Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) [TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]] PREVENTIVE CARE $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 2 contracts

Samples: www.nj.gov, www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ~~____________________________________~~ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) [TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]] PREVENTIVE CARE $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ •Second Surgical Opinion NONE ~~All~~ •All other Covered Services and Supplies ~~Per~~ •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 2 contracts

Samples: www.nj.gov, www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by [Other than contraceptives] Carrier with Copayments consistent [including network contraceptives not with N.J.A.C. 11:22-5.5(a).] [0% for covered under the Contraceptives provision] contraceptives] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment CONTRACEPTIVES: $0 copayment [included under the contraceptives provision] BREASTFEEDING SUPPORT: $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), ~~maximum30~~ Maximum 30 visits per [Calendar] [Plan] Year ~~See below for~~ Note: the ~~separate~~ limit does not apply to speech therapy ~~benefits available~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) ), maximum 30 visits per [Calendar] [Plan] Year ~~See below for the separate benefits available under the Charges for speech~~ Note: The limit does not apply to physical or occupational therapy ~~per [Calendar] [Plan] Year provided~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE Prescription Drugs [Other than contraceptives] [including network contraceptives not covered under the Contraceptives provision] [Copayments consistent with N.J.A.C. 11:22-5.5] [0% for contraceptives] [subject to the Prescription Drug Cost Sharing Limit] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50[Other than contraceptives] [including contraceptives not Included under the contraceptives provisions]50% [0% for contraceptives] Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 2 contracts

Samples: www.state.nj.us, www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 2 contracts

Samples: www.nj.gov, www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~HOME HEALTH CARE 60 visits, if Pre-Approved;~~ [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit MAXIMUM OUT OF POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [$6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the ~~Copayments~~ Copayments, Deductible and Coinsurance set forth below and are determined per ~~[Calendar] [Plan]~~ Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT ~~Preventive Care NONE All other~~ Primary Care Provider but not for Preventive Care Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ]] per visit Preventive Care NONE Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR  ~~Primary Care Provider Visits including~~ Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion ~~NONE~~ All other Covered Services and Supplies Per ~~Covered Person Dollar~~ Member [dollar amount not to exceed ~~deductible~~ the amount permitted by ~~45 CFR 156.130(b)~~N.J.A.C. 11:20-3.1(b)3i]  [Per Covered Family ~~[Dollar~~ amount ~~which is two~~ equal to 2 times the ~~individual Deductible~~per member amount.] COINSURANCE ~~Preventive Care 0%~~ [Prescription Drugs 50% ~~[Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%~~] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] Preventive Care: NONE All ~~other~~ services and supplies to which a Copayment does not apply [10% - 50%, in 510% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT ~~[amount consistent with N.J.A.C. 11:22-5.5]~~ $100 Copayment/visit/Member (~~credited toward Inpatient admission~~ waived if ~~admission occurs~~ admitted within 24 hours ~~as the result of the emergency~~).

Appears in 2 contracts

Samples: www.nj.gov, www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ~~____________________________________~~ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. ~~11:22-~~11:22- 5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ •Second Surgical Opinion NONE ~~All~~ •All other Covered Services and Supplies ~~Per~~ •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES EFFECT OF MEDICARE ON AN INDIVIDUAL HEALTH BENEFITS PLAN SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: PREVENTIVE CARE: NONE CONTRACEPTIVES: NONE [included under the contraceptives provision] BREASTFEEDING SUPPORT: NONE HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~HOME HEALTH CARE 60 visits, if Pre-Approved;~~ [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS [Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] [0% for contraceptives] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~SCHEDULE~~ MAXIMUM OUT OF ~~SERVICES AND SUPPLIES [Example Using Deductible~~POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, ~~Coinsurance] The services or supplies covered under this Contract are subject to the Copayments~~ Deductible and Coinsurance ~~set forth below~~ for all Covered Services and ~~are determined~~ Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [~~Calendar~~$6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [~~Plan~~$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF INSURANCE Example High Deductible health plan text that could be used in conjunction with an HSA Calendar Year ~~per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT~~ Cash Deductible Preventive Care NONE ~~All other Primary~~ Contraceptives, [included under the Contraceptives provision] except as stated below NONE Breastfeeding Support NONE Immunizations and Lead screening for children as detailed in the Immunizations and Lead Screening provision NONE Second surgical opinion NONE Maternity Care ~~Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity~~ (pre-natal ~~care~~visits) NONE [Prescription Drugs and] Male sterilization or Male contraceptives [~~Copayments consistent with N.J.A.C. 11:22-5.5~~Minimum deductible to qualify as a high deductible health plan under Internal Revenue Code Section 223] All other ~~services and supplies Copayment Not Applicable; Refer~~ Covered Charges [per Member [the greater of: $XXXX or the lowest amount to ~~the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR~~qualify as a high deductible health plan under Internal Revenue Code section 223] [~~PLAN~~$XXXX] ~~YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening~~ [$XXXX or the highest amount for ~~children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible~~ which deductions are permitted ~~by 45 CFR 156.130(b)~~under Internal Revenue Code 223]  [~~Per~~ $XXXX]] [per Covered Family [~~Dollar~~ the greater of: $XXXX or the lowest amount to qualify as a high deductible health plan under Internal Revenue Code section 223] [$XXXX] [$XXXX or the highest amount for which deductions are permitted under Internal Revenue Code 223] [$XXXX]] Coinsurance Coinsurance is ~~two times~~ the ~~individual Deductible.] COINSURANCE~~ percentage of a Covered Charge that must be paid by a Member. We will waive the Coinsurance requirement once the Maximum Out of Pocket has been reached. This Contract's Coinsurance, as shown below, does not include Cash Deductibles, Copayments, penalties incurred under this Policy's Utilization Review provisions, or any other Non-Covered Charge. The Coinsurance for this Contract is as follows: Preventive ~~Care~~ Care: 0% ~~Prescription Drugs 50~~Contraceptives [included under the Contraceptives provision] 0% Breastfeeding support 0% [Vision Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other Covered Charges [30%, 20%] Maximum Out of Pocket Maximum Out of Pocket means the annual maximum dollar amount that a Member or Covered Family, as applicable, must pay as Copayment, Deductible and Coinsurance for all covered services and supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member or Covered Family, as applicable, has no further obligation to ~~which a Copayment~~ pay any amounts as Copayment, Deductible and Coinsurance for covered services and supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: [per Member [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] [per Covered Family [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] Note: The Maximum Out of Pocket cannot be met with Non-Covered Charges. Limits: Therapeutic manipulation per Calendar Year 30 visits Speech therapy per Calendar Year 30 visits Note: This limit does not apply to speech therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Cognitive therapy per Calendar Year 30 visits Physical therapy per Calendar Year 30 visits Note: This limit does not apply to physical therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Occupational therapy per Calendar Year 30 visits Note: This limit does not apply to occupational therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Charges for hearing aids for a Member one hearing aid per hearing impaired ear per 24-month period [~~10% - 50%, in 5% increments~~Doula Services [Global Maximum per pregnancy [$0-$5,000 (amount to be determined by carrier) ] ~~All services and supplies~~ ] [Standard Benefit Visit limit [Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (Visit limit to ~~which a Copayment applies None EMERGENCY ROOM COPAYMENT~~ be determined by carrier)]] [~~amount consistent with N.J.A.C. 11:22~~Labor [1-~~5.5~~5 Visit(s) (Visit limit to be determined by carrier]] ~~Copayment/visit/Member~~ [Enhanced Benefit Visit limit Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (~~credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency~~Visit limit to be determined by carrier).] Labor [1-5 Visit(s) (Visit limit to be determined by carrier]]

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ~~____________________________________~~ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment CONTRACEPTIVES: $0 copayment BREASTFEEDING SUPPORT: $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), ~~maximum30~~ Maximum 30 visits per [Calendar] [Plan] Year ~~See below for~~ Note: the ~~separate~~ limit does not apply to speech therapy ~~benefits available~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) ), maximum 30 visits per [Calendar] [Plan] Year ~~See below for the separate benefits available under the Charges for speech~~ Note: The limit does not apply to physical or occupational therapy ~~per [Calendar] [Plan] Year provided~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE Contraceptives NONE Breastfeeding Support NONE Prescription Drugs [Other than contraceptives Copayments consistent with N.J.A.C. ~~11:22-5.5~~11:22- 5.5]‌ [subject to the Prescription Drug Cost Sharing Limit] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ •Contraceptives NONE •Breastfeeding Support NONE •Second Surgical Opinion NONE ~~All~~ •All other Covered Services and Supplies ~~Per~~ •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% Contraceptives NONE Breastfeeding Support NONE [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: PREVENTIVE CARE: NONE CONTRACEPTIVES: NONE [included under the contraceptives provision] BREASTFEEDING SUPPORT: NONE HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~HOME HEALTH CARE 60 visits, if Pre-Approved;~~ [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS [Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] [0% for contraceptives] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~SCHEDULE~~ MAXIMUM OUT OF ~~SERVICES AND SUPPLIES [Example Using Deductible~~POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, ~~Coinsurance] The services or supplies covered under this Contract are subject to the Copayments~~ Deductible and Coinsurance ~~set forth below~~ for all Covered Services and ~~are determined~~ Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [~~Calendar~~$6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [~~Plan~~$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF INSURANCE Example High Deductible health plan text that could be used in conjunction with an HSA Calendar Year ~~per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT~~ Cash Deductible Preventive Care NONE ~~All other Primary~~ Contraceptives, [included under the Contraceptives provision] except as stated below NONE Breastfeeding Support NONE Immunizations and Lead screening for children as detailed in the Immunizations and Lead Screening provision NONE Second surgical opinion NONE Maternity Care ~~Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity~~ (pre-natal ~~care~~visits) NONE [Prescription Drugs and] Male sterilization or Male contraceptives [~~Copayments consistent with N.J.A.C. 11:22-5.5~~Minimum deductible to qualify as a high deductible health plan under Internal Revenue Code Section 223] All other ~~services and supplies Copayment Not Applicable; Refer~~ Covered Charges [per Member [the greater of: $XXXX or the lowest amount to ~~the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR~~qualify as a high deductible health plan under Internal Revenue Code section 223] [~~PLAN~~$XXXX] ~~YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening~~ [$XXXX or the highest amount for ~~children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible~~ which deductions are permitted ~~by 45 CFR 156.130(b)~~under Internal Revenue Code 223]  [~~Per~~ $XXXX]] [per Covered Family [~~Dollar~~ the greater of: $XXXX or the lowest amount to qualify as a high deductible health plan under Internal Revenue Code section 223] [$XXXX] [$XXXX or the highest amount for which deductions are permitted under Internal Revenue Code 223] [$XXXX]] Coinsurance Coinsurance is ~~two times~~ the ~~individual Deductible.] COINSURANCE~~ percentage of a Covered Charge that must be paid by a Member. We will waive the Coinsurance requirement once the Maximum Out of Pocket has been reached. This Contract's Coinsurance, as shown below, does not include Cash Deductibles, Copayments, penalties incurred under this Policy's Utilization Review provisions, or any other Non-Covered Charge. The Coinsurance for this Contract is as follows: Preventive ~~Care~~ Care: 0% ~~Prescription Drugs 50~~Contraceptives [included under the Contraceptives provision] 0% Breastfeeding support 0% [Vision Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other Covered Charges [30%, 20%] Maximum Out of Pocket Maximum Out of Pocket means the annual maximum dollar amount that a Member or Covered Family, as applicable, must pay as Copayment, Deductible and Coinsurance for all covered services and supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member or Covered Family, as applicable, has no further obligation to ~~which a Copayment~~ pay any amounts as Copayment, Deductible and Coinsurance for covered services and supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: [per Member [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] [per Covered Family [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] Note: The Maximum Out of Pocket cannot be met with Non-Covered Charges. Limits: Therapeutic manipulation per Calendar Year 30 visits Speech therapy per Calendar Year 30 visits Note: This limit does not apply to speech therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Cognitive therapy per Calendar Year 30 visits Physical therapy per Calendar Year 30 visits Note: This limit does not apply to physical therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Occupational therapy per Calendar Year 30 visits Note: This limit does not apply to occupational therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Charges for hearing aids for a Member one hearing aid per hearing impaired ear per 24-month period [~~10% - 50%, in 5% increments~~Doula Services [Global Maximum per pregnancy [$0-$5,000 (amount to be determined by carrier) ] ~~All services and supplies~~ ] [Standard Benefit Visit limit [Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (Visit limit to ~~which a Copayment applies None EMERGENCY ROOM COPAYMENT~~ be determined by carrier)]] [~~amount consistent with N.J.A.C. 11:22~~Labor [1-~~5.5~~5 Visit(s) (Visit limit to be determined by carrier]] ~~Copayment/visit/Member~~ [Enhanced Benefit Visit limit Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (~~credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency~~Visit limit to be determined by carrier).] Labor [1-5 Visit(s) (Visit limit to be determined by carrier]]

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: PREVENTIVE CARE: NONE CONTRACEPTIVES: NONE [included under the contraceptives provision] BREASTFEEDING SUPPORT: NONE HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~HOME HEALTH CARE 60 visits, if Pre-Approved;~~ [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS [Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] [0% for contraceptives] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit MAXIMUM OUT OF POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [$6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the ~~Copayments~~ Copayments, Deductible and Coinsurance set forth below and are determined per ~~[Calendar] [Plan]~~ Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT ~~Preventive Care NONE All other~~ Primary Care Provider but not for Preventive Care Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ]] per visit Preventive Care NONE Maternity (pre-natal care) NONE Contraceptives [included under the Contraceptives provision] NONE Breastfeeding Support NONE Prescription Drugs [ Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] Copayments consistent with N.J.A.C. 11:22-5.5] [subject to the Prescription Drug Cost Sharing Limit] [0% for contraceptives][included under the Contraceptives provision] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR  ~~Primary Care Provider Visits including~~ Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Contraceptives [included under the Contraceptives provision] NONE Breastfeeding Support NONE Second Surgical Opinion ~~NONE~~ All other Covered Services and Supplies Per ~~Covered Person Dollar~~ Member [dollar amount not to exceed ~~deductible~~ the amount permitted by ~~45 CFR 156.130(b)~~N.J.A.C. 11:20-3.1(b)3i]  [Per Covered Family ~~[Dollar~~ amount ~~which is two~~ equal to 2 times the ~~individual Deductible~~per member amount.] COINSURANCE ~~Preventive Care~~ [Prescription Drugs [Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] 50% ][0% ~~Prescription Drugs 50% [Vision Benefits (~~for ~~Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%~~contraceptives] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] Preventive Care: NONE Contraceptives NONE Breastfeeding Support NONE All ~~other~~ services and supplies to which a Copayment does not apply [10% - 50%, in 510% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT ~~[amount consistent with N.J.A.C. 11:22-5.5]~~ $100 Copayment/visit/Member (~~credited toward Inpatient admission~~ waived if ~~admission occurs~~ admitted within 24 hours ~~as the result of the emergency~~).

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: PREVENTIVE CARE: NONE CONTRACEPTIVES: NONE BREASTFEEDING SUPPORT: NONE HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22- 5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22- 5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE ~~60 visits~~Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS Other than contraceptives [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit MAXIMUM OUT OF POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: •Per Member per Calendar Year [$6,850 or amount permitted by 45 C.F.R. 156.130] •Per Family per Calendar Year [$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the ~~Copayments~~ Copayments, Deductible and Coinsurance set forth below and are determined per ~~[Calendar] [Plan]~~ Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT ~~Preventive Care NONE All other~~ Primary Care Provider but not for Preventive Care Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ]] per visit Preventive Care NONE Maternity (pre-natal care) NONE Contraceptives NONE Breastfeeding Support NONE Prescription Drugs [Other than contraceptives Copayments consistent with N.J.A.C. 11:22-5.5] [subject to the Prescription Drug Cost Sharing Limit]‌ All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR ~~ Primary Care Provider Visits including~~ • Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ Contraceptives NONE Breastfeeding Support NONE •Second Surgical Opinion ~~NONE All~~ •All other Covered Services and Supplies ~~Per Covered Person Dollar~~ •Per Member [dollar amount not to exceed ~~deductible~~ the amount permitted by ~~45 CFR 156.130(b)~~N.J.A.C. 11:20-3.1(b)3i] ~~ [~~• Per Covered Family ~~[Dollar~~ amount ~~which is two~~ equal to 2 times the ~~individual Deductible~~per member amount.] COINSURANCE ~~Preventive Care 0%~~ [Prescription Drugs Other than contraceptives 50% ~~[Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%~~] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] Preventive Care: NONE Contraceptives NONE Breastfeeding Support NONE All ~~other~~ services and supplies to which a Copayment does not apply [10% - 50%, in 510% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT ~~[amount consistent with N.J.A.C. 11:22-5.5]~~ $100 Copayment/visit/Member (~~credited toward Inpatient admission~~ waived if ~~admission occurs~~ admitted within 24 hours ~~as the result of the emergency~~).

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION~~ SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES EFFECT OF MEDICARE ON AN INDIVIDUAL HEALTH BENEFITS PLAN SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS ~~CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR~~ SCHEDULE OF PREMIUM RATES ~~AND CLASSIFICATION [~~The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate ~~quote~~sheet] for this Contract for the effective date shown on the ~~face~~ first page of ~~the~~ this Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " "General Provisions." ~~____________________________________ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees]~~ SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER ~~[CALENDAR] [PLAN]~~ CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES ~~COPAYMENTS[/COINSURANCE~~COPAYMENTS [/COINSURANCE]: PREVENTIVE CARE: NONE CONTRACEPTIVES: NONE [included under the contraceptives provision] BREASTFEEDING SUPPORT: NONE HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [[ dollar amount equal to 10 times the per day ~~copayment ]/[Calendar] [Plan]~~ copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 [0] Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM ~~[at the option of the carrier,$50,~~ $~~75 or $100]~~ 100 Copayment/visit/Member (~~credited toward Inpatient Admission~~ waived if ~~Admission occurs~~ admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY:. : INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22- 5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22- 5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE ~~60 visits~~Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [~~day~~visit] [~~visit~~day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) ~~$0 Copayment~~ NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 ~~visits/[Calendar] [Plan]~~ visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION ~~DRUG~~ DRUGS [Other than contraceptives] [including network contraceptives not included under the Contraceptives provision] [50% ~~Coinsurance~~ Coinsurance] [~~May be substituted by Carrier with Copayments~~ copays consistent with N.J.A.C. 11:22-5.5(a).) may be substituted for coinsurance] [0% for contraceptives] PRIMARY CARE PROVIDER ~~For services other than Preventive Care~~ [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [~~TELEMEDICINE VISITS~~ SPECIALIST SERVICES [~~dollar~~ amount ~~not to exceed $50~~consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [ENote to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-~~VISITS [dollar amount not to exceed $50~~5.5(a)]] Copayment/visit] [~~VIRTUAL VISITS [dollar amount not~~ Note to ~~exceed $50]~~carriers: Use this item if the specialist copay exceeds the PCP copay.] ~~PREVENTIVE CARE $0 copayment~~ REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)~~] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)~~]] Copayment/visit. SKILLED NURSING ~~FACILITY/~~FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-~~5.5(a)Copayment~~ 5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit ~~SCHEDULE~~ MAXIMUM OUT OF ~~SERVICES AND SUPPLIES [Example Using Deductible~~POCKET Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, ~~Coinsurance] The services or supplies covered under this Contract are subject to the Copayments~~ Deductible and Coinsurance ~~set forth below~~ for all Covered Services and ~~are determined~~ Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: •Per Member per Calendar Year [~~Calendar~~$6,850 or amount permitted by 45 C.F.R. 156.130] •Per Family per Calendar Year [~~Plan~~$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF INSURANCE Example High Deductible health plan text that could be used in conjunction with an HSA Calendar Year ~~per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT~~ Cash Deductible Preventive Care NONE ~~All other Primary~~ Contraceptives, [included under the Contraceptives provision] except as stated below NONE Breastfeeding Support NONE Immunizations and Lead screening for children as detailed in the Immunizations and Lead Screening provision NONE Second surgical opinion NONE Maternity Care ~~Provider Visits [amount consistent with N.J.A.C. 11:22-5.5(a)] ] per visit Maternity~~ (pre-natal ~~care~~visits) NONE [Prescription Drugs and] Male sterilization or Male contraceptives [~~Copayments consistent with N.J.A.C. 11:22-5.5~~Minimum deductible to qualify as a high deductible health plan under Internal Revenue Code Section 223] All other ~~services and supplies Copayment Not Applicable; Refer~~ Covered Charges [per Member [the greater of: $XXXX or the lowest amount to ~~the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR~~qualify as a high deductible health plan under Internal Revenue Code section 223] [~~PLAN~~$XXXX] ~~YEAR  Primary Care Provider Visits including Preventive Care and immunizations and lead screening~~ [$XXXX or the highest amount for ~~children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion NONE All other Covered Services and Supplies Per Covered Person Dollar amount not to exceed deductible~~ which deductions are permitted ~~by 45 CFR 156.130(b)~~under Internal Revenue Code 223]  [~~Per~~ $XXXX]] [per Covered Family [~~Dollar~~ the greater of: $XXXX or the lowest amount to qualify as a high deductible health plan under Internal Revenue Code section 223] [$XXXX] [$XXXX or the highest amount for which deductions are permitted under Internal Revenue Code 223] [$XXXX]] Coinsurance Coinsurance is ~~two times~~ the ~~individual Deductible.] COINSURANCE~~ percentage of a Covered Charge that must be paid by a Member. We will waive the Coinsurance requirement once the Maximum Out of Pocket has been reached. This Contract's Coinsurance, as shown below, does not include Cash Deductibles, Copayments, penalties incurred under this Policy's Utilization Review provisions, or any other Non-Covered Charge. The Coinsurance for this Contract is as follows: Preventive ~~Care~~ Care: 0% ~~Prescription Drugs 50~~Contraceptives [included under the Contraceptives provision] 0% Breastfeeding support 0% [Vision Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for ~~Covered Persons~~ Members through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other Covered Charges [30%, 20%] Maximum Out of Pocket Maximum Out of Pocket means the annual maximum dollar amount that a Member or Covered Family, as applicable, must pay as Copayment, Deductible and Coinsurance for all covered services and supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member or Covered Family, as applicable, has no further obligation to ~~which a Copayment~~ pay any amounts as Copayment, Deductible and Coinsurance for covered services and supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: [per Member [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] [per Covered Family [the greater of $XXXX or the maximum amount permitted under Internal Revenue Code 223]] Note: The Maximum Out of Pocket cannot be met with Non-Covered Charges. Limits: Therapeutic manipulation per Calendar Year 30 visits Speech therapy per Calendar Year 30 visits Note: This limit does not apply to speech therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Cognitive therapy per Calendar Year 30 visits Physical therapy per Calendar Year 30 visits Note: This limit does not apply to physical therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Occupational therapy per Calendar Year 30 visits Note: This limit does not apply to occupational therapy covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Charges for hearing aids for a Member one hearing aid per hearing impaired ear per 24-month period [~~10% - 50%, in 5% increments~~Doula Services [Global Maximum per pregnancy [$0-$5,000 (amount to be determined by carrier) ] ~~All services and supplies~~ ] [Standard Benefit Visit limit [Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (Visit limit to ~~which a Copayment applies None EMERGENCY ROOM COPAYMENT~~ be determined by carrier)]] [~~amount consistent with N.J.A.C. 11:22~~Labor [1-~~5.5~~5 Visit(s) (Visit limit to be determined by carrier]] ~~Copayment/visit/Member~~ [Enhanced Benefit Visit limit Prenatal or Postpartum visits per pregnancy [1-20 Visit(s) (~~credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency~~Visit limit to be determined by carrier).] Labor [1-5 Visit(s) (Visit limit to be determined by carrier]]

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ~~____________________________________~~ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by [Other than contraceptives] Carrier with Copayments consistent [including network contraceptives not with N.J.A.C. 11:22-5.5(a).] [0% for covered under the Contraceptives provision] contraceptives] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment ~~REHABILITATION~~ CONTRACEPTIVES: $0 copayment [included under the contraceptives provision] BREASTFEEDING SUPPORT: $0 copaymentREHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), ~~maximum30~~ Maximum 30 visits per [Calendar] [Plan] Year ~~See below for~~ Note: the ~~separate~~ limit does not apply to speech therapy ~~benefits available~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) ), maximum 30 visits per [Calendar] [Plan] Year ~~See below for the separate benefits available under the Charges for speech~~ Note: The limit does not apply to physical or occupational therapy ~~per [Calendar] [Plan] Year provided~~ covered under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE Prescription Drugs [Other than contraceptives] [including network contraceptives not covered under the Contraceptives provision] [Copayments consistent with N.J.A.C. ~~11:22-~~11:22- 5.5] [0% for contraceptives] [subject to the Prescription Drug Cost Sharing Limit]‌ All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ •Contraceptives [included under the contraceptives provision] NONE •Breastfeeding Support NONE •Second Surgical Opinion NONE ~~All~~ •All other Covered Services and Supplies ~~Per~~ •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50[Other than contraceptives] [including contraceptives not Included under the contraceptives provisions]50% [0% for contraceptives] Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 1 contract

Samples: www.nj.gov

Note to carriers. Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions." ~~____________________________________~~ This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with Copayments consistent with N.J.A.C. 11:22-5.5(a).] PRIMARY CARE PROVIDER For services other than Preventive Care [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) ~~[TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]]~~ PREVENTIVE CARE $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), maximum30 visits per [Calendar] [Plan] Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined) maximum 30 visits per [Calendar] [Plan] Year See below for the separate benefits available under the Charges for speech therapy per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30-visit limit does not apply to the treatment of autism. Charges for physical and occupational per [Calendar] [Plan] Year provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits Note: The 30-visit limit does not apply to the treatment of autism. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. ~~11:22-~~11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR  • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE ~~Maternity~~ •Maternity (pre-natal care) NONE. ~~Second~~ •Second Surgical Opinion NONE ~~All~~ •All other Covered Services and Supplies ~~Per~~ •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)]  • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age 19) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] All other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] All services and supplies to which a Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance Limit: $[500] per [surgery]] Note to carriers: Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Appears in 1 contract

Samples: njintouch.state.nj.us

Common use of Note to carriers Clause in Contracts