NJ DIRECT

1 STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS & BENEFITS NJ DIRECT high deductible health plan MEMBER GUIDEBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN THE STATE health BENEFITS PROGRAM plan YEAR 2022 ADMINISTERED FOR THE DIVISION OF PENSIONS & BENEFITS BY HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY NEW JERSEY DIVISION OF PENSIONS & BENEFITS TABLE OF CONTENTS INTRODUCTION ..4 Horizon BCBSNJ Member Online Services ..5 HORIZON health GUIDE ..6 NJWELL Rewards Program ..7 NJ DIRECT HDHP ..8 health BENEFITS PROGRAM ACTIVE EMPLOYEE ELIGIBILITY ..9 ENROLLMENT .. 10 ELIGIBLE DEPENDENTS .. 11 AUDIT OF DEPENDENT COVERAGE .. 13 MULTIPLE COVERAGE UNDER THE SHBP/SEHBP IS PROHIBITED .. 13 MEDICARE COVERAGE WHILE EMPLOYED .. 14 RETIREE ELIGIBILITY.

2 14 MEDICARE COVERAGE .. 17 GENERAL CONDITIONS OF THE plan .. 17 Medical Need and Appropriate Level of Care .. 17 health Care Fraud .. 18 PRECERTIFICATION OF BENEFITS IN-NETWORK AND OUT-OF- NETWORK .. 18 NJ DIRECT HDHP SERVICES REQUIRING PRECERTIFICATION .. 18 Predetermination of Benefits .. 22 UTILIZATION MANAGEMENT (Medical Management and Review) .. 22 REASONABLE & CUSTOMARY ALLOWANCES (Out-of-Network Services) .. 22 Claims by Out-of-Network Provider Practices .. 23 Experimental or Investigational Treatments .. 24 NJ DIRECT high deductible health PLANBENEFITS .. 26 DEDUCTIBLES .. 27 OUT-OF-POCKET MAXIMUMS .. 28 Horizon MyWay HSA .. 29 COORDINATION OF BENEFITS .. 31 GENERAL BENEFITS .. 32 CHARGES NOT COVERED BY NJ DIRECT HDHP .. 51 WHEN YOU HAVE A CLAIM .. 59 APPEAL PROCEDURES.

3 61 EXTERNAL APPEAL RIGHTS .. 65 APPEAL RIGHTS EXCLUSIVE TO SUBSTANCE USE DISORDER .. 66 NJ DIRECT HDHP ADMINISTRATIVE APPEAL PROCEDURE .. 68 PRESCRIPTION DRUG 70 APPENDIX I .. 75 SPECIAL plan PROVISIONS UNDER NJ DIRECT HDHP .. 75 MEDICAL plan EXTENSION OF 75 TERMINATION FOR CAUSE .. 76 APPENDIX II .. 77 SUMMARY SCHEDULES OF SERVICES AND SUPPLIES .. 77 NJ DIRECT HDHP ELIGIBLE SERVICES AND SUPPLIES .. 77 NJ DIRECT HDHP COVEREDSERVICES .. 77 GLOSSARY .. 83 APPENDIX III .. 83 REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT .. 95 health BENEFITS PROGRAM CONTACT INFORMATION .. 103 An online version of this guidebook containing current updates is available for viewing at: sure to check the Division of Pensions & Benefits Internet home page at for forms, fact sheets, and news of any new developments affecting your health benefits.

4 4 HORIZON HD plan MEMBER GUIDEBOOK INTRODUCTION The State health Benefits Program (SHBP) was established in 1961. It offers medical and .prescription drug coverage to qualified State and local government public employees, retirees, and eligible dependents; and dental coverage to qualified State and local government/education public employees, retirees, and their eligible dependents. 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 SHBC includes the State Treasurer as the chairperson, the Commissioner of the Department of Banking and Insurance, the Chairman of the Civil Service Commission, a State employee representative chosen by the Public Employees Committee of the AFL-CIO, and a local employee representative chosen by the Public Employees Committee of the AFL-CIO.

5 The Director of the Division of Pensions & Benefits is the Secretary to the SHBC. The State 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 Code. The Division of Pensions & Benefits, specifically the health Benefits Bureau and the Bureau of Policy and Planning, is responsible for the daily administrative activities of the SHBP and the SEHBP. Every effort has been made to ensure the accuracy of the NJ DIRECT HDHP Member Guidebook; which describes the benefits provided in the contract with Horizon BCBSNJ. However, State law and the New Jersey Administrative Code govern the SHBP. If there are any discrepancies between the information presented in this booklet and/or plan documents and the law, regulations, or contracts, the law, regulations, and contracts will govern.

6 Furthermore, if you are unsure whether a procedure is covered, contact your plan before you receive services to avoid any denial of coverage issues that could result. If, after reading this booklet, you have any questions, comments, or suggestions regarding this material, please write to the Division of Pensions & Benefits, PO Box 295, Trenton, NJ 08625- 0295, call us at (609) 292-7524, or send an e-mail to NEW JERSEY DIVISION OF PENSIONS & BENEFITS 5 Horizon BCBSNJ Member Online Services Horizon Blue Cross Blue Shield of New Jersey offers you an easy, secure and quick way to track your health plan benefits and health information online. Simply register at to have immediate access to health plan benefits and health information online1. You can: Chat or send a secure email.

7 Check claims status and payments. Read Explanation of Benefits statements, and see any amount owed. Tell Horizon BCBSNJ if you have other health insurance coverage. Use our tools and resources to understand your plan and the insurance process. View and print your member ID card. View your benefit information. View your out-of-pocket expenses, authorizations, referrals and other account information. Access NJWELL Connect with health and wellness programs Check your HSA transactions and funding Find a doctor, hospital or other health care professional Have a telemedicine visit Learn what s new with your Horizon coverage 1 Not all tools and services may be compatible with every electronic device or available with every account. For assistance with the registration process, please contact the eService Help Desk via email at or by calling 1-888- 777-5075, Monday through Friday, 7 to 6 , Eastern Time.

8 You can also download the Horizon Blue app free by texting GetApp to 422-272 to get all the information you need in the palm of your hand. There is no charge to download the Horizon Blue app, but rates from your wireless provider may HORIZON HD plan MEMBER GUIDEBOOK HORIZON health GUIDE When you call the number on your SHBP Horizon-BCBSNJ member ID card, your Horizon health Guide can help with all your health care needs: answering questions, solving issues, helping with claims, finding care, scheduling appointments, connecting you to health programs, even making health and wellness benefit suggestions tailored to you. They will also provide case management support to members with complex needs or who suffer from chronic health conditions.

9 Speak to your Horizon health Guide at 1-800-414-SHBP (7427). Support for your medical care when you need it: The Horizon health Guide helps members with chronic conditions take better care of their health , understand their care choices and improve their health . This program is available at no added cost to eligible members with: Asthma. Chronic Kidney Disease (CKD). Chronic Obstructive Pulmonary Disease (COPD). Coronary Artery Disease (CAD). Diabetes. Heart Failure. For support for any medical condition or ongoing assistance in a complex situation If you have a serious health problem or need major surgery, your clinical health Guide, who is a registered nurse, can help you understand your treatment choices and find out about available specialists, hospitals, and care, while making sure you get the most out of your health plan benefits.

10 Your health Guide can work with you and your physician(s) to make sure you get the most appropriate and effective treatment. For Horizon Supportive CareSM: The Supportive Care Nurses help improve the quality of life for patients who are facing a serious or life-threatening illness, by helping to relieve symptoms, pain and stress. Our nurses collaborate with your doctors and help you and your family navigate what can be a difficult journey. For high Risk Maternity: An experienced high -risk Obstetrical Care Manager will call you to assist throughout your pregnancy by providing nursing guidance and related education. Your Horizon health Guide will: Work with your physician to make sure you know your health problem and treatment choices. Handle prior authorization requests for special services, equipment and other supplies as asked for by your physician and other health care professionals.