3.0 BENEFIT OVERVIEW

Transcription

1 3.1 Medicaid/ Benefit Matrix and Managed Care Protocols This benefit matrix provides a comprehensive overview of the benefits for preventive and medically necessary services provided to Medicaid and members enrolled in Horizon NJ Health. members enrolled in Horizon NJ Health through NJ FamilyCare A and B do not incur a copayment. Members enrolled through C and D and ADVANTAGE members are required to pay a copayment for certain services. Notwithstanding, the following is the benefit matrix for the Medicaid contract and sets forth the services that are reimbursable to the physician by Horizon NJ Health. Benefits are established by the State of New Jersey and are subject to change. Service Codes HNJH: Horizon NJ Health pays for this benefit. FFS: Medicaid Fee-for-Service pays for this benefit. Benefit Service Code Medicaid and A B C D Abortions and Related Services HNJH Coverage limited to spontaneous abortions/miscarriages (such as those under ICD-9 diagnosis codes 632, , ) FFS Coverage limited to elective/induced abortions Applied Behavior Analysis HNJH/FFS Not covered (ABA) Acupuncture HNJH when provided by a licensed physician Coverage limited to acupuncture provided by a licensed physician when performed as a form of anesthesia in connection with covered surgery Audiology Services (See EPSDT for Hearing Screenings) HNJH Coverage limited to children under the age of 16 years Blood and Blood Plasma HNJH Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations. Chiropractic Services HNJH Coverage limited to spinal manipulation Coverage limited to spinal manipulation. $5 copayment Not covered Cognitive RehabilitationTherapy (see also Rehabiliation Services - Outpatient PT, OT, Cognitive Rehabiliation Therapy and Speech Pathology) HNJH Coverage limited to 60 visits per incident, per calendar year Dental HNJH $5 copayment except for preventive dentistry visits Coverage limited to treatment for non-chronic conditions and acute illnesses and injuries. Coverage limited to 60 visits per incident, per calendar year Coverage limited to members under the age of 19. $5 copayment except for preventive dentistry visits Horizon NJ Health Physician and Health Care Professional Manual, February

2 Benefit Service Code Medicaid and A B Dental - Orthodontics HNJH only for members under the age of 21 who are demonstrating certain pathologies Diabetic Supplies and Equipment Durable Medical Equipment / Assistive Technology Devices Emergency Medical Care/ Emergency Services HNJH C only for members under the age of 21 who are demonstrating certain pathologies $5 copayment D only for members under the age of 19 who are demonstrating certain pathologies $5 copayment HNJH Coverage is limited to the specific durable medical equipment listed in section 3.11 HNJH EPSDT HNJH, including: medical examinations; dental, vision, hearing and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare A benefit package, including: medical examinations; dental, vision, hearing, and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare B benefit package $10 copayment for emergency room services, including: medical examinations; dental, vision, hearing, and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare C benefit package $35 copayment for emergency room services, except when referred by PCP for services that should have been provided in PCP s office or when member was admitted to the hospital Coverage limited to well-child care, newborn hearing screenings, preventive dental, immunizations, and lead screening and treatment Family Planning HNJH when services provided by a participating HNJH physician. 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. Certain members may only access services by participating HNJH physicians FFS when services provided by a non-participating HNJH physician. Only certain members may receive the same services noted above by non-participating HNJH physician Group Homes and DYFS HNJH when provided by a HNJH participating provider. Not covered Residential Treatment Facilities Hearing Aid Services HNJH Coverage limited to children under the age of 16 years 3-2 Horizon NJ Health Physician and Health Care Professional Manual, February 2013

3 Benefit Service Code Medicaid and A B C Home Health Agency Services HNJH Coverage includes nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment; physical therapy, occupational therapy and speech therapy services; pharmaceutical services; and durable medical equipment Home Health Agency Services Mental Health See also Mental Health/Home Health D Coverage limited to skilled nursing for home-bound member that is provided or supervised by a RN and a home health aide, when the purpose of the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member s medical condition HNJH only for DDD clients. Not covered FFS for all other beneficiaries except DDD clients Coverage as follows: For members under the age of 19, covered with no service limits For members 19 years and older, limited to 20 visits per year Hospice Services HNJH 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 19 years of age shall cover both palliative and curative care. Hospital Services - Inpatient HNJH Hospital Services - Outpatient HNJH with $5 copayment except for preventive services Infertility Diagnosis and Treatment HNJH/FFS Not covered (including sterilization reversals, and related office [medical and clinic] visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures) Intermediate Care FFS Not covered Facilities/Intellectual Disability Laboratory Services HNJH Coverage includes routine testing related to the administration of atypical antipsychotic drugs Maternity Services and Related HNJH Newborm Care and Hearing Screening Medicaid Fair Hearing FFS Members have a right to a Medicaid Fair Hearing, but the request must be filed with DMAHS within 20 days of the date of the adverse action by HNJH Medical Day Care HNJH Not covered Mental Health - Inpatient Hospital Services Including Psychiatric Hospitals Coverage includes routine testing related to the administration of atypical antipsychotic drugs $5 copayment when not part of office visit Only certain members have the right to a Medicaid Fair Hearing. The request must be filed with DMAHS within 20 days of the date of the adverse action by HNJH HNJH only for DDD clients Not covered FFS for all other members Coverage as follows: For members under the age of 19, covered with no service limits For members 19 years and older, limited to 35 days per year Horizon NJ Health Physician and Health Care Professional Manual, February

4 Benefit Mental Health Outpatient (excluding partial care services) Service Code Medicaid and A B C D HNJH only for DDD clients Not covered FFS for all members except DDD clients Coverage as follows: $5 copayment for members under the age of 19 $25 copayment for members 19 years old and older Mental Health Home Health HNJH only for DDD clients Not FFS for all members except DDD clients Coverage as follows: For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Medical Supplies HNJH Limited coverage. See also Durable Medical Equipment benefit Methadone (maintenance and administration) FFS Nurse Midwife HNJH $5 copayment for each visit (except for prenatal care visits) Nurse Practitioner HNJH $5 copayment for each visit (except for preventive care services) $5 copayment for first prenatal visit only $10 copayment for services rendered during non-office hours No copayment for preventive services or newborns covered under Fee-for-Service $5 copayment for each visit during normal office hours (except for preventive care services). $10 copayment for each home visit or office visit after normal office hours 3-4 Horizon NJ Health Physician and Health Care Professional Manual, February 2013

5 Benefit 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. Service Code HNJH FFS Medicaid and A Coverage limited to the 30 days in nursing facility. If admission to an acute hospital is required during these 30 days, the 30 day count is suspended and resumes on readmission back to the nursing facility. NOTE: If admission is for rehabilitation services only, HNJH will continue to be responsible for cost of care After 30th day in a nursing facility for non-rehabilitation services, DMAHS will disenroll the member from HNJH and the member will receive services from the Medicaid FFS program B C Coverage limited to 30 days of rehabilitation services following discharge from an acute care hospital if this is the appropriate setting for rehab to occur Not covered D Not covered Optical Appliances HNJH Select eyeglasses and contact lenses are covered as follows: Age 18 and under - Replacement eyeglasses or contact lenses annually if prescription changes. Age 19 to 59 - Replacement eyeglasses or contact lenses every two years if prescription changes Age 60 and older - Replacement eyeglasses or contact lenses annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur Optometrist Services HNJH One routine eye exam per year One routine eye exam per year $5 copayment Organ Transplants - Individual placed on transplant list while a HNJH Coverage includes all donor and recipient transplant costs for members who have transplants conducted within two months after disenrollment from Horizon NJ Health HNJH member Organ Transplants - Individual HNJH Coverage limited to transplant-related physician costs for donor and recipient placed on transplant list while in the FFS Program prior to initial enrollment with HNJH FFS Coverage limited to donor and recipient inpatient hospital costs Orthotics HNJH Not covered Outpatient Diagnostic Testing HNJH Partial Care Program FFS Not covered Partial Hospital Program FFS Not covered Personal Care Assistant (PCA) Services Personal Preference Program Services (only available through certain Waiver Programs) HNJH FFS FFS Coverage limited to maximum of 40 hours per week Coverage for any additional hours above 40 hours per week. Prior authorization required Members may contact the NJ Division of Disability Services at , option 2 Not covered Not covered Not covered Horizon NJ Health Physician and Health Care Professional Manual, February

6 Benefit Service Code Medicaid and A B C Podiatrist Services HNJH $5 copayment Prescription Drugs Retail Pharmacy Prescription Drugs Medicare Part B physician administered (typically billed with J-codes or Q-codes) Primary Care, Specialty Care, and Women s Health Services HNJH HNJH Coverage includes atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs which may be excluded from Medicare Part D coverage Coverage excludes erectile dysfunction drugs and drugs not covered by a third party Medicare Part D formulary $1 copayment for generic drugs; $5 for brand name drugs Coverage includes: atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs which may be excluded from Medicare Part D coverage Coverage excludes: erectile dysfunction drugs and drugs not covered by a third party Medicare Part D formulary HNJH $5 copayment for each visit. No copayment for well-child visits, lead screening/ treatment, age-appropriate immunizations, prenatal care or Pap smears D $5 copayment. 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 Coverage excludes over the counter drugs $5 copayment for brand name and generic drugs. If greater than a 34-day supply, $10 copayment applies. Coverage includes: atypical antipsychotics, Suboxone and Subutex or any other drug within this category when used for the treatment of opioid dependence, and drugs which may be excluded from Medicare Part D coverage Coverage excludes: erectile dysfunction drugs and drugs not covered by a third party Medicare Part D formulary $5 copayment for each visit during office hours $10 copayment for each office visit after normal office hours No copayment for well-child visits, lead screening/treatment, age-appropriate immunization, or preventive dental services $5 copayment for first prenatal visit, no subsequent copayments Private Duty Nursing HNJH for EPSDT-age children only Not covered. Exceptions may be made for special circumstances, if authorized by Horizon NJ Health 3-6 Horizon NJ Health Physician and Health Care Professional Manual, February 2013

7 Benefit Service Code Medicaid and A B C D Prosthetics HNJH 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 Radiology Services -Diagnostic & Therapeutic Rehabilitation Services - Outpatient PT, OT, Cognitive Rehabilitation Therapy and Speech Pathology Self initiated Care from a Non-participating Provider without Referral/Authorization Services Provided Outside of the United States and Territories HNJH $5 copayment when not part of an office visit HNJH Coverage limited to 60 visits per therapy per Coverage limited to 60 calendar year visits, per therapy, per calendar year $5 copayment Speech pathology services rendered for treatment of delays in speech development are not covered, unless resulting from disease, injury or congenital defects Cognitive rehabilitation therapy services are also limited to treatment for non-chronic conditions and acute illnesses and injuries HNJH Not covered The member shall be held responsible for the cost of care HNJH/FFS Not covered Sex Abuse Examinations FFS, including related diagnostic testing Social Necessity Days FFS Coverage limited to no more than 12 inpatient hospital days Not covered Specialty Foods (Medical Foods) HNJH Coverage limited to nutritional supplements requiring medical Not covered supervision for members with inborn errors of metabolism and related genetic conditions Medical foods and special diets for all other medical condition are not covered Substance Abuse HNJH only for DDD clients Not covered (Inpatient and Outpatient) FFS for all members except DDD clients Benefit limited to detoxification. For members under the age of 19, covered with no service limits For members 19 years and older, limited to 20 visits per year Transportation Emergency Ambulance (911) HNJH Coverage limited to ambulance for medical emergency only Horizon NJ Health Physician and Health Care Professional Manual, February

8 Benefit Transportation to Medically Necessary Services - Livery transportation services, such as bus and train fare or passes, car service and mileage reimbursement Transportation to Medically Necessary Services (including non-emergency ambulance, mobile intensive care units [MICUs] and invalid coach [including lift equipped vehicles]) Service Code FFS FFS Medicaid and A by LogistiCare (state transportation contractor) NOTE: Members should call LogistiCare at to book a trip by 12:00 noon at least 2 days in advance of transportation need B Not covered C by LogistiCare (state transportation contractor). NOTE: Members should call LogistiCare at to book a trip by 12:00 noon at least 2 days in advance of transportation need. HNJH case managers can contact LogistiCare at to book transportation on behalf of member D Not covered 3.2 ADVANTAGE Benefit Matrix and Managed Care Protocols Benefit Abortions and Related Services Acupuncture Audiology (See EPSDT for hearing screenings) Blood and Blood Plasma Cognitive Rehabilitation Therapy (see also Rehabilitation Services - Outpatient PT, OT, Cognitive Rehabilitation Therapy, and Speech pathology Dental Dental - Orthodontics Diabetic Supplies and Equipment Durable Medical Equipment/Assistive Technology Devices Emergency Medical Care/Emergency Services EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Family Planning Hearing Aid Services Home Health Agency Services Hospice Services Hospital Services (Inpatient) ADVANTAGE Coverage limited to spontaneous abortions/miscarriages (such as those under ICD-9 diagnosis codes 632, , ) Coverage limited to acupuncture provided by a licensed physician when performed as a form of anesthesia in connection with a covered surgery Coverage limited to children under the age of 16 years Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations Coverage limited to treatment for non-chronic conditions and acute illnesses and injuries Coverage also limited to 60 visits per incident per calendar year, $5 copayment for all dental visits Limited coverage Orthodontic services are only to be provided to children in cases where medical necessity can be proven, such as cases involving developmental and facial deformities causing functional difficulties in speech and mastication, and trauma. $5 copayment Coverage limited to the specific durable medical equipment listed in section 3.22., $35 copayment for each visit Coverage limited to well-child care, newborn hearing screenings, immunizations, and lead screening and treatment 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. All services must be delivered by HNJH participating providers Coverage limited to children under the age of 16 years Coverage limited to skilled nursing that is provided or supervised by a RN and a home health aide when the purpose of the treatment is skilled care Coverage includes medical social services that are 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 for children under 19 years of age shall cover both palliative and curative care. Horizon NJ Health is not responsible when the primary admitting diagnosis is mental health or substance abuse related 3-8 Horizon NJ Health Physician and Health Care Professional Manual, February 2013

9 Benefit Hospital Services (Outpatient) Laboratory Services Maternity Services Medical Supplies Nurse Midwife Nurse Practitioner Optical Appliances Optometrist Services Organ Transplants Outpatient Diagnostic Testing Podiatrist Services Prescription Drugs from a Retail Pharmacy Prescription Drugs Medicare Part B Physician Administered (typically billed with J-codes or Q-codes) Primary Care, Specialty Care and Women's Health Services Prosthetics Radiology Services Diagnostic & Therapeutic Rehabilitation Services - Outpatient PT, OT, Cognitive Rehabilitation Therapy, and Speech pathology Self-initiated Care from a Non-participating Provider without Referral/Authorization Transportation Emergency Ambulance (911) Transportation to Medically Necessary Services - Livery transportation services, such as bus and train fare or passes, car service and mileage reimbursement Transportation to Medically Necessary Services (including non-emergency ambulance, mobile intensive care units), $5 copayment for each visit ADVANTAGE, $5 copayment for each visit that is not part of an office visit Coverage includes routine testing related to the administration of atypical antipsychotic drugs, including related newborn care and hearing screening Coverage limited to diabetic supplies, $5 copayment for each visit, $5 copayment for each visit Select eyeglasses and contact lenses are covered as follows: Replacement eyeglasses or contact lenses annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur for one routine eye exam per year, $5 copayment if the individual is placed on transplant list while a Horizon NJ Health member. Horizon NJ Health is responsible for entire cost of non-experimental/non-investigational organ transplants. Coverage is limited to transplant-related physician costs for donor and recipient if the individual was placed on transplant list while in the FFS Program prior to initial enrollment, $5 copayment for each visit, 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 Coverage excludes over-the-counter drugs $1 copayment for generic drugs $5 copayment for brand-name drugs $10 copayment for >34-day supply No coverage for erectile dysfunction drugs Certain cough/cold, topicals, and anti-obesity drugs are not covered for certain age groups with a $5 copayment for each visit Coverage limited to the initial provision of 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 when due to congenital growth, $5 copayment for each visit that is not part of an office visit Coverage limited to 60 visits per therapy, per calendar year $5 copayment Speech pathology services rendered for treatment of delays in speech development are not covered, unless resulting from disease, injury or congenital defects. Cognitive rehabilitation therapy services are also limited to treatment for non-chronic conditions and acute illnesses and injuries The member shall be held responsible for the cost of care Coverage limited to ambulance for medical emergency only only if HNJH refers a patient to an out-of-county or out of State provider only if Horizon NJ Health refers a patient to an out-of-county or out-of-state provider 3.3 Exclusions The following services are not covered by Horizon NJ Health or the NJ Medicaid Fee-for-Service program Services identified as being not medically necessary, or those not provided, approved or arranged by a Horizon NJ Health participating physician or other provider (within his/her scope of practice), except emergency services Services or items for which the provider does not normally charge Cosmetic surgery except when medically necessary and approved Experimental organ transplants Claims arising directly from services provided by or in institutions owned or operated by the federal government, such as Veterans Administration hospitals Respite Care Horizon NJ Health Physician and Health Care Professional Manual, February

10 Rest cures, personal comfort and convenience items, and services and supplies not directly related to the care of the patient, including, but not limited to, guest meals and accommodations, telephone charges, travel expenses, take-home supplies and similar costs. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by Horizon NJ Health 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 furnished by an immediate relative or member of the Medicaid beneficiary s household, except for members enrolled in the Personal Preference Program Services involving the use of equipment in facilities in which the purchase, rental or construction has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits thereunder, and whether or not any recovery is obtained from a third party for resulting damages Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military Services or items reimbursed based on submission of a cost study in which 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 Division of Medical Assistance and Health Services Services provided in an inpatient psychiatric institution that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age Services provided outside the United States and territories Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinical) expenses, drugs, laboratory services, radiological and diagnostic services and surgical procedures Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey State Department of Health and Senior Services, New Jersey Heart Association, First Aid Rescue Squads, and so forth) shall be utilized to the fullest extent possible That part of any benefit that is covered or payable under any health, accident or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similar third-party liability, which also includes the provision of the Unsatisfied Claim and Judgment Fund Exclusions for D Members The following services are not covered for NJ FamilyCare D participants either by Horizon NJ Health or Division of Medical Assistance and Health Services (DMAHS): Biofeedback Cosmetic services Court-ordered services Custodial care Experimental and investigational services Hearing aid services for members over the age of 16 Infertility services Intermediate care facilities for individuals with intellectual disabilities Medical day care services Personal care assistant services Radial keratotomy Recreational therapy Rehabilitative services for substance abuse Religious non-medical institutional care and services Residential treatment center psychiatric programs Respite care 3-10 Horizon NJ Health Physician and Health Care Professional Manual, February 2013

11 Nursing facility services Sleep therapy Special remedial and educational services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in 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 Exclusions for ADVANTAGE Members The following services are not covered for NJ FamilyCare ADVANTAGE participants either by Horizon NJ Health or DMAHS Biofeedback Cosmetic services Cosmetic surgery except when medically necessary and approved Court-ordered services Custodial care Radial keratotomy Recreational therapy Religious non-medical institutional care and services Respite care Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military Services or items reimbursed based on submission of a cost study in which 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 Division of Medical Assistance and Health Services Services provided outside the United States and territories Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinical) expenses, drugs, laboratory services, radiological and diagnostic services and surgical procedures Sleep therapy Special remedial and educational services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Thermograms and thermography Weight-reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity, when approved by the contractor 3.4 Family Planning Horizon NJ Health members are entitled to receive family planning services. Services that prevent or delay pregnancy are covered, including: Medical history and physical examination (including pelvic and breast) Diagnostic and laboratory tests Drugs and biologicals Medical supplies and devices Counseling Continuing medical supervision Continuing care and genetic counseling Elective/induced abortions and related services are not covered under this contract, but will continue to be paid on a fee-for-service basis by Medicaid. Infertility diagnoses and treatment services, including sterilization reversals and related office (medical or clinical) drugs, laboratory, radiological and diagnostic and surgical procedures are not covered. Elective/induced abortions and related services as well as infertility diagnoses and treatment services are not covered for ADVANTAGE members. Hysterectomy is not a covered service if it is performed solely for the purpose of sterilization. Hysterectomy is a covered service if the primary medical indication for the hysterectomy is other than sterilization. See Section 3.5 Obstetrical and Gynecological Care. Horizon NJ Health is available to assist members in locating family planning services. Members can access services through Horizon NJ Health s physician network or through participating Medicaid family planning providers. ( D and ADVANTAGE members may only access services through participating Horizon NJ Health Horizon NJ Health Physician and Health Care Professional Manual, February