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Horizon NJ TotalCare (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Horizon NJ TotalCare (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Horizon NJ TotalCare (HMO D-SNP) in 2025, please refer to our full plan details page.
Horizon NJ TotalCare (HMO D-SNP) is a HMO D-SNP plan offered by Horizon Mutual Holdings, Inc available for enrollment in 2025 to people living in New Jersey. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Horizon NJ TotalCare (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Horizon NJ TotalCare (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Horizon NJ TotalCare (HMO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Horizon NJ TotalCare (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.80. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Horizon NJ TotalCare (HMO D-SNP) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for your drugs, but the specific cost-sharing amounts are not provided in the provided information. This plan's premium may be reduced if you qualify for the low-income subsidy (LIS). The plan covers drugs in the initial coverage phase, and then catastrophic coverage.
Additional Benefits
The Horizon NJ TotalCare (HMO D-SNP) plan offers a range of covered services with varying cost-sharing. Many services, such as inpatient and outpatient services, primary care, and vision and hearing services, have a 20% coinsurance. Emergency, home health, and diagnostic services have no copay, and there is no coinsurance for home health services. The plan also provides additional benefits, including coverage for OTC items up to $245 per month, and meal benefits for chronic illnesses. However, it's important to note that some services are not covered, such as routine vision and dental care, and cardiac rehabilitation services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with coinsurance costs that are defined by Medicare. Additional days, non-Medicare stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient substance abuse services. Outpatient hospital and observation services have a 20% coinsurance. Individual and group sessions for outpatient substance abuse have a 20% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by Horizon NJ TotalCare (HMO D-SNP), but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Horizon NJ TotalCare (HMO D-SNP) plan. Ground and air ambulance services are covered with a 20% coinsurance, and there is no copay; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Horizon NJ TotalCare (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, with no copay. Worldwide Emergency Services has a maximum plan benefit coverage of $60,000.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services, with a 20% coinsurance. Chiropractic Services are covered with a 20% coinsurance, but routine care is not covered. Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services are covered with a 20% coinsurance. Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services are covered with a minimum 20% coinsurance and a maximum 20% coinsurance. Podiatry Services are covered with a minimum 20% coinsurance and a maximum 20% coinsurance, including routine foot care. Additional Telehealth Benefits are covered, and include services not usually covered by Medicare plans.
Preventive Services See details
Preventive services are covered by the Horizon NJ TotalCare (HMO D-SNP) plan. The plan does not cover annual physical exams, but covers glaucoma screenings, diabetes self-management training, and barium enemas with a 20% coinsurance.
Hearing Services See details
Hearing Services under the Horizon NJ TotalCare (HMO D-SNP) plan are partially covered. Hearing exams have a coinsurance of at most 20%, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types), prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Horizon NJ TotalCare (HMO D-SNP) plan. Eye exams and eyewear are covered, with a 20% coinsurance, while routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by the Horizon NJ TotalCare (HMO D-SNP) plan; specifically, Medicare Dental Services are covered with a 20% coinsurance, while Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance ranges from 0% to 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Horizon NJ TotalCare (HMO D-SNP) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered by Horizon NJ TotalCare (HMO D-SNP), including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, with no copay. Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts each have a 20% coinsurance, with no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Horizon NJ TotalCare (HMO D-SNP) plan. Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, while Lab Services has no coinsurance. Therapeutic Radiological Services and Outpatient X-Ray Services also have a coinsurance of at most 20%. There is no copay for any of these services.
Home Health Services See details
Home Health Services are covered by the Horizon NJ TotalCare (HMO D-SNP) plan, with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Horizon NJ TotalCare (HMO D-SNP) plan. Some services that are not covered include Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. The plan does not cover additional days beyond Medicare-covered SNF services or non-Medicare-covered SNF stays. You will pay the Medicare-defined cost share for tier 1.
Other Services See details
The Horizon NJ TotalCare (HMO D-SNP) plan's "Other Services" benefit includes Over-the-Counter (OTC) Items with a maximum benefit of $245.00 every month, and Meal Benefits for chronic illnesses, but it does not cover Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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