Plan Year 2024
NJ DIRECT and NJ Educators
Health Plan Member Guidebook
For Employees and Retirees Enrolled In The School
Employees’ Health Benets Program
HorizonBlue.com/shbp
i
SEHBP Member Guidebook 2024
Contents
Introduction 1
Horizon BCBSNJ Member Online Services 2
Member Services 3
NJWELL Rewards Program 4
NJ DIRECT and the New Jersey Educators HealthPlan 5
Health Benets Program Eligibility 6
Active Employee Eligibility 6
Local Education Employees 6
Enrollment 6
Eligible Dependents 6
Supporting Documentation Required For Enrollment Of Dependent 8
Audit Of Dependent Coverage 8
Multiple Coverage Under The SHBP/SEHBP Is Prohibited 8
Medicare Coverage While Employed 9
Retiree Eligibility 9
Medicare Coverage 11
Medicare Parts A and B 11
Medicare Part D 12
General Conditions Of The Plan 15
Medical Need and Appropriate Level of Care 15
Health Care Fraud 15
Services Requiring Precertication 16
Utilization Management 18
SEHBP Benets 21
In-Network Benets 21
Out-Of-Network Benets 23
Coordination Of Benets 26
General Benets 27
Charges Not Covered By The SEHBP Plans 43
Subrogation And Reimbursement 50
When You Have A Claim 50
Medicare Claim Submission 51
Authorization To Pay Provider 52
Questions About Claims 52
Appeal Procedures 52
SEHBP Medical Appeal Procedure 52
SEHBP Plans Administrative Appeal Procedure 57
ii
SEHBP Member Guidebook 2024
Prescription Drug Benets 60
COBRA Coverage 61
Cost of COBRA Coverage 62
Duration of COBRA Coverage 62
Termination of COBRA Coverage 63
APPENDIX I 64
Special Plan Provisions Work-Related Injury Or Disease 64
Medical Plan Extension of Benets 64
Termination For Cause 64
APPENDIX II 65
Summary Schedules of Services and Supplies 65
SEHBP Plans Eligible Services and Supplies 65
SEHBP Plans Covered Services 66
APPENDIX III 71
GLOSSARY 71
APPENDIX IV 79
Required Documentation For Dependent Eligibility and Enrollment 79
Required Documentation for Dependent Eligibility and Enrollment 80
APPENDIX V 81
Health Insurance Portability And Accountability Act 81
APPENDIX VI 81
Notice Of Privacy Practices to Enrollees In The New Jersey School Employees’ Health Benets Program 81
APPENDIX VII 85
Health Benets Program Contact Information 85
Health Benets Program Publications 86
Member Guidebooks 86
An online version of this guidebook containing current updates is available for viewing at:
https://www.nj.gov/treasury/pensions/member-guidebooks.shtml. Be sure to check the
Division of Pensions & Benets Internet home page at www.nj.gov/treasury/pensionsfor
forms, fact sheets, and news of any new developments affecting your health benets.
1
Introduction | SEHBP Member Guidebook 2024
Introduction
The School Employees’ Health Benets Program (SEHBP) was established in 2007. It offers
medical and prescription drug coverage to qualied local education public employees,
retirees, and eligible dependents. Local education employers must adopt a resolution to
participate in the SEHBP.
The School Employees' Health Benets Commission (SEHBC) is the executive organization
responsible for overseeing the SEHBP. The SEHBC includes the State Treasurer, the
Commissioner of the Department of Banking and Insurance, an appointee of the Governor,
an appointee from New Jersey School Board Association, three appointees from New Jersey
Education Association, an appointee from New Jersey State AFL-CIO, and a chairperson
appointed by the Governor from nominations submitted by the other members of the
commission. The Director of the Division of Pensions & Benets is the Secretary to the SEHBC.
The School Employees’ Health Benets Program Act is found in the New Jersey Statutes
Annotated, Title 52, Article 14-17.46 et seq. Rules governing the operation and administration
of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
The Division of Pensions & Benets, specically the Health Benets Bureau and the Bureau
of Policy and Planning, is responsible for the daily administrative activities of the SHBP and the
SEHBP.
Every effort has been made to ensure the accuracy of the Member Guidebook, which
describes the benets provided in the contract with Horizon BCBSNJ. However, State law
and the New Jersey Administrative Code govern the SHBP and SEHBP. If there are any
discrepancies between the information presented in this booklet and/or plan documents and
the law, regulations, or contracts, the law, regulations, and contracts will govern. Furthermore,
if you are unsure whether a procedure is covered, contact your plan before you receive
services to avoid any denial of coverage issues that could result.
If, after reading this booklet, you have any questions, comments, or suggestions regarding
this material, please write to the Division of Pensions & Benets, PO Box 295, Trenton, NJ
08625-0295, call us at (609) 292-7524, or send an e-mail to [email protected]
2
Horizon BCBSNJ Member Online Services | SEHBP Member Guidebook 2024
Horizon BCBSNJ Member
Online Services
Horizon Blue Cross Blue Shield of New Jersey
(Horizon BCBSNJ) offers you an easy, secure and
quick way to track your health plan benets and
health information online.
Simply register at HorizonBlue.com/shbp to have
immediate access to health plan benets and health
information online.
1
You can:
• Chat or send a secure email.
• Check claims status and payments.
• Read Explanation of Benefits statements, and see
any amount owed.
• Tell Horizon BCBSNJ if you have other health
insurance coverage.
• Use our tools and resources to understand your
plan and the insurance process.
• View and print your member ID card.
• View your benefit information.
• View your out-of-pocket expenses, authorizations,
referrals and other account information.
• Access NJWELL
• Connect with health and wellness programs
• Check your HSA transactions and funding
• Find a doctor, hospital or other health care professional
• Have a telemedicine visit
• Learn what’s new with your Horizon coverage
For assistance with the registration process,
please contact the eService Help Desk via email at
[email protected] or by calling
1-888-777-5075, Monday through Friday, 7 a.m. to
6p.m., Eastern Time.
1. Not all HorizonBlue.com tools and services may be compatible with every electronic device or available with every account.
2. There is no charge to download the Horizon Blue app, but rates from your wireless provider may apply.
You can also download the free
Horizon Blue app by scanning
the QR Code or visiting the
App Store
®
or Google Play
™
.
2
3
Member Services | SEHBP Member Guidebook 2024
Member Services
When you call the number on your SHPB/SEHBP Horizon-BCBSNJ member ID card, Member
Services can help with all your health care needs: answering questions, solving issues, helping
with claims, nding care and give you information about local services for you and your family.
They can also refer you to the case management program to support members with complex
needs or who suffer from chronic health conditions. For questions related to these issues call
Member Services at 1-800-414-SHBP (7427).
Support for your medical care when you need it
The Horizon Case Management Program helps members with chronic conditions take better
care of their health, understand their care choices and improve their health. This program is
available at no added cost to eligible members with:
Asthma
Chronic Kidney Disease (CKD)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Artery Disease (CAD)
Diabetes
Heart Failure
For more information,
visit our website, chat
or call:
• Visit HorizonBlue.com/shbp
• Click Chat Monday through
Friday, 8 am to 6 pm, ET.
• Call 1-800-414-SHBP (7427),
Monday through Friday,
8 am to 6 pm, ET.
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NJWELL Rewards Program | SEHBP Member Guidebook 2024
NJWELL Rewards Program
Your benets include NJWELL, a wellness program for
eligible members and their covered spouses or partners.
Eligible members earn points toward an NJWELL
Mastercard
®
Prepaid card valued at $250 by completing
activities, including an online health assessment, a
biometric health screening, online activities, preventive
screenings and coaching between November 1 and
October 31 each year.
To nd out more about NJWELL, visit NJ.gov/NJWELL or see
HorizonBlue.com/NJWELL.
My Health Manager, powered by
WebMD
®
My Health Manager is your personalized health
guide. You can customize it to include news feeds,
articles and reminders, plus take advantage of an
online health record that gives you and your family
the ability to store, manage and maintain health
information in a centralized location.
My Health Manager also features these powerful
tools:
• NJWELL Rewards Program: link to your NJWELL Rewards page
• WebMD's Symptom Checker: Answer a few simple questions and
get information on potential causes and treatments to discuss with
your physician;
• Hospital Quality Comparison Tool: Review diagnosis and procedure
specific quality rankings of hospitals;
• Health Assessment Tool: Take an assessment that covers your
current health conditions, family health history, vital statistics, lifestyle
and life events, among other factors;
• Condition Centers: Tap into enhanced risk identification and
management tools for conditions ranging from allergies and asthma
to depression and diabetes;
• And much more: From health measurement trackers to tailored
health improvement programs, we provide all the tools you need.
Sign in or register to get started:
My Health Manager is only available to registered members, please
visit HorizonBlue.com/shbp, or download the Horizon Blue app to
register or sign in.
You are your own best health
advocate. However, to get and
stay healthy, it helps to have
some guidance. That’s why
we offer My Health Manager,
powered by WebMD
®
.
5
NJ DIRECT and the New Jersey Educators Health Plan | SEHBP Member Guidebook 2024
NJ DIRECT and the New Jersey Educators
HealthPlan
NJ DIRECT and the New Jersey Educators Health Plan (referred to as the ‘SEHBP plans’
through this Guidebook) are administered for the Division of Pensions & Benets by Horizon
Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). The SEHBP plans are self-funded.
Funds for the payment of claims and services come from funds supplied by the State,
participating local employers, and members. Refer to APPENDIX VII for more information on
contacting the SEHBP plans, the Division of Pensions & Benets, and related health services.
Except where noted, the SEHBP plans follow the same policies and parameters.
All the SEHBP plans provide both in-network and out-of-network benets.
• In-network care is provided through a network of providers that includes internists, general
practitioners, pediatricians, specialists, and hospitals. Network providers offer a full range
of services that include well care and preventive services such as annual physicals, well-
baby/well-childcare, immunizations, mammograms, annual gynecological examinations,
and prostate examinations. In-network services generally provide the highest level of
benefits available under the plan. Services may be subject to a copayment, coinsurance or
in -network deductible and coinsurance. For more information, refer to the IN-NETWORK
BENEFIT section of this Guidebook.
• Out-of-network benefits provide reimbursement for expenses for eligible services
rendered for the treatment of illness and injury. Most out-of-network care is reimbursed
at a percentage of the reasonable and customary allowance after an annual deductible
is met. Out-of-network inpatient hospital admissions are subject to a separate inpatient
deductible per admission for most of the SEHBP plan options. For more information refer
to the OUT-OF-NETWORK BENEFITS section of this Guidebook. You can also sign in to
www.HorizonBlue.com, to validate your specific out-of-network benefits.
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Health Benets Program Eligibility | SEHBP Member Guidebook 2024
Health Benets Program Eligibility
Active Employee Eligibility
Eligibility for coverage is determined by the School Employees’ Health Benets Program
(SEHBP). Enrollments, terminations, changes to coverage, etc. must be presented through
your employer to the Division of Pensions & Benets. If you have any questions concerning
eligibility provisions, you should contact the Division of Pensions & Benets' Ofce of Client
Services at (609) 292-7524, or send e-mail to: [email protected]
Local Education Employees
To be eligible for the SEHBP coverage you must be a full-time employee or an appointed or
elected ofcer receiving a salary from the board of education that participates in the SEHBP.
Each participating employer denes the minimum hours required for full-time by a resolution
led with the Division of Pensions & Benets, 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.
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 State-paid post-
retirement health care benets, but may enroll in retired group coverage at their own expense
provided they were covered up to the date of retirement. See the Health Benets Coverage
for Part-Time Employees Fact Sheet for more information.
Enrollment
You are not covered until you enroll in the SEHBP. You must ll out a Health Benets 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 rst 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 &
Benets.
Eligible Dependents
Your eligible dependents are your spouse, civil union partner or eligible same-sex domestic
partner, and your eligible children (as dened below).
Spouse — A person to whom you are legally married. A photocopy of the marriage certicate
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 Certicate or a valid certication
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
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Health Benets Program Eligibility | SEHBP Member Guidebook 2024
be subject to federal tax (see your employer or the Civil Unions and Domestic Partnerships
Fact Sheet for details).
Domestic Partner — A person of the same sex with whom you have entered into a domestic
partnership as dened 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
benets, is eligible for coverage. A photocopy of the New Jersey Certicate of Domestic
Partnership dated prior to February 19, 2007(or a valid certication 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 the Civil Unions and Domestic
Partnerships Fact Sheet 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 nancial dependency status. A
photocopy of the child’s birth certicate that includes the covered parent’s name is required
for enrollment. (Non-custodial parents, refer to the REQUIRED DOCUMENTATION FOR
DEPENDENT ELIGIBILITY AND ENROLLMENT section of this Guidebook).
For a stepchild provide a photocopy of the child’s birth certicate showing the spouse/
partner’s name as a parent and a photocopy of marriage/partnership certicate 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 certicate and additional supporting legal documentation
are required with enrollment forms for these cases. Documents must attest to the legal
guardianship by the covered employee.
Refer to the REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND
ENROLLMENT section of this Guidebook.
Coverage for an enrolled child ends on December 31 of the year in which he or she turns
age 26. See the “COBRA” section, “Dependent Children with Disabilities” and “Over Age
Children Until Age 31” section of this Guidebook 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, or developmental or physical disability, he or she
may be eligible for a continuance of coverage.
To request continued coverage, contact the Ofce of Client Services at (609) 292-7524 or write
to the Division of Pensions & Benets, Health Benets 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 le 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.
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Health Benets Program Eligibility | SEHBP Member Guidebook 2024
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 benets
plan, church plan, or entitled to benets under Medicare.
Under Chapter 375, an over age child does not have any choice in the selection of benets
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 benets.
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 rst 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 the Health Benets Coverage of Children until Age 31 under Chapter 375
Fact Sheet for details.
Supporting Documentation Required For Enrollment Of Dependent
The SEHBP is 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. For more information
about the documentation a member must provide when enrolling a new dependent for
coverage, please refer to the REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY
AND ENROLLMENT section of this Guidebook.
Audit Of Dependent Coverage
Periodically, the Division of Pensions & Benets 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 certicates, 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 nancial 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.
Multiple Coverage Under The SHBP/SEHBP Is Prohibited
State statute specically 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.
9
Health Benets Program Eligibility | SEHBP Member Guidebook 2024
Medicare Coverage While Employed
In 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 benets 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” in the “Retiree Eligibility” section,
below.
Retiree Eligibility
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”
below);
• 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 Benefit 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; and
• 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 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 locally-administered
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 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 SEHBP immediately preceding the effective date of your retirement.
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Health Benets Program Eligibility | SEHBP Member Guidebook 2024
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” of this Guidebook)
— 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 SEHBP.
Otherwise qualied 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, board of education employee, who has 25 years or more of
service credit, is eligible for State-paid health benets under the SEHBP, subject to the
applicable retiree contribution, if any.
A retiree eligible for the SEHBP may receive this benet if the 25 years of service credit is from
one or more State or locally administered retirement systems and the time credited is non-
concurrent.
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 benets 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 below). 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 SHBP or SEHBP, but who become eligible for SHBP or SEHBP coverage at
retirement, 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.
(Please refer to the RETIREE ELIGIBILITY section of this Guidebook.)
Multiple Coverage under the SHBP/SEHBP is prohibited
State statute specically 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.
11
Medicare Coverage | SEHBP Member Guidebook 2024
Enrolling in Retired Group Coverage
The Health Benets Bureau is notied when you le an application for retirement with the
Division of Pensions & Benets. If eligible, you will receive a letter inviting you to enroll in
Retired Group coverage. Early ling 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 the Health Benets
Coverage – Enrolling as a Retiree Fact Sheet 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 & Benets, Ofce of
Client Services at (609) 292-7524 or send an e-mail to [email protected]
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 Coverage
Medicare 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 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 Part
B coverage. Send your evidence of enrollment to the Health Benets Bureau, Division of
Pensions & Benets, P.O. 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 Benets
Bureau on a prospective basis.
Important: When coordinating benets with Medicare, the secondary benet under the
SEHBP plan is supplemental to the Medicare payment. The SEHBP plan will consider the
remaining Medicare coinsurance and deductible as the allowable expense and apply the
applicable copayments, coinsurance, or deductible when appropriate. If a provider is not
registered with or opts out of Medicare, no benets are payable under the 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.
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Medicare Coverage | SEHBP Member Guidebook 2024
Medicare Part D
If you are enrolled in the Retired Group of the SEHBP and eligible for Medicare, you will be
automatically enrolled in Medicare Part D and the OptumRx Medicare Prescription Drug Plan.
Important: If you decide not to be enrolled in the OptumRx Medicare Prescription Drug Plan,
you will lose your prescription drug benets provided by the SEHBP. In order to waive the
OptumRx Medicare Prescription Drug 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 & Benets.
Medicare Eligibility
In most cases, a Retired Group member and/or dependent should enroll in Medicare Part A
and Part B coverage as soon as they become eligible. Otherwise, an individual can only enroll
during Medicare’s annual “General Enrollment Period” (January 1 through March 31) and late
enrollment penalties may apply (visit www.medicare.gov or contact Medicare at 1-800-633-
4227 for more information).
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 rst day of the month during which he or she reaches age 65.
However, if he or she is born on the rst day of a month, he or she is considered to be
eligible for Medicare from the rst day of the month that 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 benets for 24 months;
The retired group health plan is the secondary payer; or
• Medicare Eligibility by Reasons of End Stage Renal Disease (ESRD)
A member usually becomes eligible for Medicare at age 65 or upon receiving Social Security
Disability benets 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 ESRD. When a person is eligible for Medicare due to ESRD, Medicare is the
secondary payer when:
o The individual has group health coverage of their own or through a family member
(including a spouse/partner); or
o 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 below are known as the Medicare Secondary Payer (MSP) rules and are federal
regulations that determine whether Medicare pays rst or second to the group health plan.
These rules have changed over time.
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Medicare Coverage | SEHBP Member Guidebook 2024
As of January 1, 2000, where the member becomes eligible for Medicare solely on the basis
of ESRD, the Medicare eligibility can be segmented into three parts: (1) an initial three-month
waiting period; (2) a "coordination of benets" period; and (3) a period where Medicare is
primary.
Three-month waiting period
Once a person has begun a regular course of renal dialysis for treatment of ESRD, there is a
three- month waiting period before the individual becomes entitled to Medicare Parts A and B
benets. During the initial three-month period, the group health plan is primary.
Coordination of benets period
During the "coordination of benets" period, Medicare is secondary to the group health
plan coverage. Claims are processed rst under the health plan. Medicare considers the
claims as a secondary payer. For members who became eligible for Medicare due solely to
ESRD, the coordination of benets period is 30 months.
When Medicare is primary
After the coordination of benets period ends, Medicare is considered the primary payer
and the group health plan is secondary. If you are eligible for Medicare by reason of ESRD
and Medicare is primary, you must enroll in Medicare A and B and submit proof of enrollment
to the SEHBP. If you do not enroll in Medicare A and B before the end of the coordination of
benets period, your SEHBP coverage will be terminated. It is your responsibility to ensure
that you le your application for Medicare so that the Medicare effective date is on or before
the date that the coordination of benets period ends.
Dual Medicare Eligibility
When the member is eligible for Medicare because of age or disability and then becomes
eligible for Medicare because of ESRD:
• If the health plan is primary because the member has active employment status, then the
group health plan continues to be primary for 30 months from the date of dual Medicare
entitlement; or
• If the health plan is secondary because the member is not actively employed, then the
health plan continues to be the secondary payer. There is no 30-month coordination
period.
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Medicare Coverage | SEHBP Member Guidebook 2024
How to File a Claim If You Are Eligible for Medicare
When ling your claim, follow the procedure listed below that applies to you.
New Jersey Physicians or Providers:
• You should provide the physician or provider with your identification number. This number
should be written on the Medicare Request for Payment (claim form) under "Other Health
Insurance;"
• The physician or provider will then submit the Medicare Request for Payment to the
Medicare Part B carrier;
• After Medicare has taken action, you will receive an Explanation of Benefits statement from
Medicare;
• If the remarks section of the Explanation of Benefits contains the following statement,
you need not take any action: "This information has been forwarded to the Plan for their
consideration in processing supplementary coverage benefits;
If the statement shown above does not appear on the Explanation of Benets, you should
indicate your SEHBP plan identication number and the name and address of the physician or
provider in the remarks section of the Explanation of Benets with a completed claim form and
send it to the address on the claim form.
Out-Of-State Physicians or Providers:
• The Medicare Request for Payment form should be submitted to the Medicare Part B
carrier in the area where services were performed. Call your local Social Security office for
information;
• When you receive the Explanation of Benefits, indicate your identification number and
the name and address of the physician or provider in the Explanation of Benefits with a
completed claim form to the address on the claim form.
Retirees Enrolled in Medicare Who Move Outside the United States
Members who reside outside the United States must still maintain their Medicare coverage
(Part A and Part B) in order to be covered under Retired Group coverage; however, Medicare
does not cover services outside the United States. For members who reside outside the United
States, the SEHBP plan covers services as if the plan was primary.
Members, who reside outside the United States, even if they reside in a country with a national
health plan, should consider that if they travel outside their country of residence they will still
need coverage. In order to have coverage at any time in the future, the member must stay
enrolled in the SEHBP, since once a member terminates coverage they will not be reinstated.
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
General Conditions Of The Plan
All benets listed in this guidebook may be subject to limitations and exclusions as described
in subsequent sections. All pertinent parts of this guidebook should be consulted regarding a
specic benet.
Even though a service or supply may not be described or listed in this guidebook, that
does not mean the service or supply is eligible for benets under the SEHBP plans.
SEHBP plans will pay only for eligible services or supplies that meet the following conditions:
• Are medically needed at the appropriate level of care (see below) for the medical condition.
(When there is a question as to medical need, the decision on whether the treatment is
eligible for coverage will be made by Horizon BCBSNJ.);
• Are listed in the “Eligible Services and Supplies” section of this Guidebook;
• Are ordered by an eligible provider for treatment of illness or injury;
• Were provided while you or your eligible covered dependents were covered by a SEHBP
plan; and
• Are not specifically excluded (listed in the “Charges Not Covered by the SEHBP plans”
section of this Guidebook).
When you use an out-of-network provider, all eligible services, supplies, tests, etc. prescribed
by your provider, including hospitalization, are reimbursed at a percentage of the reasonable
and customary allowance after deductibles and coinsurance have been met. The member is
responsible for any amount charged by the physician that is above and beyond the reasonable
and customary allowance in addition to deductibles and coinsurance.
Medical Need and Appropriate Level of Care
The medical need and appropriate level of care for any service or supply is determined by
Horizon BCBSNJ and must meet each of these requirements:
• It is ordered by an eligible provider for the diagnosis or the treatment of an illness or injury;
• The prevailing opinion within the appropriate specialty of the United States medical
profession is that it is safe and effective for its intended use; and
• That it is the most appropriate level of service or supply considering the potential benefits
and possible harm to the patient.
Please refer to the “Experimental or Investigational Treatments” section of this Guidebook.
Health Care Fraud
Health care fraud is an intentional deception or misrepresentation that results in an
unauthorized benet to a member or to some other person. Any individual who willfully and
knowingly engages in an activity intended to defraud the SEHBP will face disciplinary action
that could include termination of employment and may result in prosecution. Any member
who receives monies fraudulently from a health plan will be required to fully reimburse the
plan.
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
Precertication Of Benets In-Network And Out-Of-Network
A precertication is required for certain services and all inpatient admissions, excluding
certain admissions for treatment of substance use disorders in the rst 180 days of the plan
year. Failure to obtain a precertication may result in benets being denied. Participating
physicians and hospitals will obtain precertication on your behalf. Horizon BCBSNJ will
conduct a review of any services that were not precertied to determine eligibility. If you do
not obtain precertication, payment may not be made for services that are determined to be
not medically appropriate.
Services Requiring Precertication
Accidental Dental Injuries Air Ambulance
Alcohol and Substance Abuse Specialty Services - See Substance Use Disorder Specialty
Services.
Applied Behavioral Analysis (ABA) Cancer Clinical Trials
Durable Medical Equipment (DME) (see examples below)
• Electric, customized or motorized wheelchairs and scooters, and powered accessories;
• Electric beds/Clinitron/powered hospital beds/air mattresses/powered accessories;
• Enteral formula;
• Bone stimulators;
• Neurostimulators;
• Lymphedema pumps;
• External defibrillators;
Inpatient Admissions, including:
• All acute care confinements, exclusive of maternities, including:
o Surgical admissions;
o Medical admissions;
o Hospice admission; and
o All Skilled Nursing Facility (SNF) confinements;
o All Rehabilitation Facility confinements;
• All Sub-Acute confinements; and
• Mental health and substance use disorder confinements including Residential, Partial
Hospitalizations, and Intensive Out-Patient Admissions.(See UTILIZATION MANAGEMENT)
Home Health Care Services
Home Hospice Services
Hyperbaric Oxygen Therapy
Infertility Services, including:
• Gamete intrafallopian transfer;
• In vitro fertilization;
• Zygote intrafallopian transfer;
• Artificial insemination; and
• Hysterosalpingography.
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
Home Infusion (IV) Therapy
Lyme Disease Intravenous Antibiotic Therapy
Mental Health Specialty Services, including:
• All Mental Health Confinements(including Residential, Partial Hospitalizations, and Intensive
Out- Patient Admissions;
• Biofeedback.
Specic Medications administered in a physician's ofce or dialysis facility (review
performed by eviCore National)
• Aranesp;
• Epogen; and
• Procrit.
Pain Management (Refer to the Pain Management section of this Guidebook for additional
details.)
Private Duty Nursing in the Home (Inpatient PDN is ineligible)
Radiology (review services performed by eviCore)
• CT/CTA Scans;
• MRI/MRA;
• Nuclear Medicine/Nuclear Cardiology;
• PET and PET/CT Scans;
• Echo Stress Tests; and
• Diagnostic Left Heart Catheterization.
Reconstructive Procedures that may be considered Cosmetic
• Blepharoplasty/Canthopexy/Canthoplasty;
• Excision of excessive skin due to weight loss;
• Rhinoplasty/rhytidectomy;
• Pectus excavatum repair;
• Breast reconstruction/enlargement;
• Breast reduction/mammoplasty;
• Lipectomy or excess fat removal;
• Sclerotherapy or surgery for varicose veins;
• Facial reconstruction or repair including:
o Orthognathic surgery;
o Bone grafts;
o Osteotomies;
o Surgical management of temporomandibular joint;
• Any other potentially cosmetic procedure.
Specialty Pharmaceuticals
Spinal Disk Surgeries, including but not limited to:
• Percutaneous Laser Discectomy;
• Nucleoplasty; and
• Spinal Fusion.
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
Substance Use Disorder Specialty Services:
• All substance use disorder confinements, including residential and partial hospitalization
admissions (See UTILIZATION MANAGEMENT);
• Intensive Outpatient (IOP) Treatment; and
• Office Based Opioid Treatment (OBOT)
Surgery for Morbid Obesity including but not limited to:
• Gastroplasty;
• Gastric Bypass; and
• Bariatric Procedures.
Therapy Services
• Cognitive Therapy;
• Occupational Therapy;
• Physical Therapy; and
• Speech Therapy.
Transplants
• Lung;
• Liver;
• Heart;
• Pancreas;
• Autologous Bone Marrow;
• Cornea;
• Kidney;
• Autologous Chondrocyte Transplants; and
• Uvulopalatopharyngoplasty (UPPP).
Predetermination of Benets
A predetermination for any service may be obtained in writing in advance of services being
rendered. The written request will need to include the provider's name, address, and phone
number, the diagnosis, a description of the services to be rendered, and the anticipated
charges. Telephone contact with Horizon BCBSNJ or the Division of Pensions & Benets
about coverage does not constitute a predetermination of benets. If the actual services
rendered differ from those described in the written request, the predetermination of benets
will have no effect. A predetermination is valid for one year from the date issued. All requests
for written predeterminations must include all necessary medical documentation and must
be presented to Horizon BCBSNJ three to four weeks prior to the services being rendered.
If Horizon BCBSNJ requires additional medical information, the written response may be
delayed.
Utilization Management
Medical Management and Review
Both in-network and out-of-network treatment is subject to Utilization Management (UM), a
process used to ensure that treatment is medically needed and provided at the appropriate
level of care. When the treatment is proposed by an in-network provider, the provider is
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
responsible for the UM contact. Benets are payable for in-network treatment when they
are provided by an in-network provider, the UM organization has been notied to review the
treatment, and the UM organization has approved the treatment.
Out-of-network benets that are actually payable will also depend on whether the patient
or patient's provider has or has not contacted the UM organization in regard to propose d
medical treatment and whether the UM organization agrees that the treatment is needed and
at the appropriate level of care. If the member is utilizing a non-participating physician, they
should request their non-participating physician to contact Utilization Management at the
number listed on their ID card (1-800-664-2583).
If a member calls this number to request precertication, the UM organization’s Precertication
Department will request the phone number of the physician and will contact the physician to
obtain the clinical information needed in order to review the services requested.
For out-of-network benets when the patient or physician has failed to contact the UM
organization at Horizon BCBSNJ, treatment will be considered not certied and expenses will
not be applied to the annual out-of-pocket maximum. However, if the treatment is ultimately
determined to be eligible, reimbursement will be made at the appropriate percentage of
reasonable and customary allowances after any deductible has been met.
Reasonable And Customary Allowances
(For Out-of-Network Services)
Except where noted, the SEHBP plans cover only reasonable and customary allowances,
which are determined by a percentile of the FAIR Health national benchmark charge data or
other nationally recognized database. This schedule is based on actual charges by physicians
nationally for a specic service. In other instances, such as Ambulatory Surgery Centers (ASC’s)
and the NJ Educators Health Plan, the out-of-network allowance is derived from an alternate
nationally recognized source; it’s based on a percentage of the Centers for Medicare and
Medicaid Services (CMS) allowance.
Sign into the Horizon BCBSNJ member online services, HorizonBlue.com, to validate your
specic out-of-network benets.
Please see the Out-of-Network allowance for all plans.
SEHBP Plan Option Out-of-Network Allowance
NJ DIRECT10 90th Percentile of FAIR Health national benchmark
NJ DIRECT15 90th Percentile of FAIR Health national benchmark
NJ DIRECT1525* 90th Percentile of FAIR Health national benchmark
NJ DIRECT2030* 90th Percentile of FAIR Health national benchmark
NJ Educators Health Plan 200% of CMS
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are
Medicare eligible and select one of these two plans as supplemental to Medicare.
If your physician charges more than the reasonable and customary allowance, you will be
responsible for the full amount above the reasonable and customary allowance in addition to
any deductible and coinsurance you may be required to pay.
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General Conditions Of The Plan | SEHBP Member Guidebook 2024
Admissions for the Treatment of Substance Use Disorder (for Network Service Only)
• This section applies during the first 180 days of treatment per year whether the treatment is
inpatient or outpatient. Thereafter, inpatient treatment of substance use disorder is subject
to the above provisions governing hospital and other facility admissions.
• If a member is admitted to facility for the treatment of substance use disorder, whether for a
scheduled admission or for an emergency admission, the facility must notify Horizon BCBSNJ
of the admission and initial treatment plan within 48 hours of the admission.
• Horizon BCBSNJ will not initiate continued stay review, also known as concurrent review,
with respect to the first 28 days of the inpatient stay. Continued stay review may be required
for any subsequent days, but not more frequently than at two-week intervals. If Horizon
BCBSNJ determines continued stay is no longer a Medical Need and Appropriate Level of
Care, Horizon BCBSNJ shall provide written notice within 24 hours to the member and his or
her provider along with information regarding appeal rights.
Experimental or Investigational Treatments
The SEHBP plans do not cover treatment that is considered experimental or investigational.
Charges in connection with such a service or supply are also not covered, except in the case
of an approved clinical trial. For the purpose of this exclusion, a service or supply will be
considered experimental or investigational if Horizon BCBSNJ determines that one or more of
the following is true.
1. The service or supply is under study or in a clinical trial to evaluate its toxicity, safety, or
efcacy for a particular diagnosis or set of indications. Clinical trials include but are not limited
to phase I, II, and III clinical trials, with the exception of approved cancer trials.
2. The prevailing opinion within the appropriate specialty of the United States medical profession
is that the service or supply needs further evaluation for a particular diagnosis or set of
indications before it is used outside clinical trials or other research settings. Horizon BCBSNJ
will determine this based on:
o Published reports in authoritative medical literature; and
o Regulations, reports, publications, and evaluations issued by US Government agencies
such as the Agency for Health Care Research and Quality, the National Institutes of
Health, and the federal Food and Drug Administration (FDA).
3. The provider's institutional review board acknowledges that the use of the service or supply
is experimental or investigational and subject to that board's approval.
4. The provider's institutional review board requires that the patient, parent, or guardian give
an informed consent stating that the service or supply is experimental or investigational, part
of a research project or study, or federal law requires such consent.
5. Research protocols indicate that the service or supply is experimental or investigational. This
item applies for protocols used by the patient's provider as well as for protocols used by
other providers studying substantially the same service or supply.
6. The service or supply is not recognized by the prevailing opinion within the appropriate
medical specialty as an effective treatment for the particular diagnosis or set of indications.
7. Additionally, if it is a drug, device, or other supply that is subject to FDA approval it will be
considered experimental and investigational if it:
o Does not have FDA approval for sale and use in the United States (that is, for
introduction into and distribution in interstate commerce); or
o Has FDA approval only under the Treatment Investigational New Drug regulation or a
similar regulation; or
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SEHBP Benets | SEHBP Member Guidebook 2024
o Has FDA approval, but is being used for an indication or at a dosage that is not
an acceptable off-label use. Horizon BCBSNJ will determine if a certain use is an
accepted off-label use based on published reports in peer-reviewed, authoritative
medical literature and entries in the following drug compendia: The American Medical
Association Drug Evaluations, the American Hospital Formulary Service Drug Information,
and the United States Pharmacopoeia Dispensing Information.
SEHBP Benets
In-Network Benets
You can benet most from the SEHBP plans when you obtain your care from in-network
providers. Members have lower out-of-pocket costs when using in-network doctors and
facilities or the BlueCard
®
PPO network nationwide. As a Blue Cross and Blue Shield member,
you take your healthcare benets with you when you are abroad. Through the Blue Cross Blue
Shield Global Core program, you have access to doctors and hospitals around the world. If you
use out-of-network professionals or facilities, your out-of- network costs may be higher.
In-network care is provided through a network of providers that includes internists, general
practitioners, specialists, pediatricians, and hospitals. No referrals are needed for visits to a
specialist. If the physician participates in the Horizon Managed Care Network or the BlueCard
®
PPO network nationwide or Horizon Care Online eligible services will be covered at the in-
network level of benets.
In-network hospital admissions are covered in full for most SEHBP plan options. If the
physician does not participate in the Horizon BCBSNJ Managed Care Network or the national
network, the services will be considered out-of-network. Contact your doctor to see if he or
she participates in the Horizon BCBSNJ Managed Care or national network.
To nd current participating physicians in New Jersey contact Horizon BCBSNJ directly at
1-800-414- SHBP(7427) or visit: HorizonBlue.com/shbp
In-Network Copayments
The SEHBP plans will pay, in most cases, the full cost after the copayment for physician ofce
visits. Copayments apply to in-network provider ofce visits, unless otherwise indicated, and
vary by plan option as outlined below:
SEHBP Plan Option
PrimaryCare Ofce Visit
Copayment
Specialist Ofce Visit
Copayment
NJ Educators Health Plan $10 $15
NJ DIRECT10 $10 $10
NJ DIRECT15 $15 $15
NJ DIRECT1525 $15 $25
NJ DIRECT2030 $20
$30 for adults; $20 for children
to the end of calendar year the
child turns 26
The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are
Medicare eligible and select one of these two plans as supplemental to Medicare.
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SEHBP Benets | SEHBP Member Guidebook 2024
Annual In-Network Coinsurance
For the NJ Educators Health Plan, NJ DIRECT10, NJ DIRECT15, NJ DIRECT1525 and NJ
DIRECT2030, select in-network services require the member to pay ten percent coinsurance
instead of a copayment until the in-network coinsurance limit is reached. In-network services
and benets requiring coinsurance are durable medical equipment, ambulance transport,
oxygen therapy, outpatient private duty nursing, and some Prosthetics. In-network coinsurance
paid by the member is applied to the in- network coinsurance limit.
Annual In-Network Coinsurance Limit
Once the member reaches the in-network coinsurance limit (shown below), the SEHBP plans
will pay 100 percent of the cost of covered in-network services that are subject to coinsurance
for the balance of the plan year.
SEHBP Plan Option
Individual In-network
Coinsurance Limit
Family In-network
Coinsurance Limit
NJ DIRECT10,
NJ DIRECT15,
NJ DIRECT1525
$400 $1,000
NJ Educators Health Plan $500 $1,000
NJ DIRECT2030 $800 $2,000
The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are
Medicare eligible and select one of these two plans as supplemental to Medicare.
Annual In-Network Out-of-Pocket Maximum
The Annual In-Network Out-of-Pocket maximum is the annual limit on the amount of cost-
sharing individuals or families are required to pay for covered in network health care expenses.
In -network copayments and coinsurance apply toward the annual in-network out-of-pocket
maximum.
Active Employee Annual In-Network Out-of-Pocket Maximum
SEHBP Plan Option
Individual In-network Maximum
Out-of-Pocket
Family In-network Maximum
Out-of-Pocket
NJ DIRECT10 $400 $1,000
NJ Educators Health Plan $500 $1,000
NJ DIRECT15 $7,560 $15,120
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SEHBP Benets | SEHBP Member Guidebook 2024
Retirees’ Annual In-Network Out-of-Pocket Maximum
SEHBP Plan Option
Individual In-network Maximum
Out-of-Pocket
Family In-network Maximum
Out-of-Pocket
NJ Educators Health Plan $500 $1,000
NJ DIRECT1525 $8,039 $16,078
NJ DIRECT2030 $8,039 $16,078
Note: The NJ Educators Health Plan is ONLY offered to early retirees. The NJ DIRECT1525
and NJ DIRECT2030 Plans are ONLY offered to Medicare eligible retirees that select one of
these plans as supplemental to Medicare.
Out-Of-Network Benets
SEHBP plans include an option for using out-of-network providers for services except most
well-care, routine/preventive and lab services. When you exercise this out-of-network option,
you will be responsible for deductibles, coinsurance based on the reasonable and customary
fee schedule, and any amount exceeding the reasonable and customary allowances for all
services.
The out-of-network determination is based on the participating status of the provider such
as the physician, specialist, therapist, hospital/facility rendering the service. For example, if
you utilize a non- participating doctor and services are provided at an in-network hospital, the
doctor will be paid at the out-of-network level and the hospital will be paid at the in-network
level.
If you do not contact your plan for prior certication for selected services, your claims may
be paid at the out-of-network level of benets, if the services are deemed to be medically
appropriate, and the amount that you are required to pay will not apply to the out-of-network
maximums. Please refer to the SERVICES REQUIRING PRECERTIFICATION section of this
Guidebook for additional information.
Out-of-Network Deductible
The annual out-of-network deductible is the amount that the individual or family must meet
before covered out-of-network charges are paid by the plan. As shown below, the out-of-
network deductible varies depending on the plan option selected.
SEHBP Plan Option
Individual Out-of-Network
Deductible
Family Out-of-Network
Deductible
NJ Educators Health Plan $350
$700 in total for all, but no more
than $350 per person
NJ DIRECT10,
NJ DIRECT15,
NJ DIRECT1525**
$100
$250 in total for all, but no more
than $100 per person
NJ DIRECT2030** $200
$500 in total for all members, but
no more than $200 per person
*Certain plans have a separate inpatient deductible per admission to out-of-network hospitals. See Out-of-Network Inpatient Deductible.
**The NJ DIRECT1525 andNJ DIRECT2030 plans are ONLY offered to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
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SEHBP Benets | SEHBP Member Guidebook 2024
The benet year in which the deductible is measured runs from January 1 to December 31.
However, if treatment for an illness or injury is provided during the last three months of the
year, the allowable expenses that were applied toward the deductible may be allowed to
“carry over” toward meeting the deductible for the following year.
Deductible Examples:
Single Coverage – You incur an out-of-network doctor’s ofce visit in April and the allowable
expense is $100. This is your rst claim of the year and no other calendar year deductible has
been met; therefore, the $100 allowable expense is applied to and satises the deductible for
the following year.
Family Coverage/Aggregate – You and two covered family members incur an out-of-network
doctor’s ofce visit in May. The allowable expense is $85 per visit or $255 for all three visits.
These are your family’s rst claims of the year and no other calendar year deductible has been
met; therefore
$85 for the rst two visits is applied toward the family deductible ($170) along with $80 from
the third visit ($250). The $250 family deductible is met for the current year.
Family Coverage/Individual – You or a family member incurs an out-of-network doctor’s ofce
visit in May of the current year and the allowable expense is $100. This is the rst claim of
the year and no other calendar year deductible has been met. Therefore, the $100 allowable
expense is applied to and satises the individual deductible for the current year. The $100
allowable expense is also applied toward the $250 family deductible for the current year.
Deductible Carryover – You incur an out-of-network doctor’s ofce visit in October and
the allowable expense is $90. This is your rst claim of the year and no other calendar
year deductible has been met; therefore, the full $90 allowable expense is applied to the
deductible for the current year. Since this amount was applied in the last three months of the
current year, the full $90 will carry over and be applied toward meeting the deductible for the
following year as well if you remain in the same plan.
Out-of-Network Inpatient Deductible
The NJ DIRECT1525 and NJ DIRECT2030 have a separate inpatient deductible per admission
to out-of-network hospitals. The inpatient deductible varies by plan as shown below:
SEHBP Plan Option Out-of-Network Inpatient Deductible (per admission)
NJ DIRECT1525* $200
NJ DIRECT2030* $500
* The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY offered to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
25
SEHBP Benets | SEHBP Member Guidebook 2024
Out-of-Network Coinsurance
The SEHBP plans will pay a percentage of the reasonable and customary allowance for eligible
out- of- network charges. You are required to pay the remaining percentage of the reasonable
and customary allowance (coinsurance) as well as the difference between the allowance and
the provider’s charges. As shown below, the coinsurance level varies by plan option. The out-
of-network coinsurance is applied toward the out-of-network, out-of-pocket maximum.
SEHBP Plan Option Out-of-Network Coinsurance
NJ DIRECT10 20%
NJ DIRECT15,
NJ DIRECT1525*,
NJ DIRECT2030*,
NJ Educators Health Plan
30%
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY offered to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
Out-of-Network Out-of-Pocket Maximum
When your out-of-network, out-of-pocket maximum for the year has been reached, the SEHBP
plans will pay 100 percent of the reasonable and customary allowance for eligible services. As
shown below, the out-of-network, out-of-pocket maximum varies by plan option.
SEHBP Plan Option
Individual Out-of-Network
Out-of-Pocket Maximum
Family Out-of-Network
Out-of-Pocket Maximum
NJ Educators Health Plan,
NJ DIRECT10,
NJ DIRECT15,
NJ DIRECT1525*
$2,000 $5,000
NJ DIRECT2030* $5,000 $12,500
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
The member is responsible for any amount above the reasonable and customary allowance in
addition to deductible and coinsurance liability. Eligible services and pre-certied treatment
count toward the plan maximum out-of-pocket expense level. Expenses for ineligible services
and charges in excess of reasonable and customary allowances do not count toward your out-
of-pocket maximums and are your nancial responsibility.
The in-network out-of-pocket expenses apply to the out-of-network out-of- pocket maximum
under NJ DIRECT10.
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Coordination Of Benets
For group plans that have a Coordination of Benets (COB) provision, the following rules
determine which plan is primary:
• If you, the active employee, is the patient, the SEHBP plan is primary for you. If your
spouse/partner is the patient, and covered under a health plan provide d through his or her
employer as an active employee, that plan is the primary plan for them;
• If a member has coverage as an active employee and additional coverage as a retiree the
coverage through active employment is primary to retiree coverage;
• When Medicare is involved (except for ESRD; see ESRD section of this Guidebook), the
benefits of the plan that covers an active employee and/or his or her dependents will be
considered primary before the benefits of a plan that covers a laid-off or a retired employee
and his or her dependents;
• If a dependent child is the patient and is covered under both parents' plans, the following
birthday rule will apply.
Under the birthday rule, the plan covering the parent whose birthday falls earlier in the year
will have primary responsibility for the coverage of the dependent children. For example, if
the father's birthday is July 16 and the mother's birthday is May 17, the mother's plan would
be the primary plan for the couple's dependent children because the mother's birthday falls
earlier in the year. If both parents have the same birthday, the plan covering the parent for
the longer period will be primary.
This birthday rule regulation affects all carriers and all contracts that contain COB provisions.
It applies only if both contracts being coordinated have the birthday rule provision. If only
one contract has the birthday rule and the other has the gender rule (father's contract
is always primary), the contract with the gender rule will prevail in determining primary
coverage;
• If two or more plans cover a person as a dependent child of separated or divorced parents,
benefits for the dependent child will be determined in the following order.
• The plan of the parent with custody is primary; followed by
• The plan of the spouse/partner of the parent with custody of the child; then
• The plan of the parent not having custody of the child.
• If it has been established by a court order or judgment — Qualified Medical Child Support
Order (QMCSO) — that one parent has responsibility for the child's health care expenses,
then the plan of that parent is primary; or
• If none of the rules listed above determine the order of benefits, the plan that has covered
the patient for the longer period is the primary plan.
The SEHBP plans will provide its regular benets in full when primary. As a secondary plan, the
SEHBP plan will provide reimbursement up to the plan’s regular benet, which, when added to
the benets under other group plans, will not exceed 100 percent of the member’s liability.
Please note: The COB rules described above may change if Medicare is involved. Please refer
to the Medicare sections of this Guidebook for more information.
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General Benets
This section lists the general treatments, services, and supplies that the SEHBP plans will
consider. Expenses for these services or supplies are subject to reasonable and customary
allowances; medical need and appropriate level of care; utilization review; the Schedule of
Services and Supplies; and benet limitations and exclusions. Refer to the “Summary Schedule
of Services and Supplies” of this Guidebook. Select services require precertication (refer
to the Services REQUIRING PRECERTIFICATION section of this Guidebook for details). If a
service is not listed, please contact Horizon directly to nd out if it is covered.
The fact that an item or service is not listed below, does not automatically make the service or
item covered under the SEHBP plans.
Important Note: The recommendations and guidelines of the:
• Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention;
• United States Preventive Services Task Force;
• Health Resources and Services Administration; and
• American Academy of Pediatric/Bright Futures Guidelines for Children and Adolescents;
as referenced throughout this Handbook may be updated periodically. The Plan is subject
to updated recommendations or guidelines that are issued by these organizations
beginning on the first day of the plan year, one year after the recommendation or
guideline is issued. For further information on preventative services, please visit:
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Acupuncture
Acupuncture treatment is covered when the services are for a diagnosis related to pain
management and are rendered by a Licensed Acupuncturist or Licensed Medical Doctor (M.D.,
D.O.). Acupuncture treatment is subject to maintenance and supportive care provisions.
Examples of acupuncture services that are not eligible under the SEHBP plans include weight
loss and smoking cessation.
Alcohol and Substance Abuse Treatment
See Substance Use Disorder Treatment Allergy Testing and Treatment
Most commonly used methods of allergy testing are covered. However, some methods are
subject to medical need at the appropriate level of care and will be reviewed before eligibility
can be determined.
Ambulance
Ambulance use for local emergency transport to the nearest facility equipped to treat the
emergency condition is covered subject to medical need at the appropriate level of care. If
emergency air transport is needed, it must be medically necessary and approved by having
your physician call Horizon BCBSNJ at 1-800-664-2583.
The SEHBP plans do not cover chartered air ights, non-emergency air ambulance, invalid
coach, transportation services, or other travel, lodging, or communication expenses of
patients, providers, nurses, or family members.
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Audiology Services
Audiology services are covered when rendered by a physician or a licensed audiologist, when
such services are determined to be medically necessary and at the appropriate level of care.
See exclusions for hearing aids and hearing examinations.
Autism or Other Developmental Disability
Chapter 115, P.L. 2009, requires that the SEHBP provide:
• Coverage for expenses incurred in screening and diagnosing autism or another
developmental disability;
• Coverage for expenses incurred for medically necessary physical therapy, occupational
therapy and speech therapy services for the treatment of autism or another developmental
disability;
• Coverage for expenses incurred for medically necessary behavioral interventions (ABA
therapy) for individuals diagnosed with autism;
• A benefit for the Family Cost Share portion of expenses incurred for certain health care
services obtained through the New Jersey Early Intervention System (NJEIS).
ABA therapy is not eligible for children with developmental diagnoses.
Horizon Behavioral Health must be contacted to pre-certify ABA services for autistic children.
Horizon Utilization Management must be contacted for precertication by the provider
requesting occupational therapy, speech, and physical therapy services.
Automobile-Related Injuries
The SEHBP plans will provide secondary coverage to your mandatory New Jersey Personal
Injury Protection (PIP) unless the SEHBP plan has been elected as the primary coverage by or
for the employee covered under the SEHBP plan. This election is made by the named insured
under the PIP program and affects that member's family members who are not themselves the
named insured under another auto policy. The SEHBP plan may be primary for one member,
but not for another if the individuals have separate auto policies and have made different
selections regarding primacy of health coverage.
If the SEHBP plan is primary to PIP or other automobile insurance coverage, benets are paid
in accordance with the terms, conditions, and limits set forth in your contract and only for
those services normally covered under the SEHBP plans.
Please note: If you elect to have the SEHBP plan as primary to PIP, prior notication to your
SEHBP plan is not required. Upon receipt of an auto-related claim, your SEHBP plan will
request the submission of written documentation, such as a copy of your policy declaration
page, for verication of your selection.
The SEHBP plans are some of several health insurance plans that provides benets for
automobile- related injuries. If the covered employee has elected health coverage as primary,
these plans may coordinate benets as they normally would in the absence of this provision.
If the SEHBP plan is secondary to PIP, the actual benets payable will be the lesser of:
• The remaining uncovered allowable expenses after PIP has provided coverage, subject
to medical need at the appropriate level of care and other provisions, after application of
deductibles and coinsurance; or
• The actual benefits that would have been payable had the SEHBP plan been primary
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Biofeedback
Biofeedback to treat a medical or mental diagnosis is covered the same as any other general
condition.
Birthing Centers
As an alternative to conventional hospital delivery room care for low-risk maternity patients,
the SEHBP plans allow benets for care in participating birthing centers. Services routinely
provided by the birthing centers including prenatal, delivery, and postnatal care, will be
covered in full if the delivery takes place at the center. If complications occur during labor, and
delivery occurs in an approved hospital because of the need for emergency or inpatient care,
this care will also be covered in full. Contact Horizon BCBSNJ at 1-800-414-SHBP (7427) to
identify eligible birthing centers near you.
Blood
Blood, blood products, blood transfusions, and the cost of testing and processing blood are
covered. The SEHBP plans do not pay for blood that has been donated or replaced on behalf
of the patient.
Breast Reconstruction
If you are receiving benets in connection with a mastectomy and elect to have breast
reconstruction along with that mastectomy, the SEHBP plans will provide coverage for the
following:
• Reconstruction of the breast on which the mastectomy was performed;
• Prosthesis(es);
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Physical complications at all stages of the mastectomy, including lymphedemas.
Chiropractic Services
There is a combined In-Network and Out-of-Network 30-visit maximum benet per calendar
year for chiropractic services. The chiropractor must be licensed, the services must be
appropriate for the diagnosed condition(s), and must fall within the scope of practice of a
chiropractor in the state in which he or she is practicing. Chiropractic services are subject to a
medical necessity review process.
Congenital Defects
Surgical procedures that are necessary to correct a congenital birth defect that signicantly
impairs function are covered.
Dental Care
The SEHBP plans provide benets for the removal of bony impacted molars, and will pay for
the treatment of accidental injuries, and treatment for mouth tumors if medically necessary.
The SEHBP plans may provide coverage for the treatment of accidental dental injuries. An
accidental dental injury is considered an injury to teeth (must be sound natural teeth) which is
caused by an external factor such as damage caused by being hit by a hockey puck or having
teeth broken in a fall on the ice. Breaking a tooth while chewing on food is not considered an
accidental dental injury. Stress fractures in teeth are very common and generally undetectable
by X-ray. Stress fractures are often the cause of tooth breakage. Treatment for this type of
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tooth breakage is considered a dental service and not eligible for reimbursement. Dental
services required as the result of medical conditions or medical services rendered such as:
radiation, chemotherapy and long-term use of prescription drugs are not eligible. These dental
services should be submitted to your Dental Plan.
Hospital and anesthesia charges incurred for dental services that are medically needed and
at the appropriate level of care are covered for severely disabled members and children
when convincing documentation is submitted in advance for the medical need for the
hospitalization/anesthesia services. Charges for the actual dental procedures would not be
eligible for benets.
Orthodontia is not covered.
Diabetic Self-Management Education
Benets, limited to four visits per year, are included for expenses incurred for diabetes self-
management education to ensure that a person with diabetes is educated as to the proper
self- management and treatment of the member's condition.
Benets for self-management education and education relating to diet shall be limited to
medically necessary visits upon:
• The diagnosis of diabetes;
• The diagnosis by a physician or nurse provider/clinical nurse specialist of a significant change
in your symptoms or conditions which necessitate changes in your self- management; and
• Determination by a physician or nurse provider/clinical nurse specialist that reeducation or
refresher education is necessary.
Diabetes self-management education is covered when provided by:
• A physician, nurse provider, or clinical nurse specialist;
• A health care professional such as a registered dietician that is recognized as a Certified
Diabetes Educator by the American Association of Diabetes Educators; or
• A registered pharmacist in New Jersey qualified with regard to management education for
diabetes by any institution recognized by the Board of Pharmacy of the State of New Jersey.
Benets are provided for expenses incurred for insulin pumps for the treatment of diabetes, if
recommended or prescribed by a physician or nurse provider/clinical nurse specialist.
Dialysis
Dialysis is covered when the services are provided and billed by an eligible hospital, by a
freestanding dialysis center, or by an eligible home health care agency. The facility must
arrange for training, equipment rental, and supplies on behalf of the patient. Home dialysis
will be considered when there is documented evidence that the services cannot be performed
in an outpatient facility. Ambulance transportation/invalid coach service to and from dialysis
sessions is not eligible for coverage.
Durable Medical Equipment and Supplies
Charges for the rental of durable medical equipment needed for therapeutic use are covered.
The SEHBP plans may cover the purchase of such items when it is less costly and more
practical than renting such items. The SEHBP plans do not cover the rental or purchase of
any items that do not fully meet the denition of durable medical equipment. For in- and
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out-of-network services, it is recommended that costly durable medical equipment be
approved by Horizon BCBSNJ prior to purchase.
The SEHBP plans also covers eligible supplies including surgical dressings, blood and blood
plasma, articial limbs, larynx and eyes, casts, Inherited Metabolic Disease medical food,
certain non- standard infant formula (under one year of age), splints, trusses, braces, crutches,
respirator oxygen and rental of equipment for its use.
Deluxe models of durable medical equipment items such as, but not limited to, wheelchairs
are not eligible for benets.
Emergency Medical Services
A medical emergency is a medical condition manifesting itself by acute symptoms of sufcient
severity (including severe pain) such that a prudent layperson (including the parent of a minor
child or guardian of a disabled individual), who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in:
• Placing the health of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
• Serious impairment to bodily function; and/or
• Serious dysfunction of bodily organ or part.
With respect to emergency services furnished in a hospital emergency department, Horizon
BCBSNJ shall not require prior authorization for the provision of such services if the member
arrived at the emergency medical department with symptoms that reasonably suggested
an emergency condition based on the judgment of a prudent layperson. All procedures
performed during the evaluation (triage) and treatment of an emergency medical condition
shall be covered.
If you nd yourself in an emergency and notication prior to treatment is not reasonably
possible, go directly to the nearest emergency facility. All such treatment received during the
rst 48 hours after the onset of the medical emergency will be eligible for in-network benets,
regardless of whether such treatment is received in or out of the service area or whether such
treatment is furnished by a network provider.
Urgent and After Hours Care
Urgent care is medically necessary care for an unexpected illness or injury that should be
treated within 24 hours but is not life threatening. It is medical care you can safely postpone
until you can call a physician. Examples of urgent care include fever, earache, cuts, sprains, and
minor burns. In instances like these, call your physician rst for instructions. If your physician
determines your situation is a medical emergency, he or she will refer you directly to an
emergency facility. If it is not a medical emergency, your physician will tell you how to treat the
problem yourself or make an appointment to see you. Your physician or a covering physician
should be available 24 hours a day, every day.
Contact your physician for after-hours care or care that is required at night or on a weekend or
holiday. Again, your physician will provide instructions on how to treat your problem.
Emergency Room
Each time the member uses the hospital emergency room, the member must pay a
copayment. If the member is admitted within 24 hours, the copayment amount is waived.
There may also be additional medical charges for out-of-network emergency rooms that may
not be reimbursed in full.
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Federal Government Hospitals
The SEHBP plans will pay for eligible charges in hospitals operated by the United States
government (Veterans Administration) as if they were member hospitals, regardless of their
location, for eligible charges for nonmilitary conditions.
The SEHBP plans will pay hospitals operated by the United States government for nonmilitary
patients (i.e., patients other than military retirees and their dependents and dependents of
active duty military personnel) for eligible charges only if:
• Services are for treatment on an emergency basis for accidental injury from an external
cause; or
• Services are provided in a hospital located outside of the United States and Puerto Rico.
Gender Identity- Treatment to Afrm Gender Identity
You are covered for management, consultation, counseling, hormones, and surgical services
for purposes of afrming your gender identity and/or gender transition (diagnostically this may
be referred to as gender dysphoria) when certain criteria are met
Gynecological Care and Examinations.
Gynecological care and examinations are eligible. The SEHBP plans provide coverage for one
routine gynecological examination per year that may include one routine Pap smear, when
provided by a gynecologist.
Hearing Aids
Coverage will be provided for medically necessary expenses incurred in the purchase of a
hearing aid for covered members who are 15 years old or younger. Coverage is provided for
the purchase of a hearing aid for each hearing impaired ear once in a 24-month period, when
it is medically necessary and prescribed by a licensed physician or audiologist.
Hemophilia Treatment
Hemophilia treatment is covered in an inpatient facility or outpatient facility. Home hemophilia
treatment will be considered when there is documented medical evidence that these services
cannot be performed in an outpatient facility.
Home Health Care
Home health care services and supplies are covered only if furnished by providers on a part
-time or intermittent basis, except when full-time or 24-hour service is needed on a short-term
basis. Precertication is required for these services.
The home health care plan must be established in writing by the member's provider within 14
days after home health care starts and it must be reviewed by the member's provider at least
once every 30 days.
Eligible home health services (subject to exclusions) provided by a home health care agency
include:
• Part-time skilled nursing services provided by or under the supervision of a registered
professional nurse (R.N.);
• Physical therapy;
• Occupational therapy;
• Speech therapy;
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• Related treatment and services eligible for hospital benefits, except drugs and
administration of hemodialysis; and
• Medical social services or part-time services by a home health care aide during the period
when you are receiving eligible skilled nursing care, physical therapy, or speech therapy
services.
A prior inpatient hospital stay is not required to qualify for home health care agency benets
but the patient must be homebound and require skilled nursing care under a plan prescribed
by an attending physician.
The SEHBP plans do not cover:
• Services furnished to family members, other than the patient;
• Services provided by a companion;
• Services and supplies not included in the home health care plan; or
• Nursing home care or care that is maintenance care, supportive care, care to treat
deficiencies that are developmental in nature or are primarily custodial care in nature.
Hospice Care Benets
Benets for hospice care must be provided according to a physician prescribed course of
treatment approved by the SEHBP plans with a conrmed diagnosis of terminal illness and a
life expectancy of six (6) months or less.
The following hospice services are covered:
• Part-time professional nursing services of an R.N. or L.P.N.;
• Home health care aide services provided under the supervision of an R.N.;
• Medical care rendered by a hospice care program physician;
• Therapy services (including speech, physical and occupational therapies);
• Diagnostic services;
• Medical and surgical supplies;
• Durable medical equipment;
• Prescribed drugs;
• Oxygen and its administration;
• Up to 10 days for respite care;
• Inpatient acute care for related conditions;
• Medical social services;
• Psychological support services to the terminally ill patient;
• Family counseling related to the eligible person's terminal condition;
• Dietician services; and
• Inpatient room, board and general nursing services for related conditions.
No benet consideration will be given for any of the following hospice care benets:
• Medical care rendered by the patient's private physician (would be paid separately under the
plan);
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• Volunteer services;
• Pastoral services;
• Homemaker services;
• Food or home-delivered meals;
• Non-authorized private-duty nursing services;
• Dialysis treatment; or
• Bereavement counseling.
Inpatient benets for hospice patients are provided at the same level as those provided for
non- hospice patients. For more information on hospice care, please call Horizon BCBSNJ at
1-800-414- SHBP (7427).
Immunizations
Immunizations provided by an in-network physician or contracted, New Jersey pharmacy are
covered under the SEHBP plans unless they are for travel outside the country or work-related.
Well-child immunizations for children less than 12 months of age are the only immunizations
allowed out -of- network.
Infertility Treatment
The SEHBP plans will follow the New Jersey State Mandate for Infertility.
Charges made for services related to diagnosis of infertility and treatment of infertility once a
condition of infertility has been diagnosed. Services include, but are not limited to: approved
surgeries and other therapeutic procedures that have been demonstrated in existing peer
-reviewed, evidence- based, scientic literature to have a reasonable likelihood of resulting
in pregnancy (including microsurgical sperm aspiration); laboratory tests; sperm washing or
preparation; diagnostic evaluations; assisted hatching; fresh and frozen embryo transfer;
ovulation induction; gamete intrafallopian transfer (GIFT); in vitro fertilization (IVF), including in
vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to
a gestational carrier or surrogate; zygote intrafallopian transfer (ZIFT); articial insemination;
intracytoplasmic sperm injection (ICSI); and the services of an embryologist. This benet
includes diagnosis and treatment of both male and female infertility.
Eligibility Requirements
Infertility services are covered for any abnormal function of the reproductive systems such that
the patient has met one of the following conditions:
• a male is unable to impregnate a female;
• a female with a male partner and under 35 years of age is unable to conceive after 12
months of unprotected sexual intercourse;
• a female with a male partner and 35 years of age and over is unable to conceive after six
months of unprotected sexual intercourse;
• a female without a male partner and under 35 years of age who is unable to conceive after
12 failed attempts of intrauterine insemination under medical supervision;
• a female without a male partner and over 35 years of age who is unable to conceive after six
failed attempts of intrauterine insemination under medical supervision;
• partners are unable to conceive as a result of involuntary medical sterility;
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• a person is unable to carry a pregnancy to live birth; or
• a previous determination of infertility pursuant to the law.
In vitro fertilization, gamete transfer and zygote transfer services are covered only:
• If you have used all reasonable, less expensive and medically appropriate treatment and are
still unable to become pregnant or carry a pregnancy;
• Up to four complete d egg retrievals combine d. Egg retrievals covered by another plan or
the member (outside of the SHBP/SEHBP) will not be applied toward the SHBP/SEHBP limit
for infertility services; and
• If you are 45 years old or younger.
Covered Expenses include:
• Where a live donor is used in the egg retrieval, the medical costs of the donor shall be
covered until the donor is released from treatment by the reproductive endocrinologist;
• Intracytoplasmic sperm injections;
• In vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization
where the embryo is transferred to a gestational carrier or surrogate;
• Prescription medications, including injectable infertility medications, are covered under the
SEHBP’s Prescription Drug Plans. Private freestanding prescription drug plans arranged by
local employer groups are required to be comparable to the SEHBP Prescription Drug Plans
and must provide coverage for infertility medications for covered members and donors;
• Ovulation induction;
• Surgery, including microsurgical sperm aspiration;
• Artificial Insemination;
• Assisted Hatching;
• Diagnosis and diagnostic testing; and
• Fresh and frozen embryo transfers.
Exclusions
The following are specically excluded infertility services:
• Reversal of male and female voluntary sterilization;
• Infertility services when the infertility is caused by or related to voluntary sterilization;
• Non-medical costs of an egg or sperm donor. Medical costs of donors, including office visits,
medications, laboratory and radiological procedures and retrieval, shall be covered until the
donor is released from treatment by the reproductive endocrinologist;
• Cryopreservation is not a covered benefit;
• Any experimental, investigational, or unproven infertility procedures or therapies;
• Payment for medical services rendered to a surrogate for purposes of childbearing where
the surrogate is not covered by the carrier’s policy or contract;
• Ovulation kits and sperm testing kits and supplies;
• In vitro fertilization, gamete intrafallopian tube transfer, and zygote intrafallopian tube
transfer for persons who have not used all reasonable less expensive and medically
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appropriate treatments for infertility, who have exceeded the limit of four covered
completed egg retrievals, or are 46 years of age or older. Egg retrievals covered by another
plan or the member (outside of the SHBP/SEHBP) will not be applied toward the SHBP/
SEHBP limit for infertility services; and
• Costs associated with egg or sperm retrieval not related to an authorized IVF procedure.
Lead Poisoning Screening and Treatment
Lead poisoning screening (in-network only; out-of-network screenings are not covered).
Treatment is eligible In-Network and Out-of-Network. No copayment applies to in-network
screenings
Lithotripsy Centers
Lithotripsy services are covered when they are perform ed in an approved hospital or
lithotripsy center. For information regarding the eligibility of certain centers, please call
1-800-414-SHBP (7427).
Lyme Disease Intravenous Antibiotic Therapy
All intravenous antibiotic therapy for the treatment of Lyme disease requires precertication.
When intravenous therapy is determined to be medically appropriate, the supplies, cost of the
drug, and skilled nursing visits will be covered services. If services are not precertied and are
determined not to be medically necessary, the services will not be covered.
Mammography
Covers mammograms provided to a female member. Coverage is provided as follows:
• One baseline mammography at any age; and
• Age 40 and older, one screening mammography per year.
Mastectomy Benets
A hospital stay of at least 72 hours following a modied radical mastectomy and a hospital
stay of at least 48 hours is covered following a simple mastectomy unless the patient, in
consultation with the physician, determines that a shorter length of stay is medically needed
and at the appropriate level of care.
Maternity/Obstetrical Care
Medical care related to childbirth includes the hospital delivery and hospital stay for at least
48 hours after a vaginal delivery or 96 hours after a cesarean section if the attending provider
determines that inpatient care is medically needed and at the appropriate level of care.
As mandated per P.L. 2019, Ch. 87- A non-medically indicated early elective delivery
performed at a hospital on a pregnant woman earlier than the 39th week of gestation, is not
covered. “Non-medically indicated early elective delivery” means the articial start of the birth
process through medical interventions or other methods, also known as labor induction, or
the surgical delivery of a baby via a cesarean section for purposes or reasons that are not fully
consistent with established standards of clinical care as provided by the American College of
Obstetricians and Gynecologists.
Services and supplies provided by a hospital to a newborn child during the initial covered
hospital stay of the mother and child are covered as part of the obstetrical care benets.
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SEHBP plans also cover birthing center charges made by a provider for pre-natal care, delivery,
and post-partum care in connection with a member's pregnancy.
Professional charges billed by an eligible provider, related to the prenatal care, delivery and
postnatal care for home birth are covered.
Note: Providers do not routinely perform homebirths. The availability of a provider who
performs home births is not guaranteed.
Maternity/Obstetrical Care for Child Dependents
In some instances, SEHBP plans will pay bills related to the birth of a grandchild. In order for
benets to be available, the mother must be enrolled as a covered child. Coverage for the
grandchild ends when the mother is discharged from the hospital. The grandparent may
apply for dependent coverage of the grandchild only if he or she obtains legal custody of
the child.
Mental or Nervous Conditions
SEHBP plans cover the mental or nervous conditions the same way it would any other illness if
treatment is prescribed by an eligible provider and it is deemed to be medically needed and
at the appropriate level of care. Horizon Behavioral Health is responsible for the management
of your behavioral health benet including treatment for mental/nervous conditions and
substance use disorder provided at all levels of care: in-patient, partial hospitalization,
residential, intensive outpatient (IOP), and individual or group outpatient treatment. Eligible
providers of behavioral health care are Psychiatrists (MD), Licensed Psychologists (PhD),
Licensed Clinical Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT),
Associate Marriage & Family Therapist (AMFT)Licensed Professional Counselors (LPC),
and Certied (Psychiatric), Nurse Practitioners working within the scope of their practice.
Precertication (prior to treatment) is required for all admissions and for some specialty
services (in-network and out- of-network) including biofeedback, and Intensive Outpatient
(IOP) treatment. The precertication process will determine if the treatment to be provided is
medically appropriate and at the most appropriate level of care to t your behavioral health
needs. Medical necessity determinations for mental health services are supported by the
Horizon Behavioral Health Medical Necessity criteria.
Effective February 1 2023, electroconvulsive therapy (ECT), transcranial magnetic stimulation
(TMS) and psychological testing rendered in an outpatient setting does not require an
authorization.
Precertication is not required for routine, ofce based outpatient mental health services
incurred on or after January 1, 2013. Services may be reviewed at any time to determine
the medical necessity of the level of care being provided. Horizon may contact your treating
provider to discuss your treatment and the authorization requirement that will be applied.
Authorization is required for coverage of any treatment that Horizon determines is not
consistent with usual treatment practices for your condition based on the frequency of
sessions, duration of treatment or other factors. You will b e advised if a medical necessity
review is conducted and services will require review and authorization.
The precertication process through Horizon Behavioral Health is available 24 hours-a-
day, 7 days- a-week by calling 1-800-991-5579. In addition to helping you navigate the
precertication process, Horizon Behavioral Health can help you nd a provider, support your
treatment and manage the services you are receiving to ensure that they are appropriate
for your behavioral health needs and are supported by Horizon Behavioral Health medical
necessity criteria. The absence of precertication or authorization, when required, prior to
services being rendered, may result in the denial of payment for services.
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Newborn Home Visitation Program
The program provides at least one home nurse visit in the newborn’s home within two weeks
after birth and no more than two additional visits during the newborn’s rst three months of
life. The visit will be conducted by a registered nurse or advanced practice nurse. The program
will improve maternal health, infant health and development, and parenting skills. The visit will
include a health and wellness check of the newborn and an assessment of the physical and
mental health of the person who gave birth. The parent(s) will also receive support, including
breastfeeding education and assistance in recognizing and coping with perinatal mood
disorder. Once Horizon BCBSNJ is notied of the pregnancy, the member will be notied of
this benet. Services are covered without out-of- pocket costs when provided by an in-network
registered nurse.
Nutritional Counseling
SEHBP plans allow three visits per year in-network only for nutritional counseling that is
medically needed and at the appropriate level of care. For eating disorder diagnoses only,
there are no visit limitations for services rendered in-network or out-of-network. Deductible
and coinsurance applies to services rendered out-of-network.
Occupational Therapy (See Physical Therapy)
Organ Transplant Benets
Pre-approved services and supplies for the following types of transplants are covered:
• Lung;
• Liver;
• Heart;
• Pancreas;
• Certain autologous bone marrow;
• Cornea (pre-approval is not required in or out-of-network); and
• Kidney (pre-approval is not required in or out-of-network).
Benets only include surgical, storage and transportation services of the organ that are directly
related to the donation and billed for by the hospital.
Pain Management
Pain management services are subject to current medical guidelines and policies. Pain
management therapy administered by a licensed physician must be supported by a
comprehensive evaluation of the patient and documentation of the rationale for treatment.
The treatment of pain is multifaceted and may include therapeutic exercises, activity
modication, physical therapy, occupational therapy, pharmacological interventions, behavioral
health interventions, therapeutic and/or surgical interventions. Treatment may not achieve
complete elimination of a patient’s pain. In such cases, an increase in a patient’s level of
function and teaching the patient strategies to cope with residual pain will be the goal. If
treatment offers no appreciable improvement in the patient’s condition further services may
be considered maintenance and/or supportive care and will not be eligible for reimbursement.
Horizon BCBSNJ contracts with eviCore Healthcare to review and authorize pain management
services. Monitored anesthesia rendered as part of pain management services must also
be authorized. Participating physicians will obtain prior authorization on your behalf. If you
are using a non-participating provider, it is your responsibility to ensure that authorization
is obtained before services are rendered. Your physician can contact eviCore Healthcare
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General Benets | SEHBP Member Guidebook 2024
at 1-866-241-6603 to request authorization. If you or your physician do not obtain
prior authorization for pain management services, those services will not be eligible for
reimbursement. If services are rendered without the proper authorization, benets will be
denied. A retroactive benet review will not be conducted.
Pap Smears
Annual Pap smears provided by your participating OB/GYN are covered at the in -network
level of benets. This benet is limited to one Pap smear per year unless additional tests are
medically needed and at the appropriate level of care for diagnostic purposes. An annual Pap
smear provided out-of-network is covered, subject to any deductible and coinsurance.
Patient Controlled Analgesia (PCA)
Patient Controlled Analgesia (PCA) is covered when it is medically appropriate, prescribed by
a medical doctor, and provided under the guidance of one of the following:
• Doctor;
• Anesthesiologist; or
• Approved home care agency.
Physical Therapy/Occupational Therapy
Therapy that is medically needed and at the appropriate level of care is covered based on one
session per day. A session of therapy is dened as up to one hour of therapy (treatment and/or
evaluation) or up to three therapy modalities provided on any given day.
Physicals (In-Network Only)
One routine physical examination for you and your eligible dependents is covered in -network
each year. In-network services that are considered preventive care under the Patient Protection
and Affordable Care Act will be covered with no out-of-pocket cost (no copayment) if you
receive the services from a participating health care professional and the sole reason for the
visit is to receive the preventive services as denoted by the procedure and diagnosis code
reported on the claim.
Physicals for work-related purposes — other than employer-mandated physical examinations
that are a prerequisite for participation in an employer mandated physical tness test required
as a condition of continuing employment — sports, or other similar reasons are not covered.
Pre-Admission Hospital Review (In-Network and Out-of-Network)
All non-emergency hospital and other facility admissions must be reviewed by Horizon
BCBSNJ before they occur. You, the network hospital, or your provider must notify Horizon
BCBSNJ and request a Pre-Admission Review by phone or facsimile. Horizon BCBSNJ must
receive the notice and request at least 5 business days or as soon as reasonably possible
before the admission is scheduled to occur. For a maternity admission, such notice must be
given to Horizon BCBSNJ at least 60 days before the expected date of delivery, or as soon as
reasonably possible, to obtain in- network benets.
Pre-Admission Testing Charges
Pre-admission diagnostic X-ray and laboratory tests needed for a planned hospital admission
or surgery are covered. SEHBP plans only cover these tests if the tests are done on an in
-network outpatient or out-of-hospital basis within seven days of the planned admission or
surgery.
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However, SEHBP plans do not cover tests that are repeated after admission or before surgery,
unless the admission or surgery is deferred solely due to a change in the member's health.
Prostate Cancer Screening (In-Network Only)
One routine ofce visit per year is covered for adult members, including a digital rectal
examination and a prostate-specic antigen test for adult male members over the age of 40.
Scalp Hair Prostheses
A benet maximum of $500 in a 24-month period, per person, is covered for scalp hair
prostheses (wig) prescribed by a doctor, only if they are furnished in connection with hair loss
resulting from:
• Treatment of disease by radiation or chemicals;
• Alopecia Universalis (total is); or
• Alopecia Areata.
Second Surgical Opinion
SEHBP plans provide coverage for a second physician's personal examination of a patient
following a recommendation for any eligible surgical procedure. SEHBP plans will pay for one
consultation by a qualied specialist physician.
If the second opinion specialist does not conrm the need for surgery, SEHBP plans will
provide coverage for one additional consultation if requested by the patient. SEHBP plans
also will provide coverage for any diagnostic X-rays, laboratory tests, or diagnostic surgical
procedures required by the physicians performing the consultations.
Shock Therapy Benets
SEHBP plans provide benets for electroshock treatments, insulin shock treatments, and
other similar treatments. Benets are also payable for anesthesia in connection with the shock
treatment and for all other eligible services performed on that day for the disorder.
Skilled Nursing Facility Charges
Room and board, including diets, drugs, medicines and dressings, and general nursing services
in a skilled nursing facility are covered.
For Medicare Primary Members — the eligible benet days run concurrently with Medicare
eligible days. Once Medicare days are exhausted and the SEHBP plan becomes primary,
Horizon BCBSNJ will review continuing services for medical appropriateness and eligibility.
Precertication is required after Medicare benets are exhausted or if Medicare does not allow
benets.
Speech Therapy Benet
Speech therapy services provided by a qualied speech therapist are covered only as follows:
• To restore speech after a loss of a demonstrated previous ability to speak or impairment of
a demonstrated previous ability to speak; or
• To develop or improve speech after surgery to correct a defect that existed at birth and
impaired the ability to speak or would have impaired the ability to speak.
Speech therapy to correct pre-speech deciencies or to improve speech skills that have not
fully developed are not covered except for Autism and Pervasive Development Disorder
(PDD).
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Speech therapy services will be considered eligible for a period of one year for children
with a documented medical history of multiple cases of Otitis Media and one or more
myringotomy(ies).
Substance Use Disorder Treatment
Horizon Behavioral Health is responsible for the management of your behavioral health
benet including treatment for both mental/nervous conditions and substance use disorder
at all levels of care: inpatient, partial hospitalization, residential, intensive outpatient (IOP),
individual, and group outpatient treatment.
Except as explained below, for the treatment of substance use disorder, SEHBP plans cover
the treatment of substance use disorder the same way it would any other illness if treatment
is prescribed by an eligible provider and it is deemed to be medically needed and at the
appropriate level of care. Other than as stated below, precertication is required for certain
inpatient admissions and for some specialty care including Intensive Outpatient (IOP)
Treatment and Ofce Based Opioid Treatment (in- network and out-of-network) as noted on
the SERVICES REQUIRING PRECERTIFICATION Section of this Guidebook. The precertication
process will determine if the treatment to be provided is medically appropriate and at the
most appropriate level of care to t your behavioral health needs. Substance use disorder
treatment determinations are supported by the American Society of Addictions Medicine
(ASAM) guidelines. The precertication process through Horizon Behavioral Health is available
24 hours-a-day, 7 days-a-week by calling 1-800-991-5579.
In addition to helping you navigate the precertication process, Horizon Behavioral Health can
help you nd a provider, support your treatment, and manage the services you are receiving to
ensure that they are appropriate for your behavioral health needs and supported by the ASAM
criteria. For additional information or assistance regarding scheduled or emergency treatment
related to substance use disorder, you or your provider may call 1-800-991-5 579.
Precertication is not required for routine, ofce based outpatient substance use disorder
services incurred on or after January 1, 2013. Except as stated below for the treatment of
substance use disorder, services may be reviewed at any time to determine the medical
necessity of the level of care being provided. Horizon may contact your treating provider to
discuss your treatment and the authorization requirement that will be applied. Authorization
is required for coverage of any treatment that Horizon determines is not consistent with
usual treatment practices for your condition based on the frequency of sessions, duration of
treatment or other factors. You will be advised if a medical necessity review is conducted and
services will require review and authorization. The absence of precertication or authorization,
when required, prior to services being rendered, may result in the denial of payment for
services.
The SEHBP plans provide benets for the treatment of substance use disorder at in
-network facilities subject to the following:
a. the prospective determination of Medical Need and Appropriate Level of Care is made
by the member’s provider for the first 180 days of treatment during each year and for
the balance of the year the determination of Medical Need and Appropriate Level of
Care is made by Horizon BCBSNJ.
b. pre-authorization is not required for the first 180 days of inpatient and/or outpatient
treatment during each year but may be required for the balance of the year;
c. After the first 180 days, benefits are subject to UM requirements including medical
necessity, prior authorization, and retrospective review.
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d. concurrent and retrospective review are not required for the first 28 days of inpatient
treatment, intensive outpatient and partial hospitalization services during each year but
may be required for the balance of the year;
e. concurrent and retrospective review are not required for the first 180 days of outpatient
treatment including outpatient prescription drugs, other than intensive outpatient
treatment, during each year but may be required for the balance of the year; and
f. If no in-network facility is available to provide inpatient services Horizon BCBSNJ shall
approve an in-plan exception 24 hours and provide benefits for inpatient services at an
out- of-network facility.
The rst 180 days per year assumes 180 inpatient days whether consecutive or intermittent.
Extended outpatient services such as partial hospitalization and intensive outpatient are
counted as inpatient days. Any unused inpatient days may be exchanged for two outpatient
visits.
Inpatient or outpatient treatment may be furnished as follows:
• Care provided in a state licensed health care facility;
• Care provided in a licensed detoxification facility;
• Care provided at a licensed and state approved residential treatment facility, under a plan
which meets minimum standards of care; or
• Care provided by an eligible, licensed behavioral health professional. Eligible providers of
behavioral health services are Psychiatrists (MD), Licensed Psychologists (PhD), Licensed
• Clinical Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed
Professional Counselors (LPC), and Certified (Psychiatric) Nurse Practitioners working within
the scope of their practice.
• Care provided at a substance use disorder facility if it carries out its stated purpose under all
relevant state and local laws, and it is either:
a. accredited for its stated purpose by The Joint Commission; or
b. approved for its stated purpose by Medicare; or
c. accredited by the Commission on Accreditation of Rehab Facilities (CARF); or
d. credentialed by Horizon Behavioral Health.
Surgical Services (Out-of-Network)
• Multiple Procedures
If multiple procedures are performed during the same operative session, the procedure
with the highest Relative Value Unit (RVU) will be considered the primary procedure and
the full reasonable and customary allowance will be allowed for that primary procedure
minus any applicable member deductible and coinsurance liability. The RVU associated
with the procedure codes represents the time and skill involved in the performance of the
procedure. All eligible additional procedures performed in the same operative session will
be considered secondary procedures that are paid at 50 percent of the reasonable and
customary allowance.
• Bilateral Procedures
Bilateral procedures will be paid at 150 percent of the reasonable and customary allowance.
Services qualify as bilateral when anatomically there are two specic body parts that are
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being operated upon during the same surgery such as ears, eyes, knees, breasts, and
kidneys. A lesion on the right arm and a lesion on the left arm would not qualify as bilateral
since the skin is one body organ.
• Non-network assistant surgeons will be paid at the out-of-network level of benefits and
reimbursed based on 16 percent of the surgical allowance if the service is deemed medically
appropriate.
Telemedicine
You can access medical and behavioral health services through Horizon Care Online. To get
care from home and access condential telemedicine services through Horizon CareOnline,
sign in to Horizonblue.com/shbp, the Horizon Blue app or call 1-877-716-5657. Medicare
primary members are not eligible for this service.
See www.HorizonCareOnline.com for details. In addition, reimbursement for eligible services
performed by providers with the capability to render telemedicine is allowed at the in-network
and out- of-network level.
Temporomandibular Joint Disorder (TMJ) and Mouth Conditions
Medical and surgical services performed for the treatment of the jaw are covered. Services
in relation to the teeth in any manner are excluded. Charges for doctor's services or X-ray
examinations for a mouth condition are not eligible.
Charges for dental or orthodontic services for a TMJ diagnosis are not eligible. This exclusion
applies even if a condition requiring any of these services involves a part of the body other
than the mouth, such as treatment of TMJ or malocclusion involving joints or muscles by
methods including but not limited to crowning, wiring or repositioning of teeth and dental
implants.
Vision Care Benets
The SEHBP plans cover an annual routine eye examination by an in-network ophthalmologist
or optometrist. There are no benets available for frames, lenses, or contact lenses. Contact
lens tting examinations are also not covered. There is no out-of-network preventive vision
care benet. Any visits to an ophthalmologist or optometrist for the diagnosis and treatment
of a condition will be eligible at the in-network and out-of-network level of benets.
Charges Not Covered By The SEHBP Plans
Even though a service or supply may not be described or listed in this guidebook, that does
not make the service or supply eligible for a benet under this plan.
The following services and supplies are not covered:
• Automobile accident-related injuries or conditions: Unless the SEHBP plan has been chosen
by the member as primary, the SEHBP plan does not pay for the treatment of injuries or
conditions related to an automobile accident if automobile insurance could have or should
have covered the treatment. This exclusion applies to, but is not limited to:
o Existing motor vehicle insurance contracts;
o Motor vehicle contracts that were purchased but have since lapsed;
o Motor vehicle insurance coverage that should have been purchased; and
o Failure to make timely claims under a motor vehicle insurance policy;
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• Autopsy;
• Car Seats;
• Care that is primarily custodial in nature;
• Chair and stair lifts;
• Charges above the reasonable and customary allowance or out-of-network plan allowance.
This includes all charges above the fixed dollar benefit limit for out-of-network acupuncture,
out-of-network chiropractic services, and out-of-network physical therapy services;
• Charges billed by an Assisted Living Facility;
• Charges for services or supplies not specifically covered under the plan;
• Charges for services rendered by a member of the patient’s immediate family (including you,
your spouse/domestic partner, your child, brother, sister, or parent of you or your spouse/
domestic partner);
• Charges for services rendered by a Birth Doula;
• Charges for the completion of a claim form, photocopies of pertinent medical information,
or medical records;
• Charges for services retained by the member, such as hiring an attorney or soliciting expert
medical testimony, in connection with an external review of an appeal or complaint. Note
that charges for experts retained by the plan (or the independent review organization with
which the plan contracts to conduct the external review) to conduct the external review of an
adverse benefit determination, are not borne by the member
• Charges incurred prior to or in the course of a legal adoption;
• Charges that should have been paid by Medicare, if Medicare coverage had been in effect;
• Chiropractic services beyond the combined In-Network and Out-of-Network 30-visit
maximum benefit per calendar year;
• Cosmetic procedures — charges connected with curing a condition by cosmetic procedures.
This provision does not apply if the condition is due to an accidental injury that occurred
while the injured person is enrolled in the SEHBP plan. Among the services that are not
covered are:
o Removal of warts, with the exception of plantar warts;
o Spider vein treatment; and
o Plastic surgery when performed primarily to improve the person's appearance;
• Costs beyond the embryo transfer for a surrogate are not eligible;
• Court ordered services or treatments;
• Deluxe models of wheelchairs and other durable medical equipment;
• Dental Care – other than accidental injury and extraction of bony impacted molars
• Durable medical equipment or supplies that are specifically excluded from coverage. To
determine which equipment or supplies are eligible for coverage, call 1-800-414-SHBP
(7427);
• Educational or developmental services or supplies, or educational testing. This includes
services or supplies that are rendered with the primary purpose being to provide the person
with any of the following:
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o Training in the activities of daily living. This does not include training directly related to
the treatment of an illness or injury that resulted in a loss of a previously demonstrated
ability to perform those activities;
o Instruction in scholastic skills such as reading and writing;
o Preparation for an occupation;
o Treatment for learning disabilities;
o To promote development beyond any level of function previously demonstrated;
o Assessments/testing of academic function; and
o Services and supplies are not covered to the extent that they are determined to be
allocated to the scholastic education or vocational training of the patient regardless of
where services are rendered. Rehabilitation programs that are primarily educational or
behavioral in nature;
• Expenses for wilderness rehabilitation programs, diabetic camps, or other similar camps or
programs;
• Experimental or investigational services or supplies and charges in connection with such
services or supplies, except in the case of an approved clinical trial. refer to the Experimental
or Investigational Treatments section of this Guidebook);
• Eye care including:
o Out-of-network examinations to determine the need for glasses or lenses of any type,
typically known as refraction examinations regardless of the diagnosis;
o Lenses of any type except initial lens replacement for loss of the natural lens after
cataract surgery;
o Eyeglasses and contact lenses regardless of the diagnosis, including but not limited to
Kerataconus; and
o Low vision aids;
• Eye surgery, such as radial keratotomy, Lasik procedures, or other refractive procedures
performed for any reason;
• Foot conditions — charges for doctor's services for:
o A weak, strained, flat, unstable, or imbalanced foot, metatarsalgia, or a bunion. However,
this exclusion does not apply to an open cutting operation;
o One or more corns, calluses, or toenails. This exclusion does not apply to a charge for
the removal of part or all of a nail root and services connected with treating metabolic or
peripheral vascular disease;
• Government plan charges including a charge for a service or supplies:
o Furnished by or for the United States government;
o Furnished by or for any government, unless payment is required by law; or
o To the extent that the service or supply, or any benefit for the charge, is provided by any
law or government plan under which the member is or could be covered. This applies to
Medicare and "no-fault" medical and dental coverage when required in contracts by a
motor vehicle law or similar law.
• Health clubs and gym memberships; See HorizonbFit/shbp for information regarding a
fitness reimbursement program
• Hearing aids of any type (except as described under the “Hearing Aids” section of this
Guidebook);
• Hearing examinations to determine the need for hearing aids or the need to adjust a hearing
aid, no matter what the cause of the hearing loss, except for members who are 15 years old
or younger please refer to the Hearing Aids section of this Guidebook;
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• Herbal, Alternative or Complementary medicine treatments;
• Hot tubs, saunas, Jacuzzis or pools of any type;
• Hypnosis;
• Immunizations and preventive vaccines when out-of-network (see exceptions under
“Immunizations” in this Guidebook);
• Incidental Procedures — certain procedures are commonly performed in conjunction with
other procedures as a component of the overall service provided. An incidental procedure
is one that is performed at the same time as a more complex primary procedure and is
considered part of the primary procedure in order to successfully complete service;
• Lab services performed out-of-network regardless of diagnosis, except for services that
require an authorization, have a Medical Policy or cannot be performed by an in -network
laboratory.
• Legal fees;
• Maintenance care — care that has reached a level where additional services will not
appreciably improve the condition;
• Marriage counseling;
• Medicare services rendered by providers who are not registered with or who opt -out of
Medicare;
• Modifications to an auto to make it accessible and/or drivable;
• Modifications to a home to make it accessible for a disabled/injured person;
• Mouth conditions — charges for doctor's services or X-ray examinations for a mouth
condition. This exclusion applies even if a condition requiring any of these services involves
a part of the body other than the mouth, such as treatment of Temporomandibular Joint
disorders (TMJ) or malocclusion involving joints or muscles by methods including, but not
limited to, crowning, wiring, or repositioning of teeth. See the “Glossary” in this Guidebook
for the definition of a mouth condition;
• Nursing home care;
• Over-the-counter supplies, supplements, vitamins, medications, or drugs that do not require
a prescription order under Federal law, even if the prescription is written by a physician.
These include, but are not limited to, aspirin, vitamins, lotions, creams, oils, formulas, liquid
diets, and dietary supplements;
• Personal comfort or convenience items including telephone or television service, haircuts,
guest trays, or a private room during an inpatient stay;
• Prescription drug charges or copayments. If your prescription drug plan does not provide
benefits for a particular drug, it does not mean that it will be eligible under SEHBP plan
benefit
• Private Duty Nursing (Inpatient). Private Duty Nursing (PDN) is covered subject to MCG
guidelines. Authorization is required. PDN is characterized by the performance of skilled
services by a licensed nursing professional (RN/LPN) in the member’s home typically to take
the place of continued in-patient treatment. PDN will be part of a written short term, home
care plan leading to the training of the primary care giver(s) to deliver those services once
the member's condition is stabilized. PDN is not meant to replace a parent or caregiver, but
is meant to provide skilled support to the member at home when such services are medically
necessary to properly attend the member;
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• According to MCG guidelines, PDN is considered medically necessary for members who,
when the physician or specialist has agreed to a home care plan, the member meets MCG
medical necessity criteria and placement of the nurse in the home is done to meet the skilled
needs of the member only; not for the convenience of the family caregiver. Upon initial
discharge of a ventilator dependent member from an inpatient setting, up to 24 hours PDN
per day may be covered for a limited time to facilitate transition to home.
• Thereafter, the hours will be determined by the member meeting specific MCG guidelines
for continued PDN services. Payment for any additional home nursing care is the sole
responsibility of the member/family;
• Postage, handling and shipping fees;
• Private rooms in a hospital. If you occupy a private room in a hospital or facility, you must
pay the difference between the private room rate and the average semiprivate room rate;
• Preventive care/routine screening — unless otherwise indicated, the SEHBP plans’ out-of-
network coverage does not provide benefits for services or supplies that are considered to
be performed for any of the following:
o Routine well-care as part of a routine examination;
o Services and supplies that are provided for a diagnosis that does not indicate an illness
present at the time the service are rendered; and
o Services that are considered preventive or screening in nature;
The following services are examples of out-of-network routine services that are not
covered:
o All immunizations/vaccinations including well-child immunizations/ vaccinations (except
for children under 12 months of age);
o Flu shots/pneumonia vaccines;
o Well-care annual physicals;
o Cancer antigen tests that are performed because of a family history. Specific guidelines
apply to the eligibility of cancer antigen tests. Therefore, you may wish to request a pre-
determination of benefits prior to having services rendered;
o Prostate Specific Antigen (PSA) as part of a routine examination or recommended due
to a family history of disease. Specific guidelines apply to the eligibility of PSA for non-
routine reasons;
o Lab services performed outside of a facility regardless of diagnosis, except for services
that require an authorization, have a Medical Policy or can’t be rendered by an in-
network laboratory.
• Repatriation (returning a traveler to his/her home when unable to continue with travel due to
medical reasons);
• Self- or home-testing kits whether prescribed by a doctor or not;
• Services for cosmetic surgery (or complications that result from such surgery) on any part
of the body except for reconstruction surgery following a mastectomy or when medically
necessary to correct damage caused by an accident, an injury, therapeutic surgery or to
correct a congenital defect;
• Services or supplies that are not medically needed and/or not at the appropriate level of
care and charges in connection with such services or supplies. The fact that a physician may
prescribe, order, recommend, or approve a service or supply does not, in itself, make it
medically needed for the treatment and diagnosis of an illness or injury or make it a covered
medical expense;
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• Services that are commonly or customarily provided without charge to the patient. Even
when the services are billed, the SEHBP plans will not pay if they are usually not billed when
there is no coverage available;
• Services and supplies prescribed or provided by an ineligible provider;
• Services or supplies that require prior authorization that are not authorized before services
are rendered;
• Services rendered before the effective date of coverage or after the termination of coverage
date. However if the covered patient is hospitalized as an inpatient and coverage terminates
during the stay, that inpatient stay (as long as otherwise eligible) will be covered through to
discharge.
• Services rendered or billed by an Assisted Living Facility;
• Shoes that are not custom molded, are not attached to a brace, or can be purchased without
a prescription;
• Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not
fully developed (Exceptions: Autism and Pervasive Developmental Disorder);
• Sports physicals;
• Supportive care — supportive care is defined as treatment for patients having reached
maximum therapeutic benefit in which periodic trials of therapeutic withdrawals fail to
sustain previous therapeutic gains. In some instances therapy may be clinically appropriate
(such as treatment of a chronic condition that requires supportive care) yet it would not be
eligible for reimbursement under the SEHBP plans;
• Taxes on services/supplies;
• Telephone consultations or provider charges for telephone calls except when rendered as
Telemedicine. See ‘Telemedicine’, under GENERAL BENEFITS.
• Transport — Non-emergency transport via ambulance or transport by coach of any kind (by
land, air, or water;
• Treatment of injuries sustained while committing a felony;
• War charges for illness or injury due to an act of war. War means either declared or
undeclared, including resistance or armed aggression;
• Weight loss programs such as Jenny Craig, Weight Watchers, and the cost of food
associated with them; and
• Work-related injury or disease. This includes the following:
o Injuries arising out of or in the course of work for wage or profit, whether or not you are
covered by a Workers' Compensation policy;
o Disease caused by reason of its relation to Workers' Compensation law, occupational
disease laws, or similar laws; and
o Work-related tests, examinations, or immunizations of any kind required by your work.
Work-related injuries will not be eligible for benefits under the SEHBP plans before or
after your Workers’ Compensation carrier has settled or closed your case.
This exclusion does not apply to employer-mandated physical examinations that are
a prerequisite for participation in an employer mandated physical tness test required
as a condition of continuing employment. However, such employer mandated physical
examinations are covered in-network only.
Please note: If you collect benets for the same injury or disease from both Workers'
Compensation and the SEHBP plans, you may be subject to prosecution for insurance fraud.
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Examples of Non-Covered Services:
Example 1: A physician orders inpatient private duty nursing for a surgery patient. Since, while
conned in a hospital, nursing services are provided by the hospital, any charges for private
duty nursing will not be paid.
Example 2: A person is studying to become a therapist and is required by the school to enter
therapy. The treatment is intended to ensure that the new therapist is well-equipped to work
with patients. The treatment is not covered because it is primarily educational.
Example 3: A physician orders a drug that is FDA-approved but is not commonly used to treat
the particular condition. If the SEHBP health plan determines that the use is experimental, the
plan will not pay for the drug.
Example 4: A hospital routinely requires an assistant surgeon or Registered Nurse First
Assistant (RNFA) to be present at certain operations. The SEHBP plans will only pay for
assistant surgeons/RNFA’s that are determined to be medically necessary.
Third Party Liability
Repayment Agreement
If you have received benets from the SEHBP plans for medical services that are either auto-
related or work-related, Horizon BCBSNJ has the right to recover those payments. This means
that if you are reimbursed through a settlement, satised by a judgment, or other means, you
are required to return any benets paid for illness or injury to the SEHBP plan. The repayment
will only be equal to the amount paid by the SEHBP plan.
This provision is binding whether the payment received from the third party is the result of a
legal judgment, an arbitration award, a compromise settlement, or any other arrangement,
whether or not the third party has admitted liability for the payment.
Recovery Right
You are required to cooperate with Horizon BCBSNJ in recovering any amounts payable.
Horizon BCBSNJ may:
• Assume your right to receive payment for benefits from the third party;
• Require you to provide all information and sign and return all documents necessary to
exercise the SEHBP plan’s rights under this provision, before any benefits are provided under
your group's policy;
• Require you to give testimony, answer interrogatories, attend depositions, and comply
with all legal actions which Horizon BCBSNJ may find necessary to recover money from all
sources when a third party may be responsible for damages or injuries.
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General Benets | SEHBP Member Guidebook 2024
Subrogation And Reimbursement
Benets payable as a result of any injuries claimed against any person or entity other than this
Health Plan are excluded from coverage under this Plan. If benets are provided by this Plan
that are otherwise payable or become payable by any third party action against any person or
entity, this Plan is entitled to reimbursement only on the following terms and conditions:
• In the event that benefits are provided under this Plan, the Plan shall be subrogated to all
of the Member’s rights of recovery against any person or organization to the extent of the
benefits provided (“Member” includes any person receiving benefits hereunder including
all dependents). The Member shall execute and deliver instruments and papers and do
whatever else is necessary to secure such rights. The Member shall do nothing after loss to
prejudice such rights. The Member must cooperate with the Plan and/or any representatives
of the Plan in completing such forms and in giving such information surrounding any
accident as the Plan or its representatives deem necessary to fully investigate the incident;
• The Plan is also granted a right of reimbursement from the proceeds of any recovery
whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative
with, and not exclusive of, the subrogation right granted in the preceding paragraph, but
only to the extent of the benefits provided by the Plan;
• The subrogation and reimbursement rights and liens apply to any recoveries made by the
Member as a result of the injuries sustained, including but not limited to the following:
o Payments made directly by a third party, or any insurance company on behalf of a third
party, or any other payments on behalf of the third party;
o Any payments or settlements, judgment or arbitration awards paid by any insurance
company under uninsured or underinsured motorist coverage, whether on behalf of a
Member or other person;
o Any other payments from any source designed or intended to compensate a Member for
injuries sustained as the result of negligence or alleged negligence of a third party;
o Any Workers’ Compensation award or settlement;
o Any recovery made pursuant to no-fault insurance;
o Any medical payments made as a result of such coverage in any automobile or
homeowners insurance policy; and the Plan shall recover the full amount of benefits
provided hereunder without regard to any claim of fault on the part of any Member,
whether under comparative negligence or otherwise.
When You Have A Claim
Submitting a Claim (In-Network)
Generally, you will not have to submit any claim forms to Horizon for reimbursement for
treatment from a network provider. You will simply pay the provider the required copayment
amount and the provider will submit claims directly to Horizon for the appropriate
reimbursement.
Submitting a Claim (Out-of-Network)
If you receive treatment out-of-network, claims must be submitted for reimbursement to:
Horizon BCBSNJ,
P.O. Box 820
Newark, NJ 07101-0820
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General Benets | SEHBP Member Guidebook 2024
All behavioral health and substance use disorder claims should be mailed to:
Horizon Behavioral Health Horizon
Horizon BCBSNJ
P.O. Box 10191
Newark, NJ 07101-3189
Filing Deadline (Proof of Loss)
Horizon must be given written proof of a loss for which a claim is made under the SEHBP plan.
This proof must cover the occurrence, character, and extent of the loss. It must be furnished
within one year and 90 days of the end of the calendar year in which the services were
incurred. For example, if a service were incurred in the year 2024, you would have until March
31, 2026to le the claim.
A claim will not be considered valid unless proof is furnished within the time limit shown
above. If it is not possible for you to provide proof within the time limit, the claim may be
considered valid upon appeal if the reason the proof was not provided in a timely basis was
reasonable.
Itemized Bills are Necessary
You must obtain itemized bills from the providers of services for all medical expenses. The
itemized bills must include the following:
• Name and address of provider;
• Provider's tax identification number;
• Name of patient;
• Date of service;
• Diagnosis;
• Type of service;
• CPT 4 code; and
• Charge for each service.
Foreign Claims
Bills for services that are incurred outside of the United States must include an English
translation and the charge for each service performed. The exchange rate at the time of
service should also be indicated on the bill that is submitted for reimbursement.
Filling Out the Claim Form
Be sure to ll out the claim form completely. Include the identication number that appears on
your SEHBP plan identication card. Fill out all applicable portions of the claim form and sign
it. A separate claim form must be submitted for each individual and each time you le a claim.
Medicare Claim Submission
If a member is a New Jersey resident, has Medicare primary coverage, and receives care within
New Jersey, claims will be transmitted automatically from the Medicare carrier to the SEBHP
plan.
If a member resides in another state and has Medicare primary coverage, the member
will have to submit a copy of the Medicare Explanation of Benets, an itemized bill, and a
completed SEHBP plan claim form to Horizon BCBSNJ.
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Appeal Procedures | SEHBP Member Guidebook 2024
Authorization To Pay Provider
The providers that participate with the SEHBP plans will be paid directly for eligible services.
The member will be paid for all services rendered by non-participating providers. Once
payment has been made to the member for services rendered, Horizon will not have to pay
the benet again.
Questions About Claims
If you have questions about a hospital claim, hospital benets, a medical claim, or medical
benets or if you need a claim form, call Horizon at 1-800-414-SHBP (7427).
If for any reason the claim is not eligible, you will be notied of its ineligibility within 90 days
of receipt of your claim. To request a review of the claim, you should follow the instructions
described in the “Appeal Procedures” section.
Appeal Procedures
SEHBP Medical Appeal Procedure
Member appeals that involve medical judgment made by Horizon are considered medical
appeals. An adverse benet determination involving medical judgment is (a) a denial; or (b) a
reduction from the application of clinical or medical necessity criteria; or (c) a failure to cover
an item or service for which benets are otherwise provided because Horizon determines the
item or service to be experimental or investigational, cosmetic, or dental, rather than medical.
Adverse benet determinations involving medical judgment may usually be appealed up to
three (3) times as outlined below:
First Level Medical Appeal – The First Level Medical Appeal of an adverse benet
determination;
Second Level Medical Appeal – The Second Level Medical Appeal of an adverse benet
determination available to you after completing a First Level Medical Appeal; and
External Appeal – The third Level Medical Appeal of an adverse benet determination, which,
at your request, would generally follow a Second Level Medical Appeal. An External Appeal
provides you the right to appeal to an Independent Review Organization (IRO).
An overview of the medical appeal procedure is provided below. An SEHBP Medical Appeals
Procedure brochure will be provided with every adverse benet determination involving
medical judgment. The brochure provides a comprehensive description of the procedures.
First Level Medical Appeal
First Level Medical Appeals may be submitted in writing or verbally. Verbal appeals may be
directed to Horizon Utilization Management at 1-888-221-6392. Written appeals may be sent
to:
Horizon BCBSNJ
SEHBP Medical Appeals
P.O. Box 420
Mail Station PP 12E Newark, NJ 07101-0420
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Appeal Procedures | SEHBP Member Guidebook 2024
The member, physician or other authorized representatives acting on behalf of the member,
and with the member’s written consent to pursue an appeal of any adverse benet
determination involving medical judgment made by Horizon Blue Cross Blue Shield of
New Jersey, have one (1) year following the member’s receipt of the initial adverse benet
determination letter to request a Medical Appeal.
To initiate a First Level Medical Appeal, the following information must be provided:
• Name and address of the member or provider(s) involved;
• Member’s identification number;
• Date(s) of service;
• Nature and reason behind your appeal;
• Remedy sought; and
• Clinical documentation to support your appeal.
First Level Medical Appeals will be reviewed and decided in the following time frames:
• Standard First Level Medical Appeals are reviewed and decided within 15 calendar days of
receipt; or
• First Level Expedited (urgent and emergent) Medical Appeals are decided as soon as
possible in accordance with the medical urgency of the case, but will not exceed 72 hours
from Horizon’s receipt of the appeal request.
The member will receive a letter documenting Horizon’s First Level Medical Appeal decision.
The letter will include the specic reasons for the determination.
Expedited Review (excluding appeals related to substance use disorder)
Horizon Medical Appeal procedures may be expedited in circumstances involving urgent
or emergent care.
First and Second Level Medical Appeals are automatically handled in an expedited manner
for all determinations regarding urgent or emergent care, an admission, availability of care,
continued stay, or health care services for which the claimant received emergency services but
has not been discharged from the facility. Furthermore, if you feel that the Horizon decision
will cause serious medical consequences in the near future, you have the right to an Expedited
Medical Appeal.
You also have the right to an Expedited Medical Appeal if in the opinion of a physician with
knowledge of your medical condition, your condition is as described above or that you will
be subject to severe pain that cannot be adequately managed without receiving the denied
medical services. Expedited Medical Appeals are initiated by calling a Horizon Appeals
Coordinator at 1-888-221-6392.
Second Level Medical Appeals (excluding certain appeals related to substance use
disorder)
If you disagree with the First Level Medical Appeal decision, you have one (1) year following
receipt of Horizon’s original determination letter to request a Second Level Medical Appeal.
If you wish to make a Second Level Medical Appeal, you may do so by sending your appeal in
writing to the following address:
Horizon BCBSNJ Appeals Department
Mail Station PP-12E
P.O. Box 420
Newark, NJ 07101-0420
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Appeal Procedures | SEHBP Member Guidebook 2024
You may also initiate a Second Level Medical Appeal by calling a Horizon Appeals Coordinator
at 1-888-221-6392.
To initiate a Second Level Medical Appeal, the following information must be provided:
• Name and address of the member or provider(s) involved;
• Member’s identification number;
• Date(s) of service;
• Nature and reason behind your appeal;
• Remedy sought; and
• Clinical documentation to support your appeal.
If a Second Level Medical Appeal is received, it is submitted to the Horizon Appeals
Committee. The Appeals Committee is made up of Horizon Medical Directors and staff,
physicians from the community, and consumer advocates. A smaller subcommittee reviews
Expedited Second Level Medical Appeals. The Appeals Coordinator will advise you of the
date of your hearing. You have the option of attending the hearing in person or via telephone
conference. You may also elect to have the Appeals Committee review and decide your
Second Level Medical Appeal without your appearance.
Second Level Medical Appeals will be reviewed and decided in the following time frames:
• Standard Second Level Medical Appeals are reviewed and decided within 15 calendar days
of Horizon’s receipt; or
• Second Level Expedited (urgent and emergent circumstances, as previously described)
Medical Appeals are decided as soon as possible in accordance with the medical urgency
of the case, but will not exceed 72 hours from Horizon’s receipt of your First Level Medical
Appeal request.
If you participate in the hearing, you will be notied of the Appeals Committee’s decision
verbally by telephone on the day of the hearing whenever possible. Written conrmation
of the decision is sent to you and/or your physician or other authorized representative who
pursued the Second Level Medical Appeal on your behalf. If you choose not to appear at
the hearing, you will be notied of the Appeals Committee’s decisions in writing within ve
(5) business days of the decision. Horizon’s letter will include the specic reasons for the
determination. If Horizon’s decision is not in your favor, you have the right to pursue an
External Appeal through an Independent Review Organization (IRO).
Expedited Review of Second Level Medical Appeals (excluding appeals related to
substance use disorder)
If the circumstances previously described in the “Expedited Review” section apply in your case
you have the same right to an expedited review of your Second Level Medical Appeal.
External Appeal Rights
Standard External Appeals (excluding appeals related to substance use disorder)
If you are dissatised with the results of Horizon’s internal appeals process, and you wish to
pursue an External Appeal with an Independent Review Organization (IRO), you must submit
a written request within four (4) months from your receipt of Horizon’s nal adverse benet
determination of your Appeal. To initiate a Standard External Appeal, you should submit a
written request to the following address:
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Appeal Procedures | SEHBP Member Guidebook 2024
Horizon BCBSNJ Appeals Department
Mail Station PP-12E
P.O. Box 420
Newark, NJ 07101-0420
Upon receipt of your written request, a preliminary review will be conducted by Horizon and
completed within ve (5) business days to determine:
• Your eligibility under your group health plan at the time the service was requested or
provided;
• That the adverse benefit determination does not relate to your failure to meet eligibility
requirements under the terms of your group health plan (e.g. worker classification or similar);
• The internal appeals process has been exhausted (if required); and
• You have provided all the information and forms required to process the external review.
After the completion of this preliminary review, written notication will be issued informing
you of Horizon’s determination regarding the eligibility of your request for external review.
If your request for an external review meets the eligibility requirements, your appeal will be
assigned to an IRO by Horizon. The IRO will notify you in writing of your request’s eligibility
and acceptance for external review. The IRO will review all of the information and documents
received and will provide its written nal external review decision to the claimant and Horizon
within 45 days after the IRO rst received the request for the external review. Upon receipt
of a nal external review decision reversing an adverse benet determination, Horizon will
provide coverage or payment for the claim(s) or service(s) involved. If the nal external review
decision upholds the adverse benet determination, no further action is taken and the SEHBP
plan Medical Appeal s Process is complete.
The Standard External Appeal rights described may be expedited in the following
circumstances:
The initial adverse benet determination involving medical judgment concerns a medical
condition such that the completion of a Standard Internal Appeal would seriously jeopardize
the life or health of the member or would jeopardize the member’ s ability to regain maxi
mum function, and the member has led a request for an Expedited Internal Appeal;
OR
The nal adverse benet determination (decision upon appeal) involving medical judgment
concerns a medical condition such that the completion of a Standard External Appeal would
seriously jeopardize the life or health of the member or would jeopardize the member’s
ability to regain maximum function, or if nal adverse benet determination involving medical
judgment concerns an admission, availability of care, continued stay or a health care item or
service for which the member received emergency services, but has not been discharged from
the facility.
In instances of an expedited request, your request can be made by calling a Horizon Appeals
Coordinator at 1-888-221-6392. For Expedited External Review requests, the nal notice
of the decision must be provided as expeditiously as the member’s medical condition or
circumstances require, but in no event shall exceed 72 hours from the IRO’s receipt of the
request for Expedited External Review.
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Appeal Procedures | SEHBP Member Guidebook 2024
Appeal Rights Exclusive To Substance Use Disorder
A Member (or a Provider acting for the Member, with the Member’s consent) may appeal an
adverse benet determination with respect to substance use disorder.
The appeal process for adverse benet determinations involving medical judgment with
respect to substance use disorder consists of the following:
a. an internal review by Horizon (a "Substance Use Disorder First Level Appeal"); and
b. for appeals related to inpatient care beyond the first 28 days, a formal expedited
external review with the Independent Health Care Appeals Program at DOBI (a
"Substance Use Disorder External Appeal") followed by the option of an appeal to the
Commission; and
c. for all other substance use disorder appeals, a second level internal appeal as discussed
under the Second Level Medical Appeals section above; and
d. an external appeal for appeals denied at the second level internal appeal.
e. Commission Appeal as detailed in this Guidebook.
Substance Use Disorder First Level Appeal
A member (or a provider acting for the member, with the member’s consent) can le a
Substance Use Disorder First Level Appeal by calling or writing Horizon at the telephone
number and address in the First Level Medical Appeal section above. At the Substance Use
Disorder First Level Appeal, a member may discuss the adverse benet determination directly
with the Horizon physician who made it, or with the medical director designated by Horizon.
To submit a Substance Use Disorder First Level Appeal, the member must include the
following information:
1. the name(s) and address(es) of the member(s) or provider(s) involved;
2. the member’s identication number;
3. the date(s) of service;
4. the details regarding the actions in question;
5. the nature of and reason behind the appeal;
6. the remedy sought; and
7. the documentation to support the appeal.
First Level Appeals will be reviewed and decided in the time frames described in First Level
Medical Appeals above except First Level Medical Appeals related to inpatient care beyond
the rst 28 days will be reviewed and decided within 24 hours of receipt. Horizon will provide
the member and the provider with: (a) written notice of the outcome; (b) the reasons for the
decision; and (c) if the initial adverse benet determination is upheld, instructions for ling a
Substance Use Disorder Secon d Level Appeal.
Substance Use Disorder Second Level Appeal
This section applies to all substance use disorder appeals with the exception of appeals
related to inpatient care beyond the rst 28 days. A member (or a provider acting for the
member, with the member’s consent) who is dissatised with the results of Horizon's internal
First Level Appeal process with respect to an adverse benet determination can pursue a
Substance Use Disorder Internal Second Level Appeal. The procedures for ling a Substance
Use Disorder Second Level Appeal are the same as in those set forth above in “Second Level
Medical Appeal Rights".
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Appeal Procedures | SEHBP Member Guidebook 2024
Substance Use Disorder Appeals specic to Inpatient Care after the rst 28 days
This section applies to all substance use disorder appeals related to inpatient care beyond the
rst 28 days. A member (or a provider acting for the member, with the member’s consent) who
is dissatised with the results of Horizon's internal appeal process with respect to an adverse
benet determination can pursue a Substance Use Disorder External Appeal, an expedited
external appeal with an IRO assigned by the DOBI. All appeals led in accordance with this
paragraph must be led with the Independent Health Care Appeals Program in the New
Jersey Department of Banking and Insurance.
The IRO will complete its review of the Substance Use Disorder Second Level Appeal and issue
its decision in writing within 24 hours from its receipt of the request for the review.
Commission Appeal
Once all appeal options have been exhausted through Horizon, the member may appeal to
the School Employees’ Health Benets Commission (Commission). For information on how
to request a Commission Appeal, please refer to the Commission Appeal section of this
Guidebook.
SEHBP Plans Administrative Appeal Procedure
The member or the member’s authorized representative may appeal and request that Horizon
reconsider any claim or any portion(s) of a claim for which they believe benets have been
erroneously denied based on the SEHBP plan’s limitations and/or exclusions. This appeal may
be on an administrative nature. Administrative appeals question plan benet decisions such
as whether a particular service is covered or paid appropriately. Examples of Administrative
Appeals include:
• Visits beyond the 30-visit chiropractic limit;
• Benefits beyond the reasonable and customary allowance;
• Routine Vision Services rendered out-of-network;
• Benefits for a wig that exceed the $500/24 month limit;
• Hearing Aid for a 60–year-old member.
Adverse benet determinations involving the application of plan benets may usually be
appeal ed up to three (3) times as outlined below:
First Level Administrative Appeal – The First Level Administrative Appeal of an adverse
benet determination;
Second Level Administrative Appeal – The Second Level Administrative Appeal of an adverse
benet determination available to you after completing a First Level Administrative Appeal;
and
Commission Appeal – The Third Level Administrative Appeal of an adverse benet
determination, which, at your request, would generally follow a Second Level Administrative
Appeal. A Commission Appeal provides you the right to appeal to the School Employees’
Health BenetsCommission.
An overview of the administrative appeal process is provided below. A SEHBP Administrative
Appeals Procedure brochure will be provided with every administrative adverse benet
determination. The brochure provides a comprehensive description of the procedures.
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Appeal Procedures | SEHBP Member Guidebook 2024
First Level Administrative Appeal
The member may request an administrative appeal by calling 1-800-414-SHBP (7427) or
submitting a written appeal to:
Horizon BCBSNJ
SEHBP Appeals
P.O. Box 820
Newark. NJ 07101
The member has one (1) year following your receipt of the initial adverse benet determination
letter to request an Administrative Appeal.
The First Level Administrative Appeal should include the following information:
• Name and address of the patient and the SEHBP plan member;
• Member’s SEHBP plan identification number;
• Date(s) of service(s);
• Provider’s name and identification number;
• Physician’s name and identification number;
• The reason you think the claim/service should be reconsidered; and
• All documentation supporting your appeal.
You will receive a written response to your First Level Administrative Appeal within 30 days.
If you are not satised with this written determination, a Second Level Administrative Appeal
may be requested.
Second Level Administrative Appeal
The member may request a Second Level Administrative Appeal within one (1) year following
receipt of the initial adverse benet determination letter by calling 1-800-414-SHBP (7427),
or by writing to the address noted earlier. The member may also send an appeal via fax to
1-973-274-4599.
During the Second Level Administrative Appeal, Horizon will review any additional evidence
the member wished to supply in support of the appeal. The member will receive a written
determination of the nal decision within 30 days. This will complete the Horizon appeal
options.
Commission Appeal
Once all appeal options have been exhausted through Horizon, the member may appeal to
the School Employees’ Health Benets Commission (Commission). If dissatised with a nal
Hori zo n BCBSNJ decision on an administrative appeal , you have one (1) year from the date
of nal adverse bene t determination letter to request a Commission Appeal . Only the
member or the member’s legal representative may appeal, in writing, to the Commission. If
the member is deceased or incapacitated, the individual legally entrusted with his or her affairs
may act on the member’s behalf.
Request for consideration must contain the reason for the disagreement along with copies of
all relevant correspondence and should be directed to:
Appeals Coordinator
School Employees’ Health Benets Commission
P.O. Box 299
Trenton, NJ 08625-0299
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Appeal Procedures | SEHBP Member Guidebook 2024
The member will be advised by the Commission how to arrange a hearing date, the date of
the hearing and the option to attend and appear before the Commission.
Notication of all Commission decisions will be made in writing to the member. If the
Commission denies the member’s appeal, the member will be informed of further steps he
or she may take in the denial letter from the Commission. Any member who disagrees with
the Commission’s decision may request in writing to the Commission, within 45 days, that the
case be forwarded to the Ofce of Administrative Law. The Commission will then determine if
a factual hearing is necessary. If so, the case will be forwarded to the Ofce of Administrative
Law. An Administrative Law Judge (ALJ) will hear the case and make a recommendation to the
Commission, which the Commission may adopt, modify or reject.
If your case is forwarded to the Ofce of Administrative Law, you will be responsible for the
presentation of your case and for submitting all evidence. The member will be responsible
for any expenses involved in gathering evidence or material that will support the grounds for
appeal. The member will be responsible for any court ling fees or related costs that may be
necessary during the appeal process. If an attorney or expert medical testimony is required,
the member will be responsible for any fees or costs incurred.
If the recommendation is rejected, the administrative appeal process is ended. When the
administrative process is ended, further appeals may be made to the Superior Court of New
Jersey, Appellate Division.
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Prescription Drug Benets | SEHBP Member Guidebook 2024
Prescription Drug Benets
The School Employees’ Health Benets Commission require that all covered employees and
retirees have access to prescription drug coverage.
See the SHBP/SEHBP Prescription Drug Plans Member Guidebook for additional information
on prescription drug benets and limitations.
Certain drugs that require administration in a physician’s ofce may be covered through your
medical plan (instead of your prescription plan) under the Specialty Pharmacy Program.
The SEHBP Health Plans cover only prescription drugs administered while you are an inpatient
in a covered health care facility.
Please refer to the SHBP/SEHBP Prescription Drug Plans Member Guidebook for more
information regarding your prescription drug benets.
Note: Oral Contraceptive coverage is available through this medical plan.
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COBRA Coverage | SEHBP Member Guidebook 2024
COBRA Coverage
Continuing Coverage When It Would Normally End
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal law that
gives employees and their eligible dependents the opportunity to remain in their employer's
group coverage when they would otherwise lose coverage. COBRA coverage is available for
limited periods (see “Duration of COBRA Coverage” in this Guidebook), and the member
must pay the full cost of the coverage plus an administrative fee.
Leave taken under the federal and/or State Family Leave Act is not subtracted from your
COBRA eligibility period.
Under COBRA, you may elect to enroll in any or all of the coverage s you had as an active
employee or dependent (health, prescription drug, dental, and vision). You may also
change your health or dental plan when enrolling in COBRA. You may elect to cover the
same dependents that you covered while an active employee, or delete dependents from
coverage — however, you cannot add dependents who were not covered while an employee
except during the annual Open Enrollment period (see below) or unless a "qualifying event"
(marriage, birth or adoption of a child, etc.) occurred within 60 days of the COBRA event.
Open Enrollment — COBRA enrollees have the same rights to coverage at Open Enrollment
as are available to active employees. This means that you or a dependent who elected to
enroll under COBRA are able to enroll, if eligible, in any medical, dental, or prescription drug
coverage during the Annual Open Enrollment Period regardless of whether you elected
to enroll for the coverage when you went into COBRA. This affords a COBRA enrollee the
same opportunity to enroll for benets during the Annual Open Enrollment Period as an
active employee. However, any time of non- participation in the benet is counted toward
your maximum COBRA coverage period. If the State Health Benets Commission or School
Employees’ Health Benets Commission make changes to any benet plan available to active
employees and/or retirees, those changes apply equally to COBRA participants.
COBRA Events
Continuation of group coverage under COBRA is available if you or any of your covered
dependents who would otherwise lose coverage as a result of any of the following events:
• Termination of employment (except for gross misconduct);
• Death of the member/retiree;
• Reduction in work hours;
• Leave of absence;
• Divorce, legal separation, dissolution of a civil union or domestic partnership (makes spouse/
partner ineligible for further dependent coverage);
• Loss of a dependent child's eligibility through the attainment of age 26; or
• The employee elects Medicare as primary coverage. (Federal law requires active employees
to terminate their employer's health coverage if they want Medicare as their primary
coverage.)
Note: Employees who at retirement are eligible to enroll in SEHBP Retired Group coverage
cannot enroll for health benets coverage under COBRA.
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COBRA Coverage | SEHBP Member Guidebook 2024
The occurrence of the COBRA event must be the reason for the loss of coverage for you
or your dependent to be able to take advantage of the provisions of the law. If there is no
coverage in effect at the time of the event, there can be no continuation of coverage under
COBRA.
Cost of COBRA Coverage
If you choose to purchase COBRA benets, you pay 100 percent of the cost of the coverage
plus a two percent charge for administrative costs.
Duration of COBRA Coverage
COBRA coverage may be purchase d for up to 18 months if you or your depend ents become
eligible because of termination of employment, a reduction in hours, or a leave of absence.
Coverage may be extended up to 11 additional months, for a total of 29 months, if you have
a Social Security Administration approved disability (under Title II or XVI of the Social Security
Act) for a condition that existed when you enroll ed in COBRA or began within the rst 60
days of COBRA coverage. Proof of Social Security Administration determination must be
submitted to the Health Benets Bureau of the Division of Pensions & Benets within 60 days
of the award or within 60 days of COBRA enrollment. Coverage will cease either at the end of
your COBRA eligibility or when you obtain Medicare coverage, whichever comes rst.
COBRA coverage may be purchased by a dependent for up to 36 months if he or she
becomes eligible because of your death, divorce, dissolution of a civil union or domestic
partnership, or a child becomes ineligible for continued group coverage because of attaining
age 26, or because you elected Medicare as your primary coverage.
If a second qualifying event — such as a divorce — occurs during the 18-month period
following the date of any employee's termination or reduction in hours, the beneciary of that
second qualifying event will be entitled to a total of 36 months of continued coverage. The
period will be measured from the date of the loss of coverage caused by the rst qualifying
event.
Employer Responsibilities under COBRA
The COBRA law requires employers to:
• Notify you and your dependents of the COBRA provisions within 90 days of when you and
your dependents are first enrolled;
• Notify you and your dependents of the right to purchase continued coverage within 14
days of receiving notice that there has been a COBRA qualifying event that causes a loss of
coverage;
• Send the COBRA Notification Letter and a COBRA Application within 14 days of receiving
notice that a COBRA qualifying event has occurred;
• Notify the Health Benefits Bureau of the Division of Pensions & Benefits within 30 days of the
loss of an employee’s coverage; and
• Maintain records documenting their compliance with the COBRA law.
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COBRA Coverage | SEHBP Member Guidebook 2024
Employee Responsibilities under COBRA
The law requires that you and/or your dependents:
• Must notify your employer (if you are retired, you must notify the Health Benefits Bureau
of the Division of Pensions & Benefits) that a divorce, legal separation, dissolution of a civil
union or domestic partnership, or your death has occurred or that your child has reached
age26 — notification must be given within 60 days of the date the event occurred;
• File a COBRA Application (obtained from your employer or the Health Benefits Bureau)
within 60 days of the loss of coverage or the date of the COBRA Notice provided by your
employer, whichever is later;
• Pay the required monthly premiums in a timely manner; and
• Pay premiums, when billed, retro active to the date of group coverage termination.
Failure to Elect COBRA Coverage
In considering whether to elect continuation of coverage under COBRA, an eligible employee,
retiree, or dependent (also known as a “qualied beneciary” under COBRA law) should take
into account that a failure to continue group health coverage will affect future rights under
federal law.
You should take into account that you have special enrollment rights under federal law. You
have the right to request special enrollment in another group health plan for which you are
otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days of the
date your group coverage ends. You will also have the same special enrollment right at the
end of the COBRA coverage period if you get the continuation of coverage under COBRA for
the maximum time available to you.
Termination of COBRA Coverage
Your COBRA coverage will end when any of the following situations occur:
• Your eligibility period expires;
• You fail to pay your premiums in a timely manner;
• After the COBRA event, you become covered under another group insurance program;
• You voluntarily cancel your coverage;
• Your employer drops out of the SEHBP; or
• You become eligible for Medicare after you elect COBRA coverage. (This affects health
insurance only - not dental, prescription, or vision coverage.)
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APPENDIX I | SEHBP Member Guidebook 2024
APPENDIX I
Special Plan Provisions Work-Related Injury Or Disease
Work-related injuries or diseases are not covered under the SEHBP plans. This includes the
following:
• Injuries arising out of or in the course of work for wage or profit, whether or not your injuries
are covered by a Workers' Compensation policy.
• Disease caused by reason of its relation to Workers' Compensation law, occupational disease
laws, or similar laws.
• Work-related tests, examinations or immunizations of any kind required by your work except
employer-mandated examinations that are a prerequisite for participation in an employer
mandated physical fitness test required as a condition of continuing employment.
• Work-related injuries will not be eligible for benefits under your medical plan before or after
your Workers’ Compensation carrier has settled or closed your case.
Please note: If you collect benets for the same injury or disease from both Workers'
Compensation and your SEHBP plan, you maybe subject to prosecution for insurance fraud.
Medical Plan Extension of Benets
If you or a dependent are disabled with a condition or illness at the time of your termination
from the SEHBP, you may qualify for an extension of benets for this specic condition or
illness. You do not qualify for an extension of benets if you currently have or are eligible for
any other type of medical coverage including but not limited to Medicare. If you feel that you
may qualify for an extension of benets please contact Horizon at 1-800-414-SHBP (7427) for
assistance.
If the extension applies, it is only for eligible expenses relating to the disabling condition or
illness. An extension under the SEHBP plan will be for the time you or your dependent remains
disabled from any such condition or illness, but not beyond the end of the calendar year after
the one in which your coverage ends.
Termination For Cause
If any of the following conditions exist, you may receive written notice that you will no longer
be covered under the SEHBP plan.
• If, after reasonable efforts, the SEHBP plan and/or participating providers are unable to
establish and maintain a satisfactory, provider/patient relationship with you or you repeatedly
act in a manner which is verbally or physically abusive.
• If you permit any person who is not authorized to use the identification card(s) issued to you.
You may be liable for the cost of any claims paid for services for an ineligible individual.
• If you willfully furnish incorrect or incomplete information in a statement made for the
purpose of effecting coverage.
• If you abuse the system, including, but not limited to theft, damage to a participating
provider’s property, or forgery of prescriptions.
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APPENDIX II | SEHBP Member Guidebook 2024
Any action by the SEHBP plan under these provisions is subject to review in accordance with
the established appeals procedures. If an appeal is denied and the decision upheld, this action
is subject to appeal to the School Employees’ Health Benets Commission. No benets, other
than for emergencies, will be provided to the member and to any family members under the
coverage as of 31 days after such written notice is given by the SEHBP plan. If the School
Employees’ Health Benets Commission overrules the decision to terminate, benets will be
restored.
APPENDIX II
Summary Schedules of Services and Supplies
New Jersey statutes, administrative code, and agreements between the SEHBP and Horizon
govern this plan. The following schedules of benets are summary descriptions of plan
benets and are not a complete listing. They do not describe all the limitations or conditions
associated with the coverage as described in other sections of this Guidebook. All pertinent
parts of this Guidebook should be consulted regarding a specic benet. Health decisions
should not be made on the basis of the information provided in these schedules. Horizon will
administer the coverage listed in the Schedule of Covered Services and Supplies, subject to
the terms, conditions, limitations, and exclusions stated within this Guidebook.
Please note: The fact that a doctor may prescribe, order, recommend, or approve a service
or supply does not, in itself, make it medically needed for the treatment and/or diagnosis
of an illness or injury or make it a covered medical expense. Certain services are subject to
precertication.
SEHBP Plans Eligible Services and Supplies
In-Network: The following copayments apply to in-network ofce and emergency room visits
unless otherwise indicated on the Summary Schedule of Services and Supplies. If the member
is admitted within 24 hours, the emergency room copayment is waived.
SEHBP Plan Option
Primary Care Ofce Visit
Copayment
Specialty Care Ofce
Visit Copayment
Emergency Room
Copayment
NJ DIRECT10 $10 $10 $25
NJ DIRECT15 $15 $15 $50
NJ Educators Health Plan $10 $15 $125
NJ DIRECT1525* $15 $25 $75
NJ DIRECT2030* $20
$30 for adults; $20 for
children to end of year
the child turns 26
$125
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
In-network coinsurance applies to the following services; ambulance transport, durable
medical equipment, some foot orthotics and prosthetics, oxygen therapy and outpatient
private duty nursing. The plan benet for these services is 90 percent.
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APPENDIX II | SEHBP Member Guidebook 2024
Out-of-network: Where indicated under “Out-of-Network” services in the following pages,
the reimbursement is 80 or 70 percent of the reasonable and customary or out-of-network
allowance based on the SEHBP plan option selected, unless otherwise indicated. Before
out-of-network benets are paid, the annual in-network deductible must be satised. Out-of-
Network coverage for chiropractic services, acupuncture services and physical therapy services
will be subject to a xed dollar limit per visit.
SEHBP Plan Option
SEHBP Out-of-Network Benet Level
(Unless otherwise indicated)
NJ DIRECT10
80%
Of the reasonable and customary allowance after the
deductible is satised
NJ DIRECT15,
NJ DIRECT1525*,
NJ DIRECT2030*,
NJ Educators Health Plan
70%
Of the reasonable and customary allowance after the
deductible is satised
*The NJ DIRECT1525 and NJ DIRECT2030 plans are ONLY available to retirees that are Medicare eligible and select one of these two plans as supplemental to
Medicare.
SEHBP Plans Covered Services
Acupuncture for Pain Management Only
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary
allowance, limited to $60 per visit
Alcohol or Substance Abuse Treatment (Inpatient) - See Substance Use Disorder Treatment
Alcohol or Substance Abuse Treatment (Outpatient) - See Substance Use Disorder Treatment
Allergy Testing
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70/6 percent of the reasonable and customary
allowance
Ambulance Services
In-Network ................................... 90 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Ambulatory Surgery
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Anesthesia
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Biofeedback
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
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APPENDIX II | SEHBP Member Guidebook 2024
Chiropractic Services (No Referral Required)
Combined In-Network and Out-of-Network 30 visit maximum benet per calendar year
In-Network ................................... 100 percent coverage for maximum of 30 visits per
calendar year
Out-of-Network ........................... 80/70 percent of the reasonable and customary
allowance, limited to $35 per visit
Diagnostic X-Ray
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70percent of the reasonable and customary allowance
Dialysis Center Charges
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Durable Medical Equipment
In-Network ................................... 90 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Emergency Room
In-Network ................................... 100 percent coverage, after the emergency room
copayment*
Out-of-Network** ........................ 100 percent coverage, after the emergency room
copayment*
*For both in-network and out-of-network services, the copayment is waived if the patient
is admitted due to the emergent condition**The out-of-network benet applies if the
patient’s condition is non-emergent.
Hospital Charges
In-Network ................................... 1000 percent coverage
Out-of-Network ........................... 80/70 percent coverage, subject to precertication
A separate inpatient deductible per inpatient hospital stay applies to NJ DIRECT1525, NJ
DIRECT2030, The standard deductible applies to the NJ DIRECT10 NJ DIRECT15 and the
NJ Educators Health Plan.
Home Health Care
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Hospice Care
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Note: Inpatient Hospice Care: A separate inpatient deductible per inpatient hospital stay
applies to the NJ DIRECT1525 and NJ DIRECT2030. The standard deductible applies to NJ
DIRECT10, NJ DIRECT15 and the NJ Educators Health Plan.
Inherited Metabolic Disease Medical Foods
In-Network ................................... 90 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
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APPENDIX II | SEHBP Member Guidebook 2024
Inpatient Physician Services
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Laboratory Services
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 for non-routine services
Maternity/Obstetrical Care
In-Network ................................... 1000 percent coverage after a copayment for initial visit
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Mental or Nervous Condition Treatment (Inpatient)
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent coverage, subject to precertication
A separate inpatient deductible per inpatient hospital stay applies to the NJ DIRECT1525
and NJ DIRECT2030. The standard deductible applies to the NJ DIRECT10, NJ DIRECT15
and the NJ Educators Health Plan.
Mental or Nervous Condition Treatment (Outpatient)
In-Network Ofce Visit ................ 100 percent coverage
In-Network Outpatient Visit ........ 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Nutritional Counseling
In-Network ................................... 100 percent coverage (3 visits per year)
Out-of-Network ........................... No coverage*
*For eating disorder diagnoses only, there are no visit limitations for services rendered in-
network or out-of-network. Deductible and coinsurance applies to services rendered out-of-
network.
Physical Therapy and Occupational Therapy
In-Network Ofce Visit ................ 100 percent coverage
In-Network Outpatient Visit ........ 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary
allowance, limited to $52 per visit.
Pre-Admission Testing
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
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APPENDIX II | SEHBP Member Guidebook 2024
Preventive Care
Under the Patient Protection and Affordable Care Act, some preventive care services are
covered with no out-of-pocket cost (no copayment), when you receive the services from
an in-network health care professional and the sole reason for the visit is to receive the
preventive care services. If your health care professional provides a preventive service
as part of an ofce visit, you may be responsible for cost sharing for the ofce visit if the
preventive service is not the primary purpose of your visit or if the provider bills you for the
ofce visit separately from the preventive care.
• Annual Routine Gynecological Care and Examination (limited to one per year)
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... 80/70/60 percent of the reasonable and customary
allowance
• Annual Wellness Visit (Preventive Care) (limited to one per year)
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... No coverage
• Immunizations
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... No coverage
• Annual Routine Mammography (limited to one per year)
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... Coverage for one routine mammography is eligible at the
Out-of-Network level and is covered at 80/70 percent of the reasonable and customary
allowance
• PAP Smears
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... 80/70 percent of the reasonable and customary allowance
for an annual routine pap smear
• Prostate Cancer Screening
In-Network ............................... 100 percent coverage
Out-of-Network ....................... No coverage
• Well-Child Care
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network ....................... No coverage
• Well-Child Immunizations
In-Network ............................... 100 percent coverage (no copayment)
Out-of-Network (for children to age 12 months only) 80/70percent of the reasonable and
customary allowance
Private Duty Nursing (Outpatient)
In-Network ................................... 90 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Second Surgical Opinion Charges (Voluntary)
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
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APPENDIX II | SEHBP Member Guidebook 2024
Skilled Nursing Facility Charges
Combined In-Network and Out-of-Network Maximum of 120 Days
In-Network ................................... 100 percent coverage for up to 120 days per calendar
year
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
up to 60 days per calendar year.
Note: A separate inpatient deductible per inpatient hospital stay applies to the NJ
DIRECT1525 and NJ DIRECT2030. The standard deductible applies to the NJ DIRECT10,
NJ DIRECT15 and the NJ Educators Health Plan.
Specialist Ofce Visits
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Specialized Non-Standard Infant Formula
In-Network ................................... 90 percent coverage
Out-of-Network........................80/70 percent of the reasonable and customary allowance
Speech Therapy
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Substance Use Disorder Treatment (Inpatient)
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent coverage, subject to precertication
Note: A separate inpatient deductible per inpatient hospital stay applies to the NJ
DIRECT1525 and NJ DIRECT203 0. The standard deductible applies to the NJ DIRECT10,
NJ DIRECT15 and NJ Educators Health Plan.
Substance Use Disorder Treatment (Outpatient)
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Surgical Services
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Telemedicine*
In-Network ................................... 100/ percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Transplant Benets
In-Network ................................... 100 percent coverage
Out-of-Network ........................... 80/70 percent of the reasonable and customary allowance
Vision Examination (routine exam limited to one per year)
In-Network ................................... 100 percent coverage
Out-of-Network ........................... No coverage
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APPENDIX III | SEHBP Member Guidebook 2024
APPENDIX III
GLOSSARY
Accidental Injury — Physical harm or damage done to a person as a result of a chance or
unexpected occurrence.
Active Group Member (subscriber) — An employee who has met the requirements for
participation and has completed a form constituting written notice of election to enroll for
coverage for him or herself and, if applicable, any eligible dependents. Also includes eligible
employees or dependents who continue coverage as a subscriber in the COBRA program.
Activities of Daily Living — Day-to-day activities, such as dressing, feeding, toileting,
transferring, ambulating, meal preparation, and laundry functions.
Allowable Expense — The allowance for charges for services rendered or supplies furnished
by a health care provider that would qualify as a covered expense.
Ambulatory Surgical Center — An accredited ambulatory care facility licensed as such by the
state in which it operates to provide same-day surgical services.
Appeal — A request made by a member, doctor, or facility that a carrier review a decision
concerning a claim. Administrative appeals question plan benet decisions such as whether a
particular service is covered or paid appropriately. Medical appeals refer to the determination
of need or appropriateness of treatment or whether treatment is considered experimental
or educational in nature. Appeals to the Health Benets Commission may only be led by a
member or the member's legal representative.
Benet Period — The twelve-month period starting on January 1st and ending on December
31st. The rst and/or last Benet Period may be less than a calendar year. The rst Benet
Period begins on your coverage date. The last Benet Period ends when you are no longer
covered.
Calendar Year — A year starting January 1 and ending on December 31.
Case Manager — A person or entity designated by the plan to manage, assess, coordinate,
direct, and authorize the appropriate level of health care treatment.
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 Certicate or a valid certication
from another jurisdiction that recognizes same-sex civil unions and additional supporting
documentation are required for enrollment. The cost of civil union partner coverage may be
subject to federal tax (see your employer or the Civil Unions and Domestic Partnerships Fact
Sheet for details).
COBRA — Consolidated Omnibus Budget Reconciliation Act of 1985. This federal law requires
private employers with more than 20 employees and all public employers to allow covered
employees and their dependents to remain on group insurance plans for limited time periods
at their own expense under certain conditions.
Coinsurance — The portion of an eligible charge which is the member's nancial responsibility
for out-of-network services.
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APPENDIX III | SEHBP Member Guidebook 2024
Coordination of Benets — The practice of correlating the payments a plan makes with
payments provided by other insurance covering the same charges or expenses, so that (1) the
plan with primary responsibility pays rst, (2) reimbursement does not exceed 100 percent
of the actual expense, and (3) the plan does not pay more than it would if no other insurance
existed.
Copayment — The fee charged to a member or patient to be paid directly to the participating
provider or network specialist at the time treatment is rendered for certain covered services.
Cosmetic Services — Services rendered to rene or reshape body structures or surfaces that
are not functionally impaired. They are to improve appearance or self-esteem, or for other
psychological, psychiatric or emotional reasons.
Covered Person (member) — An employee, retiree, or COBRA participant or a dependent of
an employee, retiree, or COBRA participant who is enrolled.
Coverage — The plan design of payment for medical expenses under the program.
Custodial Care — Services that do not require the skill level of a nurse to perform. These
services include but are not limited to assisting with activities of daily living, meal preparation,
ambulation, cleaning, and laundry functions. Custodial care services are not eligible for
coverage under the plan, including those that are considered to be medically needed.
Dependent — A member's spouse, civil union partner, or same-sex domestic partner (as
dened by Chapter 246, P.L. 2003); and child(ren) under the age of 26. Children include
natural, adopted, foster, and stepchildren. If a covered child is not capable of self-support
when he or she reaches age26 due to mental illness, or developmental or physical disability,
coverage may be continued subject to approval.
Deductible — The portion of the rst eligible charges submitted for payment in each calendar
year that the out-of-network portion of the SEHBP plan requires the member or covered
dependent to pay.
Detoxication Facility — A health care facility licensed by the state as a detoxication facility
for the treatment of substance use disorder.
Domestic Partner — A person of the same sex with whom you have entered into a domestic
partnership as dened 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
benets, is eligible for coverage. A photocopy of the New Jersey Certicate of Domestic
Partnership dated prior to February 19, 2007 (or a valid certication 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 the Civil Unions and Domestic
Partnerships Fact Sheet for details).
Durable Medical Equipment — Equipment determined to be:
• Designed and able to withstand repeated use;
• Made for and used primarily in the treatment of a disease or injury;
• Generally not useful in the absence of an illness or injury;
• Suitable for use while not confined in a hospital;
• Not for use in altering air quality or temperature; and
• Not for exercise or training.
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APPENDIX III | SEHBP Member Guidebook 2024
Eligible Services and Supplies — These are the charges that may be used as the basis for a
claim. They are the charges for certain services and supplies to the extent the charges meet
the terms as outlined below:
• Medically needed at the appropriate level of care for the medical condition;
• Listed in covered services and supplies;
• Ordered by a doctor (as defined by the SEHBP plans) for treatment of illness or injury;
• Not specifically excluded (listed in the “Charges Not Covered by the SEHBP plans” section);
and
• Provided while you or your eligible family members were covered by the SEHBP plans.
Emergency — A medical condition manifesting itself by acute symptoms of sufcient severity
(including severe pain) such that a prudent layperson (including the parent of a minor child
or a guardian of a disabled individual), who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in the
following:
• Placing the health of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
• Serious impairment to bodily function; and/or
• Serious dysfunction of bodily organ or part.
Claims will be paid for emergency services furnished in a hospital emergency department
if the presenting symptoms reasonably suggested an emergency condition as would be
interpreted by a prudent layperson. All procedures performed during the evaluation (triage)
and treatment of an emergency condition will be covered.
Employer — The local education public employer that participates in the School Employees’
Health Benets Program.
Facility Charges — Charges from an eligible medical institution such as a hospital, residential
treatment center, detoxication center, ambulatory or separate surgical center, dialysis center,
or a skilled nursing center.
Family or Medical Leave of Absence — A period of time of pre-determined length, approved
by the employer, during which the employee does not work, but after which the employee is
expected to return to active service. Any employee who has been granted an approved leave
of absence in accordance with the Family and Medical Leave Act of 1993 shall be considered
to be active for purposes of eligibility for covered services and supplies under your group's
program.
Full Medicare Coverage — Enrollment in both Part A (Hospital Insurance) and Part B (Medical
Insurance) of the federal Medicare Program. State law requires that anyone who is enrolled
in the Retired Group and is eligible for Medicare must enroll in both Parts A and B of the
Medicare Program in order to be covered in the State Health Benets Program or School
Employees’ Health Benets Program.
Gestational Carrier — A woman who has become pregnant with an embryo or embryos
that are not part of her genetic or biologic entity, and who intends to give the child to the
biological parents after birth.
Government Hospital — A hospital which is operated by a government or any of its
subdivisions or agencies. This includes any federal, military, state, county, or city hospital.
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APPENDIX III | SEHBP Member Guidebook 2024
Home Health Care Agency — A provider which mainly provides skilled nursing care and
therapeutic services for an ill or injured person in the home under a home health care program
designed to eliminate hospital stays. To be eligible for reimbursement it must be licensed by
the state in which it operates, or be certied to participate in Medicare as a home health care
agency.
Hospice — A provider that renders a health care program that provides an integrated set
of services designed to provide comfort, pain relief and supportive care for terminally ill or
terminally injured people under a hospice care program
Hospital — An approved institution that meets the tests of 1, 2, 3, 4, or 5, listed below:
1. It is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission
on Accreditation of Hospitals and Medicare approved.
2. It (a) is legally operated, (b) is supervised by a staff of doctors, (c) has 24-hour-a-day nursing
service by registered graduate nurses, and (d) mainly provides general inpatient medical care
and treatment of sick and injured persons by the use of the medical, diagnostic, and major
surgical facilities in it.
3. It is licensed as an ambulatory or separate surgical center. The center must mainly provide
outpatient surgical care and treatment.
4. It is an institution for the treatment of substance use disorder not meeting all the tests of (1)
or (2) but which is:
o A licensed hospital; or
o A licensed detoxification facility; or
o A residential treatment facility that is approved by a state under a program that meets
standards of care equivalent to those of the Joint Commission on Accreditation of
Hospitals. (Educational services provided while at an approved treatment facility is not
eligible.)
5. It is a birth center that is licensed, certied, or approved by a department of health or other
regulatory authority in the state where it operates or meets all of the following tests:
o It is equipped and operated mainly to provide an alternative method of childbirth.
o It is under the direction of a doctor;
o It allows only doctors to perform surgery;
o It requires an exam by an obstetrician at least once before delivery;
o It offers prenatal and postpartum care;
o It has at least two birthing rooms;
o It has the necessary equipment and trained people to handle foreseeable emergencies.
The equipment must include a fetal monitor, incubator, and resuscitator;
o It has the services of registered graduate nurses;
o It does not allow patients to stay more than 24 hours;
o It has written agreements with one or more hospitals in the area that meet the tests
listed above in (1) or (2) and will immediately accept patients who develop complications
or require post-delivery confinement;
o It provides for periodic review by an outside agency; and
o It maintains proper medical records for each patient.
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APPENDIX III | SEHBP Member Guidebook 2024
“Hospital” does not include a nursing home. Neither does it include an institution, or part of
one, that:
o Is used mainly as a place for convalescence, rest, nursing care, or for the aged or drug
addicts;
o Is used mainly as a center for the treatment and education of children with mental
disorders or learning disabilities; or
o Provides home-like or custodial care.
Illness — Any disorder of the body or mind including substance use disorder.
Injury — Damage to the body.
Local Employee — For purposes of health benets coverage, a local employee is a full-time
employee receiving a salary and working for a Participating Local Employer. Full-time shall
mean employment of an eligible employee who appears on a regular payroll and who receives
salary or wages for an average number of hours specied by the employer, but not to be less
than 25 hours per week. It also means employment in all 12 months of the year except in the
case of those employees engaged in activities where the normal work schedule is 10 months.
In addition, for local coverage, employee shall also mean an appointed or elected ofcer of
the local employer, including an employee who is compensated on a fee basis as a convenient
method of payment of wages or salary but who is not a self-employed independent contractor
compensated in a like manner. To qualify for coverage as an appointed ofcer, a person must
be appointed to an ofce specically established by law, ordinance, resolution, or such other
ofcial action required by law for establishment of a public ofce by an appointing authority. A
person appointed under a general authorization, such as to appoint ofcers or to appoint such
other ofcers or similar language is not eligible to participate in the program as an appointed
ofcer. An ofcer appointed under a general authorization must qualify for participation as a
full-time employee.
Local Employer — Government employers in New Jersey, including counties, municipalities,
townships, school districts, community colleges, and various public agencies or organizations.
Maintenance Care — Care that does not substantially improve the condition. When care is
provided for a condition that has reached maximum improvement and further services will not
appreciably improve the condition, care will be deemed to be maintenance care and no longer
eligible for reimbursement. Maintenance care services, even those that are considered to be
medically needed, are not eligible for coverage under the SEHBP plans.
Medical Need and Appropriate Level of Care — A service or supply that the SEHBP plan
determines meets each of these requirements:
• It is ordered by a doctor for the diagnosis or the treatment of an illness or injury;
• The prevailing opinion within the appropriate specialty of the United States medical
profession is that it is safe and effective for its intended use, and that its omission would
adversely affect the person's medical condition;
• That it is the most appropriate level of service or supply considering the potential benefits
and harm to the patient; and
• It is known to be effective in improving health outcomes (for new interventions, effectiveness
is determined by scientific evidence; then, if necessary, by professional standards; then, if
necessary, by expert opinion).
With respect to treatment of substance use disorder, the determination of Medical Need
and Appropriate Level of Care shall use an evidence-based and peer reviewed clinical tool as
designated in regulation by the Commissioner of Human Services.
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APPENDIX III | SEHBP Member Guidebook 2024
Medicare — The federal health insurance program for people 65 or older, people of any age
with permanent kidney failure, and certain disabled people under age 65. Medical coverage
consists of two parts: Part A is Hospital Insurance Benets and Part B is Medical Insurance
Benets. A Retired Group member and/or spouse who are eligible for Medicare coverage
by reason of age or disability must be enrolled in Parts A and B to enroll or remain in SEHBP
Retired Group coverage.
Member — An employee, retiree, COBRA enrollee or dependent who is enrolled under the
SEHBP plans.
Mental or Nervous Condition — A condition which manifests symptoms which are primarily
mental or nervous, whether organic or non-organic, biological or non-biological, chemical or
non-chemical in origin and regardless of cause, basis or inducement, for which the primary
treatment is psychotherapy or psychotherapeutic methods or psychotropic medication.
Mental or nervous conditions include, but are not limited to, psychoses, neurotic and anxiety
disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological
or behavioral abnormalities associated with transient or permanent dysfunction of the brain or
related neurohormonal systems. Mental or nervous condition does not include substance use
disorder.
Morbid Obesity — A body mass index (BMI) greater than 40kg/m2, or a BMI greater than
35kg/m2 with associated life-threatening or disabling co-morbidities including, but not limited
to, coronary heart disease, diabetes, hypertension, or obstructive sleep apnea.
Mouth Condition — A condition involving one or more teeth, the tissue or structure around
them, or the alveolar process of the gums.
Off-Label Use — A drug not approved by the FDA for treatment of the condition in question
or prescribed at a different dosage than the approved dosage.
Out-of-Network Benets — Benets provided by the SEHBP plans when members do not use
network providers for their medical treatment or do not follow the managed care guidelines.
Out-of-Network Plan Allowance — An out-of-network plan allowance is used on the benet
determination when valid reasonable and customary data is not available. The out-of-network
allowance is used to establish a reasonable level of reimbursement. One example is the
allowance for Ambulatory Surgery Centers (ASC’s). The out-of-network allowance used for
ASC's is based on a percentage of the Centers for Medicare and Medicaid Services (CMS)
allowance. For the NJ Educators Health Plan, the reasonable and customary allowance is
based on 200% of CMS.
Participating Provider — A doctor or hospital which has a written agreement with the SEHBP
plan to provide care.
Precertication — A process by which the eligibility and medical appropriateness of services
or supplies is determined before services are rendered.
Primary Health Plan — A plan that pays benets for a member’s covered charge rst, ignoring
what the member’s secondary plan pays. A secondary health plan then pays the remaining
unpaid expenses in accordance with the provisions of the member's secondary health plan.
Provider — The term is used to dene an eligible provider and includes medical doctors,
dentists, podiatrists, acupuncturists, psychologists, psychiatrists, physician assistants, nurse
midwives, licensed clinical social workers, licensed marriage and family therapists, licensed
professional counselors, board certied behavior analysts – doctoral (BCBA-D), board certied
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APPENDIX III | SEHBP Member Guidebook 2024
behavior analysts (BCBA), ABA therapist credentialed by the National Behavior Analyst
Certication Board (BACB) or working under the direct supervision of a BCBA or BCBA-D,
chiropractors, certied nurse practitioners, clinical nurse specialists, Registered Nurse First
Assistants (RNFA), physical therapists, occupational therapists, optometrists, and audiologists
who are properly licensed and are working within the scope of their practice.
Reasonable and Customary —except where noted, SEBHP plans cover only reasonable and
customary allowances, which are determined by a percentile of the FAIR Health National
benchmark charge data or other nationally recognized database. This schedule is based on
actual charges by physicians nationally for a specic service. If your physician charges more
than the reasonable and customary allowance, you will be responsible for the full amount
above the reasonable and customary allowance in addition to any deductible and coinsurance
you are required to pay. In some instances the out-of-network allowance is derived from an
alternate nationally recognized source. One example is Ambulatory Surgery Centers (ASC’s).
The out-of-network plan allowance used for ASC’s is based on a percentage of the Centers
for Medicare and Medicaid Services (CMS) allowance. For the NJ Educators Health Plan, the
reasonable and customary allowance is based on 200% of CMS.
Residential Treatment Facility — A health care facility licensed by the State of New Jersey for
treatment of substance use disorder or meeting the same standards, if out-of-state.
Respite Care — Short-term or temporary care provided for the hospice patient in order to
provide relief, or respite to the family caregiver.
Retired Group Member — An eligible retiree of a state-administered or local public pension
fund who has met the requirements for participation and has completed a form constituting
written notice of election to enroll for Retired Group coverage in the SEHBP for him/herself
and, if applicable, any eligible dependents. Also includes a surviving spouse of a deceased
Retired Group member who has met the requirements for and has completed a form
constituting written notice of election to enroll in Retired Group coverage for him/herself and,
if applicable, any eligible dependents. Also includes a surviving dependent child of a deceased
Retired Group member who had parent- child(ren) coverage, providing he or she has
completed a form constituting written notice of election to enroll in Retired Group coverage.
School Employees’ Health Benets Commission — The entity created by N.J.S.A. 52:14-
17.46 and charged with the responsibility of overseeing the School Employee’s Health Benets
Program.
School Employees’ Health Benets Program (SEHBP) — The SEHBP was established by
Chapter 103, P.L. 2007. It offers medical and prescription drug coverage to qualied school
employees and retirees, and their eligible dependents. Local employers must adopt a
resolution to participate in the SEHBP. The School Employees’ Health Benets Program Act is
found in the N.J.S.A. 52:14-1 7.4 6 et seq. Rules governing the operation and administration
of the program are found in Title 17, Chapter 9 of the New Jersey Administrative Code.
SEHBP Member — An individual who is either a School Employees’ Health Benets Program
Active Group, Retired Group, or COBRA participant and their dependents.
Skilled Nursing Facility — A facility which is approved by either the Joint Commission on
Accreditation of Health Care Organizations or the Secretary of Health and Human Services
and provides skilled nursing care and services to eligible persons. The skilled nursing facility
provides a specic type of treatment that falls midway between a hospital that provides
care for acute illness and a nursing home that primarily provides custodial, maintenance or
supportive care as well as assistance with daily living.
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APPENDIX III | SEHBP Member Guidebook 2024
Specialty care — Services provided by a health care professional whose practice is limited
to a specic area of medicine (i.e. orthopedics, dermatology, physical therapy, chiropractic
manipulation, etc.).
Substance Use Disorder——The term as dened by the American Psychiatric Association in
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and any subsequent
editions. Substance Use Disorder includes substance use withdrawal.
Supportive Care — Care for patients that have reached the maximum therapeutic benet
in whom periodic trials of therapeutic withdrawals fail to sustain previous therapeutic gains.
Supportive care services, even those that are considered to be medically appropriate are not
eligible for coverage under the SEHBP plans.
Surgical Center — Also called a surgicenter. An ambulatory-care facility licensed by a state to
provide same-day surgical services.
Surgical Procedure — This includes cutting, suturing, treatment of burns, correction of
fracture, reduction of dislocation, manipulation of joint under general anesthesia, application
of plaster casts, electro cauterization, tapping(paracentesis), administration of pneumothorax,
endoscopy, or injection of sclerosing solution.
Surrogate — A woman who carries an embryo that was formed from her own egg inseminated
by the sperm of a designated sperm donor.
Waiting Period — The period of time between enrollment in the health benets program and
the date when you become eligible for benets.
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APPENDIX IV | SEHBP Member Guidebook 2024
APPENDIX IV
Required Documentation For Dependent Eligibility and Enrollment
The School Employees’ Health Benets Program (SEHBP) are required to ensure that
only employees, retirees, and eligible dependents receive coverage under the programs.
Employees or Retirees who enroll dependents for coverage (spouses, civil union partners,
domestic partners, children) must submit supporting documentation in addition to the
appropriate health benets application.
Dependent Eligibility Denition Required Documentation
Spouse
A person to whom you are legally
married.
A photocopy of the Marriage Certicate and a
photocopy of the front page of the employee/
retiree’s most recently led tax return* (Form
1040) that includes the spouse. If ling
separately, submit a copy of both spouses’ tax
returns.
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
Certicate or a valid certication from another
jurisdiction that recognizes same- sex civil
unions and a photocopy of the front page
of the employee/ retiree’s most recently
led NJ tax return* that includes the partner
or a photocopy of a recent (within 90 days
of application) bank statement or bill that
includes the names of both partners and is
received at the same address.
Domestic Partner
A person of the same sex with
whom you have entered into a
domestic partnership as dened
under Chapter 246, P.L. 2003,
the Domestic Partnership Act.
The domestic partner of any
State employee, State retiree,
or any eligible employee/retiree
of a SHBP/SEHBP participating
local public entity, who adopts
a resolution to provide Chapter
246 health benets, is eligible for
coverage.
A photocopy of the New Jersey Certicate of
Domestic Partnership dated prior to February
19, 2007 or a valid certicationfrom another
State of foreign jurisdiction that recognizes
same-sex domestic partners and a photocopy
of the front page of the employee/retiree’s
most recently led NJ tax return* that includes
the partner or a photocopy of a recent (within
90 days of application) bank statement or bill
that includes the names of both partners and
is received at the same address.
*Note: On tax forms, you may black out all nancial information and all but the last 4 digits of any Social Security numbers.
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APPENDIX IV | SEHBP Member Guidebook 2024
Required Documentation for Dependent Eligibility and Enrollment
Dependent Eligibility Denition Required Documentation
Children
A subscriber’s child until age 26,
regardless of the child’s marital,
student, or nancial dependency
status – even if the young adult no
longer lives with his or her parents.
This includes a stepchild, foster child,
legally adopted child, or any child
in a guardian-ward relationship upon
submitting required supporting
documentation.
Natural or Adopted Child – A photocopy
of the child’s birth certicate** showing the
name of the employee/retiree as a parent.
Step Child – A photocopy of the child’s
birth certicate showing the name of the
employee/retiree’s spouse or partner as a
parent and a photocopy of the marriage/
partnership certicate showing the names of
the employee/retiree andspouse/partner.
Legal Guardian, Grandchild, or Foster
Child – Photocopies of Final Court Orders
with the presiding judge’s signature and
seal. Documents must attest to the legal
guardianship by the covered employee.
Dependent
Children With
Disabilities
If a covered child is not capable of
self-support when he or shereaches
age 26 due to mental illness or
incapacity, or a physical disability,
the child may be eligible for a
continuance of coverage.
See “Dependent Children with
Disabilities” in this Guidebook for
additional information. You will be
contacted periodically to verify
that the child remains eligible for
continued coverage.
Documentation for the appropriate “Child”
type (as noted above), and a photocopy of
the front page of the child’s most recently
led federal tax return* (Form 1040), and if
the child resides outside of the State of New
Jersey, documentation of full time student
status must be submitted.
Continued
Coverage
for Over Age
Children
Certain children over age 26 may
be eligible for continued coverage
until age 31 under the provisions
of Chapter 375, P.L. 2005. See
“Over Age Children until Age 31”
in this Guidebook for additional
information.
Documentation for the appropriate “Child”
type (as noted above), and a photocopy of
the front page of the child’s most recently
led federal tax return* (Form 1040), and if
the child resides outside of the State of New
Jersey, documentation of full time student
status must be submitted.
*Note: On tax forms, you may black out all nancial information and all but the last 4 digits of any Social Security numbers.
**Or a National Medical Support Notice (NMSN) if you are the non-custodial parent and are legally required to provide coverage for the child as a result of the
NMSN.
New Jersey residents can obtain records from the State Bureau of Vital Statistics and
Registration Web site: www.state.nj.us/health/vital/index.shtml To obtain copies of other
documents listed on this chart, contact the ofce of the Town Clerk in the city of the birth
marriage, etc., or visit these Web sites: www.vitalrec.com or www.studentclearinghouse.org
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APPENDIX V | SEHBP Member Guidebook 2024
APPENDIX V
Health Insurance Portability And Accountability Act
The SEHBP Health Plans meet the federal Health Insurance Portability and Accountability Act
(HIPAA) of 1996 requirements.
Certication of Coverage
A Certication of Coverage form, which veries your SEHBP group health plan enrollment
and termination dates, is available through your payroll or human resources ofce, should you
terminate your coverage.
HIPAA Privacy
The SEHBP make every effort to safeguard the health information of their members and
comply with the privacy provisions of HIPAA, which requires that health plans maintain the
privacy of any personal information relating to its members’ physical or mental health. See the
Notice of Privacy Practices section of this Guidebook.
APPENDIX VI
Notice Of Privacy Practices to Enrollees In The New Jersey School
Employees’ Health Benets Program
This notice describes how medical information about you may be used and disclosed and
how you can get access to this information. Please review it carefully.
Protected Health Information
School Employees’ Health Benets Program (SEHBP) are required by the federal Health
Insurance Portability and Accountability Act (HIPAA) and State laws to maintain the privacy
of any information that is created or maintained and relates to your past, present, or future
physical or mental health. This Protected Health Information (PHI) includes information
communicated or maintained in any form. Examples of PHI are your name, address, Social
Security number, birth date, telephone number, fax number, dates of health care service,
diagnosis codes, and procedure codes. PHI is collected through various sources, such as
enrollment forms, employers, health care providers, federal and State agencies, or third-party
vendors.
The SEHBP are required by law to abide by the terms of this Notice. The SEHBP reserve the
right to change the terms of this Notice. If the SEHBP make material change to this Notice, a
revised Notice will be sent.
Uses and Disclosures of PHI
The SEHBP is permitted to use and to disclose PHI in order for our members to obtain
payment for health care services and to conduct the administrative activities needed to run
programs without specic member authorization. Under limited circumstances, we may be
able to provide PHI for the health care operations of providers and health plans. Specic
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APPENDIX VI | SEHBP Member Guidebook 2024
examples of the ways in which PHI may be used and disclosed are provided below. This list is
illustrative only and not every use and disclosure in a category is listed.
• The SEHBP may disclose PHI to a doctor or a hospital to assist them in providing a member
with treatment.
• The SEHBP may use and disclose member PHI so that our Business Associates may pay
claims from doctors, hospitals, and other providers.
• The SEHBP receives PHI from employers, including the member's name, address, Social
Security number, and birth date. This enrollment information is provided to our Business
Associates so that they may provide coverage for health care benefits to eligible members.
• The SEHBP and/or our Business Associates may use and disclose PHI to investigate a
complaint or process an appeal by a member.
• The SEHBP may provide PHI to a provider, a health care facility, or a health plan that is not
our Business Associate that contacts us with questions regarding the member's health care
coverage.
• The SEHBP may use PHI to bill the member for the appropriate premiums and reconcile
billings we receive from our Business Associates.
• The SEHBP may use and disclose PHI for fraud and abuse detection.
• The SEHBP may allow use of PHI by our Business Associates to identify and contact our
members for activities relating to improving health or reducing health care costs, such as
information about disease management programs or about health-related benefits and
services or about treatment alternatives that may be of interest to them.
• In the event that a member is involved in a lawsuit or other judicial proceeding, the SEHBP
may use and disclose PHI in response to a court or administrative order as provided by law.
• The SEHBP may use or disclose PHI to help evaluate the performance of our health plans.
Any such disclosure would include restrictions for any other use of the information other than
for the intended purpose.
• The SEHBP may use PHI in order to conduct an analysis of our claims data. This information
may be shared with internal departments such as auditing or it may be shared with our
Business Associates, such as our actuaries.
Except as described above, unless a member specically authorizes us to do so, the SEHBP
will provide access to PHI only to the member, the member’s authorized representative,
and those organizations who need the information to aid in the conduct of business (our
“Business Associates"). An authorization form may be obtained over the Internet at:
member may revoke an authorization at any time.
Restricted Uses
• PHI that contains genetic information is prohibited from use or disclosure by the Programs
for underwriting purposes.
• The use or disclosure of PHI that includes psychotherapy notes requires authorization from
the member.
When using or disclosing PHI, the SEHBP will make every reasonable effort to limit the use or
disclosure of that information to the minimum extent necessary to accomplish the intended
purpose. The SEHBP maintain physical, technical, and procedural safeguards that comply
with federal law regarding PHI. In the event of a breach of unsecured PHI, the member will be
notied.
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APPENDIX VI | SEHBP Member Guidebook 2024
Member Rights
Members of the SEHBP have the following rights regarding their PHI.
Right to Inspect and Copy: With limited exceptions, members have the right to inspect
and/or obtain a copy of their PHI that the SEHBP maintains in a designated record set which
consists of all documentation relating to member enrollment and the use of this PHI for claims
resolution. The member must make a request in writing to obtain access to their PHI. The
member may use the contact information found at the end of this Notice to obtain a form to
request access.
Right to Amend: Members have the right to request that the SEHBP amend the PHI that we
have created and that is maintained in our designated record set.
We cannot amend demographic information, treatment records or any other information
created by others. If members would like to amend any of their demographic information,
please contact your personnel ofce. To amend treatment records, a member must contact the
treating physician, facility, or other provider that created and/or maintains these records.
The SEHBP may deny the member's request if: 1) we did not create the information requested
on the amendment; 2) the information is not part of the designated record set maintained by
the SHBP or SEHBP; 3) the member does not have access rights to the information; or 4) we
believe the information is accurate and complete. If we deny the member’s request, we will
provide a written explanation for the denial and the member's rights regarding the denial.
Right to an Accounting of Disclosures: Members have the right to receive an accounting of
the instances in which the SEHBP, or our Business Associates have disclosed member PHI. The
accounting will review disclosures made over the past six years. We will provide the member
with the date on which we made a disclosure, the name of the person or entity to whom we
disclosed the PHI, a description of the information we disclosed, the reason for the disclosure,
and certain other information. Certain disclosures are exempted from this requirement
(e.g., those made for treatment, payment or health benets operation purposes or made in
accordance with an authorization) and will not appear on the accounting.
Right to Request Restrictions: The member has the right to request that the SEHBP place
restrictions on the use or disclosure of their PHI for treatment, payment, or health care
operations purposes. The SEHBP is not required to agree to any restrictions and in some
cases will be prohibited from agreeing to them. However, if we do agree to a restriction, our
agreement will always be in writing and signed by the Privacy Ofcer. The member request for
restrictions must be in writing. A form can be obtained by using the contact information found
at the end of this Notice.
Right to Restrict Disclosure: The member has the right to request that a provider restrict
disclosure of PHI to the Program s or Business Associates if the PHI relates to services or a
health care item for which the individual has paid the provider in full. If payment involves a
exible spending account or health savings account, the individual cannot restrict disclosure of
information necessary to make the payment but may request that disclosure not be made to
another program or health plan.
Right to Receive Notication of a Breach: The member has the right to receive notication in
the event that the Programs or a Business Associate discover unauthorized access or release of
PHI through a security breach.
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APPENDIX VI | SEHBP Member Guidebook 2024
Right to Request Condential Communications: The member has the right to request that
the SEHBP communicate with them in condence about their PHI by using alternative means
or an alternative location if the disclosure of all or part of that information to another person
could endanger them. We will accommodate such a request if it is reasonable, if the request
species the alternative means or locations, and if it continues to permit the SEHBP to collect
premiums and pay claims under the health plan.
To request changes to condential communications, the member must make their request
in writing, and must clearly state that the information could endanger them if it is not
communicated in condence as they requested.
Right to Receive a Paper Copy of the Notice: Members are entitled to receive a paper copy
of this Notice. Please contact us using the information at the end of this Notice.
Questions and Complaints
If you have questions or concerns, please contact the SEHBP using the information listed at
the end of this Notice.
If members think the SEHBP may have violated their privacy rights, or they disagree with a
decision made about access to their PHI, in response to a request made to amend or restrict
the use or disclosure of their information, or to have the SEHBP communicate with them in
condence by alternative means or at an alternative location, they must submit their complaint
in writing. To obtain a form for submitting a complaint, use the contact information found at
the end of this Notice. Members also may submit a written complaint to the U.S. Department
of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.
The SEHBP support member rights to protect the privacy of PHI. It is your right to le a
complaint with the SEHBP, or with the US Department of Health and Human Services.
Contact Ofce:
Division of Pensions & Benets — HIPAA Privacy Ofcer
Address:
State of New Jersey
Department of the Treasury
Division of Pensions & Benets
PO Box 295
Trenton, NJ 08625-0295
E-mail: [email protected]
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APPENDIX VII | SEHBP Member Guidebook 2024
APPENDIX VII
Health Benets Program Contact Information
SEHBP — Horizon Blue Cross Blue Shield of New Jersey
Mailing Address:
Horizon BCBSNJ
PO Box 820
Newark, NJ 07101-0820
Internet Address: HorizonBlue.com/shbp
Division of Pensions & Benets — Health Benets Bureau
Mailing Address:
Health Benets Bureau Division of Pensions & Benets
PO Box 299
Trenton, NJ 08625-0299
Internet Address: www.nj.gov/treasury/pensions/
E-mail Address: pensions.nj@treas.nj.gov
Please indicate on all correspondence whether you are a SHBP or SEHBP member
Telephone Numbers SEHBP
Horizon Blue Cross Blue Shield of New Jersey 1-800-414-SHBP (7427)
Division of Pensions & Benets:
Ofce of Client Services and Automated Information System (609) 292-7524
TDD Phone (Hearing Impaired) (609) 292-6683
State Employee Advisory Service (EAS) 24 hours a day 1-866-327-9133
New Jersey State Police
Employee Advisory Program (EAP) 1-800-FOR-NJSP
Rutgers University Personnel Counseling Service
Employee Advisory Program(EAP) (732) 932-7539
New Jersey Department of Banking and Insurance
Individual Health Coverage Program Board 1-800-838-0935
Consumer Assistance for Health Insurance (609) 292-5316 (Press 2)
New Jersey Department of Human Services
Pharmaceutical Assistance to the Aged and Disabled (PAAD) 1-800-792-9745
New Jersey Department of Health and Senior Services
Division of Aging and Community Services 1-800-792-882 0
Insurance Counseling 1-800-792-8820
Independent Health Care Appeals Program (609) 633-0660
Centers for Medicare and Medicaid Services
New Jersey Medicare — Part A and Part B 1-800-Medicare
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APPENDIX VII | SEHBP Member Guidebook 2024
Health Benets Program Publications
Fact sheets, guidebooks, and other publications are available for viewing or printing over the
Internet at: www.nj.gov/treasury/pensions
General Publications
Summary Program Description booklet — an overview of the SHBP and SEHBP
Plan Comparison Summary — Out-of-pocket cost comparison charts for State employees,
local government employees, local education employees, and all retirees.
Health Benets Coverage - Enrolling as a Retire
Health Benets Program and Medicare Parts A & B for Retirees
COBRA – The Continuation of Health Benets
Termination of Employment through Resignation, Dismissal, or Layoff
Dental Plans – Active Employees
Health Benets Retired Coverage under Chapter 330
Health Benets Coverage Continuation for Over Age Children with Disabilities
Health Benets Coverage for Part-Time Employees
SHBP Coverage for State Intermittent Employees
Dental Plans-Retirees
Health Benet Coverage of Children until Age 31 under Chapter 375
Civil Unions and Domestic Partnerships
Member Guidebooks
SHBP Member Guidebook
SEHBP Member Guidebook
Horizon HMO Member Guidebook
Horizon HDHP Member Guidebook
Horizon OMNIA Member Guidebook Tiered-Network Plan
Prescription Drug Plans Member Guidebook
Employee Dental Plans Member Guidebook
Retiree Dental Plans Member Guidebook
SEHBP Member Guidebook
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