AtlantiCare Benefits Book 2020

Glossary

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES...................4 HOW TO ENROLL.......5 MEDICAL..............6-12 PRESCRIPTION DRUG. ................13-15 ADDITIONAL MEDICAL PLAN RESOURCES........16-18 DENTAL...............19-21 VISION.....................22 LIFECENTER..............23 LIFE INSURANCE. .....24 LONG TERM DISABILITY...............25 VOLUNTARY OFFERINGS. ........26-29 SPENDING ACCOUNTS. ............30 RETIREMENT BENEFITS..................31 WELLNESS. .........32-36 LEGAL NOTICES..37-39 CONTACTS.........40-41 GLOSSARY..........42-43 FAQs...................44-46 FORMS................47-56

Tier 1 – This network tier includes all AtlantiCare and AtlantiCare affiliates and is included in all medical plan options. Services provided at LabCorp and Atlantic Medical Imaging will be payable at this benefit level. Most services will be covered at 100% or subject to a $10 copay ($150 copay for emergency room services).

Blue Card or Blue Suitcase – For Tier Two of both the Horizon Engaged and PPO plans, you have access to Blue Cross/Blue Shield network physicians and hospitals outside New Jersey (called Blue Card or Blue Suitcase providers), both nationwide and internationally through this program. You can visit the Blue Card Doctor and Hospital Finder in the Provider Directory section at www.HorizonBlue.com or call BlueCard Access at 1-800-355-BLUE (2583). Coinsurance – This is the amount that you may be required to pay after you have paid a copay or deductible. Coinsurance is usually a percentage of the charge. For example, if your plan pays 70% of the charge for a service, you will then be required to pay the remaining 30% as coinsurance. If you are using a network provider, this is a percentage of the allowable charge that your provider has agreed to accept.

Copayment – A copay is a flat dollar amount that a plan requires you to pay for a specific medical service or supply. For example, you may be required to pay a $10 copay for an office visit when using a network provider. The plan will then usually pay the remainder of the charges.

Deductible – This is a fixed dollar amount that you may have to pay out-of-pocket before your medical plan pays for a covered service. This amount may need to be met annually or for each occurrence (i.e., each hospital admission).

Explanation of Benefits (EOB) – This is a statement that shows provider information, the charges submitted for a claim, what your plan pays and what you have to pay for that medical service. This is a way to keep track of your out-of-pocket expenses as the year goes by. EOBs are not invoices.

FMLA – The Family and Medical Leave Act of 1993 (FMLA) is a United States labor law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons.

Horizon BCBS of NJ Network – These are the providers contracted with Horizon BCBS of NJ that can be used for services for Tier Two of the Engaged and PPO Plans.

Out-of-Network – You may use a doctor or hospital even if they do not participate with the Horizon BCBS PPO network or the BlueCard Program. Your claims will be paid but at the out-of-network benefit tier. This tier is only available if you enroll in the PPO Plan. Since these providers have not contracted with Blue Cross/ Blue Shield, they have not agreed to accept any rates by contract. You will have to pay a high deductible and then most services are paid at 60% of reasonable and customary charges.

Out-of-Pocket – This is the annual amount that you will have to pay for health-related services above and beyond your payroll contributions.

Out-of-Pocket Maximum – This is the highest or total amount that you will have to pay in one year. Once you reach your plan’s annual out-of-pocket maximum, the plan will cover 100% of the medically necessary costs. Please note that for all AtlantiCare medical plans, copays, deductibles, and any pre-certification penalties are not included in meeting the out-of-pocket annual maximum. Preferred Provider Organization (PPO) – Like the name implies, with the PPO plan, to receive the higher level of benefit payment, you will need to get your medical care from the doctors, hospitals and other healthcare providers who have contracted to be preferred providers with Horizon BCBS of NJ or the Blue Card Program.

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