12 I Winter 2019 www.anjc.info Medicare Q&A INSURANCE Update INSURANCE Update SHBP/SEHBP: In September, the School Employee Health Benefits Program (SEHBP) Plan Design Committee passed resolutions making several significant changes to their programs. For SEHBP active employees, which covers K-12 school employees and community college employees, a new set of plans called Horizon NJ Direct Zero and Aetna Freedom Zero were created. The main differences in these plans versus the most common NJ Direct 10 plan are: •  There will be no co-pays for in-net- work care •  The OON caps on PT, DC and acupuncture will apply ($35 cap for chiropractic services) •  All other OON care will be reim- bursed at 200 percent of Medicare fee schedule (other state plans pay 90 percent of FAIR Health rates) •  Will have higher emergency room co-pays •  Will implement MANDATORY GENERIC prescription drug rules. Plan will only pay for the cost of a generic drug and the member will be responsible for the difference between that and the actual cost of a name brand drug These plans are a new option introduced into the SEHBP and are not mandatory. The active employee would have to choose one of these plans to be enrolled. This is not the case with the other major change to the SEHBP system. Beginning in 2019 the SEHBP has contracted with Aetna to run Medicare Advantage plans for its members. The SEHBP has eliminated the option for Medicare eligible retirees to have the Horizon NJ Direct 10 or Horizon NJ Direct 15 plans as a supplemental plan to traditional Medicare. Any SEHBP retiree who had traditional Medicare with either Horizon NJ Direct 10 or 15 as their supplemental plan was automatically moved into either the Aetna Educators Medicare 10 or 15 Medicare Advantage plan. Two years ago the State Health Benefits Plan (SHBP) enacted essentially the same policy but to Horizon based Medicare Advantage plans. The SHBP Medicare eligible enrollees who were moved to Horizon Medicare Advantage plans in 2016 have been moved to Aetna Medicare Advantage plans as of Jan. 1st. The Horizon Medicare Advantage plans under the SHBP are no longer available options. Many patients do not understand what this change entails or that they have options other than the Medicare Advantage plan they were auto-enrolled in. Retirees often misunderstood this as a change to their supplemental plan, but believe they will still have traditional Medicare coverage. This is not the case. The Medicare Advantage plan, while a part of the Medicare program (Part C), actually replaced both the Medicare and the supplemental coverages. The patients’ claims will no longer be addressed by Medicare and then a commercial carrier as secondary. They will go directly to Aetna and only Aetna. The other misconception is that there are no other options. This is also not true. While these retirees were auto-enrolled in these Medicare Advantage plans if they took no action, they can choose other plan options through the SEHBP/SHBP system. There are currently five plan options for these retirees to choose outside of the Aetna Medicare Advantage plans. Each of these options begin with traditional Medicare remaining as the retirees’ primary insurance. There are then the following five options as supplemental to traditional Medicare: • Horizon NJ Direct 1525 • Horizon NJ Direct 2030 • Horizon HMO10 • Horizon HMO 1525 • Horizon HMO 2030 It is important to note that these remaining plan options will have different out-of-pocket costs to the patient but are the only available means to retain traditional Medicare with a supplemental plan through their retiree benefits with the SHBP By Matt Minnella ANJC Director of Insurance & Regulatory Affairs