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I
have just become eligible to enroll in State
Health Benefits. How can I decide which medical
plan is the best one? |
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There
is no single best plan. Plan selection is
a personal decision based on your needs. You
should review information provided by the
Division of Pensions and Benefits and the
individual carriers to familiarize yourself
with the various plans and their provisions.
Some of the main factors new enrollees usually
consider are:- Cost- Freedom of doctor/hospital
selection- Ease of claims processing- Whether
or not your doctor participates in one or
more State Health Benefits Plans |
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What
are the differences between the State Health
Benefit Program HMOs? |
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There
are two major differences. First, each HMO
has a unique network of physicians and facilities.
Secondly, HMOs have different out-of-state
service areas. Other than those differences,
State HMOs are very similar. Each has "General
Operating Procedures" and "Conditions
of Participation" which are minimum coverage
requirements instituted by the State. These
standards help to safeguard all participants
and make it easier to compare and choose between
the HMO plans. Additionally, each HMO may
offer perks such as maternity programs, educational
programs, newsletters, wellness programs,
vision care discounts, and vitamin discounts.
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What
is the role of a Primary Care Physician (PCP)
in State HMOs and NJ Plus? |
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Your
Primary Care Physician provides basic medical
services and coordinates your overall medical
care. If specialized treatment is required,
your primary care physician is responsible
for referring you to a specialist, lab, hospital,
or any other network physician or specialist.
Primary Care Physicians are typically general
practitioners, internists, or pediatricians.
HMO and NJ Plus participants may change their
Primary Care Physician as often as they like. |
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My
19-year-old son works part time and attends
school part time. Can he remain covered under
my health insurance? |
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Your
son may continue to be covered as long has
he remains your eligible dependent child through
the end of the year in which he turns 23.
The child must be unmarried and depend on
you for support. His student status has no
effect on eligibility. |
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How
can my daughter continue coverage if she loses
her status as an "eligible dependent"?
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She
can elect COBRA coverage. COBRA is a federal
law that allows for the continuation of health
benefits for specified time periods for the
employee and/or dependents when coverage terminates
due to certain qualifying events. Dependent
children of employees in the SHBP may continue
coverage under COBRA if coverage ends because
of the loss of dependent child's eligibility
through:- Independence- End of year in which
child turns 23- Marriage |
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I
currently have husband/wife coverage and my
wife is pregnant. When should I add the baby? |
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You
can add your child within 30 days of the child's
birth. Complete a NJ State Health Benefits
Program Application and give it to your departmental
benefits representative or person who handles
payroll processing. When you receive the child's
social security number a few months later,
please indicate that information on a NJ State
Health Benefits Program Application. |
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I
am a Rutgers employee who waived State Health
Benefits coverage because I wanted to continue
coverage as a dependent on my husband's plan.
My husband recently lost his job and will
soon no longer have health insurance coverage.
Can my husband and I now enroll in State Health
Benefits through Rutgers? |
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Yes,
if your spouse's employment status changes
resulting in a loss of health coverage, you
can enroll in State Health Benefits within
30 days of the of the event. Complete a NJ
State Health Benefits Program Application
and give it to your departmental benefits
representative or person who handles payroll
processing. You must also provide documentation
(a letter or certificate) from your spouse's
employer to show loss of coverage. |
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When
is it necessary to get advance approval (predetermination
of benefits) under the Dental Expense Plan? |
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You
must request a predetermination of benefits
for services that include crowns, inlays,
onlays, periodontics, prosthodontics (removable
or fixed), or orthodontics regardless of the
cost. Without advanced approval, these services
will not be reimbursed. Also, it is strongly
recommended that you ask your dentist to file
a predetermination of benefits for any dental
expenses over $300.00. Predetermination allows
you to know what services are covered and
what payments will be made before dental work
is done. |
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What
deductibles are required by members of the
Dental Expense Plan? |
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Members
of the Dental Expense Plan are required to
satisfy a $50.00 deductible per person per
calendar year. If you have family coverage,
no additional deductibles are charged after
any three members have each met their $50.00
deductible. |
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What
is the annual benefit maximum under the Dental
Expense Plan? |
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Under
the Dental Expense Plan, the most the plan
will pay for any one person per calendar year
is $3,000. This maximum applies to all eligible
services except orthodontics, which has a
separate $1,000 lifetime benefit maximum.
Members of Dental Plan Organizations (DPOs)
are not subject to annual benefit maximums.
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My
dentist dropped out of my DPO. Can I switch
dental plans? |
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No,
if your dentist leaves your DPO, you have
to select another dentist in that DPO. If
after your dentist leaves, there are no other
participating dentists within 30 miles of
your home, you have 30 days to select another
plan. |
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How
are orthodontics covered under the Dental
Expense Plan and DPOs? |
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Under
the Dental Expense Plan, eligible orthodontic
services are covered for members under age
19 at a 50 % coinsurance level, up to a lifetime
benefit maximum of $1,000. Orthdontic services
are only covered if the employee has been
a full-time employee for at least 10 months.
Under DPOs, patients under 18 years at the
start of treatment have a co-payment of $1,000
or 50% of the bill (whichever is less). Patients
over 18 at the start of treatment have a co-payment
of $1,750 or 50% of the bill whichever is
less. There is maximum treatment period of
24 months. |
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Who
administers the Prescription Drug Plan? |
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The New Jersey State Health Benefits Program
(SHBP) Employee Prescription Drug Plan is
administered by Horizon Blue Cross Blue Shield
of New Jersey through Advance PCS. This coverage
is separate and independent from the medical
insurance carrier. |
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I
did not receive my prescription card. Who
should I call? |
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Call
Advance PCS Member Services at (866) 881-5605. |
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Who
should the pharmacist call if he/she needs
assistance? |
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Please
call the Pharmacy Help Desk at (800) 364-6331. |
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How
can I find out which drug stores participate? |
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Ask
your retail pharmacist- Visit www.AdvanceRx.com
and use the online pharmacy locator- Call
Advance PCS Member Services at (866) 881-5605
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Does
the prescription drug plan have a mail order
service? How do I use it? |
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Yes,
you can receive up to a 90-day supply of medication
for one co-payment ($1 generic, $5 name brand).
Ask your doctor to write a new prescription
for up to a 90-day supply. Mail your prescription,
along with your completed order form, and
payment to: AdvanceRx.com P.O. Box 830070,
Birmingham, AL 35283-8488. You can order and
track your prescriptions online at www.AdvanceRx.com.
Your order will be delivered to your home
within 10 to 14 days from the date you mailed
your order at no additional cost to you. |
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Can
I get a 90-day supply of medication at my
local retail pharmacy? |
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Yes,
If you use a participating pharmacy you will
pay the appropriate co-payment for the purchase
of a 30, 60, or 90-day maximum supply. |
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What
does the Vision Care Reimbursement Plan Cover? |
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The
plan covers a maximum of $35 toward the purchase
of single-vision lenses and contact lenses,
and $40 toward the purchase of bifocal, trifocal
and progressive lenses. The plan does not
include reimbursement for the cost of the
examination or frames. |
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How
often can I be reimbursed? |
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Each
covered individual may receive reimbursement
for one lens purchase per contract period.
The current contract period extends from July
1, 2001 through June 30, 2003. There is no
duplication of coverage for spouses who both
work at Rutgers. |
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How
do I submit a claim? |
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Complete
one Vision Care Plan Reimbursement Form for
each lens purchase according to the form's
instructions. Submit the claim form(s) and
the original itemized receipt(s) to the address
provided on the form. |
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How
long will it take to receive my check? |
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Please
allow three to four weeks for the reimbursement
check to be processed and sent to your campus
address. |
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How
can I check to see if I am eligible to submit
a claim during a given contract period? |
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Please
allow three to four weeks for the reimbursement
check to be processed and sent to your campus
address. |
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Who
is eligible to participate in the Health Insurance
Premium Reimbursement Program for Same Sex
Sole Domestic Partners? |
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This
program is currently available to all full
time regularly appointed employees except
USP&D and AAUP members. |
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Why
are USP&D and AAUP members not covered? |
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These
members are not covered because the bargaining
units for these two groups have not accepted
the program offered by Rutgers University.
Members will be eligible when an agreement
is reached. |
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What
benefits are provided through this program? |
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Participating
employees receive reimbursement for the purchase
of medical, prescription drug, and dental
insurance for domestic partners and their
dependent children, based on a schedule of
reimbursement. The maximum reimbursement amounts
are based on New Jersey State Health Benefit
plan costs. |
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Are
there any vision benefits provided through
this program? |
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Yes.
Domestic partners and their dependent children
can take advantage of the University's Vision
Care Reimbursement Plan. |
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Is
there a program for opposite sex domestic
partners? |
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No,
Rutgers does not offer a reimbursement program
for opposite sex domestic partners. |
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How
does Rutgers define a same sex sole domestic
partnership? |
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A
same sex sole domestic partnership, as defined
by Rutgers for the purposes of this reimbursement
program, is a relationship of two individuals
of the same sex who have an exclusive mutual
commitment, similar to marriage, in which
the partners have agreed in writing to be
jointly responsible for each other's common
welfare, living expenses and financial obligations.
The individuals must be each other's sole
domestic partner and intend to remain so indefinitely. |
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