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

Transcription

1 2019 Benefits at a Glance GROUPS Choose the best health plan for you and your business. Use this brochure to compare health plans and cost-sharing.

2 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 whether it s to explain the different types of health plans or to help 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. Health plan options There are several types of health plans that you can choose from. The type of plan you choose will affect the process members follow to get care. Point-of-Service (POS) Best if members have or want a primary care provider to coordinate their care but still want the freedom to choose a particular doctor or hospital in- or out-of-network. POS plans offer the highest level of benefits when members visit providers that participate within the network, but the plans also provide the option to seek care outside of the network, as well. If you select a Plus product, 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 to an EPO health plan can save members money if you choose a plan with a high. 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. Preferred Provider Organization with a Health Savings Account (PPO with HSA) Best if members want an expansive network and the freedom to see any doctor or specialist you want, in-or out-ofnetwork, without a referral. Adding an HSA can save your members money if you choose a plan with a high. 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. Looking for a plan focused on affordability? Check out our Advantage plans on pages

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 Available through the Multiplan PHCS National network for services obtained outside of the Regional Preferred service area. 1,3 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 Lancaster Northampton Lehigh Bucks Berks Montgomery Chester SOUTHEASTERN 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. 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 are included in the AmeriHealth Advantage health systems: AtlantiCare Regional Medical Center - City Division, AtlantiCare Regional Medical Center - Mainland Division, Bayshore Community Hospital, Cape Regional Medical Center, Clara Maass Medical Center, Community Medical Center, Cooper University Hospital, Deborah Heart and Lung Center, Jersey City Medical Center, Jersey Shore University Medical Center, Monmouth Medical Center, Monmouth Medical Center - Southern Campus, Mountainside Medical Center, Newark Beth Israel Medical Center, Ocean Medical Center, Palisades Medical Center, Raritan Bay Medical Center - Old Bridge, Raritan Bay Medical Center - Perth Amboy, Riverview Medical Center, RWJ University Hospital at Hamilton, RWJ University Hospital at New Brunswick, RWJ University Hospital at Somerset, RWJ University Hospital at Rahway, 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. PA Local Value The Local Value network offers employers a more affordable rate by providing access to a subset of the Regional Preferred network in New Jersey. 4 New Castle Philadelphia Delaware Kent Sussex DE Warren Hunterdon Gloucester Salem Cumberland NJ Sussex 4 Morris Passaic Burlington Essex Union Somerset Middlesex Monmouth Mercer Camden Atlantic Cape May Bergen Ocean Hudson 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. 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. 4 These plans were designed to meet the needs of 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-of-pocket costs for hospital and facility services if they use a participating Hospital Advantage provider. Tier 2 providers are available through the AmeriHealth New Jersey Local Value network and are not available to employers based in Hunterdon County. 4,7,8 Sussex Passaic Bergen Warren Morris Essex Union Hunterdon 4 Somerset Middlesex Mercer Burlington Gloucester Camden Salem Atlantic Cumberland Cape May Hudson Hunterdon 4 Somerset Middlesex Mercer Burlington Monmouth Ocean Gloucester Camden Salem Atlantic Cumberland Cape May Sussex Passaic Bergen Warren Morris Essex Union Hudson Monmouth Ocean 8 Pin drops are for illustrative purposes only. For a complete listing of AmeriHealth Hospital Advantage providers and facilities, visit /hospitaladvantage. 4 5

4 , $45 copay, AMERIHEALTH ADVANTAGE EPO AMERIHEALTH ADVANTAGE EPO AMERIHEALTH HOSPITAL ADVANTAGE ECONOMY HSA HIGH 5 MEDIUM 5 LOW 5 ECONOMY 5 LOW HSA 5 $15 / $25 5 HIGH 8 LOW 8 8 w/int $7//$125 Max Rx 4 w/int $7//$125 Max Rx 4 MEDICAL BENEFITS Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 $1,000 / $2,000 6 $2,000 / $4,000 6 $2,500 / $5,000 6 $2,500 / $5,000 6 $2, / $5,000 6 $1,500 / $3,000 6 $1,500 / $3,000 6 $2,500 / $5,000 6 $2, / $5,000 6 $4,000 / $8,000 7 $5,000 / $10,000 7 $6,600 / $13,200 7 $6,850 / $13,700 7 $6,550 / $13,100 7,13 $5,000 / $10,000 7 $4,000 / $8,000 7 $6,850 / $13,700 7 $6,550 / $13,100 7,13 Primary Care Visits $15 copay,, $15 copay, Specialist Visits, $45 copay, $60 copay, $60 copay, $25 copay, Emergency Room Urgent Care Services 10% 40% Outpatient Surgery $100 copay per day, up to 5 days ($500), 9 $300 copay per day, up to 5 days ($1,500), 9 20% $100 copay per day, up to 5 days ($500), 9 $300 copay per day, up to 5 days ($1,500), 9 10% 40% X-rays and Diagnostic Imaging Imaging CT/PT Scans, MRIs 11 Laboratory Durable Medical Equipment $100 copay per day, up to 5 days 20% ($500), 9 $100 copay per day, up to 5 days ($500), 9 10%, $45 copay, $60 copay, $60 copay, $25 copay, $60 copay, $60 copay, 6 7

5 EPO HSA EPO HSA EPO $1,350 Ded Coins w/int $7//$125 Max Rx 4 $1,500 Ded 70% Coins w/int $7//$125 Max Rx 4 $1,500 Ded 70% Coins w/int $10/$40/$60 Rx 4 $2,500 Ded 100% Coins w/int $25/$50/$75 Rx 4 $2,500/ w/int $25/$50/$75 Rx 4 $30/$50 $500 per day/$250 Ded $20/$50 $2,000 Ded 70% Coins MEDICAL BENEFITS In-network In-network In-network In-network MEDICAL BENEFITS In-network In-network In-network $1, / $2,700 $1, / $3,000 $1, / $3,000 $2, / $5,000 $2, / $5,000 $250 / $500 $2,000 / $4,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $6,650 / $13, $5,000 / $10, $3,500 / $7,000 $4,000 / $8,000 Primary Care Visits Primary Care Visits, Specialist Visits Specialist Visits Emergency Room Urgent Care Services 2 Emergency Room 2 Urgent Care Services 1 Outpatient Surgery Outpatient Surgery $500 copay per day,, up to 5 days ($2,500) 9 $300 copay, X-rays and Diagnostic Imaging Imaging CT/PT Scans, MRIs 11 X-rays and Diagnostic Imaging Imaging CT/PT Scans, MRIs 11 10% Laboratory Laboratory Durable Medical Equipment Durable Medical Equipment 10% $500 copay per day,, up to 5 days ($2,500) 9 NEW NEW NEW 8 9

6 EPO EPO $20/$40/$250 $30/$50/$500 $30/$50 $1,500 Ded 70% Coins $30/$50 $2,500 Ded 80% Coins $100 ER $20/$40/$1,500 Ded 80% Coins $20/$40 $250/Day $2,000 Ded $50/$75/$2,500 Ded* MEDICAL BENEFITS In-network In-network In-network In-network In-network In-network In-network $0 / $0 $0 / $0 $1,500 / $3,000 $2,500 / $5,000 $1,500 / $3,000 $2,000 / $4,000 $2,500 / $5,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $6,000 / $12,000 $3,000 / $6,000 $5,000 / $10,000 $7,350 / $14,700 Primary Care Visits $30 copay,, Specialist Visits $50 copay,, Emergency Room $100 copay 2 $100 copay Urgent Care Services $250 copay per day, up to 5 days ($1,250) 9 $500 copay per day, up to 5 days ($2,500) 9 20% 20% $250 copay per day, up to 5 days Outpatient Surgery $200 copay $300 copay $200 copay, ($1,250), 9,, 20% $50 copay,, X-rays and Diagnostic Imaging Imaging CT/PT Scans, MRIs 11, 20%, Laboratory Durable Medical Equipment 20% $250 copay per day, up to 5 days ($1,250) 9 $500 copay per day, up to 5 days ($2,500) 9 20% 20% $250 copay per day, up to 5 days ($1,250), 9 $50 copay,, NEW NEW 10 11

7 POS POS $20/$40 $300/Day $30/$50 $400/Day $20/$40 $1,000 Ded 90% Coins $30/$50 $1,500 Ded 80% Coins $30/$50 $2,000 Ded 70% Coins MEDICAL BENEFITS In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network $0 / $0 $1,500/$3,000 $0 / $0 $2,500 / $5,000 $1,000 / $2,000 $2,000 / $4,000 $1,500 / $3,000 $3,000 / $6,000 $2,000 / $4,000 $3,000 / $6,000 $3,000 / $6,000 $9,000/$18,000 $4,000 / $8,000 $12,000 / $24,000 $2,000 / $4,000 $5,000 / $10,000 $2,500 / $5,000 $6,000 / $12,000 $3,500 / $7,000 $15,000 / $30,000 Primary Care Visits $30 copay, Specialist Visits $50 copay, Emergency Room $100 copay 2 $100 copay Urgent Care Services $300 copay per day, up to 5 days ($1,500) 9 $400 copay per day, up to 5 days ($2,000) 9 Outpatient Surgery $150 copay $200 copay 10% 20% $50 copay, X-rays and Diagnostic Imaging $50 copay Imaging CT/PT Scans, MRIs 11 $80 copay $100 copay, $80 copay, Laboratory Durable Medical Equipment 10% 20% $300 copay per day, up to 5 days ($1,500) 9 $400 copay per day, up to 5 days ($2,000) 9 10% 20% $50 copay, 12 13

8 POS PLUS POS PLUS $10/$20 $0/Day $20/$40 $0/Day $20/$40 $250/Day $30/$40 $300/Day $20/$40 $1,000 Ded 90% Coins $30/$50 $1,500 Ded 80% Coins $30/$50 $2,000 Ded 70% Coins MEDICAL BENEFITS In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network $0 / $0 $500 / $1,500 $0 / $0 $1,000 / $3,000 $0 / $0 $1,000 / $3,000 $1,500 / $3,000 $4,500 / $9,000 $2,000 / $4,000 $6,000 / $12,000 $2,500 / $5,000 $7,500 / $15,000 $0 / $0 $2,000 / $6,000 $1,000 / $2,000 $2,000 / $4,000 $1,500 / $3,000 $3,000 / $6,000 $2,000 / $4,000 $3,000 / $6,000 $3,000 / $6,000 $9,000 / $18,000 $2,500 / $5,000 $5,000 / $10,000 $3,000 / $6,000 $6,000 / $12,000 $4,000 / $8,000 $15,000 / $30,000 Primary Care Visits $10 copay 20% $30 copay, Specialist Visits 20%, Emergency Room $100 copay 2 $100 copay 2 $100 copay 2 $100 copay Urgent Care Services 20% Outpatient Surgery 20% $250 copay per day, up to 5 days ($1,250) 9 $125 copay $300 copay per day, up to 5 days ($1,500) 9 $150 copay 10% 20% 20%, X-rays and Diagnostic Imaging 20% Imaging CT/PT Scans, MRIs 11 $80 copay $80 copay $80 copay, $80 copay, Laboratory 20% Durable Medical Equipment 20% $250 copay per day, up to 5 days ($1,250) 9 $300 copay per day, up to 5 days ($1,500) 9 10% 20% 20%, 14 15

9 $1,350 Ded 100% Coins w/int $10/$40/$60 Rx 4 PPO HSA $2,000 Ded 90% Coins w/int $7/$35/$50 Rx 4 $2,500 Ded 70% Coins w/int $7/$35/$50 Rx 4 MEDICAL BENEFITS In-network Out-of-network In-network Out-of-network In-network Out-of-network $1, / $2,700 $3,000 / $6,000 $2, / $4,000 $5,000 / $10,000 $2, / $5,000 $5,000 / $10,000 Rx Options AmeriHealth New Jersey prescription drug programs are administered by FutureScripts 5, our pharmacy benefits manager. The FutureScripts retail network includes more than 60,000 participating pharmacies nationwide, including the area s largest retail chains. Primary Care Visits Specialist Visits Emergency Room Urgent Care Services Outpatient Surgery $1,500 / $3,000 $15,000 / $30,000 $5,000 / $10, $10,000 / $20,000 $5,000 / $10, $10,000 / $20,000 10% 10% 10% 10% FutureScripts 1 provides convenient online tools, available to members through amerihealthexpress.com, where you can easily manage prescriptions: Compare the price of brand-name drugs to generic equivalents Sign up and save money with mail order services Review prescription records Find a participating pharmacy Review your coverage and cost-sharing information Download forms By combining medical and prescription drug benefits, we can help manage your employees total health care picture, all in one place. That s why AmeriHealth New Jersey offers several Rx plan options for you to pair with your medical benefits. Rx Options 2 Generic Rx Preferred Brand Rx Non-preferred Brand Rx $7 / $35 / $50 $7 $35 $50 10% $15 / $35 / $50 $15 $35 $50 $10 / $40 / $60 $10 $40 $60 X-rays and Diagnostic Imaging $25 / $50 / $75 $25 $50 $75 Imaging CT/PT Scans, MRIs 11 10% $7 / up to $125 $7 up to $125 max Laboratory N E W $25/ up to $75 $25 up to $75 max Durable Medical Equipment 10% up to $125 up to $125 max 1 FutureScripts, a Catamaran TM company, is an independent company that provides pharmacy benefit management services. 10% 40% coinsurance 2 30 day supply. 10% 40% coinsurance 16 17

10 Technology and resources We know you don t always have the time or the resources to focus on your health. That s why we have online account management systems and personalized tools to help manage your health quickly and easily so you get the most out of your benefi ts. Health insurance that s mobile. Manage your health online at amerihealthexpress.com or download the free AHNJ On the Go app to help you make the most of your health plan. Streamlined navigation will make it easier than ever to fi nd a participating provider, view your claims and benefi t information, manage your spending account, download a temporary ID card, , or fax one directly to your doctor, and so much more! Get Connected It pays to stay in the know with AmeriHealth New Jersey Wire text messages. 1 Sign up at /getwired. Search Provider Finder. Search for a participating doctor by name, location, or specialty. Find out where a doctor went to medical school, his or her board certifi cation, and languages spoken. You can even view offi ce hours and the hospitals to which a physician has admitting privileges. Start shopping. Start saving with the Insider Discount program. Find great deals on a wide range of attractions and events, some are even FREE! Learn how to get discounted movie tickets, and so much more at /discounts. All plans within this brochure reflect member cost-sharing. Important health plan information The benefi t summaries in this brochure represent only a partial listing of benefi ts of the health plans. Some services not shown in this brochure may require a higher member coinsurance than the services shown. Benefi ts and exclusions may be further defi ned by medical policy. These managed care plans may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, please contact your broker. Medical Footnotes: 1 Emergency room copay waived if admitted. 2 Emergency room copay not waived if admitted. 3 Visit limits may apply. See benefit booklet for details. 4 Prescription mail order benefit is available at 2x applicable cost-sharing for a 90 day supply. 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 Deductible is combined for tier 1 and tier 2. 7 Out-of-pocket maximum is combined for tier 1 and tier 2. 8 AmeriHealth Hospital Advantage providers are an enhancement to your benefits. Tier 2 providers are AmeriHealth New Jersey Local Value network providers. 9 Copay is required per day, up to a maximum of 5 days per admission. Copay waived if readmitted within 10 days. 10 Individual not applicable in policies covering 2 or more people. 11 Subject to preapproval. 12 For family plans no individual will exceed a $6,650 maximum out-of-pocket. 13 For family plans no individual will exceed a $6,550 maximum out-of-pocket. *This plan does not meet Minimum Value as defined by the Affordable Care Act. It does meet Minimum Value when paired with any of our standard RX options. Your health coverage can help pay for college. We can help families keep up with the cost of attending college through an arrangement with The College Tuition Benefi t. Learn more at amerihealthnj.collegetuitionbenefit.com. Virtual health care at your fingertips. 2 Introducing telemedicine the option to access non-emergency health care virtually. You can now visit with a doctor 24/7/365 from your home, offi ce, or on-the-go in most states. Activate your account by calling or visit MDLIVE.com/amerihealthnj. 1 Please have your member ID card ready when you text to sign up. Standard message and data rates may apply. Text STOP to stop and HELP for help. Terms and conditions available at myhelpsite.net/amerihealth. Notifi cation messages within AmeriHealth New Jersey Wire are sent via automated SMS. Enrollment in AmeriHealth New Jersey Wire is not a requirement to purchase goods and services from AmeriHealth New Jersey. Wire is a trademark of Relay Network, LLC. 2 MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. *MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit

11 2019 AmeriHealth November AmeriHealth Insurance Company of New Jersey AmeriHealth HMO, Inc.