Horizon Medicare Advantage NJ DIRECT (PPO) Plans

Effective January 1, 2017, Horizon BCBSNJ will offer Medicare-eligible retired State Health Benefits Program (SHBP) members Medicare Advantage (MA) PPO plans. Currently, SHBP Medicare-eligible retired members have Original Medicare and an NJ DIRECT plan as supplemental coverage.

Participating with Horizon Medicare Advantage NJ DIRECT (PPO)

With the Horizon Medicare Advantage NJ DIRECT (PPO) plans, eligible SHBP retirees will have access to physicians and other health care professionals who participate in our Medicare Managed Care Network and the Medicare Advantage PPO network of other Blue Cross and/or Blue Shield Plans, as well as all physicians and other health care professionals who are eligible to receive Medicare payments and provide health care services to a Horizon Medicare Advantage NJ DIRECT (PPO) member.

The following plans will be offered to Medicare-eligible SHBP retirees1:

Current SHBP Retiree Coverage Corresponding Horizon Medicare Advantage NJ DIRECT (PPO) plan
NJ DIRECT10 Horizon Medicare Advantage NJ DIRECT10 (PPO)
NJ DIRECT15 Horizon Medicare Advantage NJ DIRECT15 (PPO)

1 Individuals who have been diagnosed with End Stage Renal Disease (ESRD) are not eligible to enroll in a Horizon Medicare Advantage NJ DIRECT (PPO) plan at this time. Individuals who have been diagnosed with ESRD and are currently in a NJ DIRECT10 or NJ DIRECT15 retiree plan will remain in their current plan.

The SHBP will automatically transfer Medicare-eligible SHBP retirees who are currently enrolled with Horizon BCBSNJ’s NJ DIRECT10 and NJ DIRECT15 plans into the Horizon Medicare Advantage NJ DIRECT (PPO) plan that corresponds to their current SHBP retiree coverage.

The Horizon HMO, Horizon HMO 1525, Horizon HMO 2030, NJ DIRECT 1525 and NJ DIRECT 2030 plans will remain as Medicare supplemental plan options for SHBP retirees. However, Medicare-eligible SHBP retirees in these plans can choose to enroll into a Horizon Medicare Advantage NJ DIRECT (PPO) plan beginning January 1, 2017.

The SHBP and Horizon BCBSNJ have developed the Horizon Medicare Advantage NJ DIRECT (PPO) plans to be consistent with what is covered under the current SHBP retiree plans and provide both in- and out-of-state coverage.

Your patients will not need referrals for specialty care with the Horizon Medicare Advantage NJ DIRECT (PPO) plans. However, physicians may need to get prior authorization for certain member services.

Members’ plan benefits include:

  • Access to in- and out-of-state coverage
  • All Medicare Part A and Part B benefits, and additional supplemental benefits
  • No referrals required for physicians or specialists (prior authorization required where necessary)
  • Free preventive care, including annual screenings, immunizations and nutritional counseling

Dependent coverage for SHBP Medicare-eligible retirees

The Horizon Medicare Advantage NJ DIRECT (PPO) plans are single coverage plans. For that reason, when your patients move to the Horizon Medicare Advantage NJ DIRECT (PPO) plan their dependents who are not Medicare eligible will remain active in the current coverage. Dependents may have their own member ID cards and unique member ID numbers.

Pharmacy coverage

SHBP retiree prescription drug benefits are not changing. If you need help with verifying prescription drug benefits, please call Express Scripts® (ESI) at the number on the member’s prescription drug ID card.

Submitting your claims

Under the Horizon Medicare Advantage NJ DIRECT (PPO) plans, medical claims should be sent to Horizon BCBSNJ as the primary insurer. Out-of-state providers should submit claims through their local Blue Cross and/or Blue Shield (BCBS) Plans.