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HMO PLAN STANDARDS

The SHBP has established minimum coverage requirements and operating standards for all participating HMOs that safeguard our members and make it easier to compare and choose between plans. The following is not a benefit summary but a listing of benefit coverages for which the SHBP has imposed a mandatory expectation or requirement. Operating Standards Include:

• All physician referrals will be valid for a minimum of 90 days from the date of authorization.
• Certain treatments requiring numerous visits (e.g., chemotherapy) shall not require repeated referrals.
• Member packets must include a Schedule of Benefits which will provide a list of covered services, benefit limitations and benefit exclusions, and appropriate definitions.
• The HMO will notify the State and members prior to any proposed changes in the provider network, including facilities, that alter member access to providers or services.
• There shall be no pre-existing condition restrictions.
• Network within network referral restrictions will not be permitted.
• Right to change Primary Care Providers must be permitted on at least a monthly basis.
• Scope of services covered under the well-woman OB/GYN provisions must be clearly defined, including the explicit services which must be authorized by the member's PCP. It is required that two or more well-woman OB/GYN examinations be available during the Benefit Plan Year (July 1 to June 30), and that a well-woman mammogram not require a PCP authorization.
• HMO members must be permitted to self-refer to network mental health and substance abuse practitioners.
• Extension of health benefits must be made at no cost to totally disabled members who do not elect COBRA coverage and to those whose coverage terminates at the end of the COBRA continuation period including cessation of premium payments. The extension is made available to those members who are totally disabled on the date their coverage terminates and need not require hospital confinement, and is only applicable to expenses incurred in the treatment of the disabling condition. The extension period will end on the earliest of:
  the date the total disability ends;
  one year from the date the person's coverage under the SHBP ends;
  the date the person has received the maximum benefits under the HMO's Plan for the disabling condition; or
  the person becomes covered under any replacement plan established by the employer.

The following definition for emergency care will be adhered to by all plans:
1. Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
   1. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
   2. serious impairment to bodily function; or
   3. serious dysfunction of any bodily organ or part.
   There will be a $35 maximum copayment for emergency room services; waived if admitted.

2. With respect to emergency services furnished in a hospital emergency department, a health plan shall not require prior authorization for the provision of such services if the member arrived at the emergency medical department with symptoms that reasonably suggested an emergency condition based on the judgment of a prudent layperson, regardless of whether the hospital was affiliated with the Health Maintenance Organization. All procedures performed during the evaluation (triage) and treatment of an emergency medical condition shall be covered by the Health Maintenance Organization. Minimum Coverage Requirements
   
   

Minimum Coverage Requirements

Benefit standards include:

1. Routine office visit copayments will be $5.
2. All plans will cover chiropractor visits up to a maximum of 20.
3. $100 will be the maximum annual copayment for medical appliances and durable equipment.
4. Hair prosthesis furnished in connection with hair loss resulting from the treatment of disease by radiation or chemicals will be covered.
5. Routine inoculations for adults (not related to travel or occupation) will be covered.
6. The cost of care to organ transplant donors will be covered. (Coordination of benefits will apply.)
7. Admissions at skilled nursing homes will be covered up to 120 days.
8. Hospice services will be covered in full.
9. Home health care will be covered up to a minimum of 120 visits.
10. Outpatient therapy will be covered up to 60 consecutive visits per condition.
11. Repair and replacement of prosthesis will be covered.
12. Surgical leggings will be covered if medically necessary.
13. There will be no reimbursement for vision hardware.
    
    

Mental Health and Alcohol/Substance Abuse

14. There will be no copayment charged for outpatient drug and alcohol rehabilitation treatment.
15. All plans will use standard treatment criteria established by the American Society of Addictive Medicine (ASAM).
16. Coverage for outpatient mental health services will be at a minimum 30 visits and a maximum copayment of $10.
17. Following a detoxification patients are entitled to 28 days of inpatient rehabilitation per occurrence.
    

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URL: http://www.state.nj.us/treasury/pensions/planstan0102.htm
August 31, 2001