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Medical & Hospitalization Benefits

Medical & Hospitalization Benefits

 

NJ DIRECT-10 Plan Summary
School Employee Health Benefit Program
Local Education Employees / Retirees

 

In-Network

Out-of-Network

Lifetime Maximum

Unlimited

Unlimited

Annual Deductible (Jan 1st - Dec 31st)

 

 

Hospital/Facility

None

$100 per individual / $250 per family

Professional

None

$100 per individual / $250 per family

Annual Out-of-Pocket Maximum:

 

 

Single

$400

$2,000

Family

$1,000

$5,000

Preventive Care

$10 co-pay

Deductible & 80%

Office Visits

$10 co-pay

Deductible & 80%

Maternity Care

100%

Deductible & 80%

Maternity Hospital Care

100%

Deductible & 80%

Medical Emergency

$25 co-pay

Deductible & 80%

Supplemental Services

 

 

Oxygen & Administration

90%; no co-payment

Deductible & 80%

Private Duty Nursing

90%; no co-payment

Deductible & 80%

Blood Charges

90%; no co-payment

Deductible & 80%

Durable Medical Equipment

90%; no co-payment

Deductible & 80%

 

 

 

Other Medical Plan Choices

School Employee Health Benefit Program

Local Education Employees / Retirees

AETNA HMO

1-877-782-8365

http://www.aetna.com/statenj

NJ DIRECT-15

1-800-414-7427

http://www.horizonblue.com/shbp

Types of Insurance Available Semi-Monthly Payroll/Premium Deductions

Single (Employee Only)
Member & Spouse (Partner)
Family Coverage
Parent and Child Coverage

Due to the changes to Health Insurance per Chapter 2 P.L. 2010 that are charged vary with each employee. Please check with Personnel for the cost of insurance. Premiums change every January 1st.

 A.  Open Enrollment - questions, call ext. 3102


 Open enrollment is held every October with any changes effective January 1st of the next year.  There is a 60 day waiting period for all new employees.
* Please note-If you have a dependent that has turned 23 during the year, they will automatically be continued on the medical and prescription coverage until age 26 but if you want your dependent to continue the dental insurance, they have to apply for COBRA Coverage.  They must apply no later than 60 days after the end of the year.

B.  Medical Hospitalization Coverage - questions call ext. 3102

There are many plans within the State Health Benefits that are available to all employees.  See the State Website for all of your options.

Health Benefits Rates and Information - 2017-2018

C.  Prescription Plan - questions call ext. 3102 or

https://www.express-scripts.com/index.html

The Board of Education shall provide a prescription drug insurance plan.  The co-pay is $5.00 generic mail-in, $15.00 brand name mail-in(90 day supply), $3.00 for all generic claims retail and $10.00 for allbrand name claims retail with no annual deductible.  The Board reserves the right to change the current carrier for a comparable program from another provider.  Separate cards are issued for the prescription plan.

D.  Dental Plan - questions call ext. 3102

    For more information please go to Horizon: www.horizonblue.com/members/plans-services/horizon-dental

1.  The Board of Education provides for a Dental Plan with HorizonBlue Cross Blue Shield of New Jersey.  Dependents including theemployee's spouse and children are also covered.  These four types ofcoverage:

         Single      Employee/Spouse/Partner      Parent/Child      Family
    a)  Dependents are covered as detailed under medical coverage.
    b)  Cards are issued for Dental coverage.

2.   A child with a mental or physical disability may be continued in this program after the age of 23 as long as he/she remains incapacitated and unmarried, subject to the continuance of the employee'sown coverage in this program.

3.   Claim forms are available in the Personnel Office or at the office of the building principal.

4. The Dependents to age 31 program does not apply to Dental coverage.

E.   Dependent Eligibility Age

1.  Children are eligible until age 26 for medical and prescription coverage based on the provisions of the Federal Patient Protection and Affordable Care Act (PPACA):

  • A "child" is defined as an enrollee's child until age 26, regardless of the child's marital, student, or financial dependency status - even if the young adult no longer lives with his or her parents.
  • Coverage will be extended to eligible children through December 31 of the year they turn age 26.

2.  After the age of 26, dependents are eligible for the Dependent to Age 31 Program (Chap 375) for medical and prescription only, dental is excluded.  Dependents can stay on this group until they turn 31 (specifically the 1st of the month following their 31st birthday). They can also enroll later if they lose coverage elsewhere as long as the parent is enrolled in our group.  The monthly premium for the dependent to age 31 group is approximately 60% of the single premium for medical and prescription program.

To be eligible for the Dependent to Age 31 Program, the dependent must be:

  • Unmarried
  • Have no children
  • Live in New Jersey or is a full-time student at an accredited college out of New Jersey
  • Must be under the age of 31
  • Is not provided coverage as a subscriber, insured enrollee or covered person under a group or individual health benefits plan or church plan
  • Not entitled to benefits under Medicare
  • You must attach a copy of the transcript from an accredited public or private college if attending college to the application
  • You must attach a copy of the birth certificate to the application
  • You must attach a copy of the HIPAA Certificate (proof of coverage through previous insurer) to the application

3.  Dependents are covered under dental until the end of the year in which they turn 23.  After the age of 23 dependents are eligible for dental under COBRA, and the dental can be continued for up to 36 months only.  The monthly premium for the dental is 102% ofthe single dental premium.  Application for COBRA dental must be made with 60 days of the end of the year in which the dependent turns 23.

F.   COBRA - Questions call ext. 3102

The Federal Consolidated Omnibus Budget Reconciliation Act of 1985,(COBRA), gives employees, spouses, and dependent children currently enrolled under the Township of Ocean Board of Education's health benefits program, the opportunity to purchase continued health benefits for a limited period of time after a COBRA qualifying event occurs - (18 months for employee, 36 months for dependents).  COBRA applies to employees and dependents who would otherwise lose coverage as a result of a COBRA qualifying event.

It is the responsibility of the employee to notify Patty DeAngelis for medical prescription and dental of a COBRA event as listed in items 3,5, and 6 (above) within 60 days of the event.  The COBRA participant pays 100% of the cost plus an additional 2% administrative fee.

A qualifying event (changes) such as marriage, birth of a child, divorce, separation, number of dependents, or child attaining age26 must be reported to Patty DeAngelis within 30 days of the event for change in coverage to take effect.

G.   HIPAA - questions call ext. 3102

      HIPAA:  The privacy and security of medical records of eachindividual employed with the Township of Ocean School District isguaranteed under the federal and state HIPAA legislation.  This meansthat any and all medical providers, insurance companies, and the OceanTownship School District must protect your right to medical privacy. 
You can go to the website:
http://www.state.nj.us/humanservices/home/DHS-npp_hc_provider-text_version_revised.pdf

 for more complete information about this legislation.