How does precertification/prior authorization for medical coverage work? Is it required every time a team member needs to go to a specialist?
Our healthcare plans do require prior authorizations in certain situations. In those cases, the team member (if out of network) or provider (if in network) must request a review from Horizon BCBSNJ at least five business days before the service is scheduled, or as soon before as reasonably possible. If the service is being performed in a facility on an inpatient basis, only one authorization for both the admission and the service is needed. If prior authorization is required for a supply, the request must be made before the supply is obtained. The following is the most current list of services that require prior authorization:
- All Inpatient Admissions
- Hospice (exclusive of maternity delivery)
- Rehabilitation (acute rehab, skilled nursing and sub-acute)
- Mental Health and Substance Abuse
- Air Ambulance Transportation (non-emergent)
- Bariatric/Gastric Bypass Procedures (surgery for morbid obesity, including but not limited to bariatric procedures, gastroplasty, gastric bypass – outpatient)
- Potentially Cosmetic Procedures (including cosmetic dermatology services)
- Infertility Services
- Transplant Services (except corneal transplants)
- Cardiac Radiology Services (non-emergent only, includes diagnostic cardiac catheterization and diagnostic echo stress tests)
- Pain Management
- Durable Medical Equipment (items costing over $500)
- Prosthetics (items costing over $500)
- Home Health Care Services (all skilled services in the home)
- Home Infusion Services
- Private Duty Nursing
- Home Hospice Services
- Specialty Pharmaceuticals/Drugs (examples: Botox, IVIG, Flolan and derivates; Xolair)
- Medications Administered in Physician's Office or Dialysis Center (examples: aranesp, epogen, procrit, peginesatide)
How do I locate an urgent care center within the Horizon Blue Cross Blue Shield network?
Urgent care centers are listed separately in two areas on the Horizon Blue Cross Blue Shield web site – Retail Health Center and Urgent Care Center. Get started by CLICKING HERE
and then accessing Other Healthcare Services -> Service Type -> All Healthcare Service Types, to find the urgent care center that’s most convenient to your location. If you need assistance, please contact Horizon Customer Service at 844-383-2327.
How does HMH define a “true emergency” for hospital visits?
An emergency under the Hackensack Meridian Health plans follows the “prudent layperson” rules: This is the standard by which a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.
If urgent care is closed, can team members go to the ER and avoid the $200 surcharge? If urgent care refers you to the ER, does this automatically waive the $200?
Hackensack Meridian Health would never recommend postponing care if needed. If a provider at urgent care refers a team member to the ER, the $200 will be waived. However, if urgent care is closed and a team member chooses to go to the ER for a non-emergent condition, the surcharge will apply.
How does HMH define “non-emergent” cardiac radiology services (including diagnostic cardiac catheterization and diagnostic echo stress tests)?
Non-emergent care would encompass any services that are not considered emergent. The conditions for an emergent case include:
- A delay in care that could seriously jeopardize the life or health of the patient or patient's ability to regain maximum function; or
- A delay in care that would subject the member to severe pain that cannot be adequately managed without the care or treatment requested.
If a team member goes out of area for vacation/school and has to go to urgent care, ED or dialysis, will it be covered at the Hackensack Meridian Health Partners level?
Generally, no – however, if you or any covered member has a true emergency, it’s covered at the same level, regardless of network.
Can a team member who is on dialysis travel and still be covered at the in-network rate?
The Horizon network is a national network, so a team member does not have to be in the state to receive treatment with a covered facility/provider. As long as it is a Horizon facility/provider, it would be covered at in-network level. Benefits are not paid for dialysis services when provided by an out-of-network facility/provider.
How will lab benefits be covered at HMH in-house labs?
LabCorp is considered part of the HMH Partners network, so those services will be covered 100% at all New Jersey-based LabCorp facilities (within a hospital or free standing), with the exception of Basic Plan participants who would need to meet the required deductible prior to 100% lab coverage.
Is an annual GYN visit covered in preventive care?
What is the Air Ambulance Transport policy?
Per the Horizon Medical policy, Air Ambulance Transport is considered medically necessary when:
- The time needed to transport a team member by other forms of emergency transportation, or the instability of other forms of emergency transportation, poses a threat to the team member's condition or survival; or
- When the point of pickup is inaccessible by other forms of emergency transportation.
How do providers in the “Hackensack Meridian Health Partners” tier work?
The providers within our Hackensack Meridian Health Partners tier – those who are employed by or affiliated with Hackensack Meridian Health – represent the best balance of savings and excellence.
Previously, these providers were broken into two tiers – “domestic” and “non-domestic” – but we heard from many of you that expanding access to these providers was something you wanted. So, we’ve combined them to maximize this offering. Also, know that we’re actively recruiting to expand the pool of providers to help as many of you as possible.
What if there are no HMH Partners primary care physicians or specialists near my home?
Team members enrolled in the HMH health care plan who are unable to access an HMH Partners primary care physician or specialist within 50 miles of their home will have the option to see a Horizon network primary care physician or specialist, while still receiving coverage at the HMH Partners level.
What if there is no service or physician within the HMH Partners network to treat my acute or chronic disease?
In the event that no service or physician exists to treat an acute or chronic disease at an HMH Partners facility, team members enrolled in an HMH health plan will have the right to use Horizon network facilities and physicians, and still be covered at the HMH Partners level. For all plans that cover out-of-network, if no in-network provider is available, then out-of-network providers will be covered at the HMH Partners level. Approval is not required on an ongoing basis when treating the same acute or chronic disease, unless there is a significant change in diagnosis or treatment plan.
What happens if there is no option for a second opinion from an HMH Partners physician?
In the event there is no option for a second opinion from an HMH Partners physician, team members will have the option to obtain a second opinion from an in-network physician, while still receiving coverage at the HMH Partners level in accordance with the plan they have selected.
Will Hackensack Meridian Health provide radiology services at in-network Horizon providers at HMH Partners benefit levels if there is no HMH participating provider in the area?
The Hackensack Meridian Health plan will cover radiology services when those services are rendered by a participating Horizon PPO provider at the HMH Partners benefit levels if there are no HMH Partners participating providers within 50 miles or one hour driving distance (as determined by online driving distance programs such as MapQuest, WAZE, etc.) from their residence to an HMH Partners provider. Services must be rendered in the state of New Jersey and members must obtain prior approval under the tier elevation process.
If I use an HMH facility, and the physicians who treat me are not in the HMH Partners network, will services still be covered at the HMH Partners level?
Yes. Team members enrolled in the HMH health plan who use an HMH facility for a “true emergency” or inpatient services, shall not be responsible for the in-network or out-of-network cost incurred due to a physician at the facility who is not a participant in the HMH Partners network.
Is Fresenius part of Hackensack Meridian Health Partners?
Currently, there are several Fresenius locations that are considered part of the Hackensack Meridian Health
Partners level. For more details, go to WWW.HORIZONBLUE.COM/HMH
and follow these steps:
- On the home page, click the link “Find a Doctor”
- Once on the search page, go to “What Type of Care are you Looking for?” and select “Other Healthcare Services”
- In the box that says "Enter Name, Specialty, Service or Affiliation," type "Fresenius" or "Dialysis Provider"
Why does my paycheck seem to show that I am paying for certain benefits I thought were free, like life insurance?
Certain things on your paycheck – like Medical, Dental, Vision and 401k contributions – are self-explanatory. However, other things like Group Term Life Insurance or Long-Term Disability, fall under the category of “imputed income” and are a little different. Imputed income is the value of a service or benefit provided by HMH to team members, which the IRS considers taxable income. These amounts are not being deducted from your paycheck – again, the amount listed is just the value of HMH’s contribution that is treated as income by the IRS, therefore it is added to your gross pay. The amount of imputed income is based on a few different factors. First, it only kicks in when the service or benefit provided by HMH exceeds a certain amount ($50,000). From there, it is based on a calculation of team member age and monetary value (again, beyond $50,000).
Why are the medical premiums for part-time team members a flat rate rather than based on salary?
Part-time workforces represent a wide variety of hours, experience and salary levels, making it difficult to create salary “bands” that are similar across all job functions. Because of that, it is common practice to provide benefit-eligible part-time team members with a flat rate premium, rather than breaking it up based on salary.
How were the benefit salary bands determined?
We used a market analysis to determine the benefit salary bands. Your benefit salary band is determined by your previous year’s base pay, excluding any incentives. For 2019, for example, your benefit salary band was determined by your 2018 base pay. Also, if you are promoted or take a different position during the calendar year that would place you in a higher benefit salary band, the premium increase won’t take effect until the next year.
What are the consequences if it is determined that someone lied on their tobacco attestation? Do they lose their benefits eligibility or is there another disciplinary action?
If a team member who is a tobacco user, as defined in this policy, certifies otherwise in the MyWay-PeopleSoft system and it is discovered, he/she may be subject to disciplinary action up to and including termination.
What is the tobacco cessation program? How long is it? Who is the provider/vendor of the program?
The tobacco cessation program is the Optum ‘Quit for Life’ Program. It consists of six phone sessions with a counselor. CHECK OUT THIS FLYER
with an overview of the program.
Are vaping products considered tobacco?
There are several tax advantage/Flexible Spending Account (FSA) options available during Open Enrollment. Which one should I choose?
The Dependent Care FSA is available to any eligible team member who meets the reimbursement rules, i.e., day care for a child under the age of 13. The Limited Purpose FSA is available for any team member who has elected the Basic/High Deductible medical plan and the Health Savings Account (HSA). It allows for vision and dental reimbursements. Once a team member reaches their medical deductible, medical and prescription reimbursements are allowed as well.
All other benefit-eligible team members are welcome to participate in the general Health FSA. Team members also have the option to carryover $550 in their Health Care FSA at the end of the calendar year, an option not available for Dependent Care accounts. Remember, FSAs require an annual enrollment. They do not roll over from one year to the next. You must take action each year during Open Enrollment in order to secure an FSA for the following year.
If I have money leftover in my FSA at the end of the calendar year, will I still have the opportunity to carry over a maximum of $550?
Yes, team members will still have the option to carryover $550 in their Health Care Pre-Tax Dollar Account (otherwise known as a Flexible Spending Account, or FSA) at the end of the calendar year. This option is not available for Dependent Care Accounts.
If there are two working spouses, and only one needs to select, can we select the “lower wage earner” to be the one who takes coverage, so the lower premium prevails?
If HMH is the “secondary” insurance for my spouse (versus primary based on birthdate), does the spousal surcharge still apply?
Will the spousal surcharge be applied in the following situations?
- I have a working child on my insurance? The surcharge applies to spouses only.
- My spouse is self-employed? If your spouse is self-employed and does not have access to medical coverage, the surcharge will be waived upon signature of the necessary documentation.
- My spouse is on Medicare? If your spouse is on Medicare, the surcharge will be waived upon signature of the necessary documentation.
- My spouse has Hackensack Meridian Health as his/her secondary insurance? If Hackensack Meridian Health is your spouse’s secondary coverage, you will be subject to the surcharge.
- My spouse opts out of HMH Medical but they are on Dental and/or Vision? The surcharge is applicable only to the medical plan coverage, not dental and/or vision coverage.
What is the "spousal surcharge" in the HMH medical plan?
If your spouse has access to health coverage through his/her own employer but elects to be covered by the Hackensack Meridian Health plan, there will be surcharge of $50 per month. This does not apply to spouses who are also employed by HMH and eligible for health care coverage through their own employment.
Health care costs continue to rise and our organization continues to grow. The spousal surcharge is not meant to be a penalty, but rather, an example of our culture of shared responsibility. The surcharge is consistent with industry-wide practice.
Do I need to purchase Supplemental Insurance in order to elect life insurance for my spouse and/or child?
Yes. Team members need to purchase supplemental group life Insurance for themselves in order to elect supplemental group life insurance for spouses and/or children.
How does enrollment in the High Deductible Plan help me with saving for retirement?
Enrolling in the High Deductible Plan enables you a tax-advantaged way to set aside monies that can grow tax free in a Health Savings Account (HSA). The HSA is portable and can be used to off-set health care expenses now or in retirement.
Can I enroll in voluntary benefits on MyWay-PeopleSoft?
No, team members are not able to sign up for these benefits through MyWay-PeopleSoft. We strongly encourage you to discuss these benefits with a Farmington Benefit Counselor to assess and confirm your selections. For any questions and to sign up for these benefits, Farmington Benefit Counselors can be reached at 844-428-6688, Monday – Friday from 8:00 am – 5:00 pm.