Horizon Medicare Blue Advantage (HMO)
2019 Horizon Medicare Blue Advantage (HMO) Plan Frequently Asked Questions
Our Horizon Medicare Blue Advantage (HMO) plan allows us to offer Medicare Beneficiaries access to high-quality health care and lower out-of-pocket costs for the low premiums ($0 plan premium in some counties) that the New Jersey market is demanding.
Features of our Horizon Medicare Blue Advantage (HMO) plan:
- Primary Care Physician (PCP) selection is required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.
- Referrals are not required for Horizon Medicare Blue Advantage (HMO) plan members.
- Prior authorization is required for certain services/supplies.
- Routine vision, hearing and dental benefits are included.
- Horizon Medicare Blue Advantage (HMO) plans do not include out-of-network benefits.
Horizon Medicare Blue Advantage (HMO) plan members must use physicians, other health care professionals and facilities that participate specifically in the Horizon Medicare Blue Advantage (HMO) plan, except in cases of medical emergencies. ‘
Physicians, other health care professionals and hospitals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network.
Learn more about our Horizon Medicare Blue Advantage (HMO) Plans.
- Horizon Medicare Blue Advantage (HMO) Plan Availability
- Horizon Medicare Blue Advantage (HMO) Plan Participation
- Primary Care Physician (PCP) Selection
- Referrals
- Out-of-Network Benefits
- BlueCard® (out-of-area) Benefits
- Preventive Care
- Clinical Laboratory Services
- Prescriptions
- Reimbursement
- Benefit Overview
- Prior Authorization/Precertification
- Participating Physician Responsibilities
- Mailing/Contact Information
- Member ID Cards
Horizon Medicare Blue Advantage (HMO) Plan Availability
Based on market demand, the Horizon Medicare Blue Advantage (HMO) plan is offered in 15 counties (Atlantic, Bergen, Cumberland, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Somerset, Sussex, Union and Warren) throughout New Jersey.
The Horizon Medicare Blue Advantage (HMO) plan is not offered to Medicare-eligible beneficiaries that reside in Burlington, Camden, Cape May, Gloucester, Passaic and Salem counties. However, members who reside in these counties will have other Medicare Advantage options with Horizon BCBSNJ.
Horizon Medicare Blue Advantage (HMO) Plan Participation
The Horizon Medicare Blue Advantage (HMO) plan uses a subset of physicians and other health care professionals that participate in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network.
For information about how physicians and other health care professionals in the Horizon Managed Care Network were evaluated for participation in this plan and changes to provider participation in the Horizon Medicare Blue Advantage (HMO) plan for the 2019 benefit year, please review the 2019 Horizon Medicare Blue Advantage (HMO) Plan Frequently Asked Questions.
All ancillary health care professionals in the Horizon Managed Care Network (some exceptions apply to in-network ancillary providers) are considered participating in this plan.
There are no out-of-network benefits with the Horizon Medicare Blue Advantage (HMO) plan, except in the event of an emergency. Therefore, members must receive services from physicians, health care professionals and hospitals that participate in this plan.
Physician and other health care professional participation
To make it easier for members to understand their cost sharing responsibilities, participation in the Horizon Medicare Blue Advantage (HMO) plan is at the group level. All physicians and other health care professionals who bill for services under the group practice’s Tax ID Number (TIN) are considered either participating or nonparticipating when treating members.
- All physicians and other health care professionals affiliated with a participating TIN are considered in-network when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that participating group practice’s TIN.
- If a physician or other health care professional is also affiliated with a group practice that is not participating in this plan, that physician is considered out of network for this plan when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that nonparticipating group practice as it pertains to services rendered to Horizon Medicare Blue Advantage (HMO) plan members.
Doctor & Hospital Finder
You can review your provider participation status for the Horizon Medicare Blue Advantage (HMO) plan as well as other Horizon BCBSNJ plans in our Doctor & Hospital Finder.
Primary Care Physician (PCP) Selection
PCP selection is required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan. Members will be required to select a PCP who is participating in the Horizon Medicare Blue Advantage (HMO) plan.
Horizon Medicare Blue Advantage (HMO) plan members will appear on participating PCP panels.
PCPs will be reimbursed based on their current payment methodology.
Referrals
Referrals are not required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.
Out-of-Network Benefits
The Horizon Medicare Blue Advantage (HMO) plan does not include out-of-network benefits (except in the event of an emergency).
BlueCard® (out-of-area) Benefits
The Horizon Medicare Blue Advantage (HMO) plan does not include BlueCard (out-of-area) benefits. In the event of an emergency, members should go to the nearest Emergency Room regardless of participation status.
Preventive Care
The Horizon Medicare Blue Advantage (HMO) plan covers the all preventive care services identified by the federal health care reform law at 100 percent without any cost sharing (i.e., copayment, coinsurance or deductible amounts) when provided by a physician or other health care professional who participates in the Horizon Medicare Blue Advantage (HMO) plan.
Clinical Laboratory Services
Members enrolled in the Horizon Medicare Blue Advantage (HMO) plan have a choice of receiving care for in-network laboratory services at LabCorp and Quest Diagnostics. Members are encouraged to check for in-network laboratories.
Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Medicare Blue Advantage (HMO) plan are allowed as an exception to the above-described LabCorp/Quest network use requirements.
Prescriptions
The Horizon Medicare Blue Advantage (HMO) plan includes a pharmacy benefit.
Prime Therapeutics LLC is the pharmacy benefits manager. Prior authorization (PA) may be required for some medications. Submit your pharmacy PA requests through NaviNet® or call 1-888-214-1784 if you have questions about a medicine requiring PA.
Prime Therapeutics LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.
Reimbursement
Eligible services provided to Horizon Medicare Blue Advantage (HMO) plan members by participating physicians and other health care professionals will be reimbursed at their current fee schedule.
The Horizon Medicare Blue Advantage (HMO) plan does not include out-of-network benefits except in the event of an emergency.
The following rates will apply for out-of-network care rendered to Horizon Medicare Blue Advantage (HMO) plan members in the ER or for inpatient admission as a result of an ER visit:
- If the physician is only participating in the Horizon PPO network, reimbursement will be based on amounts the physician would have received through Original Medicare.
- If the physician is participating in the Horizon PPO Network and the Horizon Managed Care Network but nonparticipating in the Horizon Medicare Blue Advantage (HMO) plan, reimbursement will be based on amounts the physician would have received through Original Medicare.
2019 Benefit Overview
| Category | Benefit |
| Participation | The Horizon Medicare Blue Advantage (HMO) plan uses a subset of physicians and other health care professionals that participate in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network. Members must use providers that participate in the Horizon Medicare Blue Advantage (HMO) plan. Members enrolled in this plan have no benefits for out-of-network services, except in the event of an emergency. |
| Primary Care Physician (PCP) Selection | PCP selection is required. Members must select a PCP that participates in the Horizon Medicare Blue Advantage (HMO) plan. |
| Referrals | Referrals are NOT required. |
| Prior Authorization | Certain services/supplies require prior authorization. |
| Well Care | Eligible preventive services are covered at 100% with no member cost sharing. Limited to one routine physical per calendar year. |
| PCP Office Visit | $10 copayment per visit to a pre-selected PCP that participates in the Horizon Medicare Blue Advantage (HMO) plan. |
| Specialist Office Visit | $25 copayment per visit to a specialist that participates in the Horizon Medicare Blue Advantage (HMO) plan. |
| Deductible | $0 deductible for medical/surgical services. |
| Diagnostic Tests/X-rays | Diagnostic radiology services (such as MRIs, CT scans): 5 copay at office or freestanding facility % of the cost for outpatient hospital Diagnostic tests and procedures: 5 copay at office or freestanding facility % of the cost for outpatient hospital Therapeutic Radiology: 0 copay at office or freestanding facility % of the cost for outpatient hospital X-rays: 5 copay at office or freestanding facility % of the cost for outpatient hospital |
| Chiropractic | $20 copayment Medicare covered services only. |
| (Short-term Therapies in an office setting) | $25 copayment per visit |
| Medical Equipment/Supplies | Durable Medical Equipment (wheelchairs, oxygen equipment, etc.) 20% of the cost Related medical supplies 20% of the cost Prosthetic devices (braces, artificial limbs, etc) 20% of the cost Diabetes monitoring supplies/therapeutic shoes or inserts $0 copay Diabetes self-management training $0 copay |
| Chemotherapy Drugs | 20% coinsurance Administrative codes are considered professional and will pay 100% in the office only. |
| Inpatient Hospital (Acute) | Our plan covers an unlimited number of days for an inpatient hospital stay. 20 copay per day for days 1 through 5 copay per day for days 6 and beyond Maximum Out of Pocket (MOOP) is $1,600 Covers inpatient substance abuse |
| Emergency Room | $90 copayment(worldwide) Copayment waived if admitted to a hospital within 24 hours for the same condition. See the “Inpatient Hospital Care” section of this booklet for other costs. |
| Urgent Care Center | $20 copayment for in-network urgent care center $25 copayment for a physician's office or other setting $90 copayment for worldwide coverage Copayment waived if admitted to a hopsital within 24 hours for the same condition. |
| Ambulatory Surgical Center | $270 copayment (one way) |
| Hospice Care | Our plan covers an unlimited number of days for an inpatient hospital stay. 320 copay per day for days 1 through 5 0 copay per day for days 6 and beyond Maximum Out of Pocket (MOOP) is $1,600 Covers inpatient substance abuse |
| Maximum Out-of-Pocket | $6,700 annually for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay for the rest of the year. Our plan has a coverage limit every year for certain in-network benefits. Contact us for all the services that apply. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
| Hearing Exam (Routine) | Exam to diagnose and treat hearing and balance issues
|
| Vision Care (Routine) | Routine eye exam (1 every year)
contact lenses not associated with cataract surgery. Member is responsible for payment beyond $100 coverage limit. |
| Part D Pharmacy Deductible | Part D deductible does not apply to Preferred generic drugs and non-Preferred generic drugs. Part D deductible applies to Preferred brand drugs, non-Preferred brand drugs, and specialty drugs. Part D deductible varies by the county in which the beneficiary resides:
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| Part D Pharmacy Cost Sharing | Preferred Pharmacy Arrangement: Members have a preferred (reduced) cost sharing responsibility when using certain preferred pharmacies including: CVS, Shop Rite, Walmart, Sam's Club, Elevate, Leader. The standard cost sharing will apply when using other pharmacies. Preferred Generic: $1 preferred copayment / $8 standard copayment Non-Preferred Generic: $9 preferred copayment / $16 standard copayment Preferred Brand: $40 preferred copayment / $47 standard copayment Non Preferred Brand: $60 preferred copayment / $70 standard copayment Specialty Drugs: Specialty drug coinsurance amounts vary by the county in which the beneficiary resides:
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Prior Authorization/Precertification
Certain services/supplies require prior authorization.
- Prior-authorization requests
1-800-664-2583 - Behavioral health and substance use disorder
Please call Horizon Behavioral Health at 1-800-626-2212. - Physical Therapy Unit
1-888-789-3457 - Medical Injectables Program
For certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, please call Magellan Rx Management at 1-800-424-4508. - eviCore healthcare
For non-emergency radiology services, advanced imaging services (MRI, CT, PET scans and nuclear medicine including nuclear cardiology), cardiac imaging services, radiation therapy and pain management services please call eviCore healthcare at 1-866-496-6200. - Horizon Care@Home Program services
For DME (including medical foods [enteral] and diabetic and other medical supplies); orthotics and prosthetics; and home infusion therapy services, call 1-855-243-3321.
Participating Physician Responsibilities
Participating Network
Horizon Medicare Blue Advantage (HMO) plan members must use physicians, other health care professionals and facilities that participate in the Horizon Medicare Blue Advantage (HMO) plan.
Horizon Medicare Blue Advantage (HMO) plan members have no out-of-network benefits (except in the event of an emergency).
Please use our Doctor & Hospital Finder to locate Horizon Medicare Blue Advantage (HMO) participating hospitals, physicians, other health care professional and ancillary providers.
Referrals
Referrals are not required for members enrolled in the Horizon Medicare Blue Advantage (HMO) plan.
However, if a patient is enrolled in the Horizon Medicare Blue Advantage (HMO) plan asks for your recommendation or guidance in regard to the selection of a hospital or specialist, please remember (and convey to your patient) that Horizon Medicare Blue Advantage (HMO) plan members have no out-of-network benefits (except in the event of an emergency).
Please use (or direct your patients enrolled in the Horizon Medicare Blue Advantage (HMO) plan to) our Doctor & Hospital Finder to locate physicians, other health care professionals and facilities that participate in Horizon Medicare Blue Advantage (HMO).
Prior Authorization (PA)
Certain services require PA. Review a list of services that require PA.
Prescription Drug PA
Certain prescription drugs require PA.
We encourage you to use the NaviNet Drug Authorization tool to quickly and easily submit and manage your drug PAs. Access NaviNet Drug Authorizations to register and for more information. Physicians are encouraged to prescribe appropriate first-line agents before using alternative drugs.
Mailing/Contact Information
Claims
Claims for services provided to members enrolled in the Horizon Medicare Blue Advantage (HMO) plan may be submitted electronically. Claims may also be submitted hard copy to the following addresses:
| Type of service | Claim submission address | Inquiry submission address |
| Professional | Horizon BCBSNJ PO Box 1609 Newark, NJ 07101-1609 |
Horizon BCBSNJ PO Box 199 Newark, NJ 07101-0199 |
| Facility | Horizon BCBSNJ PO Box 25 Newark, NJ 07101-0025 |
Horizon BCBSNJ PO Box 1770 Newark, NJ 07101-1770 |
| Pharmacy | Prime Therapeutics PO Box 64812 St. Paul, MN 55164-4812 |
Prime Therapeutics P.O. Box 64812 St. Paul, MN 55164-4812 |
Service
Horizon BCBSNJ has a number of service areas that can assist with authorizations and PAs. For these specialized service areas to perform their functions efficiently and effectively, it’s important that their time is not spent responding to basic benefits, enrollment and eligibility inquiries.
Please seek basic benefits, enrollment and eligibility information prior to contacting our Precertification Call Center for an authorization request. If you require documentation that a service does not require precertification, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.
| Service area | Phone number |
| Dental | 1-800-4-DENTAL (433-6825) |
| eviCore healthcare | 1-866-496-6200 |
| Horizon Behavioral Health | 1-800-626-2212 |
| Horizon Care@Home Program | 1-855-243-3321 |
| Horizon Pharmacy Program | 1-800-391-1906 |
| Institutional Services | 1-888-666-2535 |
| Medical Injectables Program | 1-800-424-4508 |
| Member Services | 1-800-355-BLUE (2583) |
| Physical Therapy Unit | 1-888-789-3457 |
| Physician Services | 1-800-624-1110 |
| Prior Authorization Requests | 1-800-664-BLUE (2583) |
Member ID Cards
Horizon BCBSNJ member ID cards contain the important information you need in a consistent layout so that our ID cards are easy to read and use. Members enrolled in the Horizon Medicare Blue Advantage (HMO) plan have ID cards similar to the sample ID card below.
Please note that the YKO prefix included on Horizon Medicare Blue Advantage (HMO) plan ID cards is not exclusive to this plan. The YKO prefix is also included on ID cards for members enrolled in other Horizon BCBSNJ Medicare Advantage plans.
