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What Do You Pay?

You should understand your health insurance plan — how it works and how to use it — so you can get the most out of it. You can save time and money when you know what your health plan covers before you get care.

Each insurance plan is different. That’s why understanding your plan and benefits is important. You’ll find complete plan details in your Summary Plan Description (SPD) or Benefit Booklet. But generally, this is how health insurance works:

  • The subscriber pays a premium contribution through payroll deductions for coverage.
  • Each time you see an in-network doctor or health care professional, you may pay a fixed amount called a copay.
  • For some services, instead of a copay, you may pay coinsurance — what’s left after a percentage of how much we agree to cover for a service (the amount your provider agrees to accept as payment in full from us is our allowed amount). For example, if we allow $100 for a covered service and your plan has 30% coinsurance, we would pay $70 and you would be responsible to pay $30.
  • You may also be responsible for an annual deductible — an amount you pay toward health care costs each year before your Horizon HMO Access plan starts to pay for covered services.
  • Your coverage may have an out-of-pocket maximum, sometimes called a maximum out-of-pocket, or MOOP. If it does, this amount is the most you’ll have to pay in copays, deductibles and coinsurance for eligible health care services in a calendar year.
  • Once you have met your out-of-pocket maximum, your plan will pay for eligible health care services at 100% of our allowed amount.

Sign in to view the dollar amounts applied to your deductible and maximum out-of-pocket expenses.

Limitations and exclusions: A referral from your PCP is required for most specialty care and nonemergency hospitalizations.

Prior authorization: Under your plan, Horizon BCBSNJ must authorize all nonemergency hospitalizations and some specialty care services (except for routine Ob/Gyn) before you get these types of services.

Non-covered services: Your Horizon HMO Access plan does not pay for services or supplies that are not covered under your policy. If there is a discrepancy between the information contained in this Member Handbook or your SPD or Benefit Booklet, your SPD or Benefit Booklet will prevail. Please refer to your SPD or Benefit Booklet for more details or contact Member Services.