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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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