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IHC Benefits Comparison
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Standard Plans


All standard plans
(A/50, B, C, D and the HMO plan) provide comprehensive medical coverage which includes the following:

1. office visits*
2. hospital care (unlimited days)
3. prenatal and maternity care
4. immunizations and well-child care*
5. screenings* (including mammograms, pap smears and prostate examinations)
6. x-ray and laboratory services
7. biologically based mental illness services
8. certain non-biologically based mental illness and substance abuse services
9. prescription drugs

The standard plans vary primarily based on their respective cost sharing requirements between the carrier and covered person.  The cost-sharing requirements are outlined in the chart below.

*Routine physicals/preventive carePlans A/50, B, C, and D cover the cost of routine physicals and other preventive care – up to $500 per year per covered person and up to $750 during the first year of a newborn’s life, without consideration of the deductible and coinsurance requirement.  The traditional HMO plan covers routine physicals and preventive care in the same manner as any other primary care office visits and services.  When the HMO Plan is offered with the deductible option, the deductible does not apply to preventive services.

PPO options for Plans A/50 B, C and D
The standard indemnity plans A/50, B, C and D may be offered as PPO plans (with in-network and out-of-network benefits).  The services and supplies covered are the same, but carriers may structure the PPO plans using a variety of deductible, copayment and coinsurance features.  If a covered person obtains medical care and treatment from network providers, the covered person generally will be eligible for a richer level of benefits (that is, lower cost sharing).  If the covered person seeks care and treatment from providers that are outside of the network, the covered person will be eligible for a lower level of benefits (higher cost sharing).  The in-network benefits under the plan may be subject to copayments, just as is the case with HMO coverage, or may be subject to deductible and coinsurance as with an indemnity plan. The out-of-network benefits will always be subject to a deductible and coinsurance.  Carriers are not required to sell Plans A/50, B, C, or D as PPO plans. Carriers that offer one or more of the standard health benefits plans as PPO plans are identified on the rate comparison sheets.  Contact the carriers directly for information concerning their PPO plan designs.

HMO Plan options
The HMO Plan is offered as a traditional HMO plan design (meaning services generally must be accessed through a specified network of health care providers), with most services subject to copayment requirements.  In addition an HMO may offer the HMO Plan with a design that applies deductible and coinsurance to many services and supplies.  The deductible and coinsurance are applied to the negotiated charge between the HMO and your provider, so you will not receive any balance billing above your deductible and coinsurance payments.  Carriers offering the HMO Plan subject to deductible and coinsurance are identified on the rate comparison sheet.

 

Brief Overview of the Standard Individual Health Coverage Program Plans

Cost Sharing requirement per benefit year
(12-month period)

Plan A/50

Plan B

Plan C

Plan D

HMO Plan (1)

HMO Plan (2)

Deductible options (amount of covered charges you pay before the carrier pays benefits) the carrier is required to offer 1,2

$1,000
$2,500

$1,000
$2,500

$1,000
$2,500

$1,000
$2,500

N/A

$1,000
$2,500

Coinsurance (amount of covered charges you pay after the deductible is satisfied)

50%

40%

30%

20%

50% for prescription drugs only

10%, 20%, 30%, 40%, 50% (as offered by the carrier); does not apply when copayment applies

Copayment — applies per service, except as specified otherwise below

N/A

N/A

N/A

N/A

$15 required option;
carriers may offer the following options:  $30, $40, $50

$15 ($30, $40 or $50) applies to preventive visits, services and supplies

Copayment for hospitalization

N/A

$200/day
($1,000/admit
$2,000/yr)

N/A

N/A

$150/day ($750/admit $1500/yr) 5

N/A

Copayment for ER visit (waived if admitted within 24 hours)

$100

$100

$100

$100

$100

$100

Copayment for maternity
(initial prenatal/other prenatal visits)

N/A

N/A

N/A

N/A

$25/$0 6

$25/$0 6

Maximum coinsurance amount (after which the carrier pays the covered charges) 3,4

$5,000

$3,000

$2,500

$2,000

N/A

$5,000

(1)
HMO Plan offered with copayments only (traditional)
(2)
HMO Plan offered with copayments, deductibles and/or coinsurance
1
Carriers may also offer a $5,000 and/or $10,000 deductible
2
Carriers will cover up to $500/person ($750/infant) for routine physical charges even if the deductible is not yet satisfied
3
There is always a coinsurance requirement for prescription drug costs
4
Copayments (if any) do not generally count towards satisfying the coinsurance maximum, but for the HMO Plan offered with the deductible and coinsurance option, most copayments help to satisfy the coinsurance maximum
5
Hospital admission copayment will be $300, $400 or $500/day if a covered person purchases a $30, $40 or $50 copayment option HMO plan, respectively
6
If a covered person purchased a $30, $40 or $50 copayment option for an HMO Plan, the copayment for the initial prenatal visit can be the same as the copayment option that applies to other preventive visits, services and supplies
 

Basic and Essential Health Care Plan (NOT a Standard Plan)


In addition to offering the standard plans described above, carriers must offer a Basic and Essential Health Care Plan (B&E Plan) which is a limited benefit plan.  B&E Plans do not provide comprehensive benefits like the standard plans described above.  The B&E plan provides the following coverage:

1.

90 days per year for hospitalization

2. $600 per year for wellness services
3. $700 per year for office visits for illness or injury
4. $500 per year for out of hospital testing
5. limited benefits for mental health services, alcohol and substance abuse treatment and physical therapy.

Carriers may offer B&E plans as indemnity policies (allowing covered persons to select which providers to go to), or with an HMO or EPO design (requiring covered persons to select doctors and hospitals within the carrier’s network).  Carriers are permitted to offer enhanced benefits to the B&E plan, and several carriers do.  The rate comparison sheet provides information on the type of B&E plan each carrier offers and also indicates which carriers offer the B&E plan with riders.  Rates for B&E plans may vary based on age, gender and geographic location.


 
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New Jersey Department of Banking and Insurance