Managed Health Insurance & Health Care Plans

Managed Care Plans

Carriers that offer managed care plans typically provide comprehensive benefits by contracting with a network of physicians, hospitals and other health care professionals. There are several types of managed care plans, as described below.

HMO Plans

Health Maintenance Organization (HMO) plans are network-based forms of managed care. An HMO consists of a network of physicians, hospitals and other health care professionals which provides members with medical treatment and care. You choose a Primary Care Provider or Primary Care Physician (PCP) from those participating in the HMO network. That PCP coordinates your health care, referring you to specialists in the network, when necessary. Services not provided by or referred by a PCP are not covered, except for emergency medical care. HMO plans that do not require referrals may be offered. These no referral plans are often marketed as "direct access" or "open access" plans.

You are responsible for a copayment for specified services, for example, a $30 copayment for a physician visit or a $300 per day copayment for hospitalization. There are generally no calendar year deductibles. There is generally no coinsurance requirement except that carriers provide prescription drug benefits subject to 50 percent coinsurance.

HMO plans may feature a "split copayment" for physician services, where the copayment for use of a specialist may be higher than the copayment for a PCP visit.

In addition to offering an HMO plan using a copayment for specified services, an HMO carrier may offer a plan that applies deductible and coinsurance provisions to certain services. The rate comparison sheet indicates which carriers offer deductible and coinsurance options with HMO plans.

Some carriers are offering the B&E plan as an HMO. Those carriers are identified on the rate comparison sheet. Please note: An HMO is not required to offer coverage to persons who do not reside in its approved service area. If a person covered under an HMO is outside the service area on vacation or attending school, or otherwise temporarily out of the service area, the only coverage available to the person while outside the service area is for emergency or urgent care.

PPO Plans

Preferred Provider Organization (PPO) plans are network-based forms of managed care which allow you to seek medical care and treatment either from within a network of physicians, hospitals and other health care professionals or from physicians, hospitals and other health care professionals that are outside of the PPO network. If you seek medical care and treatment from network providers, you generally will be eligible for a richer level of benefits or less 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 more cost sharing. In other words, you will probably have to pay more of the cost of services received outside of the network than you would if you obtained services within the network.

The network benefits under the plan may be subject to copayments, just as is the case with HMO coverage and/or there may be deductible and coinsurance requirements. Non-network benefits will always be subject to a deductible and coinsurance.

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

Currently, only Oxford Health Insurance is offering PPO plans. You can visit the following website for details regarding the PPO plans that are offered. www.oxhp.com/secure/brokers/nj/individual_pre_pin.html

POS Plans

Point-of-Service (POS) plans are network-based forms of managed care which allow you to seek medical care and treatment either from within a network of physicians, hospitals and other health care professionals or from physicians, hospitals and other health care professionals that are outside of the PPO network. If you seek medical care and treatment from network providers other than your designated primary care physician (PCP) you will need to get a referral from your PCP. When you use network services you generally will be eligible for a richer level of benefits or less cost sharing than if you seek care outside the network. 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 more cost sharing. In other words, you will probably have to pay more of the cost of services received outside of the network than you would if you obtained services within the network.

Sometimes a POS plan may be available that does not require referrals to visit a network provider other than your PCP. These plans are often marketed as "open access" or "direct access" plans.

The network benefits under the plan may be subject to copayments, just as is the case with HMO coverage and/or there may be deductible and coinsurance requirements. Non-network benefits will always be subject to a deductible and coinsurance.

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

Currently, only Horizon is offering POS plans. You can visit the following website for details regarding the PPO plans that are offered. http://www.horizon-bcbsnj.com/members/presale/coverage/health/individuals.html

EPO Plans

Exclusive Provider Organization (EPO) Plans are available only in connection with the B&E product. EPO plans are similar to HMO plans in that there is a network of physicians, hospitals and other health care professionals which provides members with medical treatment and care. While a member is encouraged to select a PCP, it is not required. Members can seek treatment directly from any physician in the network.

The B&E plans sold as EPO plans include copayment, deductible for wellness benefits only, and coinsurance provisions.

If a person covered under an EPO plan is outside the service area on vacation or attending school, or otherwise temporarily out of the service area, the only coverage available to the person while outside the service area is for emergency care.

Currently, Aetna, Horizon and Oxford offer the B&E plan as an EPO.