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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.

What if you get a medical bill?

Whenever you see an in-network doctor or other health care professional, you'll be asked for a copay, if one applies. For all other charges, your doctor should bill us directly by filing a claim. After we process your claim, we will generate an Explanation of Benefits (EOB) statement, which will explain how much we paid and how much you may owe. You can sign in to view your claims and EOBs.

You may receive a bill from your PCP for your share of costs, including coinsurance plus any covered amount that goes toward meeting your deductible. Before you pay your bill, check it against your EOB.

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