«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
School Employees’ Health Benefits Program (SEHBP) — The SEHBP was established by Chapter 103, P.L. 2007. It offers medical and prescription drug coverage to qualified school employees and retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the SEHBP. The School Employees’ Health Benefits Program Act is found in the N.J.S.A. 52:14-17.46 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —SEHBP Member — An individual who is either a School Employees’ Health Benefits Program Active Group, Retired Group, or COBRA participant and their dependents.
SHBP Member — An individual who is either a State Health Benefits Program Active Group, Retired Group, or COBRA participant and their dependents.
Skilled Nursing Facility — A facility which is approved by either the Joint Commission on Accreditation of Health Care Organizations or the Secretary of Health and Human Services and provides skilled nursing care and services to eligible persons. The skilled nursing facility provides a specific type of treatment that falls midway between a hospital that provides care for acute illness and a nursing home that primarily provides custodial, maintenance or supportive care as well as assistance with daily living.
Specialty care — Services provided by a health care professional whose practice is limited to a specific area of medicine (i.e. orthopedics, dermatology, physical therapy, chiropractic manipulation, etc.).
State Biweekly Employee — For health benefits purposes, state biweekly employee means a full-time employee of the State, or an appointed or elected officer, paid by the State's centralized payroll system whose benefits are based on a biweekly cycle.
Full-time normally requires 35 hours per week.
State Health Benefits Commission — The entity created by N.J.S.A. 52:14-17.27 and charged with the responsibility of overseeing the State Health Benefits Program.
State Health Benefits Program (SHBP) — The SHBP was originally established by statute in 1961. It offers medical, prescription drug, and dental coverage to qualified public employees and retirees, and their eligible dependents. Local employers must adopt a resolution to participate in the SHBP and its plans. The State Health Benefits Program Act is found in the N.J.S.A. 52:14-17.25 et seq. Rules governing the operation and administration of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
State Monthly Employee — For health benefit purposes, state monthly employee means a full-time employee of the State, or an appointed or elected officer, whose benefits are based on a monthly cycle and whose payroll system is autonomous (not paid by the State's centralized payroll system). Full-time shall mean the usual full-time weekly schedule for the particular title, which normally requires 35 hours per week.
State Monthly Employer — Employers whose benefits are based on a monthly cycle and whose payroll system is autonomous (not paid by the State's centralized payroll system). This includes state colleges and universities and participating independent state
commissions, authorities, and agencies such as:
• Rutgers, the State University of New Jersey
• Rutgers Biomedical and Health Sciences
• Palisades Interstate Park Commission
• New Jersey Institute of Technology 96 — HORIZON HMO MEMBER HANDBOOK
• Thomas Edison State University
• William Paterson University
• Ramapo College of NJ
• Rowan University
• The College of New Jersey
• Montclair State University
• New Jersey City University
• Kean University
• Stockton University
• New Jersey State Library
• New Jersey State Legislature and Legislative Offices
• New Jersey Building Authority
• New Jersey Commerce and Economic Growth Commission
• Waterfront Commission of New York Harbor
• Agencies or special projects that are supported from, or whose employees are paid from, sources of revenue other than general funds, which other funds shall bear the cost of benefits under this program Substance Abuse — The abuse of or addiction to drugs or controlled substances, not including alcohol.
Supportive Care — Care for patients that have reached the maximum therapeutic benefit in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains. Supportive care services, even those that are considered to be medically appropriate are not eligible for coverage under Horizon HMO.
Surgical Center — Also called a surgicenter. An ambulatory-care facility licensed by a state to provide same-day surgical services.
Surgical Procedure — This includes cutting, suturing, treatment of burns, correction of fracture, reduction of dislocation, manipulation of joint under general anesthesia, application of plaster casts, electrocauterization, tapping (paracentesis), administration of pneumothorax, endoscopy, or injection of sclerosing solution.
Surrogate — A woman who carries an embryo that was formed from her own egg inseminated by the sperm of a designated sperm donor.
Urgent Care — Outpatient or out-of-hospital medical care which, as determined by the Horizon HMO or an entity designated by the Horizon HMO, is required by an unexpected illness or injury that is not life-threatening or a medical emergency, but should be treated by a physician within 24 hours.
Waiting Period — The period of time between enrollment in the health benefits program and the date when you become eligible for benefits.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —NOTES 98 — HORIZON HMO MEMBER HANDBOOK APPENDIX IV
REQUIRED DOCUMENTATION FOR DEPENDENT
ELIGIBILITY AND ENROLLMENTThe State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) are required to ensure that only employees, retirees, and eligible dependents receive coverage under the programs. Employees or Retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children) must submit supporting documentation in addition to the appropriate health benefits application.
Required Documentation for Dependent Eligibility and Enrollment Dependent Eligibility Definition Required Information
New Jersey residents can obtain records from the State Bureau of Vital Statistics and Registration Web site: www.nj.gov/health/vital/index.shtml To obtain copies of other documents listed on this chart,
contact the office of the Town Clerk in the city of the birth marriage, etc., or visit these Web sites:
www.vitalrec.com or www.studentclearinghouse.org *Note: On tax forms you may black out all financial information and all but the last 4 digits of any Social Security numbers.
**Or a National Medical Support Notice (NMSN) if you are the non-custodial parent and are legally required to provide coverage for the child as a result of the NMSN.
Horizon HMO meets the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements.
Certification of Coverage A Certification of Coverage form, which verifies your SHBP or SEHBP group health plan enrollment and termination dates, is available through your payroll or human resources office, should you terminate your coverage.
HIPAA Privacy The SHBP and SEHBP make every effort to safeguard the health information of their members and comply with the privacy provisions of HIPAA, which requires that health plans maintain the privacy of any personal information relating to its members’ physical or mental health. See page 103 for the Notice of Privacy Practices.
102 — HORIZON HMO MEMBER HANDBOOK APPENDIX VI
NOTICE OF PRIVACY PRACTICES TO ENROLLEES IN THE
NEW JERSEY STATE HEALTH BENEFITS PROGRAM AND
SCHOOL EMPLOYEES’ HEALTH BENEFITS PROGRAM
Protected Health Information The State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) are required by the federal Health Insurance Portability and Accountability Act (HIPAA) and State laws to maintain the privacy of any information that is created or maintained and relates to your past, present, or future physical or mental health. This Protected Health Information (PHI) includes information communicated or maintained in any form. Examples of PHI are your name, address, Social Security number, birth date, telephone number, fax number, dates of health care service, diagnosis codes, and procedure codes. PHI is collected through various sources, such as enrollment forms, employers, health care providers, federal and State agencies, or third-party vendors.
The SHBP and SEHBP are required by law to abide by the terms of this Notice. The SHBP and SEHBP reserve the right to change the terms of this Notice. If the SHBP or SEHBP make material change to this Notice, a revised Notice will be sent.
Uses and Disclosures of PHI The SHBP and SEHBP are permitted to use and to disclose PHI in order for our members to obtain payment for health care services and to conduct the administrative activities needed to run programs without specific member authorization. Under limited circumstances, we may be able to provide PHI for the health care operations of providers and health plans. Specific examples of the ways in which PHI may be used and disclosed are provided below. This list is illustrative only and not every use and disclosure in a category is listed.
• The SHBP or SEHBP may disclose PHI to a doctor or a hospital to assist them in providing a member with treatment.
• The SHBP or SEHBP may use and disclose member PHI so that our Business Associates may pay claims from doctors, hospitals, and other providers.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
• The SHBP or SEHBP receives PHI from employers, including the member's name, address, Social Security number, and birth date. This enrollment information is provided to our Business Associates so that they may provide coverage for health care benefits to eligible members.
• The SHBP or SEHBP and/or our Business Associates may use and disclose PHI to investigate a complaint or process an appeal by a member.
• The SHBP or SEHBP may provide PHI to a provider, a health care facility, or a health plan that is not our Business Associate that contacts us with questions regarding the member's health care coverage.
• The SHBP or SEHBP may use PHI to bill the member for the appropriate premiums and reconcile billings we receive from our Business Associates.
• The SHBP or SEHBP may use and disclose PHI for fraud and abuse detection.
• The SHBP or SEHBP may allow use of PHI by our Business Associates to identify and contact our members for activities relating to improving health or reducing health care costs, such as information about disease management programs or about health-related benefits and services or about treatment alternatives that may be of interest to them.
• In the event that a member is involved in a lawsuit or other judicial proceeding, the SHBP or SEHBP may use and disclose PHI in response to a court or administrative order as provided by law.
• The SHBP or SEHBP may use or disclose PHI to help evaluate the performance of our health plans. Any such disclosure would include restrictions for any other use of the information other than for the intended purpose.
• The SHBP or SEHBP may use PHI in order to conduct an analysis of our claims data.
This information may be shared with internal departments such as auditing or it may be shared with our Business Associates, such as our actuaries.
Except as described above, unless a member specifically authorizes us to do so, the SHBP and SEHBP will provide access to PHI only to the member, the member’s authorized representative, and those organizations who need the information to aid in the conduct of business (our “Business Associates"). An authorization form may be obtained
over the Internet at: www.nj.gov/treasury/pensions or by sending an e-mail to:
email@example.com A member may revoke an authorization at any time.
• PHI that contains genetic information is prohibited from use or disclosure by the Programs for underwriting purposes.
• The use or disclosure of PHI that includes psychotherapy notes requires authorization from the member.
104 — HORIZON HMO MEMBER HANDBOOK When using or disclosing PHI, the SHBP and SEHBP will make every reasonable effort to limit the use or disclosure of that information to the minimum extent necessary to accomplish the intended purpose. The SHBP and SEHBP maintain physical, technical, and procedural safeguards that comply with federal law regarding PHI. In the event of a breach of unsecured PHI the member will be notified.
Member Rights Members of the SHBP or SEHBP have the following rights regarding their PHI.
Right to Inspect and Copy: With limited exceptions, members have the right to inspect and/or obtain a copy of their PHI that the SHBP or SEHBP maintains in a designated record set which consists of all documentation relating to member enrollment and the use of this PHI for claims resolution. The member must make a request in writing to obtain access to their PHI. The member may use the contact information found at the end of this Notice to obtain a form to request access.
Right to Amend: Members have the right to request that the SHBP or SEHBP amend the PHI that we have created and that is maintained in our designated record set.