14:46 PM

How insurance works: What’s covered starts with medical policies



They’re public and based on evidence, science, and the recommendations of the medical groups your doctors belong to and trust.  

What does my policy cover? How does a health insurer make decisions? If my doctor says I should have a test, procedure, or prescription, isn’t that all that matters?

Some people imagine a faceless bookkeeper randomly deciding what gets covered and what doesn’t. They’re wrong. Medicine is complicated because humans, injuries, and diseases are complex. Doctors and insurers consult a huge body of scientific research when deciding whether to use and cover a certain drug, procedure, or test.

Evidence-based research and best practices created by the physician organizations that oversee the different specialties or by independent organizations responsible for nationally accepted guidelines form the foundation of Horizon’s coverage and medical policies.

As a result, Horizon’s medical policy and coverage typically match up with a doctor’s recommendation. But not always. (Remember, people and diseases are complex stuff!) Only 11,097 of the 62 million member claims Horizon BCBSNJ processed in 2018 wound up under appeal, though not all were due to medical policy.

We want you to better understand how Horizon BCBSNJ decides what is covered. Here are seven things you should know:


1. Evidence rules. We start with science: clinical data and research – reviewed by independent scientists and doctors – help medical professionals and organizations create best-practices referred to as “the standard of care” for almost every condition imaginable. We also rely on nationally accepted guidelines created by independent organizations when it comes to determining things like whether care needs to be provided in a hospital, an outpatient site, or at home. Together, those standards of care and nationally accepted guidelines determine what your health insurance plan will cover.

2. Things change. To keep up with most recent research and changing recommendations, medical policies are constantly under review and updated regularly by a team of doctors, nurses and health professionals at Horizon. Horizon has hundreds of medical policies, so each generally gets a fresh look every year. Medical policies are written specifically for medical professionals, so they can be hard to understand unless you have that specialized training. But they are public and anyone can read them.

3. New Jersey’s doctors have a seat at the table. Our Clinical Policy Committee, made up of Horizon medical experts and independent physicians who see patients here in New Jersey, meets monthly to consider changes to our medical policies. They use nationally recognized standards of care and review the latest research.

4. Safe and effective trumps experimental. Medicine’s top priority is safety. It is Horizon’s too. Medical policies ensure that the services and drugs we cover for our members, are proven to be safe. But we also want our members to get effective treatments proven to achieve the desired outcome and improve health. That is one reason why insurance does not typically cover drugs, procedures, and treatments that have not yet been fully researched and evaluated by the independent experts who review safety and effectiveness.

However, this is complex stuff – so there are always exceptions to the rule. Your doctor can discuss your case and the rationale for the treatment with our doctors. In addition, you can always file an appeal including one that brings in outside, independent medical experts (who do not work for Horizon) who have the authority to make a final determination.

5. Believe in the “Blue” advantage. The Blue Cross and Blue Shield Association has a program called Technology Evaluation Center (TEC). It finds and examines the best existing scientific evidence to decide the safety and effectiveness of new medical technologies. The program is administered in partnership with Kaiser Permanente – a leading healthcare organization. It has been called “one of the best-established processes for evaluating scientific evidence for medical technologies” by Health Affairs, an organization that publishes independently reviewed medical and health research.

6. You can take part in trials. Clinical trials are the main way that the doctors and scientists who pioneer new drugs or procedures examine their safety and effectiveness.  Clinical trials often carry no cost to the participants, but Horizon covers some clinical trial costs under certain circumstances.  The type and site of the trial, the illness treated, and the potential to promote effective, quality care for everyone are factors we consider.

7. About those faceless bookkeeper. A medical policy team of licensed medical doctors, dentists, nurses, and other health care professionals are our experts. They study the research and recommendations to decide which drugs, devices, or procedures have met the safety, quality and effectiveness guidelines and become part of Horizon’s medical policies. Those same experts are the health professionals whom doctors speak to when they want Horizon to cover care that doesn’t follow our medical policies. These same Horizon medical professionals evaluate any new information or unique factors and make a decision.

So, there’s your primer on medical policies – no decoder ring necessary.