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Medical Plans
Eligibility to Enroll in the State Health Benefits Program
- Regularly appointed full-time employees (100%) with an appointment of 12 months or greater for calendar year employees or 10-months for Academic Year employees
- Legal spouse
- Same-sex domestic partner or civil union partner
- Eligible children under age 26 (including stepchildren, foster children, adopted children or children an employee is legally required to support)
When Coverage Begins
- Academic year 10-month employees with September 1 hire date = September 1 effective date
- All other employees, effective after 2 months of continuous employment, i.e., August 15 hire date = October 15 effective date
As an eligible employee, you can choose medical coverage from a selection of plans in two categories:
- NJ DIRECT (administered by Horizon Blue Cross Blue Shield of New Jersey)
- One of two Health Maintenance Organizations (HMOs)
NJ DIRECT (PPO)
- Benefits fall into two categories: services from preferred providers and those provided by non-preferred providers
- Preferred provider benefits are paid after required copay
- Non-preferred provider benefits require members to meet an annual deductible. After deductibles are met, covered claims are paid of the “reasonable and customary” allowance for most services
- Members are not required to choose a primary care physician and do not need to obtain referrals
- Certain preventative care such as annual exams, well-baby care, and certain screenings will be covered with no cost sharing
- A nationwide network of providers is available
Health Maintenance Organizations (HMO)
- Separate HMO plans administered by Aetna and CIGNA
- HMOs cover a wide range of services for preventative and diagnostic care
- Both HMO plans have a unique nationwide directory of participating providers
- Select a Primary Care Physician (PCP) to coordinate your health care
- The PCP will issue a referral if you need to see a network specialist as part of your treatment
- No deductibles or claim forms
- Standard copayments required for services
Available Plans:
NJ Direct 15, Aetna HMO, CIGNA HMO
- $15 Primary Care copay
- $15 Specialist Care copay
- $50 Emergency care copay
NJ Direct 1525, Aetna 1525, Cigna 1525
- $15 Primary Care copay
- $25 Specialist Care copay
- $75 Emergency Care copay
NJ Direct 2030, Aetna 2030, Cigna 2030
- $20 Primary Care copay
- $30 Specialist Care copay ($20 copay for children up to the 19th birthday)
- $125 Emergency Care copay
NJ Direct HD 4000, Aetna HD 4000, Cigna HD 4000
- $4000 Individual In-Network deductible
- $8000 In-Network deductible Employee + 1 or more dependents
- $20% coinsurance after deductible is satisfied
- $1,000 In-Network Individual Out-of-Pocket Maximum
NJ Direct HD 1500, Aetna HD 1500, Cigna 1500
- $1500 Individual In-Network deductible
- $3000 In-Network deductible Employee + 1 or more dependents
- $20% coinsurance after deductible is satisfied
- $1,000 In-Network Individual Out-of-Pocket Maximum ($2000 Family)
- $300 employer funded Health Savings Account
Preventive Services, Immunizations and Certain Screenings
Under the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation (HCR) Acts, certain preventive care, such as immunizations (age and population restrictions may apply), certain screenings (blood pressure, cholesterol, depression, newborn, etc.), FDA-approved contraceptive methods, and well-baby care, will be covered by all of the SHBP medical plans without member cost sharing.
As a result, primary care well visits (annual exams) will no longer require a copayment or coinsurance by the member for certain wellness services provided by an in-network provider. However, if the preventive service is not the primary reason for the office visit, the member may still be responsible for a copayment or coinsurance. Contact your medical provider or plan for more information.
| Provider Phone Numbers | |
| NJ DIRECT (PPO) | 800-414-7427 |
| Aetna (HMO) | 877-STATE NJ |
| CIGNA Healthcare (HMO) | 800-564-7642 |
