new employee orientation benefits book€¦ · information may be found in the new employee...
TRANSCRIPT
NEW EMPLOYEE ORIENTATION BENEFITS BOOK
� � UNIVERSITY HOSPITAL * � Newark, New Jersey
REV. 2/20
Benefit /Financial Overview TIME OFF BENEFITS
For additional information please visit- http://www.uhnj.org/hrweb/policies/index.htm HOLIDAYS 9 Holidays per year. For a list of the days please see the Holiday Policy.
FLOAT HOLIDAYS 6 days if on the payroll as of January1, 3 days if hired between Jan 2 - July1- 0 days if hired between July 2 - Dec. 31.
SICK DAYS 1 day per month is accrued and carried year to year, per the Sick Pay Policy. Active employees retiring from a State administered pension plan will be paid for accumulated unused sick days up to $15,000 as per the Unused Sick Time at Retirement Policy.
VACATION DAYS Vacation is accrued on a monthly basis. Accruals increase with the years of service. Use of accrued time after 90 days of employment. Please see the Vacation Policy for rates of accrual.
HEALTH BENEFITS For eligibility requirements please visit-http://www.uhnj.org/hrweb/policies/Employee-health-Insurance.pdf
MEDICAL INSURANCE Eligibility after two months of continuous employment. Premiums are based on a percentage of premium calculation. See Percentage of Premium Calculation Chart. PRESCRIPTION PLAN
DENTAL INSURANCE Eligibility after two months of continuous employment. See rate chart.
PENSION PLANS For eligibility requirements please visit http://www.uhnj.org/hrweb/benefits/retirement.htm
____PUBLIC EMPLOYEE RETIREMENT SYSTEM (PERS)
Vesting after 10 years of PERS participation Employee contribution
____DEFINED CONTRIBUTION RETIREMENT PROGRAM (DCRP)
Employer contributions are not vested until the 13th consecutive month of employment
Employee contributes 5% of annual base salary Employer contributes 3% of annual base salary
GROUP LIFE INSURANCE
____PERS Employer: 1.5 times the annual salary Employee:1.5 times the annual salary prorated the first year Employee contributes 1/2% of annual salary In combination total coverage is three (3) times base annual salary
____DCRP 1.5 times base annual salary Employer pays the cost, no employee contribution
LONG TERM DISABILTY ____PERS - DISABILITY INSURANCE COVERAGE
Upon completion of 12 months of continuous contributions in PERS. There is a 6 month waiting period.
No contribution
____DCRP- LONG TERM DISABILITY
Upon completion of 12 months of continuous contributions in DCRP. There is a 6 month waiting period.
No contribution
ADDITIONALS VOLUNTARY TAX SHELTER PROGRAMS
Information may be found in the New Employee Orientation book.
EDUCATION ASSISTANCE PROGRAM
Eligibility after 1 year of employment and satisfactory annual evaluation. Please see Education Assistance Program Policy for additional information.
Reimbursement covers tuition costs and credit by exam
Web Address for State Related Benefit Information is: http://www.state.nj.us/treasury/pensions/index.shtml
1
State Health Benefits Program (SHBP) • School Employees' Health Benefits Program (SEHBP) REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT
The State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP) are required to ensure that only employees, retirees, and eligible dependents are receiving health care coverage under the Programs. The New Jersey Division of Pensions & Benefits (NJDPB) must guarantee consistent application of eligibility requirements within the plans. Employees or retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children, disabled and/or overage children continuing coverage) MUST submit the following documentation in addition to the appropriate health benefits enrollment or change of status application. If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, dependents may not be enrolled. ANY DEPENDENTS NOT LISTED ON THE APPLICATION WILL NOT BE COVERED.
DEPENDENTS ELIGIBILITY DEFINITION DOCUMENTATION REQUIRED
A person to whom you are legally married. A copy of the marriage certificate and a copy of the front page of the employee/retiree's federal tax return• (Form 1040) from last year that in-eludes the spouse. If filing separately, submit a copy of both spouses' tax
SPOUSE returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both spouses and is received at the same address.
A person of the same sex with whom you have entered into a A copy of the marriage certificate and a copy of the front page of the civil union. employee/retiree's federal tax return• (Form 1040) from last year that in-
eludes the partner. If filing separately, submit a copy of both partners' tax CIVIL UNION returns that list the same address. If marriage occurred in the current cal-
PARTNER endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both partners and is received at the same address.
A person of the same sex with whom you have entered into a do- A copy of the New Jersey certificate of domestic partnership dated prior mestic partnership. Under P.L. 2003, c. 246, the Domestic Part- to February 19, 2007, or a valid certification from another State or foreign nership Act, health benefits coverage is available to domestic jurisdiction that recognizes same-sex domestic partners and a copy of partners of State employees, State retirees, or employees or re- the front page of the employee/retiree's N.J. tax return• from last year that
DOMESTIC tirees of a SHBP - or SEHBP - participating local public entity that includes the partner. If filing separately, submit a copy of both partners' NJ PARTNER has adopted a resolution to provide Chapter 246 health benefits. tax returns that list the same address. If Domestic Partnership occurred in
the current calendar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 days of the application) that includes the names of both partners and is received at the same address.
A subscriber's child until age 26, regardless of the child's marital, Natural or Adopted Chlld - A copy of the child's birth certificate showing student, or financial dependency status - even if the young adult the name of the employee/retiree as a parent. no longer lives with his or her parents. Step Child - A copy of the child's birth certificate showing the name of This includes a stepchild, foster child, legally adopted child, or the employee/retiree's spouse or partner as a parent and a copy of the
CHILDREN any child in a guardian-ward relationship upon submitting re- marriage/partnership certificate showing the names of the employee/retir-quired supporting documentation. ee and spouse/partner.
Legal Guardian, Grandchild, or Foster Child - Copies of final court or-ders with the presiding judge's signature and seal. Documents must attest to the legal guardianship by the employee.
If a covered child is not capable of self-support when he or she Documentation for the appropriate "child" type (as noted above) and a reaches age 26 due to mental illness or incapacity, or a physical copy of the front page of the employee/retiree's federal tax return• (Form disability, the child may be eligible for a continuance of coverage. 1040) from last year that includes the child. If Social Security disability has
DEPENDENT Coverage for children with disabilities may continue only while been awarded, or is currently pending, please include this information with CHILDREN WITH (1) you are covered through the SHBP/SEHBP; (2) the child the documentation that is submitted. Please note that this information is
DISABILITIES continues to be disabled; (3) the child is unmarried or does not only verifying the child's eligibility as a dependent. The disability status of enter into a civil union or domestic partnership; and (4) the child the child is determined through a separate process. remains substantially dependent on you for support and mainte-nance. You may be contacted periodically to verify that the child remains eligible for coverage.
Certain children over age 26 may be eligible for continued cov- Documentation for the appropriate "child" type (as noted above), and a erage until age 31 under the provisions of P.L. 2005, c. 375. This copy of the front page of the child's federal tax return• (Form 1040) from includes a child by blood or law who: (1) is under the age of last year, and if the child resides outside of the State of New Jersey, doc-
CONTINUED 31; (2) is unmarried or not a partner in a civil union or domestic umentation of full time student status must be submitted. COVERAGE FOR partnership; (3) has no dependent(s) of his or her own; (4) is a
OVERAGE resident of New Jersey or is a student at an accredited public CHILDREN or private institution of higher education, with at least 15 credit
hours; and (5) is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
*You may black out all financial information and all but the last four digits of any Social Security numbers on tax returns. To obtain copies of the documents listed above, contact the office of the town clerk in the city of the birth, marriage, etc., or visit these websites: www.vitalrec.com or www.studentclearinghouse.org Residents of New Jersey can obtain records from the State Bureau of Vital Statistics and Registration website: www.nj.gov/healthlvitallindex.shtml
2
STATE HEALTH BENEFITS PROGRAM (SHBP)
SHBP PARTICIPATING PLANS AND CONTACT INFORMATION
https://www.nj.gov/treasury/pensions/hb-active-contacts.shtml
Medical Plans
Plans available through the State Health Benefits Program:
Tiered Network Plan (Active SHBP Members only): OMNIA Health Plan (Horizon Blue Cross Blue Shield of New Jersey)
PPO Plans: NJ DIRECT15, NJ DIRECT1525, NJ DIRECT2030, NJ DIRECT2035, NJ DIRECT, NJ DIRECT2019
HMO Plan: Horizon HMO
High Deductible Health Plans (HDHP): NJ DIRECT HD1500, NJ DIRECT HD4000.
Note: Horizon HMO service area is limited to New Jersey and bordering counties of Delaware, Pennsylvania, and New York;
For more information about any participating plan, follow the link or call the plan's member services number to speak with a plan representative.
NJ DIRECT and Horizon Plans
Horizon Member Services: 1-800-414-SHBP (1-800-414-7427) orhttps://www.horizonblue.com/shbp/
Health Benefits Member Guidebookshttps://www.nj.gov/treasury/pensions/member-guidebooks.shtml
a. NJ DIRECT Member Guidebookb. Horizon HMO Member Guidebookc. Horizon OMNIA Member Guidebookd. NJ DIRECT HDHP Member Guidebook
Pharmacy Benefits
Managed by OptumRx OptumRX Website https://www.optumrx.com/oe_sonjactiveee/landing Member Services Phone: 1-844-368-8740
Also available:
Medical Plan Design https://www.nj.gov/treasury/pensions/documents/hb/oe2020/ha0895.pdf
Summaries of Benefits and Coverage https://www.nj.gov/treasury/pensions/documents/hb/oe2020/hb-sbc-state-active-20.shtml
3
4
SUMMARY OF BENEFITS AND COVERAGE
FOR MEMBERS OF THE STATE HEALTH BENEFITS PROGRAM (SHBP)
To view the information listed below, please log onto:
http://www.state.nj.us/treasury/pensions/hb-sbc-state-active.shtml
HORIZON PLANS
PPO Plans
NJ DIRECT15 NJ DIRECT1525 NJ DIRECT2030 NJ DIRECT2035 NJ DIRECT NJ DIRECT2019
HMO Plan Horizon HMO
Tiered Plan OMNIA Health
High Deductible Health Plans NJ DIRECT HD4000 NJ DIRECT HD1500
STATE ACTIVE PRESCRIPTION PLANS
State Active Prescription Plan 15 State Active Prescription Plan 1525 State Active Prescription Plan 2030 State Active Prescription Plan 2035
Prescription Drug Plan Handbook
Information regarding the Prescription Drug Plan, can be found in the Prescription Drug Plans Member Handbook at:
https://www.nj.gov/treasury/pensions/documents/guidebooks/hp0506.pdf
Civ
il U
nio
ns
and
D
om
esti
c P
artn
ersh
ips
Info
rmat
ion
for:
A
ll P
ensi
on F
unds
and
the
Hea
lth B
enefi
t Pro
gram
s
Dec
emb
er 2
018
Fact
Sh
eet
#75
P.L.
200
3, c
. 246
(C
hapt
er 2
46),
the
Dom
estic
Par
t-ne
rshi
p A
ct,
esta
blis
hed
cert
ain
right
s an
d re
spon
-si
bilit
ies
for
sam
e-se
x do
mes
tic p
artn
ersh
ips
esta
b-lis
hed
in N
ew J
erse
y pr
ior
to F
ebru
ary
19,
2007
, as
wel
l as
in
juris
dict
ions
oth
er t
han
New
Jer
sey
both
prio
r to
and
afte
r F
ebru
ary
19, 2
007.
P.L.
200
6, c
. 103
(C
hapt
er 1
03),
the
Civ
il U
nion
Law
,es
tabl
ishe
d si
mila
r rig
hts
and
resp
onsi
bilit
ies
for
sam
e-se
x ci
vil u
nion
s es
tabl
ishe
d in
New
Jer
sey
onor
afte
r F
ebru
ary
19,
2007
. F
urth
erm
ore,
sam
e-se
xdo
mes
tic
part
ners
hips
es
tabl
ishe
d in
N
ew
Jers
eyon
or
afte
r F
ebru
ary
19,
2007
, w
ill n
ot b
e en
title
d to
thos
e sa
me
right
s an
d re
spon
sibi
litie
s.
The
law
s ex
tend
pub
lic p
ensi
on,
Sta
te H
ealth
Ben
e-fit
s P
rogr
am (
SH
BP
), a
nd S
choo
l Em
ploy
ees’
Hea
lth
Ben
efits
Pro
gram
(SE
HB
P) b
enefi
ts to
sam
e-se
x ci
vil
unio
n/do
mes
tic p
artn
ers
of S
tate
, lo
cal g
over
nmen
t, an
d lo
cal e
duca
tion
empl
oyee
s an
d re
tiree
s.
Thi
s fa
ct s
heet
dea
ls o
nly
with
the
pens
ion
and
heal
th
bene
fits
exte
nded
by
Cha
pter
s 24
6 an
d 10
3. I
t do
es
not
addr
ess
the
broa
der
right
s an
d re
spon
sibi
litie
s co
vere
d by
the
law
s, n
or d
oes
it co
ver
ques
tions
of
elig
ibili
ty fo
r a
civi
l uni
on/d
omes
tic p
artn
ersh
ip s
ince
th
ey a
re o
utsi
de o
f th
e sc
ope
of t
he N
ew J
erse
y D
ivis
ion
of P
ensi
ons
& B
enefi
ts (
NJD
PB
). F
or t
he
purp
oses
of t
his
fact
she
et, “
part
ner”
will
ref
er to
bot
h do
mes
tic p
artn
ers
and
civi
l uni
on p
artn
ers.
EL
IGIB
ILIT
Y
Civ
il U
nio
ns
The
Civ
il U
nion
Law
app
lies
to a
ny S
tate
em
ploy
ee,
loca
l go
vern
men
t em
ploy
ee,
or l
ocal
edu
catio
n em
-pl
oyee
, an
d an
y re
tiree
of
thes
e em
ploy
ers
who
has
en
tere
d in
to a
civ
il un
ion,
obt
aine
d a
New
Jer
sey
Civ
il U
nion
Cer
tifica
te (
or a
val
id c
ertifi
catio
n fr
om a
noth
-er
juris
dict
ion
that
rec
ogni
zes
sam
e-se
x ci
vil u
nion
s)
and
who
is
ot
herw
ise
elig
ible
fo
r pe
nsio
n an
d/or
S
HB
P/S
EH
BP
ben
efits
.
No
te: T
he e
nact
men
t of t
he C
ivil
Uni
on L
aw e
xten
ds
heal
th a
nd p
ensi
on b
enefi
ts t
o al
l elig
ible
civ
il un
ion
coup
les;
the
refo
re,
ther
e is
no
addi
tiona
l re
solu
tion
or a
ppro
val
requ
ired
by a
n em
ploy
er a
s is
req
uire
d un
der
the
Dom
estic
Par
tner
ship
Act
.
A
civi
l un
ion
part
ner
is
defin
ed
for
pens
ion
and
SH
BP
/SE
HB
P e
ligib
ility
as
a pe
rson
of t
he s
ame
sex
to w
hom
the
elig
ible
em
ploy
ee o
r re
tiree
has
ent
ered
in
to a
civ
il un
ion
as r
ecog
nize
d un
der
Cha
pter
103
.
Do
mes
tic
Par
tner
ship
s
The
Dom
estic
Par
tner
ship
Act
app
lies
to a
ny S
tate
em
ploy
ee o
r S
tate
ret
iree
who
has
ent
ered
a s
ame-
sex
dom
estic
par
tner
ship
and
obt
aine
d a
valid
Cer
tif-
icat
e of
Dom
estic
Par
tner
ship
.
PE
NS
ION
BE
NE
FIT
S
The
law
s ad
d a
sam
e-se
x pa
rtne
r to
the
defi
nitio
n of
spo
use,
wid
ow,
wid
ower
, an
d el
igib
le s
ame-
sex
dom
estic
par
tner
to
the
Pub
lic E
mpl
oyee
s’ R
etire
-m
ent
Sys
tem
(P
ER
S),
Tea
cher
s’ P
ensi
on a
nd A
n-nu
ity F
und
(TPA
F),
Pol
ice
and
Fire
men
’s R
etire
men
t S
yste
m
(PF
RS
),
Sta
te
Pol
ice
Ret
irem
ent
Sys
tem
(S
PR
S),
Jud
icia
l R
etire
men
t S
yste
m (
JRS
), a
nd A
l-te
rnat
e B
enefi
t Pro
gram
(A
BP
), s
o th
at th
e pa
rtne
r is
co
nsid
ered
the
sam
e as
a s
pous
e.
Upo
n th
e de
ath
of a
ret
irem
ent
syst
em m
embe
r, a
copy
of t
he v
alid
Civ
il U
nion
or
Dom
estic
Par
tner
ship
C
ertifi
cate
is r
equi
red
for
verifi
catio
n be
fore
any
pen
-si
on b
enefi
ts a
re p
aid.
PE
RS
an
d T
PAF
Mem
ber
s
For
the
PE
RS
and
TPA
F, t
he o
nly
bene
fit a
dded
by
the
law
s is
for A
ccid
enta
l Dea
th. A
n el
igib
le p
artn
er is
el
igib
le t
o re
ceiv
e a
pens
ion
bene
fit if
the
em
ploy
ee
dies
thro
ugh
an a
ccid
ent i
n th
e pe
rfor
man
ce o
f his
or
her
duty
whi
le a
t w
ork.
Thi
s is
a li
fetim
e be
nefit
; but
, if
the
surv
ivin
g sp
ouse
/par
tner
sub
sequ
ently
mar
ries
or e
stab
lishe
s a
new
civ
il un
ion,
the
sur
vivo
r’s p
en-
sion
ben
efit
will
end
. H
owev
er,
a su
rviv
or’s
ben
efits
fr
om a
n A
ccid
enta
l D
eath
(or
Acc
iden
tal
Dis
abili
ty
Ret
irem
ent)
goi
ng t
o a
part
ner
wou
ld b
e su
bjec
t to
fe
dera
l ta
x. T
his
is n
ot t
he c
ase
whe
n a
surv
ivor
’s
bene
fit is
pai
d to
a s
pous
e.*
*U
nder
the
fede
ral I
nter
nal R
even
ue C
ode
(IR
C)
a ci
vil u
nion
par
tner
or
dom
estic
par
tner
is n
ot r
ecog
nize
d in
the
sam
e m
anne
r as
a s
pous
e an
d th
eref
ore
does
not
qual
ify fo
r si
mila
r tr
eatm
ent f
or fe
dera
l tax
pur
pose
s.
5
Fact
Sh
eet
#75
Dec
emb
er 2
018 Civ
il U
nio
ns
and
Do
mes
tic
Par
tner
ship
sT
his
fact
she
et is
a s
umm
ary
and
not i
nten
ded
to p
rovi
de a
ll in
form
atio
n.
Alth
ough
eve
ry a
ttem
pt a
t acc
urac
y is
mad
e, it
can
not b
e gu
aran
teed
.
Reg
ular
PE
RS
and
TPA
F r
etire
men
ts a
re n
ot im
pact
-ed
sin
ce r
etire
es c
an a
lread
y na
me
anyo
ne a
s a
join
t an
d su
rviv
or b
enefi
ciar
y of
thei
r pe
nsio
n be
nefit
. The
In
tern
al R
even
ue S
ervi
ce (
IRS
) do
es,
how
ever
, re
-st
rict
who
m a
mem
ber
can
nam
e as
a b
enefi
ciar
y un
der
Opt
ions
2,
A,
and
B,
to e
ither
a s
pous
e or
to
a no
nspo
use
bene
ficia
ry w
ithin
spe
cific
age
lim
ita-
tions
(se
e th
e R
etire
men
t —
PE
RS
and
TPA
F P
en-
sion
Opt
ions
Fac
t S
heet
for
det
ails
on
age
limits
for
no
nspo
use
bene
ficia
ries)
.*
PF
RS
an
d S
PR
S M
emb
ers
For
the
PF
RS
and
SP
RS
, th
e st
atut
ory
surv
ivor
’s
bene
fit,
prov
ided
upo
n th
e de
ath
of t
he e
mpl
oyee
or
retir
ee, c
an b
e pa
id to
a s
urvi
ving
par
tner
in th
e sa
me
man
ner
as is
don
e fo
r a
surv
ivin
g sp
ouse
. Thi
s is
a
lifet
ime
bene
fit;
how
ever
, if
a su
rviv
ing
spou
se/p
art-
ner r
ecei
ving
a P
FR
S o
r SP
RS
retir
ed s
urvi
vor’s
ben
-efi
t su
bseq
uent
ly m
arrie
s or
est
ablis
hes
a ne
w c
ivil
unio
n, t
he s
urvi
vor’s
pen
sion
will
end
(th
is d
oes
not
appl
y to
sur
vivo
rs o
f P
FR
S/S
PR
S A
ccid
enta
l D
eath
in
the
line
of d
uty
or a
ctiv
e S
PR
S s
urvi
vor
bene
fits)
.
JRS
Mem
ber
s
For
the
JRS
, the
sta
tuto
ry s
urvi
vor’s
ben
efit,
prov
ided
up
on t
he d
eath
of
the
empl
oyee
or
retir
ee,
can
be
paid
to a
par
tner
in th
e sa
me
man
ner
as is
don
e fo
r a
spou
se. T
his
is a
life
time
bene
fit; h
owev
er, i
f a s
urvi
v-in
g sp
ouse
/par
tner
is r
ecei
ving
a J
RS
sur
vivo
r’s b
en-
efit
and
subs
eque
ntly
mar
ries
or e
stab
lishe
s a
new
ci
vil u
nion
, the
sur
vivo
r’s p
ensi
on b
enefi
t will
end
.
If a
JRS
mem
ber
wis
hes
to a
lso
sele
ct a
joi
nt a
nd
surv
ivor
ret
irem
ent
optio
n, t
he I
RS
res
tric
tions
for
O
ptio
ns 2
, A
, an
d B
men
tione
d pr
evio
usly
und
er t
he
PE
RS
and
TPA
F a
lso
appl
y.
Oth
er P
ensi
on
Fu
nd
s
A p
artn
er i
s re
cogn
ized
und
er t
he A
ltern
ate
Ben
efit
Pro
gram
(A
BP
), t
he C
onso
lidat
ed P
olic
e an
d F
ire-
men
’s P
ensi
on F
und
(CP
FP
F),
the
Pris
on O
ffice
rs’
Pen
sion
Fun
d, a
nd t
he V
olun
teer
Em
erge
ncy-
Wor
k-er
’s S
urvi
vors
Pen
sion
(V
ES
P).
HE
ALT
H B
EN
EF
IT P
RO
GR
AM
CO
VE
RA
GE
Cov
erag
e un
der
the
SH
BP
or
SE
HB
P f
or a
par
tner
is
ava
ilabl
e to
any
Sta
te e
mpl
oyee
, S
tate
ret
iree,
or
an e
ligib
le e
mpl
oyee
or
retir
ee o
f a lo
cal p
ublic
ent
ity
that
par
ticip
ates
in th
e S
HB
P o
r S
EH
BP.
En
rolli
ng
a P
artn
er
To a
dd a
par
tner
to c
over
age,
an
SH
BP
/SE
HB
P-e
ligi-
ble
empl
oyee
or
retir
ee m
ust
subm
it th
e ap
prop
riate
he
alth
ben
efits
enr
ollm
ent a
pplic
atio
n, in
clud
e a
pho-
toco
py o
f th
e C
ivil
Uni
on C
ertifi
cate
or
Cer
tifica
te o
f D
omes
tic P
artn
ersh
ip w
ith th
e ap
plic
atio
n.
Chi
ldre
n of
you
r pa
rtne
r m
ay a
lso
be a
dded
(se
e a
p-pl
icat
ion
inst
ruct
ions
for
deta
ils).
TAX
AT
ION
OF
HE
ALT
H B
EN
EF
ITS
F
OR
PA
RT
NE
RS
The
IR
C a
llow
s an
em
ploy
er t
o pr
ovid
e ce
rtai
n be
n-efi
ts t
o its
em
ploy
ees
on a
tax
-exe
mpt
bas
is. T
hose
be
nefit
s ca
n al
so b
e ex
tend
ed t
o sp
ouse
s an
d de
-pe
nden
ts o
f an
em
ploy
ee o
n th
e sa
me
tax-
exem
pt
basi
s. T
he I
RC
, ho
wev
er,
does
not
rec
ogni
ze a
par
t-ne
r in
the
sam
e m
anne
r as
a s
pous
e an
d do
es n
ot
auto
mat
ical
ly r
ecog
nize
a p
artn
er a
s a
depe
nden
t for
ta
x pu
rpos
es.
The
refo
re,
your
em
ploy
er m
ay h
ave
to t
reat
the
civ
il un
ion/
dom
estic
par
tner
ship
SH
BP
/S
EH
BP
ben
efit
as t
axab
le t
o yo
u an
d w
ithho
ld f
ed-
eral
inco
me,
Soc
ial S
ecur
ity,
and
Med
icar
e ta
xes
on
its v
alue
. T
his
is a
lso
true
if
you
are
a re
tiree
and
ar
e re
ceiv
ing
empl
oyer
- or
Sta
te-p
aid
heal
th b
enefi
ts
cove
rage
.
If yo
u ad
d a
part
ner
to y
our
cove
rage
, yo
u sh
ould
ex
pect
to re
ceiv
e a
For
m W
-2 a
nd h
ave
to p
ay fe
dera
l in
com
e, M
edic
are,
and
Soc
ial S
ecur
ity t
axes
on
the
impu
ted
valu
e of
the
part
ner
bene
fit.
Sim
ilarly
, si
nce
the
part
ner’s
cov
erag
e is
a f
eder
ally
ta
xabl
e be
nefit
, an
em
ploy
ee w
ho p
artic
ipat
es in
the
S
tate
’s T
ax$a
ve (
IRC
Sec
tion
125)
Pre
miu
m O
ptio
n P
lan,
or
anot
her
empl
oyer
’s S
ectio
n 12
5 pl
an,
can-
not m
ake
pre-
tax
paym
ents
for
the
cost
of a
par
tner
’s
cove
rage
. Pre
-tax
dol
lars
may
stil
l be
used
to p
ay fo
r th
e em
ploy
ee’s
por
tion
of t
he c
ost
of h
is o
r he
r ow
n an
d de
pend
ent c
hild
ren’
s co
vera
ge (
see
the
“Cer
tify-
ing
a P
artn
er’s
Dep
ende
nt S
tatu
s” s
ectio
n).
The
par
tner
ben
efit
is n
ot s
ubje
ct t
o N
ew J
erse
y S
tate
inc
ome
tax.
If
you
live
outs
ide
of N
ew J
erse
y,
you
shou
ld c
heck
with
you
r S
tate
’s ta
x ag
ency
to d
e-te
rmin
e if
the
part
ner
bene
fit is
sub
ject
to s
tate
taxe
s.
Det
erm
inin
g t
he
Imp
ute
d In
com
e
The
SH
BP
and
SE
HB
P u
se t
he c
ost
for
Sin
gle
cov-
erag
e in
det
erm
inin
g th
e im
pute
d va
lue
of p
artn
er
cove
rage
. The
im
pute
d in
com
e fo
r fe
dera
l ta
x w
ith-
hold
ing
purp
oses
will
be
the
full
cost
of
Sin
gle
cov-
erag
e fo
r th
e pl
an in
whi
ch th
e em
ploy
ee o
r re
tiree
is
enro
lled,
less
any
am
ount
the
empl
oyee
/ret
iree
pays
to
war
ds th
e co
st o
f the
par
tner
’s c
over
age.
Cer
tify
ing
a P
artn
er’s
Dep
end
ent
Sta
tus
If a
part
ner
can
mee
t the
IRS
’s d
efini
tion
of a
dep
en-
dent
for
tax
pur
pose
s, f
ound
in
Sec
tion
152
of t
he
IRC
, the
em
ploy
er d
oes
not h
ave
to tr
eat t
he p
artn
er
cove
rage
as
a ta
xabl
e be
nefit
. The
req
uire
men
ts f
or
depe
nden
t st
atus
are
not
eas
ily m
et a
nd a
re s
tric
tly
enfo
rced
by
the
IRS
. If
an e
mpl
oyee
wan
ts t
o cl
aim
a
depe
nden
cy e
xem
ptio
n fo
r a
part
ner,
all f
our
of th
e fo
llow
ing
depe
nden
cy te
sts
mus
t be
met
:
•T
hem
embe
rof
the
hou
seho
ldo
rre
latio
nshi
pte
st;
•T
hec
itize
nor
res
iden
ttes
t;
•T
hejo
intr
etur
nte
st;a
nd
•T
hes
uppo
rtte
st.
*U
nder
the
fede
ral I
nter
nal R
even
ue C
ode
(IR
C)
a ci
vil u
nion
par
tner
or
dom
estic
par
tner
is n
ot r
ecog
nize
d in
the
sam
e m
anne
r as
a s
pous
e an
d th
eref
ore
does
not
qual
ify fo
r si
mila
r tr
eatm
ent f
or fe
dera
l tax
pur
pose
s.
6
Dec
emb
er 2
018
Fact
Sh
eet
#75
Civ
il U
nio
ns
and
Do
mes
tic
Par
tner
ship
sT
his
fact
she
et is
a s
umm
ary
and
not i
nten
ded
to p
rovi
de a
ll in
form
atio
n.
Alth
ough
eve
ry a
ttem
pt a
t acc
urac
y is
mad
e, it
can
not b
e gu
aran
teed
.
See
IRS
Pub
licat
ion
503
- Chi
ld a
nd D
epen
dent
Car
e E
xpen
ses
for
addi
tiona
l in
form
atio
n on
dep
ende
nt
stat
us fo
r fe
dera
l tax
pur
pose
s.
The
IR
S h
as s
tate
d in
priv
ate
lette
r ru
lings
tha
t an
em
ploy
er c
an r
ely
on a
n em
ploy
ee’s
writ
ten
cert
ifi-
catio
n th
at t
he d
epen
dent
mee
ts t
he I
RS
tes
ts f
or
depe
nden
cy. A
n em
ploy
ee o
r re
tiree
can
pro
vide
cer
-tifi
catio
n th
at a
par
tner
mee
ts t
he I
RC
crit
eria
for
a
depe
nden
t in
one
of s
ever
al w
ays:
•S
tate
em
ploy
ees
paid
thr
ough
Cen
tral
ized
Pay
-ro
ll ca
n su
bmit
the
Em
ploy
ee T
ax C
ertifi
catio
n —
Civ
il U
nion
Par
tner
or
Dom
estic
Par
tner
Ben
efit
form
to c
ertif
y th
eir
part
ner’s
dep
ende
nt s
tatu
s.
•E
mpl
oyee
sof
oth
ere
mpl
oyer
ssh
ould
see
the
irem
ploy
er’s
hum
an r
esou
rces
offi
cer
or b
enefi
tsad
min
istr
ator
to
dete
rmin
e ho
w t
ax d
epen
dent
cert
ifica
tion
shou
ld b
e pr
ovid
ed.
•R
etire
esc
ans
ubm
itth
eR
etire
e Ta
x C
ertifi
ca-
tion
— C
ivil
Uni
on P
artn
er o
r D
omes
tic P
artn
erB
enefi
t fo
rm t
o ce
rtify
the
ir pa
rtne
r’s d
epen
dent
stat
us.
Sin
ce a
n in
divi
dual
’s s
ituat
ion
can
chan
ge,
an e
m-
ploy
ee o
r re
tiree
who
file
s a
cert
ifica
tion
stat
ing
that
th
e pa
rtne
r mee
ts th
e IR
S d
efini
tion
of d
epen
dent
will
be
req
uire
d to
file
a n
ew c
ertifi
catio
n ev
ery
cale
ndar
ye
ar t
o co
ntin
ue t
hat
sam
e ta
x tr
eatm
ent
of t
he b
en-
efit.
Em
ploy
ees
or re
tiree
s m
ay a
lso
wis
h to
con
sult
with
a
prof
essi
onal
tax
advi
sor
or c
onta
ct th
e IR
S d
irect
ly a
t 1-
800-
TAX
-104
0 or
onl
ine
at: w
ww
.irs.
gov
Thi
s fa
ct s
heet
has
bee
n pr
oduc
ed a
nd d
istr
ibut
ed b
y:
New
Jer
sey
Div
isio
n o
f P
ensi
on
s &
Ben
efits
P.
O. B
ox 2
95, T
ren
ton
, NJ
0862
5-02
95
(609
)29
2-75
24F
or th
e he
arin
g im
paire
d: T
RS
711
(60
9) 2
92-6
683
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
7
8
9
Den
tal P
lan
s —
A
ctiv
e E
mp
loye
esIn
form
atio
n fo
r:
Sta
te H
ealth
Ben
efits
Pro
gram
(S
HB
P)
Sch
ool E
mpl
oyee
s’ H
ealth
Ben
efits
Pro
gram
(S
EH
BP
)
Feb
ruar
y 20
19
Fact
Sh
eet
#37
EL
IGIB
ILIT
Y
The
Em
ploy
ee D
enta
l Pla
ns a
re a
vaila
ble
to fu
ll-tim
e S
tate
em
ploy
ees,
ful
l-tim
e em
ploy
ees
of a
loca
l em
-pl
oyer
(co
unty
, m
unic
ipal
ity,
scho
ol b
oard
, et
c.)
that
el
ects
by
reso
lutio
n to
pro
vide
the
Em
ploy
ee D
enta
l P
lans
to
its e
mpl
oyee
s an
d th
e el
igib
le d
epen
dent
s of
thes
e em
ploy
ees.
The
Em
ploy
ee D
enta
l Pla
ns a
re
not a
vaila
ble
to r
etire
es; f
or m
ore
info
rmat
ion
on d
en-
tal p
lans
offe
red
to r
etire
es,
see
the
Den
tal P
lans
—
Ret
irees
Fac
t She
et.
New
elig
ible
em
ploy
ees
may
enr
oll b
y co
mpl
etin
g an
E
mpl
oyee
Den
tal
Enr
ollm
ent
and/
or C
hang
e F
orm
du
ring
the
first
60
days
of
empl
oym
ent.
The
app
lica-
tion
is a
vaila
ble
from
you
r hu
man
res
ourc
es r
epre
-se
ntat
ive
or b
enefi
ts a
dmin
istr
ator
.
If yo
u do
not
enr
oll
whe
n fir
st e
ligib
le,
you
have
the
op
tion
to
enro
ll du
ring
the
annu
al
SH
BP
/SE
HB
P
Ope
n E
nrol
lmen
t per
iod.
Ope
n E
nrol
lmen
t is
norm
al-
ly h
eld
in th
e fa
ll, w
ith c
over
age
effe
ctiv
e th
e fo
llow
ing
Janu
ary.
If yo
u do
not
enr
oll b
ecau
se o
f oth
er d
enta
l cov
erag
e an
d la
ter
lose
tha
t co
vera
ge,
you
can
enro
ll by
sub
-m
ittin
g a
form
with
in 6
0 da
ys o
f the
loss
of c
over
age.
Onc
e en
rolle
d, y
ou a
nd y
our
elig
ible
dep
ende
nts
mus
t re
mai
n in
the
den
tal
plan
you
ele
ct f
or a
min
-im
um o
f 12
mon
ths
befo
re y
ou c
an c
hang
e pl
ans
or
drop
cov
erag
e. I
n th
e ev
ent
that
you
wis
h to
cha
nge
dent
al p
lans
, you
will
not
be
perm
itted
to d
o so
unt
il th
e O
pen
Enr
ollm
ent p
erio
d fo
llow
ing
the
12-m
onth
per
iod.
No
te:
Dup
licat
e co
vera
ge w
ithin
any
New
Jer
sey
Sta
te-a
dmin
iste
red
dent
al p
lan
is n
ot p
erm
itted
. A
n in
divi
dual
may
be
cove
red
as a
n em
ploy
ee o
r as
a
depe
nden
t, bu
t no
t as
bot
h an
em
ploy
ee a
nd a
de-
pend
ent.
Chi
ldre
n m
ay o
nly
be c
over
ed b
y on
e pa
r-en
t.
DE
NTA
L P
LA
N C
HO
ICE
S
You
have
a c
hoic
e be
twee
n tw
o ty
pes
of d
enta
l pla
ns:
•A
Den
talP
lan
Org
aniz
atio
n(D
PO
);or
•T
heD
enta
lExp
ense
Pla
n.
Den
tal P
lan
Org
aniz
atio
ns
(DP
Os)
The
DP
Os
are
com
pani
es t
hat
cont
ract
with
a n
et-
wor
k of
pr
ovid
ers
for
dent
al
serv
ices
. T
here
ar
e se
vera
l D
PO
s pa
rtic
ipat
ing
in t
he E
mpl
oyee
Den
-ta
l P
lans
fro
m w
hich
you
may
cho
ose.
P
artic
ipat
-in
g D
PO
s ar
e lis
ted
in t
he E
mpl
oyee
Den
tal
Pla
ns
Mem
ber
Gui
debo
ok,
avai
labl
e on
the
New
Jer
sey
Div
isio
n of
Pen
sion
s &
Ben
efits
(N
JDP
B)
web
site
at:
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
In o
rder
to r
ecei
ve c
over
age,
you
mus
t use
pro
vide
rs
who
par
ticip
ate
with
the
DP
O th
at y
ou s
elec
t. B
e su
re
you
confi
rm t
hat
the
dent
ist
or d
enta
l fac
ility
you
se-
lect
is
taki
ng n
ew p
atie
nts
and
part
icip
ates
with
the
S
HB
P/S
EH
BP
Em
ploy
ee D
enta
l Pla
ns,
sinc
e D
PO
s al
sos
ervi
ceo
ther
org
aniz
atio
ns.
Whe
n yo
u us
e a
DP
O d
entis
t, di
agno
stic
and
pre
ven-
tive
serv
ices
are
cov
ered
in
full.
Mos
t ot
her
elig
ible
expe
nses
req
uire
ac
opay
men
t.S
eeth
e“D
enta
lPla
nC
ompa
rison
” cha
rt la
ter
in th
is fa
ct s
heet
. In
addi
tion,
or
thod
ontic
tre
atm
ent
is c
over
ed f
or b
oth
child
ren
and
adul
ts, s
ubje
ct to
a c
opay
men
t.
If yo
ur d
entis
t dro
ps o
ut o
f the
DP
O, y
ou m
ust s
elec
t an
othe
r pa
rtic
ipat
ing
dent
ist
from
the
DP
O.
If th
ere
are
none
ava
ilabl
e w
ithin
30
mile
s of
you
r ho
me,
or
if yo
u m
ove
and
your
DP
O c
anno
t pr
ovid
e a
dent
ist
with
in 3
0 m
iles
of y
our
hom
e, y
ou m
ay c
hang
e pl
ans
imm
edia
tely
.
Den
tal E
xpen
se P
lan
The
Den
talE
xpen
seP
lan
isa
Pre
ferr
edP
rovi
der
Or-
gani
zatio
n(P
PO
)pla
nad
min
iste
red
byA
etna
Den
tal.
The
pla
n al
low
s yo
u to
cho
ose
any
licen
sed
dent
ist
for
your
den
tal c
are;
how
ever
, you
will
pay
less
if y
ou
use
an in
-net
wor
k pr
ovid
er. T
here
is a
ded
uctib
le t
o sa
tisfy
for
som
e se
rvic
es,
and
som
e se
rvic
es a
re e
l-ig
ible
onl
y up
to
a lim
ited
amou
nt. T
he a
nnua
l pl
an
dedu
ctib
le is
$50
per
per
son/
$100
per
fam
ily in
-net
-w
ork,
and
$75
per
per
son/
$150
per
fam
ily o
ut-o
f-ne
t-w
ork.
The
ded
uctib
le d
oes
not
appl
y to
dia
gnos
tic,
prev
entiv
e, a
nd o
rtho
dont
ic s
ervi
ces.
Afte
r yo
u sa
tis-
fy t
he a
nnua
l de
duct
ible
, yo
u ar
e re
imbu
rsed
a p
er-
cent
age
of t
he r
easo
nabl
e an
d cu
stom
ary
char
ges
or P
PO
-con
trac
ted
allo
wan
ce f
or s
ervi
ces
that
are
co
vere
d un
der
the
plan
.
The
Den
tal
Exp
ense
Pla
npr
ovid
esf
ort
hef
ollo
win
gbe
nefit
s:
•D
iagn
ostic
and
Pre
vent
ive
Ser
vice
sar
epa
ida
t
Fact
Sh
eet
#37
Feb
ruar
y 20
19
Den
tal P
lan
s —
Act
ive
Em
plo
yees
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
100
perc
ent
(in-n
etw
ork)
of
the
PP
O-c
ontr
acte
d al
low
ance
and
90
perc
ent (
out-
of-n
etw
ork)
of t
he
reas
onab
le a
nd c
usto
mar
y al
low
ance
, w
ith n
o de
duct
ible
;
•B
asic
Ser
vice
ssu
cha
sfil
lings
and
ext
ract
ions
are
paid
at
80
pe
rcen
t (in
-net
wor
k)
of
the
PP
O-c
ontr
acte
d al
low
ance
and
70
perc
ent
(out
-of
-net
wor
k) o
f the
rea
sona
ble
and
cust
omar
y al
-lo
wan
ce, a
fter
dedu
ctib
le;
•M
ajor
R
esto
rativ
eS
ervi
ces,
su
ch
as
crow
ns,
are
paid
at
65 p
erce
nt (
in-n
etw
ork)
of
the
PP
O-
cont
ract
ed a
llow
ance
and
55
perc
ent (
out-
of-n
et-
wor
k) o
f th
e re
ason
able
and
cus
tom
ary
allo
w-
ance
, afte
r de
duct
ible
;
•P
rost
hodo
ntic
Ser
vice
sfo
rne
wo
rre
plac
emen
tde
ntur
es a
re c
over
ed a
t 50
per
cent
(in
-net
wor
k)of
the
PP
O-c
ontr
acte
d al
low
ance
and
40
perc
ent
(out
-of-
netw
ork)
of
the
reas
onab
le a
nd c
usto
m-
ary
allo
wan
ce,a
fter
dedu
ctib
le.R
epai
rsto
exi
st-
ing
dent
ures
are
cov
ered
at
80 p
erce
nt (
in-n
et-
wor
k) o
f th
e P
PO
-con
trac
ted
allo
wan
ce a
nd 7
0pe
rcen
t (o
ut-o
f-ne
twor
k) o
f th
e re
ason
able
and
cust
omar
y al
low
ance
s, a
fter
dedu
ctib
le;
•P
erio
dont
ics
(tre
atm
ent
of
gum
di
seas
e)
isco
vere
d at
50
pe
rcen
t (in
-net
wor
k)
of
the
PP
O-c
ontr
acte
d al
low
ance
and
40
perc
ent
(out
-of
-net
wor
k) o
f the
rea
sona
ble
and
cust
omar
y al
-lo
wan
ce, a
fter
dedu
ctib
le;
•O
rtho
dont
ics
are
avai
labl
eaf
ter
you
have
bee
na
full-
time
empl
oyee
for
10
mon
ths
(with
no
de-
duct
ible
), b
ut o
nly
for y
our c
hild
ren
unde
r the
age
of 1
9. O
rtho
dont
ic s
ervi
ces
are
reim
burs
ed a
t 50
perc
ent
(in-n
etw
ork)
of
the
PP
O-c
ontr
acte
d al
-lo
wan
ce a
nd 4
0 pe
rcen
t (o
ut-o
f-ne
twor
k) o
f th
ere
ason
able
and
cus
tom
ary
allo
wan
ce,
and
have
a se
para
te $
1,00
0 in
-net
wor
k an
d $7
50 o
ut-o
f-ne
twor
k in
divi
dual
life
time
reim
burs
emen
t be
ne-
fitm
axim
um;a
nd
•B
enefi
tM
axim
um
per
cove
red
indi
vidu
al
is
$3,0
00 a
nnua
lly i
n-ne
twor
k an
d $2
,000
out
-of-
netw
ork
for
am
axim
umo
f$3
,000
com
bine
din
-an
dou
t-of
-net
wor
k.T
his
max
imum
app
lies
toa
llel
igib
les
ervi
ces
exce
pto
rtho
dont
ic,w
hich
has
a
sepa
rate
$1,
000/
$750
ind
ivid
ual
lifet
ime
bene
fit
max
imum
.
With
the
exce
ptio
nof
em
erge
ncy
care
,ify
our
Den
tal
Exp
ense
Pla
ntr
eatm
ent
incl
udes
cha
rges
tha
tar
eex
pect
edt
oco
stm
ore
than
$30
0,i
tis
str
ongl
yre
c-om
men
ded
that
you
r de
ntis
t file
for
pred
eter
min
atio
n of
ben
efits
with
Aet
na.
With
adv
ance
app
rova
l yo
u w
ill k
now
wha
t se
rvic
es a
re c
over
ed a
nd w
hat
pay-
men
ts w
ill b
e m
ade.
Whe
n yo
u us
e an
in-
netw
ork
dent
al p
rovi
der,
you
only
pay
the
pro
vide
r an
y ap
plic
able
ded
uctib
le a
nd
the
appr
opria
te c
oins
uran
ce b
ased
on
the
disc
ount
-ed
fee
, th
ereb
y re
duci
ng y
our
out-
of-p
ocke
t co
st.
In
man
y ca
ses
the
in-n
etw
ork
dent
al p
rovi
der
will
sub
-m
it th
e cl
aim
s di
rect
ly t
o A
etna
, el
imin
atin
g th
e ne
-ce
ssity
to
file
clai
m fo
rms.
To
find
an in
-net
wor
k pr
o-vi
der,
call
Aet
na a
t 1-8
77-7
82-8
365.
Pr
Em
Ium
CO
ST
S
For
em
ploy
ees
of t
he S
tate
, th
e pr
emiu
m c
ost
for
dent
al p
lan
cove
rage
is
shar
ed b
etw
een
the
Sta
te
and
the
empl
oyee
. T
he a
mou
nt o
f yo
ur p
ayro
ll de
-du
ctio
n is
ava
ilabl
e fr
om y
our
hum
an r
esou
rces
rep
-re
sent
ativ
e or
ben
efits
adm
inis
trat
or. D
enta
l rat
es a
re
also
pos
ted
on o
ur w
ebsi
te.
Sta
tee
mpl
oyee
pre
miu
ms
can
bep
aid
ona
pre
-tax
ba
sis
thro
ugh
part
icip
atio
n in
the
Pre
miu
m O
ptio
n P
lan
(PO
P)
ofT
ax$a
ve,
abe
nefit
pro
gram
ava
ilabl
eun
der
Sec
tion
125
oft
hef
eder
alI
nter
nal
Rev
enue
C
ode
(IR
C).
Par
ticip
atio
nin
the
PO
Pi
sau
tom
atic
un
less
you
file
a fo
rm d
eclin
ing
part
icip
atio
n. T
he I
n-te
rnal
Rev
enue
Ser
vice
(IR
S)
stric
tlyr
egul
ates
en-
rollm
ent i
n th
e P
OP
and
pro
hibi
ts a
ny b
enefi
t cha
ng-
es o
utsi
de o
f an
Ope
n E
nrol
lmen
t pe
riod
or u
nles
s a
qual
ifyin
glif
eev
ent
occu
rs(
e.g.
,lo
sso
fot
her
cov-
erag
e, m
arria
ge,
divo
rce,
etc
.).
The
Tax
$ave
Fac
t
She
ete
xpla
ins
the
PO
Pin
mor
ede
tail.
For
em
ploy
ees
of
a pa
rtic
ipat
ing
loca
l em
ploy
er,
the
prem
ium
cos
t fo
r de
ntal
pla
n co
vera
ge w
ill v
ary
base
d up
on th
e po
licie
s of
that
em
ploy
er, w
ith r
egar
d to
hea
lth b
enefi
t cos
ts a
nd a
ny la
bor
agre
emen
ts b
e-tw
een
the
empl
oyer
and
the
unio
ns r
epre
sent
ing
the
empl
oyee
. Em
ploy
ees
of a
par
ticip
atin
g lo
cal e
mpl
oy-
er s
houl
d se
e th
eir
hum
an r
esou
rces
rep
rese
ntat
ive
or b
enefi
ts a
dmin
istr
ator
for
mor
e in
form
atio
n.
CH
OO
SIN
G A
DE
NTA
L P
LA
N
Your
cho
ice
of a
den
tal p
lan
is a
per
sona
l dec
isio
n. In
de
cidi
ng w
heth
er to
enr
oll a
nd w
hich
pla
n to
cho
ose,
yo
u sh
ould
con
side
r:
•T
hen
atur
ean
dam
ount
of
your
ant
icip
ated
den
-ta
lexp
ense
sfo
rth
ene
xty
ear;
•T
hec
over
eds
ervi
ces
prov
ided
by
the
Den
talE
x-pe
nse
Pla
n or
a D
PO
;
•T
hed
iffer
ence
sin
out
-of-
pock
etc
osts
for
eac
hty
pe o
f pla
n; a
nd
•T
hed
egre
eof
flex
ibili
tyth
aty
oum
ayw
anti
nse
-le
ctin
g a
dent
ist.
You
can
use
the
“Den
talP
lan
Com
paris
on”
char
tlat
-er
in t
his
fact
she
et t
o co
mpa
re b
enefi
t le
vels
und
er
each
typ
e of
den
tal p
lan.
If
you
choo
se a
DP
O,
you
mus
t se
lect
a d
entis
t w
ho p
artic
ipat
es w
ith t
hat
par-
ticul
ar D
PO
and
who
can
acc
ept
you
and
your
de-
pend
ents
as
patie
nts.
The
follo
win
g ch
art p
rovi
des
a su
mm
ary
desc
riptio
n of
a v
arie
ty o
f den
tal s
ervi
ces
unde
r th
e tw
o ty
pes
of
dent
al p
lans
offe
red
by th
e E
mpl
oyee
Den
tal P
lans
. T
he c
hart
is n
ot c
ompl
ete
and
does
not
des
crib
e al
l th
e be
nefit
s, li
mita
tions
, or
cond
ition
s as
soci
ated
w
ith c
over
age
unde
r ei
ther
type
of p
lan.
Ple
ase
refe
r to
the
Em
ploy
ee D
enta
l Pla
ns M
embe
r G
uide
book
fo
r ad
ditio
nal d
etai
ls.
10
Feb
ruar
y 20
19
Fact
Sh
eet
#37
Den
tal P
lan
s —
Act
ive
Em
plo
yees
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
DE
NTA
L P
LA
N C
Om
PAr
ISO
N
DE
NTA
L E
xP
EN
SE
PL
AN
DE
NTA
L P
LA
N O
rG
AN
IzA
TIO
N(D
PO
)IN
-NE
Tw
Or
kO
uT-
OF
-NE
Tw
Or
k
Ded
uct
ible
$50
per
pers
on p
er c
alen
dar
year
/ $1
00 p
er fa
mily
; Non
e fo
r di
agno
stic
, pr
even
tive,
and
ort
hodo
ntic
ser
vice
s
$75
per
pers
on p
er c
alen
dar
year
/ $1
50 p
er fa
mily
; Non
e fo
r di
agno
stic
, pr
even
tive,
and
ort
hodo
ntic
ser
vice
s
Non
e
Co
insu
ran
ceP
lan
pays
: 100
% D
iagn
ostic
and
Pre
-ve
ntiv
e;8
0%B
asic
Res
tora
tive;
65%
M
ajor
Res
tora
tive;
50%
Per
iodo
ntic
san
d P
rost
hodo
ntic
s*
Pla
n pa
ys: 9
0% D
iagn
ostic
and
Pre
-ve
ntiv
e;7
0%B
asic
Res
tora
tive;
55%
M
ajor
Res
tora
tive;
40%
Per
iodo
ntic
san
d P
rost
hodo
ntic
s*
Pla
n pa
ys 1
00%
(le
ss c
opay
men
t);
100%
Dia
gnos
tic a
nd P
reve
ntiv
e
Co
pay
men
tsN
one
Non
eV
arie
s de
pend
ing
on s
ervi
ce
Ben
efits
max
imu
m$3
,000
(M
axim
umo
f$3,
000
com
-bi
ned
in-
and
out-
of-n
etw
ork)
per
m
embe
ran
nual
ly(
excl
udin
gor
tho-
dont
ics)
; $1,
000
(life
time)
per
chi
ld fo
r or
thod
ontic
s
$2,0
00(
Max
imum
of$
3,00
0co
m-
bine
d in
- an
d ou
t-of
-net
wor
k) p
er
mem
ber
annu
ally
(ex
clud
ing
orth
o-do
ntic
s); $
750
(life
time)
per
chi
ld fo
r or
thod
ontic
s
Unl
imite
d
Pro
vid
er L
imit
atio
ns
Mus
t use
par
ticip
atin
g de
ntis
tA
ny li
cens
ed d
entis
tM
ust u
se D
PO
-par
ticip
atin
g de
ntis
t
Sel
ecte
d S
ervi
ces
So
me
serv
ices
list
ed b
elo
w m
ay b
e co
vere
d s
ub
ject
to
ded
uct
ible
s an
d
coin
sura
nce
as
sho
wn
ab
ove
So
me
serv
ices
list
ed b
elo
w m
ay b
e co
vere
d s
ub
ject
to
ded
uct
ible
s an
d
coin
sura
nce
as
sho
wn
ab
ove
Ser
vice
s lis
ted
bel
ow
are
cov
ered
in
fu
ll su
bje
ct t
o c
op
aym
ents
Exa
min
atio
ns
Ora
l eva
luat
ions
lim
ited
to tw
ice
per
cale
ndar
yea
r; P
lan
pays
100
%*
Ora
l eva
luat
ions
lim
ited
to tw
ice
per
cale
ndar
yea
r; P
lan
pays
90%
*O
ral e
valu
atio
ns li
mite
d to
twic
e pe
r ca
lend
ar y
ear;
Pla
n pa
ys 1
00%
x-r
ays
Cov
ered
sub
ject
to li
mita
tions
; Pla
n pa
ys 1
00%
*C
over
ed s
ubje
ct to
lim
itatio
ns; P
lan
pays
90%
*C
over
ed s
ubje
ct to
lim
itatio
ns; P
lan
pays
100
%
Cle
anin
gs
(Ora
l Pro
phy
laxi
s)Tw
o cl
eani
ngs
per
cale
ndar
yea
r; P
lan
pays
100
%*
Two
clea
ning
s pe
r ca
lend
ar y
ear;
Pla
n pa
ys 9
0%*
Two
clea
ning
s pe
r ca
lend
ar y
ear;
Pla
n pa
ys 1
00%
Flu
ori
de
Ap
plic
atio
ns
Cov
ered
onl
y fo
r ch
ildre
n un
der
age
19; T
wic
e pe
r ca
lend
ar y
ear;
Pla
n pa
ys
100%
*
Cov
ered
onl
y fo
r ch
ildre
n un
der
age
19; T
wic
e pe
r ca
lend
ar y
ear;
Pla
n pa
ys
90%
*
Cov
ered
onl
y fo
r ch
ildre
n un
der
age
19; T
wic
e pe
r ca
lend
ar y
ear;
Pla
n pa
ys
100%
*In
the
Den
tal E
xpen
se P
lan,
you
are
res
pons
ible
for
the
amou
nt th
e de
ntis
t cha
rges
abo
ve th
e re
ason
able
and
cus
tom
ary
allo
wan
ces.
11
Fact
Sh
eet
#37
Feb
ruar
y 20
19
Den
tal P
lan
s —
Act
ive
Em
plo
yees
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
DE
NTA
L P
LA
N C
Om
PAr
ISO
N
DE
NTA
L E
xP
EN
SE
PL
AN
DE
NTA
L P
LA
N O
rG
AN
IzA
TIO
N(D
PO
)IN
-NE
Tw
Or
kO
uT-
OF
-NE
Tw
Or
k
Too
th S
eala
nts
Cov
ered
for
child
ren
unde
r ag
e 19
(w
ith r
estr
ictio
ns);
Pla
n pa
ys 1
00%
*C
over
ed fo
r ch
ildre
n un
der
age
19
(with
res
tric
tions
); P
lan
pays
90%
*C
over
ed o
nly
for
child
ren
unde
r ag
e 19
; No
copa
ymen
t (lim
itatio
ns a
pply
)
ro
uti
ne
Fill
ing
sP
lan
pays
80%
*P
lan
pays
70%
*C
over
ed; C
opay
men
ts m
ay a
pply
**
Sim
ple
Ext
ract
ion
Pla
n pa
ys 8
0%*
Pla
n pa
ys 7
0%*
Cov
ered
afte
r co
paym
ent o
f $20
Cro
wn
sP
lan
pays
65%
*P
lan
pays
55%
*C
over
ed a
fter
copa
ymen
t of $
150–
$225
**
ro
ot
Can
al (
En
do
do
nti
cs)
Pla
n pa
ys 8
0%*
Pla
n pa
ys 7
0%*
End
odon
tic T
hera
py c
over
ed a
fter
copa
ymen
t of $
100–
$175
**
Den
ture
sR
epai
rof
exi
stin
gde
ntur
esc
over
eda
t80
%;*
New
or
repl
acem
ent d
entu
res
cove
red
at 5
0%*
Rep
air
ofe
xist
ing
dent
ures
cov
ered
at
70%
;* N
ew o
r re
plac
emen
t den
ture
s co
vere
d at
40%
*
Cov
ered
afte
r co
paym
ent (
with
lim
ita-
tions
)**
Ora
l Su
rger
y fo
r r
emov
al o
f Im
-p
acte
d T
oo
thP
lan
pays
80%
;* M
ay b
e co
vere
d un
-de
r th
e m
edic
al p
lan
first
, the
n de
ntal
w
ill c
onsi
der
Pla
n pa
ys 7
0%;*
May
be
cove
red
un-
der
the
med
ical
pla
n fir
st, t
hen
dent
al
will
con
side
r
Cov
ered
afte
r co
paym
ent o
f $65
Per
iod
on
tics
Pla
n pa
ys 5
0% (
with
lim
itatio
ns)
Pla
n pa
ys 4
0% (
with
lim
itatio
ns)
Cov
ered
afte
r co
paym
ent o
f: $3
0 fo
r gi
ngiv
ecto
my
(one
to th
ree
teet
h);
$55
for
root
pla
ning
(pe
rqu
adra
nt);
$100
–$17
5**
for
osse
ous
surg
ery
Ort
ho
do
nti
cA
fter
you
have
bee
n an
em
ploy
ee fo
r 10
mon
ths,
elig
ible
ser
vice
s co
vere
d at
a 5
0% c
oins
uran
ce le
vel,
up to
a
$1,0
00li
fetim
em
axim
ump
erc
hild
;C
over
ed o
nly
for
thos
e w
ho s
tart
trea
t-m
ent b
efor
e ag
e 19
(S
ee E
mpl
oyee
D
enta
l Pla
ns M
embe
r G
uide
book
for
spec
ifics
)
Afte
r yo
u ha
ve b
een
an e
mpl
oyee
for
10 m
onth
s, e
ligib
le s
ervi
ces
cove
red
at a
40%
coi
nsur
ance
leve
l, up
to a
$7
50li
fetim
em
axim
um(
max
imum
of
$1,0
00 c
ombi
ned
in-
and
out-
of-n
et-
wor
k) p
er c
hild
; Cov
ered
onl
y fo
r th
ose
who
sta
rt tr
eatm
ent b
efor
e ag
e 19
(S
ee E
mpl
oyee
Den
tal P
lans
Mem
ber
Gui
debo
ok fo
r sp
ecifi
cs)
Max
imum
trea
tmen
tis
24m
onth
s;
Cop
aym
ent a
s fo
llow
s:
Pat
ient
und
er a
ge 1
8: $
1,00
0 or
50%
of
rea
sona
ble
and
cust
omar
y ch
arge
s,
whi
chev
er is
less
;
Pat
ient
age
18
or o
ver:
$1,
750
or 5
0%
of r
easo
nabl
e an
d cu
stom
ary
char
ges,
w
hich
ever
is le
ss
*In
the
Den
tal E
xpen
se P
lan,
you
are
res
pons
ible
for
the
amou
nt th
e de
ntis
t cha
rges
abo
ve th
e re
ason
able
and
cus
tom
ary
allo
wan
ces.
** S
ee th
e E
mpl
oyee
Den
tal P
lans
Mem
ber
Gui
debo
ok fo
r D
PO
cop
aym
ent a
mou
nts.
12
Feb
ruar
y 20
19
Fact
Sh
eet
#37
Den
tal P
lan
s —
Act
ive
Em
plo
yees
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
Thi
s fa
ct s
heet
has
bee
n pr
oduc
ed a
nd d
istr
ibut
ed b
y:
New
Jer
sey
Div
isio
n o
f P
ensi
on
s &
Ben
efits
P.
O. B
ox 2
95, T
ren
ton
, NJ
0862
5-02
95
(609
)29
2-75
24F
or th
e he
arin
g im
paire
d: T
RS
711
(60
9) 2
92-6
683
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
13
EMPLOYEE GROUP DENTAL PLANS
https://www.state.nj.us/treasury/pensions/dental-plans.shtml
PLAN NUMBER PLAN NAME
WEB ADDRESS AND MEMBERSHIP SERVICES PHONE
NUMBER
305 Cigna Dental Health, Inc. www.cigna.com/sites/stateofnjdental 1-800-564-7642
307 Healthplex (International Health Care Services)
www.healthplex.com 1-800-468-0600
317 Horizon Dental Choice www.horizonblue.com 1-800-433-6825
319 Aetna DPO www.aetna.com/statenj 1-800-843-3661
320 MetLife* www.metlife.com/dental 1-866-880-2984
399 Dental Expense Plan (PPO Administered by Aetna)
www.aetna.com/statenj 1-877-782-8365
* When searching for a MetLife dental provider on their Web site, select ‘Dental HMO/ManagedCare’ as the Network Type and NJ SHBP/SEHBP Actives.
Employee Dental Plans Member Handbook Additional coverage information may be found in the Employee Dental Plans Member Handbook at: https://www.state.nj.us/treasury/pensions/documents/guidebooks/hd0379.pdf
14
15
Public Employees’ Retirement System (PERS)
Eligibility Criteria
Membership in the retirement system is generally required as a condition of employment. You are required to enroll in the PERS if:
You are employed on a regular basis in a position covered by Social Security; and You are scheduled to work at least 35 hours per week and You are not required to be a member of any other State or local government retirement system
on the basis of the same position; or if: You are receiving a monthly retirement allowance from the PERS, you are scheduled to work
more than the minimum number of hours per week required for PERS enrollment, and you earnmore than $15,000 annually. Please consult with your Benefits Services Associate as to howthis will affect your retirement.
Member Contribution Rate
Chapter 78, P.L. 2011, the Pension and Health Benefit Reform Law, increased the PERS contribution rate. The most recent increase was July 2013 which brought the contributions up to 6.78%. Subsequent increases will then be phased in over 7 years (each July 1st) to bring the total pension contribution rate to 7.5% of base salary as of July 1, 2018.
Pensionable Salary
Your contribution rate is applied to your base salary to determine pension deductions. Base salary does not include overtime, bonuses, or shift differential. Pension contributions are deducted from your salary each payday and reported to the PERS by your employer.
The PERS contribution rate for members is applied to the pensionable salary up to a compensation limit based on the annual maximum wage for Social Security deductions. Members who earn in excess of the annual compensation limit will be enrolled in the Defined Contribution Retirement Program (DCRP) in addition to the PERS unless a waiver is completed. Please see Fact Sheet #82 Defined Contribution Retirement Program (DCRP) If Ineligible for PERS, for additional information.
Designating a Beneficiary
Once the member receives a copy of the Certificate of Payroll Deductions the members can register for the Member Benefits Online System (MBOS) and complete the Designation of Beneficiary online. Your PERS membership number is required and is listed on the Certificate of Payroll Deductions.
Members may access account information through the Member Benefits Online System (MBOS) https://www.nj.gov/treasury/pensions/mbos-kit.shtml
Information for new employees transferring an active PERS account:
An Intrafund Transfer is the transfer of a pension account from one employer to another employer within the same New Jersey State-administered retirement system. To be eligible for an Intrafund Transfer:
The member must have not withdrawn from the retirement system; and It must be less than two consecutive years since the last pension contribution; and The member must meet all of the eligibility requirements for retirement system membership
with the new employer. A Report of Transfer form must be completed and submitted to the HR Benefits Services
Associate.
For information regarding your PERS membership please visit:
-Division of Pensions and Benefits PERS websitehttps://www.nj.gov/treasury/pensions/pension-active-pers.shtml
-PERS Member Handbookhttps://www.nj.gov/treasury/pensions/documents/guidebooks/persbook.pdf
16
Defi
ned
Co
ntr
ibu
tio
n R
etir
emen
t P
rog
ram
(D
CR
P)
if In
elig
ible
fo
r P
ER
S o
r TPA
F E
nro
llmen
tIn
form
atio
n fo
r:
Em
ploy
ees
belo
w th
e m
inim
um
sala
ry o
r ho
urs
requ
ired
for
PE
RS
or T
PAF
enr
ollm
ent
Mar
ch 2
019
Fact
Sh
eet
#82
The
D
efine
d C
ontr
ibut
ion
Ret
irem
ent
Pro
gram
(D
CR
P)
was
est
ablis
hed
July
1,
2007
, un
der
the
prov
isio
ns o
f N
.J.S
.A.
43:1
5C-1
et
seq.
The
DC
RP
pr
ovid
es e
ligib
le m
embe
rs w
ith a
tax
-she
ltere
d, d
e-fin
ed c
ontr
ibut
ion
retir
emen
t be
nefit
, al
ong
with
life
in
sura
nce
and
long
-ter
m d
isab
ility
cov
erag
e.
EL
IGIB
ILIT
Y
Thi
s fa
ct s
heet
add
ress
es D
CR
P m
embe
rshi
p fo
r em
ploy
ees
who
do
not
earn
the
min
imum
sal
ary
or
wor
k th
e m
inim
um h
ours
req
uire
d fo
r en
rollm
ent
in
the
Pub
lic E
mpl
oyee
s’ R
etire
men
t S
yste
m (
PE
RS
) or
Tea
cher
s’ P
ensi
on a
nd A
nnui
ty F
und
(TPA
F).
Em
-pl
oyee
s w
ho a
re a
lread
y en
rolle
d in
a N
ew J
erse
y S
tate
-adm
inis
tere
d re
tirem
ent
syst
em s
houl
d re
fer
to
the
Defi
ned
Con
trib
utio
n R
etire
men
t P
rogr
am
(DC
RP
) E
nrol
lmen
t Due
to M
axim
um C
ompe
nsat
ion
Lim
its F
act
She
et.
Ele
cted
and
app
oint
ed o
ffici
als
shou
ld r
efer
to
the
Defi
ned
Con
trib
utio
n R
etire
men
t P
rogr
am (
DC
RP
) fo
r E
lect
ed a
nd A
ppoi
nted
Offi
cial
s Fa
ct S
heet
. T
hese
fac
t sh
eets
are
ava
ilabl
e on
our
w
ebsi
te a
t: w
ww
.nj.g
ov/t
reas
ury
/pen
sio
ns
Em
ploy
ees
hire
d on
or
afte
r N
ovem
ber
2, 2
008,
and
on
or
befo
re M
ay 2
1, 2
010,
mus
t ea
rn a
min
imum
ba
se s
alar
y of
$8,
400*
or m
ore
per y
ear t
o be
elig
ible
fo
r en
rollm
ent i
n T
ier
3 of
the
PE
RS
or T
PAF.
Any
em
ploy
ee o
ther
wis
e el
igib
le to
enr
oll i
n T
ier
3 of
th
e P
ER
S o
r T
PAF
who
doe
s no
t ea
rn t
he r
equi
red
min
imum
ann
ual
sala
ry,
but
earn
s a
min
imum
bas
e sa
lary
of
$5,0
00 o
r m
ore,
mus
t be
enr
olle
d in
the
D
CR
P.
Em
ploy
ees
enro
lled
afte
r M
ay 2
1, 2
010,
mus
t wor
k a
min
imum
of
35 h
ours
per
wee
k if
a S
tate
em
ploy
ee,
or 3
2 ho
urs
per
wee
k if
a lo
cal
gove
rnm
ent
or l
ocal
ed
ucat
ion
empl
oyee
, to
be
elig
ible
for
enr
ollm
ent
in
Tie
r 4
or T
ier
5 of
the
PE
RS
or T
PAF.
Any
em
ploy
ee o
ther
wis
e el
igib
le to
enr
oll i
n T
ier
4 or
T
ier
5 of
the
PE
RS
or
TPA
F w
ho d
oes
not
wor
k th
e re
quire
d m
inim
um h
ours
, bu
t ea
rns
a m
inim
um a
n-nu
al b
ase
sala
ry o
f $5,
000
or m
ore,
mus
t be
enro
lled
in th
e D
CR
P.
EN
RO
LL
ME
NT
The
em
ploy
er i
s re
spon
sibl
e fo
r en
rolli
ng a
DC
RP
- el
igib
le e
mpl
oyee
as
of t
he s
tart
ing
date
of
empl
oy-
men
t —
by
usin
g th
e D
CR
P E
nrol
lmen
t A
pplic
atio
n av
aila
ble
on th
e E
mpl
oyer
Pen
sion
s an
d B
enefi
ts In
-fo
rmat
ion
Con
nect
ion
(EP
IC),
ava
ilabl
e on
our
web
-si
te.
Enr
ollm
ent
is r
equi
red
for
elig
ible
em
ploy
ees.
The
re
is n
o op
tion
for
wai
ver
of D
CR
P e
nrol
lmen
t for
thes
e in
divi
dual
s.
Whe
n en
rolle
d in
th
e D
CR
P,
mem
bers
co
ntrib
ute
5.5
perc
ent
of t
he b
ase
sala
ry t
o a
tax-
defe
rred
in-
vest
men
t ac
coun
t es
tabl
ishe
d w
ith P
rude
ntia
l, w
hich
join
tly a
dmin
iste
rs t
he D
CR
P i
nves
tmen
ts w
ith t
he
New
Jer
sey
Div
isio
n of
Pen
sion
s &
Ben
efits
(NJD
PB
). M
embe
r con
trib
utio
ns a
re m
atch
ed b
y a
thre
e pe
rcen
t em
ploy
er c
ontr
ibut
ion.
Con
trib
utio
ns a
re r
equi
red
from
the
date
of D
CR
P e
l-ig
ibili
ty. I
f an
y ba
ck d
educ
tions
are
ow
ed,
empl
oyer
s m
ust s
ched
ule
and
rem
it th
em to
the
DC
RP.
If E
ligib
le L
ater
for
the
PE
RS
or T
PAF
If an
em
ploy
ee e
nrol
led
in th
e D
CR
P e
arns
suf
ficie
nt
sala
ry o
r w
orks
suf
ficie
nt h
ours
at
a la
ter
date
to
qual
ify f
or e
nrol
lmen
t in
the
PE
RS
or
TPA
F, t
he e
m-
ploy
ee w
ill b
e en
rolle
d in
the
PE
RS
or T
PAF.
Upo
n be
com
ing
a P
ER
S o
r T
PAF
mem
ber,
cont
ribu-
tions
to
the
DC
RP
will
cea
se;
how
ever
, pr
ior
cont
ri-bu
tions
rem
ain
inve
sted
in th
e D
CR
P p
endi
ng r
etire
-m
ent o
r te
rmin
atio
n of
em
ploy
men
t.
Con
trib
utio
ns t
o th
e D
CR
P c
anno
t be
tra
nsfe
rred
to
the
PE
RS
or
TPA
F, a
nd s
ervi
ce c
redi
t as
a D
CR
P
mem
ber c
anno
t be
purc
hase
d as
PE
RS
or T
PAF
ser
-vi
ce c
redi
t.
A P
ER
S o
r TPA
F e
mpl
oyee
may
onc
e ag
ain
beco
me
elig
ible
for
the
DC
RP
if:
•T
hea
nnua
lsal
ary
falls
bel
owt
hem
inim
ums
al-
ary
requ
ired
for
PE
RS
or
TPA
F T
ier
3 m
embe
r-sh
ip; d
educ
tions
will
cea
se a
nd t
he m
embe
r w
illco
ntrib
ute
to th
e D
CR
P p
lan;
*The
Tie
r 3
min
imum
bas
e sa
lary
is s
ubje
ct to
adj
ustm
ent a
nnua
lly in
acc
orda
nce
with
cha
nges
in th
e C
onsu
mer
Pric
e In
dex.
17
Fact
Sh
eet
#82
Mar
ch 2
019
Defi
ned
Co
ntr
ibu
tio
n R
etir
emen
t P
rog
ram
(D
CR
P)
if In
elig
ible
for
PE
RS
or T
PAF
En
rollm
ent
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
•T
hen
umbe
rof
wor
kho
urs
falls
bel
owt
hem
in-
imum
ho
urs
per
wee
k re
quire
d fo
r P
ER
S
orT
PAF
Tie
r 4
or T
ier
5 m
embe
rshi
p; d
educ
tions
will
cea
se a
nd t
he m
embe
r w
ill c
ontr
ibut
e to
the
DC
RP
pla
n;
•T
hea
nnua
lsal
ary
isin
exc
ess
oft
hem
axim
umco
mpe
nsat
ion
limit
(mem
bers
en
rolle
d in
th
eP
ER
S o
r T
PAF
on
or a
fter
July
1,
2007
) —
see
the
Defi
ned
Con
trib
utio
n R
etire
men
t P
rogr
am(D
CR
P)
Enr
ollm
ent
Due
to
Max
imum
Com
pen-
satio
n Li
mits
Fac
t She
et; o
r
•T
hee
mpl
oyee
bec
omes
aS
tate
or
loca
lele
cted
or a
ppoi
nted
offi
cial
— s
ee t
he D
efine
d C
ontr
i-bu
tion
Ret
irem
ent
Pro
gram
(D
CR
P)
for
Ele
cted
and
App
oint
ed O
ffici
als
Fact
She
et.
Tran
sfer
of
PE
RS
or T
PAF
Mem
ber
ship
Em
ploy
ees
who
are
PE
RS
or
TPA
F m
embe
rs a
nd
tran
sfer
to
anot
her
PE
RS
or
TPA
F p
ositi
on a
re s
ub-
ject
to th
e m
inim
um s
alar
y or
min
imum
hou
rs o
f the
ir ex
istin
g P
ER
S o
r TPA
F m
embe
rshi
p tie
r if
any
of th
e fo
llow
ing
situ
atio
ns a
pply
:
•T
hem
embe
rtr
ansf
ers
toa
PE
RS
-or
TPA
F-e
ligi-
ble
posi
tion
with
out a
bre
ak in
ser
vice
;
•A
nyb
reak
ins
ervi
ceis
24
cons
ecut
ive
mon
ths
orle
ss fr
om th
e da
te o
f the
last
PE
RS
or T
PAF
pen
-si
on c
ontr
ibut
ion,
and
the
acc
ount
has
not
bee
nw
ithdr
awn;
•A
nyb
reak
in
serv
ice
is2
4co
nsec
utiv
em
onth
sor
less
from
the
end
of a
n ap
prov
ed le
ave
of a
b-se
nce;
or
•T
hem
embe
r’sjo
bis
lost
thr
ough
no
faul
tof
his
/he
r ow
n (la
id o
ff or
pos
ition
is
abol
ishe
d —
not
term
inat
edv
olun
taril
yor
for
cau
se)
and
he/s
here
turn
s to
PE
RS
or
TPA
F e
mpl
oym
ent
with
in 1
0ye
ars
of th
e te
rmin
atio
n da
te.
If a
mem
ber
tran
sfer
s in
to th
e P
ER
S o
r T
PAF
afte
r a
brea
k in
ser
vice
tha
t fa
lls b
eyon
d th
e ex
cept
ions
de-
scrib
ed a
bove
, the
mem
ber
will
be
subj
ect t
o th
e T
ier
4 or
Tie
r 5
min
imum
hou
rs r
equi
rem
ent,*
reg
ardl
ess
of th
e pr
evio
us m
embe
rshi
p tie
r st
atus
.
If th
e w
ork
hour
s fa
ll be
low
the
Tie
r 4
or T
ier
5 m
ini-
mum
req
uire
men
t, th
e em
ploy
ee w
ill b
e in
elig
ible
for
tran
sfer
int
o th
e P
ER
S o
r T
PAF
but
will
be
elig
ible
fo
r D
CR
P e
nrol
lmen
t if
the
annu
al s
alar
y is
at
leas
t $5
,000
. PE
RS
an
d T
PAF
Max
imu
m W
age
In a
dditi
on,
Tie
r 2,
Tie
r 3,
Tie
r 4,
and
Tie
r 5
mem
-be
rs a
re s
ubje
ct t
o a
max
imum
wag
e lim
it fo
r P
ER
S
or T
PAF
pen
sion
con
trib
utio
ns. T
he m
axim
um w
age
limit
for 2
019
is $
132,
900
and
is s
ubje
ct to
ann
ual a
d-ju
stm
ent.
Mem
bers
who
ear
n in
exc
ess
of th
e an
nual
m
axim
um w
age
will
be
enro
lled
in th
e D
CR
P i
n ad
di-
tion
to th
e P
ER
S o
r TPA
F. S
ee th
e D
efine
d C
ontr
ibu-
tion
Ret
irem
ent
Pro
gram
(D
CR
P)
Enr
ollm
ent
Due
to
Max
imum
Com
pens
atio
n Li
mits
Fac
t S
heet
for
mor
e in
form
atio
n.
Ves
tin
g
Em
ploy
er c
ontr
ibut
ions
are
not
ves
ted
in a
DC
RP
m
embe
r’s a
ccou
nt u
ntil
afte
r th
e m
embe
r co
mm
enc-
es th
e se
cond
yea
r of e
mpl
oym
ent,
unle
ss a
t the
tim
e of
ini
tial
empl
oym
ent
the
mem
ber
eith
er 1
) pa
rtic
i-pa
tes
in a
pro
gram
sub
stan
tially
sim
ilar
to th
e D
CR
P
prog
ram
, or
2)
is a
mem
ber
of a
noth
er N
ew J
erse
y S
tate
-adm
inis
tere
d re
tirem
ent s
yste
m.
As
a ve
sted
mem
ber,
you
have
a r
ight
to a
ben
efit a
t re
tirem
ent b
ased
on
both
the
empl
oyee
and
em
ploy
-er
con
trib
utio
ns to
the
DC
RP.
WIT
hD
RA
WA
L
With
draw
al o
ccur
s w
hen
a no
n-ve
sted
DC
RP
mem
-be
r sep
arat
es fr
om c
over
ed e
mpl
oym
ent a
nd s
ubm
its
a re
ques
t to
Pru
dent
ial f
or a
with
draw
al o
f co
ntrib
u-tio
ns. O
nly
the
mem
ber’s
con
trib
utio
ns a
re a
vaila
ble
for w
ithdr
awal
— e
mpl
oyer
con
trib
utio
ns a
re fo
rfei
ted.
A
fter
a w
ithdr
awal
, th
e in
divi
dual
is e
ligib
le f
or r
een-
rollm
ent
in t
he D
CR
P, o
r en
rollm
ent
in a
noth
er N
ew
Jers
ey S
tate
-adm
inis
tere
d re
tirem
ent
syst
em,
upon
re
turn
to c
over
ed e
mpl
oym
ent.
RE
TIR
EM
EN
T
Ret
irem
ent
occu
rs w
hen
a ve
sted
DC
RP
mem
ber
sepa
rate
s fr
om c
over
ed e
mpl
oym
ent
and
elec
ts t
o re
ceiv
e a
dist
ribut
ion
of f
unds
con
tain
ing
both
em
-pl
oyer
and
em
ploy
ee c
ontr
ibut
ions
plu
s in
tere
st. T
his
actio
n de
ems
the
form
er p
artic
ipan
t as
ret
ired
and,
th
eref
ore,
ine
ligib
le t
o re
-enr
oll
in t
he D
CR
P o
r pa
r-tic
ipat
e in
any
oth
er N
ew J
erse
y S
tate
-adm
inis
tere
d re
tirem
ent s
yste
m.
An
AB
P/D
CR
P
With
draw
al
Req
uest
A
ckno
wle
dg-
men
t R
ecei
pt m
ust
be c
ompl
eted
in o
rder
to
rece
ive
fund
s. T
his
form
is a
vaila
ble
in th
e “P
ublic
atio
ns” s
ec-
tion
of o
ur w
ebsi
te.
Ap
ply
ing
Fo
r R
etir
emen
t
Six
mon
ths
befo
re r
etire
men
t, a
mem
ber
shou
ld c
on-
tact
the
em
ploy
er a
nd P
rude
ntia
l fo
r in
form
atio
n re
-ga
rdin
g D
CR
P b
enefi
ts a
nd o
ptio
ns.
A D
CR
P m
embe
r may
ele
ct to
rece
ive
all o
r a p
ortio
n of
his
/her
acc
ount
in
alu
mp-
sum
dis
trib
utio
n,o
rin
a
varie
ty o
f pe
riodi
c pa
ymen
t m
etho
ds. P
leas
e co
n-ta
ct y
our
adm
inis
trat
ive
serv
ices
pro
vide
r fo
r m
ore
info
rmat
ion.
All
retu
rns
of c
ontr
ibut
ions
and
ear
ning
s ar
e co
nsid
ered
taxa
ble
in th
e ye
ar th
ey a
re r
ecei
ved;
th
eref
ore,
the
typ
e of
pay
out
plan
sho
uld
be c
onsi
d-er
ed c
aref
ully
prio
r to
ret
irem
ent.
The
re is
no
min
imum
retir
emen
t age
und
er th
e D
CR
P.
The
mem
ber w
ill a
utom
atic
ally
be
cons
ider
ed re
tired
, re
gard
less
of a
ge, i
f the
re is
any
dis
trib
utio
n of
ves
ted
cont
ribut
ions
.
*Tie
r 4
or T
ier
5 m
embe
rs m
ust w
ork
a m
inim
um o
f 35
hour
s pe
r w
eek
if a
Sta
te e
mpl
oyee
, or
32 h
ours
per
wee
k if
a lo
cal g
over
nmen
t or
loca
l edu
catio
n em
ploy
ee.
18
Mar
ch 2
019
Fact
Sh
eet
#82
Defi
ned
Co
ntr
ibu
tio
n R
etir
emen
t P
rog
ram
(D
CR
P)
if In
elig
ible
for
PE
RS
or T
PAF
En
rollm
ent
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
A m
embe
r may
take
a d
istr
ibut
ion
at a
ny ti
me
afte
r ter
-m
inat
ion
of e
mpl
oym
ent;
how
ever
, if y
ou re
turn
to p
ub-
lic e
mpl
oym
ent i
n N
ew J
erse
y, y
ou c
anno
t par
ticip
ate
in a
ny N
ew J
erse
y S
tate
-adm
inis
tere
d re
tirem
ent s
ys-
tem
. DC
RP
mem
bers
con
side
ring
futu
re e
mpl
oym
ent
in a
pos
ition
cov
ered
by
any
of th
e N
ew J
erse
y S
tate
- ad
min
iste
red
retir
emen
t sy
stem
s sh
ould
ca
refu
lly
cons
ider
this
impa
ct b
efor
e re
ques
ting
a di
strib
utio
n.
hea
lth
Ben
efits
at
Ret
irem
ent
It is
im
port
ant
to n
ote
that
ser
vice
tim
e fr
om e
n-ro
llmen
t in
the
DC
RP
can
not
be u
sed
to q
ualif
y fo
r S
tate
Hea
lth B
enefi
ts P
rogr
am (
SH
BP
) or
Sch
ool
Em
ploy
ees’
Hea
lth B
enefi
ts P
rogr
am (
SE
HB
P)
cov-
erag
e at
ret
irem
ent.
Ple
ase
cont
act
your
em
ploy
er’s
hu
man
res
ourc
es o
ffice
or
bene
fits
adm
inis
trat
or t
o as
k ab
out
heal
th b
enefi
t co
vera
ge o
ptio
ns a
vaila
ble
in r
etire
men
t.
LIF
E IN
SU
RA
NC
E C
OV
ER
AG
E
Whi
le e
mpl
oyed
, a
DC
RP
mem
ber
is c
over
ed b
y em
ploy
er-p
aid
life
insu
ranc
e, p
ayab
le t
o de
sign
ated
be
nefic
iarie
s in
the
am
ount
of
1.5
times
the
ann
u-al
bas
e sa
lary
on
whi
ch D
CR
P c
ontr
ibut
ions
wer
e ba
sed.
Thi
s co
vera
ge i
s av
aila
ble
with
out
a m
edic
al
exam
inat
ion
to m
embe
rs u
nder
age
60.
New
ly e
n-ro
lled
mem
bers
60
year
s of
age
or
olde
r m
ust u
nder
-go
a m
edic
al e
xam
inat
ion
to q
ualif
y.
DC
RP
mem
bers
will
con
tinue
to b
e in
sure
d fo
r up
to
two
year
s if
on a
n ap
prov
ed le
ave
of a
bsen
ce w
ithou
t pa
y fo
r pe
rson
al il
lnes
s.
No
te:
The
Int
erna
l Rev
enue
Ser
vice
(IR
S)
clas
sifie
s al
l lif
e in
sura
nce
cove
rage
ove
r $5
0,00
0 as
a f
ringe
be
nefit
sub
ject
to
taxa
tion.
Whi
le t
he a
mou
nt o
f th
e lif
e in
sura
nce
cove
rage
is
not
taxa
ble,
the
pre
miu
m
requ
ired
to p
ay fo
r th
e lif
e in
sura
nce
cove
rage
is ta
x-ab
le.
Mem
bers
can
ele
ct t
o w
aive
ins
uran
ce c
over
-ag
e ov
er $
50,0
00 a
t any
tim
e.
Upo
n re
tirem
ent,
life
insu
ranc
e un
der
the
DC
RP
re-
duce
sto
3/1
6of
the
ann
ual
base
sal
ary
onw
hich
D
CR
P c
ontr
ibut
ions
wer
e ba
sed.
Thi
s lif
e in
sura
nce
cove
rage
is a
vaila
ble
in r
etire
men
t on
ly to
:
•M
embe
rsa
ge6
0or
old
eri
fth
em
embe
rha
sco
mpl
eted
10
year
s of
par
ticip
atio
n in
the
DC
RP
; or
•M
embe
rso
fany
age
ifth
em
embe
rha
sco
mpl
et-
ed 2
5 ye
ars
of p
artic
ipat
ion
in th
e D
CR
P.
The
mem
ber
also
mus
t hav
e be
en a
n ac
tive
empl
oy-
ee in
the
12 m
onth
s im
med
iate
ly p
rece
ding
the
initi
al
rece
ipt o
f a r
etire
men
t ann
uity
pay
men
t.
Co
nver
sio
n
Oth
er t
han
the
retir
ed i
nsur
ance
ben
efit
prev
ious
ly
desc
ribed
, lif
e in
sura
nce
cove
rage
und
er t
he D
CR
P
ceas
es 3
1 da
ys a
fter
term
inat
ion
of e
mpl
oym
ent.
Dur
ing
the
31-d
ay p
erio
d fo
llow
ing
term
inat
ion
of
empl
oym
ent,
a m
embe
r m
ay c
onve
rt e
xist
ing
grou
p lif
e in
sura
nce
cove
rage
(les
s an
y am
ount
of c
over
age
carr
ied
over
into
ret
irem
ent)
into
an
indi
vidu
al p
olic
y,
with
out
med
ical
exa
min
atio
n. F
or m
ore
info
rmat
ion,
se
e th
e C
onve
rsio
n of
Gro
up L
ife I
nsur
ance
Fac
t S
heet
. LO
NG
-TE
RM
DIS
AB
ILIT
Y C
OV
ER
AG
E
A m
embe
r is
elig
ible
for
empl
oyer
-pai
d lo
ng-t
erm
dis
-ab
ility
insu
ranc
e co
vera
ge a
fter o
ne y
ear o
f par
ticip
a-tio
n in
the
DC
RP.
The
mem
ber
beco
mes
elig
ible
for
the
long
-ter
m d
is-
abili
ty b
enefi
t af
ter
six
cons
ecut
ive
mon
ths
of t
otal
di
sabi
lity
due
to a
n oc
cupa
tiona
l or
non-
occu
patio
nal
cond
ition
.
To b
e co
nsid
ered
tot
ally
dis
able
d du
e to
sic
knes
s or
ac
cide
ntal
bod
ily in
jury
, th
e m
embe
r m
ust
be u
nabl
e to
per
form
any
and
eve
ryd
uty
pert
aini
ngt
ohi
s/he
roc
cupa
tion.
The
mem
ber
need
not
be
confi
ned
to
hom
e, b
ut m
ust b
e un
der
a do
ctor
’s r
egul
ar c
are.
Ifa
mem
ber
ist
otal
lyd
isab
led,
he/
she
ise
ligib
let
ore
ceiv
e a
regu
lar
mon
thly
inc
ome
bene
fit u
p to
60
perc
ent o
f the
bas
e sa
lary
on
whi
ch D
CR
P c
ontr
ibu-
tions
wer
e ba
sed
durin
g th
e 12
mon
ths
prec
edin
g th
e on
set
of t
he d
isab
ility
. Whi
le d
isab
led,
the
mem
ber’s
an
d th
e em
ploy
er’s
man
dato
ry c
ontr
ibut
ions
are
au-
tom
atic
ally
cre
dite
d to
the
mem
ber’s
ret
irem
ent
ac-
coun
t.
The
mon
thly
inc
ome
bene
fit i
s of
fset
by
any
othe
r pe
riodi
c be
nefit
the
mem
ber
may
be
rece
ivin
g, s
uch
as W
orke
rs’ C
ompe
nsat
ion,
sho
rt-t
erm
dis
abili
ty,
or
Soc
ial S
ecur
ity.
Eig
htee
n m
onth
s af
ter
the
onse
t of l
ong-
term
dis
abil-
ity e
ligib
ility
, th
e m
embe
r m
ust
be u
nabl
e to
eng
age
ina
nyg
ainf
ulo
ccup
atio
nfo
rw
hich
he/
she
isr
easo
n-ab
ly s
uite
d by
edu
catio
n, t
rain
ing,
or
expe
rienc
e. T
o-ta
l dis
abili
ty is
not
con
side
red
to e
xist
if t
he m
embe
r is
gai
nful
ly e
mpl
oyed
, in
carc
erat
ed,
or if
the
dis
abil-
ity r
esul
ted
from
an
act
of w
ar o
r w
as i
nten
tiona
lly
self-
infli
cted
.
Long
-ter
m d
isab
ility
ben
efits
will
be
paid
as
long
as
the
mem
ber
rem
ains
dis
able
d or
unt
il th
e m
embe
r at
tain
s ag
e 70
. S
houl
d th
e m
embe
r be
gin
rece
ivin
g pa
ymen
ts u
nder
the
ret
irem
ent
annu
ity,
thes
e be
ne-
fits
term
inat
e. CO
NTA
CT
ING
Th
E D
CR
P
For
m
ore
info
rmat
ion
rega
rdin
g th
e D
CR
P,
plea
se
visi
t P
rude
ntia
l’s
DC
RP
w
ebsi
te
at:
ww
w.p
rud
enti
al.c
om
/njd
crp
or
call
toll-
free
1-8
55-
657-
5267
.
Thi
s fa
ct s
heet
has
bee
n pr
oduc
ed a
nd d
istr
ibut
ed b
y:
New
Jer
sey
Div
isio
n o
f P
ensi
on
s &
Ben
efits
P.
O. B
ox 2
95, T
ren
ton
, NJ
0862
5-02
95
(609
)29
2-75
24F
or th
e he
arin
g im
paire
d: T
RS
711
(60
9) 2
92-6
683
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
19
20
�e '(o
ur 8
�o
�-,
.Jr.q_
C!>�
<q
'-i ,
�
Defin
ed C
ontri
butio
n R
etire
men
t Pr
ogra
m (D
CRP)
Enr
ollm
ent
Info
rmat
ion
for:
w�
...-E
Due
to M
axim
um
Com
pens
atio
n Li
mits
The
Def
ined
C
ontri
butio
n Re
tirem
ent
Prog
ram
(D
CRP
) wa
s es
tabl
ishe
d Ju
ly 1,
200
7, u
nder
the
pr
ovis
ions
of N
.J.S
.A. 4
3:15
C-1
et s
eq. T
he D
CRP
pr
ovid
es e
ligib
le m
embe
rs w
ith a
tax-
shel
tere
d, d
efin
ed c
ontri
butio
n re
tirem
ent b
enef
it, al
ong
with
life
in
sura
nce
and
long
-term
dis
abilit
y co
vera
ge.
ELIG
IBIL
ITY
This
fac
t sh
eet
addr
esse
s D
CRP
mem
bers
hip
for
empl
oyee
s al
read
y en
rolle
d in
the
Publ
ic E
mpl
oyee
s' Re
tirem
ent S
yste
m (P
ERS
), Te
ache
rs' P
ensi
on a
nd
Annu
ity F
und
(TPA
F), P
olic
e an
d Fi
rem
en's
Retir
em
ent
Syst
em (
PFRS
), or
Sta
te P
olic
e Re
tirem
ent
Syst
em (S
PAS)
who
se s
alar
y exc
eeds
the
max
imum
pe
nsio
nabl
e co
mpe
nsat
ion
limit.
The
Defin
ed C
ontri
bu
tion
Ret
irem
ent P
rogr
am (D
CR
P) if
Ine
ligib
le fo
r PE
RS
or T
PAF
Enro
llmen
t and
the
Defin
ed C
ontri
bu
tion
Ret
irem
ent P
rogr
am (
DCR
P) fo
r Elec
ted
and
Appo
inte
d O
fficia
ls Fa
ct S
heet
s ar
e al
so a
vaila
ble
on
our w
ebsi
te a
t: w
ww.n
j.gov
/trea
sury
/pen
sion
s
Empl
oyee
s en
rolle
d in
the
PERS
or T
PAF
on o
r afte
r Ju
ly 1,
200
7, o
r enr
olle
d in
the
PFRS
or S
PRS
afte
r M
ay 2
1, 2
010,
are
sub
ject
to a
max
imum
com
pen
satio
n lim
it fo
r pen
sion
con
tribu
tions
. The
max
imum
co
mpe
nsat
ion
is b
ased
on
the
annu
al m
axim
um
wage
for S
ocia
l Sec
urity
(see
cha
rt) a
nd is
sub
ject
to
chan
ge a
t the
sta
rt of
eac
h ca
lend
ar y
ear.
Ther
efor
e, a
n el
igib
le e
mpl
oyee
who
ear
ns i
n ex
ce
ss o
f the
ann
ual m
axim
um w
age
will b
e en
rolle
d in
the
DC
RP in
add
ition
to th
e PE
RS, T
PAF,
PFR
S, o
r SP
RS (a
s ap
prop
riate
).
PERS
ITPA
F A
NN
UAL
MA
XIM
UM WA
GE
YEA
R M
AXI
MUM
WA
GE
2008
$1
02,0
00
2009
, 201
0, a
nd 2
011
$106
,800
20
12
$110
,100
20
13
$113
,700
20
14
$117
,000
20
15 a
nd 2
016
$118
,500
20
17
$127
,200
20
18
$128
,400
20
19
$132
,900
20
20
$137
,700
Empl
oyee
s wh
o pa
rticip
ate
in th
e D
CRP
will
rece
ive
serv
ice
cred
it in
thei
r ret
irem
ent s
yste
m a
ccou
nt a
nd
will
be e
ligib
le to
retir
e un
der t
he ru
les
of th
e re
tire
men
t sys
tem
. The
fina
l sal
ary
or fi
nal c
ompe
nsat
ion
at re
tirem
ent w
ill be
limite
d to
the
max
imum
com
pen
satio
n am
ount
s in
effe
ct w
hen
the
sala
ry w
as e
arne
d.
Empl
oyee
s wh
o pa
rtici
pate
in t
he D
CRP
bec
ause
th
eir s
alar
y ex
ceed
s th
e m
axim
um p
ensi
onab
le c
om
pens
atio
n lim
it wi
ll re
ceive
add
ition
al in
com
e ab
ove
thei
r pen
sion
am
ount
, whi
ch is
bas
ed o
n th
e am
ount
in
vest
ed in
the
DC
RP.
Janu
ary
2020
Publ
ic Em
ploye
es' R
etire
men
t Sys
tem
(PER
S)
Teac
hers
' Pen
sion
and
Annu
ity F
und
(TPA
F)
Polic
e an
d Fire
men
's Pe
nsion
Fun
d (P
FRS)
St
ate
Polic
e Re
tirem
ent S
yste
m (S
PAS)
Opt
iona
l Wai
ver
A PE
RS, T
PAF,
PFRS
, or S
PRS
mem
ber w
ho is
als
o el
igib
le fo
r the
DC
RP d
ue to
the
max
imum
com
pen
satio
n lim
it ca
n ch
oose
to v
olun
taril
y wa
ive p
artic
ipa
tion
in t
he D
CRP
by
subm
ittin
g a
DCR
P W
aive
r of
Retire
men
t Pro
gram
Par
ticip
ation
form
to th
e Ne
w Je
rsey
Divi
sion
of P
ensi
ons
& B
enef
its (N
JDPB
). If
a m
embe
r wa
ives
DC
RP p
artic
ipat
ion
and
late
r wi
shes
to p
artic
ipat
e, h
e or
she
can
app
ly fo
r DC
RP
enro
llmen
t, wi
th m
embe
rshi
p to
be
effec
tive
Janu
ary 1
of
the
follo
wing
cal
enda
r yea
r.
ENRO
LLM
ENT
Elig
ible
mem
bers
are
enr
olle
d in
the
DC
RP w
hen
the
annu
al s
alar
y ex
ceed
s th
e m
axim
um c
ompe
nsat
ion
limit.
Thi
s m
ay o
ccur
eith
er:
•Up
on e
nrol
lmen
t int
o th
e PE
RS, T
PAF,
PFR
S, o
rSP
RS w
hen
an a
nnua
l bas
e sa
lary
is r
epor
ted
on th
e En
rollm
ent
Applic
ation
that
exc
eeds
the
max
imum
com
pens
atio
n; o
r •
Whe
n an
elig
ible
mem
ber's
ann
ual s
alar
y is
in
crea
sed
to a
leve
l tha
t ex
ceed
s th
e m
axim
umco
mpe
nsat
ion
and
it is
repo
rted
by th
e em
ploy
erto
the
NJD
PB (
eith
er b
y di
rect
ly co
ntac
ting
the
NJD
PB, o
r wh
en s
ubm
itted
by
the
empl
oyer
on
the
Qua
rterly
Rep
ort o
f Con
tribu
tions
).W
hen
enro
lled
in t
he D
CRP
, m
embe
rs c
ontri
bute
5.
5 pe
rcen
t of t
he b
ase
sala
ry in
exc
ess
of th
e m
axi
mum
com
pens
atio
n lim
it to
a ta
x-de
ferre
d in
vest
men
t ac
coun
t est
ablis
hed
with
Pru
dent
ial,
which
join
tly a
d-
Fact
She
et #
79
21
This
fac
t sh
ee
t is
a s
umm
ary
an
d n
ot in
ten
d ed
to p
rovid
e a
ll in
form
atio
n.
D efin
e d C
ontr i
but io
n R
etire
men
t Pro
g ram
( DCR
P)
Alth
oug
he
very
att
em
pta
ta
cc
ura
cy
ism
ad e
,itc
an
no
tbe
gua
ran
tee
d .
Enro
llmen
t Du e
to M
axim
um C
ompe
nsat
ion
L im
its
min
ister
s th
e D
CR
P in
vest
me
nts
with
the
NJD
PB.
Me
mbe
r co
ntrib
utio
ns
are
ma
tche
d by
a th
ree
per
ce
nt
empl
oye
r co
ntri
butio
n ba
sed
on
the
sala
ry in
ex
ce
ss o
f the
ma
ximum
co
mpe
nsa
tion
limit.
It is
imp o
rtan
t tha
t an
em
ploy
er e
nro
ll a
DC
RP-
elig
ibl
e m
embe
r as
soo
n a
s it
is k
no
wn th
at t
he e
mpl
oy
ee
's a
nn
ual s
ala
ry w
ill e
xce
ed
the
ma
ximum
co
m
pen
satio
n so
the
DC
RP
acc
oun
t ca
n b
e e
sta
blish
ed
in a
dva
nc
e of
co
llec
tion
of a
ny r
equi
red
co
ntri
butio
ns.
Con
tribu
tion
s a
re re
quire
d fro
m th
e da
te o
f DC
RP
el
igib
ility.
If a
ny
back
de
duct
ion
s a
re o
wed,
em
ploy
ers
m
ust s
che
dule
an
d re
mit
the
m to
the
DC
RP.
Tran
sfer
s Em
ploy
ees
who
tra
nsfe
r em
plo
ymen
t will
no
t be
sub
ject
to m
axim
um c
ompe
nsa
tion
lim
its o
r D
CR
P e
n
rollm
ent
if:
•Th
e tr
ansf
erri
ng e
mpl
oye
e w
as
a m
em
ber o
f the
PER
S o
r TPA
F o
n o
r be
fore
Jun
e 30
, 200
7; o
r•
The
tran
sfe
rring
em
plo
yee
wa
s a
me
mbe
r of t
he
PFR
S or
SPR
S o
n o
r bef
ore
May
21,
201
O; a
ndIf
the
me
mbe
r is
trans
ferri
ng
to a
n e
ligib
le
p osit
ion
with
out
a b
reak
in s
erv
ice;
or
If a
ny
bre
ak in
se
rvic
e is
24
mo
nth
s o
r les
s fro
m th
e d
ate
of t
he la
st c
on
tribu
tion
to th
e re
tirem
en
t sy
ste
m a
nd t
he
me
mbe
r's a
cc
oun
t has
no
t be
en
with
dra
wn; o
r If
an
y br
eak
in s
erv
ice
is 2
4 m
on
ths
or l
ess
from
the
e
nd
of a
n a
ppro
ved
lea
ve of
ab
s en
ce
. If
a m
embe
r tra
nsfe
rs a
fter
a b
rea
k in
se
rvic
e th
at
falls
bey
ond
the
24
-mo
nth
exc
eptio
ns d
escrib
ed
abo
ve, t
he m
embe
r wi
ll be
sub
jec
t to
the
max
imum
c
om
pen
satio
n ru
les
and
DC
RP
en
rollm
ent.
Fact
She
et #
79
Vest
ing
A PE
RS,
TPA
F, PF
RS,
SPR
S, o
r Alte
rna
te B
en
efit
s Pr
ogr
am
(ABP
) me
mbe
r wh
o b
eco
me
s el
igib
le a
nd
is e
nro
lled
in th
e D
CR
P is
imm
edia
tely
ve
sted
in th
e
DCR
P. As
a v
est
ed m
embe
r, yo
u ha
ve a
rig
ht to
a
ben
efit
at
retir
em
ent
base
d o
n bo
th t
he
em
plo
yee
an
d em
ploy
er c
on
tribu
tions
to th
e D
CR
P.
WIT
HD
RAWAL
W
ithdr
awa
l occu
rs w
hen
a D
CR
P m
embe
r sep
ara
tes
fr om
cov
ere
d e
mpl
oym
en
t an
d su
bmits
a re
ques
t to
Prud
en
tial f
or a
with
draw
al o
f co
ntri
butio
ns.
On
ly th
e
me
mbe
r's c
on
tribu
tions
are
a
vaila
ble
fo
r wi
thdr
aw
a
l -
empl
oye
r c
on
tribu
tion
s a
re
forfe
ited.
Afte
r a
with
dra
wal,
the
indi
vidua
l is
elig
ible
for r
e-e
nro
llme
nt
in th
e D
CR
P or
enr
ollm
en
t in
ano
the
r Ne
w Je
rse
y St
ate
-adm
inist
ere
d re
tire
men
t sys
tem
upo
n re
turn
to
co
vere
d em
plo
yme
nt. RE
TIRE
MEN
T R
etire
men
t oc
cur
s wh
en
a D
CR
P m
em
ber s
epa
rate
s fr o
m c
ove
red
empl
oym
ent
and
ele
cts
to re
cei
ve
a
dist
ribut
ion
o
f fu
nds
co
nta
inin
g bo
th e
mpl
oye
r a
nd
em
plo
yee
c
ont
ribut
ion
s pl
us i
nter
est.
This
ac
tion
deem
s th
e fo
rmer
pa
rtic
ipa
nt a
s re
tired
an
d, t
here
fo
re, i
ne
ligib
le to
re-e
nro
ll in
the
DC
RP
or p
artic
ipa
te
in a
ny
oth
er N
ew J
erse
y St
ate
-adm
inis
tere
d re
tire
m
en
t sys
tem
. An
ABPID
CR
P Wi
thdr
awal
Req
uest
Ack
nowl
edg
men
t Rec
eipt
mus
t be
co
mpl
ete
d in
ord
er to
rec
eive
fu
nds.
This
form
is a
vaila
ble
in th
e "P
ublic
atio
ns"
sec
ti o
n o
f our
web
site
.
Appl
ying
for
Retir
emen
t Si
x m
on
ths
befo
re re
tire
me
nt,
a m
em
ber s
houl
d c
on
t a
ct h
is/he
r em
plo
yer a
nd P
rude
ntia
l for
info
rma
tion
rega
rdin
g D
CR
P be
nef
its a
nd
opt
ion
s.
Janu
ary 2
020
A D
CR
P m
embe
r may
ele
ct t
o re
ceiv
e al
l or a
po
rtion
o
f his
/her
ac
coun
t in
a lu
mp-
sum
dis
tribu
tion
, or
in
a v
arie
ty o
f pe
riodi
c p
aym
ent
met
hods
. Ple
ase
co
n
t ac
t yo
ur a
dmin
istra
tive
serv
ice
s pr
ovi
der
for
mo
re
info
rma
tion
. All
retu
rns
of c
ontri
butio
ns
an
d e
arn
ings
a
re c
onsid
ere
d ta
xabl
e in
the
ye
ar th
ey
are
rec
eiv
ed;
the
refo
re, t
he ty
pe o
f pay
out
pla
n s
houl
d be
co
nsi
de
red
ca
refu
lly p
rior t
o re
tirem
en
t. Th
ere
is n
o m
inim
um re
tire
men
t age
un
der t
he D
CR
P. Th
e m
embe
r will
aut
om
atic
ally
be
con
side
red
retir
ed,
r ega
rdle
ss o
f age
, if t
here
is a
ny
dist
ribut
ion
of v
est
ed
co
ntri
butio
ns.
A m
em
ber m
ay
take
a d
istri
butio
n a
t an
y tim
e a
fter
term
inat
ion
o
f e
mpl
oym
ent;
howe
ver,
if yo
u re
turn
to
publ
ic em
plo
yme
nt i
n
New
Jers
ey,
you
can
not
p arti
cip
ate
in
an
y Ne
w Je
rsey
Sta
te-a
dmin
iste
red
r etir
eme
nt s
yste
m. D
CR
P m
embe
rs c
onsid
erin
g fu
tu
r e e
mpl
oym
en
t in
a p
osi
tion
co
vere
d by
an
y o
f the
New
Je
rsey
Sta
te-a
dmin
iste
red
retir
em
ent s
yste
ms
sho
uld
care
fully
con
side
r thi
s im
pac
t be
fore
requ
est
ing
a d
istrib
utio
n.
Hea
lth B
enef
its a
t Ret
irem
ent
Ple
ase
no
te th
at s
erv
ice
tim
e fr
om
en
rollm
en
t in
the
DC
RP
can
no
t be
us
ed t
o qu
alify
fo
r St
ate
Heal
th
B en
efit
s Pr
ogr
am
(S
HBP)
or
Scho
ol
Empl
oye
es'
Hea
lth B
ene
fits
Pro
gra
m (
SEHB
P) c
ove
rage
at r
e
tire
men
t; ho
weve
r, re
tirem
en
t sys
tem
me
mbe
rs w
ho
also
pa
rticip
ate
in
the
DC
RP
thro
ugh
earn
ings
in
exc
ess
of t
he m
axim
um w
age
will
co
ntin
ue to
ear
n
cre
dit t
owa
rd S
HBP/
SEHB
P co
vera
ge th
roug
h th
eir
retir
eme
nt s
yste
m s
ervi
ce
. Pl
eas
e
con
tact
your
em
plo
yer's
hum
an
re
sour
ces
o
ffic
e o
r be
nef
its a
dmin
istra
tor
to a
sk a
bout
hea
lth
ben
efit
cove
rage
opt
ion
s a
vaila
ble
in re
tirem
ent.
22
Def in
ed C
ont r
ibut
ion
Ret
i rem
ent P
rogr
am {D
CR
P ) T
his
fac
tsh
ee
tis
asu
mm
ary
and
no
t in
ten
ded
to p
rovid
e a
ll in
form
atio
n.
Enro
llmen
t Due
to M
axim
um C
ompe
nsat
ion
Lim
its
Alth
oug
heve
rya
tte
mpt
at
ac
cur
acy
ism
ade
,itc
an
no
tbe
gua
rant
ee
d.
LIFE
INS
URAN
CE C
OVE
RAG
E W
hile
em
plo
yed,
PER
S, T
PAF,
PFRS
, o
r SP
RS
me
mbe
rs e
nrol
led
in th
e D
CRP
are
co
vere
d by
em
pl
oye
r-pa
id lif
e in
sura
nce
, pa
yabl
e to
the
ir de
signa
ted
bene
fi cia
ries
in th
e a
mo
unt o
f of 1
.5 ti
mes
the
ann
ual
b ase
sa
lary
on
whi
ch
DCRP
con
tribu
tions
are
ba
sed.
Th
is c
ove
rage
is a
vaila
ble
with
out
a m
edi
cal
exa
m
ina
tion
to
mem
bers
und
er
age
60
. Ne
wly
enro
lled
me
mbe
rs 6
0 ye
ars
of a
ge o
r o
lde
r m
ust u
nde
rgo
a
me
dic
al e
xam
ina
tion
to q
ualif
y. DC
RP m
embe
rs w
ill c
ont
inue
to b
e in
sure
d fo
r up
to
two
yea
rs if
on
an
app
rove
d le
ave
of a
bse
nce
with
out
pa
y f o
r per
sona
l illn
ess
. No
te: T
he In
tern
al R
eve
nue
Serv
ice (I
RS) c
lass
ifies
all
life in
sura
nce
co
vera
ge o
ver $
50,0
00 a
s a
frin
ge
bene
fit s
ubje
ct t
o ta
xatio
n. W
hile
the
am
oun
t of t
he
life in
sura
nce
co
vera
ge is
not
taxa
ble
, the
pre
miu
m
requ
ired
to p
ay
for t
he lif
e in
sura
nce
co
vera
ge is
tax
abl
e. M
em
bers
ca
n e
lect t
o wa
ive in
sura
nce
co
ver
age
ove
r $50
,000
at a
ny ti
me
. Up
on
retir
em
ent,
life in
sura
nce
unde
r th
e DC
RP is
r e
duc
ed
to 3
/16
of t
he a
nnua
l ba
se s
ala
ry o
n w
hic
h DC
RP c
ont
ribut
ions
wer
e b
ase
d.
This
life
insu
ranc
e c
ove
rage
is a
vaila
ble
in re
tire
me
nt
onl
y to
: •
PERS
, TPA
F, PF
RS, o
r SPR
S m
em
bers
enr
olle
din
the
DCRP
wh o
are
age
60
or o
lde
r if t
he m
em
be
r ha
s c
om
ple
ted
1 0 y
ears
of p
arti
cip
atio
n in
the
DC
RP, P
ERS,
TPA
F, PF
RS, o
r SPR
S; o
r•
PERS
, TPA
F, PF
RS, o
r SPR
S m
em
bers
enr
olle
din
the
DC
RP w
ho a
re a
ny a
ge if
the
mem
ber h
as
co
mpl
eted
25
yea
rs o
f pa
rtic
ipa
tion
in th
e DC
RP,PE
RS, T
PAF,
PFRS
, or S
PRS.
The
me
mbe
r als
o m
ust h
ave
bee
n a
n a
ctiv
e e
mpl
oy
ee
in th
e 1
2 m
onth
s im
me
dia
tely
prec
edi
ng th
e in
itia
l re
cei
pt o
f a re
tirem
ent
ann
uity
pa
yme
nt.
LON
G-T
ERM
DIS
ABIL
ITY
COVE
RAG
E A
me
mbe
r is
elig
ible
for e
mpl
oye
r-pa
id lo
ng-te
rm d
isa
bilit
y in
sura
nce
co
vera
ge a
fter o
ne y
ea
r of p
arti
cip
a
tion
in th
e D
CRP.
Th
e m
em
ber b
ec
ome
s e
ligib
le fo
r the
long
-term
dis
a
bilit
y be
nefit
s a
fter s
ix c
ons
ecut
ive m
ont
hs o
f to
tal
dis a
bilit
y du
e to
an
occ
upa
tiona
l or n
ono
cc
upa
tiona
l c
ond
ition
. T o
be
con
side
red
tota
lly d
isa
bled
due
to s
ickne
ss o
r a
ccid
enta
l bo
dily
inju
ry, t
he m
embe
r mus
t be
una
ble
to p
erfo
rm a
ny a
nd e
very
dut
y pe
rtain
ing
to h
is/h
er
oc
cup
atio
n. T
he m
embe
r ne
ed n
ot
be c
onf
ined
to
hom
e, b
ut m
ust b
e u
nde
r a d
octo
r's re
gula
r ca
re.
If a
mem
ber i
s to
tally
dis
abl
ed, h
e/s
he is
elig
ible
to
recei
ve a
reg
ula
r m
ont
hly
inc
om
e be
nefit
up
to 60
pe
rcen
t of t
he b
ase
sa
lary
on
whi
ch
DCRP
co
ntrib
utio
ns w
ere
ba
sed
durin
g th
e 12
mon
ths
pre
ced
ing
the
ons
et o
f the
dis
abi
lity.
Whi
le d
isa
ble
d, th
e m
embe
r's
and
the
empl
oye
r's m
and
ato
ry c
ont
ribut
ions
are
au
tom
atic
ally
cre
dite
d to
the
me
mbe
r's r
etir
eme
nt a
c
co
unt.
The
mo
nthl
y in
co
me
bene
fit is
offs
et b
y a
ny o
the
r pe
ri odi
c b
enef
it th
e m
embe
r may
be
recei
ving,
suc
h a
s W
ork
ers
' Co
mpe
nsa
tion,
sho
rt-te
rm d
isa
bilit
y, o
r S o
cia
l Se
cur
ity.
Eigh
tee
n m
ont
hs a
fter t
he o
nse
t of l
ong-
term
dis
abi
lity
elig
ibilit
y, th
e m
em
ber m
ust b
e un
abl
e to
eng
age
in a
ny g
ain
ful o
cc
upa
tion
for w
hic
h he
/she
is re
aso
na
bly
suite
d by
edu
ca
tion,
tra
inin
g, o
r exp
erie
nce
. To
ta
l dis
abi
lity
is n
ot c
ons
ide
red
to e
xist
if th
e m
embe
r is
ga
infu
lly e
mpl
oye
d, in
car
cer
ate
d, o
r if t
he d
isa
bil
ity r
esul
ted
from
an
ac
t of w
ar
or w
as
inte
ntio
nally
se
lf-in
flicte
d.
Janu
ary
2020
Long
-term
dis
abi
lity
bene
fits
will
be p
aid
as
long
as
the
me
mbe
r re
mai
ns d
isa
ble
d o
r un
til th
e m
em
ber
atta
ins
age
70.
Sho
uld
the
me
mbe
r be
gin
recei
ving
paym
ents
und
er t
he re
tire
me
nt a
nnui
ty, t
hese
ben
e
fits
term
ina
te.
CON
TACT
ING
TH
E DC
RP
For
mo
re
info
rma
tion
rega
rdin
g th
e
DCRP,
pl
ea
se
visit
Prud
entia
l's
DCRP
we
bsite
a
t: w
ww.p
rude
ntial.c
om/njdcrp
or c
all
toll-
free
1-8
66-
653-
2771
.
This
fact
she
et h
as b
een
prod
uced
and
distrib
uted
by:
New
Jer
sey
Divis
ion
of P
ensi
ons
& B
enefi
ts
P.O
. Box
295
, Trent
on, N
J 08
625-
0295
(6
09) 2
92-7524
For th
e he
aring
impa
ired:
TRS
711
(609
) 292
-668
3 www
.nj.g
ov/treas
ury/
pens
ions
Fact
She
et #
79
23
24
Defe
rred
Com
pens
atio
n -
NJSE
DCP
Info
rmat
ion
for:
Stat
e of
New
Jers
ey E
mplo
yees
OVE
RVIE
W
The
New
Jers
ey S
tate
Em
ploy
ees D
efer
red
Com
pen
satio
n Pl
an (N
JSED
CP)
pro
vides
you
, as
an e
ligib
le
Stat
e em
ploy
ee, a
n op
portu
nity
to v
olun
taril
y sh
elte
r a
porti
on o
f you
r wa
ges
from
fede
ral i
ncom
e ta
xes
while
sav
ing
for
retir
emen
t to
supp
lem
ent
your
So
cial
Sec
urity
and
pen
sion
ben
efits
. Und
er th
e Pl
an,
fede
ral in
com
e ta
x is
not d
ue o
n de
ferre
d am
ount
s or
ac
cum
ulat
ed e
arni
ngs
until
you
rece
ive a
dis
tribu
tion
(pay
men
t) fro
m y
our
acco
unt.
Pres
umab
ly, d
istri
bu
tion
is a
t ret
irem
ent w
hen
your
tax
rate
is e
xpec
ted
to b
e lo
wer.
PLA
N A
DMIN
ISTR
ATI
ON
Th
e NJ
SEDC
P, go
vern
ed b
y the
gui
delin
es o
f Int
erna
l Re
venu
e Co
de (I
RC) S
ectio
n 45
7 an
d th
e la
ws o
f the
St
ate
of N
ew J
erse
y, is
adm
inis
tere
d by
Pru
dent
ial
Fina
ncia
l for
the
Stat
e of
New
Jer
sey.
Indi
vidua
l par
tic
ipan
t's a
ccou
nts
are
mai
ntai
ned
by th
e Ad
min
istra
to
r and
sta
tem
ents
of a
ccou
nt a
re fu
rnis
hed
quar
ter
ly. A
ll Pl
an e
xpen
ses
are
born
e by
the
parti
cipa
nts,
an
d no
tific
atio
n of
adm
inis
trativ
e fe
es is
pro
vided
at
enro
llmen
t. The
Def
erre
d C
ompe
nsat
ion
Boar
d is
the
final
aut
horit
y on
all m
atte
rs co
ncer
ning
the
oper
atio
n of
the
Plan
; by
law,
the
Stat
e In
vest
men
t Cou
ncil h
as
the
right
to s
uper
vise
certa
in a
spec
ts o
f the
Pla
n in
clu
ding
the
inve
stm
ent o
f ass
ets.
ELIG
IBIL
ITY
FOR
ENRO
LLM
ENT
To e
nrol
l in
the
NJSE
DC
P, yo
u m
ust b
e em
ploy
ed b
y th
e St
ate
of N
ew J
erse
y or
an
elig
ible
age
ncy,
au
thor
ity, c
omm
issi
on, o
r ins
trum
enta
lity
of S
tate
gov
er
nmen
t. If
you
are
empl
oyed
thro
ugh
a co
unty
, tow
nshi
p, o
r m
unic
ipal
ity, a
nd n
ot p
aid
dire
ctly
by th
e St
ate
of N
ew
Jers
ey o
r one
of i
ts a
genc
ies,
you
are
not
elig
ible
for
the
NJSE
DC
P. H
ow T
o En
roll
You
can
obta
in a
n en
rollm
ent
pack
age
from
you
r hu
man
res
ourc
es o
ffice
or
bene
fits
adm
inist
rato
r, or
enr
oll
by c
onta
ctin
g Pr
uden
tial
Retir
emen
ts d
ire
ctly
at 1
-866
-NJS
EDCP
(1-8
66-6
57-3
327)
; a T
DD
lin
e is
also
ava
ilabl
e at
1-8
77-7
60-5
166.
You
can
al
so e
nrol
l th
roug
h Pr
uden
tial
Fina
ncia
l's w
ebsi
te:
www
.pru
dentia
l.com/njs
edcp
Upon
enr
ollm
ent,
you
agre
e th
at y
our d
efer
rals
and
an
y ea
rnin
gs b
ecom
e an
d re
mai
n St
ate
prop
erty
, wi
th th
e un
ders
tand
ing
that
all
amou
nts
due
will
be
held
in tr
ust f
or y
ou a
nd y
our
bene
ficia
ries
and
will
be p
aid
to y
ou fo
llowi
ng s
ever
ance
of e
mpl
oym
ent.
You
may
def
er b
etwe
en o
ne a
nd 1
00 p
erce
nt o
f you
r av
aila
ble
sala
ry a
fter
man
dato
ry d
educ
tions
(m
inu
s yo
ur t
ax-s
helte
red
pens
ion
or o
ther
vol
unta
ry
tax-
shel
tere
d co
ntrib
utio
ns)
with
an
annu
al d
olla
r m
axim
um in
202
0 of
$19
,500
($26
,000
for i
ndivi
du
als
age
50 a
nd o
lder
). You
then
cho
ose
how
you
want
to
inve
st a
mon
g th
e 20
inve
stm
ent f
unds
now
offe
red
thro
ugh
Prud
entia
l Fin
anci
al.
Janu
ary
2020
MAN
AGIN
G YO
UR
INVE
STM
ENTS
As
a p
artic
ipan
t in
the
NJSE
DCP,
you
hav
e th
e ab
ility
to m
ake
chan
ges
on y
our a
ccou
nt s
uch
as in
crea
se,
decr
ease
, sus
pend
, or r
esum
e de
ferra
l per
cent
ages
. Yo
u m
ay a
lso
chan
ge y
our
inve
stm
ent e
lect
ions
to
any
of th
e 20
pre
-app
rove
d pr
oduc
ts o
ffere
d un
der
Prud
entia
l. D
ISTR
IBU
TIO
N O
FYO
UR
MO
NEY
FR
OM
TH
E PL
AN
Yo
ur N
JSED
CP a
ccou
nt m
ay b
e di
strib
uted
follo
wing
se
vera
nce
of e
mpl
oym
ent d
ue to
term
inat
ion,
retir
em
ent,
or d
isab
ility.
Dist
ribut
ion
is al
so p
erm
itted
in
the
case
of a
n un
fore
seea
ble
finan
cial h
ards
hip,
as
defin
ed u
nder
IRC
Sec
tion
457,
follo
wing
app
rova
l by
the
NJSE
DC
P Bo
ard.
In-s
ervic
e di
strib
utio
ns a
re
perm
itted
on
smal
ler,
inac
tive
acco
unts
. If
your
acc
ount
bal
ance
is le
ss th
an $
5,00
0 at
the
time
of d
istri
butio
n as
a r
esul
t of s
ever
ance
of e
m
ploy
men
t, yo
u m
ust t
ake
a lu
mp-
sum
pay
men
t. If
your
acc
ount
bal
ance
is $
5,00
0 or
mor
e, y
ou m
ay
elec
t: 1.
A on
e-tim
e lu
mp-
sum
pay
men
t;2.
A po
rtion
of y
our a
ccou
nt in
a s
peci
fic d
olla
ram
ount
; or
3.Pe
riodi
c in
stal
lmen
t pay
men
ts.
Fact
She
et #
32
25
This
fact
shee
t is a
sum
mar
y an
d no
t inte
nded
to p
rovid
e al
l info
rmat
ion.
Alth
ough
eve
ry a
ttem
pt a
t acc
urac
y is
mad
e, it c
anno
t be
guar
ante
ed.
Defe
rred
Com
pens
atio
n -
NJSE
DCP
Upon
sev
eran
ce o
f em
ploy
men
t, yo
u m
ay b
egin
you
r ac
coun
t dist
ribut
ion
as s
oon
as a
dmin
istra
tivel
y fe
asib
le, y
ou m
ay e
lect
a fu
ture
dist
ribut
ion
date
, or y
ou
may
do
noth
ing.
How
ever
, you
mus
t beg
in re
ceivi
ng
dist
ribut
ion
no la
ter t
han
April
1 o
f the
yea
r fol
lowi
ng
your
atta
inm
ent o
f age
age
70
1/2
(if b
orn
befo
re J
uly
1, 1
949)
or a
ge 7
2 (if
bor
n on
or a
fter J
uly
1, 19
49),
or th
e ye
ar o
f em
ploy
men
t ter
min
atio
n, w
hich
ever
is
late
r. Fo
r dai
ly va
lued
fund
s, y
our a
ccou
nt w
ill b
e va
lue
d at
the
clos
e of
the
day
prio
r to
your
dist
ribut
ion
date
. For
mon
thly
valu
ed fu
nds,
your
acc
ount
will
be
valu
ed a
t the
clo
se o
f the
mon
th p
rior t
o yo
ur e
lec
tion
for p
aym
ent. A
Distrib
ution
Elec
tion
form
mus
t be
com
plet
ed a
nd re
turn
ed to
the
Plan
offi
ce.
Tax
Cons
eque
nces
Th
e NJ
SEDC
P is
an e
ligib
le d
efer
red
com
pens
atio
n pl
an u
nder
IRC
Sec
tion
457.
Dist
ribut
ions
from
the
Plan
may
be
elig
ible
for
rollo
ver;
howe
ver,
they
do
not q
ualif
y fo
r spe
cial
five
-yea
r or 1
0-ye
ar a
vera
ging
. Di
strib
utio
ns a
re d
efin
ed a
s pe
nsio
n pa
ymen
ts a
nd
are
subj
ect t
o fe
dera
l inc
ome
tax,
unle
ss ro
lled
over
to
ano
ther
retir
emen
t pla
n.
If Yo
u Di
e Be
fore
Di
strib
utio
n Is
Com
plet
e At
the
time
of y
our d
eath
, you
r exe
cuto
r, be
nefic
iary
, or
a fa
mily
mem
ber s
houl
d co
ntac
t Pru
dent
ial F
inan
ci
al a
t 1-8
66-N
JSED
CP.
Your
ben
efic
iary
will
be n
oti
fied
of th
e op
tions
for a
ccou
nt d
istrib
utio
n. B
enef
icia
rie
s ha
ve th
e sa
me
dist
ribut
ion
optio
ns a
vaila
ble
to
mem
bers
who
term
inat
e em
ploy
men
t; ho
weve
r, th
e m
axim
um p
erio
d fo
r per
iodi
c ins
tallm
ent p
aym
ents
to
non-
spou
sal b
enef
icia
ries
cann
ot e
xcee
d fiv
e ye
ars.
Bene
ficia
ries
rece
iving
dist
ribut
ions
are
sub
ject
to
the
sam
e ta
x co
nseq
uenc
es a
s th
e or
igin
al m
embe
r.
Fact
She
et #
32
QUE
STIO
NS
Con
tact
Pr
uden
tial
Fina
ncia
l or
th
e NJ
SEDC
P th
roug
h th
e Ne
w Je
rsey
Divi
sion
of P
ensio
ns &
Ben
ef
its in
writ
ing
or c
all 1
-866
-NJS
EDC
P. Th
e NJ
SED
CP
offic
e ca
n an
swer
you
r que
stio
ns a
bout
the
Plan
an
d yo
ur a
ccou
nt, a
nd c
an p
rovid
e an
y ne
cess
ary
form
s. Ad
ditio
nal
info
rmat
ion
on a
ccou
nt a
nd i
nves
tmen
t op
tions
is a
lso
avai
labl
e fro
m P
rude
ntia
l Fin
anci
al a
t: w
ww.p
rude
ntial.c
om/njsed
cp
This
fact
shee
t has
bee
n pro
duce
d an
d dis
tribute
d by
: N
ew J
ersey
Div
isio
n of
Pen
sion
s &
Ben
efits
P.
O. B
ox 2
95, Tre
nton
, NJ
0862
5-02
95
(609
)292
-7524
For th
e he
aring
impa
ired:
TRS
711
(609
) 292
-668
3 w
ww
.nj.g
ov/tr
easu
ry/p
ensi
ons
Janu
ary 2
020
26
Tax$
ave
Info
rmat
ion
for:
S
tate
Em
ploy
ees
who
are
Elig
ible
for
the
Sta
te H
ealth
Ben
efits
Pro
gram
(S
HB
P)
Feb
ruar
y 20
19
Fact
Sh
eet
#44
TAX
$AV
E E
LIG
IBIL
ITY
Tax$
ave,
a b
enefi
t pr
ogra
m a
vaila
ble
unde
r S
ectio
n 12
5 of
the
fed
eral
Int
erna
l Rev
enue
Cod
e (I
RC
), a
l-lo
ws
elig
ible
em
ploy
ees
of t
he S
tate
of
New
Jer
sey
to s
et a
side
bef
ore-
tax
dolla
rs to
pay
for
cert
ain
med
-ic
al,
dent
al,
and
depe
nden
t ca
re e
xpen
ses,
the
reby
av
oidi
ng fe
dera
l tax
es a
nd s
avin
g m
oney
.
An
elig
ible
em
ploy
ee is
any
full-
time
empl
oyee
of t
he
Sta
te, o
r a
Sta
te c
olle
ge o
r un
iver
sity
, w
ho is
elig
ible
to
par
ticip
ate
in t
he S
tate
Hea
lth B
enefi
ts P
rogr
am
(SH
BP
). Ta
x$av
e is
onl
y av
aila
ble
to S
tate
em
ploy
-ee
s.
Sec
tio
n 1
25 P
lan
s fo
r L
oca
l Em
plo
yees
P.L.
201
1, c
. 78
(Cha
pter
78)
, re
quire
s lo
cal g
over
n-m
ent
and
loca
l edu
catio
n em
ploy
ers
to o
ffer
Sec
tion
125
plan
s to
thei
r em
ploy
ees.
Loca
l em
ploy
ers
mus
t es
tabl
ish
thei
r ow
n S
ectio
n 12
5 pr
ogra
ms.
Loca
l go
vern
men
t an
d lo
cal
educ
atio
n em
ploy
ees
shou
ld c
onta
ct th
eir
hum
an r
esou
rces
offi
ce o
r be
ne-
fits
adm
inis
trat
or to
det
erm
ine
the
spec
ific
plan
s an
d be
nefit
s th
at a
re a
vaila
ble.
TAX
$AV
E C
OM
PO
NE
NT
PL
AN
S
Tax$
ave
cons
ists
of t
hree
sep
arat
e co
mpo
nent
pla
ns.
An
elig
ible
em
ploy
ee m
ay e
lect
to
part
icip
ate
in a
ny
com
bina
tion
— a
ll, s
ome,
or
none
of t
he p
lans
.
The
thre
e co
mpo
nent
s of
Tax
$ave
are
:
•T
heP
rem
ium
Opt
ion
Pla
n(P
OP
)al
low
san
em
-pl
oyee
to
pay
any
SH
BP
med
ical
and
/or
dent
alpa
yrol
l con
trib
utio
ns o
r pre
miu
ms
with
bef
ore-
tax
dolla
rs;
•T
heU
nrei
mbu
rsed
Med
ical
Fle
xibl
eS
pend
ing
Acc
ount
(F
SA
)al
low
san
em
ploy
eet
ose
tas
ide
mon
ey t
o pa
y fo
r qu
alifi
ed m
edic
al a
nd d
enta
lex
pens
es n
ot p
aid
by a
ny g
roup
ben
efits
pla
nun
der
whi
ch t
he e
mpl
oyee
and
dep
ende
nts
are
cove
red;
and
•T
heD
epen
dent
Car
eF
SA
allo
ws
an e
mpl
oyee
to s
et a
side
fund
s to
pay
for
antic
ipat
ed e
xpen
s-es
rel
ated
to
depe
nden
t ca
re i
n or
der
to p
erm
itth
e em
ploy
ee a
nd s
pous
e to
wor
k.
No
te:
Tax
savi
ngs
on c
omm
uter
mas
s tr
ansi
t an
d pa
rkin
g ex
pens
es a
re a
vaila
ble
as a
sep
arat
e be
ne-
fit t
o S
tate
em
ploy
ees
unde
r th
e C
omm
uter
Tax
$ave
P
rogr
am. S
ee t
he C
omm
uter
Tax
$ave
Pro
gram
Fac
tS
heet
for
deta
ils.
Pr
EM
IuM
OP
TIO
N P
LA
N (
PO
P)
If yo
u ar
e an
em
ploy
ee e
ligib
le t
o pa
rtic
ipat
e in
the
S
HB
P, y
ou c
an s
ave
on t
axes
by
part
icip
atin
g in
the
P
OP.
The
PO
Pa
llow
syo
uto
pay
any
of
your
SH
BP
m
edic
al a
nd/o
r de
ntal
pay
roll
cont
ribut
ions
or
prem
i-um
ded
uctio
ns w
ith b
efor
e-ta
x do
llars
. The
con
trib
u-tio
ns o
r pr
emiu
ms
you
alre
ady
pay
for
your
cov
erag
e ar
e de
duct
ed f
rom
eac
h pa
yche
ck b
efor
e fe
dera
l in-
com
ean
dF
ICA
(Soc
ialS
ecur
itya
ndM
edic
are)
taxe
sar
e ca
lcul
ated
, th
ereb
y re
duci
ng t
he t
axes
with
held
. T
he a
mou
nt o
f you
r sa
ving
s de
pend
s on
a v
arie
ty o
f
fact
ors,
suc
h as
the
am
ount
of
the
cont
ribut
ions
or
prem
ium
s an
d yo
ur in
com
e ta
x fil
ing
stat
us. T
he p
lan
runs
on
a ca
lend
ar-y
ear
basi
s.
If yo
u ha
ve a
pay
roll
cont
ribut
ion
or p
rem
ium
ded
uc-
tion
for
med
ical
and
/or
dent
al c
over
age,
you
are
au-
tom
atic
ally
enr
olle
din
the
PO
Pa
ndw
illp
ayl
ess
in
taxe
s.If
you
cho
ose
tod
eclin
een
rollm
enti
nth
eP
OP,
yo
u m
ust
sign
and
ret
urn
a D
eclin
atio
n of
Pre
miu
m
Opt
ion
Pla
n (P
OP
) fo
rm e
ach
year
to
your
ben
efits
ad
min
istr
ator
.
PO
Pw
illi
ncre
ase
your
tak
e-ho
me
pay
byr
educ
ing
your
tax
es;
it do
es n
ot c
hang
e th
e m
edic
al a
nd/o
r de
ntal
con
trib
utio
ns o
r pr
emiu
ms
you
are
requ
ired
to
pay.
Eff
ect
of
the
PO
P o
n S
HB
P
ru
les
and
Pro
ced
ure
s
The
Inte
rnal
Rev
enue
Ser
vice
(IR
S)
stric
tly r
egul
ates
th
eP
OP
bec
ause
of
the
tax
adva
ntag
esp
rovi
ded.
IR
S r
ules
req
uire
tha
t fo
r an
em
ploy
ee c
over
ed b
y th
eP
OP,
pay
roll
dedu
ctio
nsf
orm
edic
ala
ndd
enta
lpl
an b
enefi
ts r
emai
n th
e sa
me
for
the
entir
e pl
an
year
. T
here
fore
, no
cov
erag
e le
vel
chan
ge c
an b
e m
ade
whi
ch re
sults
in a
cha
nge
in th
e am
ount
of y
our
med
ical
and
/or
dent
al p
lan
dedu
ctio
n un
less
a q
ual-
ifyin
g ev
ent
occu
rs. I
f a
qual
ifyin
g ev
ent
does
occ
ur,
you
may
mak
e a
chan
ge b
y su
bmitt
ing
a co
mpl
eted
S
HB
P m
edic
al a
nd/o
r de
ntal
pla
n ap
plic
atio
n to
you
r em
ploy
er w
ithin
60
days
of
the
even
t or
dur
ing
the
annu
alO
pen
Enr
ollm
entp
erio
d.
27
Fact
Sh
eet
#44
Feb
ruar
y 20
19
Tax$
ave
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
Qu
alif
yin
g E
ven
ts
Pla
n el
ectio
ns i
n ef
fect
at
the
begi
nnin
g of
the
pla
n ye
ar w
ill c
ontin
ue t
hrou
ghou
t th
e ca
lend
ar y
ear
or
upon
the
occ
urre
nce
of a
qua
lifyi
ng e
vent
. T
he f
ol-
low
ing
are
cons
ider
ed q
ualif
ying
eve
nts:
•A
mar
riage
.You
may
enr
olly
our
spou
sea
nda
nyot
her
elig
ible
dep
ende
nts.
See
the
“C
ivil
Uni
onP
artn
ers,
Dom
estic
Par
tner
s,a
ndT
ax$a
ve”
sec-
tion;
•A
dditi
ono
fan
elig
ible
dep
ende
ntd
uet
obi
rth,
adop
tion,
or
lega
l gua
rdia
nshi
p;
•A
cha
nge
inf
amily
sta
tus
invo
lvin
gth
elo
sso
fel
igib
ility
of a
fam
ily m
embe
r (d
ivor
ce, d
eath
);
•A
mov
eou
tsid
ean
HM
Os
ervi
cea
rea;
•T
hete
rmin
atio
nof
you
rem
ploy
men
tfor
any
rea
-so
n, in
clud
ing
retir
emen
t;
•A
nap
prov
edu
npai
dle
ave
ofa
bsen
ce.Y
oua
reen
title
dto
ele
ctt
heP
OP
upo
nre
turn
to
activ
eem
ploy
men
t;
•A
cha
nge
iny
our
elig
ible
dep
ende
nt’s
em
ploy
-m
ent
stat
us r
esul
ting
in h
is/h
er l
oss
of m
edic
alan
d/or
den
tal c
over
age;
and
•S
uch
othe
rev
ents
that
may
be
dete
rmin
edto
be
appr
opria
te a
nd i
n ac
cord
ance
with
app
licab
leIR
S r
egul
atio
ns.
uN
rE
IMB
ur
SE
d M
Ed
ICA
L
FL
EX
IBL
E S
PE
Nd
ING
AC
CO
uN
T (
FS
A)
The
Unr
eim
burs
edM
edic
alF
SA
allo
ws
you
tos
ave
taxe
s on
out
-of-
pock
et m
edic
al a
nd d
enta
l ex
pens
-es
tha
t re
duce
you
r sp
enda
ble
inco
me.
Con
trib
utin
g m
oney
to
the
Med
ical
FS
Ac
anr
esul
tin
ar
educ
tion
in t
axes
bec
ause
the
mon
ey y
ou c
ontr
ibut
e to
you
r ac
coun
t is
fre
e fr
om fe
dera
l inc
ome,
Soc
ial S
ecur
ity,
and
Med
icar
eta
xes,
and
rem
ains
tax
-fre
ew
hen
you
rece
ive
it.
No
te:
Fed
eral
law
pro
hibi
tsp
artic
ipat
ion
inb
oth
a
FS
Aa
nda
Hea
lthS
avin
gsA
ccou
nt(H
SA
).T
here
fore
,if
you
are
enro
lled
ina
Hig
hD
educ
tible
Hea
lthP
lan
(HD
HP
),y
oua
ren
ote
ligib
leto
enr
olli
nth
isp
lan.
Und
ert
heU
nrei
mbu
rsed
Med
ical
FS
A,
each
cal
en-
dar y
ear y
ou m
ay s
et a
side
up
to $
2,50
0 of
you
r sal
a-ry
bef
ore
taxe
s in
a h
ealth
car
e sp
endi
ng a
ccou
nt, s
o th
at y
ou a
nd y
our
elig
ible
dep
ende
nts
can
be r
eim
-bu
rsed
for
elig
ible
exp
ense
s in
curr
ed d
urin
g th
e ye
ar.
Elig
ible
exp
ense
sin
clud
eco
paym
ents
and
ded
uct-
ible
s fo
r m
edic
al,
pres
crip
tion,
and
den
tal b
ills,
qua
l-ifi
ed e
xpen
ses
for
med
ical
ser
vice
s no
t co
vere
d by
he
alth
pla
ns o
r you
r Sta
te v
isio
n pl
an s
uch
as c
onta
ct
lens
es s
olut
ion,
hea
ring
aids
, et
c.,
and
othe
r he
alth
ca
re e
xpen
ses
you
can
dedu
ct o
n yo
ur i
ncom
e ta
x,
exce
pt p
ayro
ll co
ntrib
utio
ns o
r pr
emiu
m d
educ
tions
fo
rhe
alth
car
ew
hich
are
cov
ered
und
ert
heP
OP.
S
eeth
e“P
rem
ium
Opt
ion
Pla
n(P
OP
)”s
ectio
n.
Ove
r-th
e-co
unte
rdr
ugs
and
med
icin
esa
ren
ote
li-gi
ble
for
reim
burs
emen
t w
ithou
t a
pres
crip
tion
from
an
atte
ndin
g pr
ovid
er.
Thi
s in
clud
es o
ver-
the-
coun
t-er
ite
ms
such
as
alle
rgy
drug
s, p
ain
relie
vers
, co
ld
and
coug
h m
edic
ines
, sle
ep a
ids,
dig
estiv
e ai
ds, a
n-ti-
gas
med
icat
ions
, bab
y ra
sh c
ream
s, a
nd in
sect
bite
tr
eatm
ents
. To
be r
eim
burs
ed fo
r th
ese
type
s of
ove
r-th
e-co
unte
rite
ms
usin
gyo
urU
nrei
mbu
rsed
Med
ical
F
SA
,yo
um
ust
obta
ina
doc
tor’s
pre
scrip
tion
and
subm
it it
with
a c
laim
form
for
reim
burs
emen
t.
No
te:
The
Wag
eWor
ks® H
ealth
Car
e C
ard
can
be
used
to
pay
for
over
-the
-cou
nter
ite
ms
that
are
ac-
com
pani
ed b
y a
pres
crip
tion
and
fille
d by
a p
harm
a-ci
st.
Ove
r-th
e-co
unte
rite
ms
like
eyeg
lass
es,w
rists
plin
ts,
and
band
ages
, as
wel
l as
dur
able
med
ical
ite
ms
such
as
crut
ches
and
can
es, w
ill c
ontin
ue to
be
reim
-bu
rsed
with
outa
doc
tor’s
ord
er.
IRS
Pub
licat
ion
502
– M
edic
al a
nd D
enta
l Exp
ense
s,
prov
ides
a c
ompl
ete
list
of s
ervi
ces
elig
ible
for
reim
-bu
rsem
ent.
usi
ng
Yo
ur
un
reim
burs
ed M
edic
al F
SA
Firs
t,yo
um
ust
estim
ate
how
muc
hyo
uw
ills
pend
on
unr
eim
burs
ed h
ealth
car
e du
ring
the
plan
yea
r. B
ased
on
the
amou
nt y
ou e
lect
, con
trib
utio
ns w
ill b
e ta
ken
out
of y
our
payc
heck
eac
h pa
y cy
cle
thro
ugh-
out
the
cale
ndar
yea
r. It
is im
port
ant
to b
ase
this
es-
timat
e on
pas
t exp
erie
nce
beca
use
unus
ed c
ontr
ibu-
tions
mus
t be
forf
eite
d.
You
may
sub
mit
clai
ms
tot
heM
edic
alF
SA
for
unre
-im
burs
ed e
xpen
ses
betw
een
Janu
ary
1 of
the
pla
n ye
ara
ndM
arch
15
oft
hef
ollo
win
gye
ar
(e.g
.,Ja
n-ua
ry1
,20
18,
thro
ugh
Mar
ch1
5,2
019)
.Cla
imfo
rms
for
elig
ible
exp
ense
s m
ust b
e su
bmitt
ed n
o la
ter
than
A
pril
30 o
f the
follo
win
g ye
ar.
Whe
n yo
u fil
e yo
ur c
laim
, yo
u w
ill b
e re
imbu
rsed
for
up to
the
tota
l am
ount
you
hav
e el
ecte
d to
con
trib
ute,
w
heth
er o
r not
you
r con
trib
utio
ns to
dat
e ha
ve to
tale
d th
e am
ount
of
your
cla
im. W
hen
filin
g fo
r re
imbu
rse-
men
t, yo
u m
ust
verif
y th
at y
ou h
ave
not
been
rei
m-
burs
ed fo
r th
e ex
pens
e fr
om a
ny o
ther
sou
rce.
Whi
le th
e fe
dera
l gov
ernm
ent o
ffers
a fe
dera
l inc
ome
tax
dedu
ctio
n fo
r un
reim
burs
ed e
ligib
le h
ealth
car
e ex
pens
es w
hich
exc
eed
7.5
perc
ent o
f you
r ad
just
ed
gros
sin
com
e,th
eU
nrei
mbu
rsed
Med
ical
FS
Ao
ffers
ta
x-fr
ee r
eim
burs
emen
t on
eve
ry d
olla
r of
you
r el
igi-
ble
expe
nses
, whi
ch m
ay p
rovi
de im
med
iate
tax
sav-
ings
for
thos
e w
ho d
o no
t mee
t the
med
ical
exp
ense
de
duct
ion
thre
shol
d.I
nad
ditio
n,t
heU
nrei
mbu
rsed
M
edic
alF
SA
sav
esy
ouS
ocia
lS
ecur
itya
ndM
edi-
care
tax
es —
ano
ther
7.6
5 pe
rcen
t on
eve
ry d
olla
r. K
eep
in m
ind,
how
ever
, th
at y
ou c
anno
t de
duct
ex-
pens
esr
eim
burs
edb
yth
eU
nrei
mbu
rsed
Med
ical
F
SA
on
your
fede
rali
ncom
eta
x.
28
29
Feb
ruar
y 20
19
Fact
Sh
eet
#44
Tax$
ave
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
dE
PE
Nd
EN
T C
Ar
E
FL
EX
IBL
E S
PE
Nd
ING
AC
CO
uN
T (
FS
A)
If yo
u ha
ve t
o pa
y fo
r ca
re f
or y
our
depe
nden
ts i
n or
der
to w
ork,
you
may
wan
t to
tak
e ad
vant
age
of
the
Dep
ende
ntC
are
FS
Ap
lan.
Con
trib
utin
gm
oney
to
the
Dep
ende
ntC
are
FS
Ac
anr
esul
tin
are
duct
ion
in t
axes
bec
ause
the
mon
ey y
ou c
ontr
ibut
e to
you
r ac
coun
t is
fre
e fr
om f
eder
al i
ncom
e, S
ocia
l S
ecur
i-ty
,an
dM
edic
are
taxe
s,a
ndr
emai
nst
ax-f
ree
whe
nyo
u re
ceiv
e it.
The
pla
n al
low
s yo
u to
set
asi
de u
p to
$5,
000
of y
our
sala
ry b
efor
e ta
xes
each
cal
enda
r ye
ar t
o pa
y fo
r qu
alifi
ed d
epen
dent
car
e ex
pens
es
incu
rred
inth
atc
alen
dar
year
.You
then
file
cla
ims
for
reim
burs
emen
t of
elig
ible
exp
ense
s. N
ote
that
whe
n yo
ufil
eyo
urD
epen
dent
Car
eF
SA
cla
im,y
ouc
anno
tbe
ful
ly r
eim
burs
ed u
ntil
your
con
trib
utio
ns t
o da
te
are
at le
ast e
qual
to th
e am
ount
of y
our
clai
m.
Elig
ible
dep
ende
nts
incl
ude
ane
mpl
oyee
’sc
hild
ren
belo
wa
ge1
3,t
hee
mpl
oyee
’sn
on-w
orki
ngs
pous
eif
phys
ical
ly o
r m
enta
lly i
ncap
able
of
self-
care
, an
d an
y ot
her
pers
on c
onsi
dere
d a
depe
nden
t fo
r ta
x pu
rpos
es w
ho is
inca
pabl
e of
sel
f-ca
re a
nd w
ho n
or-
mal
ly s
pend
s at
lea
st e
ight
hou
rs e
ach
day
in t
he
empl
oyee
’sh
ome.
The
typ
eso
fse
rvic
ese
ligib
lef
or
reim
burs
emen
t in
clud
e a
qual
ified
day
car
e ce
nter
, nu
rser
y sc
hool
, or
sum
mer
day
cam
p (b
ut n
ot o
ver-
nigh
t ca
mp)
, ba
bysi
tting
ser
vice
s if
need
ed t
o al
low
th
e em
ploy
ee t
o w
ork,
a h
ouse
keep
er w
hose
dut
ies
incl
ude
day
care
, an
d so
meo
ne w
ho c
ares
for
an e
l-de
rly o
r in
capa
cita
ted
depe
nden
t.
IRS
Pub
licat
ion
503
– C
hild
and
Dep
ende
nt C
are
Ex-
pens
es,
prov
ides
a c
ompl
ete
list
of d
epen
dent
car
e ex
pens
es.
usi
ng
Yo
ur
dep
end
ent
Car
e F
SA
Firs
t,yo
um
ust
estim
ate
how
muc
hyo
uw
ills
pend
on
dep
ende
nt c
are
durin
g th
e pl
an y
ear.
Bas
ed o
n th
e am
ount
you
ele
ct,
cont
ribut
ions
will
be
take
n ou
t of
you
r pa
yche
ck e
ach
pay
cycl
e th
roug
hout
the
cal
-en
dar
year
. It
is i
mpo
rtan
t to
bas
e th
is e
stim
ate
on
past
exp
erie
nce
beca
use
unus
ed c
ontr
ibut
ions
mus
t be
forf
eite
d.
You
may
sub
mit
clai
ms
tot
heF
SA
for
dep
ende
nt
care
pro
vide
d be
twee
n Ja
nuar
y 1
of t
he p
lan
year
an
dM
arch
15
oft
hefo
llow
ing
year
(e.
g.,
Janu
ary
1,
2018
,thr
ough
Mar
ch1
5,2
019)
.Cla
imfo
rms
for
elig
i-bl
e se
rvic
es m
ust b
e su
bmitt
ed n
o la
ter
than
Apr
il 30
of
the
follo
win
g ye
ar.
The
fede
ral g
over
nmen
t of
fers
a d
epen
dent
car
e ta
x cr
edit
on y
our
fede
ral
inco
me
tax
that
you
can
use
in
stea
dof
the
Dep
ende
ntC
are
FS
A.Y
ouw
illh
ave
to
deci
de w
hich
met
hod
is b
ette
r fo
r yo
u ba
sed
on y
our
inco
me
and
pers
onal
tax
sta
tus.
Kee
p in
min
d, h
ow-
ever
,tha
tany
pay
men
trec
eive
dfr
omth
eD
epen
dent
C
are
FS
Aw
illre
duce
dol
larf
ord
olla
rthe
am
ount
that
ca
n be
con
side
red
for
depe
nden
t car
e ta
x cr
edit
and
vice
ver
sa.
Und
ert
hef
eder
ald
epen
dent
tax
cr
edit
prov
isio
n,
you
can
take
a d
irect
tax
cred
it on
you
r in
com
e ta
xes
rang
ing
from
20
perc
ent t
o 30
per
cent
of y
our
elig
ible
de
pend
ent c
are
expe
nses
. With
the
tax
cred
it, e
ligib
le
care
exp
ense
s ar
e lim
ited
to a
n an
nual
max
imum
of
$2,4
00 fo
r on
e de
pend
ent
or $
4,80
0 fo
r tw
o or
mor
e de
pend
ents
.
Gen
eral
ly, i
f you
r adj
uste
d gr
oss
inco
me
is m
ore
than
$2
4,00
0a
year
,us
ing
the
Dep
ende
ntC
are
FS
Ai
sbe
tter.
For
exa
mpl
e,if
you
are
pay
ing
$90
per
wee
k(a
bout
$4,
700
per
year
) fo
r da
y ca
re a
nd y
ou a
re in
th
e 15
per
cent
fed
eral
tax
bra
cket
, yo
u w
ould
sav
e $1
,060
in ta
xes
by p
ayin
g yo
ur d
ay c
are
bills
thro
ugh
your
Dep
ende
ntC
are
FS
A.
Ifyo
uar
ein
the
28
perc
ent
fede
ral
tax
brac
ket,
your
sav
ings
wou
ld b
e $1
,670
.
uS
E IT
Or
LO
SE
IT
Und
ere
ither
the
Unr
eim
burs
edM
edic
alF
SA
or
the
Dep
ende
ntC
are
FS
A,
any
unus
edc
ontr
ibut
ions
re-
mai
ning
in a
n ac
coun
t at t
he e
nd o
f the
pla
n ye
ar a
re
forf
eite
d.Y
ouh
ave
until
Apr
il30
of
the
follo
win
gye
ar
to fi
le fo
r el
igib
le r
eim
burs
emen
t.
CO
NT
INu
AT
ION
uN
dE
r C
OB
rA
The
fede
ralC
onso
lidat
edO
mni
bus
Bud
getR
econ
cil-
iatio
nA
cto
f198
5(C
OB
RA
)re
quire
sth
atm
ostg
roup
he
alth
pla
ns,i
nclu
ding
Unr
eim
burs
edM
edic
alF
SA
s,
give
em
ploy
ees
and
thei
r fa
mili
es t
he o
ppor
tuni
ty t
o co
ntin
ue t
heir
heal
th c
are
cove
rage
whe
n th
ere
is a
qu
alify
ing
even
t th
at w
ould
res
ult
in a
loss
of
cove
r-ag
eun
dera
nem
ploy
er’s
pla
n.Q
ualifi
edb
enefi
ciar
ies
can
incl
ude
the
empl
oyee
cov
ered
und
ert
heF
SA
,a
cove
red
empl
oyee
’ss
pous
e,a
ndd
epen
dent
chi
l-dr
eno
fth
eco
vere
dem
ploy
ee.E
ach
qual
ified
ben
e-fic
iary
who
ele
cts
cont
inua
tion
of c
over
age
will
hav
e th
e sa
me
right
s un
der
the
plan
as
othe
r pa
rtic
ipan
ts
orb
enefi
ciar
ies
cove
red
unde
rth
epl
an.
CO
BR
Ai
sav
aila
ble
unde
rTax
$ave
onl
yfo
rU
nrei
mbu
rsed
Med
-ic
alF
SA
s,n
otfo
rD
epen
dent
Car
eF
SA
s.
The
Tax
$ave
Unr
eim
burs
edM
edic
alF
SA
is
ane
x-ce
pted
pl
an,
and
ther
efor
e of
fers
on
ly
a lim
ited
CO
BR
A
optio
n.
One
of
th
efe
atur
es
of
alim
ited
CO
BR
Ao
ptio
nis
tha
tit
iso
nly
offe
red
for
the
re-
mai
nder
of t
he p
lan
year
— n
ot th
e fu
ll 18
mon
ths
of
CO
BR
A.
Als
o,t
hel
imite
dC
OB
RA
opt
ion
iso
nly
of-
fere
d if
the
acco
unt i
s un
ders
pent
. Thi
s oc
curs
whe
n th
e co
ntrib
utio
ns p
aid
to d
ate
are
mor
e th
an c
laim
s pa
id o
ut.
Be
awar
e th
at a
n ac
coun
t is
con
side
red
over
spen
t—
and
inel
igib
let
opa
rtic
ipat
ein
CO
BR
A
Fact
Sh
eet
#44
Feb
ruar
y 20
19
Tax$
ave
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
— if
the
con
trib
utio
ns p
aid
to d
ate
are
less
tha
n th
e cl
aim
s pa
id o
ut.
Exa
mp
le: A
rnol
d ha
s an
Unr
eim
burs
ed M
edic
al F
SA
an
nual
ele
ctio
n of
$1,
000
for
the
curr
ent
plan
yea
r. H
e te
rmin
ates
em
ploy
men
t in
July
and
has
pai
d $5
00
in p
ayro
ll (p
re-t
ax)
cont
ribut
ions
up
to h
is t
erm
ina-
tion
date
, bu
t ha
s re
ceiv
ed o
nly
$200
in
reim
burs
e-m
ent.
The
$30
0 ba
lanc
e ($
500
in c
ontr
ibut
ions
min
us
$200
in c
laim
s) is
con
side
red
unde
rspe
nt a
nd a
llow
s A
rnol
d to
par
ticip
ate
in C
OB
RA
. If
Arn
old
was
ove
r-sp
ent,
he c
ould
not
par
ticip
ate
in C
OB
RA
.
Tax$
ave
cove
rage
ter
min
ates
on
the
date
tha
t em
-pl
oym
ent
ends
. If
Arn
old
does
not
enr
oll i
n C
OB
RA
, th
e $3
00 b
alan
ce w
ill b
e fo
rfei
ted,
unl
ess
he c
an s
ub-
mit
$300
of c
laim
s in
curr
ed p
rior
to te
rmin
atio
n.
Sin
ce A
rnol
d do
es n
ot h
ave
qual
ified
exp
ense
s th
at
he c
an im
med
iate
ly s
ubm
it ag
ains
t the
$30
0 ba
lanc
e,
he e
lect
s to
par
ticip
ate
in C
OB
RA
. He
will
com
plet
e an
d re
turn
the
CO
BR
A E
lect
ion
For
m a
nd s
end
in
the
first
CO
BR
A p
aym
ent.
Onc
e hi
s fir
st p
aym
ent
has
been
rece
ived
, Arn
old
is e
ligib
le to
sub
mit
clai
ms
that
wer
e in
curr
ed a
fter
his
term
inat
ion
from
em
ploy
-m
ent.
Arn
old
can
cont
inue
to in
cur
and
subm
it cl
aim
s th
roug
h th
e en
d of
the
Tax$
ave
plan
yea
r, or
unt
il he
ha
s ex
haus
ted
his
orig
inal
ele
ctio
n fo
r th
e U
nrei
m-
burs
ed M
edic
al F
SA
ben
efit o
f $1,
000.
Arn
old’
s F
orm
W-2
will
sho
w $
500
of S
ectio
n 12
5 M
edic
al E
xpen
se P
lan
Con
trib
utio
ns.
Ele
ctio
n fo
r C
on
tin
uat
ion
Cov
erag
e
The
CO
BR
A N
otic
e an
d C
OB
RA
App
licat
ion
will
be
mai
led
to e
ach
elig
ible
par
ticip
ant
by t
he c
ompa
ny
adm
inis
terin
gth
eTa
x$av
eU
nrei
mbu
rsed
M
edic
al
FS
Af
ort
heS
tate
of
New
Jer
sey.
You
hav
e60
day
sfr
om t
he d
ate
of r
ecei
pt o
f th
e C
OB
RA
Not
ice
or t
he
last
dat
e of
cov
erag
e, w
hich
ever
is
late
r, to
ele
ct t
o co
ntin
ue c
over
age
by c
ompl
etin
g an
d su
bmitt
ing
the
CO
BR
A A
pplic
atio
n.
Fir
st P
aym
ent
for
Co
nti
nu
atio
n C
over
age
If yo
u el
ect c
ontin
uatio
n of
cov
erag
e, y
ou m
ust m
ake
your
firs
t pa
ymen
t fo
r co
ntin
uatio
n of
cov
erag
e w
ith-
in 4
5 da
ys a
fter
the
date
of
your
ele
ctio
n. (
Thi
s is
th
e da
te t
he C
OB
RA
App
licat
ion
is p
ostm
arke
d, i
f m
aile
d.)
If yo
u do
not
mak
e yo
ur fi
rst
paym
ent
with
-in
the
45
days
, yo
u w
ill l
ose
all
cont
inua
tion
of c
ov-
erag
erig
hts
unde
rth
eU
nrei
mbu
rsed
Med
ical
FS
A.
Your
firs
tpa
ymen
tm
ust
cove
rth
eco
sto
fco
ntin
ua-
tion
of c
over
age
from
the
tim
e yo
ur c
over
age
unde
r Ta
x$av
e w
ould
hav
e ot
herw
ise
term
inat
ed u
p to
the
tim
eyo
um
ake
the
first
pay
men
t.Yo
uar
ere
spon
sibl
efo
r m
akin
g su
re th
at th
e am
ount
of y
our
first
pay
men
t is
eno
ugh
toc
over
this
ent
irep
erio
d.Y
oum
ayc
onta
ct
Wag
eWor
ks,I
nc.(
see
the
“FS
AP
lan
Adm
inis
trat
ion”
se
ctio
n) t
o co
nfirm
the
cor
rect
am
ount
of
your
firs
t pa
ymen
t. In
stru
ctio
ns f
or s
endi
ng y
our
first
pay
men
t fo
r co
ntin
uatio
n of
cov
erag
e w
ill b
e sh
own
on y
our
CO
BR
A N
otic
e.
No
te:
All
CO
BR
Ap
aym
ents
are
mad
ew
itha
fter-
tax
dolla
rs,
whi
ch n
egat
es t
he t
ax s
avin
gs a
dvan
tage
of
the
FS
Ap
lan.
CO
BR
Ais
not
ata
xsa
ving
spl
an,a
nd
is o
nly
inte
nded
to p
reve
nt p
artic
ipan
ts fr
om fo
rfei
ting
cont
ribut
ions
mad
e pr
ior
to te
rmin
atio
n.
Per
iod
ic P
aym
ents
for
Co
nti
nu
atio
n C
over
age
Afte
r yo
u m
ake
your
firs
t pay
men
t for
con
tinua
tion
of
cove
rage
, you
will
be
requ
ired
to p
ay fo
r co
ntin
uatio
n of
cov
erag
e fo
r ea
ch s
ubse
quen
t mon
th o
f cov
erag
e.
Und
ert
heU
nrei
mbu
rsed
Med
ical
FS
A,
thes
epe
ri-od
ic p
aym
ents
for
cont
inua
tion
cove
rage
are
due
on
the
first
day
of
each
mon
th. I
nstr
uctio
ns f
or s
endi
ng
your
per
iodi
c pa
ymen
ts fo
r con
tinua
tion
cove
rage
will
be
sho
wn
on y
our
CO
BR
A N
otic
e an
d C
OB
RA
Ap-
plic
atio
n.
Gra
ce P
erio
ds
for
Per
iod
ic P
aym
ents
Alth
ough
per
iodi
c pa
ymen
ts a
re d
ue o
n th
e da
tes
show
n ab
ove,
you
will
be
give
n a
grac
e pe
riod
of 3
0 da
yst
om
ake
each
per
iodi
cpa
ymen
t.Yo
urc
ontin
ua-
tion
of c
over
age
will
be
prov
ided
for
eac
h co
vera
ge
perio
d as
long
as
paym
ent f
or th
at c
over
age
perio
d is
m
ade
befo
re th
e en
d of
the
grac
e pe
riod
for
that
pay
-m
ent.
If yo
u m
ake
a pe
riodi
c pa
ymen
t la
ter
than
its
du
e da
te b
ut d
urin
g its
gra
ce p
erio
d, y
our
cove
rage
un
der
the
Unr
eim
burs
edM
edic
alF
SA
will
be
sus-
pend
ed a
s of
the
due
dat
e an
d th
en r
etro
activ
ely
re-
inst
ated
(go
ing
back
to
the
due
date
) w
hen
the
peri-
odic
pay
men
t is
mad
e. T
his
mea
ns th
at a
ny c
laim
you
su
bmit
for b
enefi
ts w
hile
you
r cov
erag
e is
sus
pend
ed
may
be
deni
ed a
nd m
ay h
ave
to b
e re
subm
itted
onc
e yo
ur c
over
age
is r
eins
tate
d. I
f yo
u fa
il to
mak
e a
pe-
riodi
c pa
ymen
t bef
ore
the
end
of th
e gr
ace
perio
d fo
r th
at p
aym
ent,
you
will
los
e al
l rig
hts
to c
ontin
uatio
n co
vera
geu
nder
the
Unr
eim
burs
edM
edic
alF
SA
.
For
m
ore
info
rmat
ion
abou
tyo
ur
CO
BR
A
right
s,
plea
sec
onta
ctW
ageW
orks
,In
c.(
see
the
“FS
AP
lan
Adm
inis
trat
ion”
sec
tion
for
cont
act
info
rmat
ion)
,or
th
eU
.S.
Dep
artm
ent
ofL
abor
’sE
mpl
oyee
Ben
efits
S
ecur
ityA
dmin
istr
atio
n(E
BS
A)
iny
our
area
or
visi
tth
eE
BS
Aw
ebsi
tea
t:w
ww
.do
l.gov
/eb
sa
FS
A P
LA
N A
dM
INIS
Tr
AT
ION
Wag
eWor
ks,
Inc.
ad
min
iste
rs
the
Unr
eim
burs
ed
Med
ical
FS
Aa
ndD
epen
dent
Car
eF
SA
pla
nsfo
rth
eS
tate
of
New
Jer
sey
and
the
New
Jer
sey
Div
isio
nof
P
ensi
ons
&B
enefi
ts(
NJD
PB
).
Ifyo
uha
veq
uest
ions
abo
utth
eU
nrei
mbu
rsed
Med
i-ca
lFS
Ao
rth
eD
epen
dent
Car
eF
SA
,con
tact
Wag
e-W
orks
Cus
tom
erS
ervi
cea
t1-
855-
428-
0446
,M
on-
day
thro
ugh
Frid
ayf
rom
8:0
0a.
m.
to8
:00
p.m
.,or
vi
sit:
ww
w.w
agew
ork
s.co
m
The
Wag
eWor
ks w
ebsi
te i
s al
so a
vaila
ble
thro
ugh
the
Tax$
ave
link
on
the
NJD
PB
w
ebsi
te
at:
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
TAX
$AV
E A
dM
INIS
Tr
AT
ION
AN
d A
PP
EA
LS
The
NJD
PB
isth
eov
eral
ladm
inis
trat
oro
fTax
$ave
for
the
Sta
te o
f New
Jer
sey.
Ifyo
uha
vea
mid
-pla
n-ye
are
lect
ion
chan
ge,F
SA
re-
imbu
rsem
ent
clai
m,
or o
ther
sim
ilar
requ
est
that
is
30
Feb
ruar
y 20
19
Fact
Sh
eet
#44
Tax$
ave
Thi
s fa
ct s
heet
is a
sum
mar
y an
d no
t int
ende
d to
pro
vide
all
info
rmat
ion.
A
lthou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it c
anno
t be
guar
ante
ed.
deni
ed, i
n fu
ll or
in p
art,
you
have
the
right
to a
ppea
l th
e de
cisi
on b
y se
ndin
g a
writ
ten
requ
est
for
revi
ew
with
in 3
0 da
ys o
f the
den
ial t
o:
New
Jer
sey
div
isio
n o
f P
ensi
on
s &
Ben
efits
Tax$
ave
Pla
n A
dm
inis
trat
or
P.O
. Box
295
Tr
ento
n, N
J 08
625-
0295
Any
req
uest
for
appe
al m
ust i
nclu
de:
•T
hed
ate
oft
hes
ervi
ces
for
whi
chy
our
requ
est
was
den
ied,
if a
pplic
able
;
•A
cop
yof
the
deni
edr
eque
st,i
fava
ilabl
e;
•T
her
easo
nfo
ryo
ura
ppea
l;an
d
•A
nya
dditi
onal
doc
umen
ts,
info
rmat
ion,
or
com
-m
ents
you
thin
k m
ay h
ave
a be
arin
g on
you
r ap
-pe
al.
App
eal
requ
ests
and
sup
port
ing
docu
men
tatio
n w
ill
be r
evie
wed
and
you
will
be
notifi
ed o
f th
e re
sults
w
ithin
30
busi
ness
day
s of
rec
eipt
. In
unus
ual c
ases
, su
ch a
s w
hen
appe
als
requ
ire a
dditi
onal
doc
umen
-ta
tion,
the
rev
iew
may
tak
e lo
nger
tha
n 30
bus
ines
s da
ys. I
f yo
ur a
ppea
l is
appr
oved
, ad
ditio
nal p
roce
ss-
ing
time
is r
equi
red
to m
odify
you
r be
nefit
ele
ctio
ns.
No
te:
App
eals
are
app
rove
d on
ly i
f th
e ex
tenu
atin
g ci
rcum
stan
ces
and
supp
ortin
g do
cum
enta
tion
are
with
iny
our
empl
oyer
’s,i
nsur
ance
pro
vide
r’s,a
ndth
eIR
S’r
egul
atio
nsg
over
ning
the
plan
.
SO
CIA
L S
EC
ur
ITY
IMP
LIC
AT
ION
S
Sin
cep
aym
ents
to
the
PO
Pa
ndF
SA
slo
wer
ann
ual
earn
ings
aga
inst
whi
ch S
ocia
l Sec
urity
ded
uctio
ns o
r em
ploy
er c
ontr
ibut
ions
are
mad
e, th
ere
is a
con
cern
th
at p
artic
ipat
ion
in t
hese
pla
ns w
ould
res
ult
in r
e-du
ced
Soc
ial S
ecur
ity b
enefi
ts a
t ret
irem
ent.
Ifyo
uw
ere
born
afte
r192
8,y
ourS
ocia
lSec
urity
ben
-efi
ts a
re c
alcu
late
d us
ing
a 35
-yea
r av
erag
e of
you
r ea
rnin
gs.
A r
educ
tion
of e
ven
$2,0
00 a
yea
r ov
er
som
e po
rtio
n of
thi
s 35
-yea
r sp
an w
ould
hav
e lit
tle
effe
ct o
n yo
ur a
vera
ge s
alar
y an
d, th
eref
ore,
min
imal
im
pact
on
your
Soc
ial
Sec
urity
ben
efits
. The
Soc
ial
Sec
urity
Adm
inis
trat
ion
has
prov
ided
us
with
an
ex-
ampl
eof
an
empl
oyee
who
ret
ired
in1
998
ata
ge6
5,
who
se w
ages
had
bee
n at
the
max
imum
wag
es s
ub-
ject
to
Soc
ial
Sec
urity
ded
uctio
ns.
Upo
nre
tirem
ent,
this
ind
ivid
ual’s
mon
thly
Soc
ial
Sec
urity
allo
wan
ce
was
$1,
343.
If
that
sam
e pe
rson
had
bee
n co
ntrib
-ut
ing
$2,0
00a
yea
rfo
rth
ela
st1
0ye
ars
toa
FS
A,
the
subs
eque
nt r
educ
tion
in S
ocia
l S
ecur
ity w
ages
w
ould
hav
e pr
oduc
ed a
mon
thly
Soc
ial
Sec
urity
al-
low
ance
of $
1,33
5, a
diff
eren
ce o
f onl
y $8
per
mon
th.
CIV
IL u
NIO
N P
Ar
TN
Er
S,
dO
ME
ST
IC P
Ar
TN
Er
S, A
Nd
TA
X$A
VE
The
IRS
doe
s no
t rec
ogni
ze a
New
Jer
sey
civi
l uni
on
part
ner
or s
ame-
sex
dom
estic
par
tner
as
a de
pen-
dent
for
tax
pur
pose
s in
the
sam
e m
anne
r th
at i
t re
cogn
izes
a s
pous
e or
the
dep
ende
nt c
hild
ren
of
an e
mpl
oyee
. The
refo
re,
your
em
ploy
er m
ay h
ave
to
trea
t civ
il un
ion
or s
ame-
sex
dom
estic
par
tner
ben
e-fit
s as
fede
rally
taxa
ble.
As
a re
sult,
a p
artn
er m
ust
be a
ble
to q
ualif
y as
a
tax
depe
nden
t of
the
em
ploy
ee f
or f
eder
al t
ax fi
ling
purp
oses
— u
nder
IRC
Sec
tion
152
— b
efor
e an
out
-of
-poc
ket
med
ical
exp
ense
inc
urre
d by
the
par
tner
ca
nbe
rei
mbu
rsed
und
erth
eU
nrei
mbu
rsed
Med
ical
F
SA
,an
dbe
fore
any
pre
miu
ms
that
the
em
ploy
ee
pays
for
the
par
tner
’sc
over
age
can
bem
ade
ona
pr
e-ta
xba
sis
unde
rth
eP
OP.
See
IR
SP
ublic
atio
n 50
3 –
Dep
ende
nts,
for
add
ition
al in
form
atio
n on
the
re
quire
men
ts f
or e
stab
lishi
ng d
epen
dent
sta
tus
for
fede
ral t
ax p
urpo
ses.
If th
e ci
vil u
nion
par
tner
or
sam
e-se
x do
mes
tic p
art-
ner
is n
ot a
qua
lified
tax
depe
nden
t of t
he e
mpl
oyee
, th
epa
rtne
r’sS
HB
Pc
over
age
isc
onsi
dere
dfe
dera
lly
taxa
ble
and
the
empl
oyee
can
not b
e re
imbu
rsed
un-
der
the
Unr
eim
burs
edM
edic
alF
SA
for
any
out
-of-
pock
et m
edic
al e
xpen
se in
curr
ed b
y th
e pa
rtne
r, no
r m
ake
pre-
tax
paym
ents
for
the
cos
tof
the
par
tner
’s
cove
rage
und
ert
heP
OP.
Pre
-tax
dol
lars
may
stil
lbe
used
to
pay
for
the
empl
oyee
’sp
ortio
nof
the
cos
tof
hi
sor
her
ow
nan
dde
pend
ent
child
ren’
sco
vera
ge.
Civ
il un
ion
or s
ame-
sex
dom
estic
par
tner
SH
BP
ben
-efi
ts a
re n
ot s
ubje
ct to
New
Jer
sey
Sta
te in
com
e ta
x.
If yo
u liv
e ou
tsid
e of
New
Jer
sey,
you
sho
uld
chec
k w
ithy
our
stat
e’s
tax
agen
cyt
ode
term
ine
ifth
eci
vil
unio
n or
sam
e-se
x do
mes
tic p
artn
er b
enefi
t is
sub
-je
ct to
sta
te ta
xes.
For
add
ition
ali
nfor
mat
ion,
see
the
Civ
il U
nion
s an
d D
omes
tic P
artn
ersh
ips
Fact
She
et,
avai
labl
e on
our
w
ebsi
te.
Thi
s fa
ct s
heet
has
bee
n pr
oduc
ed a
nd d
istr
ibut
ed b
y:
New
Jer
sey
Div
isio
n o
f P
ensi
on
s &
Ben
efits
P.
O. B
ox 2
95, T
ren
ton
, NJ
0862
5-02
95
(609
)29
2-75
24F
or th
e he
arin
g im
paire
d: T
RS
711
(60
9) 2
92-6
683
ww
w.n
j.gov
/tre
asu
ry/p
ensi
on
s
31
32
33
Com
mut
er Ta
x$av
e Pr
ogra
m
Info
rmat
ion
for:
Stat
e Em
ploy
ees w
ho a
re e
ligibl
e for
the
Stat
e He
alth
Bene
fits P
rogr
am (S
HBP)
OVE
RVIE
W
The
New
Jer
sey
Stat
e Em
ploy
ees'
Com
mut
er T
ax
Savin
gs P
rogr
am (
Com
mut
er T
ax$a
ve),
a be
nefit
pr
ogra
m a
utho
rized
by
P.L. 2
011,
c. 1
62 (
Cha
pter
16
2)an
d av
aila
ble
unde
r Se
ctio
n 13
2(f)
of t
he fe
der
al I
nter
nal
Rev
enue
Cod
e (IR
C),
allo
ws
elig
ible
empl
oyee
s to
set
asi
de b
efor
e-ta
x do
llars
to p
ay fo
rm
ass
trans
it an
d co
mm
uter
par
king
expe
nses
, the
re
by a
void
ing
fede
ral t
axes
and
sav
ing
mon
ey. A
n el
igi
ble
empl
oyee
is a
ny e
mpl
oyee
of t
he S
tate
; a S
tate
colle
ge o
r uni
vers
ity; t
he S
tate
Lib
rary
; the
Pal
isad
esIn
ters
tate
Par
k C
omm
issi
on; t
he N
ew J
erse
y Bu
ild
ing
Auth
ority
; or t
he W
aterf
ront
Com
mis
sion
of
New
York
Har
bor w
ho is
elig
ible
to p
artic
ipat
e in
the
Stat
eH
ealth
Ben
efits
Pro
gram
(SH
BP),
exce
pt th
ose
part
time
empl
oyee
s m
ade
elig
ible
und
er P.
L. 2
003,
c. 1
72(C
hapt
er 1
72).C
omm
uter
Tax
$ave
con
sists
of
two
sepa
rate
com
pone
nt p
lans
, and
an
elig
ible
em
ploy
eem
ay e
lect
to p
artic
ipat
e in
one
or b
oth
of th
e pl
ans.
PRO
GRA
M B
ENEF
ITS
The
two
com
pone
nts
of C
omm
uter
Tax
$ave
are
for
mas
s tra
nsit
expe
nses
and
com
mut
er p
arkin
g ex
pe
nses
. Fo
r the
202
0 ca
lend
ar y
ear,
elig
ible
em
ploy
ees
may
ex
ecut
e sa
lary
redu
ction
agr
eem
ents
to h
ave
up to
: •
$270
per
mon
th ($
3,24
0 pe
r yea
r) de
duct
ed fr
omsa
lary
to
pay
for
mas
s tra
nsit
cost
s (in
clud
estra
in, b
us, f
erry
, and
van
pool
exp
ense
s); a
nd/o
r
•$2
70 p
er m
onth
($3
,240
per
yea
r) t
o pa
y fo
rpa
rkin
g at
wor
k or
at p
ark-
and-
ride
site
s.Pr
e-ta
x m
onie
s de
duct
ed fr
om s
alar
y ar
e no
t su
bje
ct to
fede
ral i
ncom
e ta
xes,
Soc
ial S
ecur
ity t
axes
, or
Med
icar
e ta
xes.
The
re is
a m
inim
um d
educ
tion
of $
15 fo
r eith
er m
ass
trans
it or
par
king
dedu
ction
s. Th
ere
are
no p
rovis
ions
for h
ighe
r ded
uctio
ns o
n an
af
ter-t
ax b
asis
. M
ass
trans
it be
nefit
s ca
n be
use
d to
pay
for
cost
s in
curr
ed b
y th
e em
ploy
ee fo
r th
e pu
rpos
es o
f com
m
utin
g to
and
from
wor
k. C
omm
uter
par
king
ben
efits
m
ay o
nly
be u
sed
to p
ay fo
r th
e pa
rtici
pant
's co
m
mut
er p
arkin
g ex
pens
es a
t or n
ear t
heir
work
plac
e or
ne
ar a
loca
tion
from
whi
ch th
e em
ploy
ee c
omm
utes
to
wor
k an
d ca
nnot
be
used
for o
ther
pur
pose
s. In
ad
ditio
n, In
tern
al R
even
ue S
ervic
e (IR
S) ru
les
requ
ire
that
mas
s tra
nsit
bene
fits
be d
elive
red
as t
icket
s,
paym
ent c
ards
, or v
ouch
ers
that
can
onl
y be
use
d to
pu
rcha
se m
ass
trans
it tic
kets
. Par
king
bene
fits
can
be d
elive
red
as a
pay
men
t car
d, v
ouch
er, o
r as
a re
im
burs
emen
t of e
xpen
ses.
Belo
w a
re e
xam
ples
of
how
Com
mut
er T
ax$a
ve
work
s fo
r you
:
EMPL
OYEE
RID
ES M
ASS
TR
ANSI
T US
ING
PRE-
TAX
$125
DED
UCTI
ON
PER
MO
NTH
W
ithou
t Pr
e-Ta
x W
ith P
re-T
ax
Com
mut
er
Com
mut
er
Tax$
ave
Tax$
ave
Mon
thly
Sala
ry
$3,7
50
$3,7
50
Pre-
Tax
$0
-$12
5 Co
mm
uter
Ta
x$av
e fo
r Ma
ss Tr
ansit
Sa
lary
Subje
ct
$3, 7
50
$3,6
25
to T
axes
Es
timat
ed Ta
xes
-$80
0 -$
762
Mon
thly
Mas
s -$
125
-$0
Tran
sit E
xpen
se
Take
-Hom
e Pa
y $2
,825
$2
,863
M
onth
ly S
avin
gs: $
38*
Ann
ual S
avin
gs: $
456*
(Addi
tiona
l exam
ples
liste
d on
pag
e 2)
*Exa
mpl
es a
re b
ased
on
an a
nnua
l sal
ary o
f $45
,000
. Est
imat
ed F
eder
al T
axes
: 25
perc
ent.
Taxe
s ex
empt
ed in
clud
e: F
edera
l Inc
ome,
Soc
ial S
ecuri
ty, a
nd M
edicare
. Gre
ater
savin
gs m
ay re
sult
ifyo
ur c
omm
uting
costs
are
hig
her a
nd/or
you
are
in a
hig
her f
eder
al in
com
e ta
x br
acke
t. Lo
wer d
educ
tible
s m
ay re
sult
in s
mall
er s
avin
gs a
nd in
divid
ual s
avings
may
var
y. C
onsu
lt yo
ur ta
x ad
visor.
Janu
ary
2020
Fa
ct S
heet
#67
This
fact
shee
t is a
sum
mar
y an
d no
t inte
nded
to p
rovid
e al
l info
rmat
ion.
Al
thou
gh e
very
atte
mpt
at a
ccur
acy i
s m
ade,
it ca
nnot
be
guar
ante
ed.
EMPL
OYEE
PAR
KS
AND
TH
EN
RID
ES
MA
SS TR
AN
SIT,
USI
NG P
RE-T
AX $
125
DED
UC
TIO
N PE
R M
ONT
H
FOR
MA
SS TR
ANS
IT A
ND P
RE-
TAX
$80
DED
UC
TIO
N FO
R PA
RKIN
G
With
out P
re-T
ax
With
Pre
-Tax
Com
mut
er
Com
mut
er Ta
x$av
e Ta
x$av
e M
onth
ly Sa
lary
$3
,750
$3
,750
Pr
e-Ta
x Com
mut
er Ta
x$av
e fo
r Mas
s Tra
nsit
$0
-$12
5 Pr
e-Ta
x Co
mm
uter
Tax$
ave
for P
arkin
g $0
-$
80
Sala
ry S
ubje
ct to
Tax
es
$3,7
50
$3,5
45
Estim
ated
Taxe
s -$
800
-$73
7 Mo
nthl
y M
ass
Trans
it Ex
pens
e -$
125
-$0
Mon
thly
Park
ing
Expe
nse
-$80
-$
0 Ta
ke-H
ome
Pay
$2,7
45
$2,8
08
Mon
thly
Sav
ings
: $63
* A
nnua
l Sav
ings
: $75
6*
EMPL
OYE
E U
SES
PR
E-TA
X $8
0 D
EDU
CTI
ON
PER
MO
NTH
FO
R PA
RK
ING
W
ithou
t Pre
-Tax
W
ith P
re-T
ax C
omm
uter
C
omm
uter
Tax$
ave
Tax$
ave
Mon
thly
Sala
ry
$3,7
50
$3,7
50
Pre-
Tax C
omm
uter
Tax$
ave
for P
arkin
g $0
-$
80
Sala
ry S
ubje
ct to
Tax
es
$3,7
50
$3,6
70
Estim
ated
Taxe
s -$
800
-$77
5 Mo
nthl
y Pa
rkin
g Ex
pens
e -$
80
-$0
Take
-Hom
e Pa
y $2
,870
$2
,895
M
onth
ly S
avin
gs: $
25*
Ann
ual S
avin
gs: $
300*
Com
mut
er Ta
x$av
e Pr
ogra
m
ENRO
LLM
ENT
Unlik
e th
e Se
ctio
n 125
por
tion
of th
e St
ate'
s Tax
$ ave
Pr
ogra
m (
Med
ical
and
/or
Depe
nden
t C
are
Spen
din
g Ac
coun
ts) t
hat r
equi
res
one
annu
al e
lect
ion,
the
Com
mut
er T
ax$ a
ve P
rogr
am a
llows
an
empl
oyee
to
opt i
n an
d ou
t or c
hang
e am
ount
s on
a m
onth
ly ba
si
s. E
ligib
le e
mpl
oyee
s m
ay e
nrol
l in
the
prog
ram
or
end
parti
cipa
tion
at a
ny ti
me
durin
g th
e ye
ar a
nd m
ay
chan
ge d
educ
tions
as
often
as
they
like
dur
ing
the
year
. Onc
e en
rolle
d, th
e em
ploy
ee re
mai
ns e
nrol
led
for a
ll su
bseq
uent
mon
ths
at th
e sa
me
leve
l of p
ar
ticip
atio
n un
til th
e em
ploy
ee m
akes
a c
hang
e to
the
dedu
ctio
n am
ount
s or
ele
cts
to e
nd p
artic
ipat
ion.
C
omm
uter
Tax$
ave
bene
fits a
re p
rovid
ed b
y Ed
enre
d C
omm
uter
Ben
efit
Solu
tions
. An
elig
ible
em
ploy
ee
enro
lls b
y co
ntac
ting
Eden
red
dire
ctly,
eith
er b
y ca
llin
g C
usto
mer
Ser
vice
at 1
-888
-512
-876
9 or
onl
ine
at:
ww
w.co
mm
uterb
enef
its.c
om
Upon
enr
ollm
ent,
an e
mpl
oyee
's el
igib
ility
is co
nfir
med
with
the
empl
oyer
who
will
arra
nge
for p
ayro
ll de
duct
ions
to b
egin
. Ded
uctio
ns fo
r th
e be
nefit
are
ta
ken
from
the
first
pay
roll
chec
k in
the
mon
th. T
ran
sitC
hek
will
then
pro
cess
tick
ets,
paym
ent c
ards
, or
vouc
hers
and
mai
l the
m d
irect
ly to
the
empl
oyee
. T
he t
otal
tim
e re
quire
d fo
r pr
oces
sing
befo
re t
he
bene
fit b
egin
s is
app
roxim
atel
y 45
day
s. T
he s
ched
ul
e fo
r enr
ollm
ents
/cha
nges
dur
ing
a ty
pica
l yea
r is
show
n in
the
follo
wing
cha
rt:
*Exam
ples
are
bas
ed on
an
annu
al sa
lary
of $
45,0
00. E
stim
ated
Fed
eral T
axes
: 25
perc
ent.
Taxe
s exem
pted
inclu
de: F
edera
l Inco
me,
Soc
ial S
ecuri
ty, a
nd M
edicare
. Gre
ater
savin
gs m
ay re
sult
ifyo
ur c
omm
uting
costs
are
hig
her a
nd/or
you
are in
a h
ighe
r fed
eral
inco
me
tax
brac
ket.
Lowe
r ded
uctib
les
may
resu
lt in
sm
aller
sav
ings
and
indi
vidua
l savin
gs m
ay va
ry. C
onsu
lt your
tax
advis
or.
Fact
She
et #6
7 Ja
nuar
y 20
20
34
35
Com
mut
er Ta
x$av
e Pr
ogra
m
ENRO
LLM
ENT
BEN
EFIT
PE
RIO
D PE
RIO
D Fe
brua
ry 1
-Fe
brua
ry 2
9 Ap
ril
Mar
ch 1
-M
arch
31
May
Ap
ril 1
-Ap
ril 3
0 Ju
ne
May
1 -
May
31
July
June
1 -
June
30
Augu
st
July
1 -
July
31
Sept
embe
r Au
gust
1 -
Augu
st 3
1 O
ctob
er
Sept
embe
r 1 -
Sept
embe
r 30
Nove
mbe
r Oc
tobe
r 1 -
Octo
ber 3
1 De
cem
ber
Nove
mbe
r 1 -
Nove
mbe
r 30
Janu
ary
Dece
mbe
r 1 -
Dece
mbe
r 31
Febr
uary
Ja
nuar
y 1 -
Janu
ary 3
1 M
arch
N
ote:
the
mon
thly
dedu
ctio
n fo
r the
Com
mut
er T
ax-
$ave
Pro
gram
will
gene
rally
be
take
n fro
m th
e fir
st
payc
heck
eac
h m
onth
; how
ever
, the
re m
ay b
e tim
es
when
the
dedu
ctio
n wi
ll be
take
n fro
m th
e se
cond
pa
yche
ck o
f the
mon
th.
"USE
IT O
R LO
SE IT
" PRO
VISI
ON
Em
ploy
ee e
lect
ions
are
irre
voca
ble
and,
to
avoi
d fo
rfeiti
ng b
enef
it do
llars
, em
ploy
ees
shou
ld c
aref
ully
cons
ider
how
muc
h th
ey w
ant t
o se
t asi
de to
cov
er
thei
r co
mm
utin
g ex
pens
es. T
he S
tate
is p
rohi
bite
d un
der
fede
ral
tax
regu
latio
ns f
rom
pro
cess
ing
re
fund
s to
em
ploy
ees
who
fail
to fu
lly u
tiliz
e th
e be
nefit
in
a ti
mel
y m
anne
r. Fo
r em
ploy
ees
who
elec
t to
rece
ive th
e Co
mm
uter
Ca
rd, i
t is
impo
rtant
to re
alize
that
the
stor
ed v
alue
on
the
card
is a
vaila
ble
for o
nly
as lo
ng a
s th
e em
pl
oyee
rem
ains
an
activ
e pa
rticip
ant o
f the
pro
gram
. If
an e
mpl
oyee
can
cels
his
or h
er p
artic
ipat
ion
in th
e pr
ogra
m, a
ny r
emai
ning
bal
ance
on
the
card
whe
n th
e ca
ncel
latio
n be
com
es e
ffect
ive is
forfe
ited.
This
fact
shee
t is a
sum
mar
y an
d no
t inte
nded
to p
rovid
e al
l info
rmat
ion.
Al
thou
gh e
very
atte
mpt
at a
ccur
acy
is m
ade,
it can
not b
e gu
aran
teed
.
SOCI
AL S
ECUR
ITY
IMPL
ICAT
ION
S Si
nce
paym
ents
to th
e Co
mm
uter
Tax
$ave
Pro
gram
lo
wer a
nnua
l ear
ning
s ag
ains
t whi
ch S
ocia
l Sec
urity
de
duct
ions
are
mad
e, th
ere
is a
con
cern
that
par
tic
ipat
ion
in th
ese
plan
s wo
uld
resu
lt in
redu
ced
Soci
al
Secu
rity
bene
fits
at re
tirem
ent.
If yo
u we
re b
orn
after
192
8, y
our S
ocia
l Sec
urity
ben
ef
its a
re c
alcu
late
d us
ing
a 35
-yea
r ave
rage
of y
our
earn
ings
. A re
duct
ion
of u
p to
$3,
120
a ye
ar (b
ased
on
the
max
imum
pre
-tax
trans
it be
nefit
cap
) ov
er
som
e po
rtion
of t
his
35-y
ear
span
wou
ld h
ave
little
ef
fect
on
your
ave
rage
sal
ary
and,
ther
efor
e, m
inim
al
impa
ct o
n yo
ur S
ocia
l Sec
urity
ben
efits
. How
ever
, if
you
are
conc
erne
d, y
ou s
houl
d ca
ll th
e So
cial S
ecu
rity
Adm
inis
tratio
n fo
r fu
rther
adv
ice
at 1
-800
-772
-12
13 o
r visi
t www
.ssa
.gov
ADD
ITIO
NAL
INFO
RMAT
ION
Ad
ditio
nal
info
rmat
ion
abou
t th
e Co
mm
uter
Ta
x$av
e Pr
ogra
m is
ava
ilabl
e fro
m E
den r
ed b
y cal
ling
1-88
8-51
2-87
69 o
r onl
ine
at:
ww
w.c
omm
uter
bene
fits.c
om
This
fact
shee
t has
bee
n pro
duce
d an
d dis
tribute
d by
: N
ew J
erse
y D
ivis
ion
of P
ensi
ons
& B
enefi
ts
P.O
. Box
295
, Trent
on, N
J 08
625-
0295
(6
09)2
92-752
4Fo
r the
hearin
g im
paire
d: T
RS 7
11 (6
09) 2
92-6
683
www.n
j.gov
/trea
sury
/pen
sion
s
Janu
ary
2020
Fa
ct S
heet
#67
36
HOLIDAY SCHEDULE INFORMATION
Holidays observed at University Hospital
New Year's Day Memorial Day Observance Thanksgiving Day
Martin Luther King, Jr. Birthday Observance
Independence Day Day After Thanksgiving Day
Good Friday Labor Day Christmas Day
FLOAT HOLIDAYS
Only full and part-time staff who are in active payroll status on January 1 and full-time temporary staff who have been continuously employed for six (6) months are eligible for six float holidays.
Staff hired between January 2 and June 30, will be credited with three (3) float holidays in July. Staff on unpaid leave on January 1, but return from leave prior to July 1, will be credited with three (3) float holidays.
Float Holidays must be taken between January 1 and December 31, or they are forfeited.
Float Holidays shall be reported on the time sheets as "FH".
Regular part-time staff shall be paid for Float Holidays on a prorated basis in accordance with the length of their workweek.
Float Holidays, except in the case of personal emergencies, must be requested at least one week in advance. Float Holidays may be used for religious holidays.
Supervisors shall only approve a Float Holiday if the staff member's absence does not interfere with University Hospital’s operations.
For staff members on a seven-day workweek schedule, a holiday falling on a Saturday or Sunday is observed on that day. Premium pay will be given only to staff members working the actual holiday.
Premium pay is not given for work performed on the Day after Thanksgiving or on Good Friday for non-exempt staff.
37
38
2/4/2020
Human ResourcesBenefits OfficeJanuary 2020
New Employee Benefits
Orientation
2
Welcome to University Hospital
You Made theRight Choice !
Employee Benefits
3
ADMC Bldg. #8 Claudine Cruz-Green-Benefits Services Associate
(973) 972-0885Robin Hynes-Benefits Services Associate
(973) 972-4743Diane Wieckowski-Manager Benefits Operations & Data Admin
(973) 972-3925
University Hospital Benefits Services Office
39
2/4/2020
4
BENEFITS
Medical Plan Choices
Dental PlanChoices
SupplementalBenefits
FlexibleSpendingAccounts
TimeOff
PrescriptionDrug Plan
PensionPlansNJ State
TemporaryDisability
CommuterTax$aveProgram
OptionalPre-TaxPlans
5
State Health Benefits Program (SHBP)
Eligibility Requirements
Eligibility based on regular employment Hired to work 35 or more hours a week Effective date of coverage - after two months
of continuous employment
6
Medical Benefits Under Chapter 172Eligibility
Part Time less than 35 hours per week
Enrolled in a Pension Plan
Full Cost (Direct Billing)
Available Plans
Health Maintenance Organization (HMO’s).
High Deductible Health Plans (HD’s)
Preferred Provider Organization (PPO’s)
Tiered Plans
40
2/4/2020
7
Affordable Care Act (ACA)
Private Insurance through Health Insurance Marketplace.
State Exchange Coverage for those not eligible under SHBP HealthCare.gov
8
Spouse, Same-Sex Spouse, Same-Sex Civil Union Partner
Children (under age 26) coverage ends the end of the year they turn 26
Stepchildren, Foster-Care Children Legally Adopted Children Documentation required for dependent enrollment
Eligible Dependents
9
Qualifying Event
60 day notice period for qualifying event (such as marriage, birth or adoption of a child, loss of spouse coverage etc.)
Review regulations for a Spouse, Same-Sex Spouse, Same-Sex Civil Union Partner or also employed at a State institution
41
2/4/2020
10
Open Enrollment
Annual Open Enrollment is in October
New Dependent Enrollment (if not added on at time of qualifying event)
Preferred Provider Organizations
(PPO’s)
Health Maintenance Organizations
(HMO’s)
Tiered Plans
High Deductible Plans (HD’s)
Medical Plans
12
Medical Benefits Cost
The employee will pay the greater of 1.5% of annual base salary or percentage of premium cost
Contribution is withheld the first pay after the effective date of coverage
42
2/4/2020
13
Medical Plans
PPO PLANS HMO PLANS TIERED PLANS HIGH DEDUCTIBLE (HD) PLANS
NJ DIRECT15 HORIZON HMO HORIZON OMNIA HEALTH PLAN
NJ DIRECT HD4000
NJ DIRECT15/25 NJ DIRECT HD1500NJ DIRECT20/30
NJ DIRECT20/35
NJ DIRECT
NJ DIRECT 2019
14
Health Maintenance Organizations(HMO’s)
Horizon HMO
15
Horizon HMO
Features (Covers Preventative Care)
Restricted to Network MD’s/Facilities
Member chooses his/her primary care physician
Referrals are required for most specialists
43
2/4/2020
16
Tiered Plans
Horizon Omnia Health Plan
17
Horizon Tiered PlansFeatures (Covers Preventative Care)
Restricted to Tier 1 or Tier 2 Network MD’s/Facilities
Co-pays vary depending on Tier Network
Referrals are not required for specialistsRefer to State Active Employees Medical Plan Design included in the New Employee Orientation Booklet for co-pays and out of pocket expenses.
18
NJ DIRECT15NJ DIRECT1525NJ DIRECT2030NJ DIRECT2035NJ DIRECT*NJ DIRECT2019**
*Members hired before July 1, 2019 are eligible to enroll**Members hired after July 1, 2019 are eligible to enroll
Preferred Provider Organizations (PPO)
44
2/4/2020
19
Horizon PREFERRED PROVIDER ORGANIZATIONS
(PPO’s)
Coverage in-network No primary care physician-no referrals
Preventive, routine & urgent care Refer to State Active Employees Medical Plan Design included in the New Employee Orientation Booklet for co-pays and out-of-pocket expenses.
20
Coverage out-of-network
Deductibles/Co-Insurance – Eligible expenses covered at applicable percentage of reasonable & customary expenses
Claim forms need to be filed
Refer to State Active Employees Medical Plan Design included in the New Employee Orientation Booklet for deductibles.
Horizon PREFERRED PROVIDER ORGANIZATIONS
(PPO’s)
21
High Deductible (HD) Plans
NJ Direct HD1500
NJ Direct HD4000
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2/4/2020
22
In-Network Services•$1,500 In-Network Deductible•20% In-Network Coinsurance after deductible is met•$1,000 Out-of-Pocket Maximum
Out-of-Network Services•$1,500 Deductible (combined with In-Network Deductible)•40% Out-of-Network Coinsurance after deductible is met•$3,500 Out-of-Pocket Maximum
*Amounts above are based on individual costs. All other coverage levels the amounts are doubled*
NJ DIRECT HD 1500- HIGH DEDUCTIBLE PLAN
23
NJ DIRECT HD 4000- HIGH DEDUCTIBLE PLAN
In-Network Services•$4,000 In-Network Deductible•20% In-Network Coinsurance after deductible is met•$1,000 Out-of-Pocket Maximum
Out-of-Network Services•$4,000 Deductible (combined with In-Network Deductible)•40% Out-of-Network Coinsurance after deductible is met•$6,000 Out-of-Pocket Maximum
*Amounts above are based on individual costs. All othercoverage levels the amounts are doubled*
24
Employer Health Savings Account (HSA) is available for the High Deductible Plans only.Member will receive a welcome kit with information to enrollVoluntary employee contributions to the HSA can be used for medical and prescription drug expenses
Medical Plan Summary
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2/4/2020
25
Medical Benefits
Plan ID cards given to you and eligible dependents before coverage date
Administered by
OptumRx
(844) 368-8740
Prescription Drug Plan
27
Many Pharmacies Participate (Including Most Pharmacy Chains)
ID card required for purchase
ID card will be sent to the employee and each eligible dependent prior to the effective date of coverage
Prescription Drug Plan
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2/4/2020
28
30 day supply at retail pharmacy
90 day mail order
Co-pays vary depending on medical plan enrolled Refer to the State Active Employees Medical Plan Design included in the New Employee Orientation Booklet for co-pay information.
Prescription Drug Plan
29
Subject to deductible and coinsurance Members pay 100% of prescription drug costs
until deductible is met Member then pays the applicable coinsurance
until the out of pocket maximum is met
Horizon 1500 and 4000High Deductable Plan
30
The employee will pay the greater of 1.5 % of annual base salary or percentage of premium cost.
Prescription Drug Plan
48
2/4/2020
Dental Expense Plan(PPO)
Dental Plan Organizations (DPO’s)
New Jersey Dental Insurance
Program
32
Dental Expense Plan
Aetna PPO
33
Dental Expense Plan
No geographical restrictions
Claim forms required
Eligible Expenses
Basic Preventative Care
Periodontics
Prosthodontics
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2/4/2020
34
Dental Expense Plan
In-Network $50 Deductible/Person (or $100/Family) waived
for Preventive
Eligible expenses covered at applicablepercentage of reasonable and customaryexpenses
Annual dollar maximum $3,000/member
35
Dental Expense Plan
Out-of Network $75 Deductible/Person (or $150/Family) waived for
Preventative
Eligible Expenses covered at applicable percentage of reasonable and customary expenses
Annual dollar maximum $2,000/member (Maximum of $3,000 combined In and Out of Network)
36
Dental Expense PlanNon-Covered Expenses
Supplies for home use Charges more than reasonable and customaryPredetermination of coverage for dental expenses over $300 and for specific services, e.g., crowns, periodontics, prosthodontics or orthodontics, regardless of the cost. Without advance approval, these services will not be reimbursed.
50
2/4/2020
37
Dental Expense Plan
Orthodontic Eligibility
Must have ten months employment Child under 19 years of age Not available for procedures started
before coverage began
38
Dental Expense Plan
Orthodontic Eligibility In-Network 50% to $1,000 lifetime maximum*
Orthodontic Eligibility Out-of-Network 40% to $750 lifetime maximum* (maximum of $1,000
combined in and out of network)
* Not subjected to deductible or combined with annualmaximum
39
Aetna DPO Cigna Dental Health, Inc Healthplex Horizon Dental Choice MetLife
Dental Plan Organization (DPO)
51
2/4/2020
40
Dental Plan Organization
Coverage restricted to DPO providers
Preventive/Routine Care - 100%
Co-Payment for specialized care
No claim forms required
41
Dental Plan Organization
Orthodontic Eligibility
Patient under 18 years of age at the start of treatmenthas Co-Pay of $1,000 or 50% of reasonable andcustomary charges, whichever is less
Patient 18 years of age and over at the start oftreatment has co-pay of $1,750 or 50% of reasonable and customary charges, whichever is less
Treatment plan maximum of 24 months
42
State Employee Group Dental Program
Must remain in plan for a minimum of 12 months
52
2/4/2020
43
COBRA
Death, Divorce, Dependents > Age 26 Maximum Duration 36 Months
Member Termination - Maximum Duration 18 Months
44
Coverage for Same-Sex Civil Union Partners
Applicable biweekly premiums will be deducted on an after tax basis
Imputed income will be applied
In the event that the Civil Union Partner meets the IRS Definition of Dependent for Tax Purposes, the University does not have to treat the Civil Union Partner’s coverage as a taxable benefit
Public Employees Retirement System (PERS)
Defined Contribution Retirement Program (DCRP)
Retirement Plans
53
2/4/2020
46
Are you enrolled in or have you retired from aState Administered Pension Plan?
47
Public Employees Retirement System (PERS)
48
Regular Full or Part-Time Employee
Work 35 or More Hours per Week
Begins the Date of the First Pay Period Nearest Your Hire Date
Vesting Provisions
Public Employees Retirement System (PERS)Plan Eligibility
54
2/4/2020
49
Age 65 or 30 Years of Service
1/4th of 1% per Month Decrease Under Age 65
Public Employees Retirement System (PERS)
Retirement Benefits
50
Current Rate is 7.50%
Up to a compensation limit based the annual maximum wage for Social Security deductions $137,700 for 2020
Delay in Commencement of Contribution
Special Provisions for Veterans
Public Employees Retirement System (PERS)
Mandatory Contributions
with eligibility for accrued time after 90 days of employment
51
3-Year Service Requirement
Two Loans/Year
Public Employees Retirement System (PERS)
Loan Opportunity
55
2/4/2020
52
Life Insurance
Non Contributory Portion Pays 1.5 x Base Annual Salary*
(Pro-Rated First Year)
Members enrolled at age 60 or old must prove insurability
*Subject to Annual Maximum Wage Limit for Social Security
Public Employees Retirement System (PERS)
53
Public Employees Retirement System (PERS) Life Insurance
Contributory Portion 1st Year Mandatory Contribution 1/2 of 1% Payroll Deduction Pays 1.5 x Base Annual Salary*
(Paid in Full in First Year) Imputed Income
*Subject to Annual Maximum Wage for Social Security
54
If Vested in PERS at Retirement Non-Contributory Portion will be Equal to 3/16ths of Your Base Salary
Conversion to Private Coverage
Public Employees Retirement System (PERS)
56
2/4/2020
55
Cost Free
60% base Monthly Salary
1 year Membership Requirement
6 month Waiting Period
Public Employees Retirement System (PERS)
Disability Insurance Benefits
56
Defined Contribution Retirement Program (DCRP)
57
Part-Time Employee not eligible for PERS enrollment
Work less than 35 hours per week
PERS members who meet the maximum Social Security maximum wage limit for the calendar year
Vested after 12 months of contributions
Defined Contribution Retirement Program (DCRP)
Plan Eligibility
57
2/4/2020
58
Begin Membership for the First of the Month Contribute 5.5% Employer Matches 3%
Contributions are up to the annual compensation limit of $280,000 for 2019
Retroactive Contribution
Defined Contribution Retirement Program (DCRP)
Members
59
Prudential Retirement
Defined Contribution Retirement Program (DCRP)
Investment Provider
60
Cash Distribution and Annuity Options Upon Separation of Employment
Transferable
Defined Contribution Retirement Program (DCRP)
58
2/4/2020
61
Cost Free 1.5 times Base Annual Salary up to annual
compensation limit. Pro-rated in the First Year Members enrolled at age 60 or older must prove
insurability Imputed Income
Defined Contribution Retirement Program (DCRP)
Life Insurance
62
Cost Free
60% base Monthly Salary
1 year Membership Requirement
6 month Waiting Period
Defined Contribution Retirement Program (DCRP)
Disability Insurance
New Jersey Temporary Disability
New Jersey Family Leave Insurance
Optional Contributory Plan
59
2/4/2020
64
New Jersey Temporary Disability Insurance
and
New Jersey Family Leave Insurance
(Mandatory)
65
Effective Day 1 (Based on 20 Weeks of New Jersey Employment)
2/3 of Weekly Wage to the Current Statutory Limit
Maximum - 1/3 Total Wages or Weekly Amount x 26
New Jersey Temporary Disability Insurance
66
Up to 6 weeks of Family Leave Insurance: bond with newborn, newly adopted children or care for sick family members. Effective Day 1 (Based on 20 Weeks of New Jersey
Employment) 2/3 of Weekly Wage to the Current Statutory Limit
New Jersey Family Leave Insurance
60
2/4/2020
67
Optional Contributory PlanTax Sheltered Plans
68
Employed by the State or an eligible agency Pre-Tax Contributions Up to the Annual Tax Deferral IRS
457 Limit After-Tax Roth 457 option Broad array of investment choices Settlement at Separation Prudential Retirement
New Jersey State Employee Deferred Compensation Plan (NJSEDCP)
69
Dependent Care Account (30 Day Waiting Period) Medical Spending Account (60 Day Waiting Period) Premium Option Plan (POP) Annual Open Enrollment In October
New Jersey State Employees’ Tax-Savings Program (Flexible Spending Account)
Enrollment in Dependent Care and Medical Spending Account is within 30 days from date of hire
61
2/4/2020
70
Mass Transit Commuter Costs Parking (Other Than Campus Sites) Costs Pre-Tax Basis Continuous Enrollment Cycles New Hire Eligible After 30 Days
New Jersey State Employees’ Commuter Tax$ave Program
71
Division of Pension and Benefits
Telephone Numbers
Automated Line for PERS (609) 777-1777
Customer Service for All Plans (609) 292-7524
HolidaysFloat HolidaysSick LeaveVacation AccrualLeave of Absences
Time Off Policies
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2/4/2020
73
Sick Leave Policy
New Hires Accrue One Day Per Month
Pro-rated for part time employees
Unused Days Carry Over Staff employees receive 1/2 of the Value ofUnused Days (Maximum payout of $15,000) for a non-deferred retirement.
74
Holidays
Staff members are eligible to receive up to:
9 Recognized Holidays
6 Float Holidays
15 Annual Holidays*
*Pro-rated for part time employee.
Holidays do not carry over to the following year.
75
Vacation Accruals
Years of Service Vacation Accrual
1-10 15 days/year
11-20 20 days/year
21 + 25 days/year
Pro-rated for part time employees
(Staff May Carry Over One Year Of Their Vacation Accruals)
63
2/4/2020
76
Vacation Accruals(Director Level and Above)
Years of Service Vacation Accrual
1-20 20 days/year
21 + 25 days/year
(Staff May Carry Over One Year Of Their Vacation Accruals)
77
Vacation Accruals (Staff Nurses)
Years of Service Vacation Accrual
1-3 15 days/year
4-18 20 days/year
19 + 25 days/year
Pro-rated for part time employees
(Staff May Carry Over One Year of Their Vacation Accrual)
78
Leave of Absences
Academic
Military
Personal
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2/4/2020
79
Medical FMLA Leave of Absence
Leave of Absence for employee due to illness or injury for self, family member, or leave due to birth, adoption or foster care.
Please view Medical/Family Medical Leave Act-Leave of Absence/New Jersey Paid Family Leave policy for eligibility, available leaves and information regarding benefits while on leave.
80
Educational Assistance Program (EAP)
Eligibility applies to full-time and part-time (20 ormore hours per week) employees.
Staff employees are eligible for reimbursement upto the annual limit with a grade of “C” or better.
Reimbursement covers tuition cost and credit by exam.
Please refer to the Education Assistance Program policy at time of eligibility for details and annual limitreimbursements.
81
Office of Training and Organizational Development
Offers a wide variety of training courses for the development of management and non-management staff. Consults with Departments.
Provides courses to all employees. Supervisor’s approval is required. See course listing on-line for details.
65
2/4/2020
82
University Hospital’s “Extras”
Employee Discounts- uhnj.org
Additional voluntary plans
Credit Union
Direct Deposit
Employee Assistance Program (EAP)
83
ADMC Bldg #8Claudine Cruz-Green-Benefits Services Associate
(973) 972-0885Robin Hynes-Benefits Services Associate
(973) 972-4743Diane Wieckowski-Manager Benefits Operations
(973) 972-3925
University Hospital Benefits Services Office
66
67
EMPLOYEE CERTIFICATION — I certify that all the information supplied on this form is true to the best of my knowledge and that it is verifiable. I understand that if I waive my right to coverage at this time, enrollment is not permissible until the next scheduled open enrollment or if other coverage is lost and proof of loss is provided (HIPAA). I also understand that there is no guarantee of continuous participation by medical providers, either doctors or facilities, in the plans. If either my physician or medical center terminates participation in my selected plan, I must select another doctor or medical center participating in that plan to receive the “in-network” benefit. I authorize any hospital, physician, or health care provider to furnish my medical plan or its assignee with such medical information about myself or my covered dependents as the assignee may require. Misrepresentation: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A.17:33A-6c.
7. Employee Signature: __________________________________________________________________________ Date: ______/______/______
6. Dependent Information: List all eligible dependents and attach required proof of dependency documents*
o Additional sheets attached. Any dependents not listed will be removed.
Eligible Dependents Last Name, First Name Social Security No. Circle Relationship Birth Date Gender
*See Instructions page for detailed information and Mailing Address
/ /
/ /
/ /
— —
— —
— —
Spouse / Civil Union / Domestic Partner
Child (Natural, Adopted, Foster, Step, Legal Ward)
Child (Natural, Adopted, Foster, Step, Legal Ward)
State Health Benefits Program (SHBP)STATE ACTIVE EMPLOYEE GROUP
HEALTH BENEFITS ENROLLMENT and/or CHANGE FORMHA
-0891-0
120
4. TYPE and LEVEL OF COVERAGE
Level Health Rx
o Single o oo Parent/Child o oo Member/Spouse/Civil Union o oo Member/Domestic Partner o oo Family o o
I have been offered the above coverage and I elect to waive participation for myself and my eligible dependents (see Instructions page for details). Note: Oral contraceptive coverage is available under the medical plan.
o I elect to waive Health Coverage o I elect to waive Prescription Drug Coverage
1. EMPLOYEE INFORMATION — Last Name First MI
_____________________________________________________________________________________________Gender Birth Date Social Security Number Marital Status*
_____________________________________________________________________________________________Telephone Number Personal Email Address
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Street Address City State Zip
2. EMPLOYMENT STATUS
o Full Time o Part Time o Intermittent o National Guard o ACA (Monthly only)
3. REASON FOR APPLICATION (Check one)
o New Enrollment o Transfer
o Open Enrollment o Loss of Coverage
o Adding Dependents o Deleting Dependents
o Waiver of Coverage o Other
Reason_________________________________
Date of Event _______/_______/_______
— — / /
( )
5. HEALTH PLAN (Check one box only)
o OMNIA Health Plan o NJ DIRECT/ NJ DIRECT 2019* o NJ DIRECT15 o NJ DIRECT1525 o NJ DIRECT2030
o NJ DIRECT2035 o Horizon HMO o NJ DIRECT HD1500** o NJ DIRECT HD4000
For HD Plans only – Health Savings Account (HSA)
o I wish to establish a HSA at this time and understand that I will be contacted to establish banking. By applying for and fundingmy HSA I represent that I:1) am covered under a High Deductible Health Plan (HDHP); 3) am not covered by Medicare; and2) am not covered by any other non-HDHP product; 4) cannot be claimed as a dependent on another person’s tax return.
o I am not enrolling in a HSA at this time and understand that if I choose to at a later date, I must contact my health plan.
*Members hired before July 1, 2019, will be enrolled in NJ DIRECT. Members hired after July 1, 2019, will be enrolled in NJ DIRECT 2019.**Part-time employees cannot enroll in the NJ DIRECT HD1500 plan.
Effective Dates Event Reason:
H _____ ______ ______
Rx _____ ______ ______
EMPLOYER CERTIFICATION (See Instructions on reverse)
Employer Name _________________________
Payroll # _______________________ (State Biweekly)
Union Code (Rx) Only
Location # (State Monthly)
10/12 - month employee (Enter “10 or 12”)
MEMBER ACTION
o New Enrollment o Transfer
Date Employment Began
______/______/______
o Return from Leave of Absence
______/______/______
Signature of Certifying Officer
Telephone # Date Mailed
DIVISION USE ONLY
INSTRUCTIONS FOR THE SHBP STATE ACTIVE EMPLOYEE GROUPHEALTH BENEFITS ENROLLMENT and/or CHANGE FORM
SECTION 1 – EMPLOYEE INFORMATION – Complete entire section. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed)
SECTION 2 – EMPLOYMENT STATUS – Check one block only
SECTION 3 – REASON FOR APPLICATION – Check one block only
• New Enrollment – New hire or HIPAA event• Transfer – Active health benefits coverage transferring from another SHBP/SEHBP location• Open Enrollment – Annually in October• Adding Dependents – Must be done within 60 days of event (i.e. birth, marriage, adoption – indicate reason and date)• Deleting Dependents – Removal of covered dependents (indicate reason and date)• Loss of Coverage – Enrolling because of loss of other coverage (application and HIPAA certificate submitted within 60
days of the loss of other coverage)• Waiver of Coverage – Waive (decline) coverage• Other (indicate reason and date)• Reason – indicate reason• Date of Event – indicate date
To waive (decline) coverage: If you wish to waive Health and/or Prescription Drug coverage under the provisions of N.J.S.A. 52:14-17.31a, check appropriate block. Note: Both Health and Prescription Drug coverage must be waived to avoid paying a contribution. If you are waiving coverage for yourself or any or all of your eligible dependents because of other group health coverage, you may enroll in the future. You must provide proof of the loss of other coverage and submit it with your application within 60 days of the loss of other coverage. Otherwise, you will be required to wait until the annual Open Enrollment.
SECTION 4 – TYPE AND LEVEL OF COVERAGE – Indicate by checking the appropriate block to enroll in Health and/or Rx (Prescription Drug)
• Single – coverage for you only• Parent/Child(ren) – coverage for you and any eligible child(ren) under age 26• Member/Spouse/Civil Union – coverage for you and your eligible spouse or your Civil Union Partner• Member/Domestic Partner – coverage for you and your eligible Domestic Partner• Family – coverage for you, your eligible Spouse/Civil Union Partner/Domestic Partner, and child(ren) under age 26
SECTION 5 – HEALTH PLAN – Select only one plan. The Health Benefits Summary Program Description provides you with all available options. Members who wish to enroll in a High Deductible Health Plan (HDHP) must complete a Health Savings Account (HSA) Form. Guidebooks and applications can be found on our website at: www.nj.gov/treasury/pensions
SECTION 6 – DEPENDENT INFORMATION – List all eligible dependents and attach dependent documentation proof (see attached). If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, dependents may not be enrolled. Ensure your dependents match your level of coverage (Section 4). Your child(ren) may be covered until the end of the calendar year they turn 26. Any dependents not listed will not be covered. Attach extra pages for additional dependents.
Note: Use Section 3 to delete dependents.
SECTION 7 – EMPLOYEE SIGNATURE – Read, sign, date, and attach required dependent documentation. Return the application to your employer’s human resources office for certification.
MISREPRESENTATION: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A. 17:33A-6c.
EMPLOYER CERTIFICATION – Must be completed by the Certifying Officer. The Certifying Officer’s signature confirms that:
• The employee is eligible;• The application is legible and completed in its entirety;• The employee’s selected plans and coverage levels are appropriate;• The dependent documentation provided is complete and correct;• The Employer Certification section is completed in its entirety; and• The information presented is true to the best of their knowledge.
MAIL COMPLETED APPLICATION TO: New Jersey Division of Pensions & Benefits Health Benefits BureauP.O. Box 299Trenton, NJ 08625-0299
HA-0891-0120
68
The State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) are required to ensure that only employees, retirees, and eligible dependents are receiving health care coverage under the Programs. The New Jersey Division of Pensions & Benefits (NJDPB) must guarantee consistent application of eligibility requirements within the plans. Employees or retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children, disabled and/or overage children continuing coverage) MUST submit the following documentation in addition to the appropriate health benefits enrollment or change of status application. If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, dependents may not be enrolled. ANY DEPENDENTS NOT LISTED ON THE APPLICATION WILL NOT BE COVERED.
DEPENDENTS ELIGIBILITY DEFINITION DOCUMENTATION REQUIRED
SPOUSE
A person to whom you are legally married. A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the spouse. If filing separately, submit a copy of both spouses’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both spouses and is received at the same address.
CIVIL UNIONPARTNER
A person of the same sex with whom you have entered into a civil union.
A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the partner. If filing separately, submit a copy of both partners’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both partners and is received at the same address.
DOMESTICPARTNER
A person of the same sex with whom you have entered into a do-mestic partnership. Under P.L. 2003, c. 246, the Domestic Part-nership Act, health benefits coverage is available to domestic partners of State employees, State retirees, or employees or re-tirees of a SHBP - or SEHBP - participating local public entity that has adopted a resolution to provide Chapter 246 health benefits.
A copy of the New Jersey certificate of domestic partnership dated prior to February 19, 2007, or a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic partners and a copy of the front page of the employee/retiree’s N.J. tax return* from last year that includes the partner. If filing separately, submit a copy of both partners’ NJ tax returns that list the same address. If Domestic Partnership occurred in the current calendar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 days of the application) that includes the names of both partners and is received at the same address.
CHILDREN
A subscriber’s child until age 26, regardless of the child’s marital, student, or financial dependency status – even if the young adult no longer lives with his or her parents.
This includes a stepchild, foster child, legally adopted child, or any child in a guardian-ward relationship upon submitting re-quired supporting documentation.
Natural or Adopted Child – A copy of the child’s birth certificate showing the name of the employee/retiree as a parent. Step Child – A copy of the child’s birth certificate showing the name of the employee/retiree’s spouse or partner as a parent and a copy of the marriage/partnership certificate showing the names of the employee/retir-ee and spouse/partner.Legal Guardian, Grandchild, or Foster Child – Copies of final court or-ders with the presiding judge’s signature and seal. Documents must attest to the legal guardianship by the employee.
DEPENDENTCHILDREN WITH
DISABILITIES
If a covered child is not capable of self-support when he or she reaches age 26 due to mental illness or incapacity, or a physical disability, the child may be eligible for a continuance of coverage. Coverage for children with disabilities may continue only while (1) you are covered through the SHBP/SEHBP; (2) the childcontinues to be disabled; (3) the child is unmarried or does notenter into a civil union or domestic partnership; and (4) the childremains substantially dependent on you for support and mainte-nance. You may be contacted periodically to verify that the childremains eligible for coverage.
Documentation for the appropriate “child” type (as noted above) and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that includes the child. If Social Security disability has been awarded, or is currently pending, please include this information with the documentation that is submitted. Please note that this information is only verifying the child’s eligibility as a dependent. The disability status of the child is determined through a separate process.
CONTINUEDCOVERAGE FOR
OVERAGECHILDREN
Certain children over age 26 may be eligible for continued cov-erage until age 31 under the provisions of P.L. 2005, c. 375. This includes a child by blood or law who: (1) is under the age of 31; (2) is unmarried or not a partner in a civil union or domestic partnership; (3) has no dependent(s) of his or her own; (4) is a resident of New Jersey or is a student at an accredited public or private institution of higher education, with at least 15 credit hours; and (5) is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
Documentation for the appropriate “child” type (as noted above), and a copy of the front page of the child’s federal tax return* (Form 1040) from last year, and if the child resides outside of the State of New Jersey, doc-umentation of full time student status must be submitted.
*You may black out all financial information and all but the last four digits of any Social Security numbers on tax returns. To obtain copies of the documents listedabove, contact the office of the town clerk in the city of the birth, marriage, etc., or visit these websites: www.vitalrec.com or www.studentclearinghouse.org Residents of New Jersey can obtain records from the State Bureau of Vital Statistics and Registration website: www.nj.gov/health/vital/index.shtml
State Health Benefits Program (SHBP) • School Employees’ Health Benefits Program (SEHBP)
REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENTH
B-0
840-
1217
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70
71
EMPLOYEE CERTIFICATION — I certify that all the information supplied on this form is true to the best of my knowledge and that it is verifiable. I understand that if I waive my right to coverage at this time, enrollment is not permissible until the next scheduled open enrollment or if other coverage is lost and proof of loss is provided (HIPAA). I understand that I must remain enrolled in the Dental Plan for a minimum of 12 months and that there is no guarantee of continuous participation by dental service providers, either dentists or facilities, in the DPO plans. If either my dentist or dental center terminates participation in my select-ed plan, I must select another dentist or dental center participating in that plan to receive the “in-network” benefit. I authorize any hospital, physician, dentist or dental care provider to furnish my dental plan or its assignee with such dental information about myself or my covered dependents as the assignee may require. Misrepresentation: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A.17:33A-6c.
6. Employee Signature: _________________________________________________________________________ Date: ______/______/______
5. Dependent Information: List all eligible dependents and attach required proof of dependency documents*
o Additional sheets attached. Any dependents not listed will be removed.
Eligible Dependents Last Name, First Name Social Security No. Circle Relationship Birth Date Gender
*See Instructions page for detailed information and Mailing Address
— —
— —
— —
— —
/ /
/ /
/ /
/ /
Spouse / Civil Union / Domestic Partner
Child (Natural, Adopted, Foster, Step, Legal Ward)
Child (Natural, Adopted, Foster, Step, Legal Ward)
Child (Natural, Adopted, Foster, Step, Legal Ward)
State Health Benefits Program (SHBP) • School Employees’ Health Benefits Program (SEHBP)
HEALTH BENEFITS ACTIVE EMPLOYEE GROUP
EMPLOYEE DENTAL ENROLLMENT and/or CHANGE FORMHD
-07
19
-01
20
o I have been offered the above coverage and I elect to waive participation for myself and my eligible dependents (see Instructions page for details).
1. EMPLOYEE INFORMATION — Last Name First MI
_____________________________________________________________________________________________Gender Birth Date Social Security Number Marital Status*
_____________________________________________________________________________________________Telephone Number Personal Email Address
_____________________________________________________________________________________________
_____________________________________________________________________________________________Street Address City State Zip
2. REASON FOR APPLICATION (check one)
o New Enrollment o Transfer
o Open Enrollment o Loss of Coverage
o Adding Dependents o Deleting Dependents
oWaiver of Coverage o Other
Reason________________________________________________
Date of Event _______/_______/_______
— — / /
( )
3. LEVEL OF COVERAGE
o Single
o Parent/Child
o Member/Spouse/Civil Union
o Member/Domestic Partner
o Family
Effective Dates Event Reason:
D _____ ______ ______
EMPLOYER CERTIFICATION (See Instructions on reverse)
Employer Name __________________________
Payroll # ________________________ (State Biweekly)
Union Code (Rx) Only
Location # (State Monthly or Local /Education)
10/12 - month employee (Enter “10 or 12”)
MEMBER ACTION
o New Enrollment o Transfer
Date Employment Began
______/______/______
o Return from Leave of Absence
______/______/______
Signature of Certifying Officer
Telephone # Date Mailed
DIVISION USE ONLY
-
4. DENTAL PLAN You must remain enrolled in selected plan for 12 months.
I wish to be covered under the Aetna Dental Expense Plan
o Aetna DEP/PPO
I wish to be covered under a Dental Plan Organization (DPO/DMO)
o Aetna DMO o Cigna o MetLife o Healthplex o Horizon BCBSNJ
Dentist ID Number ___________________________________
INSTRUCTIONS FOR THE NEW JERSEY EMPLOYEE DENTAL PLANS ENROLLMENT and/or CHANGE FORM
SECTION 1 – EMPLOYEE INFORMATION – Complete entire section. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed)
SECTION 2 – REASON FOR APPLICATION – Check one block only
• New Enrollment – New hire or HIPAA event• Transfer – Active dental benefits coverage transferring from another SHBP/SEHBP location• Open Enrollment – Annually in October• Adding Dependents – Must be done within 60 days of event (i.e. birth, marriage, adoption – indicate reason and date)• Deleting Dependents – Removal of covered dependents (indicate reason and date)• Loss of Coverage – Enrolling because of loss of other coverage (application and HIPAA certificate submitted within 60 days of the loss of
other coverage)• Waiver of Coverage – Waive (decline) coverage• Other (indicate reason and date)• Reason – indicate reason• Date of Event – indicate date
To waive (decline) coverage: If you wish to waive dental coverage under the provisions of N.J.S.A. 52:14-17.31a, check appropriate block. If you are waiving coverage for yourself or any or all of your eligible dependents because of other group health coverage, you may enroll in the future. You must provide proof of the loss of other coverage and submit it with your application within 60 days of the loss of other coverage. Otherwise, you will be required to wait until the annual Open Enrollment.
SECTION 3 – LEVEL OF COVERAGE – Indicate by checking the appropriate block
• Single – coverage for you only• Parent/Child(ren) – coverage for you and any eligible child(ren) under age 26• Member/Spouse/Civil Union – coverage for you and your spouse or your Civil Union Partner• Member/Domestic Partner – coverage for you and your Domestic Partner• Family – coverage for you, your eligible Spouse/Civil Union Partner/Domestic Partner, and child(ren) under age 26
SECTION 4 – DENTAL PLAN – Select only one plan. The Employee Dental Plans Member Guidebook provides you with all available options and is available on our website at: www.nj.gov/treasury/pensions If you enroll in a Dental Plan Organization (DPO), you must receive services from an in-network dentist in order to have your claims paid. You must select a participating dentist within the DPO, ensuring the dentist or facility takes new patients and participates with the Employee Dental Plans. If you enroll in the Dental Expense Plan (Aetna DEP), you may receive services from any dentist. You will be required to pay up-front for covered services until a deductible is met.
Note: After you enroll in a dental plan, you must remain enrolled for 12 months until you are permitted to terminate coverage.
SECTION 5 – DEPENDENT INFORMATION – List all eligible dependents and attach dependent documentation proof (see attached). If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, depen-dents may not be enrolled. Ensure your dependents match your level of coverage (Section 4). Your child(ren) may be covered until the end of the calendar year they turn 26. Any dependents not listed will not be covered. Attach extra pages for additional dependents.
Note: Use Section 2 to delete dependents
SECTION 6 – EMPLOYEE SIGNATURE – Read, sign, date, and attach required dependent documentation. Return the application to your em-ployer’s human resources office for certification.
MISREPRESENTATION: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A.17:33A-6c.
EMPLOYER CERTIFICATION – Must be completed by the Certifying Officer. The Certifying Officer’s signature confirms that:
• The employee is eligible;• The application is legible and completed in its entirety;• The employee’s selected plans and coverage levels are appropriate;• The dependent documentation provided is complete and correct;• The Employer Certification section is completed in its entirety; and• The information presented is true to the best of their knowledge.
MAIL COMPLETED APPLICATION TO: New Jersey Division of Pensions & Benefits Health Benefits BureauP.O. Box 299Trenton, NJ 08625-0299
HD-0719-0120
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The State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) are required to ensure that only employees, retirees, and eligible dependents are receiving health care coverage under the Programs. The New Jersey Division of Pensions & Benefits (NJDPB) must guarantee consistent application of eligibility requirements within the plans. Employees or retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children, disabled and/or overage children continuing coverage) MUST submit the following documentation in addition to the appropriate health benefits enrollment or change of status application. If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, dependents may not be enrolled. ANY DEPENDENTS NOT LISTED ON THE APPLICATION WILL NOT BE COVERED.
DEPENDENTS ELIGIBILITY DEFINITION DOCUMENTATION REQUIRED
SPOUSE
A person to whom you are legally married. A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the spouse. If filing separately, submit a copy of both spouses’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both spouses and is received at the same address.
CIVIL UNIONPARTNER
A person of the same sex with whom you have entered into a civil union.
A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the partner. If filing separately, submit a copy of both partners’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 day of the application) that includes the names of both partners and is received at the same address.
DOMESTICPARTNER
A person of the same sex with whom you have entered into a do-mestic partnership. Under P.L. 2003, c. 246, the Domestic Part-nership Act, health benefits coverage is available to domestic partners of State employees, State retirees, or employees or re-tirees of a SHBP - or SEHBP - participating local public entity that has adopted a resolution to provide Chapter 246 health benefits.
A copy of the New Jersey certificate of domestic partnership dated prior to February 19, 2007, or a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic partners and a copy of the front page of the employee/retiree’s N.J. tax return* from last year that includes the partner. If filing separately, submit a copy of both partners’ NJ tax returns that list the same address. If Domestic Partnership occurred in the current calendar year, a copy of the tax return is not required. Or, if tax return is not available, provide a copy of a bank statement or bill (dated within 90 days of the application) that includes the names of both partners and is received at the same address.
CHILDREN
A subscriber’s child until age 26, regardless of the child’s marital, student, or financial dependency status – even if the young adult no longer lives with his or her parents.
This includes a stepchild, foster child, legally adopted child, or any child in a guardian-ward relationship upon submitting re-quired supporting documentation.
Natural or Adopted Child – A copy of the child’s birth certificate showing the name of the employee/retiree as a parent. Step Child – A copy of the child’s birth certificate showing the name of the employee/retiree’s spouse or partner as a parent and a copy of the marriage/partnership certificate showing the names of the employee/retir-ee and spouse/partner.Legal Guardian, Grandchild, or Foster Child – Copies of final court or-ders with the presiding judge’s signature and seal. Documents must attest to the legal guardianship by the employee.
DEPENDENTCHILDREN WITH
DISABILITIES
If a covered child is not capable of self-support when he or she reaches age 26 due to mental illness or incapacity, or a physical disability, the child may be eligible for a continuance of coverage. Coverage for children with disabilities may continue only while (1) you are covered through the SHBP/SEHBP; (2) the childcontinues to be disabled; (3) the child is unmarried or does notenter into a civil union or domestic partnership; and (4) the childremains substantially dependent on you for support and mainte-nance. You may be contacted periodically to verify that the childremains eligible for coverage.
Documentation for the appropriate “child” type (as noted above) and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that includes the child. If Social Security disability has been awarded, or is currently pending, please include this information with the documentation that is submitted. Please note that this information is only verifying the child’s eligibility as a dependent. The disability status of the child is determined through a separate process.
CONTINUEDCOVERAGE FOR
OVERAGECHILDREN
Certain children over age 26 may be eligible for continued cov-erage until age 31 under the provisions of P.L. 2005, c. 375. This includes a child by blood or law who: (1) is under the age of 31; (2) is unmarried or not a partner in a civil union or domestic partnership; (3) has no dependent(s) of his or her own; (4) is a resident of New Jersey or is a student at an accredited public or private institution of higher education, with at least 15 credit hours; and (5) is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
Documentation for the appropriate “child” type (as noted above), and a copy of the front page of the child’s federal tax return* (Form 1040) from last year, and if the child resides outside of the State of New Jersey, doc-umentation of full time student status must be submitted.
*You may black out all financial information and all but the last four digits of any Social Security numbers on tax returns. To obtain copies of the documents listedabove, contact the office of the town clerk in the city of the birth, marriage, etc., or visit these websites: www.vitalrec.com or www.studentclearinghouse.org Residents of New Jersey can obtain records from the State Bureau of Vital Statistics and Registration website: www.nj.gov/health/vital/index.shtml
State Health Benefits Program (SHBP) • School Employees’ Health Benefits Program (SEHBP)
REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT
HB
-084
0-12
17
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EE-0681-0713
DO NOT WRITE IN THIS BOX
New Jersey Division of Pensions and Benefits ENROLLMENT APPLICATION
LOCATION NO. MEMBERSHIP NO.
APPLICANT INFORMATION: (Please Print or Type and follow the instructions on page 2 of this form)
PO BOX295 Trenton, NJ 08625-0295
Select Pension Fund: (Check one) D Teachers' Pension and Annuity Fund D Public Employees' Retirement System
1. Name:Last First (no nicknames) Middle Maiden Surname and Surname Used During Previous Membership
2. Address:Street
3. Social Security #:
5. Date of Birth: __ ! __ ! __Month Day Year
City State Zip Code
4. Gender: D Male D Female
6. Daytime Phone: ( __ )
7. Is the applicant receiving a benefit from a New Jersey State-administered or local New Jersey retirement system at this time?D Yes D No (If "Yes", please provide retirement system name)
EMPLOYER INFORMATION (Please Print or Type):
8. Employer Name: 9. T itle/Position of Applicant: ___________ _
10. County: ___________ 11. Location#: ______ Bureau#: ____ _ Payroll #: ____ _ If Applicable State - Loe.- Only
12. Is the applicant currently employed by more than one public employer? D Yes D No(If "Yes", please provide name of employer(s)) ______________________________ _
TO BE COMPLETED FOR TPAF APPLICATIONS ONLY 13 (a.) Date Employment Began: __ ! __ ! __ (Do not include temporary, substitute, or part-time service) 13 (b.) Does position require a New Jersey State Certificate issued by the State Board of Examiners within the NJ Department of
Education? D Yes D No 13 (c.) Does the applicant hold a certification issued by the State Board of Examiners within the NJ Department of Education?
D Yes D No 13 (d.) For NJ Department of Education Only: Is the position Unclassified Professional? D Yes D No
TO BE COMPLETED FOR PERS APPLICATIONS ONLY
14 (a.) Date Employment Began: __ ! __ !__ 14 (b.) Date of Regular or Permanent Appointment: __ ! __ ! __
14 (c.) Is applicant considered temporary or provisional? D Yes D No 15. Is applicant an elected official? D Yes D No
16. Is the applicant appointed by Special Resolution or Ordinance or by the Governor with Senate confirmation? D Yes D No
17. Has the applicant been awarded a professional services contract? D Yes D No
18. Current Annual Base Salary$ _________ 19. (Check one) D 10-Month Position D 12-Month Position
20. Are the work hours fixed at 32 hours (Local) or 35 hours (State) or more per week pursuant to Ch.1, P.L. 201 0? D Yes D No
EMPLOYER CERTIFICATION 21. Name of Employer Representative Completing Application: _________________________
22. Phone Number: ( ___ ) ___ -______ Ext.: ____ _I certify that this employee and position meets the eligibility criteria for the retirement system as provided by law. I further certify that I have successfully completed the online training and Annual Membership Certification required by N.J.S.A. 43:3C-15. I acknowledge that I am subject to penalty for falsifying or permitting to be falsified any record, application, form, or report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15. (Two Signatures Required)
23. ------------------ DATE: __ ! __ ! __ Signature of Certifying Officer Print Name of Certifying Officer Month Day Year
24. ------------------ DATE: __ ! __ ! __ Signature of Certifying Officer's Supervisor Print Name of Certifying Officer's Supervisor Month Day Year
NOTE: IFTHIS APPLICATION IS NOT SUBMITTED ON A TIMELY BASIS, A LATE EMPLOYER LIABILIT Y MAY BE ASSESSED.
75
EE-0681-0713 ENROLLMENT APPLICATION INSTRUCTIONS (This application to be completed by enrolling employer)
APPLICANT INFORMATION 1. Name -Enter applicant's full name (last, first, and middle initial; no nicknames). If applicant has a previous membership under a maiden or other
name, enter that name in the space provided.2. Address -Enter applicant's current mailing address.3. Social Security Number -Enter applicant's Social Security number. 4. Gender - Indicate applicant's gender. 5. Date of Birth -Enter applicant's date of birth. Proof of age is required at the time of retirement - if available, attach a photocopy of the applicant's
proof of age to this application. Do not delay submitting the Enrollment Application if proof of age is not available. ( Acceptable proof of agedocuments include: Birth Certificate (with visible seal); a U.S. Passport Card; Naturalization or Immigration papers; a current NJ Driver License orDigital Non-driver ID Card from MVC; Military records indicating your age.)
6. Daytime Phone Number -Enter applicant's daytime phone number and extension (be sure to include the area code).7. Is the applicant receiving retirement benefits - Indicate if the applicant is receiving a benefit from a New Jersey State-administered retirement
system or local New Jersey retirement system, and give the system's name.
EMPLOYER INFORMATION 8. Employer Name -Enter the full employer name. 9. County -Enter county in which the employer resides. 10. Location, Bureau, and Payroll Numbers -Enter the appropriate location, bureau or payroll number, as applicable. This information should be as
reported on your quarterly Report of Contributions (ROC).11. Title/Position of Applicant -Enter title/position of applicant.12. Multiple Public Employers - Indicate whether this applicant is employed by more than one public employer. If you answer "Yes", please indicate
the full name of each employer.
TPAF APPLICANTS ONLY 13. (a.) Date Employment Began -Enter the date on which applicant started employment. Do not include temporary, substitute, or part-time service.
(b.) New Jersey Certificate Required - Indicate whether the title/position requires a New Jersey State Certificate issued by the State Boardof Examiners within the NJ Department of Education.
(c.) Applicant has New Jersey Certificate -Indicate whether the applicant holds a New Jersey Certificate issued by the State Board of Examinerswithin the NJ Department of Education.
(d.) Unclassified Professional -For positions with the NJ Department of Education, indicate if the position is "Unclassified Professional". PERS APPLICANTS ONLY 14. (a.) Date Employment Began - Enter the date on which applicant started employment.
(b.) Permanent Appointment Date -Enter the date of the applicant's regular or permanent appointment.(c.) Temporary or Provisional - Indicate if the applicant is still considered a temporary or provisional employee.
15. Elected Official - indicate whether the applicant is an elected official. On or after July 1, 2007, a newly elected official is ineligible for enrollment inthe PERS. (See Fact Sheet #80.)
16. Appointed Official - Indicate whether the applicant is appointed. State appointees are individuals appointed by the Governor, including those requiring the advice and consent of the Senate. Local appointees are individuals appointed by the Governor, including those requiring the advice and consent of the Senate or individuals appointed in a similar manner by the governing body of a local entity (county, municipality, etc.). On or after 7/1/07, a newly appointed official who does not have an existing PERS account is ineligible for enrollment in the PERS. (See Fact Sheet #80.)
17. Professional Services Contract - Indicate whether the individual is working under a professional services contract or providing professional services without benefit of a contract.
18. Base Salary- Enter the annual base salary for the year, that is, the annual salary paid to the employee on the date the Enrollment Application is certified by the employer. Base salary is the contractual salary of the employee. Base salary should not include bonuses, overtime pay, stipends orlongevity pay, or sick or vacation time paid in lump sum. Hourly or per diem rates should not be entered.
19. 10-12 Month Position -Please indicate whether the position is a 10-month or 12-month position.20. Hours Worked - Indicate whether the applicant works the requisite number of hours. To be eligible for TPAF or PERS membership, the hours worked
by an employee enrolled after May 21, 2010, must be fixed at 35 hours or more per week for State employees to be enrolled in the PERS; 32 hoursor more per week for Local Government employees to be enrolled in the PERS; or 32 hours or more per week for State or Local Educationemployees to be enrolled in the TPAF.
EMPLOYER CERTIFICATION 21. Name of Employer Representative Completing Application - Print the name of the human resources representative or other employer
representative who completes this Enrollment Application for the applicant.22. Phone Number - Enter employer telephone number for the person who completed this application (be sure to include the area code and
extension).23. Certifying Officer -The Certifying Officer must sign their name, print their name, and date this application. Unsigned applications will be
returned.24. Certifying Officer's Supervisor -The Certifying Officer's Supervisor must sign their name, print their name, and date this application.
Unsigned applications will be returned.Please Note: The newly enrolled member's estate will automatically be designated as the beneficiary for any death benefit payable. New membersshould register with the Member Benefits Online System (MBOS) to update their beneficiary information using the online Designation of Beneficiaryapplication.
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FL-0781-0511 State of New Jersey Department of the Treasury
Division of Pensions and Benefits
PO BOX295 Trenton, NJ 08625-0295
NEW JERSEY DEFINED CONTRIBUTION RETIREMENT PROGRAM ENROLLMENT APPLICATION
FOR ELECTED OR APPOINTED OFFICIALS (Please follow the instructions on page 2 of this form)
I DO NOT WRITE IN THIS BOX LOCATION NO. IDENTIFICATION NO.
APPLICANT INFORMATION: (Please Print or Type)
1. Name:First (no nicknames) Middle Last
2. Social Security Number: ___________________ _ 3. Date of Birth: / / Month � Year
4. Gender: D Male D Female
6. Address:Street
5. Daytime Phone: (.__ __ _, ___ _
City State Zip Code
7. Is the applicant receiving a benefit from a New Jersey State-administered or local New Jersey retirement system at this time?
D Yes D No (If "Yes", please provide retirement system name)
EMPLOYER INFORMATION (Please Print or Type):
8. Employer Name: --------------------------------------
9. County: ________________
10. PERS or TPAF Location #: _________ _ Payroll#: _______ State Loe Only
11. Date Elected or Appointed Service commenced: ___ / / __ _ Month Day Year
12. Current Annual Base Salary$ ________
13. Title/Position of Applicant: -----------------------------------
14. Is the applicant an Elected Official? D Yes D No
15. Is the applicant appointed by Special Resolution or Ordinance or by the Governor of New Jersey, as described in
N.J.S.A. 43:15C-2? □ Yes □ No
EMPLOYER CERTIFICATION
16. Phone Number: ( ___ ) ___ -______ Ext.: ____ _
17.1 certify that this employee and position meets the eligibility criteria for the retirement system as provided by law. I acknowledge that I am subject to penalty for falsifying or permitting to be falsified any record, application, form, or report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15. (Two Signatures Required)
Signature of Certifying Officer Title Date
Signature of Certifying Officer's SupeNisor Title Date
NOTE: SEE INSTRUCTIONS FOR BENEFICIARY DESIGNATION INFORMATION
77
FL-0781-0511 ENROLLMENT APPLICATION INSTRUCTIONS
FOR ELECTED OR APPOINTED OFFICIALS (This application to be completed by the enrolling employer)
APPLICANT INFORMATION
1. Name - Enter applicant's full name (first, middle initial, and last name).
2. Social Security Number - Enter applicant's Social Security number.
3. Date of Birth - Enter applicant's date of birth. Proof of age is required at the time of retirement - if available, attach aphotocopy of the applicant's proof of age to this application. Do not delay submitting the Enrollment Application ifproof of age is not available. (Acceptable proof of age documents include: birth certificate; passport; naturalization orimmigration papers; or certain other records, including baptismal records, military records, census records, school orbusiness records, age recorded on marriage licenses, and insurance or children's birth records.)
4. Gender - Indicate applicant's gender.
5. Daytime Phone Number- Enter applicant's daytime phone number and extension (be sure to include the area code).
6. Address - Enter applicant's current mailing address.
7. Is the applicant receiving retirement benefits - Indicate if the applicant is receiving a benefit from a New JerseyState-administered retirement system or local New Jersey retirement system, and give the system's name.
EMPLOYER INFORMATION
8. Employer Name - Enter the full employer name.
9. County - Enter county in which the employer is located.
10. Location and Payroll Numbers - Enter the appropriate location or payroll number, as applicable.
11. Date Elected or Appointed Service Commenced - Enter the date on which applicant began service in the electedor appointed position.
12. Current Annual Base Salary- Enter the annual base salary for the year, that is, the annual salary paid to the elected or appointed official on the date the Enrollment Application is certified by the employer. Base salary is the contractual salary of the official. Base salary should not include bonuses, overtime pay, stipends or longevity pay, or sick orvacation time paid in lump sum. Hourly or per diem rates should not be entered.
13. Title/Position of Applicant - Enter official title/position of applicant.
14. Elected Official - Indicate if the applicant is an Elected Official of the State of New Jersey or of a political subdivisionthereof.
15. Appointed Position - Indicate if the applicant is appointed by Special Resolution or Ordinance or by the Governor ofNew Jersey, as described in N.J.S.A. 43:15C-2.
EMPLOYER CERTIFICATION
16. Phone Number - Enter employer telephone number for the person who completed this application (be sure to includethe area code and extension).
17. Signature - The Certifying Officer and the Certifying Officer's Supervisor must sign and date this application.Unsigned applications will be returned.
BENEFICIARY DESIGNATION
The newly enrolled member's estate will automatically be designated as the beneficiary for any death benefit payable. New members who wish to name a specific beneficiary should submit a Designation of Beneficiary using the Member Benefits Online System (MBOS) - go to www.state.nj.us/treasury/pensions/mbosregister.shtml for details; or submit a Designation of Beneficiary form to the Division of Pensions and Benefits.
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University Hospital is an Affirmative Action I Equal Opportunity Employer.
Employment is offered without regard to race, color, ethnicity, religion, gender, national origin,
sexual orientation, physical or mental ability, age or any other categorization protected by law.
150 Bergen StreetNewark, NJ 07103
NEW EMPLOYEE ORIENTATION BENEFITS BOOK
� � UNIVERSITY HOSPITAL * � Newark, New Jersey