«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»
MEDICARE COVERAGE WHILE EMPLOYEDIn general, it is not necessary for a Medicare-eligible employee, spouse, civil union or domestic partner, or dependent child(ren) to be covered by Medicare while the employee remains actively at work. However, if you or your dependents become eligible for Medicare due to End Stage Renal Disease (ESRD), and the 30-month coordination of benefits period has ended, you and/or your dependents must enroll in Medicare Parts A and B even though you are actively at work. For more information, see “Medicare Coverage” beginning on page 13 in the “Retiree Eligibility” section.
RETIREE ELIGIBILITYThe following individuals will be offered SHBP Retired Group coverage for themselves
and their eligible dependents:
• Full-time State employees, employees of State colleges/universities, autonomous State agencies and commissions, or local employees who were covered by, or eligible for, the SHBP at the time of retirement and begin receiving a monthly retirement benefit or lifetime annuity immediately following termination of employment.
• Part-time State employees and part-time faculty at institutions of higher education that participate in the SHBP if enrolled in the SHBP at the time of retirement.
• Participants in the Alternate Benefit Program (ABP) eligible for the SHBP who retire with at least 25 years of credited ABP service or those who are on a long-term disability and begin receiving a monthly lifetime annuity immediately following termination of employment.
• Certain local policemen or firemen with 25 years or more of service credit in the retirement system or retiring on a disability retirement if the employer does not provide any payment or compensation toward the cost of the retiree's health benefits.
A qualified retiree may enroll at the time of retirement or when he or she becomes eligible for Medicare. See Fact Sheet #47, Retired Health Benefits Coverage under Chapter 330, for more information.
10 — HORIZON HMO MEMBER HANDBOOK
• Surviving spouses, civil union partners, eligible same-sex domestic partners, and children of Police and Firemen’s Retirement System (PFRS) members or State Police Retirement System (SPRS) members killed in the line of duty.
The following individuals will be offered SEHBP Retired Group coverage for themselves
and their eligible dependents:
• Full-time members of the Teachers' Pension and Annuity Fund (TPAF) and school board or county college employees enrolled in the Public Employees' Retirement System (PERS) who retire with less than 25 years of service credit from an employer that participates in the SEHBP.
• Full-time members of the TPAF and school board or county college employees enrolled in the PERS who retire with 25 years or more of service credit in one or more State or locally-administered retirement systems or who retire on a disability retirement, even if their employer did not cover its employees under the SEHBP. This includes those who elect to defer retirement with 25 or more years of service credit in one or more State or locally-administered retirement systems (see “Aggregate of Pension Membership Service Credit” on page 12).
• Full-time members of the TPAF or PERS who retire from a board of education, vocational/ technical school, or special services commission; maintain participation in the health benefits plan of their former employer; and are eligible for and enrolled in Medicare Parts A and B. A qualified retiree may enroll at retirement or when he or she becomes eligible for Medicare.
• Participants in the Alternate Benefits Program (ABP) eligible for the SEHBP who retire with at least 25 years of credited ABP service or those who are on a long-term disability and begin receiving a monthly lifetime annuity immediately following termination of employment.
• Part-time faculty at institutions of higher education that participate in the SEHBP if enrolled in the SEHBP at the time of retirement.
Eligibility for SHBP or SEHBP membership for the individuals listed in this section
is contingent upon meeting two conditions:
1. You must be immediately eligible for a retirement allowance from a State- or locallyadministered retirement system (except certain employees retiring from a school board or community college); and
2. You were a full-time employee and eligible for employer-paid medical coverage immediately preceding the effective date of your retirement (if you are an employee retiring from a school board or community college under a deferred retirement with 25 or more years of service, you must have been eligible at the time you terminated your employment), or a part-time State employee or part-time faculty member who is enrolled in the SHBP or SEHBP immediately preceding the effective date of your retirement.
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —This means that if you allow your active coverage to lapse (i.e. because of a leave of absence, reduction in hours, or termination of employment) prior to your retirement or you defer your retirement for any length of time after leaving employment; you will lose your eligibility for Retired Group health coverage. (This does not include former full-time employees enrolled in TPAF and PERS board of education or county college who retire with 25 or more years of service).
Note: If you continue group coverage through COBRA (see the “COBRA” section on page 77) — or as a dependent under other coverage through a public employer — until your retirement becomes effective, you will be eligible for retired coverage under the SHBP or SEHBP.
Otherwise qualified employees whose coverage is terminated prior to retirement but who are later approved for a disability retirement will be eligible for Retired Group coverage beginning on the employee’s retirement date. If the approval of the disability retirement is delayed, coverage shall not be retroactive for more than one year.
Aggregate of Pension Membership Service Credit
Upon retirement, a full-time State employee, board of education, or county college employee who has 25 years or more of service credit, is eligible for State-paid health benefits under the SHBP or SEHBP, subject to the applicable retiree contribution, if any.
A full-time employee of a local government who has 25 years or more of service credit whose employer participates in the SHBP and has chosen to provide post-retirement medical coverage to its retirees is eligible for employer-paid health benefits under the SHBP, subject to the applicable retiree contribution, if any.
A retiree eligible for the SHBP or SEHBP may receive this benefit if the 25 years of service credit is from one or more State or locally-administered retirement systems and the time credited is nonconcurrent.
For PERS or TPAF members, Out-of-State Service, U.S. Government Service, or service with a bi-state or multi-state agency, requested for purchase after November 1, 2008, cannot be used to qualify for any State-paid or employer-paid health benefits in retirement.
Eligible Dependents of Retirees Dependent eligibility rules for Retired Group coverage are the same as for Active Group coverage except for Chapter 334 domestic partners (described below) and the Medicare requirements (see page 13).
Chapter 334, P.L. 2005, provides that retirees from local entities (municipalities, counties, boards of education, and county colleges) whose employers do not participate in the in SHBP or SEHBP, but who become eligible for SHBP or SEHBP coverage at retirement (see page 13), may also enroll a registered same-sex domestic partner as a covered dependent provided that the former employer’s plan includes domestic partner coverage for employees.
12 — HORIZON HMO MEMBER HANDBOOK Multiple Coverage under the SHBP/SEHBP is Prohibited 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.
Enrolling in Retired Group Coverage
The Health Benefits Bureau is notified when you file an application for retirement with the Division of Pensions and Benefits. If eligible, you will receive a letter inviting you to enroll in Retired Group coverage. Early filing for retirement is recommended to prevent any lapse of coverage or delay of eligibility.
If you do not submit a Retired Coverage Enrollment Application at the time of retirement, you will not generally be permitted to enroll for coverage at a later date. See Fact Sheet #11, Enrolling for Health Benefits Coverage When You Retire, for more information.
If you believe you are eligible for Retired Group coverage and do not receive an offering letter by the date of your retirement, please contact the Division of Pensions and
Benefits, Office of Client Services at (609) 292-7524 or send an e-mail to:
firstname.lastname@example.org Additional restrictions and/or requirements may apply when enrolling for Retired Group coverage. Be sure to carefully read the “Retiree Enrollment” section of the Summary Program Description.
MEDICARE COVERAGEMedicare Parts A and B
IMPORTANT: A Retired Group member and/or dependent spouse, civil union partner, eligible same-sex domestic partner, or child who is eligible for Medicare coverage by reason of age or disability must be enrolled in both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) to enroll or remain in SHBP or SEHBP Retired Group coverage.
You will be required to submit documented evidence of enrollment in Medicare Part A and Part B when you or your dependent becomes eligible for that coverage. Acceptable documentation includes a photocopy of the Medicare card showing both Part A and Part B enrollment, or a letter from Medicare indicating the effective dates of both Part A and
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —Part B coverage. Send your evidence of enrollment to the Health Benefits Bureau, Division of Pensions and Benefits, PO Box 299, Trenton, New Jersey 08625-0299 or fax it to (609) 341-3407. If you do not submit evidence of Medicare coverage under both Part A and Part B, you and/or your dependents will be terminated from coverage. Upon submission of proof of full Medicare coverage, your Retired Group coverage will be reinstated by the Health Benefits Bureau on a prospective basis.
IMPORTANT: When coordinating benefits with Medicare, the secondary benefit under Horizon HMO is supplemental to the Medicare payment. Horizon HMO will consider the remaining Medicare coinsurance and deductible as the allowable expense and apply the applicable copayments or deductible when appropriate. If a provider is not registered with or opts out of Medicare, no benefits are payable under the SHBP or SEHBP for the provider’s services, the charges would not be considered under the medical plan, and the member will be responsible for the charges.
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 Medicare Part D and the Express Scripts Medicare Prescription 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.
A member may be eligible for Medicare for the following reasons:
• Medicare Eligibility by Reason of Turning Age 65 A member (the retiree or covered spouse/partner) is considered to be eligible for Medicare by reason of age from the first day of the month during which he or she reaches age 65. However, if he or she is born on the first day of a month, he or she is considered to be eligible for Medicare from the first day of the month which is immediately prior to his/her 65th birthday.
The retired group health plan is the secondary payer.
• Medicare Eligibility by Reason of Disability A member (the retiree or covered spouse/partner or dependent) who is under age 65 is considered to be eligible for Medicare by reason of disability if they have been receiving Social Security Disability benefits for 24 months.
14 — HORIZON HMO MEMBER HANDBOOK The retired group health plan is the secondary payer.
• Medicare Eligibility by Reasons of End Stage Renal Disease A member usually becomes eligible for Medicare at age 65 or upon receiving Social Security Disability benefits for two years. A member (the retiree or covered spouse/partner or dependent) who is not eligible for Medicare because of age or disability may qualify because of treatment for End Stage Renal Disease (ESRD). When a person is eligible for Medicare due to ESRD, Medicare is the secondary payer
✓ The individual has group health coverage of their own or through a family member (including a spouse/partner).
✓ The group health coverage is from either a current employer or a former employer.
The employer may be of any size (not limited to employers with more than 20 employees).
The rules listed above, known as the Medicare Secondary Payer (MSP) rules are federal regulations that determine whether Medicare pays first or second to the group health plan. These rules have changed over time.