2022 NJ State Health Benefits Program (SHBP)
2022OVERVIEWNJ State HealthBenefits Program (SHBP)Local Government EmployeesHorizonBlue.com/shbp1-800-414-7427
At Horizon, we’re guiding members toachieve their best health.With nearly 90 years of helping New Jersey residents get the most out of theirhealth care coverage, Horizon is a leader in providing access to quality healthcare plans. Plus, we provide tools and support that make navigating health careeasier – freeing you to enjoy all that life has to offer.Horizon Health GuideOur Horizon Health Guides provide a high level of personalized service, connect you to the care you need and help youmaximize your benefits. As experts on your health coverage, services and programs, Horizon Health Guides help you onyour health journey by: Answering questions Solving issues Helping with claims Scheduling appointments Navigating a complex medical situation or chronic condition Making health and wellness benefit suggestionsHorizon Health Guides are available by phone at 1-800-414-SHBP (7427) and chat,weekdays, from 8 a.m. to 6 p.m., Eastern Time (ET).Learn more at HorizonBlue.com/shbp
Our best coverage, for your best you.OMNIASM Health PlanPPO PlansIn addition to having some of ourbest benefits, our OMNIA HealthPlan Option gives you the flexibilityto choose from New Jersey’s largestnetwork: 54,000 local doctors,specialists and health professionalsand 87 hospitals in 106 convenientlocations across New Jersey and partsof Pennsylvania and Delaware.*You also have worldwide access toover 1.7 million providers in ourBlueCard PPO program.All of our PPO plans include:To save even more, choose fromover 41,000 OMNIA Tier 1 doctorsand some of the state’s leadinghospitals for lower copayments,out-of-pocket costs and nodeductibles* – all with no referralsand no need to choose a PrimaryCare Physician.*Based on physician data as of 8/15/2021 and is subject to change.HMO PlansWith our HMO plans, you have accessto health care professionals and facilities Care in network or out of network inin the Horizon Managed Care NetworkNew Jersey, nationwide and abroadin New Jersey and parts of New York, No need to select a Primary CarePennsylvania and Delaware. You selectPhysician (PCP)a licensed Primary Care Physician(PCP) from the Horizon Managed Care No referrals necessary to see aNetwork and your PCP will refer youspecialistto specialty care when needed. In Lower out-of-pocket costs whenaddition, the Away From Home Careusing the Horizon Managed CareProgram is available to eligible HMONetwork or the BlueCard PPOmembers who are outside the State ofNetwork nationwide and Blue CrossNew Jersey, like students living awayBlue Shield Global Core abroadfrom home, long-term travelers andNJ DIRECT High Deductible Healthfamilies living apart.Plans (HDHPs) combine a highdeductible health plan with a healthsavings account (HSA). Eligiblepreventive services are covered at100 percent if in network and do nothave a deductible. You are responsiblefor eligible medical and prescriptionexpenses, up to the deductible.Active employees: Calculate yourestimated premium contribution atHorizonBlue.com/shbpcalculator.LearnLearn moremore atat HorizonBlue.com/SHBPHorizonBlue.com/shbp
2022 NJ State Health Benefits Program (SHBP)Local Government Employee Plans1PPO Plan OptionsOMNIASM Tiered Network OptionHorizonBlue.com/shbpOMNIA HEALTH PLAN1-800-414-SHBP (7427)Tier 1NJ DIRECT(employees hired priorto 7/1/19)NJ DIRECT2019NJ DIRECT10(new hires on or after 7/1/19)Tier 2IN-NETWORK (IN):Service Area AvailableNJ list ReferralNo referral requiredNo referral requiredNo referral requiredNo referral requiredNo referral requiredIndividual 0 1,500 0 100 0Family 0 3,000 0n/a 00%20% after deductible10% 510% after deductible 5 10% 5Individualn/a 4,500 800 800 400Familyn/a 9,000 2,000 2,000 1,000Individual 2,500 4,500 6,960 6,960 400Family 5,000 9,000 13,920 13,920 1,000Deductible 3CoinsuranceCoinsurance Out-of-Pocket MaximumTotal Out-of-Pocket Maximum(Copay Deductible Coinsurance)HEALTH CARE SERVICESPrimary Care Office Visit 5 20 15 15 10Annual Routine Physical (In-Network Only) 0 0 0 0 0Direct Primary Care (DPC) Doctors Office 0 0 0 0 0Horizon CareOnline (Telemedicine)Cost share may applyCost share may applyCost share may applyCost share may applyCost share may applySpecialist Office Visit 15 30 15 15 10Annual Routine Vision (In-Network Only) 15 30 15 15 10Chiropractic 15 30 15 15 10 5 office visit/ 15 outpatient facility 20 office visit/20% after deductible at 15an outpatient facility 15 107Physical/Occupational/Speech Therapy 8DIAGNOSTIC LABORATORY 9/RADIOLOGY/ADVANCED IMAGINGOutpatient Laboratory/Radiology/Advanced Imaging 1520% after deductible 0 0 0Freestanding Laboratory/Radiology/Advanced Imaging 0 0 0 0 0Urgent Care Center 15 30 15 15 10Emergency Room 100 100 150 10 150 10 75 10Ambulance 0 010%10% after deductible10%Inpatient Facility 150 per admission 1120% after deductible 0 0 0Outpatient Facility 15020% after deductible 0 0 0Outpatient Behavioral Health 15 30 office visit/20% after deductibleat an outpatient facility 15 15 10Durable Medical Equipment (DME) 0 010%10% after deductible10%Deductible - Individual 400 400 100Deductible - Family 1,000 1,000 250Coinsurance after Deductible30%30%20% 2,000 2,000 2,000Out-of-Pocket Coinsurance Maximum - Family 5,000 5,000 5,000Inpatient Hospital Deductible 500/stay 500/stay 200/stayEMERGENCY/URGENT MEDICAL SERVICESOTHER SERVICESOUT-OF-NETWORK (OON):12Out-of-Pocket Coinsurance Maximum - IndividualNo out-of-network benefits1. Check with your employer to find out if all of these plans are available to you. You can reference the HorizonBlue.com/shbpcalculator to determine your premium contribution.2. High Deductible Health Plan. NJ DIRECT HD1500 plan includes 300 Health Savings Account funding by employer.3. Deductible applies to all services that require a coinsurance.4. Includes eligible prescription cost share.5. On select services (durable medical equipment, prosthetics, orthotics, oxygen, private duty nursing, ambulance).6. Under age 26.7. Chiropractic: Horizon HMO: 20 visits per calendar year. OMNIA Health Plan: 25 visits per calendar year. All other plans: 30 visits per calendar year.8. Physical, occupational and speech therapy: OMNIA Health Plan: 30 visit maximum each per calendar year. Horizon HMO: 60 visit combined maximum per calendar year. All other plans based on medical necessity.9. Laboratory services must be rendered by an in-network participating provider, with some exceptions based on medical policy.
2022 NJ State Health Benefits Program (SHBP)Local Government Employee Plans1PPO Plan OptionsNJ DIRECT15NJ DIRECT1525NJ DIRECT2030NJ DIRECT2035Service Area pecialist ReferralNo referral requiredNo referral requiredNo referral requiredNo referral requiredIndividual 0 0 0 200Family 0 0 0HorizonBlue.com/shbp1-800-414-SHBP (7427)IN-NETWORK (IN):Deductible 3Coinsurance10%510%510% 500520% after deductibleCoinsurance Out-of-Pocket MaximumIndividual 400 400 800 2,000Family 1,000 1,000 2,000 5,000Individual 6,960 6,960 6,960 6,960Family 13,920 13,920 13,920 13,920 15 15 20 20Annual Routine Physical (In-Network Only) 0 0 0 0Direct Primary Care (DPC) Doctors Office 0 0 0 0Horizon CareOnline (Telemedicine)Cost share may applyCost share may applyCost share may applyCost share may applySpecialist Office Visit 15 25 30/adult, 20/child 6 35Annual Routine Vision (In-Network Only) 15 25 30/adult, 20/child 6 35Chiropractic 7 15 25 30/adult, 20/child 6 35Physical/Occupational/Speech Therapy 8 15 25 30/adult, 20/child 6 35 office visit/20% after deductibleat an outpatient facilityTotal Out-of-Pocket Maximum(Copay Deductible Coinsurance)HEALTH CARE SERVICESPrimary Care Office VisitDIAGNOSTIC LABORATORY 9/RADIOLOGY/ADVANCED IMAGINGOutpatient Laboratory/Radiology/Advanced Imaging 0 0 020% after deductibleFreestanding Laboratory/Radiology/Advanced Imaging 0 0 020% after deductible 30/adult, 20/child 6 35 125 300EMERGENCY/URGENT MEDICAL SERVICESUrgent Care Center 15 25Emergency Room 100Ambulance10%10%10%20% after deductibleInpatient Facility 0 0 020% after deductibleOutpatient Facility 0 0 020% after deductibleOutpatient Behavioral Health 15 25 30/adult, 20/child 6 35 office visit/20% after deductible atan outpatient facilityDurable Medical Equipment (DME)10%10%10%20% after deductibleDeductible - Individual 100 100 200 800Deductible - Family 250 250 500 2,000Coinsurance after Deductible30%30%30%40%Out-of-Pocket Coinsurance Maximum - Individual 2,000 2,000 5,000 6,500Out-of-Pocket Coinsurance Maximum - Family 5,000 5,000 12,500 13,000Inpatient Hospital Deductible 200/stay 200/stay 500/stay 600/stay10 10010OTHER SERVICESOUT-OF-NETWORK (OON):1210. Lower copayment applies to children under 19 and physician referrals.11. 150 per admission does not apply to inpatient childbirth, hospice or inpatient behavioral health/substance use disorder.12. Out-of-network cost basis: NJ DIRECT and NJ DIRECT2019: 175% of CMS (Centers for Medicare & Medicaid Services) fee schedule. 90th percentile of FAIR Health national for all other health plans with an out-of-network benefit. All plans with an out-of-network benefitalso have specified dollar limits for out-of-network chiropractic ( 35), physical therapy ( 52) and acupuncture ( 60).13. Out-of-network deductible is combined with in-network deductible.Retirees: Please visit state.nj.us/treasury/pensions for information regarding available retiree plans.This is not a complete list of all covered services. Exclusions and limitations apply to some services. Visit tml for more information.This document is for informational purposes only and does not constitute a binding agreement. The information provided by this document is not intended to replace or modify the terms, conditions, limitations and exclusions contained within health plans issued or administeredby Horizon. In the event of a conflict between the information contained in this document and your plan documents, your plan documents shall control.
2022 NJ State Health Benefits Program (SHBP)Local Government Employee Plans1NJ DIRECT HD1500 2NJ DIRECT HD4000 2HORIZON HMOService Area AvailableNationwideNationwideNJ and contiguous countiesSpecialist ReferralNo referral requiredNo referral requiredReferral requiredIndividual 1,500 4 4,000 4See DMEFamily 3,000 4 8,000 4See DME20% after deductible 420% after deductible 40%Individual 1,000 1,000Not applicableFamily 2,000 2,000Not applicableHorizonBlue.com/shbp1-800-414-SHBP (7427)IN-NETWORK (IN):Deductible 3CoinsuranceCoinsurance Out-of-Pocket MaximumTotal Out-of-Pocket Maximum(Copay Deductible Coinsurance)Individual 2,500 4 5,000 4 6,960Family 5,000 10,000 4 13,92020% after deductible20% after deductible 10Annual Routine Physical (In-Network Only) 0 0 0Direct Primary Care (DPC) Doctors OfficeNot availableNot availableNot availableHorizon CareOnline (Telemedicine)Cost share may applyCost share may applyCost share may applySpecialist Office Visit20% after deductible20% after deductible 10Annual Routine Vision (In-Network Only)20% after deductible20% after deductible 10Chiropractic 720% after deductible20% after deductible 10Physical/Occupational/Speech Therapy 820% after deductible20% after deductible 104HEALTH CARE SERVICESPrimary Care Office VisitDIAGNOSTIC LABORATORY 9/RADIOLOGY/ADVANCED IMAGINGOutpatient Laboratory/Radiology/Advanced Imaging20% after deductible20% after deductible 0Freestanding Laboratory/Radiology/Advanced Imaging20% after deductible20% after deductible 0Urgent Care Center20% after deductible20% after deductible 10Emergency Room20% after deductible20% after deductible 85 10Ambulance20% after deductible20% after deductible 0Inpatient Facility20% after deductible20% after deductible 0Outpatient Facility20% after deductible20% after deductible 0Outpatient Behavioral Health20% after deductible20% after deductible 10Durable Medical Equipment (DME)20% after deductible20% after deductible 100 deductible,then covered in fullEMERGENCY/URGENT MEDICAL SERVICESOTHER SERVICESOUT-OF-NETWORK (OON):12Deductible - IndividualSee in-network deductible 13See in-network deductible 13Deductible - FamilySee in-network deductibleSee in-network deductible 1313Coinsurance after Deductible40%40%Out-of-Pocket Coinsurance Maximum - Individual 3,500 6,000Out-of-Pocket Coinsurance Maximum - Family 7,000 12,000Inpatient Hospital DeductibleNot applicableNot applicableNo out-of-network benefits
Achieve your best healthand earn rewards.The new, improved NJWELL program is a great way to make meaningfulchanges to your wellness habits with program enhancements for eligiblemembers and their covered spouses/partners. NJWELL can help youachieve holistic well-being including: Physical fitness Emotional balanceYou can earn 250 or more inrewards each wellness year(November 1 to October 31). Preventive care Social connection Financial securityLearn more about NJWELL at HorizonBlue.com/shbp or visit theNJ Division of Pensions and Benefits website at nj.gov/njwell.With Horizon health plans, we’ve got you covered.Well Care and Preventive CarePrescription Drug CoverageServices such as an annual physical and gynecologicalexam, well baby/child medical care, immunizations and anannual vision exam are covered when using a participatingdoctor.Prescription drug coverage is available to all SHBP andSEHBP members. To learn more, refer to the PrescriptionDrug Plan information on the NJ Division of Pensions andBenefits website at nj.gov/treasury/pensions or contact youremployer for details.Behavioral Health and Substance Use DisorderWe empower our members to achieve their best physicaland mental health. Our care team will work with you,your family, caregivers and doctors to make sure you aregetting the treatment and support you need in the mostappropriate setting. Telehealth and virtual programs areavailable. Your Horizon Health Guide can direct you tothe right source.In-Network LaboratoriesOur members have access to in-network lab services. Youcan use Quest DiagnosticsTM (Quest) or LabCorp for bloodtests and other lab services. Our networks also include anumber of other participating labs that provide specializedlab services.Health ProgramsThese programs can help you take control of your healthand provide support for managing the challenges of livingwith conditions such as diabetes, hypertension, backand joint pain, and weight management issues with ourpartners Livongo, HingeHealth and WondrTM.When you’re facing a serious medical issue and needa specialist for a second opinion, you can consult withtop doctors with no out-of-pocket costs through GrandRounds.Learn more at HorizonBlue.com/shbp
Health and wellness for mind and body.Education ResourcesHorizonbFitSMGet tips for healthier living with our wide range of onlinehealth education topics.Eligible SHBP members may receive a 20 rewardfor every month they participate for at least 12 daysa month by:Pregnancy Resources Visiting a fitness facilityWith personalized support, online tools and interactiveresources for moms-to-be, PRECIOUS ADDITIONS helpsyou through your pregnancy and beyond. It includes MyPregnancy Assistant, an online tool powered by WebMD ,which has useful videos, trackers and checklists. Walking at least 10,000 stepsHealth Management ToolsHealthy Living DiscountsTrack your health securely and confidentially withMy Health Manager, powered by WebMD .With Blue365, get weekly deals from top retailersdelivered right to your inbox: Digital coaching and customized tools to manageyour health and track your progress Fitness memberships, special events and apparel Interactive, easy-to-use resources to identify health risks Weight tracker, calorie counter and nutrition help Submitting at-home workouts using virtualHorizonbFit-at-home features Or completing any combination of the above Weight management programs and specialty foodservices Discounts on eye care, including frames, lenses andcontactsMaking good health care more convenient.Direct Primary Care (DPC)ImmunizationsEligible members get unlimited access to personalizedcare with no copays. Simply choose a Direct Primary Caredoctor from Everside Health, R-Health or Sanitas MedicalCenter for you and your covered dependents.Getting vaccinated is more convenient with moreparticipating pharmacies – view our list atHorizonBlue.com/shbpflu.If you are eligible for NJWELL, your DPC provider willcredit a well visit and follow-up office visit as a completedhealth screening.Retail Health ClinicsThese clinics treat common health issues such as colds orseasonal allergies. Vaccines these pharmacies administer include flu,COVID-19, shingles, hepatitis A and B, pneumococcaland human papillomavirus (HPV). Medical claims are automatically submitted for you.Urgent Care Centers On-site board-certified nurse practitioners can diagnoseand treat conditions and prescribe medications.Urgent care centers provide immediate medical careas an alternative to visiting the Emergency Room (ER).They treat wounds, sprains and other conditions thatneed immediate attention, but are not life-threatening. Sites include MinuteClinics at select CVS/pharmacy locations. HMO members require a referral to go to a Horizonurgent care center.Telemedicine All members are responsible for applicablecopayments/coinsurance.Telemedicine is available at the touch of a buttonthrough the Horizon Blue app for eligible members.And depending on your doctor’s preferences, you canalso use telemedicine via video, chat or phone. Routine office visits are not covered at urgent carecenters.Learn more at HorizonBlue.com/shbp
Connect to care, benefitsand support anytime.With the Horizon Blue app, you can: Chat with a nurse about symptoms Get help with appointment scheduling Get quick claim status updates Video chat with doctors View and print member ID Cards Locate in-network doctorsNeed help registering for our Horizon Blueapp or our secure member website? Call theeService Help Desk at 1-888-777-5075weekdays from 7 a.m. to 6 p.m., ET.Text GetApp to422-272 for yourfree Horizon Bluedownload.**There is no charge to download the Horizon Blue app,but rates from your wireless provider may apply.Here when you need us most.Visit us online at HorizonBlue.com/shbp. Chat with us online.Contact us toll free at 1-800-414-SHBP (7427).NJ DIRECT, and OMNIASM Health Plans are administered by Horizon Blue Cross Blue Shield of New Jersey (Horizon) and Horizon HMO is administered by Horizon Healthcare of New Jersey, Inc. (HHNJ). Horizon is anindependent licensee of the Blue Cross Blue Shield Association. The Blue Cross and Blue Shield names and symbols and BlueCard , Blue365 and Blue Cross Blue Shield Global Core are registered marks of theBlue Cross Blue Shield Association. The Horizon name and symbols and PRECIOUS ADDITIONS are registered marks and HorizonbFitSM, OMNIASM Health Plans are service marksof Horizon. 2021 Horizon, Three Penn Plaza East, Newark, New Jersey 07105.All trademarks, service marks and company names are the property of their respective owners.Blue365 offers access to savings on items and services that members may purchase directly from independent vendors. Please note that the Blue Cross Blue Shield Association (BCBSA) may receive payments fromBlue365 vendors. Also, neither Horizon nor the BCBSA recommend, warrant or guarantee any specific Blue365 vendor or discounted item or service. Blue365 is not an insurance program and may be discontinued atany time.NJWELL is administered by the New Jersey Division of Pensions and Benefits. All provisions of the program are established by the Division and are subject to change. NJWELL Reward cards are issued toparticipants who are eligible for NJWELL at the time the reward is earned by The Bancorp Bank, Member FDIC, pursuant to a license from Visa U.S.A. Inc. Visa is a registered trademark of Visa Inc. Use your Visa Prepaid card anywhere Visa debit cards are accepted around the world.LabCorp, Quest Diagnostics, Everside Health and R-Health are independent from and not affiliated with Horizon.Sanitas Medical Centers are independently owned and operated by Sanitas of New Jersey LLC. Sanitas is independent from and not affiliated with Horizon. Other providers are available in our network. SanitasMedical Centers serve people insured by Horizon, Original Medicare and those self-paying for medical treatment.Grand Rounds, Hinge Health, Livongo and Wonder are independent from and not affiliated with Horizon.Horizon complies with applicable Federal civil rights laws and does not discriminate against nor does it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability,pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.Spanish (Español): Para ayuda en español, llame al 1-866-660-6528 (TTY 711). Chinese (中文): 如需中文協助，請致電 1-866-660-6528 (TTY 711).ECNA004451 (0921)
health care coverage, Horizon is a leader in providing access to quality health care plans. Plus, we provide tools and support that make navigating health care . With our HMO plans, you have access to health care professionals and facilities in the Horizon Managed Care Network in New Jersey and parts of New York, Pennsylvania and Delaware .
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834 Other long-term employee benefits are all employee benefits other than short-term employee benefits, post-employment benefits and termination benefits. Termination benefits are employee benefits provided in exchange for the termination of an employee's employment as a result of either: (a) an entity's decision to terminate an employee's employment before the normal retirement
2022 Benefit Guide. 3 23Contoes Contents About MediPhila . How your claims will be covered Online Services Co-payments In-Hospital Benefits Oncology Benefits Chronic Medicine Benefits Applying for Chronic Medicine Benefits Dentistry Benefits Maternity Benefits Medshield Mom Out-of-Hospital Benefits . emergency, you will incur a 20% penalty on
2022 Benefits Summary & Guide Welcome to the Macalester College benefits program. The 2022 Benefits Summary & Guide will acquaint you with the benefits available to faculty and staff of Macalester College. We hope you find this guide helpful as you weigh . Employee (1) 200.00 0.00 243.50 43.50 287.00 87.00 Employee (2 ) 200.00 0 .
