818 Route 202-206, Bridgewater, NJ 08807
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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/ | ||||||
| $50 Copay | Single | Wife | Child | Family | ||||
| BC/BS | 438 | 1109 | 1047 | 1320 | ||||
| Oxford | 616 | 932 | - | - | ||||
| $40 Copay | ||||||||
| HealthNet of NJ | 673 | 1211 | 1144 | 1,615 | ||||
| $30 Copay | ||||||||
| Oxford | 425 | 851 | 808 | 1277 | ||||
| HealthNet of NJ | 741 | 1333 | 1259 | 2150 | ||||
| BC/BS | 454 | 971 | 696 | 1652 | ||||
| $15 Copay | ||||||||
| HealthNet of NJ | 896 | 1612 | 1523 | 2150 | ||||
| BC/BS | 545 | 1166 | 837 | 1652 |
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