CLASS(ES) [All eligible employees] SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (using copayment for network services) [Note to carriers: Dollar amounts shown on the schedule pages are illustrative only. Refer to N.J.A.C. 11:21-3.1 for permissible ranges. Network benefits may be structured with tiers. For an example refer to the HMO contract form, Appendix Exhibit G.] THE SERVICES, SUPPLIES AND BENEFITS COVERED UNDER THIS CONTRACT ARE SUBJECT TO THE PAYMENT OF THE APPLICABLE COPAYMENTS, DEDUCTIBLE AND COINSURANCE. SERVICES [NETWORK] [NON-NETWORK] Hospital Inpatient (unlimited days) [$150] Copayment / day; Deductible/Coinsurance maximum / admission [$750]; maximum / cal. year [$1500] Outpatient Visit [$15] Copayment / visit Deductible/Coinsurance Practitioner services provided at a Hospital Inpatient Visit $0 Copayment / visit Deductible/Coinsurance Outpatient Visit [$15] Copayment / visit; Deductible/Coinsurance waived if another Copayment applies Emergency Room [$50] Copayment / visit; [$50] Copayment; waived if credited toward Inpatient admission occurs within 24 Copayment if admission hours; Deductible/Coinsurance occurs within 24 hours [Urgent Care [$30 Copayment / visit Deductible/Coinsurance] Pre-natal care [$0] Copayment / visit Deductible/Coinsurance Practitioner Services [$15] Copayment / visit Deductible/Coinsurance [Telemedicine Visits [$15] Copayment / visit N/A] [$15] Copayment / visit N/A] [E-Visits
CLASS(ES) [All eligible employees] SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (using copayment for network services) [Note to carriers: Dollar amounts shown on the schedule pages are illustrative only. Refer to N.J.A.C. 11:21-3.1 for permissible ranges. Network benefits may be structured with tiers. For an example refer to the HMO contract form, Appendix Exhibit G.] THE SERVICES, SUPPLIES AND BENEFITS COVERED UNDER THIS CONTRACT ARE SUBJECT TO THE PAYMENT OF THE APPLICABLE COPAYMENTS, DEDUCTIBLE AND COINSURANCE. SERVICES [NETWORK] [NON-NETWORK] Hospital Inpatient (unlimited days) [$150] Copayment / day; maximum / admission [$750]; maximum / cal. year [$1500] Deductible/Coinsurance Outpatient Visit [$15] Copayment / visit Deductible/Coinsurance Practitioner services provided at a Hospital Inpatient Visit $0 Copayment / visit Deductible/Coinsurance Outpatient Visit [$15] Copayment / visit; waived if another Copayment applies Deductible/Coinsurance Emergency Room [$50] Copayment / visit; credited toward Inpatient Copayment if admission occurs within 24 hours [$50] Copayment; waived if admission occurs within 24 hours; Deductible/Coinsurance [Urgent Care [$30 Copayment / visit Deductible/Coinsurance] Pre-natal care [$0] Copayment / visit Deductible/Coinsurance Practitioner Services [$15] Copayment / visit Deductible/Coinsurance [Telemedicine Visits [E-Visits [$15] Copayment / visit [$15] Copayment / visit N/A] N/A]
hmo_poscontract.docx