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 doctor, other health care professional or facility, you generally will have to pay more out of pocket than if you used in-network health care professionals. 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 REGARDINGTHE SPECIFIC REIMBURSEMENT METHOD OR FEE SCHEDULE FOR OUT-OF-NETWORK SERVICES APPLICABLE TO 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 regarding what alternate pricing methodologies may be utilized in such circumstances.
Centers for Medicare and Medicaid Services (CMS)
Medicare rates are set by CMS for reimbursement of particular medical services. Horizon BCBSNJ currently offers group administrators various options pursuant to which reimbursements for out-of-network services are established using 110%, 150%, 180% or 250% of CMS rates.
For more information, view the fee schedule posted on the CMS website.
FAIR Health is a national independent, not-for-profit company that was established following a review of out-of-network reimbursement methodologies by the New York Attorney General’s office. 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. Service charges for a particular service are arranged from low to high, and percentiles are assigned for each of these charges based upon the full range of reported charges for a particular service in a specific geographic area. Horizon BCBSNJ currently offers group administrators various options pursuant to which reimbursements for out-of-network services are established by reference to the 70th, 80th or 90th percentile of FAIR Health.
Visit the Fair Health Resources site for additional information.
Ingenix, now known as Optum Insight, Inc., is a wholly-owned subsidiary of United Heath Group Incorporated (United). Like FAIR Health, Ingenix collected billed charge information from data contributors, and then organized it by medical procedure codes (or CPTs) and geographic area (or Geozips). Each CPT in a specified Geozip was assigned a percentile. Horizon BCBSNJ is required by statute to price individual consumer and small employer health plans using the data supplied by Ingenix at the 80th percentile of the PHCS Database. 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.