2019 Benefits at a Glance

2019

Benefits at a Glance

SMALL GROUP PLANS

Choose the best health plan for you and your business. Use this brochure to compare health plans and cost-sharing.

Choose the best health plan

Choosing a health plan is a big decision. But the good news is, you don't have to make it alone. We're here to help you -- whether it's to explain the different types of health plans or to help you figure out which one makes the most sense for your business. Everything you need to get started is here. With this booklet, you'll be able to look at health plans side by side, so you can see how much your employees pay when they receive covered services. You'll also find an overview of our networks. When you're ready to purchase or have questions, contact your broker.

Your broker is ready to help you choose the

best health plan for your business.

Common health care terms

Here are simple definitions of some of the health insurance terms in this guide.

Coinsurance The percentage you pay for some covered services. If your coinsurance is 20%, your health insurance company will pay 80% of the cost of covered services, and you will pay the remaining 20%.

Copay The amount you pay when you see a doctor or get other services.

Out-of-network If you receive health care services from providers or facilities not included in your health plan, you may be subject to additional costs.

Out-of-pocket costs The amount you pay for your health care services. The health care law sets a limit on your out-of-pocket costs, called an out-of-pocket maximum. Once you pay this amount, your health plan will pay 100% of the additional covered services you receive.

Cost-sharing The amount you pay for your health care costs beyond your premium. This includes your deductible, copayments, and coinsurance fees.

Deductible The amount you pay each year before you start to receive insurance benefits.

Premium The amount you pay to your insurance company each month to pay your share of your health plan's costs. This is separate from the deductible, copayments, and coinsurance amounts you pay when you use your benefits to receive covered services.

Referral If you have an HMO plan, your family doctor (or primary care provider) will need to write you a referral before you see other network providers, such as a heart doctor (cardiologist).

2



Coverage options

All health plans are categorized by metallic tiers -- Bronze, Silver, Gold, or Platinum.

You choose a health plan based on the cost of the plan and services it covers. For most health plans, there is a fixed amount each month, known as a premium or monthly rate. In addition to the premium you pay, members may also pay each time they receive care from a doctor or hospital, have a prescription filled, or get some type of medical care. These payments are often called costsharing or out-of-pocket costs, and come in the following types: deductible, copay, and coinsurance.

BRONZE

SILVER

GOLD

PLATINUM

May be a good fit if you only get annual check-ups.

May be a good fit if you get annual check-ups and additional

care more often.

May be a good fit if, in addition to May be a good fit if you have serious chronic

annual check-ups, you see doctors conditions that require frequent doctor visits

and/or specialists more often.

and/or extended hospitalization.

MONTHLY COST

$

OUT-OF-POCKET COST

$$$$

MONTHLY COST

$$

OUT-OF-POCKET COST

$$$

MONTHLY COST

$$$

OUT-OF-POCKET COST

$$

MONTHLY COST

$$$$

OUT-OF-POCKET COST

$

As you can see, Bronze health plans generally have the lowest monthly fixed costs but likely have higher out-of-pocket costs when members get care. Platinum health plans generally cost the most each month, but will probably cost members less each time they need care. The Gold and Silver plans fall somewhere in the middle.

Health plan options

There are five types of health plans that you can choose from. The type of plan you choose for your members will affect the process your members follow to get care. Whether your members have to select a primary care provider and whether they'll need a referral from that primary care provider are the biggest differences between the plans.

Health maintenance organization (HMO) Best if members have or want a primary care provider to coordinate their care and refer them to specialists who are within the network you choose. HMO plans offer coverage for network doctors only and requires a referral. There is no out-of-network coverage.

Health maintenance organization (HMO) Plus Best if members have or want a primary care provider to coordinate their care and want the ability to self refer to specialists who are within the network. There is no out-of-network coverage and no referral is required.

Point-of-service (POS) Plus Best if members have or want a primary care provider to coordinate their care but still want the freedom to choose a doctor or hospital in- or out-of-network. POS Plus plans offer the highest level of benefits when members visit providers that participate within the network, but the plans also provide the option of seeking care outside of the network. No referral is required.

Exclusive provider organization (EPO) Best if members want the freedom to see any doctor or specialist they want with no referral, as long as they're within the network you choose. There is no out-of-network coverage.

Exclusive provider organization with a health savings account (EPO with HSA) Adding an HSA can save members money if you choose a plan with a high deductible. Members can put money into an HSA, and they won't get taxed for that part of their income. Then they can use that money to pay for approved health costs.

3



Network options

AmeriHealth New Jersey has a variety of networks ? making health insurance more affordable for you, your family, or your business. Networks differ based on geography as well as participating doctors, hospitals, and other health care providers. To determine what network is best for you, visit providerfinder.

National Access

Regional Preferred

One of the largest network of doctors, hospitals, and labs in the state of New Jersey.2 Members have access to participating physicians and providers in New Jersey, Delaware, and Southeastern Pennsylvania.3

Local Value

The Local Value network offers small employers a more affordable rate by providing access to a subset of the Regional Preferred network in New Jersey.4

The following Advantage networks are a subset of the Local Value network and are designed to offer more options focused on affordable, high-quality health care coverage.

Available through the Multiplan PHCS National network for services obtained outside of the Regional Preferred service area.1,3

Northampton

Lehigh Bucks

Berks Montgomery

Lancaster

Chester Philadelphia Delaware

SOUTHEASTERN

PA

New Castle

Kent

Sussex Passaic Bergen

Warren Morris Essex Union Hudson

Hunterdon4 Somerset

Middlesex

Mercer

Monmouth

Ocean Burlington

Gloucester Camden Salem

Atlantic

Cumberland Cape

NJ May

Sussex

AmeriHealth Advantage

AmeriHealth Advantage allows members to pay lower out-of-pocket costs for select hospitals, and physician services if they use a participating facility. Tier 2 is available through the AmeriHealth New Jersey Local Value network. These plans were designed to meet the needs of small employers based in select counties.5 Offered in collaboration with the following health systems: AtlantiCare, Cape Regional Medical Center, Cooper University Healthcare, Deborah Heart and Lung Center, Hackensack Meridian Health, and RWJBarnabas Health.6

AmeriHealth Hospital Advantage

AmeriHealth Hospital Advantage plans allow members to pay lower out-ofpocket costs for hospital and facility services if they use a participating AmeriHealth Hospital Advantage provider. Tier 2 providers are available through the AmeriHealth New Jersey Local Value network.7,8

Hudson

Sussex

Passaic

Bergen

Warren

Morris

Essex

Union

Hunterdon4 Somerset

Middlesex

Mercer

Monmouth

Ocean Burlington Gloucester Camden

Salem

Atlantic

Cumberland

Cape May

Sussex

Passaic

Bergen

Warren

Morris

Essex

Union

Hunterdon4 Somerset

Middlesex

Mercer

Monmouth

Ocean Burlington

Hudson

DE

Gloucester Camden

Salem

Atlantic

Cumberland

1 Coverage provided by Multiplan PHCS National Network. AmeriHealth New Jersey members accessing care in the AmeriHealth New Jersey service area must use the Regional Preferred network.

Cape May

2 Data derived from analysis of information provided by a third party vendor and is subject to change.

3 The AmeriHealth New Jersey service area includes all New Jersey and Delaware counties, and nine Pennsylvania counties in the Philadelphia area including: Northampton, Lehigh, Bucks, Berks,

Montgomery, Philadelphia, Delaware, Chester, and Lancaster counties.

4 The Local Value Network is not available in Hunterdon County.

5 AmeriHealth Advantage plans are only available to employers based in the following counties: Atlantic, Burlington, Camden, Cape May, Essex, Gloucester, Hudson, Mercer, Middlesex, Monmouth, Ocean, Somerset, and Union.

Members can obtain services within the listed counties at the tier 1 level. AmeriHealth Advantage members can also access tier 2 providers within the AmeriHealth New Jersey Local Value network. AmeriHealth Advantage

tier 1 hospitals are subject to change.

6 The following hospitals are included in the AmeriHealth Advantage health systems: Atlanticare Regional Medical Center ? Atlantic City Campus, Atlanticare Regional Medical Center ? Mainland Campus, Bayshore Medical

Center, Cape Regional Medical Center, Clara Maass Medical Center, Community Medical Center, Cooper Hospital/University Medical Center, Deborah Heart and Lung Center, Hackensack University Medical Center (UMC)

Hackensack UMC Mountainside, Hackensack UMC Palisades, Hackensack UMC at Pascack Valley, Holy Name Medical Center, Jersey City Medical Center, Jersey Shore University Medical Center, Monmouth Medical Center,

Monmouth Medical Center ? Southern Campus, Newark Beth Israel Medical Center, Ocean Medical Center, Raritan Bay Medical Center ? Old Bridge Raritan Bay Medical Center ? Perth Amboy, Riverview Medical Center,

Robert Wood Johnson University Hospital, Robert Wood Johnson University Hospital Hamilton, Robert Wood Johnson University Hospital Rahway, Robert Wood Johnson University Hospital Somerset, Saint Barnabas Medical

Center, and Southern Ocean Medical Center.

7 AmeriHealth Hospital Advantage providers are an enhancement to your benefits. Tier 2 providers are AmeriHealth New Jersey Local Value network providers.

8 Pin drops are for illustrative purposes only. For a complete listing of AmeriHealth Hospital Advantage providers and facilities, visit hospitaladvantage.

4



PRESCRIPTION BENEFITS 30 DAY SUPPLY4

MEDICAL BENEFITS

BRONZE

BENEFITS

EPO HSA

AMERIHEALTH ADVANTAGE

$25/$50

EPO HSA

AMERIHEALTH HOSPITAL ADVANTAGE

$50/$75

CHOOSE YOUR NETWORK

AMERIHEALTH ADVANTAGE5

Tier 1

Tier 2

AMERIHEALTH HOSPITAL ADVANTAGE9

Tier 1

Tier 2

DEDUCTIBLE INDIVIDUAL / FAMILY

$3,00012 / $6,0006

$3,00012 / $6,0006

AFTER DEDUCTIBLE MEMBER PAYS

50%

50%

MAXIMUM OUT-OF-POCKET INDIVIDUAL / FAMILY

Primary Care Visits

Specialist Visits

Urgent Care Services

Emergency Room

Outpatient Surgery Ambulatory Surgical

Inpatient Hospital Services Including Maternity

X-rays & Diagnostic Imaging Imaging CT/PT Scans, MRIs

$6,750 / $13,5007

$25 copay, after deductible

$50 copay, after deductible

$50 copay, after deductible

$75 copay, after deductible

30% coinsurance,after deductible

30% coinsurance, after deductible

50% coinsurance, after deductible

30% coinsurance, after deductible

50% coinsurance, after deductible

$200 copay per day, up to 5 days,

after deductible10

$500 copay per day, up to 5 days,

after deductible10

50% coinsurance, after deductible

$6,750 / $13,5007 $50 copay, after deductible $75 copay, after deductible

50% coinsurance, after deductible

20% coinsurance, after deductible

$500 copay per admission, after deductible11

50% coinsurance, after deductible

20% coinsurance, after deductible

50% coinsurance, after deductible

Laboratory

50% coinsurance, after deductible

50% coinsurance, after deductible

Inpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

$200 copay per day, up to 5 days,

after deductible10

$500 copay per day, up to 5 days,

after deductible10

$500 copay per admission, after deductible11

20% coinsurance, after deductible

Outpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

$50 copay, after deductible

$70 copay, after deductible

EPO HSA $50/$75

LOCAL VALUE8 REGIONAL PREFERRED

In-network $3,00012 / $6,000

50%

$6,750 / $13,500

$50 copay, after deductible $75 copay, after deductible

50% coinsurance, after deductible

50% coinsurance, after deductible $500 copay per admission, after deductible11

50% coinsurance, after deductible 50% coinsurance, after deductible

$500 copay per admission, after deductible11

$70 copay, after deductible

Rehabilitation Therapy Services3 Chiropractic Care2

Durable Medical Equipment

$50 copay, after deductible 50% coinsurance, after deductible

$65 copay, after deductible

$65 copay, after deductible

50% coinsurance, after deductible

50% coinsurance, after deductible

Generic Rx Brand Rx

Non-Preferred Brand Rx

50% coinsurance, up to $125 max, after deductible

50% coinsurance, up to $125 max, after deductible

50% coinsurance, up to $125 max, after deductible

Plan year and calendar year options available. | All Rx plans are creditable. 5



PRESCRIPTION BENEFITS 30 DAY SUPPLY4

MEDICAL BENEFITS

SILVER

BENEFITS

EPO

AMERIHEALTH ADVANTAGE

$30/$60

EPO HSA

AMERIHEALTH HOSPITAL ADVANTAGE

$50/$75

CHOOSE YOUR NETWORK

DEDUCTIBLE INDIVIDUAL / FAMILY AFTER DEDUCTIBLE

MEMBER PAYS MAXIMUM

OUT-OF-POCKET INDIVIDUAL / FAMILY

Primary Care Visits

Specialist Visits

AMERIHEALTH ADVANTAGE5

Tier 1

Tier 2

$2,500 / $5,0006

20%

50%

$7,500 / $15,0007

$30 copay $60 copay

50% coinsurance, after deductible

50% coinsurance, after deductible

Urgent Care Services

20% coinsurance, after deductible

Emergency Room

Outpatient Surgery Ambulatory Surgical Inpatient Hospital Services Including Maternity

X-rays & Diagnostic Imaging

Imaging CT/PT Scans, MRIs

20% coinsurance, after deductible

50% coinsurance, after deductible

20% coinsurance, after deductible

50% coinsurance, after deductible

50% coinsurance, after deductible

AMERIHEALTH HOSPITAL ADVANTAGE9

Tier 1

Tier 2

$1,50012 / $3,000 6

50%

$6,000 / $12,0007

$50 copay, after deductible

$75 copay, after deductible

$85 copay, after deductible

$100 copay, after deductible1

50% coinsurance, after deductible

10% coinsurance, after deductible

50% coinsurance, after deductible

50% coinsurance, after deductible

Laboratory

no charge, no deductible

no charge, after deductible

Inpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

20% coinsurance, after deductible

50% coinsurance, after deductible

Outpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

$60 copay

10% coinsurance, after deductible

50% coinsurance, after deductible

$70 copay, after deductible

Rehabilitation Therapy Services3 Chiropractic Care2

Durable Medical Equipment

$60 copay 50% coinsurance, after deductible

$65 copay, after deductible 50% coinsurance, after deductible

Generic Rx Brand Rx

Non-Preferred Brand Rx

$10 copay

50% coinsurance, up to $125 max, no deductible

$10 copay, after deductible

50% coinsurance, up to $125 max, after deductible

EPO HSA 20%/20%

LOCAL VALUE8 REGIONAL PREFERRED

In-network $2,50012 / $5,000

20% $6,750 / $13,500 20% coinsurance, after deductible 20% coinsurance, after deductible

20% coinsurance, after deductible

20% coinsurance, after deductible

20% coinsurance, after deductible no charge, after deductible

20% coinsurance, after deductible

20% coinsurance, after deductible

20% coinsurance, after deductible

50% coinsurance, after deductible $10 copay, after deductible 50% coinsurance, up to $125 max, after deductible

Plan year and calendar year options available. | All Rx plans are creditable. 6



NEW

EPO HSA 0%/30%

LOCAL VALUE8

REGIONAL PREFERRED In-network

$2,50012 / $5,000

30%

EPO HSA 0%/0%

LOCAL VALUE8 REGIONAL PREFERRED

In-network $2,50012 / $5,000

n/a

EPO $30/$70

50% COINS

LOCAL VALUE8

REGIONAL PREFERRED In-network

$2,500 / $5,000

50%

HMO $50/$7513

POS PLUS $50/$75

LOCAL VALUE8

LOCAL VALUE8

REGIONAL PREFERRED In-network

$2,500 / $5,000

REGIONAL PREFERRED In-network Out-of-network $2,500 / $5,000 $5,000 / $10,000

50%

20%

40%

$6,750 / $13,500

$6,750 / $13,500

no charge, after deductible

no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

no charge, after deductible

no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

30% coinsurance, after deductible no charge, after deductible

$7,500 / $15,000

$30 copay

$70 copay $85 copay, after deductible 50% coinsurance, after deductible

50% coinsurance, after deductible

$7,500 / $15,000

$50 copay

$75 copay

$85 copay $100 copay, after deductible1

50% coinsurance, after deductible

$7,500 / $15,000 $15,000 / $30,000

$50 copay

$75 copay

$85 copay 20% coinsurance, after deductible

40% coinsurance, after deductible

40% coinsurance, after deductible

covered at in-network level

covered at in-network level

20% coinsurance, 40% coinsurance, after deductible after deductible

50% coinsurance, after deductible

no charge, no deductible

50% coinsurance, after deductible

$60 copay

$50 copay $100 copay

20% coinsurance, 40% coinsurance, after deductible after deductible

no charge, no deductible

50% coinsurance, after deductible

no charge, no deductible

20% coinsurance, after deductible

40% coinsurance, after deductible

40% coinsurance, after deductible

$70 copay

$70 copay

40% coinsurance, after deductible

30% coinsurance, after deductible no charge, after deductible

$60 copay

50% coinsurance, after deductible no charge, after deductible

$10 copay, after deductible

$15 copay, after deductible

50% coinsurance, up to $125 max, after deductible

50% coinsurance, up to $125 max, after deductible

NEW

POPULAR PLAN

Plan year and calendar year options available. | All Rx plans are creditable.

50% coinsurance, after deductible

50% coinsurance, up to $125 max, no deductible

7

$65 copay

$65 copay

40% coinsurance, after deductible

50% coinsurance, after deductible

$10 copay

50% coinsurance, up to $125 max, after deductible

POPULAR PLAN

50% coinsurance, after deductible

$10 copay

50% coinsurance, up to $125 max, after deductible

not covered; 50%

reimbursement



PRESCRIPTION BENEFITS 30 DAY SUPPLY4

MEDICAL BENEFITS

GOLD

BENEFITS

EPO

AMERIHEALTH ADVANTAGE

$10/$30

EPO

AMERIHEALTH HOSPITAL ADVANTAGE

$30/$50

EPO HSA 10%/10%

CHOOSE YOUR NETWORK

DEDUCTIBLE INDIVIDUAL / FAMILY

AFTER DEDUCTIBLE MEMBER PAYS MAXIMUM

OUT-OF-POCKET INDIVIDUAL / FAMILY

Primary Care Visits

Specialist Visits

Urgent Care Services

Emergency Room

AMERIHEALTH ADVANTAGE5

Tier 1

Tier 2

$1,200 / $2,4006

20%

50%

$5,500 / $11,0007

$10 copay

$50 copay

$30 copay

$75 copay

$75 copay

$100 copay1

Outpatient Surgery Ambulatory Surgical

Inpatient Hospital Services Including Maternity

X-rays & Diagnostic Imaging Imaging CT/PT Scans, MRIs

20% coinsurance, after deductible

50% coinsurance, after deductible

20% coinsurance, after deductible

Laboratory

no charge, no deductible

AMERIHEALTH HOSPITAL ADVANTAGE9

Tier 1

Tier 2

$1,200 / $2,4006

20%

50%

$5,000 / $10,0007

$30 copay

$50 copay

$75 copay

$100 copay1

50% coinsurance, after deductible

20% coinsurance, after deductible

$500 copay per day,

up to 5 days10

50% coinsurance, after deductible

50% coinsurance, after deductible

$50 copay

$100 copay

no charge, no deductible

Inpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

Outpatient Treatment Mental Behavioral Health, Substance Abuse Disorder

20% coinsurance, after deductible

50% coinsurance, after deductible

$30 copay

Rehabilitation Therapy Services3 Chiropractic Care2

Durable Medical Equipment

$60 copay 50% coinsurance, after deductible

Generic Rx Brand Rx

Non-Preferred Brand Rx

$10 copay $40 copay $75 copay

$500 copay per day,

up to 5 days10

50% coinsurance, after deductible

$50 copay

$50 copay

50% coinsurance, after deductible $10 copay

50% coinsurance, up to $125 max, no deductible

Plan year and calendar year options available. | All Rx plans are creditable. 8

NATIONAL ACCESS In-network

$1,550c / $3,100 10%

$5,000 / $10,000 10% coinsurance, after deductible 10% coinsurance, after deductible 10% coinsurance, after deductible

10% coinsurance, after deductible

10% coinsurance, after deductible no charge, after deductible

10% coinsurance, after deductible

10% coinsurance, after deductible

10% coinsurance, after deductible

50% coinsurance, after deductible $10 copay, after deductible $40 copay, after deductible $75 copay, after deductible

POPULAR PLAN



NEW

EPO HSA 0%/20%

REGIONAL PREFERRED

In-network $1,35012 / $2,700

20%

EPO HSA 0%/0%

LOCAL VALUE8 REGIONAL PREFERRED

In-network $1,55012 / $3,100

EPO $30/$60

20% COINS

LOCAL VALUE8 REGIONAL PREFERRED

NATIONAL ACCESS In-network

$1,000 / $2,000

HMO $30/$6513

RX 50%/$125 MAX

REGIONAL PREFERRED

In-network $0 / $0

POS PLUS $30/$70

REGIONAL PREFERRED

NATIONAL ACCESS

In-network

Out-of-network

$1,500 / $3,000

$3,000 / $6,000

n/a

20%

10%

10%

30%

$4,900 / $9,800

$5,000 / $10,000

no charge, after deductible 20% coinsurance, after deductible

no charge, after deductible no charge, after deductible

20% coinsurance, after deductible

no charge, after deductible

$7,000 / $14,000

$30 copay $60 copay $75 copay $100 copay1

20% coinsurance, after deductible

no charge, after deductible

20% coinsurance, after deductible no charge, after deductible

20% coinsurance, after deductible 20% coinsurance, after deductible

no charge, after deductible

no charge, after deductible

no charge, after deductible

no charge, after deductible

20% coinsurance, after deductible

20% coinsurance, after deductible

no charge, no deductible

20% coinsurance, after deductible

$60 copay

$7,000 / $14,000

$6,500 / $13,000

$13,000 / $26,000

$30 copay $65 copay $85 copay

$100 copay1

10% coinsurance, up to $250 max

$500 copay per day, up to 5 days10 $50 copay $100 copay

no charge

$30 copay

$70 copay

$85 copay

$100 copay, after deductible1

10% coinsurance, up to $250 max, after deductible

$500 copay per day, up to 5 days,

after deductible10

$50 copay

$100 copay

30% coinsurance, after deductible 30% coinsurance, after deductible covered at in-network level covered at in-network level

30% coinsurance, after deductible

30% coinsurance, after deductible

no charge, no deductible

30% coinsurance, after deductible

$500 copay per day, up to 5 days10

$500 copay per day, up to 5 days,

after deductible10

30% coinsurance, after deductible

$65 copay

$70 copay

30% coinsurance, after deductible

20% coinsurance, after deductible

no charge, after deductible

$60 copay

50% coinsurance, after deductible

no charge, after deductible

50% coinsurance, after deductible

$10 copay, after deductible $10 copay, after deductible

$10 copay

50% coinsurance, up to $125 max, after deductible

$40 copay, after deductible $75 copay, after deductible

$40 copay $75 copay

POPULAR PLAN

Plan year and calendar year options available. | All Rx plans are creditable.

9

$65 copay

50% coinsurance, no deductible

50% coinsurance, up to $125 max,

no deductible

$65 copay

30% coinsurance, after deductible

50% coinsurance, after deductible

$10 copay $40 copay $75 copay

not covered, 50% reimbursement



 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download