Horizon Blue Cross Blue Shield of New Jersey - State Health Benefits Program

Frequently Asked Questions for 2008 Special Open Enrollment

A special open enrollment is scheduled for 2008 to introduce new plans to be offered by the State Health Benefits Program (SHBP). The new medical plans administered by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) are NJ DIRECT10 and NJ DIRECT15.

NJ DIRECT combines some of the best elements of the prior NJ PLUS and the Traditional Plan – giving you in-network benefits nationwide all without referrals for specialty services. Under NJ DIRECT, you can directly access physicians and hospitals without having to choose a Primary Care Physician (PCP). If you were previously enrolled in NJ PLUS, you will have access to the same network in New Jersey, but you will also have access to the national BlueCard^® PPO network outside of New Jersey.

NJ DIRECT offers you in-network benefits that include:

A copayment for most in-network services ($10 copayment under NJ DIRECT10 and $15 copayment under NJ DIRECT15)
Access to participating physicians, specialists, hospitals, and other health care professionals (same as the NJ PLUS network in New Jersey, plus ~600,000 BlueCard^® PPO providers outside of New Jersey)
A choice of physicians and hospitals without having to choose a PCP
No referrals for specialty care
Lower out-of-pocket costs and higher plan benefits when using NJ DIRECT participating providers in NJ and BlueCard^® PPO providers outside of New Jersey
Preventive services (physical exams, well-child care and immunizations) in network
No claims to file
Access to Health & Wellness Education Programs
Access to CareWise^® (24-hour nurse phoneline) and PRECIOUS ADDITIONS^® (prenatal education and information)

In addition, NJ DIRECT provides you with out-of-network benefits:

Access to licensed health care providers that do not participate in NJ DIRECT or the BlueCard^® PPO network
NJ DIRECT10 provides for reimbursement for out-of-network coverage at 80 percent of the reasonable and customary fee schedule after deductible for most services, while NJ DIRECT15 provides for out-of-network coverage at 70 percent of the reasonable and customary fee schedule after deductible for most services
Access to Health & Wellness Education Programs
Access to CareWise^® (24-hour nurse phoneline)

NJ DIRECT Frequently Asked Questions

When will my new benefits become effective?
Benefits for State Monthly, Local Government, Local Education and all retirees will be effective 4/1/08. Benefits for State Biweekly employees will be effective 3/29/08.

How are NJ DIRECT benefits different from NJ PLUS and the Traditional Plan?
Under NJ DIRECT, members can directly access physicians and hospitals without having to choose a PCP. You will have the same access to participating physicians, specialists, hospitals and other health care professionals (same network as NJ PLUS) in New Jersey. In addition, NJ DIRECT members will now have access to the National BlueCard^® PPO network of providers outside of New Jersey.

If you had the Traditional Plan previously, NJ DIRECT is similar to the Traditional Plan because it will still allow you to use out-of-network services. In addition, if you receive eligible services from a participating provider, you will now only pay a copayment for most services (this includes physical exams, well-child care and immunizations which are covered on an in-network basis).

When will I receive my open enrollment information?
Open enrollment materials will be available in conjunction with the SHBP Special Open Enrollment period that will be from January 28 through February 15, 2008.

Will I need to select a Primary Care Physician (PCP)?
No, you will not need to select a PCP as part of either NJ DIRECT10 or NJ DIRECT15.

Will I need a referral from a PCP to see a specialist?
No, you will not need a referral from a PCP to see a specialist. (Certifications will be required for some services.)

If I receive emergency treatment, must I call NJ DIRECT member services within 24 hours?
No; NJ DIRECT doesn’t require you to contact member services for emergency treatment.

Are routine services covered?
NJ DIRECT will offer physical exams, well-child care and immunizations in-network. You must utilize a participating physician in order to receive the in-network benefit. A limited number of routine services will also be covered out of network.

Will NJ DIRECT use Magellan Behavioral Health for precertification of mental health/behavioral health services?
Yes, NJ DIRECT will use Magellan Behavioral Health for precertification of all mental/behavioral health services.

Will NJ DIRECT use CareCore National, LLC (CCN) for precertification of all advanced radiological procedures?
Yes, NJ DIRECT will use CareCore for precertification of all advanced radiological procedures.

Will NJ DIRECT require precertification for certain services?
Yes, precertification will be required for certain services. Examples are Durable Medical Equipment; Inpatient admissions; Home Health Care; Cognitive, Physical, Occupational and Speech Therapies, Reconstructive Procedures that may be considered Cosmetic; Specialty Pharmaceuticals; Surgery for Morbid Obesity; and Transplants. A complete list will be available in the NJ DIRECT Member Handbook.

How do I know if my physicians participate in NJ DIRECT?
Click here and you will be directed to the NJ DIRECT provider directory page where you can print a personalized provider directory or search for specific providers by name or by specialty.

Are members and their dependents able to obtain in-network benefits while outside of New Jersey?
With NJ DIRECT, you and your dependents will have access to in-network benefits through the national BlueCard^® PPO provider network outside of New Jersey. Click here to find participating providers in and out of New Jersey.

Must I use a physician or hospital in the NJ DIRECT network or BlueCard^® PPO network?
No; you may use your out-of-network benefits, which offer care from any eligible physician or hospital outside the NJ DIRECT or BlueCard^® PPO network in exchange for higher out-of-pocket costs. Out-of-network benefits require a deductible and coinsurance (and may be subject to balance billing), while members using in-network benefits will only be responsible for a copayment, for most services.

What is the in-network copayment under NJ DIRECT?
If you select NJ DIRECT15, your office visit copayment will be $15. If you select NJ DIRECT10, your copayment will be $10. Your ID card will indicate the appropriate copayment amount.

Will I have a deductible with NJ DIRECT?
For in-network services, you will not be responsible for a deductible. For any services provided out of network, coinsurance and deductible will apply.

What are the out-of-network benefits?
NJ DIRECT10 provides reimbursement for out-of-network coverage at 80 percent of the reasonable and customary fee schedule after deductible, for most services, while NJ DIRECT15 provides reimbursement for out-of-network coverage at 70 percent of the reasonable and customary fee schedule after deductible for most services. (Detailed benefit information will be provided during your open enrollment period.)

I have surgery or a procedure scheduled after 4/1/08 and already received authorization from my prior plan. Do I need to receive authorization again?
If you received authorization from NJ PLUS or the Traditional Plan, you need not provide NJ DIRECT with any documentation. If you received authorization from a health plan other than NJ PLUS or the Traditional Plan, we will require a letter from the prior carrier that documents the authorization number, authorization date, rendering physician name and services authorized. NJ DIRECT’s policy is that we will honor a prior plan’s authorization for up to six months from the date of authorization.

Will I receive a new ID card?
Yes, new ID cards will be issued to NJ DIRECT members.

Will my ID number change?
If you are changing to NJ DIRECT from NJ PLUS or the Traditional Plan, you will receive a new ID card with a different alpha prefix than your current ID card. The new alpha prefix is NJX. However, the numeric portion of the ID number will remain the same.

When should I expect to receive my new NJ DIRECT ID card?
NJ DIRECT ID cards will be mailed in mid to late March 2008. The cards will be issued in the name of the employee. Single coverage policies will receive one ID card and all others (employee plus spouse/partner, family) will receive two cards. Additional cards can be requested, if needed.

What if I don't receive my NJ DIRECT ID card by the April 2008 effective date?
You can print a copy of a Coverage Letter from Member Online Services at www.horizonblue.com/shbp to give to your physician. The Coverage Letter is good for 10 days from when it is printed.

Where can I find more information?
In addition to the information provided on this website, you can call SHBP Member Services at 1-800-414-SHBP (7427) for information on NJ DIRECT benefits or participating provider information.

I received a postcard/brochure in the mail. What do I do?
The material you received gives you more information about NJ DIRECT. There will be a SHBP Special Open Enrollment. Please refer to a Guide to Choosing a SHBP Health Plan newsletter for more information on the automatic plan assignments and enrollment guidelines.

All current Traditional Plan and NJ PLUS members, as well as Amerihealth, Health Net and Oxford members, will be assigned to one of the NJ DIRECT plans as outlined in the Guide.

Current Horizon SHBP members may receive a solicitation from Aetna HMO or Cigna Healthcare (HMO) before or during the open enrollment. This solicitation does not impact your eligibility for NJ DIRECT. All current Traditional Plan and NJ PLUS members, as well as Amerihealth, Health Net and Oxford members, will be assigned to one of the NJ DIRECT plans unless a SHBP application is submitted to report another election.