As a member of NJ DIRECT 15, I understand that I am required to pay deductibles and coinsurance for services from “non-preferred” providers. How can I locate preferred providers to reduce my costs?

To locate preferred providers, visit the Horizon Blue Cross Blue Shield website and click on “provider directory.”

How can my daughter continue coverage if she loses her status as an eligible dependent?

She has the option to elect COBRA or Chapter 375 coverage. To compare the two plans and their eligibility criteria, visit the following webpage.

I am a Rutgers employee who waived State Health Benefits coverage because I wanted to continue coverage as a dependent on my husband’s plan. My husband lost his job and will soon no longer have health insurance coverage. Can my husband and I enroll?

Yes, if your spouse’s employment status changes resulting in a loss of health coverage, you can enroll in State Health Benefits within 60 days of the event. Complete a NJ State Health Benefits Program Application and return the completed form to your Human Resources department. You must also provide documentation (a letter or certificate) of your spouse’s employer to show loss of coverage.

I currently have husband/wife coverage and my wife is pregnant. When should I add the baby?

You can add your child within 60 days of the child’s birth. Complete a NJ State Health Benefits Program Application and provide a copy of the birth certificate and return the completed forms to your Human Resources department. When you receive the child’s social security number a few months later, please indicate that information on a NJ State Health Benefits Program Application.

I have just become eligible to enroll in State Health Benefits. How can I decide which medical plan is the best one?

There is no single best plan. Plan selection is a personal decision based on your needs. You should review information provided by the NJ Division of Pensions and Benefits and the individual carriers to familiarize yourself with the various plans and their provisions. Some of the main factors new enrollees usually consider are:

  • Cost
  • Ease of claims processing
  • Freedom of doctor/hospital selection
  • Whether or not your doctor participates in one or more State Health Benefit Plans

My 19 year old son works part-time and attends school part-time. Can he remain covered under my health insurance?

Your son may continue to be covered through the end of the year in which he turns 26.   A “child” is defined as an enrollee’s child until age 26, and is eligible to be enrolled in the SHBP regardless of the child’s marital, student, or financial dependency status even if the young adult no longer lives with his or her parents and is eligible for other employer-based coverage. 

What is the difference between the HMOs the state offers?

The service areas for Horizon HMO plans are limited to New Jersey, Delaware, and bordering counties of Pennsylvania and New York.  The Aetna HMO plans have a unique, nationwide network of physicians and facilities. Other than this difference, the HMOs are very similar. Each has “General Operating Procedures” and “Conditions of Participation” that are minimum coverage requirements instituted by the state. These standards help to safeguard all participants and make it easier to compare and choose between the HMO plans. Additionally, each HMO may offer perks such as maternity programs, educational programs, newsletters, and wellness programs including discounts on health club memberships, vision care discounts, and vitamin discounts.

What is the role of a Primary Care Physician (PCP) in the Aetna and Horizon HMOs?

Your PCP provides basic medical services and coordinates your overall medical care. If specialized treatment is required, your PCP is responsible for referring you to a specialist, lab, hospital or any other network physician or specialist.  A PCP is typically a general practitioner, internist, or pediatrician. HMO participants may change their PCPs as often as they like.