Horizon POS is a point of service program providing the advantages of an 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 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 form, you should bill us first. We will provide you with an Explanation of Payment (EOP) advising you of our payment 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. For
information on when to call for authorization please see page 56.
Most members do not need a referral from their PCP or Ob/Gyn for routine
mammography services. However, please give these members a prescription to present to the radiologist.
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 form. 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 form. You can identify these members by the YHG alpha prefix on their ID card. These groups cover annual eye exams (with a referral form) 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. Please call to verify chiropractic benefits since some accounts have varying limitations.
Pre-Existing Condition
Some Horizon POS programs have a pre-existing condition clause. Under this clause, fee-for-service* bills, for certain members, are 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, based upon the plan, up to 12 months after enrollment, unless a Certificate of Creditable Coverage (COCC) is provided. A COCC, or a letter from a previous carrier on that carriers’ letterhead indicating the effective and terminating dates of coverage, will nullify or reduce the pre-existing wait period.
Based on the member’s pre-existing limitation clause under their benefit plan, a request for prior authorization and/or claim payment is automatically subject to a screening process based upon the member’s qualifying
pre-existing time period and the specific clinical situation.
The pre-existing condition limitation does not affect benefits for other unrelated conditions, or birth defects in a covered dependent child. Genetic information will not be treated as a pre-existing condition in the absence of a diagnosis of the condition related to that information.
If a pre-existing condition exists, the member will be responsible for payment of services rendered.
* Treatment provided under capitation is not subject to pre-existing condition review.
NJ DIRECT
Horizon BCBSNJ administers two plans on behalf of the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP). The plan options are Direct Access plans, called NJ DIRECT10 and NJ DIRECT15 (NJ DIRECT for general reference).
Members have out-of-network benefits; however, members will maximize their benefits and minimize their out-of-pocket expenses by using physicians and facilities in the Horizon Managed Care Network.
Copayments
The 10 or 15 in the plan option name refers to the office visit copayment amounts. The appropriate copayment amounts are indicated on the member’s ID card.
NJ DIRECT Network
NJ DIRECT uses the Horizon Managed Care
Network and it offers some special features. With NJ DIRECT:
• Members access physicians within the Horizon Managed Care Network, without having to select a Primary Care Physician (PCP).
• Members do not need to obtain referrals to see specialists.
• Authorizations are required for some services.
• Members and their dependents have access to in-network benefits through the BlueCard PPO network outside of New Jersey.