Out-of-Network Care
Your Horizon POS plan allows you the flexibility to choose whether you receive care in network or out of network.
To get the most from your plan and save on out-of-pocket expenses, we encourage you to receive in-network care and services by following the recommendations below. Please:
- Select a PCP.
- Obtain the necessary referrals and prior authorizations, as applicable.
- Use participating physicians or other health care professionals or facilities.
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If you do not do any one of the above, your care will be considered out of network (also referred to as "non-network" or "nonparticipating"), and you will pay more for your care.
Receiving out-of-network care
If you choose to receive out-of-network care, please consider the following:
- You must contact us for approval* before you receive certain services. (This includes hospital admissions and certain surgical and diagnostic procedures.) If you dont, you will not be eligible for full benefits and our payment may be reduced.
- Most out-of-network services are subject to a deductible and coinsurance, so you will have a greater out-of-pocket expense for the care received.
| * | Please call Member Services or refer to your Benefit Certificate/Booklet for services that require prior authorization. |
Paying Out-of-Network Provider Bills
If you choose to use a provider who does not participate in Horizon's Managed Care Network, your bills will be paid according to the provided care or service.
| Out-of-network care provided by: |
Payment |
Responsibility |
| A physician or other health care professional who is not participating in any of our networks: |
Payment in full may be required at the time of service.
You must send the bill to us for reimbursement of our allowance for covered services.* |
You must pay any applicable deductible and coinsurance, plus any charges over our allowance for covered services. |
| A physician or other health care professional who participates with one of our other networks: |
Payment is not required at the time of service to any provider in another Horizon BCBSNJ Network. We will send you an Explanation of Benefits (EOB).** |
You must pay any applicable deductible and coinsurance per your network benefits.
Your provider cannot balance bill you above our allowance. |
* Please refer to the Medical Bill section of your Member Handbook for more information.
| ** Your EOB lists: |
Services received. |
Amount billed. |
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Payment made by us. |
Amount you owe for the services. |
Typical Cost Savings Hypothetical Examples
You choose to go out of network for an office consultation: the charge is $350. Since the service is performed out of network, an office visit copayment does not apply. The deductible has already been met. Our payment allowance for this service is $200, less any applicable coinsurance and/or deductible amounts. If your out-of-network coinsurance is 80/20, we would pay $160 and you would be responsible for $190.
Please note: If your physician is not participating in the Horizon BCBSNJ network, your liability will be your deductible, coinsurance and up to the full charge of the service.
| Charge |
Allowed Amount |
Deductible |
Horizon BCBSNJ Payment |
Coinsurance |
Member Liability
(You Pay) |
| $350 |
$200 |
Met |
$160 (assuming an 80% out-of-network benefit) |
$40 |
$190
($40 coinsurance plus $150 balance-billed amount) |
You choose to go in network for an office consultation: the charge is $350. Your Horizon POS plan has a $10 office visit copayment. Since the service is performed in network, the deductible does not apply. Our payment allowance for this service is $150, less any applicable copayment. We will pay $140 and you would be responsible for $10.
Please note: If your physician is participating in the Horizon BCBSNJ network, you cannot be balance-billed for any charges over and above our allowance.
| Charge |
Allowed Amount |
Deductible |
Horizon BCBSNJ Payment |
Copayment |
Member Liability
(You Pay) |
| $350 |
$150 |
N/A |
$140 |
$10 |
$10 |
Your medical bills can be impacted by your choices. The examples provided illustrates the difference between using an out-of-network physician and paying a total of $190; or using an in-network physician and paying a $10 copayment a savings of $180.
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