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The Coverage
NJ Individual Health Coverage Program Buyer's Guide

The Individual Health Coverage Program Board has established standard plans for the individual market.  The plans are standard in that they all cover the same services, supplies, and medical conditions under the terms.  The Individual Health Coverage Program Board has given carriers flexibility in deciding how to structure the managed care components of the plans (discussed earlier), and in how the cost-sharing is structured, but within certain limits. 

 
Covered Services

All standard plans (whether issued as an HMO or EPO plan or as an POS plan) provide comprehensive medical coverage which includes the following:

1. office visits
2. hospital care, including emergency services
3. prenatal, maternity and newborn care
4. immunizations and well-child care
5. screenings, including mammograms, pap smears and prostate examinations
6. x-ray and laboratory services
7. mental illness and substance abuse services
8. various therapy services
9. prescription drugs
10. pediatric dental and vision services


The above lists identifies some of the services and supplies that are covered under the standard plans. If you are interested in finding out if the standard plans cover a certain service or supply you can read the text of the standard plans on our website. Go to IHC Program Forms - you can select either of the first two listed documents.

 
Cost-sharing

Cost-sharing refers to how the costs of services covered under the plan are allocated between the carrier and the covered person.  It does not refer to the costs of services NOT covered under the plan.  Cost-sharing is usually divided into three categories:  deductibles, coinsurance and copayments.  Standard plans can have one, two or all three types of cost-sharing.  However, coinsurance and copayments cannot apply to the same services at the same time. 
 
All standard plans have a maximum amount of cost-sharing required for the covered person – referred to as a maximum out-of-pocket (MOOP) – and when the MOOP is reached, the carrier pays all of the remaining costs for covered services for the rest of the plan year.  Cost-sharing requirements begin again at the start of each calendar year.

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.  For the standard individual plans, the deductible may not exceed $2,500 per person.  The family deductible is usually double the per person deductible. 

Coinsurance

“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.  Most of the time, coinsurance applies after the deductible is satisfied.  So, for example, a plan might have a $1000 deductible, then 70% coinsurance, which means that the covered person must pay $1,000 in covered charges before the carrier pays anything, then the carrier pays 70% of the covered charges and the covered person pays 30% of the covered charges (until the MOOP is met).

The standard plans may have coinsurance requirements that vary within a range of 50% to 100%.  If a carrier is offering an EPO plan with multi-tiers in-network, different coinsurance could apply to each tier.

Copayments

Copayments are fixed dollar amounts that you pay per visit or service.  So, for instance, the copayment for a visit to you PCP may be $30, the copayment for filling a 30-day supply of a prescription using generic drugs might be $10, and if you are admitted to a hospital, you might pay $300 per day (for up to 5 days).  Often, copayments are used in a plan instead of deductibles and coinsurance. 

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.  All charges the covered person pays towards the deductible, coinsurance and copayments help to satisfy the MOOP.  In 2014, the per person MOOP cannot exceed $6,350.  The family MOOP is two times the per person MOOP.

See the rate comparison sheet for a summary of the cost-sharing for each individual plan.

 
Different Levels of Coverage

Individual plans have been designed to meet specific “actuarial values”.  The idea is that on average the plans are supposed to cover a designated percentage of the costs of the care received by the people covered under that plan.

  The lowest level of coverage has an actuarial value between 58% and 62%
  The next higher level of coverage has an actuarial value between 68% and 72%
  The next higher level of coverage has an actuarial value between 78% and 82%
  The highest level of coverage has an actuarial value between 88% and 92%

The percentages are NOT necessarily the coinsurance percentages in the plans, and cannot be used to determine any details about cost-sharing in a plan.  However, plans with lower actuarial value generally have more cost-sharing than plans with higher actuarial value.  In addition, plans with lower actuarial value generally have lower monthly premiums than plans with higher actuarial value.

Actuarial values can help you compare plans. If you are considering two plans with approximately the same actuarial value it means the plans are expected to cover, on average, the same percentage of the cost of care.

Carriers may also offer a “catastrophic” plan.  Catastrophic plans cover the same services as plans with a specific actuarial value. So what makes the plan catastrophic? The deductible. Catastrophic plans have a deductible that is equal to the MOOP. In 2014, this means the deductible is $6,350 per person. Catastrophic plans cover preventive services, and three primary care visits per year without being subject to a deductible.

Catastrophic plans can only be purchased by the following people:

1.
People under 30 years old
2.
People age 30 or older for whom the different levels of coverage are unaffordable and have received an "exemption," allowing them to forego health insurance

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.

However, changes can be made only during the Annual Open Enrollment Period or a Special 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 about maximum out of pocket.  What is it?
  Maximum out of pocket refers to the limit on how much you will have to pay 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 use in this Buyer’s Guide.  After the maximum out of pocket has been reached, all covered charges you incur during the rest of that calendar year will be paid at 100% of allowed charges by the carrier. 
   
Question 6:  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 7: 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 will reduce benefits by 50%.  Examples of services for which pre-approval is required include:  home health care, hospice care, and durable medical equipment.  Carriers may require pre-approval for certain prescription drugs and for certain therapies. 

   
Question 8: 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 9: 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.
   
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