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.

• Health Care Services, Service You May Pay

  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