NJ Direct 10/Aetna Freedom 10 v. Horizon Direct Access 10 Brown - PowerPoint PPT Presentation

NJ Direct 10/Aetna Freedom 10 v. Horizon Direct Access 10 Brown & Brown Benefit Advisors 1

Montgomery Township Board of Education SEHBP NJ Direct 10/Aetna Freedom 10 vs Horizon Direct Access 10 NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10 In-Network Non-Network In-Network Non-Network Inside NJ- Managed Care Network, including contiguous Inside NJ- Managed Care Network, including contiguous Service Areas counties; Outside NJ-Blue Card Network counties; Outside NJ-Blue Card Network Primary Care Physician Referral NO NO Required? Annual Deductible Individual $0 $100 $0 $100 Family $0 $250 $0 $250 100%; 100%; 80% of R&C 1 80% of R&C 1 Coinsurance 90% on select services 90% on select services Office Visit Copay 2 $10 Primary or Specialist Not applicable $10 Primary or Specialist Not applicable Annual Out of Pocket Maximum 3 Individual $400 $2,000 $400 $2,000 Family $1,000 $5,000 $800 $5,000 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Hospital Inpatient Services (room and 100% 80% after deductible 100% 80% after deductible board; physician visits) 100% after $25 copay 100% after $25 copay 100% after $25 copay 100% after $25 copay Emergency Room waived if admitted waived if admitted waived if admitted waived if admitted Ambulance 90% 80% after deductible 90% 80% after deductible Radiation/Chemotherapy Outpatient 100% 80% after deductible 100% 80% after deductible X-Ray and Lab Tests 100% 80% after deductible 100% 80% after deductible 100% 80% after deductible 100% 80% after deductible Home Health Care Unlimited Unlimited 100% 80% after deductible 100% 80% after deductible Skilled Nursing Facility Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year 100% 80% after deductible 100% 80% after deductible Hospice Unlimited Unlimited Brown & Brown Benefit Advisors 2

NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10 In-Network Non-Network In-Network Non-Network Surgery/Anesthesia 100% 80% after deductible 100% 80% after deductible Physician Office Visits Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Annual Physical Exams 100% No coverage 100% 80% (No deductible) Annual Well Child Care 100% No coverage 100% 80% (No deductible) Immunizations (except if travel or job 100% No coverage 100% 80% (No deductible) related) Annual OB-Gyn Exam 100% 80% (No deductible) 100% 80% (No deductible) Annual Mammogram 100% 80% (No deductible) 100% 80% (No deductible) (baseline; women over 40) Annual Prostate screening 100% No coverage 100% 80% (No deductible) (men over 50) Office Visit copay for 1st prenatal Office Visit copay for 1st prenatal 80% after deductible 80% after deductible Maternity (including pre-natal) visit, then 100% visit, then 100% Includes coverage for child dependents Includes coverage for child dependents Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Infertility services Subject to limitations set by NJ Mandates Subject to limitations set by NJ Mandates Allergy Testing and Treatment Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Acupuncture Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Chiropractic Care 30 visits per calendar year combined in and out-of-network 30 visits per calendar year combined in and out-of-network Short Term Therapies (Physical, Office Visit Copay 80% after deductible Office Visit Copay 80% after deductible Cognitive, Occupational, Respiratory, Unlimited Unlimited Speech) Wigs (if needed due to specific $500 maximum every 2 years 100% 80% after deductible diagnosis like Chemo) 80% after deductible per hearing 100% per hearing aid per 24 months, Hearing Aids $1,000 per hearing aid/24 months, for children to age 15 aid per 24 months, for children to age 15 for children to age 15 Brown & Brown Benefit Advisors 3

NJ Direct 10/Aetna Freedom 10 Horizon Direct Access Design 7 Education 10 In-Network Non-Network In-Network Non-Network Durable Medical equipment/Medical 90% 80% after deductible 90% 80% after deductible Supplies Specialized Non-Standard Infant 90% 80% after deductible 90% 80% after deductible Formula Inherited Metabolic Disease 90% 80% after deductible 90% 80% after deductible Inpatient Mental Illness/Substance Same as any other illness 4 Same as any other illness 4 Same as any other illness 4 Same as any other illness 4 Abuse/Alcohol Treatment Outpatient Mental Illness/Substance Same as any other illness 4 Same as any other illness 4 Same as any other illness 4 Same as any other illness 4 Abuse/Alcohol Treatment Routine Vision Exam 100% No coverage Office Visit copay 80% after deductible Vision Hardware No coverage $50 reimbursement eligible every 24 months Child Dependent Termination age Children covered to end of year age 26 Children covered to end of year age 26 Required for certain services Required for certain services Prior-Authorization *Comparison is for illustrative purposes only. Written plan documents supersede any errors on this illustration. 1 Reasonable and Customary fee schedule based at the 90th percentile of FAIR Health. You are responsible for any charges in excess of Reasonable and Customary allowances. 2 Copayments apply to in-network primary care and specialist office visit services unless otherwise indicated. 3 Out-of-Pocket maximum includes deductible, coinsurance and copayments. Charges in excess of Reasonable and Customary do not count toward out-of-pocket maximum. 4 Mental health/substance abuse, must be coordinated through the mental health administrator. Brown & Brown Benefit Advisors 4

NJ Direct 15/Aetna Freedom 15 v. Horizon Direct Access 15 Brown & Brown Benefit Advisors 5

Montgomery Township Board of Education SEHBP NJ Direct 15/Aetna Freedom 15 vs Horizon Direct Access 15 NJ Direct 15/Aetna Freedom 15 Horizon Direct Access Design 7 Education 15 In-Network Non-Network In-Network Non-Network Inside NJ- Managed Care Network, including contiguous Inside NJ- Managed Care Network, including contiguous Service Areas counties; Outside NJ-Blue Card Network counties; Outside NJ-Blue Card Network Primary Care Physician Referral NO NO Required? Annual Deductible Individual $0 $100 $0 $100 Family $0 $250 $0 $250 100%; 100%; 70% of R&C 1 70% of R&C 1 Coinsurance 90% on select services 90% on select services $400/$1000 2 Coinsurance Maximum Office Visit Copay $15 Primary or Specialist Not applicable $15 Primary or Specialist Not applicable Annual Out of Pocket Maximum 3 Individual $5,720 $2,000 $400 $2,000 Family $11,440 $5,000 $800 $5,000 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Hospital Inpatient Services (room and 100% 70% after deductible 100% 70% after deductible board; physician visits) 100% after $50 copay 100% after $50 copay 100% after $50 copay 100% after $50 copay Emergency Room waived if admitted waived if admitted waived if admitted waived if admitted Ambulance 90% 70% after deductible 90% 70% after deductible Radiation/Chemotherapy Outpatient 100% 70% after deductible 100% 70% after deductible X-Ray and Lab Tests 100% 70% after deductible 100% 70% after deductible 100% 70% after deductible 100% 70% after deductible Home Health Care Unlimited Unlimited 100% 70% after deductible 100% 70% after deductible Skilled Nursing Facility Up 120 days/calendar year Up 60 days/calendar year Up 120 days/calendar year Up 60 days/calendar year 100% 70% after deductible 100% 70% after deductible Hospice Unlimited Unlimited Brown & Brown Benefit Advisors 6