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:

1. office visits
2. hospital care
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

Indemnity 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.  

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.  The coinsurance paid by the covered person under each plan is as follows:  

1. Plan A/50         50%
2. Plan B              40%
3. Plan C              30%
4. Plan D              20%

When offered as PPO or POS the coinsurance applies to the network and/or non-network benefits.  So, a Plan C PPO could be a plan that requires the covered person to pay 30% for network services, or it could be a plan that requires the covered person to pay 30% for non-network services.

Carriers that are offering Plans A/50, B, C and/or D must offer a $2,500 deductible. Carriers may offer $1,000, $5,000 and/or $10,000 deductible levels.  Please refer to the rate comparison sheet for information on which plans the carriers are offering and the deductible levels available with each.

The maximum out of pocket for each plan offered as an indemnity plan is the sum of the selected deductible plus the following amount, according to plan:

1. Plan A/50                     $5,000
2. Plan B                          $3,000
3. Plan C                          $2,500
4. Plan D                          $2,000

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 which is 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.

For plans offered as PPO or POS plans the maximum out-of-pocket for network services cannot exceed $5,000 and the maximum out of pocket for non-network services cannot exceed three times the maximum for network services.  The plans may have a combined maximum out of pocket for both network and non-network services or may have separate out of pockets for network and non-network services.  Please consult the carrier’s benefit descriptions for information on how the maximum out of pocket provisions operate.

Note: Under Plan B, in addition to the selected calendar year deductible, a $200 per day hospital confinement deductible applies for each of the first five days of hospitalization, to a maximum of $2,000 per person in each year.

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 $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 subject to deductible and coinsurance are identified on the rate comparison sheet.

PPO Plans

PPO and POS plans are consistent with the standard indemnity plans described above except that carriers may structure the PPO and POS plans using a variety of deductible, copayment and coinsurance features. Some of these features depend on whether or not you obtain medical care and treatment from network physicians, hospitals and other health care professionals inside of the network. As mentioned earlier in this Buyer's Guide, if you obtain medical care and treatment from network providers, you generally will be eligible for a richer level of benefits or lower cost sharing. If you seek care and treatment from providers that are outside of the network, you will be eligible for a lower level of benefits or higher cost sharing.

The 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. Non-network benefits will always be subject to a deductible and coinsurance.

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.

As noted earlier in this Buyer’s Guide, the POS plan may be purchased as a direct access or open access plan, meaning referrals are not required.

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 90 days per year for hospitalization, $600 per year for wellness services, $700 per year for office visits for illness or injury, $500 per year for out of hospital testing, and limited benefits for mental health services, alcohol and substance abuse treatment and physical therapy.  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 as HMO or EPO meaning you need 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 have offer riders with enhanced benefits.

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.  Please note that since the rates may vary based on age, gender and geographic location, we cannot provide comprehensive rate information.  The rate comparison sheets include information for sample ages and locations.  Contact the carriers for detailed rate information.  

Links to the carrier website for those carriers offering the B&E plan with an optional benefit rider are provided below. 

AmeriHealth: www.amerihealth.com/health_plans/index.html
Horizon: www.horizon-bcbsnj.com/members/presale/coverage/health/individuals.html
Oxford: www.oxhp.com/secure/brokers/nj/individual_pre_pin.htm

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 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 discussed above.  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 deductible, coinsurance and copayment during any calendar year.  You may hear it referred to as the “MOOP.”  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%.  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 deductible and coinsurance 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 deny benefits initially because you or your doctor did not submit all the necessary information.  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, as 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 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.  Carriers are only required to offer at least 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.  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, a significant difference among carriers is the network of physicians.  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 HMO only carriers must offer Plan A/50.  Such Plan A/50 may be offered as indemnity, PPO or POS.  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.  Those offerings may be indemnity, PPO or POS.  And, if a company has an affiliated HMO, one of the three required offerings may be an HMO plan.