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II) NJ Individual Health Benefits Plan HMO Standard Plan Descriptions Jump to Rates
This information is for illustrative purposes only - See individual contract for details and exclusions.
| COVERAGE DESCRIPTION - PLAN HMO STANDARD | .................... | Copay Options: ($15/30/40/50) |
| Annual Deductible | $1,000 or $2,500 per person / $2,000 or $5,000 per family | |
| Coinsurance | options for 50%, 40%,30%,20% | |
| Maximum Annual Coinsurance Limit | No greater than $5,000 | |
| Lifetime Maximum | Unlimited | |
| FACILITY BENEFITS | ||
| Inpatient Services and Supplies (Subject to pre-approval) | $150/300/400/500 copay per day up to 5 days per admission | |
| Inpatient Hospital: Semi-Private | Maximum copay $1,500/3,000/4,000/5,000 per year/per person | |
| 365 days per year | ||
| Rehabilitation Center Services | Subject to inpatient hospital copayment | |
| (Subject to pre-approval) | Copayment will not apply if the admission is immediately preceded by a hospital inpatient stay | |
| Emergency Room | Separate $100 copay | |
| (waived if admitted, credited toward inpatient | ||
| admission, if admission occurs within 24 hours as a result of the emergency) | ||
| Home Health Care (Subject to pre-approval) | Unlimited | |
| Skilled Nursing (Subject to pre-approval) | Unlimited | |
| Hospice Charges (Subject to pre-approval) | Unlimited | |
| Mental/Nervous Health and Substance Abuse | ||
| Outpatient (Subject to pre-approval) | $15/30/40/50 copay, maximum 20 visits per year | |
| Inpatient (Subject to pre-approval) | $150/300/400/500 copay per day up to 5 days per admission | |
| Maximum 30 inpatient 30 inpatient days per year (1 inpatient day may be exchanged for 2 outpatient visits or partial hospital days); Maximum copay: $1,500/3,000/4,000/5,000 per year/per person | ||
| Alcoholism | ||
| Outpatient (Subject to pre-approval) | Same as above | |
| Inpatient (Subject to pre-approval) | Same as above | |
| PROVIDER BENEFITS | ||
| Primary (Preventive) Care | $15/30/40/50 copay | |
| well baby, routine physical exam, mammography, pap smears, vaccinations and screenings | ||
| Maternity Office Visits | $25 copay initial visit | |
| Surgical - Outpatient and Inpatient | $15/30/40/50 copay (Outpatient only) | |
| Therapy Services | ||
| Inpatient basis only | $15/30/40/50 copay | |
| Speech, physical, occupational and cognitive therapies covered for 60 day period per incident of illness or injury (Subject to pre-approval and copay) | ||
| Chelation, chemotherapy, dialysis, infusion and radiation | Unlimited (Subject to pre-approval and copay) | |
| OTHER SERVICES | ||
| Prescription | 50% coinsurance, for a prescription card, at carrier option | |
| Durable Medical Equipment | $15/30/40/50 copay | |
| (Subject to pre-approval) | ||
| Blood/Blood Products/Processing | ||
| Inpatient | Subject to inpatient copay | |
| NJ HMO Monthly Premium | Husband/ | Parent/ | ||||||
| Single | Wife | Child | Family | |||||
| $50 Copay | ||||||||
| AmeriHealth | $559 | $1,118 | $1,156 | $1,576 | ||||
| HealthNet of NJ | $965 |
$1,738 |
$1,641 |
$2,317 |
||||
| $40 Copay | ||||||||
| HealthNet of NJ | $1,055 | $1,898 | $1,793 | $2,532 | ||||
| $30 Copay | ||||||||
| Aetna | $926 | $1,852 | $1,668 | $2,768 | ||||
| AmeriHealth | $668 | $1,336 | $1,216 | $1,884 | ||||
| HealthNet of NJ | $1,161 | $2,089 | $1,974 | $2,787 | ||||
| Horizon Blue Cross | $670 | $1,433 | $1,028 | $2,030 | ||||
| $15 Copay | ||||||||
| Aetna | $1,359 | $2,717 | $2,448 | $4,061 | ||||
| AmeriHealth | $1,491 | $2,982 | $2,714 | $4,205 | ||||
| HealthNet of NJ | $1,404 | $2,527 | $2,387 | $3,370 | ||||
| CIGNA | $1,257 | $2,425 | $2,262 | $3,493 | ||||
| Horizon Blue Cross | $805 | $1,723 | $1,235 | $2,439 | ||||
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