All standard plans (A/50, B, C, D whether issued as indemnity, PPO, or POS and the HMO plan) provide comprehensive medical coverage which includes the following:

Indemnity, including PPO and POS Plans 

Plans A/50, B, C, and D whether issued as indemnity or as PPO or POS also 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. The deductible and coinsurance do not apply to preventive care services.  However, to the extent a PPO or POS plan applies a copayment to network physician services, the copayment is required to be paid for network preventive care services.  There is no dollar limit associated with the amount of preventive services a covered person seeks from his or her network physician.

Carriers may offer the standard plans using a PPO or POS feature (that is, with both network and out-of-network benefits), but are not required to do so. The PPO or POS plans offered may require referrals to specialists in order for services to be covered at the network level, or the plans may be open access or direct access plans, in which case, the PPO or POS plan does not require referrals to specialists in the network to receive network benefits. You will need to contact a carrier directly to get more information about its PPO and/or POS plan designs.

Standard Plan Coinsurance

Plans A/50, B, C, and D and any PPO or POS developed using these plans provide benefits for similar services, but they have varying coinsurance requirements and maximum out of pocket amounts.  “Coinsurance” is a term used to express the promise by the carrier to share, on a percentage basis, payment for allowed charges for covered health care services with the covered person.  The standard plans A/50 through D have specified coinsurance requirements, but the actual coinsurance amount may vary depending on whether the plan is offered with or without a network feature.  The coinsurance paid by the covered person towards allowed charges under each plan when offered without a network (that is, a plain indemnity plan) is as follows: 

However, when the standard plans are offered with a network feature (that is, as PPO or POS products), then the network and non-network coinsurance amounts can vary within a range of 50% to 100%, and the carrier may have a copayment requirement instead of a coinsurance requirement for network covered services. Varying cost-sharing designs are acceptable for PPO and POS products, so long as the plan-designated coinsurance applies to either the network or non-network benefits. So, a Plan C PPO could be a plan that requires the covered person to pay 30% for network services and 50% for non-network services, or it could be a plan that requires the covered person to pay 30% for non-network services, and a $30 copayment for network services.

Standard Plan Deductibles

Deductibles are the amount of allowed charges for which the covered person is responsible before the carrier agrees to pay anything towards covered charges. 

Standard Plan Maximum Out-of-Pocket (MOOP)

The MOOP is the maximum amount of allowed charges for covered services that a covered person/family is obligated to pay before the carrier agrees to pay for all of the allowed charges for covered health care services.  For the standard health benefits plans, allowed charges the covered person pays towards the deductible, coinsurance and copayments help to satisfy the MOOP.

The MOOP for plans A/50 through D is always stated as the sum of the selected deductible plus a specified dollar amount, as follows:

For example, if you buy a Plan C with a $1,000 deductible, after meeting the $1,000 deductible, the carrier will pay 70% and you will pay 30% of covered charges.  The maximum out of pocket will be $1,000 (your deductible) plus another $2,500 due to your 30% coinsurance requirement, for a total of $3,500.  Please note that while most covered charges are paid at 100% after the maximum out of pocket has been reached, prescription drug charges continue to be paid at the plan coinsurance even after the maximum out of pocket has been reached.  Therefore, in this example you would continue to be responsible for 30% of your prescription drug bills.

PPO or POS plans may have a combined MOOP for network and non-network services, or may have separate MOOPs for network and non-network services.  The MOOP for network services cannot exceed $5,000 and the MOOP for non-network services cannot exceed three times the MOOP for network services.  Please consult the carrier’s benefit descriptions for information on how the MOOP provisions operate.

Carriers are not required to sell PPO or POS plans. Carriers that do offer PPO or POS plans are identified on the rate comparison sheets. Contact the carriers directly for information concerning their PPO or POS plan designs.

See the Individual Plans Summary chart for a more detailed outline of the standard individual plans, coinsurance amounts, deductibles and copayments.  See the rate comparison sheet for standard plan premiums.

HMO Plans

HMO Plans cover many of the same services as Plans A/50 through D. Unlike Plans A/50 through D, however, there are generally no deductibles with an HMO Plan. You pay a copayment rather than coinsurance when services are rendered, but you must use the pre-approved network of physicians. All HMO plans must offer the HMO Plan with the $30 copayment option, and each HMO determines which other copayment amounts -- $15, $40 and/or $50 -- to offer.  The rate comparison sheet specifies the options each carrier has selected.  Other copayments apply to inpatient hospitalizations, emergency room visits and maternity care, and carriers may apply a higher copayment for use of specialist services. Rates vary based on the copayment selected. Prescription drugs are covered subject to 50% coinsurance.

In addition to offering an HMO with a copayment feature, an HMO may offer HMO coverage 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 HMO Plans subject to deductible and coinsurance are identified on the rate comparison sheet. The deductibles may be as follows:

The coinsurance offered with an HMO Plan may range from 20% to 50%.  When a carrier offers an HMO Plan with deductibles and coinsurance, then a MOOP applies also.  The MOOP will be satisfied by the charges the covered person pays towards the deductible and the coinsurance, and the carrier may specify that copayments will apply to the MOOP as well.  The MOOP for the HMO Plan cannot exceed $5,000.  As with the other standard individual plans, the 50% coinsurance requirement for the prescription drug benefit remains in place even after the MOOP is satisfied for an HMO Plan.    

As discussed above, the HMO plan may be offered such that no referrals are required.  Such a design is often referred to as “direct access” or “open access.”

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 covers only:

Some carriers offer B&E Plans as indemnity policies allowing you to select which providers to go to, while other carriers offer the B&E Plan with an HMO or EPO delivery system, meaning you need to select doctors and hospitals within the carrier’s network in order to have the covered services paid for by the B&E Plan. 

In addition to offering the B&E Plan, carriers are permitted to offer riders that enhance the benefits of the B&E Plan, and several carriers do:

The B&E rate comparison sheet allows consumers to compare rates by age, gender and geographic territories for B&E Plans, with and without riders, but consumers must contact the carriers for more information about the delivery system associated with a carrier’s B&E Plan, and the enhanced benefits that a carrier’s rider may provide.

B&E has limited benefits

Frequently Asked Questions About Benefits

Question 1: Does the list of covered services ever change?

The New Jersey Individual Health Coverage (IHC) Program Board reviews the standard individual plans regularly to ensure that the plans meet the changing requirements of state and federal law and the needs of New Jersey residents. Your carrier will notify you of any changes that may affect your plan.

Question 2: What if I receive my contract and I am not satisfied with the level of benefits provided?

You have a 30-day period during which you may examine the policy or contract and the benefits included. If you are dissatisfied, you may return your policy or contract for a full premium refund, less any claims paid or services provided.

Question 3: Is there anything I must do if I want to switch from group coverage to individual coverage or from one individual plan to another?

You cannot be covered by more than one health plan at a time if one of the plans is an individual plan. If you are switching from group coverage to individual coverage, or if you are changing from one individual plan to another, you must notify the existing carrier within 30 days of the date your new plan takes effect to request that your existing coverage be canceled. To avoid being subject to a new pre-existing conditions exclusion, you should make sure there is no more than a 31-day gap between the date the existing coverage ends and the date the new coverage begins. As an exception to this rule, a "federally defined eligible individual" may have a lapse in coverage of up to 63 days.

However, there are some restrictions regarding switching from one individual plan to another, as earlier discussed.  For some plan changes, you will be required to wait until the November Open Enrollment Period. 

Question 4: If I switch individual plans or change to a new carrier, and there is no lapse in coverage, will I have to satisfy a new deductible?

No. The standard individual plans include a deductible credit provision which applies to charges incurred during the same calendar year. However, you must switch with no lapse in coverage from one plan to another -- or from one carrier to another -- to qualify for the credit. That is, you must have continuous coverage. If there is a lapse in coverage of a period as brief as one day, there will not be any deductible credit. You must provide proof to the new carrier that you incurred charges toward the deductible under the prior plan. 

Question 5:  I am confused with maximum out of pocket.  What is it?

Maximum out of pocket refers to the limit on how much you will have to pay for allowed charges, in the form of deductible, coinsurance and copayment requirements during any calendar year.  You may hear it referred to as the “MOOP,” which is also the term we sometimes used in this Buyer's Guide. After the maximum out of pocket has been reached, all covered charges, except those for prescription drugs, during the rest of that calendar year will be paid at 100% of allowed charges by the carrier.  Coinsurance for prescription drugs does not count toward the maximum out of pocket and must continue to be paid even after the maximum out of pocket has been reached.

To calculate the maximum out of pocket for an indemnity plan, you ADD the selected deductible to the specific amount shown in the indemnity plan section of this Buyer’s Guide.  Let’s say you select a Plan C with a $1,000 deductible.  You will add the $1,000 deductible to the amount shown for Plan C which is $2,500.  The maximum out of pocket is $1,000 + $2,500 which is $3,500.  The maximum out of pocket for network plans cannot exceed $5,000 with the maximum out of pocket for non-network services limited to 3X the network level.

Question 6: I have satisfied my deductible and reached the maximum out of pocket under my plan, but I want to switch coverage to another carrier or switch to another plan with the same carrier. Will I receive credit under my new plan for both the deductible and coinsurance I already met?

As explained above, you will be entitled to deductible credit, provided there is no lapse in coverage between the date the first plan ends and the new plan begins. But while there is deductible credit, please note that there is no coinsurance credit.  So, if you have already applied coinsurance charges toward satisfying the maximum out of pocket, or entirely satisfied the maximum out of pocket, you should carefully consider whether it makes sense to switch immediately, or wait until January 1 when a new annual deductible and coinsurance requirement begins anew.

Question 7: What are my rights if, for example, my carrier does not pay a benefit for something I think is covered?

Ask your carrier about its grievance and appeal process. Provide all information you, your doctor or other provider have to support your position. Sometimes carriers reduce or deny benefits initially because you or your doctor did not submit all the necessary information.  Carriers may deny benefits for different reasons, including:  (a) because the health care service or supply is not covered under the contract; (b) because the service or supply is not rendered by an appropriate health care provider, and (c) because the carrier has determined the specific covered service or supply is not “medically necessary.”  If a denial is based on a determination that the covered service or supply is or was not medically necessary, you have the right to pursue an independent appeal through the Independent Health Care Appeals Program if you are not satisfied with the outcome of the carrier’s internal appeal process.  Additionally, you may contact the Department of Banking and Insurance.  For concerns about quality of care, choice of providers or access to network providers, or medical necessity denials, call 609-777-9470.  For concerns with claims denials, or enrollment or termination matters, call 609-292-7272.

Question 8: What does Pre-Approval mean?

Many services and supplies require carrier pre-approval. Pre-approval gives the carrier the opportunity to evaluate the medical need before you incur charges and to advise you, up front, what will be covered. If you do not secure pre-approval when required, the carrier has no obligation to provide benefits.  Examples of services for which pre-approval is required include:  home health care, hospice care, durable medical equipment, the exchange of unused inpatient days for additional outpatient visits for treatment of non-biologically based mental illness.  Carriers may require pre-approval for certain prescription drugs and for certain therapies. 

Question 9: Are there any differences between the standard plans offered by the carriers?

There are some options available to carriers when they offer the standard plans.  For one thing, carriers are not required to offer all of the standard plans; they are only required to offer three of the standard plans.  So, the plans offered by one carrier may not be the same as the plans offered by another carrier.   Plans A/50 – D, as offered, must feature a $2,500 deductible.  Carriers may choose to make $1,000, $5,000 or $10,000 deductibles available.  HMO carriers must make the $30 copay plan available, but may make other copays available and may offer the HMO with deductible and coinsurance requirements.  Additionally, an HMO has the option to apply a higher copay to specialist services as compared to the copay required for visits to a PCP.  As discussed above, there are some options regarding the list of services for which pre-approval is required.

For managed care plans -- plans offered with a PPO, POS, HMO or EPO delivery system (with respect to B&E Plans) -- a significant difference among carriers is the network of physicians and other health care providers.  When considering a plan you may find it helpful to contact your doctor’s office to find out what plans the doctor belongs to.  For HMO and EPO plans, you will generally be limited to seeking care from providers in the network, so if your doctor does not belong to the plan you will have to select another doctor.

Question 10: Do I have to wait to change carriers if I still have a claim outstanding?

No. Your previous carrier will still process claims incurred while your plan was in effect and reimburse you, as appropriate.

Question 11: I’m due to deliver my baby next month. How long can I stay in the hospital?

Congratulations! By law in New Jersey, carriers must cover a minimum of 48 hours following a routine delivery and 96 hours following a cesarean section. Your doctor may determine that a longer stay is medically necessary, which would entitle you to additional time in the hospital.

Question 12:  Which plan should I buy to get coverage for infertility?

None of the individual plans will cover treatment for infertility. 

Question 13:  Why are there so many differences between the plans each company is selling?  Aren’t all of the companies required to sell the same things?

Carriers are no longer required to offer all of the standard plans and all of the deductible options associated with the standard plans.  All carriers, other than unaffiliated HMOs, must offer Plan A/50.  Such Plan A/50 may be offered as an indemnity, PPO or POS product.  So, while the plan will be a Plan A/50, how it is delivered can be different.  In addition to Plan A/50, at least two additional plans must be offered by carriers (other than unaffiliated HMOs).  The carriers may also decide whether to offer each additional plan as an indemnity, PPO or POS product.  And, if a company has an affiliated HMO, one of the three required standard plan offerings may be an HMO plan, rather than Plan B, C or D.