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|Health Maintenance Organizations (HMOs) in New Jersey|
|Definitions and Background|
A Health Maintenance Organization (HMO) provides and/or arranges for the delivery of comprehensive health care services and supplies to its members in a designated geographic service area in exchange for prepaid premiums. HMOs combine the financing and delivery of comprehensive healthcare services and supplies. An HMO arranges with health care providers to furnish services and supplies to its members; sets standards for selecting providers; and establishes formal programs that encompass preventive medicine, quality assurance and utilization management.
Members typically select a Primary Care Provider (PCP) who provides for all the member’s primary medical care. In most plans the PCP is a physician who is responsible for referrals and access to specialists and other services. (This is called the gatekeeper function.) However, in many plans a referral is not necessary to obtain routine ob/gyn services for a female member; and some plans have open access features in which members may obtain a wide range of specialist services within the HMO network without the necessity of a referral. Typically the member’s financial responsibility for covered in-network services has consisted of a fixed copayment depending on the type of service for each visit.
In recent years, HMOs have offered Point Of Service (POS) benefit plans. A POS plan allows a member to obtain healthcare services from network providers, or receive reimbursement, subject to the terms of the contract, from the HMO for medically necessary healthcare services obtained from providers outside the HMO network. The member’s financial responsibility for covered out-ofnetwork services resembles that of an indemnity health insurance plan, with a deductible and coinsurance structure that generally results in a higher payment by the member than if he or she obtained services or supplies from a network provider. In addition, the member who uses an out-ofnetwork provider may also be responsible for any balance of the bill that exceeds the usual, reasonable and customary (UCR) charge as determined by the HMO. The HMO would pay the UCR amount less any deductible or coinsurance paid by the member.
More recently, in some plans the member’s financial responsibility for covered in-network services
may also include deductibles and/or coinsurances.
|Medicare and Medicaid|
In 1991 the New Jersey Legislature enacted N.J.S.A. 30:4D-76, “Managed Care Plan for Medicaid Recipients.” New Jersey HMOs were solicited by the Department of Human Services (DHS) to provide enrollment opportunities for Medicaid recipients. Following the approval of the federal Center for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration (HCFA)) on 06/07/1995, recipients of Aid for Families with Dependent Children (AFDC) were required to select an HMO for the provision of their health care services and supplies. NJ KidCare and NJ FamilyCare are new initiatives providing free or subsidized HMO Medicaid-level coverage for children and adults in low income families who would not ordinarily be eligible for Medicaid coverage because they exceed the family income limit.
Some New Jersey Medicare recipients are enrolled in HMOs through Medicare Advantage contracts. In these arrangements, the HMO receives a capitation payment from CMS and an additional premium from the recipient, who may receive certain benefits above those of regular Medicare, but must use the HMO’s network of facilities and providers. The Medicare recipient must still pay the Part B premium for Medicare coverage.
|HMOs Authorized In New Jersey|
Aetna Health, Inc.
|AmeriChoice of New Jersey, Inc., d/b/a UnitedHealthcare Community Plan
Four Gateway Center, 4th Floor
Newark, NJ 07102
Web site: www.americhoice.com
|AMERIGROUP New Jersey, Inc.
d/b/a Americaid Community Care
4425 Corporation Lane, Suite 100
Virginia Beach, VA 23462
Web site: www.amerigroupcorp.com
|AmeriHealth HMO, Inc.
259 Prospect Plains Road, Building M
Cranbury, NJ 08512
Web site: www.amerihealth.com
|Bravo Health Pennsylvania, Inc.
1500 Spring Garden St., Suite 800
Philadelphia, PA 19130
Web site: www.mybravohealth.com
CIGNA HealthCare of New Jersey, Inc.
|Coventry Health Care of Delaware, Inc.
2751 Centerville Road, Suite 400
Wilmington, DE 19808
Web site: www.cvty.com
Geisinger Health Plan
|Healthfirst Health Plan of New Jersey, Inc.
25 Broadway, 9th Floor
New York, NY 10004
Web site: www.healthfirstnj.com
|Horizon HealthCare Plan of New Jersey
d/b/a Horizon HMO (formerly called HMO Blue, is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey)
3 Penn Plaza East
Newark, NJ 07102
Web site: www.horizon-bcbsnj.com
|Oxford Health Plans (NJ), Inc.
48 Monroe Turnpike,
Trumbull, CT 06611
Web site: www.oxhp.com
WellCare Health Plans of New Jersey, Inc.
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| Copyright © 2011,
State of New Jersey
New Jersey Department of Banking and Insurance