«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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4 — HORIZON HMO MEMBER HANDBOOK HORIZON HMO Except where identified, Horizon HMO benefits described in this member handbook are identical for SHBP and SEHBP members.
Horizon HMO is administered for the Division of Pensions and Benefits by Horizon Healthcare of New Jersey, Inc., a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. Both companies are independent licensees of the Blue Cross and Blue Shield Association.
Horizon HMO covers in-network benefits only.
Care is provided through a network of providers which includes internists, general practitioners, pediatricians, specialists, pharmacies and hospitals. Network providers offer a full range of services that include well-care and preventive services such as annual physicals, well-baby/well-child care, immunizations, mammograms, annual gynecological examinations, and prostate examinations. In-network services are generally covered in full after a member copayment, and, depending on the plan, may be subject to a copay or in-network deductible and coinsurance. See page 27 for additional in-network benefit information.
Horizon HMO is self-funded. Funds for the payment of claims and services come from funds supplied by the State, participating local employers, and members.
Refer to page 109 for additional information on contacting Horizon HMO, the Division of Pensions and Benefits, and related health services.
Eligibility for coverage is determined by the State Health Benefits Program (SHBP) or School Employees’ Health Benefits Program (SEHBP). Enrollments, terminations, changes to coverage, etc. must be presented through your employer to the Division of Pensions and Benefits. If you have any questions concerning eligibility provisions, you should contact the Division of Pensions and Benefits' Office of Client Services at (609) 292-7524, or send e-mail to: firstname.lastname@example.org
STATE EMPLOYEESTo be eligible for State employee coverage, you must work full-time for the State of New Jersey or be an appointed or an elected officer of the State of New Jersey (this includes employees of a State agency or authority and employees of a State college or university). For State employees, full-time requires at least 35 hours per week or more if required by contract or resolution.
The following State employees are also eligible for coverage in Horizon HMO.
State Part-Time Employees — Part-time employees of the State and part-time faculty at institutions of higher education that participate in the SHBP are eligible for HMO coverage if they are members of a State-administered pension system. The employee or faculty member must pay the full cost of the coverage. Part-time employees will not qualify for employer or State-paid post-retirement health care benefits, but may enroll in retired group coverage at their own expense provided they were covered up to the date of retirement. See Fact Sheet #66, Health Benefits Coverage for Part-Time Employees, for more information.
The following State employees are eligible for coverage in Horizon HMO.
State Intermittent Employees — Certain intermittent State employees who have worked 750 hours in a Fiscal Year (July 1 - June 30) are eligible for coverage. Intermittent employees who maintain 750 hours of work per year continue to qualify for coverage in subsequent years. See Fact Sheet #69, SHBP Coverage for State Intermittent Employees, for more information.
New Jersey National Guard — A member of the New Jersey National Guard who is called to State active duty for 30 days or more is eligible to enroll in at the State's expense. Upon enrollment, the member may also enroll eligible dependents. The Department of Military and Veteran's Affairs is responsible for notifying eligible members and the Division of Pensions and Benefits of members who are eligible for coverage.
6 — HORIZON HMO MEMBER HANDBOOK
LOCAL EMPLOYEESTo be eligible for local employer coverage, you must be a full-time employee or an appointed or elected officer receiving a salary from a local employer (county, municipality, county or municipal authority, board of education, etc.) that participates in the SHBP or SEHBP. Each participating local employer defines the minimum hours required for full-time by a resolution filed with the Division of Pensions and Benefits, but it can be no less than 25 hours per week or more if required by contract or resolution. Employment must also be for 12 months per year except for employees whose usual work schedule is 10 months per year (the standard school year).
The following local employees are also eligible for coverage in Horizon HMO.
Local Part-Time Employees — Part-time faculty members employed by a county or community college that participates in the SEHBP are eligible for coverage if they are members of a State-administered pension system. The faculty member must pay the full cost of the coverage. Part-time faculty members will not qualify for employer or Statepaid post-retirement health care benefits, but may enroll in retired group coverage at their own expense provided they were covered up to the date of retirement. See Fact Sheet #66, Health Benefits Coverage for Part-Time Employees, for more information.
ENROLLMENT You are not covered until you enroll in the SHBP or SEHBP. You must fill out a Health Benefits Program Application and provide all the information requested. If you do not enroll all eligible members of your family within 60 days of the time you or they first become eligible for coverage, you must wait until the next Open Enrollment period. Open Enrollment periods generally occur once a year usually during the month of October.
Information about the dates of the Open Enrollment period and effective dates for coverage is announced by the Division of Pensions and Benefits.
ELIGIBLE DEPENDENTSYour eligible dependents are your spouse, civil union partner or eligible same-sex domestic partner, and your eligible children (as defined below).
Spouse — A person to whom you are legally married. A photocopy of the marriage certificate and additional supporting documentation are required for enrollment.
Civil Union Partner — A person of the same sex with whom you have entered into a civil union. A photocopy of the New Jersey Civil Union Certificate or a valid certification from another jurisdiction that recognizes same-sex civil unions and additional supporting documentation are required for enrollment. The cost of a civil union partner's coverage may be subject to federal tax (see your employer or Fact Sheet #75, Civil Unions, for details).
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Domestic Partner — A person of the same sex with whom you have entered into a domestic partnership as defined under Chapter 246, P.L. 2003, the Domestic Partnership Act. The domestic partner of any State employee, State retiree, or an eligible employee or retiree of a participating local public entity that adopts a resolution to provide Chapter 246 health benefits, is eligible for coverage. A photocopy of the New Jersey Certificate of Domestic Partnership dated prior to February 19, 2007 (or a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic partners) and additional supporting documentation are required for enrollment. The cost of same-sex domestic partner coverage may be subject to federal tax (see your employer or Fact Sheet #71, Benefits Under the Domestic Partnership Act, for details).
Children — In compliance with the federal Patient Protection and Affordable Care Act (PPACA), coverage is extended for children until age 26. This includes natural children under age 26 regardless of the child’s marital, student, or financial dependency status. A photocopy of the child’s birth certificate that includes the covered parent’s name is required for enrollment (non-custodial parents, see page 100). For a stepchild, provide a photocopy of the child’s birth certificate showing the spouse/partner’s name as a parent and a photocopy of marriage/partnership certificate showing the names of the employee/retiree and spouse/partner.
Foster children and children in a guardian-ward relationship under age 26 are also eligible. A photocopy of the child’s birth certificate and additional supporting legal documentation are required with enrollment forms for these cases. Documents must attest to the legal guardianship by the covered employee (see page 100).
Coverage for an enrolled child ends on December 31 of the year in which he or she turns age 26 (see the “COBRA” section on page 77, “Dependent Children with Disabilities”, below, and “Over Age Children Until Age 31” page 9 for continuation of coverage provisions).
Dependent Children with Disabilities — If a child is not capable of self-support when he or she reaches age 26 due to mental illness, developmental, or physical disability, he or she may be eligible for a continuance of coverage.
To request continued coverage, contact the Office of Client Services at (609) 292-7524 or write to the Division of Pensions and Benefits, Health Benefits Bureau, P. O. Box 299, Trenton, New Jersey 08625 for a Continuance for Dependent with Disabilities form. The form and proof of the child's condition must be given to the Division no later than 31 days after the date coverage would normally end.
Since coverage for children ends on December 31 of the year they turn 26, you have until January 31 to file the Continuance for Dependent with Disabilities form. Coverage for children with disabilities may continue only while (1) you are covered through the SHBP or SEHBP, and (2) the child continues to be disabled, and (3) the child is unmarried, and (4) the child remains dependent on you for support and maintenance. You will be contacted periodically to verify that the child remains eligible for continued coverage.
8 — HORIZON HMO MEMBER HANDBOOK Over Age Children Until Age 31 — Certain children over age 26 may be eligible for coverage until age 31 under the provisions of Chapter 375, P.L. 2005, as amended by Chapter 38, P.L. 2008. This includes a child by blood or law who: is under the age of 31;
is unmarried; has no dependent(s) of his or her own; is a resident of New Jersey or is a full-time student at an accredited public or private institution of higher education; and is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
Under Chapter 375, an over age child does not have any choice in the selection of benefits but is enrolled for coverage in exactly the same plan or plans (medical and/or prescription drug) that the covered parent has selected. The covered parent or child is responsible for the entire cost of coverage. There is no provision for dental or vision benefits.
Coverage for an enrolled over age child will end when the child no longer meets any one of the eligibility requirements or if the required payment is not received. Coverage will also end when the covered parent’s coverage ends. Coverage ends on the first of the month following the event that makes the dependent ineligible or up until the paid through date in the case of non-payment.
See Fact Sheet #74, Health Benefits Coverage of Children until Age 31 under Chapter 375, for details.
SUPPORTING DOCUMENTATION REQUIRED
FOR ENROLLMENT OF DEPENDENTThe SHBP and SEHBP are required to ensure that only eligible employees and retirees, and their dependents, are receiving health care coverage under the program. Employees or retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children, disabled dependents, and over age children continuing coverage) must submit supporting documentation in addition to the enrollment application. See page 99 for more information about the documentation a member must provide when enrolling a new dependent for coverage.
AUDIT OF DEPENDENT COVERAGEPeriodically, the Division of Pensions and Benefits performs an audit using a random sample of members to determine if enrolled dependents are eligible under plan provisions. Proof of dependency such as a marriage, civil union, or birth certificates, or tax returns are required. Coverage for ineligible dependents will be terminated. Failure to respond to the audit will result in the termination of ALL coverage and may include financial restitution for claims paid. Members who are found to have intentionally enrolled an ineligible person for coverage will be prosecuted to the fullest extent of the law.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —
MULTIPLE COVERAGE UNDER THE SHBP/SEHBP ISPROHIBITED State statute specifically prohibits two members who are each enrolled in SHBP/SEHBP plans from covering each other. Therefore, an eligible individual may only enroll in the SHBP/SEHBP as an employee or retiree, or be covered as a dependent.
Eligible children may only be covered by one participating subscriber.
For example, a husband and wife both have coverage based on their employment and have children eligible for coverage. One may choose Family coverage, making the spouse and children the dependents and ineligible for any other SHBP/SEHBP coverage; or one may choose Single coverage and the spouse may choose Parent and Child(ren) coverage.