, and front page of member s most recent NJ State tax return that includes the partner or proof of joint debt or ownership. 10
Required Documentation for Dependents Active Local Government Employees Children Natural Child Child s birth certificate showing employee as a parent. It MUST show the employee as the parent. Adopted Child Placement letter from adoption agency or DYFS, and birth certificate if available. Step Child Child s birth certificate showing employee s spouse or partner as a parent, and the marriage or partnership certificate showing the names of the employee and spouse/partner. Legal Guardian or Foster Child Final court order with judge s signature and seal attesting to legal guardianship by the member. Dependent Children with Disabilities Same documentation as for other dependent children and front page of the employee s most recent Federal tax return that includes the child. If the child has been awarded Social Security Disability or the award is pending, please include this information with the documentation. 11
Applying for Coverage in SHBP Active Local Government Employees The Annual Open Enrollment period is October 1 October 31, 2014. Applications are due at the Division of Pensions and Benefits no later than November 14, 2014. Effective date of coverage for changes during Open Enrollment is January 1, 2015. Properly certified application WITH documentation should be submitted promptly to ensure timely processing and enrollment. 12
2015 Annual Open Enrollment NJWELL Year 2
NJWELL Year 2 November 1, 2014 October 31, 2015 Earn up to $200 in 2015 Here s How it Works You and your covered spouse/partner can participate. You can earn points and points translate to rewards. How to Earn Your Points To Get Started Biometric Screening You and your covered spouse/partner can each earn 100 points by participating in a Biometric Screening Health Assessment You and your covered spouse/partner can each earn 150 points by completing a short online Health Assessment. Become a Champion: Volunteer as a Wellness Champion to promote this program at your location! More Ways to Earn in 2015 Age/Gender Appropriate Screenings Flu Shots Online Coaching Online Activities Wellness and Disease Management Programs 14
2015 Annual Open Enrollment 2015 Benefit Information
Medical Benefits 2015 HMO Plans Active Local Government Employees Understanding the HMO Plans A Health Maintenance Organization (HMO) provides predictable costs with a modest copay for most services in network. Preventive care is covered 100% with no copay. Your Primary Care Physicians (PCP) is your first point of contact for any of your health needs and can refer you to a specialist whenever you need one. Aetna HMO Aetna HMO 1525 Aetna HMO 2030 Aetna HMO 2035 Horizon HMO Horizon HMO 1525 Horizon HMO 2030 Horizon HMO 2035
Medical Benefits 2015 PPO Plans Active Local Government Employees Understanding the PPO Plans A Preferred Provider Organization (PPO) plan allows you to visit any health care professional, in or out of the network. Plans have a modest deductible, which must be satisfy before the plan s kicks in. The amount you pay out of pocket depends on where you received care. There are no referrals with these PPO plans. Preventative services are covered at 100% when visiting a physician within the network. Aetna Freedom 10 Aetna Freedom 15 Aetna Freedom 1525 Aetna Freedom 2030 Aetna Freedom 2035 NJ DIRECT 10 NJ DIRECT 15 NJ DIRECT 1525 NJ DIRECT 2030 NJ DIRECT 2035
Medical Benefits 2015 PPO Plans Active Local Government Employees Understanding the High Deductible Health Plans A High Deductible Health Plan allows you to get more value with a low premium in exchange for a high deductible. Need to see a doctor enjoy the freedom to choose any health care professional in or out of the network. You can also build a tax advantaged Health Savings Account (HSA) to put money aside for qualified health care expenses or even save towards retirement with pretax dollars. In 2015, you may contribute up to $3,350 for individuals and up to $6,650 per family. There is a $300 employer contribution when members open an HSA when enrolled in the Aetna Value HD1500 or the Horizon NJ Direct HD1500 plan. Preventative services are also covered at 100% when visiting a physician within the network. Aetna Value HD1500 NJ DIRECT HD1500 Aetna Value HD4000 NJ DIRECT HD4000 18
Prescription Drug Benefits Express Scripts (Formerly Medco) Contact Phone Number 1 866 220 6512
SHBP Employee Prescription Drug Plan Aetna HMO Aetna HMO 1525 Aetna HMO 2030 Aetna HMO 2035 Aetna Value HD1500 Aetna Value HD4000 Aetna Freedom 10 Aetna Freedom 15 Aetna Freedom 1525 Aetna Freedom 2030 Aetna Freedom 2035 Horizon HMO Horizon HMO 1525 Horizon HMO 2030 Horizon HMO 2035 NJ DIRECT HD1500 NJ DIRECT HD4000 NJ DIRECT 10 NJ DIRECT 15 NJ DIRECT 1525 NJ DIRECT 2030 NJ DIRECT 2035 Retail: Tier 1 $3 $7 $3 $7 Subject to Subject to $3 $3 $7 $3 $7 Retail: Tier 2 $10 $16 $18 $21 Subject to Subject to $10 $10 $16 $18 $21 Retail: Tier 3 $10 $35 $46 *see below Subject to Subject to $10 $10 $35 $46 *see below Mail Order: Tier 1 $5 $18 $5 $18 Subject to Subject to $5 $5 $18 $5 $18 Mail Order: Tier 2 $15 $40 $36 $52 Subject to Subject to $15 $15 $40 $36 $52 Mail Order: Tier 3 $15 $88 $92 *see below Subject to Subject to $15 $15 $88 $92 *see below *You pay the applicable generic copayment as listed above, plus the cost difference between the brand drug and generic drug. All amounts shown are when members go in network Retail Pharmacy Up to a 30 day supply Mail Order Pharmacy Up to a 90 day supply
Aetna Prescription Drug Plan through the Medical Plan Aetna HMO Aetna HMO 1525 Aetna HMO 2030 Aetna HMO 2035 Aetna Value HD1500 Aetna Value HD4000 Aetna Freedom 10 Aetna Freedom 15 Aetna Freedom 1525 Aetna Freedom 2030 Aetna Freedom 2035 Retail: Tier 1 $5 $7 $3 $7 Subject to Subject to $5 $5 $7 $3 $7 Retail: Tier 2 $10 $16 $18 $21 Subject to Subject to $10 $10 $16 $18 $21 Retail: Tier 3 $20 $35 $46 *see below Subject to Subject to $20 $20 $35 $46 *see below Mail Order: Tier 1 $5 $18 $5 $18 Subject to Subject to $5 $5 $18 $5 $18 Mail Order: Tier 2 $15 $40 $36 $52 Subject to Subject to $15 $15 $40 $36 $52 Mail Order: Tier 3 $25 $88 $92 *see below Subject to Subject to $25 $25 $88 $92 *see below *You pay the applicable generic copayment as listed above, plus the cost difference between the brand drug and generic drug. All amounts shown are when members go in network Retail Pharmacy Up to a 30 day supply Mail Order Pharmacy Up to a 90 day supply
Horizon Prescription Drug Plan through the Medical Plan Horizon HMO Horizon HMO 1525 Horizon HMO 2030 Horizon HMO 2035 NJ DIRECT HD1500 NJ DIRECT HD4000 NJ DIRECT 10 NJ DIRECT 15 NJ DIRECT 1525 NJ DIRECT 2030 NJ DIRECT 2035 Retail: Tier 1 $5 $7 $3 $7 Subject to Subject to 10% 10% 15% 15% 20% Retail: Tier 2 $10 $16 $18 $21 Subject to Subject to 10% 10% 15% 15% 20% Retail: Tier 3 $20 $35 $46 *see below Subject to Subject to 10% 10% 15% 15% 20% Mail Order: Tier 1 $5 $18 $5 $18 Subject to Subject to 10% 10% 15% 15% 20% Mail Order: Tier 2 $15 $40 $36 $52 Subject to Subject to 10% 10% 15% 15% 20% Mail Order: Tier 3 $25 $88 $92 *see below Subject to Subject to 10% 10% 15% 15% 20% * You pay the applicable generic copayment as listed above, plus the cost difference between the brand drug and generic drug. All amounts shown are when members go in network Retail Pharmacy Up to a 30 day supply Mail Order Pharmacy Up to a 90 day supply
Changes to Dental Plans in 2015 Active Local Government Employees What are the changes to the 2015 SHBP Dental Program? Atlantic Southern Dental Foundation (BeneCare) and Community Dental Associates will no longer be offered in Plan year 2015. Current participants in the above plans MUST select a new carrier before October 31, 2014. MetLife, a new DPO, will be made available to employees beginning in January. Who are the carriers available in 2015? DPO Carriers Dental Expense Plan Aetna Cigna HealthPlex Aetna Horizon MetLife 23
Dental Benefits 2015 DPO and DEP Dental Plans Dental Plan Organization (DPO) A network only plan with no deductible; it s a fixed copay schedule plan There are a variety of network options among the carriers, please reach out to the carriers to understand the dental network best for you an your family. Dental Expense Plan (DEP) Covers dental services in or out ofnetwork from a licensed dentist with a deductible Nationwide coverage Administered by Aetna 24
Aetna Tools, Programs and Services
Aetna Resources and Programs 26
Aetna Extras Discount Programs 27
Aetna Online Member Resources www.aetnastatenj.com 28
Aetna Online Employer Resources www.aetnastatenj.com/employer 29
Horizon BCBS Tools, Programs and Services 30
Horizon Blue Cross Blue Shield of New Jersey Programs & Services Blue 365 wellness discounts, including fitness centers, weight loss programs, nutrition tools and more. Smart Eyes vision hardware discounts My Health Manager powered by WedMD Chronic Care Programs Asthma, Diabetes, Coronary Artery Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease and Heart Failure Precious Additions prenatal education program Nurse Line 24/7 access to a nurse via online or telephone New Jersey s first retail health insurance center, Horizon Connect Member Portal review claims, EOBS, precertifications and more Case Management and Member Advocacy Program Minute Clinics located in 29 CVS Pharmacies in New Jersey For more details on these programs and services: Contact SHBP/SEHBP Member Services at Horizon BCBSNJ toll free at 1 800 414 7427(SHBP), Monday Friday, 8 a.m. 6 p.m. or 24/7 at www. horizonblue.com/shbp 31
Health Benefits Program Application SHBP Local Government Active Employee Group PPO & HMO 32
High Deductible Health Plan Application SHBP Local Government Active Employee Group (HDHP) 33
Health Savings Account Contribution Form Contribution Form Used when employees enroll in a High Deductible Health Plan Pre tax contributions can be deducted from employee paychecks if they complete this authorization form and submit this form back to the benefits administrator. Additional account set up will still need to be done with the medical carrier. 34
Banded Tier Cost of Active Health Benefits The following table summarizes the different circumstances about employee contributions and collective negotiations agreements in accordance with the Department of Community Affairs (DCA) Local Finance Notice dated November 23, 2011. Status of contract/employee Existing employee as of 6/28/11 CNA expires after 6/28 CNA expired prior to 6/28 While the CNA is in effect the employee makes health benefits contributions pursuant to current contract provisions until it expires; then implement c.78 phase in. Employee makes health benefits contributions at the c. 78 Year 1 phase in rate upon implementation regardless of: when new contact commences, what a previously negotiated contract provided, or contract negotiation status. New employee hired after 6/28/11 While the CNA is in effect the employee makes health benefits contributions pursuant to current contract provisions until it expires; then implement c.78 phase in. For employees hired after the CNA expires: the employee makes health benefits contributions at the c. 78 Year 4 phase in rate (full contribution) upon starting employment; except that, if an employee is hired the day after a CNA expires, the employee contributes at the Year 1 phase in rate (this employee is considered an existing employee on the day the c.78 health care contribution commences) Employee makes health benefits contribution at the c.78 Year 4 phase in rate (full contribution) upon starting employment.
Banded Tier Cost of Active Health Benefits For additional information and for further guidance, please visit the Department of Community Affairs website at www.state.nj.us/dca/divisions/dlgs/lfns/11/2011 20R.doc or contact the DCA at dlgs@dca.state.nj.us. Please refer to the Division of Pensions and Benefits website to access the premium calculator to determine costs at http://www.state.nj.us/treasury/pensions/hb percentagehome.shtml
Waiving Coverage Active Local Government Employees Local government employees are permitted to waive their SHBP medical and prescription coverage provided they have other health care coverage of their own or as a dependent. Local government employees who waive coverage can thereby avoid the contribution of a percentage of the premiums for health and/or prescription drug coverage required under Chapter 78, P.L. 2011. Local government employers may offer an incentive to employees who waive medical and prescription coverage. The waiver incentive cannot be more than 25% of the amount saved by the employer or $5,000, whichever is less. Members are not eligible for waiver incentive if other medical coverage is from the SHBP/SEHBP. To waive coverage under the SHBP, a local government employee must submit an SHBP Coverage Waiver/Reinstatement Form and an SHBP Application for Active Local Employees. To reinstate coverage under the SHBP, a local government employee must complete an SHBP Coverage Waiver/Reinstatement Form and an SHBP Application for Active Local Government Employees. The member must notify the SHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage. Reinstatement will be effective immediately following the loss of the employee's other health plan coverage. 37
Waiving Coverage Remember: Waiving Coverage Requires an Application AND a Waiver Form 38
Waiving Coverage Remember: Waiving Coverage Requires an Application AND a Waiver Form Waiver Form Example 39
Dental Application 40
COBRA Active Local Government Employees COBRA is a federally regulated law that gives employees and their eligible dependents the opportunity to remain in their employer's group coverage when they would otherwise lose coverage because of certain qualifying events. COBRA coverage is available for limited time periods and the member must pay the full cost of the coverage plus an administrative fee. 41
Chapter 375 Active Local Government Employees Understanding Chapter 375 Under Chapter 375, an over age child (aged 26 31) 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. Dental coverage is not available. Chapter 375 Billing The covered parent is billed directly and therefore responsible for the cost of Chapter 375 coverage. Bills cannot be sent to any address but the covered parent s address. 42
Chapter 375 When Coverage Ends Active Local Government Employees Ch. 375 When Coverage Ends When the child no longer meets any one of the eligibility requirements When the covered parent s coverage ends Example: retirement, termination of employment, divorce, or death of the covered parent. Coverage may also be terminated in the event of non payment of the required premiums. NO reinstatement of benefits if termination is due to non payment of premiums. Chapter 375 coverage ends on the first of the month following the event that makes the child ineligible or up until the paid through date in the case of non payment. Applications are not required when a dependent ages out. Our system automatically terminates the coverage. Note: There is no provision for the continuation of group coverage under COBRA for a child due to the loss of Chapter 375 coverage. Nor is there any provision for conversion to non group coverage. See Fact Sheet #74 for more information. 43
Reminder About Important Dates Active Local Government Employees The Annual Open Enrollment period is October 1 October 31, 2014. Applications are due at the Division of Pensions and Benefits no later than November 14, 2014. Effective date of coverage for changes during Open Enrollment is January 1, 2015. Properly certified application WITH documentation should be submitted promptly to ensure timely processing and enrollment. Annual Open Enrollment is for: Active members COBRA subscribers Chapter 375 subscribers 44
Identification Cards Active Local Government Employees If the employee receives an identification card with an error, such as a misspelling or address correction, the EMPLOYEE should call the Office of Client Services at 609 292 7524. If the employee needs to update their Primary Care Physician or dentist, they should call the CARRIER. If the employee needs a duplicate card or never received their card, they should call the CARRIER. 45
EPIC Homepage
State Health Benefits Homepage 47
State Health Benefits Inquiry 48
State Health Benefits Inquiry 49
State Health Benefits Inquiry Click on Select Here for more info 50
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