Skip to main content

Out-of-Network Payments

If your health plan includes benefits for out-of-network services or supplies, and you choose to receive services or supplies from an out-of-network provider (doctor, other health care professional or facility), you generally will have to pay more out of pocket than if you used in-network doctors, health care professionals and facilities. Out-of-network providers are not contractually required to accept Horizon BCBSNJ’s reimbursement as full payment for the services and may bill you for the balance of the charges above Horizon BCBSNJ’s reimbursement.

Horizon BCBSNJ uses many sources to calculate its reimbursement rate for out-of-network services, including industry resources provided by entities such as FAIR Health, the Centers for Medicare & Medicaid Services (CMS), and other databases. Horizon BCBSNJ uses these fee schedules to calculate a reimbursement allowance that corresponds to your out-of-network benefits, taking into account your coinsurance, copayment, out-of-network deductible or any other member out-of-pocket costs.

PLEASE REVIEW YOUR COVERAGE DOCUMENTS, SUCH AS YOUR BENEFIT BOOKLET, OR CONTACT YOUR GROUP ADMINISTRATOR OR HORIZON BCBSNJ MEMBER SERVICES FOR INFORMATION ABOUT THE SPECIFIC REIMBURSEMENT METHOD OR FEE SCHEDULE FOR OUT-OF-NETWORK SERVICES FOR YOUR PLAN.

Where the corresponding fee schedule does not provide for a reimbursement allowance for a particular service, Horizon BCBSNJ may look to comparable fee schedules to determine the reimbursement allowance. Your coverage documents will provide further information about what alternate pricing methodologies may be used in such circumstances.

Centers for Medicare & Medicaid Services (CMS)

Medicare rates are set by CMS for reimbursement of particular medical services.

In the large group market (51 or more employees), depending on group size, the out-of-network reimbursement methodology can vary:

  • Health plans for groups with 51 to 99 employees:
    • Can have an out-of-network reimbursement set by the health plan design; or
    • Can choose from a set of out-of-network reimbursement options: 110%, 150%, 180% or 250% of CMS rates
  • Health plans for groups with 100 or more employees can choose from a set of out-of-network reimbursement options: 110%, 150%, 180% or 250% of CMS rates

If CMS does not have a reimbursement rate for a specific service, reimbursement is made at one of the alternate pricing methodologies. Please review your coverage document for details.

For the Small Employer Health market (one to 50 employees), the out-of-network reimbursement level depends on if the plan complies with all of the Affordable Care Act (ACA) market reform rules (a post-ACA plan), or if it is a transitional policy plan that retains pre-ACA plan specification. Transitional policy plans are also known as “grandmothered” plans originally issued prior to 2014 and have been continuously renewed as allowed for under state and federal laws.

If the health plan is:

  • Post-ACA, the out-of-network reimbursement levels are determined by product. For ACA-compliant plans with out-of-network benefits, the reimbursement level is 150% of CMS rates. If CMS does not have a reimbursement rate for a specific service, reimbursement is made at the Horizon Allowance.
  • Grandmothered, or transitional pre-ACA, the out-of-network reimbursement levels are based on the Prevailing Healthcare Charges System (PHCS) database/schedule.

For more information, view the fee schedule posted on the CMS website.

FAIR Health

Fair Health is a national independent, not-for-profit company established following the New York Attorney General’s office review of out-of-network reimbursement methodologies. FAIR Health promotes transparency in health care reimbursements and provides consumers with a mechanism to estimate the cost of out-of-network services.

FAIR Health relies on a database of billions of billed medical and dental services. Charges for a particular service are arranged from low to high, and percentiles are assigned to each based on the full range of reported charges for a particular service in a specific geographic area. The geographic area may refer to a local or national aggregate for pricing.

In the large group market (51 or more employees), depending on group size, the out-of-network reimbursement methodology can vary:

  • Health plans for groups with 51 to 99 employees:
    • Can have an out-of-network reimbursement set by the health plan design; or
    • Can choose from a set of out-of-network reimbursement options: 70th, 80th or 90th percentile of FAIR Health
  • Health plans for groups with 100 or more employees can choose from a set of out-of-network reimbursement options: 70th, 80th or 90th percentile of FAIR Health

If FAIR Health does not have a reimbursement rate for a specific service, reimbursement is made at one of the alternate pricing methodologies. Please review your coverage document for details

Horizon BCBSNJ updates its FAIR Health cost data on an annual basis.

Visit the Fair Health Resources website for additional information.

Ingenix

Ingenix, now known as OptumInsight, Inc., is a wholly owned subsidiary of UnitedHeath Group Inc. Like FAIR Health, Ingenix collected billed charge information from data contributors, and then organized it by medical procedure codes (or CPT® codes) and geographic area (or Geozips). Each CPT code in a specified Geozip was assigned a percentile. Pursuant to a 2009 settlement between United and the New York Attorney General, Ingenix discontinued updates of its databases.

For more information, visit the Optum website.
 

CPT® is a registered trademark of the American Medical Association.