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.
Health Care Services
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Primary Care Physician (PCP) office visits | Copay | PCP selection is required for Horizon HMO and Horizon Away from Home plans. |
| Specialist office visits and consultations | Copay | PCP referral is required |
| Other practitioner office visits | Copay | PCP referral is required |
| Preventive care, screenings, immunizations | No Charge For most members, preventive care services are not subject to a copay. |
PCP only One routine physical per calendar year |
| Well child care, screenings, immunizations | No Charge | PCP only |
Tests and Imaging
Laboratory Corporation of America® (LabCorp), Quest Diagnostics (Quest) and AtlantiCare Clinical Laboratories are Horizon BCBSNJ’s participating testing facilities. If you use a testing facility other than LabCorp, Quest or AtlantiCare Clinical Laboratories, your tests will not be covered and you will have to pay the total cost of the lab services.
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Laboratory services | No Charge | Copay if outpatient department is used |
| X-ray/radiology services | No Charge | Copay if outpatient department is used |
Hospital Services/Outpatient Surgery
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Hospital services | Copay | Authorization required |
| Doctor/surgeon services | Copay | Authorization required |
| Ambulatory surgical center | Copay | Authorization required |
Emergency and Urgent Medical Services
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Emergency Room (ER) services | Copay | $0 if admitted |
| ER services – health care professional | Copay | $0 if admitted |
| Emergency medical transportation (e.g., ambulance) | No Charge | Authorization required in nonemergency situations |
| Urgent care center | Specialist Copay |
Behavioral Health Services (including mental health and substance use disorder)
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Outpatient/inpatient services | Copay |
Maternity Services
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Prenatal and postnatal care | Copay | Initial visit only |
| Delivery and all inpatient services | Copay |
Recovery/Special Health Services Exceptions
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| In-home health care | No Charge | 100 days per calendar year |
| Rehabilitation services | Copay | |
| Skilled nursing facility – Extended care center | No Charge | 60 days per calendar year |
| Durable medical equipment (DME) | Coinsurance |
Vision Care Services
There is a $50 or $100 reimbursement for vision hardware if the Rider is purchased.
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Eye exam | Specialist Copay | One routine exam per benefit period |
| Frames/Lenses | Not covered |
Other Covered Services
| Service | You May Pay | Limitations & Exceptions |
|---|---|---|
| Chiropractic care | Copay | 12 visits per year |
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.
