Member Handbook.

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www.horizonNJhealth.com

210 Silvia Street

West Trenton, NJ 08628 1-877-7NJ-HEALTH (1-877-765-4325)

TDD/TTY: 1-800-654-5505

Horizon NJ Health, a partnership, is a product of Horizon HMO. Horizon HMO is a wholly owned subsidiary of Horizon Blue Cross Blue Shield of New Jersey.

Si desea recibir un ejemplar en español del manual para los miembros de Horizon NJ Health,

llame a Servicios para Miembros, sin cargo, al 1-877-7NJ-HEALTH (1-877-765-4325).

Esta oficina atiende durante las 24 horas, todos los días.

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What is Inside

Becoming a Member

Premiums and Co-Payments

Member Services

Your Horizon NJ Health ID Card

Your Personal Doctor

Emergency

Your Benefits and Services

Your Family and Horizon NJ Health

Your Rights and Responsibilities

More About Horizon NJ Health

Bills

Ending Your Membership

Fraud, Waste and Abuse

Complaint/Grievance and Appeal Procedures

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Welcome

You and your family deserve quality health care coverage and now that you have joined Horizon NJ Health, you can count on it.

You will find that Horizon NJ Health covers the NJ FamilyCare/Medicaid Program benefits plus additional benefits, special programs and your own personal doctor. You also get the special comfort of knowing that you are with the plan backed by Horizon Blue Cross Blue Shield of New Jersey. And the best part is all of this is covered at little or no cost to you.

So welcome and thanks for joining Horizon NJ Health. Take a look through this member handbook to understand all the benefits we offer.

Remember – if you have questions any time, day or night – call our Member Services

department toll free at 1-877-7NJ-HEALTH (1-877-765-4325). If you have hearing or speech

difficulties, please call our TDD/TTY number toll free at 1-800-654-5505.

You may also write to Horizon NJ Health at: Horizon NJ Health

Member Outreach Department 210 Silvia Street

West Trenton, NJ 08628.

We are here to help you.

Words to Learn

There are many words in this handbook and the medical world that you may not know. Look for this sign (

☆

) for definitions that will help you get the most from your Horizon NJ Health membership.

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Special Needs Members

Horizon NJ Health has a Care Coordination Unit (CCU) to help our members with special health care needs. If you or a family member has a complex or chronic medical condition, physical or developmental disability or a catastrophic illness, you may be eligible for care management. If you have special health care needs, please show this by answering the questions on your Plan Selection Form when you sign up for Horizon NJ Health.

You can ask for an evaluation to see if you qualify for the special needs program. Or you may have your PCP, specialist, social worker, community-based case

manager or any other concerned agency ask for an evaluation for you. Call our Member Services department toll free at 1-877-7NJ-HEALTH to ask for an evaluation to see if you qualify for this program. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

A Horizon NJ Health Care Coordination nurse or social worker, familiar with where you live, will complete a screening assessment. The Care Coordination team will let you know what level of care management you or your family member needs. You will work with the Care Coordination team and your PCP or specialist to create a plan of care that addresses your physical and

psychosocial needs. This will be done no later than 10 days after the effective date of enrollment if your Plan Selection Form has indicated that you have special needs. If special conditions are identified by a provider, a care plan will be completed within 30 days.

Your care plan will list community resources as part of your overall health care support system. We will help you connect with these resources to include them as part of your care plan.

Depending on your level of care, you will get a copy of your care plan. You can use this as a reference when making appointments with different providers. As your needs change, your care plan will be updated.

Your care plan will also tell you how you can contact your specific Care Coordinator. You can talk about any problems or concerns you may have with your Care Coordinator.

Keeping Your

Membership

Once you are a member of

Horizon NJ Health, you will continue to be a member until you disenroll or you lose Medicaid eligibility or if special circumstances require DMAHS to disenroll you, such as a nursing facility stay greater than thirty days.

Most members must have their eligibility checked every year. AFDC/TANF members are checked for eligibility every six months.

If your application was first processed at your local County Board of Social Services, they will contact you when it is time for a renewal.

If your NJ FamilyCare ID number begins with a 23 or 24, you may call the Health Benefits Coordinator toll free at 1-800-701-0710 to find out your renewal date or to ask for a renewal form. People with hearing or speech difficulties may call 1-800-701-0720.

Renewal Process

• A Renewal Application must be completed every year.

• You must include a current month of income verification, and family size and other

supporting documentation when you send in your renewal application.

• Return all materials in the self-addressed envelope provided with your renewal

application 30 days before your renewal date. If you have questions or need help

completing the Renewal Application, call the Horizon NJ Health Outreach Center toll free at 1-800-637-2997 for help. People with hearing or speech difficulties can use our TDD/TTY service at 1-800-654-5505.

Please look at the section on Ending Your Membership in this handbook for more information on the disenrollment process.

Becoming a Member

Who Can Join?

You can join Horizon NJ Health if you live in New Jersey and you are receiving Medicaid through one of these programs:

• Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF)

• AFDC-related New Jersey Care for Pregnant Women and Children

• Supplemental Security Income (SSI) for Aged, Blind, Disabled (ABD) and Essential Spouses • New Jersey Care for Aged, Blind, Disabled and

Essential Spouses

• Division of Youth and Family Services You can also join if you qualify for the NJ FamilyCare Program.

Eligibility for the NJ FamilyCare/Medicaid Program is based on the number of people in your family and your family’s total monthly income. You, your spouse and/or your family members must be New Jersey residents and, in most cases, you must have been without medical insurance for at least three months.* There are some exceptions to this rule, so please call Member Services.

Signing Up and Getting Started

To become a Horizon NJ Health member, call the NJ State Health Benefits Coordinator toll free at 1-800-701-0710. People with hearing difficulties may call the State's TDD/TTY number toll free at 1-800-701-0720. Your membership must be approved by the Division of Medical Assistance and Health Services (DMAHS).

It will take about 30 to 45 days for your membership to start. Until Division of Medical Assistance and Health Services (DMAHS)

approves your membership, your current health insurer will most likely continue to provide your health care services. For services you were receiving with your previous insurer, Horizon NJ Health will coordinate your care once your membership becomes effective.

The Health Benefits Coordinator will share your answers to the health care questions on the enrollment application with Horizon NJ Health. By signing your enrollment application,

you allow the release of your medical records to Horizon NJ Health.

At the time you sign up with Horizon NJ Health, it is also important that you tell the Health Benefits Coordinator and

Horizon NJ Health about any doctors that you are currently seeing.

Selecting Your

Horizon NJ Health Doctor

You and each of your family members will need to choose a personal Horizon NJ Health doctor, known as a Primary Care Provider (PCP). Take a look through the Horizon

NJ Health Provider Directory for a PCP near you. A copy of the Directory is included in your Horizon NJ Health Welcome Kit, by calling Member Services and on the Horizon NJ Health Web site at www.horizonNJhealth.com.

You can have a different PCP for each family member. For example, you can choose a

pediatrician for your child and a general family doctor for yourself. An authorized person acting for you may help you in choosing a PCP. Member Services can also help you with your choice of doctors.

*Legal immigrants who are lawfully admitted for permanent residence, including parents and their children, can apply for the NJ FamilyCare Program, even if they have lived in this country less than five years.

☆

Provider –

the person or location (such as a hospital) that gives medical care

☆

Specialist

-a doctor who h-as been specially trained in a chosen field of medicine

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Your Horizon NJ Health

ID Card

Always Carry it With You

Before your membership begins, a Horizon NJ Health ID card for each covered member in your family is mailed to you. Always carry your Horizon NJ Health ID card with you. It is one of the most important cards you have.

Show your card when you need health care; when you are seeing your personal Horizon NJ Health doctor or dentist; when you have been referred to a specialist; when you get a

prescription; for lab work or at the hospital emergency room (ER). You can use your card as long as you are a member.

What is on the Card

• Name of the Enrollee

• Effective date – The effective date is your starting date of enrollment with Horizon NJ Health and the date your benefits begin. • Your Primary Care Provider’s (PCP) name and

phone number.

• Shows if you have dental benefits. • The amount of co-payments you pay for

visiting your doctor, the emergency room or filling a prescription (if any).

• Our toll free Member Services phone number is on the back of the card.

• Information on what to do in case of an emergency is on the back of the card.

If it is Lost or Stolen

If your ID card is lost or stolen, call Member Services right away. We will cancel your old card and send you a new one.

Your Health Benefits Identification

(HBID) Card

As well as your Horizon NJ Health ID card, you should also carry your Health Benefits Identification (HBID) card sent to you by the State of New Jersey. You will need this card to get certain services not covered by your membership with Horizon NJ Health (see the Your Benefit and Services section).

Premiums

and Co-payments

Families in the

NJ FamilyCare Program may be required by the State of New Jersey to pay a premium or co-payment for service.

Premiums for NJ FamilyCare D members range from $40.00 each month for a family, to $133.00* a month. The amount is based upon the

family’s income level. If you do not pay your monthly premiums on time, it may result in disenrollment from the program. The NJ FamilyCare Program will collect all premiums. Children under 21 years of age and

pregnant women do not have co-payments. Your co-payment amount is indicated on your member ID card.

The family limit on all monthly premiums and co-pays for members may not exceed five percent of the annual family income. It is important for members to keep track of their monthly payments and notify the State if their contributions exceed 5% of the family income in one calendar year.

Member Services

(1-877-7NJ-HEALTH)

Our helpful, multilingual Member Services staff is ready to help you get the most out of your Horizon NJ Health membership, 24 hours a day, 7 days a week, including weekends and holidays. Any time you have a question about your

benefits, how Horizon NJ Health works or how to get the care you need, give us a call. The toll free numbers are printed on your member ID card and on our Web site at

www.horizonNJhealth.com. To help you learn how Horizon NJ Health works and how to get the most out of your benefits,

a Member Services Outreach staff will call you at the start of your membership. This is the perfect time to ask any questions you may have.

We also offer educational and outreach activities throughout the year. Member Services will be happy to give you the details about times and locations of outreach events. Call

1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Translation Services

and Audio/Visual

Information

We have staff members

who know many languages, including sign language. When we do not have someone who speaks your language, we will find someone who does. We can arrange for a translator to talk over the phone with you and your doctor to help during your doctor’s visit. The translator will make sure your doctor knows what you are saying and you know what the doctor is saying. With the

translator’s help, you can get answers to all of your questions. Horizon NJ Health can coordinate a sign language interpreter to be with you at the doctor’s office.

There is no cost to you to use our translation or sign language interpreter services and they are easy to use. Just call Member Services toll free at 1-877-7NJ-HEALTH.

All Horizon NJ Health information for members is available in Spanish. If you need information printed in another language, call Member Services.

Materials for the visually and hearing impaired are also available through Member Services.

Horizon NJ Health

Independent licensees of the Blue Cross and Blue Shield Association.* Horizon NJ Health, a product of Horizon HMO*

BC/BS Plan Codes 280/780

*

www.horizonNJhealth.com

NAME

MEMBER ID NO: YHZ DOCTOR PHONE ISSUE DATE EFFECTIVE

Dental No Copayments

Horizon NJ Health

Independent licensees of the Blue Cross and Blue Shield Association.* Horizon NJ Health, a product of Horizon HMO*

BC/BS Plan Codes 280/780

*

www.horizonNJhealth.com

NAME

MEMBER ID NO: YHZ DOCTOR PHONE ISSUE DATE EFFECTIVE

Plan Dental Emergency PCP Copay Specialist Copay Rx Generic Rx Brand

Primary Care

Provider Phone

Primary Care

Provider

Member

ID Number

Effective

Date

Issue

Date

Copay

Amount

Dental Benefit

Indication

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Premium

-the monthly cost of health insurance paid by the member

☆

Copayment

-the amount a person must pay for a health care service at the time the service is given

*2009 Figures

☆

Benefit

-service given to an person paid for by the insurance plan

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Your Personal Doctor

Where All Your Care Begins

As a member of Horizon NJ Health, you choose a personal doctor or a nurse practitioner, called a Primary Care Provider (PCP) from a list of doctors and dentists that work with Horizon NJ Health. This list, called a Provider Directory, is updated each month. If you need an updated list, please call Member Services at

1-877-7NJ-HEALTH or visit the Horizon

NJ Health Web site at www.horizonNJhealth.com. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Your PCP Arranges for

All of Your Care

Call your doctor's office first – at any time, 24 hours a day, whenever you need medical care. Your doctor will know how to help. All non-emergency health care services must be made through your Horizon NJ Health PCP.

Your health services are covered 24 hours a day, 7 days a week. Horizon NJ Health covers the services of all Primary Care Providers, specialists, certified nurse midwives, certified nurse

practitioners, clinical nurse specialists, physician assistants and independent clinics. Your PCP may use other health care practitioners to help give timely care for you and your family.

If you are a member with a special medical need, you may ask to have a Horizon NJ Health

participating specialist as your PCP. This request must be made through Horizon NJ Health's Care Coordination Unit (CCU). Call Member Services and they will put you in touch with a

CCU Case Manager.

Make an Appointment Right Away

After you have become a member of Horizon NJ Health, we will call you to make sure you have received your Horizon NJ Health ID Card, new member materials and answer any questions you may have.

We also want you to call the office of your Primary Care Provider (PCP) and make an appointment for a checkup. Why? Because a baseline physical will let your doctor measure your health now, review your past health history and help avoid any future health problems. Your PCP’s office should schedule appointments for routine visits within 28 days of your request.

Now would also be a good time to schedule a dental exam. Children and adults should have their teeth cleaned at least once a year.

If your effective date of enrollment is different from that given to you by your Health Benefits Coordinator, Horizon NJ Health will notify you, or where applicable, an authorized person of the new date of enrollment.

If you need to see your PCP before you get your ID card, call Member Services. A Member Services Representative will make arrangements for you to see your PCP.

Very Important: Keep Your

Appointments!

It is the only way your doctor and dentist can make sure that you and your family are getting the quality care you deserve. If you cannot keep an appointment, call and let your doctor or dentist know immediately.

What if?

Questions and Answers About

Your Doctor and Your Care

Q.What if I cannot reach my doctor

right away?

A. There could be times – maybe at night or on weekends – when your doctor is not in the office. Call your doctor's office anyway. Someone from that office will be able to help or they will have a doctor call you. If your situation is an emergency, call 911 or go to the nearest emergency room.

Q.What if I want a second opinion?

A. You can ask for another doctor's opinion for any medical or surgical diagnosis. Just talk to your PCP. He or she will make all of the arrangements or if you want, you may call Member Services for help finding another doctor.

Q.What if I want to change my doctor?

A. You can change your PCP at any time.

Member Services will help you choose a new doctor and send you a new Horizon NJ Health ID card with the new doctor’s name and phone number. Horizon NJ Health reserves the right to deny a request to change to a new PCP. Some situations where Horizon NJ Health may deny a request include:

• A member has already changed their PCP twice in a given year

• If a PCP asks that a member not be included on his or her list of patients

• If a PCP has too many patients to take any more

Creating a positive, healthy relationship with your PCP is important. If your PCP believes that he/she cannot do this with a member, your PCP may ask that the member be

changed to another PCP. Other times where a PCP may ask that a member be changed to another provider include:

• Unable to solve conflicts between the member and their PCP

• If a member fails to follow health care instructions where such non-compliance stops the physician from safely or ethically proceeding with the member's health care services

• If a member has taken legal action against the PCP

Q.What if I need to see a specialist?

A. Your PCP will make the arrangements to send you to a

participating specialist and your PCP will give you a

Referral Form to take with you. You must have a Referral Form to see a participating

specialist. An eye doctor for a medical problem (such as cataracts or an eye infection) or a heart specialist, are types of doctors you need a Referral Form to see.

• You do not need a referral form to visit your Ob/Gyn or for a mammogram.

If you have a condition that needs ongoing care from a participating specialist, you can ask your PCP for a “standing referral.”

A “standing referral” is a referral that lets you to go to your specialist as often as the

specialist needs to see you to treat your medical condition or the specialist may be able to act as your PCP and specialty care provider.

Q.What if my condition requires care from a doctor who does not participate

with Horizon NJ Health?

A. Horizon NJ Health contracts with thousands of doctors and

specialists throughout New Jersey. If we do not have a doctor to care for your condition, we will work with your PCP or dentist to make sure you get the care you need. You may also get special approval from Horizon NJ Health for an out-of-network provider, if your medical condition requires. If you use an

out-of-network provider without approval from Horizon NJ Health, you will be responsible to pay for those services.

Emergency!

Go or Not Go?

When should you – as a prudent layperson* – go to the hospital emergency room? ONLY go when your situation is an emergency, involving a severe illness or injury. If an emergency exists, go to the nearest emergency room (ER) or call 911. In an emergency, you do not need to get approval from Horizon NJ Health or a doctor to go to the emergency room. Sometimes it can be hard to tell if you have a real emergency.

*A prudent layperson is someone “…who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (Or with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.”

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Referral Form

-a p-aper -authorizing a patient's visit to a specialist

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Your Benefits and Services

As a member of Horizon NJ Health, you get the benefits and services you are entitled to with the NJ FamilyCare Program.

You pay little or nothing for the medical care and services you get through Horizon NJ Health. Make sure you know how Horizon NJ Health works, especially when it comes to emergency care, seeing your own doctor and when you need a referral. Otherwise, by using services not in the plan, you might be billed for services that are not covered by Horizon NJ Health or authorized by your Primary Care Provider. Before care is given, your doctor should tell you if a service is not covered and that you will be billed for that service.

If you are not sure whether a service is covered, just call Member Services and ask. Call toll free at 1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Utilization Management

Horizon NJ Health wants to make sure you are receiving the best, most proper care for your health. To do this, we have a Utilization Management (UM) Process. This process assures that you get prompt, efficient and quality service from doctors, hospitals, dentists and other providers.

Our staff of dedicated UM nurses and doctors will work with your PCP and specialists.

Horizon NJ Health will help with referrals to specialists, admissions, discharges and length of stay issues when a member is admitted to a hospital or ambulatory surgical center. We will offer advice to doctors about alternatives and disease management programs, when necessary. Most of all, we work hand in hand with your PCP or specialist to assure that you get the continuous care you need throughout your illness and

recovery. If you have questions about our Utilization Management Process, please call our Member Services department at

1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Dental Services

Good oral health is important to your body’s overall health. You should visit your dentist at least once a year for a check-up and cleaning. Dental visits should start when a child turns one year old. Your dental benefits will depend upon your age and benefit plan. Let your dentist know what coverage you have when you schedule your appointment.

You do not need a referral from your PCP or prior authorization from Horizon NJ Health for routine dental care, such as cleanings and

X-rays. If you need to make an appointment with a dental specialist, an oral surgeon for example, you will need to get a referral from your dentist. You can review a list of participating dentists in a Horizon NJ Health Provider Directory.

If you need a directory or help selecting a dentist, call Member Services.

Vision Services

Members are covered for one routine eye exam every year. You do not need a referral from your PCP for routine eye care. If

you need more exams during the year, or you need a vision specialist, such as an

Ophthalmologist, you will need to get a referral from your PCP.

Vision services are only available from participating Horizon NJ Health

eye doctors. Check the

Provider Directory for a list of eye doctors.

Here are some examples of emergency situations when you should definitely go: • Chest pain

• Broken bones

• Difficulty breathing, moving or speaking • Poisoning

• Heavy bleeding • Drug overdose • Car accident

• When you are in labor during pregnancy, follow your Ob/Gyn’s instructions on what to do when labor starts

If your situation is a real emergency, it is most important that you get the care you need

immediately. Go to the nearest hospital or provider to treat your emergency, even if the hospital or provider does not participate with Horizon NJ Health. All hospitals must provide emergency care.

Emergency

Checklist

Something has happened and someone is hurt.

Now what? Here are some questions you should ask:

• Is it severe or life threatening?

• If there is time, call your doctor's office. Tell them what has happened.

• No time? Call 911 for an ambulance. Tell them your name, where you are and the type of emergency.

Once at the emergency room, they will perform an ER Screening Exam to find out if an emergency exists. This is a covered benefit for all Horizon NJ Health members.

You are covered for emergencies 24 hours a day, 7 days a week. This includes follow-up care both in and out of the hospital. In the case of an emergency, call your doctor if you can, your doctor will know how to help. He or she can send you to the closest participating hospital and let the hospital know you are coming. If there is no time to call your doctor, call 911.

Within 24 hours, call your Horizon NJ Health doctor to tell him or her of the visit to the ER. If you cannot call, ask a friend or family

member to make the call. You should visit your PCP for follow-up care, not the ER. Your PCP will coordinate your care after the emergency.

Out of Town?

If you have an emergency out of town, go to the nearest hospital and remember to show the hospital staff your Horizon NJ Health ID card. You do not need to get prior approval from Horizon NJ Health for emergency services.

If you need medical attention that is not an emergency, call your doctor right away to get help finding medical care from a provider in the area. Horizon NJ Health will need to coordinate your care between your local doctor and the out of network doctor.

Urgent Care

If you are not sure if your illness or injury is an emergency, call your doctor or dentist first. Some examples of illness or injury that can wait until you talk to your doctor or dentist are: • Cold, cough or sore throat

• Earache • Cramps

• Bruises, small cuts or minor burns • Rashes or minor swelling

• Backaches related to pulled muscle • Toothache

• Swelling around a tooth

Remember, if your child is sick, your doctor will see your child the same day for most cases.

If your situation is not an emergency, but it is medically necessary for you to get treatment within 24 hours, call your doctor. This is known as urgent care. Your doctor will make the necessary arrangements to treat your medical condition within 24 hours.

If it is not an emergency, your doctor can make the arrangements for you to come into the office quickly for care.

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Ambulatory

surgical center

-site that provides surgical care but does not provide overnight care

☆

Ophthalmologist

-a doctor who tre-ats

people with eye problems, who treats eye diseases and does surgery

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Benefit Package

Medicaid and

NJ FamilyCare A NJ FamilyCare B NJ FamilyCare C NJ FamilyCare D

Mental Health Services

Horizon NJ Health provides mental health benefits for members of the Division of

Developmental Disabilities (DDD) only. Members can call Magellan Behavioral Health toll free at 1-877-695-5612, Monday to Friday from 8:00 a.m. to 6:00 p.m. Hearing and speech impaired persons may use their TTY equipment or service to call 1-973-515-2874.

Most Horizon NJ Health members get mental health and/or substance abuse services through the Medicaid Program. You do not need a referral from your PCP to see a mental health or substance abuse provider. If you need medication to help your mental health and/or substance abuse needs, your mental health and/or substance abuse

provider can prescribe the medication for you. If you think you or a member of your family needs help with a mental health or substance abuse problem, you can contact:

1. Your PCP;

2. The mental health or substance abuse association for your county; or

3. A Horizon NJ Health Care Manager at

1-877-7NJ-HEALTH. One of our Care Managers can help you get the care you need.

To get services for adults 18 years and older, call your PCP or the NJ Division of Mental Health Services at 1-800-382-6717. To get services for children younger than 18 years of age, call the Office of Child Behavioral Health at

1-877-652-7624. You can also call Member

Services. Mental health/substance abuse benefits are based on your NJ FamilyCare Program plan. Please call Member Services if you have a question on a specific benefit.

What Horizon NJ Health

Covers

To get benefits covered by the Medicaid Program, call your Medicaid caseworker, a Medical Assistance

Customer Centers (MACC) office in your area, your PCP or Horizon NJ Health Member Services to arrange to see a provider of your choice.

Benefit

Covered by Medicaid Program with case management

Coverage limited to when performed as a form of anesthesia in connection with covered surgery

Covered

Coverage is limited to spinal manipulation

Covered

Covered with a $35

co-payment for emergency room services, except when referred by a PCP for services that should

have been provided in PCP’s office or when admitted to the hospital

Covered with a $5 co-payment except for preventive dentistry visits

Covered with a $10 co-payment for emergency room services

Coverage is limited to preventive dental services (including X-rays and sealants) for children under the age of 12.

Coverage limited to spinal manipulation with a $5 co-payment

Covered

Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations

Not Covered

What Horizon NJ Health Covers

Abortions and Related Services

Durable Medical Equipment &

Assistive Technology Devices

Diabetic Supplies and Equipment

Dental

Chiropractic Services

Blood and Blood Plasma

Audiology

Acupuncture

Emergency Medical

Care/Emergency Services

Coverage is limited to well-child care, newborn hearing screenings, immunizations, lead screening and treatment

EPSDT (Early and Periodic

Screening, Diagnosis and Treatment)

Coverage includes medical exams, dental, vision, hearing, and lead screening services. Covered for treatment services identified through the exam that are covered by the member’s benefit package

Covered for members under the age of 16

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Coverage includes medical history and physical exams (including pelvic and breast), diagnostic and lab tests, drugs and biologicals, medical supplies and devices,

counseling, continuing medical supervision, continuity of care and genetic counseling. Except for members earning up to 33% of FPL, services must be rendered by a Horizon NJ Health provider Covered, when services are provided by a Horizon NJ Health Provider or covered by

Medicaid Program with case management when not provided by a Horizon NJ Health Provider

Benefit

Covered by Medicaid Program with case management by a Horizon NJ Health provider

Family Planning

12 Member Services 1-877-7NJ-HEALTH

Benefit Package

Medicaid and

Services Not Covered by Medicaid,

the NJ FamilyCare Program or

Horizon NJ Health

Services not covered by either

Horizon NJ Health or New Jersey Medicaid or the NJ FamilyCare Program include:

• All services not medically necessary, provided, approved or arranged by a Horizon NJ Health participating physician or other provider (within his/her scope of practice) except emergency services

• Cosmetic services or surgery except when medically necessary and approved

• Experimental organ transplants

• Infertility diagnosis and treatment services (including sterilization reversals, and related office [medical and clinic] visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures)

• Rest cures, personal comfort, convenience items, services and supplies not directly related to the care of the patient

• Custodial care covered by Horizon NJ Health for FamilyCare A members for the first 30 days

• Respite care

• Services involving the use of equipment in facilities, the purchase, rental or construction that have not been approved by the State of New Jersey

• Services provided by or in a Veteran's Administration institution

• Services provided without charge. Programs offered free of charge through public or voluntary agencies should be utilized to the fullest extent possible

• Services provided by or in an institution owned or operated by the federal government, such as Veteran's Administration institution

• Services provided without charge. Programs offered free of charge through public or voluntary agencies should be utilized to the fullest extent possible

• Services provided or initiated while on active duty in the military

• Services provided outside the United States and territories

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Covered, including drugs and DME. For ABD members, covered by Medicaid Program with case management

Covered, including room and board in an institutional (non-private) residence

Covered

Covered by Medicaid Program

Coverage is limited to skilled nursing for home bound members that are provided or supervised by a RN and a home health aide when the purpose f the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member’s medical condition

Covered with a $5 co-payment except for preventive services

Not Covered

Hospital Services (Inpatient)

Hospital Services (Outpatient)

Intermediate Care Facilities/

Mental Retardation

Hospice Services

Home Health & Visiting Nursing

Services

Not Covered

Group Homes and DYFS Residential

Treatment Facilities (Services)

Covered. Routine testing related to the administration of clozapine and other atypical anti-psychotic drugs for non-DDD members is covered by Medicaid Program

Covered with a $5 co-payment when not part of office visit. Routine testing related to the administration of clozapine and other atypical anti-psychotic drugs is covered by Medicaid Program

Laboratory Services

Covered Covered for members under

the age of 16

Hearing Aid Services

(9)

Not Covered

Benefit Package

Medicaid and

• Services resulting from any condition or accidental injury related to employment when benefits are available from any workers’

compensation law, temporary disability benefits law, occupational disease law or similar law • Any service covered under any other insurance

policy or other private or governmental health benefit system or third party liability

• Any service or items furnished for which the provider does not normally charge

• Services provided by an immediate relative or household member

• Services billed for which the corresponding health care records do not adequately and legibly reflect the requirements of the procedure described or procedure code utilized by the billing provider

• Services or items reimbursed, based upon submission of a cost study when there are no acceptable records or other evidence to

substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the Medicaid program

• Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals over 21 years of age and under 65 years of age

• Specialty Foods for members with metabolic conditions and genetic disorders

Services Not Covered by Medicaid, the

NJ FamilyCare Program or Horizon

NJ Health for NJ FamilyCare D

• Biofeedback

• Court-ordered services

• Experimental and investigational services • Radial keratotomy

• Recreational therapy

• Rehabilitative services for substance abuse • Religious non-medical institutions care and

services

• Residential treatment center psychiatric programs

• Skilled nursing facility services • Sleep therapy

• Special remedial and educational services • Temporomandibular joint disorder treatment,

including treatment performed by prosthesis placed directly in the teeth

Benefit

Covered

Covered for DDD members by Horizon NJ Health. Non-DDD members are covered by Medicaid Program

Coverage limited to diabetic supplies

Covered by Medicaid Program, limited to 20 visits per year

Medical Day Care

Medical Supplies

Mental Health - Inpatient Hospital

Services Including Psychiatric

Hospitals

Mental Health Outpatient Services

Mental Health, Home Health

Covered for DDD members by Horizon NJ Health. Non-DDD members are limited to 35 days per year and are covered by

Medicaid Program

Covered for DDD members by Horizon NJ Health with a $25 co-payment. Non-DDD members are covered by Medicaid Program with a $25 co-payment

Nurse Midwife (Maternity)

Covered

Covered with a $5 co-payment for each visit (except for prenatal care visits)

Covered with a $5 co-payment for first prenatal visit only

Nurse Midwife (Non-maternity)

Covered

Covered with a $5 co-payment

Covered with a $5 co-payment, except for preventive care services. $10 co-payment for non-office hours visit and home visits

Nurse Practitioner

Covered

Covered with a $5 co-payment for each visit (except for preventive care services)

Covered with a $5 co-payment for each visit during normal office hours (except for preventive care services). $10 co-payment for non-office hours visit and home visits Covered, including related newborn care

(10)

Covered

All members may have a yearly eye exam regardless of age.

Members who need additional exams require a referral from their PCP

16 Member Services 1-877-7NJ-HEALTH

Benefit Package

Medicaid and

• Thermograms and thermography • Weight reduction programs or dietary

supplements, except surgical operations, procedures or treatment of obesity when approved by Horizon NJ Health

Your Family

and Horizon NJ Health

Wellness Services for You and

Your Family

We want your family to get quality care and to stay well. That is why Horizon NJ Health has many services and programs to keep your family healthy.

Women's Services and Prenatal Care

If you are going to have a baby or if you need women's health services, you can call an

Obstetrician/Gynecologist (Ob/Gyn) or a Certified Nurse Midwife (CNM) directly and make an appointment. You do not need a referral from your Horizon NJ Health PCP. You must choose an Ob/Gyn or a CNM who is part of the Horizon NJ Health network. It is important that you visit your Ob/Gyn for regular care.

If you are 18 years of age or older or sexually active, you should have a PAP test once a year. Your Ob/Gyn can

coordinate all of your care. For a list of participating doctors, check your Provider Directory or call Member Services.

If you think you are pregnant, call your Ob/Gyn or CNM right away for an appointment. As a mother-to-be, you can join the Mom's GEMS Program. GEMS stands for “Getting Early

Maternity Services.” Mom's GEMS is designed to help you get good prenatal care, regular checkups, nutrition advice and post-partum information after your baby is born.

Benefit

Optical Appliances

Members are eligible for eyeglasses or contact lenses from the select assortment of fashion frames or contact lenses manufacturers covered by the plan. Eyeglasses and contact lenses are covered as follows:

Members ages 0-20 or 60 and older are eligible for eyeglasses or contact lenses every year if their prescription changes, or more frequently if medically necessary

Members ages 21 to 59 are eligible for eyeglasses or contact lenses every two years if their prescription changes, or more frequently if medically necessary.

Contact lenses are covered for the initial contact lens supply and related fees in full when the selected plan covered brands are prescribed. Cost above the $100 contact lens allowance will be an out of pocket expense to the member if not medically necessary. If contact lenses are medically necessary the allowance of $100 per lens is covered and any addition cost requires prior authorization.

The benefit period is measured from the date the eyeglasses or contact lenses are dispensed

If the individual is placed on a transplant list prior to initial enrollment with Horizon NJ Health, coverage is limited to transplant related physician costs for donor and recipient. The Medicaid Program with case management

covers the donor and recipient inpatient hospital costs

For members placed on a transplant list while a Horizon NJ Health member, coverage includes all donor and recipient transplant costs for members who have transplants conducted within two months after disenrollment from Horizon NJ Health

Covered with a $5 co-payment. All members may have a yearly eye exam regardless of age.

Covered for one routine eye exam per year with a $5 co-payment per visit

Optometrist Services

15

Horizon NJ Health will cover the first 30 days of nursing facility care. After the 30th consecutive day in a nursing facility, the member will be

disenrolled from Horizon NJ Health and receive services from the Medicaid FFS program

Not Covered

Nursing Facility Care

Organ Transplants

☆

Prenatal

Care

-care for pregnant women

☆

PostPartum

-care for a woman after she has delivered a baby

☆

PAP Test

-a cervic-al cancer test

(11)

Benefit Package

Medicaid and

If you are pregnant or have children, you may be eligible for an extra program called WIC (Women, Infants and Children). This program gives you nutritional benefits, such as free milk, eggs, and cheese. To apply to WIC in New Jersey, contact your local WIC agency to set up an appointment. They will tell you what to bring to the WIC appointment to help see if you can join. If you would like more information, call our Member Services number at 1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Family Planning Services

Are you interested in family planning and contraceptive services? These are available through Horizon Blue Cross Blue Shield of New Jersey. To find out where you can get these services, call Horizon Blue Cross Blue Shield of New Jersey Medicaid Managed Care Family

Planning Unit at 1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our

TDD/TTY service at 1-800-654-5505.

When you call, a representative will help you find the services you need and will tell you about the location of the doctors and clinics that are closest to you. Remember to take your Horizon NJ Health ID card when you go to your

appointment. You can also get family planning and contraceptive services from other clinics and doctors who accept Medicaid and the NJ FamilyCare Program, but who are not in the Horizon NJ Health network. Use your HBID card (see page 4 for more information about this card) if you visit them.

For NJ FamilyCare D, Family Planning Services are only available through Horizon NJ Health, not through the Medicaid Program. There are exceptions to this rule for certain NJ FamilyCare D members. Call Member Services for more details.

Benefit

Covered Not Covered

Outpatient Diagnostic Testing

When authorized by the Division of Medical Assistance and Health Services, one (1) mental health inpatient day may be exchanged for up to four (4) home health visits or four (4) outpatient services, including partial care. This is limited to an exchange of up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits.

Partial Care Services

Covered

Orthotics

Covered

Orthodontic Treatment Services

Covered for members under the age of 19 when

orthodontia services were prior authorized and begun (banding or extraction of teeth as part of an authorized comprehensive orthodontic treatment plan) while enrolled with Horizon NJ Health as a Medicaid or NJ FamilyCare

Plan A, B, or C member Member must be eligible for FamilyCare and continue enrollment with Horizon NJ Health until services are completed

Horizon NJ Health is not responsible for completion of orthodontia services that were prior authorized and initiated when the member was enrolled with another Medicaid HMO

(12)

Benefit

20 Member Services 1-877-7NJ-HEALTH

Benefit Package

Medicaid and

up until they are 21 years old.

CHAMPS is a program that helps keep your child’s immunizations and well-child visits on track. By making sure your child is immunized, you can protect your child from serious illnesses, such as:

• Mumps • Diphtheria • Polio • Tetanus • Rubella • Hepatitis B • Chicken Pox • Pertussis • Influenza • Pneumococcal

Invasive Disease

CHAMPS helps screen children for medical problems early and keeps checking for problems as the child grows. The doctor checks vision, teeth, hearing, nutrition, growth and development.

Our doctors also give lead screenings to find out if your child has been exposed to dangerous levels of lead in paint or other sources.

Your child's Horizon NJ Health doctor will be able to give these checkups, treat the problems and call in specialists, if they are needed. Horizon NJ Health covers all these services for members up to the age of 21 years.

19 Is Your Family

Growing or Changing?

Do you have a new family member or a new baby? Call Member Services and tell us right away and we will add your new family member to your Horizon NJ Health membership. Also, it is

very important to be sure to tell your Board of Social Services caseworker or the Health Benefits Coordinator. Your child must be

enrolled in Medicaid or the NJ FamilyCare Program to be enrolled in Horizon NJ Health.

CHAMPS

CHAMPS stands for “Children’s Health Assessment and Maintenance of Preventive Services.” Designed for Horizon NJ Health kids, CHAMPS helps maintain the health of your children from birth and all the way

☆

EPSDT

-stands for Early and

Periodic Screening, Diagnostic and Treatment. This is a

group of tests that are required for children up to age 21 to make sure children are

getting appropriate care

Covered Covered with a

$5 co-payment

Covered with a $5 co-payment. Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails and other hygienic care in the absence of a pathological condition is not covered

Podiatrist Services

Not Covered

Personal Care Assistant Services

When authorized by the Division of Medical Assistance and Health Services, one (1) mental health inpatient day may be exchanged for two (2) days of treatment in partial

hospitalization up to the maximum number of covered inpatient days.

(13)

Benefit

Benefit Package

Medicaid and

Horizon NJ Health also covers prescription and non-prescription drugs, in-home ventilator services and private duty nursing, when recommended as a result of EPSDT screening.

Test Your Child for

Lead Poisoning

It is important that your child be tested for lead poisoning, first at

9 months to 18 months old,

preferably at 12 months, and again by age 2. Lead case management

is given to all Horizon NJ Health pediatric members up to

6 years of age who have high blood lead levels. Lead case managers are nurses who work with you to help keep your child lead free. The lead program gives you information about keeping your home

lead free and safe. You will get information on blood lead levels, preventive measures including housekeeping, hygiene, appropriate nutrition and why it is so important that you follow your doctor’s instructions when dealing with lead problems.

A Horizon NJ Health nurse will work with your child’s PCP, the Department of Health, WIC and laboratories to make sure that any high blood lead levels found in your child are lowered, so that your child stays healthy. For more

information about lead, please call Horizon NJ Health toll free at 1-800-682-9094 and ask for the Lead department. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Horizon NJ Health's

Asthma “Breathe Easy” Program

Horizon NJ Health has a special program for our members who have asthma. It is the Asthma “Breathe Easy” Program, which can help you or your child greatly lower the risk of asthma attacks.

Peak flow meters and spacers are available with a prescription from your PCP.

Through the program you will learn what “triggers” your asthma attacks and how to avoid them. It really works. This program has helped many children and adults. To find out more about

Covered by Medicare Part B

Co-payments for Medicare Part B covered drugs, classified as DME and utilized in a member’s home, are covered by Medicaid. For example, oral immunosupressants, albuterol when administered through a nebulizer, and insulin and certain other drugs administered through an infusion pump

Covered for all members except ABD members and other dual eligible individuals with a $5 co-payment. If a greater than 34-day supply, a $10 co-payment applies. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Covered by Medicaid for all ABD eligibles and other dual eligible individuals with a $5 co-payment. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Brand and generic Suboxone and Subutex, atypical

antipsychotic drugs and methadone (including administration) are covered by Medicaid for all members Covered for all members except ABD members and other

dual eligible individuals. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups

Covered by Medicaid for all ABD eligibles and other dual eligible individuals. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents.

Certain cough/cold and topicals are not covered for certain age groups

Brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including

administration) are covered by Medicaid for all members

Prescription Drugs

(Retail Pharmacy)

Covered for all members except ABD members and other dual eligible individuals with a $1 co-payment for generic drugs and a $5

co-payment for brand name drugs. No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain cough/cold and topicals are not covered for certain age groups Covered by Medicaid for all ABD eligibles and other dual eligible individuals.

No coverage for erectile dysfunction drugs, anti-obesity and cosmetic agents. Certain

cough/cold and topicals are not covered for certain age groups Brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including adminis-tration) are covered by Medicaid for all members

Prescription Drugs

(14)

28 Member Services 1-877-7NJ-HEALTH

Benefit Package

Medicaid and

Member Services 1-800-656-3729

Member Services 1-877-7NJ-HEALTH

24 Member Services 1-877-7NJ-HEALTH

27

Benefit

23

the Asthma “Breathe Easy” Program, talk to your Horizon NJ Health doctor or call toll free at 1-800-682-9094 and ask for the Asthma Program. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Diabetes Disease

Management Program

Horizon NJ Health has a special program designed for any member who has been diagnosed with diabetes. The Diabetes Disease Management Program can help members learn to better manage their diabetes.

You can get prescriptions for insulin and syringes from your Horizon NJ Health PCP. Diabetic testing machines and supplies are also available with a prescription from your PCP.

The program’s Diabetes Educators can also give you diabetic education materials about meal planning, insulin and medication use and will help members find a diabetic specialist and/or nutritionist. For more information about the program, call 1-800-682-9094 and ask for the Diabetes Disease Management Program, talk to your doctor or call Member Services.

Congestive Heart Failure Program

The Horizon NJ Health Congestive Heart Failure (CHF) Program is available to help you improve your quality of life, reduce hospitalizations and emergency room visits and to provide you with more information about CHF.

Through the CHF Program, members are given helpful hints to reduce symptoms of CHF, such as how a proper diet and

medications can control blood pressure. The program can help coordinate your health care between your PCP and specialist.

To find out more about the CHF program, talk with your PCP or call Horizon NJ Health toll free at 1-800-682-9094 and ask for the CHF Management Program.

Covered for children under the age of 21

Private Duty Nursing is covered when authorized by Horizon NJ Health.

Private Duty Nursing

Covered

Coverage limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect Repair and replacement services are covered only when needed due to congenital growth

Prosthetics

Covered

Covered with a $5

co-payment when not part of an office visit

Radiology Services

(Diagnostic & Therapeutic)

Covered by

Medicaid Program with case management

Covered by Medicaid Program with case management for 60 days per therapy, per year

Covered by Medicaid Program with case management, with a $5 co-payment

Limited to 60 business days per therapy, per year. Speech therapy for

developmental delay is not covered

Rehabilitation Services

(Outpatient Physical Therapy,

Occupational Therapy and Speech)

Covered

Covered with a $5 co-payment for each visit.

No co-payment for well-child visits, lead screening/treatment, age-appropriate immunizations, prenatal care, or PAP smears

Primary Care, Specialty Care

and Women's Health Services

Covered with a $5 co-payment for each visit during office hours. $10 co-payment for each home visit or office visit after normal office hours No co-payment for well-child visits, lead screening/

treatment and age-appropriate immunizations, or preventive dental services for children under 12

$5 co-payment for first prenatal visit, then no subsequent co-payments

(15)

HIV/AIDS Program

Horizon NJ Health has a case management program to help members diagnosed with HIV or AIDS. The program works closely with members and their providers to create and coordinate the best plan of care. Please call toll free 1-800-682-9094 to enroll in this case

management program. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Prescription Services

Most prescription and non-prescription drugs are covered at a low cost to you, as long as your doctor orders them and they are part of the approved Horizon

NJ Health formulary. A committee of doctors and pharmacists review the list to make sure that the medicines are safe and effective.

If your doctor decides that you must have a medication that is not included in the formulary, he or she can call and get special permission for you to get the medication.

While you are waiting for a prior authorization determination for your medication, the

☆

Prescription

-an order written by a doctor for a drug, test, or other health service

☆

Formulary

-a list of -approved medicines that Horizon NJ Health covers

Hypertension Program

Hypertension is most commonly called high blood pressure. Horizon NJ Health’s Hypertension Management program will help members learn about high blood pressure, its signs and symptoms, medications and how to manage their blood pressure. Call Horizon NJ Health toll free at 1-800-682-9094 and ask for the Hypertension Management Program.

COPD Program

COPD stands for Chronic Obstructive Pulmonary Disease. The program is available to members with COPD to help them learn more about this disease and

how to reduce symptoms. Call 1-800-682-9094, toll free and ask for the COPD Management program.

☆

COPD

-a lung dise-ase that makes it hard to breathe

Benefit

Benefit Package

Medicaid and

Covered. Invalid coach transportation is not covered for members who choose to see a provider outside of their county of residence

Transportation to a Medical Day program is not covered

Covered by Horizon NJ Health when the member is requesting transportation to a non-hospital service provider located more than 30 miles from the member’s residence and a participating provider closer to home to provide medically necessary covered services is not available

Coverage limited to ambulance for medical emergency only

Covered by Horizon NJ Health only if referred out of county when the services could have been rendered in county

Not Covered

Transportation Services–Higher

Mode (ambulance, mobile intensive

care units, invalid coach)

Transportation Services–Lower Mode

(public transportation, livery, clinic

van, taxicab or a county-administered

transportation service)

Waiver and demonstration program

services (except DDD-waiver)

Self-initiated care from a

non-participating provider

without referral or authorization

The member shall be held responsible for the cost of care, except for care delivered in an emergency situation

Sex Abuse Examinations

Social Necessity Days

Covered by Medicaid Program, limited to no more than 12 inpatient hospital days Not Covered

(16)

27

pharmacy will provide a 72-hour supply of your medication. The Horizon NJ Health Pharmacy Department will work with your doctor to fulfill your prescription needs. If you have questions, call toll free at 1-800-682-9094.

You can have prescriptions filled at any

participating pharmacy. For a list of pharmacies or to find the pharmacy nearest to you, call Member Services. The participating pharmacies are also listed in the Provider Directory and on the Horizon NJ Health Web site at www.horizonNJhealth.com. Horizon NJ Health requires the use of formulary generic medications when available.

Visit the Horizon NJ Health Web site at

www.horizonNJhealth.com for more information on pharmaceutical management procedures including the formulary listing, policies and limitations. Limitations include quantity limits, days supply/fill limitations, age limits, and gender restrictions. In addition, paper copies of the pharmaceutical management procedures are available by contacting the Pharmacy Department at 800-682-9094.

The Pharmacy Lock-In

Members who see many different doctors may have many types of drugs prescribed to them. This can be dangerous. The Pharmacy Lock-In program is designed to coordinate a member’s care given by pharmacies and doctors. To make sure your pharmacy care is coordinated; you should use only one pharmacy to fill your prescriptions. This will let the pharmacist learn

about your health and be better able to help you with your medication needs. Members who use many pharmacies or

doctors may be reviewed each month to make sure that they get

the proper coordination of care. If it is decided that using only one pharmacy will help the member get better care, the member may be "locked-in" to using only one pharmacy. We will send letters to the

member, pharmacy and doctor when a "lock-in" is needed.

Individual Care for You

There may be times when you need more than just health care services. Horizon NJ Health has established a special program for our members who need extra personal care. Our Care

Coordination Unit is here to help coordinate complex health care and psychosocial needs for Horizon NJ Health members who have been identified as having special needs. This includes members with Developmental Disabilities, Physical Disabilities, Complex Chronic illness, Severe Mental illness or substance abuse for DDD registered members. Horizon NJ Health can offer help with:

• Acute Case Management for Adults and Children

• Asthma • Cancer

• Community Programs • Congestive Heart Failure • Diabetes

• End Stage Renal Disease • Immunizations

• Infant Care

• Infectious Disease – HIV/AIDS • Lead screenings

• Pregnancy • Sickle Cell • Special Needs

Call our Social Case

Management Program if you have questions or concerns about: • Baby Needs

• Parenting Assistance • Personal Care

• Attendants (Home Health Aides) • Housing Issues

• Advocacy • Food • Clothing • WIC • Medicaid

• Mental Health Programs • Substance Abuse Programs • Domestic Violence

• Support Groups • Transport Programs

Call Member Services if you need more information on these services. Member Services are available 24 hours a day, seven days a week at 1-877-7NJ-HEALTH. People with hearing or speech difficulties can call our TDD/TTY service at 1-800-654-5505.

Homebound?

Need Medical Transportation?

If you are a homebound member and you need special services or transportation for your medical care, call Horizon NJ Health, toll free at 1-877-7NJ-HEALTH and we can help arrange transportation for you. Remember – do not call an ambulance for routine transportation. Call us at 1-877-7NJ-HEALTH and we can help arrange the care you need. For Mobility Assistance Van call Horizon NJ Health. For Livery in Essex, Hudson and Atlantic Counties call Logisticare at 1-866-527-9933. For Livery service in other counties please call the county welfare agency.

Your Rights and

Responsibilities

As a member of Horizon NJ Health, you have certain rights that you can expect from Horizon NJ Health and you have responsibilities that Horizon NJ Health can expect from you.

Your Member Rights

• You have the right:

• To have access to a Primary Care Provider or a backup doctor, 24 hours a day, 365 days a year for urgent care.

• To obtain a current directory of doctors within the network.

• To have a choice of specialists and a description of the referral process. • To have a second opinion.

• To request a standing referral when a medical condition warrants.

• To receive care from an out of network provider when a participating Horizon NJ Health provider is not available.

• If a member has a chronic disability, to be referred to specialists who are experienced in treating their disability.

• To have a doctor make the decision to deny or limit a member’s coverage.

• To have no “gag rules” in Horizon NJ Health. That means doctors are free to discuss all medical treatment options even if the services are not covered.

• To know how Horizon NJ Health pays its doctors, so a member will know if there are financial incentives or disincentives tied to medical decisions.

• To be treated with respect and with

recognition of their dignity and right to privacy, at all times.

• To receive care without regard to race, color religion sex, age or national origin.

• To participate with their doctor in making decisions about their health care.

• To information and open discussion about the member’s own medical condition, and the right to choose from different ways of treating their condition, regardless of cost or benefit coverage.

• The right to have the member’s medical condition explained to a family member or guardian, if the member is unable to understand and have it documented in the member’s medical records.

• To refuse medical treatment with an understanding of the results of refusal. • To call 911 in a potential life-threatening

situation – without prior approval from Horizon NJ Health.

• To have Horizon NJ Health pay for a medical screening exam in the emergency room to determine whether an emergency medical condition exists.

• To postpartum stays in the hospital no less than 48 hours for a normal vaginal

delivery and no less than 96 hours following a cesarean section. • To receive up to 120 days of

continued coverage – if medically necessary – from

a doctor who has been terminated by Horizon NJ Health including: – up to 6 months after

surgery – 6 weeks after

childbirth – 1 year of

psychological or oncologic treatment No coverage may be continued if the doctor is terminated for cause.