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AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (AmeriHealth New Jersey) have begunoffering new qualified health plans both on and off the Health Insurance Marketplace. These commercial products areavailable to small groups and individuals for coverage beginning January 1, 2014.
AmeriHealth New Jersey is offering several standard products, as well as two tiered products, on the Health InsuranceMarketplace. The products fall into the following categories:
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
- POS (Point of Service) Plus
- HSA (Health Savings Account)
- EPO (Exclusive Provider Organization) - includes two tiered products
Member ID cards for these products will include standard information, such as the network name and basic copaymentsfor primary care and specialist services. In addition, these products will follow our current administrative, claimspayment, and medical policies. Providers participating with AmeriHealth New Jersey will also be participating providersfor these products by virtue of the network in which they are currently contracted. Participating providers will bereimbursed in accordance with their payment rates for commercial products.
EPO tiered products
Included in these new commercial products are two tiered EPO products: Cooper Advantage and Tier 1 Advantage.Providers that participate in AmeriHealth New Jersey's Value Network will be participating with both Cooper Advantage andTier 1 Advantage. These tiered products will have benefit designs with different member cost-sharing by tierand will offer members a lower out-of-pocket cost (e.g., copayment) for certain services when they select a provider inthe first benefit tier.
The following describes these two tiered products:
- Cooper Advantage. This product was developed for residents and small employers headquartered in Burlington,Gloucester, and Camden counties. Members who purchase this product will have access to participating providers inthe Value Network. Within that network, facility and professional providers will be assigned to one of two tiers. Tier 1will be comprised of mostly Cooper facilities and physicians, and members will have lower out-of-pocket costs formost services when using these providers.
- Tier 1 Advantage. This product will be available to New Jersey residents and employers statewide. Members whopurchase this product will have access to participating providers in the Value Network. Within that network, hospitalsand ambulatory surgical centers will be assigned to one of two tiers based on cost. Lower-cost facilities will be placedin Tier 1, and members will have lower out-of-pocket costs for most services when using Tier 1 providers.
Benefit tier placements for EPO tiered products
Where applicable, Value Network participating providers have been categorized into one of two benefit tiers for thesenew tiered products:
- Tier 1: Members pay the lowest cost-sharing for most services.
- Tier 2: Members pay a higher cost-sharing for most services compared to Tier 1.
The benefit tier placements for 2014 will remain in place from January 1, 2014, through December 31, 2014. AmeriHealthNew Jersey will re-evaluate the benefit tiers each subsequent year and will provide advance written notice of anychanges to provider benefit tier placements that will become effective on January 1 of the following year.
When seeing members covered under either of these two tiered products, please take into consideration thebenefit tier placement for facilities that you are affiliated with or may refer members to, as this will affect members'out-of-pocket costs. You can review benefit tier placements by searching for specific providers on our website by selecting Find a Provider.
Note: The NaviNet® web portal will be updated to provide the correct tier cost-sharing for members with these products. Please continue to use NaviNet as you do today to confirm member eligibility and benefits.
If you have any questions about our new products, please email our Provider Relations Services team.
NaviNet® is a registered trademark of NaviNet, Inc.