School Employees Health Benefits Program (SEHBP)
Medical coverage is provided under the School Employees Health Benefits Program (SEHBP). The plan provides coverage for the employee, spouse, children until age 26, and children over age 26 who may have mental or physical challenges. Effective June 28, 2011, (Chapter 78 P.L. 2011) employees are required to contribute a certain percentage of income towards their medical insurance premiums. The rate of contribution varies by income.
Full-time employees are eligible for coverage 60 days from date of hire. Employees may choose from the following options:
- Health Maintenance Organizations (HMOs): When you enroll in an HMO you select a Primary Care Physician (PCP) from a group of participating providers contracted by the HMO. All services other than emergencies are coordinated through the PCP. The co-payment for HMO in-network primary doctor visits and visits to a referred specialist is $10. You have a choice of two HMOs: Aetna HMO and Horizon HMO.
- Preferred Provider Organizations (PPOs): These plans provide both in network and out-of-network medical services. You are not required to choose a Primary Care Physician and do not need a referral for in-network services. You have a choice of three PPO plans: NJ Direct 10, NJ Direct 15 and Aetna Freedom.
- The copayment for NJ DIRECT10 in-network primary doctor visits and visits to a network specialist is $10. Most out-of-network services are reimbursable at 80% of the “reasonable and customary” allowance after deductibles are met.
- The copayment for NJ DIRECT15 in-network primary doctor visits and visits to a network specialist is $15. Most out-of-network services are reimbursable at 70% of the “reasonable and customary” allowance after deductibles are met.
To view or download a copy of the NJ Direct Member Handbook, click here.
For changes to health coverage, the open enrollment is October of each year for a January 1 effective date.
For a Plan Comparison Summary click here.
|For more information on these plans you may visit the State website at: