2019 Horizon Medicare Blue Advantage (HMO) Plan: Frequently Asked Questions

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1 2019 Horizon Medicare Blue Advantage (HMO) Plan: Frequently Asked Questions Horizon Blue Cross Blue Shield of New Jersey has completed an assessment of the Horizon Managed Care Network and Horizon Hospital Network to ensure that providers and hospitals that participate in the Horizon Medicare Blue Advantage (HMO) plan for the 2019 benefit year meet our criteria for participation. Below are answers to questions physicians and/or other health care professionals may have about Horizon Medicare Blue Advantage (HMO) plan and the 2019 changes to provider participation status. Q1. When will changes to provider participation in the Horizon Medicare Blue Advantage (HMO) plan take effect? A1. Changes to physician and/or other health care professional participation status in the Horizon Medicare Blue Advantage (HMO) plan will be effective January 1, For 2019 there will be no changes in the participation status of any network hospitals that currently participate in this plan. The Online Doctor & Hospital Finder will be updated on October 1, 2018 to display information about changes in participation status with the Horizon Medicare Blue Advantage (HMO) plan that will be effective January 1, Physicians and other health care professionals are encouraged to access our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder to review their participation status for all group practices with which they are affiliated. Q2. Why is Horizon BCBSNJ making this change now? A2. Horizon BCBSNJ has conducted an assessment of the Horizon Managed Care Network to identify physicians and health care professionals that meet the participation criteria for the Horizon Medicare Blue Advantage (HMO) plan. We may also make changes throughout the year. Q3. How will physicians and other health care professionals be notified of a change to their participation status for the Horizon Medicare Blue Advantage (HMO) plan for the 2019 benefit year? A3. Letters will be mailed only to those Horizon Managed Care Network group practices that will have a change to their participation status for the Horizon Medicare Blue Advantage (HMO) plan for the 2019 benefit year. EC001146A (0918) An Independent Licensee of the Blue Cross and Blue Shield Association

2 The 2019 provider participation status for the Horizon Medicare Blue Advantage (HMO) plan will be published in the Online Doctor & Hospital Finder on October 1, Providers are encouraged to access our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder to review their participation status for each location and to identify other participating providers Q4. How will members know if their physician or other health care professional will no longer be participating in the Horizon Medicare Blue Advantage (HMO) plan after January 1, 2019? A4. Letters will be mailed to members who have received services from physicians and/or other health care professionals who will be no longer be participating in the Horizon Medicare Blue Advantage (HMO) plan for the 2019 benefit year. The Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder will be updated on October 1, 2018 to display information about changes to participation status with the Horizon Medicare Blue Advantage (HMO) plan that will be effective January 1, Q5. Can a member continue to receive treatment from a physician or other health care professional who is no longer participating in the Horizon Medicare Blue Advantage (HMO) plan after January 1, 2019? A5. Members enrolled in the Horizon Medicare Blue Advantage (HMO) plan do not have out-of-network benefits except in the case of an emergency. Any physician, hospital or other health care professionals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network. If members enroll in the Horizon Medicare Advantage (HMO) plan for the 2019 benefit year they will need to select a physician and/or other health care professional that participates with the Horizon Medicare Blue Advantage (HMO) plan to receive benefits. Q6. When will the Online Doctor & Hospital Finder be updated? A6. The Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder will be updated on October 1, 2018 to indicate if a physician s and/or other health care professional s participation status in the Horizon Medicare Blue Advantage (HMO) plan is changing for the benefit year beginning January 1, Q7. Which network is used for the Horizon Medicare Blue Advantage (HMO) plan? A7. Members that choose the Horizon Medicare Blue Advantage (HMO) plan have access to a subset of the physicians and other health care professionals in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network. Members have access to all ancillary providers in the Horizon Managed Care Network. 1 There are no out-of-network benefits for the Horizon Medicare Blue Advantage (HMO) plan, except in the event of an emergency. Therefore, members must receive services from physicians, other health care professionals and hospitals that participate with this plan. 1 Some exceptions apply to in-network ancillary providers.

3 Provider participation status for the Horizon Medicare Blue Advantage (HMO) plan is published in the Online Doctor & Hospital Finder. Physicians and other health care professionals are encouraged to access our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder to review their participation status and to identify other participating providers. Q8. Will the Horizon Medicare Blue Advantage (HMO) plan continue to be offered to Medicare-eligible beneficiaries in 15 counties throughout New Jersey for 2019? A8. For 2019, the Horizon Medicare Blue Advantage (HMO) plan will continue to be offered in 15 counties throughout New Jersey. It is not offered to Medicare-eligible beneficiaries that reside in Burlington, Camden, Cape May, Gloucester, Passaic and Salem counties. Q9. Why is the Horizon Medicare Blue Advantage (HMO) plan not offered to Medicare-eligible beneficiaries in all New Jersey counties? A9. For 2019, Horizon Medicare Blue Advantage (HMO) plan will not be offered in certain New Jersey counties due to market demand. Q10. How can I identify members enrolled in the Horizon Medicare Blue Advantage (HMO) plan? A10. You should ask members to present their Horizon BCBSNJ member ID card to confirm enrollment in the Horizon Medicare Blue Advantage (HMO) plan. As always, physicians and other health care professionals have convenient access to important Horizon BCBSNJ information on NaviNet. Q11. Are any benefit rule changes planned for the Horizon Medicare Blue Advantage (HMO) plan for 2019? A11. No, there are no benefit rule changes planned for the Horizon Medicare Blue Advantage (HMO) plan in Plan details include: Members do not have out-of-network benefits except in the case of an emergency. Any physicians, hospitals or other health care professionals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network. Members are required to select a Primary Care Physician (PCP) that participates with the Horizon Medicare Blue Advantage (HMO) plan. Members do not need referrals. Q12. Is participation in the Horizon Medicare Blue Advantage (HMO) plan at the group practice level or the practitioner level? A12. To make it easier for members to understand their cost sharing responsibilities, participation in the Horizon Medicare Blue Advantage (HMO) plan is at the group level. All physicians and other health care professionals who bill for services under the group practice s Tax ID Number (TIN) are considered either participating or nonparticipating when treating members. All physicians and other health care professionals affiliated with a participating TIN are considered in-network when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that participating group practice s TIN.

4 If a physician or other health care professional is also affiliated with a group practice that is not participating in this plan, that physician is considered out of network for this plan when they bill for services rendered to Horizon Medicare Blue Advantage (HMO) plan members under that nonparticipating group practice as it pertains to services rendered to Horizon Medicare Blue Advantage (HMO) plan members. Q13. Does my participation status in the Horizon Medicare Blue Advantage (HMO) plan impact my participation in the Horizon Managed Care Network? A13. Nonparticipation in the Horizon Medicare Blue Advantage (HMO) plan will not impact your participation in the Horizon Managed Care Network Effective January 1, 2019, if your practice is nonparticipating with Horizon Medicare Blue Advantage (HMO) plan, your practice will also be nonparticipating in the Horizon Medicare Blue Select (HMO-POS) plan. Your practice will continue to participate with the remaining Horizon BCBSNJ plans that use the broad Horizon Managed Care Network and Horizon Hospital Network. The Horizon Medicare Blue Advantage (HMO) and Horizon Medicare Blue Select (HMO-POS) plans use the same subset of physicians and other health care professionals in the Horizon Managed Care Network, as well as a subset of facilities in the Horizon Hospital Network. Horizon BCBSNJ will offer the Horizon Medicare Blue Select (HMO-POS) plan only to Medicare-eligible beneficiaries in Union county during open enrollment with an effective date of January 1, Q14. How can physicians and other health care professionals verify participation in the Horizon Medicare Advantage plans? Q14. Physicians and other health care professionals can verify participation in all of the Horizon Medicare Advantage plans on their profile page on the Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder. Physicians and other health care professionals should review their participation status for all group practices with which they are affiliated. Q15. How are physicians, specialists and other health care professional practices selected to participate in the Horizon Medicare Blue Advantage (HMO) plan? A15. The physicians and other health care professionals in the Horizon Managed Care Network are evaluated for participation with the Horizon Medicare Blue Advantage (HMO) plan based on criteria that includes one or more of the following: 2 Referrals and admitting patterns to a hospital that is participating in the Horizon Medicare Blue Advantage (HMO) plan, where applicable. Cost efficiency metrics Risk-adjusted cost efficiency at the group practice level using Episode Treatment Group (ETG) data, where applicable. To qualify for the ETG analysis, practices were required to have a minimum of 50 episodes of care, as determined by Horizon BCBSNJ, between July 2016 and June 2017 that were processed no later than September 30, Geographic access and coverage standards.

5 Q16. Where can physicians and other health care professionals find additional information regarding Horizon BCBSNJ s criteria for participation in the Horizon Medicare Blue Advantage (HMO) plan? A16. Additional information can be found in our administrative policy, Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network. To access this information, please log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and: Mouse over References and Resources and select Provider Reference Materials Mouse over Policies & Procedures and select Policies Select Administrative Policies Q17. Can nonparticipating group practices apply to be participating with the Horizon Medicare Blue Advantage (HMO) plan? A17. No. Nonparticipating group practices cannot apply to be participating with the Horizon Medicare Blue Advantage (HMO) plan. Horizon BCBSNJ will periodically evaluate participation with the Horizon Medicare Blue Advantage (HMO) plan and may make changes to participation status.. Q18. Who should I contact with questions about my participation status with the Horizon Medicare Blue Advantage (HMO) plan? A18. If you have questions related to your participation status, contact your Network Specialist. Call Physician Services at and select the prompt for More Options and then Network Relations. All hospitals should contact their Network Hospital Specialist.