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SEHBP Plan Reforms

Yesterday, following an agreement between Gov. Murphy and the New Jersey Education Association, the School Employee Health Benefits Program’s (SEHBP) Plan Design Committee passed several resolutions enacting reforms to reduce costs under the plan.  The SEHBP covers all employees of K-12 schools and community colleges that opt into the state program.

The two major changes are the migration of the vast majority of SEHBP retirees to Medicare Advantage plans and the creation of a new plan option with a focus on incentivizing in-network care. 

ONLY THE NEW PLAN OPTION will have the same out-of-network (OON) caps on chiropractic, physical therapy and acupuncture that the SHBP plans have enacted in recent years.  These plans will also waive co-pays and have a lower reimbursement methodology for all OON services than the other SEHBP plans.  The main difference between these reforms and what occurred with the SHBP OON cap is that the SHBP applied these caps to ALL plans offered under the program.  In the SEHBP, no changes are being implemented to the existing NJDirect10, NJDirect15 nor all the other currently available plan options.  These OON caps are only being implemented on the new plan option that members would have to choose over their current plan. 

SEHBP retirees who are Medicare eligible (65 years or older) who currently have traditional Medicare with either the NJDirect10 or NJDirect15 plan as their secondary will be automatically enrolled in newly created Medicare Advantage plans.  When the SHBP instituted this change, affected retirees were able to change to another plan option besides NJDirect10 or 15 and stay on traditional Medicare with the state plan as secondary rather than moving into the Medicare Advantage plan.  It appears this will be the case with the SEHBP as well.  Confirmation and more information on this are to come.

The Governor’s office put out a press release on the changes yesterday – click here.

While these measures were passed by the SEHBP Plan Design Committee Monday, they will be voted on by the School Employees Health Benefits Commission tomorrow, Wednesday, Sept. 19, to be finalized.  We are continuing to gather more information on these changes and will update membership as more details become available. 

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