Employee Dental Plans

1 Employee Dental Plans Member GuidebookPensions & BenefitsHD-0379-0122 The Dental Plan Organizations and The Dental Expense Plan For the State Health Benefits Program and the School Employees Health Benefits ProgramEmployee Dental Plans Member guidebook January 2022 Page 2 State Health Benefits Program School Employees Health Benefits Program TABLE OF CONTENTSI ntroduction ..4 Employee Dental Plans Eligibility ..4 State Employees ..4 Local Employees ..4 Eligible Dependents ..5 Retirees ..5 COBRA Coverage ..5 Employee Dental Plans ..5 General Conditions of the Dental Plans ..5 Enrollment ..5 Limitation On Changing Dental Plans ..5 Dual Dental Enrollment Is Prohibited ..5 Other Enrollment Information ..5 Dental Plan Choices ..6 Levels of Coverage ..6 Dental Plan Premiums .. 6 State Employees.

2 6 Local Government and Local Education Employees ..6 Extension of Coverage Provisions ..6If Eligibility Ends While Undergoing Treatment ..6 For Children Over the Age of 26 With Disabilities ..6 Transition of Care ..6 Orthodontics Takeovers From Previous Insurance Carrier ..6 Special Provisions of the Employee Dental Plans ..7 Coordination of Benefits With Other Insurance Plans ..7 Third Party Liability ..7 Repayment Agreement ..7 Recovery Right ..7 HIPAA Privacy ..8 Audit of Dependent Coverage ..8 Health Care Fraud ..8 The Dental Plan Organizations ..8 Considerations in Choosing a DPO ..8 Covered Services ..9 Orthodontics ..17 More Expensive Services ..17 Emergency Services Out of Area ..18 Services Not Covered by the DPO ..18 The Dental Expense Plan ..18 Annual Deductible .. 18 Reasonable and Customary Charges.

3 18 Dental Expense Plan Benefits (Chart) ..19 Covered Services ..19 Annual and Lifetime Benefit Maximums ..19In-Network and Out-of-Network Integration ..19In-Network Claims (Chart) ..20 Out-of-Network Claims (Chart) ..20 Additional Provisions of the DEP ..20 How Payments Are Made ..20 Filing Deadline Proof of Loss ..20 Itemized Bills Are Necessary ..20 Predetermination of Benefits ..20 Alternative Procedures ..21 Services Eligible For Reimbursement ..21 Orthodontic Services Eligible For Reimbursement ..21 Orthodontic Benefits ..22 Services Not Eligible for Reimbursement ..22 Orthodontic Charges Not Eligible Under the DEP ..22 Appendix IClaim Appeal Procedures ..23 Appendix II Glossary ..24 Appendix IIIA vailable Dental Plans (Chart) ..25 Appendix IVTax$ave ..26 Appendix VNotice of Privacy Practices to Enrollees.

4 26 Protected Health Information ..26 Uses and Disclosures of PHI ..26 Restricted Uses ..27 Member Rights ..27 Questions and Concerns ..28 Page 3 January 2022 Employee Dental Plans Member GuidebookSchool Employees Health Benefits Program State Health Benefits ProgramHealth Benefits Contact Information ..29 Addresses ..29 Telephone Numbers ..29 Health Benefits Publications ..29 General Publications ..29 Health Benefit Fact Sheets ..29 Health Plan Member Guidebooks ..29 Employee Dental Plans Member guidebook January 2022 Page 4 State Health Benefits Program School Employees Health Benefits Program INTRODUCTIONThe State Health Benefits Program (SHBP) was es-tablished in 1961. It offers medical, prescription drug, and Dental coverage to qualified State and local gov-ernment public employees, retirees, and eligible de-pendents.

5 Local employers must adopt a resolution to participate in the SHBP. The State Health Benefits Commission (SHBC) is the executive organization responsible for overseeing the SHBP . The State Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article et seq. Rules governing the operation and admin-istration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative School Employees Health Benefits Program (SEHBP) was established in 2007. It offers medical, prescription drug, and Dental coverage to qualified lo-cal education public employees, retirees, and eligible dependents. Local education employers must adopt a resolution to participate in the SEHBP. The School Employees Health Benefits Commis-sion (SEHBC) is the executive organization responsi-ble for overseeing the SEHBP.

6 The School Employees Health Benefits Program Act is found in the New Jersey Statutes Annotated, Title 52, Article et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative New Jersey Division of Pensions and Benefits (NJDPB), specifically the Health Benefits Bureau and the Bureau of Policy and Planning, are responsible for the daily administrative activities of the SHBP and the SEHBP . The Employee Dental Plans consist of the Dental Plan Organizations (DPOs) and the Dental Expense Plan (DEP). The Employee Dental Plans are available to full-time employees of the State of New Jersey, State colleges and universities, certain independent State agencies, and adopting local government and local education employers.

7 Before making any enrollment decision, you should carefully review the standards of eligibility and the conditions, limitations, and exclu-sions of the benefit coverage offered under each plan. The complete terms of Employee Dental Plans cover-age are described in the DPO and DEP contracts with amendments .Every effort has been made to ensure the accuracy of the Employee Dental Plans Member guidebook . However, State law and the New Jersey Administrative Code govern the SHBP and SEHBP. If there are dis-crepancies between the information presented in this guidebook and/or plan documents and the law, regula-tions, or contracts, the law, regulations, and contracts will govern. Furthermore, if you are unsure whether a Dental service or procedure is covered, contact your Dental plan before you receive services to avoid any denial of coverage issues that could , after reading this guidebook , you have any questions, comments, or suggestions regarding the information presented, please write to the New Jersey Division of Pensions & Benefits, Box 295, Trenton, NJ 08625-0295, call us at (609) 292-7524, or send email to: Dental Plans ELIGIBILITYE ligibility for coverage is determined under the provi-sions of the SHBP.

8 Enrollments, terminations, chang-es to coverage, etc. must be presented through your employer to the Health Benefits Bureau of the NJDPB. If you have any questions concerning eligibility pro-visions, you should see your employer s benefits ad-ministrator. You can also contact the NJDPB Office of Client Services at (609) 292-7524 or by email at: EmployeesTo be eligible for State Employee coverage, you must work full-time for the State of New Jersey or be an ap-pointed or an elected official of the State of New Jersey (this includes employees of a State agency or authori-ty and employees of a State college or university). For State employees, full-time requires 35 hours per week or more if required by contract or part-time employees covered under 2003, c. 172 (Chapter 172), and State intermittent employees covered by negotiated agreements between the State of New Jersey and the Communications Workers of America (CWA) are not eligible for coverage under the Employee Dental Plans .

9 Local EmployeesTo be eligible for Employee Dental Plans local employ-er coverage, you must be a full-time Employee or an appointed or elected official receiving a salary from a local government/education employer (county, munic-ipality, county or municipal authority, board of educa-tion, etc.) that participates in the SHBP or the SEHBP and has adopted a resolution to provide Dental benefits under the Employee Dental Plans . Each participating local employer defines, in its reso-lution, the minimum hours required to be considered a full-time Employee , but it can be no less than 25 hours per week or more if required by contract. Employment must also be for 12 months per year except for employ-ees whose usual work schedule is 10 months per year (the standard school year). Local part-time employees covered under Chapter 172 are not eligible for coverage under the Employee Den-tal Plans .

10 Page 5 January 2022 Employee Dental Plans Member GuidebookSchool Employees Health Benefits Program State Health Benefits ProgramEligible DependentsYour eligible dependents are your spouse, civil union partner, or eligible same-sex domestic partner and/or your eligible children. See the NJDPB website for defi-nitions of eligible dependents and required documenta-tion: : There is no provision for Dental coverage under 2005, c. 375 (Chapter 375), which provides medi-cal and/or prescription drug coverage to over age chil-dren until age 31 .RetireesThe Employee Dental Plans are not available to retir-ees. At retirement, retirees who are eligible for enroll-ment into the Retired Group of the SHBP or SEHBP may elect to enroll for coverage in the Retiree Dental Plans . Note: Employees who, at retirement, are eligible to en-roll in the Retired Group of the SHBP or SEHBP can-not continue Employee Dental Plan coverage under COBRA.