State Health Benefits Program

2019-2023 EXECUTIVE BRANCH STATE WORKER CONTRACT INFORMATION AND HEALTH BENEFIT RESOURCES

CWA PPO PLAN DOCUMENTS

Direct Primary Care

Better Care at a Reduced Cost

The State Health Benefits Program (SHBP) introduced the Direct Primary Care pilot program focused on to provide quality health care while reducing health care costs for union members and their families!

Any active SHBP member in a PPO or tiered network plan can join the Direct Primary Care program. You can join anytime during the year— not just during open enrollment.

When you visit a Direct Primary Care facility, you will pay absolutely NO COPAYS no matter how many times you see the doctor. It provides:

  • Unlimited access to a personal physician for members and their families.
  • Same-day and next-day appointments
  • Evening and weekend hours
  • Longer appointments
  • Little to no time in the waiting room
  • Access to the doctor via cell phone, e-mail, and digital messaging
  • On-site lab draws at no cost.
  • On-site dispensing of a 7-day supply of medications for acute conditions at no additional cost to you
  • On-site immunizations at no cost.

This care is all provided at NO COST with no co-pay or deductible and works with your current health plan. No need for you to change plans— just your doctor.

TIERED NETWORK INCENTIVES CONTINUE

Both Horizon and Aetna have designed specific tiered networks for the State Health Benefits Plan— Horizon OMNIA and Aetna LIBERTY.  If you choose to go into either of these plans, your premium will drop by 25%. If you are a state employee (or a local government employee where the union has negotiated incentives), you will also receive an incentive rebate of $1000 for single coverage, $1500 for Parent-Child or Spouse coverage, and $2000 for Family Coverage. This incentive is paid by gift card within the first quarter of Plan Year 2018, and is deemed reportable income for tax purposes.

Before you switch plans to Omnia or Liberty, please research your doctors and hospitals carefully. You will save if you go to Tier 1 providers but you could pay more if you go to Tier 2 providers. You must use doctors and hospitals that are in the plans.  If you use a Tier 1 doctor or hospital, you will have a $5 copay for a primary physician and a $15 copay for a specialist.  If you use a Tier 2 doctor or hospital, you will have a deductible and 70% will be paid for. BUT— except for emergencies or if you are out of state— if you voluntarily go to a doctor or practice that isn’t in Tier 1 or 2 it won’t be covered.

You are okay if it is emergency services in or out of state – then it is treated as Tier 1.

If you have a doctor that you are very attached to, who is not a Tier 1 doctor and who does not use a Tier 1 hospital, CWA does not recommend that you switch to a tiered network plan. (But check – because if your doctor or hospital isn’t in Horizon’s Omnia, s/he or it may be in Aetna’s Liberty.)

If your doctor is in the Tiered Network, and if you can use Tier 1 doctors and hospitals, you will save a great deal of money.  (Please note: the Tiered network charges $7 generic and $16 brand for prescription copays which may be slightly higher than your copays in a Direct plan.) You can check and see if your doctor(s)/ hospitals are in Aetna Liberty at aetna.com/docfind/custom/statenj and Horizon Omnia at doctorfinder.horizonblue.com.

To find out more about the Tiered Networks, go here: http://www.nj.gov/treasury/pensions/hb_open_enrollment_2016/sbc/sbc019.pdf and here: http://www.nj.gov/treasury/pensions/hb_open_enrollment_2016/sbc/sbc020.pdf

COMBINE DIRECT PRIMARY CARE WITH A TIERED NETWORK PLAN

THE SWEET SPOT— See if you can combine the DPCMH with a Tiered Network plan. EVERY primary care doctor who is in R-Health or Paladina practices is automatically a Tier 1 doctor in the Tiered Network plans. If you switch to the Tiered Network and combine it with the DPCMH, you would save 25% off of your premium, you would get the $1000 – $2000 incentive, and you would get CONCIERGE primary health care with no co-pays, no gate keeper, in office lab draws, no wait times, and a personal physician who you and your family can develop a relationship with.This incentive is paid by gift card within the first quarter of Plan Year 2017, and is deemed reportable income for tax purposes.

NJ WELLNESS

“I like my doctor and I want to stay in the Direct 15 plan. Is there anything that I can do to save money?”

Sign up for the NJ Wellness Plan – NJWELL – and you can earn up to $250 annually in incentives.  By enrolling in NJWELL and participating in health assessments, screenings, flu shots, online coaching, and activities participants can earn points towards gift cards. Information on NJWELL can be found at: http://www.state.nj.us/treasury/pensions/njwell/

RECOMMENDATIONS

CWA has been on the cutting edge of trying to push back health care costs without cost-shifting.  Chapter 78 has harmed our members, caused healthcare to be too expensive, and has encouraged cost-shifting instead of cost containment.

The Direct Primary Care Medical Home model of health care is a pilot project that has the potential to save hundreds of millions of dollars in healthcare cost while providing the best healthcare available.  If this is something that works for your family, we recommend that you investigate it.  The Tiered Network will only work for people who are willing to switch doctors or who, UPON REVIEW, see that their doctors are in the Tiered Network.  The Networks are very large, and so it may be that this will work for you.  CWA urges our members to consider these options.