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New Jersey Health Insurance Coverage Benefits

Benefits

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:

office visits
hospital care
prenatal and maternity care
immunizations and well-child care
screenings, including mammograms, pap smears and prostate examinations
x-ray and laboratory services
biologically based mental illness services
certain non-biologically based mental illness and substance abuse services
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:

Plan A/50 -- 50%
Plan B -- 40%
Plan C -- 30%
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:

Plan A/50 -- $5,000
Plan B -- $3,000
Plan C -- $2,500
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.

Further explanation and details of the standard individual plans, coinsurance amounts, deductibles and copayments are outlined at the end of this Buyer's Guide.

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