Frequently Asked Questions About New Jersey Health Insurance Delivery Systems

Frequently Asked Questions About Delivery Systems

Question 1: What plan should I choose if I want to keep my present doctors?

Check with your doctors to find out if they participate in any HMO, PPO, POS or EPO plans listed as available through the New Jersey Individual Health Coverage Program. If they do not participate and you are unwilling to select new doctors, you may want to avoid HMO or EPO plans since those plans do not provide non-network coverage. If you select a PPO or POS plan, you would be able to access care as non-network care. With an indemnity plan, you may use any doctor you choose.

Question 2: How can I compare costs between an indemnity plan and a managed care plan or even one managed care plan to another?

You should compare not only the premium cost of the plans, but also your potential out-of-pocket costs for various services. Consider your medical care utilization over the course of an average year. How many doctor visits do you generally have? Be sure to include visits to specialists. What would those visits cost under the terms of various plans you are considering?

Question 3: What are Allowed Charges?

Allowed charges are the allowances carriers use for various services under an indemnity plan and non-network services under a PPO or POS plan. For example, a provider may bill you $500 for a service. The carrier will determine what the allowed charge is for that service. If the allowed charge for the service is $460, the carrier will calculate benefits based on the $460 charge. The provider may require you to pay the $40 difference. Carriers are required to use standards established in accordance with the IHC Program rules to determine the amount of an allowed charge. While the IHC Program requires carriers to determine allowed charges according to specific rules, the IHC Program cannot give you information on what the allowed charge will be for a service you plan to use.

Question 4: What if I want to change from one individual plan to another? Can I do it whenever I like?

It depends on the plan you have and the plan with which you want to replace it. You must wait for the November Open Enrollment period to make certain plan changes. For example, if you have an HMO plan, you can only switch to an HMO plan with a lower copayment or to a non-HMO plan during the November Open Enrollment period. However, if you bought an individual HMO for the first time, and realize the plan is not for you during the first 90 days, you may replace the HMO with a non-HMO at any time during the first 90 days. If you have a B&E plan, either with or without a rider, you may only replace it with a standard individual plan or with a B&E plan with a different rider during the November Open Enrollment period. You can only switch to a plan that has a higher monthly premium during the November Open Enrollment period.

Except as stated above, you can switch to a plan with a lower premium at any time or you can switch to a plan with the same or greater deductible, same or greater coinsurance or same or greater copayments, at any time, provided the new plan has no lower deductible, coinsurance or copayment.

If you are covered under a B&E plan with a rider, you can switch to a B&E plan without a rider at any time.

Question 5: Am I covered under my HMO plan if I need to use a doctor or hospital outside of New Jersey?

Coverage for services provided outside the service area of the HMO is generally limited to medical emergencies and urgent care. Sometimes HMO carriers allow members to use doctors or hospitals located in another state if the doctor or hospital belongs to that HMO's network in that other state. Contact your HMO for details.

Question 6: If I am covered under Plan C issued as an indemnity plan and admitted to the hospital on an emergency basis and am not able to call to notify the carrier, can the carrier still apply a penalty for not requesting authorization?

It depends. The standard plans issued as indemnity coverage require that you request authorization for an emergency admission within 48 hours after admission, or the next business day, whichever is later, or as soon as reasonably possible. If you are not able to call, a hospital representative, your doctor or a family member may call on your behalf. If authorization is not requested, as required, and it was reasonably possible for you to have provided notice, your benefits will be reduced by 50%.

Question 7: If I use the services of an emergency room or facility, but am not admitted, must I call the carrier to request authorization?

Yes. The standard plans issued as indemnity coverage require that you request authorization for emergency treatment within 48 hours after treatment, or the next business day, whichever is later, or as soon as reasonably possible. If authorization is not requested, as required, your benefits will be reduced by 50%.