Appendix B - Medical Plan Summaries.pdf
PDF 74 KB Posted
- Solicitation number
- RFP_F - 25
- Issued by
- Hudson County, New Jersey
About this file
The document presents medical and prescription plan details for the City of Jersey City, covering three different group insurance plans administered by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ): Group #08503J, Group #086220, and Group #08518E. These comprehensive medical plans offer various coverage options with different deductibles, coinsurance rates, and out-of-pocket maximums for single and family enrollments, including in-network and out-of-network services across multiple plan tiers.
The plans feature diverse benefit structures, including preventive care, routine vision care, office visits, specialist consultations, diagnostic services, short-term therapies, hospitalization, outpatient services, and prescription coverage. Each plan variant (such as Direct Access, Open Access, OMNIA, and H.S.A.) provides unique cost-sharing arrangements, with copayments ranging from $0 to $100 and coinsurance rates between 60% and 100%. Out-of-pocket maximums vary significantly across plans, from as low as $400 to as high as $16,600 for single and family coverages, respectively. The plans also include provisions for out-of-network provider reimbursement, typically using Horizon Allowance or a percentage of Fair Health and CMS rates.
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City of Jersey City Medical & Prescription Plans
Group #08503J
Deductible: in-network out-network in-network out-network in-network out-network in-network out-network in-network out-network Tier 1 Tier 2
Single $0 $250 $0 $250 $0 $250 $0 $500 $0 $500 $0 $1,500
Family $0 $500 $0 $500 $0 $500 $0 $1,000 $0 $1,000 $0 $3,000
Coinsurance 100% 70% 100% 70% 100% 70% 100% 60% 100% 60% 100% 80%
Max. Out-of-Pocket:
Single $400 $2,000 $400 $2,000 $400 $2,000 $400 $2,000 $400 $2,000 $2,500 $4,500
Family $800 $5,000 $800 $5,000 $800 $5,000 $800 $5,000 $800 $5,000 $5,000 $9,000
Max. Life Benefit unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited unlimited
Preventive Care: $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Routine Vision Care: $10 30% AD $20 30% AD $20 30% AD $35 40% AD $35 40% AD $15 $30
Emergency Room:
Urgent Care: $10 30% AD $20 30% AD $20 30% AD $35 40% AD $35 40% AD $15 $30
Office Visits: $10 30% after $20 30% after $20 30% after $25 40% after $25 40% after $5 $20 copayment deductible copayment deductible copayment deductible copayment deductible copayment deductible copayment copayment
Specialist Visits: $10 30% after $20 30% after $20 30% after $35 40% after $35 40% after $15 $30 copayment deductible copayment deductible copayment deductible copayment deductible copayment deductible copayment copayment
Diagnostic:
Labs: $0 30% AD $0 30% AD $0 30% AD $0 40% AD $0 40% AD $0 AD $0/20% AD
X-Rays: $0 30% AD $0 30% AD $0 30% AD $0 40% AD $0 40% AD $0 AD $0/20% AD
Complex Image: $0 30% AD $0 30% AD $0 30% AD $0 40% AD $0 40% AD $0 AD $0/20% AD
Short Term Therapies:
Physical, Occupational $10 30% after $20 30% AD $20 30% AD $25 40% AD $25 40% AD $5 $20
Speech, and deductible
Respiratory
Chiropractic Visits: $10 30% AD $20 30% AD $20 30% AD 25 40% AD $25 Not Covered $15 $30
Hospitalization: $0 30% AD & $0 30% AD & $0 30% AD & $0 40% AD & $0 40% AD &
$200 $200 $200 $200 $200 $150 20% AD
copayment copayment copayment copayment copayment
Outpatient:
Hospital: $0 30% after $0 30% after $0 30% after $0 40% after $0 40% after $150 20% after
ASC: $0 deductible $0 deductible $0 deductible $0 deductible $0 deductible $150 deductible
Durable Medical: 10% 30% AD 10% 30% AD 10% 30% AD 10% 40% AD 10% 40% AD $0 20% AD
Prescription:
OON Provider Reimbursement:
Institutional:
Professional:
ASC:
Horizon Allowance
70th of Fair Health
160% of CMS
Horizon Allowance
70th of Fair Health
160% of CMS
Horizon Allowance
70th of Fair Health
160% of CMS
Open Access
$50 copayment
Direct Access 8
Open Access
Direct Access 10
Open Access
$75 copayment
Stand Alone Plan
Direct Access 8
Open Access
$100 copayment
Stand Alone Plan
$100 copayment
Stand Alone Plan
Direct Access 10
Open Access
$100 copayment
Stand Alone Plan
Limited to 25 Visits
30 visits max / therapy
/ year
BENEFITS Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ
8503J 8503J 8503J 8503J 8503J 8503J
Limited to 30 Visits Limited to 30 Visits
Stand Alone Plan
Direct Access 8 OMNIA BC
Open Access
$100 copayment
Stand Alone Plan
Horizon Allowance
70th of Fair Health
160% of CMS
Horizon Allowance
70th of Fair Health
160% of CMS
Limited to 30 Visits Limited to 30 VisitsLimited to 30 Visits n/a n/a n/a
Group #086220
Deductible: in-network out-network in-network out-network in-network out-network in-network out-network in-network out-network
Single $0 n/a $1,000 n/a $0 $100 $0 $1,000
Family $0 n/a $2,000 n/a $0 $250 $0 $2,000
Coinsurance 100% n/a 100%/80% n/a 100% 70% 100% 60% 100% 80%
Max. Out-of-Pocket:
Single $2,500 n/a $3,500 n/a $400 $2,000 $650 $5,000
Family $5,000 n/a $7,000 n/a $800 $5,000 $650 $10,000
Max. Life Benefit unlimited n/a unlimited n/a unlimited unlimited unlimited unlimited
Preventive Care: $0 n/a $0 n/a $0 $0 $0 $0
Routine Vision Care: $40 n/a $40 n/a $10 30% AD $10 40% AD
Emergency Room:
Urgent Care: $40 n/a $40 n/a $10 30% AD $10 40% AD
Office Visits: $20 n/a $20 n/a $10 30% after $10 40% after copayment copayment copayment deductible copayment deductible
Specialist Visits: $40 n/a $40 n/a $10 30% after $10 40% after copayment copayment copayment deductible copayment deductible
Diagnostic:
Labs: $0 n/a $0/20% n/a $0 30% AD $0 40% AD
X-Rays: $0 n/a $0/20% n/a $0 30% AD $0 40% AD
Complex Image: $0 n/a $0/20% n/a $0 30% AD $0 40% AD
Short Term Therapies:
Physical, Occupational $20 n/a $20 n/a $10 30% AD $10 40% AD
Speech, and
Respiratory
Chiropractic Visits: $20 n/a $20 n/a $10 30% AD $10 40% AD
Hospitalization: $250 / day n/a 20% after n/a $0 30% AD & $200 40% AD &
(5 day max) deductible $200 $200 copayment copayment copayment
Outpatient:
Hospital: $200 n/a 20% AD n/a $0 30% after $0 40% after
ASC: $100 n/a 20% AD n/a $0 deductible $0 deductible
Durable Medical: $0 n/a 20% AD n/a 10% 30% AD 0% 40% AD
Prescription:
OON Provider Reimbursement:
Institutional:
Professional:
ASC:
Stand Alone Plan Stand Alone Plan Stand Alone Plan
$0 No deductible deductible n/a
Major Medical
Open Access
$0
$100
$200
$500
$1,000 unlimited
$0
30 visits max / therapy
/ year
20% AD
$0
$0
20% AD
Limited to 30 Visits
20% AD
20% AD
20% after
$100 after deductible
EPO 2
Open Access
20% after $100 copay
Direct Access 10
Open Access
$25 copayment
Limited to 25 Visits Limited to 30 Visits
BENEFITS
86220 86220 86220 86220
Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ Horizon BCBSNJ
86220
20% after deductible
20% AD
$0
Direct Access 8
Open Access
$25 copayment
Stand Alone Plan
EPO 1
Stand Alone Plan
Open Access
Limited to 25 Visits n/a n/a n/a n/a n/a n/a 80th of Fair Health
80th of Fair Health
80th of Fair Health
20% AD
30 visits max / therapy
/ year
Limited to 30 Visits
30 visits max / therapy
/ year
Horizon Allowance
80th of Fair Health
160% of CMS
Horizon Allowance
80th of Fair Health
160% of CMS
Group #08518E
Deductible: in-network out-network Tier 1 Tier 2
Single $2,000 $2,500
Family $4,000 $5,000
Coinsurance 80% 60% 80% 50%
Max. Out-of-Pocket:
Single $8,300 $10,000 $4,500 $6,650
Family $16,600 $20,000 $9,000 $13,300
Max. Life Benefit unlimited unlimited unlimited unlimited
Preventive Care: $0 $0 $0 $0
Routine Vision Care: limited not covered limited not covered
Emergency Room:
Urgent Care: 20% AD 40% AD $40 AD $50 AD
Office Visits: 20% after 40% after $20 after $40 after deductible deductible deductible deductible
Specialist Visits: 20% after 40% after $40 after $50 after deductible deductible deductible deductible
Diagnostic:
Labs: 20% AD 40% AD 20% AD 50% AD
X-Rays: 20% AD 40% AD 20% AD 50% AD
Complex Image: 20% AD 40% AD 20% AD 50% AD
Short Term Therapies:
Physical, Occupational 20% AD 40% AD 20% AD 50% AD
Speech, and
Respiratory
Chiropractic Visits: 20% AD 40% AD 20% AD 50% AD
Hospitalization:
20% after 40% after 20% after 50% after deductible deductible deductible deductible
Outpatient:
Hospital: 20% AD 40% after 20% after 50% after
ASC: 20% AD deductible deductible deductible
Durable Medical: 20% AD 50% AD 20% AD 50% AD
Prescription:
OON Provider Reimbursement:
Institutional:
Professional:
ASC:
n/a n/a n/a
Tier 1 Deductible
Open Access
20% after ded
40% after
Horizon BCBSNJ
8518E
Horizon BCBSNJ
8518E
$2,500
$5,000
OMNIA H.S.A.
Open Access
20% after $100 copay
Direct Access H.S.A.
20% after deductible
BENEFITS
Horizon Allowance
80th of Fair Health
160% of CMS
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