BENEFITS INFORMATION
TO: School Employees’ Health Benefits Program Participating Local Education
Employers
FROM: New Jersey School Employees’ Health Benefits Program
SUBJECT: SEHBP Special Open Enrollment — Local Education Employers
The State Health Benefits Commission, at its December 11, 2008 meeting, voted to
approve the following changes to benefits under the School Employees’ Health Benefits
Program:
• Allows for the coordination of benefits (COB) between NJ DIRECT10 and NJ
DIRECT15. Previous to this decision, there was no COB between the two
plans.
• A change to NJ DIRECT10 that allows the copayments a member makes to innetwork
providers to count toward the in-network out-of-pocket maximum.
Previously the copayments were applied toward the in-network out-of-pocket
maximum, however the member was required to continue to pay the
copayment after the maximum was reached. Now the member will be
reimbursed at the end of the year for any copayments paid above the innetwork
out-of-pocket maximums.
• A transition program for members enrolled in NJ DIRECT10 that limits the
annual out-of-network out-of-pocket eligible expenses a member pays to
Horizon contracted providers who are not in the NJ DIRECT network to $400
after a $100 deductible per individual. Once the transition program ends on
December 31, 2009, the annual out-of-network out-of-pocket maximum for
these providers will revert to $2,000 after a $100 deductible per individual.
The Commission approved a Special Open Enrollment to allow members to change
medical plans. The Special Open Enrollment period will begin on February 1, 2009 and
end on February 28, 2009. All plan changes made during this open enrollment will be
effective on May 1, 2009.
Please Note: This Special Open Enrollment will only allow members to change medical
plans. Members will not be permitted to add dependents or make any changes to dental
or prescription drug coverage.
For changes made during this Special Open Enrollment, completed employer-certified
Health Benefits Applications should be forwarded to the Health Benefits Bureau as soon
as they are received from employees. The last day that certified applications may arrive
at the Health Benefits Bureau is March 6, 2009.
Health Benefits Special Open Enrollment Page 2
January 29, 2009
MEDICAL PLANS
The SEHBP currently offers Local Education employees a choice of one of four medical
plans.
• NJ DIRECT10 — a Preferred Provider Organization administered by Horizon
Blue Cross Blue Shield of New Jersey that offers a selection of both in-network
coverage with a $10 copayment and out-of-network coverage subject to
deductibles and coinsurance; or
• NJ DIRECT15 — a Preferred Provider Organization administered by Horizon
Blue Cross Blue Shield of New Jersey that offers a selection of both in-network
coverage with a $15 copayment and out-of-network coverage subject to
deductibles and coinsurance; or
• Aetna HMO or CIGNA HealthCare HMO — standard Health Maintenance
Organization (HMO) plans that offer in-network coverage through a primary
care physician for a $10 copayment.
A side-by-side comparison of medical plan benefits is available in the Plan Comparison
Summary for Local Education Employees, available for viewing or printing at the SEHBP
Web site: www.state.nj.us/treasury/pensions/sehbp.htm
HEALTH BENEFITS APPLICATIONS — The Health Benefits Application is available for
printing from the SHBP Web site at: www.state.nj.us/treasury/pensions/shbp.htm
PLAN HANDBOOKS, AND HEALTH PLAN COMPARISON SUMMARY CHARTS —
Plan Member Handbooks (NJ DIRECT, Aetna HMO, CIGNA HealthCare HMO), and the
SEHBP Plan Comparison Summary chart are available as online publications on the
SEHBP Web site at: www.state.nj.us/treasury/pensions/sehbp.htm Please encourage
your employees to access these materials online. Bulk supplies of printed copies are no
longer available.