The Affordable Care Act has created many options for young adults to get health coverage, but it has also created a lot of confusions about what to do when you hit certain age milestones. One of the most common questions I get in our office is some variation of this from the 26 year old or their parents:

I’m turning 26, what are my options for the special enrollment period? Depending on the health plan you are enrolled in, your health coverage will be terminated on the date you turn 26, the end of the month you turn 26, or the end of the calendar year that you turn 26. In New Jersey your options will be, NJ Continuation, COBRA, Dependent to 31 coverage, individual health insurance either on or off the exchange.

Don’t Panic – Step by Step Process

The good news is that this process doesn’t need to be as complicated as many make it. The key is to get an early jump on on the planning, and at least being aware of whats coming ahead and gathering up the information.

Step 1: Call your health insurance broker or HR Rep and remind them of your upcoming birth date. I recommend calling at least two months ahead for a smooth process, but don’t fret if its last minute. More time means less stress.

Step 2: Ask these questions:

1. Will my plan terminate on my birth date, at the end of the month, or the end of the calendar year? Small group and individual plans in NJ will usually be that day or the end of the month. The mid size and large group plans will typically be the end of the calendar year.
2. Is our plan subject to NJ Continuation or COBRA? This matters as it dictates your timelines on when you need to get paperwork in and your first payment. This doesn’t mean you are going this route, you are still just collecting info.
3. Can you give me the cost of COBRA and/or NJ Continuation? When you terminate from the plan, they are required to send you the paperwork outlining everything, but ideally you get this information ahead of time so you can make an informed decision.
4. What will my cost be for Dependent to 31 coverage? Small group plans price each person at their age, but mid size and large group plans will discount your rate. More to follow on this later on in the article.
5. Ask for a plan summary and any information you can get on the current insurance so you are up to date. For me the key info is the network(is it local or nationwide), the copays for doctors, deductible for hospital, prescription copays and the maximum out of pocket.

Step 3: Get Individual Health Quotes

It seems like a lot so far, but I promise its not as bad as it looks. Now I want you to go online and get an individual health quote to see what the price will be for an individual health plan. Depending on your income and current situation, you may be eligible for an advanced premium tax credit. (Same coverage, but may be cheaper)

My favorite tool for this is Health Sherpa.

Go to that site and put your information in. I suggest getting a quote for the Horizon BCBS Advantage Silver and the Omnia Bronze H.S.A. The Advantage Silver plan because it’s probably the closest thing you will find to a group plan benefits and the Omnia Bronze H.S.A.

The 2019 price for those two plans are:

• 26 year old Advantage Silver EPO – $351.84 /month
• 26 year old Omnia Bronze H.S.A -$285.25/month

Remember, use the Health Sherpa tool to see what your price is based on your income.

I’m going to spend the rest of the article covering how I compare everything. Cost will be the biggest driver of everything, but sometimes other things come into play.

Evaluating Your Options – NJ Continuation

NJ Continuation works a lot like COBRA in many respects, but the big difference are the notification deadlines and how soon you have to pay. This option is for health plans offered in the small group market (20 or less employees)

When you terminate from the plan, the employer who runs the plan has to offer you this coverage. Unfortunately, this doesn’t happen timely so you will want to call ahead and get what you need.

If you decide to enroll, you will have 30 days to elect the coverage and will owe the premium to your parents employer. They are responsible for paying your premium on your behalf, so your checks will likely go directly to them. If you like the coverage, and their are no better options, you can keep it for up to 18 months.

Cost: Whatever the premium is for a 26 year old on the plan you were covered by plus 2%.

Network and coverage: Exactly the same as what you had before.

Evaluating Your Options – COBRA

COBRA is a term most people are familiar with. All you need to know is that it’s a law to protect you from having a large break in coverage. It gives you the right to continue your coverage. Unlike NJ Continuation, you can continue the same exact plan for up to 36 months under COBRA due to loss of dependency status.

You will have 60 days to elect coverage from the later of when you receive the paperwork, or you terminate from the plan. From the election date, (the date you send everything back), you have another 45 days to make your first premium payment.

Cost: Whatever the premium is for a single employee on the plan you were covered on plus 2%. Every open enrollment, the prices and plans will change.

Network and coverage: Exactly the same as what you had before. Also, the option to change just like any other active employee during open enrollment periods.

Evaluating Your Options – Dependent to 31 Coverage (Chapter 375)

Dependent to 31 coverage introduced to allow dependents to remain covered by their parents health plan when they aged off at age 19 or 23, which was the old law. The new law is obviously 26, but Chapter 375 is still an option for New Jersey based plans.

If you want the absolute best coverage and price, this is most likely going to be your best option.

With Chapter 375 plans, you remain tethered to your parents. What that means is you have the exact same plan as your parents at all times. If they change plans, you are also changing. You are not included on their plan though, so you will have your own ID card and you will get your own bill sent to your home of record. Your payments will go right to the health carrier.

With Dependent to 31, to remain eligible you must be:

• Under Age 31
• Unmarried
• Have no dependents of your own
• A NJ Resident or a full time student at an accredited public or private institution
• Not provided coverage in another health plan

Cost: with Horizon BCBS, you only pay 60.8% of the premium for a single employee. Remember with COBRA, you pay the whole premium plus 2%.

Network and Coverage: Same as your parents.

Evaluating Your Options – Individual Coverage on and off the exchange

If you are very price sensitive, this is probably going to be your best choice. However, as far as the benefits go, they will be worse plans than any of the other options. The individual plans will share the same names as the group plans like Horizon Omnia Silver, but the benefits are not the same.

With the individual plans, you will not have the option for nationwide coverage, so if that is important to you, you will need to consider your other options and if they have it available.

My suggestion is to you use Health Sherpa for pricing and purchasing.

Cost: Depends on your plan selection and tax credit if applicable

Network and coverage: Depends on what you select.

Evaluating Your Options – Networks

Understanding the networks in NJ can be one of the more confusing things, so I will do my best here. The key takeaway is that they can be vastly different and that is a big driver of the price.

In Order of Best to Worst (Just my personal Opinion and I’m only considering two companies)

• Horizon Direct Access – these have access to the BlueCard, and also out of network benefits
• Horizon other plans with BlueCard: I didn’t name the plans because they can vary. If your plan has BlueCard attached though, your options are nationwide in network access.
• Amerihealth POS with National Access – Amerihealth has a great local network and they also have a version of the BlueCard. In my opinion its not as good, but only because its not as seamless as BCBS when traveling. In certain areas, the network density seems a little low. Don’t let this detract from their offerings, it is still fantastic.
• Horizon Advantage Plans or other non Omnia Plans – this is what I call their “normal” network. All of NJ, the Philadelphia region, parts of DE and NYC.
• Amerihealth Regional Preferred – I think this is equivalent to Horizon’s “normal” network. Very strong in NJ and Philadelphia region. Probably stronger in PA actually since Amerihealth is owned by Independence BCBS.
• Horizon BCBS Omnia – This is the same exact network as the Advantage series plans, but the big difference is they use a Tiered structure. You will have different benefits depending on what Tiers your provider falls under. Again, its the same providers but your payments will differ.
• Amerihealth Local Value Plans – these have alot of different names, but they fall under the Local Value Network. The Local Value network is somewhere around 79% of the providers that the Regional Preferred network has. Also, the last time I checked, you can only use NJ providers with this network. The only exception might be a hospital or two in Philadelphia. Double check their network online before purchasing.

Wrapping up – What would I do?

I put alot of information here in the hopes that you can get what you need to make your decision. In my experience in dealing with hundreds of these cases, it usually comes down to price and/or coverage.

My personal choice would be Dependent to 31 if my parents had a good plan and if I was on a budget, in inexpensive plan on the exchange.

When our family recently had a baby, we were trying to figure out the coverage for breast pumps with our Horizon BCBS Omnia plan. I work in the business and had a difficult time getting the answers, so I’m sharing some the information I learned here to help others in NJ.

So are breast pumps covered by Horizon BCBS? Yes! Breast pumps are covered without pre-authorization as long as the cost is below $250.00 and they are ordered through one of the durable medical providers that I will list below. They can be ordered no sooner than fifteen days prior to your expected delivery date.

The process with Horizon BCBS was extremely easy and pain free. Most expecting moms have already done a lot of research on which pump they prefer, and you will be pleased that you can get the top models like:

• Spectra S2Plus
• Medela Pump In Style
• Ameda Finesse
• Lansinoh Signature Pro

I won’t go into much detail at on which are better or worse, but I will give you the information I’ve gained while working as an insurance broker and dad for what the process will look like.

Choosing your Durable Medical Provider (DME)

For some reason, we initially had trouble finding the list of providers that we could order the pump from. I was able to come up with this list through a lot of searching. It may not be all of providers available as of this writing, but hopefully you will find one that works for you.

We used Edgepark and the experience was fantastic. They also have a good website showing the models they have available.

How to order the breast pump?

I will focus in on the process we went through using Edgepark, since it’s the only one we have used.

During one of my wife’s visits to the doctor, he provided a prescription to order the pump. I called Edgepark and they took my information including my health plan and also the expected delivery date. The pump can be ordered fifteen days before the expected date so I was asked to call back then.

Fast forward to fifteen days out, I called again to order the pump and there were no issues at all. I had a prescription ready to send over, but the office at Edgepark coordinated directly with our doctor and Horizon BCBS to make the process seamless for us. A few days after the call, we had the pump at our doorstep and the Horizon BCBS Omnia Silver plan covered it 100%.

On their website, Edgepark states you can order the pump earlier on in the pregnancy and they will hold the order from you until the fifteen day out mark.

Does it matter which Horizon BCBS plan I have?

From my research, the coverage is the same on all of the plans. This includes the Horizon Small Group Plans, Individual Plans and Midsize plans. Your card might say:

• Horizon Omnia
• Horizon Omnia Bronze H.S.A
• Horizon Omnia Silver
• Horizon Omnia Silver H.S.A
• Horizon Omnia Gold
• Horizon Omnia Platinum
• Horizon Advantage Silver

And so on. The good news is that the providers(at least Edgepark), will call Horizon for you and confirm benefits. I don’t recommend calling the 800 number with Horizon as the reps you get unfortunately don’t understand some of the nuances of each of the plans.

How much does the breast pump cost with Horizon BCBS insurance?

From what I have read and experienced, there is no copay involved to order the pump. The coverage guidelines state that they will pay up to $250.00 before an authorization is required so my best guess is that if you exceed that amount, you will be paying out of pocket.

The plan summaries in many cases say that durable medical equipment is covered at 50% coinsurance, meaning you pay 50%. Fortunately, it doesn’t seem to apply to the pumps. If you have had other experiences, please let me know and I will update my post.

Related Questions

How do I claim a breast pump on insurance? You won’t have to. As long as you order directly through the durable medical provider, they will handle the claims process. In my experience in working with Horizon, they don’t usually like it when you purchase something on your own and then try to be reimbursed.

Does insurance cover breast milk bags? No. Based on my research and by reviewing the Horizon BCBS Medical Policy Manual, they will cover the pump, tubing for the breast pump, adaptor for the breast pump, breast shield and splash protector.

Do you get a free breast pump with each pregnancy? Yes. Horizon states they will cover a pump for each subsequent delivery.

What do I need to do to add coverage for my newborn? This is a pretty straightforward process and an enrollment form needs to be submitted to Horizon BCBS within 60 days of birth. I don’t suggest waiting that long and personally, I added my children within a week of delivery. Some parents want to wait until you get your child’s Social Security Number, but the form can be submitted without it and then the information can be updated later. Horizon will use a placeholder for the SSN until one is received.

You can speak with your broker ahead of time to get the enrollment form or download it directly from the website. Adding the baby sooner prevents any mistakes with possibly forgetting altogether and your pediatrician also wants to see that they have been named the primary care provider for your child. Believe it not, many new parents have forgotten to do this more often than you would expect.

Hi everyone, today I answer an question from a client. Comparing the Amerihealth Advantage HSA Bronze vs Horizon BCBS Omnia Bronze HSA.

Email from Client:

I think I narrowed down my choices to AmeriHealth and Horizon, Bronze HSA. Amerihealth is about $150 a month cheaper than Horizon, and I think all the copays, coinsurance, etc. are very close. I checked that my doctors accept AmeriHealth, so that’s the way I will probably go.

What do you think?

Video Transcription via Rev.com

Mike:                    Hi everyone, it’s Mike for NewJerseyinsuranceplans.com. Today I’m going to go over the network differences between Horizon Blue Cross, and Amerihealth. Now, the reason I’m going over this is that, a lot of the plans within our Horizon Blue Cross and Amerihealth, they sound very similar. For example, Amerihealth has a plan called their Advantage plan. Horizon has a plan called their Advantage plan.

As far as our network is concerned, they are very different plans. So today I wanna go over how the different plans work and also compare that their Omni plans within Horizon. And the first screen you’re looking at here is something I will make available. But it’s just a spreadsheet I made, and these are the individual plans in New Jersey for 2018.

So, I combined all the rates into one spreadsheet, and then down at the bottom here I have some links where you can download the plan guides, and the rate sheets and applications if you need them. Now, we’re just gonna look at everything in one spot, and you can scroll over and pull your age and the price for whatever plan you’re looking at.

So, the first carrier I’ll go over will be Amerihealth. And within the Amerihealth plans, you’ll have access to a few different networks. So, the first one and what I call their normal network is called, Regional Preferred. Now, with the Regional Preferred network you can see you have all of New Jersey, you’ll have part of Delaware, and part of the Philadelphia region. So this would be your teaching hospitals in the Philadelphia region.

So, Jefferson Penn, Chop, you know all the big ones that you would tend to go to in the Philadelphia region. Now, Amerihealth also sells some lesser priced plans that are part of their local value network. So the local value network is about 82% of their New Jersey based hospitals. As you can see how it’s highlighted here. You can only go to New Jersey.

So that’s something pretty big to keep in mind because when you’re looking at the prices and comparing them to Horizon, it’s always not apples and apples. If the price is close, you have to make sure you’re not looking at a local value plan and comparing it to one of the plans with Horizon, where they may have the full network. So as we go down the list, we can continue down to their Amerihealth Advantage series, or their tier one Advantage series.

With Amerihealth Advantage, you have to live in one of these Highland counties, and you can receive a lower premium for your plan. If you purchase one of their tier one Advantage plans, you can see here that it’s still all of New Jersey, and you can pay a lower co-pay if you use what they consider a Tier one provider. So, you can go on their network and look up to see where your provider falls and if they’re considered Tier one and pay a low co-pay. So it’s not so bad.

Now if we look at the Horizon Blue Cross plans, you’ll notice some similar names down. Now these are the small group networks, they will work exactly the same as individual. So I’m just going to show you here. So, within Horizon Blue Cross you have what they call their Omni network, and you have what they call their Advantage network.

So this is one of the guides I also make available on that link you saw here. So, for 2018, these are the Advantage series plans within Horizon Blue Cross, and they have their Advantage Silver, which is what they’ve had for years. They have their Advantage Bronze, which is new for this year, and Advantage Essentials. Now, unlike Amerihealth, Horizon Blue Cross’s advantage plans have access to their full network.

So you can go anywhere in New Jersey that’s in network, anywhere in the Philadelphia region that’s in network, New York, parts of Delaware. It’s their full network. You don’t need a referral for these plans. You don’t have to worry about anything being Tier one or Tier two. You just use the network. Very simple. Now they … A few years ago, they came out with what they call their Omni plans.

Now with their Omni plans, the network is identical in every way. So, if a doctor takes their Advantage plan, they will take Omni. What will change though, is the tier that they fall under. So, similar to Amerihealth, where they have both Tier one and Tier two, these Omni plans also have Tier one and Tier two. So you just have to look up your providers and see what tier they fall into. And you’re co-pay or co-insurance will depend, depending on the tier they refer into.

So again, just a big thing to keep in mind is when comparing rates … And I’ll go back to the rate sheet here. When you compare say, their Omni bronze HSA, that’s the Horizon plan, you can compare it to the Amerihealth plan. The prices aren’t that much different between these two, but the networks are very different. So, on this one you can use Horizon’s full network. This one here, New Jersey only and, it’s going to use the tier system.

So that’s it for today. Just wanted to go … A quick review of the 2018 networks with Horizon Blue Cross and Amerihealth, ’cause I know it can be very confusing. If you have any questions, please contact me anytime at [email protected], and have a great day. Thanks. Bye-bye.

Hi everyone, just a short video comparing the networks of Horizon BCBS and Amerihealth.

Video Transcription via Rev.com

Mike:                    Hi everyone, it’s Mike for NewJerseyinsuranceplans.com. Today I’m going to go over the network differences between Horizon Blue Cross, and Amerihealth. Now, the reason I’m going over this is that, a lot of the plans within our Horizon Blue Cross and Amerihealth, they sound very similar. For example, Amerihealth has a plan called their Advantage plan. Horizon has a plan called their Advantage plan.

As far as our network is concerned, they are very different plans. So today I wanna go over how the different plans work and also compare that their Omni plans within Horizon. And the first screen you’re looking at here is something I will make available. But it’s just a spreadsheet I made, and these are the individual plans in New Jersey for 2018.

So, I combined all the rates into one spreadsheet, and then down at the bottom here I have some links where you can download the plan guides, and the rate sheets and applications if you need them. Now, we’re just gonna look at everything in one spot, and you can scroll over and pull your age and the price for whatever plan you’re looking at.

So, the first carrier I’ll go over will be Amerihealth. And within the Amerihealth plans, you’ll have access to a few different networks. So, the first one and what I call their normal network is called, Regional Preferred. Now, with the Regional Preferred network you can see you have all of New Jersey, you’ll have part of Delaware, and part of the Philadelphia region. So this would be your teaching hospitals in the Philadelphia region.

So, Jefferson Penn, Chop, you know all the big ones that you would tend to go to in the Philadelphia region. Now, Amerihealth also sells some lesser priced plans that are part of their local value network. So the local value network is about 82% of their New Jersey based hospitals. As you can see how it’s highlighted here. You can only go to New Jersey.

So that’s something pretty big to keep in mind because when you’re looking at the prices and comparing them to Horizon, it’s always not apples and apples. If the price is close, you have to make sure you’re not looking at a local value plan and comparing it to one of the plans with Horizon, where they may have the full network. So as we go down the list, we can continue down to their Amerihealth Advantage series, or their tier one Advantage series.

With Amerihealth Advantage, you have to live in one of these Highland counties, and you can receive a lower premium for your plan. If you purchase one of their tier one Advantage plans, you can see here that it’s still all of New Jersey, and you can pay a lower co-pay if you use what they consider a Tier one provider. So, you can go on their network and look up to see where your provider falls and if they’re considered Tier one and pay a low co-pay. So it’s not so bad.

Now if we look at the Horizon Blue Cross plans, you’ll notice some similar names down. Now these are the small group networks, they will work exactly the same as individual. So I’m just going to show you here. So, within Horizon Blue Cross you have what they call their Omni network, and you have what they call their Advantage network.

So this is one of the guides I also make available on that link you saw here. So, for 2018, these are the Advantage series plans within Horizon Blue Cross, and they have their Advantage Silver, which is what they’ve had for years. They have their Advantage Bronze, which is new for this year, and Advantage Essentials. Now, unlike Amerihealth, Horizon Blue Cross’s advantage plans have access to their full network.

So you can go anywhere in New Jersey that’s in network, anywhere in the Philadelphia region that’s in network, New York, parts of Delaware. It’s their full network. You don’t need a referral for these plans. You don’t have to worry about anything being Tier one or Tier two. You just use the network. Very simple. Now they … A few years ago, they came out with what they call their Omni plans.

Now with their Omni plans, the network is identical in every way. So, if a doctor takes their Advantage plan, they will take Omni. What will change though, is the tier that they fall under. So, similar to Amerihealth, where they have both Tier one and Tier two, these Omni plans also have Tier one and Tier two. So you just have to look up your providers and see what tier they fall into. And you’re co-pay or co-insurance will depend, depending on the tier they refer into.

So again, just a big thing to keep in mind is when comparing rates … And I’ll go back to the rate sheet here. When you compare say, their Omni bronze HSA, that’s the Horizon plan, you can compare it to the Amerihealth plan. The prices aren’t that much different between these two, but the networks are very different. So, on this one you can use Horizon’s full network. This one here, New Jersey only and, it’s going to use the tier system.

So that’s it for today. Just wanted to go … A quick review of the 2018 networks with Horizon Blue Cross and Amerihealth, ’cause I know it can be very confusing. If you have any questions, please contact me anytime at [email protected], and have a great day. Thanks. Bye-bye.