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 NJPAIP.COM and  NJHIP.COM  Presents NJ Health Insurance Plans Buyers Guide

• Introduction
• Obtaining Coverage
• Eligibility
• Frequently Asked Questions About Eligibility
• Key Features of the Individual Health Coverage Program
• Frequently Asked Questions About NJHIP Plan Features and Rates
• Delivery Systems
• Frequently Asked Questions About Delivery Systems
• Benefits
• Example I: Individual Enrolled in Plan C
• Example II: Individual Enrolled in an HMO Plan
• Example III: Individual Enrolled in a PPO Plan
• Frequently Asked Questions About NJHIP Benefits
• Description of the NJHIP Standard Health Benefits Plans
• New Jersey Individual Standard Indemnity Plans Summary
• Standard HMO Plan

  Introduction

  In 1992, the New Jersey Legislature created the Individual Health Coverage (IHC) Program to ensure that people without access to employer or government sponsored health care programs could purchase health coverage for themselves and their families from a variety of private carriers. Prior to that time, few insurance companies offered policies to individuals and coverage was often inadequate, especially for people with chronic illnesses or injuries. NJ Health Insurance Quotes

  Today, individuals -- regardless of their age or health status -- are guaranteed renewable health coverage under standard health benefits plans designed by the Individual Health Coverage Program Board.

  This Buyer’s Guide* provides general information on individual health benefits plans and is designed to help you shop for the plan that best meets your needs. Health benefits plans are available for a Single person, Husband and Wife, Family or Adult and Child(ren). To assist you with your plan selection, enclosed with this Buyer's Guide is a list of participating carriers, their current rates and their telephone numbers. The rate comparison sheets are updated periodically, so please note the date that appears at the bottom of the rate sheet.

  Individual health coverage may be purchased from a variety of carriers as either an indemnity plan (commonly known as a "traditional" or "fee-for-service" plan) or a managed care plan (a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)). These plan options are explained in detail in this Buyer's Guide.

  * This Buyer's Guide is only a summary of the New Jersey Individual Health Coverage Program and is intended to help consumers make informed decisions concerning health coverage; contract provisions govern the terms and conditions of coverage.

  Obtaining Coverage

  To obtain coverage, we suggest you follow these steps: NJ Health Insurance Quotes

  1. Review this Buyer’s Guide to learn more about individual health coverage in New Jersey, the standard plans available, and the benefits they provide.
  2. Review the enclosed list of participating carriers and the rate comparison sheets. For additional information, you may contact the carriers directly. You may also decide to contact a licensed insurance producer, sometimes known as an agent or broker, who can help you make an informed decision, at no additional cost to you. However, some carriers do not offer coverage through insurance producers, so you will have to contact those carriers directly.
  3. Review the carrier’s materials and select the carrier that best meets your needs.
  4. Apply by completing the application provided by that carrier.
  5. Complete application. If your coverage will take effect within the next month, you must either include the first premium payment with your application, or authorize the carrier to deduct the premium payments from your checking account before the effective date.

Since coverage applied for during October as part of an Open Enrollment Period application does not take effect until the following January 1, the payment of the first premium either by check, or pre-authorized checking account deduction, may be delayed until December, even though you are applying in October.

Upon receiving your application and premium payment, your carrier will send you an identification card and a policy or contract which will indicate the effective date of your coverage. (Check the enrollment materials regarding the effective date of coverage. The effective date of coverage generally depends on the date of receipt of the completed application materials and premium payment.)

If you are currently covered under a group plan and are applying for an individual plan during the Open Enrollment Period, that individual coverage takes effect on January 1. You must terminate the current group coverage no later than December 31.

As explained below, you are eligible to purchase an individual health benefits plan if you are:

1. a resident of New Jersey;NJ Health Insurance Quotes
   
2. not eligible for coverage under a group health plan, governmental plan or church plan; and
   
3. not eligible for coverage under Medicare.

1. Residency -- A New Jersey resident is defined as someone whose primary residence is in New Jersey and who is present in New Jersey for a least six months of the calendar year. For non-Health Maintenance Organization (HMO) coverage, residency requirements apply only to the individual who applies for coverage -- the policyholder. The policyholder’s spouse, children or other dependent(s) do not have to reside in New Jersey. However, they must reside in the United States and there are some benefit restrictions if care and treatment are received outside the United States. If you choose to purchase coverage from a Health Maintenance Organization (HMO), all covered persons must reside in that HMO’s service area.

2. Group Coverage -- Generally, you are considered eligible for group coverage if your employer or union -- or your spouse’s employer or union -- makes a group plan available and you satisfy all the conditions for participation imposed by that group plan. Even if you choose not to participate in that group plan, you are still eligible for group coverage -- and, therefore, ineligible for individual health coverage. (You may have an opportunity to purchase an individual health benefits plan during the Open Enrollment Period in October of each year even if you are eligible for group coverage. However, there are specific rules that apply to the Open Enrollment Period, so it is best to consult with an insurance producer or carrier before doing so.)

3. Medicare -- You are not eligible to purchase an individual health benefits plan, if you are already eligible for Medicare, regardless of whether or not you apply for all available benefits under Medicare. Thus, if you are age 65 and eligible for Medicare, but do not sign up for Medicare, you are still eligible for Medicare and, therefore, you are ineligible to purchase an individual health benefits plan. Most people become eligible for Medicare because of their age (65 or older), but a person may become eligible for Medicare prior to age 65 because of a disability, including end-stage renal disease.

While you may not purchase an individual health benefits plan if you are already eligible for Medicare, if you are already covered under an individual health benefits plan when you first become eligible for Medicare, you may elect to retain your coverage under the individual health benefits plan. The individual health benefits plan would apply a "coordination of benefits" provision, which means that Medicare would pay benefits first, then the individual health benefits plan would pay benefits as the secondary payor.

Even when a Medicare-eligible person fails to enroll for Medicare, the individual health benefits plan will still act as secondary payor, applying the "coordination of benefits" rules against the benefits Medicare would have paid, if the person had enrolled. Although a Medicare eligible person may elect to continue existing coverage under an individual health benefits plan, the individual health benefits plan is not a Medicare Supplement Plan and may not be used as a substitute for Medicare.

Persons who are already covered under an individual health benefits plan and then become eligible for Medicare should contact the New Jersey Department of Health and Senior Services, Division of Senior Affairs at 1-800-792-8820 for information concerning Medicare Supplement Plan options.

Yes, provided New Jersey is your primary residence and you are present in New Jersey for at least 6 months of the year. The policyholder is required to be a New Jersey resident. These residency requirements do not apply to dependents.

No, visitors do not generally satisfy the residency requirement and should investigate coverages available where they reside.

Yes, if you relocate to New Jersey with the intention of being present in New Jersey for at least 6 months of the year, and meet all other eligibility requirements, you may purchase coverage.

No. However, your carrier may offer a plan with similar benefits in other states. You should check with your insurance company or HMO regarding a plan termination date before you move.

Yes. However, the individual health benefits plan will not act like a Medicare Supplement Plan and it will not replace Medicare coverage. The benefits for which you are eligible under Medicare will be coordinated with the benefits of the individual health benefits plan. Medicare would pay benefits first, then the individual health benefits plan would pay benefits as the secondary payor. In addition, the only individual health benefits plan you may be covered under once you become eligible for Medicare is the plan you are covered under at the time you become eligible for Medicare. You may not elect another option under the plan or switch to another carrier.

No. However, while there are no "short-term" plans, you may purchase one of the standard New Jersey individual health benefits plans for him and keep it until he becomes eligible for coverage under a group or other plan. He cannot be covered under more than one health plan, so he must notify his carrier regarding the cancellation of his individual health benefits plan when he becomes eligible for a group plan. Another option to cover him would be COBRA. You should check with your employer to find out if the employer is subject to the requirements of COBRA. If the employer is subject to COBRA, your son could elect to continue coverage under your group plan for a limited time.

A policyholder’s children -- including those for whom you have legal custody or guardianship, as well as those with whom you have a blood or legal relationship, who depend on you for most of their support and maintenance and who live in your household -- are eligible for coverage under your plan until their 19th birthday. Children who are and remain full-time students may be covered until their 23rd birthday. Coverage will end earlier, if the child graduates or is otherwise no longer a full-time student. Dependents who are incapacitated may be covered indefinitely, provided documentation is supplied to the carrier as requested, and your plan remains in effect.

Yes. If you wish to purchase coverage for one child, you will be charged the single rate. If you wish to purchase coverage for more than one child, you will be charged the parent and child(ren) rate. In addition, carriers have the option to offer a "child(ren) only" rating tier. The carriers, if any, which have elected to offer this "child(ren) only" rate are identified on the rate comparison sheet.

Yes. A dependent child, for the purpose of an individual health benefits plan, includes a child related to you by blood, if the child depends on you for most of the child’s support and maintenance and resides in your household.

No. Even if you waive or postpone coverage under Medicare, you are considered eligible for Medicare and thus ineligible for IHC coverage. If you are concerned that Medicare may not provide adequate coverage, you may purchase another type of health plan specifically designed to supplement Medicare coverage. You may obtain free information on plans that supplement Medicare by contacting the New Jersey Department of Health and Senior Services, Division of Senior Affairs at 1-800-792-8820.

Yes. Although COBRA is a continuation of a group plan, eligibility for coverage under COBRA does not preclude the purchase of an IHC plan. You may choose to continue your coverage under COBRA for some, all, or none of the permissible continuation period. You may elect to maintain your dental or vision coverage, if available, under COBRA since dental and vision coverage is not available with the IHC plans. Once you purchase an IHC plan, you may not maintain health coverage under COBRA, and therefore, you will have to cancel your health coverage under COBRA.

Question 12: May I purchase an individual health benefits plan if I have group coverage?

The law generally prohibits you from purchasing an IHC plan if you are covered by or eligible for a group health plan. However, if you are required to pay a portion of the premium for your group coverage, you may be eligible to purchase an individual health benefits plan during the Open Enrollment period in October of each year, subject to certain restrictions. You would be required to terminate your coverage under the group plan no later than the date your individual coverage takes effect.

Please note that, even if you are eligible, you may not purchase an individual health benefits plan that provides the same or similar level of coverage as the group plan for which you are eligible.

An insurance producer or carrier representative can help you evaluate your particular circumstances and the options that may be available to you during the Open Enrollment Period which occurs each year during the month of October. The IHC coverage would not take effect until January 1 following the Open Enrollment Period.

The Individual Health Coverage Program requires each carrier to:

• guarantee coverage and renewability for all eligible people regardless of health, subject to the pre-existing conditions provision, as applicable;
• establish community rates -- which are rates that apply to all people who purchase the same IHC plan and do not vary based on an individual person’s age, gender, occupation, geographic location or health status;
• offer standardized individual health benefits plans (referred to as Plans B,C,D,E and/or an HMO or PPO Plan) to make it easier for you to compare benefits and costs among the many participating carriers offering coverage.

Provided you satisfy the eligibility requirements described in the Eligibility Section, you cannot be denied coverage for any reason including your past or current health condition. However, the "pre-existing conditions" provision may limit coverage during the first 12 months. You also are guaranteed renewal of your policy, provided you remain a resident of New Jersey and do not become eligible for coverage under a group plan, your premium is paid in a timely fashion and you do not commit fraud.

Except as stated below, if you have been uninsured for more than 31 days prior to the effective date of coverage, you are subject to a 12-month waiting period for coverage of "pre-existing conditions."

A "pre-existing condition" is an illness or accidental injury which manifests itself in the six months before individual coverage begins and for which:

• a person sees a doctor, takes prescribed drugs, receives other medical care or treatment or had medical treatment recommended by a doctor, or
• an ordinarily prudent, or careful, person would have sought medical advice, care or treatment.

A pregnancy which exists on the date coverage begins is a pre-existing condition and will be subject to the limitations described above. However, certain complications of pregnancy will not be excluded for coverage as pre-existing conditions.

During the 12-month, "pre-existing condition" waiting period, you will be covered for all other conditions subject to the terms of your contract or policy. After the "pre-existing condition" waiting period has ended, all illnesses and injuries -- including those related to the "pre-existing condition"

-- will be covered subject to the terms of your contract or policy.

The "pre-existing condition" waiting period is waived for treatment of conditions which were treated or diagnosed and were covered under "creditable coverage" that terminated no more than 31 days prior to the effective date of your new individual health benefits plan.

Under the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), "creditable coverage" is the term used to define the types of prior coverage a person may have had. It is a very broad definition and includes, but is not limited to: individual and group plans, whether insured or self-funded, Medicare, Medicaid, and CHAMPUS. The standard policy forms contain a complete definition of "creditable coverage".

You are credited for time satisfied under a "pre-existing condition" limitation period for any creditable coverage, provided there is no more than a 31-day lapse between your prior and your new coverage.

You will be required to provide your new carrier with proof of the prior "creditable coverage," so that the waiver or credit may be applied. Your prior plan should provide you with a certificate of creditable coverage to be used for such proof. If you do not have more than a 31-day lapse in coverage, you may change health plans without having to satisfy any new "pre-existing condition" waiting period. If you have only partially satisfied the "pre-existing condition" waiting period under prior coverage, you will have to satisfy only the balance of a "pre-existing condition" waiting period under your new coverage.

EXCEPTION: If an eligible person is a "federally defined eligible individual" the "pre-existing condition" waiting period requirement will not apply, provided there has been no more than a 63-day lapse in coverage between the date the prior "creditable coverage" ends and the date the individual health benefits plan coverage begins.

A "federally defined eligible individual" is defined as "a person who has been covered for at least 18 months under a group health plan, governmental plan, church plan, or health insurance coverage offered in connection with any such plan; who is not eligible for coverage under Medicare or Medicaid; and who does not have another health benefits plan, or hospital or medical service plan." The prior creditable coverage must not have been terminated, based on a factor relating to nonpayment of premiums or fraud. In addition, if the person was offered the option of continuation of coverage under a COBRA continuation provision or similar State continuation option, the person must have elected that continued coverage and have exhausted that continuation coverage.

While all individual health benefits plans are community rated, rates vary from carrier to carrier and from one individual health benefits plan to another. That is, one carrier’s price for Plan D is not likely to be the same as another carrier’s price for Plan D. And, because Plan D provides greater benefits than Plan B, Plan D will generally be priced higher than Plan B. The list of carriers and their rates for various plans provided with this Buyer’s Guide can assist those interested in purchasing individual health coverage with a comparison of rates.

It depends on whether you were covered under prior coverage. If you were covered for the condition for which you are to be hospitalized under prior coverage and that coverage ended no more than 31 days before your new coverage begins (i.e., March 1, in this example), your new coverage will cover the condition, subject to the terms of the new plan.

If you are a "federally defined eligible individual," as defined on page (11,) and your prior group coverage ended no more than 63 days before your new coverage begins, your new coverage will cover the condition, subject to the terms of the new plan.

If you had no prior coverage, or if any prior coverage ended more than 31 days prior to the effective date (March 1, in this example), the new coverage will not cover a pre-existing condition until the end of the required 12-month "pre-existing condition" waiting period.

Yes. Conditions which first manifest themselves after your new coverage begins (i.e., March 1, in this example) are covered, subject to the terms of the new plan.

If there is no more than a 31-day lapse in coverage between the date your prior plan ends and the date your new plan begins, there will be no new "pre-existing condition" waiting period, provided your previous plan also covered you for the condition or you had coverage under the previous plan for at least 12 months, and, therefore, satisfied the 12-month "pre-existing condition" waiting period. However, if you did not entirely satisfy the 12-month "pre-existing condition" waiting period under the prior plan, you will be required to satisfy the balance of the waiting period under the new plan.

For example, if you bought a plan from one carrier on March 1 and were required to satisfy a 12-month "pre-existing condition" waiting period, and cancelled that coverage on October 1 to buy coverage with another carrier, you would have already satisfied 7 months of the 12-month waiting period. The new carrier would then apply those 7 months to the "pre-existing condition" waiting period, so you would have to satisfy just 5 months of the waiting period while covered with the new carrier.

There is a 31-day grace period, so you have until May 31 to pay the premium. Coverage stays in force during the grace period. If you do not pay the premium by the end of the grace period, coverage ends as of the end of the grace period. If you incur charges during the grace period and submit a claim to your carrier, your benefit will be reduced by the amount of unpaid premium. For the purpose of the portability provision of the plans, however, the permissible 31-day lapse period is measured from the last date coverage is in force on a premium-paying basis, not the end of the grace period.. In this example, premiums are paid through April 30, so May 1 would be the beginning of the lapse period.

Each carrier evaluates the benefits required to be provided under each of the standard individual health benefits plans and determines how much the carrier expects it will cost to provide those benefits. Carriers must also price plans to comply with a provision of the law which requires them to pay out at least 75 cents in benefits, services or supplies to their covered individuals for every dollar collected in premiums.

No, not necessarily. The rates for any given individual health benefits plan are not adjusted only based on your utilization of health benefits or lack of utilization. Rather, carriers review utilization by all persons covered by the same type of individual health benefits plan. Any adjustment will apply to everyone covered under the specific plan, not just persons who may have submitted claims.

Carriers are not required to "lock-in" or guarantee their rates for any specific amount of time, however, some carriers elect to do so. The rate comparison sheets show the duration of the rate guarantees for each carrier. For more specific information on rates -- or any available rate guarantee -- contact the carriers directly.

Individual health coverage may be purchased from a variety of carriers as either an indemnity plan (commonly known as a "traditional" or "fee-for-service" plan) or as a managed care plan (HMO or PPO). These options are outlined in more detail below.

Generally, indemnity plans allow you to choose any physician or hospital and require you to file a claim after treatment and expenses are incurred. Thus, your choice of a licensed health care provider is made by you. The indemnity plans do, however, incorporate some elements of cost-containment, such as requiring pre-authorization of non-emergency hospitalizations and prior review and approval for certain services (for example, non-emergency surgery and certain tests and procedures).

The policy issued by your carrier carefully outlines the procedures you must follow. If you have questions about those procedures, you should contact your carrier or producer for further assistance.

Indemnity plans typically require you to satisfy a deductible before the carrier will pay benefits based on the covered charge. You are responsible for your coinsurance share. The standard individual health benefits plans have various deductibles and coinsurance requirements.

"Covered charges" are charges for services and supplies which are covered by the policy or contract and which are less than or equal to the reasonable and customary charge for the service or supply.

For example, assume you have chosen Plan C with a $1,000 deductible. You receive a bill for $4,000 and the entire amount is considered a "covered charge." You will be responsible for the first $1,000, as your deductible. Of the remaining $3,000, your carrier pays 70 percent -- or $2,100. You would be responsible for the 30 percent balance -- or $900. Subsequent covered charges during that same year would be paid at 70 percent by the carrier, with you responsible for paying 30 percent. Once your 30 percent share reaches the coinsurance cap of $2,500, the carrier pays for all further "covered charges" at 100 percent for the rest of the calendar year.

In the example above, the carrier considered the entire amount of the bill as a "covered charge." Sometimes the billed amount exceeds the "reasonable and customary charge" for the service. When this happens, the carrier only pays benefits based on the "reasonable and customary charge." The covered person is responsible for the balance.

Health care services and treatments are covered as stated in the individual policy. There also may be limitations on the amount that is reimbursed for a provided service.

Carriers which offer managed care plans typically provide comprehensive benefits by contracting with a network of physicians, hospitals and other health care professionals.

Health Maintenance Organization (HMO) plans are network-based forms of managed care. An HMO consists of a network of physicians, hospitals and other health care professionals which provides members with medical treatment and care. You choose a Primary Care Provider or Primary Care Physician (PCP) from those participating in the HMO network. That PCP coordinates your health care, referring you to specialists in the network, when necessary. Services not provided by or referred by a PCP are not covered, except for emergency medical care.

You are responsible for a copayment for specified services, for example, a $15 copayment for a physician visit or a $150 per day copayment for hospitalization. There are no calendar year deductibles. There is generally no coinsurance requirement except that carriers have the option to provide prescription drug benefits subject to either 50 percent coinsurance or a $15 copayment per prescription or refill. The rate comparison sheets list the election made by each HMO carrier.

There are two ways an HMO may provide access to services and supplies -- through a fully staffed health center or through a physician who is a member of the network. An HMO is not required to offer coverage to persons who do not reside in its approved service area.

PPO Plans

Preferred Provider Organization (PPO) plans are network-based forms of managed care which allow you to seek medical care and treatment either from within a network of physicians, hospitals and other health care professionals or from physicians, hospitals and other health care professionals that are outside of the PPO network. If you seek medical care and treatment from network providers, you generally will be eligible for a richer level of benefits. If you seek care and treatment from providers that are outside of the network, you will be eligible for a lower level of benefits.

The network benefits under the plan may be subject to copayments, just as is the case with HMO coverage. Non-network benefits will always be subject to a deductible and coinsurance.

Carriers are not required to sell PPO plans. Carriers that do offer PPO plans are identified on the rate comparison sheets. Contact the carriers directly for information concerning their PPO plan designs.

Check with your doctors to find out if they participate in any HMO or PPO 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, an indemnity plan may be best suited to your needs.

You should compare not only the premium cost of the plans, but also your potential out-of-pocket costs for various services.

Reasonable and customary charges (which some carriers may refer to as "Usual and Prevailing Charges") are the allowances carriers use for various services under an indemnity plan. For example, a provider may bill you $500 for a service. The carrier will determine what the reasonable and customary charge is for that service. If the reasonable and customary charge 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 a reasonable and customary charge.

Question 4: What if I want to change from a managed care plan to an indemnity plan?

You may switch from an HMO or PPO to an indemnity plan at anytime. However, you may apply to switch from an indemnity plan to an HMO or PPO plan only during the open enrollment period in October, and coverage takes effect the following January 1.

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

Yes, but coverage for services provided outside the service area of the HMO is limited to medical emergencies (contact your HMO for details).

Question 6: If I am 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?

Yes, the standard indemnity plans 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, 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 indemnity plans 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%.

All plans cover the following:

• office visits
• hospital care
• prenatal and maternity care
• immunizations and well-child care
• screenings, including mammographies, pap smears and prostate examinations
• x-ray and laboratory services
• certain mental health and substance abuse services
• prescription drugs

Plans B, C, D and E also cover the cost of routine physicals and other preventive care -- up to $300 per year per covered person and up to $500 during the first year of a newborn’s life. The deductible and coinsurance do not apply to these services. The deductible and coinsurance do not apply to preventive care services.

Plans B, C, D and E all offer similar coverage, but they have varying coinsurance requirements and coinsurance maximums. For example, under Plan C, once your deductible is met you would pay 30 percent of covered charges, while your carrier would pay 70 percent. Once your 30 percent share reaches $2,500, your carrier would begin to pay 100 percent of covered charges. Under Plan D, once your deductible is met, you would pay only 20 percent of covered charges, while your carrier would pay the other 80 percent. Once your 20 percent share reaches $2,000, your carrier would begin to pay 100 percent of covered charges.

Plans B, D and E provide a choice of deductibles of $500 or $1,000. Plan C offers deductible options of $1,000 or $2,500. Under Plan B, the carrier pays 60 percent of covered charges; under Plan C the carrier pays 70 percent of covered charges; under Plan D the carrier pays 80 percent of covered charges, and under Plan E, the carrier pays 90 percent of covered charges, after the deductible is met.

The federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA") established certain federal tax advantages for self-employed individuals who establish Medical Savings Account Plans (MSAs) on or after January 1, 1997. An MSA is an investment account held in trust for the account holder. Annual tax-free contributions are made to the account which must be maintained in conjunction with a high deductible insurance policy. The account holder may draw on the account to pay for qualified medical expenses not covered under his or her health insurance policy, for non-qualified medical expenses, or leave the funds to accumulate on a tax-free basis.

Carriers may elect to offer Plans C and/or D with deductible options of $1,500 or $2,250 for single coverage and $3,000 or $4,500 for other than single coverage. For such $3,000 or $4,500 deductible options, please note that no benefit will be payable for any covered person until the entire deductible has been satisfied. These deductible options, combined with an out-of-pocket feature of $3,000 for single coverage or $5,500 for other than single coverage, create health benefit plans that could be used as MSA Plans. These high deductible plans are available to any person who is eligible to purchase an individual health benefits plan, whether or not the person is interested in setting up an MSA or able to qualify for MSA plan tax advantages under federal law.

The rate comparison sheets identify carriers that have elected to offer these high deductible options. Please note that the $2,500 deductible option available with Plan C does not create a plan that could qualify as an MSA.

Further explanation and details of the standard individual health benefits plans, coinsurance amounts, deductibles and copayments are outlined in the fold-out charts located at the end of this Buyer’s Guide.

HMO Plans covers many of the same services as Plans B through E. Unlike Plans B through E, however, there are 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. HMO Plans offer copayment options of $10, $15 and $20 for physician and outpatient services. Other copayments apply to inpatient hospitalizations, emergency room visits and maternity care. Rates vary with the copayment. Prescription drugs may be covered subject to either a 50% coinsurance or a $15 copayment, at the option of the carrier. Refer to the rate comparison sheets to find out which options the HMO carriers have elected.

PPO plans are consistent with the standard indemnity plans described above except that carriers may structure the PPO plans using a variety of deductible, copayment and coinsurance features. All PPO plans include a $10,000 coinsured charge limit instead of the coinsurance cap used by indemnity plans. 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 PPO 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. If you seek care and treatment from providers that are outside of the network, you will be eligible for a lower level of benefits.

The network benefits under the plan may be subject to copayments, just as is the case with HMO coverage. Non-network benefits will always be subject to a deductible and coinsurance.

Carriers are not required to sell PPO plans. Carriers that do offer PPO plans are identified on the rate comparison sheets. Contact the carriers directly for information concerning their PPO plan designs.

*Note: In making the decision among an indemnity plan, a PPO Plan and an HMO Plan, you must also consider the cost of the monthly premiums you pay. In these examples, the premiums for the three plans illustrated would not be the same. There are also differences to consider in terms of your ability to select hospitals and physicians. Here, the covered person in Example I selects any physician and hospital. The covered person in Example II selects from those physicians, hospitals and facilities that participate in that HMO. In Example III, the covered person was able to choose both providers that participate in the PPO network and those that do not.

The New Jersey Individual Health Coverage (IHC) Program Board reviews the standard individual health benefits plans annually to ensure that the plans meet the changing requirements of state law and the needs of New Jersey residents. Your carrier will notify you of any changes that may affect your plan.

Generally, individual health benefits plans purchased prior to August 1, 1993, may continue to be renewed by your health insurance company or HMO, but are not available for new sales.

You have a 30-day period during which you may examine the policy or contract and the benefits included. If you are dissatisfied, you may return your policy or contract for a full premium refund, less any claims paid or services provided.

The Open Enrollment Period in October of each year provides an opportunity for people with standard individual health benefits plans to buy a richer individual health benefits plan.

For example, if you currently are covered by Plan C (70%/30% coinsurance) and want to purchase Plan D (80%/20% coinsurance), you may do so only during the Open Enrollment Period in October. Coverage purchased during the Open Enrollment Period becomes effective on January 1 of the following year. However, if you want to purchase a less rich plan, such as switching from Plan D to Plan C, you can do so at any time. Contact your carrier or insurance producer for details about how to make these kinds of changes.

If you have an individual health benefits plan that was issued prior to August 1, 1993, you may purchase any one of the standard individual health benefits plans at any time and are not required to wait until the Open Enrollment Period in October. Similarly, if you currently do not have health insurance and you meet the eligibility requirements of the individual health coverage program, as previously described, you may purchase a standard plan at any time.

You cannot be covered by more than one health benefits plan at a time, if one of the plans is an individual health coverage plan. If you are switching from group coverage to individual coverage, or if you are changing from one of the standard individual health benefits plans to another, you must notify the existing carrier within 30 days of the date your new plan takes effect to request that your existing coverage be cancelled . To avoid being subject to a new pre-existing conditions exclusion, you should make sure there is no more than a 31-day gap between the date the existing coverage ends and the date the new coverage begins. As an exception to this rule, a "federally defined eligible individual" may have a lapse in coverage of up to 63 days.

However, if you are changing from one IHC plan to another IHC plan that provides a higher level of benefits, the change can only be requested during the October Open Enrollment Period each year. Such coverage takes effect the following January 1 (see question 10 under Eligibility Section for further clarification).

No. The standard individual health benefits plans include a deductible credit provision which applies to charges incurred during the same calendar year. However, you must switch with no lapse in coverage from one plan to another -- or from one carrier to another -- to qualify for the credit. That is, you must have continuous coverage. If there is a lapse in coverage of a period as brief as one day, there will not be any deductible credit. You must provide proof to the new carrier that you incurred charges toward the deductible under the prior plan.

As explained in question 6 above, you will be entitled to deductible credit, provided there is no lapse in coverage between the date the first plan ends and the new plan begins. There is no coinsurance credit. You would be required to satisfy the coinsurance cap under the new plan in order to be eligible for 100% benefits under the new plan. If you have already met your coinsurance cap, you should consider whether it may be best to delay changing plans until January when the full deductible and coinsurance requirements will start anew.

Ask your carrier about its grievance and appeal process. Provide all information you, your doctor or other provider have to support your position. Sometimes carriers deny benefits initially because you or your doctor did not submit all the necessary information.

Many services and supplies require carrier pre-approval. Pre-approval gives the carrier the opportunity to evaluate the medical need before you incur charges and to advise you, up front, what will be covered. If you do not secure pre-approval, as required, the carrier has no obligation to provide benefits.

There are some variations permitted. HMO carriers have an option to cover prescription drugs subject to a 50% coinsurance or a $15 copayment. Carriers may elect to offer coverage for autologous bone marrow transplants as part of the standard individual health benefits plans or as an option benefit rider. When comparing the rates of one carrier to another, it is wise to ask how coverage for certain transplants is provided and how coverage is provided for prescription drugs.

No. Your previous carrier will still process claims incurred while your plan was in effect and reimburse you, as appropriate.

The coinsurance cap is the amount you pay because of your coinsurance share. On Plan C, for example, the carrier pays 70% and you pay 30% after the deductible is met. Once your 30% share reaches the coinsurance cap, $2,500 for Plan C, benefits are paid at 100% for the rest of the calendar year. The coinsured charge limit is a dollar amount of covered charges that you must incur before benefits are payable at 100%. So, it includes amounts you pay as deductible, amounts the carrier pays as carrier coinsurance, plus amounts you pay as your coinsurance share.

Congratulations! By law in New Jersey, carriers must cover a minimum of 48 hours following a routine delivery and 96 hours following a cesarean section. Your doctor may determine that a longer stay is medically necessary, which would entitle you to additional time in the hospital.

The charts on the following pages illustrate the categories of benefits contained in the four standard indemnity plans and the standard HMO plan offered by carriers participating in the Individual Health Coverage Program. You should consult an agent, broker or carrier for detailed information on benefits and exclusions (see below)¹.

The plans, labeled B through E, are of increasing value. Plans B through E cover the same medical and hospital charges, but differ in how much (what percentage) the covered person pays toward these charges. Under Plan B, for example, the covered person pays 40%; under Plan C, the covered person pays 30%; under Plan D, the covered person pays 20%; and under plan E, the covered person pays 10%. Plan B also requires the covered person to pay an additional charge for hospital confinement. Plans B, D and E are each offered with two individual deductible options: $500 and $1,000, and Plan C is offered with deductible options of $1,000 and $2,500.

The PPO plans carriers offer must be based on an indemnity plan. The services covered under plans B - E are the same services that would be covered under a PPO plan. Since these plans can be offered with and without copays, with different coinsurance levels, it is not possible to illustrate in this Buyer’s Guide the benefit structure of the PPO plan a particular carrier may be offering. Contact the carrier directly for information concerning PPO plan design.

Note: Carriers will pay benefits for covered charges on what is called a "reasonable and customary" standard. All carriers are required to use the same standard. Thus, if a provider charges more for a service or supply than the "reasonable and customary" allowance for that service or supply, the carrier will pay only the "reasonable and customary" allowance, and the covered person may be responsible for the difference. NJ Health Insurance