Eligibility to Enroll in the State Health Benefits Program

Eligibility for Dependents

  • Legal spouse
  • Same-sex domestic partner or civil union partner
  • Eligible children under age 26 (including stepchildren, foster children, adopted children or children an employee is legally required to support)

When Coverage Begins

  • Academic year 10-month employees with September 1 hire date = September 1 effective date
  • All other employees, effective after 2 months of continuous employment, i.e., August 15 hire date = October 15 effective date

 

As an eligible employee, you can choose medical coverage from a selection of plans:

Preferred Provider Organization (PPO)

  • Benefits fall into two categories: services from preferred providers and those provided by non-preferred providers
  • Preferred provider benefits are paid after required copay
  • Non-preferred provider benefits require members to meet an annual deductible. After deductibles are met, covered claims are paid of the “reasonable and customary” allowance for most services
  • Members are not required to choose a primary care physician and do not need to obtain referrals
  • Certain preventative care such as annual exams, well-baby care, and certain screenings will be covered with no cost sharing
  • A nationwide network of providers is available

Health Maintenance Organization (HMO)

  • Separate HMO plans administered by Aetna and Horizon
  • HMOs cover a wide range of services for preventative and diagnostic care
  • Both HMO plans have a unique nationwide directory of participating providers
  • Select a Primary Care Physician (PCP) to coordinate your health care
  • The PCP will issue a referral if you need to see a network specialist as part of your treatment
  • No deductibles or claim forms
  • Standard copayments required for services

Tiered Network (TN)

  • Unique network of physicians and facilities
  • Managed care network; no Out-of-network coverage
  • Lower cost sharing when using Tier 1 In-network providers when compared to Tier 2 In-network providers
  • Other copayment required, deductible only required for Tier 2 provider services

High Deductible Health Plans (HD)

  • Must pay all costs up to the deductible amount before plan pays for covered services; preventative care covered at no cost (In-network only)
  • In-network Coinsurance after deductible for preferred providers
  • Out-of-network Coinsurance after deductible for non-preferred providers
  • Prescription is integrated with the plan and subject to deductible and coinsurance
  • Access to contribute to optional Health Savings Account (HSA)

 

Available Plans:

Aetna Freedom 15, NJ Direct 15, Aetna HMO, Horizon HMO*

  • $15 Primary Care copay
  • $15 Specialist Care copay
  • $100 Emergency Care copay

Aetna Freedom 1525, NJ Direct 1525

  • $15 Primary Care copay
  • $25 Specialist Care copay
  • $100 Emergency Care copay

Aetna Freedom 2030, NJ Direct 2030

  • $20 Primary Care copay
  • $30 Specialist Care copay ($20 copay for children up to the 26th birthday)
  • $125 Emergency Care copay

Aetna Freedom 2035, NJ Direct 2035

  • $20 Primary Care copay
  • $35 Specialist Care copay
  • $300 Emergency Care copay

*The Horizon HMO plan has a limited service area of New Jersey, Delaware, New York and bordering counties in Pennsylvania.

Horizon OMNIA, Aetna Liberty

  • Tier 1/Tier 2
  • $5/$20 Primary Care copay
  • $15/$30 Specialist Care copay
  • $100 Emergency Care copay

NJ Direct HD 4000, Aetna HD 4000

  • $4000 Individual In-Network deductible
  • $8000 In-Network deductible Employee + 1 or more dependents
  • 20% coinsurance after deductible is satisfied
  • $1,000 In-Network Individual Out-of-Pocket Maximum
  • Health Savings Account

NJ Direct HD 1500, Aetna HD 1500

  • $1500 Individual In-Network deductible
  • $3000 In-Network deductible Employee + 1 or more dependents
  • 20% coinsurance after deductible is satisfied
  • $1,000 In-Network Individual Out-of-Pocket Maximum ($2000 Family)
  • $300 employer funded Health Savings Account

Preventive Services, Immunizations and Certain Screenings

Under the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation (HCR) Acts, certain preventive care, such as immunizations (age and population restrictions may apply), certain screenings (blood pressure, cholesterol, depression, newborn, etc.), FDA-approved contraceptive methods, and well-baby care, will be covered by all of the SHBP medical plans without member cost sharing.

As a result, primary care well visits (annual exams) will no longer require a copayment or coinsurance by the member for certain wellness services provided by an in-network provider. However, if the preventive service is not the primary reason for the office visit, the member may still be responsible for a copayment or coinsurance. Contact your medical provider or plan for more information.