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More Types of New Jersey Health Insurance Coverage Benefits

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. As discussed above, the HMO plan may be offered such that no referrals are required. Such a design is often referred to as "direct access" or "open access."

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.

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