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NJ Insurance Plans - Mike Sheeran, CFP

New Jersey Health Insurance - Reviews and Recommendations

Best health insurance in NJ? It’s not what you think

April 5, 2019 By Mike

Photo by Charles ?? on Unsplash

The question everyone asks when it comes time to picking their health insurance. It’s definitely a tough one and their own situation will play into the answer I give. I’ve been in the health insurance game for over ten years, and I’ll share what I believe to be the best plan is in NJ and what you should be looking at for your family. Most people think it’s one of the Platinum plans available. I disagree 100%.

What is the best health insurance plan? The Horizon Blue Cross Omnia Bronze H.S.A is in my opinion the best choice overall in NJ when you are selecting a plan for your family or small business. The combination of low premiums, easy to understand network tier structure, extra perks like BFit(gym reimbursement), telemedicine and its H.S.A qualified status all contribute to its success.

Read on and I’ll go over how the plan works, and why I think it belongs in your top list of health plans whether you are a family looking for coverage or a small business.

Evaluating Cost and Value of a Health Plan

When I am working on quotes for a small business or family, the first thing people want to know is the cost. I evaluate all of the plans with Amerihealth NJ, Horizon BCBS and any other carriers that are available at the moment. Across all of the age groups, the Bronze H.S.A will be one of the lowest.

The best way to compare the plans is to take the monthly cost for your plan and get the annual total. Then add the annual total to the maximum out of pocket. The maximum out of pocket(MOOP), is the most you can pay in a calendar year for your claims. If you hit that number, you are then covered 100%. I’ll show a few examples.

I’ll compare the Horizon Omnia Bronze H.S.A and the Amerihealth EPO H.S.A Advantage $250/$50 plan. My rates are for a 51 year old in the 08201 zip code in 2019.

PlanOmnia H.S.AAmerihealth H.S.A
Maximum Out of Pocket(MOOP)$6,550$6,750
Annual Premium$6,234$4,878
Total$12,784$11,628

You’ll see here the total cost if the 51 year old had the worst case scenario. The full premium and hitting the max out of pocket. The Amerihealth plan is actually cheaper. The premium is 28% less which is very significant. If you came looking for the cheapest premium, look no further and go with the Amerihealth plan I mentioned.

The Horizon plan falls behind in the premium comparison, but among the other Horizon plans, it will be the lowest cost plan.

Horizon Omnia Bronze H.S.A Benefits

The Bronze H.S.A plan is HSA qualified so it has a large upfront deductible before benefits will be paid.

In this case, the deductible is $3,000 that you need to pay before Horizon pays anything. When you visit a provider, they apply the network discount and you pay based on that amount. Once the deductible has been met, you pay copays or coinsurance until the year is over or you hit the max out of pocket of $6,550 per person or $13,100 for a family.

Full Omnia Bronze H.S.A Summary of Plan Benefits – Individual Market 2019

Horizon BCBS Omnia Bronze Network

The Horizon Omnia network for small groups and individuals is exactly the same as their Advantage plans. It is all of NJ, the Philadelphia region, a small part of Delaware and New York City.

The big thing that makes a plan Omnia from a consumers perspective is the use of a Tiered network.

Omnia Tiers

Each quote you get for a Horizon Omnia product will show Tier 1 and Tier 2 benefits. Depending on how your provider is classified, they will be one or the other. Tier 1 providers will have a lower deductible and copay than Tier 2 providers. I don’t have data to support this, but there is no discernable difference between the quality of providers in either Tier. Horizon BCBS has their own way of deciding who goes into what Tier, but that discussion is a whole other issue.

Tiers on the Omnia Bronze H.S.A

The one thing I really don’t like about Omnia, the Tiers, doesn’t affect this plan. With the Omnia Bronze, the deductible in Tier 1 is $3,000 and the deductible in Tier 2 is also $3,000. That makes it simple. Some of the plans have different deductibles and it can be very confusing to try and compare anything out.

When visiting providers, any claim that goes towards Tier 1 will also count towards your Tier 2 deductible. It will fill both buckets. When you visit Tier 2 providers, it only fills the Tier 2 bucket until that one is full($3,000). If you happen to reach that first, you won’t have to pay any more deductible in either tier for the rest of the year.

H.S.A Qualified

This plan is H.S.A qualified. Going into the details of an H.S.A will be saved for another post, but I will give some of the details and benefits below.

Certain health plans are deemed HSA qualified by the IRS and they carry with them certain benefits.

  • Health Savings Account (basically a bank account for health expenses)
  • Federally Tax Deductible – Reduces your taxable income on federal taxes
  • The deduction can also help you qualify for other or additional tax benefits that you may be phased out of because of high income
  • Contribution to an H.S.A can help you qualify for extra health insurance tax credit if you purchase a plan on the exchange. Sometimes this can mean thousands in extra tax credit
  • Contributing to the account is voluntary, but you can deposit up to $3,500 if you are single and under age 55
  • No use it or lose it rules – it’s your money until you take it out
  • Funds used for qualified health expenses are tax free!
  • Some banks let you invest your money into index funds and other mutual funds. They will grow tax deferred and will come out tax free if used for medical expenses
  • At age 65, if you still have money in the account, you can take it out for any reason and pay normal income taxes. (Only if you don’t want to save it for medical expenses) If taken out before then for non-medical expenses, there is a penalty and you will pay taxes on the withdrawal.

Those are the big benefits of the H.S.A. I can’t stress enough how important it is to have the extra flexibility for a tax deduction. For most people, they won’t have large enough expenses in a year to deduct much if anything of their health care costs. The H.S.A is a fix for that. Also, the health insurance tax credit is a cliff based on your Modified Adjusted Gross Income.

If your income is below the threshold, you can get a large credit, possibly thousands of dollars. If you are a dollar over that limit, you get zero! With the H.S.A, you can make a last minute contribution and get the credit by lowering your taxable income.

HRA – Health Reimbursement Arrangement

The Horizon Bronze H.S.A is perfect for this set up. A HRA is something employers will set up for their employees. As employees have claims, they are able to be reimbursed by their employers on a tax free basis. The HRA makes this work.

When we are helping small employers shop their health insurance, the goal is to always maximize benefits at the lowest possible price. Many employers have Gold and Platinum level plans because they want good plans for their employees. These plans are extremely expensive and there will be many employees who never use the benefits. Money wasted.

We recommend buying the lowest priced plan with a good network, the Horizon Omnia Bronze H.S.A. This way they can cover their employees with the lowest possible premium, but give them good benefits by reimbursing the employees as the claims are incurred. Platinum benefits for Bronze prices. We see up to 30% savings when moving to an HRA setup and this plan is perfect for it.

Telemedicine

Horizon offers Telemedicine on all of their Omnia plans. This is the way of the future in my opinion.

If you have an illness that doesn’t require an emergency room visit, you can download the Telemedicine app and reach a doctor through your cell phone from the comfort of your home.

I have personally used this a few times and the experience was fantastic. One morning I felt terrible and was pretty sure I had the flu. The last thing I wanted to do was to get to a doctor with the way I felt. I installed the app on my phone and was teleconferencing a doctor within a few minutes. I went over my symptoms, held the phone at my face so the doctor could get a look at me and they were able to make a quick diagnosis over the phone. The doctor called a prescription into my local pharmacy and it was ready fifteen minutes later. I saved myself the time and hassle of getting to an urgent care center or waiting for my primary care doctor to be able to see me.

Telemedicine does have a cost, which is somewhere around $50 until the deductible is met. The price changes from time to time so don’t hold me to that amount. It is definitely cheaper than your alternatives though.

Gym Reimbursements – BFit

For a long time the BFit program was only available to large group employees. BFit will reimburse you up to $20 month/$240 annually for regularly going to the gym.

The only catch is the gym must participate with the program and you need 12 documented visits per month. It’s actually pretty easy and great benefit.

Horizon BFit

Discounts Galore – Horizon Blue365 Deals

Just like the BFit program, this is available on all of the plans. It is definitely worth mentioning though because many people don’t know about it.

My recommendation is you check through site to see what they have and go back often before making purchases to see if you can save some money. As I write this, they are showing a 20% Reebok discount and up to 40% off Davis Vision Products. There are hundreds of deals that may work out great for you.

See more here – Blue365 Deals

Summary

Hopefully you will agree that the Bronze H.S.A plan is a solid choice. Once you look past the large deductible and compare actual benefits, you will find this plan hard to beat. The Amerihealth plan I mentioned is a solid choice, but will not have everything this plan does. Also, you will come to find the Platinum, Gold and Silver plans will cost you thousands more over the course of the year when compared to the Bronze and its max out of pocket.

Similar Questions

Which health insurance company is best? There is really no answer for this. It is subjective based on your location, the plan you choose and other demographics. Each state will have its leaders and in NJ we have Horizon BCBS, Amerihealth and Oxford Health.

How do I choose the best health insurance? I hope you use my guide above to see the types of things I look at. Overall cost, network, other perks like gym reimbursements and H.S.A options are great.

Is it illegal to not have health insurance? No, absolutely not. There used to be federal tax penalty for not having health insurance but that has gone away. Some states like NJ, have started their own tax penalty to bolster the insurance pool. It’s not illegal to not have it, but you will pay a tax penalty in some cases.

How do I get cheap health insurance? If cost is your number one driver, I suggest using the Health Care Exchange and do what you can to lower your modified adjusted gross income. You can play with different incomes and see what your price is on Health Sherpa. See my link here.

Filed Under: NJ Health Insurance

Horizon BCBS Dental (Young Grins, Family Grins, Healthy Smiles – Review and Plan Designs)

April 2, 2019 By Mike


Photo by Jon Tyson on Unsplash

One of the most common calls I get are from families looking for dental insurance in New Jersey. There are a few carriers in NJ that offer benefits, but I think Horizon BCBS has the most comprehensive offerings right now. While they offer great options, it can be difficult for most people to figure out what they are buying and what the best choice is without wasting their hard earned money.

What affordable dental plans are offered by Horizon BCBS for individuals? For 2019, the plans are:

  • Horizon Young Grins
  • Horizon Family Grins
  • Horizon Family Grins Plus
  • Horizon Healthy Smiles
  • Horizon Health Smiles Plus
  • Horizon Centurion Dental
  • Horizon Individual Dental

By looking at the names, its not clear at all what plans may be best. In this blog post, I’ll review the networks, cost and benefits for each option so you can make an informed decision.

If you want to want to skip right to the summary pdf of the plans, see the bottom of the post where I will have a link to Horizon’s plan guide.

Horizon Dental Networks

I think the easiest place to start with the review is by going over the Horizon BCBS dental networks. Depending on which plan you buy, you will have access to different providers and also out of network benefits in some cases.

Horizon Dental PPO Network

Normally you expect the PPO network to be larger, but not in this case. The plans that use the PPO network are:

  • Young Grins
  • Family Grins
  • Healthy Smiles
  • Dental Centurion
  • Dentists within 25 miles of 08201: 368

I did a 25 mile radius search from my home zip code of 08201 to give you an idea of the size. Your areas will each be different of course, but one of the keys to not wasting money on dental insurance is to make sure your dentist is part of the network. This will keep your out of pocket costs to a minimum.

These plans also have in-network benefits only so if your provider doesn’t participate, there are no benefits at all.

Horizon Traditional Network

The Traditional Network is Horizon’s premium network for dental plans. Dental plans using this network will have far more in-network benefits, and also you will usually have out of network benefits.

The plans with the Traditional Network are:

  • Family Grins Plus
  • Healthy Smiles Plus
  • In-Network Dentists within 25 miles of 08201: 519. That’s almost 41% more in-network dentists than the PPO.

Horizon Individual Dental

This is one of the older Horizon dental plans and has its own network.

  • In-network dentists within 25 miles of 08201: 93

How to look up your dentist to see if they are in-network

Its a pretty straightforward process.

First go to: https://doctorfinder.horizonblue.com/

In the drop down box for “What are you looking for?”, you will select dentists.

Next you will select your plan in the “Choose a Plan to Start” box and then continue on with your zip code.


Plan Summaries for Horizon Dental Benefits in 2019

I’ll provide short summaries of each of the plans here and will include Horizon’s plan guide at the bottom of the blog post.

Plans with ACA Compliant Pediatric Dental

When the Affordable Care Act(ACA) was introduced, the law required that health plans include pediatric dental as one of the essential health benefits. Each carrier responded differently, and Horizon’s answer was the Young Grins plan and later the the Family Grins and Family Grins Plus plans.

If you purchase individual health insurance through Horizon, you will automatically be enrolled in Young Grins, and will have the option to upgrade to one of the other options. The key thing is that even though everyone is enrolled, benefits and premiums are only for children age 19 on the Young Grins.

If you decide to upgrade, you can cover your whole family, including adults on the the Family Grins and Family Grins Plus.

Young Grins

The Young Grins plan covers preventive care at 100%, basic at 80% and major at 50% for covered services. There is no maximum benefit and they even cover cosmetic orthodontia up to $2,000.

On this plan, they will charge you for up to your three oldest dependents under age 19.

Family Grins

The Family Grins plan has identical benefits for your children under age 19, but also includes some basic benefits for adults.

Adults will get preventive benefits covered at 100%, but everything else will be a network discount. All that means is if your dentist is participating, you will have a lower fee than if you had no insurance.

Family Grins Plus

Of the plans that comply with the ACA, the Family Grins Plus plan is by far the best. If you remember from above, it has the larger Traditional network, it also has national in-network coverage and out of network benefits if needed.

The Plus plan looks a lot like an employer plan with preventive benefits covered at 100%, Basic at 80% and Major at 50%. There is an annual maximum of $1000 per adult(over age 19) so that is where this plan falls a little short in my opinion.

Summary of the ACA Compliant Plans

If you need to waive out of other pediatric dental benefits, these are the only ones that will count. The plans I mention below are not considered as credible waivers as far as the ACA is concerned. It doesn’t mean they are better or worse, the benefits are just different. You will not be fined for not having dental, buy may find yourself paying for more than one plan in some cases.

Non Compliant Dental Plans

With that title, the benefits sound terrible, but these are actually better in some respects. In my opinion, these are better for adults over age 19.

Horizon Healthy Smiles

The Horizon Healthy Smiles plan uses the PPO network.

Horizon offers different levels of benefits for this plan so you have the option of:

  • 100/80/50
  • 80/50/50
  • 100/80/50 without waiting period
  • 80/50/50 without waiting period

The first number is preventive care(cleanings and x rays)

The second number is basic (fillings)

The third is major.

So for a 100/80/50 plan, you get 100% coverage for preventive, 80% for basic and 50% for major. You pay the smaller percentage. If you had a filling(basic), you would pay 20% after any applicable deductible.

Horizon Healthy Smiles Plus

The Healthy Smiles Plus plan is the best option for adults in my opinion. This plan uses the larger traditional network, has in-network benefits nationwide, and also has out of network benefits.

Just like the regular Healthy Smiles plan, Horizon offers multiple options.

  • 100/80/50
  • 80/80/50
  • The same as above without wait.

The Health Smiles Plus plan is only a few dollars more per month than the regular plan so I think this is a solid option.

Horizon Centurion Dental

This is the most basic plan Horizon offers and is also the least expensive.

It uses the PPO network and offers discounted services as long as you use an in-network dentist. Many people think that discount dental plans are the best value overall and I can argue this either way. The Centurion plan is a great way to save some money without overspending on premium.

Horizon Individual Dental

The Individual Dental plan has the smallest network of the bunch, but the benefits are pretty good considering the premium. If your dentist is in-network, its also a good value.

Preventive benefits will be covered 100% in year 1 as well as your basic benefits. Most of the major benefits will scale in with your your out of pocket decreasing over a three year period.

Benefit Comparison with Charts and Premiums

You can download the Horizon BCBS Dental Guide Here.

My Personal Choice

My opinion on dental insurance changes from time to time and my usual argument is that you are just dollar swapping with the insurance company. Meaning, you pay out $400-$500 in premium and they basically pay out the same in benefits. I still hold that opinion, but I believe there is more benefit beyond the numbers.

I see too many people neglecting their dental hygiene and therefore health by not having insurance. So even if you are dollar swapping, it seems people are more likely to make regular visits by having the insurance in place. Also, if you do end up needing some more substantial work done, it will be considerably cheaper by having the insurance.

I would choose the Family Grins Plus Plan for my family. One, because it meets the ACA guidelines and has good coverage for my kids and two because I want the extra benefits for myself and my wife.

Related Questions

What is Horizon Dental Option Plan? The Dental Option plan uses the traditional network, has nationwide benefits and also out of network benefits. Its offered in the small, midsize and large employer market.

What is Horizon Dental Choice? The HDC plan is a DMO. Basically an HMO for dental. You choose your primary dentist and they refer you out to specialists. This plan isn’t offered to individuals. You will usually have very good benefits on these plans, but give up some freedom by needing to get your referrals.

Are dental plans worth it? I think so, especially if you can get it through work. The premiums will usually be lower and you can pay the premiums pre-tax. As an individual, there is a behavior element that I believe makes people see their dentists more frequently, and hopefully lead to better overall health.

Which health insurance offers dental? In NJ, all individual and small group plans must include pediatric dental as either a rider or directly included in health plan.

Filed Under: NJ Dental Insurance

Special Enrollment Period Turning 26 (Options and Recommendations)

March 30, 2019 By Mike

Photo by George Moses on Unsplash

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.

Filed Under: NJ Health Insurance

Are breast pumps covered by Horizon Blue Cross Blue Shield?

March 28, 2019 By Mike

breast pumps
Photo by Valeria Zoncoll on Unsplash

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.

Provider NamePhone Number
Allcare Medical800-784-7786
Bell Pharmacy732-985-1211
Edgepark Medical Supplies800-321-0591
Family Medical Equipment877-697-8002
First Choice Medical Equipment609-844-0221
Montgomery Medical Equipment610-630-6357
Surgical Shop845-425-2617

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.

Filed Under: NJ Health Insurance

Amerihealth Advantage HSA Bronze VS Horizon BCBS Omnia Bronze HSA

November 8, 2017 By Mike

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.

Filed Under: NJ Health Insurance

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