Products

This section provides an overview of many of the products we offer and/or service.

Additional product information is available.

Your Responsibilities

The following responsibilities apply to you as a participating physician or other health care professional:

• You may collect copayment amounts as indicated on the member’s ID card.
• You are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.
• You are required to accept our allowance for eligible services as payment in full.

Pre-existing Exclusions

The Affordable Care Act removed the pre-existing medical condition exclusion for both new employer-based health insurance plans and new individual health insurance plans. Health insurance companies cannot charge higher premiums for current and past health problems, gender and a person’s occupation. Also, insurers cannot refuse to sell coverage or renew coverage because of a pre-existing medical condition and cannot deny claim payments because of a pre-existing medical condition.

The ACA does not require health insurers to remove the pre-existing condition exclusion from Medicare, Medigap and Medicaid plans. Horizon BCBSNJ currently only applies a pre-existing condition waiting period on Medigap coverage.

The effective date of the removal of the pre- existing condition exclusion will vary.

The State Health Benefits Program and Federal Employee Program® do not have pre-existing condition restrictions.

HORIZON MANAGED CARE NETWORK

If you are a participating Horizon Managed Care Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you. Note that the Horizon Medicare Blue Advantage (HMO) uses a subset of the Managed Care Network.

HMO¹

• Horizon HMO
• Horizon HMO Access
• Horizon HMO Access Value
• Horizon HMO Coinsurance
• Horizon HMO Coinsurance Plus
• Horizon HMO (SHBP and SEHBP)
• Horizon HMO1525 (SEHBP)
• Horizon HMO2030 (SEHBP)

Direct Access

• Horizon Direct Access
• Horizon Advantage Direct Access
• Horizon Direct Access Value
• NJ DIRECT10 (SHBP and SEHBP)
• NJ DIRECT15 (SHBP and SEHBP)
• NJ DIRECT1525 (SHBP and SEHBP)
• NJ DIRECT2030 (SHBP and SEHBP)
• NJ DIRECT2035 (SHBP and SEHBP)
• NJ Educators Health Plan (SEHBP)
• CWA Unity Direct (SHBP)
• CWA Unity DIRECT 2019 (SHBP)
• NJ DIRECT (SHBP)
• NJ DIRECT 2019 (SHBP)

EPO¹

• OMNIA Health Plans
• Horizon Advantage EPO
• Horizon Patient-Centered Advantage EPO

1. Members enrolled in these plans do not have out-of-network benefits, except in the event of an emergency

Consumer-Directed Healthcare (CDH)

• Horizon HMO Access HSA
• Horizon HSA/HRA (Direct Access)
• OMNIA HSA/HRA
• NJ DIRECT HD1500 (SHBP)
• NJ DIRECT HD4000 (SHBP)

POS

• Horizon POS

Medicare Advantage

• Braven Health^SM Plans
• Horizon Medicare Blue Value (HMO)1
• Horizon Medicare Blue Value w/Rx (HMO)1
• Horizon Medicare Blue Choice w/Rx (HMO)1
• Horizon Medicare Blue Advantage (HMO)1
• Horizon Medicare Blue Select (HMO-POS)
• Horizon Medicare Blue Access Group (HMO-POS)
• Horizon Medicare Blue Access Group w/Rx (HMO-POS)
• Horizon Medicare Blue Access Group w/Rx Value (HMO-POS)
• Horizon Medicare Blue (PPO)
• Horizon Medicare Blue Group (PPO)
• Horizon Medicare Blue Group w/Rx (PPO)
• Horizon Medicare Blue Group w/Rx Ideal (PPO)
• Horizon Medicare Blue Group w/Rx Complete (PPO)

HORIZON MANAGED CARE NETWORK NJPA

Certain Individual and Small Group Market plans (HMO, POS and Advantage EPO plans without BlueCard benefits) are part of the Horizon Managed Care Network NJPA. Member ID cards for this plan say “NJPA” along with the plan name.

HORIZON HMO

Horizon HMO members select a PCP who will either provide the necessary care or refer them to the appropriate specialist or facility. Members receive full benefit coverage, including coverage for preventive care, when services are provided or referred by their PCP.

Copayments

Horizon HMO offers various office visit copayments. Carefully check the member’s ID card for the copayment amount due for an office visit.

Coinsurance

Some Horizon HMO members are required to pay a coinsurance payment for most services that are not performed in an office setting.

Well Care

Well care, such as routine adult physicals and well child care, are covered under capitation. If you are a fee-for-service PCP, well care is also covered and billable. Immunizations are billable for capitated and fee-for-service PCPs (subject to plan limitations).

Obstetrical/Gynecological Care

Horizon HMO members may go directly to participating Ob/Gyns for obstetrical and gynecological-related care. They do not require a referral from their PCP for these services. However, certain infertility services require prior authorization.

Most members do not need a referral from their PCP or Ob/Gyn for routine mammography services (CPT Codes 76090, 76091 and 76092). Give these members a prescription to present to the radiology center.

Annual Vision Exam

If included in their contract, members are eligible for one routine vision exam per year by a participating physician or other health care professional. This service does not require a referral from the PCP. Members are also eligible for a vision hardware reimbursement every two years.

Most members who have diabetes may go directly to a participating eye care physician for a dilated retinal exam without a referral from their PCP. Advise the member to check their Horizon HMO member handbook or Evidence of Coverage for specific details.

Chiropractic Coverage

Most Horizon HMO members may go directly to participating chiropractors. This means they may not require a referral from their PCP to visit a participating chiropractor (subject to plan limitations).

Behavioral Health/Substance Use Disorder Care

Physicians may contact Horizon Behavioral Health to refer most patients for behavioral health or substance use disorder care.

HORIZON HMO ACCESS AND HORIZON HMO ACCESS VALUE

Under Horizon HMO Access plans, members may receive care from Horizon Managed Care Network specialists without a referral.

Members enjoy both the benefits of working with a selected PCP and the freedom to coordinate their needs without a referral. Members may not self-refer to PCP-type providers; they must use their preselected PCP.

Split Copayments

Horizon HMO Access plans include split copayments for physician services. A lower office visit copayment applies to visits to preselected PCPs. A higher office visit copayment applies to office visits to non-preselected PCPs, all other participating PCP-type physicians and other health care professionals, and to participating specialist office visits.

Other Copayments

Horizon HMO Access includes various inpatient and outpatient facility copayments and other professional health care services.

Coinsurance

Some Horizon HMO Access members are required to pay a coinsurance payment for most services not performed in an office setting, including Durable Medical Equipment.

Referrals

Horizon HMO Access members may visit participating specialists without a referral. Preapproval is required for some services.

Out-of-Network Benefits

Horizon HMO Access members have no out-of-network benefits.

Prescriptions

Member charges for prescription drug services do not accumulate to the maximum out of pocket (MOOP).

Well Care

Well care such as routine adult physicals, annual Ob/Gyn exams, well child care and immunizations are covered and billable. Coverage limitations exist and vary per contract.

Annual Vision Exam

Some Horizon HMO Access members are eligible for an annual vision exam or vision hardware reimbursement. Since this program does not use referrals, they are not needed. Coverage limitations exist and vary per contract.

Horizon HMO Access Value

The Horizon HMO Access and the Horizon HMO Access Value plans are identical except that Horizon HMO Access Value includes:

• A higher specialist copayment amount
• A lower maximum out-of-pocket amount
• A higher hospital inpatient copayment amount

HORIZON HMO COINSURANCE AND HORIZON HMO COINSURANCE PLUS

The Horizon HMO Coinsurance and Horizon HMO Coinsurance Plus plans are managed care products. They require PCP selection, use of the Horizon Managed Care Network and referrals/ precertification to receive benefits. Out-of-network services are not covered under these plans.

These plans offer 100 percent coverage after office visit copayment for all services received in a network practitioner’s office. For all other network services, coverage is subject to deductible and coinsurance.

The deductible applies to all services rendered outside of the physician’s office except for:

• Diagnostic lab work and X-ray
• Emergency Room care
• Prescription drugs

HORIZON HMO (SHBP AND SEHBP) HORIZON HMO1525 (SEHBP)

HORIZON HMO2030 (SHBP AND SEHBP)

Horizon BCBSNJ offers members of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) access to the following HMO options:

• Horizon HMO10
• Horizon HMO15
• Horizon HMO1525
• Horizon HMO2030

These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network.

Horizon HMO members must select a Primary Care Physician (PCP) and referrals are required.

The numbers in the health plan names reflect the physician office visit copayment levels:

• Horizon HMO10 and Horizon HMO15 feature a $10 and $15 physician (PCP and specialist) office visit copayment, respectively.
• Horizon HMO1525 and Horizon HMO2030 plan options feature split copayment levels. The lower copayment level in each of these plans ($15 and $20) applies to office visits to PCPs. The higher copayment level in each of these plans ($25 and $30) applies to office visits to specialists.

These plans also offer:

• 100% coverage for preventive services (physical exams, well-child care, immunizations) in network. All SHBP and SEHBP plans offer preventive care services, as defined by the Patient Protection and Affordable Care Act (PPACA) with no member cost share (no copayment, not subject to deductible) when provided by a participating practitioner.
• Access to specialty care with a referral from your PCP. (Referrals are not required for chiropractic care).
• Guest Membership in our “Away from Home” care program if you or a covered family member will be traveling or out of the area for a longer period.

HORIZON DIRECT ACCESS

Our Horizon Direct Access products allow members to visit participating specialists without a referral from a PCP. Horizon Direct Access is similar to a POS product by offering two levels of benefits: in network and out of network.

Members are encouraged to select a PCP to help them access the appropriate medical care, however, it is not required. PCPs are encouraged to refer members to participating physicians and other health care professionals.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office copayment, a deductible or coinsurance. Patients who receive care out of network, pay a higher share of the costs, sometimes including higher deductibles, coinsurance and/or copayment amounts.

No Referrals

This product does not require referrals for in-network professional services. PCPs do not need to complete referrals for the member to receive care from a specialist or facility.

Prior Authorization

Please obtain prior authorization when referring a Horizon Direct Access member to an in-network or out-of-network facility for inpatient and outpatient care.

By obtaining the authorization, your patient may incur lower out-of-pocket expenses.

In-Network Benefits

To receive the highest level of benefits, members must access care from a participating physician, other health care professional or facility in the Horizon Managed Care Network. When a Horizon Direct Access member receives care from a participating physician, other health care professional or network facility, they are covered at the in-network level of benefits and incur lower out- of-pocket costs.

Out-of-Network Benefits

Out-of-network benefits apply when members do not use a Horizon Managed Care Network physician, health care professional or facility.

Members pay a higher share of the costs for out-of- network care, usually including deductible and/or coinsurance amounts.

Help your Horizon Direct Access members save money by encouraging them to receive all medical care and services from our large, comprehensive network of participating physicians, facilities and other health care professionals. This can significantly reduce their out-of-pocket costs and paperwork submissions and may also increase their satisfaction with your services.

We recognize that there may be instances in which a service is not available in network. If a member’s care is coordinated by their PCP and the proper authorization is obtained, eligible and medically necessary out-of-network services may be covered at the in-network level of benefits.

Horizon Direct Access and BlueCard

Horizon Direct Access is a managed care product. These ID cards display the PPO-in-the-suitcase logo indicating that these members have access to PPO physicians and health care professionals when receiving services outside of New Jersey.

Well Care

Well care, such as routine adult physicals, annual Ob/Gyn exams, well child care and immunizations, is covered and billable. Coverage limitations exist and vary per plan.

Annual Vision Exam

Some Horizon Direct Access members are eligible for an annual vision exam or vision hardware reimbursement. Since this plan does not use referrals, they are not needed. Coverage limitations exist and vary per benefit plan.

Chiropractic Coverage

Horizon Direct Access members are eligible for chiropractic care from a participating chiropractor. Referrals are not needed. Coverage limitations exist and vary per benefit plan.

HORIZON ADVANTAGE DIRECT ACCESS

Horizon Advantage Direct Access plan are similar to Horizon Direct Access plans but include:

• Split copayments: Lower office visit copayments for PCP visits and higher office visit copayments for all other physicians. Members are not required to select a PCP; however, the lower copayment for PCP services is only available for a PCP-type doctor (a participating physician specializing in family practice, general practice, internal medicine or pediatrics).
• Separate (and higher) out-of-network deductible amounts and maximum out-of- pocket (MOOP) levels to help discourage out-of-network utilization. The deductible and MOOP do not cross accumulate between the in-network and out-of-network benefits.
• These plans also include a $2,000 benefit maximum for out-of-network ambulatory surgery centers.

NJ DIRECT

Horizon BCBSNJ administers 10 direct access plans on behalf of the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).

All NJ DIRECT plans:

• Do not require PCP selection or referrals.
• Allow members to receive care in or out of network.
• Require prior authorization for certain services (refer to the online prior authorization list).
• Use the Horizon Managed Care Network in New Jersey and the national BlueCard PPO network outside of New Jersey.
• Cover eligible preventive care services, as outlined in the federal health care reform law, the Patient Protection and Affordable Care Act (PPACA), with no member cost share when rendered in network.

NJ DIRECT copayment plans

SHBP/SEHBP members may select a copayment plan:

• NJ DIRECT10
• NJ DIRECT15
• NJ DIRECT1525
• NJ DIRECT2030
• NJ DIRECT2035
• NJ Educators Health Plan
• CWA Unity DIRECT
• CWA Unity DIRECT 2019
• NJ DIRECT
• NJ DIRECT 2019

For these plans, NJ DIRECT will pay the full cost of in-network services (based on contracted rate), in most cases, after appropriate member copayment per visit. Services rendered out of network are subject to deductible and a percentage of coinsurance based on plan allowance.

The number in the plan name (10, 15, 1525, 2030 or 2035) refers to the primary and specialty provider office visit copayment.

• NJ DIRECT10 and NJ DIRECT15 have primary and specialty office visit copayments of $10 or $15.
• NJ DIRECT1525 has a primary office visit copayment of $15; specialty office visit copayment is $25.
• NJ DIRECT2030 has a primary office visit copayment of $20; specialty office visit copayment is $30 for adults, but $20 for children. A child is defined as eligible until the end of the year in which age 26 is reached. Once the 26th year is completed, the member is considered an adult (including disabled dependents who have extended coverage).
• NJ DIRECT2035 has a primary office visit copayment of $20; specialty office visit copayment is $35/20 percent after deductible at an outpatient facility.
• Primary office visit copayments apply to primary care physicians (internists, general practitioners, family practitioners, pediatricians, PAs, APRNs.)
• Specialty office visit copayments apply to in-network specialist visits including non-routine Ob/Gyn services, short-term therapist visits (occupational therapy, speech therapy, physical therapy, respiratory therapy, and cognitive therapy) and chiropractic visits.
• The NJ Educators Health Plan has a primary office visit copayment of $10; specialty office visit copayment is $15.
• The CWA Plans, the NJ Direct and NJ DIRECT 2019 plans have a primary and specialist copayment of $15.
• The Emergency Room copayment (waived if admitted) varies by plan.
• The appropriate copayment amounts are indicated on the member’s ID card.
• In-network behavioral health services may be subject to office visit copayment.

High-Deductible (HD) Health Plans
SHBP members may select one of two high-deductible plans.

• NJ DIRECT HD1500
• NJ DIRECT HD4000

In the High-Deductible Health Plans, all eligible services (except for eligible preventive services) are subject to deductible, coinsurance and out-of- pocket maximums before services will be considered for benefit. No copayments apply.

The plan is combined with a Health Savings Account (HSA) that can be used to pay for qualified medical expenses.

• The number in the plan’s name (1500, 4000) refers to the individual deductible, which is doubled for non-single contracts, and is combined for in- and out-of-network medical services and prescription drugs.
• Members are responsible for expenses, in and out of network, up to the deductible.
• After the annual deductible is met, the member is responsible for 80 percent of the contracted rate in network and 60 percent of the plan allowance out of network.
• If eligible expenses reach the out-of-pocket maximum, eligible services will be covered at 100 percent, subject to all provisions of the plan.

For more information about NJ DIRECT, visit HorizonBlue.com/SHBP.

SHBP/SEHBP: Multiple coverages prohibited

A New Jersey state law enacted in 2010 prohibits multiple coverage under the State Health Benefits Program (SHBP) and/or the School Employees’ Health Benefits Program (SEHBP).

This means:

• An employee or retiree cannot be enrolled for coverage as both a subscriber and a dependent under the SHBP and/or SEHBP.
• An employee cannot be enrolled for coverage as an employee and as a retiree under the SHBP/SEHBP.
• Children cannot be enrolled as dependents for coverage under both SHBP/SEHBP covered parents.
• NJ DIRECT members who have coverage under a non-SHBP/SEHBP plan can maintain enrollment in NJ DIRECT and the non- SHBP/SEHBP plan.

OMNIASM HEALTH PLANS

Our OMNIA Health Plans give enrolled members the flexibility to visit any New Jersey health care professional in our broad Managed Care Network.

OMNIA Health Plan members incur lower out-of-pocket costs when they use OMNIA Tier 1 doctors, hospitals and other health care professionals.

These products are offered to individual consumers purchasing coverage on and off the Health Insurance Marketplace (Exchange) as well as to employer groups of all sizes, including the New Jersey SHBP.

OMNIA Health Plan Metallic Levels
OMNIA BRONZE

Our lowest premium Bronze plan offers members the lowest monthly premium but highest out-of-pocket costs compared to other OMNIA Health Plans. Bronze plans, on average, pay for 60 percent of the covered medical expenses; members pay 40 percent.

OMNIA SILVER

Our Silver plan offers mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA SILVER HSA

Our Silver plan offered in conjunction with a Health Savings Account (HSA) includes mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA SILVER VALUE

Our lowest premium Silver plan offers mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA GOLD

Our lowest premium Gold plan offers higher monthly premium and lower out-of-pocket costs compared to other OMNIA Health Plans. Gold plans, on average, pay for 80 percent of the covered medical expenses; members pay 20 percent.

OMNIA PLATINUM

Our lowest premium Platinum plan offers highest monthly premium and lowest out-of-pocket costs compared to other OMNIA Health Plans. Platinum plans, on average, pay for 90 percent of the covered medical expenses; members pay 10 percent.

Other OMNIA Health Plans

Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts that select OMNIA Health Plans will have the ability to customize their OMNIA Health Plan benefits programs to include a range of benefit options, including BlueCard coverage and variations in Tier 2 out-of-pocket costs.

OMNIA Tier Status

All Horizon Managed Care Network physicians, other health care professionals and in-network hospitals are participating with OMNIA Health Plans; however, OMNIA members will have lower cost sharing when they use physicians, health care professionals and hospitals with the OMNIA Tier 1 designation.

To make it easier for members to understand their cost-sharing responsibilities, all physicians and other health care professionals affiliated with, or who practice under or on behalf of a group practice, will participate with OMNIA Health Plans at the same tier when treating members under a particular Group Tax ID Number (TIN).

Ancillary facilities and ancillary professionals that participate in our Horizon Managed Care Network will be designated OMNIA Tier 1. Some exceptions apply.

Use our Online Doctor & Hospital Finder to review OMNIA tier status information.

OMNIA Tier Awareness Administrative Policy We encourage all participating managed care network physicians and other health care professionals to review our OMNIA Tier Awareness administrative policy.

This policy includes guidelines that participating physicians and other health care professionals are required to follow when they treat, help to coordinate the care of, refer, recommend or advise patients enrolled in OMNIA Health Plans to seek specialty care and/or treatment at a health care facility or hospital.

The guidelines of this policy are designed to help ensure that patients enrolled in OMNIA Health Plans understand the benefit and cost-sharing implications of using physicians, other health care professionals and facilities designated as OMNIA Tier 1 or Tier 2.

To access this policy, registered NaviNet users should log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

• Mouse over References & Resources and select Provider Reference Materials.
• Mouse over Policies & Procedures.
• Select Policies, then Administrative Policies.
• Select Tier Awareness Policy.

No Out-of-Network Benefits

Members enrolled in OMNIA Health Plans do not have ANY benefits for out-of-network services.

OMNIA Health Plan members must use physicians, other health care professionals and hospitals who participate in the Horizon Managed Care Network and Horizon Hospital Network*, except in cases of medical emergencies.

* OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard® coverage, that are not available in the individual consumer and small employer markets.

Primary Care Physician (PCP) Selection

OMNIA Health Plan members are NOT required to select a Primary Care Physician (PCP).

Referrals

Referrals are not required for OMNIA Health Plan members to see a participating Horizon Managed Care network specialist.

Prior Authorizations

Prior authorizations are required for certain services.

Preventive Care

Eligible preventive services (physical exams, well-child care, immunizations, etc.) are covered with no member cost-sharing when provided by a doctor or other health care professional participating in the Horizon Managed Care Network.

Cost Sharing

OMNIA Health Plan member cost sharing (copayments, deductibles and coinsurance amounts) will vary based on the type of plan, the place of service and the tier status of the provider of service. Carefully review the OMNIA Health Plan member’s Horizon BCBSNJ ID card for the appropriate cost sharing amount.

Laboratory Services

Members are required to use an in-network clinical laboratory provider. You or the member can use our Online Doctor & Hospital Finder to locate in-network laboratories.

Pharmacy/Prescription Benefits

Each standard OMNIA Health Plan includes a pharmacy benefit.¹ OMNIA Health Plan members must use a participating pharmacy. Cost sharing varies based on the plan.

¹ Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts have the option to include a pharmacy benefit in their OMNIA Health Plans.

BlueCard Benefits

Our standard OMNIA Health plans available on– and off the Health Insurance Marketplace (exchange) to consumers and small employer groups DO NOT include BlueCard Benefits.

OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard coverage.

The PPO-in-a-suitcase logo will be displayed on ID cards of any members enrolled in OMNIA Health Plans that include BlueCard benefits.

HORIZON ADVANTAGE EPO

Horizon Advantage Exclusive Provider Organization (EPO) plans provide in-network only benefits through the Horizon Managed Care Network.

PCP Selection

Members enrolled in Horizon Advantage EPO plans are NOT required to select a Primary Care Physician.

Referrals

Referrals are NOT required for members to see specialists who participate in the Horizon Managed Care Network.

No Out-of-Network Benefits

Members enrolled in Horizon Advantage EPO plans have NO benefits for out-of-network services. Members enrolled in Horizon Advantage EPO plans must use physicians who participate in our Horizon Managed Care Network (except in the case of medical emergencies).

Members enrolled in Horizon Advantage EPO plans have no benefits for services provided by physicians and other health care professionals participating in the Horizon PPO Network.

BlueCard Program Access

Certain employer groups may choose to provide their members with access to the BlueCard® PPO program.

If a member’s Horizon Advantage EPO ID card includes the: PPO-in-the-suitcase logo or the empty-suitcase logo, they have access to the BlueCard® PPO program for services provided outside our local service area.

The PPO-in-the-suitcase logo identifies a member who has benefits for medical services received outside Horizon BCBSNJ’s service area. It does not mean that these members can see a participating Horizon PPO Network physician or other health care professional.

Horizon Advantage EPO plans must use physicians who participate in our Horizon Managed Care Network (except in the case of medical emergencies).

HORIZON PATIENT-CENTERED ADVANTAGE EPO

The Horizon Patient-Centered Advantage EPO plan is offered to employer groups and provides in-network only benefits through the Horizon Managed Care Network. This plan builds upon our patient-centered programs, which include our Patient-Centered Medical Home (PCMH) and Accountable Care Organization (ACO) programs.

Our Horizon Patient-Centered Advantage EPO plan is similar to our other Horizon Advantage EPO plans, except this plan uses different member cost-sharing levels to encourage enrolled members to select and use a Primary Care Physician (PCP) affiliated with one of our established PCMH and/or ACO practices. Horizon Patient-Centered Advantage EPO members incur a lower out-of-pocket expense when they select and use a PCP who participates in one of our patient-centered programs. No PCP selection is required. However, members pay less out of pocket when they select and use a PCP who participates in our patient-centered programs.

Referrals are not required for members to see specialists who participate in the Horizon Managed Care Network. Preventive services, screenings and immunizations are covered with no member cost sharing when services are received from an in-network provider. Except in the case of medical emergencies, members have no benefits for out-of-network services. Referrals are not required to see specialists. Members must use LabCorp or Quest Diagnostics for laboratory services.

Member cost sharing for primary care and specialist visits vary for each plan. Please confirm specific benefits for members enrolled in the Horizon Patient-Centered Advantage EPO plan.

CONSUMER-DIRECTED HEALTHCARE (CDH) PLANS

Horizon BCBSNJ offers innovative Consumer- Directed Healthcare (CDH) products that incorporate a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) with a high-deductible medical plan. In addition, Horizon BCBSNJ provides a wide variety of tools and resources to help your patients make their health care decisions.

Key Features of CDH Plans

Copayments – Physicians, other health care professionals and facilities should collect copayments during visits (if applicable).

Copayment information will appear on the member’s ID card.

No referrals required for specialists – This reduces the administrative process for you and members.

Individual spending accounts – Horizon MyWay plans are combined with individual spending accounts, such as Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) and Flexible Spending Accounts (FSAs). Members can draw from these accounts to pay for medical expenses not covered by their health plan, including deductibles and coinsurance.

The member’s ID card will indicate whether a member has a HRA or HSA.

Members without a card can pay online or through the Horizon MyWay mobile app, which offers a range of tools to help them manage their health spending and supplemental accounts.

Preventive Care – Generally, to promote wellness, routine preventive care services that are coded as such are covered at 100 percent. This includes childhood immunizations.

The following services are examples of preventive care:

• Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals
• Routine prenatal and well-child care
• Child and adult immunizations
• Tobacco cessation programs
• Obesity/weight-loss programs
• Age-specific screenings

Horizon MyWay – Direct Access Plan Design The Horizon MyWay Direct Access product combines a high-deductible Horizon Direct Access plan with a spending/savings account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.

You can identify Horizon MyWay HRA/HSA Direct Access members by the following ID card prefixes:

• JGB
• JGE
• JGH

Horizon MyWay – PPO Plan Design

The Horizon MyWay PPO product combines a high-deductible PPO plan with a medical account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members can maximize benefits by using participating PPO physicians, health care professionals and participating facilities.

You can identify Horizon MyWay HRA/HSA PPO members by the following ID card prefixes:

• JGA
• JGD
• JGG

Horizon MyWay – HMO Access Plan Design The Horizon MyWay HMO Access product combines a high-deductible Horizon HMO Access plan with a spending/savings account. This health plan offers in network benefits only and covers preventive care at 100 percent. Members must use participating managed care physicians, other health care professionals and contracting facilities.

You can identify Horizon MyWay HSA HMO Access members by the following ID card prefix:

• YHH

SHBP/SEHBP High-Deductible Plans

The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) committees offer enrolled members access to two high-deductible plans designs: NJ DIRECT HD1500 and NJ DIRECT HD4000. These plans offer in- and out-of-network benefits and include $0 copayments for preventive care services. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.

You can identify NJ DIRECT HD1500 and NJ DIRECT HD4000 members by the following ID card prefix:

• NJX

Horizon Advantage EPO HSA/HRA

The Horizon Advantage EPO HSA/HRA plans combine our Exclusive Provider Organization plan with either a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA). These plans provide in-network only benefits through the Horizon Managed Care Network. Members enrolled in Horizon Advantage EPO plans are NOT required to select a Primary Care Physician and referrals are not required for members to see specialists who participate in the Horizon Managed Care Network.

You can identify Horizon Advantage EPO HSA/HRA members by the following ID card prefixes:

• JGR
• JG
• JGT

HORIZON POS

Horizon POS is a point-of-service program providing the advantages of a HMO, but incorporating patient cost sharing and an option for members to access care from any physician without a referral from their PCP, at a lower level of benefits.

Horizon POS has two levels of benefits: in network and out of network. To receive the highest level of benefits, members must access care through their PCP (and obtain referrals as appropriate).

When members’ care is not coordinated through their PCP, the lower, or out-of-network, benefits apply. Members are given the choice to seek services either in network or out of network at each point of service.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office visit copayment, a deductible and/or coinsurance. Patients who go out of network or see a specialist without a PCP referral pay a higher share of the costs, including higher deductibles, coinsurance and copayment amounts.

Employers or association groups select the level of cost sharing for their employees. Horizon POS is designed to encourage members to maximize their benefits by using their PCP.

When Horizon POS members who have not selected you as their PCP come to you without a referral, you should bill us first. We will provide you with an Explanation of Payment (EOP) advising you of our reimbursement and the amount you can collect from your patient.

Well Care

Well care, such as routine adult physicals and well child care, is covered under capitation. If you are a fee-for-service PCP, well care is also covered and billable. Immunizations are billable for capitated and fee-for-service PCPs (subject to plan limitations).

Obstetrical/Gynecological Care

Female Horizon POS members may go directly to participating Ob/Gyns for obstetrical and gynecological-related care. They do not require a referral from their PCP.

Most members do not need a referral from their PCP or Ob/Gyn for routine mammography services. However, give these members a prescription to present to the radiology center.

Annual Vision Exam

Some Horizon POS members are eligible for an annual vision exam or vision hardware reimbursement. This service does not require a referral. If the services are not covered, the member is responsible for these charges.

Certain Horizon POS members are eligible for annual exams only when the PCP issues a referral. You can identify these members by the YHG alpha prefix on their ID card. These groups cover annual eye exams (with a referral) for dependents 17 years or younger only.

Most members who have diabetes may go directly to a participating eye care physician or professional for a dilated retinal exam without a referral from their PCP.

Chiropractic Coverage

Most Horizon POS members are eligible for chiropractic care. Some members may require a referral from their PCP to visit a participating chiropractor. Call to verify chiropractic benefits since some accounts have varying limitations.

HORIZON PPO NETWORK

If you are a participating Horizon PPO Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you.

PPO

• BCBS Service Benefit Plan (FEP PPO)
• BlueCard PPO
• Horizon Advantage PPO
• Horizon High Deductible PPO Plan D
• Horizon PPO

Indemnity

• Basic BlueSM Plan A
• BlueCare®
• Comprehensive Health Plan
• Comprehensive Major Medical
• Horizon Basic Health Plan A
• Horizon Basic Plan A/50
• Horizon Comprehensive Health Plan A
• Horizon High Deductible Plan C
• Horizon High Deductible Plan D
• Horizon MSA Plan C
• Horizon MSA Plan D
• Horizon Traditional Plan B, C, D
• Major Medical
• Medallion
• Network Comprehensive Major Medical
• Wraparound

Fixed Fee

• Medical/Surgical Fixed Fee 14/20 Series
• Medical/Surgical Fixed Fee 500 Series
• Medical/Surgical Fixed Fee 750 Series
• Student Program

Consumer-Directed Healthcare (CDH)

• Horizon MyWay HRA
• Horizon MyWay HSA

HORIZON PPO

Horizon PPO plans provide members a choice of physicians and hospitals without having to select a Primary Care Physician (PCP).

Members incur lower out-of-pocket costs and higher plan benefits, and do not need to file claims, when they receive care from Horizon PPO Network physicians, other health care professionals or facilities.

Members may also choose to use their out-of- network benefits, which provide access to care from any physician or hospital outside the network in exchange for higher out-of-pocket costs.

Nationwide and worldwide access to medical care is available through the BlueCard PPO program. .

FEDERAL EMPLOYEE PROGRAM

The Federal Employee Program® (FEP®) is a fee-for-service plan (with standard, basic and focus options) with a preferred provider organization that is sponsored and administered by the Blue Cross and Blue Shield Association and participating Blue Cross and/or Blue Shield Plans.

FEP is a traditional type plan that encourages members to use Preferred or in-network physicians, other health care professionals and facilities to receive the highest level of benefits.

FEP members may be identified by their unique ID card. Member ID numbers include an R prefix and 8 digits.

Plan highlights include:

• PPO reimbursement levels
• Referrals are not required
• Some services may require prior authorization

Standard Option

Members have the freedom to receive covered services from both Preferred and Nonpreferred health care professionals, hospitals and facilities.

Members who have the Standard Option have a calendar year deductible, and services are subject to a copayment or coinsurance. The annual deductible is $350 per person/$700 per family.

Routine care provided by a preferred health care professional is covered in full.

Office visits for:

• Primary Care Provider (PCP)/other health care professional preferred: $25 copayment. Specialist preferred: $35 copayment,
• Specialist nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.
• Lab, X-ray and other diagnostic tests preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.
• Preventive Care adult and children preferred: No member liability. Non-Preferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
• Maternity professional care preferred: No member liability. Nonpreferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
• Physical, occupational, speech therapies
  • 75-visit limit for any one or a combination of all three.
  • $20 copayment per visit. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
• Surgery preferred: Subject to deductible then 15 percent of Plan allowance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
• Inpatient hospital preferred: $350 per admission copayment, unlimited days. Nonpreferred: $450 per admission copayment, 35 percent of allowance and any difference between allowance and charge.
• Outpatient hospital (medical/surgery) preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between allowance and charge.

Basic Option

Member’s benefits are limited to care performed by Preferred health care professionals, hospitals and facilities, except in certain situations, such as emergency care.

With the Basic Option, members do not have a calendar year deductible; however, most care under the Basic Option is subject to a copayment amount. Routine care provided by a preferred health care professional is covered in full.

Office visits for:

• PCP/other health care professional office visit: $30 copayment.
• Specialist office visit: $40 copayment.
• Blood tests, EKG, Lab tests, pathology services Preferred: $0.
• EEG/Ultrasound/X-rays Preferred: $40 copayment.
• Bone density, CT scans, MRI/Pet scans preferred: $100 copayment in an office.
• Preventive care adult and children preferred: $0.
• Maternity professional care preferred: No member liability, inpatient $175 copayment.
• Physical, occupational, speech therapies: 50 visit limit any one or combination of all three.
• Surgery preferred: $150 in office, $200 in non-office setting per performing surgeon.
• Inpatient hospital preferred: $175 per day copayment, up to $875 per admission for unlimited days.
• Outpatient hospital (medical/surgery) preferred: $100 copayment per day, per facility.

FEP Blue Focus

The FEP Blue Focus product is designed for federal employees who are:

• Low utilizers of health care services
• Not planning any inpatient stays and/or major surgeries
• Use mostly generic medications
• Managing their chronic conditions

Federal employees who choose FEP Blue Focus must stay in-network and do not need referrals for specialty care.

• Primary Care Physician/Specialists: $10 per visit for your first 10 primary and or specialty care visits.
• Urgent Care $25 copay
• Inpatient hospital, Outpatient hospital and Surgery: 30% of our allowance
• ER (medical emergency): 30% of our allowance
• Lab work (such as blood tests): $0 for the first 10 specific lab tests
• Diagnostic services (such as sleep studies, X-rays, Cat scans): 30% of our allowance
• Just as the Standard and Basic Options precertification of inpatient hospital stays is required.
• Limited benefits and additional services that will require prior authorization such as high-tech radiology services (MRI, CT/PET scan)

Bariatric surgery must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

FEP Inquiry/Claim Submission:

Providers should submit claims electronically through NaviNet or through their vendor using Payer ID 22099. If necessary, mail inquiries/claims to:

Horizon BCBSNJ
Federal Employee Program PO Box 656
Newark, NJ 07101-0656

To enroll a member in our Chronic Care Program, call 1-888-334-9006, Monday through Friday, between 8 a.m. and 7 p.m., Eastern Time, or visit HorizonBlue.com/chronic-care.

For more information about FEP® plans, call 1-800-624-5078 or visit fepblue.org.

HORIZON INDEMNITY PLANS

These products combine hospital, medical/surgical and major medical-type benefits into one product. After a deductible, we will pay a percentage of our applicable allowance for eligible services. There are no office visit copayments; however, the patient is responsible to pay the deductible, coinsurance and any amount charged for ineligible services.

The following pages include brief benefit descriptions of:

• Horizon Comprehensive Health Plans A, B, C, D, E
• Horizon Traditional Plans B, C, D
• Basic BlueSM Plan A
• BlueCare
• Comprehensive Health Plan (CHP)
• Comprehensive Major Medical (CMM)
• Horizon Basic Health Plan A/50
• Network Comprehensive Major Medical

HORIZON COMPREHENSIVE HEALTH PLAN A

These plans are available to employee groups of two to 50 employees under the Small Employer Insurance Reform Act.

HORIZON TRADITIONAL PLANS B, C, D

These plans are available to individuals under the Individual Health Insurance Reform Act.

Brief benefit description:

• Deductible Ranges from $1,000 to $2,500 (Individual); $2,000 to $5,000(Family)
• Coinsurance Varies 80/20%, 70/30%, 60/40%
• Office Visits/ Medical Care: Covered after deductible
• Well Child Care/ $300 annually pet covered person (except newborns). $500 maximum for newborns up to age 1 year. Not subject to deductible or coinsurance.
• Lab and X-ray Covered after deductible

Maternity Related

Requires subscribers and/or physicians and other health care professionals to notify us within 12 weeks of medical confirmation of pregnancy. If we are not notified, payment of maternity claims will be reduced by 50 percent.

BASIC BLUE PLAN A

Basic Blue Plan A is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

This limited hospitalization plan covers 30 days of inpatient care and some professional services. The plan does not provide benefits for behavioral health and substance use disorder care services.

Brief benefit description:

• Deductible $100/Individual,$300/Family
• Coinsurance 50/50%
• Office Visits/Medical Care: Covered after deductible
• Well Child Care/ Covered Adult Physicals
• Lab and X-ray Covered after deductible

BLUECARE®

BlueCare is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

• Deductible $500; two deductibles per family
• Coinsurance 80/20%
• Office Visits/Medical Care Covered after deductible
• Well Child Care/ Not covered Adult Physicals
• Lab and X-ray Covered after deductible

COMPREHENSIVE HEALTH PLAN (CHP)

This plan is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

• Deductible $100 to $1,000
• Coinsurance 80/20%
• Office Visits/ Covered after deductible
• Medical Care
• Well Child Care/ Not covered Adult Physicals
• Lab and X-ray Covered after deductible

COMPREHENSIVE MAJOR MEDICAL (CMM)

Brief benefit description:

• Deductible Ranges from $100 to $1,000
• Coinsurance Varies 80/20%, 70/30%
• Office Visits/ Medical Care Covered after deductible
• Well Child Care/ Call physician.
• Adult Physicals Services for patient benefits if no indication appears on ID card.
• Lab and X-ray Covered after deductible

HORIZON BASIC PLAN A/50

This plan is available to individual, nongroup customers.

Brief benefit description:

• Deductible $1,000, $2,500, $5,000 or $10,000 (Individual); $2,000, $5,000, $10,000 or $20,000 (Family)
• Coinsurance 50/50%
• Office Visits/ Covered after deductible Medical Care
• Well Child Care/ Covered Adult Physicals
• Lab and X-ray Covered after deductible

NETWORK COMPREHENSIVE MAJOR MEDICAL (NETWORK CMM)

Brief benefit description:

• Deductible Ranges from $100 to $1,000
• Coinsurance Varies 80/20%, 70/30%
• Office Visits/ Covered after deductible Medical Care
• Well Child Care/ Call Physician Adult Physicals Services for patient benefits if no indication appears on their ID card.
• Lab and X-ray Covered after deductible

FIXED FEE CONTRACTS

Series 14/20 Student Program

These programs cover medical and surgical services performed at a hospital and in a physician’s office. Major medical types of service are not covered unless the patient has separate major medical coverage. The term Fixed Fee Contracts accurately describes these products because payment for an eligible service is fixed.

Service Benefits are paid-in-full benefits extended to certain individuals covered under a Fixed Fee Contract. Payments are not considered payment in full unless the subscriber meets specified income limits, which vary depending on whether the contract is for Single or Family coverage and the subscriber’s marital status.

Service Benefits Requirements

The patient must advise you within 120 days of the last day of rendering an eligible service that they qualify for Service Benefits. You may request proof of income by asking for a copy of the Federal Tax Form 1040 for the calendar year preceding the date of service. The subscriber must furnish proof within 45 days of your request.

Service Benefits Income Limits

If you are not notified of Service Benefits eligibility within 120 days of the last date of service, or proof of income is not furnished within 45 days of your request, the customer is disqualified from receiving Service Benefits. The Service Benefits feature described on this page is not related to, or part of, the BCBS Service Benefit Plan (a.k.a., the Federal Employee Program® [FEP®]). Income is defined as the gross annual income from all sources for the calendar year prior to the year services were rendered. The income limits are listed below.

Income limits for 14/20 Series

Single, unmarried:	$14,000
Single, married:	$20,000
Parent and child:	$20,000
Husband and wife:	$20,000
Family:	$20,000
Student:	N/A

Service Benefit Payments

If your covered patient is enrolled under a fee schedule contract, you must accept our payment for eligible services as payment in full if the subscriber’s income makes him or her eligible for paid-in-full Service Benefits.

If the patient is not eligible for Service Benefits, the combined payment from us, from the patient or from any other source, shall equal your usual or reasonable fee for the procedure performed. You will not submit a fee to us that is higher than the fee usually accepted by you as payment in full for services performed.

Student Program

Deductibles, copayments and/or coinsurance amounts are part of these contracts. Some groups incorporate cost containment and utilization review programs. For patient-specific information, we recommend reading the patient’s ID card for special benefit messages and phone numbers of dedicated service teams.

Major accounts have unique benefits. For patient-specific information, call Physician Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.

MEDICARE PLANS

These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network (for Medicare Advantage plans) or that participate with Medicare (Medicare Supplemental plans).

HORIZON MEDICARE ADVANTAGE PRODUCTS

We are an approved Medicare Advantage (MA) Organization and offer several Medicare Advantage products to Medicare beneficiaries in place of Medicare Parts A and B:

• Braven Health Plans
• Horizon Medicare Blue Value (HMO)
• Horizon Medicare Blue Value w/Rx (HMO)
• Horizon Medicare Blue Choice w/Rx (HMO)
• Horizon Medicare Blue Advantage (HMO)
• Horizon Medicare Blue Select (HMO-POS)
• Horizon Medicare Blue Access Group (HMO-POS)
• Horizon Medicare Blue Access Group w/Rx (HMO-POS)
• Horizon Medicare Blue (PPO)
• Horizon Medicare Blue Group (PPO)
• Horizon Medicare Blue Group w/Rx (PPO)
• Horizon Medicare Blue Group w/Rx Ideal (PPO)
• Horizon Medicare Blue Group w/Rx Complete (PPO)

Members enrolled in these products use our extensive Horizon Managed Care Network and must go to providers who accept Medicare assignment. These products are offered to individuals and group account members.

• Members enrolled in this plan use a subset of the Horizon Managed Care Network.

Braven Health Plans

Braven Medicare Plus (HMO)
Braven Medicare Choice (PPO)
Braven Medicare Freedom (PPO)
Braven Medicare Group (HMO-POS)
Braven Medicare Access Group (HMO-POS)

Effective January 1, 2021, Horizon BCBSNJ will introduce Braven Health Plans.

Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has partnered with Hackensack Meridian Health to form Healthier New Jersey Insurance Company d/b/a Braven Health.

Braven Health, an affiliate of Horizon BCBSNJ, will offer affordable Medicare Advantage health plans with access to the Horizon Hospital Network and the Horizon Managed Care Network. Braven Health individual plan options will be offered to New Jersey’s Medicare-eligible population who reside in Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic and Union counties. Braven Health members may also live in other counties if they are enrolled through their employer.

• $0 PCP copay; $20 specialist copay
• Prescription drug coverage is included.
• Chiropractor services
  • Braven Medicare Plus HMO $20
  • Braven Medicare Choice PPO $20 INN /$30 OON
  • Braven Medicare Freedom PPO $20 INN /30% OON

Braven Health Network Participation

Your network participation status with Braven Health plans will be the same as your participation status in the Horizon Managed Care Network or the Horizon Hospital Network.

If you participate in the broad Horizon Managed Care Network, you are participating with:

• Braven Medicare Choice (PPO)

• Braven Medicare Freedom (PPO)

• Braven Medicare Group (HMO-POS)

• Braven Medicare Access Group (HMO-POS)

If you participate in the subset of the Horizon Managed Care Network, you are participating with:

•Braven Medicare Plus (HMO)
The subset used by the Braven Medicare Plus (HMO) plan is the same subset used for our existing Horizon Medicare Blue Advantage plans.

Overall Braven Health will not create significant administrative changes for participating providers.

• Braven Health will follow Horizon BCBSNJ’s policies and procedures, including its medical policies.
• Horizon BCBSNJ will provide back-office operations, including network management, claims, customer service and provider services required to operate a Medicare Advantage plan.
• Braven Health will have its own Payer ID 84367. All trading partners and direct submitters will need to register for Braven Health EDI prior to January 1, 2021.

Horizon Medicare Blue Value (HMO)

This HMO plan requires members to choose a PCP. Members receive benefits at an in-network level only. Referrals are not required for enrolled members to seek specialty care from a Horizon Managed Care network physician, other health care professional or facility.

Members enrolled in this plan use the Horizon Managed Care Network.

Members can convert Medicare Advantage to Medicare Advantage with Prescription Drug coverage:

• Horizon Medicare Blue Value w/Rx (HMO).
• Horizon Medicare Blue Choice w/Rx (HMO).

Horizon Medicare Blue Choice w/Rx (HMO)

These HMO plan require members to choose a PCP. Members receive benefits at an in-network level only. Referrals are not required for enrolled members to seek specialty care from a Horizon Managed Care network physician, other health care professional or facility.

Members enrolled in these plans use the Horizon Managed Care Network.

HORIZON MEDICARE BLUE ADVANTAGE (HMO)

The Horizon Medicare Blue Advantage (HMO) plan is offered in 15 counties throughout New Jersey. It will not be offered to Medicare-eligible beneficiaries that reside in Burlington, Camden, Cape May, Gloucester, Passaic and Salem counties.

Members that choose the Horizon Medicare Blue Advantage (HMO) plan have access to a subset of the physicians and other health care professionals, as well as a subset of facilities in the Horizon Hospital Network. Members will also have access to all ancillary providers in the Horizon Managed Care Network.

There are no out-of-network benefits for the Horizon Medicare Blue Advantage (HMO) plan, except in the event of an emergency. Therefore, members must receive services from doctors, health care professionals and hospitals that participate with this plan. Provider participation status for the Horizon Medicare Blue Advantage (HMO) plan will be published in the Online Doctor & Hospital Finder.

• $0 plan premium in 12 counties; $75 plan premium in 3 counties.
• $10 PCP copay, $25 Specialist copay.
• Prescription drug coverage is included.

Members have access to a subset of the physicians and other health care professionals that participate in the Horizon Managed Care Network, as well as all in-network ancillary providers. Ancillary providers can be classified into three categories: diagnostic (e.g. laboratory tests, radiology, genetic testing) therapeutic (e.g. rehabilitation, physical and occupational therapy) and custodial (e.g. hospice care, long-term acute care, nursing facilities, urgent care).

Members will have access to a subset of facilities in the Horizon Hospital Network. Members do not have out-of-network benefits except in the case of an emergency. Any physicians, hospitals or other health care professionals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network.

Members are required to select a Primary Care Physician (PCP) that participates in the Horizon Medicare Blue Advantage (HMO) plan. Members do not need referrals.

Horizon Medicare Blue Select (HMO-POS)

The Horizon Medicare Blue Select (HMO-POS) plan is offered to Medicare-eligible beneficiaries who reside in Union County.

Horizon Medicare Blue Select (HMO-POS) members who are in this individual plan will have access to a subset of the Horizon Managed Care Network in New Jersey. The plan offers in-network and out-of-network benefits and does require a PCP selection. Members do not need referrals.

In-network level of benefits are available when members obtain services from participating physicians and hospitals.

Horizon Medicare Blue Access Group (HMO-POS)

This point-of-service plan is a group offering giving members the option of selecting a PCP. If a PCP is not selected, the member incurs higher copayments. Members can receive benefits at in- and out-of-network levels. No referrals are needed for additional services.

Members enrolled in this plan use the Horizon Managed Care Network. Members can convert Medicare Advantage to Medicare Advantage with Prescription Drug coverage.

Horizon Medicare Blue (PPO), Horizon Medicare Blue Group (PPO)

Horizon Medicare Blue Group w/Rx (PPO) Horizon Medicare Blue Group w/Rx Ideal (PPO) Horizon Medicare Blue Group w/Rx Complete (PPO)

We offer Medicare Advantage plans to allow enrolled group and consumer members to obtain in-network benefits outside our local service area by leveraging a Blue Cross and Blue Shield Association (BCBSA) program that makes Blue Plans’ provider networks available to other Plans’ enrolled Medicare Advantage (MA) PPO members.

Similar to the BlueCard network arrangement, our MA PPO plans will allow members who travel to, or reside in another service area, to obtain in-network care as long as they use a practitioner or facility that participates in another Blue Plan’s MA PPO network.

You will be able to identify Horizon Medicare Blue (PPO) members – as well as other Plans’ MA PPO members– by the MA-in-the-suitcase logo included on the member’s ID card.

Horizon Medicare Advantage (PPO) offers in-network and out-of-network benefits and covers all Medicare Part A and Part B benefits, and additional supplemental benefits.

No PCP selection or referrals are required for members enrolled in Horizon Medicare Advantage (PPO) plans.

Like all of our Medicare Advantage plans, Horizon Medicare Advantage (PPO) members use the Horizon Managed Care Network to access the in-network level of benefits in New Jersey.

Members enrolled in these MA PPO plans who see participating PPO network physicians or other health care professionals (who do not also participate in the Horizon Managed Care Network) will access their out-of-network benefits.

Enrolled employer group members who reside or travel in another service area may receive care at the in-network level of benefits as long as they use a practitioner or facility that participates in that other Blue Plan’s MA PPO network. The member may only go to providers enrolled in Medicare.

Enrolled employer group members who reside in a state where there is no Blue Plan MA PPO Network will receive the in-network level of benefits in accordance with the CMS Employer Group Waiver Plan policy. They may only go to providers enrolled in Medicare.

Group members may convert their Medicare Advantage coverage to Medicare Advantage with Prescription Drug (MAPD) coverage – Horizon Medicare Blue Group w/Rx (PPO).

Well Care

Our Medicare Advantage products cover services coded as preventive, such as prostate screening and gynecological exams (subject to plan limitations). These services can be obtained without a referral from the PCP when provided by participating physicians and other health care professionals.

Chiropractic Care

Our Medicare Advantage members may go directly to participating chiropractors for manual manipulation of the spine to correct subluxation that can be demonstrated by X-ray. This means they do not require a referral from their PCP to visit a participating chiropractor. Members are also eligible for an unlimited amount of chiropractic visits per year. X-rays ordered by chiropractors are not covered.

Chiropractors should call Physician Services to verify copayment.

Case Management

New members are asked to complete and return a health assessment questionnaire within one month of enrolling in any of our Medicare Advantage products. Members identified as high risk are assigned a case manager to help you coordinate the member’s care.

Copayments and Coinsurance

Our Medicare Advantage plans offer various office visit copayments. In other health care settings, coinsurance may be required. Copayment amounts and coinsurance percentages, if applicable, are printed on the member’s ID card.

Audiology/Hearing Aid Benefits

Audiology Distribution, LLC, doing business as HearUSA, works with Horizon BCBSNJ to administer hearing benefits and provide related products and services through their HearUSA network of independently practicing audiologists, hearing care professionals and company-owned hearing centers.

Members enrolled in MA plans with NO out-of-network benefits

Members enrolled in Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/ Rx (HMO) and Horizon Medicare Blue Advantage (HMO) must use a HEARx Center for audiology services and hearing aids that are medically necessary, including batteries.

If these members reside in a New Jersey county without a HearUSA Center, they may request that their Primary Care Physician (PCP) refer them to a participating Horizon Managed Care Network audiologist. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

Members enrolled in MA plans with out-of-network benefits

Members enrolled in Horizon Medicare Blue Access Group (HMO-POS) and Horizon Medicare Blue Access Group w/Rx (HMO-POS) may use a HearUSA center for in-network audiology services and hearing aids, including batteries, that are medically necessary.

If these members choose to use their out-of- network benefits (understanding that they will incur more cost sharing), they may obtain services from a non-HearUSA provider.

If these members reside in a New Jersey county without a HearUSA Center, they may use any participating Horizon Managed Care Network audiologist on an in-network basis. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

Use our Online Doctor & Hospital Finder to find a HearUSA location If you are not already enrolled in our Chronic Care Program, call 1-888-334-9006, Monday through Friday, between 8 a.m. and

7 p.m., ET, or visit HorizonBlue.com/chronic-care.

Visit HorizonBlue.com/doctorfinder, select Other Health Services and:

• Select Audiology within the Service Type menu.
• Enter your ZIP Code and indicate a Search Radius, or select your County.
• Click Search.

Emergency and Urgent Care Definitions

For our Medicare Advantage products, a medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child,
• Serious impairment of bodily functions, or
• Serious dysfunction of any bodily organ or part.

Emergency services include a medical screening examination and inpatient and outpatient services that are needed to stabilize an emergency medical condition.

For our Medicare Advantage products, urgently needed services are those services required to prevent a serious deterioration of a covered person’s health that results from an unforeseen illness, injury or condition that requires care within 24 hours.

MEDICAL RECORD STANDARDS FOR MEDICARE MEMBERS

According to the Centers for Medicare & Medicaid Services (CMS), all information included within a medical record must be legible for review by an approved CMS coder and must include the following information to document a face-to-face encounter.

• The physician or other health care professional must authenticate the services provided or ordered by including either a handwritten or electronic signature along with his/her credentials. The following types of signatures are not acceptable:
  • Stamp signatures
  • Signature of a physician other than the treating physician
  • Signature of a nurse or other office professional on the physician’s behalf
  • Statements that indicate: Signed but not read; Dictated but not signed/read; etc.
• The medical record should include sufficient information to ensure that a reviewer can determine the date on which a particular service was performed/ordered.
• The medical record should include sufficient documentation to support the diagnoses billed.
• Each page of a medical record must include the patient’s name.

The official instruction (Change Request 6698) may be accessed at cms.gov/transmittals/ downloads/R327PI.pdf.

Medical Record Retention

Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years for all Medicare Advantage members.

Medical Necessity Determinations

The medical necessity review and determination process for Horizon Medicare Advantage products is different than that of other managed care products.

If you or the member disagrees with a coverage determination we have made, the decision may be appealed. We have up to 14 days to determine whether an initial request for a service is medically appropriate and covered. If additional clinical information is required, we may have up to an additional 14 days to make a determination.

In some cases, the standard pre-service review process could endanger the life or health of the member. As a participating physician or other health care professional, you may request an expedited 72-hour pre-service determination for a Medicare Advantage patient if, in your opinion, the health or the ability of your patient to function could be harmed by waiting for a medical necessity determination.

Expedited determinations may be requested by calling 1-800-664-BLUE (2583).

Non-expedited determinations may be requested in writing to:

Horizon BCBSNJ Utilization Management Appeals Department
210 Silvia Street, TT-02T
West Trenton, NJ 08628 Fax: 1-877-798-5903

Medicare Part D Prescription Drug Determinations

Requests for a coverage determination will be responded to within 24 hours for an expedited request (or sooner if the member’s health requires us to) or within 72 hours for a non-expedited coverage determination.

Part D drug coverage determinations include:

• Prior authorization determinations for those drugs that require prior authorization.
• Requests that we cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary).
• Requests that we waive a restriction on the plan’s coverage for a drug, including:
  • Being required to use the generic version of a drug instead of the brand name drug.
  • Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called step therapy.)
  • Quantity limits. For some drugs, there are restrictions on the amount of the drug patients can have.
• Requests that we pay for a prescription drug the member already purchased (a coverage decision about payment).
• Expedited Medicare Part D drug determinations may be requested by calling 1-800-693-6651.

Non-expedited Medicare Part D drug determinations may be requested in writing to:

Prime Therapeutics LLC
Attn: Medicare Appeals Department 1305 Corporate Center Drive
Bldg. N10
Eagan, MN 55121
Fax: 1-800-693-6703

HORIZON MEDICARE ADVANTAGE MEMBER APPEALS

Members have the right to appeal any decision regarding our reimbursement or our denial of coverage based on medical necessity. Appeals may be requested verbally or in writing.

Medical records and your professional opinion should be included to support the appeal.

Based on the medical circumstances of the case, a Horizon BCBSNJ physician reviewer will determine if the request qualifies as an expedited appeal.

However, the member, physician or other authorized representative acting on behalf of the member may request an expedited appeal based on the medical circumstances of the case.

If coverage of services is denied, you must inform your Medicare Advantage patient of their appeal rights. At each patient encounter with a Medicare Advantage enrollee, you must notify the enrollee of their right to receive, upon request, a detailed written notice from the Medicare Advantage organization regarding the enrollee’s benefits. You may issue the appeal rights directly to the member in your office at the time of the denial, or contact

Member Services and we will issue the appeal rights to the member.

Details about how to pursue various appeals and appeal levels will be communicated in writing as part of each coverage determination and/or appeal determination notification.

Medical Appeals for Medicare Services

Generally, we have 30 days to process an appeal pertaining to the denial of a requested service (pre-service appeal for service), and 60 days to process an appeal pertaining to post-service denial of claim payment (appeal for payment).

Expedited appeals are processed within 72 hours. To file an expedited appeal, the member may call Member Services at 1-800-365-2223.

Pre-service medical appeals may be faxed to 1-609-583-3021 or mailed to:

Horizon Medicare Advantage
Utilization Management Appeals Department
210 Silvia Street, TT-02T
West Trenton, NJ 08628

Post-service appeals may be faxed ton1-732-938-1340 or mailed to:

Horizon Medicare Advantage Appeals Coordinator
Three Penn Plaza East, PP-12L
Newark, NJ 07105-2200

A completed Appointment of Representative (AOR) form or other court-appointed document indicating the member’s consent may be required for a physician to pursue post-service appeals on behalf of the member.

Medicare Part D Prescription Appeals

Generally, we have up to seven days to process an appeal pertaining to a post-service denial of coverage decision or claim for a Medicare Part D prescription drug and up to 72 hours to process an appeal pertaining to a coverage decision of a Medicare Part D prescription drug the member has not yet received. Expedited appeals are processed within 24 hours.

To file an expedited Medicare Part D appeal, the member may call 1-800-693-6651.To request a Medicare Part D prescription drug appeal in writing, members may fax to 1-800-693-6703 or write to:

Prime Therapeutics LLC
Attn: Medicare Appeals Department
1305 Corporate Center Drive
Bldg. N10
Eagan, MN 55121

Subcontractors and Medicare

Participating offices that have entered into business arrangements with a subcontractor must ensure that all contracts with those entities include language that requires them to comply with all applicable Medicare laws and regulations.

Nine-Digit ZIP Codes Required for Claim Submissions

CMS requires the use of nine-digit ZIP codes on all Medicare Advantage claim submissions in certain locations where a five-digit ZIP code spans more than one pricing area.

The New Jersey, New York and Pennsylvania towns that require the use of nine-digit ZIP codes are listed below.

New Jersey                                             Pennsylvania

08512 – Cranbury                                   18036 – Coopersburg

07726 – Englishtown                               18042 – Easton

08827 – Hampton                                    18055 – Hellertown

08525 – Hopewell                                    18951 – Quakertown

07735 – Keyport                                       18077 – Riegelsville

08530 – Lambertville                                18092 – Zionsville

07747 – Matawan

08540 – Princeton

08558 – Skillman

08560 – Titusville

New York

11208 – Brooklyn

10925 – Greenwood Lake

10964 – Palisades

10965 – Pearl River

10590 – South Salem

10983 – Tappan

To avoid delays in claim processing, we recommend that physicians and other health care professionals within these areas bill with the complete nine-digit ZIP code for all patients.

If you’re unsure of your nine-digit ZIP code, visit the United States Postal Service’s ZIP Code Lookup.

For more information and for similar ZIP codes requiring +4 extension that are outside our service area, please visit the CMS Prospective Payment Systems - General Information web page.

MEDICARE SUPPLEMENTAL (MEDIGAP)

We offer a variety of Medicare Supplemental Products to our members who have Original Medicare as their primary insurance coverage.

As of January 1, 2020:

• Horizon Medicare Blue Supplement Plans C and F, which pay the Medicare Part B deductible, will no longer be sold to the following individuals:

• Age 65+: individuals who turned age 65 on or after January 1, 2020.
• Under Age 65: individuals whose Medicare Part B effective date is on or after Plan availability is now based on the following criteria:

• In the Age 65+ market, whether the applicant turned 65 before January 1, 2020, or on/after January 1, 2020.
• In the Under Age 65 market, whether the applicant’s Part B effective date is before January 1, 2020, or on/after January 1, 2020.

• For the Age 65+ market, Horizon Medicare Blue Supplement Plan G is now available with any of the Guaranteed Issue Rights.
• For the Under Age 65 market, the enrollment opportunities have been revised, with the most notable being that persons who have a Part B effective date on or after January 1, 2020 have 12 months from their Part B effective date (rather than 6 months) to enroll.

Horizon Medicare Blue Supplement Plan D

Horizon Medicare Blue Supplement Plan D is available for the Age 65+, Age 50 to 64 and Under Age 50 markets.

These Medigap products supplement or fill the gaps of eligible services paid by Medicare and have also been referred to as complementary coverage in the past.

As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), we offer a new set of standardized Medigap plans. The new plans, to distinguish them from the previously offered Medigap plans (which we continue to service, but no longer sell), are identified by a YHW prefix on their ID card and are referred to as Horizon Contemporary Medigap Plans.

We offer the following Horizon Contemporary Medigap Plans:

• Plan A
• Plan C – ages 50 to 64
• Plan C – age 65+
• Plan C – under age 50
• Plan F
• Plan G
• Plan K
• Plan N

For more information about Horizon Contemporary Medigap Plans, visit HorizonBlue.com/medicare.

Horizon Contemporary Medigap Plans are the only Medigap plans we offer for sale. For members enrolled in one of our existing Medigap plans (see below), there will be no change in benefits. However, members may choose to enroll in one of the new Horizon Contemporary Medigap Plans, as long as they meet the requirements for that new plan.

• Horizon Medigap Plans A
• Horizon Medigap Plan C
• Horizon Medigap Plan F
• Horizon Medigap Basic Plan I
• Horizon Medigap Plan I with Rx
• Horizon Medigap Plan J
• BCBSNJ 65
• BCBSNJ 65 Select
• Super 65

Members enrolled in the above Medigap plans are identified by a YHR prefix on their ID card.

Pre-Existing Condition

Medigap plans include a pre-existing condition clause. Under this clause, claims for certain members, may be subject to review.

A pre-existing condition is an illness or injury, whether physical or mental, which manifests itself in the six months before a covered person’s enrollment date, and for which medical advice, diagnosis, care or treatment would have been recommended or received in the six months before his/her enrollment date.

The restriction could remain on the member’s policy as noted below unless a Certificate of

Creditable Coverage (COCC) is provided. (A COCC, or a letter from a previous carrier on that carrier’s letterhead indicating the effective and terminating dates of coverage, will nullify or reduce the pre-existing wait period.)

• For beneficiaries age 65 and over, the pre- existing condition limitation waiting period is six months from the date of enrollment.
• For beneficiaries under age 65, the pre-existing condition limitation waiting period is three months from the date of enrollment.

Based on the member’s pre-existing limitation clause under the benefit plan, review of claims in excess of $10,000.00 will be conducted to determine if a pre-existing condition exists. If a pre-existing condition exists, the member will be responsible for payment of services rendered.

Medicare Part D

We also offer Medicare Part D Prescription Drug coverage to our members who have Original

Medicare as their primary insurance coverage.