STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY …

1 STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS & BENEFITS 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 SHBP MEMBER guidebook GGUIDEBOOK i TABLE OF CONTENTS INTRODUCTION .. 1 HORIZON BCBSNJ MEMBER ONLINE 2 HORIZON HEALTH GUIDE .. 3 MY HEALTH MANAGER, POWERED BY WEBMD .. 4 NJ DIRECT AND CWA UNITY 5 HEALTH BENEFITS PROGRAM ELIGIBILITY .. 6 ACTIVE EMPLOYEE ELIGIBILITY .. 6 STATE EMPLOYEES .. 6 LOCAL GOVERNMENT EMPLOYEES .. 6 ELIGIBLE 7 SUPPORTING DOCUMENTATION REQUIRED FOR ENROLLMENT OF 8 AUDIT OF DEPENDENT COVERAGE .. 8 MEDICARE COVERAGE WHILE 9 RETIREE 9 Aggregate of Pension Membership Service 10 Eligible Dependents of Retirees.

2 10 Multiple Coverage under the SHBP/SEHBP is 11 Enrolling in Retired Group 11 MEDICARE 11 Medicare Parts A and B .. 11 Medicare Part D .. 12 Medicare 12 Coordination of benefits 13 When Medicare is primary .. 13 Dual Medicare Eligibility .. 13 How to File a Claim If You Are Eligible for Medicare .. 13 GENERAL CONDITIONS OF THE 14 Medical Need and Appropriate Level of 15 Health Care Fraud .. 15 PRECERTIFICATION OF BENEFITS .. 15 IN-NETWORK AND OUT-OF-NETWORK .. 15 SERVICES REQUIRING 15 Predetermination of Benefits .. 18 UTILIZATION MA NAGEME NT .. 18 REASONABLE AND CUSTOMARY ALLOWANCES (FOR OUT-OF-NETWORK SERVICES) .. 19 Claims by Out-of-Network Provider Practices .. 19 Admissions for the Treatment of Substance Use Disorder (for Network Service Only).

3 20 Experimental or Investigational Treatments .. 20 SHBP 21 IN-NETWORK 21 In-Network Copayments .. 23 In-Network Deductible .. 23 Annual In-Network 23 ii NEW JERSEY DIVISION OF PENSIONS & BENEFIT S Annual In-Network Coinsurance Limit .. 24 Annual In-Network Out-of-Pocket 24 Local Government Employees Annual In-Network Out-of-Pocket Maximum:.. 24 STATE Employees Annual In-Network Out-of-Pocket 25 Retirees Annual In-Network Out-of-Pocket Maximum .. 25 OUT-OF-NETWORK 25 Out-of-Network Deductible .. 26 Out-of-Network Inpatient Deductible .. 27 Out-of-Network 27 Out-of-Network Out-of-Pocket 28 COORDINATION OF BENEFITS .. 29 GENERAL BENEFITS .. 30 30 Alcohol and Substance Abuse Treatment .. 31 Ambulance .. 31 Audiology 31 Autism or Other Developmental Disability.

4 31 Automobile-Related Injuries .. 31 Biofeedback .. 32 Birthing Centers .. 32 Blood .. 32 Breast Reconstruction .. 32 Chiropractic Services .. 32 Congenital Defects .. 33 Dental Care .. 33 Diabetic Self-Management Education .. 33 Dialysis .. 34 Durable Medical Equipment and Supplies .. 34 Emergency Medical 34 Urgent and After Hours Care .. 35 Emergency 35 Federal Government Hospitals .. 35 Gender Identity- Treatment to Affirm Gender 35 Gynecological Care and 35 Hearing 35 Hemophilia Treatment .. 35 Home Health Care .. 36 Hospice Care 36 Infertility Treatment .. 37 Lead Poisoning Screening and Treatment .. 39 Lithotripsy 39 Lyme Disease Intravenous Antibiotic Therapy .. 39 39 Mastectomy Benefits .. 39 Maternity/Obstetrical Care .. 40 Maternity/Obstetrical Care for Child Dependents.

5 40 Mental or Nervous 40 Newborn Home Visitation Program .. 41 Nutritional Counseling .. 41 Organ Transplant 41 Pain 41 Pap Smears .. 42 Patient Controlled Analgesia (PCA).. 42 Physical Therapy/Occupational Therapy .. 42 SHBP MEMBER guidebook GGUIDEBOOK iii Pre-Admission Hospital Review (In-Network and Out-of-Network).. 42 Pre-Admission Testing Charges .. 43 Prostate Cancer Screening (In-Network Only).. 43 Scalp Hair Prostheses .. 43 Second Surgical 43 Shock Therapy Benefits .. 43 Skilled Nursing Facility 43 Speech Therapy Benefit .. 43 Substance Use Disorder 44 Surgical Services (Out-of-Network) .. 45 46 Temporomandibular Joint Disorder (TMJ) and Mouth Conditions .. 47 Vision Care 47 CHARGES NOT COVERED BY THE SHBP PLANS .. 47 THIRD PARTY LIABILITY.

6 53 Repayment Agreement .. 53 Recovery Right .. 53 SUBROGATION AND 53 WHEN YOU HAVE A CLAIM .. 54 Submitting a Claim (In-Network).. 54 Submitting a Claim (Out-of-Network).. 54 Filing Deadline (Proof of Loss) .. 54 Itemized Bills are Necessary .. 55 Foreign Claims .. 55 Filling Out the Claim Form .. 55 MEDICARE CLAIM SUBMISSION .. 55 AUTHORIZATION TO PAY PROVIDER .. 55 QUESTIONS ABOUT CLAIMS .. 55 APPEAL 56 SHBP MEDICAL APPEAL PROCEDURE .. 56 Second Level Medical Appeals (excluding certain appeals related to substance use disorder).. 57 EXTERNAL APPEAL RIGHTS .. 58 APPEAL RIGHTS EXCLUSIVE TO SUBSTANCE USE DISORDER .. 59 SHBP PLANS ADMINISTRATIVE APPEAL PROCEDURE .. 61 prescription drug BENEFITS .. 63 COBRA COVERAGE .. 63 COBRA Events .. 64 Cost of COBRA 64 Duration of COBRA Coverage.

7 64 Employer Responsibilities under 65 Employee Responsibilities under COBRA .. 65 Failure to Elect COBRA Coverage .. 65 Termination of COBRA Coverage .. 66 APPENDIX 66 WORK-RELATED INJURY OR DISEASE .. 66 MEDICAL PLAN EXTENSION OF BENEFITS .. 66 TERMINATION FOR CAUSE .. 67 APPENDIX II .. 67 SUMMARY SCHEDULESOF SERVICES AND 67 SHBP PLANS ELIGIBLE SERVICES AND SUPPLIES .. 68 SHBP PLANS COVERED 69 iv NEW JERSEY DIVISION OF PENSIONS & BENEFIT S APPENDIX III .. 74 GLOSSARY .. 74 APPENDIX IV .. 83 REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT .. 83 REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT .. 84 APPENDIX V .. 85 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY 85 Certification of Coverage .. 85 HIPAA Privacy.

8 85 APPENDIX VI .. 85 NOTICE OF PRIVACY PRACTICES TO ENROLLEES IN THE NEW JERSEY STATE HEALTH BENEFITS 85 Protected Health Information .. 85 Uses and Disclosures of PHI .. 85 Restricted Uses .. 86 Member Rights .. 87 Questions and Complaints .. 88 APPENDIX VII .. 88 HEALTH BENEFITS PROGRAM CONTACT 88 Addresses .. 88 Telephone Numbers .. 89 HEALTH BENEFITS PROGRAM PUBLICATIONS .. 90 General Publications .. 90 Member Guidebooks .. 90 An online version of this guidebook containing current updates is available for viewing at: Be 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. SHBP MEMBER guidebook 1 INTRODUCTION The STATE He alth Be ne fits Program (SHBP) was established in 1961.

9 It offers medical and prescription drug coverage to qualified STATE and local government public employees, retiree s, a n d eligible dependents; and dental coverage to qualified STATE and local government/educatio n p u b lic 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 lo ca l employee representative chosen by the Public Employees Committee of the AFL-CIO.

10 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 fo u n d in Title 17, Chapter 9 of the New JERSEY Administrative Code. The Div ision of Pe nsions & Be nefits, specifically the Health Benefits Bureau and th e Bu r ea u o f 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 SHBP 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.