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Home > Insurance Division > Life and Health > Life & Health Actuarial > HMO Performance Report
2008 New Jersey HMO Performance Report
Choosing Your HMO

Your choice of an HMO can influence your health

Looking at HMO quality, along with choice of providers, benefits offered, and costs, can help you decide on an HMO that best meets your needs.

Quality of Care and Service
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  • Look to see how well the HMO performs in each section of this report.
  • Pay special attention to the health issues that are most important to you and your family.
  • Do not focus on small differences in a single measure that may not be meaningful. To compare HMOs, look at all the factors that contribute to an HMO’s performance and at large differences in the measures.

Choice of Providers
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  • Make sure that your preferred doctor, hospital and other providers participate in the HMO’s network by looking in the HMO’s provider directory. It is important to confirm your provider’s participation by calling the HMO’s member services department or the provider directly, prior to enrollment. Click here for ways to contact the HMO.
  • Decide whether the HMO has enough of the kinds of doctors you are likely to need and whether they are located near your home or work.
  • Once you have selected a provider, make sure the doctor has office hours and a location convenient for you and your family.

Benefits
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  • Find out what types of health benefit plans the HMO offers by reviewing the member handbook or calling the member services department.
  • Consider your special needs and circumstances such as chronic health conditions, elder care, frequent travel, language, retirement and starting a family.
  • Decide whether there is a good match between the health benefits offered by the HMO and what you think you may need.
  • Find out what types of care or services the HMO does not cover.

Cost
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  • Try to get an idea of how much you are likely to pay in premiums, co-payments, coinsurance and deductibles each year.
  • Find out if the HMO covers services by providers outside the HMO’s network and how much it will cost for these services.
  • See if there are any limits on how much you are responsible for paying in case of major illness (out-of-pocket maximum).
  • Find out if the HMO places limits on the amount of benefits it will pay (annual or lifetime maximums).
  • The HMO might also have internal limits on specific services, such as dollar, day or visit limits for specific services.

Accreditation

NCQA, also known as the National Committee for Quality Assurance, is a non-profit organization committed to assessing, reporting on and improving the quality of care provided by the nation’s carriers offering managed care health benefits plans. To find out if your carrier is NCQA accredited, call toll-free (888) 275-7585 or visit the web site: www.ncqa.org.

URAC, also known as the American Accreditation HealthCare Commission is a non-profit organization originally focused on the accreditation of utilization review programs. URAC now provides accreditation services for many types of health care organizations, including HMOs. For information on URAC’s accreditation services, visit the web site: www.urac.org.

JCAHO, also known as the Joint Commission on Accreditation of Healthcare Organizations, is an independent, non-profit organization that evaluates and accredits various types of health care networks including health carriers, hospitals, home health care organizations and others. For more information on JCAHO's accreditation services, visit the web site: www.jcaho.org

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Copyright © 2008, State of New Jersey
New Jersey Department of Banking and Insurance