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State Health Benefits ProgramWaiver Of EnrollmentFor Other Dental CoverageThe one-time dental plan enrollment opportunity canbe deferred if an otherwise eligible individual hasother group dental coverage, either as a dependentof a spouse, civil union partner, or domestic partner,through their own employment under an employer plan,or through an eligible retiree group association. An eligible retiree group association is an association whosemembership is limited based on the former employment of the retiree or retiree’s dependent.School Employees’ Health Benefits ProgramENROLLING IN THE RETIREE DENTAL PLANSHow to EnrollFor new retirees or individuals becoming eligible for Retired Group SHBP or SEHBP coverage, the NJDPB willinclude dental enrollment materials at the same time itsends the Retired Group health plan offering, which isgenerally within 30 to 60 days of retirement or eligibility for retiree group plan coverage. To enroll in dentalcoverage, complete a Retiree Dental Plan Application.Proof of the other group dental plan termination of coverage must be submitted in the form of a HIPAA Certification of Coverage form or a letter from the employeralong with the Retiree Dental Plan Application.If you are covered under a group dental plan as a dependent or as an employee through other employmentwhen first offered enrollment, you may opt to waive theRetiree Dental Plans and elect to enroll at a future dateif your other coverage has ended. To waive coverage,complete the Cancel/Decline/Waive Retired Coverageform. To enroll at a later date, you must remit a RetireeDental Plan Application to the NJDPB within 60 daysof the loss of the other dental coverage. Proof of lossof coverage must be submitted with the enrollment application. Acceptable documentation includes a letterfrom the employer providing date of termination of coverage, a HIPAA Certification of Coverage form, etc.Eligible DependentsEnrolling DependentsYour eligible dependents are your spouse, civil unionpartner, or eligible same-sex domestic partner and/oryour eligible children.You may enroll your eligible dependents when you enroll.A retiree or eligible survivor may elect to waive enrollment at the time of retirement or first offering andretain the right to enroll at a later date. The individual must submit an enrollment application within 60days of the loss of the other group dental coverage.Applications are available on the NJDPB website:www.nj.gov/treasury/pensionsFor definitions of eligible dependents and more information about supporting documentation, visit our website at: www.nj.gov/treasury/pensionsIf you have a new dependent, you may enroll the dependent effective the date you acquired the dependent,provided you submit a completed Retiree Dental PlanApplication within 60 days of the dependent’s eligibility.Note: Extended coverage provisions under P.L. 2005,c. 375 (Chapter 375), for certain over age childrenand the extension of coverage under the provisions offederal COBRA law do not apply to the Retiree DentalPlans. When Retiree Dental Plans coverage ends foryourself or your dependents, there are no other provisions for extending coverage.If you do not enroll an eligible dependent because ofother coverage and that coverage is lost, you can enrollthat dependent providing you submit a completed Retiree Dental Plan Application within 60 days of the theloss of coverage. A copy of your dependent’s HIPAACertification of Coverage form must be submitted withthe enrollment application. Coverage for that depen-Retiree Dental Plans — Member GuidebookJanuary 2021dent will be effective the date of the qualifying event(date of loss of other coverage).If you do not enroll a dependent within 60 days of eligibility, there will be at least a two-month waiting periodfrom the date a completed Retiree Dental Plan Application is received until the dependent is covered. Coverage for that dependent will be effective the first day ofthe month following a minimum 60-day waiting period.A dependent added in this manner may be added to aretiree’s contract only once.Levels of CoverageThere are four levels of coverage offered through theplan: Single: covers the retiree only. Member (Retiree) and Spouse/Partner: coversthe retiree and a spouse, civil union partner, or eligible same-sex domestic partner. Parent and Child(ren): covers the retiree and allenrolled eligible children. Family: covers retiree, spouse/partner, and all enrolled eligible children.Dual Dental Plan Enrollment is ProhibitedYou and your spouse/partner may be covered under adental plan as an SHBP or SEHBP eligible employee/retiree or as a dependent, but not as both. For example,if two retirees are married to each other and both areeligible for SHBP and/or SEHBP enrollment, each mayelect to enroll for single coverage only, or one retireemay enroll the other as a dependent if the other personwaives dental plan coverage. Furthermore, two employees/retirees cannot each enroll the same childrenas dependents under their respective dental coverage.Page 4

School Employees’ Health Benefits ProgramRetiree Dental Plans PremiumsMost retirees will pay the full cost of the Retiree DentalPlans. The State does not pay for the cost of coverage.However, under certain circumstances, a local publicemployer that participates in the SHBP or SEHBP mayelect to pay for or share the cost of coverage for its retirees under P.L. 1999, c. 48 (Chapter 48).*Premium payments are deducted from your monthlypension check. If your monthly pension check amountis not sufficient to cover the full premium, you will bebilled monthly in advance of the coverage period.You will also be billed directly for coverage if you receive a pension not paid by the NJDPB, i.e., the Alternate Benefit Program (ABP).*Chapter 48 allows some local employers to pay all ora portion of the premium cost of the plan for eligibleretirees as a result of collective negotiation agreements.To do this, an eligible employer must file a Chapter 48Resolution pertaining to the Retiree Dental Plans withthe Health Benefits Bureau of the NJDPB. These provisions would not apply to any local retiree who receivesretiree health coverage at State (as opposed to localemployer) expense.When Coverage BeginsCoverage under a Retiree Dental Plan will becomeeffective the same date as your Retired Group healthplan coverage, provided that a Retiree Dental Plan Application is completed. The effective date of coverage for a retiree (andeligible dependents) who was covered for healthcoverage as an active employee in the SHBP orSEHBP is approximately one month after the dateof retirement, and generally coincides with the datethat coverage as an active employee is terminated.Page 5State Health Benefits Program The effective date of coverage for a new retiree(and eligible dependents) who was not covered asan active employee in the SHBP or SEHBP is thedate of retirement. The effective date of coverage for members whoretire from a board of education, vocational/technical school, or special services commission, participate in their employer’s health plan (not SEHBP)and enroll in the SEHBP Retired Group when theyenroll in Medicare, will be the date that their Medicare Parts A and B are effective. The effective date of coverage for a survivingspouse or partner and eligible children is the datethe coverage terminates as a dependent due to thedeath of the retiree.End of CoverageYour coverage under a Retiree Dental Plan terminatesif: You formally request termination in writing, or bycompleting a Cancel/Decline/Waive Retired Coverage form; Your retirement is canceled; Your pension allowance is suspended; You do not pay your required premiums; Your former employer withdraws from the SHBPand/or SEHBP (this may not apply to certain retirees of education, police, and fire employers); Your Medicare coverage ends;Coverage for your dependents will end if: Your coverage ceases for any of the reasons previously listed; Your dependent is no longer eligible for coverage(divorce of a spouse; dissolution of a civil unionor same-sex domestic partnership; child turns age26 unless the dependent child qualifies for continuance of coverage due to disability); Your enrolled dependent enters the Armed Forces;or Your dependents becomes enrolled on their ownthrough the SHBP or SEHBP in a dental plan as asubscriber.In general, once Retiree Dental Plans coverage is terminated it will not be reinstated.Survivor CoverageIf you, the retired member, predecease your covereddependents, your surviving dependents may be eligiblefor continued coverage in a Retiree Dental Plan. Surviving dependents are generally notified of their rights tocontinued coverage at the time the NJDPB is notified ofthe death of the retiree; however, they may contact theNJDPB Office of Client Services for enrollment formsor for more information. It is imperative that survivorsnotify the NJDPB as soon as possible after your deathbecause their dependent coverage terminates the 1stof the month following the date of your death.EXTENSION OF COVERAGE PROVISIONS The SHBP and/or SEHBP is discontinued; orOnce coverage is terminated for you or any of your dependents, there is no eligibility for continuation of theRetiree Dental Plans under the provisions of COBRA. You become ineligible for Retired Group medicalcoverage through the SHBP or SEHBP.There is no conversion to an individual policy authorized under thi

Dental Plan Application to the NJDPB within 60 days of the loss of the other dental coverage . Proof of loss of coverage must be submitted with the enrollment ap-plication . Acceptable documentation includes a lette