![]() ![]() We require 75 percent of your eligible employees (those working 25 hours or more) to participate in a group plan you offer. We require the employer to contribute a minimum of 10 percent to the cost of the group health benefits plan. Nonpayment of premiums, fraud, violation of contribution or participation rules, termination of the plan by us or enrollees move outside the service area.We will continue to renew coverage at the option of the plan sponsor except for the following reasons: Disclosure of information as required by the Health Insurance Portability and Accountability Act (HIPAA): 1. For further information on your policy, you may also call Member Services at 1-800-355-BLUE (2583). In the event of a conflict between the information contained in these benefit highlights and the actual terms of your group policy, the terms of the policy will prevail. For complete information and verification of all your benefits, refer to your group health benefits policy. All payments are based on medical necessity and appropriateness of services. Once this balance is met, then all covered members in the family are in benefits. There are two ways a family may meet the family aggregate: 1) Every covered person’s contribution goes toward the MOOP before all covered persons are in benefits or 2) One covered person may meet the individual MOOP and be in benefits, while the other covered family members’ contributions met the balance of the family MOOP. The family Maximum Out of Pocket (MOOP) is two times the individual MOOP and is a family aggregate. ‡ Amounts shown represent individual cost-sharing. The true family aggregate requires the entire family deductible to be met before the covered family members are in benefits. The family deductible is two times the individual deductible and is a true family aggregate. † Amounts shown represent individual cost-sharing. ***All payments based on our allowable amounts. Though the requirement to select a PCP has been eliminated for most services, Horizon BCBSNJ encourages members to select a PCP to coordinate their medical care. ** Selection of a PCP is not a requirement to receive network benefits. Prior authorization may be required for certain services. These benefit highlights are only a summary of the standard Small Employer Health (SEH) Plan B in a Point of Service format with an office rider offered by Horizon BCBSNJ. Prescription Drugs All MMRx charges accumulate to the network Maximum Out of Pocket Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights* Other Services (continued) Limited to 30 inpatient days per calendar year Limited to 20 outpatient visits per calendar year One inpatient day may be exchanged for two outpatient visits Biologically Based Mental Illness Inpatient Outpatient In practitioner’s office Not in practitioner’s office Durable Medical Equipment/ Medical Supplies Requires preapproval In practitioner’s office Not in practitioner’s office Limit of 30 visits per calendar year combined network and non-network Speech/Cognitive Rehabilitation Therapy In practitioner’s office Not in practitioner’s office Limit of 30 visits per calendar year combined network and non-network Physical/Occupational Therapy In practitioner’s office Not in practitioner’s office Limit of 30 visits per calendar year combined network and non-networkįor Non-Biologically Based Mental Illness/Substance Abuse and Alcoholism services, you must call Magellan Behavioral Health at 1-80 to obtain authorization for inpatient care and a referral for outpatient care to receive the network level of benefits. Non-Biologically Based Mental Illness and Substance Abuse Inpatient OutpatientĨ0% after deductible 80% after deductible ![]() Therapeutic Manipulations In practitioner’s office Not in practitioner’s officeġ00% after deductible 80% after deductibleĦ0% after deductible 60% after deductibleĪlcoholism In practitioner’s office Not in practitioner’s office Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights* Other Services ![]() Requires prior authorization.Įxtended Care/Rehabilitation Combined limit of 120 days per calendar yearĨ0% after deductible 60% after deductible Must begin within 14 days of preceding hospital stay Requires preapprovalĨ0% after deductible Requires preapprovalĦ0% after deductible Requires preapproval Inpatient care Semi-private room or intensive care unit. Not subject to deductible and coinsurance. $750 each year per covered dependent child through end of calendar year in which child attains age one $500 maximum per covered person per calendar year. Maximum Out of Pocket‡ Network Non-Networkġ00% practitioner services 80% hospital and other settings 60% prescription drugs Horizon MyWay HSA Horizon Direct Access 100/80/60 Benefit Highlights* Plan** ![]()
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