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«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»

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Note: The following preventive medications are covered with a doctor’s prescription with a zero-dollar copayment for certain members meeting specific criteria (see the Prescription Drug Plans Member Handbook for specific limits related to age, gender, and medical condition): Aspirin, Fluoride, Folic Acid, Iron supplements, and certain drugs that assist with Smoking Cessation.

3. A private (non-SHBP/SEHBP) prescription drug plan that is at least equal to the Employee Prescription Drug Plan.

RETIREE PRESCRIPTION DRUG COVERAGE

Retirees enrolled in a SHBP or SEHBP medical plan have access to the Retiree Prescription Drug Plan. Plan benefits are available through participating retail pharmacies, by mail order through Express Scripts, and from specialty pharmacy services provided through Accredo, Express Scripts’ specialty pharmacy.

The plan features a three-tier copayment design. Retail pharmacy services require a copayment for up to a 30-day supply of prescription drugs. Mail order participants can receive up to a 90-day supply of prescription drugs for one mail order copayment.

Specialty pharmacy services are only provided via mail through Accredo. If your doctor has prescribed a specialty pharmaceutical, you will not be able to fill the prescription at a retail pharmacy.

Medicare Part D If you are enrolled in the Retired Group of the SHBP/SEHBP and eligible for Medicare, you will be automatically enrolled in the Express Scripts Medicare Prescription Plan, a Medicare Part D plan.

Important: If you decide not to be enrolled in the Express Scripts Medicare Prescription Plan, you will lose your prescription drug benefits provided by the SEHBP/SHBP.

However, your medical benefits will continue. In order to waive the Express Scripts Medicare Prescription Plan, you must enroll in another Medicare Part D plan. To request that you not be enrolled, you must submit proof of other Medicare Part D coverage to the Division of Pensions and Benefits.

74 — HORIZON HMO MEMBER HANDBOOK

RETIREE PRESCRIPTION DRUG COPAYMENTS

The amount that retired members and their eligible dependents pay for prescription drugs is determined by the medical plan the retiree selects.

Effective January 1, 2016, copayments for retiree prescription drug coverage are as follows.

STATE RETIREES AND LOCAL GOVERNMENT RETIREES

–  –  –

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal law that gives employees and their eligible dependents the opportunity to remain in their employer's group coverage when they would otherwise lose coverage. COBRA coverage is available for limited time periods (see “Duration of COBRA Coverage” on page 78), and the member must pay the full cost of the coverage plus an administrative fee.

Leave taken under the federal and/or State Family Leave Act is not subtracted from your COBRA eligibility period.

Under COBRA, you may elect to enroll in any or all of the coverages you had as an active employee or dependent (health, prescription drug, dental, and vision). You may also change your health or dental plan when enrolling in COBRA. You may elect to cover the same dependents that you covered while an active employee, or delete dependents from coverage — however, you cannot add dependents who were not covered while an employee except during the annual Open Enrollment period (see below) or unless a "qualifying event" (marriage, birth or adoption of a child, etc.) occurred within 60 days of the COBRA event.

Open Enrollment — COBRA enrollees have the same rights to coverage at Open Enrollment as are available to active employees. This means that you or a dependent who elected to enroll under COBRA are able to enroll, if eligible, in any medical, dental, or prescription drug coverage during the Annual Open Enrollment Period regardless of whether you elected to enroll for the coverage when you went into COBRA. This affords a COBRA enrollee the same opportunity to enroll for benefits during the Annual Open Enrollment Period as an active employee. However, any time of non-participation in the benefit is counted toward your maximum COBRA coverage period. If the State Health Benefits Commission or School Employees’ Health Benefits Commission make changes to any benefit plan available to active employees and/or retirees, those changes apply equally to COBRA participants.

COBRA Events

Continuation of group coverage under COBRA is available if you or any of your covered

dependents who would otherwise lose coverage as a result of any of the following events:

• Termination of employment (except for gross misconduct).

• Death of the member/retiree.

• Reduction in work hours.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

• Leave of absence.

• Divorce, legal separation, dissolution of a civil union or domestic partnership (makes spouse/partner ineligible for further dependent coverage).

• Loss of a dependent child's eligibility through the attainment of age 26.The employee elects Medicare as primary coverage. (Federal law requires active employees to terminate their employer's health coverage if they want Medicare as their primary coverage.) Note: Employees who at retirement are eligible to enroll in SHBP or SEHBP Retired Group coverage cannot enroll for health benefits coverage under COBRA.





The occurrence of the COBRA event must be the reason for the loss of coverage for you or your dependent to be able to take advantage of the provisions of the law. If there is no coverage in effect at the time of the event, there can be no continuation of coverage under COBRA.

Cost of COBRA Coverage If you choose to purchase COBRA benefits, you pay 100 percent of the cost of the coverage plus a two percent charge for administrative costs.

Duration of COBRA Coverage COBRA coverage may be purchased for up to 18 months if you or your dependents become eligible because of termination of employment, a reduction in hours, or a leave of absence.

Coverage may be extended up to 11 additional months, for a total of 29 months, if you have a Social Security Administration approved disability (under Title II or XVI of the Social Security Act) for a condition that existed when you enrolled in COBRA or began within the first 60 days of COBRA coverage. Proof of Social Security Administration determination must be submitted to the Health Benefits Bureau of the Division of Pensions and Benefits within 60 days of the award or within 60 days of COBRA enrollment. Coverage will cease either at the end of your COBRA eligibility or when you obtain Medicare coverage, whichever comes first.

COBRA coverage may be purchased by a dependent for up to 36 months if he or she becomes eligible because of your death, divorce, dissolution of a civil union or domestic partnership, or a child becomes ineligible for continued group coverage because of attaining age 26, or because you elected Medicare as your primary coverage.

If a second qualifying event — such as a divorce — occurs during the 18-month period following the date of any employee's termination or reduction in hours, the beneficiary of that second qualifying event will be entitled to a total of 36 months of continued coverage. The period will be measured from the date of the loss of coverage caused by the first qualifying event.

78 — HORIZON HMO MEMBER HANDBOOK Employer Responsibilities Under COBRA

The COBRA law requires employers to:

• Notify you and your dependents of the COBRA provisions within 90 days of when you and your dependents are first enrolled;

• Notify you and your dependents of the right to purchase continued coverage within 14 days of receiving notice that there has been a COBRA qualifying event that causes a loss of coverage;

• Send the COBRA Notification Letter and a COBRA Application within 14 days of receiving notice that a COBRA qualifying event has occurred;

• Notify the Health Benefits Bureau of the Division of Pensions and Benefits within 30 days of the loss of an employee’s coverage; and

• Maintain records documenting their compliance with the COBRA law.

Employee Responsibilities Under COBRA

The law requires that you and/or your dependents:

• Must notify your employer (if you are retired, you must notify the Health Benefits Bureau of the Division of Pensions and Benefits) that a divorce, legal separation, dissolution of a civil union or domestic partnership, or your death has occurred or that your child has reached age 26 — notification must be given within 60 days of the date the event occurred;

• File a COBRA Application (obtained from your employer or the Health Benefits Bureau) within 60 days of the loss of coverage or the date of the COBRA Notice provided by your employer, whichever is later;

• Pay the required monthly premiums in a timely manner; and

• Pay premiums, when billed, retroactive to the date of group coverage termination.

Failure to Elect COBRA Coverage In considering whether to elect continuation of coverage under COBRA, an eligible employee, retiree, or dependent (also known as a “qualified beneficiary” under COBRA law) should take into account that a failure to continue group health coverage will affect future rights under federal law.

You should take into account that you have special enrollment rights under federal law.

You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days of the date your group coverage ends. You will also have the same special enrollment right at the end of the COBRA coverage period if you get the continuation of coverage under COBRA for the maximum time available to you.

–  –  –

• Your eligibility period expires;

• You fail to pay your premiums in a timely manner;

• After the COBRA event, you become covered under another group insurance program;

• You voluntarily cancel your coverage;

• Your employer drops out of the SHBP or SEHBP;

• You become eligible for Medicare after you elect COBRA coverage. (This affects health insurance only, not dental, prescription, or vision coverage.)

–  –  –

Work-related injuries or disease are not covered under Horizon HMO.

This includes the following:

• Injuries arising out of or in the course of work for wage or profit, whether or not your injuries are covered by a Workers' Compensation policy.

• Disease caused by reason of its relation to Workers' Compensation law, occupational disease laws, or similar laws.

• Work-related tests, examinations or immunizations of any kind required by your work except employer mandated examinations that are a prerequisite for participation in an employer mandated physical fitness test required as a condition of continuing employment.

• Work-related injuries will not be eligible for benefits under your medical plan before or after your Workers’ Compensation carrier has settled or closed your case.

Please note: If you collect benefits for the same injury or disease from both Workers' Compensation and Horizon HMO, you may be subject to prosecution for insurance fraud.

–  –  –

If you or a dependent are disabled with a condition or illness at the time of your termination from the SHBP or SEHBP, you may qualify for an extension of benefits for this specific condition or illness. You do not qualify for an extension of benefits if you currently have or are eligible for any other type of medical coverage including but not limited to Medicare. If you feel that you may qualify for an extension of benefits please contact Horizon HMO at 1-800-414-SHBP (7427) for assistance.

If the extension applies, it is only for eligible expenses relating to the disabling condition or illness. An extension under Horizon HMO will be for the time you or your dependent remains disabled from any such condition or illness, but not beyond the end of the calendar year after the one in which your coverage ends.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

TERMINATION FOR CAUSE

If any of the following conditions exist, you may receive written notice that you will no longer be covered under Horizon HMO.

• If, after reasonable efforts, Horizon HMO and/or participating providers are unable to establish and maintain a satisfactory, provider/patient relationship with you or you repeatedly act in a manner which is verbally or physically abusive.

• If you permit any person who is not authorized to use the identification card(s) issued to you. You may be liable for the cost of any claims paid for services for an ineligible individual.

• If you willfully furnish incorrect or incomplete information in a statement made for the purpose of effecting coverage.

• If you abuse the system, including, but not limited to theft, damage to a participating provider’s property, or forgery of prescriptions.

Any action by Horizon HMO under these provisions is subject to review in accordance with the established appeals procedures. If an appeal is denied and the decision upheld, this action is subject to appeal to either the State Health Benefits Commission or School Employees’ Health Benefits Commission. No benefits, other than for emergencies, will be provided to the member and to any family members under the coverage as of 31 days after such written notice is given by Horizon HMO.

If the State Health Benefits Commission or School Employees’ Health Benefits Commission overrules the decision to terminate, benefits will be restored.

82 — HORIZON HMO MEMBER HANDBOOK APPENDIX II

SUMMARY SCHEDULE OF SERVICES AND SUPPLIES



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