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

NJ DIRECT Open Enrollment

Open enrollment is scheduled from October 1, 2008 to October 31, 2008 for the plans offered by the State Health Benefits Program (SHBP) and the School Employees' Health Benefits Program (SEHBP). The medical plans administered by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) are NJ DIRECT10 and NJ DIRECT15.

NJ DIRECT offers you in-network benefits nationwide without referrals for specialty services. Under NJ DIRECT, you can directly access physicians and hospitals without having to choose a Primary Care Physician (PCP). You will also have access to the national BlueCard^® PPO network outside of New Jersey.

Prescription Drug Coverage – All NJ DIRECT members have prescription drug coverage through the Active Employee Prescription Drug Plan, NJ DIRECT or a private prescription drug plan. Please refer to the Member Handbook for more details about prescription drug coverage.

Easy Service – NJ DIRECT members have access to toll-free customer service Monday through Friday, 8 a.m. to 6 p.m., Eastern Time, to get the help they need. Members also have access to our interactive Member website, www.HorizonBlue.com/shbp, to look up a claim status and enjoy other online services to make their health care experience more satisfying. Here are a few examples of self-service features available: participating physician and hospital search, eligibility confirmation, ID card requests, visit My Health Manager, view claims and print a statement of claim payments.

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 New Jersey 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)

Frequently Asked Questions

When will my new benefits become effective?
Coverage changes made during Open Enrollment will become effective January 1, 2009 for all State, Local Government and Local Education employees and January 3, 2009 for State employees paid by the State's Centralized Payroll.

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

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. (Certification 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 and imaging procedures such as: CT/CTA scans, MRI/MRA/PET scans and nuclear medicine; nuclear cardiology, echo stress tests, and diagnostic left heart catheterization.

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 is available in the NJ DIRECT Member Handbook, which is located on the SHBP/SEHBP website.

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.

What if I don't receive my NJ DIRECT ID card by the effective date of my coverage?
You can print a copy of a Coverage Letter from Member Online Services at www.horizonblue.com/shbp/self_service.asp 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 or access the SHBP/SEHBP web site here.