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The new web sites for health care providers are operational and if you are changing plans you should use the 'Doc find' & 'Hospital Find' options on the providers' web sites to see if your doctors etc. are in-network.

Please note that the best way to find your doctors or hospitals in these searches is to input your zip code and use within 5, 10 or 15 miles radius from your zip code to find a list of providers within your area. This eliminates having to spell your doctor's or hospital name exactly as they are in the system in order for them to show up on the search.

It would be wise to also check with your doctor(s) office to be sure they are in network of the plan you’ve chosen.

NJ Direct 15- 1-800-414-7427 (More FAQs directly from Horizon Direct 15 appear further below in this document)

http://www.horizonblue.com/shbp/ (for members residing in NJ) 

http://www.bcbsa.com/healthtravel/finder.html (For members residing outside of NJ
or for any members traveling - Choose "Guest" and input "NJX" for identification prefix - type of plan is PPO)

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Aetna - http://www.aetna.com/statenj/     - 1-877-STATE NJ
Cigna - http://www.cigna.com - 1-800-564-7642

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The new health benefit plans will take effect on April 1, 2008 for State monthly employees.  Even though you’re paid bi-weekly – you are considered state monthly.

All of the plans are available nationwide. There are no longer specific service areas in different states. But you should check with your provider to verify their plan participation.

Employees in NJ Plus and Traditional Plan will automatically move to NJ Direct 15 UNLESS you want to change to either Aetna or Cigna HMOs.

Employees in the Amerihealth, Healthnet or Oxford HMOs will be moved to NJ Direct 15 UNLESS they wish to choose Aetna or Cigna HMOs.

Retirees in Traditional Plan will move to NJ Direct 10.

Both NJ Direct 15 & 10 are administered by Horizon Blue Cross Blue Shield

The above applies to all Active, Retired & Cobra members.

During the term of the agreement, people who plan to retire outside of New Jersey in NJ Direct 10 (or NJ Direct 15 due to years of service per the agreement) will be covered under Blue Cross/Blue Shield Blue Card Network.

Members in the Traditional Plan who are undergoing special or other treatments that have already been approved (pre approval for pending treatment as well) will not be required to seek new approvals in NJ Direct 15. When they move in Direct 15, they are advised to notify Horizon that they were already previously approved under the Traditional Plan to avoid any complications

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NJ Direct 15 & 10

For in network only, co-insurance (such as for durable medical goods) counts against the $400 in network out of pocket maximum.  Co-pays do not go towards the out of pocket (same as old NJ Plus)

For out of network – the 30% payments for out of network and other items DO count towards out of pocket maximum.

Deductibles and annual/lifetime maximums from Traditional & NJ Plus plans will carry over into NJ Direct Plans.

Choosing a Primary Care Physician is always encouraged but there is no requirement to do so.

Referrals are NOT needed in NJ DIRECT 15 either in or out of network. There was an incorrectly worded sentence on the Guide to Choosing a SHBP Health Plan. You may need pre certification for certain procedures like x-rays, MRIs, etc. the same as was required  under NJPlus

NJ Direct 10 is only available for retirees and is the successor to the Traditional Plan. It is also available to Local employees (municipal employees, school employees etc). where negotiated in the city, town etc. Please note that the State does not negotiate this for local employees - your cities & towns do. Some localities do not use the State plan and thus do not buy in. NJ Direct 10 is not available for active State employees.

Both NJ Direct 15 & 10 will use the NJ Plus network in New Jersey (not the Traditional Plan network).

LabCorp is the exclusive laboratory provider for NJ Direct  in New Jersey.  Lab services outside of New Jersey will be a function of the BCBS local plan's network.  Detailed information like this will be available in the SHBP handbook. SHBP does not yet have a projected completion date.

If you live in New Jersey and are moving into NJ Direct 15 you can begin searching for providers now using the Horizon web site listed further below..

Out of State members moving to NJ Direct 15 (&10) will use the Blue Cross/Blue Shield Blue Card Network – and no longer use the NJ Plus Network for PA & NY – or anywhere else in the U.S. There will be clear information on the ID card regarding how out-of-state providers should handle NJ DIRECT members.

If a person in NJ Direct goes to an out of network physician who recommends a hospitalization in an in-network hospital, for payment purposes, is this considered an in-network or out-of-network hospitalization?   The person who asked this question reported that they had called Horizon three times on this issue and received two different answers.
Similarly, if an out of network provider orders lab work from an in-network lab, is the lab work considered out of network or in network?

Hospitalization benefits are based on the participating status of the hospital so the 'hospital' days would be in-network.  It is important to distinguish the professional component from the hospital component on the claim. The non-participating doctor's services would be considered out of network.
The same is true for Lab. If a participating lab is utilized, benefits are in-network but non-par doc services would be out of network.

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NJ DIRECT Frequently Asked Questions (from Horizon web site)

How are NJ DIRECT benefits different from NJ PLUS and the Traditional Plan?
Under NJ DIRECT, members can directly access physicians and hospitals without having to choose a PCP. You will have the same access to participating physicians, specialists, hospitals and other health care professionals (same network as NJ PLUS) in New Jersey. In addition, NJ DIRECT members will now have access to the National BlueCard® PPO network of providers outside of New Jersey.

If you had the Traditional Plan previously, NJ DIRECT is similar to the Traditional Plan because it will still allow you to use out-of-network services. In addition, if you receive eligible services from a participating provider, you will now only pay a copayment for most services (this includes physical exams, well-child care and immunizations which are covered on an in-network basis).

When will I receive my open enrollment information?
Open enrollment materials will be available in conjunction with the SHBP Special Open Enrollment period that will be from January 28 through February 15, 2008.

Will I need to select a Primary Care Physician (PCP)?
No, you will not need to select a PCP as part of either NJ DIRECT15 or NJ DIRECT10 (Retirees).

Will I need a referral from a PCP to see a specialist?
No, you will not need a referral from a PCP to see a specialist. (Certifications will be required for some services.)

If I receive emergency treatment, must I call NJ DIRECT member services within 24 hours?
No; NJ DIRECT doesn’t require you to contact member services for emergency treatment.

Are routine services covered?
NJ DIRECT will offer physical exams, well-child care and immunizations in-network. You must utilize a participating physician in order to receive the in-network benefit. A limited number of routine services will also be covered out of network.

Will NJ DIRECT use Magellan Behavioral Health for precertification of mental health/behavioral health services?
Yes, NJ DIRECT will use Magellan Behavioral Health for precertification of all mental/behavioral health services.

Will NJ DIRECT use CareCore National, LLC (CCN) for precertification of all advanced radiological procedures?
Yes, NJ DIRECT will use CareCore for precertification of all advanced radiological procedures.

Will NJ DIRECT require precertification for certain services?
Yes, precertification will be required for certain services. Examples are Durable Medical Equipment; Inpatient admissions; Home Health Care; Cognitive, Physical, Occupational and Speech Therapies, Reconstructive Procedures that may be considered Cosmetic; Specialty Pharmaceuticals; Surgery for Morbid Obesity; and Transplants. A complete list will be available in the NJ DIRECT Member Handbook.

How do I know if my physicians participate in NJ DIRECT?
Click here and you will be directed to the NJ DIRECT provider directory page where you can print a personalized provider directory or search for specific providers by name or by specialty.

Are members and their dependents able to obtain in-network benefits while outside of New Jersey?
With NJ DIRECT, you and your dependents will have access to in-network benefits through the national BlueCard® PPO provider network outside of New Jersey. Click here to find participating providers in and out of New Jersey.

Must I use a physician or hospital in the NJ DIRECT network or BlueCard® PPO network?
No; you may use your out-of-network benefits, which offer care from any eligible physician or hospital outside the NJ DIRECT or BlueCard® PPO network in exchange for higher out-of-pocket costs. Out-of-network benefits require a deductible and coinsurance (and may be subject to balance billing), while members using in-network benefits will only be responsible for a copayment, for most services.

What is the in-network copayment under NJ DIRECT?
If you select NJ DIRECT15, your office visit copayment will be $15. If you select NJ DIRECT10, your copayment will be $10. Your ID card will indicate the appropriate copayment amount.

Will I have a deductible with NJ DIRECT?
For in-network services, you will not be responsible for a deductible. For any services provided out of network, coinsurance and deductible will apply.

What are the out-of-network benefits?
NJ DIRECT15 provides reimbursement for out-of-network coverage at 70 percent of the reasonable and customary fee schedule after deductible for most services, while NJ DIRECT10 (FOR RETIREES) provides reimbursement for out-of-network coverage at 80 percent of the reasonable and customary fee schedule after deductible, for most services. (Detailed benefit information will be provided during your open enrollment period.)

I have surgery or a procedure scheduled after 4/1/08 and already received authorization from my prior plan. Do I need to receive authorization again?
If you received authorization from NJ PLUS or the Traditional Plan, you need not provide NJ DIRECT with any documentation. If you received authorization from a health plan other than NJ PLUS or the Traditional Plan, we will require a letter from the prior carrier that documents the authorization number, authorization date, rendering physician name and services authorized. NJ DIRECT’s policy is that we will honor a prior plan’s authorization for up to six months from the date of authorization.

Will I receive a new ID card?
Yes, new ID cards will be issued to NJ DIRECT members.

Will my ID number change?
If you are changing to NJ DIRECT from NJ PLUS or the Traditional Plan, you will receive a new ID card with a different alpha prefix than your current ID card. The new alpha prefix is NJX. However, the numeric portion of the ID number will remain the same.

When should I expect to receive my new NJ DIRECT ID card?
NJ DIRECT ID cards will be mailed in mid to late March 2008. The cards will be issued in the name of the employee. Single coverage policies will receive one ID card and all others (employee plus spouse/partner, family) will receive two cards. Additional cards can be requested, if needed.

What if I don't receive my NJ DIRECT ID card by the April 2008 effective date?
You can print a copy of a Coverage Letter from Member Online Services at www.horizonblue.com/shbp to give to your physician. The Coverage Letter is good for 10 days from when it is printed.

Where can I find more information?
In addition to the information provided on this website, you can call SHBP Member Services at 1-800-414-SHBP (7427) for information on NJ DIRECT benefits or participating provider information.

All current Traditional Plan and NJ PLUS members, as well as Amerihealth, Health Net and Oxford members, will be assigned to one of the NJ DIRECT plans as outlined in the Guide.

Current Horizon SHBP members may receive a solicitation from Aetna HMO or Cigna Healthcare (HMO) before or during the open enrollment. This solicitation does not impact your eligibility for NJ DIRECT. All current Traditional Plan and NJ PLUS members, as well as Amerihealth, Health Net and Oxford members, will be assigned to one of the NJ DIRECT plans unless a SHBP application is submitted to report another election.

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Health coverage outside of United States

The same kind of coverage that currently exists will continue. See below for some answers we received from the state on travel both in the U.S. & foreign.

"The nature of the travel is not relevant.  It does not matter if it's work related.  In fact, if the actual illness or injury is work related, the health plan won't pay at all - any work related claims go directly to Workers' Compensation.
 
... the rules of the game then are that the Horizon plans will pay for eligible services anywhere.  In most cases in the United States, participating hospitals or doctors will bill Horizon through the local Blue Cross/Blue Shield plan.  If the doctor or hospital does not participate, they may require payment from the patient, who could then file the claim with Blue Cross directly.  In many foreign countries, payment is required from the patient.  To handle this, one can obtain temporary travelers' health coverage or one can rely upon use of a credit card. Then again, one can file the claim with Horizon after the fact;  a detailed copy of the medical bill is required.  Such treatment is usually covered as "out of network".

The 1.5% salary deduction for health benefits is from employees' regular base salary. Summer pay & overload should not be included in the deduction because they are not part of base salary. Be sure to check your deductions if you are in this category.

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During the Special Open Enrollment (1/28 – 2/15/08) the following applies:

Health plan changes only.
There are no Prescription Drug or Dental Plan changes.
No adding dependents.
No new enrollments.
ID cards will be issued mid March 2008
Eventually, on-line enrollment in Jan. 2009 will replace paper forms.

Your campus HR benefits staff should (we hope) be able to update you further if needed.

Keep an eye on the State Health Benefits site for any additional timely information - http://www.state.nj.us/treasury/pensions/shbp.htm

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