Member Benefits and Services

Transcription

1 Member 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. The medical care and services you get through Horizon NJ Health are free or low cost. Your benefit package is determined by your income level, the number of people in your family and is set by the NJ FamilyCare Program. If you are not sure whether a service is covered, just call Member Services and ask. Call toll free at NJ-HEALTH ( ). People with hearing or speech difficulties can use our TTY service at: What Horizon Abortions & Related Services by Fee-for-Service for elective/induced abortions. by Horizon NJ Health for spontaneous abortions/miscarriages Acupuncture when provided by a licensed doctor Coverage is limited to when performed as a form of anesthesia in connection with covered surgery by a licensed doctor Audiology for members under the age of 16 Blood & Blood Plasma Coverage is limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations Chiropractic Services Coverage is limited to spinal manipulation Coverage is limited to spinal manipulation with a $5 copayment Not 1

2 Cognitive Therapy Coverage limited to 60 visits per therapy, per incident, per calendar year Coverage is limited to treatment for non-chronic conditions and acute illnesses and injuries. Limited to 60 visits per therapy, per incident, per calendar year Dental Preventive and diagnostic services (exams, cleaning and x-rays) are covered twice each year. Restorative services (fillings, root canals and crowns) are covered for teeth that need repair due to disease or injury Periodontic services (prevention, diagnosis and treatment of gum disease) are covered * Prior authorization needed for crowns, removable dentures, full and partial dentures, orthodontic, periodontics and oral surgery services with a $5 copayment, except for preventive dentistry with a $5 copayment, except for preventive dentistry Diabetic Supplies & Equipment Durable Medical Equipment & Assistive Technology Device Coverage is limited to specific equipment. Talk to your doctor or call Member Services for more information Emergency Medical Care/ Emergency Services with a $10 copayment for Emergency Room services with a $35 copayment for Emergency Room services, except when referred by a PCP for services that should have been provided in the PCP s office or when admitted to the hospital EPSDT (Early & Periodic Screening, Diagnosis & Treatment), including medical exams, dental, vision, hearing and lead screening services. for treatment services identified through the exam Coverage is limited to well-child care, newborn hearing screenings, immunizations and lead screening and treatment 2

3 Family Planning. by Fee-for-Service when services are not given by a Horizon NJ Health doctor. Coverage includes medical history and physical exams (including pelvic and breast), diagnostic & lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling Coverage includes medical history and physical exams (including pelvic and breast), diagnostic & lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling Medical Services Received at Group Homes & DYFS Residential Treatment Facilities Hearing Aid Services Home Health Agency Services Hospice Services, including nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment; physical, occupational and speech therapy services; pharmaceutical services; and durable medical equipment in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospice care for children under age 21 shall cover both palliative and curative care Not for members under the age of 16 Coverage is limited to skilled nursing provided or supervised by a registered nurse and home health aide when the purpose of the treatment is skilled care. Coverage includes medical social services necessary for treatment of the member s medical condition in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospice care shall cover both palliative and curative care 3

4 Hospital Services (Inpatient) Hospital Services (Outpatient) with a $5 copayment, except for preventive services Intermediate Care Facilities Intellectual Disability by Fee-for-Service Not Laboratory Services Maternity Services, including routine testing related to the administration of atypical antipsychotic drugs, including related newborn care and hearing screening, including routine testing related to the administration of atypical antipsychotic drugs, with a $5 copayment when not part of an office visit Medical Day Care Not Medical Supplies Limited coverage. Talk to your doctor or call Member Services for more information. Mental Health Inpatient Hospital Services (Including Psychiatric Hospitals) for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service Mental Health Outpatient Services (Excluding Partial Care Services) for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service 4

5 Mental Health Home Health for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service by Fee-for-Service Methadone (Maintenance and Administration) by Fee-for-Service Nurse Midwife with a $5 copayment for each visit, except for prenatal care visits with a $5 copayment for the first prenatal care visit. $10 copayment for services rendered during non-office hours. No copayment for preventive services for newborns covered under Fee-for-Service Nurse Practitioner with a $5 copayment for each visit, except for preventive care services with a $5 copayment for each visit during office hours, except for preventive care services. $10 copayment for visits during non-office hours Nursing Facility Services (Custodial Care, Rehabilitation, Post-acute Care, Skilled Nursing Care and Services in Special Nursing Facilities, Such as Ventilator Facilities, Pediatric Long-term Care and Treatment for AIDS) Coverage limited to 30 days of nursing facility care. If admitted to an acute hospital during those 30 days, the 30-day count is suspended and resumes upon readmission to the nursing facility. After 30 days in a nursing facility, the member will be disenrolled from Horizon NJ Health and receive services from Fee-for- Service. The 30-day limit does not apply to inpatient rehabilitation services Coverage limited to rehabilitation services only following discharge from an acute care hospital if this is the appropriate setting for rehab to occur. Custodial care is not covered. Not 5

6 Optical Appliances for select eyeglasses and contact lenses as follows: Age 18 and under and 60 and older Replacement eyeglasses or contact lenses annually if prescription changes Age 19 to 59 Replacement eyeglasses or contact lenses every two years if prescription changes Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. Contact lens exams and fittings are covered only when deemed medically necessary over glasses Optometrist Services for one routine eye exam per year for one routine eye exam per year with a $5 copayment Organ Transplants for transplant-related medical costs for the donor and recipient, including donor and recipient inpatient hospital costs Orthodontic Services Coverage is limited to members up to age 21 who require these services due to medical need, including developmental problems or jaw injury. Coverage is limited to members up to age 19 who require these services due to medical need, including developmental problems or jaw injury. Coverage is limited to members up to age 19 who require these services due to medical need, including developmental problems or jaw injury with a $5 copayment. Orthotics Not Outpatient Diagnostic Testing Partial Care Program by Fee-for-Service 6

7 Partial Hospital Program Personal Care Assistant Services Podiatrist Services Prescription Drugs (Retail Pharmacy) by Fee-for-Service by Horizon NJ Health for up to 40 hours per week. by Fee-for-Service for any additional hours with prior approval Not. Routine hygienic care of feet, including the treatment of corns and calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered., including atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs that may be excluded from Medicare Part D coverage. No coverage for erectile dysfunction drugs and drugs not covered by a third-party Medicare Part D formulary with a $5 copayment. Routine hygienic care of feet, including the treatment of corns and calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered. with a $1 copayment for generic drugs and a $5 copayment for brand-name drugs. Includes atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs that may be excluded from Medicare Part D coverage. No coverage for erectile dysfunction drugs and drugs not covered by a third party Medicare Part D formulary When authorized by the Division of Medical Assistance and Health Services, one mental health inpatient day may be exchanged for two days of treatment in partial hospitalization up to the maximum number of covered inpatient days. with a $5 copayment. Routine hygienic care of feet, including the treatment of corns and calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered with a $5 copayment for brand-name and generic drugs. If greater than a 34-day supply, a $10 copayment applies. Includes atypical antipsychotics, Suboxone & Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs that may be excluded from Medicare Part D coverage. No coverage for over-the-counter drugs, erectile dysfunction drugs and drugs not covered by a third party Medicare Part D formulary 7

8 Prescription Drugs (Doctor-Administered) by Medicare Part B Primary Care, Specialty Care & Women s Health Services with a $5 copayment for each visit. No copayment for well-child visits, lead screening/treatment, age-appropriate immunizations, prenatal care or Pap smears with a $5 copayment for each visit during office hours. $10 copayment for each visit during non-office hours. No copayment for well-child visits, lead screening/treatment, age-appropriate immunizations or preventive dental services. $5 copayment for first prenatal visit, then no subsequent copayments Private Duty Nursing for members under age 21 if authorized by Horizon NJ Health Prosthetics Radiology Services (Diagnostic & Therapeutic) Coverage is 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 with a $5 copayment when not part of an office visit 8

9 Rehabilitation Services (Outpatient Physical Therapy, Occupational Therapy & Speech Therapy) for 60 visits per therapy, per incident, per calendar year with a $5 copayment; limited to 60 visits per therapy, per incident, per calendar year. Speech therapy for developmental delay, unless resulting from disease, injury or congenital defects, is not covered. Cognitive rehabilitation therapy services limited to treatment for non-chronic conditions and acute illnesses and injuries Sex Abuse Examinations & Related Diagnostic Testing by Fee-for-Service Social Necessity Days by Fee-for-Service; limited to no more than 12 inpatient hospital days Not Specialty Foods (Medical Foods) Coverage is limited to nutritional supplements requiring medical supervision for members with inborn errors of metabolism and related genetic conditions. Medical foods and special diets for all other medical conditions are not covered Not Substance Abuse (Inpatient and Outpatient) for DDD members by Horizon NJ Health. Non-DDD members are covered by Fee-for-Service Substance Abuse (Day Treatment/Partial Hospitalization) by Fee-for-Service Not 9

10 Substance Abuse (Outpatient & Intensive Outpatient) by Fee-for-Service Not Substance Abuse (Residential Halfway House & Short-term Residential) by Fee-for-Service Not Sub-acute Medically Managed Detoxification & Enhanced Medically Managed Detoxification by Fee-for-Service Not Transportation Services Emergency Ambulance (911) Coverage is limited to ambulance for medical emergencies only Transportation to Medically Necessary Services Livery Transportation (Bus & Train Fare or Passes, Car Service, Mileage Reimbursement) by Fee-for-Service through LogistiCare. To schedule, call LogistiCare at (TTY: ). Not Transportation to Medically Necessary Services Non-emergency Ambulance, Mobile Intensive Care Units & Invalid Coach by Fee-for-Service through LogistiCare. To schedule, call LogistiCare at (TTY: ). Not 10

11 Services not covered by Horizon NJ Health or the Fee-for-Service program Services not covered by Horizon NJ Health or the NJ FamilyCare program include: All services not medically necessary, provided, approved or arranged by a Horizon NJ Health participating doctor (within his or her scope of practice) except emergency services Any service or items for which a provider does not normally charge Cosmetic services or surgery except when medically necessary and approved Experimental procedures, or procedures not accepted as being effective, including experimental organ transplants Services provided by or in an institution run by the federal government, such as the Veterans Health Administration Respite care Rest cures, personal comfort, convenience items and services and supplies not directly related to the care of the patient. Examples include guest meals and telephone charges. Services in which health care records do not reflect the requirements of the procedure described or procedure code used by the provider Services provided by an immediate relative or household member Services involving the use of equipment in facilities in which its purchase, rental or construction has not been approved by the State of New Jersey Services resulting from any work-related condition or accidental injury when benefits are available from any workers compensation law, temporary disability benefits law, occupational disease law or similar law Services provided or started while on active duty in the military Services or items reimbursed based on submission of a cost study in which there is no evidence to support the costs allegedly incurred or beneficiary income to make up for those costs. If financial records are not available, a provider may verify costs or available income using other evidence that the NJ FamilyCare program accepts. Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to those over 21 years of age and under 65 years of age Services provided outside the United States and its territories Infertility diagnoses and treatment services (including sterilization reversals and related medical and clinic office visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures) Services provided without charge. Programs offered free of charge through public or voluntary agencies should be used to the fullest extent possible. Any service covered under any other insurance policy or other private or governmental health benefit system or third-party liability 11

12 Services not covered by NJ FamilyCare or Horizon NJ Health for NJ FamilyCare D Biofeedback Cosmetic services Custodial care Court-ordered services Experimental and investigational services Radial keratotomy Recreational therapy Rehabilitative services for substance abuse Religious non-medical institutional care and services Residential treatment center psychiatric programs Sleep therapy Special remedial and educational services Temporomandibular joint disorder treatment, including prostheses placed directly on the teeth Thermograms and thermography Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by Horizon NJ Health 12

13 Limited Durable Medical Equipment and Supplies by NJ FamilyCare D Coverage is limited to the following: Apnea Monitors Bathroom Equipment (Permanently Affixed Equipment Not ) Catheterization and Related Supplies Commodes DME Repairs Enteral Nutrition and Related Services/Supplies Hospital Beds (Manual, Semi-Electric and Full Electric) and Related Equipment Insulin Pumps and Related Supplies Manual Wheelchairs (Motorized Wheelchairs Not ) Nebulizers and Related Supplies Ostomy/Ileostomy/Jejunostomy Supplies Oxygen and Related Equipment/Supplies Pacemaker Monitors Parenteral Therapy and Related Services/Supplies Patient Lifts and Related Equipment Pressure Mattresses/Pads (Low Air Loss and Air Fluidized Beds Not ) Respiratory Assist Devices and Related Supplies Suction Machines and Related Supplies Total Parenteral Nutrition (TPN) Equipment and Related Supplies Tracheostomy Supplies Traction/Trapeze Apparatus Wheelchair Accessories Wound Care Supplies Wound Vac and Related Supplies Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise, an independent licensee of the Blue Cross and Blue Shield Association Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, NJ (04/14) 13