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Horizon Medicare Advantage Special Needs Plan

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Horizon Medicare Blue Solutions Comparison

	Horizon Medicare Blue Solutions	Horizon Medicare Blue Solutions (Enhanced Plan)
Eligibility	Entitled to Medicare Part A and enrolled in Medicare Part B; live in New Jersey; receive Medicaid from the state	Have evidence of Medicare Part A and Part B coverage or be enrolled in Medicare Part C coverage; live in New Jersey; have full Medicaid coverage or full Medicaid coverage with Qualified Medicare Beneficiary (QMB) eligibility
Choice of health care specialists	Must use network health care specialists	Must use network health care specialists
Cost sharing and out-of-pocket limit	Cost sharing is based on level of Medicaid eligibility $3,250 out-of-pocket limit	Not applicable
Hospital coverage	$0 for Medicare-covered stays or $75 copay per day for days 1-10*	100% coverage
Outpatient services/surgery	$0 copay for Medicare-covered surgical visit; $0 copay for Medicare-covered hospital facility visit	100% coverage†
Doctor office visits	$10 copay per primary care physician visit; $20 copay per specialist visit* (referral required)	100% coverage (Referral required for specialist)
Emergency care (worldwide)	$50 copay; copay waived if admitted within 24 hours	100% coverage
Transportation	$0 copay for Medicare-covered ambulance†	100% coverage emergency ambulance and invalid coach services†
Outpatient prescription drugs	(Deductibles and copays depend on your income and institutional status) $0 or $56 annual deductible; $0 to $2.25 copay or 15% coinsurance for generic drugs (including brand drugs treated as generic); $0 to $5.60 copay or 15% coinsurance for all other drugs up to $4,050 out-of-pocket maximum. After your out-of-pocket costs reach $4,050, you pay $0 for any drugs; or $2.25 copay for generics (including brand drugs treated as generics) and $5.60 copay for all other drugs.*	100% coverage including Medicaid-covered non-prescription drugs not covered under Medicare Part B or Medicare Part D
Skilled nursing facility	$0 for Medicare-covered stay or $0 copay per day for days 1 - 20; $124 copay per day for days 21 - 100; 100 day/benefit period; no prior hospital stay required. Prior authorization required.	100% coverage per benefit period†
Home health care	$20 copay per visit* †	100% coverage†
Diagnostic tests, x-rays and lab services	$0 copay for lab services and diagnostic tests; $20 copay for x-rays* †	100% coverage
Durable medical equipment	$0 copay †	100% coverage†
Routine physical exams	$10 copay for one routine exam per year	100% coverage
Preventive screenings available (Refer to Summary of Benefits)	100% coverage for Medicare-covered screenings	100% coverage
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	100% coverage	100% coverage
Routine vision services	$0 copay for diagnosis and treatment for diseases and conditions of the eye; $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery	100% coverage including optometrist and optical appliances
Dental services	Not covered	100% coverage †
Hearing services	$0 copay for diagnostic hearing exams. Routine hearing exams and hearing aids are not covered	100% coverage †
Clinical trials	Not covered	100% coverage†
Personal care assistant, (EPSDT) private duty nursing and medical day care	Not covered	100% coverage†
Monthly Plan Premium^§	$108.60	$0

* Cost sharing is based on your level of Medicaid eligibility
† Prior authorization may be required for some services
^§ You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party

Last Updated: December 22, 2008