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Changes to Small Employer Health Plans and SHOP Renewals for 2019

October 17, 2018

Applies to: Small Employer market (on and off the Small Business Health Options Program [SHOP])

Horizon Blue Cross Blue Shield of New Jersey has updated its small employer health plan portfolio for 2019. These changes will become effective when a small employer customer renews into one of the impacted Horizon BCBSNJ health plans.

We are pleased to announce that all small employer OMNIA℠ Health Plans for 2019 will automatically include HorizonbFit, our fitness incentive program. After members enroll in the program, they become eligible to receive a $20 reward for every month in which they make at least 12 visits to any of the 4,000 participating gyms and fitness facilities across the United States. Members can earn up to $240 a year in rewards. Learn more at HorizonbFit.com.

In addition to the health plan changes, small employer customers that want to purchase or renew a health plan on the Small Business Health Options Program (SHOP) for 2019 must do so through a broker.

2019 Plan Changes

OMNIA Bronze HSA 2018 2019
Behavioral Health/Substance Use Disorder — Office Visit — OMNIA Tier 1 $50 after deductible $30 after deductible
Home Health Care 50% after deductible $30 after deductible
Urgent Care Center — OMNIA Tier 1 $50 after deductible $75 after deductible
Second/Third Surgical Opinion — OMNIA Tier 1 and Tier 2 No charge No charge after deductible

OMNIA Silver 2018 2019
Behavioral Health/Substance Use Disorder — Outpatient Facility — OMNIA Tier 1 $50 after deductible $30 after deductible
Medical Deductible — OMNIA Tier 1 — Single $1,000 $1,250
Prescription Drug Deductible (excluding generics) – OMNIA Tier 1 — Single $150 $200
Maximum Out-of-Pocket (MOOP) Limit — OMNIA Tier 1 — Single $7,350 $7,900
Maximum Out-of-Pocket (MOOP) Limit — Tier 2 — Single $7,350 $7,900
Behavioral Health/Substance Use Disorder — Office Visit — OMNIA Tier 1 $50 $30
Home Health Care $50 after deductible $30
Urgent Care Center — OMNIA Tier 1 $50 $75
Accidental Dental — Outpatient Facility — OMNIA Tier 1 $50 after deductible $250 after deductible

OMNIA Silver HSA 2018 2019
Coinsurance — Tier 2 60% 50%
Maximum Out-of-Pocket (MOOP) Limit — OMNIA Tier 1 — Single $5,500 $6,650
Maximum Out-of-Pocket (MOOP) Limit — Tier 2 — Single $6,550 $6,650
Behavioral Health/Substance Use Disorder — Office Visit — OMNIA Tier 1 $20 after deductible $10 after deductible
Behavioral Health/Substance Use Disorder — Office Visit — Tier 2 $50 after deductible $25 after deductible
Home Health Care 85% after deductible $10 after deductible
Urgent Care Center — OMNIA Tier 1 $20 after deductible $40 after deductible
Urgent Care Center — Tier 2 $50 after deductible $75 after deductible
Second/Third Surgical Opinion — OMNIA Tier 1 and Tier 2 No charge No charge after deductible

OMNIA Gold 2018 2019
Prescription Drug Deductible — OMNIA Tier 1 — Single N/A $250
Maximum Out-of-Pocket (MOOP) Limit — OMNIA Tier 1 — Single $3,500 $4,000
Maximum Out-of-Pocket (MOOP) Limit — Tier 2 — Single $6,350 $6,500
Behavioral Health/Substance Use Disorder — Outpatient Facility — OMNIA Tier 1 $20 after deductible $10 after deductible
Behavioral Health/Substance Use Disorder — Office Visit — OMNIA Tier 1 $25 $10
Behavioral Health/Substance Use Disorder — Office Visit — Tier 2 $50 after deductible $30 after deductible
Home Health Care $20 after deductible $10
Urgent Care Center — OMNIA Tier 1 $25 $50
Urgent Care Center — Tier 2 $50 after deductible $75 after deductible
Accidental Dental — Outpatient Facility — OMNIA Tier 1 $20 after deductible $250 after deductible
Prescription Drug Copayment $10/60%/50%/50% $10/$40/$75/$75after drug deductible

OMNIA Platinum 2018 2019
Maximum Out-of-Pocket (MOOP) Limit — OMNIA Tier 1 — Single $1,750 $1,900
Maximum Out-of-Pocket (MOOP) Limit — Tier 2 — Single $2,750 $3,000
Alcoholism — Outpatient Facility — OMNIA Tier 1 $15 No charge
Partial Hospitalization — Behavioral Health $15 No charge
Behavioral Health/Substance Use Disorder — Office Visit — OMNIA Tier 1 $15 $10
Behavioral Health/Substance Use Disorder — Office Visit — Tier 2 $35 $15
Home Health Care $15 $10
Urgent Care Center — OMNIA Tier 1 $15 $30
Urgent Care Center — Tier 2 $35 $70
Accidental Dental — Outpatient Facility — OMNIA Tier 1 $15 $150
Prescription Drug Copayment $5/90%/70%/70% $5/$15/$30/$30

Horizon Advantage EPO Gold 100 $25/$45 2018 2019
Behavioral Health/Substance Use Disorder — Office Visit $45 $25
Behavioral Health/Substance Use Disorder — Outpatient Facility $45 $25
Home Health Care $45 $25
Urgent Care Center $45 $75
Accidental Dental — Outpatient Facility $45 $250

Horizon Advantage EPO Gold 100 $30/$50 2018 2019
Behavioral Health/Substance Use Disorder — Office Visit $50 $30
Behavioral Health/Substance Use Disorder — Outpatient Facility $50 $30
Home Health Care $50 $30
Urgent Care Center $50 $75
Occupational Therapy — Outpatient Professional $30 No charge
Physical Therapy — Outpatient Professional $30 No charge
Speech Therapy — Outpatient Professional $30 No charge

Horizon Advantage EPO Gold 100/80 $20/$40 2018 2019
Maximum Out-of-Pocket (MOOP) Limit — Single $4,500 $5,500
Behavioral Health/Substance Use Disorder — Office Visit $40 $20
Home Health Care 80% after deductible $20
Urgent Care Center $40 $75

Horizon Advantage EPO Silver 100/70 2018 2019
Deductible — Single $2,100 $2,200
Maximum Out-of-Pocket (MOOP) Limit — Single $7,350 $7,900
Behavioral Health/Substance Use Disorder — Office Visit $50 $30
Imaging — Outpatient Facility $100 $100 after deductible
Imaging — Outpatient Professional No charge No charge after deductible
Laboratory/Radiology (non-complex) — Outpatient Facility $75 $100
Home Health Care 70% after deductible $30
Urgent Care Center $50 $75

Horizon Advantage EPO Silver 100/50 2018 2019
Maximum Out-of-Pocket (MOOP) Limit — Single $7,350 $7,900
Behavioral Health/Substance Use Disorder — Office Visit $50 $30
Home Health Care $50/50% after deductible $30
Urgent Care Center $50 $75
Outpatient Professional 50% 50% after deductible
Physical Therapy — Outpatient Professional $30 50% after deductible
Occupational Therapy — Outpatient Professional $30 50% after deductible
Blood & Blood Products, Blood Transfusions, Blood Testing and Processing 50% after deductible and $50 50% after deductible
Imaging –​ Outpatient Facility $75 $100 after deductible

Horizon Advantage EPO 100/80 $50 2018 2019
Maximum Out-of-Pocket (MOOP) Limit — Single $5,750 $6,500
Home Health Care 80% after deductible $50
Urgent Care Center $50 $75
Cognitive Rehabilitation/Speech/Physical/Occupational Therapy — Office Visit $30 $40

Horizon Direct Access® Platinum 100/70 BlueCard 2018 2019
Behavioral Health/Substance Use Disorder — Office Visit $40 $20
Occupational/Physical Therapy — Outpatient Professional $20 No charge
Home Health Care $40 $20
Urgent Care Center $40 $75
Nutritional Counseling (Non-preventive) — Outpatient Facility No charge $40
Nutritional Counseling (Non-preventive) –
Outpatient Professional
$40 No charge

Horizon Direct Access Gold 100/80/60 BlueCard 2018 2019
Deductible — In-Network $1,500 $2,000
Deductible — Out-of-Network $2,500 $4,000
Maximum Out-of-Pocket (MOOP) Limit — In-Network — Single $3,000 $5,000
Maximum Out-of-Pocket (MOOP) Limit — Out-of-Network — Single $7,500 $8,000
Primary Care Visit $20 $30
Specialist Visit $40 $50
Behavioral Health/Substance Use Disorder — Office Visit $40 $30
Home Health Care 80% after deductible $30
Urgent Care $40 $75
Orthotics & Prosthetics Professional 80% after $20 copayment $30

Horizon Direct Access HSA Silver 100/70/60 BlueCard 2018 2019
Coinsurance — In-Network 80% 70%
Maximum Out-of-Pocket (MOOP) limit — In-Network — Single $6,500 $6,650
Emergency Room (ER) Deductible then $100 and 80% Deductible then $100 and 70%
Behavioral Health/Substance Use Disorder — Office Visit $50 after deductible $30 after deductible
Home Health Care 80% after deductible $30 after deductible
Urgent Care $50 after deductible $75 after deductible
Second/Third Surgical Opinion No charge No charge after deductible

Horizon Advantage EPO HSA Bronze 100 2018 2019
Hospice No charge after deductible $100 after deductible
Second/Third Surgical Opinion 50% after deductible No charge after deductible

Horizon HMO Platinum 2018 2019
Home Health Care No charge $30
Urgent Care Center $30 $60

Horizon POS Platinum 100/60 2018 2019
Primary Care Visit $50 $30
Behavioral Health/Substance Use Disorder — Office Visit $50 $30
Alcoholism — Outpatient Facility $50 $0
Home Health Care $50 $30
Cognitive Rehabilitation/Speech/Occupational/Physical
Therapy — Outpatient Professional
$30 No charge
Cognitive Rehabilitation/Speech/Occupational/Physical
Therapy — Outpatient Facility
$50 No charge
Well Baby/Child Care (Considered Routine) — Outpatient Facility $50 No charge
Urgent Care $50 $75

Small employer customers that offer a health plan that will be modified for 2019 will receive two Summary of Benefits & Coverage documents — one that mirrors their 2018 health plan effective until the time of their renewal, and one for use on and after their renewal that includes the modifications to the plan effective upon renewal.

Beginning November 1, 2018, full Summary of Benefits & Coverage documents for 2019 small group health plans will be available on HorizonBlue.com and when you sign in to Broker Online Services at HorizonBlue.com/brokers.

If you have questions, please contact your Horizon BCBSNJ sales executive or account manager.

Published on: October 31, 2018, 06:22 a.m. ET
Last updated on: May 15, 2020, 07:57 a.m. ET